Bringing research into the real world: the challenges of scaling up
Adrian Bauman: The researcher/policy maker partnership is in evolution, internationally. It’s the true way that we’re going to do applied research that’s going to improve health faster, where it happens.
Gretchen Miller: Hello there. Welcome to Prevention Works, the podcast of The Australian Prevention Partnership Centre. I’m your host, Gretchen Miller. This episode, we’re talking about scaling up. That’s where you take some research that’s worked and bring it to larger populations, a challenge for health departments all over the world. Why do we struggle with it? Why isn’t it consistently handled, and why does research that could be scaled up die on the vine? And, of course, what can we do to fix it? We’re always solutions-focused here on Prevention Works.
Andrew Milat: Often, we have policymakers who may have a PhD or have done research. They are far more research literate, and then you get a critical mass of people within bureaucracies who actually understand and use research and that becomes quite normative behaviour.
Gretchen Miller: Our guests today have both insight and solutions. Professor Adrian Bauman, who, amongst many other things, is Professor of Public Health at the University of Sydney, as well as a researcher and an influencer of public policy, and Dr Andrew Milat, who is a policy maker and the Director of the Evidence and Evaluation Centre for Epidemiology and Evidence at the NSW Ministry of Health. He’s also Adjunct Associate Professor at the University of Sydney. He’s also been a health researcher. Welcome to you both.
You’re both close to the end of research through the Prevention Centre that’s come up with a tool that helps policymakers work out how best to scale up projects. We’ll get to how that works later in the show. But first, let’s discuss what we’re dealing with and why we might need a tool in the first place.
Adrian, a simple example of scaling up. Say in a clinical setting with a vaccination or a new treatment protocol, how does it work?
Adrian Bauman: Simply in clinical settings, laboratory scientists do research and they discover a new drug or a new therapy. They test it in a controlled trial of a few people. If it works, scaling up is getting that drug to everyone with that condition in New South Wales or Australia or the world, not just the people that participated in the trial.
Gretchen Miller: Okay, so, it’s how you get it out there, and it’s a reasonably simple matter. But for a more complex health policy, issues of public health, things get a lot more challenging. I think it starts even right at the beginning, even when you’re choosing your volunteers.
Adrian Bauman: It does, and in public health, we still do trials with people that volunteer, but the people that don’t volunteer will be very different. You might test how we’re going to implement a physical education policy in two keen schools, and it works well. But how do we get it to the rest of the schools in Australia? So that kind of idea is, the differences between the schools that participate in the study and those that don’t are even greater than they are in the clinical example we looked at earlier.
We have to start collecting evidence somewhere. If we’re doing a study in general practice, we get enthusiastic GPs willing to participate. And they enroll keen patients who are willing to change their lifestyles or do the screening behaviour that is being requested in the trial. We’ve got to generate some evidence – can it work? And then once we know it can work in those selected people, we’ve got to take it out to the rest of general practice across the system, and that’s a much more challenging task.
Gretchen Miller: What happens? What are some of the problems of scaling up with public health? One of the issues that we have to deal with is how a government responds to research. I know that this is actually an international issue of how researchers and policymakers and governments work with the research to bring them to a bigger population.
Adrian Bauman: When you have evidence that something works, it’s got to fit with current government priorities, the capacity for governments to fund it, and a system that can deliver it. Those things might not all line up at the same time. When we talk about prevention, we’re working across government agencies, we’re working with sport and recreation and education and agriculture and transport and urban planning and town planning and local government and non-government organisations and community groups, and it’s a much more complex milieu in which we have to design and implement scaled up prevention programs.
There may be a delay between generating evidence – we want to make that change, and we want to make everybody healthier – and governments’ capacities to implement it maybe a little further down the track when the other elements line up.
Gretchen Miller: Now, the two of you are part of a quite different relationship between researchers and policymakers in New South Wales, in a way that bucks the trend, basically. Before we get there, though, Andrew, as a policy maker, what are the general challenges for scaling up from your perspective?
Andrew Milat: I think scaling up really should be our core business in policy making and working in government. Because at the end of the day, I think the public will only get the full benefits of these promising pieces of research, of effective interventions if we take them and try to scale them up across systems. The challenges are many, as Adrian pointed out, obviously, some of the information may be there that may tell us that an intervention may be effective, but the real challenge for us as policymakers is how do we take that information from research and then apply it across whole systems?
Though there may be very strong evidence from a randomised controlled trial that really works with, for example, using the same example of GPs, GPs that are quite motivated, the public who may be early adopters and interested in engaging with a particular intervention. Our challenge is to really get out there with people across the whole system, perhaps general practitioners who may be less engaged or less interested in implementing interventions, and those sections of the public that may be a bit more challenging to reach with the interventions more broadly.
We have to really think about how we can move things on a system level and not just at that individual research level.
Gretchen Miller: There are some interesting challenges around really simple things like does a community have a place in which a practice can happen?
Andrew Milat: It does. Certainly, when we’re thinking about promising interventions, and how they may be scaled up across the state, I think we have to be far more flexible. There’s this constant challenge for us, it’s called fidelity adaption challenge. Where we know that through research, there may be a couple of elements of a particular intervention that are really important for its success. But we know the reality of implementing things on a community level or a system level is that we may not be able to meet all of those requirements. That’s where we have to adapt to the local context.
That’s a real ongoing challenge. We have some really tangible examples, particularly in the prevention space, where there was lots of promising evidence, for example, in the space of diabetes prevention. What that involves is getting people through general practices who are at risk of diabetes and then referring them to lifestyle behaviour change programs.
Now, the evidence from the randomised control trials from overseas and in other contexts showed that really required face to face sessions with people to teach them about better eating and being more physically active. But to scale that up across the whole system is really challenging, because, as you said, you need the facilities to actually have that face to face interaction, you need lifestyle counsellors to be able to be physically in different locations across a whole state or a whole country.
What happened in the end, for example, with programs like that in many areas, and including in Australia, those types of programs are offered in different modalities. People in rural areas may not have access to lifestyle counsellors. What we’ll often do is offer those services over a telephone. In some cases, face to face modalities do work, so I think we have to be a lot more flexible and innovative in the way that we actually implement the evidence from the research when we’re doing it on a practical policy level and statewide level.
Gretchen Miller: Okay. We might unpack these issues a bit more shortly, but in the interests of demystifying the process of scaling up, let’s go right back to first principles. Andrew, as a policy maker, there’s something you want to improve in public health policy. Where do you start?
Andrew Milat: Yeah, I think that’s a really good point. Because often, the way that policymaking happens in reality is there are lots of different things. There may be an ongoing agenda that we’re committed to, and we have been investing in over many years. What we try to do is to create what we call research pipelines. For example, prevention is an issue that we know is important. So, we have invested in New South Wales over the past 15 years in various research partnerships. We’ve collaborated with our colleagues in other jurisdictions, we work with multiple research academics and agencies.
That’s a really consistent long term vision for how we want to move the system and feed information into our decision making. The reality is though, sometimes things just come out of the blue as well. They may be new government priorities, there may be things that we have to action, and they are quite challenging because often we are operating in a space where there is less evidence available for what is the right action, what is the right path to go down.
I think there are challenges in both fields. But I think the way that I see it as my one of my core jobs is to really anticipate what the future is and try to ensure that we have pipelines in place to really give us the best quality evidence to inform our decision making. But that’s not always possible. But that’s really one of the core goals of my job.
Gretchen Miller: Adrian, with your research hat on, where do things actually begin for you? Right back to the beginning.
Adrian Bauman: They begin with doing a systematic review of what does the evidence to date show? Does it answer the question that the policy maker wants? If it doesn’t, then you need to decide and define what research you’ll do to actually generate that evidence. What’s the least you can do? What’s the most useful you can do, what’s the most applied you can do? And, if you build scalability in early, what’s the most generalisable you can do so that you’ve got different kinds of people from different backgrounds participating in the research so that you don’t have to repeat the trial too many times?
Gretchen Miller: Is research always triggered by policymakers, or does it come from experts on the ground? Secondly, is building scalability early critical to all research?
Adrian Bauman: Building scalability early is critical to all research. Currently in our traditional health funding – NHMRC traditional social science funding, ARC grants and other kinds of government and scientific grants, scalability is not considered. But it is in Canada, and it is in England and they realise in their traditional funding bodies that you need to think about what are the consequences of this research for broader health or broader social policy? It’s actually built into the grant proposal. It’s not currently, it’s only in the applied research that you do with government where it exists in Australia, but it should be embedded in making research more useful in terms of what it does at the very beginning planning stage when the researcher’s got an idea, a light bulb goes on in their mind.
Gretchen Miller: Okay. That leads me to that other question, it’s not always obviously then triggered by policy makers.
Adrian Bauman: It certainly isn’t. Primary research, NHMRC research, government funding research schemes are investigator initiated, which means they’re triggered by an idea that these patterns occur in the data or in a population or in a group, why don’t we investigate that a bit further? It may have low policy relevance, but be very good science.
Gretchen Miller: That is a key question, Adrian, how long generally at the moment does it take to get from research to public policy?
Adrian Bauman: It’s an incredibly difficult thing to map the trajectory or timeline from initial research to public policy. But the best estimates are around 17 years.
Gretchen Miller: Which is gob smacking.
Adrian Bauman: Which is incredibly long and we’re doing all kinds of good things in research that could improve population health faster than that. That’s why building scalability in early is an important parameter.
Andrew Milat: Certainly in New South Wales, at risk of sounding parochial, talking about my jurisdiction, there has been an explicit objective of our NSW Health to actually speed that time from the generation of research and speed the time of collaboration between academics and clinicians at the coalface. We’ve created a scheme called the Translational Research Grant Scheme. That scheme, one of its core premises is to actually focus on the issue of scalability. It has a translational framework and we explicitly request sections of the applications refer to scalability and how that research is being done in a way that can be applied across whole systems.
There are a couple of other unique features of that scheme. It has to be led by a clinician or a person working in a health setting. The chief executives of hospitals and LHDs actually must commit to actually implementing changes. We explicitly asked for the types of research to really focus on how they can take those promising things from all around the world that’s in research and apply them to the New South Wales health system and how that can be scaled up.
There are certainly some examples of research funding schemes in Australia that have the explicit intent of actually scaling up programs more rapidly than what currently occurs, and the Translational Grant Scheme is one of those.
Gretchen Miller: Okay, Andrew, we’re dealing with a very complex interplay of many stakeholders. How does scaling up work in the real world, in a real health department? How do you start the process? We could look at the example of say, school canteens and healthy eating. What were the issues? How did you go about the communications with so many stakeholders including parents who have passionate opinions about what a canteen should offer, from give me a break, I don’t want to make lunch today, to it’s important my child eats healthfully every day and you’re responsible for it. How do you manage it all?
Andrew Milat: Obviously, it’s a very complex undertaking, and it requires lots of consultation with the various stakeholders. Evidence is a really important part of every process. But that evidence comes in many different forms. Certainly, when we are thinking of scaling up initiatives, the research evidence is a fundamental part of that process. But we also want to talk to stakeholders ultimately using the example of canteens, we want to talk to people who are running canteen services.
Gretchen Miller: This is parents, yes? So, non-experts really.
Andrew Milat: Well, it can be parents, it can be commercial providers. There are lots of different arrangements for how canteens are organised in New South Wales. That’s just a great example where often our conception may be that it’s parents running schools, but in many schools, that is the case. But in many cases it’s actually commercial providers.
When we are going in and thinking about solutions where we want to scale things up, we have to really talk to everyone involved. We need to do important things like formative research, we need to talk to parents, we need to talk to the kids, we need to find out about how actually things will be implemented on the ground and what some of those challenges and enablers will be. That’s by no means a simple task.
Gretchen Miller: But you did actually do that. School canteens underwent a revolution really, and it was successful.
Andrew Milat: Indeed, and I think it’s through a process of once again, starting with the research. Adrian’s team did play an important role in that process in terms of doing some really important research, going out there talking to stakeholders, giving us a sense of what those barriers were. We work with the peak bodies as well in that space, School Canteens Association. We worked with a lot of the suppliers and the commercial entities as well.
I think it’s a really great example where we have collaboration amongst many stakeholders to actually implement a change that, as you say, has transformed the way that food services are provided in schools.
Gretchen Miller: So, Adrian, back to you again. You’ve done lots of international research on this, some of it with the Prevention Centre. Which nations are your best role models for scaling up, and which really struggle? How can we learn?
Adrian Bauman: I’ve got a rather radical view about which countries do well at scaling up. I think it’s also economies of size. Smaller countries, particularly countries without a middle tier of government, which we have in Australia with our federated states or provinces in Canada make things more complicated. Countries that do well are Finland, Norway, Sweden, Denmark, and New Zealand in particular, because they go straight from national policy to the effect or that the local government, local school board level and they seem to be able to implement well. They’ve also got a collectivist view of national identity. Whereas for example, in the United States, every school board is an independent fifedom who will do things their own way, and that makes it much more difficult to scale up.
Gretchen Miller: The Australian Prevention Partnership Centre with yourself and Andrew have been looking at the issues of scaling up for some time. There’s been research ongoing into this. It continues to be a central plank in your ongoing research and funding to 2023. Tell me a little about that journey, what you’ve found and what you’ll implement.
Adrian Bauman: Really, through The Australian Prevention Partnership Centre, we’ve been working across jurisdictions with several states and territory governments and with the Federal government to try and work out what their issues and programs are to develop case studies of scale up. With Andrew, we are building tools that enable people thinking about scaling up to test whether they’re ready for scale up, whether the program is feasible and whether they’re going to be able to scale up.
That tool will be able to take enthusiasts and reality test them in their context about scaling up their particular program. Some will continue, some might say, we’ve got to build more resources or capacity in the field or other things. Really, we are contributing to the field’s capacity to scale up and how we monitor that when they do.
Gretchen Miller: This is Prevention Works, the podcast of The Australian Prevention Partnership Centre, and we’re talking about scaling up. Shortly, we’ll get to some details about that tool that Andrew and Adrian have been working on. I wanted to talk though, about your relationship. You guys have actually modeled a really successful way of communicating between researchers and a health department. Can you tell me a little bit about that.
Adrian Bauman: Very simply, NSW Health has had stability for a long time in the prevention area of the workforce. Some jurisdictions have rapid turnover. So, every time I as a researcher turn up, I’m talking to a different policy maker. Developing a long-term relationship with policymakers is essential to develop the trust and collaboration that forms these research policy maker partnerships that makes them work.
The second piece is that the government agency has to want to invest in this, has to see this as important, it has to become a priority so that resources can flow to make this happen.
Andrew Milat: I think reflecting on the relationship they would have had over many years, I think in New South Wales, what has been unique, I agree, the stability in the senior leadership of the organisation has been a major contributor to that consistent vision and commitment to the use of research evidence in policy and practice. We’ve also invested over time in priority-driven research centres, which is quite unique across the country.
Gretchen Miller: What does priority-driven research centres mean?
Andrew Milat: A priority-driven research center is something like The Australian Prevention Partnership Centre. It’s where us as policymakers make a commitment to actually funding a research centre to do a program of research over a longer period of time. Often the relationship that governments have with the research community is that we may want an evaluation of a policy or program. We get an academic on board to evaluate that particular program. They produce a product and then it’s finished. Or the researchers may be doing research that may be of interest to us as policymakers, independent of us, and then we take that information and integrated into the policy process.
I think what’s unique about New South Wales is we’ve been investing in that priority-driven research for about 20 years. Adrian’s group, alongside the Prevention Centre, also provides a priority-driven research centre around physical activity and nutrition and obesity. We’ve created a scheme called the Translational Research Grant Scheme. One of its core premises is to actually focus on the issue of scalability. It has a translational framework and we explicitly request sections of the applications refers to scalability and how that research is being done in a way that can be applied across whole systems.
There are a couple of other unique features of that scheme. It has to be led by a clinician or a person working in a health setting. The chief executives of hospitals and LHDs must commit to actually implementing changes. And we explicitly asked for the types of research to really focus on how they can take those promising things from all around the world, that’s in research and apply them to the New South Wales health system and how they can be scaled up.
There are certainly some examples of research funding schemes in Australia that have the explicit intent of actually scaling up programs more rapidly than what currently occurs, and the Translational Grant Scheme is one of those. I think the other thing that’s really contributed to the unique approach that we have in New South Wales is that we’ve had successive governments over many years, making a consistent and strong commitment to prevention. That has allowed us to, as Adrian said, develop close relationships.
In actual fact, what’s quite unique, I think, is that many of the policymakers have actually done PhDs and then become researchers in their own right over time. Adrian’s group, but also the Prevention Centre, has been an important contributor to that. Whereby often, we have policymakers who may have a PhD or have done research, they are far more research literate. And then you get a critical mass of people within bureaucracies, who actually understand and use research. That becomes quite normative behaviour.
That’s quite an interesting social experiment that one day it’d be great to write up the whole thing of what’s happened in our jurisdiction over time, because we do see a much greater level of integration and conjoined appointments and collaboration between the research community in prevention anyway, and policymakers in NSW Health.
Gretchen Miller: So, it’s a movable thing. Researchers become policymakers, policymakers become researchers, and then you get a real enmeshment of understanding and knowledge. It sounds really quite extraordinary. Do you think that policymakers and researchers on the whole, internationally and in Australia, that policymakers and researchers talk to one another enough?
Andrew Milat: Certainly, my observation as a policymaker in New South Wales, I think we have been a little bit spoilt In terms of the nature and quality of the relationships that we have. But nothing is perfect at the end of the day. Certainly, my experience in talking to colleagues in other jurisdictions, is that there is less of a relationship. But certainly I think a lot of the initiatives that have been happening across the country like the Partnership Centre, like investments in things like the Partnership Grants through the NHMRC, the creation of things like the Translational Research Grants, we are seeing almost like a shift almost to a tipping point where we are seeing a lot more integration between the research community and policymakers. But that is very variable across the country, and it’s variable by issue. It may be very strong in prevention, it may be less strong in other areas. I think there’s a lot of work to be done in that space for my reflections. But Adrian would offer I think a very strong perspective on that.
Adrian Bauman: The researcher/policy maker partnership is in evolution internationally. On both sides there was a reticence to engage. For researchers, many think that policymakers are not doing pure enough research, or scientific enough research or scientific enough evaluations. It takes too long for policymakers to deliver their products, and there may be political barriers and issues that get in the way.
From the policymakers’ perspective, the researchers were taking too long to publish the results of their trials, and they needed evidence and results more quickly and more rapidly. Understanding both of those has been an evolution and is an evolution occurring internationally. It’s faster in some areas and in some countries, it’s the true way that we’re going to do applied research that’s going to improve health faster, where it happens.
Gretchen Miller: What place does politics play in critical factors like the timing of grants, the sustainability of projects? How do you allow for that, Adrian?
Adrian Bauman: Researchers have to develop new kinds of patience, almost a transcendental Zen state in dealing with politics, because politics can suddenly cut the funding line of NHMRC or other grant funding, it can remove grants that have already been awarded for funding. It can change policy directions at right angles so everything you thought you were doing is suddenly irrelevant.
It will come around and it will come back to where you were. But being a patient researcher is a necessary new researcher quality in interacting with policymakers in the political landscape. Because it’s not the policy makers making the politics, it’s the political masters across all of our systems.
Gretchen Miller: Absolutely. Does that mean looking elsewhere for funding is becoming an issue?
Adrian Bauman: We’re looking in research environments in Australia more and more broadly for places to get funding as funding becomes more difficult in many environments. Applied research is one of those, but if you can’t do a piece of work with government, you might be able to do it with a non-government organisation like the Heart Foundation or the Cancer Council, and then come back to government later with the same piece of work. It requires great flexibility and creativity on the part of researchers to be working across multiple opportunities.
Gretchen Miller: It’s that actually taught? As a scientist, are you taught how to actually practise in the real world?
Adrian Bauman: I don’t think you can teach that in a didactic way, in the same way as politicians don’t learn other than by apprenticeship. But we encourage our mid-career researchers to come along and meet with policymakers and see how they work and become part of that system communication.
Gretchen Miller: That’s big P politics. Tell me about the small P politics of communities. That fragile engagement between government and small communities who have their own idea about what they need. How does NSW Health work with communities?
Adrian Bauman: When you’re bringing sectors, agencies, disciplines and the community together, that’s a stakeholder mix that’s very diverse. Initially, they may not all want to play together in the same project, and that may take a process of persuasion and revisiting them. It may be an iterative process over time. It doesn’t all happen, let’s have a committee and everything’s wonderful.
Gretchen Miller: Okay. What’s your position on this, Andrew?
Andrew Milat: I think this is part of the alchemy of policymaking and scale up itself. Whenever you’re implementing an intervention, as I said previously, the research is really fundamental to that, that’s where we start. But the reality is we need to think about many different things. There may be resistance to a particular practice change. I think one of our biggest challenges in health systems is that we really need to convince practitioners who are at the coalface who are working in hospitals and in the communities, that whatever we’re asking them to do and scale up is better than current practice.
Often, we work with key figures in that space. Maybe influencers, key academics or clinicians, and then we work with them to be champions for a change process. We also need to think of many other things. Obviously, working with communities. We may alter the way that we implement a program. For us, for example, there may be evidence that a highly skilled health professional in the randomised control literature is telling us must implement this intervention. But as a policy maker, we may want to implement it with a workforce that may be a bit cheaper.
You gave the example of allied health professionals. For example, some of the initial falls prevention programs that were implemented –
Gretchen Miller: Falls prevention?
Andrew Milat: Yeah, falls is an important issue for all the people, there is evidence that if you do balance based physical activity that you can actually prevent falls in all the people. It’s a really serious thing because if you have a fall and you’re on older person, you get some catastrophic outcomes for older people that may fracture a hip and their survival rate is very low after something like that.
We’re trying to avoid it, but the initial trials that were done in New Zealand, for example, showed that physiotherapists were implementing these programs. Subsequently, we commissioned some research and implemented programs in the community that showed that competency-based people, so, fitness leaders. could equally do those programs equally well.
Gretchen Miller: And be more affordable.
Andrew Milat: And be more affordable for the system. We’re constantly balancing evidence, stakeholder opinion, what clinicians are telling us and members of the community, the efficiency of your program, workforce availability. We’re looking at a whole range of things when we’re thinking about scaling up. That’s an ongoing challenge, and the challenge for us as policymakers is that that does vary from issue to issue.
Gretchen Miller: Indeed. One really interesting set of communities where this becomes almost a model for how to manage other communities is Indigenous Australia. There has been a practice in Australia of assuming all Indigenous communities are the same and can be treated the same. It’s simply isn’t the case. How do you go about managing that incredibly complex issue as a policy maker?
Andrew Milat: Look, I think it’s one of the key challenges that we face, and arguably one of the most fundamental things that we should be doing as part of any program that we implement. Certainly, we do think the needs of those at greatest need in our communities, obviously, when it comes to Aboriginal populations and communities, it’s particularly important that we have community control of whatever happens in those settings.
That’s one of the real lessons that I think we’ve learned over many years in New South Wales, is the importance of community control and engagement with the Aboriginal community. Thankfully, in recent years, we’ve had a number of changes in the way that we do business. For example, me as a policymaker, if I want to do any program implementation and evaluation of statewide initiatives in Aboriginal communities, we must go through something called the Aboriginal Health and Medical Research Council. That council does a bit of a culture check on what we’re proposing to do. We’re required also to go out and do formal consultations with the broader community across New South Wales. It’s not good just to talk to urban Aboriginal people in Mount Druitt or Blacktown, we need to go out to Dubbo, we need to go out to other parts of southern and western New South Wales. We have to engage the broader community.
You’re right, they are different, and we need to really take that process seriously. We’ve invested greatly. It does take us more time to implement things in Aboriginal communities. But we, I think, universally agree that the importance of actually engaging with communities far outweighs the challenges of actually going out there and the resources involved in that process.
Gretchen Miller: How did that work in the Aboriginal Health knockout challenge?
Andrew Milat: That’s a great example. This is an initiative that was created by Aboriginal staff within what was then the Department of Health in NSW Health. Through a consultation process, these Aboriginal staff members who worked in chronic care, spoke to communities, went out there and spoke to some of the peak bodies. And really, were thinking of a positive way of engaging with lifestyle behaviour change. And then the idea of the knockout challenge came about. Raylene Gordon, who’s currently the head of the Aboriginal Health and Medical Research Council, came up with the initiative with Aboriginal communities and began to implement it.
Certainly, it’s an interesting example because it had elements of it that as a public health practitioner, I would say this with some trepidation, but with great honesty, is that it was a little bit boring. We would make it a bit more boring in a public health sense. They made it tailored to Aboriginal communities, far more interesting. There’s a competitive element in there, it’s aligned to the rugby league knockout challenge. So, there is an existing community event that they could leverage off. It’s a fun activity where people compete against one another to achieve lifestyle goals and nutrition and physical activity and to lose weight. And a way of really engaging and building community cohesion and connections amongst people in the community.
It was a very innovative approach led by community and then scaled up by the department at the time. Now, it continues to this day and continues to grow.
Gretchen Miller: I’m interested in why things might die on the vine which you have envisaged would take off.
Adrian Bauman: One of the reasons that things might die on the vine is you’ve actually worked out that something is scalable, affordable and effective. But there isn’t enough money in the system to make it run. Because all of a sudden, your pilot studies that might have gone on in one region cost $500,000, but you want 50 million to disseminate it across a much, much larger region. That financial impulse has to come from somewhere. The system hasn’t got the flexibility at that particular time, or even for a series of years, to transfer large resources to make your program happen without making other things suffer as a consequence.
Gretchen Miller: So, money is one thing. What else could cause you to come up short?
Adrian Bauman: Sometimes the values of governments will change over time and what’s a preventive priority or a health priority in one government might not be in a successive government in the same jurisdiction or nationally. So, priorities will change, and therefore the things that get funded at scale will also change.
Gretchen Miller: What as a researcher can you do to take these things into account?
Adrian Bauman: There is also a researcher role in advocacy, partnering for advocacy to actually pressure government, encourage government, persuade government, encourage the community, mobilise parents in schools, to mobilise general community opinion that this is an important issue. That’s something that’s done outside of government, has to be done outside of government, to create the groundswell to prioritise that particular issue.
Gretchen Miller: So, researchers really need to have that as part of their research is actually is advocacy.
Adrian Bauman: You can teach health advocacy, that is actually teachable. People need to understand that advocacy for their issue and its broader implications is part of health research training.
Gretchen Miller: Okay, Andrew, to stop something that could be of great value to the community from dying on the vine, what do you need to do as a researcher and policy maker?
Andrew Milat: I think as a policy maker we’re in a really challenged position sometimes when it comes to promising programs that may not have resources, because we are operating in an environment of finite resources. There is an opportunity cost that we have here by implementing something that may be promising within a finite budget, having to stop doing something else. That’s a constant balancing act. And that’s a real challenge.
Certainly, I think one of the things that can be done to really build the case for stopping things dying on the vine is they really have to demonstrate in partnership with researchers why this is better than current practice. As Adrian said, providing the evidence and generating that evidence that says that really, this is more cost effective than what is currently happening. Those arguments are quite hard to really challenge.
Adrian Bauman: But there are values-based decisions in doing that. If you want a healthy diet program, but you have to take money out of tobacco control or HIV treatment, then there are values decisions that governments have to make that make it very difficult and complex. Those kinds of things make this a challenging area in a restricted financial space.
Gretchen Miller: I guess the thing is, of course, about prevention, as we know, as we talk about a lot on this show, is it’s incredibly tricky to prove that it’s cheaper because if it works, you can’t see it.
Adrian Bauman: You can only assign epidemiological evidence that if people did this, they would reduce their risks of chronic disease by this much, and the government would save this much money in 20 years’ time. The prevention often has benefits that are reaped outside of the political cycle. And that’s a real challenge for governments to stay the course in the political context in which they live.
Gretchen Miller: I can see you laughing about that, Andrew. 20 years’ time, how does that work for you?
Andrew Milat: Look, I think it can be challenging because some of those benefits that we see from prevention programs are further down the track. But once again, it’s about building those cases and often research can be done without thinking about projecting forward about the number of people in New South Wales that would benefit from a program.
I think that’s the point I was trying to make before was, it’s really important that if you have some promising research, you’ve trialed it, its been replicated, that the case is really built. You need to know what the total eligible population for this particular program is, then you need to do some modelling about if this t2kg weight loss in this lifestyle behaviour change program were to be replicated across New South Wales, how many people would benefit?
I think it’s really important that the research community more broadly can really think in a way that can build persuasive arguments to convince political leaders but also policy makers of the merits of the program and ultimately what the benefits will be further down the track.
Gretchen Miller: To help take all of that into account, Adrian and Andrew, you’ve developed this tool for scaling up. Now, is it aimed at policymakers is aimed at researchers, and when will it be available?
Adrian Bauman: It’s aimed at people in the field, policymakers and practitioners who want to scale up a program or a project to help them decide if they’re ready for it in terms of all that things needed for optimal scale up. It’s really aimed at practice. It’s aimed at the doers in the system, not the researchers.
Andrew Milat: Yeah, and I think, as Adrian said, it’s aimed at the doers. I think we have a couple of little resources in it as well. We’ve tried to develop a spider web plot that tells the users whether they have strong evidence, they may be weak in acceptability, they may be stronger in the potential workforce that might be used. We’ve got a series of domains that come out of that guide that really help us as policymakers, for example, to think through where we might need to generate more evidence, where we may need to talk more to stakeholders. And really gives people a picture of, really, the utility of this particular intervention for scale up.
Importantly, it offers a summary template that can be sent up the line to decision makers to make that decision a bit easier. I think it is firmly placed in that space of decision makers and practitioners who are trying to make these decisions, and convince other people of the merits of a particular program as to whether it should be scaled up. But more broadly, I think the research community can also benefit from this scalability assessment tool, because it’s another reminder of the types of issues that we confront as policymakers when we’re thinking through whether something should be scaled up or not. And then perhaps targeting research in a way that really feeds into filling some of those gaps. I think it’s a useful tool for all of those groups, but particularly for those that are practising.
Gretchen Miller: What a great place to leave it, and what a wonderful discussion. Invaluable, demystifying happening today, I think. Professor Adrian Bauman from the University of Sydney and Dr Andrew Milat from the NSW Ministry of Health. Thank you both for joining me.
There’s a transcript on the Prevention Centre website and further information about the research. If you’ve enjoyed the conversation today, please leave us a review on iTunes. This has been Prevention Works, I’m Gretchen Miller and I’ll see you next time.
Host: Gretchen Miller