What happens to NICE public health guidelines after publication in terms of how they are viewed and used by local government officers? – A realist inquiry

Background: In 2013, many public health responsibilities were returned to local government control. The structures, inherent customs and practices, differed to those in the NHS where the specialism had previously been hosted. At the same time, the remit of a repurposed National Institute for Health and Care Excellence was extended to impact upon local authorities. Post 2013, NICE public health guidance lands in a shifting world of local democracy and accountability.

Methods: This realist inquiry identified, tested and refined theories to explain how NICE guidance was received in local government, following its release, and why this reception occurred. The initial theories were surfaced using: mind maps as access points to several literature forays and a Delphi consensus panel to check for explanatory relevance. Three hypotheses were targeted; two on the nature of decision-making and one on the uniqueness of individual authorities. These hypotheses were tested by methodically reviewing the literature using theory-guided searches, data extraction and synthesis, and by primary data collection during fieldwork located within public health practice in 3 local councils.

Findings: The inquiry identified patterns of visibility of NICE guidelines within decision-making processes which were explained by identifying how knowledge is exchanged between officers and politicians. Mechanisms operating within these exchanges such as mutual respect, trust, and evidence weaving begin to point to the emergence of the ‘craft’ of public health practice in local government.

Conclusions: Findings confirmed the usefulness of three key transferable knowledge explanations: mutual exchange of resources by local bureaucratic elites; the trick to balancing knowledges (nature of decision-making) and the pre-eminence of place. When presented to local government officers these explanations resonate and illustrate the strength of realist inquiry in adding to our understanding of contemporary public health craft practices and how these might be developed.