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Investing in prevention: the need to make the case now

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This is the first in a series of four blogs, by PHE Chief Economist Brian Ferguson, looking at health economics and the case for investing in prevention initiatives:

I've recently been running a series of workshops here at PHE to talk about the key economic principles that help make the case for increasing investment in public health.

As the public health budget is required to work harder and harder, it’s vital that we address a number of questions that continue to be heard across the NHS, local government and central government:

  • Does prevention save the health service money?
  • Are public health initiatives really providing the best value for money?
  • How can we better incentivise local authorities, NHS commissioners and health care providers to invest more in prevention and early intervention?

As health economists, it is our job to answer these questions and explain why investing in prevention is so important in the current financial context of budget reductions and funding gaps.

Pre-election, the NHS deficit stood at between £22-30bn, while the gap between local government income and expenditure is forecast to rise to around £14bn by 2019-20.  These figures do not take into account the latest Spending Review announcements, as the exact scale of the cuts facing local government, for example, is still under debate.

The LGA has calculated that the figures amount to a 24% real terms reduction in funding for local government.

Getting serious

The NHS Five Year Forward View, published in October 2014, gave a very clear message on prevention:

'If the nation fails to get serious about prevention then recent progress in healthy life expectancies will stall, health inequalities will widen, and our ability to fund beneficial new treatments will be crowded-out by the need to spend billions of pounds on wholly avoidable illness.'

Diabetes is a good example of the potential cost of failing to take prevention seriously. Diabetes UK estimates that the NHS is already spending about £10bn a year on diabetes. Almost three million people in England already live with diabetes and another seven million people are at risk. By preventing those at-risk people from becoming diabetic, the NHS could potentially save billions of pounds in avoidable treatment costs.

Therefore, it is just plain common sense that investing in prevention is necessary to help reduce the long-term cost of treatment and to maintain a sustainable health service.  But why is this so challenging in reality?

Evidence and cost effectiveness

One reason is that public health interventions can suffer from a lack of what is usually deemed to be ‘high strength’ evidence, such as randomised controlled trials (RCTs).  Unfortunately there will be many situations where we will never have such evidence, but we nevertheless have to use the evidence available to us, including less robust evidence like case studies, and make assumptions in order to invest in areas that we know are likely to be cost-effective.

No-one ever undertook an RCT to produce evidence of the cost-effectiveness of wearing seat belts in motor vehicles– yet the impact on population health has been enormous by any standards.

When local authorities and NHS organisations are under pressure to cut costs within reduced budgets, making the case for investment of any kind can be difficult. Making the case for investment in activity that can’t always guarantee immediate cost savings and may not reap a return for a number of years might seem impossible.  But that doesn’t mean it isn’t the right thing to do.

We do not actually know what the whole health and social care system currently spends on prevention.  A figure of 4-5% is typically quoted for England, which roughly reflects the money spent on the public health grant as a proportion of total government spending on health.

However, that figure masks the range of (largely) secondary prevention activities undertaken within the NHS.  A recent WHO report stated that on average around 3% of national health sector budgets are currently spent on public health and prevention.

No-one ever undertook an RCT to produce evidence of the cost-effectiveness of wearing seat belts in motor vehicles– yet the impact on population health has been enormous by any standards.

But there is a growing consensus that a shift in resource allocation is essential to delivering a National Health Service fit for purpose in the 21st century. In its 2013 report, Closing the NHS funding gap, health services regulator Monitor observed:

'The NHS was developed to provide largely episodic care. It generally treats people when they fall ill. But this care model will not be sufficient to meet the health needs of a growing, diverse and ageing population with high rates of chronic diseases, obesity and mental health problems. A 21st century NHS will need to deliver care that meets the health needs of today and focuses more on preventing illness and supporting individuals in maintaining active and healthy lifestyles.'

Having a clear idea of what we currently spend on prevention across the system, and an aspiration about what the percentage of total government spend needs to be to improve health and reduce health inequalities, are important pieces of information to help enable this system-wide shift.

Otherwise it begs the question: how will we know when we have got there?  Related to this is a critical question of what the relative cost-effectiveness of preventive activity is, compared with treatment, focusing particularly on the health care budget.

Making the case

In this series of four blogs I will make the case for investment in preventive activity by examining three key economic principles that underpin this argument:

  • Prevention is cost-effective;
  • Prevention will save the health service money in the long-term; and
  • The benefits of prevention reach far beyond the health system.

As public health professionals, from commissioners to councillors and local health workers, we can use these statements, backed by evidence, to develop a genuinely long-term approach to the economics of prevention – a long overdue and once-in-a-lifetime opportunity.

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  1. Comment by Miguel Garcia-Sanchez posted on

    There is a genuine need to understand the case for prevention, so I welcome this series of blogs. At Aldaba, we have evaluated a number of preventative interventions and learned that many of the arguments policy makers repeat cannot be verified when we collect data for specific preventative interventions. An example is reductions in GP visits through interventions that provide wellbeing activities in the community. Some more information on our work is available at:

  2. Comment by Michael Day posted on

    I run a not for profit, university-owned company, which offers, develops and supports the smoking prevention programme for young people - ASSIST. This has a 10,000 student RCT evidence base and has been shown to be equally effective in dissuading young people from taking up smoking, irrespective of social background. It would seem that in England, money available for this sort of prevention programme is often very small when compared with cessation services, although the balance would seem to be a little different in Scotland. We have also commissioned studies into the cost-effectiveness of the intervention, in order to help us to make the economic case to those who wish to examine this.
    I look forward to reading the blogs!

  3. Comment by Prof Ric Fordham posted on

    The case for prevention should also be made in terms of the efficiency and opportunity cost arguments made for new technologies elsewhere eg. Pharmaceuticals. When I reviewed cost per QALY studies a few years ago the majority of PH interventions (of all kinds) came under the then more generous cost per QALY threshold that pharma has long enjoyed. Even if this is less generous nowadays most PH would still fall below and be around half the price. So in theory we could get twice as efficient at producing health gain via public health measures!

  4. Comment by Dr Gretchen Bjornstad posted on

    This is such an important issue, particularly in the current economic climate, and I look forward to the rest of this series. For information about how interventions for children and families might save public money across a range of policy areas, the Dartington Social Research Unit conducts cost-benefit analyses based on evidence from randomised controlled trials and quasi-experimental studies. The results are presented on:

  5. Comment by Michael Craig Watson posted on

    Need for increased investment in public health
    "......To conclude, we strongly believe that the cuts must stop and there needs to be a major upgrade in investment in public health, as this will improve people’s health and wellbeing, tackle inequalities and relieve pressure on our overloaded NHS."

  6. Comment by Dr Hannah Rose Douglas posted on

    While there is now a wide agreement at the top of the NHS that interventions that prevent disease are cost-effective, the challenge is in separating those public health interventions that are cost-effective from those that are not, especially those currently being invested in with public funds. NICE Public Health Guidance has long advocated the implementation of effective public health interventions for smoking cessation, diabetes prevention etc. on the basis that interventions that work are cost-effective. But NICE has also recognised that the key challenge is in identifying the evidence that a particular prevention approach works. So while prevention is cost-effective not all interventions aimed at prevention are cost-effective. Interventions to increase the use of seatbelts above current levels may be a huge waste of money compared with alternative uses of those tax-pounds. It's great that these issues are on the agenda and I too am looking forward to Brian Ferguson's next blogs.

    • Replies to Dr Hannah Rose Douglas>

      Comment by Tony Fuqua posted on

      There is tension between research/evaluation attempting to provide evidence of community-based programmes that tackle clinical outcomes, and those that provide social impact- and in both cases with an attention on cost efficiency. This NICE necessity, resting on RCTs and protracted evaluations, dampens the ability of the NHS and the Voluntary Community Social Enterprise sector (VCSE) to implement programmes that have impact at scale; and so consequently we see very little development or investment in "at scale prevention delivery". The lack of investment in VCSE infrastructure and its ability to deliver public health innovation and value for money is a particular concern.

      It seems that research and evaluation finance would be better spent on evaluating the NHS system's efficiency around clinical practice where we think longer term prevention can lead to savings, to identify where financial resource can be unlocked now to provide the finance to get at scale programmes up and running. With the Success Regime now in full swing in Devon there is the opportunity to do this. The Regime's consultation should integrate the VCSE into the discussion around the Forward View and unlock the investment needed to kick start at scale prevention programmes.

      Can we really afford to wait for 20 year's of evaluation to tell us that getting people physically and socially active does produce cost savings and help to prevent chronic conditions; when the international body of evidence is so compelling; when the gap in health inequalities continues to widen at alarming rates; when the NHS deficit is screaming at us so loudly?

  7. Comment by Susan posted on

    Sad but the reality!
    To add to which there are so many other 'rare conditions' that in combination have a grate impact while prevention of such have not been seriously insisted on and unfortunately significantly costly. Priority in this case I think should be purposively applied based on not just the magnitude of the effects.

  8. Comment by Tim Fielding posted on

    I welcome this series of blogs but would also like to see a fourth question added..."does prevention save the local authority money?".

    Although it would be great to think all parties involved in allocating resources for preventative work will be able to appreciate the wider value to to the whole health and social care system, the reality in local authorities given the current financial pressures can be very different.

    The ability to separate out and specify some of the specific savings to local authorities (in addition to those to health), such as reduced costs for social care, would be extremely beneficial to being able to make the case for preventative public health investment, particularly once the ring fence comes off.

  9. Comment by John Reid posted on

    It may be helpful to develop this blog and comments, to summarise later in 2016 the strategic and technical challenges for economists and for support to public health policy leaders, commissioners and practitioners.

    Given the various initiatives, tools and papers referred to, it might be useful to develop a historical and updatable timeline with UK and international landmarks .

    For instance I hope the blog will take a wide view of economics as illustrated in the various health inequalities papers linked to the Marmot report and subsequently. Wider population measures to secure good health as defined capital goods and linked to population prosperity and productivity can be added to the focus on specific preventive interventions programmes.

    The role of fiscal measures and the debate about taxation and supportive regulation need to be included in this debate. The eventual decision later this year about the so-called 'sugar tax' may need to be displayed in economic terms showing more direct costs and opportunity costs. Hopefully whole population strategies, with diverse components from fiscal to personal interventions, need their own economic analysis and evaluation. The full long-term costs of continuing failure to address obesity in terms of wider determinants must be shown if strategies remain ineffective.