Investing in prevention: time for systems
to work together
Association of Directors of Public Health conference
2nd November 2015
Professor Brian Ferguson
Chief Economist
What do we spend on prevention across
the PH, NHS and social care systems?
• We don’t really know, but a figure of 4% is often quoted (recent LGA
report 5%)
• Suspect largely based on a PH spend of around £5bn and an NHS
spend of around £120bn
• If we included all primary, secondary and tertiary prevention, the
figure would be much higher than 4%
• This is why we are interested in much more than the PH grant when
we talk about the economics of prevention
• The prize?
– a higher % of ‘protected’ preventive spend
– essential if the NHS is going to do things differently
– funding gaps are largely predicated on ‘business as usual’ (and
history tells us that they will only get worse)
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NHS 5-year forward view
• The health and wellbeing gap: 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.
• Public Health England’s new strategy sets out priorities for tackling
obesity, smoking and harmful drinking; ensuring that children get the
best start in life; and that we reduce the risk of dementia through
tackling lifestyle risks, amongst other national health goals.
• Progress?
– Prevention Board
– Diabetes Prevention Programme
– NHS Efficiencies work
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Wanless got it right
• Wanless (2007): “Without improvements in productivity and greater
efforts to tackle the causes of ill-health, even higher levels of
investment in the NHS will be required than envisaged by the fully
engaged or solid progress scenarios”
• ‘Fully engaged scenario’: levels of public engagement in relation to
their health are high: life expectancy increases go beyond current
forecasts, health status improves dramatically and people are
confident in the health system, and demand high quality care. The
health service is responsive with high rates of technology uptake,
particularly in relation to disease prevention. Use of resources is
more efficient.
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The prevention challenge
Demonstrate
return on
investment
Do the most
costeffective
things
Save the
system
money
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Cost-effectiveness, RoI and cost savings
• An intervention can only be cost-effective relative to other
interventions or some sort of ‘standard’ or threshold (e.g. the NICE
£20,000 cost/QALY threshold)
• Will that intervention demonstrate a return on investment?
– i.e. the benefits will ultimately outweigh the costs
– if so over what time period?
• Will costs ultimately be saved? – i.e. over time will we spend less to
achieve desired outcomes than what would have happened without
the intervention?
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One system working together
• across the NHS, public health and social care
• a focus on individuals - integrated care pathway work
from Commissioning for Value programme
• integrated budgets and joined-up commissioning
• genuinely commissioning for population health
• King’s Fund report Feb.’15 “Population health systems:
going beyond integrated care”
 population-based budgets to align financial incentives with
improving population health
 community involvement in managing their health and designing
local services
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Open debate about the methodological
and practical challenges
•
have we the tools to produce business cases for public health investment
(identifying value gained from resources invested)?
•
do we have a ‘common currency’ for assessing impact of health & wellbeing? (local government unlikely to see value of QALY approach)
•
identifying the impact of cost-effective interventions on health inequalities
•
learning from other sectors that routinely use CBA and undertake impact
assessments of policies with multiple outcomes (what approaches do they
use to ROI?)
•
dealing with externalities (e.g. alcohol-related harm)
•
discounting – will prevention ever be prioritised if the playing field is level?
•
training and awareness-raising activities about what health economics
can and cannot deliver
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Opportunities and challenges
• Using all of local government resources to improve health and
wellbeing
• Doing this in an integrated way across the public health, NHS and
social care systems
• Maintaining a focus on the most cost-effective (upstream) preventive
interventions
• Timescales within which can expect to see a ROI
• Incentive issues across the system (investing in one sector with the
benefits / savings realised elsewhere)
• Cashable savings - getting money out of the system now
• The cost-effectiveness threshold for public health interventions
• Does serious system change to invest in prevention require an
element of double-running costs?
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Some personal reflections
• HM Treasury is hungry for examples of where investing in
prevention and early intervention has demonstrably worked – real
case studies….
• ….not unfulfilled promises of ‘invest to save’
• Radical solutions welcome to HMT? (in all the years of NHS growth
did the system of delivery change radically?)
• The ‘bar’ is being set higher for preventive interventions and we
have to challenge that
• Whilst a focus on short-term cashable savings is justifiable and
important, we need to keep our eye on the long-term prize….
• Getting a larger share of the overall cake (c.£125bn, not c.£5bn)
focused on preventive activity
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Take-home messages
• We have a once-in-a-lifetime opportunity to shift the balance of
resources towards prevention and early intervention
• It requires a sustained focus on outcomes and investing in areas of
proven cost-effectiveness
• It requires us to operate collectively as a system with the right
incentives in place
• Closing the funding gaps will not be achieved by more of the same
• We need to get the system incentives right and be clear and realistic
about timescales for ROI…..
• And be realistic about cashable savings – the scope and how these
might be achieved
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