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Mike Kelly: Putting a Price on Good Health

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Keynote address: PTPHN Conference 2007

Keynote address: PTPHN Conference 2007
Professor Mike Kelly, Putting a Price on Good Health.

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  • What is NICE ? The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.
  • Centre for Public Health Excellence The Centre for Public Health Excellence at NICE develops guidance on the promotion of good health and the prevention of ill health. Its guidance is for those working in the NHS, local authorities and the wider public, private and voluntary sectors. Initially, NICE will publish guidance that was commissioned by the former Health Development Agency. From the end of 2005, our guidance will be in the form described below.
  • Mike I am going to put a graph here of some of the modelling work done by Chris Godfrey, illustrating the cost effectiveness but pointing out the dilemma of opportunity costs, especially in current NHS climate
  • Mike I am going to put a graph here of some of the modelling work done by Chris Godfrey, illustrating the cost effectiveness but pointing out the dilemma of opportunity costs, especially in current NHS climate
  • NICE has just launched its new website, integrating all public health and clinical work into one site. You can find more information on NICE and our work by visiting the website at www.nice.org.uk

Mike Kelly: Putting a Price on Good Health Mike Kelly: Putting a Price on Good Health Presentation Transcript

  • Professor Mike Kelly Director of the Centre for Health Excellence National Institute for Health and Clinical Excellence Perspectives of Public Health Practice: Peninsula Teaching Public Health Network, St Mellion , Cornwall, 7 th March 2008 Putting a Price on Good Health
  • NICE’s role in public health
    • The National Institute for Health and Clinical Excellence (NICE) is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health.
  •  
    • The Centre for Public Health Excellence at NICE develops public health guidance.
  • Audiences
    • The NHS
    • Local government
    • Education
    • The utilities
    • Private and voluntary sectors
    • Other arms of government
  • Two types of public health guidance
    • Programme guidance
    • 18 months
    • Programme Development Group (PDGs)
    • Intervention guidance
    • one year
    • Public Health Interventions Advisory Committee (PHIAC)
    • Public health intervention guidance: recommendations on types of activity usually provided by local health, local authority or other front line service.
    • Public health programme guidance: broad strategic activities for the promotion of good health and the prevention of ill health. This guidance may focus on a topic (e.g. maternal and child health), a disease cluster (e.g. obesity), or on a particular setting (e.g. schools or workplaces) .
  •  
  • The principles of cost effectiveness and value for money should be applied to public health?
    • 1 Strongly agree
    • 2. Agree
    • 3. Neither agree nor disagree
    • 4. Disagree
    • 5. Strongly disagree
  • Putting a price on public health
    • Is prevention better than cure?
    • Is prevention more cost effective than acute interventions?
    • Can we assess the economic value of health improvement?
    • Does it matter?
  • It matters because:
    • of competing resource demands locally.
    • the answer helps to build the case for public health.
    • the expenditure of public money is involved.
    • of the demands on acute services
    • health improvement matters
    • "We are not tinkers who merely patch and mend what is broken... we must be watchmen, guardians of the life and the health of our generation, so that stronger and more able generations may come after"
    • Dr Elizabeth Blackwell (1821-1910), The First Woman Doctor
  •  
  • Picture quiz. The portrait is?
    • Joseph Bazalgette
    • Edwin Chadwick
    • John Snow
    • William Gairdner
    • Joseph Porter KCB
  •  
  • Wanless 2
  •  
  • Securing Good Health for the Whole Population (2004)
    • There are long and short term benefits arising from public health interventions
    • There are growing pressures on acute services
    • It is important to establish evidence based expenditure decisions for public health
    • The same principles for ascertaining clinical cost effectiveness can be applied to public health
  •  
  • Picture quiz
    • John Stewart Mill
    • Jeremy Bentham
    • John Maynard Keynes
    • Adam Smith
    • Karl Marx
  • Health economics
    • 1. Is about the end of the post code lottery
    • 2. Is about rationing
    • 3. Is about value for money
    • 4. Is about maximising utility
    • 5. Is inherently unfair to the poor
  • Applying economic analysis
    • Complex pathways of causation
    • Absence of “D” in R&D in public health
    • Effectiveness in the short, medium and long run.
    • Individual vs population measures
    • The equity vs efficiency problem
  • Age standardised death rates per 100,000 population for circulatory diseases under 75 by area of deprivation
  • Age standardised death rates per 100,000 population for cancer under 75 by area of deprivation
  • The health gradient Health state Social difference Lo Hi Lo Hi
  • Shifting the curve Health state Social difference Lo Hi Lo Hi
  • Different shapes of the gradient: low and middle income countries (Victora 2007)
  • Other important economic problems
    • Measuring costs and benefits across health, education, criminal justice
    • Opportunity costs across different sectors
    • Lack of good cost data and mixed evidence of effectiveness
  • Problems with the evidence of effectiveness
    • The research doesn’t exist
    • The research doesn’t say what you thought it said
    • The research doesn’t answer the question
    • The research is of poor/dreadful quality methodologically
    • There isn’t a qualitative or grey literature to fill the gaps
    • The findings are utterly equivocal
  • Interventions completed
    • Promoting physical activity in primary care (March 06)
    • Smoking cessation in primary care (March 06)
    • Preventing teen conceptions and STIs (Feb 07)
    • Substance misuse and vulnerable young people (March 07)
    • Supporting the smoking ban (April 07)
    • Alcohol and Schools (Nov 2007)
  • Interventions under development
    • Primary Schools and children’s mental well being (universal and targeted approaches) (March 08)
    • Mental health and older people (April 08)
    • Physical activity in the workplace (May 08)
    • Reducing mortality in highly disadvantaged communities (June 08)
    • Preventing the uptake of smoking in children (July 08)
    • Mental health and the workplace (Nov 08)
    • Needle exchange schemes (Feb 09)
    • Improving the uptake of immunisation (April 09)
    • Secondary schools and mental well being (tba)
  • Programmes
    • Obesity (Dec 06)
    • Behaviour change (Oct 07)
    • Physical activity and the environment (Jan 08)
    • Smoking cessation services (Feb 08)
    • Community engagement (Feb 08)
    • Maternal and child nutrition (March 08)
    • Physical activity, play and sport in pre school and school aged children (Jan 09)
    • Long term sickness incapacity (Feb 09)
    • Health literacy in schools with reference to sex education – PSHE (Sept 09)
    • Alcohol
  • Methods
    • Review of the best available evidence
      • assess quality and strength of evidence
      • assess applicability
    • Economic appraisal
      • economic evaluations and modelling
      • public sector perspective, QALYs
    • Evidence for consultation
    • Involvement of stakeholders
  • What is the NICE value for money threshold?
    • 1. £10,000
    • 2. £20,000
    • 3. £30,000
    • 4. £40,000
    • 5. None of these
  • Assessing Cost Effectiveness Probability of rejection Cost per QALY ( $ ’000) 17 34 51 68 85 0 1
  • What QALY values have typically emerged in public health?
    • 1. More than £50,000
    • 2. Between £50,000 and £30,000
    • 3. Between £30,000 and £10,000
    • 4. Between £10,000 and £5,000
    • 5. Less than £5,000
  • Economic modelling Brief interventions in primary care for smoking cessation Cost per QALY using all health care costs, based on 50 year old male cohort (Parrott and Godfrey, University of York) Brief opportunistic advice from a GP (5 minutes) £230
  • Economic modelling Cost per QALY using all health care costs, based on 50 year old male cohort Brief opportunistic advice from a GP (10 minutes) £585
  • Economic modelling Cost per QALY using all health care costs, based on 50 year old male cohort Brief opportunistic advice from a GP + Advice to use NRT £1271
  • Economic modelling Cost per QALY using all health care costs, based on 50 year old male cohort Brief opportunistic advice from a GP + Telephone helpline £471-769
  • Economic modelling Cost per QALY using all health care costs, based on 50 year old male cohort Brief opportunistic advice from a practice nurse in primary care £821-2914
  • Economic modelling Cost per QALY using all health care costs, based on 50 year old male cohort Brief opportunistic advice from a staff nurse in hospital setting £244-1184
  • Who pays?
    • Everything is cheap
    • Therefore opportunity cost?
    • Or relative cost effectiveness
  • Future directions
    • Combining modelling and logic modelling.
    • Using programme theories and theories of change approaches
  • Visit www.nice.org.uk