2. Prevention – for own sake and to control
cost (cost / case v total no of cases)
• case is strong
• So why haven’t we done in it in the NHS?
• lack of incentives
• complexity of evidence
• lack of specificity especially on prevention
with long term
• confidence in economic modelling?
• requires culture change, which takes time
3. Prevention
• being able to take calculated risks
• time horizons
• multiple (often conflicting) objectives
• between sectors
• efficiency / inequalities / equity
• Cost-effectiveness and efficiency are not
the same as cost-cutting / cost savings
4. Prevention
• will it release cash in the short term? Or medium to
long term - highly uncertain
• Even when highly cost effective (most of the public
health interventions that have been analysed are
highly cost-effective)
• SAVE vs or slow rate of growth
• Wider approach (cost-benefit) recognising return on
investment techniques is to be welcomed
• discounting.
5. Even if its cost effective – ie net cost
• Crowd out downstream interventions
• Change the net social good of investment
• Factoring in downstream investments
often not done – reducing future burden
from heart failure.
7. Take obesity as an example
• Do you need to win an argument about evidence, or is
it about cash, or is it about hearts and minds
• At what point do you intervene – bariatric surgery to
structural policy interventions
• Evidence re “community focused weight management”
– poor
• McKinsey report – NB perhaps some hidden agendas
re what they did / didn’t emphasise (their other
clients?)
• Find the primary studies. Appraise them. Contextualise
them
• Population impact– scale is important. Bariatric vs
sugar tax?
http://www.mckinsey.com/Insights/Economic_Studies/How_the_world_could_better_fight
_obesity
8. Take obesity as an example
• individual approach to effecting change at individual level
versus population wide policies affecting whole pops -
sugar tax, active travel, etc
• Clinical effectiveness at individual level,
• population impact and questions of economics
• cost to implement (cost to who),
• return (to who),
• time frame and horizon by which you need to see
results.
9. Take obesity as an example
• ROI tools – NICE. Challenge the
assumptions – do they work for you?
• Appendix T is where all the interesting
details hang out.
• Weight loss and lifestyle as a means of
preventing conversion from risk status
(obese) to disease (eg diabetes), and delay
of down the line complications of that
disease
12. Population impact of weight
management
• 60% obese – 300k
• £300k spend on T2. 730 people a year
complete. 0.24% of at risk pop.
• If 100% success rate – 240 years to
“address obesity”
• Of our 730, 20% loose 5% of weight at 12w
• Slim chance of keeping off at 12m
• 142 “successes” in pop of 300k
https://gregfellpublichealth.wordpress.com/2018/10/30/population-impact-of-weight-
management-services/
13. Oceans and teaspoons – diabetes
prevention
• DPP trial.
– NNT = 7 at 5yrs
– Is it THAT effective in real life?
– SSHaRR model. Sheffield paramaters - £1.7k / 480
people / 120 benefit clinically, 25 cases of DM avided
out to 5y. NHS saves £192k not net of intervention
costs
• Philly sugar tax
– £60k to implement in pop of 0.5m
– 700 cases of DM avoided (10y)
– £40m (10y) saved
https://gregfellpublichealth.wordpress.com/2016/11/28/preventing-diabetes-comparing-
service-to-policy-based-approaches-on-emptying-an-ocean-with-a-teaspoon/
14. Others have written lots on tools
http://www.kingsfund.org.uk/publications/ex
ploring-system-wide-costs-falls-older-
people-torbay
23. Economic tools to aid decision
making
July 2015
PHE Return on Investment Tools
http://www.yhpho.org.uk/default.aspx?RID
=194888
24. Tools included in the review
24
Tackling obesity Reducing smoking Reducing alcohol drinking
NICE ROI – Physical Activity Tool
NSMC - Behaviour Change Value
for Money Tool – Obesity
NICE PH 41 Walking and Cycling –
Costing Template
Weight Management Economic
Assessment Tool
Health Economic Assessment Tool
(HEAT)
Sport England Model for
Estimating the Outcomes and
Values in the Economics of Sport
(MOVES)
NICE ROI – Tobacco Tool
NICE - Brief interventions and
referral for smoking cessation.
NICE - Varenicline for smoking
cessation
NICE - Workplace interventions to
promote smoking cessation
NSMC- Behaviour Change Value
for Money Tool – Tobacco
Return on Investment calculator,
BTS
NICE ROI – Alcohol Tool
NSMC- Behaviour Change Value
for Money Tool - Alcohol
Services for the identification and
treatment of hazardous drinking,
… - Commissioning and
benchmarking tool
PHE Alcohol Ready Reckoner
Alcohol System Model, NHS East
of England
Ensuring the best start in life Reducing dementia risk NHS Health Checks
NICE ROI Children and Young
People
NSMC- Behaviour Change Value
for Money Tool - Breastfeeding
--- Health Checks Ready Reckoner
General tools
Health England Leading Prioritisation (H.E.L.P.) online tool
Greater Manchester Cost Benefit Analysis tool
Socio-Technical Allocation of Resources tool (STAR)
Informing Investment to reduce health Inequalities (III)
26. • YPHO
– http://www.yhpho.org.uk/resource/view.aspx?RID=195885
– helpful stuff bringing together many and a range of tools
that bring forward a focus on "investing in prevention"
• The LGA doc is all a bit motherhood and apple pie.
The links at the end of it are useful
– http://www.local.gov.uk/documents/10180/11493/Money+w
ell+spent+-
+Assessing+the+cost+effectiveness+and+return+on+inves
tment+of+public+service+interventions/25c68e94-ff2c-
4938-a41c-32853b4d4a9d
• This ppt very helpfully sets out the NICE approach to
return on investment
– http://www.lho.org.uk/Download/Public/18359/1/140129%2
0London%20K&I%20network%20-%20Kay%20Nolan%20-
%20NICE%20return%20on%20investment%20tools.ppt
27. QALY league Tables – use them at
your peril
Questions to ask
• was the time horizon appropriate.
• Was the comparator appropriate – best supportive
care, placebo, nothing, current management
• Was costing structure appropriate?
• Was the end point / outcome measured
appropriate….clinically meaningful and
sensible……surrogate endpoints for short trials.
Back to contents
28. • the health warning is thus.....
• all these things are done at different points in time, with
different methods, and often different comparators
• so if trying to do relative comparison to say x is more
cost effective than y so we should do more of x..... is
fraught with this sort of danger....
• and then without knowing the detail of how the cost
effectiveness of x was derived...... whether you use
method (a) to value quality of life, of cost etc..... or
method (b) can make a massive difference.....to the
absolute value of the cost effectiveness metric .....
• difficult stuff
29. Whatever way you cut it, the basic
economic principles still apply
• You can use and abuse the principles at your
leisure
• Do so with caution – credibility
• However – remember others will also –
“street fighting with evidence”.
• Or they may just ignore evidence – it might
not be a debate that’s about evidence – it
might be about belief and ideology.
• Use evidence wisely to crowd out less cost
effective investments – net social gain.
30. why we might invest in pre school and
primary school and NOT NHS??
http://www.huffingtonpost.com/2015/04/20/
anti-poverty-
programs_n_7087622.html?utm_hp_ref=w
hats-working
