This document discusses issues related to prevention and return on investment (ROI) in healthcare. It addresses why prevention has not been more widely implemented in the NHS despite the economic case. Barriers include lack of incentives, complex evidence, and culture change. Cost-effectiveness does not equal cost savings. Prevention may release cash in long term rather than short term. ROI tools can oversimplify and make unrealistic assumptions. Obesity prevention is used as an example, highlighting challenges around individual versus population interventions and timeframes for cost savings.

1. Prevention
esp ROI and economic issues

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.

6. Prevention and ROI

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

10. Weightwatchers 1000 to 10
Dr Carl Heneghan

11. Small probability of attaining
normal body weight vs impact of
5% loss, or 10%

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

15. Matrix
Prioritising Investment in Preventative
Health
http://help.matrixknowledge.com/file.axd
?file=HE_final_report.pdf

17. NICE
Teenage pregnancy, tobacco, obesity, activity
http://www.nice.org.uk/advice/lgb10

18. Owen et al
http://jpubhealth.oxfordjournals.org/content
/34/1/37

19. OECD
http://www.euro.who.int/en/about-us/partners/observatory/publications/policy-briefs-
and-summaries/promoting-health,-preventing-disease-is-there-an-economic-case

20. Even WHO are at it
http://www.euro.who.int/__data/assets/pdf_
file/0009/278073/Case-Investing-Public-
Health.pdf?ua=1

21. Kings Fund – pretty infographics
and good intelligence.
www.kingsfund.org.uk/publichealth or
www.local.gov.uk/health

22. NICE ROI Tools
https://www.nice.org.uk/About/What-we-
do/Into-practice/Return-on-investment-
tools

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)

25. Determinants
http://www.instituteofhealthequity.org/projects/understanding-the-economics-of-
investments-in-the-social-determinants-of-health

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