Prevention as cost control (3)
This is the final in a series of short blogs exploring the notion of prevention as a mechanism for cost control in health care.
Previous blog have set out some of the clinical, financial and economic arguments underpinning this and some of the policy context. They also explored the notion that in addition to considering cost per case, the total number of cases is important. Here I will consider some different approaches to “prevention”, particularly focused on local level interventions, using cardiovascular and other lifestyle risk factors to illustrate the point.
There is a great deal of research[i] that enables us to quantify the contributions of prevention and treatment to the trends in mortality due to coronary heart disease. Recent years have seen a near 50% fall in coronary heart disease mortality rates:
This improvement is equitable across deprivation quintiles and there is good evidence that treatment can partially redress inequity in risk and disease incidence. This is good.
Improved treatments (particularly pharmacological – statins and blood pressure medicines) account fore approx 40%.
Risk factor improvements account for approximately 39% of the fall in mortality. However, increases in obesity and diabetes offset some of these benefits, potentially increasing mortality by 4% and 8% respectively.
This is not inevitable and there are things that can be changed to reverse this, both health care and broader polices in areas such as tobacco control, nutrition and obesity, activity, alcohol
The NHS is working hard to treat morbidity that is a consequence of “poor lifestyle choices”. In his 5 Year Forward View, Simon Stephens placed “prevention” at the centre of medium term policy. Stephens also strongly made the point that Local and National Government had a crucial role to play in prevention.
Simon Stephens highlighted the role of personal responsibility. This is important, obviously locally it is the centre piece of the New Deal – and this should be recognised.
However, many are not struck by the rhetoric of individual responsibility being the whole picture. Compared against the billions of pounds industry spends on advertising fast food, cigs, booze etc…. it’s hardly surprising that we “make the wrong choices”.
One has to then question the extent to which your choice is truly “free” and the extent to which it is influenced by commercial, economic, environmental and social cues. Wanless made these points in the 1990s and many others have made a similar point before Wanless and since.
What to focus on
There is good NICE and equivalent guidance setting out targets (salt, lack of activity, trans fats etc). The devil is always in the detail of how to implement. NICE and other bodies often carry little detail on the “how”, especially at local level.
Why individual level interventions are of limited population impact
The NHS has a critical role in this – this is mainly at the level of “preventive” interventions delivered at the level of the individual: smoking cessation, alcohol brief intervention, weight management. These can be termed “clinical preventive services”. With perhaps the exception of stop smoking (which is spectacularly good value for money and massively under implemented across the system), and alcohol in primary care (ditto) most of the approaches to healthy lifestyles are based on individual level interventions, weight management etc, which have marginal individual level effects (other than bariatric surgery but that’s a cost issue) and limited to no population impact.
Interventions need to shape the behaviour of individuals. Interventions delivered at the level of individual can be spectacularly effective and almost certainly be net cost saving for the NHS[ii]. We do, however, retain a tendency to heap on intervention after intervention in this individualistic model which arguably often add cost but little value[iii].
Interventions implemented at the level of the individual may be cost effective (and sometimes cost SAVING) and thus good value for money, but they:
– might not make a big impact on population level outcomes
– might not be implementable at scale, or affordable at scale – even if we had the capacity and skills (which we don’t)
– are arguably inequitable unless very carefully targeted.
The importance of policy-level interventions
Policy interventions that aim to “make the healthy choice the easy choice” are considerably more effective than individual level interventions. A recent paper in the BMJ[iv] was a stunning exposition of how interventionist approaches are significantly better (by a magnitude of 50 times) than less intervention for health gain and equity; there is much to be learned from national approaches to both tobacco and alcohol control – targeting availability, acceptability and affordability.
Policy interventions should thus shape the exposure to risk and or the environmental and economic cues that drive behaviour, in a large population, and are arguably more progressive and equitable. Govt (local and national) has critical role in prevention through population wide policies. Perhaps this can be framed as:
A key role of local government in the NHS is to prevent stuff in order to protect the social institution that is the NHS. (Simon Stephens)
Stronger policies have a stronger effect, while weak and insipid PH policies will have weak and insipid effects; but stronger policies will be more strongly resisted on both ideological and commercial grounds[v]. In the Berkley sugar tax example, industry was reported to have spent $30 per voter on lobbying councillors against the proposed policy (whilst at the same time arguing strongly that it would be an ineffective option). Advocates for the policy did make an investment promoting their case. When highly effective[vi] policy interventions are fiercely resisted by industry, this should not be a deterrent. Industry will not want such effective policies to happen but the health sector should shout louder that they need them to happen.
There are a vast array of potential policy options available.
Some will be more palatable than others. These options have been scattered around a large body of guidelines and advice. Some have been implemented, some have not, some may never been implemented. Obvious targets in the area of CVD include:
– food and nutrition policy at local level – particularly around the use of regulatory powers around fast food, labelling, publicly procured food,
– local tobacco control programmes and population policies to further de-normalise smoking
– creative use of licensing and point of sale enforcement for alcohol and tobacco
– active transport policy – focused on behaviour change rather than traffic engineering.
– aggressive local approach to sugar and salt.
There are constraints
It is unlikely that one person or department within a CCG or a council has “all the answers”. There will be many creative, interesting and potentially powerful policy ideas that may have a significant impact. There is also no single big idea – there will be lots of ideas.
It is important to be mindful that there may be political and broader economic constraints (eg cost of implementing or enforcing). The number of genuinely free (to public purse) policy ideas that affect large populations is vanishingly small. Local Government would also need to consider and be clear what ARE their powers and authority and the extent to which there is political mandate for far reaching policies.
There are also political issues – inevitably “policy interventions” will stray into debates about “free choice” and “the nanny state”. This is difficult territory.
Local Government may consider it should remain neutral to any proposed population policy. Thus any advocate of a strong population health policy should be prepared to put their case forward and counter arguments from those that are opposed to it.
Of course there is a strong drive towards the self regulation of those commercial interests that mould our choices. This market led solution is the ideal. History tells us that industry self regulation will be weak, slow, delayed and watered down so as to be ineffectual (alcohol, food and tobacco all have cogent examples here). Thus whilst industry self regulation is important – it is unlikely to be effective.
In addition to individually focused interventions to prevent disease – and so avert future cost, there is a pressing need for a more rounded debate about population-focused policies that encourage the healthy choice to be the default. Some of these will be nationally focused (for example plain packs, minimum unit pricing), some may be locally focused. There are difficult economic and political issues to consider, which should not be ducked.
The evidence is increasingly clear that population policy can shape the attitude, behaviour and choice of whole populations. It is thus an important part of the armoury for anyone seeking to consider prevention as a means of cost control.
References and selected sources
[i] Hotchkiss. Explaining trends in Scottish coronary heart disease mortality between 2000 and 2010 using IMPACTSEC model: retrospective analysis using routine data. http://www.bmj.com/content/348/bmj.g1088
[ii] Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. http://www.nice.org.uk/guidance/cg115
[v] O’Keefe doi:10.1136/bmjopen-2013-002837