Dave Buck has written an excellent blog on The King’s Fund website about the problems of ROI in public health – Talking about the ‘return on investment of public health’: why it’s important to get it right
@drchrisgibbons set out some thoughts on the matter. Thoughts on ROI in a changing Public Health paradigm
Here are mine
I agree with all of the concerns Dave sets out, and then some.
I agree with any of Daves arguments on the to the bag of cash we call the PH grant, or the broader points re use / misuse of ROI. I retain my fear that only focusing out narrative on that will lock in a model and view of public health that it’s about the cigs, the health visitors and sexual health.
Skills v models
The PHE ROI tools are mostly excellent. They often tell us what we know, even if it’s a useful quantification. Sadly I rarely have time or energy to engage with them. My very stripped down PH team are in a similar position also. Some of the ROI tools assume a level of (even rather basic) knowledge of economic principles that bluntly isn’t there in many of our teams. Mine is a bit special as we have an in house health economist and corporate capability development in this space is one of his unwritten missions.
Often ROI evidence that is available isn’t quite suited to the the decision problem at hand. Mostly models can’t factor in downstream changes that may not be anticipatable in a complex adaptive system.
Thus my preference is to have skilled people with a very wide understanding of a wide range of systems and methodologies. That can then be turned to applying health economic thinking to any problem, not just the that have an ROI model someone’s done for us.
What levels of the system should ROI considerations focus on – In any model, low level operational stuff tends to dominate and system.
My view, as per what Chris has written is that we need to land the ROI debate in a much bigger context – public service reform, whole of govt / HMT perspective.
Interventions that affect individuals are often the default, tend to focus on specific interventions (often for “high risk” identifiable individuals).
Results in rarely a focus in paradigms shifting. To identify the paradigm shifting stuff……..What are the Policy opinions – track back the logic model. What are the structural things that slow down the ambition, big landscape changing things
ROI has got to reflect that context.
Downstream v upstream focused models
In my view, much of the ROI literature hugely over focuses on the downstream issues and individual level interventions. We talk ROI around “lifestyle sort of stuff” but thus sets the ROI in behavioural choices, and need to completely reframe as commercial determinant etc. Over emphasis on this locks in a model that may not be optimally helpful for a longer term gain.
As I, and others, have said the “evidence base” is massively over weighted to interventions focused on individuals and downstream “treatment”, and biomedical paradigm stuff. This drives what we prioritise for implementation, at the expense of upstream stuff. It also drives what gets pumped into the ROI models. So we focus on pedometers not the national cycling infrastructure, or weight management services not structural food industry interventions, pharmacotherapy for drug use not poverty.
Setting, or at least informing, the National ask
This out debate around ROI in this space should go full throttle for focusing on the national ask.
How can we use the ROI narrative to focus on how national agencies, Govt departments thing and set rules and processes for how stuff gets done….. – how do we influence these to effect how programmes get developed and prioritised – DfT, DH, DfE, HMT, etc. Regulators and inspectors OFSTEAD, CQC. Frameworks – NPPF, NHS planning guidance etc.
Collectively these all shape “the rules”. Influencing the expectation and ask of these sectors will have structural impact on obesity.
What’s the ask around here….how can ROI be framed in national context
The stock points around non level playing field, double standards arguments are always in play
For example- we sweat the ROI around a £3.50 preventive investment in cardiovascular but ignore the value of the £350m that’s currently in that same space
Im told some areas are investing millions in the roll out of lung cancer screening (I’d bet a months pay it doesn’t pass muster against threshold in standard econ analysis) and zero new cash (actually net disinvestment over recent years) in tobacco. What does this tell us about desire for (or actually understanding of!) allocative value….
We invest in healthcare as a means to improve health
H care is one of many Investments to improve health
Prevention is by far the greatest value in terms of investment
We don’t expect investment in healthcare to be cost SAVING
Why do we expect investment in preventative interventions to be cost saving
Explaining all this simply and pithily in a way that doesn’t make people’s brain hurt and in a way folk engage with is a bit tricky
Well done Dave – keep on at this