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Public Health

Left shift. Show me the evidence

we all want “better evidence” on “prevention”

Was thinking about that q of “if only we had good evidence on prevention”

Apols this is a bit policy wonky …..but sort of important

Yes we DO all want “better evidence” on “prevention”

Alot call for harder edged evidence on return on investment to back up a shift in our model from one based on fixing people and things that are broke

1 it’s hard. Here is a high level overview

In terms of medium term cost benefit. At macro level in my space Wanless did it 20 years ago https://www.southampton.gov.uk/moderngov/documents/s19272/prevention-appx%201%20wanless%20summary.pdf. Never bettered. Wanless  fully engaged population slows rate of growth of NHS spend, only way to make long term growth sustainable.

In terms of the package of interventions within the PH Grant – Claxton https://www.york.ac.uk/che/news/news-2019/che-research-paper-166/  (investment in “prevention” (in this case oriented narrowly about things within the spend that is PH grant) yields 4 times more health than treatment. If you go “prevention” more broadly that yield is probably even greater (tho nobody has ever done the analysis)

Ferguson (sadly paywalled) – https://www.lgcplus.com/services/health-and-care/brian-ferguson-treasury-should-end-its-obsession-with-public-health-spending-09-06-2021/ (level playing field please)

My effort https://gregfellpublichealth.wordpress.com/2021/05/12/why-money-spend-on-public-health-is-a-sound-investment/… on the value of prevention

LGA https://www.local.gov.uk/sites/default/files/documents/prevention-shared-commitm-4e7.pdf

 IlCUK –  https://ilcuk.org.uk/countries-need-to-up-spending-commitments-on-health-promotion-urge-think-tanks/ Since increasing spending on health promotion to 6%, Canada has seen a fall in avoidable mortality from 150 / 100k in 2000 to 116/100k in 2017. UK – reaching this target would require a £2.7bn investment: just 4.5% of the £60bn spent on COVID-19 measures.

Then for more tightly defined interventions …. Take your pick of gold class evidence base.

often (mostly) evidence is framed ONLY in the context of NHS demand and costs (critical weakness of Wanless and most others that followed). If you frame health in the context of economic productivity and benefit system into the mix it would have the impact of improving the investment: return ratio (though not making it any easier to quantify!)

2 We often frame it wrongly and have double standards on the evidential bar

The wrongly framed search for smoking gun level evidence about single interventions that make a tiny difference in a massive complex system of stuff vs overall approach across a complex system and sector

Certainly within the space of “public health” broadly and narrowly constrained the evidence base is way better than many other areas of both medical and social policy. It is a tricky thing though on what “passes” as good enough evidence base wise. This is in play for both micro level stuff of individual interventions and macro level – the whole shooting match.

putting “prevention” in an economic context? Prevention in a “health” context is way beyond NHS in intervention terms. And way beyond NHS and social care demand. Illness or lack of wellness =  Second or third biggest constraint on economic growth?? (skills, health, carer (often secondary to illness or preventable disability). Some of it plain isnt countable – economic productive benefit of healthier folk

Same in play for social care demand ….. Booze leads to BP …. Leads to stroke ….. leads to social care demand (and lost work life / more poverty and lost income for those not able to work)

same in play for benefit system. More folk a bit more healthy = less folk off sick and claiming benefits.

3 We often think in a sector specific way, not a whole society and long term way 

Definitely work to do on cost in the externalities, cost in the counterfactuals….. the consequence of doing nothing and costing in ALL the externalities.

The NZ Well Being budget example – if you want a cost driven system build a  super prison designed to bring financial value for money, a smaller cost/prisoner. But as soon as mental health and community indicators start to determine policy, the super-prison does not look such a good investment.

Who benefits – the benefits of investment in prevention wont accrue in the space that makes the investment and will accrue in the future (back to that NAO report on PSR). Often the return bit of ROI on prevention is locked up somewhere – NHS estate, criminal justice.

Hospital boss wont give up investment in hospital without cast iron guarantee of cashable return. We don’t get it. Too difficult. Leaps of faith needed. Also the other problem for her is a baseline that forever creeps up (more people in the city = more health care) and a messy system

There is a well documented lack of level playing field – we don’t ask for “evidence base” for “treatment”, well we do, but we have a much higher bar seemingly for the evidential standard for “prevention” v “treatment” or acute response 

See this blog on whole society budgeting

“Budgeting is where New Zealand steps out in front. Measuring is good, it enables one to see at least. But reframing all Government budgeting around it is quite something else, requiring re-writing of financial law and substantial changes to budgeting processes. Every spending proposal by Government must demonstrate delivery of wellbeing outcomes. The Government is currently developing its cost benefit tools to facilitate these new computations.

Such a focus on outcomes plays havoc with Government silos. No wellbeing outcome is achievable without extensive inter-departmental cooperation. Pursuing wellbeing economics changes absolutely everything about Government. And it changes policies.”

4 So all up it is a bit hard

And we will definitely think short term, sector specific and money not outcomes. That is why we don’t do very well on “prevention” ….. easy to say, hard to shift I accept

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