Prevention and Promotion Programme
Report on Identification of Potential High Impact Prevention Interventions
Author:Dr Julie Bishop
Date:31 August 2010 / Version:0a
Publication/ Distribution:
- Prevention and Promotion Programme Board
- Internet/Intranet
Purpose and Summary of Document:
This paper details the outcomes of the work undertaken to date by the Prevention and Promotion National Programme to identify high impact prevention interventions. It describes the process for scoping and further refining the programme and an initial screening process to identify potential high impact public health action areas and interventions. The next phase of the process is outlined.
Date: 310810 / Version: 0a / Page: 1 of 13
Public Health Wales / Report on Identification of Potential High Impact Prevention Interventions
1Background
In his Foreword to the Annual Operating Framework (AOF) for NHS Wales 2010-11 Paul Williams, Director General Health and Social Services, Chief Executive NHS Wales, identifies a number of challenges for NHS Wales (WAG, 2009). The first two being to improve the quality of health services that we provide, and to increase efficiency and reduce waste – within the context of a tighter financial settlement.
The AOF brings public health to the forefront of the strategic and operational agenda, incorporating a wide range of actions identified in “Our Healthy Future” into AOF Targets for 2010-11.
“Our Healthy Future” is wide ranging, andidentifies six Themes:
- Health through the life-course
- Reducing inequities in health
- Healthy sustainable communities
- Prevention and early intervention
- Health as a shared goal
- Strengthening the evidence and monitoring progress
The AOF highlights the publication of the Five-Year Strategic Framework for the NHS in Wales, early in 2010. Fourteen High Value Opportunities are identified, including “Drive highest-value prevention campaigns”. A number of National Programmes have been established, including ‘Prevention and Promotion’ which is jointly led by Bob Hudson, Chief Executive of Public Health Wales and Dr Tony Jewell, Chief Medical Officer.
A Programme Board has been established to oversee this work with representatives from Health Boards, Welsh Assembly Government, Local Government and Public Health Wales. The first task of the Board was to define the scope of the programme and identify the potential high impact opportunities.
This workstream needs to be considered alongside other areas of work, for example development of new Health, Social Care and Well Being and Children and Young People’s plans and the implementation of Our Healthy Future. These areas of work considered together should encompass the breadth of action required to improve public health.
2What is the potential for Prevention and Promotion, as part of the Five Year Strategic Framework?
Recognising the potential for improved prevention and health promotion is not new and there is much activity across the NHS and other sectors directed at prevention and promotion. Traditionally this has been directed at improving health outcomes for the population, and reducing health inequalities/inequities. “Our Healthy Future” provides a framework for further prioritisation and development of these activities.
The WHO defines Health Promotion as:
“the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions”
Disease Prevention is generally considered to have three elements:
- Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures.
- Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the diseaseand emergence of symptoms. Population screening programmes are secondary prevention.
- Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications.
In spite of this activity, there are few identifiable and defined programmes or interventions that are delivered in a systematic way. Those which do exist, with the exception of tobacco initiatives, tend to be those more medically focused secondary prevention programmes such as screening and risk factor management for heart disease in primary care.
The Five Year Strategic Framework brings an additional imperative – that of reducing the financial burden on the care system by better prevention and promotion that keeps people in better health for longer, thus reducing the need for care.
The programme needed to explicitly consider action that reduces the burden on the health and social care system and to think in terms of a triple aim to judge the high impact interventions we pursue:
- Improving health outcomes for all, by preventing avoidable ill health, disability and death
- Reducing Inequity and Inequalities (through levelling up)
- Reducing the inappropriate financial burden on the care system
Therefore the added value of the national programme will come from identifying those effective high impact interventions that will deliver this triple aim and how best they can be delivered. In focusing on ‘upstream’ interventions the Programme will encompass primary and secondary prevention.
The Programme seeks to identify the areas where there are interventions that would support a sound business case for additional NHS investment, demonstrating returns on that investment in terms of improved health and reduced health and social care costs, within the five year timeframe of the strategic framework.
3The economic case for prevention.
Economic assessment of the value of health and social care interventions is still a relatively under-developed (Suhrcke M et al, 2007; Richardson A, 2009; Trust for America’s Health, 2009) area although considerable progress has been made by bodies such as NICE who use an economic assessment as a component of the appraisal process of new technologies and interventions, including public health interventions (NICE, 2009). The cost effectiveness of interventions is judged against pre-determined criteria, usually the cost per QALY (quality adjusted life year) the cost of an additional year of healthy life.
There has been a tendency for prevention and health promotion interventions to be judged by different criteria to those for treatment. That is, there is an inappropriate emphasis on the potential to save money or reduce costs, when funding decisions are made, rather than on an interventions impact on health and wellbeing. It is an important principle that prevention and promotion interventions should be judged by the same criteria as treatment and care - their ability to produce health gain at a reasonable cost. Using this approach, a number of public health interventions have been judged to be cost effective (Matrix Insight, 2009).
Whether prevention and health promotion interventions can be cost saving and cash releasing is a different question and the one with which this programme has been tasked, in common with the over National Programme areas.
Identifying the potential economic benefit of prevention and health promotion activities is relatively straightforward, a reasonable amount of work has already been done to consider the cost to the NHS of certain health related behaviours. For example, work undertaken for ASH Wales and the British Heart Foundation (Phillips, C and Bloodworth A (2009) found that:
- Smoking cost NHS Wales an estimated £386 million in 2007/8, equivalent to £129 per head and 7% of total healthcare expenditure in Wales.
- Secondary care accounts for 67% and primary care 33%. £235.6 million is spent on hospital admissions and £21.5 million on outpatient attendances, while £49.3 million is spent on GP and Practice Nurse consultations and £79.3 million on prescriptions.
- Smoking accounts for an estimated 22% of adult hospital admission costs.
On one level, it appears fairly self evident that if you help someone stop smoking, you significantly reduce their risk of lung cancer and other smoking related diseases and the costs of treatment associated with them, in practice however, it is less straightforward. The first difficulty is the timeframe for action; the impact of smoking on the development of lung cancer is long term, as therefore, is the time that will lapse before the benefit of stopping smoking is fully realised. For example, a smoker who stops in their early forties may not have developed lung cancer or another smoking related disease if they had continued smoking for a further decade or more – the ‘savings’ therefore, are too long term to be of benefit in reducing costs to the healthcare system in the present. The second difficulty is that everyone dies eventually of something and a significant amount of an individual’s use of health and social care services will be at this end of life stage. If this argument was followed to its conclusion however, we would also cease to treat any disease or illness for the same reason.
This Programme will need to identify interventions that have a negative net cost per QALY gained; that is the cost per QALY considering the cost of the intervention as well as the cost saved through health treatment avoided:
incremental cost of intervention – cost savingNet cost per QALY gained / = / ______
QALYs gained
Source: Matrix Insight, 2009
An alternative approach is to look at the Return on Investment (ROI). The return on investment compares the savings as a result of a programme minus the programme cost to the cost of the intervention. A positive ROI indicates the programme generates savings in excess of the cost of implementation (Trust for America’s Health, 2009).
The timescale and resources available to this Programme will mean that it will not be possible to undertake this work from first principles and will be limited to the available published literature in this area.
The final issue is the realistic potential of any intervention to be cash releasing. Removing costs from the health and social care system is dependent on being able to permanently reduce service levels, for example, reduce staffing levels, reduce the number of beds, reduce prescribing levels. In practice, interventions which reduce demand have not reduced costs as these resources have been deployed in other ways, which in itself is a benefit to the system. Realising the potential for cash releasing savings is beyond the remit of this Programme and will rest with the Service at the implementation stage.
4What is a high impact intervention?
In order to have a ‘high impact’ on the utilisation of health and social care resources and population health, interventions will need to be identified in areas that meet the criteria below:
- high impact in relation to the current burden of preventable disease
- high impact in relation to the current use of NHS resources
- high impact based on the intervention effect
In practice, identifying high impact interventions from an almost infinite list of public health interventions is not practical. Therefore an approach has been adopted that seeks to identify where the greatest potential impact is in terms of the burden of preventable disease on the NHS and then look at effective interventions.
The scope of the Prevention and Promotion Programme was further refined at the initial programme group meeting and it was agreed in principle that this work should:
- Focus on those areas with the greatest impact on population health outcomes or inequalities
- Focus on those areas likely to impact directly on utilisation of health and other public sector services
- Focus on interventions where there is proven effectiveness that can be quantified
- Focus on a return on investment within the five year period of the plan
- Only include those areas where the powers exist currently in Wales to take action and are deliverable within the timeframe outlined
It was agreed that a screening matrix should be developed to assist in narrowing the potential areas of activity for further work.
5Initial ‘Screening’ Process
To assist in the first stage of this process an initial screening matrix has been developed. The determinants of health have been used as a framework to identify the potential areas for action, rather than disease areas. This approach has been taken as interventions will tend generally to address risk factors e.g. smoking or unemployment, rather than the disease itself. In addition, risk factor approaches have the potential to impact on a number of diseases. In some instances this has been broken down further for example to distinguish between interventions focusing on individual behaviour change from those that require wider policy or legislative change, recognising that the powers to implement these may not rest with the Welsh Assembly. These sub-categories have not been used in the initial screening phase.
Population Screening programmes have not been specifically included in this assessment as there is a well established process for identifying screening programmes through the National Screening Committee. There is potential to incorporate existing and new programmes within a wider programme of work at a later date.
A series of screening criteria have been identified reflecting the principles outlined above.
•The extent of the public health problems attributable to the risk factor/determinant and the likely future trends
•The current burden on health, social care and wider public sector resources
•Potential for further action
•Deliverability – extent of current programmes/resources
•Ability to act (Wales and the NHS)
•Impact on inequalities
5.1Implementation
At the Programme Group meeting it was agreed that a small sub group would be assembled to undertake the initial screening and that the recommendations would be reported to the next full group meeting. The sub group membership included:
- A representative from the Directors of Public Health
- A representative from local government
- Representatives from WAG
- Representatives from Public Health Wales including Health Intelligence, Health Improvement and Health and Social Care Quality
The group considered each of the potential high impact areas against the screening criteria. The process was largely subjective, drawing on the expertise within the group. It is recognised that a further stage will be required to validate the assessment and quantify the benefits and impacts. The group did have information from Patient Episode Database Wales (PEDW) on hospital admissions (spells) and occupied bed days to assist in the process.
The group also recognised that the methodology is pragmatic and was designed to reduce a long, almost infinite list of potential public health action areas to a more manageable list for further work.
5.2Emerging High Impact Areas
The process undertaken reaffirmed the outcome of the initial full group meeting in that there is a need to continually reiterate that this is not about all health improvement or public health action. Equally it is important that in producing outcomes and recommendations it is clear to others that public health action areas not identified as a priority according to the very narrow criteria in this programme does not signal that they are not of value or that there is potential for disinvestment from these areas.
5.2.1Phase 1 – High Impact Areas
The areas that scored most highly were the major lifestyle areas of tobacco use, alcohol use, diet and physical inactivity. The group recognised that within these broad areas there would need to be further focus and that it was important in doing so to acknowledge that this sits within a wider strategic approach that addresses all aspects i.e. in identifying smoking cessation as a potential high impact area, recognition is needed that wider action on prevention is also important and will need to be encompassed in work elsewhere.
These areas score highly as a result of the impact they have on major causes of morbidity and mortality such as cardiovascular disease, cancer and respiratory diseases. In addition, there were known interventions that were potentially of benefit.
Injury prevention was also identified as an area that had potential, particularly if the focus was on reducing injuries to the elderly. This has the added benefit of drawing on the substantial research work already undertaken in this field in Wales in recent years that has yet to be fully translated in action. Injury prevention is also an example of the potential to fully avoid healthcare costs, rather than reduce or change healthcare utilisation as in the case of chronic conditions.
Health at work was also identified as an area for further exploration particularly with a focus on the NHS workforce. Additional work is required to assemble and collate the evidence base in this area.
5.2.2Phase 2 – High Impact Areas
The sub-group also identified the following areas as having potential but needing some additional work to confirm this and have therefore identified these for the second phase of the work.
The group recognised the significant impact that mental health issues have on NHS, Social Care and wider public sector resources and the potential for the problem to increase due to the economic climate. Additional work is required to narrow the scope of this work through the identification of effective interventions.