By Dr Eleanor Roy, CIPFA, Technical and Policy Health and Social Care Manager
Given the current demands on public services and their budgets, there is a growing consensus that a stronger case must be made for investment in preventative public health. There is mounting evidence that preventative investments are cost-effective, generating a better outcome than the next best use of resource.
NHS England’s Long Term Plan focuses on population health and a shift to Integrated Care Systems. Alongside this, health and social care secretary Matt Hancock set out his vision for prevention late last year. This increased recognition of the value of preventative approaches from government is welcome, but there is a need to improve evaluation of preventative investments, both to inform decision-making and increase transparency around such investments.
In evaluating such investment, there appears to be a ‘cross-sector flow problem’. That is, costs and benefits may fall on different budgets and organisations. This can inhibit cost-effective public health programmes as decision-makers don‘t consider the long-term impact on other parts of the system. The move towards place-based planning, requires local decision-makers to consider the costs and benefits of preventative spend across organisations. In other words, we need to think not in terms of the NHS pound or the local government pound, but the place-based pound.
There are several features of revenue investment in public health that make assessment and evaluation problematic. However, the fact that it is difficult does not mean we shouldn’t seek to make improvements. This is why the Chartered Institute of Public Finance and Accountancy (CIPFA) has partnered with Public Health England (PHE) to evaluate such investments. We have proposed a common, transparent approach to evaluate the costs and benefits of preventative investments in public health. In considering a potential framework, we identified a number of key requirements:
- A balanced evaluation of the financial and economic costs and benefits;
- A whole-system, placed-based view, unrestricted by organisational focus;
- Consideration of the financial sustainability of the investment, and its impacts;
- Allow for assessment of the comparative degree to which appropriate preventative investment is in place – across organisations, time and/or place.
To take the first step to achieving this ambition, CIPFA and PHE identified the existing tools and resources that could be utilised across different types of intervention, different organisations and at local, regional or national level to evaluate preventative investment. For example, cost benefit analysis (CBA) methodology can provide a balanced evaluation of the financial and economic costs and benefits of preventative investment. The Green Book/New Economy CBA model is well-suited to judging the merits of such investments and allows a whole-system view to facilitate decisions on a place-based basis.
It is vital that the potential impact on future sustainability is taken into account when making investment decisions. What is perhaps more important is the potential impact of not making the investment. Spending decisions can be inappropriately made based on short-term views, while the full impact is ignored. Adopting the principles of existing international guidance and elements of the prudential code may go some way to addressing this.
We need a clear understanding of current investment in prevention, nationally and locally, and ambition on spending to improve health and reduce health inequalities. Knowing how and where money is spent on prevention and by who, is essential in supporting decision-making across the system. These are important enablers of a shift the focus to prevention.
The suggested approach would enable preventative investment to be measured in a consistent manner, backed by a shared understanding of good practice. This would not only help to make the case for investment, but increase transparency and allow for analysis of such interventions over time and place. Local circumstances and priorities will of course vary, but organisations can use appropriate methodology to provide local context and assess the value gained in their local systems.
The overall ambition must be to change the way that prevention is considered. It should be viewed and treated as an investment and properly reported as such. While this change will not happen overnight, our report takes the first steps towards recognising the need and explores, with finance professionals, how this could be achieved. We hope it will shift thinking and be a catalyst for change in the near future.
This article first appeared in HSJ.