Matt Jones, a Senior Manager at Attain, discusses the recent focus on the prevention agenda…
Prevention has been discussed across our NHS landscape for decades. The Wanless report1 from 2004 focused particularly on prevention and the wider determinants of health in England and on the cost-effectiveness of action that can be taken to improve the health of the whole population and reduce health inequalities. These recommendations have often been overlooked, but have been reiterated in the Five Year Forward View2, which suggested a ‘radical upgrade in prevention and public health’ with the NHS becoming ‘a more activist agent of health-related social change’.
Evidence shows that prevention interventions that have been considered by the National Institute for Health and Care Excellence (NICE), the agency which decides which drugs and treatments are available on the NHS, are generally highly cost-effective3. Despite this and a range of other positive evidence, there continues to be challenges in investing in and delivering the prevention agenda – the NHS only spends 4% of its budget on prevention4. Historically, the NHS has focused on dealing with the consequences of ill health rather than the causes – the attention of commissioners has, understandably, largely been focussed on their acute, primary and community providers in an attempt to deal with the increasing demand for services at the point that people are treated.
Additionally, prevention interventions tend to require investment and patience, ultimately meaning that commissioners risk investing in prevention, whilst at the same time funding the same level of provider-focussed interventions today. However, the increasing cost of treating an ageing population, combined with the impact of population growth, means that the current spending focus on treating the health problem, rather than the tackling the cause of the health problem is not sustainable – prevention offers us another way.
Tracing the root causes of service demand
Deciding which prevention interventions to pursue requires an understanding of the underlying causes of service demand. The World Health Organisation describes these social determinants of health as ‘the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources’.5
Joint Strategic Needs Assessments and Health Profiles, some of the local tools we can use to determine the drivers for increased demand for services, often paint a picture of the challenges and problems but struggle to identify and appropriately target prevention initiatives at the root case. As a result, commissioners often focus on individual prevention programmes, rather than designing a comprehensive approach. Frequently, therefore, initiatives do not reduce demand, sometimes have unintended (negative consequences), are difficult for service users to access, or simply tackle the symptoms rather than the cause. Ultimately, the driver for demand remains in the long-term.
Analysis, benchmarking, evidence-based evaluation and coherent, long-term planning can start to overcome some of these challenges.
Identification of root causes of demand for an East London CCG
Attain has worked with a proactive and forward thinking CCG in East London to discover the underlying causes of the challenges that their healthcare system is facing.
Essentially, our work was delivered in three phases:
- Scoping – to determine the project aims and to take an inventory of the current and planned prevention projects
- Analysis – of the challenges faced by the health system in the local area, using primary and secondary research sources. This list included a broad range of issues from late diagnosis of long-term conditions to the high level of alcohol attributable hospital admissions and high levels of excess winter deaths
- Root cause analysis (RCA) – to trace these challenges back to their underlying social determinants. These included determinants grouped into genetic, cultural, environmental, financial, educational and psychological areas.
This analysis is now being used to assess the appropriateness of current and planned preventative interventions and critically, the identification of needs that are not being met. It is also supporting the design of holistic, an evidence-based intervention plans to deliver value-for-money health prevention for the local population. Excitingly, these plans recognise that not all prevention interventions have a long return time – many interventions can yield results in months rather than years.
Overall this work has given commissioners an evidence base upon which to make informed decisions about their prevention plans and provided a framework to assess existing prevention interventions and evaluate future interventions.
There are obvious benefits to a prevention focus – not least avoided morbidity and mortality – however, there are also hidden benefits to the wider health and social care economy. Pooling of resources across care sectors significantly increases the probability that prevention programmes will be a success with improved health outcomes, common risk factors better addressed, and duplication of program efforts reduced. As the Five Year Forward View states6: a ‘radical upgrade in prevention’ is needed in order to ‘protect the health of our future population; ensure the sustainability of an NHS that is facing unparalleled demand and cost pressure and maintain economic prosperity’. As the population continues to age and long-term conditions continue to strain finite NHS budgets, the prevention agenda will maintain this recent focus and commissioners and providers will need to have the insight and evidence upon which to make strategic choices for prevention investment.
1 Securing Good Health for the Whole Population Derek Wanless, 2004
2 Five Year Forward View, NHS England, 2014
3 The cost-effectiveness of public health interventions, J Public Health, 2011
4 Marmot M. Fair society healthy lives, 2010
5 World Health Organisation, 2012
6 Five Year Forward View, NHS England, 2014