On the value for money of public health care

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 12

Abstract

From 2005 the National Institute for Health and Clinical Excellence (NICE) began assessing selected public health care interventions and programmes for their value for money, with a view to providing guidance on whether the assessed care ought to be provided by the public sector in England and Wales. Prior to this, NICE had only assessed clinical care interventions, for which it had been criticised because public health may have a larger impact on population health than clinical care.

Purpose of health policy or idea

It is generally recognised that public health care can have a very large impact on population health, and, moreover, that particular non-assessed public health interventions may have little or no impact on population health. In 2005, the National Institute for Clinical Excellence was renamed the National Institute for Health and Clincal Excellence (but remains NICE), and had its remit extended to consider the effectiveness and value for money of selected 'aspects' of public health care. The public health care that NICE assesses is of two types: 'interventions' and 'programmes'.

Public health interventions are defined as clearly defined local actions that aim to reduce the chance of occurence of particular illnesses, or which promote a healthier lifestyle. Stated examples by NICE include providing an accessible needle exchange scheme for drug addicts, and encouraging breast feeding in new mothers. NICE has formed a committee - the Public Health Interventions Advisory Committee (PHIAC) - to consider and interpret the effectiveness and cost-effectiveness evidence of those public health interventions that are selected for assessment. PHIAC has a multidisciplinary membership of 26 health care professionals, practitioners, technical experts, and representatives from the general public and community groups. PHIAC utlimately produces recommendations on whether an intervention represents good value for money and hence whether it ought to be provided in the NHS. It also identifies gaps in the evidence base and makes recommendations for research. The guidance is published on the NICE website, and the process from initial consideration to publication of the guidance is meant to take 12 months.   

Public health programmes are defined as multi-agency packages of policies, services and policies. For these, assessment can be a highly complex and difficult process, because many sectors of public service are potentially involved (e.g. education, environment etc) that do not hold 'health' as their primary outcome. Examples of public health programmes, explicitly stated by NICE, are services to help support physical activity targets, ranging from traffic calming measures to fun runs, and smoking cessation advice from primary care specialists, pharmacies, local authorities and employers. NICE has formed a multidisciplinary group - which varies its membership depending on the programme under consideration - to develop guidance based on its consideration of the effectiveness and cost-effectiveness of public health programmes - the Programme Development Group (PDG). The PDG is comprised of up to 16 members, including prodessionals, community members and technical experts, and takes 18 months to develop its guidance on any particular programme.

NICE guidance on public health interventions and programmes is reviewed over time. As a rule, the guidance is revisited three years after its publication with a view to assess whether it requires updating in the light of new evidence. If important new evidence comes to light within this three year period, the guidance may be revised within the three year time period.

Main points

Main objectives

NICE has specified that the public health activities that are selected for assessment can include 'downstream' issues such as lifestyles, and 'upstream' issues that focus on the wider determinants of health, including education, housing, the environment, transport etc. The guidance produced by NICE in this area can focus upon the whole range of 'health determining factors', including health promotion campaigns around both personal behaviours and environmental factors, and the structural determinants of health. Recommendations will be made at the level of the individual, family, community, and organisation (employers, health care providers). The objective is to improve the effectiveness and cost-effectiveness of implemented public health interventions and procedures.

Type of incentives

On the whole, the policy development is not about issuing incentives - it is about creating evidence-based guidance. However, some specific interventions under assessment may relate to incentives. For example, personal financial incentives to quit smoking and to engage in other healthy lifestyle behaviours.

Groups affected

The policy potentially affects everyone in society.

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

With appropriate methodological developments, and given the topicality of discussions around public health (e.g. in relation to environmental impacts on health, unhealthy lifestyle behaviours etc.) it seems sensible to me to attempt to assess the value for money of public health care interventions, many of which have not thus far been assessed for either their costs or their benefits.

Political and economic background

NICE had faced criticism for its focus on clinical interventions in the first few years of its 'life'. Many individuals and groups (particularly, of course, public health specialists) argued that public health interventions are far more important in impacting on population health than are clinical interventions. Consequently, in the face of this criticism, NICE has its remit extended in 2005. The policy development was not therefore the result of fundamental changes in political or economic directions.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

These issues and questions have been covered above.

Approach of idea

The approach of the idea is described as:
amended: The approach is ammended in the sense that NICE has had its scope extended.

Stakeholder positions

Due to the fact that the influence of public health policies extend to many branches of the public sector, the influence and involvement of a great many stakeholders is of importance. According to NICE, the relevant stakeholders include the national public, community, patient and carer organisations that represent those towards whom the guidance is directed to public health and health care professionals; providers, purchasers, local government and the voluntary sector; the Department of Health, the Home Office and the Department of Education and Skills; various NHS agencies; and research and academic organisations with an interest in public health.

Influences in policy making and legislation

The stakeholders are invited to provide comments on the scope of the draft guidance, the effectiveness and cost-effectiveness review (this is released to the stakeholders for a four week consultation period), and the draft recommendation (also released for a four week consultation period) for all assessments. Clearly, then, a large number of stakeholders are involved in the process, and they are likely to have some influence on the content of the analyses and on the final recommendations.

Possibly the main stakeholder group that effected this change was the public health community, and those sympathetic to public health policy, as well as those who, on the contrary, believe that many public health interventions and programmes do not represent a worthwhile use of public resources. As far as I know, parliamentary approval for the extension of NICE's remit was not required.

 

Legislative outcome

n/a

Adoption and implementation

A toothless tiger?

The Government decided to extend NICE's scope of responsibilities following their growing realisation that NICE's existing remit was too limited if they were serious about assessing the effectiveness and cost-effectiveness of interventions that impact on population health. However, whereas NICE has mandatory power over providers within the health care sector, its recommendations for public health interventions and programmes also reach out to non-health communities over which NICE has no power. Thus, implementation of recommendations is voluntary only.

Monitoring and evaluation

The methods by which to assess the economic evaluation of public health interventions and programmes is currently under review. There are a number of features of public health that render it, for many, more complex than clinical health care, not least its tendency to impact on and be impacted by many areas of the public sector, beyond the NHS. Moreover, there is ongoing discussion about whether 'health' and the 'maximisation of health' are the appropriate dimensions of concern for public health policies. Currently, however, the dominant form of analysis as propagated by most of those involved in the methodolgy development process appears to be QALYs and, hence, cost-utility analysis, which has also been the recommended form of analysis by NICE in its assessments of clinical health care interventions, to date. It is possible that this could change over time. In terms of monitoring the guidance, as noted above, the recommendations arising from all evaluations are, in theory, reviewed after three years.

Results of evaluation

NICE guidance is mandatory for its assessment of clinical interventions, but even there it has been reported that only half of local purchasers of health care adhere to the guidance. The guidance over public health interventions and programmes is aimed at stakeholders that very often lie outside the health care sector, over which NICE has no mandatory power. Acting upon the recommendations is therefore, largely, voluntary, and thus the expectation that it will have a substantive effect can legitimately be questioned.

Expected outcome

Only time will tell.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

References

Sources of Information

National Institute for Health and Clinical Excellence. The public health guidance development process. An overview for stakeholder including public health practitioners, policy makers and the public. London, 2006.

McDaid D, Drummond M, Suhrcke M. Investing in and implementing population health strategies. WHO Policy Brief, Copenhagen, 2008.

Department of Health. NICE 18th work programme: clinical guidelines and public health guidance referred in March 2008. London, 2008.

 

Reform formerly reported in

NICE - HTA: external evaluation report published Process Stages: Implementation, Evaluation, Policy Paper, Legislation, Idea, Pilot

Author/s and/or contributors to this survey

Adam Oliver

Suggested citation for this online article

Adam Oliver. "On the value for money of public health care". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/uk/a12/5