What are the best societal investments for improving people’s health?BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3377 (Published 30 August 2018) Cite this as: BMJ 2018;362:k3377
- Laura Webber, director of public health modelling1,
- Kalipso Chalkidou, director of global health policy2,
- Susie Morrow, chair3,
- Brian Ferguson, chief economist4,
- Klim McPherson, emeritus professor5
- 1UK Health Forum, London, UK
- 2Centre for Global Development, Imperial College London, UK
- 3Wandsworth Living Streets Group, London, UK
- 4Public Health England, London, UK
- 5New College, University of Oxford, Oxford, UK
- Correspondence to: L Webber
The NHS has transformed medicine and improved lives.1 But the ageing population along with the burden of non-communicable, mental, and neurological diseases have put its financial viability and sustainability into question. The next decade is projected to be the most financially austere in NHS history,2 even if recent pledges materialise. Reorienting the NHS to invest in cost effective disease prevention is essential if the health system is to be sustained. Disease prevention has four key benefits that show how cost effective it is both in and beyond the health and social care system (fig 1). We focus on the role of the NHS in disease prevention and the role of cross government agencies in tackling the wider determinants of health.
Health in all policies
Social and environmental influences are thought to contribute to around 50% of the variation in health status, indicating that access to universal healthcare alone is not sufficient to improve population health.3 Strong preventive interventions tackling the social determinants of health often fall outside the usual scope of healthcare, yet accrue benefits for the health sector.45 Including health as a key outcome of policies and intersectoral governance on health is therefore an important step in improving population health and reducing health inequalities.6
The United Kingdom’s recent industrial strategy acknowledges the importance that infrastructure investments can have on society, with a focus on how investment can support the needs of an ageing population.7 The post-Brexit rewriting of laws and policies provides an opportunity for (public) health to be put at the centre of policy making8 and for health to be embedded in new institutional norms. Other policy making avenues provide similar opportunities, such as the ongoing changes to devolution and the movement of public health to local authorities in England.9 We make the case for a “health in all policies” approach as the best investment for people’s health and recommend that NHS funding protects preventive services (as promised in the Five Year Forward View).
Common risk factors and their costs
Preventing disease is key to reducing pressure on the NHS. In 2006-07, ill health related to poor diet cost the NHS £5.8bn (€6.5bn; $7.4bn).10 The cost of physical inactivity was £0.9bn, smoking was £3.3bn, alcohol £3.3bn, and overweight and obesity cost £5.1bn.10 Recent analysis quantified the NHS and social care (as opposed to broader societal) cost of pollutants nitrogen dioxide and fine particulate matter at £157.2m in 2017, increasing to a staggering £19bn cumulative cost by 2035.11 Mental illness is estimated to cost £22.5bn a year (NHS, social care, and other agencies).12 Obesity is projected to increase, and will likely drive further increases in non-communicable diseases.13 Risk factors and non-communicable diseases tend to be more prevalent in the most deprived groups, with health inequalities estimated to cause over 700 000 deaths and 33 million cases of ill health in the EU as a whole in 2004, accounting for 20% of total healthcare costs and 1.4% of gross domestic product after lost productivity was taken into account.55
The wider social determinants of these risk behaviours—such as poverty, lack of adequate education, unemployment, austerity, inadequate social benefits, poor quality social housing, and poor public transport—are strong contributors to the inequalities in health and increased prevalence of mental and neurological diseases.3 By reducing exposure to these common determinants the disease burden can be reduced.
Generating evidence for prevention: methods and means
Evidence for the effects of public health interventions on risk factors often relies on statistical modelling studies, as randomised controlled trials are not always feasible or ethical and frequently lack a commercial sponsor. Modelling is a crucial part of the decision making process, providing evidence for policy, as shown in the case of minimum unit pricing of alcohol1516 and the sugar sweetened beverage levy.1718 Models are often complicated and led by assumptions, however, which makes leveraging policy change more difficult than when evidence is cited from traditional drug trials. Calls for guidelines to standardise reporting of public health modelling studies are therefore well warranted.19
The National Institute for Health and Care Excellence (NICE) is England and Wales’s cost effectiveness watchdog, but its emphasis is typically on drugs and clinical services. Although NICE has enabled the development of public health guidance, some of this is now outdated and held “static.”20 Furthermore, NICE’s decisions on technology adoption carry a funding direction that encourages the health service to invest in the latest drug. The same does not apply to public health guidance, meaning that uptake of this guidance is largely voluntary. Recent empirical evidence shows that NICE’s guidance on newer drugs receives a higher priority than good health practice already elsewhere in the system.21
Economic case for prevention and the reasons for inaction
Although the ultimate aim of prevention is not to save money, an increasing body of literature makes the economic case for prevention of ill health.13222324 Despite this, just 3% of European health budgets are invested in public health.25 Thus maintaining or reducing healthcare costs without negatively affecting health outcomes requires that cost effective prevention interventions are at the forefront of healthcare. Apprehension about the initial costs of disease prevention, combined with pressure on existing budgets, result in inaction while investment in ever increasing treatment costs continues.26 Because the benefits of prevention are often long term and rarely show return on investment in the lifetime of a parliament or tenure of a minister of health, they must also overcome challenges to get political backing.
Best investments for society’s health
In one review of over 500 studies analysing primary or secondary prevention interventions, only two were cost saving: childhood immunisations and counselling adults on low dose aspirin.29 An additional 15 were cost effective. But the included studies focused on clinical preventive services only, rather than prevention outside of the health system, and rarely considered non-healthcare costs.
A more recent review of return on investment for a broad range of public health interventions in developed countries with universal healthcare reported substantial cost saving.27 In this context, cost saving refers to the overall social costs and benefits, including long term health benefits and government savings beyond the health system, rather than short term cashable savings to the NHS specifically.30 Savings are therefore realised only after the increased pensions and social care costs owing to prolonged life expectancy without contraction of morbidity are factored in. National regulatory interventions produced the highest return on investment so are likely to be the best investment for population health, while also narrowing health inequalities.3132
We explore some of the options for potentially cost saving interventions, outside of healthcare, yet argue that a combination of interventions is likely to be required for maximum effect.33
Fiscal and pricing policies
Price is a major determinant of consumption, and there is strong evidence globally that fiscal and pricing policies are a win-win for population health.34 But pricing policies are underused, possibly owing to lack of political will, public acceptability, and conflicted interests (such as the tobacco, food, and alcohol industries opposing public health interventions for commercial reasons). Such policies have the dual benefit of generating revenue while reducing disease by disincentivising the consumption of unhealthy commodities and promoting healthy behaviour.35 An example of strong fiscal policy for health is tobacco tax. The UK has the highest pack price of any EU country (£9.91 for 20 cigarettes),36 double the European average,37 which has contributed to decreasing tobacco consumption over the past three decades. Nevertheless, evidence shows that gains can still be made. Increasing the tobacco duty escalator to 5%, for example, is estimated to avoid 75 200 new cases of smoking related disease by 2035, saving £49m in NHS costs and £192m in societal costs in a single year.3839 Arguments against taxes as regressive are unfounded, as those in the lower income bracket tend to have more unhealthy behaviours and live in more polluted areas, so carry a disproportionately high disease burden. They have the most to benefit, especially in an NHS style system that is inherently equitable and serves as an “equaliser” moving resources from the rich to the poor and from the healthier to the sick.
UK fiscal policy around other behavioural risk factors lags behind that of tobacco, and trends in those risk factors reflect that. Obesity is one such example where prevalence has increased over the past 30 years, with predictions of nearly three in four people being overweight or obese by 2035.13 The introduction of the sugar sweetened beverage levy in the UK represents progress, but swift and sustained action to make the leaps seen in comprehensive tobacco control is crucial. Policy regressions have led to alcohol duty as a share of total tax receipts dropping to just over half what it was in 1978,40 further compounded by the alcohol duty escalator freeze and the coalition government’s change of direction on minimum unit pricing of alcohol in 2013 in England.4142 Nevertheless, Scotland’s success in implementing minimum unit pricing in 2018, after extensive legal challenge, is a key turning point in getting alcohol policy back on the agenda. Such policies are crucial given the UK’s large increases in liver disease over the past 40 years, largely as a result of alcohol consumption and obesity.43
More broadly, the effect of investments in wider social infrastructure (such as social policy and education) on health shouldn’t be undermined. Fuel duty is an important policy outside of health that could incentivise people towards active travel. Policy decisions to freeze rates of fuel duties since 2011 has been estimated to cost the exchequer about £5.4bn a year in 2017-18 terms.44 This freeze has incentivised inactive travel (driving) and has cost a substantial amount that could otherwise have been allocated to improving active travel infrastructure. Car ownership and use is skewed towards higher income groups, so tackling the subsidies involved would help reduce inequalities.45
Promoting physical activity
Changes to the built environment have repeatedly been shown to be cost effective. Recent NICE economic modelling showed that changes to transport infrastructure, frequency of and access to public transport, and open space access are highly cost effective ways to increase physical activity and improve health even when they generate just a modest increase in physical activity.46 The guidance noted that physical infrastructure interventions would not necessarily decay in their effects, unlike behavioural interventions, and these could even increase over time. This is a good example of a “health in all policies” approach, where town planning and transport policy can include effect on health as a primary policy outcome.
Tackling social determinants of health
Evidence from several countries shows that increased social welfare spending is correlated with reductions in mortality, but healthcare spending is not.47 This emphasises the need to maintain and improve investment in social welfare programmes as a key determinant of population health. Public Health England commissioned a series of evidence reviews around effective interventions for improving social determinants of health. These covered early intervention, education, employment, ensuring a health living standard for all, and healthy environment, providing a 12 step plan for action.48 Examples include parenting programmes such as An Equal Start49; Adult Education Gloucestershire, which reported improvements in wellbeing and reduced stress50; and individual placement support programmes that integrated employment specialists into community mental health teams and supported service users into employment, education, or training.5152 NHS England’s Healthy New Towns project works with 10 housing developments to shape the health of communities and consider new ways of health services delivery.53 It is a welcome example of joined up cross government action on upstream determinants of health.
Conclusion and recommendations
We present some of the options for investing in society’s health. We need a broader approach that focuses on maintaining people’s health rather than the consequences of disease. Evidence calls for a “health in all policies” approach to societal health as the norm. We think that NHS funding for prevention should be protected and extended through an explicit and guaranteed NHS benefits package,54 which includes prevention, a national commission for health promoting fiscal policies, and a NICE funding direction for public health interventions. We need rigorous, validated, and comprehensible epidemiological and economic modelling to reliably inform policy on the best investments for society’s health.
Investment in prevention is key if the NHS is to be sustainable
A battery of preventive approaches is necessary—there is no silver bullet
Times when national and government policies are under intense review—such as Brexit in the UK—offer the opportunity for taking a “health in all policies” approach to public health
Health in all policies should be the norm; we need a proactive solution ensuring that NHS funding protects preventative services and a level playing field for assessing preventive and curative interventions
We recommend a national commission on health promoting fiscal policies, a guaranteed NHS health benefits package that includes prevention; and a NICE funding direction for public health interventions
We thank William Savedoff.
Contributors and sources: LW is director of public health modelling at the UK Health Forum and leads a team that builds statistical models and tools to simulate the health and cost impacts of public health policy interventions over the long term. LW is an honorary assistant professor at the London School of Hygiene and Tropical Medicine. KC is director of global health policy at the Center for Global Development and professor of practice in global health at Imperial College London. KC led the establishment of NICE International, and, more recently, of the international Decision Support Initiative (iDSI). SM is a patient and lay person representative. She is chair of Wandsworth Living Streets group and was a lay member of the NICE Public Health Advisory Committee, which advised on the NICE guideline on physical activity and the environment, published in 2018. BF is chief economist for Public Health England and holds an honorary chair at the University of York. Previously, he held positions as chair of the UK and Ireland Association of Public Health Observatories, deputy director of the Centre for Health Economics, University of York, and professor of health economics at the University of Leeds. KM is visiting professor of public health epidemiology in the Department of Primary Health Care; emeritus fellow of New College, and former chair of the UK Health Forum. LW drafted the article; KC planned the article, supported drafting, and edited the final version of the manuscript. SM drafted the environment and physical activity section, commented on, and edited the article; BF commented and edited drafts of the final manuscript; KM supported planning of the manuscripts and commented on drafts. LW is the guarantor.
Competing interests: The authors have no conflicts of interest to declare.