OHE’s submission for the DHSC’s next 10 years of planning

Prevention is key to addressing these issues. Investing in prevention can be 3-4 times more cost-effective than investing in treatment. For example, recent review at OHE found that the preventable socioeconomic burden of cervical cancer in the UK amounts to £406 million, equivalent to 40% of the nation’s combined spending on immunisation and early detection programs pre-COVID-19. An increased long-term focus on prevention should therefore be a core priority of the 10 Year Health Plan.

Q2. What does your organisation see as the biggest challenges and enablers to move more care from hospitals to communities?

Prevention budgets:

We have ample evidence that demonstrates prevention is cost-effective (3-4 times more than treatment), provides great societal value (e.g. adult immunisation provide 19x their cost in societal returns) and that it is likely to be good for the economy (e.g. as preventable multimorbidity leads to lower work-force participation pre-retirement)

However, current prevention (including public health and immunisation) budgets do not reflect this value and are of high risk to be the first to be cut.

• • PRIORITY: High
  • LEVEL: Central

Capacity:

The NHS lacks the capacity to meet its stated ambitions. Our 2023 Prevention Whitepaper found that the NHS diabetes prevention programme (DPP) has been shown to reduce the chance of developing diabetes by 37% (NHS England, 2022c) and is highly cost-effective. However, access to the DPP is only available for up to 200,000 people per year versus an estimated 13.6 million people who are eligible.

While relieving overburdened hospitals is a key incentive for shifting care to community settings, the capacity of community services must also be carefully evaluated. For example, can community services such as pharmacies and GP practices handle the additional workload under current conditions? Is the necessary community infrastructure already in place to support such a transition? If community services are asked to provide additional services, but are not adequately funded or supported, then the success of this shift will not translate to patient outcomes.

In unpublished work by OHE considering the implications of increased delivery of pharmacy-based vaccinations, we considered the framing of such a shift to key stakeholders involved (GPs, Pharmacies, Patients, NHS), highlighting the potential benefits, but also acknowledging potential disincentives which would hinder the success of such a change.

• • PRIORITY: High
  • LEVEL: Local

Productivity:

The Darzi Review rightfully pointed out that the NHS has a productivity problem, contributing to long waiting lists at hospitals.

A more productive NHS should necessarily mean a healthier society, but part of the problem is how we measure productivity in the health service. We worked on a Health Foundation funded study that proposed a more holistic framework that focuses on valued health outcomes to measure output in primary care – the principles of this approach could be extended across the health service.

However, what we found during our study was that there is a stark lack of data on actual health outcomes collected or used in the health service. Instead the focus is on process and activity levels. This will pose a challenge in moving care from hospitals to communities as collection of data and reporting of health outcomes would become increasingly fragmented.

What we measure matters. If we continue to measure activity alone in the NHS as an indicator of success, we will continue to see the same problems regardless of whether care happens in hospitals or in communities.

• • PRIORITY: Medium
  • LEVEL: Central

Understanding implications for access (and inequalities):

Many intersecting factors lead to inequitable healthcare access. Our recent research on inequality in dementia found that there were more than 110 inequalities for people affected by dementia in England, Wales, and Northern Ireland.

Moving care into the community provides an attractive solution to address inequalities, in particular for certain disadvantaged groups where community services may be preferred or more utilised. However, there needs to be a clear understanding of the regional differences in accessibility and availability of community services and resources, so that this shift does not exacerbate existing inequalities.

More research on health inequalities is pivotal. It is important to understand where the gaps in the landscape are so that future reforms and changes can work on addressing them.

It is also important to consider various dimensions of access other than availability of services, i.e. awareness and acceptability. Making more services available in the community is important but for this shift to be successful patients (and referring physicians) need to be aware that those services exist and find them convenient for use.

• • PRIORITY: High
  • LEVEL: Local and central

Q3. What does your organisation see as the biggest challenges and enablers to making better use of technology in health and care?

Digital health technologies have the potential to be highly cost effective, given their low marginal costs. OHE conducted a summary of the digital health landscape in the UK in 2022 which identifies key challenges and enablers to adoption of technology in health and care:

• Enabler: Avoid unnecessarily complex regulatory frameworks when considering both regulated medical devices and unregulated consumer health products so as to not hinder market entry. We suggested that a feasible approach to faster market entry for low-risk technologies would be encouraging the use of soft regulation for those technologies which would otherwise fall in the unregulated products bracket. The Digital Technology Assessment Criteria (DTAC) standards and the digital playbooks, which bundle a range of products that adhere to a minimum standard of regulations is a good example of a framework that can boost user confidence and uptake.
• Enabler: There needs to be flexibility in value assessments of digital health technologies (DHT) similar to the NICE 2022 guidance of different appraisal pathways

Additional challenges:

• Lack of digital literacy in both the general population and the healthcare workforce
• We have the regulation in place to support technological innovation in healthcare but lack the capital investment to do so.
• Understanding inequality implications of increased use of technology from a patient perspective is a key challenge to implementing this change. Where might digital solutions enable access for harder to reach groups or those where face-to-face services are a barrier to access? Where would increased use of technology exacerbate these inequalities for those who with lower digital literacy?
  • PRIORITY: High
  • LEVEL: Local and central

Q4. What does your organisation see as the biggest challenges and enablers to spotting illnesses earlier and tackling the causes of ill health?

Understanding healthcare system incentives for early detection and prevention

The health economics literature shows that healthcare providers respond to incentives (both financial and reputational). In the context of early detection of cancer, work published by OHE has shown that hospitals responded to increased payments for diagnostic imaging scans for suspected cancer patients with significant increases in activity.

While incentives can provide a useful tool for increased activity around early detection and prevention, misalignment of these incentives in the healthcare system could also hinder improvement. Examples include

• Fragmented care, funding and accountability
• Focus of NHS targets on treatment of disease, rather than prevention
• NHS performance metrics focused on acute, reactive care
• Constraints and pressure felt by the workforce meaning priority must be given to acute care

A clear understanding of how incentives currently operate within the NHS is essential for driving meaningful change

• • PRIORITY: High
  • LEVEL: Local and central

Improving Uptake

OHE’s Prevention Whitepaper shows that uptake of existing programmes is suboptimal, with many of the interventions having scope to reach a greater number of people. For example, the optimisation of hypertension treatment is an area with poor uptake, combined with poor diagnosis rates. It is estimated approximately 4 million people with hypertension do not have a diagnosis, and of those diagnosed, 30% are not managed optimally. Poor uptake is often linked to inability to access services, which has implications for service design.

Increased monitoring of implementation and outcomes should be implemented in the medium to long term at the provider level. This monitoring could be used to increase accountability and incentivise desired action. Whilst there is typically strong support amongst clinicians for prevention activities in theory, without proper incentivisation and monitoring, treatment will always be prioritised. This ties into the framework we proposed at the primary care level (Health Foundation research, Q2).

• • PRIORITY: High
  • LEVEL: Local and Central

Prevention-first mindset

Prevention can have substantive returns on government investment through cost savings within the healthcare system, as well as wider socioeconomic benefits related to productivity and performance. For example, OHE published a report (funded by IFPMA) showing that adult immunisation programmes return up to 19 times their initial investment to society when the full spectrum of benefits are valued.

Policymakers may currently overlook the long-term gains of prevention programmes due to short term costs. Increasing stakeholder understanding of the high returns to investment for prevention is critical to increasing the priority of prevention schemes

• • PRIORITY: High
  • LEVEL: Local and Central

Behavioural change for both personal health and health of the NHS

Members of the public should also be encouraged to see health as an investment. They should be empowered to take ownership of their health and feel a social responsibility to do so in order to safeguard the NHS – much like the messaging used to drive people to vaccinate and socially distance during the COVID-19 pandemic.

We suggest in our Prevention Whitepaper that prevention activities should be positioned as in investment in health, much like pensions, mortgages and savings, and that awareness campaigns, developed in collaboration with behavioral scientists, can help nudge behavior in this direction.

We have also found compelling evidence that personal behavioural changes can benefit both individuals and the NHS. Our research into vegan diets, funded by the Vegan Society, found that with 100% adoption of plant-based diets in England, the total health care cost savings for the NHS could be around £6.7 billion, and that there could be 2.1 million fewer cases of disease across England.

• • PRIORITY: High
  • LEVEL: Local and Central

Q5. Please use this box to share specific policy ideas for change. Please include how you would prioritise these and what timeframe you would expect to see this delivered in, for example: • Quick to do, that is in the next year or so • In the middle, that is in the next 2 to 5 years • Long term change, that will take more than 5 years

Changes in the next year or so:

As with the commendable effort of engaging public opinion with this survey, there needs to be further accounting of societal preferences in HTA decision making. In our research, we’ve found that incorporating patient voices in HTA has wide-ranging benefits for both patients and industry – therefore improving both public trust in HTA processes and guiding industry research and development towards interventions that healthcare systems, and patients, value most.

We’ve also found that accounting for societal preferences allows HTA processes to better balance efficiency with equity (ie: what’s fair for society). For instance, we found that NICE’s severity modifier policy – although a welcome and well-intentioned evolution from its previous end-of-life policy – does not align with the levels at which the public categories severity.

It’s therefore crucial that the NHS takes into account the perspectives of those it serves – the public – in order to be fit for purpose and for the future.

Changes in the next 2 to 5 years (with benefits that begin to occur in the medium term and continue into the long term)

Increasingly, innovation in the use of payment models tend to lag far behind pharmaceutical innovation, coming at a real cost to patients wherein life-saving interventions remain out of reach due to short term budget implications.

The UK is a world leader in novel incentive models of payment – NICE and NHS England’s pioneering trial of the ‘subscription’ model for antibiotics, has the potential to develop a sustainable antibiotic market and therefore tackle the major global health crisis of antimicrobial resistance if adopted world-wide.

Health economics has a pivotal role to play in this arena in proposing innovative payment models that bridge industry incentives and maximises value-for-money for payers. This presents a significant opportunity for the UK to be a world leader in innovative financing in healthcare, informed by health economics tools.

Innovative financing could also benefit the UK’s focus on prevention. The UK could benefit from a dedicated prevention fund (similar to those available for cancer or innovative medicines), financed outside of core NHS budgets in the short-term by government or social impact bonds. In the long term, the savings generated would likely more than outweigh the initial investment and the fund would effectively pay for itself.

We know that primary intervention through public health interventions is substantially cost-saving, with a median return on investment of more than 14:1.Therefore, this focus must necessarily elevate prevention above short-term political cycles, to a position where all parties accept that programmes initiated now may only reap benefits under successive governments. A cross party initiative must be instated to persuade politicians and policy makers of the importance of this approach.