Economic evaluation of a real life public health intervention: Natural England’s Walking for Health Scheme

Marc Suhrcke

University of East Anglia,

Norwich Medical School

Why does it matter?

Economic evaluation as one important input into decision-making

Wanless (2004): Highlighted the need for economic evaluations of public health interventions

Confirmed by other studies, incl. systematic reviews (e.g. Schwappach/Boluarte/Suhrcke 2007)

Fairly careless treatment of the costing side in existing economic evaluations of “similar” public health interventions

Economic evaluation studies of primary prevention of CVD, by prevention category (n=195)

170

205

0

20

40

60

80

100

120

140

160

180

Clinicalprevention

Health promotion Screening

No

. o

f st

ud

ies

Source: Schwappach/Boluarte/Suhrcke 2007

Intervention targets by study setting (n=195)

% of studies

1. Dyslipidemia 31%

2. Smoking 22%

3. High blood pressure 13%

4. High blood glucose levels 7%

5. Dietary intake 7%

6. Obesity 6%

7. Physical inactivity 3%

8. Atrial fibrillation 2%

9. Various 11%

Source: Schwappach/Boluarte/Suhrcke 2007 4

What is the Walking for Health (WfH) “intervention”?

The largest led walk intervention and one of the largest public health interventions for physical activity in the UK

Natural England (NE) launched WfH in 2000.

WfH supported over 520 local schemes with over 60,000 organised walks in the 2010-2011 financial year; almost 100,000 registered participants

WfH schemes are developed in local areas, led by volunteers, supported and funded through local partnerships (e.g. primary care trusts, local authorities or voluntary community groups).

Predominantly elderly, retired participants

Substantial variation in size

Supported by certain national level resources and structures

Steps in the costing methodology

1) Selection of schemes (2 pilots, 6 for main study)

2) Identification of resource use development of a resource use inventory and questionnaire

3) Measuring and/or estimation of resource use

4) Resource valuation

5) Estimation of local level costs (at scheme level)

6) Estimation of national costs of WfH

7) Estimation of individual travel costs for participants

8) (Modest) sensitivity analysis

“Counting beans +”A number of slightly more involved issues to tackle

Cost perspective

Economic costs, not financial costs “opportunity costs”

Voluntary workers

Donated goods & services (eg office space)

Productivity costs

What are set-up, what are operating costs

Costs to participants

Costs attributable to the interventions

Data gaps

Information sources

WfH Database

Natural England central budget

Relevant literature

Questionnaires / interviews

Resource use inventory

Fixed Cost

Programme level (national/local)• Personnel expenses: Administrative and organisational staff, support staff• Material expenses: Facilities maintenance, rent and utilities; office equipment including computers,

advertising/marketing for the programme; recruitment of participants• External suppliers for cost/benefit analysis and evaluation

Additional societal resources• Environmental maintenance

Programme level (nat./loc.)• Personnel expenses:

Training of walk leaders and volunteers

• Material expenses: educational material

Programme level (national/local)• Personnel expenses: Volunteer staff, walk leaders• Material expenses: Technical equipment of walk leaders and

volunteers, transportation and travel, special maintenance work for the programme

• Insurance

Individual level• Time and productivity cost• Equipment (walking shoes, clothes)• Travel cost• Cost to family members

Additional societal resources• Costs to NHS, social care, employers etc.

Set up Operation Evaluation

Variable Cost

Main characteristics of the six selected WfH schemes

Scheme name Local Authority

Region Provider Location** Scheme size

Number of registered walks

Total attendance

Number of walk hours

Breckland and Brandon

Breckland EA CSP Rural districts Large 557 9,383 11,508

Heart and Sole Chelmsford EA Local Authority

Other urban and significant rural

Large 367 4,283 2,224

Stepping out in Suffolk*

Suffolk Coastal

EA Local Authority

Rural districts Large 371 4,842 4,970

Horsforth Healthy Walking Group

Leeds Yo Voluntary community group

Major urban and large urban

Small 62 1,964 3,425

Havering Walking for Health Initiative

Havering Lo Local Authority

Major urban and large urban

Medium 280 8,891 12,852

Mayfair Walking for Health

South Shropshire

WM Community Centre, PCT, Local Authority

Rural districts Medium 322 2,633 3,476

What gaps have we identified and what assumptions are used?

Gaps and assumptions

Gaps Assumptions

Set-up resources & costs

Labour No statistics to determine variable labour resources (eg nr of walk leaders, nr walks)

--

No estimates provided on the economic cost of volunteers

Used 2010 median gross hourly earnings (Annual Survey of Hour s & Earnings, ONS)For 2010: £7.97

No split by gender and by age Treated all volunteers equally

Non-labour All in kind/ donated (own or Council) --

Investment in office space per FTE Covered under recurring cost through depreciation

One-time purchases of office equipment

Covered under recurring cost through depreciation

Other costs (supplies & material, marketing, transport, etc)

Assumed other set-up costs are negligible

SET UP COSTS – LABOUR (1) Description e.g. SmallStarting the idea Meeting to set-up the scheme, objectives, etc Negligible

Recruiting volunteers

Preparing the course, collating application forms and booking a venue plus giving the training course.

1 day assistance to training course by walk leaders (varies from 6-20)

2 days

6 people attending the course = 6 days

Marketing and promotion

The following figures vary greatly. The costs depend on a number of factors such as size of the community and what established network exists already in the community (GPs, local community 3rd sector organisations (e.g. Age Concern), schools, etc

Travelling to promote the Scheme

Produce posters

1 day

0.5 day

Negligible

Route planning and risk assessment

Setting up the routes and risk assessing the routes. The latter consists of walking the route, and then completing the associate risk assessment paperwork. Costs are variable and depend on the number of routes that need to be risk assessed (0.5 h per route) and the length of the walk.

1.5h – 1 day

Funding Time spend applying for funding Negligible

SET UP COSTS (NON-LABOUR) (2) Description e.g. SmallFacilities, incl rent and utilities

Coordinators of small voluntary led schemes use their own houses

Included under recurring

Office equipment (e.g. telephones, computers, fax machines, desks, chairs)

The minimum office equipment to run a scheme effectively is a desk and a chair, a computer (mainly for emailing info to people), a printer, to print off the posters, and a telephone to get in contact with people.

Included under recurring

Supplies and materials (e.g. office supplies such as paper, ink, pens)

Includes mainly paper, and print cartridges Negligible

Marketing & promotion Mostly word of mouth. Poster templates and promotional leaflets are downloaded from the NE website. There is also a promotional DVD provided by NE

Negligible

Transportation Variable costs: it includes mileage for distributing posters (which depends on size of local area), mileage to training venue, etc

£0.40 per mile

Educational materials & Insurance

Provided by NE (and thus included under costs NE) None

b) Gaps and assumptions: recurring costs

Gaps Assumptions

Recurring resources & costs

Labour No estimates provided on the economic cost of volunteers

Used 2010 median gross hourly earnings (Annual Survey of Hour s & Earnings, ONS)For 2010: £7.97

No homogeneous units of work reported by the schemes

Used OECD average of1.640,6 working hours per year

Non-labour Mostly in kind/ donated --

Cost of office space per square meter or per FTE was unavailable

When not reported, used the office space cost per FTE for the 67 buildings of the Communities and local government and as per OCG report

When not reported, prorated the office space cost per FTE by the part-time hours worked

Lack of info on costs of office equipment

Depreciation office equipment per coordinator(s) (1 computer, 1 printer, 1 phone) plus recurring costs of cartridges, broadband and phone estimated at average market price

Other resources Represent a small percentage of total costs

Supplies and materials Walking equipment

Transportation

Variable depending on multiple factorsDonated/ paid depending on funding available

Estimating travel costs.

Why travel costs?

Starting point: info from WfH database

Postcodes of (almost) all walks

Postcodes of (almost) all walkers

Number of participants in each walk (but we don’t know who participated!)

Estimate: distance and time (based on car travel times) that each walker participating in the scheme would need to travel to reach each walk within their region (using GIS methods/software)

Travel cost calculation:

Travel expenditure = Travel time (minutes) * speed (miles per minutes) * cost per mile

Time costs = Travel time * (a*wage) [0<a<1]

What are the costs of WfH?

Total recurring (economic) costs for a local scheme: £15,000 – £60,000 p.a.

Costs per organised walk: £231 - £368

Costs per hour walked: £14.4 - £22.8

Costs per participant: £17.2 - £27.3

Labour costs make up ca. 2/3 of annual total costs

Volunteer costs account for ½ of total labour costs

No straightforward link between size and costs of scheme

Total national economic cost: £14.3 - £22.7 million

Example of travel costs: Havering WfH scheme

Type of costs Costs (£)

(1) Total travel time costs 4,672

(2) Costs of car use 26,471 

(3) Total travel costs =(1)+(2) 31,143

(4) Costs per registered walk (organised walk)

111

(5) Costs per attendee 3.50

(6) Costs per hour walked 2.42

 [C1]I don’t understand what is contained in (1) and (2)? Are the costs of car use both time and out-of-pocket costs? What is then included in (1)?

Concluding remarks

Is WfH a “costly” intervention? Probably not.

Is WfH an efficient use of financial resources? We cannot (yet) say, without info on benefits

If local authorities want to develop more of a value for money argument, there is a great need for more transparent mechanisms for collecting/identifying economic costs

What health (and other) benefits might there be? (as reported by WfH scheme contacts)

Friendship, company and community cohesion

Improvements in physical and mental health

Modelling the short and long term health and expenditure effects using the Multi-disease Model built for public health interventions

Need an estimate of individuals additional walking

Need estimates of uptake

Can incorporate information on relationship between exercise and different diseases

ACKNOWLEDGEMENT

This work was undertaken by the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research Centre of Excellence. This project has been funded by Natural England.

Funding from the British Heart Foundation, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.