Making the case for public health interventionsA tailored report for Croydon, Kingston, Merton and Richmond local authorities

Responding to change in SW LondonSouth West LondonAcademic, Health and Social CareSystem

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Contents

1. Introduction 3

2. Spendingandcosts 8

3. Healthandbehaviours 22

4. Returnoninvestment 36

5. Returnoninvestment:furtherexamples 68

6. Commentaryonfindingsandsomerecommendations 73

v Annex–AnalysisofLGAdatabaseoffourboroughs’priorities 80

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1 Introduction

ThisreportpresentstailoredinformationforCroydon,Kingston,MertonandRichmondlocalauthoritiestohelpthemmakethecaseforpublichealthinterventions.ItbuildsontheworkofTheKing’sFundandLocalGovernmentAssociationwhoproducedasetofinfographics1summarisinginformationontheeconomicandwidercaseforpublichealthinterventionsinlate2014.WearegratefulfortheassistanceofTheKing’sFundintheproductionofthisreport.

Allpartsofthehealthandsocialcaresectorsareunderincreasingfinancialpressureandlearninghowtorespondinatimeofausterity.Inthiscontext,thisworkprovidesacontributiontotheevidencewhichdemonstratesthevalueofpublichealthinterventions.Whenreadingthispaper,itisimportanttoacknowledgeanumberofchallengesandcaveats.Someofthesearelistedbelowandothersaddressedinthefinalsection,‘Commentaryonfindingsandsomerecommendations’.

• Thereisavariedarrayofspecificationsforreturnoninvestment,anumberofdifferentmethodologiesandno‘correctway’toidentifyandreportonit.Itis,however,mostimportantthatwhatisincludedandwhatisnotincludedregardingthemethodchosenismadeexplicit.

• Returnoninvestmentdoesnotnecessarilysignifyadirectcashreturnonanyinvestmentmadeasthevalueofanyinvestmentisoftenrealisedintermsofimprovedhealthforindividualsand/orsavingsmadeacrossthehealthandsocialcaresystem.

• Itisalsoimportanttoacknowledgethatthereturnsarenotnecessarilyimmediatebutcanbeexperiencedoveranumberofyears.

• Thebenefitsaccruedfrominvestinginpublichealthinterventionscanbecomplex/hardtoquantifydirectlybutthisdoesnotunderminethevalueofdoingthistypeofanalysis;ratheritcallsformoreworktobedonebothtoachievesomegreaterconsistencyintheuseofterminologyandintheanalysisoftheimpactandcostconsequences–particularlyforotherpartsoflocalgovernment.

• Thepaucityofdataandinformationandsomeofthemethodologicalchallengesareaddressedinthelastsectionofthisreport.

1.1 Scopeofthisreport

Thebulkofthispaper‘tailorsandunpacks’thejointinfographicspublishedbyTheKing’sFundandtheLocalGovernmentAssociation(LGA)inSeptember2014.Wearegratefultobothorganisationsfortheirsupportinreproducingthismaterialinthisreport.Sections2and3aretailoredversionsoftheseslidesforthefourSWLondonboroughs.Foreaseofinterpretation,thesearesetoutwiththeoriginalslidepresentedfirst,andthenthetailoringandunpacking,followedbysources.

Section2broadlycorrelatestothefirsthalfofTheKing’sFund–LGAslidesonthefunding,spending,contextandburdenofpublichealthinEngland.Thesehavebeenadaptedtoeachofthefourboroughswherepossible.

1Seewww.kingsfund.org.uk/audio-video/public-health-spending-roi

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Section3looksathealthandbehaviours,againadaptedtotheboroughsasappropriate.

Section4includestheunpackingofreturnoninvestmenttosetoutwhichsectorsororganisationsthereturnsflowtoand,wherepossible,overwhichtimeperiod.Inseveraloftheseexamples,additionaldatahasbeenaddedfromotherstudies.Forallofthese,wherefeasible,thereisa‘percentageofbreakdown’summarywhichsetsoutwherethereturnsflow.

Section5alsoincludesnewmaterialoninterventionsrelatedtoearlyyears,alcohol,andtrafficcalmingmeasuresastheyarerelevanttothefourboroughs’priorities(seeannex).

1.2 Caveats

ThematerialinthepaperhasbeendevelopedinordertobeofmostusetothefourSWLondonboroughs.Thishasinvolvedmakingjudgementsonthefollowingfactors.

1. Selectionofmaterial:WherepossiblethedirectsourcesfromTheKing’sFund-LGAinfographicshavebeenused.Insomecaseseitherthismaterialisnolongeravailable,orwasnotabletobebrokendownusefully,inwhichcaseithasbeensupplementedbyadditionalmaterial.

2. Tailoringofmaterial:Eitherboroughordatafromnationaladministrativesourceshasbeenusedinordertotailormaterialtothesouth-westLondonsystem.Thebulkofthisguidewaswritteninthefirsthalfof2015,usingcomparabledataacrossboroughs.Theboroughsmayhavemorespecificdataandsomecomparabledatawillsincehavebeenupdatedfromnationalsources.AnumberofslidesfromtheoriginalKing’sFund-LGApublicationhavenotbeenamended.Forexample,thefirstslideinsection2,ontheimportanceofpublichealth,hasnotbeenamendedbecauseitisrelevantandusefulasitis.ThevastmajorityofthedataandsourcesusedinthisreportwereaccesseduptoJuly2015.Insomespecificcasestheyhavebeenupdated(forexampleontheadviceofboroughs)ortoreplacelinkswhichhaveceasedworkingbeyondthatdate(forexample,duetoareformattingintheOfficeforNationalStatistics’website.TheyarecorrectasatbeginningofApril2016.

3. Sources:Forsomeareasthereisadearthofmaterialand,forothers,arelativeglut.Forexample,forhousinginterventions,choiceshadtobemadeaboutwhattopresentbutthereareotherchoiceswhichcouldhavebeenmadeabouttheselectionofdata.Housingisanareawhereamorecompletesetofmaterialcouldbedeveloped.

4. Tools:Forphysicalactivityintervention,theNationalInstituteforHealthandCareExcellence(NICE)physicalactivityreturnoninvestmenttoolhasbeenusedtoshowhowforoneoftheboroughs,Croydon,aphysicalactivityinterventioncouldleadtoreturnsoninvestment.ThiscouldberepeatedforotherboroughsandotherNICEtoolscouldbeusedforalcoholandtobacco.However,theyhavenotbeenusedfurtherhere.

5. Thereisotherworkinprogressinthisarea:PublicHealthEnglandhascommissionedareviewoftheavailabilityandusefulnessofreturnoninvestmenttoolsforpublichealth2anditisalso

2Seewww.yhpho.org.uk/default.aspx?RID=194888

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developingandreleasingrelatedinfographicsaspartoftheirHealthMattersseries,forexampleonalcohol.3

1.3 Commentaryandrecommendations

Followingthefirstdraftofthisreport,theDirectorsofPublicHealthexpressedsomeconcernaboutthepaucityofmaterialonthereturnoninvestmentforpublichealthinterventiontosocialcare.Section6respondstothis.

1.4 Conclusion

ThereisalargeamountofmaterialavailablethatcaninformDirectorsofPublicHealthonthelikelyreturnoninvestmentoftheiractivity.Thispapersummarisesandpersonalisessomeofthatinformation.

However,duetothewiderange,ageandmethodologiesofstudiesandtheparticularneedsofDirectorsofPublicHealth,thereisnosinglestudythatwill‘hitthespot100percent’.Thisrequiresbespokestudiesandanalysis.

NICE’sandothertoolsforspecificsortsofinvestment(suchasphysicalactivityandalcohol)seektofillthegapbetweenthesebespoke(andtime-intensive)studiesandthetranslationofother’sworkthatisthefocusofthispaper.

Itishopedthatthissetofinformationisusefulininformingtheboroughs’workandthecommunicationofittoothers.

3www.gov.uk/government/publications/health-matters-harmful-drinking-and-alcohol-dependence/health-matters-harmful-drinking-and-alcohol-dependence

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2 Spendingandcosts

2.1. Thecontributionofvariousfactorstohealth

Thisisrelevanttoalltheboroughs,pointingoutwhattheevidencesuggestsaretherelativecontributionsofhealthcare,widerdeterminantsandbehaviourstohealth.Thisisscene-settingandtailoringisnotneeded.Itcanbeusedbytheboroughs,asitis.

Theimportanceofpublichealth

Ourhealthisdeterminedbyourgenetics,lifestyle,thehealthcarewereceiveandourwidereconomic,physicalandsocialenvironment.Althoughestimatesvary,thewiderenvironmenthasthelargestimpact.

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Sources:

Infographics

www.kingsfund.org.uk/time-to-think-differently/trends/broader-determinants-health#messages,drawnfromhttp://books.google.co.uk/books?id=J3Uer_Iv0V8C&lpg=PA305&ots=uJaQtUbsuH&dq=info%3AuRpgQOigYAUJ%3Ascholar.google.com&lr&pg=PA305#v=onepage&q&f=falseandhttp://content.healthaffairs.org/content/21/2/78.full.htmlandCanadianInstituteforAdvancedResearchinwww.nlgn.org.uk/public/wp-content/uploads/Healthy-Places_FINAL.pdf

2.2Spendingandgrantonpublichealthperhead

In2013/14,averageNHSspendingperheadwas£1,742;averagepublichealthgrantforEnglandwas£49perhead.ThegrantsfortheboroughsarerepresentedinTable2.2.1.

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Table2.2.1

Publichealthgrantperhead

Borough 2013/14 2014/15

Croydon £49 £50

Kingston £53 £54

Merton £43 £43

Richmond £40 £40

AveragespendonNHSandpublichealth

In2013/14theDepartmentofHealthspentmorethan£106billiononhealth,socialcareandpublichealthinEngland.AverageNHSspendingperheadwas£1,742whileforthefourSWLondonboroughs,thegrantforpublichealthspendingrangedfrom£40to£53perhead.The2014/15grantforthefourboroughswaswithinasimilarrange.

Sources:

InfographicsandTable2.2.1

BasedonDepartmentofHealthrevenuedepartmentalexpenditurelimit,NHSEnglandrevenuedepartmentalexpenditurelimit(bothout-turns),localauthoritygrantsandpopulationestimatesfrom:www.gov.uk/government/uploads/system/uploads/attachment_data/file/335166/DH_annual_accounts_2013-14.pdfandwww.gov.uk/government/publications/ring-fenced-public-health-grants-to-local-authorities-2013-14-and-2014-15

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2.3 PublichealthgrantatEnglandandboroughlevel

Thisiscontextualinformation.Thereisnoborough-levelequivalentsinceitisnotpossibletosplittheoveralltotaltoboroughlevel,althoughthe£2.66billioncouldbepartitionedintoborough-leveldata.

Atboroughlevel,however,thereisinformationontheoveralllevelofpublichealthgrantsetoutinTable2.3.1.

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Table2.3.1

Boroughpublichealthallocations,total

Borough 2013/14 2014/15

Croydon £18,312,000 £18,825,000

Kingston £9,049,000 £9,302,000

Merton £8,985,000 £9,236,000

Richmond £7,676,000 £7,891,000

Sources:

InfographicandTable2.3.1

www.england.nhs.uk/allocations-2013-14/andwww.gov.uk/government/uploads/system/uploads/attachment_data/file/325522/PHE_Annual_Report_and_Accounts_2013_to_2014.pdfandwww.gov.uk/government/uploads/system/uploads/attachment_data/file/335166/DH_annual_accounts_2013-14.pdf

Spendingonpublichealth

In2013/14theDepartmentofHealthspentaround£5.48billiononpublichealth–around5.1percentoftheirtotalspending.Almosthalfofthis–£2.66billion–wasgiventolocalauthoritiesasgrants.

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2.4. Representationofspreadofpublichealthbudgetsperheadbyarea

Thismapfor2014/15representsthespreadofpublichealthgrantsandcouldbeupdatedwiththefourboroughsdata,usingthefinalcolumns’datainTable2.4.1.

Table2.4.1

Boroughtotalpublichealthgrant2014/15

Borough 2014/15

Croydon £50

Kingston £54

Merton £43

Richmond £40

Rangeofallocations

In2014/15theDepartmentofHealthallocated£2.79billiontolocalauthoritiesinpublichealthgrants.Thisrangedfrom£185perheadto£22perhead.Forthefoursouth-westLondonboroughsthegrantforpublichealthspendingrangedfrom£40to£54perhead.

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Sources:

InfographicandTable2.4.1

www.gov.uk/government/publications/ring-fenced-public-health-grants-to-local-authorities-2013-14-and-2014-15

2.5. Populationgrowthovertime

InTable2.5.1,theEnglishprojectionsabovehavebeencomplementedwithborough-specificprojectionsfromOfficeforNationalStatistics(ONS),basedonmid-2012projections.

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Table2.5.1

Predictedpopulationgrowthintheborough2014–34

Borough 2014 2034 Growth

65–84 85+ 65–84 85+ 65–84 85+

Croydon 42,000 6,400 67,900 13,400 62% 109%

Kingston 19,100 3,500 29,300 6,900 53% 97%

Merton 21,400 3,400 32,300 6,600 51% 94%

Richmond 24,000 4,300 36,100 8,900 50% 107%

Thisshows,forthefourboroughs,abiggerchallengeinthegrowthofthe65–84agegroupthanforEnglandasawhole,growingbyatleast50percentandasimilarchallengeforthe85+,withpopulationsettodoubleorthereabouts.

Ageingpopulation

Overthenext20yearsthenumberofpeopleinEnglandaged65–84willincreasebymorethanathird,andthenumberaged85andabovewillmorethandouble.ForfourSWLondonboroughsthegrowthinthoseaged65–84isforecasttobebetween50percentand62percentand,forthoseaged85+,between94percentand109percent.

Sources:

Infographics:

www.ons.gov.uk/ons/publications/re-reference-tables.html?edition=tcm%3A77-335242

Table2.5.1:

TheKing’sFundanalysisofwww.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections/datasets/z1zippedpopulationprojectionsdatafilesuk

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2.6. Lifeexpectancygrowthovertime

Itwasnotpossibletosourcelifeexpectancyatbirthdatabackto1981atboroughlevel.ThefiguresinTable2.6.1belowgobackto1991andincludeEnglandasareferenceatthisdate.

Table2.6.1

ChangesinlifeexpectancyovertimefortheboroughsandEngland,1991to2012

Borough 1991–93 2010–12 Changeinlifeexpectancy

M F M F M F

ENGLAND 73.6 79.1 79.1 82.9 5.5 3.8

Croydon 74.2 79.2 79.2 83.2 5 4

Kingston 75.5 80.3 81.4 84.8 5.9 4.5

Merton 74.7 80.0 80.2 84.2 5.5 4.2

Richmond 74.9 80.6 81.7 85.9 6.8 5.3

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Itisworthnotingthatforallfourboroughs,lifeexpectancyishigherthantheEnglandaverage.

Overtheperiod1991–93to2010–12,inalltheboroughs,exceptCroydon,malelifeexpectancygrewfasterthantheEnglandaverageand,forfemales,lifeexpectancyineachboroughgrewfasterthantheEnglandaverage.

Lifeexpectancy

TheaveragelifeexpectancyinEnglandhasbeenincreasing.In1991itwas73.6yearsformenand79.1forwomen;thishadincreasedto79.1and82.9respectivelyby2010–12.Overthesametimeperiod,inthefoursouth-westLondonboroughs,lifeexpectancyincreasedbybetween5and6.8yearsformenandbybetween4and5.3yearsforwomentoreachbetween79.2and81.7yearsformenandbetween82.9and85.9yearsforwomenrespectively.

Sources:

Infographic:www.ons.gov.uk/ons/dcp171776_237747.pdf

Table2.6.1:TheKing’sFundanalysisofwww.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/lifeexpectancyatbirthandatage65bylocalareasintheunitedkingdom/2014-04-16

2.7. Lifeexpectancyvariations,highestandlowest

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Thelifeexpectancyfortheresidentsofthefoursouth-westLondonboroughscanbecomparedagainsttheseregionalandlocalauthorityfiguresusingthedatainTable2.6.1.

Tomakethisamoremeaningfulcomparison,acloserlookwastakenatthelifeexpectancywithinareabydeprivationinthefourboroughsandthesefiguressetagainstthedataforWestminsterintheright-handsideoftheinfographicabove.SeeTable2.7.1below.

Table2.7.1

LifeexpectancyinthefourboroughsbydeprivationagainstWestminster,2010to2012

Borough Mostdeprived10% Leastdeprived10% Difference

M F M F M F

Westminster 76.5 81.6 89.1 89.1 12.6 7.5

Croydon 75.2 80.2 83.6 87.1 8.4 6.9

Kingston 78.1 81.8 84.4 87.5 6.3 5.7

Merton 76.7 83.4 84.8 86.2 8.1 2.8

Richmond 77.5 82.3 87 88.8 9.5 6.5

Lifeexpectancyvariations

Therearewidevariationsinlifeexpectancybetweendifferentpopulations.Inthefoursouth-westLondonboroughs,thedifferencebetweenthemostdeprived10percentandtheleastdeprived10percentofthepopulationrangesfromunder3yearstoalmost7yearsforwomenandfrommorethan6yearstomorethan9yearsformen.

Sources:

InfographicsandTable2.7.1

www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&source=web&cd=6&ved=0ahUKEwjo8-aUqNTLAhVEPhQKHYnsDK8QFgg6MAU&url=http%3A%2F%2Fwww.phoutcomes.info%2Fdocuments%2FLife_Expectancy_Deciles_2002-04_2010-12.xls&usg=AFQjCNFmgbSzs-pn6nK606TMDnVC_KeiOA&cad=rja

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2.8. HealthylifeexpectancyinequalitiesbyCCGandbylocalauthority

TheinfographicshowsthebiggestgapinEnglandforfemalelifeexpectancybyclinicalcommissioninggroup(CCG).InTable2.8.1wepresenthealthylifeexpectancyforthefoursouth-westLondonboroughs.

Table2.8.1

Healthylifeexpectancydatafortheboroughs’CCGs,againstEnglandfor2010to2012

Borough Male Female

ENGLAND 63.5 64.8

NHSCroydon 63.9 64.6

NHSKingston 67.0 68.3

NHSMerton 65.3 66.3

NHSRichmond 69.2 71.0

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RichmondhasthefifthhighestmaleandthirdhighestfemalehealthylifeexpectancyofanyCCGinEngland.Theotherboroughs’healthylifeexpectanciesareclosertotheEnglandaverage.

Wecanalsolookatthisdatafor2009–11byboroughinTable2.8.2,basedonupper-tierlocalauthorities.

Table2.8.2

Healthylifeexpectancydatafortheboroughs,againstEnglandfor2009to11

Borough M F

ENGLAND 63.2 64.2

Croydon 62.1 65.8

Kingston 63.5 64.4

Merton 64.5 65.9

Richmond 70.3 72.1

Richmondhasthehighesthealthylifeexpectancyofanyupper-tierlocalauthorityinEnglandforbothfemalesandmales.Theotherboroughs’healthylifeexpectanciesareclosertotheEnglandaverage.

Healthylifeexpectancy

Thelengthofourlifeisimportantbutsoishowmanyyearsofourlivesarespentingoodhealth.Inthefoursouth-westLondonboroughsmencanexpecttolivetobetween62.1yearsand70.3yearsingoodhealth,andwomentobetween64.4yearsand72.1years,comparedtotheEnglandaveragesof63.2and64.2yearsrespectively.

Sources:

Infographic

www.ons.gov.uk/ons/dcp171776_356961.pdf

Table2.8.1

www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/articles/healthylifeexpectancyatbirthandatage65clinicalcommissioninggroups/2014-03-21

Table2.8.2

www.ons.gov.uk/ons/dcp171778_327530.pdf

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2.9. Disability-freelifeexpectancyinequalities

TheaboveisbasedonfullEnglanddata,basedonmiddlesuperoutputareas(MSOA)(around6,700statistical‘communities’withaveragepopulationsofaround5,000).Thisdisability-freelifeexpectancydataisonlyavailablefor1999–2003(althoughitisbeingupdatedinOctober2016).

Giventime,thiscouldconceivablybeupdatedfortheboroughs(intermsofwheretheirMSOAssatinthedistribution)althoughitwouldnottranslatewellintoasimpleinfographicormessage.

Disability-freelifeexpectancy

Accordingtothelatestdata(1999–2003)peoplelivinginthepoorestneighbourhoodsinEnglandwill,onaverage,die7yearsearlierthanthoseintherichest.Theyalsolivetheirliveswithmoreillness.Theaveragedifferencebetweenthepoorestandrichestneighbourhoodsindisability-freelifeexpectancyis17years.

Sources:

Infographics:www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review/fair-society-healthy-lives-executive-summary.pdf

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3 Healthandbehaviours

3.1. Healthbehavioursinadults

ThisisbasedonsummariesofHealthSurveyforEnglanddata.Thisdatacannotbecutdowntoboroughlevel.However,anapproximationofratesandoverallnumbersfromothersourcesisavailabletodevelopequivalentinfographicsatboroughlevel.

Boroughfigures(andtheEnglandratesandnumbersinthetablesbelow)aretakenfromvariousmodelledestimatesincludinglocaltobaccoprofiles,localalcoholprofiles,obesityprofilesandthePublicHealthOutcomesFramework.ThesearesetoutinTables3.1.1and3.1.2.

Wherelocalauthoritieshavetheirowndata,thisshouldbeusedinpreference.Therearealsoalternativelocal-authority-basedsourcesforrelatedinformationincluding,forexample,admissionratesandmortalityfromliverdiseaseforalcoholinthePublicHealthOutcomesFramework.

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Table3.1.1

Estimatesofratesperboroughforsmoking,overweightandobesity,alcoholuseandphysicalactivity,inadults,variousyears

Borough Smoking(2013,18+)

Overweightorobese(2012,16+)

Alcohol(2008–09,16+,minusabstainers)

Physicallyinactiveadults(2014,16+)

Higherrisk Increasingrisk ENGLAND 18.4% 63.8% 6.75% 20% 27.7%

Croydon 17.0% 62.1% 6.70% 18.05% 25.6%

Kingston 15.1% 55.1% 8.03% 21.03% 26.7%

Merton 13.9% 58.3% 7.19% 21.04% 23.6%

Richmond 11.4% 47.6%4 7.76% 21.33% 15.7%

Table3.1.2

Estimatesofnumbersperborough*forsmoking,overweightandobesity,alcoholuseandphysicalactivity,inadults,variousyears

Borough Smoking(2013,18+)

Overweightorobese(2012,16+)

Alcohol(2008–09,16+,minusabstainers)

Physicallyinactiveadults(2014,16+)

Higherrisk Increasingrisk

ENGLAND 7,861,385 28,080,334 2,970,882 8,802,612 12,191,618

Croydon 48,227 182,202 19,658 52,959 75,111

Kingston 22,377 75,358 10,982 28,762 36,516

Merton 21,945 94,529 11,658 34,115 38,266

Richmond 17,086 73,1245 11,921 32,767 24,118

*Numbersinadults(assumingratesaboveapplytomostrecentpopulations,mid-2014OfficeforNationalStatisticsestimates)

4LocalestimateproducedbyLondonBoroughofRichmonduponThames,2015,ObesityNeedsAssessment,suggeststhatthishasfallenfrom47.6percentin2012to44.5percent.

5GiventheLondonBoroughofRichmonduponThames’morerecentupdate,thereareanestimated65,317overweightorobeseadults16andover,comparedto73,124in2012.

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Healthandbehaviour

Itisestimatedthatthousandsofadultsinourfoursouth-westLondonboroughscouldimprovetheirlifestylewhichwouldhelpthemtolivelongerandhealthier.Thelatestdatasuggeststhat:

• thenumberofadultssmokingrangesfrom17,086to48,227• between73,124and182,202adultsareoverweightorobese• between10,982and19,658adultsaredrinkingalcoholathighrisktotheirhealth,anda

further28,762to52,959aredrinkingatincreasingrisk• Finally,between24,118and75,111adultsarephysicallyinactive.

Sources:

Infographic:www.hscic.gov.uk/searchcatalogue?productid=13888

Table3.1.1

www.tobaccoprofiles.info/andwww.noo.org.uk/visualisationandwww.lape.org.uk/data.htmlandwww.phoutcomes.info/search/physical%20activity

Table3.1.2

AsTable3.1.1and

www.ons.gov.uk/ons/data/web/explorer/dataset-finder/-/q/dcDetails/Social/MYEDE?p_p_lifecycle=1&_FOFlow1_WAR_FOFlow1portlet_dataset_navigation=datasetCollectionDetails

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3.2 Clusteringofunhealthybehavioursinadults

ThisslideisbasedonanalysisofdatafromtheHealthSurveyforEngland,undertakenandpublishedbyTheKing’sFundatEnglandlevel.

Thedatasetistoosmalltobreakdowntoboroughlevel.However,asubsequentstudyatLondonlevel,in40deprivedcommunities,hassincebeenundertaken.Thisstudylookedattherelationshipwithwork,whichthestudyintheinfographicdidnot.Thiscouldberelevanttotheboroughs,particularlyamongtheirdeprivedpopulations.

Inbrief:

‘Oneofthestarkestfindingsinthisstudyisthatpeoplewhoreportunabletoworkhavemorethanthreetimeshigheroddsofreportingahighernumberofriskbehavioursthanthoseinfull-timepaidemploymentandmoretwoandahalftimestheriskofbelongingtothemaximalbehavioursclass.Sixty-sevenpercentofthoseunabletowork,illordisabledreportedatleastthreeriskbehaviours.Thelatentclassanalysesalsorevealedthatafteradjustingforothersociodemographicfactors,thosewhowerenotinemploymentweremorelikelytoreportalifestylecharacterisedbyhighsedentarytime,lowlevelsofphysicalactivityandlowfruitandvegetableconsumption.’

MoredetailissetoutinBox3.2.1.

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Box3.2.1

Combinationsofclustersofbehavioursincommunitiesfrom40deprivedareasofLondon

Multipleunhealthybehaviour

Multipleunhealthybehaviourshaveacumulativeeffectonhealth.Someoneinmid-lifewhosmokes,drinkstoomuch,exercisestoolittleandeatspoorlyisfourtimesaslikelytodieoverthenext10yearsassomeonewhodoesnoneofthosethings.StudiesindeprivedpartsofLondonsuggestthatthosewhoareunabletowork,areillordisabledareatparticularrisk.Morethantwo-thirdsofthisgroupreportreportedatleastthreeriskbehaviours.Weneedtodomoretohelpandsupportthisgroup.

Sources:

Infographic

http://www.kingsfund.org.uk/publications/clustering-unhealthy-behaviours-over-time

Box3.2.1

http://jpubhealth.oxfordjournals.org/content/early/2015/03/11/pubmed.fdv028.full.pdf+html

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3.3 Disability-adjustedlifeyears,themainburdens

ThiscontextslidebasedisontheGlobalBurdensofDiseasestudythatlookedatthecontributiontohealth(definedasdisability-adjustedlifeyearslost)ofthemainbehaviouralcausesofhealth.

Thisisnotdirectlytranslatabletoboroughlevelduetothemethodologyanddifferentprevalencesandage-structures.However,itisusefulcontext.Bothmentalhealthandmusculo-skeletalconditionstendtobeunder-acknowledgedindebatesandpoliciesonhealthatnationalandlocallevel.Thisslide’sintentionistohighlightthisinbalance.

Disability-adjustedlifeyears

FortypercentoftheUK’soveralldisability-adjustedlifeyearslostarecausedbytobacco,highbloodpressure,overweightandobesity,andlowphysicalactivitythroughtheircontributiontodiseasessuchasheartdisease,strokeandlungcancer.

Sources:

Infographics

www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60355-4/fulltext

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3.4 Costburdenofhealthbehavioursbyborough

Thesearenationalfiguresonthecostburdenofkeybehaviouralriskfactors.Eachistakenfromadifferentstudy,withdifferentmethodologiesandtimelines.ThesefiguresalsorelateonlytotheNHScostsofthesebehaviours,otherstudiesincludeawiderangeofcoststovariousothersectors.

Ideally,separatestudieswouldbeavailableatboroughlevel.Intheabsenceofthesestudies,itispossibletogetasenseofwhatthismeanslocally,byscalingdownbypopulationsizeinTable3.4.1(wehaveusedadultpopulation16+asthescalar)andfurthertakingintoaccountinformationonborough-levelprevalenceestimates,inTable3.4.2.

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Table3.4.1Cost-burdenestimatesoflifestyleburdensbyborough,byscalingto16+Englandpopulations

Borough Smoking Obese Alcohol Physicalinactivity

ENGLAND £5.2billion £4.2billion £3.5billion £1.1billion

Croydon£34,664,373

£27,998,147

£23,331,790

£7,332,848

Kingston£16,158,340

£13,050,967

£10,875,805

£3,418,110

Merton£19,156,668

£15,472,693

£12,893,911

£4,052,372

Richmond£18,149,821

£14,659,471

£12,216,226

£3,839,385

Wecangoalittlefurtherbyscalingthesecosts‘again’,thistimetoscaleTable3.4.1totheprevalencefiguresinTable3.1.2(weusedthehigherrisknumbersforalcoholinthescaling).Thisreducestheoverallburdensforsmoking,buthasdifferentialeffectsfortheothers–basedonthescalingoftheirprevalencetotheEnglandaverage.

Table3.4.2

Cost-burdenestimatesoflifestyleburdensbyborough,byscalingto16+EnglandpopulationsandestimatesofboroughprevalencecomparedtoEngland

Borough Smoking Obese Alcohol Physicalinactivity

ENGLAND £5.2billion £4.2billion £3.5billion £1.1billion

Croydon £32,026,866 £27,252,115 £23,158,961 £6,776,928

Kingston £14,753,267 £11,271,289 £12,938,180 £3,294,713

Merton £14,471,613 £14,138,840 £13,734,403 £3,452,562

Richmond £11,244,998 £10,937,160 £14,044,135 £2,176,114

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However,thisinducesadditionalassumptionsthatthe‘burden’statisticsinTable3.1.2areappropriatetotheoverallcost-burdencalculationsabove.

Alloftheseassumethatunitcostsoftreatment(aswellasotherfactors)areatEnglandlevelsintheboroughs,sotheseareindicativefiguresonly.Inaddition,thecostfigurescomefromvariousyears.

Forthisreason,itmaybebesteithertoleavethisasa‘contextslide’,ortousethesimplicityof3.4.1,ratherthanapotentiallymore‘spuriouslyaccurate’3.4.2.

Costofunhealthylifestyles

UnhealthylifestylescosttheNHSacrosstheUnitedKingdombillionsofpoundseveryyear.Estimatesforthefoursouth-westLondonboroughsarehardtodevelopwithaccuracybutsomefiguressuggestthatsmokingcoststheNHSintheseboroughsbetween£11millionand£32million,obesitybetween£10millionand£27million,alcoholbetween£12millionand£23millionandphysicalactivitybetween£3million£7millioneveryyear.

Sources:

Infographic

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_128209andhttps://responsibilitydeal.dh.gov.uk/wp-content/uploads/2013/02/Generic-RD-Flyer-Final.pdfandButlandB,JebbS,KopelmanP,McPhersonK,ThomasS,Mardell,ParryV(2007).Tacklingobesities:futurechoices–projectreport(2nded).London:ForesightProgramme,GovernmentOfficeforScienceandAllenderS,BalakrishnanR,ScarboroughP,WebsterP,Rayner,M(2009).‘Theburdenofsmoking-relatedillhealthintheUnitedKingdom’.TobaccoControl,vol18,pp252–5.

Table3.4.1

AsinfographicplusTheKing’sFundanalysisusingpopulationscalar:www.ons.gov.uk/ons/data/web/explorer/dataset-finder/-/q/dcDetails/Social/MYEDE?p_p_lifecycle=1&_FOFlow1_WAR_FOFlow1portlet_dataset_navigation=datasetCollectionDetails

Table3.4.2

Table3.2.1plussourcedataunderlyingTable3.1.2.

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3.5 Mentalillnessprevalence

Thisslideisbasedonnationalstudies,thatdonotcontaindatabasedonboroughpopulations.

Therearedataonmentalhealthprevalencebylocalauthorities.ThemostusefulsourceisCommunityMentalHealthProfiles(datafor2014hasalsobeenpublishedforCCGsbyPublicHealthEngland).Forinstance,thishasdatafortheprevalenceofdiagnoseddepression(italsohasdataonlearningdisabilitiesanddementia).OthersourcesofinformationincludethePublicHealthOutcomesFrameworkonlowwellbeingscores,suicidesandvariouswiderdeterminantsofmentalhealthandadmissionsrates,etc.

Table3.5.1combinessomeofthisinformation.

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Table3.5.1

Mentalhealthindicatorsbyborough

Borough Suicide(2011–13,per100,000age-standardised,allages)

Highanxiety(2013/14,adults16+)

Diagnoseddepression(2011/12,18+)

Estimated%withcommonmentalhealthdisorder(2014/15,16–74yrs)

ENGLAND 8.8 20.0% 11.68% 15.6%

Croydon 6.2 21.9% 7.43% 15.9%

Kingston 7.0 21.3% 7.32% 15.6%

Merton 7.96 21.3% 8.9% 16.1%

Richmond 6.4 18.7% 6.74% 15.8%

Mentalhealth

Mentalillnessisbyfarthemostcommonillnessforpeopleaged15–44andtheincidencerisesfurtherwithage.Latestdatasuggeststhatinthefoursouth-westLondonboroughsbetween18.7and21.9percentofadultshadhighanxietyandbetween6.74and8.9percentwerediagnosedwithdepression.

Source:

Infographics

http://cep.lse.ac.uk/pubs/download/special/cepsp26.pdfandwww.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60355-4/fulltext

Table3.5.1

Derivedfromwww.nepho.org.uk/cmhp/andwww.phoutcomes.info/andhttp://fingertips.phe.org.uk/search/common%20mental%20health%20disorder

6ForMertonmorerecentdatafor2013/14suggeststhatsuiciderateshadfallento7.2per100,000.

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3.6 Theprevalenceofmusculo-skeletalproblems

Thisdatacomesfromnationallevelstudies.Itisnotpossibletoappropriatelyscaleittoboroughlevel.Thisinformationisthereforecontextual.However,otherdatarelevanttothisisavailablelocally–basedonCCGboundaries–inthegeneralpracticeprofiles,assetoutinTable3.6.1.

Table3.6.1

Exampleofmusculo-skeletalproblemsbyborough,againstEngland

Long-termbackproblem(2013/14,18+)

Arthritisorlong-termjointproblem(2013/14,18+)

ENGLAND 10.2% 13.2%

NHSCroydon 9.8% 10.2%

NHSKingston 7.7% 9.1%

NHSMerton 9.2% 9.3%

NHSRichmond 8.7% 8.0%

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Musculo-skeletalproblems

Asof2010,musculo-skeletalproblems,suchasbackpainandarthritis,arethemostcommonconditionstolimitpeople’sdailyactivitiesandthelargestsinglecauseofyearslivedwithdisability.In2013/14,acrossfoursouth-westLondonboroughs,between8.7and9.8percentofadultshadlong-termbackproblemsandbetween8and10.2percenthadarthritisorlong-termjointproblems.

Sources:

Infographic:http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)60355-4/fulltextandhttp://www.arthritiscare.org.uk/@2118/GetaGrip

Table3.6.1

http://fingertips.phe.org.uk/profile/general-practice/data#mod,1,pyr,2014,pat,19,par,-,are,-,sid1,2000009,ind1,-,sid2,-,ind2,-

3.7 Children’slifestylebehavioursovertime

Thisisderivedfromself-reportedresponsesfromtheHealthSurveyforEngland.Therearenonationaladminisitrativedatathatarecollectedatboroughlevel.

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Itislikelythatsimilartrendsareexperiencedintheboroughsandtheremaybelocalhealthandlifestylesurveysofchildrenintheboroughsthatcouldprovidesimilardata.

Nationalinformationonthementalhealthofchildrenishardtocomebyandoutdated.Thelastnationalsurveyofchildrenandyoungpeople’smentalhealthwasundertakenin2004.Thegovernmenthasrecentlyannouncedanewsurvey,involving9,500children,theirparents,carersandteachers.Forthefirsttime,thiswillgatherinformationfromtheunder5sandfromolderadolescents,greatlyimprovingourunderstandingoftheneedsofthesegroups.Fromthis,estimatesofhowmanychildreninthepopulationarelivingwithamentaldisorderwillbepossible.Itwillalsoexaminetheissuesthatleadtomentalillhealth,likebullyingorothersocialpressures.

Whilethenationaldataneedstobeupdatedweknowfromtheearliersurveyandotherdatathat1in10childrenandyoungpeopleaged5–16sufferfromadiagnosablementalhealthdisorderandbetween1in12and1in15childrenandyoungpeopledeliberatelyself-harm.Itisunlikelythatthishasimproveddramatically.OtherworkbyUNICEF,putstheUnitedKingdominthemiddleofthepack(16thof29countries)onwiderindicatorsofchildwellbeingamongrichcountries,withtheNetherlandsandScandinaviancountriesdoingbest.

Improvementinchildren’shealthbehaviours

Children’shealthbehaviourshaveimproveddramaticallyovertime.Reporteduseofdrugs,smokingandalcoholhaveallroughlyhalvedoverthepast10years.Around1in10youngpeoplehaveadiagnosablementalhealthdisorder,theUnitedKingdomisinthemiddleofthepackamongotherrichcountriesintermsofindicatorsofwiderchildwellbeing.

Sources:Infographic:www.hscic.gov.uk/searchcatalogue?productid=15144

Mentalhealth

www.gov.uk/government/speeches/improving-children-and-young-peoples-mental-health-careandwww.youngminds.org.uk/training_services/policy/mental_health_statisticsandwww.unicef-irc.org/publications/pdf/rc11_eng.pdf

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4 Returnoninvestment

4.1. Boroughspendandactivityonsexualhealth

TheinfographicisbasedonHealthProtectionAgency(nowPublicHealthEngland)nationaldataandnationalreturnstotheDepartmentofHealthonpublichealthgrantplannedspend.

Fortheboroughs,wecanlookatreturnstotheDepartmentofHealth(summarisedaspartofthewidersetoflocalauthorityfiguresbytheDepartmentofCommunitiesandLocalGovernmentAssociation)onplannedspendingofthepublichealthgrantanditssexualhealthcomponents(Table4.1.1).

Thisdatawascorrectatthetimeofwritingthisreportassubmittedbylocalauthorities.However,thismaydifferfromfinalout-turnspendingdatabylocalauthorities.

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Table4.1.1

Sexualhealthspendingandbreakdownbytypeofspend2014/15

Spendsexualhealthservices(2014/15)

STItestingandtreatment

Contraception Advice

England £671,334,000 £383,482,000 £184,089,000 £103,763,000

Croydon £6,406,073(14/15forecastoutturn)

£4,323,532 £1,531,868 £54,000

(£61,115healthpromotion+£412,626–adviceprevention)

Kingston £3,343,000 £2,100,000 £489,000 £754,000

Merton £3,018,000 £2,060,000 £601,340 £360,000

Richmond £2,815,000 £159,000 £593,000 £2,063,000

Absolutenumbersofnewdiagnosesofsexuallytransmittedinfectionsbylocalauthorityarenotpublishednationally,althoughratesare.The‘SexualHealthBalancedScorecard’includesaratefor‘acutesexuallytransmittedinfectionsdiagnosis’for2011data,setoutinTable4.1.2(thisisnotnecessarilytheequivalentofthe450,000figureshownintheinfographicabove).

Table4.1.2

Acutesexuallytransmitteddiseaseinfectiondiagnosisandratesofdiagnosisofinfection,2011

Acutesexuallytransmittedinfectionsdiagnosis(2011),count

Acutesexualtransmittedinfectionsdiagnosis(2011)per100,000

England - 729.1

Croydon 4556 1318.4

Kingston 1531 906.2

Merton 21282088(2012)

1019.21,048(2014)

Richmond 1230 644.2

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Table4.1.3

Newsexuallytransmittedinfections(STI)diagnoses,2014

AllnewSTIdiagnoses(excludingchlamydiaaged<25)

AllnewSTIdiagnoses(excchlamydiaaged<25)(2014),count

AllnewSTIdiagnoses(excchlamydiaaged<25)(2014),per100,000

England 289,899 829

Croydon 3,279 1,321

Kingston 1,213 1,059

Merton 1,712 1,220

Richmond 1,094 863

Sexualhealth

In2014/15thefoursouth-westLondonboroughsspentbetween£2millionand£6milliononsexualhealthservicesincludingadvice,contraceptionandtreatment.Datafrom2011showsthatbetween1,230and4,556casesofacutesexuallytransmittedinfectionswerediagnosedinthefoursouth-westLondonboroughsanddatafrom2014showsthatbetween1,094and3,279newdiagnosesofsexuallytransmittedinfections(excludingchlamydiainthoseunder25)werediagnosedinthefoursouth-westLondonboroughs.

Sources:

Infographics

www.hpa.org.uk/hpr/archives/2014/hpr2414_AA_stis.pdfandwww.gov.uk/government/uploads/system/uploads/attachment_data/file/335962/RA_Budget_2014-15_Statistical_Release.pdf

Table4.1.1www.gov.uk/government/uploads/system/uploads/attachment_data/file/365591/RA_2014-15_data_by_LA_-_Nat_Stats_Release_-_Revised_22-Oct-2014.xlsTable4.1.2www.apho.org.uk/addons/_118371/atlas.htmlTable4.1.3http://fingertips.phe.org.uk/profile/sexualhealth

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4.2 Examplecostsofhealthservices

Thisslideisacontextslide.Thefigureshavebeendrawnfromdiversesources,somefromgovernmentadministrativedataandsomefromresearchstudies.Theadministrativedatacouldpossibelybebrokendownfurtherbasedonlocalreferencecosts(thesewouldbeA&Eattendanceandambulancejourneydata).Otherdataisdrawnfromspecificstudies.

Spendingandcosts

Thecostsofhealthandcareservicesarenotwidelyknown.Somecostscanbeavoidedorreducedthroughcost-effectivepublichealthinterventions.

Sources:

Infographics

www.pssru.ac.uk/pdf/uc/uc2010/uc2010_s10.pdfandwww.pssru.ac.uk/project-pages/unit-costs/2013/andwww.gov.uk/government/uploads/system/uploads/attachment_data/file/261154/nhs_reference_costs_2012-13_acc.pdf

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4.3 Thereturnoninvestmentforwalkingandcycling

SinceTheKing’sFund-LGAinfographicswenttopress,theDepartmentofTransportpublishedalargereviewoftheeconomicsofcyclingandwalking(inNovember2014).

Cycling

Arangeofsummaryinformationonthereturnoninvestmentofcyclingisavailableintheabovereport–withbreakdownsofthereturns.Themostsignificantisthemonetaryvaluationofthehealthgains.ExamplesaregiveninTable4.3.1below,butthereareothersinthereport–thisrequiresDirectorsofPublicHealthtoassessthatwhichismostrelevanttothem.

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Table4.3.1

Annualvaluesattributedtoeachadditionalcyclist,cyclingregularlyforoneyear(assumes50percentofcycletripsreplaceacartrip)

Benefits(annualforeachadditionalcyclist)

Urban Rural

On-road Percentage(on-road)

Off-road On-road Off-road

Valueoflossoflife £408.67 68% £408.67 £408.67 £408.67

NHSsavings £28.30 4.7% £28.30 £28.30 £28.30

Productivitygains £47.69 7.9% £47.69 £47.69 £47.69

Pollution £34.57 5.7% £34.57 £6.49 £6.49

Congestion £68.34 11% £68.34 £34.42 £34.32

Ambience £13.20 2.2% £53.60 £13.20 £53.69

TOTAL £601.06 100% £641.46 £538.66 £479.06

Walking

ArangeofsummaryinformationonthereturnoninvestmentforwalkingisavailableintheaboveDepartmentofTransportreview.MorerecentlyNICEhasdevelopedtoolsonhowlocalareascanmodelthereturnoninvestmentforinterventions–includingwalking–toincreasephysicalactivity.Thisincludespre-populateddataforlocalauthorities.AnexampleoftheoutputforCroydonisgivenbelowinTable4.3.2.

RunningtheNICEmodelforCroydondeliversthefollowingresults,basedonacommunitywalkinginterventionthatreaches2.5percentofadults.Givenpre-populateddataonpopulationlevels,effectivenessandcostsfortheinterventiongivesatotalcostof£345,000whichdeliversthefollowingbenefitsovertime:

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Table4.3.2

Returnoninvestmentforacommunitywalkinginterventionthatreaches2.5percentofCroydon’sadults

2years 5years 10years Lifetime

Healthgains

QALYs 31 31 32 35

SocietalperspectiveBCR

Benefit-costratio(includingallcostsavingsandthevalueofhealthgains)

3.39 5.61 8.84 9.07

Benefit-costratio(includingallcostsavings)

1.61 3.82 7.01 7.05

HealthcareperspectiveBCR

Benefit-costratio(includinghealthcarecostsavingsandthevalueofhealthgains)

1.78 1.80 1.85 2.08

Benefit-costratio(includingonlyhealthcarecostsavings)

0.00 0.01 0.02 0.06

Othersectorsperspective

Benefit-costratio(includingonlyproductivitygains)

1.16 2.75 5.05 5.05

Benefit-costratio(includingonlysocialcarecostsavings)

0.00 0.00 0.00 0.00

Benefit-costratio(includingonlytransportbenefits)

0.45 1.06 1.94 1.94

TheNICEtoolincludesfiguresforothercalculationsincludingnetpresentvalue.Italsoincludesmultipleinterventionsforcyclingandwalkingforbothchildrenandadults,whichcanbeanalysedincombination–andforeachborough.

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Returnoninvestment–transport

Thecoststosocietyoftransport-inducedpoorairquality,ill-healthandroadaccidentsexceed£40billionperyear.Thebenefitsofayear’scyclinginanurbanareaarewortharound£600peryear,ofwhichabout70percentisfromadditionalqualityoflifeandtheremaindersavedcoststotheNHS,pollution,congestionandimprovedproductivity.Communitywalkinggroupshavebeenestimatedtoreturnover£3forevery£1investedover2yearsinplaceslikeCroydon.Mostofthesereturnsarebasedonimprovedqualityoflifeandproductivity.

Sources:

Infographic

http://webarchive.nationalarchives.gov.uk/+/http:/www.cabinetoffice.gov.uk/media/308292/urbantransportanalysis.pdfandwww.erpho.org.uk/viewResource.aspx?id=21632andwww.apho.org.uk/resource/item.aspx?RID=91553

Table4.3.1

www.gov.uk/government/uploads/system/uploads/attachment_data/file/371096/claiming_the_health_dividend.pdf

Table4.3.2

TheKing’sFundanalysisofwww.nice.org.uk/about/what-we-do/into-practice/return-on-investment-tools/physical-activity-return-on-investment-toolandwww.nice.org.uk/Media/Default/About/what-we-do/Into-practice/Return-on-Investment/NICE-return-on-investment-physical-activity-technical-report.pdf

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4.4 Thebreakdownofcostsrelatedtounintendedpregnancies

Thisinformationcamefromwww.teenagepregancyassociates.co.uk.Thatlinkisnowbrokenandtheanalysisisnotavailable.

Severalalternativesourcesexistontheallocationoftheoverallcostsofteenagepregnancy,althoughmostarebasedonUSdata.

Forexample,theNationalCampaigntoPreventTeenandUnplannedPregnancyestimatedthefollowingfor2010,showninTable4.4.1.Thisisbasedonestimatedcostsforteenbirths(undertheageof20)andforthefollowing14years.

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Table4.4.1

TeenagepregnancycoststodifferentsectorsintheUnitedStates,2010

US,2010 Percentage

Numberofpregnancies 372,000 -

Averageannualcostforfirst15yearsoflife $1,682 -

Totalcosttotaxpayersin2010(toage15) $9.4billion -

Totalcostsassociatedwithteenmothers $7.2billion

Ofwhichpublicsectorhealthcare $2.1billion 29%

Ofwhichchildwelfare $3.1billion 43%

Ofwhichincarceration $2billion 28%

ClearlythesecostsarenotdirectlytranslatabletoEnglandortheboroughs.However,thebreakdownofcostsmaybeindicativeofwherecostsfallinthesystem.

Morerecently,researchhasbeenpublishedbyDevelopmentEconomicsforBrook(sexualhealthadviceandservices)andtheFPA(sexualhealthcharity),onthefinancialandeconomicimpactsofunintendedpregancyatallages.ThisincludeseconomicestimatesoftheNHScosts,widerpublicsectorcostsandpotentiallossofearningsandtaxreceiptsassociatedwithunintendedpregancyandsexuallytransmittedinfections.

Thefollowingcosts(Table4.4.2)assumetrendratesinunintendedpregnanciescontinuebasedonabaselineestimateof450,000unintendedpregancies(acrossallageranges)intheUnitedKingdomin2011.Thecostestimatesareforcumulativecostsbetween2013and2020,althoughbreakdownsbyyearareavailable.Further,differentscenariosareavailableontheevolutionofunintendedpregnancy.

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Table4.4.2

EstimatedcostsofunintendedpregnanciesintheUnitedKingdom,cumulated2013–2020

NHScosts

Socialwelfarespending Personalsocialservices Education Childhealthcare

Min Max Mean Min Max Mean

2013-2020cumulative

£5,294million

£52,347million

£66,995million

£59,671 £5,764million

£23,651million

£14,705 £8,717million

£2,264million

Percentage* 5.8% - - 66% - - 16% 9.6% 2.5%

*Assumesmeancostsforsocialwelfarespendingandpersonalsocialservicesspending.

Themostinformativewaytolookatthisistheratios,therelativecostsofunintendedpregancytodifferentbudgets,ratherthantheabsolutenumbers.

Thesecouldbebrokendownperunintendedpregnancy(bydividingby450,000)orpresentedonanannualbasis.

Returnoninvestment–unintendedpregnancies

Thereareestimatedtobearound450,000unintendedpregnanciesperyearintheUnitedKingdom,acrossallage-ranges.Thesehavebeensuggestedtobeassociatedwitharound£90billionofcostsover7yearsthatotherwisewouldn’thavebeenincurred,ofwhicharound6percentfallontheNHS,16percentonpersonalsocialservices,10percentoneducationand2.5percentonchildcare.However,aroundtwo-thirdsofthesecostsarelikelytobesocialwelfarecosts.

Sources:

Infographic

http://teenagepregnancyassociates.co.uk/tpa-evidence.pdfAssetoutabovethislinkisnowbroken.

Table4.4.1

https://thenationalcampaign.org/resource/counting-it-key-data-2013

Table4.4.2

Derivedfromwww.fpa.org.uk/sites/default/files/unprotected-nation-sexual-health-full-report.pdf

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4.5 Breakdownofreturnsfromaschool-basedsmokingpreventionintervention

TheinformationabovederivesfromaCanadianstudytranslatedintotheEnglishsituation.Thepotentialsavingspercentages,setoutinTable4.5.1,arederivedfromthesource.Theannualsavingsarebasedonaschool-basedsmokingpreventionprogrammeofmodestsuccess.

Theseestimatesareconservativeandexcludedisease-relatedcostsfromenvironmentaltobaccosmoke,propertydamagecosts,thecostofcreatingseparatelyventilatedpublicsmokingareas,increasedlifeinsurancecostsforsmokers,thecostofdeathsbeforeage45andworklostduringsmokingbreaksawayfromtheworkplace.

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Table4.5.1

Breakdownofreturnsintermsofannualsavingsofaschool-basedsmokingpreventionprogramme,Canada

Annualsavings(Canada,1996)

Percentage

Directcosts

Primarycare CAN$4 0.37%

Hospitalvisits CAN$91 8.3%

Medication CAN$2 0.18%

Indirectcosts

Sickdays CAN$543 50%

Earlydeath CAN$454 41%

TOTAL CAN$1,094

Returnoninvestment–school-basedinterventions

School-basedpublichealthinterventionscanbegoodinvestments.Forexample,smokingpreventionprogrammesinschoolscanreturnasmuchas£15forevery£1spent.Mostofthesereturnsareinreducedsickdaysandproductivitylossesandthevalueofpreventingearlydeaths,althoughtherearealsosomesavingsinhospitalvisits,primarycareandmedication.

Sources:

InfographicandTable4.5.1(derivedfrom)

www.ncbi.nlm.nih.gov/pubmed/11007656

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4.6 Breakdownofreturnsfromconductdisorderprevention

ThisdatacomesfromaLondonSchoolofEconomicsstudyontheeconomicsofmentalhealthpromotionandprevention.

Themediancostofan8–12weekgroup-basedparentingprogrammeisestimatedat£952perfamily,whilethatofindividualinterventionsis£2,078.Assuming80percentofpeoplereceivegroup-basedinterventionsand20percentreceiveindividualinterventions,inlinewithNICEguidance,theaveragecostoftheinterventionworksoutat£1,177perfamily.Animportantingredientofsuccessinthedesignandimplementationoftheseprogrammesismaximisingtheengagementof‘at-risk’families,asthereisevidencethatsomeservicessufferfromlowratesoftake-upandhighratesofdrop-out.

Table4.6.1setsoutthebreakdownofreturns.

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Table4.6.1

Grosspay-offsperchildfromparentinginterventionsatage5withconductdisorder(2008/09prices)

Age6 Age7-15 Age17+ Total Percentage

NHS -£168 -£912 -£917 -£1,278 13.7%

Socialservices -£24 -£29 -£14 -£67 0.7%

Education -£132 -£304 £0 -£437 4.7%

Criminaljustice

£0 £-1,247 -£340 -£1,588 17.1%

Publicsectortotal

-£324 -£2,493 -£551 -£3,368 36.2%

Voluntarysector

-£3 -£6 -£5 -£15 0.2%

Victimcosts(crime)

£0 -£3,361 -£810 -£4,171 44.9%

Lostoutput(crime)

£0 -£995 -£232 -£1,227 13.2%

Othercrimecosts

£0 -£377 -3129 -£506 5.4%

Othersectortotal

-£3 -£4,740 -£1,176 -£5,919 63.7%

TOTAL £-328 -£7,223 -£1,727 -£9,288 100%

Table4.6.1showsthattotalgrosssavingsover25yearsamountto£9,288perchildandthusexceedtheaveragecostoftheinterventionbyafactorofaround8to1.Savingstothepublicsectorcometo£3,368perchild,including£1,278accruingtotheNHS.Undertheassumptionsmade,theinterventionwillprovideapositivereturntothepublicsectorinyear8,andtotheNHSinyear14,aftertheintervention.Nobenefitsareassumedfromarangeofotherpotentialwiderimpactssuchasimprovedemploymentprospects,reducedadultmentalhealthissues,andimprovedoutcomesforthechild’sfamilyandpeers;thesearelikelytobesubstantial,makingtheinterventionanevenbetterinvestment.

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Therearesimilarfiguresandanalysisthatcouldbepresentedfromthisstudyforthefollowing:• healthvisitingandreducingpost-nataldepression• school-basedsocialandemotionallearningprogrammestopreventconductproblemsin

childhood• school-basedinterventionstoreducebullying• earlydetectionforpsychosis• earlyinterventionforpsychosis• screeningandbriefinterventioninprimarycareforalcoholmisuse• workplacescreeningfordepressionandanxietydisorders• promotingwellbeingintheworkplace• debtandmentalhealth• population-levelsuicideawarenesstrainingandintervention• bridgesafetymeasuresforsuicideprevention• collaborativecarefordepressioninindividualswithtypeIIdiabetes• tacklingmedicallyunexplainedsymptoms• befriendingofolderadults(seesection4.10).

Returnoninvestment–parentingprogrammes

Parentingprogrammestopreventconductdisorderpayback£8oversixyearsforevery£1invested.Themajorityofthesereturnsareinreductionsincrimeanditsconsequencestothevictimandsociety,althoughalmost15percentareduetoreducedNHScosts.

Sources:

InfographicandTable4.6.1(derivedfrom)www.lse.ac.uk/businessAndConsultancy/LSEEnterprise/pdf/PSSRUfeb2011.pdf

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4.7 Breakdownofreturnsfromlarge-scalecommunityphysicalactivityinterventions

BeActiveisaschemeprovidedfreeofchargetoallBirminghamresidentswholivewithintheBirminghamCityCouncilarea.Theaimoftheschemeistotacklehealthinequalityandassociateddeprivationlevels,byofferingaccesstofreephysicalactivitysessionsforall1.1millioncitizensofthecity.Participantscantakepartinfreeswimming,exerciseclassesorthegymatanyCouncil-runleisurecentreduringoff-peakhours,whichvaryaccordingtoeachcentre,andsomecommunitybasedactivities.

Atthetimeofanalysis,BeActivehad140,000+activeusersperyear.Table4.7.1showsthereturnbreakdownperuser.Theschemecostsanestimated£34peruserperannum.

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Table4.7.1

BenefitsandtheirdistributiontovariousagenciesfromBeActive

Benefitsperuser Total Primarycare

Secondarycare

Localauthority

HMTreasury

Employers

Realisablebenefits £365 £24 £45 £0 £45 £297

Allcostsavings(includingrealisablebenefits)andproductivitygains

£647 £125 £226 £0 £45 £297

QALYsgained £2,713 £977 £1,736 £55 £0 £297

TOTAL £3,361 £1,103 £1,961 £55 £45 £297

Percentage 100% 32.8% 58.3% 1.6% 1.4% 8.8%

TheeconomicevaluationaccruesthevastmajorityofthegainstotheNHS,throughthehealthbenefitstotheusers.Box4.6.1showstheoveralleconomicevaluationsummaryforBeActive

Box4.7.1

SummaryofeconomicevaluationofBeActive

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Returnoninvestment–leisureservices

Freeaccesstocouncilleisureservicesatoff-peaktimeshasbeenestimatedtoreturn£23forevery£1invested.Themajorityofthesegainsareduetoqualityoflifegainsamongresidents.

Source:

Infographic,Table4.7.1(derivedfrom)andBox4.7.1derivedfromwww.optimitymatrix.com/wp-content/uploads/2013/09/28-Matrix_Be-Active_Final-report.pdf(theweblinkhaschangedsincethisinfographicwasproduced,althoughthesourceisthesame).

4.8 Breakdownofreturnoninvestmentforhousingimprovement

ThisinfographicderivesfromareviewoftheeconomicimpactofimprovinghousingbytheHousingLearningandImprovementNetwork(LIN)and,withinthat,aspecificstudyfromtheCharteredInstituteofHousing,whichthenreferredbacktoastudybytheBuildingResearchEstablishment(BRE).

Box4.8.1showsasummaryfromtheCharteredInstituteofHousing.

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Box4.8.1

CharteredInstituteofHousingsummaryofBREworkontheeconomicsofhousingimprovement

TheHousingLINpieceincludesmultipleexamplesofeconomicreturnstohousinginterventionandcitesmultiplesources.AlargenumberofstatisticsonreturnsoninvestmentareavailablefromtheHousingLIN.

TheBuildingResearchEstablishmenthasproducedasummaryhealthimpactassessment(HIA)oftheimpactofhomeimprovementin32homesinDerbyshire.DerbyCityCouncilhasfacilitatedhousingimprovementsinBrindleyCourt,oneofthepoorerprivatesectorhousingblocksofflatsinDerby.ThequantitativeHIAcalculatesthesavingstotheNHSandthewidersociety.

AsummaryofthisispresentedinTable4.8.1.

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Table4.8.1

AveragecostofworksbyhazardwithestimatedannualcostbenefitandmeanpaybackperiodtoNHSandsociety,DerbyshireHIAofhomeimprovementsto32homes.

Hazard Meancosttorepair

MeanNHSsavings

MeanpaybackperiodtoNHS

Meansavingstosociety

Meanpaybacktosociety

Dampandmould

£221 £68 8 £170 3

Excesscold £1,249 £706 15 £1,764 6Intruderentry £500 £27 19 £68 8Domestichygieneandpests

£97 £1 97 £1 39

Foodsafety £145 £1 17 £1 7Personalhygieneandsanitation

£165 £111 1 £278 1

Fallingonlevelsurfaces

£110 £166 1 £415 0

Fallingonstairs

£100 £13 8 £33 3

Fallingbetweenlevels

£642 £40 27 £101 11

Electricalsafety

£246 £13 123 £31 49

Fire £176 £22 19 £56 8Hotsurfaces £55 £3 18 £8 7Structuralcollapse

£116 £4 29 £10 12

ThisanalysiswasundertakenwiththeBRE’sHousingHealthCostCalculator(HHCC)whichisavailablehere,www.bre.co.uk/page.jsp?id=3021

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Returnoninvestment–housing

Housinginterventionstokeeppeoplewarm,safeandfreefromcoldanddampareanefficientuseofresources.Every£1spentimprovinghomestoreduceseriousfalls,excesscoldandovercrowdingreturns£70,£34andmorethan£6respectivelytotheNHSinreduceddemandanduseover10years.

Sources:

Infographic

www.housinglin.org.uk/_library/Resources/Housing/Support_materials/Viewpoints/Viewpoint_21_Prevention_and_Early_intervention.pdf

Box4.8.2

www.insidehousing.co.uk/analysis/in-depth/house-proud-health/6508221.article

Table4.8.1

www.bre.co.uk/filelibrary/pdf/casestudies/Derby_retro_Final_report.pdf

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4.9 Breakdownofthereturnoninvestmentforreducingworklessness

ThestatisticonthecosttotheeconomyofillhealthandworklessnessisfromDameCarolBlack'sreviewofthehealthofBritain'sworkingagepopulation.MoredetailsofwherethesecostsfallareinTable4.9.1

ThereturnoninvestmentstatisticsarefromBusinessintheCommunity,detailedresultsareonlyavailabletomembers.

However,othersimilarstudiesexistandTable4.9.2outlinestheresultsofastudybytheOctaviaFoundation.

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Table4.9.1

Thecostsofworkingageill-healthtotheUKeconomy(2007)

Breakdownofthecostofworkingageill-healthtotheUKeconomy

2007(£billion)

Worklessness–benefits 29

Healthcare 5-11

Foregonetaxes 28–36

TOTALGOVERNMENT 62–76

Worklessness–lostproduction

63

Sicknessabsence 10

Informalcare 25–45

Healthcare 5–11

TOTALECONOMY 103–129

TheOctaviaFoundation’semploymentandtrainingprogrammewaspartofawiderprojectinvolvingotherprovidersinWestminster.TheprogrammewasopentoallWestminsterresidentsofadultworkingage,whowereunemployed(orworkingforlessthan16hoursaweek)andnotinfull-timeeducation.MostreferralscamefromstaffincommunityorganisationsincludingtheHarrowRoadPartnership,KensingtonVolunteerCentre,andhousingassociations.Atotalof188peopleenrolledfortheOctaviaFoundationprogramme,36ofwhomwerehelpedintowork.Afewself-referralswerealsoreceived.TheinterventionissetoutinBox4.9.1.

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Box4.9.1

TheinterventionoftheOctaviaFoundationprogrammeonreducingworklessness

AsocialreturnoninvestmentanalysiswasundertakenusingtheNewEconomicsFoundationprinciplesandbasedonthemethodsofBusinessinTheCommunity.Theoverallcostoftheprogrammewas£96,931whichgeneratesasocialreturnof£399,357over5years,aratioof4.12to1.

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Table4.9.2

BreakdownofreturnstoOctaviaFoundationprogrammeonreducingworklessness

Yr Noinwork

Benefitssaved(JSA&HB)

Part-timework17%(-)

Incometax&NI16%(+)

Healthbenefit

Dropoff50%frompreviousyr

Deadweight15%discount

Attribution20%discount

Netimpact

1 14 £121,023 £20,574 £16,072 £7,112 - £18,545 £24,726 £80,361

2 14 £126,162 £21,448 £16,754 £7,112 £40,181 £19,287 £25716 £123,758

3 8 £75,171 £12,779 £9,983 £4,064 £61,879 £11,466 £15,288 £111,564

4 - - - - - £55,782 - - £55,782

5 - - - - - £27,891 - - £27,891

TOTAL £399,357

Returnoninvestment–helpingpeoplebacktowork

Worklessnesscoststheeconomymorethan£100billioneveryyear,includingupto£11billiontotheNHS,upto£45billionininformalcareand£10billioninsicknessabsence.Programmesgettinglong-terminactivepeoplebacktoworkhavebeenshowntohavereturnsworthover£4forevery£1spent.Thesegainsincludethereductioninbenefitpayments,andthehealthimprovementsforthosehelped.

Sources:

InfographicandTable4.9.1

www.gov.uk/government/publications/working-for-a-healthier-tomorrow-work-and-health-in-britainandwww.bitc.org.uk/our-resources/report/social-return-investment-ready-work

Box4.9.1andTable4.9.2

www.octaviafoundation.org.uk/assets/0000/1500/SROI_Report_Guardian_Version.pdf

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4.10 Breakdownofreturnoninvestmentforbefriendingprogrammes

ThisdatacomesfromaLondonSchoolofEconomicsstudyontheeconomicsofmentalhealthpromotionandprevention.

Themodellookedatthecost-effectivenessofbefriendinginterventionsintermsoftheeducationindepressivesymptomsandtheconsequentdeclineintheuseofhealthservicesbytherecipientoftheintervention.Theinterventionisassumedtobetargetedatlonelyandisolatedindividualsagedover50.Theanalysisincludedcosts/savingsassociatedwiththeuseofmentalhealthservices,primarycare,hospitalservicesandmedication;homehelps,butnoothersocialcareservices,wereincluded.Themodeldidnotfactorinanybenefitstothebefriender.

Theanalysissuggestedthatthecostofbefriendingservicesofanhourperweekorfortnightwouldbe£85perannum,reducingNHScostsbyaround£40inyearonethroughthereductionoftreatmentfordepressivesymptoms.Iftheanalysisincludesthequalityoflifebenefitsassociatedwithreduceddepressivesymptoms,thenbefriendingschemeshavethepotentialtocreatefurtherimprovementsworth£270perperson,anoverallreturnof£3.65forevery£1invested.

Theauthorsconcludethatbefriendinginterventions–fortheisolatedolderpeople–arethereforeunlikelytoachievecostsavingstothepublicpurse,buttheydoimproveanindividual’squalityoflifeatalowcost.

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Returnoninvestment–befriending

Socialsupportplaysanimportantroleinincreasingresiliencetoillness,helpingrecoveryandimprovingwellbeing.BefriendingcanreduceNHScostsforthosesupportedbyaround£40perannumbut,moreimportantly,improvequalityoflifeassociatedwithreduceddepressivesymptomswortharound£270perperson.Befriendinginterventionsreturnmorethan£3invalueforevery£1spentand,whileunlikelytoachieveoverallsavingsforthepublicpurse,doimprovequalityoflifeatlowcost.

Sources:

Infographic

www.lse.ac.uk/businessAndConsultancy/LSEEnterprise/pdf/PSSRUfeb2011.pdf

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4.11 Breakdownofreturnoninvestmentformotivationalinterviewingforalcoholanddrugaddiction

TheimmediatesourceforthisinfographicisanAlcoholConcernpublicationontheoveralllearningfromitsresearchactivities,thisthenreferstoaDepartmentofHealthpublication,nowintheNationalArchives,whichreferstotheprimarysource,theUnitedKingdomAlcoholTreatmentTrial.

Theinterventioncomparedtheimpactofsocialbehaviourandnetworktherapy,anewtreatmentforalcoholproblems,withthatofmotivationalenhancementtherapy.Bothareformsofmotivationalsupport.

TheinterventiontookplaceinseventreatmentsitesaroundBirmingham,CardiffandLeedsandcovered742clientswithalcoholproblems.Economicdatawerecollectedonquality-adjustedlifeyears(QALYs),costsoftrialtreatments,andconsequencesforpublicsectorresources(healthcare,otheralcoholtreatment,socialservices,andcriminaljusticeservices).

Table4.11.1outlinesthedistributionofthereturnoninvestmentoverayearbasedoncostsbeforeandaftertreatment.Inpracticetheresultsaresimilarforbothmethods,sowepresentonlythemotivationalenhancementtherapyhere;fulldetailsareavailableinthereference.

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Table4.11.1

Costsofpublicsectorresourcesat2000/01prices,relatedtoalcoholproblemsincohortof347patients(whoreceivedmotivationalenhancementtherapy).Costpermemberofcohort.

Sector Costdifferencebetweensixmonthsbeforerandomisationandsixmonthsbeforefollow-up

Percentageofcostreduction

Healthcare -£221 31%

Criminaljustice -£168 23%

Otheralcoholtreatment -£316 44%

Socialcare -£16 2%

TOTAL -£722 100%

Costofspecialistalcoholtreatmentinthetrial

£129 -

Ratioofcostreductiontocostsoftreatment

£5.6to£1 -

Returnoninvestment–alcoholmotivationalsupport

Every£1spentonmotivationalinterviewinganddevelopingsupportivenetworksforpeoplewithalcoholaddictionreturnsmorethan£5forevery£1spenttothepublicpurse.Around30percentofthesereturnscomefromreductioninNHSdemand,25percentfromreductionsincriminaljusticecosts,and45percentfromreductionsinotheralcoholtreatment.Therearealsosmallreductionsinsocialcarecosts.

Sources:

InfographicsTheweblinkhaschanged,althoughthesourceremainsthesamehttps://www.alcoholconcern.org.uk/help-and-advice/publications/page/3/Table4.11.1(derivedfromTable3inthefollowing)http://nrl.northumbria.ac.uk/3009/1/heather_Cost%20effectiveness%20of%20treatment%20for%20alcohol%20problems.pdf

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4.12 Breakdownofreturnoninvestmentfordrugtreatment

ThisinfographicderivesfromtheNationalTreatmentAgency,theprimarysourceofwhichistheDrugTreatmentandOutcomesTrial(DTOR).Therearecomplexanalysesinthetrial.Table4.12.1isasummaryofthebreakdownofthereturnscomprisingthe2.5:1overallreturnintheinfographic.

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Table4.12.1

Costs,savingsandvalueofQALYsgainedfromstructureddrugtreatmentover51weeks,2006/07,in£s

Sector Cost Percentage

Costofstructureddrugtreatment

£4,531 -

Savingsinhealthandsocialcare

£1,686 14%

Savingsinreportedoffences £10,145 85%

ValueofQALYsgained* £125 1%

Totalbenefits £11,956 100%

Benefit-costratio 2.64 -

*Basedon0.05QALYsvaluedat£25,000perQALY

Returnoninvestment–drugtreatment

Every£1spentondrugstreatmentsavessocietymorethan£2.50.Almost15percentofthesesavingsareduetoreductionsinhealthandsocialcarecostswhereas85percentareduetoreductionsinoffending.

Sources:

Infographics

www.nta.nhs.uk/uploads/vfm-crimepresentationvfinal.pdf

Table4.12.1

Derivedfromwww.dtors.org.uk/Content/PDF/DTORS_CostEffect_Main.pdf

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5 Returnoninvestment:furtherexamples

Theanalysisoftheboroughs’healthandwellbeingboardprioritiesshowedsignificantdifferencesacrosstheboroughs(seeannex).Wethereforepresentthreemorereturnoninvestmentanalysesfromaselectionofthosepriorities.

5.1 Earlyyears

Place2Beisaprogrammeaimedatimprovingtheemotionalhealthofchildreninschools.ThefocusofthisstudyisonthePlace2Be’sindividualandgroupcounsellingasmorerobustoutcomemeasuresareavailablefortheseinterventions.

Resultsfromtheprogrammesuggestthatwithoutit50percentofthesechildren’smentaldisordersandproblemswouldhavecontinuedthroughoutchildhoodand50percentwouldhavepersistedintoadulthoodandcontinuedovertheindividual’slifetime.

AtthetimeoftheanalysistherewerePlace2Beteamsbasedin172primaryandsecondaryschoolsacrosstheUnitedKingdom,supporting58,000childrenuptotheageof13,ofteninareasofgreatdeprivation.Serviceswereavailabletochildrencopingwitharangeofcomplexproblemssuchasbereavement,familybreakdown,alcoholanddrugmisuse,domesticviolence,physicalandemotionalabuse,traumaandbullying.

Overall,intheyearofthisanalysis,2,344childrenreceivedsupportatatotalcostof£2million.Thereturnsarebasedonmodelledimprovementinmentalhealthandtheirconsequencesovertime.TheoveralltrajectoryisgiveninBox5.1.1.

Box5.1.1

Breakevenpointandannualnetcost-savingofPlace2Beovertime,2007/8prices

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Box5.1.2showshowthebenefitovertimebreaksdown.Thetotalbenefitisestimatedat£15.1million,areturnof£7.50forevery£1spent.Ofthisreturnthelargemajority(58percent)isintermsofthehealthbenefitsthataccruetotheindividual.NHSandsocialcaresave,around£370,000,benefitpaymentsarereducedbyarounddoublethisamount.

Box5.1.2

ThereturnsofPlace2Beovertime

Returnoninvestment–improvingmentalhealthresilience

Interventionstoimprovementalhealthandresilienceinschoolscanreturnmorethan£7forevery£1spentovertime,withmostofthisgainintermsofimprovedhealth,followedbyincreasedproductivityandreductionsinNHSandsocialcareuse.

Sources:

Box5.1.1andBox5.1.2www.place2be.org.uk/media/1845/Cost%20Effective%20Positive%20Outcomes%20for%20Children%20and%20Families.pdf

5.2 Alcohol–returnoninvestmentforbriefintervention

TheinformationbelowisderivedfromastudybytheLondonSchoolofEconomics.

Interventionisbasedonbriefinterventionsinprimarycaresettingswhichcanreducealcoholconsumptionbyabout12percentperindividual,achievedthroughuniversalscreeningbyGPsfollowedbya5-minuteadvicesessionforthosewhoscreenpositiveforharmfuldrinking.Table5.2.1below,thereturnsarebasedonusingtheAlcoholUseDisordersIdentificationTest(AUDIT)which,foracohortof1,000patients,costs£17.41perhead.

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Table5.2.1setsoutthereturnoninvestmenttobriefinterventionduringGPconsultation.

Table5.2.1

Costs/pay-offsperheadforscreeningandbriefadvicewhilstattendingGPconsultation(2009/10prices)

Year1 Years2-5 Years6-7 Total Percentageoftotal

NHS -£10.55 -£24.61 -£3.91 -£39.07 19%

Crime -£28.49 -£66.02 -£10.49 -£105.00 51%

Productivitylosses

-£16.20 -£38.24 -£6.05 -£60.48 30%

Total -£55.23 -£128.87 -£20.45 -£204.55 100%

Giventheoverallcostperheadof£17.41,thetotalreturnsaremorethan£3to£1inyearone,risingtomorethan£11to£1over7years.Around20percentofthesereturnsflowtotheNHS,50percenttocrimereductionandtheremaindertoreductionsinproductivitylosses.

Returnoninvestment–briefinterventionsinharmfuldrinking

Simpleinterventionswithharmfuldrinkersinprimarycarearelikelytopayback£3forevery£1inyear1,risingtomorethan£11inthenextsevenyears.Ofthisreturn,20percentwillbeinreducedNHScosts,withtheremainderbeingreductionsinthecostofcrimeandproductivitylosses.

Sources:

Table5.2.1

www.lse.ac.uk/businessAndConsultancy/LSEEnterprise/pdf/PSSRUfeb2011.pdf

5.3 20mphspeedzones

Trafficcalmingandspeedlimitsaremajorpublichealthstrategiesforfurtherreducingroadinjuries,especiallyforvulnerablepedestrianssuchaschildrenandolderpeople.Acost-benefitanalysishasrecentlybeenconductedonmandatoryzonesinlocalareas.

Theanalysistookintoaccountmedicalcostssaved,thevalueofhumanlifesavedandthevalueoflostoutputsaved.

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InterventioncostsweretakendirectlyfromstudiesinLondonfor47percentofthe399mandatory20mphzonesthatwereconstructedinLondonasof2007/08.Inlow-casualtyareas(mean,0.62casualtiesperkmofroadperyear)averagecostswere£75,100;inhigh-casualtyareas(mean,1.6casualtiesperkmperyear)averagecostswere£75,800.

Theresultssuggestthat,inlow-casualtyareas,trafficcalmingschemesdonotcovertheircostsintermsofreturns.Intheseareas,thenetreturnintermsofthecostsofreducedcasualtieswas£49,700.Inhigh-casualtyareasitwas£166,400,anoverallreturnof£2.20forevery£1spent;thereturnsflowovertimewithmorethanathird,36percent,accruinginthefirstyear.

ThebreakdownofthesereturnswillbesimilartothatinTable5.3.1,whichisderivedfromtheworkfortheDepartmentofTransportabove.

Table5.3.1

DepartmentofTransportassessmentofthecostofroadaccidentcasualties,2012

Casualty-related Accident-related

Lostoutput

Medicalandambulance

Humancosts

Policecosts

Insuranceandadmin

Damagetoproperty

Total

Fatal £1,040million

£9million £2,042million

£29million

£1million £19million

£3,139million

Serious £526million

£315million

£3,582million

£44million

£4million £108million

£4,578million

Slight £389million

£165million

£1,854million

£67million

£15million

£318million

£2,871million

All £1,995million

£490million

£7,478million

£139million

£19million

£508million

£10,589million

Damageonlyaccidents

- - - £77million

£124million

£4,332million

£4,533million

All £1,995million

£490million

£7,478million

£217million

£143million

£4,840million

£15,122million

Percentageofall

13% 3.2% 49% 1.4% 0.9% 32% 100%

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Returnoninvestment–20mphzones

20mphzonesinhighroadtrafficareashavethepotentialtoreturnover£2invalueforevery£1spentandoverathirdofthisreturnislikelytoaccrueinthefirstyear.Aroundhalfofthereturnisinthepreventionofdeathandtrauma,followedbyreductionsindamagetopropertyandlostproductivityandmedicalandpolicecosts.

Sources:

Returnoninvestmentcalculation

http://jpubhealth.oxfordjournals.org/content/35/1/40.full.pdf+html

Table5.3.1,derivedfromwww.gov.uk/government/uploads/system/uploads/attachment_data/file/254720/rrcgb-valuation-methodology.pdf

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6 Commentaryonfindingsandsomerecommendations

Whentheinitialreport(sections2,3,4and5)wasfirstreceived,itgeneratedconsiderablediscussionandraisedanumberofquestionsaboutapproachandmethodologiesandparticularlyabouttheapparentpaucityofmaterialonreturnoninvestmenttosocialcare.Thissectionexplorestheseissuesfurther.

6.1 Commentary

Thebreakdownsoffindingsincludeavariedarrayofspecificationsof‘returnoninvestment’.Box6.1.1stylisticallysummarisesthisarrayofdifferentmethodologies.First,itisimportanttosaythereisno‘correct’waytoidentifyandreportonreturnoninvestment.Manychoicesarepossible,whatisimportantisthatthereisexplicitnessaboutwhatisincluded,andwhatisnot.

Box6.1.1

Choicesinestimatingreturnoninvestmenttopublichealth

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Table6.1.1

Breakdownandinclusionofsocialcareinpublichealthreturnoninvestment(ROI)topics

Section Topic* SummaryROI Breakdown Socialcare

4.1 Sexualhealthspending n.a. n.a. n.a.

4.2 Costsofhealthservices n.a. n.a. n.a.

4.3 ROIcycling&walking

Cycling Valueofeachadditionalcyclistfor1yr=£600 68%valueofhealth;4.7%NHSsavings;8%productivity;6%pollution;11%congestion;2%ambience.

Notincluded

Walking 3:1(yr1)to9:1(lifetime)forcommunitywalkinggroups 9:1(allcostssavings+valueofhealth)

7:1(allcostsavings)

5:1(productivitygains)

0.06:1(healthcarecostsavings)

Notincluded

3.4 ROIunintendedpregnancy CumulatedUK7yearcostsof1year’sunintendedpregnancy=£90billion

NHScosts5.8%;socialwelfarespending;16%personalsocialservices;education10%;childhealthcare2.5%

16%ofoverallcosts(≈£14.7billion)plusgiventransferofresponsibilitiesapartof2.5%(≈£2.2billion)

4.5 ROIschool-basedsmokingcessation

Annualsavingsofmoderatelyeffectiveprogramme15:1 Primarycare0.5%;hospitalvisits8%;medication<0.5%;sickdays(productivity)50%;valueofhealth(avoidedearlydeath)41%

Notincluded

4.6 ROIconductdisorderprevention

Parentinginterventionsatage5(over25years)8:1 NHS14%;socialservices≈1%;education5%;criminaljustice17%;volsector<0.5%;victimcosts(crime)45%;lostoutput(crime)13%;othercrimecosts5%

≈1%,£67perchild(intervenedwith)

4.7 ROIlarge-scalephysicalactivityintervention

BeActivescheme,freeanddiscounteduseofleisureservices21:1

Primarycare33%;Secondarycare58%;LA2%;HMT1.5%;employers9%

≈2%(£55perperson)butunclearwhetherthisissolelysocialcare

4.8 ROIhousingimprovement Every£1spentonhousingimprovementtoreducefalls,excesscoldandovercrowding£70;£34and£6totheNHS

PaybacktoNHSand‘widersociety’for13categoriesofhousing Notincluded(explicitly,maybein

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Section Topic* SummaryROI Breakdown Socialcare

over10years hazarde.g.dampandmould,falls,electricalsafety. wider‘paybacktosociety’)

4.9 ROIworklessness 4:1ROIfromworklessnessreductionprogrammes PrimeeffectsthroughNHSandbenefitspaymentssaved,complexanalysismeansspecificbreakdownhard.

Notincluded

4.10 ROIbefriending 3.65:1benefitsoverallforevery£1spent Inc,mentalhealthservices,primarycare,medications,hospitalservicesand‘homehelps’plusqualityoflifebenefits.Latteraccountfor87%ofreturns.

Notincluded(explicitly,maybein‘homehelps’).

4.11 ROImotivationalinterviewingdrugs/alcohol

5:1returnsforevery£1spent 31%healthcare;23%criminaljustice;44%otheralcoholtreatmentavoided;2%socialcare

≈2%socialcare(£16perperson).

4.12 ROIdrugtreatment 2.5:1returnsforevery£1spent 14%healthandsocialcare; 14%(£1,686)butin‘healthandsocialcare’,notunpacked.

5.1 Earlyyearsemotionalsupportinschools

7.5:1overthelifetime(60yearspost-intervention) 58%valueofhealthbenefits;productivity23%l11%healthandsocialcare;benefits5%;education2%;carerburden1%

11%(£1.5billion)in‘healthandsocialcare’,notunpacked.

5.2 Briefinterventionforalcohol

3:1inyearone,risingto11:1over7years. 19%NHS;51%crime;30%productivity Notincluded

5.3 20mphspeedzones Inhighcasualtyarea2.2:1(inlowcasualtyareas<1:1) 13%productivity;3%medicalandambulance’49%valueofhealth/life;1%police;1%insurance;32%propertydamage

Notincluded

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Box6.1.1showsthatthemainchoicesarewhatsectorstoincludeintermsoftheimpactsofpublichealthinvestment.IncludedintheboxarethemaingovernmentsectorsfromTable6.1.1.Insomecases,however,thereturnsaredefineddifferently,forexampleintermsofcategoryof‘harm’suchascongestion,pollutionorpropertydamage(seeTable6.1.1),andinsomecasesthereisamix.Oftenproductivityisincluded(intermsofthevalueoflostoutputtotheeconomy)andinmany‘valueoflife’isimportant,ie,themonetisedvalueofhealthimprovement,usuallytothepersonreceivingthepublichealthintervention.Oftenvalueoflife,whenincluded,isthelargestsinglesourceofreturnoninvestment,soitisimportanttobeawareofwhetherthisisinthefiguresornot.Finally,somestudiesincludereturnsoveraspecificshorttime-period(usuallytheyearinwhichtheinterventiontookplace),butmanyincludelonger-termbenefitsandreturns(andsometimescosts)andcumulatethereturnsoveralongerperiod.

Inafinalstep,abespokecombinationofvariousreturns(oftencombiningactualcostsavingsandamonetisedabstractvalueofhealth)isrelatedtothepublichealthcostofinterventioninastatementsuchas‘thereturnoninvestmentover5yearsis2.5:1’.Sometimes,themetricisdifferent,forexample,‘gettingoneextrapersontocyclereturns£600’.

6.2 Recommendations

Theprocessofunpackingthereturnsshowshowvariedandnon-standardisedtheapproachesaretoreportingonreturnoninvestment.Ontheonehand,moststudiesdoincludevariousmeasuresoftheimpacttotheNHS.ThisisveryusefulandhelpsDirectorsofPublicHealthinconversationswithCCGandlocalauthoritycolleaguesaroundbudgetpooling,budgetsharingandgenerallymakingthecaseforagreatercontributionfromtheNHSforservices,oratleastagreaterrecognitionoftheimpactoflocalauthorityactionsonNHSdemandandcosts.

However,therearesomeissueswiththemethodologiesusedinmanystudiesthatcouldbeaddressed,withtheexplicitsupportandactionofinfluentialagenciessuchasPublicHealthEnglandand,inthelongerterm,theNationalInstituteforHealthResearch(NIHR)andNICE.

Recommendation1:Morestandardisationofinclusionandreportingcriteriaforreturnoninvestmentstudies

Oneoftheobviousissuesisalackofstandardisationofinclusioncriteriaandreportingofreturnoninvestmentstudies.Withoutthis,itmakesitveryhardforDirectorsofPublicHealthtobeabletocompareacrosscompetinginterventionsforfunds.Whiletherewillalwaysbeagoodcaseforstudiesinspecificareastoincludebespokereturns,PublicHealthEngland(withNICEandNIHRintheirownworkandcommissioningofstudies)shoulddevelopstandardisedminimuminclusionandreportingcriteriaforreturnoninvestmentstudies.

Recommendation2:Agreaterexplicitrecognitionandaccountingforthelinksbetweenpublichealthandsocialcare

Oneofthekeyissuesisthelackofinformationontheimpactofpublichealthinterventionsonsocialcare.

Thisisduetoanumberoffactorsincludingthefollowing.

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• Theresearchquestionaddressedinthisreport.Thisisframedaroundunpackingexistingstudiesofpublichealthreturnoninvestmentintotheconstituentpartswhatevertheirsource,ratherthanaskingmorespecificquestionssuchas,‘Q1:Whichpublichealthinterventionshavedemonstratedareturnoninvestmentthroughreducingdemandonsocialcare?’or‘Q2:Whatmodellingwouldberequiredtodemonstratethereturnstopublichealthinterventionintermsofreducedsocialcaredemandandcosts?’.

• Thetypesofpublichealthinterventioninthesetofstudiesassessedinthefindingsdocument.Forexample,itisunlikelythatcyclingorwalkinginterventionswouldhaveadirectimpactonsocialcarecosts(exceptpotentiallyintheverylongterm).

• Exclusionwhensocialcareisclearlyrelevant.Insomecasessocialcarecostshavebeenexcludedwhentheyareclearlyrelevantintermsofacomprehensiveassessmentofreturnoninvestment.Forexample,BRE’stoolonthereturnoninvestmentofhousingimprovementfocussesonNHScosts(seetable6.1.1)ratherthanincludingsocialcare.

• Undercountingofsocialcareimpactwhereassessed.Forexample,socialcareisonlyassessedasaround2percentofthereturnsintermsofmotivationalinterviewingfordrugandalcoholtreatmentand1percentintermsofinterventionforconductdisorder(Table6.1.1).Thelatterinparticularisclearlyanundercounting.

• LackofunpackingbetweenNHSandsocialcareimpact.SomestudiesbundleNHS(orhealthcare)andsocialcarereturnstogether.Anexampleisthereturnoninvestmentofdrugtreatmentandbefriending(Table6.1.1).Thesestudiesshouldreportthemseparately.

• Inclusioninwidercategoriesofreturn.BeyondtheNHS,socialcaremaybeincludedinsomeofthereturnoninvestmentfiguresbutitisunclearduetothewidecategoriesreported.

Thesefactorscouldbeaddressedaspartofguidance(includingformingpartsoftendercriteriaforreturnoninvestmentstudies)issuedunderrecommendation1.

Recommendation3:PublicHealthEnglandshouldincludesocialcarecostsasacore(whererelevant)initsfutureworkonthereturnoninvestmentofpublichealth

Thereis‘evidenceofabsence’intermsofthewidereffectsofpublichealthinterventiononsocialcaredemandandcosts(seetheevidenceforthisinannex1).Thisisreflectedintheanalysisabove,andmorewidely(forexampletheLGA’srecentpublicationonobesityanditsimpactsonsocialcaremakesastrongcaseforimpact,butisunabletoquoteanydirectstudiesthathavequantifiedit.7)

PublicHealthEnglandhasrecentlyadvertisedandsubsequentlyrecruitedfora‘healtheconomicsframework’toselectarangeofconsultancy(andother)organisationstoofferhealtheconomicsandreturnoninvestmentservicesonanongoingbasis.Thisisanidealopportunitytofollowthroughontheaboverecommendationsacrossitsuseofthisframework,andtocommissionaspecificpieceof

7Seewww.local.gov.uk/documents/10180/11463/Social+care+and+obesity+-+a+discussion+paper+-+file+1/3fc07c39-27b4-4534-a81b-93aa6b8426af

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workon‘Q2:Whatmodellingwouldberequiredtodemonstratethereturnstopublichealthinterventionintermsofreducedsocialcaredemandandcosts?’.

6.3 SocialcareAbrief(andunsystematic)searchforrelevanttermsshowshowrarepublishedstudiesarethatdoincludesocialcareintheirreturnoninvestmentinformation.SearchingPubmedindexedtermsfor‘publichealth/economics’and‘socialcarecosts’returnednohits,searchingGoogleScholarfor‘returnoninvestmentpublichealth’(freetext)with‘socialcare’(exactphrase)alsoreturnednohits.Searchingfor‘publichealth’and‘returnoninvestment’and‘socialcare’intheHealthEconomicsEvaluationDatabase(HEED)8returnedthreehits,oneanabstractofaconferencepaper,oneaQALYgovernmentreviewofthecost–benefitanalysisofdrugtreatmentservicesandthefinalhitareviewoftheeconomicsofearlyintervention(Box6.3.1).

Box6.3.1

Theeconomicsofearlyeducation–abstract

AbroadersearchinGoogleScholarwith‘returnoninvestmentpublichealthsocialcare’(freetext)returnedthousandsofhits,butwithverylittleprecision.Onerelevantstudy(NICE’sconceptualreportassessingmethodsforeconomicevaluationofpublichealth9)didrefertoareviewundertakenbyMatrixofperspectiveadoptedandcostsincludedineconomicevaluationsofpublic8http://onlinelibrary.wiley.com/book/10.1002/9780470510933?9www.nice.org.uk/media/default/About/what-we-do/NICE-guidance/NICE-guidelines/Public-health-guidelines/Additional-publications/Cost-impact-proof-of-concept.pdf

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healthinterventions,10whichinreturnreferstothesource11–researchforthePublicHealthResearchConsortiumofthechallengesofapplyingstandardeconomicevaluationmethodologytopublichealth.Thisincludedareviewofeconomicevaluationstudiesinpublichealthandtheperspectivesincluded.AsummaryofthisissetoutinTable6.3.1showingthat,outof154includedstudies,allincludedhealthcarecostsbutonlysixstudiesincludedsocialcare(4percent).

Table6.3.1

Perspectivesadoptedandcostsincludedineconomicevaluationsofpublichealthinterventions

6.4 Conclusion

ThereisalargeamountofmaterialavailablethatcaninformDirectorsofPublicHealthonthelikelyreturnoninvestmentoftheiractivity.Thefindingsdocumentsummarises,tailorsandunpackssomeofthatinformationforDirectorsofPublicHealthofthefourSWLondonboroughsofCroydon,Kingston,MertonandRichmond.

However,therearesomekeyweaknessesinwhatiscurrentlyavailableincludingminimumstandardsofinclusionandreportingcriteria,andlackofevidenceonthelinksbetweenpublichealthinvestmentandsocialcarecostsandimpact.PublicHealthEngland(andNICEandNIHR)candothingstoaddresstheseissues,andwemakerecommendationstothateffect.

10ThisreviewisstatedtobeonNICE’swebsite,butseemsnolongeravailablethere.11http://phrc.lshtm.ac.uk/project_2005-2011_d105.html

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Annex

AnalysisofLGAdatabaseoffourboroughs’priorities

TheLGA’sdatabase(http://www.local.gov.uk/health-and-wellbeing-boards/-/journal_content/56/10180/6111055/ARTICLE)summariesEngland’shealthandwellbeingboardprioritiesinto30differentcategories.AnalysisofthefourlocalauthoritiesinthedatabaseispresentedinFiguresA1andA2,whichshowstheLGA’sjudgementontheirprioritiesfromamongthisset.

FigureA1

Healthandwellbeingboardprioritiesbyborough

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FigureA2

Healthandwellbeingboardprioritiesbynumberofcommonpriorities

Ourinterpretationofthisisasfollows:

1. Thereisawidediversityinprioritiesacrossthehealthandwellbeingboards,withMertonhavingthehighestnumberofpriorities(9)andCroydonthefewest’(3).

2. Thereisawidediversityintheexpressedprioritieswithnosinglepriorityrepresentedacrossallboroughs.Nosinglepriorityissharedbyallfourboroughs.KingstonandMertonsharealcoholandsubstanceabuse,healthyliving,obesity(inadultsandchildren)andsmokingincommon.

3. Themostcommonprioritiesaresharedbycombinationsoftwoboroughs.Theseprioritiesare:alcoholandsubstanceabuse,healthinequalities,healthyliving,mentalhealthandwellbeing,obesityinadults,obesityinchildrenandsexualhealth.MertonalsoshareshealthinequalitiesasaprioritywithCroydon.Finally,KingstonandRichmondsharementalhealthandwellbeingasapriority.

4. Eachoftheboroughsisrepresentedinatleastoneoftheabovepriorities.Thesearethereforeprimecandidatesforthetargetedlookatnewreturnoninvestmentliterature,overandabovetheexistingreturnoninvestmentliteraturealreadyknowntoTheKing’sFund.

Ref:102521