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Abstract
Objectives The UK government is proposing to cease cutting the local authority public health grant by reallocating part of the treatment budget to preventative activity. This study examines whether this proposal is evidenced based and, in particular, whether these resources are best reallocated to prevention, or whether this expenditure would generate more health gains if used for treatment.
Methods Instrumental variable regression methods are applied to English local authority data on mortality, healthcare and public health expenditure to estimate the responsiveness of mortality to variations in healthcare and public health expenditure in 2013/14. Using a well-established method, these mortality results are converted to a quality-adjusted life year (QALY) basis, and this facilitates the estimation of the cost per QALY for both National Health Service (NHS) healthcare and local public health expenditure.
Results Saving lives and improving the quality of life requires resources. Our estimates suggest that each additional QALY costs about £3800 from the local public health budget, and that each additional QALY from the NHS budget costs about £13 500. These estimates can be used to calculate the number of QALYs generated by a budget boost. If we err on the side of caution and use the most conservative estimates that we have, then an additional £1 billion spent on public health will generate 206 398 QALYs (95% CI 36 591 to 3 76 205 QALYs), and an additional £1 billion spent on healthcare will generate 67 060 QALYs (95% CI 21 487 to 112 633 QALYs).
Conclusions Additional public health expenditure is very productive of health and is more productive than additional NHS expenditure. However, both types of expenditure are more productive of health than the norms used by National Institute for Health and Care Excellence (£20 000–£30 000 per QALY) to judge whether new therapeutic technologies are suitable for adoption by the NHS.
- public health
- health economics
- health policy
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Contributors All authors (SM, JL and KC) contributed to the concept and design of this paper. SM led on the analysis and drafting, and the final paper was edited and approved by all three authors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting these criteria have been omitted. SM is the paper’s guarantor.
Funding This paper reports independent research funded by the National Institute for Health Research Policy Research Programme (NIHR PRP) through its Policy Research Unit in Economic Evaluation of Health & Care Interventions (EEPRU, grant reference 104/0001).
Disclaimer The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care (DHSC).
Competing interests All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare: financial support from the National Institute for Health Research Policy Research Programme for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; and no other relationships or activities that could appear to have influenced the submitted work.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are not available in a public, open access repository but all of the raw data are in the public domain and are available electronically. The healthcare expenditure data are available in the 2013-14 CCG Programme Budgeting Benchmarking Tool. This is available from https://www.england.nhs.uk/progbudgeting/ (accessed 14 July 2020). The socioeconomic variables have been constructed from the 2011 Population Census.These are available from the Office for National Statistics at https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/2011censuskeystatisticsforlocalauthoritiesinenglandandwales (accessed 14 July 2020). The public health expenditure data are available from ‘Local authority revenue expenditure and financing England: 2013–2014 individual local authority data—outturn which is available from https://www.gov.uk/government/statistics/local-authority-revenue-expenditure-and-financing-england-2013-to-2014-individual-local-authority-data-outturn (accessed 14 July 2020)’. The instruments for public health expenditure are available in ‘Exposition Book Public Health Allocations 2013-14 and 2014-15:Technical Guide and this is available from https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/213324/Public-Health-Weighted-Capitation-FormulaTechnical-Guide-v0.13.pdf (accessed 14 July 2020). The DFT variable for healthcare expenditure is available from the Department of Health’s website at-https://www.networks.nhs.uk/nhsnetworks/health-investment-network/news/2012-13-programme-budgeting-data-is-now available (accessed 14 July 2020) and the MFF and prescribing cost age indices are available from the exposition books for the 2011/2012 allocations at https:/www.gov.uk/government/publications/exposition-book-2011-2012(accessed 14 July 2020).