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• • Over the past 160 years, we have witnessed the fastest improvements in mortality in the UK in history, with life expectancy almost doubling for men and women. Progress was driven initially by preventing childhood deaths and subsequently by the prevention of illness in older people. Prevention has also improved the quality of the lives we live by delaying chronic diseases until later life. Over the past ten years, improvements in life expectancy have stalled, although not equally across all parts of society.

 

• • Responsibility for prevention is spread across several different organisations in the UK, but a mainstay is through the Public Health Grant to Local Authorities. This grant funds vital services, such as smoking cessation, drug and alcohol services, children’s health services and sexual health services, as well as broader public health support across the local authority and NHS. There has been a 24% real-term cut, equivalent to £1bn, in the grant from 2015/16 compared to 2021/22.

 

• • Previous research has already shown that the Public Health Grant represents good value for money, especially when compared to NHS spend or HM Treasury thresholds. One study found that the cost per additional year in good health from public health interventions was £3,800, compared to £13,500 for NHS clinical interventions.

 

• • Not all public health interventions are equally effective or cost-effective. A granular approach is needed to disentangle the effects of different interventions, from smoking cessation to physical activity and sexual health services. Furthermore, public health interventions will impact health inequalities differently; some may inadvertently increase inequalities, whereas others may reduce the gap.

 

• • Here we review the effectiveness and cost-effectiveness of public health interventions paid for by the Public Health Grant. We use three methods: first, we build on a series of papers by Owen and colleagues that review public health interventions that NICE has evaluated; second, we undertake a high-level review to identify additional important studies; and third, we consider the inequalities impact of public health interventions based on research by Griffin and colleagues. We focus on the most cost-effective interventions – those below the £20,000 per additional year of healthy life threshold, which is the lower end of what the National Institute for Health and Care Excellence (NICE) judge to be cost-effective.

 

• • In total, we identified 134 public health interventions that were cost-effective. The largest group was smoking interventions (67), followed by physical activity (14), public health advice (diabetes and skin cancer prevention) (8), sexual health (8), children’s services (8), health at work interventions (8), air pollution (6), substance misuse (6), public mental health (5), domestic violence and abuse (2) and weight management (2). In the case of fifty of these, the cost of implementing the intervention was cheaper and provided more health gain than the comparator of standard practice at the time of the research, which may be an alternative intervention, or no intervention (dominant Incremental Cost Effectiveness Ratio; ICER). The other 86 would be considered cost-effective because the health benefits outweigh the costs at a £20,000 per additional year of healthy life threshold.

 

• • The most significant impact on reducing health inequalities came from smoking and domestic violence interventions – the difference was 3-3.5 times more than any other interventions. Other public health inequalities-reducing interventions included population level and community diabetes programmes, hepatitis testing, support for looked after children, Sure Start programmes and workplace programmes. Public health interventions that were more likely to increase inequalities were straightforward advice and screening in primary care and A+E, walking buses and physical activity interventions.

 

• • We do not argue that interventions that increase inequalities should not be implemented at the expense of overall population health improvements. Instead, local planners need to understand the potential trade-offs between overall population health improvement and inequalities with evidence of how interventions could be modified to mitigate negative consequences. For example, by delivering services with a greater intensity in more disadvantaged areas, rolling out new initiatives first in more disadvantaged areas and ensuring services are culturally competent.

 

• Investment in prevention represents excellent value for money compared to health care spend or HM Treasury willingness to pay values, as long as the funds are used for the evidence-based interventions. As the country emerges from an inequalities-compounding pandemic, there is good evidence that specific public health interventions, such as smoking and domestic abuse activities, will reduce the health gap. While there is currently much focus on addressing the backlog of NHS procedures, we must not lose sight of the public health backlog which is currently storing up future health problems.

Authors: John Ford, Nnenna Ekeke, Anwesha Lahiri, Michael P. Kelly

A commissioned report by Cambridge Public Health, University of Cambridge, for the Health Foundation

October 2021

For further information please contact Dr John Ford: jf653@medschl.cam.ac.uk