Prevention: Still better than a cure

The NHS in Wales is in a peculiar position in policy terms. Although it has been protected from the same level of budget cuts seen by other departments across the UK, it has still seen a real terms fall in its available budget – and that during a time of increased demand more widely.  At the same time, many services that work alongside and beyond the NHS are under even greater pressure, and this has arguably served to further inflate demand. Increasingly, the NHS is being looked to for support, for help in reducing demand before people ever interact with health services.

This preventative approach is at the heart of recent legislation in Wales. It is a key part of the Housing (Wales) Act, shifting approaches to homelessness to one where there is a duty to help to prevent placed on local authorities. The philosophy: get in there early, sustain tenancies and address issues to avoid homelessness in the first place. The same principle flows through the Social Services & Wellbeing (Wales) Act, and other legislation passed in this Assembly.

Prevention works. Early intervention works. It should be obvious to everyone. The now hackneyed phrase “prevention is better than cure” has become commonplace for a reason. From nudge theory to get citizens to change behaviour, to thinking innovatively about how, when and where people interact with services, all sectors across all levels of government are looking at how preventative working can be expanded.

There is however, a ‘preventative problem’, which remains a barrier to implementing preventative working across Wales. At its simplest, it is threefold:

1. Funding pressure leads to a focus on crisis spending rather than investment in prevention;

2. Preventative activity can be difficult to measure in terms of impact;

3. Even if preventative activity can be measured, often savings are delivered across multiple levels of government and across different departments and sectors, and so it can be difficult to leverage support from the areas benefiting.

The first point is something that has to be decided at a local level, by commissioners. Unfortunately, that call is often hard to make, especially because of the second problem: measuring the impact of prevention. With budgets stretched to the limit, how can commissioners make a strong case for services that stop problems that may arise, rather than focusing on problems that already exist?

It is the second problem that is most difficult to address. For some select services it is easier. Smoking cessation activity, for example, results in a quantifiable saving for the NHS that is more readily evidenced. It makes financial sense to invest in it.

It hasn’t traditionally been so clear-cut for more complex services like those within the Supporting People Programme.

This is a flagship Programme initially set up by the last Labour Government in England. It is aimed at a variety of people: those experiencing or at risk of homelessness; those with mental health problems; those with substance misuse problems; those who are experiencing domestic abuse; those with learning disabilities who wish to live their own lives; those older people who want to remain independent for as long as possible.

Those operating within this Programme have always known that it makes an impact. And not just on one area, but on many. By maintaining independent living it can save money for social services. By preventing homelessness it can save money for A&E, for children’s services, for community justice.

But knowing it and proving it are two different things.

This has left the Supporting People Programme in an awkward position. Knowing it makes a difference – and a significant difference. But only anecdotally or on a limited scale (one study in Carmarthenshire from 2010 demonstrated savings of around £2.30 for every £1 spent).

This week, the argument has been blown wide open for the first time. It is positive news for the Supporting People Programme, but it may suggest that the way we approach healthcare in Wales needs a shift towards innovative, preventative activity.

The emerging findings report from Welsh Government should be read by all individuals working at a strategic level in the NHS.

The full report can be read here.

In short: from an indicative, provisional analysis (the full report will be published in early 2016), the Supporting People Programme has its first clear data that it has a positive impact on the health service.

By linking data from local authorities with a health database based in Swansea, some exciting early findings have been suggested:

• In the twelve months before support began, people using Supporting People services were estimated to use GP services around twice as frequently as the general population.

• For the majority of the Supporting People client groups, an overall pattern shows that GP usage increases initially before dropping off to below pre-support levels.

• For some of the Supporting People client groups, a similar pattern can be seen with the number of A&E visits.

In short: with just a snapshot over time of two specific areas of the NHS, savings can be seen from the Supporting People Programme, sometimes from as soon as three months after receiving support.

When the full report is published in early 2016, this should prompt us to consider new approaches for the NHS.

The early findings suggest that the Supporting People Programme saves money for the NHS. This could mean the Programme can finally look towards the next stage of the ‘preventative problem’: convincing other services and departments to commit resources towards your work, or at the very least convincing government to protect your existing resource.

How a new approach in the NHS could work is beyond the scope of this article for now – but the report should give us pause. Could the NHS financially support a programme that helps it reduce burdens on its own budget?This is something we are specifically calling for Welsh Government to commit to using a small proportion of any consequential from the Spending Review yesterday. Could it accept a small, specific reduction in its funding to enable the Programme to expand? Is this part of the mix of “prudent healthcare”, or an additional consideration?

We might be closer to those answers after the election in 2016, but these are the difficult questions we should be asking when it comes to the future of Welsh services over the approaching years of continued austerity.

We need to be spending wisely, in the right place, at the right time.