Dataset Information

A national Programme Budgeting and Marginal Analysis (PBMA) of health improvement spending across Wales: disinvestment and reinvestment across the life course.

ABSTRACT:

Background

Wales faces serious public health challenges, with relatively low life expectancies and wide inequalities in life expectancy with associated pressures on the National Health Service (NHS) at a time of financial recession. This has led to growing recognition of the need to better understand the range of health improvement and prevention programmes across Welsh Government, NHS, local government and voluntary sector agencies.

Methods

The Minister for Health and Social Care commissioned Public Health Wales, the single national public health organisation, to establish a Health Improvement Advisory Group, to oversee a Programme Budgeting and Marginal Analysis (PBMA) expert panel. The panel drew on evidence from a range of sources to explore potential alternative modes of health improvement initiative delivery across Wales. Electronic voting was used to agree an appropriate time horizon for health improvement programme outcomes, main objective of the health improvement review and criteria for evaluating candidate services for disinvestment and investment. The panel also used electronic voting to state whether they wished to disinvest or invest in a candidate service.

Results

The review identified a budget of £15.1 million, spanning 10 Welsh Government priority areas, and 6 life course stages. Due to lack of evidence the panel recommended total disinvestment in 7 out of 25 initiatives releasing £1.5 million of resources, and partial disinvestment in a further 3 interventions releasing £7.3 million of resources. The panel did not recommend increasing investment in any of the 25 initiatives under review. Marginal analyses prioritised child health, mental health and wellbeing and tobacco control as key areas for investment.

Conclusions

Wales is championing a concept of "prudent healthcare". The PBMA exercise undertaken here was a transparent evidence-based tool to reach decisions about potential for disinvestment and reinvestment in health improvement strategies. It also demonstrates the potential wider application at a national level across government public health functions, to ensure resources are most cost-effectively deployed, with due consideration for equity.

SUBMITTER: Edwards RT

PROVIDER: S-EPMC4246570 | biostudies-literature | 2014 Aug

REPOSITORIES: biostudies-literature

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Publications

A national Programme Budgeting and Marginal Analysis (PBMA) of health improvement spending across Wales: disinvestment and reinvestment across the life course.

Edwards Rhiannon Tudor RT Charles Joanna M JM Thomas Sara S Bishop Julie J Cohen David D Groves Sam S Humphreys Ciaran C Howson Helen H Bradley Peter P

BMC public health 20140812

<h4>Background</h4>Wales faces serious public health challenges, with relatively low life expectancies and wide inequalities in life expectancy with associated pressures on the National Health Service (NHS) at a time of financial recession. This has led to growing recognition of the need to better understand the range of health improvement and prevention programmes across Welsh Government, NHS, local government and voluntary sector agencies.<h4>Methods</h4>The Minister for Health and Social Care ...[more]

PMID: 25118054

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Project description:IntroductionIn any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting.MethodsThe PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting.ResultsThe PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth.DiscussionThe PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from.Knowledge transfer statementThis study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.

Project description:BackgroundA recent HTA review concluded that there was a need for RCTs of exercise referral schemes (ERS) for people with a medical diagnosis who might benefit from exercise. Overall, there is still uncertainty as to the cost-effectiveness of ERS. Evaluation of public health interventions places challenges on conventional health economics approaches. This economic evaluation of a national public health intervention addresses this issue of where ERS may be most cost effective through subgroup analysis, particularly important at a time of financial constraint.MethodThis economic analysis included 798 individuals aged 16 and over (55% of the randomised controlled trial (RCT) sample) with coronary heart disease risk factors and/or mild to moderate anxiety, depression or stress. Individuals were referred by health professionals in a primary care setting to a 16 week national exercise referral scheme (NERS) delivered by qualified exercise professionals in local leisure centres in Wales, UK. Health-related quality of life, health care services use, costs per participant in NERS, and willingness to pay for NERS were measured at 6 and 12 months.ResultsThe base case analysis assumed a participation cost of £385 per person per year, with a mean difference in QALYs between the two groups of 0.027. The incremental cost-effectiveness ratio was £12,111 per QALY gained. Probabilistic sensitivity analysis demonstrated an 89% probability of NERS being cost-effective at a payer threshold of £30,000 per QALY. When participant payments of £1 and £2 per session were considered, the cost per QALY fell from £12,111 (base case) to £10,926 and £9,741, respectively. Participants with a mental health risk factor alone or in combination with a risk of chronic heart disease generated a lower ICER (£10,276) compared to participants at risk of chronic heart disease only (£13,060).ConclusionsResults of cost-effectiveness analyses suggest that NERS is cost saving in fully adherent participants. Though full adherence to NERS (62%) was higher for the economics sample than the main sample (44%), results still suggest that NERS can be cost-effective in Wales with respect to existing payer thresholds particularly for participants with mental health and CHD risk factors.Trial registrationCurrent Controlled Trials ISRCTN47680448.

Project description:BackgroundThe nationwide integration of palliative care best practices into general care settings is challenging but important in improving the quality of palliative care. This is why the Dutch National Quality Improvement Programme for Palliative Care has recently been launched. This four-year programme consists of about 70 implementation trajectories of best practices. A large evaluation study has been set up to evaluate this national programme and separate implementation trajectories.Methods/designThis paper presents the protocol of the evaluation study consisting of a quantitative effect evaluation and a qualitative process evaluation. The effect evaluation has a pre-test post-test design, with measurements before implementation (month 0) and after implementation (month 9) of a best practice. Patients are eligible if they have a life expectancy of less than six months and/or if they are undergoing palliative treatment and provided they are physically and mentally capable of responding to questionnaires. Bereaved relatives are eligible if they have been involved in the care of a deceased patient who died after a sickbed between six weeks and six months ago. Three types of measurement instruments are used: (1) numerical rating scales for six symptoms (pain, fatigue, breathlessness, obstipation, sadness and anxiety), (2) the Consumer Quality Index Palliative Care - patient version and (3) the version for bereaved relatives.The process evaluation consists of analysing implementation plans and reports of the implementation, and individual and group interviews with healthcare professionals. This will be done nine to eleven months after the start of the implementation of a best practice.DiscussionThis mixed-method evaluation study gives more insight into the effects of the total programme and the separate implementation trajectories. However, evaluation of large quality improvement programmes is complicated due to changing, non-controlled environments. Therefore, it is important that an effect evaluation is combined with a process evaluation.Trial registrationNTR-4085.

Project description:ObjectivesChild dental caries is a global public health challenge with high prevalence and wide inequalities. A complex public health programme (Childsmile) was established. We aimed to evaluate the reach of the programme and its impact on child oral health.SettingEducation, health and community settings, Scotland-wide.InterventionsChildsmile (national oral health improvement programme) interventions: nursery-based fluoride varnish applications (FVAs) and supervised daily toothbrushing, community-based Dental Health Support Worker (DHSW) contacts and primary care dental practice visits-delivered to the population via a proportionate universal approach.Participants50 379 children (mean age=5.5 years, SD=0.3) attending local authority schools (2014/2015).DesignPopulation-based individual child-level data on four Childsmile interventions linked to dental inspection survey data to form a longitudinal cohort. Logistic regression assessed intervention reach and the independent impact of each intervention on caries experience, adjusting for age, sex and area-based Scottish Index of Multiple Deprivation (SIMD).Outcome measuresReach of the programme is defined as the percentage of children receiving each intervention at least once by SIMD fifth. Obvious dental caries experience (presence/absence) is defined as the presence of decay (into dentine), missing (extracted) due to decay or filled deciduous teeth.Results15 032 (29.8%) children had caries experience. The universal interventions had high population reach: nursery toothbrushing (89.1%), dental practice visits (70.5%). The targeted interventions strongly favoured children from the most deprived areas: DHSW contacts (SIMD 1: 29.5% vs SIMD 5: 7.7%), nursery FVAs (SIMD 1: 75.2% vs SIMD 5: 23.2%). Odds of caries experience were markedly lower among children participating in nursery toothbrushing (>3 years, adjusted OR (aOR)=0.60; 95% CI 0.55 to 0.66) and attending dental practice (≥6 visits, aOR=0.55; 95% CI 0.50 to 0.61). The findings were less clear for DHSW contacts. Nursery FVAs were not independently associated with caries experience.ConclusionsThe universal interventions, nursery toothbrushing and regular dental practice visits were independently and most strongly associated with reduced odds of caries experience in the cohort, with nursery toothbrushing having the greatest impact among children in areas of high deprivation.

Project description:BackgroundChildsmile is Scotland's national child oral health improvement programme. To support the delivery of prevention in general dental practice in keeping with clinical guidelines, Childsmile sought accreditation for extended duty training for dental nurses to deliver clinical preventive care. This approach has allowed extended duty dental nurses (EDDNs) to take on roles traditionally undertaken by general dental practitioners (GDPs). While skill-mix approaches have been found to work well in general medicine, they have not been formally evaluated in dentistry. Understanding the factors which influence nurses' ability to fully deliver their extended roles is necessary to ensure nurses' potential is reached and that children receive preventive care in line with clinical guidance in a cost-effective way. This paper investigates the supplementation of GDPs' roles by EDDNs, in general dental practice across Scotland.MethodsA cross-sectional postal survey aiming to reach all EDDNs practising in general dental practice in Scotland was undertaken. The survey measured nurses': role satisfaction, perceived utility of training, frequency, and potential behavioural mediators of, preventive delivery. Frequencies, correlations and multi-variable linear regression were used to analyse the data.ResultsSeventy-three percent of practices responded with 174 eligible nurses returning questionnaires. Respondents reported a very high level of role satisfaction and the majority found their training helpful in preparing them for their extended role. While a high level of preventive delivery was reported, fluoride vanish (FV) was delivered less frequently than dietary advice (DA), or oral hygiene advice (OHA). Delivering FV more frequently was associated with higher role satisfaction (p?<?0.001). Those nurses who had been practising longer reported delivering FV less frequently than those more recently qualified (p?<?0.001). Perceived difficulty of delivering preventive care (skills) and motivation to do so were most strongly associated with frequency of delivery (p?<?0.001 for delivery of FV, DA and OHA).ConclusionsThis study has provided insight into EDDNs' experiences and demonstrates that with appropriate training and support, EDDNs can supplement GDPs' roles in general dental practice in Scotland. However, some barriers to delivery were identified with delivery of FV showing scope for improvement.

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Dataset Information

A national Programme Budgeting and Marginal Analysis (PBMA) of health improvement spending across Wales: disinvestment and reinvestment across the life course.

Background

Methods

Results

Conclusions

Publications

A national Programme Budgeting and Marginal Analysis (PBMA) of health improvement spending across Wales: disinvestment and reinvestment across the life course.

Similar Datasets

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