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.

Figure 1

Spending by life course stage of the 25 health improvement initiatives. Spending on the 25 health improvement initiatives by each life course stage.

Figure 2

Investment and disinvestment decisions made by the panel for each of the 25 initiatives. Candidates for investment and disinvestment recommendations from votes made by the PBMA panel (n = 12) for the 25 initiatives under review. Please note the initiatives considered as pilots (Teenage Pregnancy Pilot, Steroids and Image Enhancing Drugs and Champions for Health) were not included in the voting.

Figure 3

Results of the marginal analysis exercise - proportion of the total allocation of the hypothetical £5 million for the 6 life course stages from the 9 respondents.