• Abstract and Figures
• Public Full-text

Assessing the Value for Money of Health Trainer

Services `

Final Report Graham Lister April 2010 It is important to stress that, in the absence of long term studies of behaviour and health outcomes, which are not available for HTS, or many other public health interventions, assessment of value for money must apply reasonable assumptions based on the available evidence and expert judgements from practitioners. These must be discussed with Commissioners who must review them and apply local perspectives and values. The Department of Health takes no responsibility for the estimates and assumptions set out in this report, which are the responsibility of the author and a Stakeholder Panel established to represent Commissioner and Provider views. Please also note that this document has been updated as a result of the first annual review of the Portsmouth Ready Reckoner Tool.

Acknowledgements

While the author takes full responsibility for the content of this report and any errors or omissions, it is important to note that its production would not have been possible without the enthusiastic support and input from many Health Trainer Service Providers and Commissioners. Particular thanks are due to Ian McAleer, Rosemary Kemp, Dr Helen Walters, Brian Leigh, Sarah Jewell, Alex Ollivier, Barry Gillespie, Chris Love, Janice Lowndes, Elaine Varley, Tracey Fearn, Julie Hirst, Mary Packer, Anne Shirley, Alyson McGregor, Campbell Todd, Claire Roberts, Michela Littlewood. I am also grateful to Nicola Rumsey for her comments and for the support of other health economists including Steve Feast, Cam Donaldson and Mark Pennington and to my friend Herb Nahapiet for his knowledge of the Criminal Justice System. This assessment was funded by the Department of Health Central Health Trainer Team with a contract for £25,000 and completed over a three month period from January to March 2010. The Department of Health has made it clear that this assessment, must be viewed as a contribution to local commissioning decisions rather than a central evaluation. The Portsmouth Ready Reckoner Tool that uses this evaluation was separately funded by NHS Portsmouth at a cost of £10,000 and an annual update at a cost of £1,500. I am particularly grateful for the support of colleagues from Portsmouth. In 2014 a further update to the evaluation tool was requested by Em Rhaman of NHS Wessex Health Education. These reviews are included in the final section of this report, Graham Lister PhD, MSc, BSc Fellow of the Judge Business School of Cambridge University Visiting Professor in Health and Social Care at London South Bank University Associate of the National Social Marketing Centre.

b Assessing the VfM of HTS: Executive Summary Health Trainer Services provide an innovative approach to improving health and addressing health inequality in areas of multiple deprivation. They provide opportunities for people to address their health and lifestyle choices with trained staff drawn from their communities, able to help them access the services they need and to engage with health and community services and groups. This project is aimed at helping those who commission and provide these services to understand, explain and improve their value for money, as a contribution to further development of Health Trainer Services (HTS). The method for assessing value for money, developed in close consultation with experienced HTS commissioners and providers, takes as its starting point an analysis of the objectives of the services and their impacts on the agencies and people involved. In each case a set of indicators is proposed so that the performance of the HTS in relation to its objectives can be measured and compared to costs. This provides a framework to clarify outcomes and sets the specific measures of value for money (VfM) in the context of national and local World Class Commissioning objectives. The potential health gain and costs savings that can be achieved in each area of behaviour change was estimated from international and national statistics and studies. The impact of 1 to 1 behaviour change was assessed by a panel of HTS practitioners drawing on local studies of the extent and persistence of behaviour change. These estimates were then applied to the potential health gain and savings to indicate the expected impact of each successfully completed 1 to 1 behaviour change intervention. Other types of intervention including: signposting, mapping of community facilities and engagement with local community groups were then valued by comparing the costs and outcomes with broadly similar interventions in Primary Care. This made it possible to assess the impacts on all those involved: the NHS, Local Authorities, Offender Management Services, clients, communities and Health Trainers themselves. These estimates were then adjusted to reflect the value of addressing disadvantaged groups by applying a factor derived from the Health England Leading Priorities review (or alternatively by a locally determined weight) and compared to the cost of providing the service. This provides an estimate of the net cost per equity weighted unit of health gain. This is necessarily a complex process reflecting services which are multifaceted and varied to respond to local needs and values, but it can be boiled down to a simple set of assumptions about the effectiveness of HTS interventions applied to the measures of performance for a local service. The values applied can be varied to respond to local circumstances and the outcome can be calculated. This method was then applied to a set of 5 case studies to test the method and the lessons it provides about the VfM of HTS. It showed that HTS can achieve high levels of value for money as measured in this way but it also highlighted the variability between services, the problems of data collecting and the difficulty of capturing some aspects of the value of HTS. The assessment method needs to be developed and refined through application in a range of different circumstances in a learning environment in which commissioners and providers share the lessons they learn and work together to improve the VfM of HTS. The method can be improved by research to provide knowledge to underpin expert judgements about the impacts of health risk and persistence of behaviour change. The report also provides estimates of potential health gains and costs savings that could be improved by research and national consensus with others working in the fields of health promotion, health equity and healthy communities. This has been a very encouraging start in addressing VfM as a key challenge for HTS and other health promotion services.

4 Assessing Value for Money for Health Trainer Services: Final Report

Contents Page Introduction 3 Developing the Assessment Method 5 NICE Guidelines 5 World Class Commissioning and the Marmot Report 5 Outline of the Assessment Method 6 The Objectives of Health Trainer Services 7 Local Stakeholder Values 8 Health Gains 12 Potential for Health Improvement 12 Health Gains Attributable to HTS Behaviour Change Support 16 Cost Savings to the NHS 19 Cost Savings from Behaviour Change Support 17 Community Engagement, Mapping and Signposting 21 Health Inequality 23 Disadvantage and Health 23 The Value of Reducing Health Inequality 25 Benefits to Other Stakeholders 26 Local Authorities 26 Offender Management Services 27 Clients 27 Communities 30 Health Trainers and Health Trainer Champions 31 Applying Assessment 32 Commissioning Decisions 32 Comparison with other Health Promotion Initiatives 33 Uncertainty and Sensitivity 34 Case Studies to Test the Assessment Method 36 A Inner City Health Trainer Service 36 B Community Support HTS 38 C Rural Communities HTS 39 D Jointly Funded Urban HTS 41 E Offender Health Trainer Services 42 Preliminary Conclusions 45 The Portsmouth Ready Reckoner 2.0 47 Annex A Summary of Assumptions Agreed with the Stakeholder Panel 48 Annex B Glossary of Terms 49 References 52

5 6 Assessing Value for Money for Health Trainer Services Introduction This report was commissioned by the Health Trainer Central Programme Team of the Department of Health (DH) to increase their understanding of the value and impact of Health Trainer Services (HTS) and in response to requests from regional HTS leaders who felt a need to provide information on the value for money of HTS to local Commissioners. The report sets out to identify an approach and methodology for assessing the value for money of HTS based on a set of agreed assumptions, it has been tested by application to a small number of established HT services in order to create a better understanding of its usefulness, limitations and potential as described in this report. The assumptions agreed by a Stakeholder Panel of 12 people with practical experience of Commissioning and Providing HTS and an independent Chair and secretary are based on: local knowledge and understanding of HTS, international and national data sources and evidence including studies of other behaviour change services such as smoking cessation and diet and exercise, findings from local surveys of HTS clients and the National Health Trainer Data Collection and Reporting System (DCRS) (1). The assumptions agreed by the Stakeholder Panel and evidence on which they are based are explained throughout this paper, key assumptions are summarised at Annex A. The assessment method relies on the statistical, research and cost data available with all their flaws, gaps and inconsistencies and on assumptions agreed with a Stakeholder Panel. It applies the logic of health economics to this data to produce an indication of value for money in terms of benefits per unit costs of the service less savings to the NHS and other stakeholders. The aim is to make the best interpretation of the data available from DCRS and other studies and data sources, within the limits of a £25,000 review conducted over 3 months. The case study findings are only intended to indicate the application of this approach to assessing the value for money of HTS within the context of each case looked at, bearing in mind the limitations regarding quality and availability of information. These case studies demonstrate local strengths and weaknesses in terms of value for money in order to widen understanding of local practice and to assess the assumptions used, availability of data, potential for wider usage of the approach and the need for further adjustment and development. Clearly in practice VfM reviews should be guided by local Commissioner values and priorities and should be set alongside qualitative reviews. The report highlights key findings and sets out recommendations for potential application of the assessment process at national and local levels. Where the current assessment lacks clear evidence it has adopted a cautious approach, applying estimates that would be considered conservative in relation to studies of similar public health interventions. As experience is gained in applying and developing this methodology and as further research evidence becomes available it is hoped to refine and improve these estimates, through a shared learning process with Commissioners, Providers and researchers. It is important to distinguish this value for money assessment tool from the National Evaluation Programme, which, when it reports next year, may be expected to provide insight into the processes and values of HTS and further research evidence to inform value for money assessment.

3 The Stakeholder Panel has made it clear that if Commissioners are to be convinced of the value for money of Health Trainer Services it is essential to show that HTS will save money for the NHS, or at least can achieve health gains at low cost relative to other interventions. This is therefore a priority for the assessment. The potential health gains from the service are also valued for their contribution to health equity. In addition likely impacts on other public sector services, clients and communities are identified as required by World Class Commissioning. It is equally important to ensure that the approach is acceptable and useful to HTS stakeholders at National and local levels, for this reason the approach to assessment and its final outcome will be agreed with a formal group now known as the HTS Local Evaluation & Knowledge Gathering subgroup. This group can also play an important role in the further evolution of value for money assessment which will inevitably require further refinement and development as well as annual review to ensure that the latest available evidence is applied. The application of this approach should bring greater clarity to both qualitative and quantitative reviews and should therefore enhance the ability of HTS to share and learn from experience. Assessment such as this is inevitably complex and requires some calculation but hopefully can be explained in relatively straightforward terms to Commissioners. This will require that regional HTS leaders (Hub Leads) should participate in a teaching learning session to gain a shared understanding of the approach. Given appropriate training materials they will then be able to share the approach with local HTS Commissioners. It is hoped that this will help ensure that the method developed can be used for local service assessment, while making it possible to apply local costs and outcome indicators and the local values and priorities of Commissioners and Providers. Value for money assessment is important at each stage in the design, commissioning and implementation of HTS. The components of the assessment provide clues as to how to improve value for money at every stage, as examples: by focussing on disadvantaged clients, and high value activities, by ensuring health trainers have the skills necessary to encourage clients to stick to their Personal Health Plan goals, by increasing the value of community engagement aspects and signposting and by controlling costs. The project to develop a method for assessing the value for money of HTS proceeded through 4 main stages: first, a scoping review helped to gain an understanding of HTS, the objectives of assessment and the approach to be taken, this was agreed with the HTS Local Evaluation & Knowledge Gathering subgroup. Second a Stakeholder Panel was established to provide expert input to the methodology and assumptions and to guide data collection. It was originally intended to complete the method review before applying the method to a sample of 5 HTS identified by the Panel. In the event it was necessary to undertake these stages in parallel, due to difficulties in arranging meetings but care was taken to ensure that the panel could not foresee what the outcome of evaluation would be so that this did not prejudice their judgements. The evidence and assumptions were used to develop an Excel spreadsheet which supported the calculation of health gains, cost savings and net cost per unit of health gain, weighted for disadvantage of the client community, for each case. This provided a basis for considering the advantages and disadvantages of the assessment method and its application to the specific cases. Case study findings were fed back to the respondents to allow for comments and corrections. The final report was then submitted to the HTS Local Evaluation and Knowledge Gathering subgroup.

4 Developing the Assessment Method NICE Guidelines In developing this assessment method the eight guidelines developed by NICE for good practice in behaviour change intervention (BCI) design and evaluation have been borne in mind. These rather general guidelines (2) can be broadly summarised as: 1. Planning of BCI should take into account barriers that prevent people from making positive changes ~ this reinforces the importance of emotional wellbeing. 2. The social context should be taken into account ~ in this case disadvantage. 3. There is a need for the education and training of those responsible for BCI planning, implementation and evaluation ~ hence the proposal to disseminate this assessment approach through teaching /learning sessions. 4. Individual-level interventions should apply psychological concepts to optimise motivation and support behaviour change ~ which is a foundation for HTS. 5. Investment in community level interventions must be based on relationship building ~hence the importance of community engagement aspects. 6. Population level interventions must be based on good information from and understanding of communities ~ a case for linking local and national HTS goals. 7. All interventions should be subject to rigorous evaluation and monitoring. 8. Evaluation should include cost effectiveness. The method of assessment also follows earlier NICE policy briefing (3) which notes that it is important to establish a common economic framework for appraisal that reflects the “complex multi-dimensional and layered” character of public health outcomes and suggests the development of a “pragmatic framework” as a first step. It also applies the Health England Leading Priorities method for evaluating health inequality impact (4). World Class Commissioning and the Marmot Commission World Class Commissioning (WCC) provides an important context to the development of value for money evaluation. WCC asks PCTs to commission services with LAs and the community to achieve joint strategic objectives with improved value for money (5). Strategic objectives include two national aims of: improving health promotion and health services to increase healthy life and to address inequality issues to reduce the Index of Multiple Deprivation (IMD covers 7 fields of deprivation: income, employment, health and disability, education and skills, barriers to housing and services, living environment and crime). PCTs and local partners are asked to identify up to 8 local strategic objectives (e.g.: reducing childhood obesity, improving emotional well being, improving teenage sexual health and reducing deaths from cancer and cardio vascular disease). The report by Sir Michael Marmot (6), which quotes examples of HTS, stresses the importance of addressing inequality through joint work between NHS, Local Authorities (LA’s) and Communities. Marmot also recognises the contribution of HTS to government and local priorities: to improve health, well being and care, to address inequalities in health and other factors and engage hard to reach groups, build positive social capital and improve access to and use of services; with improved value for money in the long term. The report estimates the cost of inequality as £5.5 billion to the NHS and £31-33 billion to the economy.

5 Outline of the Assessment Method Several different approaches to the analysis of value for money have been employed:  Cost – offset: how much money is saved for each £ spent  Cost – effectiveness: how much of a specific outcome (DALY) per £ spent  Cost – consequence: description and measures of outcomes per £ spent  Cost – utility: outcomes weighted by value/priority to commissioners per £  Cost – benefit: outcomes valued in economic terms per £ spent All value for money analyses starts with an understanding of objectives of the service and measures of the costs and impacts for each stakeholder. Cost-offset is relevant to the extent that HTS may substitute for other services, this has been applied in relation to HTS signposting. The cost-effectiveness of HTS can be measured in terms of health gain and the long term savings to the NHS and other stakeholders arising from health improvement over the lifetime of the clients. Health gain is estimated as the improvement expected in the probability of long term positive health outcomes, recognising that some clients would have changed their behaviour without intervention and that many clients do not manage to sustain their change or achieve only marginal health improvement. The consequences for other stakeholders, including Local Authorities and other public services, clients and community groups are shown using a cost-consequences approach. The measures of impact are then weighted using a cost- utility approach to value impacts on disadvantage and health equity. The method of assessment proposed applies estimates and assumptions in 9 steps: 1. Agree the objectives and measures of costs and impacts for each stakeholder 2. Set out a social impact matrix and indicators for each impact. 3. Estimate potential health gains available per person at risk in each field of behaviour including those originally targeted: diet and activity linked to obesity, alcohol misuse and smoking and examples of areas of needs identified by local services, such as emotional well being, drug addiction and sexual health. 4. Estimate potential cost savings to the NHS per unit of health gain in each field. 5. Estimate potential savings to other stakeholders: Local Authorities, Offender Management Services, Clients, Communities and Heath Trainers/Champions. 6. Survey extent and persistence of health gain achieved by behaviour change. 7. An expert panel of stakeholders is asked to assess the health gains from behaviour change, community engagement and impact on other stakeholders. 8. Impact on health inequality is taken into account using Health England Leading Priorities, which suggests a weighting for health outcomes depending upon the extent of disadvantage and inequality is addressed. 9. Net costs of the service after savings are compared with the value of health gain after weighting for disadvantage. This approach clarifies the objectives and outcomes of the service and provides a way of quantifying impacts on health gain, health equity and cost savings and hence value for money in these terms. It is important to stress that such outcomes can only be as good as the assumptions and evidence on which they are based. Local application of this assessment method must ensure that users think through the evidence and assumptions and ensure that they reflect local needs and values.

6 The Objectives of Health Trainer Services “The impact of Health Trainers on Other Government Departments agendas” sets out the outcomes of health trainer services and their relation to government objectives: 1. Increasing capacity and capability through building the workforce with the right skills in place to tackle health inequality. a. Department of Health (DH) better health, well being and care for all b. Department of Work and Pensions (DWP) maximising employment opportunities and increasing overall employment rate c. Department for Business Innovation and Skills (DIUS) increasing numbers of working age population qualified to at least level 2 or level 3 d. Cabinet Office build more cohesive, empowered and active communities and increasing participation in volunteering 2. Reaching the “hard to reach” a. DH promoting and achieving better health, well being and better care for all and preventing people falling out of work and on to incapacity benefits b. DH /Ministry of Justice /Ministry of Defence (MoD) specific objectives of: improved health and fitness and reduced costs of reoffending. c. DWP reducing unemployment and benefits claimants particularly in worst performing neighbourhoods 3. Delivering sustained improvement to the health of people in England through behaviour change. a. DH promoting and achieving better health and wellbeing, demonstrated by self reported measures of people’s overall health and well being, reductions in morbidity and mortality and specifically cancers and circulatory disease under 75 and behaviour leading to ill health. b. DH and DWP tackling poverty, improving independence and well being in later life as measured by life expectancy at 65. c. DH and Department for Culture Media and Sport promoting better health and well being for all by increased adult participation in sport d. DH and Home Office reducing harm caused by Alcohol and Drugs as measured by alcohol related hospital admission rates 4. Providing access to and encouraging appropriate use and uptake of NHS and other local services. a. DH better health and well being for all and better care for all and better value for all b. DH /Ministry of Justice /Government Equalities Office/ MoD address the disadvantage that individuals experience because of their gender, race, disability, age, sexual orientation, religion or belief. c. DH/ Department for Transport access to services and facilities by public transport, walking and cycling.

7 Local Stakeholder Values Health trainer (HT) service outcomes may be valued differently by local stakeholders: NHS, Local Authorities, the Offender Management Service, Clients and Communities:  NHS agencies may focus on health outcomes and financial savings to health budgets while addressing inequality, inclusion and engagement.  Local Authorities may view health trainers as contributing to their objectives for community well being and engagement and developing positive social capital (7) (this includes bonding within families and communities, bridging between communities and linking to engage people in services and leaders) and may save costs to social care and community wellbeing services.  Offender management health trainer services may contribute to the 7 pathways (8) to reducing reoffending covering alcohol and drugs, physical and mental health, employment education and training, accommodation, finance benefits and debt and children families and community support. Reduced reoffending will reduce costs to the Criminal Justice System and the wider social costs of crime.  For clients objectives may include the opportunity to talk through issues and thereby feel a greater sense of control and reduction in anxiety, direction to appropriate services as well as support for specific behaviour change and its health and economic impact for them and their families.  For communities it will reduce pain and grief and for community host organisations HTS may provide additional contact and services and rental income. And for Health Trainers and Health Champions themselves programmes may provide an entry point to employment and qualifications and a stimulus to their own health as well as opportunity to serve their community.  There may be further perspectives to be considered, as examples: the Army and other Employers – but these have not been examined to date. These impacts include potential savings for each of the stakeholders: for the NHS this will be the reduced costs generated by healthier clients, for local authorities this will include reduced social care costs, for the Criminal Justice System economic benefits will include a reduction in costs due to lower rates of recidivism (there may also be societal savings from reduced crime levels). Clients may achieve cost savings from lower expenditure, on cigarettes, alcohol and drugs and higher levels of income from employment. Impacts on Health Trainers and communities will include opportunities for qualifications and human values of health, though these are not economic benefits . To help PCTs to commission services on behalf of all local stakeholders it is helpful to set out the service objectives and impacts in a social impact matrix. This social impact matrix was developed in consultation with the Local Evaluation and Knowledge Gathering Sub Group and the Stakeholder Panel as shown in table1.

8 Table 1 Social Impact Matrix for Health Trainer Services

Objectives Improve Reduce Reach “hard Improve Improve health inequality in to reach” access to and value for wellbeing health and groups and uptake of money Stakeholders and care other fields build social services capital NHS Improved Improved Improved Improved use Reduced health status access for access for of NHS NHS costs and wellbeing those with hard to reach services and load on greatest other Improved Self help Including HTS needs services self care groups Local Improved Improved Empowered Better use of Reduced Authorities community focus on communities other local social wellbeing disadvantage Social capital services and support Volunteering support costs Offender Offender Reduced Offender and Links to NHS/ Reduced Management health and crime community community costs of Services wellbeing dependency contact services crime Clients Control of life Talking to Contact, Direction to Reduced choices someone like Links and relevant costs of me support services illness Community Personal Improved Employment Links with Route into hosts + Health health and community and skills community Qualification Trainers and wellbeing health development services and Work Champions Rent

The social impact matrix needs to be thought through for each local service, recognising that there is no such thing as a “typical” HTS. This should help in the design of new services and in providing a common core for all qualitative and economic assessments. Applying this approach at least to provide a common core for qualitative and quantitative assessments should ensure greater clarity in local evaluation reports, which though of high quality in many cases, lack consistency. While the framework is intended to provide a common way of evaluating HTS impacts and benefits, it is not intended to limit innovation. If this matrix does not recognise all the benefits of a particular HTS it should be developed or adapted. National arrangement for sharing lessons from the practical application of both quantitative and qualitative reviews of HTS should further enhance the value of evaluation and value for money assessment. This should also provide for regular updating of the approach to take into account emerging evidence, for example arising from the National Evaluation study, national studies of the health impacts and cost consequences of behaviour risk factors and local findings to guide best practice in HTS. For each impact it is important to develop a way of recognising and measuring the extent of the impact. A set of indicators proposed for each of these factors is shown in table 2. Table 2: Indicators of HTS Outcomes

9 1 NHS  Improved health status indicated by o Number of clients achieving or partially achieving PHP goals by field of change  Well being, indicated by o Number of clients showing improvement on WHO-5 well being index o Number of clients showing improvement on General Health scale  Self care, indicated by o Number of client showing improved Self Efficacy scores o Persistence of PHP goals after 1 year  Reduced Health Inequality, indicated by o Percentage of clients from most deprived IMD postcode areas  Improved access for hard to reach groups, indicated by o Number of clients from hard to reach groups  Community Engagement o Mapping of and contact with groups o Participation in events  Self help groups o Number of clients joining or forming self help groups  Improved direction and use of NHS services, indicated by o Number of clients directed to appropriate NHS services o Quality of HTS Management  Cost saving, indicated by o Long term saving from health status improvements o Reductions in demand for and hence cost of other services

2 Local Authorities  Improved community social wellbeing, indicated by o Number of events and projects between community groups and health trainers  Improved focus on disadvantage, indicated by o Extent of joint working between LA and HA in disadvantage supported by HTS  Empowered and active communities, indicated by o HTS generated representation of community groups on NHS, LA or other  Social Capital, indicated by o Bonding – extent to which HT projects reinforce other community ties o Linking – extent of signposting within the voluntary/community sector o Bridging - HT generated activities engaging hard to reach groups  Volunteering, indicated by o Number of Health Champions and other volunteers generated  Better use of local services and support systems o Number of clients directed to local services  Reduced social support costs, indicated by o Extent to which HTS contribute to reducing social support costs

10 3 Offender Management Services  Access to the 7 pathways to reduce risks of reoffending, indicated by o Number of clients enrolled  Reduced crime dependency, indicated by o Self Efficacy scores for offenders  Personal development, indicated by o Number of HTs seeking and gaining level 2 and level 3 qualifications  Links to NHS or other Community Services, indicated by o Number of clients directed to services (and if possible number contacting them)  Reduced Reoffending, indicated by o Estimated impact  Reduced costs, indicated by o Reduced cost to Criminal Justice System o Reduce cost of crime to society

4 Clients  Taking control of life choices, indicated by o Number of clients improving Self Efficacy scores  Talking to someone like me, indicated by o Extent to which Health Trainers and Champions reflect client group  Contact and support, indicated by o Number of clients and number of sessions attended o Social groups and contacts formed  Direction to relevant services, indicated by o Number of client referrals less DNA  Reduced costs of illness, indicated by o Reduced costs to household of cigarettes, alcohol, junk food etc o Reduced informal care costs

5 Community Host Organisations, Health Trainers and Health Champions  Personal health and wellbeing, indicated by o Feedback from Health Trainers and Champions (and or survey)  Improved community health, indicated by o Value of health gain in terms of human values (which gives a threshold value)  Employment and skills development, indicated by o Number of trainers employed (from disadvantaged areas/ groups) o Number of trainers and champions gaining qualifications at level 2 and level3 o Numbers of HTs moving on to other employment and qualifications  Links with community services, indicated by o Local feedback  Rent and employment income, indicated by o Payments o Projected benefits of qualifications

11

12 Health Gains Potential for Health Improvement Health Trainer Services were initially targeted at four areas where it was felt there was evidence that would suggest that HTS behaviour change support processes (BCP) might be most helpful (9). These were smoking, diet, activity and alcohol harm reduction. Healthy eating and activity have many benefits in addition to weight control, as highlighted in the Health Trainer Handbook (10). However, it appears that the majority of clients in these fields focussed on reducing obesity, for this reason and because of data difficulties healthy eating and activity have been lumped together as obesity reduction. As HTS developed they responded to local needs, developing further training in various areas, most saw support for emotional wellbeing as an aspect of the HTS role or at least a very positive “side effect” and some developed more specialised training in this field. A useful definition of emotional wellbeing is offered by the Mental Health Foundation: ‘A positive sense of wellbeing which enables an individual to be able to function in society and meet the demands of everyday life; people in good mental health have the ability to recover effectively from illness, change or misfortune.’ HTS also developed specific responses in relation to issues such as illicit drug use and unsafe sex, though these should be regarded as simply examples of responses to local needs. In these notes both the originally targeted fields and examples of responses to local needs are illustrated There are many different studies that estimate the impact of health risk behaviours such as poor diet and inactivity, alcohol abuse and smoking to the probability of specific disease outcomes such as Type 2 Diabetes, Cardio Vascular Disease and Cancer. The problem with such studies is that they often involve double counting, deaths attributed to specific causes often exceed the known total, and, fortunately, we only die once. In order to overcome this problem, the relationship between health risk behaviour and health outcomes was estimated in a series of rapid reviews (11) using Population Attributable Fractions (PAF) published by the World Health Organization and World Bank (12) (13). These are estimates of how much each behaviour risk factor contributes to each health outcome and hence how much of the total burden of disease can be reduced by addressing factors such as: alcohol abuse, smoking, diet and activity to reduce obesity. This avoids double counting but has disadvantages including, that they are estimates for all high income countries rather than specifically England and are based on data for 2001 and 2005. For this estimate PAFs have been applied to Disability Adjusted Life Years for the UK in 2002 (14) and then adjusted by population to England to estimate how much of each outcome can be attributed to each behavioural risk factor. In relation to other health risk behaviours identified in response to local needs PAFs have also been estimated as follows:  Emotional wellbeing is assumed to be related to long term risks of mental illness. While this is not a simple relationship, emotional wellbeing is key to many aspects of physical and mental health and conversely diet, activity, socialisation and reduced dependency on alcohol, tobacco and other drugs can enhance emotional wellbeing (15). Note that only preventable mental disorders were considered.  Illicit drug use outcomes were updated from the household survey of adult psychiatric morbidity (16).  Preventable outcomes of unsafe sex impacts were limited to specific diseases: Chlamydia, Gonorrhoea, Syphilis and HIV/AIDs. However, as 45% of HIV/AIDS

13 cases are associated with illicit drug use, for this purpose, HIV/AIDS outcomes associated with unsafe sex are reduced by 45%. While unplanned pregnancy may be a consequence of unsafe sex, this outcome was not considered. Using PAFs makes it possible to identify the potential health burden associated with each of the most common behaviour risks leading to poor health outcomes. The potential for health gain by the reduction of behavioural risks can be estimated as reduction in Disability Adjusted Life Years (DALYs), Years Lived with Disability (YLD) weighted for disability and Premature Deaths under 74 (PD) and Premature Years of Life Lost (PYLL) excluding infants. These different measures of health gain are important because they indicate the nature of the impact of prevention on health and care costs for the NHS, other social services and clients and their carers.  Disability Adjusted Life Year (DALY) estimates give a weight to disability agreed by an international jury of health administrators and compares Years of Life Lost with life expectancy in Japan (the highest in the world). DALY estimates are internally consistent and avoid double counting. They are estimated as years lost - a reduction in DALYs is a health gain. Quality Adjusted Life Years (QALYs) are based on patient surveys of the weight to be given to their quality of life, they are similar to DALYs reduced but can vary widely depending upon the measurement system applied and when and how patients are surveyed.  Years Lived with Disability (YLD) weighted for level of disability and PYLL can be estimated from the formula DALYs = YLD +YLL and estimates of the average age of death for relevant conditions. YLD provides a way of estimating the cost of care.  Premature Deaths (PD), estimated as deaths before 74, show the targeted risk factors account for some 38% of total premature deaths compared to the overall estimate taken from National Statistics mortality tables for England 2006 (17). The Population At Risk (PAR) identifies how many people are at risk of poor health as a consequence of a specific cause or behaviour. Estimates depend on how the level of risk is defined. For behaviour change interventions it is reasonable to include people with recognisable but only marginally elevated levels of risk, because at this level interventions can help people avoid long term problems by minor behaviour changes. Rates of health risk have been applied to population estimates for England in 2006.  Smoking prevalence rates for adults in 2006 are reported by the British Heart Foundation (18) as 23% for men and 21% for women, all smoking poses a risk to long term health.  The household survey (15) identified 24% of adults (33% of men and 16% of women) as at risk of alcohol abuse in 2007 as indicated by an Alcohol Use Disorder Identification Test (AUDIT) score of 8 or more and 4% of people at risk of major harm with a score of 16 or more. Addressing the needs of people with less severe alcohol risk will contribute to long term harm reduction.  The risk of poor diet and inactivity resulting in obesity was identified by the NHS Information Centre in 2005 (19) at 23% of men and 25% for women, 47% of obese men and 42% of obese women had some form of longstanding illness in 2003. In relation to local need factors PARs were identified as:  The household survey of adult psychiatric morbidity (16) shows that in 2007, 17.6% adults between 15 and 64 in England met criteria for one or more common mental disorders (CMD), more than half of these presented with mixed anxiety, depressive

14 and somatisation disorders, most would be unlikely to warrant any form of treatment, only 4% actually receive treatment. Women (19.7%) were more likely than men (12.5%) to present CMD. HTS helps clients to talk and to meet people, thus improving emotional wellbeing for people who would not be considered for any formal service. Clients with recognizable mental health problems would signposting to specialist mental health services.  Illicit drug use in the past year was identified by the household survey (16) as affecting 9.2% of people (12% of men and 6.7% of women) drug dependence was identified in 3.4% of adults - this falls to 0.9% excluding regular use of cannabis.  It is extremely difficult to estimate the number of people put at risk by unsafe sexual practices, clearly a great many people would fall in this category, if any occasion of unprotected sex were considered. However, if the at risk group is considered to comprise those who have unprotected sex with several partners a figure of perhaps 5% of adults between 15 and 75 seems to be indicated by the National Survey of Sexual Attitudes and Lifestyles carried out in 2000-2001 (20). With respect to low fruit and vegetable consumption and physical inactivity the same sources indicate that 2.7% and 3.2% of the burden of disease is attributable to these causes separately. However, an analysis of 1397 clients from Bradford HTS collected in 2008 indicate that clients were 20% more likely to identify their problem as weight control than as healthy eating problems. It is recognised that there are also problems of anorexia and other eating disorders as well as health risks from colon cancer and other factors not necessarily related to obesity. Physical activity and weight control also have many other benefits including emotional wellbeing and socialisation. These were taken into account in the later analysis of these factors.

Table 3 a: Total Potential Health Gain Estimates Per Year England Target Areas

Risk Factor % DALYs DALYs PYLL YLD P D PAR 2001 2005 2007 Smoking 12.7 800,000 480,000 320,000 41,000 8,200,000 Alcohol Misuse 4.4 277,000 96,000 181,000 8,500 9,600,000 Diet and Activity 7.2 454,000 192,000 262,000 13,000 8,900,000 Total these causes 24.3 1,531,000 768,000 763,000 62,500 Total all cause 100 6,300,000 2,400,000 3,400,000 165,000

When considering potential health gains with respect to locally identified client needs the field noted by all HTS consulted was emotional wellbeing. An important distinction was drawn between people with mental illness, for which HTS is generally not equipped and emotional wellbeing which was an issue for the majority of clients. In total mental illness accounts for 26% of DALYs, however, emotional wellbeing is only assumed to be relevant to specific long term mental health outcomes: non-psychotic disorders, depression and anxiety related conditions accounting for 7.8% of DALYs, excluding: post-traumatic distress, obsessive-compulsive and panic disorders, psychotic conditions such as schizophrenia and organic psychoses such as dementia and Alzheimer’s. This is therefore a conservative assumption.

15 Table 3b Total Potential Health Gain Estimates Per Year England Local Needs

Risk Factor % DALYs DALYs PYLL YLD P D PAR 2001 2005 2007 Emotional 7.8 490,000 57,000 433,000 2,700 6,500,000 Wellbeing Illicit Drug Use 1.4 88,000 24,000 64,000 2,000 3,400,000 Unsafe sex 0.7 50,000 12,000 38,000 1,500 2,000,000 Total these causes 9.9 628,000 93,000 535,000 6,200 Total all cause 100 6,300,000 2,400,000 3,400,000 165,000

The average health gains per year can be estimated for each person whose behaviour is changed to reduce their risk of illness or death, by dividing the total potential health gains by the population at risk in each field. This provides the basis for estimating the average impact of avoiding health risks per year for a targeted group of 1,000 people. It is important to note that avoiding health risk does not mean that people are returned to perfect health or healthy behaviour, only that they have on aggregate improved their health risk to move out of the “at risk” category. Table 4 sets out the potential for health gain in each of the fields covered by this review in the targeted fields 4a.

Table 4a: Potential Health Gain for 1,000 People Avoiding Health Risk Target

Risk Factor DALYs PYLL YLD P D

Smoking 97.6 58.5 39.0 5.0 Alcohol Misuse 28.9 10 18.9 0.9 Diet and Activity 51.0 21.6 29.4 1.5

The potential for health gain in fields of behaviour change identified by local services from Personal Health Plans, sometimes met by the provision of further training for Health Trainers, was as shown in table 4b.

Table 4b Potential Health Gains for 1,000 People Avoiding Health Risk Local

Risk Factor DALYs PYLL YLD P D Emotional Wellbeing 75.4 8.8 66.6 0.4 Illicit Drug Use 25.9 7.1 18.8 0.6 Unsafe sex 25.0 6.0 19.0 0.8

16 Health Gains Attributable to HTS Behaviour Change Support It is clearly unrealistic to assume that behaviour change has the same impact on everyone or that poor health outcomes can be completely eliminated. Behaviour cannot be turned on and off like a switch. Most behaviour change happens as people realise the need to gain control of their own life and health choices, over a period of time, as indicated by the Transtheoretical Model of behaviour change (21). Even modest first steps can help people to begin to take charge of their lifestyle choices and bring order to sometimes difficult and chaotic lives. This is particularly applicable to HTS clients. Estimates of health gain must consider the overall improvement in the probability of clients achieving better health, the extent of change they achieve and the likely persistence of the clients with better health choices. Personal Health Plan Goals ranged from stopping smoking and reducing anxiety to minor changes in diet and activity. Some initial changes may only have a limited impact on health but may motivate the client to achieve further change. The extent of change must also be considered in the light of the broad view taken of the population at risk. For people with minor health risks, relatively small changes may be sufficient to improve their health risk significantly. An analysis of scores for health outcomes before and after Health Trainer intervention drawn from the DCRS (1) is shown in table 5a:

Table 5a Pre and Post HTS Intervention Health Related Measures

Average values Sample Change Outcome size Before After (%) BMI 5778 - 4.90% Fruit & vegetable portions consumed per 5081 + 65.58% day Fried, high fat and snack portions 11585 - 78.33% consumed per day Alcohol 1928 - 45.32% Smoking 4128 - 60.09% Vigorous exercise 3038 + 105.95% sessions per week Moderate exercise 4100 + 35.71% sessions per week

These health outcome measures are also reflected in scores recorded for client’s perception of self efficacy health and well being as shown in table 5b. While the relationship between health risks and self assessment scores is complex, studies suggest that self reported health scores are relatively good indicators, at least of mortality (22). In the absence of definitive evidence the Stakeholder Panel assumed that health risk improvements reflect these scores.

17 Table 5b Improvement in Self Efficacy, Health and Wellbeing Scores due to HTS

Average values Health and Wellbeing Sample Change measures size Before After (%) Self Efficacy 6562 + 8%

General Health 6532 + 37%

WHO-5 3672 + 37.5%

On this basis an initial improvement in health risks of 35% has been assumed by the Stakeholder Panel for clients completing a behaviour change support process and achieving their Personal Health Plans, clearly this broad assumption could be refined as further evidence becomes available. HT behaviour change programmes motivate clients and help them to formulate their own Personal Health Goals and Plans. HTs record the field in which goals are set and whether clients feel they have partially or fully achieved these goals but not the extent of change involved. A study carried out in Wakefield showed that the percentage of clients who completed a behaviour change process stating that they were maintaining their Personal Health Goals was 85% after 3 months but fell to 71% after a year in a sample of 1226 clients. This is successful, compared to other behaviour change interventions. Nevertheless in discussion with the Stakeholder Panel it was decided that it is reasonable to assume that at the end of 5 years only 10-20% of clients would maintain their goals, though these might then persist for the rest of their lives. These assumptions are relatively conservative, they reflect the fact that the clients targeted are disadvantaged in many different ways and often live in difficult circumstances and are drawn from groups with high levels of poor health. Many other studies of health promotion interventions assume a lifetime of benefits based on outcomes after only a few months or weeks. It is important to bear this in mind when comparing a conservative assessment of HTS with claims made for other initiatives. Gains which occur in the future must be discounted to reflect the Social Time Preference Rate, which is currently set by the Treasury (23) at 3.5% per year. This discount rate reflects the fact that social benefits achieved now are considered more valuable than benefits that will arise in the future. This is calculated by multiplying health gains for each year from 1-5 by discount factors (0.966, 0.9335, 0.902, 0.871, 0.0842) to give the current value of gains discounted at 3.5%. Long term continuing health gains to age 80 are estimated by multiplying annual health gains by a another discount factor (e.g. for 30 years multiply annual gains by19.7 and for years 6-34 multiply by 15.25). The extent of health risk reduction assumed to arise from HTS must be offset against the propensity of clients to achieve the same level of health risk reduction without support. The Stakeholder Panel considered that this was unlikely to be high for the target client thus for the purpose of this assessment it is assumed that only 5% would improve their health to a comparable extent if clients were not supported.

18 Table 6a: Long Term Health Gain 35% Risk Improvement, 15% Persistence Target

Risk Factor Health Gain per 1,000 Clients

DALYs PYLL YLD PD

Smoking 112 67.1 44.7 5.7 Alcohol Misuse 33.2 11.5 21.7 1.0 Diet and Activity 58.5 24.8 33.7 1.7

Table 6b: Long Term Health Gain 35% Risk Improvement, 15% Persistence Local

Risk Factor Health Gain per 1,000 Clients

DALYs PYLL YLD PD

Emotional 86.5 10.1 76.4 0.5 Wellbeing

Illicit Drug Use 29.7 8.1 21.6 0.7 Unsafe sex 28.7 6.9 21.8 0.9

It was noted that while some HTS provide explicit support for emotional wellbeing it is also identified as a secondary issue for many clients. Some HTS commented that for up to 70% of their clients emotional wellbeing was an issue, figures from clients of the Bradford HTS showed that this was an issue for over 50% of clients, which is the figure accepted by the Stakeholder Panel and used in this assessment. The stakeholder Panel also considered the extent to which HTS provides support for emotional wellbeing as a product of interventions directed towards other primary PHP goals. There is no simple way of assessing this but based on experience the extent of emotional wellbeing health gain achieved in for such clients was assumed to be equal to 50% of the impact of HT services directly targeted at emotional well being, this nevertheless represents a significant health gain and cost savings to the NHS. This would add 22 DALYs, 0.25 PYLL, 19 YLD and 0.01 PDs per thousand clients in all categories, except of course emotional wellbeing itself. For clients who complete the behaviour change process but only partially achieved their PHP goals a broad estimate of health gains adopted by the Stakeholder Panel is based on the assumption that clients will achieve 50% of the gains of those fully achieving their goals. This is because a review of Personal Health plan Goals from the Wakefield study noted earlier shows they are very variable, some people set ambitious goals and in only partially achieving them change more than clients who set limited goals. And partial achievement still means that clients had taken a step towards a process of health improvement. Again this assumption may be varied to reflect local conditions and experience.

19 Cost Savings to the NHS Cost Savings from Behaviour Change Support Specific estimates of the costs to the NHS arising from behaviour risk factors have been established by rapid reviews of the evidence in each field. These have been updated to 2008/9 prices by inflating the figures to reflect increases in Hospital and Community Health Services (HCHS) prices for England. For the original HTS targeted fields:  The review of costs to the NHS of smoking related diseases drew on Smoking and Public Health 2004 (24) updated to reflect the ASH report “Beyond Smoking Kills”(25) and National Statistics for 2006 (26).  The analysis of the costs to the NHS of alcohol misuse took as its starting point the Cabinet Office Alcohol Harm Reduction Strategy (Cabinet Office Strategy Unit 2004) (27) updated from the work of Balakrishna et al (28).  The review of the NHS costs of obesity drew on Tackling Obesity in England (Comptroller & Auditor General 2001) (29), updated in response to the 2007 Foresight report “Tackling Obesity: Future Choices” (30). There are also reports available specifically focussed on the costs to the NHS of physical inactivity and inactivity, a 2007 study (31) of UK NHS costs arising from physical inactivity gave an estimate of £1 billion. A similar study of the cost arising from low fruit and vegetable consumption (32) gives an estimate of £6 billion. It would be possible to draw up similar estimates of the cost consequences of these health targets, but it would be extremely difficult to establish the relevant population at risk in these fields and there remains a danger of double counting. The figures suggest that estimates based on obesity alone are conservative. For fields of activity developed in response to local needs:  Evidence to examine the cost to the NHS related to emotional wellbeing included costs of uni-polar depression and anxiety from the Sainsbury Paper of 2003 (33) updated to 2008/9 and omitting children and the Kings Fund Study of 2007 (34) and the recent Department of Health, framework for wellbeing development (15) .  The review of the NHS cost of illicit drug use drew on the government “Drug Strategy for England” (35) and the household survey (16).  The review of the NHS costs of HIV and other sexually transmitted diseases drew on a range of resources including data from the National Institute for Health and Clinical Excellence costing report in this field (36) (37). The costs to the NHS for England identified in these reports updated to 2008/9 costs and adjusted where necessary to reflect the population of England are set out in tables 7a and 7b applied as a cost per DALY to the estimated health gains from HTS behaviour change programmes shown in table 6. These tables show potential saving to the NHS for each client completing a behaviour change programme assuming 35% improvement in health risks, 85% achievements of PHP goals in the first year and persistence falling to 15% after 5 years but then maintained by those clients until they are 80. The values suggested depend upon the assumptions and quality of data available. Local Commissioners must take their own decisions and may wish to assume greater or lower levels of savings based on local priorities and evidence.

20 Table 7a: Savings to NHS at 35% change 15% persistence Target

Risk Factor NHS Costs DALYs Potential Savings per Savings 2008/9 Savings per Client Support including £m DALY Emotional £ £ Wellbeing £ Smoking 2,800 800,000 3,500 392 524 Alcohol misuse 2,800 277,000 10,020 332 465 Diet and Activity 3,700 454,000 8,150 477 609 Total these causes 9,300 1,531,000

Table 7b: Savings to NHS per BCP at 35% change 15% persistence Local

Risk Factor NHS Costs DALYs Potential Savings per Savings 2008/9 Savings per Client Support including £m DALY £ Emotional £ Wellbeing £ Emotional Wellbeing 3,000 490,000 6,122 530 530 Illicit Drugs 1,000 88,000 11,360 338 470 Unsafe sex 600 50,000 12,000 344 477 Total these causes 4,600 628,000

NHS cost saving do not take into account the fact that people who live longer due to improved health may generate long term costs to the NHS, this is a health economics convention. To introduce this as an additional cost in this case would bias this assessment in comparisons with all other evaluations. However, if Commissioners wish to take this into account they may do so, relevant costs are estimated in table 7c by multiplying Premature Years of Life Lost (PYLL) up to age 74 by the average cost per capita of NHS services in 2008/9, which was £1,840. Table 7c Premature Years of Life Lost Saved and Increased NHS Costs

Risk Factor PYLL reduction per Long term cost increase to NHS per support due to 1,000 clients reduced premature deaths £ Smoking 67.1 123 Alcohol misuse 11.5 21.2 Diet and Activity 24.8 45.6 Emotional 10.1 18.6 Wellbeing Illicit Drug Use 8.1 14.9 Unsafe sex 6.9 12.7

21 Community Engagement, Mapping and Signposting There is a danger that assessing HTS in terms of 1 to 1 behaviour change support, could divert attention from the role of Health Trainers and Champions in wider community engagement and building social capital for disadvantaged communities and groups. Many studies illustrate the importance of engagement and social capital to health but this relationship is difficult to evaluate. Perhaps the clearest illustration was the estimate made by Derek Wanless (38) in 2002 that by 2022/3 a future in which the public was not fully engaged would increase NHS costs by 20% more than a future in which there was slow progress in this regard, he also noted this would increase personal social service costs by 10%. The Marmot review (6) also refers to the importance of social capital in addressing health inequality and estimates the cost of inequality as £5.5 billion to NHS England (6%) and £31-£33 billion in total to society. These savings, applied to 30% of the population of England (since the review suggests it is not just the most disadvantaged who benefit) indicate a potential saving per capita of £360 per year by reducing health inequality and improving access to health and social support. International studies also show that the development of positive social capital has long term impacts on health and wellbeing, some studies have tried to quantify this, for example Putnam (39) claimed that people who do not belong to a social group roughly reduce their risk of death over the next year by half when they join a group. This claim was confirmed in a study by Kawachi and Berkman (40) who found a strong relationship between per capita group membership and lower age adjusted mortality. Many other economic and social benefits have also been attributed to increased social capital (41). In this country the White Paper “Choosing Health” of 2004 (42) called for investment in Health Trainers and Champions not only to provide guidance and support for personal health improvement but also to promote engagement for disadvantaged and hard to reach groups and as a community resource linking people to NHS, Local Authority and community run services. At an early stage in the development of HTS, Social Movement Theory to achieve large scale change in health behaviours and the NHS (43) was a formative influence. Thus the activities of HTS in signposting people, connecting and supporting social groups to address health and other needs and mapping and communicating with social support structures are central to the objectives of HTS and have social and economic benefits that must be taken into account. The value of signposting can also be compared with other NHS brief interventions, for example short GP interviews for smoking cessation were estimated by NICE (44) to cost £112 in 2006, this may be updated to £120 in 2008/9 values. Health England (4) found examples of brief interventions for smoking cessation, alcohol advice and diet, activity and obesity support cost £11, £105 and £136 in 2007/8 These were shown to be highly cost effective and to save the NHS: £31, £123 and £3,301 per person generating health gains of: 0.009, 0.0233 and 1.52 QALYs per person. HTS communication and signposting is not intended to follow the model of health professional referral. It takes as its starting point client and community needs for disadvantaged communities and groups who would otherwise not access NHS, LA and community services easily. Thus if successful HTS signposting is considered (i.e. those that are followed by clients) the Stakeholder Panel proposed that HTS signposting should be considered as of equivalent value to Primary Care brief interventions, i.e. £120 for 70% of signpost that were expected to be taken up by clients, and to contribute to reducing the burden of disease for disadvantaged communities. It is important to be aware of the potential for double counting such benefits. In this case an assumption

22 might be made that services to which clients are signposted generate health gains of 0.0233 (the level claimed for alcohol advice see above). However, these health gains are the product of both signposting and the services to which clients are directed, thus only the additional benefits due to the impact on inequality by signposting disadvantaged groups has been considered as health gains attributable to HTS from signposting.

Table 8: Signposting from DCRS February 2010 sample size 11,738

Depending upon community needs, the services accessed and the effectiveness of HTS local Commissioners and Local Authorities may wish to assume a higher or lower value both in terms of value and health impact. It was noted that while some signposting, whether by Primary Care Teams or HTS is relatively limited in nature (just giving out a leaflet for example) other examples were found of much more extensive support to clients, taking time to explain and helping people to understand why and how to use services and sometimes accompanying them to services. Commissioners may wish to give a different value to such very different levels of service. All the HTS visited had undertaken mapping exercises to establish and maintain contact with local services provided by the NHS, LAs, Community Organisations and local groups at a very local level. They also participated in events and group meetings. This is essential to improve communications and engagement and build social capital. Such mapping, contact and engagement processes must be valued by Commissioners and Local Authorities based on local needs and circumstances. The Stakeholder Panel considered how much it would cost to maintain such contacts without HTS. For example, Health Visitor Services, Community Workers or Local Neighbourhood Teams or extension of Local Involvement Networks (funded at £0.5 per capita) could provide equivalents mapping and contacts. On this basis the Stakeholder Panel suggested that a value of £20,000 - £60,000 per annum could be attributed to mapping but local Commissioners may value this more or less depending upon local needs the quality of contacts and how they are used by the NHS and Local Authorities. Participation in local events and group meetings was also be valued at £120 per event or meeting to recognise this important aspect of engagement. It is essential to distinguish HTS support for engagement from full Community Development which, though linked, involves the creation of new groups and structures, requiring a wider range of skills.

23 Health Inequality

Disadvantage and Health For most of the health risks addressed by HTS interventions there is an association between disadvantage, hard to reach groups and health risk but it varies for each field of health behaviour and is more complex than might be supposed:  In 2006 29% of men and 27% of women in manual households smoked compared to 18% of men and 16% of women in non manual households (45). Smoking rates also vary between ethnic groups: general population 24% men and 23% women, Black Caribbean 25% m 24% w, Indian 20% m 5% w, Pakistani 29% m 5% w, Bangladeshi 40% m 2% w, Chinese 21% m 8% w, Irish 30% m 26% w according to the 2004 health survey for England (46).  Alcohol consumption measured as maximum daily consumption or days on which 3 or more units were consumed is significantly higher amongst non manual households than manual (47). Consumption by ethnic minority groups is also significantly lower than the general population for all ethnic minority groups except for Irish people (46)  Obesity is strongly linked to occupational class, in 1998 (48) 12 per cent of men in managerial and professional classes were obese compared to 20 per cent in the skilled manual group and 19 per cent in the unskilled class. For women the link was even stronger: 15 per cent of professional women were obese in England in 1998 compared with 31 per cent of unskilled women. The 2004 survey (46) found that 22.7% of men and 23.2% of women in the general population were obese. With the exception of Black Caribbean and Irish men (25.2%), men from minority ethnic groups had markedly lower obesity prevalence rates than those in the general population. Bangladeshi and Chinese men had the lowest obesity rates (5.8% and 6.0% respectively). Among women, obesity prevalence was highest in the Black Caribbean (32.1%), Black African (38.5%) and Pakistani (28.1%) groups, and lowest (7.6%) among the Chinese group.  Low fruit and vegetable consumption is related both to occupational class and the deprivation of the neighbourhood of residence (49) but in general ethnic minorities are more likely to eat recommended levels of fruit and vegetables. The 2004 survey (46) found that among men, 23% of the general population met the recommended guidelines of consuming five or more portions of fruit and vegetables a day. With the exception of Irish men, the proportion of men meeting the guidelines was significantly higher among all minority ethnic groups. Over a third of Indian and Chinese men met the five-a-day recommendation (37% and 36% respectively). Levels of consumption were lower in other minority ethnic groups: the proportion consuming five or more portions ranged from 26% among Irish men to 33% among Pakistani men. In the general population, a significantly higher proportion of women than men met the five- a-day recommendation (27% and 23% respectively). The percentage eating five or more portions was higher among Chinese and Indian women (42% and 36% respectively) than the general population.  With respect to physical activity, the 2004 Health Survey for England found that 44% of men and 30% of women aged 16-54 reached the recommended levels of physical activity for health benefits. Participation in sport and exercise and walking is related to social status, with men and women in non manual classes being more likely to

24 take part in these activities. According to the 1999 Health Survey for England men and women from minority ethnic groups based in the UK were less likely to be physically active at a healthy level. The lowest levels of activity were found in the Bangladeshi community, only 18% of men and 7% of women met the recommended physical activity levels 59% of men and 65% women from the Bangladeshi community reported no physical activity in the past four weeks. Lower levels of activity are also found in South Asian and Chinese men and women living in the UK. Black Caribbean men and women living in the UK are the most physically active, 37% men and 25% women met the recommended physical activity levels. For locally identified health improvement fields the relationship between health and disadvantage was as follows:  In relation to emotional wellbeing the most recent trend data shows a clear link between income and occupational class and health risk (50). Adults in the poorest 20% are much more likely to be at risk of developing a mental illness as those on average incomes: 22% compared with 9% for men and 24% compared with 16% for women. People from manual backgrounds are at somewhat higher risk of developing a mental illness compared to those from non-manual occupations. Self reporting of mental illness shows some variation between ethnic groups but it has to be borne in mind that there are strong cultural norms applying in this field. For the general population 2.8% of men and 3.4% of women over 16 reported a long standing mental disorder in the 2004 survey (46), amongst ethnic groups the reported levels were: Black Caribbean 2.7% m, 2.9% w, Black African 3.5% m, 1.7% w, Indian 3.3% m, 1.7%w, Pakistani 2.9%m, 4.9% w, Bangladeshi 2.1%m, 3.0% w, Chinese 0% m, 2.0% w, Irish 1.0% m 3.7% w.  The British Crime Survey of 2003-4 (51) shows that illicit drug use does not vary greatly by level of household income or social class, but unemployed respondents had higher rates of drug use than employed people. It appears that living in inner city areas, being young and male, going to nightclubs are the most relevant predictors of illicit drug use. The British Crime Survey of 2001/2 (52) found that amongst 16- 24 year-olds, levels of drug use were lower for black people than for those from a white or mixed background. Around a tenth of people from a white or a mixed background had used a Class A drug in the last year (10% and 8% respectively), compared with 2% of black people. A similar pattern was found for the 25-35 year old group.  The evidence for an association between unsafe sex and social class or ethnicity appears very limited. It seems more likely that unsafe sex is linked to lack of appropriate sex education as several commentators point out. Since HTS also have the objective of increasing social support and engagement for hard to reach groups it is also relevant to note differences in perceived levels of social support reported by the 2004 survey (46). This shows that while for the general population 16% of men and 11% of women reported a severe lack of social support, equivalent figures for ethnic groups show: Black Caribbean 25% m, 20% w, Black African 23% m, 23% w, Indian 29% m, 22% w, Pakistani 38% m, 30% w, Bangladeshi 35%m, 33% w, Chinese 30% m, 26% w, Irish 17% m 11% w. Moreover the disparity between the general population and minority groups in this regard was reported to have increased since it was last surveyed in 1999. This seems a more fundamental issue than any specific health deficit for these groups and is an important reason for HTS to address such hard to reach groups.

25 The Value of Reducing Health Inequality There are many Government and Departmental policies intended to address inequality in health and other fields and as noted, there have been calculations of the cost of lack of social engagement and the cost of inequality and even targets such as reducing the Index of Multiple Deprivation. So it is clear that addressing inequality is a national objective for World Class Commissioning and specifically for HTS, however, there are as yet no indications as to how much can or should be spent to reduce inequality. Perhaps the best indication of the value placed on health equality was given by the recent Health England (4) review of public health priority setting. This review conducted a “Discrete Choice” survey of 99 health Commissioners asking them to consider the priority of projects with different outcome in terms of cost effectiveness, reach and impact on disadvantage. These were measured as follows:  Cost effectiveness was measured as the net costs to the NHS of the project, after discounting projected savings for each QALY gained - £ cost per QALY (or DALY),  Reach of the project measured the proportion of the population affected by the intervention  Disadvantage impact was measured as the percentage of those affected in the most disadvantaged 20% of the population compared to percentage of overall population affected. From this survey they derived weights reflecting the value or “utility” that Commissioners gave to these factors. This produces a mathematical equation relating utility to the measures of cost effectiveness (C), reach (R) and impact on disadvantaged groups (D). The formula is given as follows: Utility = e(-0.0000586x C + 0.0435987 x R + 0.119895x D) This formula can be worked out with a calculator or spreadsheet (e = 2.71828) but would be very difficult to explain this to most decision makers. For example, a project producing one QALY (or reducing one DALY) for a net cost of £500 and reaching 1% of the population with no special focus on the most disadvantaged 20% would produce a utility of 1.1 whereas a project similar in other respects but with a focus solely on disadvantage people so that 5% of disadvantaged people were affected would have a utility of 1.77. For the range of values appropriate to HTS it appears that a focus on disadvantage adds value of about 30% to 60%. It might be better to use a simpler rule of thumb, to value impacts on the most disadvantaged 20% and hard to reach groups at say 50% more than impacts on those without disadvantage. This is a decision for local Commissioners but it may be helpful to provide indicators based on the Health England study. This could be applied by increasing the DALY value for services to disadvantaged groups or as a separate priority score. This health equity weighting can also be used to assess the impact of health gains from signposting, in this case it is possible to base cost per health gain only on the additional benefit of helping disadvantage people to access services.

26 Benefits to Other Stakeholders The following sections provide broad assessments of the social and economic impacts on other stakeholders arising from behaviour change facilitated by HTS. Commissioners may wish to consider their own estimates of such values and whether these savings to other stakeholders support a case for joint funding with Local Authorities and Offender Management Services. The possible impacts on Clients, Communities and Health Trainers and Champions are shown because they provide a context to the Commissioning decision. It is not suggested that the saving to clients can be added to other savings or that the value of qualifications to HTs should be treated in this way, but they illustrate the impact of HTS on these stakeholder and are therefore a relevant context. There are areas of overlap between these latter estimates and some areas in which experts would disagree as to their interpretation, these are clearly indicated. The estimate based on the social value of a QALY is relevant because it provides an upper limit to the investment decision, for if a the net cost of health gain were higher than this it would indicate that the cost to society would be higher than the value achieved. Local Authorities Health Trainer services contribute to Local Authority objectives and duties in respect of Community Wellbeing. In particular Local Authorities are taking a broad range of initiatives to develop social capital and address issues such as worklessness disadvantage and isolation. HTS also have implications for Local Authority expenditure on social care services for adults and in related field such as neighbourhood development and support for drug action, AIDS, sexual assault and alcohol harm reduction. The cost of these services funded by Local Authorities may be broadly estimated from the Department of Communities and Local Government Statistics (53). A crude allocation of the budgets relevant to health and social care for adults suggests that in 2008 net expenditure amounted to £5.4 billion. While it is obviously a very simple way of allocating these costs, it is reasonable to suggest that they reflect Years Lived with Disability, weighted for disability, each YLD resulting in social care costs of about £1,588. As health gain will result in reductions in YLD, this will produce savings in LA expenditure. Commissioners may wish to examine the case for joint funding in more detailed local reviews as the scope for mutual benefit and savings clearly depends upon the way local agencies work together in these fields.

Table 9a Estimate of Social Costs Saving to Local Authorities Target

Risk Factor YLD Social Reduction in Savings to LA Savings to LA Care Cost YLD per 1000 Social Care per Social Care Impact BC support at BC support £ including Emotional per YLD £ 35%/15% Wellbeing £ Smoking 320,000 1,588 44.7 71 101 Alcohol misuse 181,000 1,588 21.7 34.5 64.8 Diet and Activity 262,000 1,588 33.7 53.5 83.8 Total these causes 763,000 1,588 Total all cause 3,400,000

27 Table 9b Estimate of Social Cost Saving to Local Authorities Local

Risk Factor YLD Social Reduction in Savings to LA Savings to LA Care Cost YLD per 1000 Social Care per Social Care Impact BC support at BC Support £ including Emotional per YLD £ 35%/15% Wellbeing £ Emotional 433,000 1,588 76.4 121 121 Wellbeing Illicit Drug Use 64,000 1,588 21.6 34.3 64.5 Unsafe Sex 38,000 1,588 21.8 34.6 64.8 Total these causes 535,000 Total all cause 3,400,000

Offender Management Services Health Trainer Services working in the field of offender management generate health gains and hence savings to the NHS and address the needs of a disadvantaged group. It is also recognised that health and emotional wellbeing are important pathways to reducing reoffending, which is the largest determinant of costs to the Criminal Justice System (CJS) and the wider social costs of crime. The total population of offenders in prisons in England and Wales in 2008 was 83,000, about 5% of whom are women. The total number of people in the Offender Management System included those on pre and post release supervision - 56,000 and offenders under a court order – 147,000 (54). Of the offenders over 18 released from prisons: about a quarter were formerly in some form of care. Many have low levels of literacy and numeracy and a variety of learning difficulties and disabilities including dyslexia, 50% have reading skills at or below that of an 11 year old, 7% have an IQ of less than 70. Nearly half of all males and one third of females in custody were excluded from school and 50% of male and 70% of female offenders achieved no qualifications at school or college. Prior to conviction, two thirds were unemployed, and one third homeless. On entering prison more 70% of prisoners had drug abuse problems and infection rates of HIV and hepatitis C are between 15-20 times those of the general population. But 80% of them had never had contact with drug treatment services (55). Nearly three quarters of prisoners in custody suffer from two or more mental disorders. On release from prison over 40% lose contact with their family and over 50% are not registered with GPs or dentists. Probation Services priorities are to protect the public and support the courts, focussing on serious offenders. Two thirds of those released from prisons receive no statutory support other than the release grant of £47, those who have served more than 12 months in prison and are over 21 are given probation orders. A larger number of offenders are not given a prison sentence but receive Supervision and Court Orders, that could require them to undertake unpaid work, attend the Probation Office and/or attend courses such as anger management and consequential thinking skills, for this group Probation Services start at 18. On average 67% of ex-offenders re-offend within 2 years. Young adults are most likely to reoffend but most achieve some level of normalisation by their early thirties, though 10-15% of offenders continue in “a life of crime”. Highest rates of reoffending (90%) are committed by those with drug treatment and testing orders.

28 Without minimizing the responsibilities of offenders for their behaviour, it is apparent that a great deal of reoffending reflects failures of care, education, health and offender management services. Joint efforts to address reoffending offer both potential economic and social benefits and the fulfilment of a duty of care to the individuals and society The target for reducing reoffending rates set for the National Offender Management Service, when it was created in 2004, was to reduce the rate of reoffending by 10% by 2010. Key aspects of policy were to create local partnerships including with the NHS and Local Authorities and to address the 7 pathways to reducing reoffending: accommodation, education, training and employment, physical and mental health, drugs and alcohol, finance, benefits and debt, children and families and community and attitudes thinking and behaviour. Offender Management Health Trainer Services (OMHTS) respond to this policy and address issues relating to: physical health, drugs and alcohol and mental wellbeing. Evidence suggests that reoffending behaviour change programmes can reduce reconviction rates by 14%, and alcohol and drug addiction services can reduce reconvictions by 11% (56). A study of support for released prisoners, which included enabling them to open a bank account, showed rates of reoffending reduced to 35% (57). An economic evaluation of a programme in which offenders were mentored and supported by ex-offenders, showed reductions in reoffending of 40% and benefits of at least £10 for every £1 spent (58). This suggests OMHTS can be expected to reduce reoffending behaviour by at least 10% above the predicted level for its clients. The total cost of crime to England and Wales estimated in 1999/2000 (55), adjusted for the retail price index, suggests the total economic cost of crime in 2008/9 was £75 billion, of which about £15 billion relates to costs of the CJS including the police, courts, prison and probation services. It has been further estimated that £11 billion costs to CJS relate to reoffending (56). On average each reoffending prisoner is estimated, by the Cabinet Office paper of 2002, to generate costs to the CJS of £65,000 (56) per year in 2008 values. Even assuming that OMHTS clients have a lower propensity to reoffend, say 50% and if OMHTS support reduced their reoffence rate to 45% on average, each OMHTS behaviour change process would, on average, generate saving to the CJS of £3,250 per year, which is the value of such a service to the Criminal Justice System. If economic cost to society are commensurate with these gains, based on the 2000 study (55) total impact would be over £16,000 for each behaviour change support process completed. While the last figure includes a broad range of social costs, even on the basis of savings to the Criminal Justice System OMHTS must represent good value for money, if it can achieve appreciable reductions in reoffending. This is before considering any health gains, savings to the NHS or impact on equity. Commissioners will wish to take their own view of the assumptions and estimates used in this assessment but it does suggest that by any standards and whatever reasonable assumptions are applied, this service offers outstanding value for money. It also shows the great potential for extending joint working by Offender Management Services, the NHS and Local Authorities with community organisations. The approach may also have great potential value if applied to support other offenders within the system and/or matching it with other elements of Offender Management and social support to provide an integrated approach to the seven pathways to reduce reoffending.

29 Clients HTS have major long term financial implications for clients because improved health can reduce expenditure on addictions like cigarettes, alcohol and drugs, reduce the need for informal care due to infirmity and improve employment income. Expenditure on cigarettes is estimated by reference to figures published by the UK Tobacco Manufacturers Association giving a total of £13.1 billion or £1,600 per smoker. Expenditure on alcohol above the recommended guidelines (25%) is assumed to be consumed by the population at risk plus average per capita consumption, updated by reference to “Consumer Trends ONS 2009” (59), and trends since then (basically consumption has decreased and prices have increased). This gives an estimate of £17.2 billion or £1,792 per excessive drinker. Expenditure on illicit drugs is very difficult to capture the suggested figure is updated from a paper by Edward Bramley-Harker in 2001 (60) to give an estimate of £7.6 billion or some £2,235 per user per year. These figures are the average for people at risk, for those with serious addictions the cost will be greater. The increased health risk also increases the risk of having to live with disabilities requiring informal care in the home in addition to any long term residential care. The informal care costs for families arising from health risk behaviour have been estimated by apportioning the total cost of informal care on the basis of Years Lived with Disability weighted for disability -YLD. Estimates of the total cost of informal care were updated from the 2007 report by Carers UK (61) which calculates the total value of informal care for England at £70.5 billion in 2006/7 values based on a replacement cost of £14.5 per hour but for the current review it was assumed that carer time should be valued not at replacement labour cost but at a leisure cost of £5.5 per hour in 2008/9, this gives a total cost of £26.7 billion in 2008/9. On this basis it is possible to estimate the savings to clients from attending a behaviour change support process assuming that on average they achieved a 35% change persisting in 15% of cases after 5 years. Table 10: Savings to Clients and Savings from HTS Behaviour Change Support

Risk Factor Expenditure Informal Care Cost per Lifetime costs Savings to a on Products per person at person at discounted to Client of HTS per person at risk per year risk per current BC 35/15% risk per year £ year values £ £ £ £ Smoking 1,600 306 1,906 37,548 2,186 Alcohol misuse 1,792 148 1,940 38,220 2,225 Diet and Activity 231 231 4,551 265 Emotional 523 523 10,304 610 Wellbeing Illicit Drug Use 2,235 148 2,383 46,947 2,733 Unsafe sex 149 149 2,935 171

This shows the average values of a behaviour change support to clients, with the probability of achieving behaviour change over five years and over the long term as assumed in the central case. It does not imply they would be prepared to pay this amount. The cost per person at risk provides an argument that could be explained in simple terms to clients.

30 Health risk behaviour also generates significant costs for employers. A previous study (11) estimated the total annual costs to employers from health risk related absenteeism and lost productivity (called presenteeism i.e. impaired performance at work). Updating these figures to 2008/9 shows annual costs to employers: from mental wellbeing £3,523 million, from smoking, £4,624 million, from alcohol misuse £3,523 million, from poor diet and activity £3,523 million, from illicit drugs £1,100 million and as a consequence of unsafe sex £308 million, a total of £8,300 million. These costs estimates may be compared to estimate of the cost to the economy of working age ill health estimated by Dame Carol Black’s review at over £100 billion in total (62). Estimates of costs to employers could be used to generate savings per behaviour change to employers. In this light these estimates are very conservative. Note that some economists argue that expenditure on products should not be regarded as economic costs because they deliver value (pleasure) to the consumer, but this does not take into account the addictive nature of these products. It is also argued that these expenditures are transfer costs (i.e. they transfer value to others in society who make and sell the products), by this reasoning drug dealers would be the beneficiaries of such transfers. Alcohol and cigarettes expenditures include significant transfers to central Government in the form of taxes and duties. It is also fair to say that while presenteeism is accepted in the US not all UK economists agree. Taking these factors into account these figures should be seen as a context to Commissioning rather than direct economic impacts. The seven pathways addressed by Offender HTS: accommodation, education, training and employment, physical and mental health, drugs and alcohol, finance, benefits and debt, children and families and community and attitudes thinking and behaviour, remind us that many of the clients of other HTS feel trapped by these same factors. By helping people to develop the confidence to address their health and lifestyle choices – as measured by self efficacy scores, HTS can help clients begin to address some of these issues and to feel in control of the lives and choices, while it is impossible to value this it lies at the heart of wellbeing and the contribution of HTS. It also indicates the possibilities for further development of services.

Communities For Communities the impact of poor health in terms of the pain and grief caused by illness and death is not an economic cost in the conventional sense, but it represents values for which people would be willing to pay. These are sometimes called the human values of health. In discussion with Professor Cam Donaldson it was suggested that a reasonable estimate of the value of a QALY gain or DALY reduction, pending the outcome of current research, could be based on the upper estimate of the non fatal injury value derived by from the Department of Transport willingness to pay survey of 1992, (63) which in 2008 prices gives an estimate of £27,000. As this estimate is for non fatal injury it does not imply permanent loss of earnings. The values derived from this analysis are not economic costs in the sense that they could be realised as gains to the economy, they do, however, represent the potential value to society. This is close to the figure used by the National Institute of Health and Clinical Excellence of £30,000 used as a threshold in evaluating the cost benefit of interventions – though in practice a range of between £20,00 and £70,000 may be used. Applying this value to the estimates of health gain would suggest the values shown in table 11.

31 Table 11: Human Values to Communities per Behaviour Change Support Process

Risk Factor Human Values of DALYs reduced Human Values of DALYs per client support reduced per client support £ including emotional wellbeing £ Smoking 3,024 3,608 Alcohol misuse 896 1,408 Diet and Activity 1,580 2,164 Emotional Wellbeing 2,336 2,336 Illicit Drug Use 802 1,386 Unsafe sex 775 1,359

Commissioners may wish to regard these values as upper threshold limits because if, after taking into account the cost savings indicated in previous sections, costs per behaviour change process completed were above these values then the cost would be greater than the value to society and would be beyond the NICE threshold. There may also be more direct economic benefits to the community organisations hosting HTS arising from transfer costs of rents and management charges to HTS. Health Trainers and Health Trainer Champions HTS offer a route to training, qualifications and work for people with little previous qualifications or work experience most often from disadvantaged groups. The national qualification that is recognised for Health Trainer Champions is the Royal Society of Public Health Understanding Health Improvement (UHI) Award at level 2 of the National Qualifications Framework (NQF). At the time of writing, the UHI is in the process of being transferred to the new Qualifications and Credit Framework (QCF). To be recognised as a Health Trainer individuals are required to achieve the City and Guilds Certificate for Health Trainers at level 3 of QCF. While it is difficult to put a value on the lifelong impact of qualifications at level 2, a recent study found that the impact of a attaining level 3 qualifications is considerable, with an estimated increase in earnings of £8,740 per annum after 7 years, though it should be noted that this estimate seems high and was based on a small cohort (64). Over a period of ten years it would produce a flow of increased income worth over £45,000 after discounting to current values at 3.5%. Even half this level is a very significant value to HTS trainees. Skills for Health, the Sector Skills Council for Health, have now managed to gain Train to Gain funding for the C&G Health Trainer Certificate. Train to Gain’s unit cost per learner was estimated as £970 (not including employment costs of trainees) in a report by the National Audit Office in 2009 (65). While some Commissioners appear to take these values into account and see considerable benefit in providing routes to work for disadvantaged people, others do not seem to value this so highly and may not be so assiduous in selecting Health Trainers and Champions from disadvantaged groups. However, it was reported by delegates at the UKPHA 2010 national conference that in such cases they often experience costs and continuity issues due to higher levels of staff turnover. As noted previously these figures provide a context to Commissioning decisions but are not conventional economic benefits to offset the cost of services.

32 Applying Assessment Commissioning Decisions Commissioning decisions are complex, they depend upon national and local priorities and conditions. Thus it is important to note that there is no single formula to determine what value for money means for all Commissioners. It may be helpful to start by discussing the objectives and outcomes of HTS set out in Table 1 of this note with PCTs, Local Authorities and Communities in the light of local priorities and needs. Local service evaluations can be very useful in setting out a description of the way HTS services operate and providing facts and figures and assessment of qualitative factors such as management, responses of clients and feedback from Health Trainers and Champions. This can be supported by a quantitative analysis of value for money as set out in table 12. It is important to ensure Commissioners understand how this has been developed and that they accept or adapt the assumptions and data which lead to these values.

Table 12: Value for Money Assessment for Commissioners using Central Values Impacts Number Health Total Value or Total Gain per Health NHS value or 1000 Gain Cost saving DALY DALY saving £ per unit £ BC -Smoking 112 524 BC - Alcohol 33.2 465 BC – Diet and Activity 58.5 609 BC – Emotional Wellbeing 86.5 530 BC – Other 29 470 Engagement and Mapping 40,000 Signposting and events 23.3 120 Local Authority savings 65-121 Offender Man’t Services 3,250 Other considerations Total Cost Savings Total Cost of HTS Net cost per DALY Health Equity adjustment % disadvantaged HELP weighted Local DALYS weighting Net cost /weighted DALY

In table 12 the central assumptions established by the Stakeholder Panel have been applied. The numbers of impacts of other interventions would be based on clients achieving relevant PHP goals and 75% of those partially achieving such goals. Note also that the number of impacts of emotional wellbeing would include 25% of all other behaviour change interventions on the assumption that these also contribute to

33 emotional wellbeing. The estimates for “Other” interventions are based on behaviour goals for illicit drug. To apply these estimates and assumptions to local HTS it is simply necessary to estimate:  The cost of the service (usually contract value less VAT and development costs)  The numbers of behaviour change processes completed by PHP primary goal  The numbers achieving their goals and those partially achieving them  Contacts and activities including mapping, events and communications  The number and types of signposting/ referral and rates of take up.  The numbers of offenders and cost to Offender Management Services.  The % of clients from the most disadvantaged groups.  Any local variations in assumptions about the extent and persistence of behaviour change, the value of Community Development, Signposting and Events, the value placed on addressing disadvantage and other variables. The number of clients achieving behaviour change PHP goals in a full year plus 50% of those partially achieving them in each field can be multiplied by the estimate of NHS Savings per behaviour change process to generate NHS savings. This can be added to the value of signposting and events by multiplying assigned value by the number of clients. If appropriate an agreed value should then be added for mapping, engagement and social support activities. This total value is subtracted from the annual cost of the HTS service (note that all costs should exclude VAT which is a transfer cost to government) to give a net cost to the NHS. Any value added to other public sector partners can then be taken into account, whether or not the service is jointly funded. This will give a net cost that can be compared with the DALYs generated by behaviour change and any other benefits such as reductions in costs to clients and employment for HTS taken into account. The total value of health gain should then be adjusted to reflect the impact on health equity, perhaps by increasing the notional value by 30-50%. The cost per DALY can thus be compared to cost per QALY calculations for other aspects of health and care services. This may well be negative indicating that the service generates great cost savings than its own cost. Comparison with other Health Promotion Initiatives The Health England study (4) provides a basis for comparing the priority of HTS with other interventions. The study evaluated 14 interventions in diet and physical activity, alcohol, smoking, STI and teenage pregnancy, mental health and use of statins against the following criteria: 1. Cost effectiveness: Cost per QALY gained, including the healthcare costs avoided and quality of life gains associated with the long-term health impact. 2. Reach: The proportion of the total population benefitting for the intervention. 3. Inequality score: The ratio of the proportion of the most disadvantaged 20% of the population eligible for the intervention to the proportion of the whole population eligible for the intervention.

34 4. Affordability: The budget required to fund the intervention if all eligible people received the intervention These measures can be established for Health Trainer Services to provide a base line for comparison with other services. However, it is important to note that this review has taken a relatively conservative approach to measures of cost effectiveness that is often not followed by other studies. There are no established standards for such reviews so comparisons of “costs per QALY” may have little validity. Many studies fail to take into account the clients’ underlying propensity to change and assume that lifelong benefits result from behaviour change observed over a short term, not allowing for subsequent reversion to habits or the need for further intervention. For example studies of smoking cessation may be based on quit rates after 4 weeks and as Mark Twain observed, “Giving up smoking is the easiest thing in the world. I know because I've done it thousands of times.” Uncertainty and Sensitivity Value for money figures are obviously based on a great many estimates, which have the potential for errors and so it is more appropriate to say that value for money is assessed within a 20% range rather than to attempt to specify uncertainty limits. This would arise if cost had been under estimated by 10% and benefits over estimated by the same amount or vice versa. Throughout this review a cautious approach has been taken to cost estimates drawing on two different sources wherever possible and adopting a relatively conservative approach to the estimates. It would have been possible to quote higher estimates of potential health impacts since in many instances there are estimates available that double count health gains. Estimates based on the WHO Population Attributable Fractions used here may be inaccurate but in total they are conservative because they avoid double counting. The outcomes of any value for money study involving the projection of potential health gains depends upon the assumptions made about the extent of health improvement, the clients’ likely persistence in behaviour change and the extent to which people would have changed without the intervention. These have been based upon the judgement of a Stakeholder Panel of Commissioners and Providers with experience in the field. However, it is impossible to know the future and therefore, while this review quotes a central value it is also be useful to explore the impact of different assumptions about these factors. Table 13 sets out the value of savings to the NHS and health gains assuming a 20% change in health risk rather than 35% and 20% and 10% persistence in long term change rather than 15%. This tests the sensitivity of outcomes to different assumptions.

Table 13a: Health Gain and NHS Saving: 20% change 20%, 10% persistence Target

Risk Factor Health Gain per 1000 BCP DALY NHS Savings per BCP £ 20% HR 20% Per 10% Per 20% HR 20% Per 10% Per Smoking 64 142 982 224 498 285 Alcohol Misuse 19 42 24 190 423 242 Diet and Activity 33 74 43 272 607 347

35 Table 13b: Health Gain and NHS Saving: 20% change 20%, 10% persistence Local

Risk Factor Health Gain per 1000 BCP DALY NHS Savings per BCP £ 20% Cge 20% Per 10% Per 20% Cge 20% Per 10% Per Emotional Wellbeing 49 110 63 403 674 386 Illicit Drugs 17 38 22 193 429 246 Unsafe sex 16 37 21 197 438 251

This table is before considering the impact of emotional wellbeing improvement arising for people with other primary Personal Health Planning Goals. Clearly the figures could be reworked for any number of combinations of assumptions. Commissioners may wish to consider the impact of different assumptions and local values. While this requires some arithmetic all figures necessary for such calculations are available in these notes. Accuracy and consistency of such value for money assessments could be improved by developing Population Attributable Fractions for England and by establishing clearer guidelines and tools for the estimation of cost impacts and value for money evaluation. It would be useful to establish a consensus group to ensure greater consistency in value for money studies to help Commissioners apply the approach suggested by World Class Commissioning. This is a task for the National Centre for Health and Clinical Excellence and Health England and this study has drawn this issue this to their attention. This assessment has drawn on evidence from international sources regarding the burden of health, national statistics and morbidity data, estimates of costs to the NHS and to other stakeholders, research studies of similar interventions, activity and cost data from national and local sources and equally important the expert judgement of the Stakeholder Panel based on their experience. While it is important to be aware of the shortcomings of all forms of evidence the World Health Organisation’s Knowledge Management for Public Health initiative (KM4PH), for which the author served as rapporteur, stresses the need to draw on all these sources of knowledge for public health (66). The old fashioned view that evidence can only be found in research studies and reports is convenient for academics but a hindrance to public health development. Assessments of value for money in Public Health often focus on the difficulties of the data and lack of evidence and therefore to retreat to broad descriptive assessments that avoid any commitment. This assessment has attempted to provide the best interpretation of the evidence and knowledge that is available and to provide clear answers. This does not mean that methodological and data difficulties have somehow been overcome. It is important to ensure that those who use such assessments understand these constraints and can explore alternative evidence and assumptions. No doubt much of this can be improved as further evidence becomes available, but you have to start somewhere. As Major Greenwood (67), a more eminent predecessor of mine at Cambridge remarked: “Making the best the enemy of the good is a sure way to hinder any statistical progress. The scientific purist who will wait for medical statistics until they are nosologically exact is no wiser than Horace’s rustic waiting for the river to flow away”.

36 Case Studies to Test the Assessment Method In this section the assessment method is applied to 5 case studies selected by the Stakeholder Panel to provide a range of examples of Health Trainer Services. The Panel suggested several other possible case studies but these proved to be beyond the budget for the review, which had originally intended to encompass only 4 case studies. Thus the review cannot claim to have examined all types of HTS and these trial assessments only apply to the selected examples. It is also important to distinguish these brief case studies to try out the assessment method agreed by the Stakeholder Panel, with an input of two days for each, from full local service evaluation requiring a much greater input. The criteria for selecting HTS for case study review were that they should be relatively well established, represent a range of different types of service in terms of commissioners, providers and services provided and should make use of DCRS (for ease of data collection). In the event it proved to be necessary to use local data in many cases since DCRS was either unavailable or inconsistent with local data. The Health Trainer Services used to try out the assessment method were as follows: A. An Inner City HTS providing a range of services funded by a PCT and managed by its Community Health Public Health Development Group. B. Community Support HTS: an urban HTS funded by a PCT and provided by a Community Enterprise, encompassing a range of community based services. C. Rural Communities HTS: serving largely rural communities, though including some areas of urban deprivation commissioned by a PCT in partnership with other agencies, provided by a partnership of social enterprises. D. A jointly funded urban HTS funded by a PCT and a Local Authority, commissioned by the PCT and provided by a social enterprise E. An Offender Management Health Training Service (OMHTS), funded by several different PCTs with management input mentoring and support provided by the Offender Management Service.

A. Inner City Health Trainer Service Services This service was set up in 2005 from an existing health education programme it started recruiting and training health trainers in 2006. Its initial objectives were focussed on community development and signposting, later extending to include 1 on 1 motivation support. The services are funded and commissioned by a PCT and managed by the PCT’s Community Health Public Health Development Group. Services originally focussed on physical activity and healthy eating but now provide support for a range of needs defined by clients including smoking and sexual health and some more specialised emotional wellbeing support. Health trainers are well integrated in a wide range of community health programmes, visiting events and groups for contact and signposting, as examples: working with a football club on a workless project, delivering condoms to sauna’s, they also spend some time with community activities e.g. as walk leaders and occasionally will visit disabled clients. Services are focussed on the 10 most disadvantaged wards in the City as defined by IMD and on BME groups and are based in host organisations that provide specific aspects of community health support (but not primary care). Clients are contacted by self referral, through host organisations and events as well as some referrals from other Public Health and Primary Care agencies.

37 Resources On a stable state basis the service contract cost was £615,000 per year in 2008/9. HTS were provided by 19 Health Trainers who provided 15 WTE input about half were from BME groups and for about half of them HT was an important route to work. The HTS has recently recruited and provided training for Health Champions but they are not yet fully operational so their cost and outcomes have been excluded. Services were managed by input from senior PCT staff plus Programme Manager, Support and administration staff. Outcomes According to data provided by the service providers 696 new clients were supported in 2008/9 with a total of 2,688 contacts. It appears that 566 clients were supported in behaviour change with up to 6 sessions each during a 12 month period. Of these clients 8 had primary goals relating to smoking, 7 relating to alcohol, 235 in relation to diet, 276 related to exercise, and 31 relating to emotional wellbeing. Of the behaviour change clients for whom evidence was available, 44% stated they achieved their PHP goals and 38% said they partially achieved them. Signposting support was given to 130 clients, who were signposted as follows: exercise referral 38, HP services 10, Community groups 59, GPs 6 and not specified 17. Health Trainers also attended 413 events including: community groups, parents groups, health walks, open days, health promotion events, local clubs, religious groups, sports groups tenants groups and women’s and men’s group. As HTS appeared to be very well integrated with other aspects of health promotion and to a lesser extent Local Authority Services this aspect has been valued at £60,000. Services are highly focussed on high IMD wards and communities. Clients from the most deprived quintile of IMDS postcodes are recorded in DCRS as 79.5% of total clients using the service. Applying the assessment method These estimates can be used to assess the likely value for money of this HTS as defined by the assessment method agreed by the Stakeholder panel. Applying these figures suggests  Health gain from behaviour change and signposting would be 25 DALYs  Net cost to the NHS after savings and offsets of £303,00 would be £312,000  Savings to Local Authorities would be £24,000  Net cost of the service would be £288,000 per annum  Net cost per unweighted DALY would be £11,600  Net cost per equity weighted DALY would be £8,100 to £8,300 This could be considered reasonable value for money, it is within the range of threshold values applied by NICE and would compare with other interventions included in the Health England comparative table of public health interventions. Local Commissioners might value the service more highly taking into account the value of engagement and communications with local communities and the benefits of providing a route to work for HTs. It also seems likely that the extension of this service including the use of Health Champions will improve the value for money further.

38 B Community Support HTS Services This service was conceived in 2006 and started operations in 2007. It is funded by a PCT and provided by a Community Enterprise working with local community host organisations that provide support for disadvantaged groups. Its objectives start with the views of communities of place and their need for health and wellbeing, rather than a focus on health needs or services per se. Its services are focussed on economically deprived neighbourhoods as defined by IMR, BME groups, Carers, Homeless, Drug and Alcohol Users plus probation and prison HTS. Services provided include one to one behaviour change programmes plus a wide range of community development activities. Clients are contacted largely by self referral and through host organisations and events, there were no referrals from Public Health or Primary Care. The service avoids being too closely identified with Public Health or Primary Care but is a community based resource. The development of the Community Health Atlas, sometimes sold (for example to Pharmacists) was illustrative of an impressive community based approach to health and development. However, this strength may also indicate a weakness in the lack of health promotion engagement. There was only 1 referral to this service from NHS sources in 2008/9. Resources On a stable state basis the service contract cost is estimated at £280,000 per year in 2008/9. (total cost was £284,000 however, about £4,000 of this related to service development). The front line services are provided by 17+ people who provide 10 WTE input at HT level and 4 people who provide 1½ WTE input as HCs plus 5 offenders working with the Probation Service and providing 1.3 WTE and 5 prison inmates providing 3 WTE. They are managed by a Programme Manager a Coordinator plus an Administration and Data support staff. There are also 10 trained Health Champions working in Children’s Centres, but while they have links with Health Trainers they do not operate as part of the team nor do they provide data. Outcomes According to data provided by the service providers 293 new clients were supported in 2008/9, 145 were self referrals (including as a result of leaflets), 41 from third parties including probation officers and host organisation staff, 1 from NHS sources and 98 from other sources. Behaviour change support was provided for 73 clients 8 with primary goals relating to smoking, 7 to alcohol, 33 in relation to diet, 20 related to exercise and 5 relating to emotional wellbeing. Of the 29 behaviour change clients for whom evidence was available, 38% stated they achieved their PHP goals and 31% said they partially achieved them. Signposting support was given to 190 clients. Clients were signposted as follows: addiction counselling 5, homeless centres 2 community services 1 alcohol and drug services 10, dentists 69 GPs 19, gym 24, leisure centre 15, helpline 1, stop smoking19, other NHS 4 and other support19. Health Trainers also attended 20 external events and 8 internal events, 33 community groups are regularly visited, it is not clear how many events this means in total 720 have been assumed, nor is it clear how many of these groups and events were initiated by HTS. Services are highly focussed on high IMD wards and communities. Data recorded on the DCRS is rather different showing a lower level of clients achieving or partially their personal health plan goals this may be because of timing differences. Clients from the most deprived quintile IMDS postcodes are recorded in DCRS as 41% of the total, this was increased by 30% for offenders.

39 Applying the assessment method These estimates can be used to assess the likely value for money of this HTS. As the data are confused, it has been assumed that the number of Offenders (including clients of Prison and Probation Service based HTS) is broadly 30% of the total, suggesting that about 22 Offenders would be engaged with some form of Offender Management Health trainer Service and that about 8.5 of these would achieve their PHP goals. Costs to OMS have been assumed at £5,000. It has been assumed that while Community Development is a high priority, the value of work in this field for the NHS is not fully realised since their appears to be little contact with NHS or Local Authority services, (though it could also be argued that a community approach demands such an independent perspective). This aspect has therefore been valued at £40,000. Since these are the areas with the highest value for money assessment it is important to recheck these assumptions. Applying these figures suggests  Health gain from behaviour change and signposting would be 4.5 DALYs  The net cost to the NHS after savings of £162,000 would be £118,000  Savings to Local Authorities would be £2,800  Savings to the Criminal Justice System would be £22,000  Net cost of the service to the Public Sector would be £93,000 per annum  Net cost per unweighted DALY would be £21,000  Net cost per equity weighted DALY would be £16,000 On this basis this service offers value for money which would be close to the NICE limit of £20,000 per unweighted DALY, and would be relatively costly in relation to other public health interventions shown by Health England. However, the focus on disadvantage and in particular the impact of Offender Management HTS as part of this service makes it more acceptable after weighting DALYs for equity. Taking into consideration all other possible impacts such as the benefit of providing a route to work for Health Trainers and/or making more generous assessments of the value of support for Community Development, would give a marginally more positive outcome, but it is difficult to understand how each WTE HT only manages 1 to 1 behaviour change for 6 people, signposting support for 17 people and attendance at 60 events on average per year. In subsequent discussion with the service provider it was noted that this was regarded as a start up period in which training and service development was a priority. They are now performing significantly better. C Rural Communities HTS Services This Community Development Service was formed in late 2006 by partnership between public and voluntary sector organisations bringing together a number of linked projects and volunteer programmes to address health inequalities in the most deprived neighbourhoods of a largely rural county. Its HTS component aims to work with individuals from targeted communities to carry out lifestyle risk assessment and enable them to achieve changes in their behaviour. This also involves bringing these people into more effective contact with community groups and health improvement services. Health Trainers provide 1 to 1 behaviour support but they also focus on community development creating and running community groups and events. They also produce a community toolkit mapping health and community support resources.

40 Resources The Community Development service, which includes HTS has a budget of £469,000 from the PCT and Lottery funding. It is coordinated at County level by a programme leader supported by an assistant and 4 Community Health Development Workers, with administrative support staff. There are 13 Health Trainers 5 of whom are in training, 8 trained to level 3 plus 3 Health Champions in training, trained HTs provide 7 WTE input. Following initial assessment it was considered only half the time of the Coordinator and none of Community Development worker time should be included, reductions in the relevant budgets for travel and administration brought the total cost of HTS to £318,000 Outcomes According to data provided by the service provider the service has supported 420 clients since inception. Of clients using the service 20% were referred from other sources, including community health teams, Local Authority and voluntary services, 27% heard about the service through word of mouth, a poster or leaflet, local media or promotional events and 53% from other sources. The main issues addressed by clients were: diet 35%, emotional wellbeing 25%, exercise 13%, housing 7%, debt 5%, smoking 3% (only direct health issues have been considered here). Behaviour change support was provided for 140 new clients in 2008/9. Evidence available from the service provider suggested that 70% of clients stated they achieved their PHP goals and 13% said they partially achieved them. Comparable figures from DCRS showed data from 78 clients indicating that of 125 clients, 52% fully achieved their goals 15% partially achieved them. Clients were referred to a very wide range of health and social support organisations, the service provider notes that 152 referrals were made to other agencies and support services including the Citizen’s Advice Bureau, Link into Learning, Young People and Family Services, Drug and Alcohol services and local colleges, however DCRS reports record only 5 referrals during 2008/9. The service also set up and ran a total of 44 community groups as follows: Walking groups x10, Shape Up programmes x 10, Yoga groups x 1, Cycling groups x 1, Swimming x 3, Chair Exercise Classes x 3, Keep Fit x 1, Discussion Groups x 1, Art Groups x 1, Advanced Health Problem Support Group x 1, Craft groups x 1, Gardening x 1, Yap and Yarn (sewing/knitting and gossip) x 2, Older Peoples Group x 1, Self Help Group in partnership with Rethink x 1, Long Term Conditions Group x 1, Healthy Cooking Groups x 3, Active Buggy Group x 1, Be Kind to Yourself Groups x 1. It is not clear how many events this means in total 528 have been assumed. Clients from the most deprived quintile IMD wards are recorded in DCRS as 23%, and the local service leader gave a figure of 27%, however, she also noted that even in Wards not shown as having a high IMD, services are targeted, at small postcode areas (Super Output Areas) with estates and people with multiple deprivation, however, it was not possible to estimate the impact on the disadvantage of HTS clients Applying the assessment method The estimates of activity and outcome given by the provider have been applied to assess the likely value for money of this HTS as shown by the methodology agreed by the Stakeholder Panel. Community development is clearly the main focus of this service and hence a value of £60,000 has been assumed for this aspect though as discussed commissioners may wish to set a higher value. Since these are the areas with the highest value for money assessment it is important to recheck these assumptions. Applying these figures suggests  Health gain from behaviour change and signposting would be 7.5 DALYs

41  The net cost to the NHS after savings of £179,000 would be £139,000  Savings to Local Authorities would be £7,000  Net cost of the service to the Public Sector would be £132,000 per annum  Net cost per unweighted DALY would be £18,000  Net cost per equity weighted DALY would be £16,000 to £17,000 On this basis this service offers value for money which would be within the NICE limit of £20,000 per DALY, but would be relatively costly in relation to other public health interventions shown by Health England. It appears from the data available that each WTE HT manages 1 to 1 behaviour change for 20 people, signposting support for 22 people and attendance at 75 events on average per year. One possible explanation is that the service is developing as a combination of HTS and Community Development activities which add further value but are not captured in the data at present. Discussion with the Stakeholder Panel suggests that these elements should be separately valued as linked elements of Community Development for Health. It also appears that IMD ward scores may not reflect disadvantage in small pockets of deprivation sufficiently well in rural areas. It must be stressed, that this assessment is on the basis of unchecked local estimates.

D Jointly Funded Urban HTS Services This service developed in response to both the national Choosing Health programme and a local public health initiative focusing on smoking, diet and physical activity and alcohol consumption and the high levels of circulatory disease and cancer in this “spearhead” PCT with one of the most urgent need in relation to health inequality. The initiative was joined by the Local Authority, who provide 1/3rd of funding, recognising worklessness and its association with poor health as major problems. The service recruited HTs in 2006 and began operations in 2007. Initially as an NHS provided service, which was later contracted out to a community social enterprise. Services include 1 to 1 behaviour change, signposting and referral, work with communities and groups. Behaviour change services usually include 4 -6 visits, HTs review cases after 4 visits with their manager. Services are targeted at the top 10 most deprived wards as defined by IMD scores and on workless areas and estates (super output areas). It is provided from community centres, neighbourhood offices, town hall and healthy living centres. The service produces its own map of health and social support resources, combining neighbourhood profiles and health improvement information and maintains contact with these groups and individuals. Resources On a stable state basis the service contract cost was reported to be £360,000 per year in 2008/9. The service is commissioned through the PCT which provides direction and links to a steering group including NHS and LA representatives. Services are provided by 16 Health Trainers who provided 13 WTE input, 10 of these are trained to level 3 others are still undergoing training from level 2 to 3. For most HTs this is an important route to work, most are recruited from the areas they serve with about 4 out of area recruits. The Social Enterprise provides a lead manager, and 2 case managers, information support officer and administration staff.

42 Outcomes According to data provided by the service provider 1176 client contacts were recorded in 2008/9 with. It appears that 395 clients were supported in behaviour change with up to 6 sessions each during a 12 month period and 301 did not require this support but presumably were signposted to other services. Of these clients 33 had primary goals relating to smoking, 17 relating to alcohol, 37 in relation to diet, 228 related to exercise, and 66 relating to emotional wellbeing (recorded as lack of confidence, social isolation and stress/anxiety) and 11 had other local issues including getting into work and education. Of the behaviour change clients for whom evidence was available, 86% stated they achieved their PHP goals and 12% said they partially achieved them. Signposting and referral support was given to 780 clients, who were directed as follows: community groups 155, exercise and diet 82, smoking cessation 34, social support 32, Mental health 25, other NHS 19, non NHS therapy 18, drugs and alcohol 16, other 88 and not specified or not required 284. Health Trainers also attend events and meetings across the area and hold “stalls at many such events to publicise their services but there are no records of the numbers of events, as a basis for this assessment a low assumption of 20 such events is included in this estimate. Clients from the most deprived quintile of IMDS postcodes are recorded in DCRS as 76% of total clients using the service. Applying the assessment method These estimates can be used to assess the likely value for money of this HTS as defined by the assessment method agreed by the Stakeholder panel. Because of the focus on community development and the engagement of the Local Authority a relatively high value of £60,000 has been assumed in this case. Applying these figures suggests  Health gain from behaviour change and signposting would be 32 DALYs  The net cost to the NHS after savings of £309,000 would be £51,000  Savings to Local Authorities would be £27,000  Net cost to the Public Sector would be £24,000 per annum  Net cost per unweighted DALY would be £740  Net cost per equity weighted DALY would be £530 to £540 This could be considered very good value for money, it shows that the net cost of the service is low and improves health significantly. It would score reasonably high in comparison to other interventions included in the Health England comparative table of public health interventions. Local Commissioners might value the service even more highly taking into account the value of engagement and communications with local communities and the benefits of providing a route to work for HTs. It must be noted however, that this assessment is on the basis of unchecked local estimates.

43 E Offender Health Trainer Service Services This Offender Health Trainer Service (OHTS) was initiated by a PCT and implemented in collaboration with its local Probation Service in 2006. It started operations in 2007 to improve the health and wellbeing of offenders over 18 in areas of deprivation. The idea spread and the services are now funded and commissioned by all four PCTs in the Probation Service area, who manage the service plus a Community Enterprise that provides the service in one PCT area. The focus of the service is on 1 to 1 work with ex offenders in motivational interviews and ongoing support. For low level risk clients HTs may see them off site, for example, accompanying them to support groups or health services. Common problems addressed include smoking cessation, alcohol abuse, weight loss and issues like literacy and numeracy which often lead to exclusion. In addition HTs are involved in signposting and making contact with other relevant agencies with health connections (a high proportion of ex offenders are not registered with Doctors or Dentists). They have mapped out relevant local health services for offenders in information sheets that are updated every 6 months. In some local areas within the Probation Area HTs support local drop in centres on a weekly basis to provide follow up support. They are also involved in spreading messages about avoiding criminal behaviour and health issues e.g. Chlamydia screening and access to psychological therapies to hard to reach people. Clients are contacted by self referral, posters and cards enable ex offenders to make contact with HTs on a confidential basis. Resources On a stable state basis the total service contract costs from 4 PCTs was estimated as £165,000 per year in 2008/9 (the contract costs). Other support costs including accommodation and other management and support from the Probation Service - this might be estimated at say £50,000. HTS are provided at 6 Probation Offices usually adjacent to Courts and Police Stations. HTs are recruited from ex offenders, who must be three clear of a probation order and 2 years clear of addiction (90% have had drug or alcohol addiction problems). The importance of OHTS as a route to qualifications and work for HTs drawn from ex offenders is particularly significant – 2 have already moved on to other full time employment. Services are provided by 10 Health Trainers who provide about 6 FTE input – the training they receive varies according to the PCT from 10 weeks to 9 months. Each HT is targeted to contact 8 new offenders a month (most work up to 16 hours a week). They are supported by Probation Officers who provide mentoring services plus a Programme Manager who directs the service drawing on Probation Office support. Outcomes Neither the OHTS nor DCRS were able to supply detailed data on the activity and outcomes of the service for 2008/9. However, a broad estimate, provided by the local service manager, suggests that the service supported around 1050 new clients in 2008/9. About 50% of these were referred to the service by Offender Managers after talking to the clients and responding to their requests, 40% were generated by HT’s as a result of giving presentations to offenders at weekly induction meetings and 10% were self referral in response to advertisements in the reception areas of Probation Offices. It was broadly estimated that 40% of clients are signposted to other services (of these about 30% are accompanied to these services) and 60% visit HTs for 4-6 times for

44 behaviour change support. It is assumed all clients were in the most disadvantaged quintile. There was no information available on the success of clients in meeting their personal health plan goals or indeed completing BCP and no follow up studies had been undertaken to examine impact upon reoffending and none of this information could be independently checked. However, the experience of local staff was very positive about the outcomes of this service which had been recognised in a national award programme. Applying the assessment method The lack of data poses a challenge for assessment. Under these circumstances it might be reasonable to take a very conservative view of the numbers of clients, the success rate in attaining personal health plans and all other aspects where no detailed data are available. Thus for the purpose of examining the application of the assessment method new clients have been estimated at 750, it is assumed that only half clients are signposted and half participate in 1 to 1 behaviour change support, split equally between five areas: smoking, diet, activity, alcohol, emotional wellbeing (this will again produce a conservative figure) with the proportion achieving or partially achieving personal health goals set at 30% in each case (a low estimate). No account has been taken of participation in events and meetings since no data were available. The impact on reoffending is also assumed at a low estimate of 5% applied only to clients assumed to fully achieve Personal Health Plan goals. Applying this cautious approach shows that under such conditions the impact of OHTS would be:  Health gain from behaviour change and signposting would be 15 DALYs  The net cost to the NHS after savings of £105,000 would be £60,000  Savings to Local Authorities would be £13,000  Savings to the Criminal Justice System would be £267,000  Net savings to the Public Sector would be £219,000 per annum  Net savings per DALY would be £15,000  Net savings per equity weighted DALY would be £22,000 to £24,000. While it remains to be proven, even applying the most conservative estimates shows OHTS to be likely to be extremely cost effective, and wider consideration of the social impact of crime suggest savings to society of over £1.5 million a year in this case. That is unless the estimated figures bear no relation to reality. Extension of the service and development of other services addressing the 7 pathways to reducing reoffending by peer support could extend the benefits of collaboration between Offender Management Services, NHS and Local Authorities. However, a prerequisite for further development is collection of relevant data and a full evaluation including the impact on reoffending. As the case studies were designed to assess how the approach could be used for self assessment no attempt was made to monitor the type of information used or to audit its accuracy, since this would imply external evaluation. In further applications it would be useful to ask users how helpful they found various sources of information including DCRS and how such information can be improved to help them to monitor and demonstrate the impact and performance of their services.

45 Preliminary Conclusions For most aspects of Health Trainer Services the assessment method appears to provide a consistent framework for evaluating value for money with sufficient flexibility to reflect variations of the accepted core services and sufficient breath to capture the main components of HTS. It shows that, at least in some cases, it is possible to demonstrate high levels of value for money from Health Trainer Services. However it is important to note that assessment of value for money should be regarded as only one element of a more comprehensive evaluation of services including those impacts set out in Table 1 as this wider view provides a vital context to the assessment of value for money. The case studies also demonstrated great variation between cases that could not be explained in terms of funding or numbers of HTs. The variations included: the numbers of clients engaged in 1 to 1 behaviour change, signposting and events attended, the numbers completing behaviour change support and crucially the percentages of clients stating that they had fully or partially achieved their goals and the percentage of disadvantaged clients. Further investigation may be helpful to discover the reason for such variation and how to improve the way data are defined and collected. For example % of clients from high IMD wards may not fully reflect the disadvantage of clients. While the method can be used to assess the value for money in providing 1 to 1 behaviour change, supporting signposting and referral and routine aspects of community engagement, in some HTS there may be other elements of the service that cannot be captured in this way. In particular it seems that HTS links to Community Development, to help create new groups and structures (rather than simply supporting or attending existing events) is beyond the scope of this assessment approach. One solution to this would be to clarify the targeting and management of such services to distinguish these wider aspects of Community Development from general provision of HTS. It also became apparent that data recorded by DCRS and at local level was inconsistent both for specific HTS and between HTS. The aim of this review was to develop a methodology that could be used locally to support self evaluation and therefore local data were applied, without any attempt to check or audit the figures. Currently key data issues at both central and local levels include lack of information on events, very sparse and inconsistent information on achievement of health goals and inconsistent information on primary health goals, signposting and referral. Steps are already in hand to capture information on events and to improve other aspects of data definition and capture including data on community engagement, which will be available in the next version of DCRS. However, experience suggests that any health information system that is not regularly used for local purposes will lack consistency. Thus one benefit of applying value for money assessment is to encourage local users to consider what information they need to monitor and improve the value of their services. It is therefore suggested that rather than attempting to perfect the information system before applying it, the focus should be on enabling local commissioners and providers to use information in assessing value for money, which will give them a better idea of the need to improve record keeping. It would be helpful for local users to apply this approach to their services and share the results and lessons learnt, which may include the need to reassess some of the values and assumptions and/or to include other elements in the value for money assessment. The Local Evaluation and Knowledge Gathering Sub Group has a vital role to play in enabling these exchanges and developments. It is important to stress that this is a tool to help local users explore and understand the value for money of their services and how

46 to improve it. It is not intended to be used as a top down assessment because it requires local understanding of services and local interpretation of values and targets for health improvement and equity. Clearly it is early days, both in terms of the development of HTS and in developing value for money assessment, thus a cautious approach is needed to both, but caution may be best served by involving local HTS Commissioners and Providers in this development. It is suggested that value for money assessment should be rolled out by Hub Leads as an evolving tool for local application that can continue to be developed and improved through use and experience. At the same time Hub leads and the Local Evaluation and Knowledge Gathering sub-group should encourage local and national sharing of the lessons learnt. This will require Hub Leads to gain a good understanding of the approach and be able to share this with local service leaders. In order to facilitate this, it is suggested that they should participate in teaching/learning sessions and be provided with training materials and a tool to make it possible to apply the assessment method without having to do a lot of detailed calculations. This initiative could be led by a PCT on behalf of colleagues. The assessment method will need to be refined and continuously improved both by local application and by extending the approach to capture aspects of HTS as they develop, and innovate for example to provide a wider range of social and community support. The approach could also be developed to address other services for health improvement and to reduce health inequality, for example to compare the value for money of health trainers with other aspects of health promotion such as social marketing. This should provide a stimulus to further research to underpin (or confound) expert judgement of factors such as the extent of impact on health risk, the persistence of behaviour change, the impact on emotional wellbeing, the value and outcome of community engagement and the use of small area data to target disadvantage. Studies could proceed by local investigation to provide evidence that can then be extended to other HTS by guiding the use and development of DCRS. At national level the estimates of the potential health gain and cost savings from behaviour change provided by this review show the potential benefits of establishing a national consensus on these issues. Indeed it is surprising that this baseline work has not yet been addressed and that there is so much variation in the practice of estimating health gains and cost savings from public health interventions. It would be helpful to develop national estimates of Population Attributable Fractions and clearer guidelines on the evaluation of public health interventions. To this end discussions are scheduled with NICE and Health England and contact has been established with the Healthy Communities Programme. At regional level interest has been shown by Health Observatories. Further development of the approach will benefit Health Trainer Services by providing a better basis for comparison between health promotion services and promoting a shared understanding of what good value for money means in these fields. With these challenges in mind, it is it is not useful at this stage to claim that the value for money of all HTS has been proven, or that a definitive approach to the assessment of value for money has been established, one can only draw preliminary conclusions and observe that this is an important task well begun.

47 The Portsmouth Ready Reckoner: 2 2012

This is the first annual update of the Portsmouth Ready Reckoner. It has been updated to reflect current work with the Department of Health, Health England, NICE and WHO, led by the National Social Marketing Centre (NSMC) on the value for money of other forms of behaviour change. This included a survey of practitioners, commissioners from PCTs and LAs and other experts. The main updates include:  Adjustment to the Results page to show the impacts and value for money in terms of QALYs as well as DALYs, this was requested by the review panel for the national programme chaired by Fiona Adshead. Basically it ensures that we can all speak in the same terms recognising that both QALYs and DALYs have advantages and disadvantages. This uses a conversion factor developed by Franco Sassi of the OECD to whom we are most grateful.  Some revision to the National Data on the Burden of Disease. This is in line with the latest version of the World Health Organisation Burden of Disease Tool applied to the UK and adjusted for England. We are most grateful to colleagues at the WHO and NICE for this update which was produced on 15 May 2011 but applies to 2004 data.  Other updates to the National Data to reflect the fact that disease outcomes today are the product of behaviour over a period of 20-30 years. Depending upon the nature of the behaviour and outcomes. Thus for example the outcomes relating to obesity reflect the number of people at risk some 20 years ago when many less people were obese, taking this into account increases the expected health gain per person from addressing obesity now.  Our survey also highlighted the need to apply sensitivity analysis in all such evaluations, the Results sheet therefore provides a facility for varying all assumptions used in the tool by plus or minus any percentage chosen by the user.  In order to avoid confusion and some controversy the facilities for weighting outcomes for disadvantaged clients and for using the HELP weighting system has been clarified and moved from the Results page to the Context page. We note that the Department of Health does not agree with weighting QALY outcomes but suggests disadvantage should be recognised in other ways.  An additional impact of Alcohol Harm Reduction has been taken into account to reflect the reduction of costs to the Criminal Justice System of alcohol related crime. These updates should bring the Portsmouth Ready Reckoner up to date and into line with other behaviour change evaluation tools. It would still be desirable to continue to develop and improve the PRR, in particular if further evidence can be obtained as to the long term impacts on behaviour change and health outcomes. It is hoped to develop further training and support for behaviour change planning and evaluation including the use of this and similar tools (see http://www.nsmcentre.org.uk/resources/vfm).

48 Updates to Health Trainer Service Evaluation Tool: 3 2014 Introduction The Health Trainer Service Evaluation Tool is designed to help you evaluate the Value for Money of Health Trainer Services, taking into account the latest estimates of the Burden of Disease in England from the World Health Organisation and views from Public Health England, NICE and a wide range of health commissioners and providers who responded to a questionnaire. The original evaluation tool supported by Portsmouth NHS was based on a wide range of data set out in the report by Graham Lister1, it is important to read this as an introduction and explanation. We must stress that the Evaluation Tool is only as good as the data and assumptions on which it is based it must be updated as new research reveals the cost and impact of the behaviour changes that HTS support. This second update was commissioned by Em Rhaman PH Workforce Development Manager at Health Education Wessex and undertaken by Professor Graham Lister and Ian McAleer. It updates the values used in the tool to 2014/15 prices and provides a facility for further upgrade with inflation in future years. Recent studies have allowed us to update data on the health impacts and cost to the NHS and Local Authorities of behaviours addressed by Health Trainer Services (HTS). In brief, the tool requires users to enter the cost of HTS and details of the targeted population and intermediate outcomes achieved. The intermediate outcomes include support for community development and the number of clients reaching personal health improvement targets in each area and those benefiting from emotional support. The tool calculates the likely long term impact on health and other outcomes, taking into account studies that show the rate at which HTS clients either persist with behaviour change or fall back into previous behaviour (most behaviour change is only maintained for a relatively short time). The estimate of the health impact of behaviour in each field is derived from WHO Global Burden of Disease studies applied to UK outcomes. Comparing current estimates of the Burden of Disease in England with estimates of the population exhibiting the causal behaviour over the prior period of 20 years provides a best estimate of the marginal impact of one person’s behaviour change over one year. This is applied to the projected behaviour of those clients partially or fully achieving their intermediate behaviour change goals over their remaining life. This then makes it possible to compare costs with the discounted value of future health and other impacts The tool addresses some complex issues of value and impact and depends upon many estimates and assumptions. It provides a range of estimates of value for money and Social Return on Investment including sensitivity analysis to examine the impact of changes to the basic assumptions and the discount factor used. We suggest commissioners and providers of HTS should come together to apply the tool and share their understanding of the data and assumptions, note that these assumptions can be updated and adjusted to reflect both new data and local conditions. We suggest that it is

1 Graham Lister (2010) ”Assessing the Value for Money of Health Trainer Services” available from http://www.building-leadership-for-health.org.uk/evaluating-behaviour-change/

49 helpful to set this qualitative evaluation alongside qualitative studies that demonstrate how HTS changes people’s lives and health. This tool and others like it, with training materials are available from the web site noted below. Updates to Burden of Disease Estimates The most significant updates arise from the Government Policy Paper “Living Well for Longer”2 and the study of the updated WHO 2010 Global Burden of Disease findings to UK data by the Institute of Health Metrics and Evaluation3. The data presented in these papers show significant differences from previous estimates of the burden of disease measured in Disability Adjusted Life Years (DALYs) arising from key behavioural causes for the UK. This is both because of real changes since 2004 when the data was last applied and because the method of calculating DALYs applied by IHME has changed. In previous versions DALYs included weightings depending on the age and also included internal discounting (at 3%). This meant that it was necessary to apply correction factors to convert DALYs to an estimate of Quality Adjusted Life Years (QALYs). Both QALYs and DALYs assess the quality of life of those affected and the period for which they are affected. QALYs are determined from patient surveys (and therefore vary depending how and when the survey is undertaken) , while DALYs are based on expert judgements (and it might be argued are international rather than reflecting UK values) . In effect it simplifies this issue, now QALYs gained are equivalent to DALYs reduced. Detailed aspects of the new analysis (i.e. breakdown in terms of Years of Life Lost and Years Lived with Disability) are taken from the Institute of Health Metrics and Evaluation web site.4 However this analysis does not cover every behaviour addressed by Health Trainer Services so where no new data is available other sources have been used. Updates of the Cost Impacts of Conditions addressed by HTS Estimates of the cost to the NHS from the causes and conditions addressed by Health Trainer Services are most often based on the Population Attributable Fraction (PAF) associated with each behaviour (i.e. how much of each disease outcome is due to each behavioural cause) costs to the NHS of each disease outcome (for example from the NHS Programme Budget5) can then be attributed to each behaviour. The problem with such estimates is that there are many gaps and they apply different assumptions and sources. It would be useful to have a consistent set of estimates based on an agreed source of PAFs and NHS costs. However until such time as Health England can

2 Department of Health (2013) “Living Well for Longer: a Call to Action to Reduce Avoidable Premature Mortality” 2013 3 Prof Christopher JL Murray MD et al (2013) “UK health performance: findings of the Global Burden of Disease Study 2010” The Lancet available at http://www.thelancet.com/journals/lancet/article/PIIS0140- 6736(13)60355-4/fulltext data 4 Institute of Health Metrics and Evaluation: GBD Compare web site at http://viz.healthmetricsandevaluation.org/gbd-compare/# 5 NHS Networks (2014) 2012-13 “Programme Budgeting is Now Available” http://www.networks.nhs.uk/nhs-networks/health-investment-network/news/2012-13-programme- budgeting-data-is-now-available

50 establish a consistent approach to such estimates we must rely on the best available evidence. Estimates of costs have been updated and revised over the past two years see below:  The Government Alcohol Strategy6 estimates the annual cost to the NHS of alcohol related illness and accidents in England at £3.5 billion in 2009-2010 price levels equivalent to £3.24 b in 2008/9 expenditure levels.  Alcohol related crime in England is estimated to give rise to annual costs of £11 billion in 2010-2011 prices1 equivalent to £ 10.65b in 2008/9 when adjusted by RPI.  Lost productivity related to alcohol is estimated to cost £7.3 billion per year in 2008/9 for the UK1 . Adjusting for England on the basis of population suggests £6.120 b.  The cost to the NHS of poor diet related ill health was estimated as £5.8 billion7 for the UK in 2006-7. This suggests a cost estimate for NHS England of £5.7 b in 2008/9.  The cost to England’s economy of lost employment productivity due to absence and premature death attributable to obesity was estimated as £2.5 billion in 2002/3 prices8 Adjusting by the Retail Price Index this is equivalent to £3.0 b in 2008/9.  UK NHS Costs associated with physical inactivity £ 0.9 billion in 2006-77. Adjusting for population and prices suggests an estimate of NHS costs for England of £1.17 b in 2008/9.  UK NHS costs related to smoking are estimated as £ 3.3 billion in 2006-77. Adjusting for population and costs suggests an estimate of NHS costs for England of £3.24 b in 2008-9.  The cost to the economy of the additional time off work and lost working days due to early deaths associated with smoking is estimated at £1.4 billion for the UK in 20119 A wide range of measures have been suggested for the economic impact of “fag breaks” an estimate of £2.9 b10 for the UK in 2008/9 prices gives a total employment impact of £3.5 b for England 2008/9.  Cost of illicit drug use in England is estimated11 as £1.2 billion in cost to the NHS including mental health and drug related services in 2003/4 adjusted for NHS

6Secretary of State for the Home Department (March 2012) “The Government’s Alcohol Strategy.” HM Government 7 Scarborough, P. Bhatnagar, P. Wickramsinghe, KK. Et al (May 2011) “The economic burden of ill health due to diet Physical inactivity, smoking, alcohol and obesity in the UK: an update of the 2006-07 NHS Costs. Journal of Public Health , Oxford vol 33:4 pp.527 535 8 House of Commons Select Committee (2004) “Obesity: Third Report of Session 2003/4. The stationery Office london 9 Stephen F Weng, Shehzad Ali and Jo Leonardi-Bee “Smoking and Absence from Work: systematic review and meta analysis of occupational studies” Addiction Vol 108 Issue 2 pp 307-319. 10 Robert Nash & Henry Featherstone (2010) “Cough up: Balancing tobacco income and costs in society” Policy Research Note 11 National Audit Office (March 2010) “Tackling problem drug use“ National Audit Office HMG

51 expenditure this equates to £1.7 b in 2008/9 assuming expenditure has increase in line with NHS expenditure.  Wider costs to society of drug related crime in England is estimated12 at £13.9 billion in 2003/4 costs adjusted for RPI this would equate to £16.6 b in 2008/9.  The cost to the NHS of treating people with mental illness was estimated13 cost of mental as £6.5b, LA social care costs as £1.4 b and the economic cost of lost output as £23.1 b in 2002/3 values. In 2008/9 prices this suggests costs of some £8b to the NHS, £2.6 b to LA services and £42 b in lost output. But not all mental illness manifests as emotional wellbeing problems. Thus while 20% of the burden of disease has been associated with mental illness only 7.8% is attributable to mental wellbeing. Thus the estimates have been adjusted for this proportion to show the cost impact of emotional wellbeing as £3.2 b for NHS costs, £1 b for LA social care costs and £16 b for economic impacts. We have been unable to find a convincing study of the employment impact of drug misuse but it is unreasonable to suppose that early deaths and poor productivity do not result from drug misuse, thus until someone provides a better measure an indicative value of £1.7 b in 2008/9 (equivalent to treatment costs) is included to indicate the probable impact.

Adjusting for England and Inflation in Costs These health impact figures have been adjusted where necessary from UK population estimates, to apply to NHS England. Expenditure increases have been set to a baseline of 2008/914 and then increased in line with net NHS expenditure for England to 2014/15. Local Authority costs have similarly been increased to 2014/15 values and other costs adjusted in line with the Retail Price Index (RPI) movements. Clearly these are broad assumptions, it is known that rates of disability and death associated with behavioural factors are generally worse in Scotland Northern Ireland and Wales than for England so these are likely to be slightly overstated. Increasing all costs to the NHS by overall expenditure increases ignores the possible redistribution of expenditure between services and increasing other costs by RPI is also a broad estimate. The tool now includes a facility to adjust for inflation beyond 2014/15.

Social Return on Investment

12 Home Office, Measuring different aspects of problem drug use: methodological developments 2006, The economic and social costs of Class A drug use in England and Wales, 2003/04 http://www.homeoffice.gov.uk 13 The Sainsbury Centre for Mental Health (2003) “Policy 3: The economic and social cost of mental illness”. London 14Rachael Harker (2012) “ NHS Funding and Expenditure standard note SN/SG/724 April 2012House of Commons Library

52 As in the previous version of the tool a facility is provided to estimate the Social Return on Investment based on a standard value for a QALY. The tool also makes it possible to apply a weight for impact on disadvantage and/or to use the Health England Leading Prioritisation15 based formulae. However, neither DH or Public Health England support the use of differential weights for impacts on disadvantaged groups – they suggest an alternative approach - the Health Inequalities Intervention toolkit available from the London Health Observatory16. Sensitivity Analysis Varying the Social Time Preference Rate A facility has also been introduced to make it easier for users to test the sensitivity of outcomes to higher or lower assumptions concerning the extent of change achieved and the persistence of changes as well as variations in the discount rate used to represent the social time preference rate (the rate at which future social benefits such as health improvements are discounted to an equivalent present value). While the Treasury Green Book still recommends a discount rate of 3.5% for the first 30 years and 3% thereafter, NICE recommend that the sensitivity to different assumptions about social time preference should be tested at say 1.5% and 6%. It is not clear on what basis this is proposed but in order to reflect this advice a facility is provided. Further Research and Training As HTS and other health and wellbeing services are now the responsibility of Local Authorities we suggest that it would be timely to provide further training and research to support the use of this and similar tools. It is important for policy makers, commissioners and providers to gain a shared understanding of the value for money of behaviour change and how it can be measured. We also note that a further tool is in development to assess the health and other wellbeing impacts of all forms of Social Capital. Here again we suggest research and development should be matched by mutual exchange and shared learning opportunities as it is important to develop our understanding together and to make sure that any tools developed meet the needs of decision makers. Graham Lister 23/05/2014

15 Matrix Consulting Ltd Health England Leading Prioritisation http://help.matrixknowledge.com/ 16 London Health Observatory at: www.lho.org.uk/LHO_Topics/Analytic_Tools/Health- InequalitiesInterventionToolkit.aspx

53 Annex A Summary of Main Assumptions Agreed By the Stakeholder Panel

Assumption Central Range Basis Value

Extent of health risk 35% per 20%-50% Survey of self reported WHO 5 Wellbeing for clients fully client scores and General Health Assessment achieving PHP goals scores from DCRS

Persistence of 85% 70% -10% Survey data for persistence over 3 behaviour over 5 reducing months 6 months and 12 months from 90%-20% years and long term to 15% Wakefield

Impact of other 25% of 15%- 35% Data from Bradford showing more than behaviour change value of 50% clients consider emotional wellbeing interventions on e w per an important outcome and 50% impact emotional wellbeing client assumed by Panel

Extent of health risk 50% of 25%- 75% Review of PHP goals which were very reduction for clients the variable some partially achieved gaols partially achieving above were more than some fully achieved and PHP goals partially achieved showed progress

Value of signposting £120 £60 - Cost of Primary Care brief interventions and participation in per £180 noting that some signposting was quite events, groups and client or limited while in other cases clients were meetings meeting accompanied and supported

% of successful 70% 60%-80% Based on survey and Stakeholder Panel signposting experience (though this was variable)

Value of mapping, £40,000 £20,000 - Comparison with cost of maintaining communications and per year £60,000 such relationships by other means e.g. engagement neighbourhood teams or community workers

Value of impacts on £65 - See Based on social care and wellbeing costs Local Authorities £120 estimates to LAs for adult non elderly clients per BCP allocated on the basis of weighted YLD – LAs also share community dev benefits

Value of impacts on £3,250 Societal Costs from national studies, reduced Criminal Justice per cost up to reoffending assessed at 5%– other System client £16,000 studies show 8%- 15% reduction

Value of benefits to See Used to inform decision but not as an other stakeholders assess economic value for Commissioners ments

Value of impact on HELP 30%-60% Derived from Health England Leading health equity figures Priorities model

54 Annex B Glossary of Terms Alcohol Use Disorders Identification Test (AUDIT): is a simple ten-question test developed by the World Health Organization to determine if a person's alcohol consumption may be harmful. A score of 8 or more in men (7 in women) indicates a strong likelihood of hazardous or harmful alcohol consumption. A score of 20 or more is suggestive of alcohol dependence Behaviour Change Intervention (BCI): any form of intervention intended to help people change their behaviour, this may include: regulation, financial incentives and information provision but is more commonly applied to interventions at community level and 1 to 1 support based on psychological concepts to optimise motivation and behaviour change. Behaviour Change Process: this term is used to refer to 1 to 1 support for clients over a period of months and 4-8 meetings provided by Health Trainers to help clients address issues concerning behaviour change to improve their health and well being. Brief Interventions: usually refer to short motivational interviews to encourage or support positive health choices including referral to specialist support services. Common Mental Disorders (CMD): states of anxiety, depression and somatisation disorders (long term conditions producing physical symptoms as a result of psychological factors) affect around 17.5 % of people. They form a significant part of the work-load for primary care and are costly as they are associated with high service use, however, most people with such disorders exhibit them at low levels and are unlikely to be offered specific mental health services until they develop more severe presentations. Community Engagement: is the process of building relationships with individuals and organisations to build trust through common action and communications. It can build social capital and empower and enable communities and groups to work together towards shared goals. Cost – offset: how much money is saved for each £ spent Cost – effectiveness: how much of a specific outcome (DALY) per £ spent Cost – consequence: description and measures of outcomes per £ spent Cost – utility: outcomes weighted by value/priority to commissioners per £ Cost – benefit: outcomes valued in economic terms per £ spent Criminal Justice System: consists of three main parts: (1) law enforcement (police); (2) adjudication (courts and judiciary); and (3) correction (jails, prisons, probation and parole). In a criminal justice system, these operate together under the rule of law. Crime dependency: depending upon criminal behaviour to support personal needs such as drug or alcohol dependency or livelihood or social recognition (gang culture). Disability Adjusted Life Years (DALYs): a measure of the burden of disease including premature mortality and years lived with disability. Estimates of DALYs give a weight to disability from 0 to 1 agreed by an international jury of health administrators and compares Years of Life Lost with life expectancy in Japan (the highest in the world). DALY estimates are internally consistent. DALY estimates by cause can avoid double counting. They are estimated as years lost - a reduction in DALYs is a health gain. Emotional wellbeing: is defined by the Mental Health Foundation as “A positive sense of wellbeing which enables an individual to be able to function in society and meet the demands of everyday life; people in good mental health have the ability to recover effectively from illness, change or misfortune”.

55 Equity and equality: are not quite synonymous, inequity implies an unjust barrier to achieving equality, for example difficulties in accessing services, while there may be many reasons for inequality. It should be a clear public service objective to achieve equity and a target to reduce inequality as far as possible. General Health Scale: there are a great many instruments intended to measure personal perceptions of health. In this case the simplest measure is a visual analogue scale of perceived health status, scored by respondents drawing a cross on a line between Poor and Perfect to represent their perception of their health. Hard to Reach Groups: a term sometimes used to describe sections of the community that are difficult to involve in public participation, however, there are many different reason why people do not engage and it can be stigmatizing to lump them all together as “hard to reach”, it may have more to do with how services are offered than the groups. Health Gain: improvement in population health measured as QALYs gained or reduction in DALYs lost. Health Trainers: people, who are often drawn from the communities they serve, who are trained to a level 3QCF to provide motivational and other support for clients and community groups to help them identify and achieve their personal health plan goals. Health Trainer Champions (also referred to as Health Champions):people who are trained to level 2 NQF who provide signposting and other support for community groups and individuals to help achieve healthier lifestyles. HUB Leads: Regional coordinators for HTS Index of Multiple Deprivation (IMD): a statistical measure covering 7 fields of deprivation: income, employment, health and disability, education and skills, barriers to housing and services, living environment and crime. Mapping: here refers to the process of identifying and forming links with community resources including formal and informal services relevant to the client group considered, This does not simply mean the production of a directory but ongoing contact and two way communications. Offender Management Services: manage offenders in prison or in the community, to stop them re-offending. Recognizing that many offenders are from socially excluded groups it attempts to offer them the chance to engage with society in meaningful ways, to change their behaviour and attitudes and to address their offending behaviour. Offender pathways: to avoid reoffending assistance is directed at 7 pathways to address: accommodation needs, finance benefits and debt, education training and employment, children and family issues, health, drugs and alcohol abuse and attitudes and thinking. Personal Health Plan: clients of the HTS behaviour change process are encouraged to articulate step by step personal goals and actions for improving their health. Health trainers record whether clients feel they have fully or partially achieved these goals however the great variation in average responses suggest inconsistency between HTS. Population At Risk: the people who share a specific risk, in this case to their health, as a result of behaviour that increases their risk of death and disease. Population Attributable Fraction (PAF): is the estimate of the proportional reduction in population disease or mortality that would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario (eg. no tobacco use).

56 Premature Deaths (PD) and Premature Years of Life Lost (PYLL): no of people dying earlier than expected, in this case 74 (it is also possible to estimate PD to age 81) and total years of life lost prematurely (i.e. before the given age) in a population. Quality Adjusted Life Years (QALYs): measure health gain based on patient surveys of the weight to be given to their quality of life usually from 0 to 1 (with 0 equivalent to death). Measures of QALYs can vary widely depending upon the measurement system applied and when and how patients are surveyed. The most used QALY measure in Europe is the EuroQoL EQ 5D. In general for patients in mid life QALYs gained are equivalent to DALYs reduced there is a complicated scale for relating one to another but since QALYs are inconsistent this seems rather pointless. Self Efficacy Scales: many different scales and measures have been developed to measure aspects of self efficacy, meaning positive belief in ones power to control action and the ability to achieve personal goals. In this case a very simple general measure of self efficacy uses a scale of 5 points from strongly disagree to strongly agree applied to 8 questions about belief in respondent’s ability to achieve goals and succeed in tasks. Signposting and referral: clients may be referred to behaviour change services by other service providers and may refer or signpost clients on to other services. In practice the terms “signposting” and “referral” are not used consistently in current HTS. Moreover signposting can range from a very brief interventions including handing out a leaflet to much more intensive support, for example, talking through issues and helping the client to understand their need for specialist help or even accompanying the client to a service. Social Capital: the value of shared trust and connections within and between communities and networks including bonding within families and communities, bridging between communities and linking to engage people in services and action with community leaders or service providers. Social movement theory: seeks to explain why social mobilization occurs and to find ways to build and harness mass movements for social purposes. Social Time Preference Rate: is the rate at which society is willing to trade off present social benefits for future benefits. It is set by the Treasury in a publication called “The Green Book” and may be varied from time to time, currently it is set at 3.5%. This is the discount rate used to compress a stream of future benefits and costs into a single present value amount. Thus, present value is the value today of a stream of payments, receipts, or costs occurring over time, as discounted at the social time preference rate. Present value calculations of benefits and costs are compared to determine benefit-cost ratios or value for money. There are equations for working this out but everyone just looks up the figures in a table. WHO 5 Well Being Score: The WHO-5 Well-being Index is a short, self-administered questionnaire covering 5 positively worded items, related to positive mood (good spirits, relaxation), vitality (being active and waking up fresh and rested), and general interests (being interested in things). It has shown to be a reliable measure of emotional functioning and a good screener for depression. Years Lived with Disability and Years of Life Lost: the length of life lived with a health impairment, in this case weighted for the extent of disability as in DALYs and premature deaths measured as years of life lost compared with life expectancy in Japan. These measures are consistent in that DALYs = YLD + YLL.

57 References 1. Department of Health “National Health Trainer Data Collection and Reporting System” Birmingham. February 2010. 2. National Institute of Health and Clinical Excellence 2007 “Behaviour Change at Population, Community and Individual Levels (Public Health Guidance 6)” London NICE. 3. Kelly, M. P. McDaid, D. Ludbrook, A. Powell, J. 2005 “Economic Appraisal of Public Health Interventions” London, Health Development Agency 4. Matrix 2009 “Prioritising investments in preventative health” Health England, London 5. Department of Health 2009 “World Class Commissioning Competencies” London Gateway reference 8754 6. Marmot, M 2010 “Fairer Society Healthier Lives: Strategic review of Health Inequalities Post 2010”The Marmot Review UCL London 7. Rosalyn Harper National Statistics 2002 “The Measurement of Social Capital in the United Kingdom” Office of National Statistics London 8. National Offender Management Service 2005 “The National Reducing Re- Offending Delivery Plan” Ministry of Justice, London 9. Abraham, C. Kelly, M. West, R. Michie, S. 2009 “The UK national institute for health and clinical excellence public health guidance on behaviour change: A brief Introduction” Psychology Health and Medicine. Vol 14 Jan 2009 pages 1-8 London 10. Michie, S. Rumsey, N. Fussell, A. Hardeman, W. Johnston, M. Newman, S. Yadley, L. 2008 “Improving Health: Changing Behaviour: NHS Health Trainer Handbook British Psychological Society, Department of Health London 11. Lister, G. Fordham, R. Mugford, M. Olukoga, A. E Wilson, E. McVey, D. 2006 “The Societal Costs of Potentially Preventable Illnesses: A Rapid Review” London, National Consumers Council http://www.nsms.org.uk/images/CoreFiles/NSMC- R10_societal_costs.pdf 12. Lopez, A. D. Mathers, C. D. Ezzati, M. Jamison, D.T. Murray, J. L. 2006 “Global Burden of Disease and Risk Factors” New York, Oxford University Press and the World Bank 13. Ezzati, M. Lopez A, D. Rodgers, A. Murray C, J, L. 2004 “Comparative Quantification of Health Risks: Global Burden of Disease Attributable to Selected Major Risk Factors” Geneva, World Health Organization. 14. Green, S. and Miles, R. 2007 “The Burden of Disease and Illness in the UK” Oxford Healthcare Associates, Oxford 15. Department of Health New Horizons: 2009 “Flourishing People, Connected Communities: A framework for developing well-being” London Crown Copyright 16. McManus, S. Meltzer, H. Brugha, T. Bebbington, P. Jenkins, R. (Editors) 2009 “Adult psychiatric morbidity in England, 2007: Results of a household survey” A survey carried out for The NHS Information Centre for health and social care by the National Centre for Social Research and the Department of Health Sciences, University of Leicester. London National Statistics

58 17. National Statistics. 2007 “Health Statistics Quarterly 34 Web supplement: Death Registration England and Wales 2006 All causes” London, Crown Copyright. 18. British Heart Foundation Statistics Website 2007 “Smoking Prevalence 2006” accessed 04/02/2010 http://www.heartstats.org/datapage.asp?id=884 19. NHS Information Centre 2006 “Statistics on Obesity, Physical Activity and Diet: England, 2006 20. Johnson, A. Fenton, K. Copas, A. Mercer, C. McCadden, A. Carder, C. Ridgway, G. Wellings, K. Macdowall, W. Nanchahal. K. “National Survey of Sexual Attitudes and Lifestyles II, 2000-2001” National Centre for Social Research London 21. Prochaska, J. O. and DiClemente, C. C.1982. "Transtheoretical therapy: Toward a more integrative model of change." Psychotherapy: Theory, Research and Practice 19(3): 276-288. 22. Idler, E. L. Benyamin, Y. 1997 “Self-Rated Health and Mortality: A review of Twenty Seven Community Studies” Journal of Health and Social Behaviour Vol 38: 21-37 23. HM Treasury 2009 “The Green Book: Appraisal and Evaluation in Central Government” TSO London 24. Naidoo, B. Warm, D. Quigley, R. Taylor, L. 2004 “Smoking and public health: a review of reviews of interventions to increase smoking cessation, reduce smoking initiation and prevent further uptake of smoking”. London: Health Development Agency. 25. Action on Smoking and Health 2008 “Beyond Smoking Kills” London 26. The Information Centre. 2007 “Statistics on Smoking, England 2006” London National Statistics 27. Cabinet Office Strategy Unit 2003 “Alcohol misuse: How much does it cost” London Cabinet Office 28. Balakrishna, R. Allender, S. Scarborough, P. Webster, P. Rayner, M. 2009 “The Burden of Alcohol Related Ill Health in the United Kingdom” Journal of Public Health June 3 29. Comptroller & Auditor General 2001 “Tackling Obesity in England” London: HMSO. 30. Foresight 2007 “Tackling Obesity Future Choices- Project Report” Chief Scientific Adviser to Government London HMSO 31. Allender, S. Foster,C. Scarborough, P. Rayner, P. 2007 “The burden of physical activity-related ill health in the UK.” London, Journal of Epidemiology and Community Health Volume 61: 344-348 32. Rayner, M. Scarborough, P. 2005 “The burden of food related ill health in the UK” London, Journal of Epidemiology and Community Health Volume 59: 1054-1057 33. Sainsbury Centre 2003 Policy Paper 3 “The Economic and Social Cost of Mental Illness in England” Sainsbury Centre London. 34. McCrone, P. Dhanasiri, S. Patel, A. Knapp, M. Lawton-Smith, S. 2008 “Paying the Price: The Cost of Mental Healthcare to 2026” Kings Fund London

59 35. HM Government 2008 “Drugs: protecting families and communities: The 2008 Drug Strategy” London, Central Office for Information on behalf of HMG 36. The UK Collaborative Group For HIV And STI Surveillance 2004. Focus on Prevention. HIV and other Sexually Transmitted Infections in the United Kingdom in 2003. London: Health Protection Agency Centre for Infections. 37. National Institute for Health and Clinical Excellence 2007 “One to one interventions to reduce the transmission of sexually transmitted infections (STIs) including HIV and to reduce the rate of under 18 conceptions especially among vulnerable and at risk groups, Costing Report” London NICE 38. Derek Wanless 2002 “Final Report : Securing Our Future Health: Taking a Long- Term View”, MH Treasury London 39. Putnam, R. D. 2000. “Bowling Alone”, Touchstone, New York 40. Kawachi, I. And Berkman, L. 2000. “Social Cohesion, Social Capital, and Health” in Lisa F.Berkman and Ichiro Kawachi (eds.) Social Epidemiology, Oxford University Press, Oxford 41. Mayer P. 2003 “The Wider Economic Value of Social Capital and Volunteering in South Australia” Government of South Australia, Adelaide 42. Department of Health 2002 “Choosing Health” Department of Health London 43. Bate, P. and Bevan, H. and Robert, G. 2005 “Towards a million change agents: A review of the social movements literature: implications for large scale change in the NHS” NHS Modernisation Agency, Birmingham 44. National Institute for Health and Clinical Excellence 2006 “Costing Report: Brief Interventions and referral for smoking cessation in primary care and other setting” NICE London 45. British Heart Foundation 2008 “Socio-economic differences in smoking” British Heart Foundation Statistics Web site accessed on 08/03/2010 at http://www.heartstats.org/datapage.asp?id=887 46. Health and Social Care Information Centre 2005 “Health Survey for England 2004: The Health of Minority Ethnic Groups”, London National Statistics 47. Office for National Statistics 2006. “Smoking and drinking among adults, 2005. General Household Survey”. Office for National Statistics, London 48. Office for National Statistics “Obesity among people aged 16 and over: by social class of head of household and gender, 1998: Social Trends 32” Office for National Statistics, London 49. Shohaimi, S. Welch, A. Bingham, S. Luben, R. Day, N. Wareham, N. Khaw K. “Residential area deprivation predicts fruit and vegetable consumption independently of individual educational level and occupational social class: a cross sectional population study in the Norfolk cohort of the European Prospective Investigation into Cancer (EPIC-Norfolk)” J Epidemiol Community Health. 2004 August; 58(8): 686– 691. doi: 10.1136/jech.2003.008490 London 50. NHS Information Centre 2008 “Health Survey for England 2007: Latest Trends NS” Department of Health London

60 51. Chivite-Matthews, N. Richardson, A. O'Shea, J. Becker, J. Owen, N. Roe, S. Condon, J. 2005 “Drug misuse declared: Findings from the 2003-04 British Crime Survey” Home Office Statistical Bulletin 04/05, London 52. Aust, R. and Smith, N 2003 “Ethnicity and drug use: key findings from the 2001/2002 British Crime Survey” Home Office Statistical Bulletin 209, London 53. Local Government Finance Analysis and Capital Finance division of Communities and Local Government 3 December 2009 “Statistical Release: Local Authority Revenue Expenditure And Financing England 2008-09 Final Outturn” Department for Communities and Local Government. London 54. Ministry of Justice Statistics Bulletin 2009 “Probation statistics annual brief 2008” Ministry of Justice London 55. Sam Brand and Richard Price 2000 “Home Office Research Study 217: The economic and social costs of crime” Economics and Resource Analysis Unit Home Office London 56. Social Exclusion Unit 2002 “Reducing Reoffending by Ex-prisoners” Cabinet Office London 57. Paul A Jones 2008 “Banking on a Fresh Start” Faculty of Health and Applied Social Sciences, Liverpool John Moores University, Liverpool 58. Frontier Economics 2010 “St Giles Trust Through the Gates: An analysis of economic impacts” Pro Bono Economics, London 59. National Statistics 2008 “Consumer Trends Quarter 4 2007” London HMSO 60. Edward Bramley-Harker 2001 “Sizing the UK market for illicit drugs” RDS Occassional paper 74 The Research, Development and Statistics Directorate, The Home Office London 61. Buckner, L. Yeandle, S. 2007 “Valuing Carers –Calculating the cost of unpaid care” Carers UK and University of Leeds London, HMSO. 62. Dame Carol Black 2008 “Working for a healthier tomorrow” London TSO 63. Mason, H. Marshall, A. Jones-Lee, M. Donaldson, C. 2006 “Estimating a monetary value of a QALY from existing UK values of prevented fatalities and serious injuries” Social Value of a QALY Research Team Department of Health, The Research Findings Register. Summary number 1728 London 64. Franz Buscha, Jo Blanden, Patrick Sturgis, Peter Urwin, 2009 “Earnings and Occupational Status Returns to Lifelong Learning” University of Westminster, Centre for Employment Research, Economics Department, University of Surrey and Centre for Economic Performance, London School of Economics, University of Southampton 65. National Audit Office 2009 “Train to Gain: Developing the skills of the workforce” Department For Business, Innovation And Skills Learning And Skills Council. The Stationary Office, London. 66. Graham Lister and Muir Gray 2005 “Building Leadership for Health: Knowledge Management for Public Health: a set of training resources on knowledge management” available from the World Health Organisation Geneva 67. Greenwood, M. 1948 “Medical Statistics from Graunt to Farr:The Fitzpatrick Lectures for Years 1942 and 1943.” Cambridge, UK; Cambridge University Press-

61

Load more

  65

Copy Link