Investment in behaviour change interventions must be justifiable. Rowena Merritt and colleagues present a set of tools that help demonstrate their cost effectiveness.

Whether the aim is reducing smoking prevalence or increasing screening uptake, the key to success in public health is often behavioural.

It is crucial to demonstrate that interventions represent good value for money.

Online tools from the National Social Marketing Centre can help achieve this, enabling organisations to reach reliable conclusions about their work without having to outsource evaluation.

“There are five tools available in Excel spreadsheet format, each designed to address a different health area: smoking, obesity, bowel cancer screening, alcohol and breastfeeding,” explains NSMC director John Bromley.

The tools have two important uses: commissioners can use them to help plan for proposed social marketing and behaviour change programmes by estimating the likelihood that they will provide value for money; and they can also be used to evaluate whether social marketing and behaviour change interventions were good value for money on completion.

“Users enter a range of data, such as start-up costs and audience size and, if they choose, the weighting for disadvantaged groups. Each tool will calculate a remarkably detailed range of health and social outcomes for services, organisations and individual clients. For example, they’ll show the intervention’s health gain in quality adjusted life years and corresponding monetary value, as well years of life saved, deaths averted and money saved by clients through giving up smoking – even the savings on street cleaning through reduced cigarette littering,” says Mr Bromley.

Dispelling confusion

A collaborative approach to developing the tools was led by an advisory panel of experts, chaired by Fiona Adshead, former deputy chief medical officer for England. It brought together practitioners and experts working at national and local levels, including Mike Kelly of the National Institute for Health and Clinical Excellence and the LSE’s Julian Le Grand.

“Previously, there was no agreement on how to evaluate value for money”, says Mr Bromley. “Practitioners told us that this made evaluation confusing, because there were no assurances on the most reliable approach to choose. By working closely with NICE and leading health economists, we were able to reach an expert consensus on the best methods.”

NICE’s role involved advising on the indicators for each health area and how the costs should be calculated. It also reviewed existing studies on health outcomes, savings to the NHS and other impacts for each indicator of behaviour change, including the World Health Organisation’s global burden of disease data.

“We asked practitioners what they wanted from the tools. As well as help defending their programmes, they wanted to show what behaviour change is worth,” adds Mr Bromley.

NHS Tameside and Glossop were among the local organisations that piloted the tools. As well as looking at current smoking in pregnancy, pharmacy local enhanced service and commissioning for quality and innovation (CQUIN) programmes, they used the tool to model expectations for an additional smoking in pregnancy incentive scheme.

“We’ve used NICE modelling in the past, so the fact NICE was involved gave us confidence that it was a robust system,” says deputy director of public health Elaine Michel.

“With this tool, we could tell where there were levels of uncertainty, so we were confident about what could be claimed,” she says.

Why incentives pay

NHS Tameside and Glossop run an opt-out scheme for pregnant smokers aged 20-30. A CQUIN payment is made to the local hospital to refer young women to the smoking cessation service. The team also looked at the viability of an additional incentive scheme.

“We wanted to model the level of investment required to reward women for giving up smoking,” says Ms Michel. “Even at double the value of the existing Smokefree North West scheme, it was very cost-effective.

“Looking at this scenario helped us think about the resource level and return of quitting that would be required to demonstrate good value.

Performance test

The tool helped NHS Tameside see that its smoking in pregnancy intervention, which appeared to be underperforming, did in fact represent value for money.

“We were getting a quit rate of around 5 per cent on the face of it, it looked like we weren’t achieving the health gain we wanted at a cost-effective level,” says Ms Michel.

“However, when we ran it through the tool, it proved to be very cost-effective.

“It gives us more confidence about the level of investment we’ll need to achieve the required quit level.”

The tools can be used to plan and evaluate programmes and measure performance against targets, as well as to see how different approaches measure up against each other.

Ms Michel says: “It helps us to work in a standardised way and to compare interventions. In the past, although we could model achievements, we couldn’t say what they would turn into in terms of cost-effectiveness, reduced spend or increased life expectancy.

“And having the costs and savings broken down by QALY is very helpful in communicating the benefits to NHS colleagues; with local authority colleagues, it’s the social outcomes that have the most resonance”.

“Since [the tools]  can be used for both current and planned work, commissioners can judge whether there is a case for reinvesting in live programmes, or whether new work would better achieve cost-effective impacts,” says Mr Bromley. “And because they make clear what information is required for the estimates, local teams now have benchmarks for effective data collection.”

Tameside and Glossop Smoking Cessation

Intervention and informationPublic sector savingsSocial impacts
Total NHS and public sector cost: £17,555Cost savings to NHS from Health Gain: £9,749Total deaths avoided: 0.34
Number of clients: 600Local authority service savings arising from:Total years of life added: 1.43
 Social care: £1,475Total years lived with disability weighted for disability reduced: 1.35
 Street cleaning: £202Reduced expenditure on cigarettes: £56,117
 Fire and emergency: £222Reduced informal care: £6,617
 Total: £1,899Increased employment income and pension, less tax and reduced benefit payments: £13,842
  Net benefit from the intervention: £76,574


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