Health economic skills for advancing health policy: capturing effects of prevention and intervention beyond traditional health services

Health systems around the world are lagging behind the needs of their patients. Larger, older populations with increasing numbers of long-term conditions are increasing demand on health services. Until recently, services have tried to target resources on those at highest risk of emergency care. However, this approach has not worked well. More recently, services have focused on prevention as a potential means of reducing demand. The NHS Long Term Plan advocates prevention, working beyond traditional health services (e.g. social work and social prescribing) and using policy levers such as new ways of financing and organising services. We need research to provide evidence for these new approaches, particularly for patients with multimorbidity who currently experience the worst outcomes.

I will:
1) Examine the relative effects of NHS/Local Authority public spending on prevention and priority outcomes;
It has been proposed that only around 10% of health outcomes depend on access to traditional medical services. During austerity, the NHS budget has been relatively protected, but there have been substantial cuts in some Local Authorities. Building on work by colleagues and others, I will use publically available data on public spending and work out the relative benefits of spending in the health care system, and spending on other services that can affect health. This will help decisions about where to spend public money.

2) Map Vanguard new care models using my published framework and examine what combination of interventions works to affect specific outcomes;
From 2015, 50 Vanguard new care models were funded by NHS England. All had roughly the same aims, but with some variation in approach. I will use my previous multimorbidity framework to map interventions in Vanguards. I will then see if different types of interventions in a Vanguard lead to particular outcomes. This will build on work at UoM through the Vanguard National Programme Evaluation. Furthermore, while the whole of England has developed Sustainability and Transformation Plans (STPs) (2016), only 14/44 STPs have taken the additional step (in 2018) of forming an integrated care system (a.k.a accountable care organisation, ACO). These organisations will have greater financial and operational freedoms. I will examine the effects on health, experience and cost outcomes of this extra organisational integration over and above STP formation. I will use individual-level outcomes from hospital episode statistics (HES) to measure activity and costs, but also the GP Patient Survey (GPPS) which records patient quality of life and patient experience. The results will help commissioners decide what mix of interventions to provide to get defined outcomes.

3) Build a model to examine and simulate within-system effects of new policy changes
Salford has been one of the first health systems in England to trial the ACO approach, and is a relative leader in integrated care policy in England. I will work with local linked data (held at UoM), the Salford integrated care record, to begin to build a microsimulation model to examine within-geographical system effects on the impact of future policy decisions, and develop the model as a tool to inform policymakers. A recent vignette commissioned by the MRC Methodology Research Programme Advisory Group highlighted the underuse of this type of modelling applied to health service delivery, primarily due to lack of stakeholder engagement. It also focused on "modelling flows and interactions between organisations and sectors within health and social care" as an area where development of methods has potential. I will aim to address these gaps. Results will inform local policy direction and roll-out.

Research visits throughout the project and yearly stakeholder engagement meetings will keep the project policy and clinically relevant increasing dissemination and impact.

The Fellowship research has three specific objectives:
1) Examine the relative effects of NHS/Local Authority public spending on prevention and priority outcomes; I will use a variety of publically-available data (e.g. NOMIS, ONS, and NHS Digital) and fixed-effects regression and decomposition methods for analysis. The outcomes will include theoretical expectations from improved prevention, e.g. 1) economic productivity, 2) hospital utilisation, 3) prevalence of disease/multimorbidity. I will draw on my formal training in econometrics and heterogeneity/decomposition methods.
2) Map Vanguard new care models using my published framework and examine what combination of interventions works to affect specific outcomes; I will first map already well-described Vanguard care models to my published Foundations Framework. I will then exploit variation in the interventions and quasi-experimental analysis to determine the effectiveness of the various intervention mix on outcomes. At a national level, I will use advanced econometric analysis to compare effects of formalised ACO organisational and financial integration (14/44 STPs) with STP formation (effectively, joint commissioning). These analyses will draw on advances in programme evaluation methods. I will use individual-level data from HES and GPPS to construct outcome measures. I will draw on my formal training in econometrics and specific training on microeconomics for policy evaluation.
3) Build a model to examine and simulate within-system effects of new policy changes; At a local level, I will work with linked (health and social care data) from the Salford integrated care record and local policymakers to construct a microsimulation model. This work will build on previous examples of comprehensive models for use in evaluating health and health-related policies, e.g. the Population Health Model (POHEM) and Future Elderly Model (FEM). I will draw on my formal training in microsimulation for public policy.

This research will benefit a number of stakeholders, including:

1) Academics
I will aim to publish my research in high-impact journals. The research project has been designed around the direction of advancing health policy, to capture effects of prevention and intervention beyond traditional health services. Currently, this movement is largely driven by theory combined with the occasional case study of good practice (e.g. Kaiser Permanente in the US, or Gesundes Kinzigtal in Germany). Evidence from systems radically different from the NHS is unlikely to be ideal. For example, with very little baseline primary care activity in the US - any intervention acting through the mechanism of strengthening traditional primary care might already be at a ceiling in the NHS. I will provide context and policy-relevant evidence based on the robust econometric evaluation skills I develop.

I will address gaps in the current literature:
- I will build on my colleagues' work as part of the recent NHSA Health for Wealth report. This report decomposed health and other effects on productivity. They recommended that "increasing the NHS budget by 10% in the Northern Powerhouse will decrease economic inactivity rates by 3 percentage points". I will examine the estimated impact of increasing spending in other public sector areas, such as social care.
- I will build on our previously published Foundations Framework to examine optimal mix of interventions for new care models. I will provide evidence to inform roll-out of ACOs as part of the NHS Long Term Plan, providing novel ACO evidence in an NHS context and examining the effects of organisational/funding integration above and beyond service delivery-only integration. This research will address a priority research area identified in the recent Academy of Medical Sciences, 'Multimorbidity: a priority for global health research' report (particularly priority 6: How can healthcare systems be better organised to maximise the benefits and limit the risks for patients with multimorbidity?).
- I will also work with local policymakers/other stakeholders on linked data to inform a microsimulation model for local policymakers to simulate future policy effects on prioritised outcomes. Working closely with policymakers to build models in order to facilitate implementation is flagged as under-utilised in health services research in a recent MRC vignette.

Beyond academia, I will work to ensure these results/methods can be understood and accepted by policymakers/practitioners/patients so recommendations are more likely to be acted upon. I will work with a dedicated stakeholder group throughout the project to ensure this.

2) Policymakers
This research will be directly relevant to inform the implementation of the NHS Long Term Plan. I will aim to work closely with policymakers through the UoM established routes (e.g. PRUCOMM), as well as aiming to work more directly with local policymakers (especially in Greater Manchester/Salford through the NIHR Applied Research Collaboration (ARC)). I will write a number of policy briefs when appropriate opportunities are presented (e.g. public enquiries) and will also proactively target important individual actors.

3) Practitioners
Results of the research, particularly around effective interventions, can be directly useful to clinicians who implement these interventions on the ground. Results can help inform clinical guidelines for the treatment of multimorbidity. I will work with collaborators at The University of Edinburgh, who are directly involved in producing NICE multimorbidity guidelines, to ensure my research and results are as useful as possible to feed into future recommendations.

4) Patients
Ultimately, patients will benefit from service delivery and organisational changes which result in beneficial outcomes. As well as academic and policy outputs, I will produce lay summaries of results and blogs of key messages in a widely digestible form.