Comment / Measuring productivity and the impact of prevention

The vital role of prevention in healthcare was recognised in the launch of an inquiry into the prevention of ill health by the Commons Health and Social Care Committee. While an aging population places increasing pressure on healthcare services, as highlighted in a recent Health Foundation report, prevention and productivity are regularly cited as ways to contain the costs of care and make healthcare services sustainable for the long-term. 

What is prevention?

Prevention is concerned with reducing or delaying the need to receive intensive forms of care, such as at a hospital. It falls into two broad categories. 

First, there are public health policies that aim to reduce health harming behaviours such as smoking. Improving the environment people live in can also improve health. Public health policies generally have an impact over the long-term. 

A second form of prevention relies on less intensive forms of healthcare – for example through community care, pharmacists and GPs – to reduce or delay hospital admissions. The availability and quality of less intensive forms of care can have short-term and long-term effects. The point where prevention ends and healthcare begins is important when considering how prevention relates to productivity. 

How is productivity measured and what does it cover?

The measurement of health system productivity focuses on healthcare activity. The expectation is that providing more volume and higher quality of healthcare will generate more health, the ultimate goal of a health system. Also, it is generally believed that more costly forms of care generate more health in themselves than less costly forms. 

This is the broad approach used in work at the Centre for Health Economics, University of York. It is based on recommendations from the System of National Accounts. This recognises the need to use cost, volume and quality of activity when it is not possible to know the value of outputs – in this case, the health gained and a patient’s value of it. The York measure considers short-term productivity growth, between one year and the next. It includes primary, community and secondary care. Therefore, less intensive forms of care are included, but not public health policies.

What happens when public health improves?

At face value, improvements in prevention could lead to healthcare provision, especially in hospitals, appearing less productive. During the recent Covid-19 pandemic, hospitals were initially asked to cancel all elective care, as a preventative measure. The latest York report reflects the reduction in patients treated at that time. Measured productivity in the year 2020/21 was over 24% lower than in 2019/20, despite the treatment of patients with Covid-19 and inclusion of additional services provided by the NHS such as vaccination. The measure did not include the health generated by preventing Covid-19 infections.

However, the Covid-19 example is a rare case of a public health measure that had a short-term impact and, by nature, reduced the number of patients treated in hospital. In contrast, reducing the number of people smoking reduces the risk of a range of respiratory diseases, which might require hospitalisation, but over the long-term. 

Further, the persistence of waiting lists shows there is more demand for healthcare than can be provided. Reducing the need for some people to attend hospital, is more likely to reduce waiting times for other patients than the number of patients treated in hospital from one year to the next. A shift in resources towards public health is, therefore, unlikely to make hospitals appear less productive using present measures and looking at the short-term. Current healthcare productivity measures are also not well suited to measuring the longer-term health benefit of public health policies.

The role of less intensive care

Some of the benefits from less intensive forms of care, such as reducing the need for hospital admission in the short-term, are not given a specific value in current measures of productivity. However, there is potential to incorporate this type of prevention within quality adjustment. For example, giving a higher value for primary care activity when a higher proportion of patients with specific conditions have blood pressure below a recommended maximum. This indicates good management of symptoms, which in turn may reduce future need of hospital care. Expanding quality measures further, to incorporate activity with a prevention element, may better account for shorter-term impacts of prevention and move healthcare productivity measurement closer to health productivity. 

Health productivity measurement is a holy grail for supporting the allocation of resources. In the absence of the vast amount of data required to directly measure this, short-term healthcare productivity measures provide a valuable and robust measure for comparing healthcare systems over time. While we might expect public health-based prevention to produce more health at a lower cost, it is unrealistic for this to be captured within current productivity measures. Key decisions about the level of funding for longer-term prevention can be treated as separate issue and don’t reduce the importance of also tracking the productivity of existing service delivery.

Dr Gaughan worked with senior research fellow Dr Adriana Castelli and research fellow Dr Anastasia Arabadzhyan on this comment and the Centre for Health Economics' 2020/21 productivity update.