Programme Budgeting and
Marginal Analysis of a £15 million
Welsh Government Health
Improvement Fund
Professor Rhiannon Tudor Edwards
CHEME, Bangor University
PBMA – The Team
A National Programme Budgeting and Marginal Analysis
(PBMA) of Health Improvement Spending Across Wales:
Disinvestment and Reinvestment Across the Life Course.
The Team:
Rhiannon Tudor Edwards, Joanna M Charles, Sara Thomas, Julie
Bishop, David Cohen, Sam Groves, Ciaran Humphreys, Helen
Howson, Peter Bradley (on behalf of the Public Health Wales
Health Improvement PBMA team)
Professor Sir Michael Marmot
on Desert Island Discs
“ Medicine is failed prevention.”
and…..
“If Economists come up with any
proposals that harm children, then those
Economists must rethink what they are
doing.”
Desert Island Discs
Broadcast: Sunday 06 July 2014
Professor of Epidemiology and
Public Health
Public Health Challenges in Wales

Some of worst life expectancies in the UK (19 year differential between best
and worst)

Smoking causes about 1 in 5 deaths – prevalence currently 23% -highest in
young Males aged 25-34 at 38%.

About 45% of the population drink above guideline amounts of alcohol.

Over 1,000 people a year die from alcohol in Wales. Over 55,000 hospital
admissions in Wales are due to alcohol.

Under a third of adults meet physical activity guidelines – with over 30% of
adults taking no exercise in a week. 57% of the Welsh adult population is
overweight or obese.
Definition of PBMA
PBMA is a process that helps decision-makers maximise the
impact of public health resources on the health needs of a
local population.
● Programme budgeting - an appraisal of current resource
allocation in specified programmes.
● Marginal analysis - the appraisal of the added benefits and
added costs of a proposed investment (or the lost benefits and
lower costs of a proposed disinvestment).
(adapted from Brambleby and Fordham 2003)
PBMA Stages (Brambleby and Fordham, 2003)
1.
Choose a set of meaningful programmes
2.
Identify current activity and expenditure in those programmes
3.
Think of improvements
4.
Weigh up incremental costs and incremental benefits and prioritise a list
5.
Consult widely
6.
Decide on changes
7.
Effect the changes
8.
Evaluate progress
HIP PBMA Process
Results of Investment and
Disinvestment Decisions
Recommendations of
PBMA group

Total disinvestment in 7 out of 25 initiatives at a total cost of £1.5
million.
(The Cooking Bus, Smoke Bugs, Skin Cancer Awareness, Health Challenge Wales Website, Mind, Exercise,
Nutrition… Do it! (MEND), Mental Health First Aid and Smokers Helpline)

Partial disinvestment in a further 3 interventions at a total cost of
£7.3 million.
(Designed to Smile, The National Exercise Referral Scheme and Smoking Resources)

The panel did not recommend increasing investment in any of the
25 initiatives.
HIP PBMA Process continued
The Media Fallout
Government pressure to show the returns on investment
to the NHS of investing in health improvement – very
difficult in the short term.
Response to Media Fallout

Dr Patricia Riordan, director of health and healthcare
improvement for PHW, said

"I think it's a concern when you are made aware through the
evidence that your resources have not been targeted
appropriately and this is what I say - we need now to refocus
those resources to programmes that we know deliver the
outcomes"

"What we are doing today in Public Health Wales is
acknowledging that we need to do things differently now”

"It is no longer acceptable to do things the way we did them in
the past - we need now to look forward to a whole
transformational change”
Back to Theory
Allocative Efficiency – what should society do to improve society’s health and
well-being?
* Improve child health and education
Technical Efficiency – what technical method should be employed to achieve
allocative efficiency goals?
What is the most cost-effective way of improving child nutrition in a school setting?
E.G. In England - As of September 2014 all state-funded schools in England, including
academies and free schools, will have a legal duty to offer free meals for all 4 to 7 year
olds under the Universal Infant Free School Meals policy.
In Wales Free Healthy School Breakfasts for all primary school children of all ages in
maintained schools.
What I think about all this
today…






Start with an allocative efficiency goal, e.g., we need to improve
child nutrition and education
Find out all Government spending across all departments to get a
complete picture
Review the evidence of effectiveness and cost-effectiveness – this
is the technical efficiency question
Anticipate media fall out and have a good news story ready (we
are disinvesting in X to reinvest in Y)
Monitor uptake of public health programmes, potential barriers
to uptake (equity concern) and link with routine data collection
systems (Government, schools, primary care)
Publish findings to add to the emerging evidence base
Thank you Diolch yn Fawr
Ebost/E-mail:
r.t.edwards@bangor.ac.uk
Twitter: @ProfRTEdwards