The opportunity and challenge to improve health in the Plymouth population is great. Life Expectancy in Plymouth is consistently below the England average for both males and females. This is closely associated with levels of deprivation, which for the most part explains the well documented and long standing health inequalities that exist amongst our local population. Our data demonstrates that local people in our most deprived neighbourhoods not only live shorter lives, but they also live more of their lives in poor health.
Thrive Plymouth is our city wide initiative to create a social movement to work collaboratively to reduce health inequalities and improve the health of local people. We know that 4 lifestyle behaviours [smoking, diet, alcohol and physical inactivity] are key drivers of more than half of the premature deaths in the city and that these lifestyle behaviours are modifiable. We also know that to enable people to adopt healthier lifestyles is a very complex issue, influenced by social determinants, including environments, education, income, people’s own sense of wellbeing and emerging evidence is now demonstrating the lifelong impacts of adverse childhood experiences.
As is detailed in the Life Expectancy and Public Health Indicator reports, in terms of the 4 lifestyle behaviours, our local position is worse than England average in relation to the prevalence of smoking tobacco and of being overweight or obese. It is in line with the England average in terms levels of physical activity in adults and is better than England average for hospital admissions for certain alcohol specific conditions.
Current services commissioned for general health improvement include an integrated health improvement service delivered by Livewell Southwest and called One You Plymouth. This service is provided for the whole local population and delivers a person-centred and holistic offer. It is structured to inform, enable and support people, according to their needs and preferences, to make lifestyle improvements and includes smoking cessation, tier 1 and 2 weight management, physical activity interventions and brief interventions for alcohol. It also includes capacity building by the provision of training to local people and organisations, for example Make Every Contact Count [MECC] training and mental health awareness and prevention training. The service targets face to face support within the most deprived neighbourhoods of the city and is aligning delivery to be present in the wellbeing hubs. In a year the service provides advice to around 5,500 individuals. 1,500 receive face to face interventions and around 1,000 people receive training of one type.
Additionally there are investments in Primary Care [GPs and Pharmacies] to support smoking cessation and to deliver NHS Healthchecks to the eligible population. There are also small investments with VCSE providers to support health improvement in some groups with additional needs. Current investment is approximately £1.33 million per year.
The costs to the NHS of unhealthy lifestyles is considerable and so the opportunities are not only in improving health but also in reducing health-care costs.
There is a wide range of evidence on the effectiveness and cost effectiveness of public health interventions. Of the public health interventions considered by NICE, 30 are cost saving, 141 were estimated to cost less than the £20,000 per quality-adjusted life year (QALY) threshold and of those 69 cost less than £1,000 per QALY (Owen L et al : The cost-effectiveness of public health interventions. Journal of Public Health 2011, Vol 34. No1 pp 37-45).
The QALY is a generic measure of disease burden, including both the quality and the quantity of life lived. It is used in economic evaluation to assess the value for money of medical interventions. One QALY equates to one year in perfect health.
As an example, for every £1 invested in stop smoking services £2.37 will be saved on treating smoking-related diseases and reduced productivity and £12.87 would be saved overall if QALY gains are valued at £20,000 per QALY (Pokhrel, S. & Owen, L et al. Cost of disinvesting from stop smoking services: an economic evaluation based on the NICE Tobacco Return on Investment model. The Lancet, 2016).
Generally health improvement and promotion interventions have been found to have a median return on investment of 2.2 and a median cost-benefit ratio of 14.4. (Masters, R. et al. Return on investment of public health interventions: a systematic review. Journal of Epidemiological Community Health 2017, 71:827-834).
Analysis of the NHS Health Checks programme identifies a cost per QALY of £3,000. Healthcare system savings are identified through the prevention of heart attacks and strokes and the early detection and treatment of disease. The investment made in our health improvement services is therefore impactful not only on individuals, but on our health and care system as a whole.
You may have noticed that in the recent national announcements around reaching smoke free status in 2030, Plymouth was noted for piloting the ‘Swap to Stop’ scheme which supported people giving up tobacco by swapping to e-cigs. This is now a national programme; but at the time we piloted it, it was seen as innovative and ground-breaking. We are still in touch with some of our cohort of ‘swap to stop’ people who have remained off all tobacco products ever since.