Marc Suhrcke University of East Anglia, Norwich Medical School

1. Economic evaluation of a real life public health intervention: Natural England’s Walking for Health Scheme Marc SuhrckeUniversity of East Anglia, Norwich Medical School

2. Why does it matter? • Economic evaluation as one important input into decision-making • Wanless (2004): Highlighted the need for economic evaluations of public health interventions • Confirmed by other studies, incl. systematic reviews (e.g. Schwappach/Boluarte/Suhrcke 2007) • Fairly careless treatment of the costing side in existing economic evaluations of “similar” public health interventions

3. Economic evaluation studies of primary prevention of CVD, by prevention category (n=195) Source: Schwappach/Boluarte/Suhrcke 2007

4. Intervention targets by study setting (n=195) Source: Schwappach/Boluarte/Suhrcke 2007

5. What is the Walking for Health (WfH) “intervention”? • The largest led walk intervention and one of the largest public health interventions for physical activity in the UK • Natural England (NE) launched WfH in 2000. • WfH supported over 520 local schemes with over 60,000 organised walks in the 2010-2011 financial year; almost 100,000 registered participants • WfH schemes are developed in local areas, led by volunteers, supported and funded through local partnerships (e.g. primary care trusts, local authorities or voluntary community groups). • Predominantly elderly, retired participants • Substantial variation in size • Supported by certain national level resources and structures

6. Steps in the costing methodology • Selection of schemes (2 pilots, 6 for main study) • Identification of resource use  development of a resource use inventory and questionnaire • Measuring and/or estimation of resource use • Resource valuation • Estimation of local level costs (at scheme level) • Estimation of national costs of WfH • Estimation of individual travel costs for participants • (Modest) sensitivity analysis

7. “Counting beans +”A number of slightly more involved issues to tackle • Cost perspective • Economic costs, not financial costs  “opportunity costs” • Voluntary workers • Donated goods & services (eg office space) • Productivity costs • What are set-up, what are operating costs • Costs to participants • Costs attributable to the interventions • Data gaps

8. Information sources • WfH Database • Natural England central budget • Relevant literature • Questionnaires / interviews

9. Resource use inventory

10. Main characteristics of the six selected WfH schemes

11. What gaps have we identified and what assumptions are used?

12. Gaps and assumptions

13. SET UP COSTS – LABOUR (1)

14. SET UP COSTS (NON-LABOUR) (2)

15. Gaps and assumptions: recurring costs

16. Estimating travel costs. • Why travel costs? • Starting point: info from WfH database • Postcodes of (almost) all walks • Postcodes of (almost) all walkers • Number of participants in each walk (but we don’t know who participated!) • Estimate: distance and time (based on car travel times) that each walker participating in the scheme would need to travel to reach each walk within their region (using GIS methods/software) • Travel cost calculation: • Travel expenditure = Travel time (minutes) * speed (miles per minutes) * cost per mile • Time costs = Travel time * (a*wage) [0<a<1]

17. What are the costs of WfH? • Total recurring (economic) costs for a local scheme: £15,000 – £60,000 p.a. • Costs per organised walk: £231 - £368 • Costs per hour walked: £14.4 - £22.8 • Costs per participant: £17.2 - £27.3 • Labour costs make up ca. 2/3 of annual total costs • Volunteer costs account for ½ of total labour costs • No straightforward link between size and costs of scheme • Total national economic cost: £14.3 - £22.7 million

18. [C1]I don’t understand what is contained in (1) and (2)? Are the costs of car use both time and out-of-pocket costs? What is then included in (1)? Example of travel costs: Havering WfH scheme

19. Concluding remarks • Is WfH a “costly” intervention? Probably not. • Is WfH an efficient use of financial resources? We cannot (yet) say, without info on benefits • If local authorities want to develop more of a value for money argument, there is a great need for more transparent mechanisms for collecting/identifying economic costs • What health (and other) benefits might there be? (as reported by WfH scheme contacts) • Friendship, company and community cohesion • Improvements in physical and mental health • Modelling the short and long term health and expenditure effects using the Multi-disease Model built for public health interventions • Need an estimate of individuals additional walking • Need estimates of uptake • Can incorporate information on relationship between exercise and different diseases

20. ACKNOWLEDGEMENT This work was undertaken by the Centre for Diet and Activity Research (CEDAR), a UKCRC Public Health Research Centre of Excellence. This project has been funded by Natural England. Funding from the British Heart Foundation, Economic and Social Research Council, Medical Research Council, the National Institute for Health Research, and the Wellcome Trust, under the auspices of the UK Clinical Research Collaboration, is gratefully acknowledged.