Should prevention be treated as capital investment? (Joanna Lane)

[00:00:00] Dear listeners, welcome to Faces of Digital Health, a podcast about digital health and how healthcare systems around the world adopt technology with me, Tjaša Zajc Health systems in Europe spend between 6-13% of their GDP on healthcare expenditure and 3% of healthcare budget goes to prevention

[00:00:26] Joanna Lane has spent decades working on health and regional development across Europe and argues that prevention should be reclassified from expenditure to capital investment It should be financed the way that we finance energy grids, transport and pensions So in this discussion, she explains what the Horizon Europe project Invest for Health learned from 8 regional testbeds

[00:00:55] Why Public Health Wells disinvested around 10 million British pounds to reinvest that money and how health systems' own procurement and hiring can improve the determinants of health We also talked about what finance ministers need to hear before they will treat prevention as an investment

[00:01:19] Enjoy the show and if you haven't yet, make sure to subscribe to the podcast wherever you listen to your shows Check out our newsletter which you can find at fodh.substack.com That's fodh.substack.com And find Faces of Digital Health on YouTube or LinkedIn to follow our latest shows and reports Now let's dive in today's discussion

[00:02:00] Joanna, hi and thank you so much for joining me on Faces of Digital Health To talk about how we can perceive prevention more as an investment You've been researching the field of reshaping or reshaping the understanding of prevention for over 30 years What progress has been made so far?

[00:02:26] Oh, the evidence for prevention is fabulous There's some very detailed evidence The problem with prevention compared to treatment is that if prevention works you don't get an outcome often, it's invisible A person doesn't go to hospital A person doesn't have to go into care So these are hidden benefits of very good prevention So this is problematic but having been in this field for actually over 40 years now

[00:02:54] What you find is that one of the problems with prevention is it's difficult to scale And I've worked locally but I've also worked nationally And with a national agency you have big budgets You have an advertising agency You're looking at the workplace You're looking at schools You're looking at different settings And you have the budget to be able to do that But if you're working locally, you're often working on small budgets

[00:03:22] And these budgets, if for example there's a problem With an annual budget And they need to put more money into treatment They will take it away from prevention We should be focusing on prevent rather than Or preempt Act first rather than repair So instead of waiting for people to get ill Getting a disease Going to hospital Needing treatment Needing surgery Or growing old Having several things at the same time Happening with hypertension

[00:03:51] Maybe diabetes Obesity Or different things happening You want to get in Much further upstream And If you can get in early enough Then you're delaying things happening Or sometimes things won't happen It depends Obviously it's different for each person But One of the problems that We looked at in the Invest for Health project Was precisely that How do we

[00:04:21] How do we try and Change How prevention And health Disease prevention And health promotion Is More investable So let's talk a little bit about that So this project that you just mentioned It took place in four regions If I'm not It took place actually in eight regions We started off with the initial tranche of four regions In Sweden In Nordrhein-Westphalia In West Wales And in Galatia

[00:04:50] And then it expanded to a region in Italy A region in Serbia Another region in Sweden And elsewhere So It expanded And we took what we'd learned With the initial regions And tried it out again What did you learn from the initial regions? So I guess one of the challenges with projects like this Is that they really need to take a long time So you show that maybe a preventative measure Had a long-term impact So what did you find out

[00:05:18] And what could you translate to other regions After the first four? Yeah The point is not about an intervention per se Because an intervention could be looking at cerebral palsy Trying to deal with people being able to continue living with it Or it could be dealing with people with diabetes type 2 So there are many different ways in which you can work on prevention It can be upstream, midstream It's rarely downstream because that's where tertiary and hospital care is

[00:05:47] One of the things that we were looking at particularly was that Back in 2017 I'd helped to advocate for a high-level task force To look at boosting social infrastructure investment over the long term And this was taken forward by the European Long-Term Investors Association And DG Ekfin from the Commission And so I was involved in this I was on the task force I was also helping to run the whole thing

[00:06:16] And one of the ideas that we came out with here Was smart capacitating investment And that meant don't look just about investing in education Or in long-term care Or in social housing Look at how these things connect together Create flexible infrastructure And so a report was published in January 2018 And when the opportunity came along I helped put together a proposal

[00:06:44] To get Invest for Health funded So that we could actually take this idea That we'd had in a working group That I was coordinating for this task force And which was chaired by Lee Franson And try and strengthen the concept more And then test it in terms of Translating into finance model Business models, business plans That sort of thing And this is what we did And so we strengthened the concept We had a better understanding of it

[00:07:14] We published different articles on it We've engaged with people In those four initial regions And then what we tried to do Is translate it into If you like A finance model But also a business model Because the finance model Sits within a business model To do it in a way Which was aligned with What we saw as the Elements of smart compensating investment Which is things like Sharing risk It's about But I'll come back to that

[00:07:42] The point is that When we worked with these test beds We thought that we could just Give them Like a template And that they could go away And adapt it to local circumstances But it was Different Because They have their own context Their own situation Their own funding Their own assets Their own problems And so what they did was They actually Found ways Of Creating the investment Themselves

[00:08:11] But guided by Some of the ideas Behind smart Capacitating investment Which was quite interesting And so what we came up with And particularly with Syrian Research Institute In Budapest They came up with A Financing Modern toolkit And this is what Regions can go away And use And what we also set up Was a Competency building Training program Which we tested out Particularly with the The second tranche

[00:08:41] Of four regions So we did a lot of Training with them And so eventually What we're able to offer Is something which is What we're able to offer Is that Regions can come to us In different ways They can come to us And say We want to know How to develop Pitch So that we can make A pitch to A national fund Or to a regional fund And get funding For this great Prevention idea And so it can help With them with that But they could also Come to us and say Actually

[00:09:10] We want to know How we can Scale up funding For prevention Not just to make A bigger pot of money But to make that Money Last longer Because prevention You can have Quick wins with prevention But you Also Some parts of prevention Take a long time So you need to invest In them for the long term That is not something That health systems Do They don't understand that For them Treatment You've got A drug

[00:09:39] Is prescribed You've got Particular patient Sensitive treatment Program You've got codes For the illness All those It's black and white It's visible Prevention That's not the case It's invisible For them And so This is what This is why We've got to think about Funding it differently Yes And one of the things I would say Because we've got a paper That will come out Shortly on this And I'm going to Raise it tomorrow

[00:10:09] In the review meeting Commission Is that Problem with prevention Fundamentally Basic problem Is it's seen As expenditure So It's in a budget That is Renewed annually Or maybe every Two or three years But that's where it is It's a piece of expenditure I think we've got to Change it And we've got to Reclassify it As capital investment It's soft infrastructure But it's capital investment In the same way In the long term

[00:10:38] You invest in energy grids You invest in transport routes You invest in digital infrastructure You invest in pensions This is all long term And this is how we need to see Prevention Where Do you have examples Of where somebody Would already Achieve the state of Enlightenment To see Prevention As an investment We know that in Europe Healthcare systems

[00:11:08] Attribute 6 to 13 percent Of their GDP To healthcare And 3 percent Of healthcare budgets Go into prevention Are there any Bold countries Or regions That would be Willing to Take a different Approach What keeps you Going for 40 years To try to change This perception Of what prevention Should be And what kind of An impact It can have I have to be honest And say I haven't been trying For 40 years

[00:11:38] To change prevention That would be exhausting But it's more More recently In the past few years I've focused on How to finance Things differently And be innovative With the financing So that's where I'm focused If you like Repeat the question again So do you see Any good examples Of countries Or regions That are doing Interesting pilot Projects in Prevention Or what are Some of the Good examples Of taking

[00:12:07] Prevention More seriously If I just look At Slovenia So we have Really good Prevention programs Or screening programs Because prevention Obviously has Several layers But we've got Great screening programs For colorectal cancer Breast cancer There's now For quite a few years Now they've been Trying to set up Screening programs For lung cancer And for prostate cancer So are there Any examples That really inspire you When it comes to

[00:12:37] Investments in prevention One of the things That inspires me For example Is in Wales And Public Health Wales Obviously like any Other national agency Has quite a nice Budget to do Public health work Of which prevention Is part of that And to do Health promotion work And they went Through an exercise A few years ago Of doing a Kind of marginal Cost analysis Of existing

[00:13:07] Investments In health promotion To see Were these Still having An impact Or could we If you like Disinvest In order to Reinvest And I think That's really An important step Because so often We think We've got a Great idea Where's the money But perhaps Sometimes we've Got to pause And think What are we Doing now That is actually A waste of money And we need To be able To identify that And they went Through that process

[00:13:36] And they Basically Disinvested About 10 million Pounds So maybe 12-13 million euros And were able To reinvest it To address To invest In Interventions Which were more Relevant And had More proven Value And I think If you could Repeat that Exercise In regions Across Europe

[00:14:07] That's a very Important first Start To disinvest In order to Reinvest And it's a very Basic thing to do So for me That's one of The first things That inspired me But it's also About recognizing For example That we talk About the 3% Thing Saying 3% Is spent on Health, Emotional and Disease prevention Actually that Wasn't the case During COVID A lot more Was spent on Particularly disease Prevention Creation And getting Out vaccines

[00:14:36] But as soon As the Epidemic Was said It's past It's over People regressed Into their Thinking And so Instead of Keeping investing Upstream In prevention And health Motion It goes back To what's Protected Which is Acute And there Was of course The long Tale of There was Long COVID There was Long tale Of NCDs Which had not Been diagnosed Early enough And so they Developed Further So people

[00:15:05] Need different Forms of Treatment So that's Where the Money is Taken up And so The amount That was Found for Doing more Upstream Work Got lost Yeah because It's not Just about Acute health Issues It's just About acute Issues That society Has in In general If before It was Held Because of COVID Now it's Defense Because of The geopolitical Uncertainty Geopolitical Uncertainties Like energy

[00:15:34] And war And climate These are Creating things That are You've got to Start to Prioritise You've got to Think about Just because We're doing Something locally What is the Impact of that On our Contribution to The environment What is it To making sure That we use Energy more Sustainably So those Sorts of things You've got to Think about And for me I started to See I went Through this Period Where I was Working with

[00:16:03] Regions in The UK Where I was Looking at What regional Spend on Healthcare in Terms of Things like Procurement Employment Being an Innovation Partner Capital Investment What was The ripple Effect of That spending On local Economies And local Communities And if you Look at it Like that That's a Big amount Actually being Spent on Communities Far bigger Than you Actually get For prevention

[00:16:33] Programs If you like Preventative Interventions And so Particularly if You start to Pursue an Agenda around Like having At least 15% 20% Of our Procurement Activity Be local Procurement Through local Companies So that You're reducing Transportation Effects on The environment And you're Also getting People locally To be To be able To earn Or companies To earn it And then people Taking salaries

[00:17:03] From those Companies and Their families Spending it Locally That is Brilliant And likewise With employment If you start To take a Policy of Inclusive Employment So for Example You're Trying to Employ more Younger People who Are finding That they're Not able To get Training or Employment So what We call Needs Then that Can have Quite a Big impact Because if You can Get them Some work For a While Maybe as An intern Or maybe Paid part Time work Or something It gets Something on Their cv And so They're able To build On that

[00:17:33] And you Can reference Them And so on And likewise With older People Used to Think you Retire at 60 You retire At 65 Most people Or many Apart from The very Rich Cannot afford To retire Anymore They feel They've got To keep Working And so What are The opportunities For these People who Have a lot Of experience A lot Of insights And so I think An inclusive Employment Policy Practice Is very Important So that All these Sorts of Things Which are

[00:18:03] Added value From the Money that's Being spent By healthcare Which actually Has an Impact on The determinants Of health Both social And economic How often Do you see That Ministries Like the Finance Ministries And Ministries For economy Are involved In these Discussions Because I Feel like Exactly Because what You just Said If somebody Is in Poor health They can't Work They become A burden To society Instead of

[00:18:33] Being a Productive Member of Society I don't Think that Connection Is Seen Often Enough When we Talk about Why Investing in Prevention Is so Important Yeah I was Once in A meeting With the Finance Minister For lower Austria And we're Having this Chat because He'd been To a Policy Forum That my Health Custardet When it Was an Interreg 3C Funded Network Operation Had a Policy

[00:19:02] Forum In Bilbao And the Health Minister From Basque Country Was there He'd been In post For a Number Of Years This Finance Minister Had been In post For a Number Of Years So You're Able To have A Conversation With Them Which Was About What About Longer Term Horizons And Longer Term Investment And Not Just Doing The Short Term Because Of Course In

[00:19:32] Meeting This Finance Minister In Lower Austria And I Said Just Imagine That Right Now I'm Your Health Minister Sitting Down With You And I'm Saying Finance Minister Instead Of I'm Saying I Need You To Increase Our Budget By 115 Million Euros Because There's More Demand On From Older People And We're Getting More Instances Of Diabetes And Cancers I'm Going To Other Ministers Because We're All Competing For The Same Money

[00:20:01] But If I Say To Say To You For That 115 Million Extra That You Invest I Can Guarantee A Ripple Effect In Terms Of Local Employment Local Procurement Capital Investment Contract Which That's Big Added Value The Finance Minister Said To Me I

[00:20:31] Don't Know If You Came Along To Me And Put That Argument To Me I Would Be Quite Interested In It But No One Does But Do We Have Numbers That Could Illustrate That Yes We Have That We Have Numbers For Example For Local This They Have Actually Got Figures And Others Have Developed

[00:21:01] These Figures Across You But Every One Euro You Get Five Euro Or Maybe It's A Three Euro Turn On Investment Or Added Value So There Is Evidence Out There For This How Do You Design The Evidence To A Degree I Think When It Comes To Prevention And Especially Putting Numbers On It It's Always A Little Bit Tricky Because As I Said Before There's Several Layers Of Prevention One Is Looking

[00:21:31] At Screening Programs So You Have Early

[00:22:00] To Show Direct Correlations Or Causations With So How Like How Do You See That I Think There Are Examples Like For Example In Scotland Where I Previously Was A Director Of Research And Evaluation Of What Was The Health Education Board For Scotland They Talk About The 20 Minute Neighborhood So That You Can Walk Wherever You Need To Within 20 Minutes You Can Get To Work You Can Go To A Transport Hub You Can Go To The Shops

[00:22:30] 20 Minute Neighborhood That's A Lovely Idea It's A Sustainable Idea And To Embed That In The Planning Of New Builds And So On I Think Is One Of Those Important Ideas Because It Can In Turn Generate Benefits Which Can Be Measured In Certain Ways But There's Another Thing There's For Example For Example Older People We

[00:23:04] Ill Maybe They Go Into Hospital Or They Go Into Long Term Care Or A Nursing Home And We Don't Really Get Into Depth About How They Feel About It And This Is Quite Important And So If You I Would For Example Move Away Which They've Done In Denmark From Having If You Like Isolated Nursing Homes To Or Nursing Residences To Having Something

[00:23:34] Which Is A Community Hub Which Combines Day Classes For Education It Combines A Coffee Shop It Combines Children Doing Kindergarten It Could Combine Older People Meeting With And Mentoring Younger People It Can Involve Day Care For Old People Or People With Certain Illnesses So You Bring Everything Together In A Community Hub You Have A

[00:24:28] There's One Trend That We Are Currently Also Seeing And That Longevity And Some People Call Longevity A Beautiful Rebranding Of Prevention Because Now You Can Have All Sorts Of Sensors You Can Measure Everything And Suddenly It's Fashionable To Know How Many Steps You Did A

[00:24:58] Devices And Wearable Stake So How Do You See The Perception Of Longevity From That Perspective Yeah Basically I'm Really Not Sure How I See The Perception Of Longevity From That Perspective Put The Question To Me Again So Maybe I Guess Maybe The Question Here Is Where Do You See The Balance Or The Relationship Between What Public Policies Should Do And Invest In Prevention Versus What

[00:25:28] An Individual Can Do Because Like Today You Can Measure So Many Things That It's Getting Harder And Harder To Not To Have An Excuse Why You're Not Taking Care Good Care Of Your Health Yeah A Project That Trust Up In Norway And It Was About If You Like Developing E-Health Solutions

[00:25:58] And Also M-Health Apps To Help People Do Independent Living In The Place Where They Age Where They're Living And So Then You Build In Remote Monitors Into The Home You Build In Chat Box Into The Home You Make Sure They're Connected With Their Care Manager Or Friends In Their Community You Want Them To Go Out And Meet Their Friends And Socialize But Sometimes They Can't Do It So You Want To Keep In Contact All The Time

[00:26:28] And Digital Solution Which Was Gathering Data From Different Sources And Then It Translated Into What's The How Do We Adapt Treatment For This Particular Person And I Think That's A Very Good Idea Problem With Digital Solutions Is Digital Solutions Come Thick And Fast They Develop Them Much Faster Than

[00:27:03] It It A Lot Faster Often But Problem Is That There Are Two Ways To Look At Digital Solutions Or Digital Health Solutions One Of Them Is That You're Targeting The Consumer Market And The Second One Is That You're Targeting The Institutional Markets So Maybe For Older People Someone Who's Multimorbid Or Something Then And They Need To Be Monitored Or They've Got Early Onset Dementia Then You Could Be Looking At

[00:27:32] Prescribing A Digital Solution A Digital M Health App Or Something You Could Be Looking Doing It Through Social Prescribing For So That's One Thing Because Doing Monitoring In That Context Is Part Of The Treatment Plan And It's Making Sure That People Are Able To Live Very Positive Lives As Independent As Possible Even If It's Assisted Living In Some Ways On The Other Hand You've Got Consumer Market

[00:28:03] And These Are Wonderful Stuff Which Are Really Pitched Really Well Sold Really Well In The Consumer Market But Unless You Are A Real Fitness Fanatic I Go Running Several Days Of The Week Or I Do Some Long Cycling And I'm Wearing My Apple Watch And I've Got It

[00:28:53] So So What Would You Say That Means For Personal Responsibility Versus Just Preventative Measures On A National Level It's Much Harder To Just Tell People Don't Eat Sugar Don't Drink Alcohol But We Know That What Would Actually Make An Impact Is If You Actually Have A Policy That Kind Of Mandates Schools Not To

[00:29:22] The Machines With Candies And To Limit The Consumption Of Alcohol And The Availability Of Alcohol How Do You See That Kind Of Relationship I Think Certainly There Needs To Be Much More Done At An Early Age And

[00:29:52] People Know About Is When They Have A Heart Attack When They're 40 That's Too Late And As This Is An Inherited Disorder We Should Be Doing That Screening In Children Or At Least As They're Turning Into Teenagers So Then We Can Help To Help Them To And Help Their Families To Create An Approach To Life Which They Know They Have This Genetic Trigger of

[00:30:22] To

[00:30:52] School nurse would, we'd all queue up outside her office and she'd check us out, things like that. And so this is important to have. And you're right about having decent food available, healthy food that's available. But often schools are having to compete with others for funding. And particularly child poverty has been growing in the EU. And these children do need good foods.

[00:31:20] Often their parents will, or their mother or their father will prioritize feeding them rather than feeding themselves. So you've got to look at the, got to deal with things both at a systemic level, a systems level, whether it's education, the workplace, hospitals, community, or whatever it is. But you've also, yes, you're relying on people's behavior.

[00:31:49] And so when I go back to the retention issue, about 8% retention rate for some of these digital health solutions, that's an issue around, that's a behavioral issue. Getting bored with something or thinking, I don't have time to do this. Or it told me stuff and I seem to be okay. So I'll ignore it now. And there are those sorts of things. So there are, there's a degree of responsibility.

[00:32:11] But the problem is that sometimes politicians push too far on it's the individual's responsibility and not society's responsibility. Yeah, I agree with that. So if we slowly wrap up the discussion, if you had one message for health ministers or finance ministers, what would it be? Maybe you already have a message that you keep repeating at every possible opportunity.

[00:32:40] Let me put it this way. We're working on a paper called Financing Patient Health Capacity. Well, no, sorry, Productive Health Capacity. And we've been working with people like InvestNL and the Radical Health Foundation to develop a paper. And there's also a white paper alongside it, which is looking at what are the metrics that we need to be measuring

[00:33:04] or that Eurostat or national statistics agencies need to be measuring so that we can start to look at prevention as capital investment and not simply as expenditure. And in a sense, the way that we want what we want to do is we want to get some of these figures through demonstration projects. We want to get pension funds or others to fund some demonstrators.

[00:33:28] And we want to be able to run regular workshops with finance ministries and the departments of planning and budget within health ministries to say, we need to do things differently and this can bring benefits. And instead of the money just going down a black hole and you think, what's the benefit of funding disease prevention or particularly health promotion? You can see measurable effects through longer term investment.

[00:33:56] But you still have the quick wins as well. So going back to what I talked about with smart capacitating investment earlier on, which was one of the things we focused on in the Invest for Health project, we need to look at three layers, if you like. There's a layer for smart capacitating investment and that should be a projected layer of funding for prevention.

[00:34:17] So it shouldn't be something that's up to a change in the political priorities after a year or after an election, but it's seen as short to medium term. And then you've got the notion of using social outcome funds as a way with smart capacitating investment as the driver for it.

[00:34:39] And social outcome funds could themselves host, you know, many social impact bonds, which can be trying things out in local communities that could have a particular focus. And then you've got the level of patient capital. So we've got to do things at these three levels financially to get the funding of prevention right and to be able to scale it and sustain it.

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