Most health and care systems can point to a prevention programme that has delivered results - but far fewer can point to one that is now routinely commissioned and funded.

When an effective prevention programme ends, its benefits often end with it. Three obstacles stand in the way of enduring change:

• Timing.
  Prevention requires investment from the outset. But its benefits, such as fewer emergency admissions, shorter hospital stays and people living independently for longer, accrue over several years. Funding for new services is usually agreed for a fixed term, which often ends before the benefit can be robustly evidenced.
   
• The business case.
  The benefits rarely accrue to the organisation that bears the cost. A falls prevention service commissioned by a local authority, for example, may reduce hip fractures, but much of the financial benefit accrues to the acute trust and the ambulance service. Each organisation realises only part of the benefit, so none can easily justify the full cost alone.
   
• The decision.
  Even where the shared business case is clear, boards may not have the authority to commit resources across organisations. Partnership boards can agree on a direction, but few can move resources from one organisation to another. The result is a familiar pattern: a service demonstrates benefit, its funding period ends, and nobody is in a position to make the decision to continue.

Where has spending growth been concentrated?

Growth in health spending has been concentrated in acute care. Between 2016/17 and 2022/23, spending on acute hospital care in England grew by 4.4% a year in real terms, compared with 0.5% a year for community health services.

The public health grant, meanwhile, which funds local authorities’ prevention services, has fallen by 26% per person in real terms since 2015/16.

Those decisions were justifiable at the time, because resources are allocated in line with rising demand for urgent care. Each year the pattern continues, however, a greater share of resources is committed to acute and urgent care, and the shift towards prevention becomes harder to fund.

What needs to be in place for prevention to become routine practice?

Three conditions are required to sustain preventative approaches: outcomes agreed across organisations, clarity on which organisations contribute and which benefit, and precision about where savings will arise. The third condition is often the most challenging.

Savings from prevention arise from reduced use of high-cost services, reduced pressure on the workforce and services, and slower growth in demand. Typically only the first is cash-releasing, so business cases that do not distinguish between the three may overstate the savings that can be realised.

Where all three conditions met, however, a prevention service can move from initial investment into routine funding. The experience of Oxfordshire and South Northamptonshire demonstrates this in practice.

Macmillan Cancer Support’s End of Life Care Fund, launched in 2021 in partnership with Social Finance, has funded the Rapid Intervention for Palliative and End of Life Care (RIPEL) service there since 2022. RIPEL brings together four services: home hospice care, hospital rapid response, a palliative care hub and hospice outreach. Its aim is to reduce unplanned hospital admissions for people in their last year of life.

Social investment met the initial costs, with repayment contingent on agreed outcomes. The local health system has since taken on funding of the service, and Macmillan has received outcome repayments for reinvestment in further services.

How are FCC and Social Finance approaching this?

FCC and Social Finance are jointly committing £500,000 of resources to develop the Orchestrator, a programme designed to help health and care systems, local authorities, regional bodies and their partners make a lasting shift towards prevention. The partnership is supported by a grant from FCC, matched by expert time and resources from Social Finance.

The Orchestrator begins with how funding flows across a system. It is designed to help local partners:

• understand their challenges
• agree the outcomes they intend to achieve
• identify where costs and benefits fall
• redirect resources from crisis response towards earlier support.

The aim is for preventative approaches to become part of routine funding and service delivery. The partnership combines Social Finance’s 20 years’ experience in outcomes-based contracting, finance and system transformation with FCC’s experience in innovation adoption, implementation and evaluation.

Both are necessary to deliver enduring change; a funding model without implementation capacity is unlikely to be delivered, while implementation without a funding model is unlikely to outlast its initial funding.

What should system leaders do first?

System leaders should establish the conditions for a lasting decision before a new service begins.

• A shared understanding of the cost of crisis care.
  Establish where people currently use high-cost crisis services, and what this costs each organisation. This becomes the baseline for every subsequent decision.
   
• An independent convenor.
  An organisation with no stake in any one partner’s position can broker agreement on outcomes, contributions and benefits.
   
• Funding for the transition.
  A new service usually has to operate alongside existing services until demand for them reduces. Upfront investment repaid on outcomes, or a risk and gain share agreed between organisations, can fund that transition.
   
• Evidence designed for the decision.
  Agree the outcome measures, the baseline, the date of the funding decision and who will make it, so that the evidence is available when the decision is due.
   
• Capacity to implement.
  Secure the workforce, data and change support required to deliver the service consistently and at scale.

The Orchestrator programme can help health and care leaders do so. If you have a prevention opportunity you’d like to discuss, contact John Grumitt at john@futurecarecapital.org.uk or find out more here.