Funding Health Promotion Activities to Reduce Avoidable Hospital Admissions in Frail Older Adults (HomeHealth): Further Challenges to the "Cost-Effective but Unaffordable" Paradox.

Introduction: Health promotion initiatives are often promoted as being worth the investment given future cash-savings. This paper uses the findings of HomeHealth, a health promotion service for older adults with mild frailty, to examine how economic evaluation relates to local decision making in England.

Methods: The HomeHealth trial randomised 388 participants aged 65+ years with mild frailty to receive HomeHealth (195 participants) or treatment as usual (193 participants). Health and social care resource use and carer time were self-completed at baseline, 6 months and 12 months. Primary and secondary healthcare resource use and medications were collected from patient files at 12 months post recruitment, covering the past 18 months. Stakeholders including commissioners were consulted on the results of the trial and budget impact.

Results: Participants allocated to HomeHealth had a significant reduction in emergency hospital admissions at 12 months (incident rate ratio (IRR) 0.65; 95% confidence interval (CI) 0.45-0.92) and unpaid carer hours at 6 months (- 16 h (95% CI - 18 to - 14 h) or - £360 (95% CI - 369 to - 351) per patient). Although the intervention is cost saving overall due to fewer emergency admissions, at a cost of £457 per patient commissioners do not have the budget to fund it.

Discussion: This case study illustrates the problem with using standard economic evaluation methods to argue for implementation of health promotion initiatives in publicly financed healthcare systems. Although HomeHealth resulted in reduced emergency admissions and may be cost saving to the system as a whole, it is not locally cash releasing. Health promotion initiatives are unlikely to be funded from local budgets without significant system-wide changes.