1. Purpose of the paper

The purpose of the paper is to set out the current economic evidence supporting UK Health Security Agency (UKHSA) in its strategic discussions with the Department for Health and Social Care (DHSC), the plans to develop this evidence ahead of further discussions this year, including for the forthcoming Spending Review, and to set out the general health economic capability within the Agency.

2. Recommendations

The Advisory Board is asked to:

• note the current economic evidence supporting UKHSA in its strategic discussions with DHSC;
• comment on plans to further extend this evidence over the first half of 2025;
• agree to a further paper to come to the Board at a later point, setting out in more detail the current health economic capability within UKHSA and potential options for its development

3. Current economic evidence supporting UKHSA’s strategic discussions

Current economic evidence available to support the Agency in its strategic discussions, including its value-for-money (VfM) and how it fits within wider Governmental objectives can be categorized into three categories:

• whole-of-agency – providing an overarching economic evidence base and an estimated benefit-cost ratio for all UKHSA activities
• programmatic – evidence focused on thematic areas such as pandemic preparedness or national security
• micro – evidence relating to specific projects or activities

This section (and wider note) focuses on the whole-of-agency assessments and provides a summary of the remainder.

In April 2024, UKHSA’s Executive Committee (ExCo) considered the current position of the Agency’s evidence available to support it in forthcoming Spending Review and other strategic discussions.  It encompassed a selection of case studies (covered in section 4.2) and a whole-of-Agency value-for-money (VfM) assessment conducted by Frontier Economics in 2022.

ExCo asked for a new VfM assessment of the Agency. After a review of potential methods, a robust literature review (following protocol developed with the support of the Knowledge and Library Services and the Evidence Review team) was conducted to gather relevant existing evidence of the VfM of interventions, activities and capabilities likely to fall within the remit of UKHSA.

This looked at any intervention targeting infections, infectious diseases and chemical, biological, radiological and nuclear threats across a range of capabilities (e.g., prevention, vaccination, surveillance). The literature search identified over 13,000 articles, which were screened on abstract and sifted down to 486 for full text review. This review also made novel use of Artificial Intelligence, by using a Large Language Model to help label articles, speeding the review process and prioritising the UK based evidence. The literature review resulted in the inclusion of 117 papers for the calculation of the whole-of-Agency benefit cost-ratio (BCR).

Summary economic outcomes from identified papers were averaged for specific UKHSA capabilities and then these were weighted by their funding to produce an overall UKHSA BCR of 7.2 or £7.20 of benefit for every pound spent on the Agency. This was based on conservative assumptions used for evidence synthesis or where evidence was lacking. Sensitivity analysis suggested higher ratios were consistent with the activities of the agency with a range of 5-21 generated.

For context, a review[1] by the Centre for Economic Performance at London School of Economics, found a range of BCRs for government activity ranging from 0 for smaller class sizes to an average of 3 for road building to 12 for more police and 27 for structured well-being classes in schools. In Impact Assessments, DHSC use a figure of approximately 4.5 for additional NHS spending and the National Institute for Health and Care Research has modelled an estimate of 13.

This work also highlighted areas of UKHSA activity where there is currently no or little published academic evaluations. This work is set out in detail in Annex A, but it is important to note the lack of evidence for key activities such as data analysis, modelling and for central enabling services.

The work has been shared for comment with DHSC and we are working with the Department on how to share with HM Treasury for further review as well.

4. Further supporting evidence

Alongside this overarching VfM assessment, case studies have been developed to assess the BCR of specific activities and thereby support the overall assessment.

These case studies cover:

• mpox response – a BCR of up to 14.9 with up to 166,000 cases prevented, £110million in NHS resources saved and £242m in loss productivity averted.
• trial and implementation of HIV Pre-Exposure Prophylaxis – a BCR of at least 8.7
• respiratory syncytial virus summer immunization – a BCR of at least 5.8

In addition to this work, the team has also now concluded cataloguing ICD-10 codes related to infections and infectious diseases enabling an assessment of their burden on NHS hospitals (admitted care) in England using administrative data. This has found that over 20% of secondary care bed days in 2023/24 were attributable to infectious disease or infections – at a cost to the NHS of £5.9billion[2][3]. The work has also been helpful for several other projects conducted by others across UKHSA, including to map out diseases that exert significant pressures on general acute and critical care beds.

Programmatic work in the form of direct support for priority bid areas is also underway. Health Economists are working with modellers to look at different scenarios assessing the impact of different levels of pandemic preparedness. Other areas include Public Health Grant Sexually-Transmitted Infection work and supporting the Tuberculosis Task and Finish Group.

Finally, there is project/activity-level evidence which has primarily been generated through UKHSA’s investment appraisal process as programmes and projects develop their business cases. This helps to support developing cost-benefit analysis across the Agency. However, there is further to go in this area with £239million approved in 2024 on the basis of Amber-rated economic cases.

The Board is asked to note the above existing economic evidence.

5. Future evidence development in first half of 2025

Looking ahead to the first half of 2025, there is further work planned on showing the VfM of UKHSA’s day-to-day activity, particularly with relation to prevention activities such as health protection operations and incident responses, and looking at UKHSA’s work to support flu vaccine effectiveness.

There will also be further work to understand the size of the problem with the ICD-10 list mentioned in section 4.3 being used to count deaths with infectious disease listed on the death certificate.

Finally, there will be further work to understand how infectious diseases impact the NHS by making use of the SIREN survey to understand the impact of respiratory illness on the NHS’ workforce and on the economy from a collaboration with the Office for National Statistics including looking at impact of hospitalisations on labour market outcomes using HM Revenue & Customs data linked with hospital administrative data.

The Board is asked to comment on this work plan including other areas of interest.

6. Mapping current economic capability within UKHSA

The evidence above has been developed in part directly to support strategic discussions, but also in part due to other wider processes. In general, economics and health economics specifically are undertaken to:

• generate evidence for specific bodies such as National Institute for Health and Care Excelllence/Joint Committee on Vaccination and Immunisation (JCVI) as well as to support procurement of vaccines and their economic evaluation
• support government processes requiring VfM assessments, particularly through the investment appraisal
• informing internal policy development, including work on health inequalities
• strategic analysis to support external conversations with HM Treasury and DHSC
• generate evidence on interventions to inform policy and practice at national and local levels to best prevent infections and their consequences

This is undertaken by teams within the Agency, though only two people are members of the Government Economic Service which is unusual for Government, and the work is often part of a wider remit. Teams with embedded economists or those who undertake some economic analysis as part of their role includes:

• central economics – 4.8 FTE, covering business cases, impact assessments, strategic and policy support, and wider professional support
• health economics within Antimicrobial Resistance (AMR) & Healthcare Associated Infections (HCAI) Division – 0.8 FTE, covering modelling to estimate burden of HCAI & AMR and model-based evaluations of interventions to inform policy and practice
• health economics within Modelling Division – 0.8 FTE, covering cost-utility analysis, primarily of vaccination for JCVI but also other interventions (e.g. screening) and for other customers
• embedded economists within Commercial, Vaccines & Countermeasures Delivery; Centre for Pandemic Preparedness; and Blood Safety, Hepatitis, STI & HIV Division – 3 FTE

Does the Board agree that a paper further outlining the cross-Agency economic capability, including an assessment of demand, and options for its future development be brought back to it at a later date?

Michael West

Deputy Chief Economist

January 2025

7. Annexe A

1. The value-for-money rapid literature review identified 117 papers for inclusion. The below tables show a breakdown of those by type of intervention covered and the most common diseases covered.

Table 1. Number of Papers by Type of Intervention

Type of Intervention	Count of papers
Antiviral and Prophylaxis	12
Case finding and Contact Tracing	11
Diagnostic tests	4
Data analytics and modelling	0
Genome sequencing	1
Guideline development	0
Infection control	5
Mass media or public health campaign	3
Outbreak response	2
Pandemic preparedness	1
Prevention	6
Public health intervention	6
Public Health Surveillance	2
Research and development	1
Screening or testing	26
Treatment	9
Vaccination or immunisation	28
Total	117

Table 2. Most Common Diseases Covered by the Included Studies

Disease area	Count of papers
Hepatitis C	21
COVID-19	10
Influenza	9
Pertussis	8
HIV	6
HPV	5

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[1] Centre for Economic Performance report

[2] Does not include wider costs to the NHS such as associated GP care or wider economic costs

[3] This is compared to an estimated c£38bn total spent on inpatient care

*[ExCo]; Executive Committee *[BCR]: benefit cost-ratio *[HM]: His Majesty’s *[AMR]: antimicrobial resistance *[HCAI]: healthcare associated infections *[JCVI]: Joint Committee on Vaccination and Immunisation *[STI]: sexually transmitted infection *[HIV]: human immunodeficiency virus *[FTE]: full time equivalent *[HPV]: human papillomvirus