Shifting towards prevention in the National Health Service (NHS) in Wales: Use of programme budgeting and marginal analysis (PBMA) as a framework for resource allocation in type 2 diabetes prevention and treatment

The increasingly earlier onset of type 2 diabetes in the UK population creates significant challenges for health and social care systems. Working with a South Wales National Health Service (NHS) Health Board, our aim was to achieve collective decision-making about resource allocation to shift the balance of spending towards prevention and away from less cost-effective treatment in managing type 2 diabetes. To allocate a hypothetical £1 million recurrent budget over five years using an invest-to-save principle, we implemented a rigorous programme budgeting and marginal analysis (PBMA) approach, which was novel in its use of iterative stakeholder interviews. Overseen by a Steering Group, a PBMA Panel reviewed current diabetes spending, its cost-effectiveness, and value. The Panel identified and prioritised potential candidate services for introduction or expansion through an online survey and three online meetings. The Panel anonymously voted on funding priorities. The criteria chosen to be used in this PBMA exercise by the Panel were: clinical and cost-effectiveness, reducing health inequalities, user acceptability, patient-centeredness, accessibility, and patient empowerment. The Panel’s final voting supported investment in three key areas: expanding community diabetes specialist nurse capacity for medication reviews; extending the All-Wales Diabetes Prevention Programme to General Practitioner (GP) clusters currently without access; and increasing the number of diabetes specialist nurses specialising in perioperative care. The PBMA process provided a transparent, consultative, and evidence-based framework for deciding on a strategic direction toward more preventative type 2 diabetes services within the Health Board.