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

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 | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article 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treatment Rhiannon Tudor Edwards, Ned Hartfiel, Limssy Varghese, Oliver Williams, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8138716/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract 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. Type 2 diabetes health economics public health prevention programme budgeting and marginal analysis (PBMA) evidence-based decision-making Figures Figure 1 Figure 2 Figure 3 Figure 4 Contribution to Health Promotion This study illustrates how the PBMA process can provide a transparent, consultative and evidence-based framework for resource allocation. The PBMA Panel prioritised shifting resources toward prevention and shifting resources toward early identification of type 2 diabetes. "Invest-to-save" programmes with future cost-saving potential were also prioritised by the PBMA Panel. Following the PBMA exercise, the Cardiff and Vale University Health Board is considering broader implementation of the framework. Background Diabetes is a global public health challenge, with 830 million people living with the condition worldwide, and leads to 1.6 million deaths each year (World Health Organization [WHO], 2024). Nine in ten people with diabetes have type 2 diabetes, which occurs when the pancreas does not make enough insulin, or the body becomes resistant to insulin. In the United Kingdom (UK), diabetes is one of the most common chronic diseases, and its prevalence is increasing (National Institute for Health and Care Excellence [NICE], 2022). One in five adults currently live with diabetes or prediabetes in the UK, with more than five million people diagnosed with diabetes (Diabetes UK, 2025; NICE, 2022). Wales has the highest proportion of people living with diabetes in the UK (Public Health Wales, 2024). There has been a 40% increase in the number of people living with diabetes in Wales in the last 10 years, with the condition currently affecting 220,000 people (8% of the adult population) (Public Health Wales, 2023a, 2024). In 2021/22 diabetes-related hospital spells cost the Welsh National Health Service (NHS) an average of £4,518 per spell (excluding spells requiring amputations). In 2022/23, £105 million was spent on drugs to manage diabetes in Wales (Public Health Wales, 2023a). Diabetes-related care accounts for 10% of the NHS budget in Wales (Public Health Wales, 2024). Over half of the cases of type 2 diabetes could be prevented or delayed with behaviour changes (Public Health Wales, 2023a). For example, obesity accounts for 80-85% of the overall risk of developing type 2 diabetes, with physical inactivity and smoking also known risk factors (NICE, 2023). To meet the demands of national constraints on resource allocation, a structured approach to both investment and disinvestment is needed to address worsening health outcomes and inequalities. To improve population health, there is a need to refocus on prevention and health promotion, allocate funding to these areas within the NHS and related sectors, and assess the outcomes of these investments (Anderson et al., 2021). A focus on prevention across the health and social care system in Wales In 2023, Public Health Wales outlined its vision for a healthier Wales, prioritising the development of a sustainable health and care system focused on prevention and early intervention (Public Health Wales, 2023b). This emphasis on prevention and co-production of health is further reinforced by Welsh health economists who, in their 2024 publication, explored the health economics of well-being and "well-becoming" across the life course (Edwards and Lawrence, 2024). A focus on prevention in tackling type 2 diabetes in Wales In response to the high prevalence of type 2 diabetes in Wales, Public Health Wales launched the "Tackling Diabetes Together" programme in April 2024. This initiative encompasses a range of strategies for preventing and managing type 2 diabetes, aiming to reduce associated disability and premature death (Public Health Wales, 2024). By engaging diabetes experts, clinicians, communities, and individuals with lived experience of diabetes, the programme seeks to achieve system-wide improvements by 2028, including a reduction in new diabetes cases and improved care and outcomes for those living with the condition. One example of this collaborative approach is the partnership between Welsh Health Boards and Diabetes UK Cymru to develop innovative local diabetes programmes with the potential for national rollout. In 2024, Cardiff and Vale University Health Board (CaVUHB), one of the largest NHS organisations in Europe, which serves a population of nearly 500,000 across Cardiff and the Vale of Glamorgan, proposed actions over the next three years to reduce health inequalities and improve and protect the health of people in the region, including addressing the predicted increase in new cases of type 2 diabetes (CaVUHB, 2024a, 2024b). Frameworks for resource allocation in type 2 diabetes prevention and management Diabetes management is complex as there are several factors that clinicians need to take into consideration when making decisions about the most effective and cost-effective management pathway for the patient. Some of the challenges include assessing the patient’s diet, their understanding of the condition, willingness to use self-management strategies, and type of medication available (Aldaghi and Muzik, 2024). At present, the majority of spending in the NHS is on treatment rather than prevention of type 2 diabetes. Programme budgeting and marginal analysis (PBMA) and multi-criteria decision analysis (MCDA) are both frameworks for setting priorities and identifying key services to evaluate for investment and disinvestment (Collins et al., 2023; Lloyd-Williams, 2019). PBMA is an evidence-based decision-making process that helps decision-makers maximise the impact of healthcare resources on a local population's health needs, while also considering other goals, such as equity or, as in this case, a shift in resources toward prevention (Brambleby and Fordham, 2003; Charles et al., 2016; Edwards et al., 2014; Edwards and McIntosh, 2019; Donaldson et al., 2010). Programme budgeting involves appraising resource allocation within specified programmes. Marginal analysis involves the appraisal of the added benefits and added costs of a range of investment options or the forgone benefits and lower costs of a proposed disinvestment in those specified programmes (Brambleby and Fordham, 2003; Donaldson et al., 2010). This paper describes how CaVUHB used PBMA to inform resource allocation decisions impacting the balance of funding and delivery for diabetes prevention and treatment services. This study was classified as a service evaluation according to the Medical Research Council/Health Research Authority Decision Tool, as it involved the analysis of pre-existing administrative data regarding a service already in use. As the project was designed for internal management to improve resource allocation, and did not involve primary research on human subjects, the Cardiff and Vale University Health Board Joint Research Office waived the requirement for formal ethical approval and participant consent. Consequently, this evaluation was conducted outside the remit of the Declaration of Helsinki. METHODS PBMA is a tool for increasing co-production, shared decision-making, and reducing low-value interventions (Winrow and Edwards, 2020). Resource allocation decisions are not always a simple choice between investment and disinvestment. Some programmes can absorb a degree of funding reduction, perhaps through better targeting, while still operating. Understanding opportunity costs and the interconnectedness of programmes is essential, as changes in funding for one programme can affect the others (Brambleby and Fordham, 2003). The eight stages of a PBMA exercise are: 1) choose a set of meaningful programmes/initiatives; 2) identify current activity and expenditure in those programmes/initiatives; 3) think of improvements; 4) weigh up incremental costs and incremental benefits and prioritise a list; 5) consult widely; 6) decide on changes; 7) effect the changes, and 8) evaluate progress. Based on these eight stages, our PBMA process followed the process shown in Figure 1. [insert - Figure 1. Flowchart on priority setting of the PBMA process] The PBMA Steering Group and the PBMA Panel A Steering Group was established to facilitate the PBMA process. Members of the Steering Group included a chairperson (CaVUHB Executive Director of Public Health), finance staff, a Public Health Wales Specialty Registrar, and Bangor University health economists. The Steering Group created a 17-member PBMA Panel who were responsible for making the investment and prioritisation recommendations. Between March and November 2024, the Steering Group and PBMA Panel conducted a PBMA exercise to optimise health outcomes in type 2 diabetes management by evaluating existing services and potential investments over five years. The PBMA panel included representation from the Vice Chair of CaVUHB, Diabetes UK Cymru, clinicians (primary and secondary care), nursing staff (primary and secondary care), budget-holding healthcare managers (therapies, medicines management, Primary, Community and Specialist Medicine), finance managers, service users and business support staff within CaVUHB (see Supplementary File). The Steering Group invited Panel members to participate in the PBMA exercise via email, explaining that participation was voluntary and that they could withdraw at any time. As this initiative was a service development project instigated by CaVUHB and sponsored by the Executive Director of Public Health, formal ethics approval was not required. The Steering Group and PBMA Panel met online three times over eight months to identify high-value programmes for potential investment, establish decision-making criteria, and prioritise programme options for future funding. Health economists from Bangor University conducted interviews (supplementary file 1) with PBMA Panel members prior to the first meeting, and held additional individual meetings with both Panel members and diabetes experts between meetings. These discussions provided the research team with a broader understanding of the strengths and limitations of the type 2 diabetes services within CaVUHB. The team then used this information to categorise the services according to the five stages of the Value in Healthcare model: prevention, early accurate diagnosis, optimising intervention, supportive treatment, and end-of-life care (Figure 2). This categorisation aligns with the value-based care approach promoted in Wales since 2014 through Prudent Healthcare (Welsh Value in Health Centre, 2024). [insert - Figure 2. Type 2 diabetes services in CaVUHB] Background Report Prior to the first online PBMA Panel meeting in July 2024, the Steering Group developed a 20-page "Background Report" based on a rapid review and interviews with Panel members. This report facilitated the selection of 19 relevant services for evaluation. Concise summaries of each service, including links to further resources, were compiled and distributed to the 17 Panel members before the meeting. The Background Report also highlighted the following 12 key areas of local importance to the Health Board, which emerged as recurring themes during the Panel member interviews: Importance of diabetes prevention programmes Greater focus on diabetes structured education programmes More equitable access to diabetes care Greater focus on primary and community care Importance of early diagnosis Improved pre-surgery optimisation Importance of diabetes specialist nurses Review the effectiveness of type 2 diabetes remission services Prescribing medications for better outcomes Establishing an integrated patient database for diabetes care within CaVUHB Better monitoring of diabetes care outcomes Importance of prevention and care of paediatric diabetes Service User Online Survey Alongside the Background Report, a Type 2 Diabetes Service User Online Survey was conducted within CaVUHB in July and August 2024. This survey gathered feedback from individuals with lived experience of type 2 diabetes regarding effective aspects of current pathways and areas for potential improvement. PBMA Panel Meetings The PBMA Panel met online three times between April and August 2024. These meetings covered the PBMA process, Panel roles and responsibilities, the establishment of decision-making criteria, and the discussion and prioritisation of candidate interventions for investment. The following describes in more detail the events of each meeting: Meeting 1: Introduced PBMA Panel and described PBMA process including roles and responsibilities, time commitment, and electronic voting Discussed how Panel members would make decisions based on criteria such as evidence of clinical effect, cost-effectiveness, and patient empowerment Presented results of the Background Report on diabetes prevention programmes Proposed programmes for resource reallocation - what is working well and not working well Discussed type 2 diabetes activities that CaVUHB is currently not doing but should be doing Discussed how the Health Board could prioritise the budget in future Meeting 2: Presented programme budget (Health Board finance staff) Presented findings of the Type 2 Diabetes Service User Survey Discussed engagement with the PBMA process – Panel member participation and the number of proposed programmes suggested Reviewed criteria for decision-making and clarified expectations before Meeting 3 Created an evidence table for Panel members to review before Meeting 3 Meeting 3: Discussed and voted on candidate programmes for investment and prioritisation Completed a marginal analysis task – priority ranking exercise Discussed next steps for implementing recommendations, evaluating progress, and reflecting on the PBMA process The programme budget CaVUHB finance staff were asked to provide a detailed breakdown of spending on type 2 diabetes prevention and treatment across primary, secondary, and tertiary care services within the Health Board for the 2022/2023 fiscal year. Finance staff were further requested to present this spending data per capita and stratified by life-course stage (e.g., childhood, adolescence, working age, and older adults). Health Boards in Wales are required to retrospectively classify annual expenditure into 23 categories of disease (plus sub-disease areas). These disease areas are defined with reference to the International Classification of Diseases, Tenth Revision (ICD-10) designed through the WHO. Diabetes is a sub-category of the disease programme “Endocrine, Nutritional and Metabolic Problems”. The Welsh mapping guidance for programme budgeting is reviewed annually, updating the recommended methodology where possible. The recommended methodology varies for different expenditure types and settings of service delivery as there are differences in the data capture for disease areas for which the expenditure relates. This process of calculation is complex, with some methods of allocation subjective. However, it allows the health system to track expenditure by disease area over time. The following information about the 2022-2023 programme budget for type 2 diabetes in CaVUHB was sourced from a routine national return and is publicly available: Admitted patient care: £2,102,538 Outpatient care: £2,299,761 Primary care and community care: £20,637,034 Marginal analysis of candidates for investment and prioritisation In Panel Meeting 3, a high-level priority ranking exercise was created to guide resource allocation toward prevention rather than treatment within the Health Board. This exercise used voting and ranking methods to identify the Panel's top priority candidates for investment and prioritisation. RESULTS Establishing criteria for candidate programme appraisal After Meeting 1, Panel members received an online survey to identify candidate programs for investment or disinvestment, and to suggest criteria for evaluating those programmes (Table 1 ). Twelve of 17 (71%) Panel members responded to the Panel Member Online Survey. Table 1 Criteria for appraising candidate programmes Criteria Definition Clinical effectiveness (10 responses) How well the candidate programme works in real-world practice. Cost-effectiveness (8 responses) Measures the value of the candidate programme relative to its cost. It determines whether the benefit gained is worth the resources spent. Addressing health inequalities (7 responses) Measures how effectively the candidate programme addresses unfair, avoidable, and systematic differences in health between groups. Consider stakeholder views (6 responses) Perspectives, opinions, and interests of individuals or groups who are affected by or have an interest in the candidate programme. User acceptability (6 responses) How well the candidate programme is liked and accepted by the people who are intended to use it. Pragmatism (2 responses) Taking a practical approach by doing what works and focusing on real-world consequences and solutions. Alignment with the Wellbeing of Future Generation Act 2015 (1 response) All public organisations consider the long-term and wider impacts of their decisions on the wellbeing of Wales, including its people, environment, culture, and communities. Home first approach (1 response) Focused on community-based healthcare and easy access to services by making them closer to home. Sustainability (1 response) Care and support provided to patients transitioning from hospital to ongoing assessment and recovery, with the goal of minimising unnecessary hospital stays. Alignment with value-based healthcare (1 response) Value-based healthcare is the equitable, sustainable and transparent use of the available resources to achieve better outcomes and experiences for every person. ALT TEXT: Table showing the criteria for appraising candidate programmes and number of responses, and the definition for the criteria [insert - Table 1 . Criteria for appraising candidate programmes] Results of Service User Online Survey The final selection of criteria was informed by responses to both the Panel Member Online Survey and the Service User Online Survey. The voluntary Service User Online Survey received 43 responses. While valuable, the absence of a defined sampling frame means we cannot determine how representative this feedback was. Key themes emerging from these responses as areas for improvement included service accessibility, patient empowerment, proactive care, increased education and training, attentive and non-blaming care, minimising medication use, reducing cancelled appointments, and decreasing waiting times. Based on the input from both surveys, the following criteria were finalised for candidate appraisal: Clinical and cost-effectiveness Reducing health inequalities User acceptability and patient-centeredness Accessibility Patient empowerment Potential candidate programmes for investment and prioritisation The Panel Member Online Survey requested candidate programmes for investment and prioritisation. Panel members were asked to submit candidates based on their knowledge and experience. The survey provided detailed instructions on the information required for each candidate submission, including an example to ensure consistency in the level of detail provided. The Panel Member Online Survey yielded 27 responses from 12 Panel members regarding potential high-value interventions. While some candidate submissions lacked extensive supporting evidence, several shared common themes. The Steering Group consolidated those submissions with common themes, resulting in six final candidates for investment and prioritisation (Table 2 ). Table 2 PMBA Panel responses on potential candidates for investment and prioritisation Candidates Reasons provided by the PBMA Panel 1. Structured education for children, young people and their families • Type 2 diabetes in children leads to more severe complications and higher costs • Prevalence of type 2 diabetes in children and young people is growing • Structured education for children and young people could reverse diabetes and prevent long-term complications 2. Medicine optimisation (reducing variation in prescriptions/unnecessary medications) • Wastage should be tightly managed in primary care • Stopping inappropriate prescription could ease shortages of medicines (e.g., glucagon-like peptide-1 receptor agonists [GLP-1RA]) • Stopping unnecessary insulin prescription • Reducing variation in prescribing costs across CaVUHB 3. Community Diabetes Hub • Faster access closer to home improves patient experience, reduces complications, and eases pressure on hospitals • Community hubs can facilitate early accurate diagnosis through monitoring • Prioritise management of patients in primary care to reduce waiting list in secondary care 4. All Wales Diabetes Prevention Programme (AWDPP) expansion to all GP clusters • AWDPP has high uptake with 85% attendance • Fills gap for those aged 16–18 years who cannot access adult diabetes services • Need solution to mixed funding model for AWDPP which continues until March 2025 (Welsh Government and cluster fund) 5. Peri-operative care (diabetic specialist nurse/reducing hospital stays/optimisation pre-op) • Improving the Peri-operative Pathway for People with Diabetes (IP3D) - a model for peri-operative care which can reduce length of stay and save bed days • Patients with diabetes have an average hospital stay two days longer than other patients, resulting in poorer outcomes and increased costs for the Health Board • Surgical patients with diabetes have increased length of stays for elective surgery 6. NERS (National Exercise Referral Scheme) for pre-diabetes • The National Exercise Referral Scheme (NERS) is a low-cost intervention • Combining NERS with Move More Eat Well (MMEW) could prevent diabetes by addressing both diet and exercise for at-risk individuals • The current weight management pathway is under resourced • Effective weight management is crucial for preventing the development of type 2 diabetes ALT TEXT: Table showing the PMBA Panel responses on the potential six candidates for investment and prioritisation [insert - Table 2 . PMBA Panel responses on potential candidates for investment and prioritisation] Six candidates identified Candidate 1 - T2D Structured Education for Children and Young People (CYP) and Families Due to the increasing prevalence of type 2 diabetes and the potential development of complications in the young population, early diagnosis and the right intervention were considered important for CYP to maintain long-term health and prevent aggressive complications. Candidate 2 - Medicines Optimisation Includes reviewing medication waste in primary care, optimising prescribing practices for improved patient outcomes, reducing prescribing variations across GP clusters, and identifying inappropriate insulin use. More frequent medication reviews can address these concerns, supporting patients in using the most appropriate medications at the correct dosages, with regular follow-up. A diabetes specialist nurse (DSN) was proposed as a suitable healthcare professional to conduct these reviews. Candidate 3 - Community Diabetes Hub (CDH) Further development of a Community Diabetes Hub (CDH) to enhance primary care delivery. This includes early intervention after a type 2 diabetes diagnosis and consistent patient follow-up in primary care. Proposed investments in the CDH focused on securing dedicated clinical space in Central Cardiff and expanding the DSN team. This dedicated space would serve as a central hub for the multidisciplinary team, facilitating improved communication and care coordination, and accommodating urgent appointments. Candidate 4 - All Wales Diabetes Prevention Programme (AWDPP) Expansion of AWDPP to reduce the variation of care across the nine GP clusters in CaVUHB. Since the AWDPP is not currently available in all clusters, expansion to the remaining clusters was considered important. Candidate 5 - Perioperative Care Includes the need for an inpatient DSN, reducing length of stay in the hospital, and improving the perioperative pathway for patients. Optimising the perioperative pathway for patients is expected to reduce length of stay. Patients with type 2 diabetes have higher rates of post-operative readmissions, causing distress and increased costs (NHS England, 2024). Evidence suggests that funding DSNs for inpatient perioperative care is cost-effective. Candidate 6 - National Exercise Referral (NERS) Pathway for Prediabetes Importance of a physical activity intervention for people with prediabetes. The current NERS scheme is not adequately equipped to meet the increasing demand for physical activity interventions for people with type 2 diabetes. Staying physically active with at least 30 minutes of moderate exercise each day can help prevent type 2 diabetes and its complications (WHO, 2024). Conversion of candidate programmes into implementable options Between Meeting 2 and Meeting 3, the Steering Group converted the six candidates proposed by the PBMA Panel into six implementable options on which they could vote as follows: Type 2 Diabetes Structured Education for Children, Young People (CYP) and their families ◊ Completing T2D Structured Education for CYP and their families Medicines optimisation ◊ Additional community Diabetes Specialist Nurses (DSNs) to conduct medication reviews Community Diabetes Hub (CDH) ◊ Additional clinical space for CDH in Central Cardiff All Wales Diabetes Prevention Programme (AWDPP) ◊ Extension of AWDPP to three additional GP clusters Perioperative care ◊ Additional DSNs in perioperative care National Exercise Referral Scheme (NERS) for prediabetes ◊ Develop and fund a NERS pathway for prediabetes in Cardiff and Vale The identification of these six candidates recognises the importance of primary prevention (reducing the incidence of disease), secondary prevention (detecting the early stages of disease and intervening before full symptoms develop), and tertiary prevention (managing disease after diagnosis to slow or stop its spread) (Public Health Wales, 2024 ). The six candidates are mapped alongside the prevention triangle in Fig. 3 . [insert - Fig. 3 . Six candidates alongside prevention triangle for maximising health outcomes in type 2 diabetes] Invest-to-Save Evidence Health economists from Bangor University also provided evidence from published literature suggesting potential "invest-to-save" outcomes for certain programmes. For example, deploying community DSNs to conduct medication reviews for patients with type 2 diabetes, and additional DSNs in perioperative care, may improve patient outcomes and potentially generate savings for reinvestment (NHS England, 2024). These savings could be realised through reduced medication costs (e.g., deprescribing, reduced prescription variation) and fewer GP consultations. Within CaVUHB, data indicates that patients with diabetes undergoing elective surgery have longer average lengths of stay than those without diabetes, often due to suboptimal diabetes management. DSNs could provide education on glycaemic management before and after surgery, potentially reducing readmissions and shortening hospital stays, thus contributing to cost savings (see Supplementary File). Evidence-based decision-making – assessment of availability of evidence for each criteria To provide the PBMA Panel with comprehensive information, a red, amber, green (RAG) rating system was used to indicate the strength of evidence available for each criterion (Fig. 4 ). The predominantly green ratings for the six candidate programmes (left-hand column) reflect the substantial evidence base supporting the prevention and treatment of type 2 diabetes. [insert - Fig. 4 . RAG status on amount of evidence to compare the six evidence-based options against criteria] Outcome of the PBMA Panel voting exercise During the first voting round at Meeting 3 in October 2024, the PBMA Panel was asked to rank the six options according to their investment priorities. The results are as follows: 1st: Extension of All Wales Diabetes Prevention Programme to additional GP clusters 2nd: Additional Community Diabetes Specialist Nurses to conduct medication reviews 3rd: Additional Diabetes Specialist Nurses in Perioperative Care 3rd: Additional Clinical Space for Community Diabetes Hub 5th: Type 2 Diabetes Structured Education for children, young people and their families 6th: National Exercise Referral Scheme for pre-diabetes To gauge the relative strength of the priorities identified in the first vote, PBMA Panel members were asked to indicate their strength of preference by stating what percentage of potential funding they would allocate to each of the six candidate programmes. The results are as follows: 23%: Additional Diabetes Specialists Nurses to conduct medication reviews 20%: Extension of All Wales Diabetes Prevention Programme to additional GP clusters 17%: Additional Diabetes Specialist Nurses in Perioperative Care 15%: Additional Clinical Space for Community Diabetes Hub 14%: Type 2 Diabetes Structured Education for Children, Young People and their families 12%: National Exercise Referral Scheme for pre-diabetes In the final vote, the PBMA Panel was asked to reinvest any savings identified from the initial vote, specifically those associated with programmes expected to generate cost savings. The results for prioritisation of future reinvestment are as follows: 1st: Extension of All Wales Diabetes Prevention Programme to additional GP clusters 2nd: Additional Community Diabetes Specialist Nurses to conduct medication reviews 3rd: Additional Clinical Space for Community Diabetes Hub 4th: Type 2 Diabetes Structured Education for Children, Young People and their families 5th: Additional Diabetes Specialist Nurses in Perioperative Care 6th : National Exercise Referral Scheme for pre-diabetes PBMA Feedback Survey Following Meeting 3, a PBMA Feedback Survey was distributed to all 17 Panel members, with a response rate of 70% (12 out of 17). The survey consisted of five questions. For the first three questions, Panel members rated the PBMA process on a scale of 1 to 10 in the following areas (mean scores reported): 1. PBMA Panel engagement: 8.0 2. Helpfulness in determining funding priorities: 7.2 3. Recommendation of PBMA for future use: 7.0 Panel members were also asked about what aspects of the PBMA process they found helpful. Panel members reported finding several aspects of the PBMA process valuable. They appreciated the supporting documentation, including the Background Report and the evidence booklets for the six candidate interventions. Many valued the process as an opportunity for balanced discussion of priorities, with one participant highlighting the open environment for discussion and contribution to evidence generation, which fostered a deeper understanding of current services. The Panel also commended the consultative nature of the PBMA, the researchers' unbiased approach, the inclusion of patient representatives, and the opportunities for learning and discussion about other programmes. Some members also noted the benefit of collaborating with colleagues on service improvement, while one participant emphasised the unique platform the PBMA provided to showcase key areas for Health Board investment. Finally, Panel members were asked how they thought the PBMA process could be improved. While Panel members generally agreed that the PBMA process was effective overall, some felt the timeframe was too short for adequate consideration. Others suggested that greater clarity regarding the implementation of prioritised interventions and the impact of the voting process would be beneficial. One suggestion was to include information on the potential reach of each programme candidate to further inform prioritisation. DISCUSSION This study evaluated the application of a PBMA framework within a local Health Board (CaVUHB) in Wales to inform resource allocation for the type 2 diabetes care pathway. A 17-member Panel developed recommendations, submitted to the CaVUHB Strategic Diabetes Programme Board, aimed at improving this pathway. Panel members rated the PBMA process highly, averaging 8 out of 10 for engagement, 7.2 out of 10 for helpfulness in determining funding priorities, and 7 out of 10 for future usefulness. CaVUHB considered the exercise a valuable demonstration, exploring the impact, utility, and resource implications of the PBMA approach. Following the Panel's recommendations, CaVUHB is planning broader implementation of the framework across the Health Board. What is already known on the application of PBMA in healthcare settings The PBMA framework has demonstrated versatility and applicability across diverse healthcare settings in the UK and internationally, informing resource allocation decisions at both national and local levels. In Wales, several PBMA exercises have been conducted. Edwards et al. ( 2014 ) undertook a comprehensive national PBMA of health improvement spending, examining opportunities for disinvestment and reinvestment across the entire life-course. Another Welsh example is the PBMA exercise conducted by Charles et al. (2014), which focused on reshaping resource utilisation within respiratory care pathways in North Wales. The PBMA framework has also been successfully applied in England across a range of clinical areas. Madden et al. ( 1995 ) utilised PBMA to prioritise resource allocation in the context of heart disease. Their work explored how to maximise the impact of spending on heart disease prevention and treatment. Similarly, Ratcliffe et al. ( 1996 ) applied PBMA principles to maternity care, and more recently, Holmes et al. ( 2018 ) employed PBMA within dental care. These examples collectively illustrate the breadth and adaptability of the PBMA framework as a tool for evidence-informed resource allocation in the UK healthcare context. Specific to diabetes care, we note an early PBMA exercise in primary care (Scott et al., 1998 ). Interest in PBMA seems to be cyclical. Our paper is novel in that it adopted a much more iterative process of evidence gathering relating to the criteria to be used by the Panel to judge the relative merit of the various candidates for expansion. This iterative process took the form of one-to-one interviews with key stakeholders, which were not done in the previous PBMAs we were involved in cited above. Strengths of this study The PBMA exercise provided valuable insights into current service provision and gaps in care for individuals at risk of or living with type 2 diabetes within CaVUHB. Data gathered from approximately 20 services and 14 interviews with diabetes professionals offered a comprehensive overview of the pathway. The PBMA process broadened Panel members' understanding of the type 2 diabetes pathway, exposing them to programmes outside of their specific area of expertise. In-depth reviews of each candidate programme were conducted through individual consultations with relevant Panel members, who shared their perspectives on the effectiveness of current services, areas for improvement, suggestions for innovation, and knowledge of successful previous programmes. Evidence of clinical and cost-effectiveness, as well as alignment with NICE guidelines, was compiled for each programme to inform investment and prioritisation decisions. Cost and benefit estimates were developed for each programme, and potential cost savings were presented to the Panel. The Panel established evaluation criteria, and the Steering Group explained the RAG rating system used for assessment. This PBMA exercise successfully improved Panel members' understanding of the type 2 diabetes pathway, aligning with the four-point PBMA success criteria defined by Tsouparas and Frew (2011): 1) a greater understanding of the area under interest; 2) evidence of either full or partial implementation of recommendations; 3) reallocation of resources, and 4) adoption of framework for future use. The PBMA process successfully enhanced understanding. With respect to the ultimate impact on implementation, resource reallocation, and broader adoption of the PBMA framework within CaVUHB, this is now formally planned following recent press releases. Limitations of this study The voluntary nature of the Service User Online Survey, coupled with the absence of a defined sampling frame, introduces the possibility of sampling bias and limits our ability to ensure the representativeness of the responses. A key gap in the evidence booklets was information regarding the potential reach of each candidate programme and the estimated number of individuals who could benefit. Furthermore, "reach" was not identified as a key criterion by Panel members when asked how they would prioritise candidates, but is central to Health Board planning. Estimating the financial cost of each candidate programme proved challenging due to resource and time constraints within the eight-month PBMA process. While the Steering Group aimed to create a representative PBMA Panel, it is possible that some relevant expertise was inadvertently excluded. Additionally, attendance at Meeting 3 ( n = 15), during which the voting occurred, was not 100%. While 15 of the 17 Panel members participated in the vote, the absence of two members could have potentially influenced the outcomes. CONCLUSION The PBMA process proved rigorous and enabled CaVUHB to strategically prioritise investments in type 2 diabetes services to improve health outcomes, with a focus on prevention. Key priorities identified included: increasing the number of diabetes specialist nurses in community and hospital settings, expanding access to the All-Wales Diabetes Prevention Programme, enhancing the physical space for community-based diabetes services, improving diabetes education for children and young people, and providing structured exercise programmes for those at risk of diabetes. The PBMA process incorporated multiple inputs, including a background report, interviews with Panel members and diabetes experts, evidence booklets (incorporating NICE guidelines and clinical/cost-effectiveness data), appraisal criteria, a service user survey, and PBMA Panel discussions culminating in electronic voting for funding prioritisation and subsequent resource reallocation. Prioritisation focused on shifting resources toward prevention and early identification of type 2 diabetes, aiming to prevent disease progression, reduce readmissions, minimise adverse events, and improve post-surgical recovery. Clinical and cost-effectiveness evidence, alongside NICE guideline alignment, informed programme selection. Emphasising long-term benefits like reduced type 2 diabetes incidence and prevalence, the PBMA process prioritised "invest-to-save" programmes with future cost-saving potential. This value-based healthcare approach prioritised programmes delivering the best patient outcomes at the lowest cost, improving resource allocation and improving population health within existing budgets. Declarations Acknowledgments The authors extend their sincere gratitude to the 17-member PBMA Panel. Their extensive expertise and experience were instrumental in shaping the investment and prioritisation recommendations that formed the cornerstone of this PBMA process. Funding This work was supported by Cardiff and Vale University Health Board and Public Health Wales. Declaration of Interest The authors declare no conflicts of interest that pertain to this work. Author Contributions Rhiannon T. Edwards : Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review and editing, Ned Hartfiel : Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – review and editing Limssy Varghese : Formal analysis, Investigation, Writing, Visualisation, References Oliver Williams : Conceptualization, Funding acquisition, Investigation, Formal analysis, Project administration, Methodology, Writing - review and editing Dmytro Babelyuk : Voting tools planning and development, visualisation, assistance with content presentations to the panel, data analysis Catherine Lawrence : Writing – original draft, Writing – review and editing Julia Cottam : Conceptualization, Data curation, Methodology, Formal analysis, Resources, Writing - review and editing Claire Beynon : Conceptualization, Funding acquisition, Writing - review and editing Data availability The data underlying this article will be shared on reasonable request to the corresponding author. Ethical approval According to the Medical Research Council HRA Decision Tool, this work is deemed service evaluation, rather than research. Further, the Joint Research Office of Cardiff and Vale University Health Board confirmed that: ‘we would consider this project is not best defined as research, and it does not therefore require HRA/HCRW Approval, nor confirmation of Capacity and Capability from the Cardiff & Vale UHB R&D Office. There is no requirement to seek favourable opinion from an NHS Research Ethics Committee (REC) before beginning this project.’ References Aldaghi, T. and Muzik, J. (2024) Multicriteria decision-making in diabetes management and decision support: Systematic review. JMIR Medical Informatics , 12 , e47701. https://doi.org/10.2196/47701 Anderson, M., Pitchforth, E., Asaria, M., Brayne, C., Casadei, B., Charlesworth, A. et al. (2021) LSE–Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. The Lancet, 397, 1915-1978. https://doi.org/10.1016/S0140-6736(21)00232-4 Brambleby P. and Fordham, R. (2003) What is PBMA? What is…? series. http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/pbma.pdf. Accessed 24 September 2024 Cardiff and Value University Health Board. (2024a) Cardiff and Vale Local Public Health Plan 2024-27. https://cavuhb.nhs.wales/patient-advice/local-public-health-team/key-publications/c-amp-v-lph-plan-final-en-240326-3-pdf/ (2024a). Accessed 24 September 2024 Cardiff and Vale University Health Board. (2024b) Cardiff and Vale UHB Annual Report 2023 – 2024. https://senedd.wales/media/hbmjiy3s/gen-ld16585-e.pdf Accessed 24 September 2024 Charles, J. M., Brown, G., Thomas, K., Johnstone, F., Vandenblink, V., Pethers, B. et al. (2016) Use of programme budgeting and marginal analysis as a framework for resource reallocation in respiratory care in North Wales, UK. Journal of Public Health, 38 (3), e352-e361. https://doi.org/10.1093/pubmed/fdv128 Collins, M., Mazzei, M., Baker, R., Morton, A., Frith, L., Syrett, K. et al. (2023) Developing a combined framework for priority setting in integrated health and social care systems. BMC Health Services Research, 23 (1), 879. https://doi.org/10.1186/s12913-023-09866-x Diabetes UK. (2025) One in five adults now live with diabetes or prediabetes in the UK. https://www.diabetes.org.uk/about-us/news-and-views/one-five-adults-now-live-diabetes-or-prediabetes-uk Accessed 24 September 2024 Donaldson, C., Bate, A., Mitton, C., Dionne, F. and Ruta, D. (2010) Rational disinvestment. QJM: An International Journal of Medicine , 103 (10), 801-807. https://doi.org/10.1093/qjmed/hcq086 Edwards, R. T. and Lawrence, C. L. (eds) (2024) Health economics of well-being and well-becoming across the life-course. Oxford University Press, Oxford Edwards, R. T. and McIntosh, E. (eds) (2019) Applied health economics for public health practice and research. Oxford University Press, Oxford Edwards, R. T., Charles, J. M., Thomas, S. Bishop, J., Cohen, D., Groves, S. et al. (2014) A national programme budgeting and marginal analysis (PBMA) of health improvement spending across Wales: disinvestment and reinvestment across the life course. BMC Public Health, 2, 837. https://doi.org/10.1186/1471-2458-14-837 Holmes, R. D., Steele, J. G., Exley, C., Vernazza, C. R. and Donaldson, C. (2018) Use of programme budgeting and marginal analysis to set priorities for local NHS dental services: learning from the north east of England. Journal of Public Health, 40 (4), e578-e585. https://doi.org/10.1093/pubmed/fdy075 Lloyd-Williams, H. (2019) The role of multi-criteria decision analysis (MCDA) in public health economic evaluation. In: Edwards, R. T. and McIntosh, E. (eds) Applied health economics for public health practice and research, pp. 301-312. Oxford University Press, Oxford Madden, L., Hussey, R., Mooney, G. and Church, E. (1995) Public health and economics in tandem: programme budgeting, marginal analysis and priority setting in practice. Health Policy, 33, 161-168. https://doi.org/10.1016/0168-8510(95)93676-r National Health Service England. (2024) Improving the perioperative pathway for patients with diabetes. https://gettingitrightfirsttime.co.uk/associated_projects/improving-the-perioperative-pathway-for-patients-with-diabetes. Accessed 24 September 2024 National Institute for Health and Care Excellence. (2022) Type 2 diabetes in adults: management. https://www.nice.org.uk/guidance/ng28/chapter/Context. Accessed 24 September 2024 National Institute for Health and Care Excellence. (2023) Diabetes - type 2: What are the risk factors? Clinical knowledge summaries. https://cks.nice.org.uk/topics/diabetes-type-2/background-information/risk-factors. Accessed 24 September 2024 Public Health Wales. (2023a) 48,000 additional people with diabetes in Wales by 2035 – new analysis. https://phw.nhs.wales/news/48000-additional-people-with-diabetes-in-wales-by-2035-new-analysis. Accessed 24 September 2024 Public Health Wales. (2023b) Our long-term strategy 2023-2035. https://phw.nhs.wales/about-us/working-together-for-a-healthier-wales/phw-long-term-strategy-pdf. Accessed 24 September 2024 Public Health Wales. (2024) Tackling diabetes together is key to people living longer, healthier lives in Wales. https://phw.nhs.wales/news/tackling-diabetes-together-is-key-to-people-living-longer-healthier-lives-in-wales. Accessed 24 September 2024 Ratcliffe, J., Donaldson, C. and Macphee, S. (1996) Programme budgeting and marginal analysis: a case study of maternity services. Journal of Public Health, 18 (2), 175-182. https://doi.org/10.1093/oxfordjournals.pubmed.a024477 Scott, A., Currie, N. and Donaldson, C. (1998) Evaluating innovation in general practice: a pragmatic framework using programme budgeting and marginal analysis. Family Practice, 15 (3), 216-222. https://doi.org/10.1093/fampra/15.3.216 Tsourapas, A. and Frew, E. (2011) Evaluating ‘success’ in programme budgeting and marginal analysis: a literature review. Journal of Health Services Research & Policy, 16 (3), 177-183. https://doi.org/10.1258/jhsrp.2010.00905 Welsh Value in Health Centre. (2024) Value-based healthcare for Wales. NHS Wales. https://vbhc.nhs.wales/value-based-healthcare-for-wales. Accessed 24 September 2024 Winrow, E. and Edwards, R.T. (2020) Programme budgeting and marginal analysis, and developing a business case for a new service. In: Gulliford, M. Jessop. E. (eds) Healthcare public health: Improving health services through population science, pp. 110-118. Oxford University Press, Oxford World Health Organization. (2024) Diabetes. https://www.who.int/news-room/fact-sheets/detail/diabetes. Accessed 24 September 2024 Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile.docx InterviewScheduleforPBMAType2DiabetesPanelMembers.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 18 May, 2026 Reviewers agreed at journal 17 May, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers agreed at journal 13 Mar, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 23 Feb, 2026 Reviewers agreed at journal 18 Feb, 2026 Reviewers invited by journal 10 Feb, 2026 Editor assigned by journal 05 Feb, 2026 Editor invited by journal 20 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 19 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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type 2 diabetes prevention and treatment","fulltext":[{"header":"Contribution to Health Promotion","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003eThis study illustrates how the PBMA process can provide a transparent, consultative and evidence-based framework for resource allocation.\u003c/li\u003e\n \u003cli\u003eThe PBMA Panel prioritised shifting resources toward prevention and shifting resources toward early identification of type 2 diabetes.\u003c/li\u003e\n \u003cli\u003e\"Invest-to-save\" programmes with future cost-saving potential were also prioritised by the PBMA Panel.\u003c/li\u003e\n \u003cli\u003eFollowing the PBMA exercise, the Cardiff and Vale University Health Board is considering broader implementation of the framework.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eDiabetes is a global public health challenge, with 830 million people living with the condition worldwide, and leads to 1.6 million deaths each year (World Health Organization [WHO], 2024). Nine in ten people with diabetes have type 2 diabetes, which occurs when the pancreas does not make enough insulin, or the body becomes resistant to insulin. In the United Kingdom (UK), diabetes is one of the most common chronic diseases, and its prevalence is increasing (National Institute for Health and Care Excellence [NICE], 2022). One in five adults currently live with diabetes or prediabetes in the UK, with more than five million people diagnosed with diabetes (Diabetes UK, 2025; NICE, 2022).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWales has the highest proportion of people living with diabetes in the UK (Public Health Wales, 2024). There has been a 40% increase in the number of people living with diabetes in Wales in the last 10 years, with the condition currently affecting 220,000 people (8% of the adult population) (Public Health Wales, 2023a, 2024). In 2021/22 diabetes-related hospital spells cost the Welsh National Health Service (NHS) an average of £4,518 per spell (excluding spells requiring amputations). In 2022/23, £105 million was spent on drugs to manage diabetes in Wales (Public Health Wales, 2023a).\u003c/p\u003e\n\u003cp\u003eDiabetes-related care accounts for 10% of the NHS budget in Wales (Public Health Wales, 2024). Over half of the cases of type 2 diabetes could be prevented or delayed with behaviour changes (Public Health Wales, 2023a). For example, obesity accounts for 80-85% of the overall risk of developing type 2 diabetes, with physical inactivity and smoking also known risk factors (NICE, 2023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo meet the demands of national constraints on resource allocation, a structured approach to both investment and disinvestment is needed to address worsening health outcomes and inequalities. To improve population health, there is a need to refocus on prevention and health promotion, allocate funding to these areas within the NHS and related sectors, and assess the outcomes of these investments (Anderson et al., 2021).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA focus on prevention across the health and social care system in Wales\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn 2023, Public Health Wales outlined its vision for a healthier Wales, prioritising the development of a sustainable health and care system focused on prevention and early intervention (Public Health Wales, 2023b). This emphasis on prevention and co-production of health is further reinforced by Welsh health economists who, in their 2024 publication, explored the health economics of well-being and \"well-becoming\" across the life course (Edwards and Lawrence, 2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA focus on prevention in tackling type 2 diabetes in Wales\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn response to the high prevalence of type 2 diabetes in Wales, Public Health Wales launched the \"Tackling Diabetes Together\" programme in April 2024. This initiative encompasses a range of strategies for preventing and managing type 2 diabetes, aiming to reduce associated disability and premature death (Public Health Wales, 2024). By engaging diabetes experts, clinicians, communities, and individuals with lived experience of diabetes, the programme seeks to achieve system-wide improvements by 2028, including a reduction in new diabetes cases and improved care and outcomes for those living with the condition. One example of this collaborative approach is the partnership between Welsh Health Boards and Diabetes UK Cymru to develop innovative local diabetes programmes with the potential for national rollout. In 2024, Cardiff and Vale University Health Board (CaVUHB), one of the largest NHS organisations in Europe, which serves a population of nearly 500,000 across Cardiff and the Vale of Glamorgan, proposed actions over the next three years to reduce health inequalities and improve and protect the health of people in the region, including addressing the predicted increase in new cases of type 2 diabetes (CaVUHB, 2024a, 2024b).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFrameworks for resource allocation in type 2 diabetes prevention and management\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiabetes management is complex as there are several factors that clinicians need to take into consideration when making decisions about the most effective and cost-effective management pathway for the patient. Some of the challenges include assessing the patient’s diet, their understanding of the condition, willingness to use self-management strategies, and type of medication available (Aldaghi and Muzik, 2024). At present, the majority of spending in the NHS is on treatment rather than prevention of type 2 diabetes. Programme budgeting and marginal analysis (PBMA) and multi-criteria decision analysis (MCDA) are both frameworks for setting priorities and identifying key services to evaluate for investment and disinvestment (Collins et al., 2023;\u0026nbsp;Lloyd-Williams, 2019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePBMA is an evidence-based decision-making process that helps decision-makers maximise the impact of healthcare resources on a local population's health needs, while also considering other goals, such as equity or, as in this case, a shift in resources toward prevention (Brambleby and Fordham, 2003; Charles et al., 2016; Edwards et al., 2014; Edwards and McIntosh, 2019;\u0026nbsp;Donaldson et al., 2010). Programme budgeting involves appraising resource allocation within specified programmes. Marginal analysis involves the appraisal of the added benefits and added costs of a range of investment options or the forgone benefits and lower costs of a proposed disinvestment in those specified programmes (Brambleby and Fordham, 2003; Donaldson et al., 2010).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis paper describes how CaVUHB used PBMA to inform resource allocation decisions impacting the balance of funding and delivery for diabetes prevention and treatment services. This study was classified as a service evaluation according to the Medical Research Council/Health Research Authority Decision Tool, as it involved the analysis of pre-existing administrative data regarding a service already in use. As the project was designed for internal management to improve resource allocation, and did not involve primary research on human subjects, the Cardiff and Vale University Health Board Joint Research Office waived the requirement for formal ethical approval and participant consent. Consequently, this evaluation was conducted outside the remit of the Declaration of Helsinki.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003ePBMA is a tool for increasing co-production, shared decision-making, and reducing low-value interventions (Winrow and Edwards, 2020). Resource allocation decisions are not always a simple choice between investment and disinvestment. Some programmes can absorb a degree of funding reduction, perhaps through better targeting, while still operating. Understanding opportunity costs and the interconnectedness of programmes is essential, as changes in funding for one programme can affect the others (Brambleby and Fordham, 2003). The eight stages of a PBMA exercise are: 1) choose a set of meaningful programmes/initiatives; 2) identify current activity and expenditure in those programmes/initiatives; 3) think of improvements; 4) weigh up incremental costs and incremental benefits and prioritise a list; 5) consult widely; 6) decide on changes; 7) effect the changes, and 8) evaluate progress. Based on these eight stages, our PBMA process followed the process shown in Figure 1.\u003cbr\u003e\u0026nbsp;\u003cbr\u003e[insert -\u003cstrong\u003e\u0026nbsp;Figure 1.\u0026nbsp;\u003c/strong\u003eFlowchart on priority setting of the PBMA process]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe PBMA Steering Group and the PBMA Panel\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA Steering Group was established to facilitate the PBMA process. Members of the Steering Group included a chairperson (CaVUHB Executive Director of Public Health), finance staff, a Public Health Wales Specialty Registrar, and Bangor University health economists. The Steering Group created a 17-member PBMA Panel who were responsible for making the investment and prioritisation recommendations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBetween March and November 2024, the Steering Group and PBMA Panel conducted a PBMA exercise to optimise health outcomes in type 2 diabetes management by evaluating existing services and potential investments over five years. The PBMA panel included representation from the Vice Chair of CaVUHB, Diabetes UK Cymru, clinicians (primary and secondary care), nursing staff (primary and secondary care), budget-holding healthcare managers (therapies, medicines management, Primary, Community and Specialist Medicine), finance managers, service users and business support staff within CaVUHB (see Supplementary File).\u003c/p\u003e\n\u003cp\u003eThe Steering Group invited Panel members to participate in the PBMA exercise via email, explaining that participation was voluntary and that they could withdraw at any time. As this initiative was a service development project instigated by CaVUHB and sponsored by the Executive Director of Public Health, formal ethics approval was not required. The Steering Group and PBMA Panel met online three times over eight months to identify high-value programmes for potential investment, establish decision-making criteria, and prioritise programme options for future funding.\u003c/p\u003e\n\u003cp\u003eHealth economists from Bangor University conducted interviews (supplementary file 1) with PBMA Panel members prior to the first meeting, and held additional individual meetings with both Panel members and diabetes experts between meetings. These discussions provided the research team with a broader understanding of the strengths and limitations of the type 2 diabetes services within CaVUHB. The team then used this information to categorise the services according to the five stages of the Value in Healthcare model: prevention, early accurate diagnosis, optimising intervention, supportive treatment, and end-of-life care (Figure 2). This categorisation aligns with the value-based care approach promoted in Wales since 2014 through Prudent Healthcare (Welsh Value in Health Centre, 2024).\u003c/p\u003e\n\u003cp\u003e[insert\u003cstrong\u003e\u0026nbsp;-\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFigure 2.\u0026nbsp;\u003c/strong\u003eType 2 diabetes services in CaVUHB]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBackground Report\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to the first online PBMA Panel meeting in July 2024, the Steering Group developed a 20-page \"Background Report\" based on a rapid review and interviews with Panel members. This report facilitated the selection of 19 relevant services for evaluation. Concise summaries of each service, including links to further resources, were compiled and distributed to the 17 Panel members before the meeting. The Background Report also highlighted the following 12 key areas of local importance to the Health Board, which emerged as recurring themes during the Panel member interviews:\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cli\u003eImportance of diabetes prevention programmes\u003c/li\u003e\n \u003cli\u003eGreater focus on diabetes structured education programmes\u003c/li\u003e\n \u003cli\u003eMore equitable access to diabetes care\u003c/li\u003e\n \u003cli\u003eGreater focus on primary and community care\u003c/li\u003e\n \u003cli\u003eImportance of early diagnosis\u003c/li\u003e\n \u003cli\u003eImproved pre-surgery optimisation\u003c/li\u003e\n \u003cli\u003eImportance of diabetes specialist nurses\u003c/li\u003e\n \u003cli\u003eReview the effectiveness of type 2 diabetes remission services\u003c/li\u003e\n \u003cli\u003ePrescribing medications for better outcomes\u003c/li\u003e\n \u003cli\u003eEstablishing an integrated patient database for diabetes care within\u0026nbsp;CaVUHB\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eBetter monitoring of diabetes care outcomes\u003c/li\u003e\n \u003cli\u003eImportance of prevention and care of paediatric diabetes\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eService User Online Survey\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eAlongside the Background Report, a Type 2 Diabetes Service User Online Survey was conducted within CaVUHB in July and August 2024. This survey gathered feedback from individuals with lived experience of type 2 diabetes regarding effective aspects of current pathways and areas for potential improvement.\u003cbr\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePBMA Panel Meetings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe PBMA Panel met online three times between April and August 2024. These meetings covered the PBMA process, Panel roles and responsibilities, the establishment of decision-making criteria, and the discussion and prioritisation of candidate interventions for investment. The following describes in more detail the events of each meeting:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeeting 1:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eIntroduced PBMA Panel and described PBMA process including roles and responsibilities, time commitment, and electronic voting\u003c/li\u003e\n \u003cli\u003eDiscussed how Panel members would make decisions based on criteria such as evidence of clinical effect, cost-effectiveness, and patient empowerment\u003c/li\u003e\n \u003cli\u003ePresented results of the Background Report on diabetes prevention programmes\u003c/li\u003e\n \u003cli\u003eProposed programmes for resource reallocation - what is working well and not working well\u003c/li\u003e\n \u003cli\u003eDiscussed type 2 diabetes activities that CaVUHB is currently not doing but should be doing\u003c/li\u003e\n \u003cli\u003eDiscussed how the Health Board could prioritise the budget in future\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eMeeting 2:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePresented programme budget (Health Board finance staff)\u003c/li\u003e\n \u003cli\u003ePresented findings of the Type 2 Diabetes Service User Survey\u003c/li\u003e\n \u003cli\u003eDiscussed engagement with the PBMA process – Panel member participation and the number of proposed programmes suggested\u003c/li\u003e\n \u003cli\u003eReviewed criteria for decision-making and clarified expectations before Meeting 3\u003c/li\u003e\n \u003cli\u003eCreated an evidence table for Panel members to review before Meeting 3\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eMeeting 3:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDiscussed and voted on candidate programmes for investment and prioritisation\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCompleted a marginal analysis task – priority ranking exercise\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDiscussed next steps for implementing recommendations, evaluating progress, and reflecting on the PBMA process\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eThe programme budget\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCaVUHB finance staff were asked to provide a detailed breakdown of spending on type 2 diabetes prevention and treatment across primary, secondary, and tertiary care services within the Health Board for the 2022/2023 fiscal year. Finance staff were further requested to present this spending data per capita and stratified by life-course stage (e.g., childhood, adolescence, working age, and older adults).\u003c/p\u003e\n\u003cp\u003eHealth Boards in Wales are required to retrospectively classify annual expenditure into 23 categories of disease (plus sub-disease areas). These disease areas are defined with reference to the International Classification of Diseases, Tenth Revision (ICD-10) designed through the WHO. Diabetes is a sub-category of the disease programme “Endocrine, Nutritional and Metabolic Problems”.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Welsh mapping guidance for programme budgeting is reviewed annually, updating the recommended methodology where possible. The recommended methodology varies for different expenditure types and settings of service delivery as there are differences in the data capture for disease areas for which the expenditure relates. This process of calculation is complex, with some methods of allocation subjective. However, it allows the health system to track expenditure by disease area over time. The following information about the 2022-2023 programme budget for type 2 diabetes in CaVUHB was sourced from a routine national return and is publicly available:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eAdmitted patient care: £2,102,538\u003c/li\u003e\n \u003cli\u003eOutpatient care: £2,299,761\u003c/li\u003e\n \u003cli\u003ePrimary care and community care: £20,637,034\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eMarginal analysis of candidates for investment and prioritisation\u0026nbsp;\u003cbr\u003e\u003c/strong\u003eIn Panel Meeting 3, a high-level priority ranking exercise was created to guide resource allocation toward prevention rather than treatment within the Health Board. This exercise used voting and ranking methods to identify the Panel's top priority candidates for investment and prioritisation.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eEstablishing criteria for candidate programme appraisal\u003c/h2\u003e \u003cp\u003eAfter Meeting 1, Panel members received an online survey to identify candidate programs for investment or disinvestment, and to suggest criteria for evaluating those programmes (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Twelve of 17 (71%) Panel members responded to the Panel Member Online Survey.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCriteria for appraising candidate programmes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCriteria\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDefinition\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical effectiveness\u003c/p\u003e \u003cp\u003e(10 responses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow well the candidate programme works in real-world practice.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCost-effectiveness\u003c/p\u003e \u003cp\u003e(8 responses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeasures the value of the candidate programme relative to its cost. It determines whether the benefit gained is worth the resources spent.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAddressing health inequalities \u003c/p\u003e \u003cp\u003e(7 responses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeasures how effectively the candidate programme addresses unfair, avoidable, and systematic differences in health between groups.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsider stakeholder views \u003c/p\u003e \u003cp\u003e(6 responses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePerspectives, opinions, and interests of individuals or groups who are affected by or have an interest in the candidate programme.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUser acceptability\u003c/p\u003e \u003cp\u003e(6 responses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHow well the candidate programme is liked and accepted by the people who are intended to use it.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePragmatism\u003c/p\u003e \u003cp\u003e(2 responses)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTaking a practical approach by doing what works and focusing on real-world consequences and solutions.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlignment with the Wellbeing of Future Generation Act 2015\u003c/p\u003e \u003cp\u003e(1 response)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll public organisations consider the long-term and wider impacts of their decisions on the wellbeing of Wales, including its people, environment, culture, and communities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome first approach\u003c/p\u003e \u003cp\u003e(1 response)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFocused on community-based healthcare and easy access to services by making them closer to home.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSustainability\u003c/p\u003e \u003cp\u003e(1 response)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCare and support provided to patients transitioning from hospital to ongoing assessment and recovery, with the goal of minimising unnecessary hospital stays.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlignment with value-based healthcare\u003c/p\u003e \u003cp\u003e(1 response)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue-based healthcare is the equitable, sustainable and transparent use of the available resources to achieve better outcomes and experiences for every person.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eALT TEXT: Table showing the criteria for appraising candidate programmes and number of responses, and the definition for the criteria\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[insert - Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Criteria for appraising candidate programmes]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eResults of Service User Online Survey\u003c/h2\u003e \u003cp\u003eThe final selection of criteria was informed by responses to both the Panel Member Online Survey and the Service User Online Survey. The voluntary Service User Online Survey received 43 responses. While valuable, the absence of a defined sampling frame means we cannot determine how representative this feedback was.\u003c/p\u003e \u003cp\u003eKey themes emerging from these responses as areas for improvement included service accessibility, patient empowerment, proactive care, increased education and training, attentive and non-blaming care, minimising medication use, reducing cancelled appointments, and decreasing waiting times.\u003c/p\u003e \u003cp\u003eBased on the input from both surveys, the following criteria were finalised for candidate appraisal:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eClinical and cost-effectiveness\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eReducing health inequalities\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eUser acceptability and patient-centeredness\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAccessibility\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePatient empowerment\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePotential candidate programmes for investment and prioritisation\u003c/h2\u003e \u003cp\u003eThe Panel Member Online Survey requested candidate programmes for investment and prioritisation. Panel members were asked to submit candidates based on their knowledge and experience. The survey provided detailed instructions on the information required for each candidate submission, including an example to ensure consistency in the level of detail provided.\u003c/p\u003e \u003cp\u003eThe Panel Member Online Survey yielded 27 responses from 12 Panel members regarding potential high-value interventions. While some candidate submissions lacked extensive supporting evidence, several shared common themes. The Steering Group consolidated those submissions with common themes, resulting in six final candidates for investment and prioritisation (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePMBA Panel responses on potential candidates for investment and prioritisation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCandidates\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReasons provided by the PBMA Panel\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Structured education for children, young people and their families\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Type 2 diabetes in children leads to more severe complications and higher costs\u003c/p\u003e \u003cp\u003e\u0026bull; Prevalence of type 2 diabetes in children and young people is growing\u003c/p\u003e \u003cp\u003e\u0026bull; Structured education for children and young people could reverse diabetes and prevent long-term complications \u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Medicine optimisation (reducing variation in prescriptions/unnecessary medications)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Wastage should be tightly managed in primary care\u003c/p\u003e \u003cp\u003e\u0026bull; Stopping inappropriate prescription could ease shortages of medicines (e.g., glucagon-like peptide-1 receptor agonists [GLP-1RA])\u003c/p\u003e \u003cp\u003e\u0026bull; Stopping unnecessary insulin prescription\u003c/p\u003e \u003cp\u003e\u0026bull; Reducing variation in prescribing costs across CaVUHB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Community Diabetes Hub\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Faster access closer to home improves patient experience, reduces complications, and eases pressure on hospitals\u003c/p\u003e \u003cp\u003e\u0026bull; Community hubs can facilitate early accurate diagnosis through monitoring\u003c/p\u003e \u003cp\u003e\u0026bull; Prioritise management of patients in primary care to reduce waiting list in secondary care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. All Wales Diabetes Prevention Programme (AWDPP) expansion to all GP clusters\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; AWDPP has high uptake with 85% attendance\u003c/p\u003e \u003cp\u003e\u0026bull; Fills gap for those aged 16\u0026ndash;18 years who cannot access adult diabetes services\u003c/p\u003e \u003cp\u003e\u0026bull; Need solution to mixed funding model for AWDPP which continues until March 2025 (Welsh Government and cluster fund)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Peri-operative care (diabetic specialist nurse/reducing hospital stays/optimisation pre-op)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Improving the Peri-operative Pathway for People with Diabetes (IP3D) - a model for peri-operative care which can reduce length of stay and save bed days\u003c/p\u003e \u003cp\u003e\u0026bull; Patients with diabetes have an average hospital stay two days longer than other patients, resulting in poorer outcomes and increased costs for the Health Board\u003c/p\u003e \u003cp\u003e\u0026bull; Surgical patients with diabetes have increased length of stays for elective surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. NERS (National Exercise Referral Scheme) for pre-diabetes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; The National Exercise Referral Scheme (NERS) is a low-cost intervention\u003c/p\u003e \u003cp\u003e\u0026bull; Combining NERS with Move More Eat Well (MMEW) could prevent diabetes by addressing both diet and exercise for at-risk individuals\u003c/p\u003e \u003cp\u003e\u0026bull; The current weight management pathway is under resourced\u003c/p\u003e \u003cp\u003e\u0026bull; Effective weight management is crucial for preventing the development of type 2 diabetes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eALT TEXT: Table showing the PMBA Panel responses on the potential six candidates for investment and prioritisation\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[insert - Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. PMBA Panel responses on potential candidates for investment and prioritisation]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSix candidates identified\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eCandidate 1 - T2D Structured Education for Children and Young People (CYP) and Families\u003c/strong\u003e \u003cp\u003eDue to the increasing prevalence of type 2 diabetes and the potential development of complications in the young population, early diagnosis and the right intervention were considered important for CYP to maintain long-term health and prevent aggressive complications.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCandidate 2 - Medicines Optimisation\u003c/strong\u003e \u003cp\u003eIncludes reviewing medication waste in primary care, optimising prescribing practices for improved patient outcomes, reducing prescribing variations across GP clusters, and identifying inappropriate insulin use. More frequent medication reviews can address these concerns, supporting patients in using the most appropriate medications at the correct dosages, with regular follow-up. A diabetes specialist nurse (DSN) was proposed as a suitable healthcare professional to conduct these reviews.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCandidate 3 - Community Diabetes Hub (CDH)\u003c/strong\u003e \u003cp\u003eFurther development of a Community Diabetes Hub (CDH) to enhance primary care delivery. This includes early intervention after a type 2 diabetes diagnosis and consistent patient follow-up in primary care. Proposed investments in the CDH focused on securing dedicated clinical space in Central Cardiff and expanding the DSN team. This dedicated space would serve as a central hub for the multidisciplinary team, facilitating improved communication and care coordination, and accommodating urgent appointments.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCandidate 4 - All Wales Diabetes Prevention Programme (AWDPP)\u003c/strong\u003e \u003cp\u003eExpansion of AWDPP to reduce the variation of care across the nine GP clusters in CaVUHB. Since the AWDPP is not currently available in all clusters, expansion to the remaining clusters was considered important.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCandidate 5 - Perioperative Care\u003c/strong\u003e \u003cp\u003eIncludes the need for an inpatient DSN, reducing length of stay in the hospital, and improving the perioperative pathway for patients. Optimising the perioperative pathway for patients is expected to reduce length of stay. Patients with type 2 diabetes have higher rates of post-operative readmissions, causing distress and increased costs (NHS England, 2024). Evidence suggests that funding DSNs for inpatient perioperative care is cost-effective.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCandidate 6 - National Exercise Referral (NERS) Pathway for Prediabetes\u003c/strong\u003e \u003cp\u003eImportance of a physical activity intervention for people with prediabetes. The current NERS scheme is not adequately equipped to meet the increasing demand for physical activity interventions for people with type 2 diabetes. Staying physically active with at least 30 minutes of moderate exercise each day can help prevent type 2 diabetes and its complications (WHO, 2024).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eConversion of candidate programmes into implementable options\u003c/h2\u003e \u003cp\u003eBetween Meeting 2 and Meeting 3, the Steering Group converted the six candidates proposed by the PBMA Panel into six implementable options on which they could vote as follows:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eType 2 Diabetes Structured Education for Children, Young People (CYP) and their families \u0026loz; Completing T2D Structured Education for CYP and their families\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMedicines optimisation \u0026loz; Additional community Diabetes Specialist Nurses (DSNs) to conduct medication reviews\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eCommunity Diabetes Hub (CDH) \u0026loz; Additional clinical space for CDH in Central Cardiff\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAll Wales Diabetes Prevention Programme (AWDPP) \u0026loz; Extension of AWDPP to three additional GP clusters\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePerioperative care \u0026loz; Additional DSNs in perioperative care\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eNational Exercise Referral Scheme (NERS) for prediabetes \u0026loz; Develop and fund a NERS pathway for prediabetes in Cardiff and Vale\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe identification of these six candidates recognises the importance of primary prevention (reducing the incidence of disease), secondary prevention (detecting the early stages of disease and intervening before full symptoms develop), and tertiary prevention (managing disease after diagnosis to slow or stop its spread) (Public Health Wales, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The six candidates are mapped alongside the prevention triangle in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e[insert - Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Six candidates alongside prevention triangle for maximising health outcomes in type 2 diabetes]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eInvest-to-Save Evidence\u003c/h2\u003e \u003cp\u003eHealth economists from Bangor University also provided evidence from published literature suggesting potential \"invest-to-save\" outcomes for certain programmes. For example, deploying community DSNs to conduct medication reviews for patients with type 2 diabetes, and additional DSNs in perioperative care, may improve patient outcomes and potentially generate savings for reinvestment (NHS England, 2024). These savings could be realised through reduced medication costs (e.g., deprescribing, reduced prescription variation) and fewer GP consultations. Within CaVUHB, data indicates that patients with diabetes undergoing elective surgery have longer average lengths of stay than those without diabetes, often due to suboptimal diabetes management. DSNs could provide education on glycaemic management before and after surgery, potentially reducing readmissions and shortening hospital stays, thus contributing to cost savings (see Supplementary File).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEvidence-based decision-making \u0026ndash; assessment of availability of evidence for each criteria\u003c/h2\u003e \u003cp\u003eTo provide the PBMA Panel with comprehensive information, a red, amber, green (RAG) rating system was used to indicate the strength of evidence available for each criterion (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The predominantly green ratings for the six candidate programmes (left-hand column) reflect the substantial evidence base supporting the prevention and treatment of type 2 diabetes.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e[insert - Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. RAG status on amount of evidence to compare the six evidence-based options against criteria]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eOutcome of the PBMA Panel voting exercise\u003c/h2\u003e \u003cp\u003eDuring the first voting round at Meeting 3 in October 2024, the PBMA Panel was asked to rank the six options according to their investment priorities. The results are as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e1st: Extension of All Wales Diabetes Prevention Programme to additional GP clusters\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e2nd: Additional Community Diabetes Specialist Nurses to conduct medication reviews\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e3rd: Additional Diabetes Specialist Nurses in Perioperative Care\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e3rd: Additional Clinical Space for Community Diabetes Hub\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e5th: Type 2 Diabetes Structured Education for children, young people and their families\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e6th: National Exercise Referral Scheme for pre-diabetes\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTo gauge the relative strength of the priorities identified in the first vote, PBMA Panel members were asked to indicate their strength of preference by stating what percentage of potential funding they would allocate to each of the six candidate programmes. The results are as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e23%: Additional Diabetes Specialists Nurses to conduct medication reviews\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e20%: Extension of All Wales Diabetes Prevention Programme to additional GP clusters\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e17%: Additional Diabetes Specialist Nurses in Perioperative Care\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e15%: Additional Clinical Space for Community Diabetes Hub\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e14%: Type 2 Diabetes Structured Education for Children, Young People and their families\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e12%: National Exercise Referral Scheme for pre-diabetes\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eIn the final vote, the PBMA Panel was asked to reinvest any savings identified from the initial vote, specifically those associated with programmes expected to generate cost savings. The results for prioritisation of future reinvestment are as follows:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e1st: Extension of All Wales Diabetes Prevention Programme to additional GP clusters\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e2nd: Additional Community Diabetes Specialist Nurses to conduct medication reviews\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e3rd: Additional Clinical Space for Community Diabetes Hub\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e4th: Type 2 Diabetes Structured Education for Children, Young People and their families\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e5th: Additional Diabetes Specialist Nurses in Perioperative Care\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e6th : National Exercise Referral Scheme for pre-diabetes\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePBMA Feedback Survey\u003c/h2\u003e \u003cp\u003eFollowing Meeting 3, a PBMA Feedback Survey was distributed to all 17 Panel members, with a response rate of 70% (12 out of 17). The survey consisted of five questions. For the first three questions, Panel members rated the PBMA process on a scale of 1 to 10 in the following areas (mean scores reported):\u003c/p\u003e \u003cp\u003e1. PBMA Panel engagement: 8.0\u003c/p\u003e \u003cp\u003e2. Helpfulness in determining funding priorities: 7.2\u003c/p\u003e \u003cp\u003e3. Recommendation of PBMA for future use: 7.0\u003c/p\u003e \u003cp\u003ePanel members were also asked about what aspects of the PBMA process they found helpful. Panel members reported finding several aspects of the PBMA process valuable. They appreciated the supporting documentation, including the Background Report and the evidence booklets for the six candidate interventions. Many valued the process as an opportunity for balanced discussion of priorities, with one participant highlighting the open environment for discussion and contribution to evidence generation, which fostered a deeper understanding of current services. The Panel also commended the consultative nature of the PBMA, the researchers' unbiased approach, the inclusion of patient representatives, and the opportunities for learning and discussion about other programmes. Some members also noted the benefit of collaborating with colleagues on service improvement, while one participant emphasised the unique platform the PBMA provided to showcase key areas for Health Board investment.\u003c/p\u003e \u003cp\u003eFinally, Panel members were asked how they thought the PBMA process could be improved. While Panel members generally agreed that the PBMA process was effective overall, some felt the timeframe was too short for adequate consideration. Others suggested that greater clarity regarding the implementation of prioritised interventions and the impact of the voting process would be beneficial. One suggestion was to include information on the potential reach of each programme candidate to further inform prioritisation.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study evaluated the application of a PBMA framework within a local Health Board (CaVUHB) in Wales to inform resource allocation for the type 2 diabetes care pathway. A 17-member Panel developed recommendations, submitted to the CaVUHB Strategic Diabetes Programme Board, aimed at improving this pathway. Panel members rated the PBMA process highly, averaging 8 out of 10 for engagement, 7.2 out of 10 for helpfulness in determining funding priorities, and 7 out of 10 for future usefulness. CaVUHB considered the exercise a valuable demonstration, exploring the impact, utility, and resource implications of the PBMA approach. Following the Panel's recommendations, CaVUHB is planning broader implementation of the framework across the Health Board.\u003c/p\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eWhat is already known on the application of PBMA in healthcare settings\u003c/h2\u003e \u003cp\u003eThe PBMA framework has demonstrated versatility and applicability across diverse healthcare settings in the UK and internationally, informing resource allocation decisions at both national and local levels. In Wales, several PBMA exercises have been conducted. Edwards et al. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) undertook a comprehensive national PBMA of health improvement spending, examining opportunities for disinvestment and reinvestment across the entire life-course. Another Welsh example is the PBMA exercise conducted by Charles et al. (2014), which focused on reshaping resource utilisation within respiratory care pathways in North Wales.\u003c/p\u003e \u003cp\u003eThe PBMA framework has also been successfully applied in England across a range of clinical areas. Madden et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) utilised PBMA to prioritise resource allocation in the context of heart disease. Their work explored how to maximise the impact of spending on heart disease prevention and treatment. Similarly, Ratcliffe et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e1996\u003c/span\u003e) applied PBMA principles to maternity care, and more recently, Holmes et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) employed PBMA within dental care. These examples collectively illustrate the breadth and adaptability of the PBMA framework as a tool for evidence-informed resource allocation in the UK healthcare context. Specific to diabetes care, we note an early PBMA exercise in primary care (Scott et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e1998\u003c/span\u003e). Interest in PBMA seems to be cyclical. Our paper is novel in that it adopted a much more iterative process of evidence gathering relating to the criteria to be used by the Panel to judge the relative merit of the various candidates for expansion. This iterative process took the form of one-to-one interviews with key stakeholders, which were not done in the previous PBMAs we were involved in cited above.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths of this study\u003c/h2\u003e \u003cp\u003eThe PBMA exercise provided valuable insights into current service provision and gaps in care for individuals at risk of or living with type 2 diabetes within CaVUHB. Data gathered from approximately 20 services and 14 interviews with diabetes professionals offered a comprehensive overview of the pathway. The PBMA process broadened Panel members' understanding of the type 2 diabetes pathway, exposing them to programmes outside of their specific area of expertise.\u003c/p\u003e \u003cp\u003eIn-depth reviews of each candidate programme were conducted through individual consultations with relevant Panel members, who shared their perspectives on the effectiveness of current services, areas for improvement, suggestions for innovation, and knowledge of successful previous programmes. Evidence of clinical and cost-effectiveness, as well as alignment with NICE guidelines, was compiled for each programme to inform investment and prioritisation decisions.\u003c/p\u003e \u003cp\u003eCost and benefit estimates were developed for each programme, and potential cost savings were presented to the Panel. The Panel established evaluation criteria, and the Steering Group explained the RAG rating system used for assessment.\u003c/p\u003e \u003cp\u003eThis PBMA exercise successfully improved Panel members' understanding of the type 2 diabetes pathway, aligning with the four-point PBMA success criteria defined by Tsouparas and Frew (2011): 1) a greater understanding of the area under interest; 2) evidence of either full or partial implementation of recommendations; 3) reallocation of resources, and 4) adoption of framework for future use. The PBMA process successfully enhanced understanding. With respect to the ultimate impact on implementation, resource reallocation, and broader adoption of the PBMA framework within CaVUHB, this is now formally planned following recent press releases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLimitations of this study\u003c/h2\u003e \u003cp\u003eThe voluntary nature of the Service User Online Survey, coupled with the absence of a defined sampling frame, introduces the possibility of sampling bias and limits our ability to ensure the representativeness of the responses. A key gap in the evidence booklets was information regarding the potential reach of each candidate programme and the estimated number of individuals who could benefit. Furthermore, \"reach\" was not identified as a key criterion by Panel members when asked how they would prioritise candidates, but is central to Health Board planning. Estimating the financial cost of each candidate programme proved challenging due to resource and time constraints within the eight-month PBMA process. While the Steering Group aimed to create a representative PBMA Panel, it is possible that some relevant expertise was inadvertently excluded. Additionally, attendance at Meeting 3 (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;15), during which the voting occurred, was not 100%. While 15 of the 17 Panel members participated in the vote, the absence of two members could have potentially influenced the outcomes.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe PBMA process proved rigorous and enabled CaVUHB to strategically prioritise investments in type 2 diabetes services to improve health outcomes, with a focus on prevention. Key priorities identified included: increasing the number of diabetes specialist nurses in community and hospital settings, expanding access to the All-Wales Diabetes Prevention Programme, enhancing the physical space for community-based diabetes services, improving diabetes education for children and young people, and providing structured exercise programmes for those at risk of diabetes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe PBMA process incorporated multiple inputs, including a background report, interviews with Panel members and diabetes experts, evidence booklets (incorporating NICE guidelines and clinical/cost-effectiveness data), appraisal criteria, a service user survey, and PBMA Panel discussions culminating in electronic voting for funding prioritisation and subsequent resource reallocation.\u003c/p\u003e\n\u003cp\u003ePrioritisation focused on shifting resources toward prevention and early identification of type 2 diabetes, aiming to prevent disease progression, reduce readmissions, minimise adverse events, and improve post-surgical recovery. Clinical and cost-effectiveness evidence, alongside NICE guideline alignment, informed programme selection.\u003c/p\u003e\n\u003cp\u003eEmphasising long-term benefits like reduced type 2 diabetes incidence and prevalence, the PBMA process prioritised \"invest-to-save\" programmes with future cost-saving potential. This value-based healthcare approach prioritised programmes delivering the best patient outcomes at the lowest cost, improving resource allocation and improving population health within existing budgets.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003cbr\u003e\u003c/strong\u003eThe authors extend their sincere gratitude to the 17-member PBMA Panel. Their extensive expertise and experience were instrumental in shaping the investment and prioritisation recommendations that formed the cornerstone of this PBMA process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003cbr\u003e\u003c/strong\u003eThis work was supported by Cardiff and Vale University Health Board and Public Health Wales.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest that pertain to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRhiannon T. Edwards\u003c/strong\u003e: Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review and editing,\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eNed Hartfiel\u003c/strong\u003e: Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – review and editing\u0026nbsp;\u003cbr\u003e\u003cstrong\u003eLimssy Varghese\u003c/strong\u003e: \u0026nbsp;Formal analysis, Investigation, Writing, Visualisation, References\u003cbr\u003e\u003cstrong\u003eOliver Williams\u003c/strong\u003e: Conceptualization, Funding acquisition, Investigation, Formal analysis, Project administration, Methodology, Writing - review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDmytro Babelyuk\u003c/strong\u003e: Voting tools planning and development, visualisation, assistance with content presentations to the panel, data analysis\u003cbr\u003e\u003cstrong\u003eCatherine Lawrence\u003c/strong\u003e: Writing – original draft, Writing – review and editing\u003cbr\u003e\u003cstrong\u003eJulia Cottam\u003c/strong\u003e: Conceptualization, Data curation, Methodology, Formal analysis, Resources, Writing - review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClaire Beynon\u003c/strong\u003e: Conceptualization, Funding acquisition, Writing - review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data underlying this article will be shared on reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;Ethical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the Medical Research Council HRA Decision Tool, this work is deemed service evaluation, rather than research. Further, the Joint Research Office of Cardiff and Vale University Health Board confirmed that: ‘we would consider this project is not best defined as research, and it does not therefore require HRA/HCRW Approval, nor confirmation of Capacity and Capability from the Cardiff \u0026amp; Vale UHB R\u0026amp;D Office. There is no requirement to seek favourable opinion from an NHS Research Ethics Committee (REC) before beginning this project.’\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAldaghi, T. and Muzik, J. (2024) Multicriteria decision-making in diabetes management and decision support: Systematic review. \u003cem\u003eJMIR Medical Informatics\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e, e47701.\u0026nbsp;https://doi.org/10.2196/47701\u003c/li\u003e\n \u003cli\u003eAnderson, M., Pitchforth, E., Asaria, M., Brayne, C., Casadei, B., Charlesworth, A. \u003cem\u003eet al.\u003c/em\u003e (2021) LSE\u0026ndash;Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. \u003cem\u003eThe Lancet,\u003c/em\u003e 397, 1915-1978. https://doi.org/10.1016/S0140-6736(21)00232-4\u003c/li\u003e\n \u003cli\u003eBrambleby P. and Fordham, R. (2003) What is PBMA? What is\u0026hellip;? series. http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/pbma.pdf. Accessed 24 September 2024\u003c/li\u003e\n \u003cli\u003eCardiff and Value University Health Board. (2024a) Cardiff and Vale Local Public Health Plan 2024-27. https://cavuhb.nhs.wales/patient-advice/local-public-health-team/key-publications/c-amp-v-lph-plan-final-en-240326-3-pdf/ (2024a). Accessed 24 September 2024\u003c/li\u003e\n \u003cli\u003eCardiff and Vale University Health Board. (2024b) Cardiff and Vale UHB Annual Report 2023 \u0026ndash; 2024. https://senedd.wales/media/hbmjiy3s/gen-ld16585-e.pdf Accessed 24 September 2024\u003c/li\u003e\n \u003cli\u003eCharles, J. M., Brown, G., Thomas, K., Johnstone, F., Vandenblink, V., Pethers, B. \u003cem\u003eet al.\u0026nbsp;\u003c/em\u003e(2016) Use of programme budgeting and marginal analysis as a framework for resource reallocation in respiratory care in North Wales, UK.\u0026nbsp;\u003cem\u003eJournal of Public Health,\u003c/em\u003e \u003cem\u003e38\u003c/em\u003e(3), e352-e361. https://doi.org/10.1093/pubmed/fdv128\u003c/li\u003e\n \u003cli\u003eCollins, M., Mazzei, M., Baker, R., Morton, A., Frith, L., Syrett, K. \u003cem\u003eet al.\u0026nbsp;\u003c/em\u003e(2023) Developing a combined framework for priority setting in integrated health and social care systems. \u003cem\u003eBMC Health Services\u0026nbsp;\u003c/em\u003e\u003cem\u003eResearch, 23\u003c/em\u003e(1),\u0026nbsp;879. https://doi.org/10.1186/s12913-023-09866-x\u003c/li\u003e\n \u003cli\u003eDiabetes UK. 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Bishop, J., Cohen, D., Groves, S. \u003cem\u003eet al.\u0026nbsp;\u003c/em\u003e(2014) A national programme budgeting and marginal analysis (PBMA) of health improvement spending across Wales: disinvestment and reinvestment across the life course. \u003cem\u003eBMC Public Health,\u003c/em\u003e 2, 837.\u0026nbsp;https://doi.org/10.1186/1471-2458-14-837\u003c/li\u003e\n \u003cli\u003eHolmes, R. D., Steele, J. G., Exley, C., Vernazza, C. R. and Donaldson, C. (2018) Use of programme budgeting and marginal analysis to set priorities for local NHS dental services: learning from the north east of England. \u003cem\u003eJournal of Public Health, 40\u003c/em\u003e(4), e578-e585. https://doi.org/10.1093/pubmed/fdy075\u003c/li\u003e\n \u003cli\u003eLloyd-Williams, H. (2019) The role of multi-criteria decision analysis (MCDA) in public health economic evaluation. In: Edwards, R. T. and McIntosh, E. (eds) Applied health economics for public health practice and research, pp. 301-312. 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(1996) Programme budgeting and marginal analysis: a case study of maternity services.\u0026nbsp;\u003cem\u003eJournal of Public Health, 18\u003c/em\u003e(2),\u0026nbsp;175-182. https://doi.org/10.1093/oxfordjournals.pubmed.a024477\u003c/li\u003e\n \u003cli\u003eScott, A., Currie, N. and Donaldson, C. (1998) Evaluating innovation in general practice: a pragmatic framework using programme budgeting and marginal analysis. \u003cem\u003eFamily Practice,\u0026nbsp;15\u003c/em\u003e(3), 216-222. https://doi.org/10.1093/fampra/15.3.216\u003c/li\u003e\n \u003cli\u003eTsourapas, A. and Frew, E. (2011) Evaluating \u0026lsquo;success\u0026rsquo; in programme budgeting and marginal analysis: a literature review.\u0026nbsp;\u003cem\u003eJournal of Health Services Research \u0026amp; Policy, 16\u003c/em\u003e(3),\u0026nbsp;177-183. https://doi.org/10.1258/jhsrp.2010.00905\u003c/li\u003e\n \u003cli\u003eWelsh Value in Health Centre. (2024) Value-based healthcare for Wales. NHS Wales. https://vbhc.nhs.wales/value-based-healthcare-for-wales. Accessed 24 September 2024\u003c/li\u003e\n \u003cli\u003eWinrow, E. and Edwards, R.T. (2020) Programme budgeting and marginal analysis, and developing a business case for a new service. In: Gulliford, M. Jessop. E. (eds) Healthcare public health: Improving health services through population science, pp. 110-118. Oxford University Press, Oxford\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. (2024) Diabetes. https://www.who.int/news-room/fact-sheets/detail/diabetes. Accessed 24 September 2024\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type 2 diabetes, health economics, public health, prevention, programme budgeting and marginal analysis (PBMA), evidence-based decision-making","lastPublishedDoi":"10.21203/rs.3.rs-8138716/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8138716/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe 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.\u003c/p\u003e","manuscriptTitle":"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","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 10:05:09","doi":"10.21203/rs.3.rs-8138716/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-18T14:02:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76093531463364586078878999085828935640","date":"2026-05-17T23:17:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"318651271019825314882308884661673596499","date":"2026-04-27T05:08:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149887704773304208215215342236138754129","date":"2026-03-13T23:53:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"314076287544254384130250436558727605697","date":"2026-02-24T01:15:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"161729975903258444323146245019194160852","date":"2026-02-23T15:50:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126027986739555558612497147717080568053","date":"2026-02-18T21:39:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-10T19:50:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-05T18:43:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-20T06:18:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T21:25:04+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-19T21:20:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d5ea597-d347-4c83-8f49-4c646bd264d7","owner":[],"postedDate":"February 16th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-18T14:02:40+00:00","index":167,"fulltext":""},{"type":"reviewerAgreed","content":"76093531463364586078878999085828935640","date":"2026-05-17T23:17:53+00:00","index":166,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T10:05:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-16 10:05:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8138716","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8138716","identity":"rs-8138716","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}