Jonathan Ingles: Cole — how much do you think it costs to prevent someone from dying of cholera versus treating them after they've got it?
Cole Bryant: Oh, this is a trap. You've got a number. What is it — give me the number.
Jonathan Ingles: Sanitation: eleven dollars per disability-adjusted life year averted. Treating the diarrheal disease you get without it: one thousand and sixty-two dollars. Same outcome, ninety-six times the cost.
Cole Bryant: Bro. Stop. That's — okay, that should end the conversation, right? That should be the whole debate done.
Jonathan Ingles: Except it doesn't. Governments fund treatment at ten times the rate of prevention anyway. The WHO documents it across most health systems in their expenditure database. So the question we're actually here to sit inside today is — the math is not hidden. Why doesn't the money follow it.
Cole Bryant: And the UK version of that question is, I mean — the NHS spends £182 billion on treatment, and the entire Public Health Grant is £3.9 billion. That's 46 to one. That's not a funding gap, that's a funding canyon.
Jonathan Ingles: And the grant shrank. Down 26% per person in real terms from 2015 onward. While every health secretary in that period gave a speech about prevention being the priority.
Cole Bryant: So stated preference says one thing, revealed preference does something completely different — and that gap is kind of the whole mystery here, isn't it.
Jonathan Ingles: And here's why that gap exists. Prevention is a smoke alarm. If it works, nothing happens. And 'nothing happening' is invisible. Treatment is the fire truck. You see it arrive, you see the house get saved, you can name the firefighter.
Cole Bryant: Wait — that's the whole thing right there. The cases that never happen can't be counted. Like you literally cannot point at the person who didn't get cholera.
Jonathan Ingles: That's the counterfactual problem. The beneficiary is statistical. Anonymous. You can't put them on a poster.
Cole Bryant: Okay and — no wait, this is what gets me — John Snow figured this out in the 1800s. He mapped the cholera outbreak, pulled the pump handle off Broad Street, cases dropped. That's like the founding story of prevention working at a population level. And the system that came after that still optimized for treating sick people.
Jonathan Ingles: Because Snow's win was never legible to a budget committee. You can't invoice for an epidemic that didn't spread.
Cole Bryant: Bro. That's — yeah. And then COVID is the one moment where prevention actually gets political traction — vaccines, lockdowns, the whole thing — but only because the threat became impossible to ignore. The death count was on the news every single night.
Jonathan Ingles: Visibility was forced. The disease made itself legible. That's not prevention winning — that's an exception that proves the rule.
Cole Bryant: Right — but then, okay, so if visibility is the whole explanation, why doesn't better data fix it? Martin, Lomas and Claxton put out research in 2020 showing prevention costs £3,800 per quality-adjusted life year versus £13,000 for NHS treatment. That data exists. People cite it. The public health grant still got cut 26% per person. So it's not — I mean, it can't just be that we don't know.
Jonathan Ingles: Exactly. Visibility is the surface explanation. The layer underneath it is who captures the return. The entity paying for prevention never sees the savings. That's a different problem entirely.
Cole Bryant: Wait — so the council that funded the vaccination program never gets that money back. Like the NHS trust spends less on treating measles ten years later, but the council's budget just... sees a cost. There's no column for 'hospital bills that didn't happen.'
Jonathan Ingles: That's the exact mechanism. Wrong pockets. The payer and the saver are structurally different entities. So next budget cycle, that vaccination line is the one that looks expendable.
Cole Bryant: Bro. That finance officer is staring at a spreadsheet and the prevention spend is just — it's just red. There's no green column showing the future hospital costs it avoided.
Jonathan Ingles: And the Demos report from 2025 and the Institute for Government both point to this — ring-fenced budgets, cross-budget accountability, tracking preventative expenditure explicitly. The mechanism exists on paper. But it only works if you actually close the savings-capture gap first. Otherwise you're just adding reporting requirements to a broken incentive.
Cole Bryant: Okay but even — wait, actually — even if you somehow fixed the budget architecture, there's another thing quietly working against prevention that I don't think people realize. HM Treasury's Green Book. The standard discount rate is 3.5%.
Jonathan Ingles: The appraisal framework. Yeah.
Cole Bryant: At 3.5%, a benefit that arrives twenty years from now — the vaccination you gave a five-year-old — it gets mathematically shrunk down to something that can't compete with a treatment that pays off this quarter. There's supplementary guidance that lets you use 1.5% for long-horizon health effects, but the *choice* of rate literally determines whether prevention wins the cost-effectiveness comparison. Like, the government's own math is built to undercount prevention's value by default.
Jonathan Ingles: The infrastructure of evaluation is tilted before anyone argues about the numbers. That's not fixable with better data. Which — and we'll get to this — is exactly why the £14.3 return-per-pound figure exists and gets cited constantly and still doesn't move the money.
Cole Bryant: The math isn't the problem. That's — I mean, that's the uncomfortable part, isn't it.
Jonathan Ingles: But the uncomfortable part has a name. There's actual experimental data on this — BMC Medical Informatics and Decision Making, between-subjects studies. When you force people to compare prevention and treatment directly, they choose prevention. Every time. But when you ask them to allocate funds independently, as a separate judgment, they put more money into treatment. Same people. Same values. Different framing.
Cole Bryant: Wait — so the preference reversal is in the structure of the question, not in what people actually believe?
Jonathan Ingles: Support for prevention is a luxury opinion. It holds when nothing is at stake. The moment you're actually moving money, it collapses.
Cole Bryant: Okay that — no, wait, that's actually a bigger problem than I thought, because — I mean, this isn't even bad politicians or captured institutions, right? This is like, a well-intentioned policymaker who genuinely believes in prevention, sits down to write a budget under pressure, and their brain just... treats the upfront cost of prevention as certain and heavy, and the future benefit as fuzzy and maybe. That's prospect theory. The certain cost today feels enormous compared to a probabilistic benefit in fifteen years.
Jonathan Ingles: And treatment flips it. The cost only hits after someone's already sick — it never feels like a choice, it feels like an emergency response. Which means it's never really competing on the same psychological ledger.
Cole Bryant: Bro. So the £14.3 return per pound — that number is real, Martin Lomas and Claxton's 3.4 times productivity advantage is real — and it still doesn't move, because no individual decision-maker experiences that return. They just experience the cost.
Jonathan Ingles: Which means it's not a knowledge problem and it's not an irrationality problem. Everyone in that room is responding rationally to their own position. The system is the irrational actor.
Cole Bryant: So educating policymakers about the ROI — which is kind of what everyone recommends — that's just... not the lever.
Jonathan Ingles: Frankly, no. Because they already know. The problem isn't what's in the room. It's what's not in the room — which is any mechanism that makes the future savings feel as real as today's budget line.
Cole Bryant: And if — the cholera thing though. Eleven dollars versus a thousand and sixty-two. That math existed in John Snow's century. The pump handle came off, the cases stopped. And we built the entire modern health system *after* that proof, and still landed at 46-to-one the wrong way. So like — it's not that the evidence wasn't there early enough. It was there *first*.
Jonathan Ingles: And COVID is the final test case for me. Eighty-five modelling studies. Systematic review. Every category of intervention — NPIs, vaccines, the lot — cost-effective. The evidence was as clean as it's ever been, the political pressure was as high as it will ever get. And the moment the acute phase ended, prevention funding collapsed back. If a pandemic can't hold it, I don't know what ordinary institutional reform does.
Cole Bryant: That's — yeah. That's the question that just sits there, isn't it. Not 'how do we convince anyone' — that ship's sailed, the £14.3 return is cited *constantly* — but who actually controls the budget, and who receives the savings when prevention works. Because until those are the same entity, the spreadsheet will always make cutting prevention look rational.
Jonathan Ingles: Demos, Institute for Government — ring-fenced budgets, preventative expenditure tracking, cross-budget accountability. The tools exist. I'm just not certain any of them survive contact with a government that already watched the public health grant fall 26% and called it a priority.
Cole Bryant: Pull the pump handle. Cases stop. Can't invoice for it. That's still the whole problem. Good conversation, man.
