Cost of Improving Access to Psychological Therapies (IAPT) programme: An analysis of cost of session, treatment and recovery in selected Primary Care Trusts in the East of England region Muralikrishnan Radhakrishnan a, * , Geoffrey Hammond b , Peter B. Jones c , Alison Watson b , Fiona McMillan-Shields d , Louise Lafortune a a NIHR CLAHRC for Cambridgeshire and Peterborough, Cambridge Institute of Public Health, University of Cambridge Forvie Site, Robinson Way, Cambridge CB2 0SR, UK b NIHR CLAHRC for Cambridgeshire and Peterborough, 18 Trumpington Road, Cambridge CB2 8AH, UK c NIHR CLAHRC for Cambridgeshire and Peterborough, Department of Psychiatry, University of Cambridge Herchel Smith Building, Cambridge CB2 0SZ, UK d NHS East of England, Victoria House, Capital Park, Cambridge CB21 5XB, UK article info Article history: Received 18 November 2011 Received in revised form 26 September 2012 Accepted 1 October 2012 Keywords: CBT Cost IAPT Depression Anxiety Disorders abstract Recent literature on Improving Access to Psychological Therapies (IAPT) has reported on improvements in clinical outcomes, changes in employment status and the concept of recovery attributable to IAPT treatment, but not on the costs of the programme. This article reports the costs associated with a single session, completed course of treatment and recovery for four treatment courses (i.e., remaining in low or high intensity treatment, stepping up or down) in IAPT services in 5 East of England region Primary Care Trusts. Costs were estimated using treatment activity data and gross financial information, along with assumptions about how these financial data could be broken down. The estimated average cost of a high intensity session was £177 and the average cost for a low intensity session was £99. The average cost of treatment was £493 (low intensity), £ 1416 (high intensity), £699 (stepped down), £ 1514 (stepped up) and £877 (All). The cost per recovered patient was £1043 (low intensity), £2895 (high intensity), £ 1653 (stepped down), £2914 (stepped up) and £1766 (All). Sensitivity analysis revealed that the costs are sensitive to cost ratio assumptions, indicating that inaccurate ratios are likely to influence overall esti- mates. Results indicate the cost per session exceeds previously reported estimates, but cost of treatment is only marginally higher. The current cost estimates are supportive of the originally proposed IAPT model on cost-benefit grounds. The study also provides a framework to estimate costs using financial data, especially when programmes have block contract arrangements. Replication and additional anal- yses along with evidence-based discussion regarding alternative, cost-effective methods of intervention is recommended. Ó 2012 Elsevier Ltd. All rights reserved. Introduction Large, multinational epidemiological studies indicate that approximately 16% of the population experience depression and anxiety over a lifetime (Kessler et al., 2003; Singleton, Bumpstead, O’Brien, Lee, & Meltzer, 2001). In UK, a 2006 report from Centre for Economic Performance (CEP) stated that “crippling depression and chronic anxiety are the biggest causes of misery in Britain today” (CEP, 2006). The financial cost of depression in the UK was esti- mated at approximately 105 billion pounds in 2009/2010, of which 30 billion is thought to be work related (Sainsbury Centre, 2010). Furthermore, it has been estimated that a cross subsidy of £7e10 billion on social security benefits payments are made to cover the unemployment costs of people with high prevalence mental health problems (CEP, 2006). To alleviate the distress and costs associated with depression and anxiety disorders, the UK Department of Health announced an unprecedented increase in funding for the provision of psycho- logical therapies in the National Health Services in 2007 (DoH, 2007). With the possible exception of the closure of asylums and the associated increase in community based mental health treat- ment in the 1960s, the Improving Access to Psychological Therapies (IAPT) programme represents the biggest shift in policy in UK * Corresponding author. Tel.: þ44 1223 746557; fax: þ44 1223 762515. E-mail addresses: [email protected](M. Radhakrishnan), [email protected](G. Hammond), [email protected](P.B. Jones), [email protected](A. Watson), [email protected](F. McMillan-Shields), [email protected](L. Lafortune). Contents lists available at SciVerse ScienceDirect Behaviour Research and Therapy journal homepage: www.elsevier.com/locate/brat 0005-7967/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.brat.2012.10.001 Behaviour Research and Therapy 51 (2013) 37e45
Transcript
at SciVerse ScienceDirect
Behaviour Research and Therapy 51 (2013) 37e45
Contents lists available
Behaviour Research and Therapy
journal homepage: www.elsevier .com/locate/brat
Cost of Improving Access to Psychological Therapies (IAPT) programme: Ananalysis of cost of session, treatment and recovery in selected Primary Care Trustsin the East of England region
Muralikrishnan Radhakrishnan a,*, Geoffrey Hammond b, Peter B. Jones c, Alison Watson b,Fiona McMillan-Shields d, Louise Lafortune a
aNIHR CLAHRC for Cambridgeshire and Peterborough, Cambridge Institute of Public Health, University of Cambridge Forvie Site, Robinson Way, Cambridge CB2 0SR, UKbNIHR CLAHRC for Cambridgeshire and Peterborough, 18 Trumpington Road, Cambridge CB2 8AH, UKcNIHR CLAHRC for Cambridgeshire and Peterborough, Department of Psychiatry, University of Cambridge Herchel Smith Building, Cambridge CB2 0SZ, UKdNHS East of England, Victoria House, Capital Park, Cambridge CB21 5XB, UK
a r t i c l e i n f o
Article history:Received 18 November 2011Received in revised form26 September 2012Accepted 1 October 2012
0005-7967/$ e see front matter � 2012 Elsevier Ltd.http://dx.doi.org/10.1016/j.brat.2012.10.001
a b s t r a c t
Recent literature on Improving Access to Psychological Therapies (IAPT) has reported on improvementsin clinical outcomes, changes in employment status and the concept of recovery attributable to IAPTtreatment, but not on the costs of the programme. This article reports the costs associated with a singlesession, completed course of treatment and recovery for four treatment courses (i.e., remaining in low orhigh intensity treatment, stepping up or down) in IAPT services in 5 East of England region Primary CareTrusts. Costs were estimated using treatment activity data and gross financial information, along withassumptions about how these financial data could be broken down. The estimated average cost of a highintensity session was £177 and the average cost for a low intensity session was £99. The average cost oftreatment was £493 (low intensity), £1416 (high intensity), £699 (stepped down), £1514 (stepped up) and£877 (All). The cost per recovered patient was £1043 (low intensity), £2895 (high intensity), £1653(stepped down), £2914 (stepped up) and £1766 (All). Sensitivity analysis revealed that the costs aresensitive to cost ratio assumptions, indicating that inaccurate ratios are likely to influence overall esti-mates. Results indicate the cost per session exceeds previously reported estimates, but cost of treatmentis only marginally higher. The current cost estimates are supportive of the originally proposed IAPTmodel on cost-benefit grounds. The study also provides a framework to estimate costs using financialdata, especially when programmes have block contract arrangements. Replication and additional anal-yses along with evidence-based discussion regarding alternative, cost-effective methods of interventionis recommended.
� 2012 Elsevier Ltd. All rights reserved.
Introduction
Large, multinational epidemiological studies indicate thatapproximately 16% of the population experience depression andanxiety over a lifetime (Kessler et al., 2003; Singleton, Bumpstead,O’Brien, Lee, & Meltzer, 2001). In UK, a 2006 report from Centre forEconomic Performance (CEP) stated that “crippling depression andchronic anxiety are the biggest causes of misery in Britain today”
(CEP, 2006). The financial cost of depression in the UK was esti-mated at approximately 105 billion pounds in 2009/2010, of which30 billion is thought to be work related (Sainsbury Centre, 2010).Furthermore, it has been estimated that a cross subsidy of £7e10billion on social security benefits payments are made to cover theunemployment costs of people with high prevalence mental healthproblems (CEP, 2006).
To alleviate the distress and costs associated with depressionand anxiety disorders, the UK Department of Health announced anunprecedented increase in funding for the provision of psycho-logical therapies in the National Health Services in 2007 (DoH,2007). With the possible exception of the closure of asylums andthe associated increase in community based mental health treat-ment in the 1960s, the Improving Access to Psychological Therapies(IAPT) programme represents the biggest shift in policy in UK
M. Radhakrishnan et al. / Behaviour Research and Therapy 51 (2013) 37e4538
mental health service provision in the past 50 years. Based oneconomic arguments and clinical evidence, IAPT was developed topromote access to National Institute for Health and Clinical Excel-lence (NICE) approved Cognitive Behavioural Therapy (CBT) basedtalking therapies as an appropriate evidence-based psychologicalintervention for depression and anxiety disorders (Clark et al.,2009). There are two tiers of IAPT therapy, depending on clinicalseverity, and corresponding to NICE steps 2 and 3 for the treatmentof depression and anxiety. More intense therapy is delivered bymore experienced clinicians in the higher tier. The lower tierprovides treatment for the majority of referrals from primary careand other sources.
IAPT represents a public health approach to the treatment ofmild to severe depression and anxiety (Layard, 2006; Richards &Suckling, 2009). The rationale for widespread implementation ofthe IAPT programme, besides aiming to decreasing the prevalenceof mental illness in the UK, was that economic gains associatedwith increased productivity and reemployment of treated indi-viduals would dwarf all costs associated with the programme; thatproviding psychological therapy to people not now in treatmentwould result in “the cost to the government to be fully covered bythe savings in incapacity benefits and extra taxes that result frommore people being able to work” (Layard, Clark, Knapp, & Mayraz,2007). Layard et al. (2007) also argued that these stepped care,expanded psychological therapies programmes would cover thecost to the government by the extra output in GDP produced by thetreated person, savings to the exchequer in incapacity benefits andextra taxes as a result of more people being able to work.
IAPT services have been commissioned throughout England,with more than 300 new therapists recruited for training in theEast of England (EoE) alone between 2008 and 2011. By substan-tially increasing the number of therapists, IAPT is intended tofacilitate increased referrals and reduced waiting times, with thepotential to increase patient reported satisfaction and reduce self-reported depression and anxiety (CEP, 2006; Layard, 2006). Thefunding for the IAPT programme was contingent on the successfulimplementation of a new treatment programme in two demon-stration sites: Doncaster in Northern England and Newham in EastLondon. The outcomes of these pilots would be used to argue thatthe increased funding from the Government could deliver betterclinical outcomes in terms of magnitude of improvement andtreatment volume to justify the investment (Richards & Suckling,2009).
A recent evaluation of both demonstration sites indicated that atleast 55% of patients who attended at least two sessions (includingan assessment interview) recovered and 5% transitioned fromunemployment into part- or full-time employment (Clark et al.,2009). Overall, this study demonstrated that the talking therapiesmodel can be effective in the treatment of depression and anxiety.Whilst that recent evaluation reported on clinical outcomes andimprovements in employment status, no attempt was made toreport on the costs incurred by the programme. The cost of theprogramme is an important consideration for psychologicaltherapy implementation. Given that IAPT therapy sessions areprovided by high and low intensity therapists (subsequently calledpsychological well-being practitioners or PWPs) who differ mark-edly in their training and salary costs, there could be a significantdifference in the session costs delivered by each types. The cost ofa typical course of completed treatment is also an important facetof cost to consider. Now that recovery of patients is an importantindicator of IAPT programme’s performance, it is crucial to estimatethe cost of a recovered patient through the IAPT programme and itsactivities. This study is an attempt to estimate the cost of session,completed treatment and recovered patient using financial datafrom 5 Primary Care Trusts (PCTs) in the EoE region.
Methods
IAPT services are based on a stepped-care model: patientsreceive either high or low intensity interventions, as deemedappropriate by a standard initial assessment (Clark et al., 2009).Initial analysis of outcomes data collected in selected PCTs in EoEalso revealed that a significant number of patients transitionedfrom high intensity to low intensity interventions and vice versa.The cost per session, cost of treatment and cost of recovery asso-ciated with these four types of treatment course were estimatedusing financial data and patient reported outcomes measures(PROMS) collected on a per session basis for 5 PCTs in the EoE forfinancial year 2009e2010.
Patients were included in the analysis if they had at least 2 ormore sessions and ended their treatment between 1 April 2009 and31 March 2010. This includes patients who successfully completedtreatment (i.e., treatment that ended following an agreementbetween the therapist and patient), deceased during the treatment,declined to continue with treatment, dropped out of treatment, orwere found unsuitable for treatment by IAPT therapists.
Theprimaryclinical outcomewasrecoveryat treatmentendpoint.It was assessed based on the change in severity of depression andanxiety symptoms measured by two brief questionnaires as part ofthe IAPT routine clinical dataset (DoH, 2008): the Patient HealthQuestionnaire Depression scale (PHQ-9) (Cameron, Crawford,Lawton, & Reid, 2008; Kroenke, Spitzer, & Williams, 2001) and theGeneralised Anxiety Disorder scale (GAD-7) (Spitzer, Kroenke,Williams, & Lowe, 2006). This information was stored on PC-MIS,the clinical record keeping software used for IAPT nationally.
For the current analysis, patients who fulfilled the pre-definedcriteria for clinical “caseness” at their initial session and transi-tioned into “non caseness” at their final session were consideredrecovered, irrespective of whether they completed the recom-mended number of treatment sessions or had any other treatmentoutcome (e.g., declined treatment, found unsuitable for furthertreatment). To be classified as clinical caseness at baseline, indi-viduals had to score 10 points or more on the PHQe9 and 8 pointsor more on the GAD-7 at their initial assessment session (Clarket al., 2009). So, individuals were classified as cases if their PHQ-9and GAD-7 scores were above these clinical thresholds and wererequired to be below the threshold on both measures at their finaltreatment session to be classified as recovered.
Costing was undertaken from a programme perspective. Onlythe costs directly incurred by the IAPT programme in the EoE wereconsidered; this does not include costs incurred from a widerperspective, i.e., costs to other sector of the health and social caresystem, or costs to the patient.
Financial information on the total spend on IAPT programmesfrom five PCTs in the EoE region were sourced for the 2009e2010financial year (1 April 2009 to 31 March 2010) from reportsprepared by Mental Health Strategies for the Department of Health(Mental Health Strategies, 2010). The PCTs included in the studywere Bedfordshire, Cambridgeshire, North & East Hertfordshire,Suffolk and West Hertfordshire (anonymised on request). PCTsselected for inclusion had complete data (i.e., achieved the nationaltarget of 90% completeness) on IAPT sessions and clinical outcomesfor the entire period assessed.
Cost per session
Financial information for each of the 5 PCTs provided the overalltotal spend for the financial year: the proportion of the totalamount spent on low and high intensity sessions was not specified.Therefore, a framework was developed to allocate total IAPTexpenditure to either high or low intensity activity (Fig. 1).
Fig. 1. Framework for estimating cost of session, treatment and recovery.
M. Radhakrishnan et al. / Behaviour Research and Therapy 51 (2013) 37e45 39
The first step involved apportioning the total IAPT expenditurein the specified year to the volume of high or low intensity inter-ventions delivered over that period. Unpublished financial datafrom one PCT revealed that ‘high intensity activity’ cost 1.8 timesmore than ‘low intensity activity’. A local tariff developed for EoEIAPT services arrived at a similar cost ratio (i.e., 1.7) when cost items(salaries and overheads) were considered individually (Nolan,2009). Hence, a cost ratio of 1.8 was used for the base case anal-ysis. However, this cost ratio does not factor in the time therapistsdevote to administrative tasks and training. In the tariff estimation,Nolan (2009) assumed that the capacity of PWPs, with a possible 9patient contacts per day needs to be reduced by 35% and that ofhigh intensity therapist, with a possible 7 patient contacts needs tobe reduced by 45% to account for these activities. Using theseassumptions, the price tariff estimated by Nolan (2009) showeda cost ratio of 2.8. A sensitivity analysis using low and high costratios was performed to see how the results are affected by theseassumptions.
To arrive at the total costs attributed to ‘high intensity’ and‘low intensity’ sessions, the cost ratio (i.e., 1.8 for the base case)was multiplied by the total session ratio. Then, to estimate theper session costs, the total high intensity and low intensitysession costs were divided by the total number of high and lowintensity sessions delivered during the referenced financial year,respectively.
Cost of a Single course of treatment
Using the per session cost estimate, the cost for a single courseof treatment delivered by different IAPT providers was estimated.For this, all patients from the 5 PCTs who ended treatmentregardless of the reason (i.e., those who completed treatment,deceased, declined, dropped out or were found not suitable forIAPT) were included in the analysis. Each patient’s entire treatmentcourse was traced back to their initial session to ascertain thenumber of sessions they received, including the initial assessment
Table 1Baseline demographics and clinical characteristics of patients.
Total
n %
Sample size 8464 100
Age Group<18e25 1401 16.6%26e35 2059 24.3%36e45 2266 26.8%46e55 1555 18.4%56e65 877 10.4%Older than 65 306 3.6%
M. Radhakrishnan et al. / Behaviour Research and Therapy 51 (2013) 37e4540
session. The median number of sessions received during the courseof treatment was assessed separately for four groups of patientsand was multiplied by the session cost associated with the corre-sponding PCT to produce the cost of a single course of treatment.The median rather than the mean was used due to non-normallydistributed sessional data. A weighted average of all treatmenttypes was also estimated.
Cost per recovered patient
To estimate the cost per recovered patient, two estimates wererequired: the total cost of treating all the patients and the numberof patients who recovered in all treatment endpoint categories(completed deceased, declined, dropped out and not suitable). Thetotal cost of treatment was calculated by multiplying the cost oftreatment course by the number of patients who underwenttreatment in all categories. The cost of providing a single session(usually the initial assessment) to those who attended only onesession was also estimated by multiplying the respective sessioncost by the number of patients, and added to the total costs. Thetotal cost was then divided by the number of patients who recov-ered to arrive at the cost per recovered patient for each PCT for thefour different treatment courses. Because the assessment sessioncan be for “signposting” or to check suitability for further treatmentand not necessarily for treatment per se, the cost per recoveredpatient is presented with and without the assessment costs.
Results
In total, 10,789 patients completed or ended IAPT treatment forvarious reasons between 1 April 2009 and 31March 2010, of whom21.2% attended only 1 session (Fig. 2). Among those who attended 2or more sessions, 4844 (44.9%) successfully completed the allottedtreatment (i.e., after an agreement between the therapist andpatient to end treatment). A significant number of patients droppedout of treatment (n ¼ 1961; 18.2%) and 861 (8%) were foundunsuitable for IAPT treatment after attending 2 or more sessions.Table 1 presents the baseline demographic and clinical character-istics of the 8464 patients who attended 2 or more sessions. 4325patients (51.1%) belonged to the agegroup26e45years; themajorityof patients (5576, 65.9%) were women. There were 5155 patients(60.9%) in full time or part time employment at baseline. Referrals tothe IAPT programme were through general practitioners for 7511patients (88.7%).UsingbaselinePHQ-9 scorebands to assess severity
Fig. 2. Distribution of patients who ended IAPT treatment (2009e2010).
of depression, 2146 patients (25.4%) were classified as havingmoderate depressive symptoms, 1987 patients (23.5%) withmoderate-severe depressive symptoms and 1787 patients (21.1%)with severe depressive symptoms. For the GAD-7 scores at baseline,2365 patients (27.9%) were classified with moderate anxietysymptomsand3348patients (39.6%)with severeanxiety symptoms.
Of the 8464 patients treated, 4854 patients (57.3%) received lowintensity treatment, 2230 patients (26.2%) received high intensitytreatment, 252 patients (3.0%) were stepped down in their treat-ment and 1128 (13.3%) were stepped up. Of the 3371 patients(39.8%) who achieved recovery, 1992 patients (59.1%) received lowintensity treatment exclusively, 884 patients (26.2%) received highintensity treatment exclusively, 101 patients (3.0%) were steppeddown and 394 patients (11.7%) were stepped up. For all PCTs,a recovery rate of more than 50% was observed for individualscompleting treatment irrespective of the therapy course theyreceived (Table 2). The baseline and final severity scores on thePHQ9 and GAD7 for the different treatment course are presented inTable 3.
a Recovery Rate ¼ # Patients Recovered/#Patients Treated.
M. Radhakrishnan et al. / Behaviour Research and Therapy 51 (2013) 37e45 41
Cost per session
Table 4 presents the total IAPT spend in the five PCTs assessed,the total session ratio (proportion of low and high intensitysessions), the proportion of the total cost allocated to high and lowintensity activity and the estimated cost per session. All the PCTsspent in excess of £2 million on the IAPT programme, with PCT Dspending the most (approximately £4 million). High intensitysessions account for more than 55% of total costs for all of the PCTs.Across all PCTs, the average cost for a low intensity session was£98.59 and ranged from £78.31 to £150.17. The average cost of a highintensity session was £176.97, and ranged from £140 to £270.41
across PCTs. The overall cost per session was £137.73 for all PCTs,and ranged from £112.70 to £214.01.
Cost of a course of treatment
For all PCTs combined, the median number of sessions receivedwas 5 for individuals remaining on low intensity treatment and 8for individuals remaining on high intensity treatment. People whostepped down from high to low intensity sessions receiveda median of 3.5 sessions of low intensity interventions and 2 highintensity sessions. Those who stepped up from low intensityintervention received approximately 1 low intensity session and 8high intensity sessions. Table 5 presents the estimated cost oftreatment for the four different treatment courses across PCTs. Forall PCTs, the estimated cost for a completed course of exclusivelylow intensity treatment was £493 and ranged between £313 and£901 across PCTs. The estimated cost of a completed course of highintensity treatment was £1416 and ranged from £987 to £1793across PCTs. The estimated cost of a completed treatment course forindividuals who were stepped down was £699 and ranged from£579 to £946 across PCTs. The estimated cost of a completedtreatment course for individuals who were stepped up was £1514and ranged from £1206 to £1891 across PCTs. Overall, the estimatedcost of completed treatment, irrespective of the treatment course,was £877 and ranged from £686 to £1227 across PCTs.
Cost per recovered patient
The overall total cost of treating all categories of patients underdifferent therapy courses are given in Table 6. Irrespective of thetherapy course received, those who completed treatment accoun-ted for the majority of the total IAPT expenditure (over 70%). At£2,559,111, high intensity therapy is the highest single total costacross all treatment courses for all PCTs, followed by low intensitytherapy, stepped up and then stepped down. Table 7 presents thecost per recovered patient for the different therapy courses. For thelow intensity therapy, the estimated cost per recovered patient is£1043 for all PCTs (ranging from £687 to £1952 across PCTs). For thehigh intensity therapy, the cost per recovered patient is £2895 andvaried significantly across PCTs from £1849 to £4066. For thestepped down therapy, the estimated cost per recovered patient is£1653 and ranges from £1012 to £2111 across PCTs. For the steppedup therapy, the cost per recovered patient is £2914 and ranged from£2341 to £3629. Stepping up to high intensity therapy yields thehighest cost per recovered patient, followed by remaining in highintensity, stepping down and remaining in low intensity treatment.Overall, including all therapy courses, the cost per recoveredpatient is £1766 and varies from £1301 to £2773 across PCTs. Whenassessment costs are excluded from the total costs, the cost perrecovered patient reduced for all treatment courses but notmarkedly.
Sensitivity analysis
For the base case analysis, it was assumed that high intensitysessions cost 1.8 times more than low intensity sessions. To checkthe robustness of results, the cost ratio was varied, using low tohigh ratio estimates of 1.6, 2.0 and 2.8 (Table 8). When the cost ratiowas reduced to 1.6 from the base case of 1.8, the cost per session,treatment and recovery for low intensity session increased by 7.6and 7.1% and decreased for the high intensity session by 4.3 and4.1% respectively. When the cost ratio was increased to 2.0 timesfrom the base case, the reverse was observed e the cost persession, treatment and recovery for a high intensity sessionincreased by 3.7% and decreased 6.5% for a low intensity session.
Table 4Estimated cost per session.
Total spend in £’s Total sessions (ratio) Total cost in £’s (%) Cost per session (£)
High intensity Low intensity High intensity Low intensity High intensity Low intensity All
PCT A 2,029,000 7875(0.485) 8357(0.515) 1,276,165(62.9%) 752,835(37.1%) 162.05 90.09 125.00PCT B 2,188,000 7436(0.407) 10838(0.593) 1,209,210(55.3%) 978,790(44.7%) 162.61 90.31 119.73PCT C 2,521,000 6254(0.531) 5526(0.469) 1,691,165(67.1%) 829,835(32.9%) 270.41 150.17 214.01PCT D 4,050,000 19729(0.549) 16207(0.451) 2,780,857(68.7%) 1,269,143(31.3%) 140.95 78.31 112.70PCT E 2,647,000 7415(0.484) 7912(0.516) 1,662,389(62.8%) 984,611(37.2%) 224.18 124.45 172.70
All PCTs 13,435,000 48711(0.499) 48838(0.501) 8,619,787(64.2%) 4,815,213(35.8%) 176.97 98.59 137.73
M. Radhakrishnan et al. / Behaviour Research and Therapy 51 (2013) 37e4542
A similar pattern is observed with stepping therapies, although thefluctuation in costing as a result of changes in the ratio represents3.5% or less of the original estimated cost in any scenario. Usinga ratio of 2.8 (Nolan, 2009) to factor in administrative and super-vision activity results in a similar pattern as a 2.0 ratio but themagnitude of the changes is more pronounced (Table 8). Thesensitivity analysis reveals that the costs of high and low intensitytreatments are sensitive to this assumption. However, the overallaggregated costs of session, treatment and recovery are not sensi-tive to this assumption and they remained rather stable.
Discussion
Key findings
This analysis provides, to the knowledge of the authors, one ofthe first cost analysis of psychologically based talking therapies inthe UK that is based on routine outcome data and actual publicsector spending. Financial information on the total spend on IAPTprogrammes from five PCTs in the EoE region was combined withclinical outcomes to estimate the costs associated with four
Table 5Estimated cost of treatment (£s) (25the75th percentile).
PCT A PCT B PCT C
Low intensityCompleted 450(360e541) 452(271e542) 901(451e12Deceased 541(541e541) 361(361e361) e
High intensityCompleted 1620(1134e2269) 1626(976e2358) 1622(1082e2Deceased e e 541(541e54Declined 486(324e810) 650(325e813) 811(541e13Dropped out 648(486e1134) 488(488e976) 811(541e13Not suitable 324(324e648) 325(325e650) 811(541e10
Stepped downCompleted 775(432e1513) 723(253e1590) 841(421e19Deceased e e e
treatment courses (i.e., remaining in low or high intensity treat-ment, stepping up or down). Although the IAPT programme hasbeen found to be effective in reducing symptoms of anxiety anddepression (Clark et al., 2009), the actual cost of the program inrelation to outcomes has not been estimated or discussed in thecurrent evidence base. That information is important not only toimprove the cost-effectiveness of IAPT but also to inform futureservice design and planning.
Layard et al. (2007) estimated that the cost of providinga standard course of roughly ten sessions of CBT is £750 or £75 persession. However, these costs were based on an average sessioncost of treatment in community mental health teams and treat-ment in a specialist post traumatic stress disorder clinic, neither ofwhich implemented the talking therapies organisation model (i.e.,stepped care and two tier workforce). Compared to the results inthis study (where the costs for a low and high intensity session areestimated at approximately £99 and £177, respectively), theseestimates seem to be a significant underestimation of the actualcost of session provided in the EoE. However, when the overallcost of completed treatment of £877 is compared with Layard’sestimate of £750, it is only marginally higher, with variations
PCT D PCT E All PCTs
01) 313(235e470) 747(498e996) 493(296e592)157(157e157) e 197(197e197)
Total 1,141,780 981,500 939,968 1,484,484 1,404,633 5,952,366
M. Radhakrishnan et al. / Behaviour Research and Therapy 51 (2013) 37e45 43
across PCTs. This might be because the number of sessionsprovided is lower than the originally proposed 10 meetings.Substituting the cost of treatment estimates in the cost-benefitcalculations proposed by Layard et al. (2007), the IAPT programmestill emerges as a cost beneficial programme. The results aresupportive of the originally proposed model. Although the costestimates provided here likely incorporate significant start-upcosts and are also influenced by the fact that the majority of low
intensity trainees are relatively inexperienced during the periodcovered by the data, it would be beneficial to reflect on reducingthe cost per session, as it is significantly higher than what wasoriginally proposed. Such cost reduction will also make the IAPTprogramme more efficient. It is clear from this study that the costestimates are driven by the investment, volume of servicesprovided, recovery rates achieved and cost ratio. Staff attritionrates might also be important (for e.g., PCTs report a 10% attritionrate for PWPs). Careful consideration of variation in cost driversfrom region to region is important when considering how gen-eralisable the study results are to other regions in UK. In spite ofthis, this study will be of interest to policy makers, commissionersand researchers as it provides a framework to estimate cost oftreatment, cost per session and cost of recovery based on routinePROM and actual financial data.
Among those who completed treatment, the recovery rate wasmore than 50% in all types of therapy, which is in line with whatClark et al. (2009) report. This rate is also similar to what was ex-pected as a national target when the IAPT programme rolled out(Layard et al., 2007). There is some debate about the nationaltargets considering the fact that natural rate of recovery is about30% for depression and much lesser for anxiety disorders (Layardet al., 2007). As Clark et al. (2009) points out, natural recoveryvaries with the prior duration of a clinical disorder, and the nationaltarget is reasonable given that it was derived from trials literature.The effectiveness of the interventions is likely to increase asworkers become more experienced. Recent reports also point outthat the current IAPT measure of recovery may be problematicbecause some mild patients will be classified as “recovered” byvirtue of their PHQ/GAD scores dropping below the clinical cut-offeven though the change may not be clinically meaningful, andrecommend using measures like ‘Reliable Change Index’ (Gyani,Shafran, Layard, & Clark, 2011).
Implications
Additional analyses performed by the authors suggest that thereare a number of ways to reduce current costs with psychologicallybased talk therapies clinics. Preliminary analysis of IAPT activity inJune 2010 would suggest that the average number of patients seenper day by a high intensity therapist was approximately threewhileit was approximately five individuals for a PWP. Significant fluc-tuation in the level of daily activity and the median number ofsessions provided was also observed across PCTs. Interestingly,longer median sessions were not necessarily associated with bettertreatment outcomes in this study, although a recent study reportsa positive association between numbers of sessions and outcomes(Gyani et al., 2011). As such, an increase in daily activity would beone of the most readily observable methods to decrease sessionalcosts, although this would have to be donewithout a correspondingdrop in treatment effectiveness. In addition, standardised treat-ment packages of a set duration agreed upon by the clinician and
The italic value is % change from the base case, when the cost ratios are varied.
M. Radhakrishnan et al. / Behaviour Research and Therapy 51 (2013) 37e4544
patient at the outset of treatment may be an effective method tostandardise treatment duration and outcomes.
Increases in treatment volume may also be realised by changesin the way treatments are delivered. The use of technology medi-ated treatment, in particular telephone mediated interventions,might be instrumental to bring down the per session cost andthereby the cost of treatment and recovery. Psychological inter-ventions delivered by telephone are more convenient and, ina growing number of situations, have been found to be as or moreeffective at reducing symptoms in patients treated with CBT basedinterventions. In a small scale study of telephone treatment forpatients with obsessive compulsive disorder, a 40% reduction inclinician treatment time for telephone therapy is being reported(Lovell et al., 2006; Robinson, Berman, & Neimeyer, 1990). Recentanalysis of actual IAPT data has also found equivalent reduction inanxiety and depression resulting from face-to-face and telephonemediated treatment in propensity score matched patient cohorts inthe low intensity setting (Hammond et al., 2012). If suitable, andaccepted by patients and clinicians, telephone mediated therapymay allow for an increase in productivity while simultaneouslyreducing the need for additional treatment facilities and travel, twoof the largest non-salaried costs reported in IAPT. The scientificliterature also suggests that telephone-based delivery may alsohave the potential to remove patient perceived barriers to initiatingtreatment (Mohr et al., 2006).
Other therapymodalitieshave thepotential to increase thevolumeof patients treated, although additional research is required to assesstheir efficacy. Online CBT delivered by a therapist in real time wasfound to be cost-effective (based on a £20,000 per Quality AdjustedLife Year threshold) compared with usual care in the treatment ofdepression inprimary care in theUK and could be a useful alternativeto face-to-face CBT (Hollinghurst et al., 2010). Group psycho-educational workshop interventions have been mentioned in NICEguidelines within the context of low intensity treatments and mayrepresent a valid way to reduce cost for PWPs. However, moreresearch is required to investigate if group based interventions areeffective and cost effective compared to one to one therapy.
Further investigation into predictors of response in the high andlow intensity settings and into predictors of treatment course (i.e.,stepping up or stepping down) is required to inform cliniciansabout the likely response to treatment. Similarly, identification ofdistinct patient typologies (known as a patient casemix) and theirobserved response to treatment should provide clinicians with
useful information to help them correctly allocate individuals intohigh or low intensity treatments.
A significant proportion (at least 22%) of the total costs oftreatment goes for the treatment of those who decline, drop out orare found unsuitable for treatment. Some of these costs could bereduced by reviewing the current way the system is working.Following up of those who decline and drop out could be facilitatedto complete treatment. Similarly, it takes a median of more than 2sessions to identify patients who are found not suitable for treat-ment. If they could be identified during the initial assessmentsession, this could potentially reduce the overall operating cost ofthe programme.
The cost per recovered patient in this study should not be usedas a basis for an economic evaluation, since the type, distribution,and baseline severity of patients is likely to vary greatly acrossregions. If a proper economic evaluation is to be performed, one ofthe first steps would be to derive a nationally representativecasemix sample that comprehensively characterises the types ofpatients presenting to talking therapies services. Reduction inanxiety and depression (PHQ-9 and GAD-7) in each casemix couldthen be directly compared along with the resulting clinician time,and provide the ability to identify standardised, cost-effectiveexamples of effective, good clinical practice.
Limitations
One limitation of this study was that a pivotal assumption in thecosting approach was based on observed data in a single PCT.Specifically, the observed cost ratio of 1.8 to 1 for high to lowintensity costs was derived from itemised costing for the one PCTbudget and applied to the costing data for all other PCTs. Thesensitivity analysis reveals that the cost per session, treatment andrecovered patients is sensitive to this assumption, indicating thatvariation in this ratio across PCTs or across regions are likely toinfluence the overall estimates of session, treatment course costs.However, additional information provided from other PCTs indicatethat this ratio is representative of the difference in staffing costs,which is also affirmed by the costs used for estimating the local tariff(Nolan, 2009). Average salary information submitted from four PCTs(unpublished data) showed that the ratio of low to high intensityaverage salary was between 1.6 and 1.8, similar to the costing ratioused in the analysis. Given that the IAPT therapies are highly humanresources intensive and that the vast majority of the workers aresalaried (and that these salaries form themajority of the total spendfor high and low intensity services), it is expected that the ratio usedis a reliable approximation of the true difference in overall costs.
Another limitation of the study is that no details on the break-down of IAPT budgets were available. This might be problematic inthe interpretation of the cost estimates, since the cost items includedin each PCTs budget can differ. For instance, nationally some IAPTbudgets cover complete premises costs and some cover only part ornone of the premises costs. Most of the PCTs included in the analysisstarted operations in 2008 and there could be set-up costs too,which would diminish as IAPT services gets established andperforms higher volumes. In the absence of the breakdown of thecosts, we cannot account for these variations. Cost of treatmentfacilities, the cost of procurement as well as the level of integrationwith the local mental health PCTS may lead to different cost esti-mates. This iswhywehave taken to a capacity basedmodel to look atcosting, by dividing a PCT’s total budget by the amount of recordedactivity. However, analysis from one PCTs data revealed that 3/4th ofthe IAPT budget comprised of staff salaries, and the rest for over-heads. We expect similar proportions in all PCTs and do not thinkvariations in overheads like premises and set-up costs will influencecost estimates markedly. This being the case, the estimated costs
M. Radhakrishnan et al. / Behaviour Research and Therapy 51 (2013) 37e45 45
might be to some extent overestimated, as we did not have data onindividual cost items. The costing approach used in this analysis alsoreflects the fact that it is difficult to ascertain individual cost itemsdirectly from PCTS, as financial monitoring at this level is not inpractice due to block contract arrangements. As such, the develop-ment of a more accurate micro costing approach is advocated inorder to confirmor improve upon the estimates used in this analysis.This remains an important area for future research. Furthermore, thecosts assessed here are based on the direct and overhead costs oftreatment e a broader societal perspective, is advocated to accountfor potentially significant costs to patients in terms of medication,travel and income loss linked to attending treatment.
Conclusion
This is one of the first assessments of costs of talking basedpsychological therapies in the UK. Results indicate that costscurrently compare to previous estimates, and supports the origi-nally proposed model on costebenefit grounds. We invite replica-tion and additional analyses along with evidence-based discussionabout alternative, cost-effective methods of intervention. It is likelythat improvements in current IAPT practice cannot occur untilcurrent practice is scrutinised and treatment approaches that areboth effective and financially viable are identified, studied, andhighlighted.
Financial disclosure
The NIHR Collaboration for Leadership in Applied HealthResearch & Care (CLAHRC) for Cambridgeshire & Peterborough(http://www.clahrc-cp.nihr.ac.uk) hosted the study and is, itself,hosted by the Cambridgeshire & Peterborough NHS FoundationTrust. All authors and their employers are partners in the CLAHRC.The views expressed in this manuscript are those of the authors andnot necessarily those of the NHS, the NIHR or the Department ofHealth. The funders had no role in study design, data collection andanalysis, decision to publish, or preparation of the manuscript.
Ethical approval
The study design for routine analyses of IAPT data in the East ofEngland was reviewed by the National Research and Ethics Service(NRES) that considered the work to be an evaluation of existingservices using anonymous clinical data not requiring researchethics approval.
Conflict of Interest
None declared.
Acknowledgements
The authors thank Caroline Lee, Christine Hill and Carol Braynefor comments on an earlier version of the manuscript, and data
managers in the participating PCTs for their cooperation and help.The authors also thank the anonymous reviewers for their helpfulcomments.
References
Cameron, I. M., Crawford, J. R., Lawton, K., & Reid, I. C. (2008). Psychometriccomparison of PHQ-9 and HADS for measuring depression severity in primarycare. British Journal of General Practise, 58, 32e36.
Centre for Economic Performance. (2006). The depression report: A new deal fordepression and anxiety disorders. London: London School of Economics andPolitical Science Centre for Economic Performance.
Clark, D. M., Layard, R., Smithies, R., Richards, D. A., Suckling, R., & Wright, B. (2009).Improving access to psychological therapy: initial evaluation of two UKdemonstration sites. Behaviour Research and Therapy, 47, 910e920.
Department of Health. (2007). Press release: Johnson announces £170 million boostto mental health therapies. Wednesday 10 October 2007 12:51. GNN ref152603P.
Department of Health. (2008). Improving access to psychological therapies (IAPT)commissioning toolkit. Department of Health: Crown.
Gyani, A., Shafran, R., Layard, R., & Clark, D. M. (2011). Enhancing recovery rates inIAPT services: Lessons from analysis of the year one data. Available at: www.iapt.nhs.uk.
Hammond, G., Croudace, T., Radhakrishnan, M., Lafortune, L., Watson, A., McMillan-Shields, F., et al. (2012). Comparative effectiveness of cognitive therapiesdelivered Face-to-face or over the telephone: an observational study usingpropensity methods. PLoS ONE, 7, e42916.
Hollinghurst, S., Peters, T. J., Kaur, S., Wiles, N., Lewis, G., & Kessler, D. (2010). Cost-effectiveness of therapist-delivered online cognitiveebehavioural therapy fordepression: randomised controlled trial. The British Journal of Psychiatry, 197,297e304.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., & Merikangas, K. R. (2003).The epidemiology of major depressive disorder: results from the Nationalcomorbidity survey replication (NCS-R). Journal of the American Medical Asso-ciation, 289, 3095e3105.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a briefdepression severity measure. Journal of General Internal Medicine, 16, 606e613.
Layard, R. (2006). The case for psychological treatment centres. British MedicalJournal, 7548, 1030e1032.
Layard, R., Clark, D., Knapp, M., & Mayraz, G. (2007). Cost benefit analysis ofpsychological therapy. National Institute Economic Review, 202, 90e98.
Lovell, K., Cox, D., Haddock, G., Jones, C., Raines, D., Garvey, R., et al. (2006). Tele-phone administered cognitive behaviour therapy for treatment of obsessivecompulsive disorder: randomised controlled non-inferiority trial. BritishMedical Journal, 333, 883e885.
Mental Health Strategies. (2010). 2009/10 national survey of investment in adultmental health services. Report prepared for the Department of Health, availableat: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117488 Accessed 03.01.11.
Mohr, D. C., Hart, S. L., Howard, I., Julian, L., Vella, L., Catledge, C., et al. (2006).Barriers to psychotherapy among depressed and nondepressed primary carepatients. Annals of Behavioural Medicine, 32, 254e258.
Nolan, G. (2009). Developing a local tariff for IAPT services in NHS East of England.Cambridge: NHS East of England.
Richards, D., & Suckling, R. (2009). Improving access to psychological therapies:phase IV prospective cohort study. British Journal of Clinical Psychology, 48,377e396.
Robinson, L. A., Berman, J. S., & Neimeyer, R. A. (1990). Psychotherapy for thetreatment of depression: a comprehensive review of controlled outcomeresearch. Psychological Bulletin, 108, 30e49.
Sainsbury Centre. (2010). The economic and social costs of mental health problems in2009/10. London: Sainsbury Centre for Mental Health.
Singleton, N., Bumpstead, R., O’Brien, M., Lee, A., & Meltzer, H. (2001). Psychiatricmorbidity among adults living in private households, 2000. London: TheStationary Office.
Spitzer, R. L., Kroenke, K., Williams, J. B., & Lowe, B. (2006). A brief measure forassessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine,166, 1092e1097.
