Martin Knapp & Paul McCronePSSRU, London School of Economics
King’s College London, Institute of Psychiatry
Best Practice in Mental Health GP Led Commissioning
25 March 2011
Investing in Mental Health: the
Economic Case
N of people by disorder, England 2007 & 2026
1.24
2.28
0.21
0.580.61
2.47
0.117
1.14
1.45
2.56
0.940.69
2.64
0.1220.24
1.23
0
1
2
3
DEP ANX SCH BPD EAT PER CHI DEM
Num
ber
of p
eopl
e (m
illio
n)
McCrone, Dhanasiri, Patel, Knapp, Lawton-Smith, Paying the Price, King’s Fund, 2008
Current & projected future prevalence
Context: current & projected future costs
7.58.9
4
14.9
0.1
7.9
0.1
5.2
12.214.2
34.8
0.2
12.3
0.1
6.58.2
0
5
10
15
20
25
30
35
DEP ANX SCH BPD EAT PER CHI DEM
Tota
l cos
ts (
£ bi
llion
)
Cost by disorder, England 2007 & 2026
McCrone, Dhanasiri, Patel, Knapp, Lawton-Smith, Paying the Price, King’s Fund, 2008
Aim - model the costs and economic pay-offs of initiatives to prevent mental illness and promote mental well-being.
o Look at evidence-based mental health interventions (incl. non-NHS) – must have well-established outcomes
o Looked at 16 different areas and interventionso Use simple decision analytic modelling o Close liaison with DH officials; consultation with experts As far as the robust evidence base allows:o Include promotion, primary & secondary preventiono Look at widest range of economic impactso Estimate impacts over long time periodso If in doubt, adopt conservative estimates
Our approach
o Examine interventions from 2 perspectives:- pay-offs to society as a whole and- cash savings to the public sector
o The wider impacts are important, given the high ‘external’ costs of many MH problems … but are they considered?
o Over and above the economic pay-offs estimated here there are health and QOL benefits to individuals (‘patients’ etc)
Please be aware that …a. The findings are not definitive – they provide platform for
discussionb. These are simple, partial and incomplete modelsc. The interventions modelled are not necessarily the only
ones that are economically attractive
Please note …
What economic case needs to be made?
Costs are higher
Costs are lower
Outcomes are worse
Outcomes are better
What economic case needs to be made?
Costs are higher
Costs are lower
Outcomes are worse
A non-starter
Outcomes are better
What economic case needs to be made?
Costs are higher
Costs are lower
Outcomes are worse
A non-starter
Outcomes are better
A winner – but check the
timing and spread of impacts
What economic case needs to be made?
Costs are higher
Costs are lower
Outcomes are worse
A non-starter
A delight to penny-pinchers; a nightmare to everyone else
Outcomes are better
A winner – but check the
timing and spread of impacts
What economic case needs to be made?
Costs are higher
Costs are lower
Outcomes are worse
A non-starter
A delight to penny-pinchers; a nightmare to everyone else
Outcomes are better
?? Do the outcomes justify the
higher costs?
A winner – but check the
timing and spread of impacts
Many causes; widespread impacts
Mental health
Health care
Each of these links is evidence-based
Social careHousing Education Crim justice
NHS
LAsCLG
DfEMoJ
BenefitsEmployment
DWPFirms
Vol sectorIncome
CVOs
AllMortalityIndiv
Genes Family IncomeEmply’tResilience
TraumaPhys env
EventsChance
Parenting for conduct disorderTarget Prevalence of conduct disorder = 4.9% among
children aged 5-10Inter-vention
Mix of individual and group-based parenting programmes at age 5; average cost = £1,177 per family
Outcome evidence
Based on data from 20 RCTs, effectiveness = 33% (but low take-up, high drop-out)
Economic pay-offs
Reduced use of NHS, social care and special education services and reduced crime, from age 5-30. Excluded: employment / earnings, social security, adulthood MH, mortality
Findings Total return of £7.89 for every £1 invested, including savings in public expenditure of £2.86
Early intervention teams for psychosisTarget Young people aged 15-35 in general population with
first-episode psychosis. Estimated number per year = 6900.
Inter-vention
Multidisciplinary team intervention including medical and non-medical professionals. Emphasis on assertive approach to maintaining contact and heavy emphasis on vocational recovery.
Outcome evidence
Reduction in relapse rate (Craig et al, 2004), improvement in vocational recovery and quality of life (Garety et al, 2006).
Economic pay-offs
Reduction in: readmission rates, costs of homicide and suicide, and lost employment.
Findings Average cost savings in the short-term of £5777 pa, medium-term £4774 pa and long-term £2600 pa. Return for £1 spent: £5.82 short term, £7.69 medium term, £4.47 long term.
Early detection of psychosisTarget Young people aged 15-35 in general population with
prodromal symptoms of psychosis. Estimated number per year = 15,763.
Inter-vention
Early detection service (based on OASIS in South London; Valmaggia et al 2009). Consists of psychological and pharmacological treatment.
Outcome evidence
Reduced rate of transition to full psychosis and reduced duration of untreated psychosis for those who do develop it.
Economic pay-offs
Reduction in inpatient costs and lost employment, reduction in homicide rate, reduction in suicide rate.
Findings Short-term cost increase of £2228 per person pa, medium term cost saving of £3022 pa and long-term saving of £2604 pa. Annual return for £1 spent: £5.87 short term, £7.42 medium term, £5.05 long term.
Workplace well-being programmesTarget Working-age adult population accessed through their
place of employment Inter-vention
Multi-component health promoting programme, including a health risk appraisal and information and advice tailored to the employee’s readiness to change health-related behaviours. Cost = £80 per year employee per year
Outcome evidence
Quasi-experimental evaluation in UK company reported significantly reduced stress levels, reduced absenteeism and improved productivity (Mills et al 2007).
Economic pay-offs
Reductions in sickness absence and presenteeism; reduced costs of avoidable mental health problems to NHS
Findings Total savings = £9.69 for every £1 invested
Other interventions examined Post-natal depression –
health visitors (universal or targeted)
School-based social and emotional learning programmes
School-based anti-bullying initiative
Workplace screening for depression risk, then CBT
Debt counselling Alcohol misuse - GP screen
and advice
Suicide – population awareness scheme + CBT for people at risk
Suicide – ‘hotspots’ - e.g. safety barriers on bridges
Co-morbid diabetes and depression – collab. care
Medically unexplained symptoms – CBT
Older people – befriending schemes (various)
Dementia - physical exercise programmes
[previously done] Anti-stigma campaigns
NHSOther public sector
Non-public sector
Total
Early identification and intervention as soon as mental disorder arises Early intervention for conduct disorder 1.08 1.78 5.03 7.89Health visitor interventions to reduce postnatal depression 0.40 - 0.40 0.80
Early intervention for depression in diabetes 0.19 0 0.14 0.33Early intervention for medically unexplained symptoms b 1.01 0 0.74 1.75
Early diagnosis and treatment of depression at work 0.51 - 4.52 5.03
Early detection of psychosis 2.62 0.79 6.85 10.27Early intervention in psychosis 9.68 0.27 8.02 17.97Screening for alcohol misuse 2.24 0.93 8.57 11.75Suicide training courses provided to all GPs 0.08 0.05 43.86 43.99Suicide prevention through bridge safety barriers 1.75 1.31 51.39 54.45
Promotion of mental health and prevention of mental disorderPrevention of conduct disorder through social and emotional learning programmes 9.42 17.02 57.29 83.73
School-based interventions to reduce bullying 0 0 14.35 14.35Workplace health promotion programmes - - 9.69 9.69Addressing social determinants and consequences of mental disorder Debt advice services 0.34 0.58 2.63 3.55Befriending for older adults 0.44 - - 0.44
Summary of findings
o Very conservative models even so, many interventions look good value for money.
o Some are self-financing from NHS perspectiveo Some are very low cost: a small shift in expenditure from
treatment to prevention/promotion could generate efficiency gainso Many have broad pay-offs - both within public sector, and more
widely (educational performance, employment/earnings, crime).o Pay-offs may span many years; need to invest for the longer termo Process parameters - targeting, take-up rates, drop-out rates –
are important. It may be most cost-effective to increase take-up among high-risk groups, or improve ‘completion’ rates.
o Each modelled intervention is evidence-based – each has been shown to be effective (to achieve good outcomes) …
o … which means that there are health and QOL gains to individuals over and above the economic pay-offs here
Conclusions
Rebeea’h Aslam 1
Florence Baingana 1
Annette Bauer 1
Jennifer Beecham 1,4
Eva-Maria Bonin 1
Sarah Byford 2
Adelina Comas 1
Sara Evans-Lacko 2
Chris Fitch 5
Nika Fuchkan 1
Derek King 1
Martin Knapp 1,2
Canny Kwok 1
Paul McCrone 2
David McDaid 1
Team; and further informationIris Molosankwe 2
Gerald Mullally 1
A-La Park 1
Michael Parsonage 3
Margaret Perkins 1
Andres Roman 1
Marya Saidi 1
Azuso Sato 1
Madeleine Stevens 1
Jamie Vela 1
1 PSSRU, LSE2 KCL, IOP3 Centre for Mental Health4 PSSRU, Univ of Kent5 Royal Coll. Psychiatrists
Further details of work to date:
Report published by the DH, Jan 2011
More work likely to be undertaken in 2011
Contact:[email protected]@kcl.ac.uk