03/06/2016 Making mental health count: an economic perspective David McDaid PSSRU, LSE Health & Social Care London School of Economics and Political Science E-mail: d.mcdaid@lse.ac.uk Open Minds, Congres geestelijke gezondheid Brussels, May 26 2016 Mental health budgets under pressure • Cuts to mental health budgets more visible during austerity • But also an opportunity to meet challenge • Economic arguments can help 1
03/06/2016 Importance of economic case for decision making • Historically mental health services have been vulnerable when funding pressures in health care systems • Economic arguments can help mental health to be judged on a level playing field vis a vis other potential interventions • Using economic techniques can be used to look at the short, mid and long term costs and benefits of effective interventions. • Can also be used to quantify benefits that go beyond health sector – very important for encouraging cross sectoral investment Economics can be used to influence reforms 2
03/06/2016 Example : Mental health promotion Programme of work for the Dept of Health in England. Aim: to inform national policy development and local commissioning. Short timescale, no opportunity for new data collection … so again we used decision modelling. 5 Knapp, McDaid, Parsonage, Mental Health Promotion …, Department of Health, 2011 Economic pay-offs per £1 invested Economic pay-offs per £1 Other Non- public public Total in each intervention investment NHS sector sector Early identification and intervention as soon as mental disorder arises Early intervention for conduct disorder 1.08 1.78 5.03 7.89 Health visitor interventions to reduce postnatal depression 0.40 - 0.40 0.80 Early intervention for depression in diabetes 0.19 0 0.14 0.33 Early intervention for medically unexplained symptoms 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 10.27 Early intervention in psychosis 9.68 0.27 8.02 17.97 Screening for alcohol misuse 2.24 0.93 8.57 11.75 Suicide training courses provided to all GPs 0.08 0.05 43.86 43.99 Suicide prevention through bridge safety barriers 1.75 1.31 51.39 54.45 Promotion of mental health and prevention of mental disorder Prevention of conduct disorder through social and emotional 9.42 17.02 57.29 83.73 learning programmes School-based interventions to reduce bullying 0 0 14.35 14.35 Workplace health promotion programmes - - 9.69 9.69 Addressing social determinants and consequences of mental disorder Debt advice services 0.34 0.58 2.63 3.55 6 Befriending for older adults 0.44 - - 0.44 3
03/06/2016 Policy impact Commissioned by Labour government; published by Coalition government Multiple impacts in mental health policy in England Heavily cited in English national mental health policy Influenced policy on health visitors for maternal depression; suicide prevention strategy; debt management services; early intervention for children Cited numerously in local government policies & internationally Making mental health count: some further areas for exploration 4
03/06/2016 Making mental health count: some examples • Benefits of early intervention in the community • Benefits of early action to protect physical health • Partnership with police to provide immediate support for people in crisis • Partnerships with the housing sector in supporting recovery The economic case for action Builds on Schizophrenia Commission • Report Looking at: Early Detection for Psychosis • Early Intervention for Psychosis • Intervention in Psychosis • Protection of Physical Health • Individual Placement and Support • (IPS) for Employment Supported Education • Family Therapy • Criminal Justice System Diversion • Crisis Resolution Home Treatment • Teams Housing interventions • Social welfare advice • Knapp, Andrew, McDaid, Park et al 2014 5
03/06/2016 Early intervention for first episode psychosis Economic argument 6
03/06/2016 Economic benefits of EI programmes including vocational services Impact of employment support Small reduction in suicidal behaviour Park, McCrone & Knapp et al Early intervention in Psychiatry 2016 Embedding EI Within Community Mental Health Centres RCT of integrated multi- component psychosocial care for first episode psychosis Community Mental Health Centres Veneto, Emilia-Romagna, Florence, Milan, Bolzano. Specialist training for CMHC staff Suggests that service model is feasible and effective but longer term follow up analysis needed. No impacts on hospital admissions or length of stay Ruggeri et al 2015 Sachizophrenia Bulletin 7
03/06/2016 Protecting physical health Overlap between long term conditions and mental health problems £1 in every £8 for long term conditions due to mental health needs Long Term Conditions and Mental Health,Kings Fund - Naylor, Parsonage, McDaid et al 2012 8
03/06/2016 Impacts on chronic disease management In Long Term Conditions and Mental Health - Naylor, Parsonage, McDaid et al 2012 9
03/06/2016 Reducing contacts with criminal justice system The economic case for action • Partnership working across sectors • High costs of criminal justice system • Potential economic benefits of working more closely with the police to divert appropriately from criminal justice system Knapp, Andrew, McDaid, Park et al 2014 10
03/06/2016 Department of Health 2014. https://www.gov.uk/government/news/extra-funding-for- mental-health-nurses-to-be-based-at-police-stations-and-courts-across-the-country Partnership working: Street Triage Police and community mental • health services work together to ensure people get appropriate care when police are called to a person in distress. Pilot schemes around England • operating 7 days per week – late afternoon to early morning Provided advice and guidance to • aid decision making / manage risk. Identify where mental illness • likely to exist and enable most appropriate pathway to care. 11
03/06/2016 Street Triage in Oxfordshire 1 mental health professional working with mobile police team in Oxford city 40% reduction in detentions under S 136 Mental Health Act Improvement in service user experience Cost savings to police over 1 year of € 50,000 Savings to health system have not been quantified Additional funding provided to run service after pilot phase Accommodation and Housing Support 12
03/06/2016 Focus in England on Relative Cost of Acute Beds Source: Crisp N et al (eds). Old Problems, New Solutions: Improving Acute Psychiatric Care for Adults in England. Royal College of Psychiatrists 2016. Summary of evidence from local studies reviewing the number of service users in bed-based services who no longer require service Source: Crisp N et al (eds). Old Problems, New Solutions: Improving Acute Psychiatric Care for Adults in England. Royal College of Psychiatrists 2016. 13
03/06/2016 Opportunities for the Housing Sector on Path to Recovery McDaid & Park 2016. Mental Health and Housing: potential economic benefits of improved transitions along the acute care pathway to support recovery for people with mental health needs (Housing Associations Charitable Trust London) McDaid & Park 2016. Mental Health and Housing: potential economic benefits of improved transitions along the acute care pathway to support recovery for people with mental health needs (Housing Associations Charitable Trust London) 14
03/06/2016 Financial and economic incentives to promote integrated care Making the case o In making mental health count will not be enough to identify economic costs and benefits . Must also o Identify who pays and who benefits from mental health services o Distinguish between realisable cash savings and freeing up health and other system resources o Identify physical health as well as mental health benefits o Identifying time frame for benefits and costs o Identify resource implications of reform and reorganisation 15
03/06/2016 Promoting partnership working and integrated care • The way in which mental health services are funded, as well as payment mechanisms, will have a profound impact on partnership working and pace towards integrated care • Potentially can be a major barrier or facilitator to system reform • Mechanisms where funding linked to individual service users, rather than to service providers, can help promote continuity of care • In the English system, detailed contracts are still needed to encourage partnership working (and share costs and risks) across sectors Making the case o Making an economic argument can help mental health count! o There are economic benefits to partnership working between specialist and primary care services and with other sectors o Examples include mental health promotion services, e.g. in schools, early intervention for psychosis, early intervention in the criminal justice system, better partnerships with housing sector organisations o Important to look at ways of incentivising many different actors in fragmented mental health system to work together. 16
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