Priorities for mental health · and anxiety during the perinatal period 3 Treatment of conduct disorder in children up to age 10 14 4 Early intervention services for first-episode

REPORT

Economic report for the NHS England Mental Health Taskforce

Michael Parsonage, Claire Grant and Jessica Stubbs

Priorities for mental health

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ealth REPORT Priorities for mental health

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Contents

Executive summary 4

1 Introduction 8

2 Identificationandtreatmentofmaternaldepression 10 andanxietyduringtheperinatalperiod

3 Treatmentofconductdisorderinchildrenuptoage10 14

4 Earlyinterventionservicesforfirst-episodepsychosis 18

5 Expandedprovisionofliaisonpsychiatryservicesinacutehospitals 21

6 Integratedphysicalandmentalhealthcareinthe communityforpeoplewithlong-termphysicalhealthconditions 25 andco-morbidmentalhealthproblems

7 Improvedmanagementofpeoplewithmedicallyunexplained 29 symptomsandrelatedcomplexneeds

8 Expandedprovisionofevidence-basedsupportedemployment 33 servicesforpeoplewithseverementalillness

9 Community-basedalternativestoacutepsychiatricinpatient 36 careforpeoplewithseverementalhealthillnessattimesofcrisis

10 Interventionstoimprovethephysicalhealthofpeoplewithsevere 40 mentalillness

References 44

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Executive Summary

Thisreportprovidesaneconomicanalysisofpossibleprioritiesforserviceimprovementinmentalhealth.ItwascommissionedbyNHSEnglandasaninputtothefive-yearstrategyrecentlyproducedbytheindependentMentalHealthTaskforce.

After10yearsofsubstantialexpendituregrowth,theNHSisnowhalfwaythroughadecadeofausterityandisrequiredtofindproductivityimprovementsofaround£22billionayearby2020/21.Essentiallythismeansfindingmorewaysofgeneratingimprovedhealthoutcomesatlowercost.

PastexperiencesuggeststhatproductivityincreasesintheNHScomemainlyfromthedevelopmentanddisseminationofimprovementsinclinicalinterventions,ratherthanfromlarge-scalereorganisationsorsystemchanges.

Thereisastrongevidencebaseforarangeofinterventionsinmentalhealthwhichproducebetteroutcomesatlowercost.However,thesearenotalwayswidelyavailableortheireffectivenessisreducedbypoorimplementation.

Akeyingredientofanymentalhealthstrategyshouldthereforebetopromotethewideradoptionofbestpractice,asrepresentedbythedeliveryofspecificevidence-basedinterventionsinlinewithnationalguidelines.

Insomecasesthismaybeacceleratedbysupportingsystems-relatedchangessuchasnewpaymentmechanisms,particularlyforintegratedservicesoperatingatthemental/physicalhealthinterface,buttheseshouldalwaysbeseenasmeanstoanendratherthanendsinthemselves.

Thefundamentalneedistodefinewhatbestpracticelookslikeintermsofevidence-basedinterventionsandservicemodels,andthentodeliverthesethroughouttheNHS.

Thisreportexaminesninepossibleareasforserviceimprovementwherethereisgoodevidenceofcost-effectiveinterventions,withspecificcostedproposals.Thenineareascanbegroupedunderthreemainheadings.

Prevention and early intervention

Identification and treatment of maternal depression and anxiety during the perinatal period

Some15-20%ofwomensufferfromdepressionoranxietyduringpregnancyorinthefirstyearafterchildbirth,butabouthalfofallthesecasesgoundetectedanduntreated.Thisisdamagingandcostly,notonlybecauseoftheadverseimpactonthemotherbutalsobecausematernalmentalillnessroughlydoublestheriskofsubsequentmentalhealthproblemsinthechild.Accordingtooneestimate,thelong-termcosttosocietyofasinglecaseofperinataldepressionisaround£74,000,mostlybecauseofadverseimpactsonthechild.Theeffectivetreatmentofmothersoffersthegenuineprospectofprimarypreventioninrelationtothedevelopmentofmentalhealthproblemsinchildren.Theavailableevidencestronglysupportstheprovisionofpsychologicaltherapyasthemosteffectiveintervention,butthisiscurrentlyavailabletoonlyasmallminority.

Proposal:improvetheidentificationofperinataldepressionandanxiety(viamorescreeningandassessment)andprovidepsychologicaltherapytoallwhowouldbenefitinlinewithNICEwaitingtimestandards.Estimatedcostafterfullimplementation=£53millionayear.Thevalueofsubsequentreductionsinhealthserviceusebybothmothersandchildrenwouldmorethancoverthiscostovertime,withabouttwo-thirdsofcostsbeingrecoveredwithinfiveyears.

Treatment of conduct disorder in children up to age 10

About5%ofyoungchildrensufferfromconductdisorder,definedaspersistentdisobedient,disruptiveandaggressivebehaviour,andtheconditioncontinuesintoadolescenceandbeyondinabouthalfofallcases.Itisassociatedwithawidearrayofadverseoutcomesextendingoverthelifecourse,includingcontinuingmentalhealthdifficulties,poorphysicalhealthoftenasaresultofriskybehavioursincludingsmoking,drinkinganddruguse,pooreducationalattainmentleading

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todifficultiesinthelabourmarket,andhighratesofinvolvementincriminalactivity.Thelifetimecostsofconductdisorderhavebeenestimatedataround£275,000percase.AverylargebodyofevidencedemonstratestheeffectivenessofparentingprogrammessuchasTriplePandIncredibleYearsinimprovingoutcomesatrelativelylowcost(around£1,270perchild).

Proposal:all5-year-oldchildrentobescreenedduringtheirfirstyearatschool,followedbytheprovisionofanevidence-basedparentingprogrammewhereaneedisindicated.Estimatedcostafterfullimplementation=£51millionayear.Economicanalysisindicatesthatevery£1investedintheseprogrammesgeneratessavingsinpublicexpenditureofnearly£3overthenextsevenyears,includingsavingsof95pintheNHS.Overthelongertermthevalueofsavingsinpublicexpenditureislikelytoberoughlydoubled.

Early intervention services for first-episode psychosis

First-episodepsychosisaffectsabout15,000peopleayear,mostofwhomareagedbetween15and35.Delayinprovidingtreatmentandsupportcanleadtopoorerclinicalandsocialoutcomesoverthelifetime.Schizophreniaisthemostcommoncauseofpsychosisandit is estimated that this condition costs the exchequerover£7billionayear,equivalenttoacostperpersonaffectedofaround£36,000ayear.Earlyinterventionservicesprovidedbydedicatedmultidisciplinaryteamsarestronglyeffectiveinimprovingoutcomesandreducinghealthservicecosts.

Proposal:increasetheprovisionofearlyinterventionservicestocoverthefullpopulationof15,000peoplewhoexperienceafirstepisodeofpsychosiseachyear.Estimatedcostafterfullimplementation=£77millionayear.Economicanalysisindicatesthatbecauseoftheimpactofearlyinterventionontheuseofmentalhealthservices,particularlyinpatientcare,thefullcostofadditionalprovisionwouldberecoveredwithinayear.OverthreeyearsthesavingstotheNHSalonewouldoutweighthecostsofinterventionbyafactorofmorethanthreetoone.

Better mental health care for people with physical health conditions

Expanded provision of liaison psychiatry services in acute hospitals

Abouthalfofallpatientsbeingtreatedforphysicalhealthproblemsinacutehospitalshaveaco-morbidmentalhealthproblemsuchasdepressionordementia.Mostofthesecasesofmentalillnessgoundetectedbymedicalstaff,leadingtopoorerhealthoutcomesandsubstantiallyincreasedcostsofcare,equivalenttoaround15%oftotalexpenditureinacutehospitals(£6billionayearintotal,or£25millionayearforatypicalgeneralhospitalof500beds).Thereisgrowingevidencethatadedicatedproactiveliaisonpsychiatryserviceworkingwithmedicalstaffcansubstantiallyreducethisburdenofextracosts,particularlyamongelderlyinpatients,whoshouldbeaprioritygroupforintervention.

Proposal:extendtheprovisionofliaisonpsychiatryservicestoallacutehospitalsinlinewithnationalguidance.Estimatedcostafterfullimplementation=£119millionayear.Itisestimatedonreasonablyconservativeassumptionsthatevery£1investedintheseserviceswouldleadtosavingsofaround£2.50becauseofreducedbeduseassociatedwithshorterlengthsofstayandlowerratesofre-admission.

Integrated physical and mental health care in the community for people with long-term physical health conditions and co-morbid mental health problems

About30%ofallpeoplewithalong-termconditionsuchasdiabetesorasthmahaveaco-morbidmentalhealthproblem,equivalenttosome4.6millionpeopleinEngland.Onlyaboutaquarterofthesecasesofco-morbidmentalillnessaredetectedand,intheabsenceoftreatment,co-morbiditiesareassociatedwithpoorerclinicaloutcomes,lowerqualityoflife,reducedabilitytomanagephysicalsymptomseffectivelyandsignificantlyincreasedcostsofcare.OnaveragetheNHSspendsanextra£2,400ayearinphysicalhealthcarecostsoneverysinglepatientwhohasco-morbidphysicalandmentalhealthproblemsasagainstaphysicalconditiononitsown.Attheaggregate

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levelthisaddsuptoanextra£11billionayear,equivalentto10%ofthetotalNHSbudget.

Moreintegratedservicesareneeded,withthestrongestevidencerelatingtothecollaborativecaremodelrecommendedinNICEguidance.Thisisastructuredapproachinvolving:carecoordinationbyacasemanager;systematicpatientmanagementbasedonprotocolsandthetrackingofoutcomes;deliveryofcarebyamultidisciplinaryteamwhichincludesaliaisonpsychiatrist;andcollaborationbetweenprimaryandspecialistcare.Evidenceindicatesthatcollaborativecareleadstobetteroutcomesand,atleastforsomephysicalconditionssuchasdiabetesandchronicrespiratoryproblems,savingsinphysicalhealthcarecostswhicharemorethansufficienttocoverthecostsoftheintervention.

Proposal:providecollaborativecareforthemostcostlyandcomplex10%ofallpeoplewithlong-termconditionsandco-morbidmentalhealthproblems.Estimatedcostafterfullimplementation=£290millionayear.Thescopeforoffsettingsavingsvariesfromcondition to condition and a conservative assumptionmightbethatovertimetheincreasedprovisionofcollaborativecarewouldbebroadlycost-neutralfromanNHSperspective.

Improved management of people with medically unexplained symptoms and related complex needs

Medicallyunexplainedsymptoms(MUS)arephysicalsymptomsthatdonothaveareadilyidentifiablemedicalcauseoraredisproportionatetotheseverityofanyunderlyingmedicalillness.Theyareacommon,distressingandcostlyprobleminallhealthcaresettings,oftenassociatedwithfrequentGPconsultationsandreferralstosecondarycarefortheinvestigationofphysicalsymptoms.TheestimatedcostofMUStotheNHSisaround£3.25billionayear,withthemostcostly5%ofpatientseachcostingabout£3,500ayearintheavoidableover-useofphysicalhealthservices.Thereisevidencethatcognitivebehaviouraltherapyisconsistentlyeffectiveinimprovingoutcomes.PatientswithMUSvarygreatlyinthenatureandseverityoftheirproblemsand

specialistservicesforthosewithcomplexproblemsarelargelynon-existent.

Proposal:everyCCGshouldaimtocommissionaspecialistMUSservice,onthecollaborativecaremodel,tosupportpatientswiththemostcomplexandcostlyproblems.Estimatedcostafterfullimplementation=£127millionayear.Thereisinsufficientevidencetomakeadetailedassessmentofpossiblecostsavings,but-aswithcollaborativecareservicesforpeoplewithlong-termconditionsandco-morbidmentalhealthproblems-areasonableassumptionmightbethatovertimetheMUSinterventioniscost-neutralfromanNHSperspective.

Improved services for people with severe mental illness

Expanded provision of evidence-based supported employment services for people with severe mental illness

Mostpeoplewithseverementalillnesswouldliketowork,butonlyasmallminoritydoso.Alowrateofemploymentjustamongthosewithschizophreniaisestimatedtocosttheeconomyaround£3.4billionayearandthereisalsoevidencethatthosenotworkingmakemoreuseofmentalhealthservicesthanthoseinemployment,irrespectiveoftheseverityoftheirillness.Traditionalvocationalrehabilitationservicesfocusontraining,jobpreparationandshelteredwork,butthereislittleevidencethatthisleadsontocompetitiveemploymentandmoreemphasisisnowbeingputongettingpeopleintoacompetitivejobasquicklyaspossible,withcontinuingsupporttoensurethatthejobismaintained(‘placethentrain’ratherthan‘trainthenplace’).Thebest-evidencedmodelofthisapproachisIndividualPlacementandSupport(IPS),withstudiesfromaroundtheworldshowingthatthisistwotothreetimesaseffectiveasanyotherinterventionintermsofemploymentoutcomes.ThereisalsoevidencethatIPSservicesresultincostsavingsofaround£3,000ayearbecauseofreduceduseofmentalhealthcare.Thesesavingsmaybesustainedforanumberofyearsandcomparewithaone-offcostofIPSsupportofaround£2,700perclient.

Proposal:itisbroadlyestimatedthatthe

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numberofmentalhealthserviceuserscurrentlyreceivingIPSservicesisonlyabout10,000–20,000ayear.Itisproposedthat20,000moreplacesshouldbemadeavailable,atacostof£54millionayear.Theavailableevidencesuggeststhatthiscostwouldbemorethanoffsetbysavingsofaround£100millionoverthenext18monthsbecauseofreduceduseofmentalhealthservices.

Community-based alternatives to acute inpatient care for people with severe mental illness at times of crisis

Severementalillnessessuchasschizophreniaandbipolardisorderarecharacterisedbyperiodiccrisesorrelapses.Therateofrelapseinpeoplewithschizophreniaisestimatedataround3.5%permonth,ormorethan40%inthecourseofayear.Relapseisnotonlyamajorclinicaleventbutalsoaverycostlyone,withevidencesuggestingthatthecosttotheNHSofasinglecrisisepisodeforsomeonewithschizophreniaisaround£20,000,verylargelyintheformofacuteinpatientcare.Community-basedalternativestoinpatientcareattimesofcrisistakeavarietyofforms,withthestrongestevidencerelatingtocrisisresolutionteams,firstintroducedintheNHSinaround2001asameansofprovidingintensivehometreatmentforpatientswhowouldotherwisebeadmittedtohospital.Thereisevidencethat,whenimplementedwithfidelity,crisisresolutionteamsprovideeffectivesupportforpeopleexperiencingcrises,leadtogreaterpatientsatisfactionandcanresultinreducedhospitaladmissions.Economicanalysissuggeststhatevery£1investedincrisisresolutionteamsyieldssavingsintheNHSof£1.68.

Proposal:spendingoncrisisresolutionteamspeakedin2010/11andhassincefallenbyatleast8%inrealterms,despitean18%increaseinaveragemonthlyreferrals.Itisestimatedthatadditionalexpenditureofaround£29millionayearwouldbeneededtorestoreprovisiontoitspreviouspeakand£63millionayeartoallowalsoforan18%increaseinreferrals.Usingthebenefit:costratiogivenabove,theseincreaseswouldbemorethanoffsetbysavingsof£49millionayearand£106millionayearrespectively.

Interventions to improve the physical health of people with severe mental illness

Themortalityrateamongmentalhealthserviceusersis3.6timeshigherthaninthegeneralpopulation,resultinginadifferenceinlifeexpectancyof15-20years–andifanythingthegapiswidening.Themajorityofexcessmortalityisfromdiseasesthatarethemajorcausesofdeathinthegeneralpopulation,particularlycirculatorydiseases,respiratorydiseasesandcancer.Importantcontributorycausesincludesmoking,obesity,poordiet,illicitdruguse,physicalinactivityandlong-termuseofantipsychoticmedication.

Byfarthestrongestevidenceoninterventionstoimprovethephysicalhealthofpeoplewithseverementalillnessrelatestosmokingcessation.Smokingratesamongallpeoplewithmentalhealthproblemsarehighandthereisalsoastronglinkbetweentheseverityofmentalillnessandsmokingbehaviour,i.e.thosewithmoresevereproblemsaremorelikelytosmokeandtosmokemoreheavily.Theeconomiccostofsmokingamongallpeoplewithmentalhealthproblemswasestimatedat£2.34billionin2009/10,including£0.72billionspentbytheNHSontreatingdiseasescausedbysmoking.NICEguidanceonsmokingcessationinthegeneralpopulationshowsthatarangeofinterventionsareextremelycost-effectiveandseparateevidenceindicatesthatstrategieswhichworkforthegeneralpopulationarejustaseffectiveforthosewithseverementalillness.

Proposal:themosteffectivemulti-componentinterventionevaluatedintheNICEguidanceonsmokingcessationshouldbemadeavailableto150,000mentalhealthserviceusersatanestimatedcostof£67.5million.Economicanalysisindicatesoffsettingsavingsofaround£100millionspreadoveranumberofyears,associatedwithlowerNHSspendingonsmoking-relateddiseases.Moreprofoundly,thosewhosuccessfullyquitsmokingwouldonaveragegainanincreaseinlifeexpectancyofaroundsevenyears.

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Chapter 1: Introduction

Thisreportprovidesaneconomicanalysisofpossibleprioritiesforserviceimprovementinmentalhealth,asaninputtothefive-yearstrategybeingdevelopedbytheindependentMentalHealthTaskforce,commissionedbyNHSEngland,whosereportwaspublishedin2016.

Background

TotalNHSexpenditurealmostdoubledinrealtermsinthetenyearsfrom2000,buttheserviceisnowhalf-waythroughadecadeofausterityandfacesthedauntingchallengeofgeneratingproductivityimprovementsofaround£22billionayearby2020/21inordertosquarethecircleofrisingcostsanddemandsandrelativelyflatbudgets.Ifoverallstandardsofcarearetobemaintained,morewaysmustbefoundofproducingbetterhealthoutcomesatlowercost.ThefundamentalaimofalltreatmentsintheNHSistoimprovehealthandwellbeingbutthosewhichalsosavemoneyareofparticularvalue,astheyreleaseresourceswhichcanbeusedtoaccommodatecostanddemandpressureswithinexistingbudgets.

AsnotedinarecentKing’sFundreport,pastexperienceintheNHSsuggeststhatproductivityincreasescomemainlyfromthedevelopmentanddisseminationofimprovementsinclinicalinterventions,ratherthanfromlarge-scalereorganisationsorsystemchanges(Alderwicketal.,2015).Forexample,shorterlengthsofstayinacutehospitalshavebeenamajorsourceofefficiencygainfortheNHSoverseveraldecades,drivenbyaseriesofimprovementsinclinicalpracticesuchastheuseofnewanaestheticsandminimallyinvasivesurgery.Attheaggregatelevelitistheaccumulationofthesechangesandtheirwidespreadadoptionthatmatter,ratherthananysingleadvance.

Inmentalhealth,asintherestoftheNHS,opportunitiestoproducebetteroutcomesatlowercostmaytakeavarietyofforms.Oneistoreduceexpenditureoncarewhichisineffectiveorunnecessary.Forexample,estimatesgivenlaterinthisreportindicatethatthecostsofhealthcareamongpatientsbeingtreatedfor

physicalconditionsorsymptomsareincreasedbyaround£14billionayearbecauseoftheimpactonphysicalhealthcareofco-morbidmentalhealthproblemsthatgounrecognisedanduntreated.(Strikingly,thismeansthattheNHSspendsasmuchondealingwiththeindirectconsequencesofmentalillnessasonthedirectcostsoftreatingit.)Muchofthisextraspendingonphysicalhealthcareisunnecessaryandavoidable.

Anotherwayofraisingproductivityistoincreasetheprovisionofinterventionswhichareknowntobeeffectiveandgoodvalueformoney.Unmetneedisamajorprobleminmentalhealth.Thisisparticularlythecaseamongchildrenandyoungpeople,asonlyaboutaquarterofthosewithaclinicallydiagnosablementalhealthproblemarecurrentlyreceivinganytreatment–andthenumbersmayevenbefallingbecauseofcutsinchildandadolescentmentalhealthservices(CAMHS)expenditureinrecentyears.Under-treatmentisnotbecauseofanylackofevidenceontheavailabilityofinterventionsthatwork;onthecontrary,anumberofwell-researchedinterventionsarenotonlyeffectiveinimprovingmentalhealthbutarealsogoodvalueformoney,insomecasesoutstandinglyso.Under-provisioncomesataheavyprice,asmostmentalhealthproblemswhichdevelopearlyhaveastrongtendencytopersistthroughoutthelifecourse,oftenwithanarrayofdamagingandcostlyconsequences,notonlyforindividualsandtheirfamiliesbutalsofortheNHS,otherpublicservicesandwidersociety.Asinsomeotherareasofmentalhealth,thecurrentserviceresponseisbestdescribedastoolittle,toolate,withtreatmentbeingprovided(ifatall)onlyafterproblemshavebecomeentrenchedandmoredifficulttomanage.

Athirdwayofincreasingproductivityistoreducethemisuseofresourcesthatisassociatedwithwideandunwarrantedvariationsinhowcareisdeliveredbydifferentservicesaroundthecountry.Mostcommonly,poorperformancearisesbecauseservicesaredeliveringtoomanyinterventionsthatarenot

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evidence-based,butitmayalsoresultfromshortcomingsinimplementationsuchasthepoortargetingofinterventions,lowratesoftake-upandhighratesofdrop-out,anduseofinadequatelytrainedstaff.Arangeofevidencesuggeststhatoutcomesforwell-implementedprogrammesaretypicallytwotothreetimesbetterthanforpoorlyimplementedones.

Commontoproblemsinalltheseareasisafailuretofollowbestpracticeintermsofdeliveringevidence-basedinterventionsinlinewithnationalguidelines.Theopportunitiesforimprovementarenothypothetical,astheyarealreadybeingdeliveredinsomepartsoftheNHS,andareessentiallyaboutputtingknowledgeintopracticeonamuchwiderscalethaniscurrentlythecase.Organisationalandotherbarrierstoimprovedperformancecertainlyexistandsupportingchangeswouldbehelpfulinanumberofareas,includingbudgetingandpaymentsystems,organisationalculture,informationsystemsandtrainingprogrammes.Butthesearebestseenasmeanstoanendratherthanendsinthemselves,thekeyobjectivesbeingtodefinewhatbestpracticelookslikeintermsofspecificevidence-basedinterventionsandservicemodelsandthentoimplementthesethroughouttheNHS.

Areas for service improvement

Atotalofninepossibleareasforserviceimprovementareanalysedinthisreportandthesecanbegroupedtogetherunderthreemain headings:

Prevention and early intervention

1. Identificationandtreatmentofmaternaldepressionandanxietyduringtheperinatalperiod,includingasapreventivemeasureagainstthedevelopmentofmentalhealthproblemsinchildren.

2. Treatmentofconductdisorderinchildrenuptoage10.

3. Earlyinterventionservicesforfirst-episodepsychosis.

Better mental health care for people with

physical health conditions

4. Expandedprovisionofliaisonpsychiatryservicesinacutehospitals,particularlyinsupportofelderlyinpatients.

5. Integratedphysicalandmentalhealthcareinthecommunityforpeoplewithlong-termconditionsandco-morbidmentalhealthproblems.

6. Improvedmanagementofpeoplewithmedicallyunexplainedsymptomsandrelatedcomplexneeds.

Improved services for people with severe mental illness

7. Expandedprovisionofevidence-basedsupportedemploymentservices.

8. Community-basedalternativestoacuteinpatientcareattimesofcrisis.

9. Interventionstoimprovethephysicalhealthofpeoplewithseverementalillness.

Theanalysisofeachofthesepossiblepriorityareas covers:

• Ashortreviewofrelevantevidenceonwhythisisapriorityarea,highlightingthescaleandcostoftheproblematexistinglevelsofserviceprovision,includingtheextentofunmetneed.

• Asimilarshortreviewoftheevidenceontheavailabilityofinterventionsinthisareawhicharebotheffectiveandgoodvalueformoney.

• Identification,descriptionandcostingofaspecificproposalforserviceimprovement.

• Subjecttodataavailability,quantitativeanalysisofthedownstreamconsequencesofthespecifiedserviceimprovement,includingthepossiblescaleoffuturecostsavingsintheNHSasaresultofbetterhealth.

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developmentofchildren,withseriousandcostlylong-termconsequences(NICE,2014).

Therisksoftheseadversedevelopmentaloutcomesinchildrenareroughlydoubledasaresultofperinatalmentalillness,aftercontrollingforotherpotentialinfluences.Accordingtooneestimate,morethanamillionchildrenintheUKsufferfromneurodevelopmentaldisordersandtheproportionoftheseattributabletopre-andpostnatalanxietyanddepressionisoftheorderof10%(Glover,2014).

Anumberofdifferentmechanismshavearoleinexplainingthelinksbetweenmaternalmentalillnessanddevelopmentalproblemsinthechild.Recentadvancesinneurosciencehaveparticularlyhighlightedtheimportanceofchangesintheenvironmentinthewombwhichcancriticallyalterneurologicaldevelopmentinthefoetus,withapermanenteffectonthechild(Glover,2013).Particularimportanceattachestotheimpactofmaternalstressonthedevelopingbrainandagrowingbodyofevidencesuggeststhatstressexposureduringpregnancyisasignificantriskfactorforawiderangeofadverseoutcomesinthechild,includingemotionalandbehaviouralproblems(O’Donnelletal.,2014).

Inthepostnatalperiod,psychologicalratherthanbiologicalfactorsaremorerelevant,particularlytheriskthatmaternalmentalillnessmayleadtoparentingpatternsorbehaviourswhichhaveadamagingimpactonmother-infantattachment,forexamplebehaviourswhicharehostile,intrusiveordisengaged(Field,2010).Some–butnotall–formsofinsecureattachmentareinturnriskfactorsforrelationshipproblemsinthechild,withpotentiallyadverselong-termconsequences(ManningandGregoire,2006).

Comprehensiveestimatesofthecostsofperinatalmentalhealthproblems,coveringthoserelatingtothechildaswellasthemother,aregiveninarecentstudy(Baueretal.,2014).Incontrasttomostcost-of-illnessstudies,

Scale and cost of the problem

Mentalhealthproblemsareverycommonintheperinatalperiod,definedastheperiodduringpregnancyandthefirstyearafterchildbirth.Thesetakeavarietyofforms,includingpsychosis,post-traumaticstressdisorder,depressionandanxiety,andtheycallforacoordinatedserviceresponse,includingspecialistsupportforwomenwiththemostcomplexandseriousconditions.Thefocushereisonmaternaldepressionandanxiety,mainlybecausethesearethemostcommonmentalhealthproblemsintheperinatalperiod,butthecaseforimprovementintheseareasshouldalwaysbeseenaspartofawidercaseforstrategicchangeinperinatalmentalhealthcare.

Evidencefromarangeofsourcesindicatesthataround15-20%ofallneworexpectantmotherssufferfromclinicallydiagnosabledepressionoranxietyatsomepointintheperinatalperiod(Heronetal.,2004).Mostattentionhastraditionallybeengiventoproblemsinthepostnatalperiod,particularlypostnataldepression,butdatafromlongitudinalsurveysincreasinglysuggeststhatmaternaldepressionandanxietyareasleastascommonduringpregnancyastheyareintheyearafterchildbirth.Onlyaminorityofcasesofpostnataldepressionandanxietyareinfactnewcases,arisingforthefirsttimeafterchildbirthratherthanbeingacontinuationofconditionswhichinitiallydevelopedduringpregnancy(Heronetal.,2004).

Thesestudiesalsoconfirmthatthereisahighdegreeofco-morbiditybetweendepressionandanxietyintheperinatalperiod,asaroundtwo-thirdsofallwomenwithdepressionatthistimehaveaco-existinganxietydisorder.

Perinataldepressionandanxietyareofmajorimportanceasapublichealthissue,notonlybecauseoftheirhighprevalenceandtheiradverseimpactonthewellbeingofmothersbutalsobecausetheyhavebeenshowntocompromisethehealthyemotional,behavioural,cognitiveandevenphysical

Chapter 2: Identification and treatment of maternal depression and anxiety during the perinatal period

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theseestimatesincludeanimputedmonetaryvaluationoftheadverseeffectofmentalillnessonthequalityoflife.Keyfindingsare:

• Takentogether,perinataldepressionandanxietycarryatotallong-termcosttosocietyofabout£8.0billionforeachone-yearcohortofbirthsintheUK.Thisisequivalenttoacostofjustunder£10,000foreverysinglebirthinthecountry.

• Nearlythree-quarters(72%)ofthiscostrelatestoadverseimpactsonthechildratherthanthemother.

• Overafifthoftotalcosts(£1.7billion)arebornebythepublicsector,withthebulkofthesefallingontheNHSandsocialservices(£1.2billion).

• Themostreliableestimatesrelatetodepression,includingcaseswithco-morbidanxiety,anditisestimatedthattheaveragelong-termcosttosocietyofonecaseofperinataldepressionisaround£74,000.

Evidence on the effectiveness of interventions

The2014NICEguidelineonantenatalandpostnatalmentalhealthnotesthatevidenceoninterventionsaimedatpreventingthedevelopmentofperinataldepressionandanxiety“isonlyjustbeginningtoemergeandisatpresentmeagre”(NICE,2014).Therecommendationsintheguidelinearethereforemainlyfocusedontreatmentoptions,buteveninthisareatheavailabilityofevidencespecificallyrelatingtotheperinatalperiodissurprisinglylimited.

Guidanceisthereforebasedontheprinciplethatbecausethenatureofmostmentalhealthproblemsduringtheperinatalperiodislittledifferentfromthatofthesameproblemsatothertimesinawoman’slife,itisreasonabletoassumethattreatmentsdevelopedforthegeneraladultpopulationarelikelytobeequallyeffectiveintheperinatalcontext.OneimportantqualificationisthatmedicationcarriesriskstothebabybothinpregnancyandduringbreastfeedingandasaresultpsychologicaltherapyisgenerallyrecommendedbyNICEasthefirst-linetreatmentformaternaldepression

andanxietythroughouttheperinatalperiod.

Alargebodyofevidencedemonstratestheeffectivenessofstructuredpsychologicalinterventionssuchascognitivebehaviouraltherapy(CBT)andinterpersonalpsychotherapy(IPT)inthetreatmentofdepressionandanxietyinthegeneraladultpopulation.Thisincludesgoodratesofrecoveryintheshorttermandsignificantlyreducedratesofrelapseinthelongerterm(LayardandClark,2014).Thesecondoftheseisparticularlyimportant,asdepressionandanxietyarebestcharacterisedaschronicconditions,typicallyfollowingarelapsing-remittingcourse,oftenovermanyyears.ItappearsthatstructuredinterventionssuchasCBTpromotethedevelopmentofgeneralisablecopingskillsthatofferprotectionagainstfurtherepisodesofillness.

Intermsoftheimpactonmeasuredoutcomes,meta-analysescarriedoutbytheWashingtonStateInstituteforPublicPolicy(WSIPP)indicatethatCBTforadultdepressionhasaneffectsizeof0.694,basedonresultsfrom44randomisedcontrolledtrials,whileCBTforadultanxietyisevenmoreeffective,withaneffectsize0.836,basedonresultsfrom22trials(WSIPP,2015).Asaruleofthumb,aneffectsizeof0.2isconventionallyregardedassmall,0.5asmediumand0.8aslarge.

ThesefindingsontheeffectivenessofCBTinthegeneralpopulationnecessarilyleaveoutofaccountanyconsiderationofthespecificimpactofperinataldepressionandanxietyonthechild.Totheextentthatsuccessfultreatmentofthemotherreducesthescaleoftheseadverseeffects,theoveralleffectivenessofinterventionisfurtherenhanced.Lackoflong-termfollow-updataininterventionstudiesprecludesanyquantificationofthisindirectbenefit,butgiventhestrengthoftheevidencedemonstratingalinkbetweenpoormaternalmentalhealthandincreasedrisksforthechild,itseemsimplausibletoarguethatbettermaternalmentalhealthwillnotmitigatetheseriskstosomedegree.Tothatextent,theeffectivetreatmentofmotherswithperinataldepressionandanxietycanbecharacterisedasagenuineexampleofprimarypreventioninrelationtothedevelopmentofmentalhealthproblemsinchildren.

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The costs and benefits of intervention

Verylittleinformationisavailableontheeconomicsofinterventionforperinataldepressionandanxiety,andsuchstudiesasdoexistsufferfromanumberoflimitations.Forexample,theytypicallymeasurecostsandbenefitsfromahealth-onlyperspective,ignoringcostsfallingoutsidetheNHSandbenefitsotherthanimprovedhealthoutcomes;theyadoptashorttimehorizon,usuallyoneyear;andtheyfocusexclusivelyonthemother,withoutanyallowanceforimpactsonthechild.

Thisrelativelynarrowapproachlargelyreflectslimitationsimposedbytheavailabledata,butatthesametimeitisboundtomeanthattheneteconomicbenefitsofinterventionaresystematicallyunder-estimated.Forexample,itwasnotedabovethatadverseimpactsonthechildaccountforover70%ofthetotallong-termcoststosocietyofperinataldepressionandanxiety.Giventhehighabsolutevalueoftotalcosts,evenarelativelysmallimprovementinchildoutcomeswouldgeneratesignificantsavingsovertime.

Theliteratureondepressionandanxietyinthegeneraladultpopulationshowsthatevidence-basedpsychologicalinterventionsareextremelygoodvalueformoney.Forexample,detailedcost-benefitestimatesproducedbyWSIPPbasedontheirsystematicevidencereviewsindicatethatevery$1investedinCBTfordepressionandanxietygeneratesbenefitsofover$100forsocietyasawhole(WSIPP,2015).Mostlythesebenefitstaketheformofincreasedearnings,someofwhichaccruetothetaxpayerviaincreasedtaxrevenuesandreducedsocialsecuritypayments.However,therearealsosignificantsavingsinfuturehealthservicecostswhichovertimearesufficienttocoverthecostsoftheinterventionseveraltimesover.

A specific proposal for service improvement

Currentprovisionoftreatmentforperinataldepressionandanxietyfallswellbelowthestandardsrecommendedinnationalguidance.The main shortcomings are:

• About50%ofallcasesgoundetectedand

untreated,despitetheopportunitiesforidentificationprovidedbyroutinecontactwithuniversalhealthservicesincludingGPs,midwivesandhealthvisitors(NICE,2014).

• Amongthosewhodogetprofessionaltreatment,themajorityaregivenmedicationandonlyaminorityreceiveanyformoftalkingtherapyorcounselling(4Children,2011);thisisthereverseofwhatisrecommendedbyNICE.

• NICEwaitingtimestandardsrelatingtoassessmentandprovisionoftreatmentaremissedinmanycases(Hogg,2013).

Toremedytheseshortcomings,anumberofchangesareneeded.First,toimprovetheidentificationofcasesofdepressionandanxiety,allwomenshouldregularlybeaskedduringtheirroutinecontactswithuniversalservicesthesimplequestionsonmentalhealthrecommendedbyNICEforuseduringpregnancyandafterchildbirth(theso-calledWhooleyquestions).Second,allthosewhoscreenpositive(i.e.giveresponsesthatindicateapossiblementalhealthproblem)shouldbereferredtotheirGPoranIAPT(ImprovingAccesstoPsychologicalTherapies)serviceformoredetailedassessment.Third,psychologicaltherapyshouldthenbeprovidedasappropriate,dependingonthefindingsoftheassessment.Finally,assessmentsandtheprovisionoftreatmentshouldconformtoNICEwaitingtimestandards.

ItisestimatedthatmakingtheseimprovementswouldrequireadditionalNHSexpenditureofaround£53millionayearatthenationallevel,including£12.5milliononassessmentsand£40.5milliononpsychologicalinterventions(estimatesgiveninBaueretal.,2014,updatedto2015/16prices).

Relevantunitcostsare:£95perassessment,basedonthecostofonesessionprovidedbyanIAPTtherapist(Curtis,2014);and£590percourseofpsychologicaltherapy,basedonNICEmodellingworkwhichassumesthatwomenwithmildtomoderateproblems(72%ofthetotal)receive6-8sessionsoffacilitatedguidedself-helpatacostof£233percase,whilethosewithmoderatetosevereproblems(theremaining28%)receiveintensivepsychologicaltherapy

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intheformof16sessionsofCBTatacostof£1,503percase.

These costings assume that no extra expenditureisneededtocovertheinitialscreeningofwomenusingtheWhooleyquestionsduringroutinecontactswithuniversalservices.Moreimportantly,noallowanceismadeeitherforthecostofanyoverallincreaseinthecapacityofIAPTservicesthatmaybeneededtomeettheNICEwaitingtimestandardsforperinatalmentalhealth.Thisismainlybecauseofalackofnationaldataontheextenttowhichthesestandardsarecurrentlybeingmissed.Inprinciple,thestandardscouldbemetbyIAPTservicesgivinghigherprioritytowomenwithperinatalmentalhealthproblemsattheexpenseofotherusers.Alternatively,adedicatedsub-servicecouldbesetupwithinIAPTwhichfocusesexclusivelyonperinatalmentalhealthcare.Totheextentthateitheroftheseoptionsisinpracticelikelytorequiresomeincreaseinoverallcapacity,thecostsofserviceimprovementgivenabovewillbeunder-estimates.

TheoverallfinancialimpactontheNHSdependsnotjustontheupfrontcostofexpandedserviceprovision,butalsoontheextenttowhichbettertreatmentofperinatalmentalhealthproblemsleadstoreductionsinthefutureuseofhealthcare.Inestimatingthelikelyscaleofsuchsavings,littleevidenceisavailablewhichrelatesspecificallytotheperinatalcontext,butabroadguidemaybeprovidedbyaneconomicanalysisofthegeneralroll-outofIAPTservicesbetween2011/12and2014/15carriedoutbytheDepartmentofHealth(DH,2011).ThisincludesestimatesofsavingsintheNHSandelsewhereinthepublicsectorduringtheperiodofroll-outplusthetwofollowingyears.

Themainfindingsofthisassessmentareasfollows.First,fromtheperspectiveofsocietyasawhole,thebenefitsofserviceexpansionwhicharemeasurableinmonetarytermsexceedthecostsofexpansionbyafactorofsixtoone.Second,every£1spentontheroll-outgeneratessavingsof£1.75fortheexchequer.Andthird,financialsavingsintheNHSovertheassessmentperiodcovermorethantwo-thirdsofthetotalroll-outcost.TheseestimatesconfirmthattheprovisionofIAPTservices

forcommonmentalhealthproblemssuchasdepressionandanxietyisgenerallyverygoodvalueformoney,thoughnotnecessarilycost-savingfromanNHSperspectiveintheshorttomediumterm.OveralongertimehorizonitispossiblethatcostsintheNHSwillbefullyrecovered.Thisisparticularlylikelyinthecontextofperinatalmentalhealthproblems,whereeffectiveinterventionoffersthescopeforfuturesavingsinhealthcarecostsnotonlyamongthewomenreceivingtreatment,butamongtheirchildrenaswell.

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includingviolentcrime,oftenstartingatanearlyage;

• highratesofinvolvementinshort-lived,abusiveormutuallyviolentpersonalrelationships.

Expressingafewoftheseadverseoutcomesinquantitativeterms,childrenwithconductdisorderaretwiceaslikelyastheirpeerstoleaveschoolwithnoeducationalqualifications,threetimesmorelikelytobecometeenageparents,fourtimesmorelikelytobecomedependentondrugs,sixtimesmorelikelytodiebeforeage30,eighttimesmorelikelytobeonachildprotectionregisterand20timesmorelikelytoendupinprison.Allofthesemultiplesarecalculatedaftertakingintoaccountpossibleconfoundingvariablessuchassocio-economicbackgroundandcognitiveability.

Anunsurprisingconsequenceofthisarrayofnegative outcomes is that conduct disorder imposesaveryheavycostburden,bothonthepublicsectorandonsocietyasawhole.Onestudywhichfollowedasampleofchildrenfromage10untiltheywere28foundthatthecumulativecostofpublicservicesusedbythosewhohadconductdisorderatage10wasaround£90,000perheadhigherintoday’spricesthanamongthosewithnoproblems,equivalenttoextraspendingofaround£5,000ayear(Scottetal.,2001).Abouttwo-thirdsoftheadditionalcostfellonthecriminaljusticesystem,withmostoftheremainderbeingdividedbetweentheeducationsectorandhealthandsocialservices.

Anotherstudyhasattemptedabroad-basedestimateofthelifetimecostsofconductdisordermeasuredfromasocietalperspective,coveringthecostsofadverseoutcomesrelatingtomentalillness,drugmisuse,smoking,suicide,unemploymentandcrime(FriedliandParsonage,2007).Overall,itiscalculatedthatthelifetimecostoftheseadverseoutcomesamongpeoplewhohadearly-onsetconductdisorderisaround£275,000percaseintoday’sprices,againmeasuredagainstabaselinegivenbypeoplewhohadnoconductproblemsinchildhood.


Conductdisorder,definedaspersistentdisobedient,disruptiveandaggressivebehaviour,isthemostcommonmentalhealthconditionfoundamongchildrenandyoungpeople.Twosub-groupsaredistinguishedaccordingtoageofonset(Moffitt,1993).Inthefirst,theconditionbecomesapparentatanearlyage(before10,withevidenceofseriousbehaviouralproblemsoftenemergingasearlyastwoorthree)andisassociatedwithahighdegreeofpersistenceintolaterlife,whileinthesecondtheconditionbeginsinadolescenceandcontinuesbeyondthisphaseinonlyasmallminorityofcases.Thefocushereisoncasesofearlyonset.

Accordingtothemostrecentlyavailablenationaldata,theprevalenceofconductdisorderamongchildrenaged5-10is4.9%,equivalenttoaround30,000childrenineachone-yearcohortinthisagerangeinEngland(Greenetal.,2005).Morethantwiceasmanyboysareaffectedasgirls,andtheconditionalsohasastrongsocio-economicgradient,beingnearlythreetimesascommonamongchildrenfromunskilledandworklesshouseholdsasamongthosefromprofessionalandmanagerialgroups.

Averysubstantialbodyofevidencedemonstratesthatearly-onsetconductdisorderisassociatedwithawiderangeofadverseoutcomes,notonlyinchildhoodbutthroughoutlife.Theseinclude:

• continuingmentalhealthdifficulties(uniquelyamongchildhoodmentalhealthconditions,early-onsetconductdisorderisariskfactorforallmajoradultpsychiatricdisorders);

• poorphysicalhealth,includinghighratesofprematuremortality,oftenassociatedwithalcoholanddrugmisuseandotherriskybehaviours;

• pooreducationalattainment,leadingontodifficultiesinthelabourmarketincludinghighratesofunemployment;

• highratesofinvolvementincriminalactivity

Chapter 3: Treatment of conduct disorder in children up to age 10

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protocols,qualityoftherapisttrainingandsupervision,andpracticaldelivery(e.g.providingtransportandcrèchesforparentsattendingprogrammes).Poorimplementationreducestheimpactofparentingprogrammesbyhalformore(Furlongetal.,2012).

Animportantunresolvedquestionintheliteratureistheextenttowhichthebenefitsofparentingprogrammes,particularlyimprovedchildbehaviour,persistovertime.Thisisanunder-researchedarea,asfewstudieshavecollecteddataonoutcomesforperiodslongerthanthreeorsixmonths.Wherelonger-terminformationhasbeencollected,thisprovidessome evidence that treatment gains are maintainedat12and18months(Bywateretal.,2009),at4years(Muntzetal.,2009)andat8-12years(Webster-Strattonetal.,2011),butotherstudieshavefoundpoormaintenanceofgainsevenat12-monthfollow-up.

Onepossibleexplanationfortheseconflictingfindingsisthattheymayinpartreflectdifferencesintheinitialseverityofproblemsamongthechildrenbenefitingfromanintervention.Supportforthisisgiveninarecentstudywhichcomparesseven-yearfollow-updatafortworandomisedtrialsofthesameparentingprogramme,oneinvolvingagroupofclinic-referredchildrenwithseverityofbehaviouralproblemsataroundthe97thpercentileandtheotheracommunitysamplewithlesssevere,sub-thresholdproblemsataroundthe82ndpercentile(Scottetal.,2014).Thecomparisonfound:first,thattheinitialtreatmenteffectoftheinterventionwasalmosttwiceaslargeintheclinicsampleasinthecommunitysample;andsecond,thatthesegainswereverylargelymaintainedatseven-yearfollow-upintheclinicsample,whereasamongthecommunitysampletheinterventionwasnotassociatedwithanyimprovementinlong-termoutcomes.Boththesefindingshighlighttheimportanceoftargetinginterventionsonthosewiththegreatestneeds.

Evidence on the effectiveness of interventions

Childrenwithconductdisorderarehighlylikelytorequireclinicalintervention,butalthoughthemajorityofparentsseekadvice,usuallyfromteachersorGPs,onlyaboutaquartergetthehelptheyneed(Greenetal.,2005).Generallyspeaking,thefirstlineoftreatmentisparenttraining(Scott,2008)andtheevidencebaseonbehaviouralparentingprogrammessuchasIncredibleYearsandTriplePincludeswelloverahundredrandomisedcontrolledtrials,withfindingssummarisedandassessedinanumberofsystematicreviewsandmeta-analyses,includingaCochranereview(Furlongetal.,2012)andareviewbyNICE(2013).

Allofthesereviewsagreethatparentingprogrammesareaneffectiveinterventionforchildhoodconductproblems.Keyfindingsincludethefollowing:

• Parentingprogrammessignificantlyincreasethequalityofparenting,bothbyincreasingpositiveparentingpracticesandreducingnegativeones;thereisalsosomeevidencethattheyreducechildmaltreatment(Lundahletal.,2006).

• Parenttrainingprogrammesareeffectiveinreducingchildproblembehaviour.Overall,aroundtwo-thirdsofchildrenwithconductdisordershowclearimprovementsandthemajorityofthesemovebelowtheclinicalthresholdforamentalhealthdiagnosis.

• Parentingprogrammesalsoleadtobetterbehaviouramongthesiblingsofchildrenwithconductdisorder,andtheyimprovethementalhealthandwell-beingofparents.

• Ingeneral,thescaleofimprovementislargestamongchildrenwiththemostsevereproblems,but-beyondthis-parentingprogrammesworkequallywellacrossawiderangeoffamilyandchildvariables,includingsocio-economicstatusandethnicity.

• Acriticaldeterminantofprogrammesuccessiseffectiveimplementation,includingsuchfactorsastherapistadherencetotreatment

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The costs and benefits of intervention

Evidenceontheeconomiccaseforinterventioninearly-onsetconductdisorderisinrelativelyshortsupplyandsuchstudiesasdoexistfocuslargelyontheextenttowhichimprovedoutcomesinchildrenareassociatedwithshort-termcostsavingsinhealth,educationandotherpublicservices.Thisinevitablyunderstatesthefullbenefitsofeffectiveintervention,manyofwhichaccrueoverthelongertermandtobeneficiariesotherthantheexchequer.Possiblereductionsincrimeprovideagoodexample:thepeakperiodforoffendingisbetweenages15and25(i.e.around10-20yearsafterthefirstonsetofconductdisorder)andonlyabout20%oftheoverallcostsofcrimefallonthecriminaljusticesystem(BrandandPrice,2000).

Whatisclearisthatbecausethelong-termcostsofconductdisorderaresohigh,onlyasmallimprovementinoutcomesisneededtosupportastrongvalue-for-moneycaseforintervention.Asnotedearlier,itisbroadlyestimatedthatonalifetimesocietalbasisthecostofearly-onsetconductdisorderisaround£275,000percase.Setagainstthis,theaveragecostofanevidence-basedparentingprogrammeintoday’spricesisonlyaround£1,270perchild(basedonNICE,2013).Asaresult,aninterventionwhichsucceedsinreducingtheoverallcostsofconductdisorderbyjust1%wouldpayforitselfmorethantwiceoverfromasocietalperspective.

Theabsenceoflong-termfollow-updataineffectivenesstrialsmeansthatthefullvalue-for-moneycaseforinterventioncanonlybeassessedusinganeconomicmodellingapproachwhichextrapolatesshort-termeffectsintothefuture.Perhapsthemostdetailedavailablestudyofthistypesuggeststhatonrelativelyconservativeassumptions,theestimatedmonetaryvalueofbenefitstosocietyovera25-yearperiodassociatedwithaparenttraininginterventionforchildrenagedfivewithestablishedconductdisorderexceedsthecostoftheprogrammebyafactorofaround14to1(Boninetal.,2011).Morethanathirdofthebenefits(36%)taketheformofcostsavingsinthepublicsector,mainlytheNHS,educationandthecriminaljusticesystem.


Nationaldataonthecoverageofevidence-basedparentingprogrammesisnotavailable,butitiswidelyacceptedthat:

• thereisasizeablegapbetweenavailabilityandneedinmostifnotalllocalities;

• agooddealofexistingprovisionisnotevidence-basedand/orispoorlyimplemented;

• muchofitgoestochildrenwithsub-thresholdproblems.

Toaddresstheseshortcomings,itisproposedthateachyearlocalcommissionersshouldfundevidence-basedparentingprogrammesinsupportofallfive-year-oldchildreninEnglandwithconductdisorder,withidentificationbeingbasedontheuniversalscreeningofchildrenduringtheirfirstyearatschoolusingavalidatedinstrumentsuchastheStrengthsandDifficultiesQuestionnaire(SDQ).Allowingforapossibleover-predictionofcasesusingtheSDQandalsoforarisingbirthrate,thiswouldrequiretheprovisionofamaximumofaround40,000trainingplacesayear.Allowingforatake-uprateof75%,thisreducesto30,000placesayear.Asnotedabove,costperplaceis£1,270,implyingtotalexpenditureof£38millionayear,allofwhichisassumedtobeontopofexistingprovision.

ToestimatethenetfinancialimpactofsuchaprogrammeontheNHSandotherpublicservicesintheshortandmediumterm,useismadeofanadjustedversionofestimatesoriginallymadebyNICE(NICE,2013)whichassessthepublicexpenditureimplicationsofaparentingprogrammeinsupportofthree-year-oldchildrenwithconductdisorderoveraseven-yeartimehorizon.Twoadjustmentsareincorporated.First,itisassumedthattheinterventionisprovidedatchildagefiveratherthanthree,inlinewiththeproposalforserviceimprovementmadeabove.Andsecond,estimatedsavingsineducationcostsareincreasedtoallowforthefactthatNICE’soriginalfigurescoveronlythecostsassociated

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withspecialeducationalneeds,whereasmorerecentresearchindicatesthatthebulkofextraeducationcostscausedbychildconductdisorderfallonmainstreameducation,e.g.employmentofmoreclassroomassistants(Snelletal.,2013).

Estimatedpublicexpendituresavingsovertheseven-yearappraisalperiodamountto£3,758perchild,tobesetagainstaninterventioncostof£1,282.Inotherwords,every£1investedintheprogrammegeneratessavingsinpublicspendingof£2.83.Thebreakdownofthesesavings is:

NHSandsocialcare £1,207

Education £2,215

Criminaljustice £336

Thelargestsavingsthusaccruetotheeducationsector,thoughthesavingswithinhealthandsocialcarearealsoalmostenoughtocoverthefullcostsoftheinterventionontheirown.Savingsinthecriminaljusticesystemaresmallmainlybecauseoftheshorttimehorizonoftheappraisal,andoveralongerperiodthesewouldbecomethelargestsingleitem.Publicsectorsavingsoverafive-yearperiod,confinedtohealth/socialcareandeducation,areroughlytwicethecostoftheintervention.

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• Preventingrelapse.

(NCCMH,2014;McCroneetal.,2010).

These aims are achieved through multidisciplinaryteamsprovidingabroadrangeoftreatments,ideallywithextendedopeninghoursandaccess365daysayear.Thetreatmentsincludeenrichedassertivecommunitytreatment,age-appropriateevidence-basedpharmacologicalandpsychosocialinterventions,cognitivebehaviouraltherapy,familyinterventionsandvocationaltherapy(DepartmentofHealth,2011;Poweretal.,2007;Bertelsenetal.,2008;Craigetal.,2004;NCCMH,2014).

EIPteamsforpeopleaged14-35wereintroducedintotheNHSfollowingpublicationoftheNationalServiceFrameworkformentalhealthin1999,withdetailedguidancesetoutinasubsequentPolicyImplementationGuide(DepartmentofHealth2001).Sincethen,EIPteamshavebeenrolledoutacrossEngland,althoughneveronascalesufficienttosupportallcasesoffirst-episodepsychosis.Thereisalsoevidencethatserviceprovisionhasbeencutbackinrecentyears(Rethink,2014;McNicoll,2015),withthesecondofthesesourcesindicatingthatoverallspendingonEIPteamsfellby26%between2010/11and2014/15.

Thereisalsoevidenceoflongwaitingtimesinsomeareas,withdatafromthe2014MentalHealthMinimumDatasetshowing21%ofpeoplewaitingmorethan9weeksand12.5%waitingmorethan18weeksfortheirfirstface-to-facecontactwithanEIPteam(citedinDepartmentofHealth,2014a).Inresponsetothis,anewwaitingtimestandardhasbeenintroducedfor2015/16,withmorethan50%ofpeopleexperiencingafirstepisodeofpsychosistobetreatedwithaNICE-approvedcarepackagewithintwoweeksofreferral(DepartmentofHealth,2014b).


ThetreatmentofpeoplewithpsychosiscoststheNHSaround£2billionayear,overhalfofwhichisassociatedwithpsychiatricinpatientcare(Knappetal.,2014).Themostcommoncauseofpsychosisisschizophrenia,andithasbeenestimatedthatforsocietyasawholetheoverallcostofthisconditionisaround£11.8billionayearin2010/11prices,takingintoaccountwiderimpactssuchaslostoutputandinformalcareaswellascoststotheNHS(Andrewsetal.,2012).Thesamestudyalsoputsthetotalcostofschizophreniatotheexchequeratabout£7.2billionayear,combiningpublicservicecostsandlosttaxrevenue.Theseestimatescorrespondtoanannualaveragecosttosocietyofaround£60,000perpersonwithschizophreniaand£36,000totheexchequer.

Accordingtoasystematicreviewoftheevidence,first-episodepsychosis(thefirsttimeapersonexperiencesapsychoticepisode)affectsaround15,000peopleayearinEngland,mostofwhomareagedbetween15and35(Kirkbrideetal.,2012).Thereisunequivocalevidencethattreatingfirst-episodepsychosisquicklyandeffectivelyleadstoimprovedlong-termoutcomes(Normanetal.,2005;Birchwoodetal.,1998).Thereverseisalsotrue:adelayinreceivingtreatmentandsupportforthefirstpsychoticepisodecanleadtopoorerclinicalandsocialoutcomesoverthelifetimeoftheaffectedindividual(Loebeletal1992;McGorryetal.,1996).

EarlyInterventioninPsychosis(EIP)servicesarespecificallydesignedtoaddresstheneedsofpeoplewithfirst-episodepsychosisforthefirstthreetofiveyears.WhiletheexactcomponentsofEIPservicesvaryfromplacetoplace,theiraimsinclude:

• Maximisingengagementwithyoungpeople;

• Reducingtimetotreatment;

• Minimisingimpairment;

• Promotingpsychosocialrecovery;

Chapter 4: Early intervention services for first-episode psychosis

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Evidence on the effectiveness of intervention

ArecentreviewoftheevidenceaspartofthedevelopmentoftheNICEClinicalGuidelinesonpsychosisandschizophrenia(NCCMH,2014)comparedEIPserviceswithstandardcare.ThereviewfoundstrongevidencethatEIPservicesleadtoreductionsin:

• Thenumberofpsychiatrichospitaladmissions;

• Theoverallnumberofinpatientbeddaysusedperpatient;

• Contactwithservicesattheendoftheintervention;

• Theriskofsubsequentrelapse;

• Theriskofsuicide.

ThereviewalsofoundthatEIPservicesareassociatedwithimprovedemploymentandeducationoutcomes,betterserviceengagementandhigherlevelsofclientsatisfaction.Overall,theevidenceisclearthatEIPiseffectiveacrossallservice,clinicalandsocialoutcomesatpost-treatmentfollow-up(Craigetal.,2004;Poweretal.,2007;NCCMH,2014;Alvarez-Jiménezetal.,2011).

Long-termfollow-upofserviceusersdischargedfromEIPservicestousualcaresuggeststhatthebenefitsofEIPteamsmaynotbemaintainedoncetreatmentisdiscontinued.Thishighlightsaneedtoimprovetheskillsofconventionalcommunitymentalhealthteamsinsupportingpeoplebeyondfirstepisode-psychosis(NCCMH,2014).

Evidence on the cost-effectiveness of intervention

Economicevidenceonearlyinterventionforpsychosisisnotextensive,butstudiesfromanumberofcountriesincludingAustralia,Denmark,ItalyandHongKongaswellasthiscountryreachbroadlysimilarconclusions.Inparticular,thereisstrongagreementthatEIPiscost-effectivecomparedwithstandardcare,withpositiveoutcomesachievedatalowerunitcost.Theinterventionisalsolikelytobeassociatedwithcostsavingsbothinthehealth

serviceandintheeconomymorewidely,forexamplebecauseoftheimpactofeffectiveearlyinterventiononemployability.

TheannualcostofprovidingEIPservicesishigherperpatientthanprovidingstandardcare,butthisismorethanoffsetbycostsavingsduetoreducednumbersofinpatientbeddays,lowerratesofrelapseandotherimprovementsinpatientoutcomes.Moreover,someofthesesavingsaretypicallyrealisedveryquickly,meaningthatthecostsofEIPservicesaremorethanfullyrecoveredfromyearoneonwards.Theoverallscaleofcostsavingsinthehealthservicevariesfromstudytostudy,butbroadlyitisfoundthat,forpatientssupportedbyanEIPservice,totalhealthservicecostsarelowerby20-50%comparedwithstandardcareforperiodsuptofiveyears(seeforexampleMcCroneetal.,2010;Mihalopoulosetal.,2009;Cochietal.,2000;andHastrupetal.,2013).

DetailedeconomicmodellingofthecostsandbenefitsofEIPservicesinthiscountryhasbeenundertakenbyMcCroneandcolleagues(2009),withresultsupdatedin2012(Andrewsetal.,2012)andextendedin2014(Parketal.,2014).UsingdatafromtheLambethEarlyOnset(LEO)studyandothersources,itisestimatedthatEIPservicesreducetheprobabilityofacompulsoryadmissionfrom44%to23%inthefirsttwomonthsofpsychosisandfrom13%to6%ineachtwo-monthperiodthereafter.Thistranslatesintosizeablecostsavingsandoverallitisestimatedthatat2010/11pricestheintroductionofanEIPservicelowerstheoverallcostofmentalhealthservicesperpatientby£5,493inthefirstyearofpsychosisandby£15,742duringthefirstthreeyears.Itshouldbenotedthatthesearenetsavings,i.e.aftertakingintoaccountthecostsofEIPprovision.

Thefollow-upworkbyParketal.reportsbroaderpublicandsocietalbenefits,withbenefitsassociatedwithimprovedemploymentoutcomesvaluedat£2,087perpersoninyears1-3andreducedsuicideandhomicideoutcomesvaluedat£6,222perpersoninyears4-10.ThisfurtherstrengthenstheeconomiccaseforEIPservices.

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GiventhestrengthoftheevidenceandinlinewithNICEguidelines,itisrecommendedthatEIPservicesareexpandedtocoverthefullpopulationof15,000peoplewhoexperienceafirstepisodeofpsychosiseachyear.Thisiswellaboveexistinglevelsofprovision.FigurescitedbytheDepartmentofHealth(2014a)indicatethataround16,500peoplearecurrentlyreceivingtreatmentfromEIPservices,butbecausetreatmenttypicallylastsforthreeyears,thisimpliesthatonlyaboutathirdofthese,i.e.5,500people,arenewcaseseachyear.Thisleavesashortfallofaround9,500placesayear,whichweincreaseto10,000toallowamarginofcapacitytoensurethatthenewwaitingtimestandardismet.

BasedondatausedintheeconomicmodellingworkbyMcCroneandcolleagues,itisestimatedthatintoday’spricesthecostofEIPservicesis£2,560perpatientperyear,or£7,680perpatientoverthreeyears.Thetotalcostoftreatingacohortof10,000morepatientswouldthereforebe£25.6millioninthefirstyearand£76.8millionoverthreeyears.Thelatterfigurealsocorrespondstototaladditionalexpenditureneededeachyearinsteadystate,withathirdofthisamountinanyoneyeardealingwithnewcases,athirdwithcontinuingtreatmentforthosewhowerenewcasesinthepreviousyearandsimilarlyathirdforthosewhowerenewcasestwoyearspreviously.ExtraspendingonEIPservicescouldthereforebephasedinoverthreeyears,withbaselineexpenditurebeingincreasedby£25.6millioninyear1,£51.2millioninyear2and£76.8millioninyear3,andthenremainingatthishigherlevelinfutureyears.Thisensuresthatfromyear3onwardsall15,000newcasesoffirst-episodepsychosiseachyearwouldreceivethreeyearsoftreatmentbyanEIPservice.

Theseestimatesofextraexpendituredonotofcourseallowfortheverysubstantialcostsavingsthatareassociatedwithearlyintervention.AgainbasedondatainthemodellingworkbyMcCroneetal.,itisestimatedthatintoday’spricesthetotalvalueofsavingsintheNHStobesetagainstthesecostsis£8,510perpatientinthefirstyearand£24,728

perpatientoverthreeyears.Foraone-yearcohortof10,000newpatients,thetotalsavingstobesetagainstthecostofadditionalEIPprovisionaretherefore£85.1millioninyearoneand£247.3millionoverthreeyears.Asbefore,thefigureof£247.3millionalsocorrespondstoaggregateannualsavingsinsteadystate.AggregatenetsavingsintheNHS,i.e.grosssavingslesstheincreasedcostsofintervention,buildupfrom£51.2millioninyearoneto£170.5millionayearinsteadystate.

Onefurtherpointmaybenoted.Intheirimpactassessmentofthenewwaitingtimestandardforearlyinterventioninpsychosis,theDepartmentofHealthuseafigureof£6,000ayearforthecostofEIPservices.Thisismorethandoublethefigureusedhere,whichisbasedontheactualcostsofanEIPteaminsouthLondon,whereastheDHestimatederivesfromadvicefromaclinicalexpertonwhatitwouldcosttoprovideNICE-accordanttreatment,includinganexpandedworkforcewithincreasednumbersoftherapistsandvocationalworkerscomparedwithatypicalEIPteam.UnfortunatelyitisnotstatedbyDHwhetherthismoreintensivelevelofprovisionisassociatedwithincreasedbenefitsincludingcostsavings,becauseifnot,itisnotclearwhyitshouldbeintroduced.Settingthistooneside,itremainsthecasethatevenataunitcostof£6,000ayearwithbenefitsunchanged,earlyinterventionforpsychosisisgoodvalueformoneyfromanNHSperspective,withnetcostsavingsof£2,510perpatientinyearone(£25.1millionfor10,000patients)and£6,728perpatientoverthreeyears(£67.3millionintotal).

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Liaisonpsychiatryservicessupportthementalhealthneedsofpeoplewhoarebeingtreatedprimarilyforphysicalhealthconditions,providingarareexampleofintegratedcareatthephysical/mentalhealthinterface.Forthemostparttheseservicesworkwithpatientsinacutehospitalsettingsandtheiravailabilityhasexpandedconsiderablyinrecentyears.Thereneverthelessremainmajorgapsincurrentprovisionandwidevariationsfromplacetoplace.Somehospitalshavelargemultidisciplinaryteamswhileothershavelittlemorethanavisitingcommunitypsychiatrist.

Mentalhealthsupportisneededinacutehospitalsforthreerelatedreasons:

• Averyhighproportionofpatientsinthesehospitalshavediagnosablementalhealthconditions;

• Manyoftheseconditionstypicallygoundetectedanduntreated;

• Intheabsenceofeffectiveinterventiontheyleadtopoorerhealthoutcomesandsignificantlyincreasedcostsofcare.

Peopleaged65andovernowaccountforovertwo-thirdsofallinpatientsinacutehospitals(HealthandSocialCareInformationCentre,2015)andtheoverallprevalenceofmentalhealthconditionsamongthisgroupisestimatedataround60%(RoyalCollegeofPsychiatrists,2005).Themostcommonproblemsaredementia,deliriumanddepression.Theprevalenceofmentalhealthproblemsinyoungerinpatientsisaroundhalftherateinolderpeople,implyinganoverallprevalenceofphysical/mentalhealthco-morbiditiesintheinpatientpopulationofsome50%.

Manycasesofmentalillnessamonghospitalinpatientsgoundetectedbymedicalstaff.Estimatesofdetectionratesvarybetweenstudiesbutarecommonlyputataround50%andmaybeevenlowerforsomeconditionssuchasdelirium.Therearevariousreasons

forthis.Forexample,thepresenceofphysicalillnesscanmakethedetectionofmentalhealthproblemsmoredifficult.Hospitalstaffoftenhavelittletrainingorexpertiseintheidentificationofmentalhealthconditions.Andtheymayfocusexclusivelyontheprimaryhealthconditionforwhichapatienthasbeenadmitted.

Mentalhealthproblemsareverycommoninothersettingswithinacutehospitals.Forexample,mentalillnessistheprimarycauseofabout5%ofallA&Eattendances(RoyalCollegeofPsychiatrists,2004),includingsignificantnumberswithpsychosis,andalcoholmisuseisimplicatedinafurther10%ofattendances(RoyalCollegeofPhysicians,2001).Self-harmisanotherlargeandgrowingproblem,withthenumbersattendingemergencydepartmentsestimatedataround200,000ayear(NHSEngland,2013).AndallA&Edepartmentsarefamiliarwiththephenomenonoffrequentattenders,whoaremainlypeoplewithuntreatedmentalhealthproblemsalongsideotherdifficultiessuchassocialisolation.

Co-morbidmentalhealthproblemsleadtomuchpooreroutcomesforpeoplewithphysicalhealthconditions.Forexample,mortalityratesforpeoplewithco-morbidasthmaanddepressionaretwiceashighasamongpeoplewithasthmaonitsown(Waltersetal.,2011),whilepeoplewithchronicheartfailureareeighttimesmorelikelytodiewithin30monthsiftheyalsohavedepression(Jungeretal.,2005).Deliriumincreasestheriskofdeathorsubsequentinstitutionalisationinolderadults(Witloxetal.,2010).Andabout1%ofadultswhohavepresentedtohospitalwithself-harmdiebysuicideinthefollowingyear,whichisabout100timeshigherthantherateinthegeneralpopulation(RoyalCollegeofPhysiciansandRoyalCollegeofPsychiatrists,2003).

ConcerningtheimpactonNHScosts,evidencereviewedinNayloretal.(2012)showsthatco-morbidmentalhealthproblemsaretypicallyassociatedwithincreasesof45-75%inthecostsofphysicalhealthcareforlong-termconditions.Increasesofthisorderare

Chapter 5: Expanded provision of liaison psychiatry services in acute hospitals

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observedacrossawiderangeofphysicalhealthconditionsandarebasedoncostsmeasuredafteradjustmentfortheseverityofphysicaldisease.

Basedonthisandotherevidence,ithasbeenestimatedthattheextracostofphysicalhealthcareinacutehospitalsassociatedwithco-morbidmentalhealthproblems(includingmedicallyunexplainedsymptoms)isoftheorderof£6billionayear.Thisisequivalenttoaround15%oftotalexpenditureinthesehospitals(Parsonageetal.,2012).Foratypicalgeneralhospitalof500beds,thiscorrespondstoanextracostofaround£25millionayear.

Evidence on the effectiveness and cost-effectiveness of interventions

Evidenceontheimpactofliaisonpsychiatryservicesisrelativelylimitedinextentandquality.Thisisforanumberofreasons.Liaisonpsychiatryinterventionsareinherentlycomplexandthereforenoteasytoevaluateusingrandomisedcontrolledtrials,whichworkbestwhenappliedtosingle-componentinterventionsintightlycontrolledsettings.Thepatientsseenbyliaisonpsychiatryservicesareheterogeneousinnatureandalsosupportedbyotherservices,makingitdifficulttoisolatethespecificimpactoftheliaisonpsychiatryinput.Liaisonpsychiatryinterventionstypicallyhavemultipleoutcomes,whichcomplicatestheinterpretationofresults.Andtherearewidevariationsinmodelsofservicedelivery,reducingtheextenttowhichfindingscanbecomparedorgeneralised.Forexample,someservicesfocusmainlyonrapid-responsesupportandpatientmanagementinthewardsandinA&E,whileothersconcentratemoreontheprovisionofpsychologicalandothertreatmentsinoutpatientclinics.

Asnotedinarecentsystematicreview(WoodandWand,2014),perhapsthemainconclusiontobedrawnfromtheexistingevidenceisthatliaisonpsychiatryservicescanbeverycost-effective,reflectingthesavingstheyareabletogenerateinhospitalcostsparticularlyamongolderpatients.Abodyofevidencegoingbackover30yearsshowsthattheeffectivemanagementofelderlyinpatientswithmentalhealthconditionscansignificantlyreduce

lengthsofhospitalstay(LevitanandKornfeld,1981).Estimatesofsavingsvarybetweenstudiesbutgenerallysuggestreductionsintherange2-5daysperpatient,correspondingtocostsavingsof£550–£1,275percase,basedonthenationalcostofan“excess”ormarginalhospitalbed-day(DepartmentofHealth,2014a).Furthersavingscomefromreducedratesofhospitalre-admissionandinstitutionalisationafterdischarge,withonestudyshowingthatasampleofolderpatientswithmentalhealthconditionsweretwiceaslikelytoreturntoindependentlivingiftheyreceivedliaisonpsychiatrysupportasamatchedsamplereceivingcareasusual(Coleetal.,1991).

EvaluationoftheRAIDliaisonpsychiatryserviceinBirminghamCityHospital(a24/7,rapidresponse,all-ages,all-conditionsservice)identifiedatotalreductionof14,500beddaysinthefirstfullyearaftertheservicewasintroduced,equivalenttosavingsof£3.55million(ParsonageandFossey,2011).Abouthalfofthissavingrelatedtoshorterlengthsofstayinhospitalandhalftoreducedratesofre-admission.(Reducedratesofdischargetoinstitutionalcarewerealsoidentifiedbutnotcosted.)Some90%ofthefinancialbenefitsresultedfromreducedbeduseamongolderpatients,eventhoughthisgroupaccountedforonly60%ofreferralsfrominpatientwards.Overall,thefinancialbenefitsattributabletoRAIDexceededthecostoftheservicebyafactorof4to1.(Interestingly,analmostidenticalfindingwasreportedinaUSstudy,alsopublishedin2011,whichevaluatedtheimpactofaliaisonpsychiatryservicebasedonaveryproactivemodelofprovision,includingcasefindingbasedonthereviewofalladmissions,rapidinterventionandclosefollow-up(Desanetal.,2011).Thefindingsinclude“averyconservativeestimate”thatthefinancialsavingsassociatedwithreducedbeduseexceededthecostsoftheservicebyafactorof4.2to1.)

TheRAIDservicewassubsequentlyrolledouttootherhospitalsintheBirminghamandSolihullareaandanin-houseevaluationreportedbroadlycomparableresults,withidentifiedfinancialsavingsexceedingthecostsofadditionalprovisionbyafactorof3to1(Wyatt,2013).Mostofthesavingscamefromreduced

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lengthsofstayratherthanreducedratesofre-admission,althoughinterestinglyitwasalsofoundinthisstudythatpatientsseenbytheRAIDserviceinA&Eweresignificantlylesslikelythanmatchedcontrolstobeadmittedasinpatients,afindingnotreportedintheoriginalevaluation.


Recentguidanceonthecommissioningofliaisonpsychiatryservicesinacutehospitalshassetoutspecificationsforfourservicemodels,describedasCore,Core24,Enhanced24andComprehensive(Aitkenetal.,2014).Thesedifferintherangeandquantityofservicesprovided,withthebasicCoremodelrepresentingaminimumclinicallyappropriatelevelofprovisionandtheothermodelsaddingonservicesasrequired,forexampletomeettheneedsofhospitalswithlargeandbusyemergencydepartments.Theestimatedcostsoftheseservicemodelsareintherange£0.7–£1.4millionper500beds.

AccordingtoanestimateproducedbytheDepartmentofHealth(DH),providingappropriateliaisonpsychiatryservicesinallacutehospitalsinEnglandinlinewiththisguidancewouldcostaround£183millionayearin2014/15prices(DepartmentofHealth,2014b).Incomparison,estimatedtotalNHSspendingonliaisonpsychiatryservicesin2014/15isputataround£68million.Subjecttovariouscaveats,thesefiguresindicatealargeshortfallincurrentprovision,withaggregatespendingneedingtomorethandoubleinordertomeetthespecifiedservicestandards.TheDHdocumentjustreferencedsetsoutanillustrativepathfortheincreaseinannualexpenditurethatwouldberequiredtoachievethisobjectiveoverthenextfiveyears.Includinganallowanceforset-upcosts,thisshowsextraannualspendingof£30millionin2015/16risingprogressivelyto£119millionin2019/20.

Thisisapathforgrossratherthannetadditionalexpenditureand,inlinewiththefindingsoftheoriginalRAIDevaluation,DHassumethatevery£1spentontheadditionalprovisionofliaisonpsychiatryserviceswouldgeneratefinancialsavingsintheNHSof£4,

fallingprogressivelyto£3.50asservicesarerolledouttoanincreasingnumberofhospitals.Forvariousreasonsthisisprobablyontheoptimisticsideandamorerealisticassessmentmighttake,asanupperlimit,aninitialreturnof£3forevery£1invested,inlinewiththefindingsoftheRAIDroll-outstudy,fallingovertimeto£2.50.Bytheendofthefive-yearperiod,thisimpliesarecurringnetfinancialsavingtotheNHSofover£170millionayear,basedonadditionalspendingof£115millionayeartofillthegapbetweencurrentandtargetprovisionofliaisonpsychiatryservicesandcostsavingsassociatedwithreducedinpatientbeduseof£287.5millionayear(=£115millionx2.5).

Itisimportantthatnew-andindeedexisting-servicesaretargetedatthoseareasofactivitywhichtheevidencesuggestswillyieldthegreatestbenefits.Intermsofsupportforinpatients,thisisparticularlylikelytomeanastrongfocusonelderlypeople,notonlybecauseofthehighlevelofneedinthisgroupbutalsobecauseofthegreateropportunitiesforcostsavings.Averagelengthofstayismorethantwiceashighamongelderlyinpatientsasamongthoseofworkingage(7.9dayscomparedwith3.7days(HSCIC,2015))andthemuchshorterdurationofstayinthelattergroupnecessarilylimitsthescopeforreductionsinhealthcareuseandcost.

Similarly,inemergencydepartments,servicesshouldseektoworkwiththosewhomakeheavyuseofA&E,keepingaregisteroffrequentattenderscombinedwithregularreviewofthesepatientsandproactivecasemanagement.EvaluationofaserviceontheselinesinHullshowedevidenceofareductionof60%inthenumberofpatientswithmentalhealthproblemswhoattendedA&Efiveormoretimesayear(citedinParsonageetal.,2012).

Finally,thereisastrongcaseforsayingthattheprovisionofliaisonpsychiatryservicesinacutehospitalsshouldbefundedbytheacutehospitalsthemselvesratherthanfromamentalhealthbudget.Oneobviousreasonforthisisthatallthefinancialbenefitsofliaisonsupporttaketheformofcostsavingsinthosehospitalswherethesupportisprovided.Anotheristhatfundingonthisbasispromotesmoreintegrated

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andholisticcare,withliaisonpsychiatrybeingacknowledgedasanessentialingredientintheprovisionofhigh-qualityandefficientacutehospitalcare.

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Chapter 6: Integrated physical and mental health care in the community for people with long-term physical health conditions and co-morbid mental health problems


TheageingofthepopulationcombinedwithbetterwaysofdealingwithacuteepisodesofphysicalillnessmeanthatthebulkofNHSresourcesareincreasinglydevotedtothecareofpatientswithchroniclong-termhealthconditions.Overall,itisestimatedthatmorethan15millionpeopleinthiscountryhaveoneormorelong-termconditionssuchasdiabetes,asthma,cardiovasculardiseaseorarthritisandthatspendingontheseconditionsnowaccountsforaround70%ofthetotalNHSbudget(DepartmentofHealth,2010).

Poorphysicalhealthisamajorriskfactorforpoormentalhealthandresearchevidenceacrossawiderangeofconditionsindicatesthatpeoplewithchronicphysicalillnessesaretwotothreetimesmorelikelytoexperiencementalhealthproblemsthanthegeneralpopulation.Accordingtoonereview,atleast30%ofallthosewithalong-termphysicalconditionhaveaco-morbidmentalhealthproblem(CimpeanandDrake,2011),equivalenttoaround4.6millionpeopleinEngland.(Seentheotherwayround,nearlyhalfofallpeoplewithamentalhealthproblemhaveaco-existinglong-termphysicalillness.)

Co-morbidmentalhealthproblemsareparticularlycommonamongpeoplewithmultiplelong-termphysicalconditionsandindeedtheoverallnumberofphysicalconditionsismorepredictiveofmentalill-healththanthepresenceofanyparticularphysicalillness(Gunnetal.,2010).Onestudyfoundthattheprevalenceofmentalhealthproblemsamongpeoplewiththreeormorelong-termconditionswas40-50%,withstrongassociationsbetweenallformsofmulti-morbidityandsocio-economicdeprivation(MercerandWatt,2007).

Theco-existenceofphysicalandmentalhealthproblemshasanumberofseriousadverseconsequences,bothforpatientsandforthe

healthsystem.Theseincludepoorerclinicaloutcomes,lowerqualityoflife,reducedabilitytomanagephysicalsymptomseffectivelyandsignificantlyincreasedcostsofcare.

Thefollowingexamplesillustratetheadverseimpactonpatients:

• Depressionleadstoatwo-tothree-foldincreaseinmortalityratesamongpeoplewithcoronaryheartdisease(Barthetal.,2004)whilemortalityratesforpeoplewithco-morbidasthmaanddepressionaretwiceashighasamongthosewithasthmaalone(Waltersetal.,2011).

• Peoplewithonelong-termphysicalconditionandco-morbiddepressionhavemuchlowerqualityoflifethanthosewithmultiplelong-termphysicalconditionsbutnodepression(Moussavietal.,2007).

• Ratesofnon-compliancewithrecommendedmedicaltreatmentsarethreetimeshigheramongpatientswhoaredepressedthanamongthosearenot(DiMatteoetal.,2000).

ConcerningtheimpactonNHSspending,evidenceacrossarangeoflong-termconditionsindicatesthatthepresenceofaco-morbidmentalhealthproblemincreasesthecostsofphysicalhealthcarebyaround45-75%percase(Nayloretal.,2012).Taking60%asamid-point,thisimpliesthatonaveragetheNHSspendsanextra£2,400ayearoneveryindividualpatientwhohasco-morbidphysicalandmentalhealthproblemsasagainstaphysicalconditiononitsown.(Averagetotalcostsperpatientareestimatedat£6,400ayearintheformercaseand£4,000ayearinthelatter).Attheaggregatelevel,extraspendingonphysicalhealthservicescoststheNHSnolessthan£11billionayear,equivalentto10%ofthetotalhealthservicebudget.

Thecostincreasesassociatedwithmentalhealthco-morbidityrisesharplyinlinewiththenumberoflong-termphysicalconditions

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fromwhichapatientsuffers.Thus,accordingtoUSdatareportedinNayloretal.(2012),forapatientwithonechronicphysicalconditiontheadditionalcostsofphysicalhealthcareassociatedwithmentalhealthco-morbidityarearound$2,050ayear.Thisincreasesto$4,150ayearifthepatienthastwochronicconditions,$6,450ayearforthreeconditions,andupto$25,350ayearforsixconditions.

Co-morbidmentalhealthproblemsalsohavewidereconomiccosts.Forexample,onestudyfoundthatindividualswithdiabetesandco-morbiddepressionareseventimesmorelikelytotaketimeoffworkthanthosewithdiabetesonitsown(Das-Munshietal.,2007).


Arecentstudyofcancerpatientswithmajordepressionfoundthatlessthanaquarterreceivedadequatetreatmentfortheirmentalhealthcondition(Walkeretal.,2014).Onereasonforinadequatecareisthatmanycasesofco-morbidmentalillnessgoundetected,implyinganeedformoreactivecase-finding,inlinewithNICEguidelines(NICE,2009).Improvedidentificationis,however,onlyusefuliflinkedtoeffectivetreatmentprogrammes.Thereisnowasubstantialbodyofevidencetoindicatethat,whilestand-alonementalhealthinterventionscanbeeffectiveinsomecircumstances,moresignificantbenefits,includingmuchgreatertake-upofmentalhealthinterventions,flowfromawhole-personapproachwhichseekstointegratetreatmentforphysicalandmentalhealthneedsinaseamlessway.

ThestrongestevidenceforintegrationrelatestothecollaborativecaremodelrecommendedinNICEguidance,whichhasnowbeenthesubjectofmorethanahundredtrials,mostlyintheUSbutwithasmallnumberinNHSsettingsaswell.Collaborativecareisaformofsystematicteam-basedcarewithanumberofingredients,including:acasemanagerresponsibleforthecoordinationofdifferentcomponentsofcare;astructuredcaremanagementplan,sharedwiththepatient;systematicpatientmanagementbasedonprotocolsandthetrackingofoutcomes;deliveryofcarebyamultidisciplinary

teamwhichincludesaliaisonpsychiatrist;andcollaborationbetweenprimaryandspecialistcare.(ForanexampleintheUKcontext,seeWalkerandSharpe,2009.)

Thepublishedliteratureoncollaborativecareindicates that:

• Thereisconsistentandrobustevidencethatthisapproachiseffectiveintreatingmentalhealthproblemsamongpeoplewithchronicphysicalillnessandconsequentlyinimprovingtheirgeneralqualityoflife.

• Thecostofcollaborativecareisrelativelylow,implyingthattheapproachisnotonlyeffectivebutalsocost-effective;indeed,NICEmodellingsuggestsacostperquality-adjustedlife-year(QALY)gainedofonlyaround£4,000,whichiswellbelowthecut-offrangeof£20,000-£30,000usedbyNICEtoassesswhetherinterventionspassavalue-for-moneytest.

• Theimpactonphysicalhealthoutcomessuchasmortalityratesislessclear-cut,butthismaylargelyreflectshortfollow-upperiods,whichareonly6or12monthsinmostresearchstudies.

• Thereisareasonablebodyofevidencetoshowthat,atleastforsomeconditions,collaborativecarecanleadtosavingsinphysicalhealthcarecostswhicharemorethansufficienttocoverthecostsoftheintervention(see,forexample,Simonetal.,2007).

• AUSeconomicmodellingstudybasedonasystematicreviewoftheevidenceoncollaborativecareforpatientswithphysicalillnessandco-morbiddepressionindicatesthat,fromasocietalperspective,every$1investedinthisinterventionyieldsbenefitsofaround$5(WSIPP,2015).Overhalfthebenefitsrelatetoincreasedemploymentandearningsamongprogrammeparticipants,butitisalsothecasethatbenefitsexceedcostsfromapurelypublicsectorperspective.

Recentyearshaveseenagrowingnumberoflocalinitiativesinthiscountrytoprovidemoreintegratedcareforpeoplewithco-morbidphysicalandmentalhealthproblems.Many

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ofthesearedescribedinareportpublishedbytheNHSConfederationMentalHealthNetwork(2012),whichnotesthatthephysicalconditionsmostcommonlycoveredarediabetes,chronicobstructivepulmonarydisease(COPD)andcoronaryheartdisease.

Anumberoftheseserviceshavebeensubjecttolocalevaluationandinsomecasesprovideevidenceofsubstantialcostsavingsassociatedwiththeimpactofintegratedcareonphysicalhealthcareuse.OneoftheserelatestoabreathlessnessclinicinHillingdonforpatientswithCOPDwhichincludestheuseofcognitivebehaviouraltherapyandpsycho-educationtoaddressanxiety,panicattacksanddepression.Asmall-scaleevaluationfoundthat,comparedwithcontrols,patientsattendingtheclinicreducedtheiruseofacutehospitalservicestosuchanextentthatoverasix-monthperiodtheresultingfinancialsavingsexceededthecostsoftheinterventionbyafactorofaround4to1.SimilarfindingsarereportedforanumberofotherservicessupportingpatientswithCOPD,coronaryheartdiseaseanddiabetes.

Thesefindingsshouldbetreatedwithadegreeofcaution,asthestudiesinquestionareoftenbasedonsmallsamplesizes,donotalwaysusecontrolorcomparisongroupsandareinvariablybasedonshortfollow-upperiods(althoughthelastoftheseislikelytomeanthatifanythingthescaleoffinancialsavingsisunder-estimatedratherthanthereverse).Thescopeforsavingsmayalsovarybytypeofchronicillness.Forexample,ahigh-qualityevaluationofacollaborativecareserviceinOxfordforpatientswithcancerandco-morbiddepressionhassofarfoundonlyverysmallreductionsintheuseofphysicalhealthcareservices(Duarteetal.,forthcoming).Theinterventionisneverthelessverycost-effectiveusingthestandardNICEmetricofcostperQALYgained,asthiscomesinatlessthan£10,000,wellbelowthecut-offrangeof£20,000-£30,000.Apossibleexplanationisthattheuseofphysicalhealthcareservicesmaybeinherentlymorevariableinsomechronicillnessesthanothersdependingonthepatient’smentalstate,e.g.patientswithCOPDorheartdiseasemaybeparticularlypronetopanicattacksleadingtofrequentuseofemergencycare,whilethisislesscommonamongthosewithcancer.


Healthservicesarenotcurrentlyorganisedinawaythatsupportsanintegratedresponsetoco-morbidphysicalandmentalhealthproblems,anditisclearthatimprovementsareneededonanumberoffronts.Someoftheseareofasystemsnature,forexamplechangestobudgetingandpaymentmethodsintheNHSinordertosupportcareorganisedaroundtheindividualratherthanaroundeachdiseasetheymayhave.Othersinclude:

• Moretrainingofphysicalhealthcareprofessionalstobuildtheirmentalhealthskills;

• Increaseddetectionofco-morbidmentalhealthproblems,linkedtocarepathwaysforlong-termconditionswhichshouldalwaysincludesupportformentalhealthneeds;

• CloserworkingbetweenGPsandIAPTserviceswiththelatterhavingamajorroletoplayintheprovisionoftalkingtherapyfortheverysizeablenumbersofpatientswithchronicphysicalconditionswhoseco-morbidmentalhealthproblemsareofamildtomoderatenature.

Thespecificproposalmadehereisfortheincreasedprovisionofcollaborativecareservicesforthosewithmorecomplexneeds,particularlywheretheseresultinhighcoststotheNHS.Thismightinclude,forexample,patientswithmultiplelong-termphysicalconditions,andindeedthesuggestionhasbeenmadeintheUSliteraturethatapossibleapproachtoorganisingcollaborativecareservicesistoidentifyclustersofco-existingphysicalillnesseswithcompatiblemanagementguidelines,e.g.diabetesandcoronaryheartdisease(Katonetal.,2010).Asnotedearlier,theexcesscostsofphysicalhealthcareassociatedwithmentalhealthco-morbiditiesincreasesharplyinlinewiththenumberofchronicillnesses,implyingthatthepotentialeconomicbenefitsofimprovedmentalhealthtreatmentaregreatestinthosewithmultiplephysicalconditions.Suchbenefitsmightaccrueif,forexample,bettermentalhealthresultsinimprovedadherencetorecommendedmedicaltreatmentsacrossthewholerangeofphysical

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conditionsfromwhichapatientissuffering.

Thepresenceofmultiplechronicillnessesisnot,however,theonlycauseofcomplexityorhighcostandamoregeneralapproachmightbetoprioritiseallpatientsinwhomthemanagementoftheirmedicalcondition(s)iscomplicatedbyapsychiatricdisorderatadiagnosticthresholdabovewhichbasicGPcareisunlikelytobeeffective.Thereisnostraightforwardwayofestimatingtheoverallnumbersofpatientswhomeetthiscriterion,butasafirstapproximationitmaybeputataround10%ofallthosewithlong-termconditionsandco-morbidmentalhealthproblems,i.e.around0.46millionpeople.

Forcostingpurposes,useismadeofanestimateof£630perpatientrelatingtotheOxfordcollaborativecareserviceforpatientswithcancerandco-morbiddepressionmentionedabove.Thisincludesanallowanceforrelevanttrainingcostsandistowardstheupperendoftherangeforunitcostssuggestedintheliterature.Itisalsomeasuredasanadditionalcost,i.e.overandabovethecostofcareasusual.Onthisbasis,totalextraNHSexpenditureoncollaborativecareservicestosupport0.46millionpatientswouldbearound£290millionayear.

These are increases in gross rather than netexpenditureand,asseen,thereisgoodevidenceintheliteraturethatcollaborativecareservicescangeneratesavingsinhealthservicecostswhichmorethanoutweighthecostsofintervention.Aconservativeassumptionmightbethat,overtime,theincreasedprovisionofcollaborativecarewouldbecost-neutralfromanNHSperspective,i.e.every£1ofspendingoncollaborativecarewouldbeoffsetby£1ofsavingsresultingfromthereduceduseofphysicalhealthservices.

Finally,asawayofgivingrealitytotheconceptofwhole-personcare,thereisastrongcaseforsayingthatthecostsofcollaborativecareshouldbebuiltintothebudgetforthephysicalhealthconditiontowhichtheservicerelates.Forexample,ifcancerpatientsneedtreatmentfordepression,thisshouldbefundedoutofthesamebudgetasanyothertreatmentforcancerpatients.Thecaseisparticularlystrengthenedwhenitisnotedthat:(i)thecostofcollaborative

careforacancerpatientis£630ayear,whichisonlyabout2%oftheoverallaveragecostoftreatingacancerpatientataround£30,000ayear(NHSEngland,2011);and(ii)intermsofcostperQALYgained,collaborativecareisconsiderablymorecost-effectivethanmanyconventionalphysicaltreatmentsforcancer.Indeed,bydisplacinglesscost-effectivetreatments,thefullcostsofcollaborativecarecouldbemetwithinexistingbudgetsforcancer.Thisimpliesthatifanyfuturesavingsinphysicalhealthcarecostsarerealised,theoveralloutcomecouldgenuinelybedescribedasbetterhealthatlowercost.

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Medicallyunexplainedsymptoms(MUS)aredefinedasphysicalsymptomsthatdonothaveareadilyidentifiablemedicalcauseoraredisproportionatetotheseverityofanyunderlyingmedicalillness.Thesymptomsarenonethelessrealandcancausesignificantdisabilityanddistress.

TheinitialpresentationofMUSisalmostinvariablyinprimarycaresettingsandbecausepatientsdonotseethemselvesashavingapsychologicalproblem,theremaybealengthyintervalbeforetheGPisabletomakeanaccurateassessment.Inthemeantime,significantcosts(andrisksofiatrogenicharm)maybeincurredthroughfrequentre-attendanceattheGPsurgeryand–insomecases–multiplereferralstosecondarycarefortheinvestigationofphysicalsymptoms.Evenwhenadiagnosisiseventuallymade,theGPmayfinditdifficulttomanagethecase,particularlyasthepatientwilloftenbeunwillingtoengagewithmentalhealthservices.

PatientswithMUSformaheterogeneousgroup,withwidevariationsintheseverityandpresentationofsymptoms.Manysufferfromco-morbidanxietyordepressionandthereisalsoevidencethatMUSarefrequentlyco-morbidwithfeaturesofpersonalitydisorder(Sternetal.,1993).OnlyaminorityofpatientswithMUShaveproblemswhicharesufficientlyseveretomeritaclinicaldiagnosisofpsychiatricdisorderandforlessseriouscasestheprognosisisgenerallygood,withthemajorityresolvingwithinayearwithouttheneedforspecifictreatment(Hartmanetal.,2009).However,amongmoreseriousandcomplexcasestheoutlookislessgood,particularlyforthosewithspecificsomaticsyndromessuchasfibromyalgia(chronicwidespreadpain),irritablebowelsyndromeandchronicfatiguesyndrome,andproblemsinthesecasesmaypersistforyearsratherthanweeksormonths(CairnsandHotopf,2005).

Medicallyunexplainedsymptomsareacommon

andcostlyprobleminallhealthcaresettings.Forexample,theyaccountforatleast20%ofallnewconsultationswithGPs(Escobaretal.,1998)andtheirprevalenceamonghospitaloutpatientsmaybeevenhigher,withonestudyfindingthattheproportionofnewattenderswithMUSwasintherangeof50-60%inallofthefollowingoutpatientdepartments:chest,cardiology,gastroenterology,rheumatology,neurology,gynaecologyanddental(Nimnuanetal.,2001).AsignificantproportionofpatientswithMUSbecomefrequentusersofservicesinbothprimaryandsecondarycare.

TheoverallcostofMUStotheNHSinEnglandisestimatedataround£3.25billionayearintoday’sprices,equivalenttoacostofaround£700perheadamongallindividualsidentifiedwithMUSincludingthosewithsub-thresholdproblems,risingtoabout£3,500ayearamongthemostcostly5%(basedondatainBerminghametal.,2010).About40%ofthisadditionalspendingfallsonprimarycareand60%onsecondarycare.EvidencefromtheUSshowsthathigherspendingonhealthcareamongpeoplewithMUSisnotattributabletotheimpactonserviceuseofco-existingdepressionorothermentalhealthproblems(Barskyetal.,2005).Medicallyunexplainedsymptomsalsohavewidereconomiccosts,withthestudybyBerminghametal.estimatingthatsicknessabsenceassociatedwithMUScoststheeconomyabout£5.9billionayear,againmeasuredintoday’sprices.


Althoughstillrelativelylimitedinoverallscale,agrowingbodyofevidenceontheeffectivenessandcost-effectivenessofpsychologicalandotherinterventionsforpatientswithMUSsuggeststhefollowingconclusions:

• ThereissomeevidencethattrainingGPstoprovideabetterexplanationofapatient’sproblems(‘symptomre-attribution’)canimprovethemanagementofMUS,including

Chapter 7: Improved management of people with medically unexplained symptoms and related complex needs

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betterdoctor-patientrelationships,althougharecentstudyfoundlittleevidenceofapositiveimpactonpatientoutcomes(Morrisetal.,2007).

• AreviewoftheefficacyofinterventionsforMUSbasedon34randomisedcontrolledtrialsfoundthatcognitivebehaviouraltherapy(CBT)is“thebestestablishedtreatment”andis“consistentlyeffective”inimprovingpatientoutcomes(Kroenke,2007).

• Thisreviewdidnotcoverthetreatmentofspecificfunctionalsomaticsyndromessuchasirritablebowelsyndrome,butthereisevidencefromotherstudiesthatCBTisalsoeffectivefortheseconditions,asaresomeotherformsofpsychotherapysuchasgradedexercise(Guthrie,2006;Whiteetal.,2011).

• There is moderate evidence that antidepressantdrugsimproveoutcomesandthatthisbenefitisnotpredictedbythepresenceofdepressionandanxietydisorders.

• Theevidenceoncost-effectivenessforCBTandrelatedpsychologicalinterventionssuggeststhattreatmentcanleadtosomecostsavingsassociatedwiththereduceduseofhealthservicesaftertreatment,butthatthesesavingsmaynotalwaysfullyoffsetthecostoftheintervention(seeforexampleCreedetal.,2003andMcCroneetal.,2008).

Acommonlimitationofresearchstudiesinthisareaisthattheirfindingsareusuallybasedonrelativelyshortfollow-upperiods,typically6or12months.Thereis,however,someevidencethatthebenefitsofCBTforMUSmaybemaintainedforlongerthanthisandmayevenincreaseprogressively(Lidbeck,2003).

Thishasimportantimplications,particularlyforthecost-effectivenessofinterventions.Forexample,aneconomicmodellingstudycarriedoutfortheDepartmentofHealthhasfoundthatifthebenefitsofacombinedGPtrainingandCBTinterventionforpatientswithMUSaremaintainedoverthreeyears,thecostsoftheprogrammearefullyoffsetbythevalueofsubsequentreductionsinhealthserviceuse

(McDaidetal.,2011).Alsotakingintoaccountreductionsinsicknessabsence,theinterventionisextremelygoodvalueformoneyfromasocietalperspectiveaswellasbeingcost-neutralfortheNHS.ThepaybackperiodfortheNHSisasshortasoneyeariftheinterventionisspecificallytargetedathigh-costpatients.

Littleevidenceisavailableontheeffectivenessandcost-effectivenessofdifferentservicemodelsforthedeliveryofsupportforpeoplewithMUS,eventhoughthisisinmanywaysmoreimportantthanthequestionofwhatworksintermsofspecificclinicalinterventions.Amajorreasonforthisisthatclinicalinterventionscanonlyworkifpatientstakethemup.Asseen,manypeoplewithMUSdonotattributetheirproblemstotheirmentalstateandareconsequentlyunwillingtoaccesshelpfromtraditionalmentalhealthservices.Inanyeventtheseservicesarenotgenerallywellequippedtodealwithpsychosomaticconditions.

AnothercriticalconsiderationisthatpatientswithMUSareheterogeneousonmanydomainsandvarygreatlyintheseverityoftheirproblems.Somespecialistservicesareavailable,albeitonalimitedscale,forthosewiththemostcomplexandseriousdifficulties,includingforexampletheYorkshireCentreforPsychologicalMedicine(ahighlyspecialistinpatientunitbasedatLeedsGeneralInfirmarywhichdeliversassessmentandtreatmentforpatientswiththemostintractableandpersistentproblems),andtheBathCentreforPainServices(whichoffersintensiveresidentialtreatmentforpatientsdisabledbycomplexchronicpainwhichhasfailedtorespondtoconventionalpainmanagementinterventions).PatientoutcomesattheBathCentreincludeanaverageincreaseof30%ingeneralabilitytofunctionwiththecurrentlevelofpain,areductioninpsychosocialdisability,a50%reductioninGPvisitsandathree-foldincreaseinworkinvolvement(NHSConfederation,2012).Specialistservicesforpatientswithspecificfunctionalsomaticsyndromesarealsoprovidedinoutpatientclinicsrunbyhospital-basedliaisonpsychiatryservicesinsomelocalities,forexamplethechronicfatiguesyndromeservicesatBartsandKing’sCollegeHospitalsinLondon.

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Furtherexpansionofthesespecialistservicesisalmostcertainlyjustifiedintermsofhealthneed,butthesheerscaleofthechallengeofMUSmeansthatthegreatmajorityofpatientswillcontinuetobemanagedinprimarycare.AkeyrequirementhereismoresupportforGPs,particularlyinthemanagementofpatientswithcomplexproblems.AnexampleofaservicemeetingthisneedisprovidedbythePrimaryCarePsychotherapyConsultationService(PCPCS)whichsupportsGPsinHackneyandtheCityofLondon.

ThePCPCSisasmallmultidisciplinaryteamofprofessionalsfrompsychology,psychiatry,nursingandsocialworkwhichhastwomainfunctions:first,tosupportGPsandpracticestaffintheirmanagementofpatientswithcomplexneedsthroughtrainingandcasediscussions;andsecond,toprovideadirectclinicalservicetopatientsreferredbyGPsintheformofassessmentsandpsychologicalinterventionsofupto16sessions.Referralsrunat40-50amonth.

Asmallevaluationoftheservice,basedonasampleof282patientsdirectlytreatedbythePCPCS,shows:moderatetolargeimprovementsinpatientoutcomesacrossarangeofmeasures;anestimatedcostperQALYofaround£11,000,whichiswellbelowtheNICEthresholdrangeof£20,000-£30,000;areductioninNHSserviceuseofover£460perpatientattheendofa12-monthfollow-up,equivalenttoaboutathirdoftheaveragecostofacourseoftreatmentbytheservice;andveryhighlevelsofGPsatisfaction(Parsonageetal.,2014).

AnothermodelofprovisionisgivenbyaprimarycarepsychologicalhealthserviceintheLondonboroughofKensingtonandChelseawhichprovidesacontinuumofsupportforpatientswithcomplexneedsincludingMUS,bridgingGPsandspecialistmentalhealthservices.TheserviceisheadedbyaprimarycareliaisonpsychiatristandincludescommunitypsychiatricnursesandthelocalIAPTteamwithinasingleintegratedstructure.TheinputprovidedbytheliaisonpsychiatristenablestheservicetosupportpatientswithmorecomplexneedsthanwouldbeseenbyatypicalIAPTservice.AcombinedliaisonpsychiatryandIAPTservicehasalsobeendevelopedinCambridgeto

addressthementalhealthneedsofpatientswithlong-termphysicalhealthconditionsaswellasthosewithMUS.


PatientswithMUScanberoughlydividedintothreegroupsdependingonwhethertheirsymptomsaremild,moderateorsevere.Forthoseinthefirstgroup,problemsareusuallyshort-livedandnospecificinterventionisrequiredexceptperhapsmoretrainingforGPsinrecognitionandsymptommanagement.Forthosewithmoderateandmorepersistentproblems,acombinationofself-helpandCBTmaybeausefulstrategy,tobeprovidedinprimarycaresettingsbyIAPTservicesworkingcloselywithGPs.

Thisleavesagroup,accountingforaround5%ofallthosewithMUS,whoseproblemsareparticularlysevere,persistentandcomplex.Dedicatedclinicalservicesforthesepatientsarelargelynon-existentinthiscountry,despitethehighcoststhattheirproblemsimposeontheNHS,andtofillthisgapitisproposedthat,overtime,everyCCGshouldaimtocommissionaspecialistMUSserviceinitslocalitythatwouldworkacrosstraditionalboundariesbetweenprimaryandsecondarycareandbetweenmentalandphysicalhealth.

Suggestedfeaturesoftheservicemightinclude:

• Thetargetgroupwouldbepatientswithpersistentcomplexproblemsthatresultinfrequentuseofhealthservicesinbothprimaryandsecondarycaresettings(i.e.themostcostly5%ofallthosewithMUS).Manyofthesepatientshaveacomplexmixofmentalandphysicalhealthproblems,oftencombinedwithahistoryofsocialdifficulties,isolation,neglectandtrauma.

• Theservicewouldbeprovidedbyasmallmultidisciplinaryteamheadedbyaliaisonpsychiatristandwouldhavereadyaccesstospecialistmedicalopiniontohelpclarifythenatureofcurrentandnewsymptoms.

• Itwouldprovidebothtrainingandclinicalinterventions.

• Training in the recognition and management

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ofMUSwouldbegivenbothtoGPsandtohospitalconsultants,particularlythoseinspecialitiessuchasneurologyandgastroenterologywheretheprevalenceofMUSisknowntobeveryhigh.

• Similarly,referralstotheserviceforclinicalinterventionswouldbeacceptedfrombothGPsandhospitalconsultants.

• Thenumberofpatientsreceivingclinicalinterventionsmightbeoftheorderof400-500ayear.

TakingthePCPCSserviceinCityandHackneyasapossiblemodel,thecostofeachspecialistteamwouldbeoftheorderof£0.6millionayear,implyinganationalcostofaround£127millionayearifservicesaresetupinallCCGareas.Thisisofcourseagrosscostand,giventhattheserviceistargetedatfrequenthealthcareusers,thenetcosttotheNHSislikelytobemuchlowerorindeednegative.Asnotedearlier,themostcostly5%ofpatientswithMUScosttheNHSaround£3,500ayear,or£10,500overthreeyears.Thiscompareswithaninterventioncostofaround£1,350perpatient,againbasedonthePCPCSmodel.Iftheservicereducestheuseofhealthcarebyjust15%ayearforthreeyears,thiswouldmorethancoverthefullcostsofintervention.Proportionatecostsavingsofthismagnitudearewellwithintherangesuggestedbytheavailableliterature.Limitationsintheevidenceruleoutaprecisecalculation,butareasonableassumptionisthatovertimeaspecialistMUSserviceonthelinesproposedwouldbecost-neutralfromanNHSperspective.

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Employmentratesforpeoplewithsevereandenduringmentalhealthproblemsareverylow.Forexample,astudyof37differentcountriesfoundthat,onaverage,only19%ofpeoplediagnosedwithschizophreniawereinpaidemployment,againstanaverageinthegeneralpopulationof75%(Haroetal.,2011).Employmentratesforpeoplewithschizophreniainthiscountryareevenlowerataround8%,comparedwithanationalaverageof71%(Bevanetal.,2013).Itisestimatedthatthecosttotheeconomyassociatedwiththislowrateofemploymentamongpeoplewithschizophreniaisaround£3.4billionayear(Andrewetal.,2012).

Studiesreportthattheproportionofallpeoplewithseverementalillnesswhoarewillingandabletoworkisashighas70%(Maciasetal.,2001).However,notallgetthehelptheywouldlike.Forexample,the2014surveyofmentalhealthserviceuserscarriedoutbytheCareQualityCommissionfoundthat,amongallthosewantingtowork,26%saidthattheyweredefinitelyreceivingsupportforwork,29%saidthattheywerereceivingsupport‘tosomeextent’forhelporadvicefindingorkeepingwork,and44%saidthattheywerenotreceivinghelpfindingorkeepingworkbutwouldlikesome(CareQualityCommission,2014).

Theevidencethatworkisbeneficialisstrong.Stableemploymentembodiesrecovery,(especiallyforyoungeradultswitharecentdiagnosis),enhancesincomeandqualityoflife,andpromotescitizenshipandcontributiontosociety(SchizophreniaCommission,2012;CareQualityCommission,2014;Bondetal.,2012;Bushetal.,2009;Repper&Perkins2003).Thereverseisalsoseen:withoutemploymentanindividualhaslimitedincome,routinesandchoicesandexperiencessocialisolation,allofwhicharerecognisedstressors.

Vocationalrehabilitationservicesforpeoplewithseverementalillnessareoftwomaintypes:‘placethentrain’or‘trainthenplace’.

Thefirstquicklyfindsandplacessomeoneinacompetitivejob,thereaftersupportingthemtomakethejobwork.Thesecondspendstimepreparingapersonthroughtrainingorshelteredorvoluntaryworkthatmayormaynoteventuallyleadtocompetitiveemployment.

‘Placethentrain’vocationalrehabilitationisoftenreferredtoassupportedemploymentandthemostwell-definedandwidelyresearchedsupportedemploymentprogrammeisIndividualPlacementandSupport(IPS).Thekeyprinciplesofthisapproachare:

• Itaimstogetpeopleintocompetitiveemployment;

• Itisopentoalthosewhowanttowork;

• Ittriestofindjobsconsistentwithpeople'spreferences;

• Itworksquickly;

• Itbringsemploymentspecialistsintoclinicalteams;

• Employmentspecialistsdeveloprelationshipswithemployersbaseduponaperson'sworkpreferences;

• Itprovidestimeunlimited,individualisedsupportforthepersonandtheiremployer;

• Benefitscounsellingisincluded.

(AdaptedfromBondetal.,2008.)

Evidence on the effectiveness and cost-effectiveness of IPS

There is extensive evidence demonstrating the effectivenessofIPScomparedwithalternativeinterventions,includingtwoCochraneReviewsandaNICEClinicalGuideline(NCCMH,2014;Kinoshitaetal.,2013;Bondetal.,2014;Bondetal.,2012;Bondetal.,2008;Crowtheretal.,2001).

ThesereviewsconsistentlyreportthatIPSismoreeffectivethanotherservicesacrossarangeofemploymentoutcomes.TheNICE

Chapter 8: Expanded provision of evidence-based supported employment services for people with severe mental illness

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ClinicalGuidelinesreportemploymentratesof50%forthoseusingIPSservicescomparedwith20%inacontrolgroup.VerysimilarfindingsaregivenintheCochranereview(Kinoshitaetal.,2013),whichalsofoundIPStobemoreeffectiveatincreasingthelikelihoodofanyemployment,increasingthedurationofemployment,increasingjobtenureandreducingtimetofirstjob.Bondetal.(2014)reportemploymentratesashighas82%forIPSagainst42%foracontrolserviceinareviewofemploymentsupportforpeoplewithseverementalillnessagedunder30.

IPSwasfirstdevelopedandevaluatedintheUSandameta-analysis(Bondetal.,2012)comparingIPSservicesintheUSwiththoseinothercountriesfoundsomewhathigherIPS-relatedemploymentratesintheformer(62%comparedwith47%).However,therewereconsistentlypositivefindingswhereverthesetting:50%forIPScomparedwith20%forotherservices.ThesefindingsareverysimilartothoseinaEuropeansix-sitestudywhichreportedemploymentratesof55%forIPScomparedwith28%forotherservices.OneofthesesiteswasinLondon,whichreportedemploymentratesof48%forIPSand17%forapre-vocationalservice(Burnsetal.,2007).

Twofurtherconclusionshavebeenestablishedintheresearchliterature.Thefirstisthathigh-fidelityIPSprogrammes(i.e.thoseadheringcloselytothekeyprinciplesoftheintervention)producebetteremploymentoutcomesthanlowfidelityones(Henryetal.,2014).Linkedtothis,thereisevidencethatregionaltrainersresponsibleformaintainingfidelityofservicescanhaveamarkedimpactonemploymentrates(CentreforMentalHealth,2012).Thesecondisthatscoringwellonthefidelityscaleneedstobeaccompaniedbyprovisionofa‘therapeuticdose’.Inotherwords,thefrequencyofcontactbetweenemploymentspecialistsandtheirclientsneedstobemaintainedatahighleveltobeeffective;‘cuttingcorners’willunderminetheeffectivenessoftheintervention(Latimer2010).

Overall,theevidencefortheeffectivenessofIPSisextremelystrong.Further,thereisnoevidencethatbeinginpaidworkisdamagingtomentalhealth.Emergingfindingsalsoprovideevidencethatemploymentoutcomes

aremaintainedoverthelongtermandareassociatedwithreduceduseofmentalhealthservices.

Afive-yearstudyofIPSfromSwitzerland(Hoffmannetal.,2014)reportedthat44%ofthosereceivingIPSwereemployedforatleast50%ofthetimeoverfiveyears,comparedwithjust11%inacontrolgroup.Timeinemployment,tenureoflongestjobandyearlyincomewereallbetterfortheIPSgroupatfiveyears.(ThesefindingssupportthepropositionthatifIPScanmakepeoplemoreemployable,itspotentialbenefitsmayextendovermanyyears.)

Theadditionalstrikingfindingfromthisstudywastheimpactonmentalhealthserviceuse,asitwasfoundthatwhilethosereceivingIPSspentanaverageof38.6daysinhospitaloverthefive-yearperiod,thecorrespondingtimespentinhospitalamongthoseinthecontrolgroupwas96.8days,adifferenceof58.2days.TranslatingthisfindingtotheEnglishsettingequatestoasavingofaround£20,000perpersonoverfiveyears.

AUSstudywitha10-yearfollow-up(Bushetal.,2009)identifiedthreetrajectoriesinemploymentpatternsamongpeoplewithseverementalillnessbasedonnumbersofhoursworked:steadywork(27%),intermittentwork(30%)andnowork(42%).Duetosimilaritiesinoutcomes,theresultsfortheintermittentworkandnoworkgroupsweremergedintoa‘minimumwork’groupforcomparisonwiththesteadyworkgroup.Again,thefindingsrelatingtomentalhealthcareresourceusewerestriking,asservicecostsforanaveragesteadyworkerwere$14,473peryearcomparedwith$31,108ayearforanaveragememberoftheminimumworkgroup.Overthe10yearsofthestudythisresultedinreducedhealthservicecostsof$166,350persteadyworker(equivalenttoaround£120,000intoday’sprices).Asnoted,thesteadyworkersaccountedfor27%ofthesample,implyingthatsavingsaveragedoverthegroupasawholewerearound$44,915perhead(£32,400).

Reductionsinhealthservicecostswerealsoreportedinthesix-siteEuropeanstudy(Knappetal.,2013).Inparticular,only20%ofIPSparticipantswerehospitalisedatanytime

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otherwise.Inpractice,someofthecostcouldbemetbyusingIPSinsteadof,ratherthanaswellas,lesseffectiveprogrammesofthe‘trainthenplace’variety.Thecostestimateof£54millionayearshouldthereforeberegardedasanupperlimit.

Allowanceshouldalsobemadeforreductionsinthefutureuseofmentalhealthservices,whichtheevidencesuggestsarelikelybothintheshorttermandinthelongerterm.Thethreestudiescitedabovewithrelevantdatashowsavingsof£5,125over18months,£20,000overfiveyearsand£32,400over10years.Measuredonanannualisedbasis,theseareallwithintherangeof£3,000-£4,000ayear.Eventakingthelowerendofthisrange,thefiguressuggestthatIPSwouldpayforitselfwithinayear(costofintervention=£2,700,savings=£3,000).

Aconservativeassumptionmightbetoincludeonlythosesavingswhichrelatetothefirst18months.Onthisbasis,£54millionofadditionalexpenditureonIPSserviceswouldbeoffsetbysubsequentsavingsof£102.5millionbecauseofreduceduseofmentalhealthservices.

duringan18-monthperiodcomparedwith30%ofthoseintraditionalservices,whiletheproportionoftimespentinhospitaloverthe18monthswasonly4.6%forIPSclientsagainst8.9%forthoseintraditionalservices.Overall,thedifferenceincostswasaround£5,125perpersonover18months.

Finally,basedoneconomicmodelling,ithasbeenestimatedbyNICEthatsupportedemploymentgenerally,ratherthanIPSspecifically,hasacostperQALYgainedof£5,723comparedwith‘treatmentasusual’,whichiswellbelowtheacceptabilitythresholdof£20,000-£30,000.OnelimitationofthisanalysisinthecurrentcontextisthattheinterventionwasnotexclusivelyIPS,despitethewidebodyofevidenceassociatedwiththisformofsupportedemployment.Anotheristhatsupportedemploymentwascomparedwith‘treatmentasusual’,whichistypicallyalow-costinterventionwithlittleornovocationalcomponent.NICEhighlightsthatamorelikelycomparatorwouldbepre-vocationaltrainingwhichitconcludeswouldbebothmorecostlyandlesseffective.Inotherwords,onthisbasisofcomparison,supportedemploymentresultsinbetterhealthatlowercost.

Specific proposal for service improvement

LittleinformationisavailableonthenumbersofmentalhealthserviceuserscurrentlyreceivingIPSservices,buttheyarebroadlyestimatedtobeintherange10,000–20,000ayear.Takingtheupperendofthisrangeasastartingpoint,theproposalmadehereisthatoverthenextfiveyearstheprovisionofIPSplacesshouldbedoubled,i.e.from20,000ayearto40,000ayear.Itisalsoproposedthatadditionalsupportshouldbetargetedatyoungerpeoplewithseverementalillness(thoseaged18-30),partlybecauseoftheevidencenotedabovethatIPSisparticularlyeffectivewiththisgroup.

Basedonanumberofsources,itisestimatedthattheaveragecostofIPSsupportisaround£2,700perclient.Thetotalcostof20,000additionalplaceswouldthereforebe£54millionayear.Tobeconservative,itisassumedthatallofthisexpenditureisontopofexistingprovisionforvocationalsupport,whetherIPSor

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Severementalillnessessuchasschizophreniaandbipolardisorderarecharacterisedbyperiodiccrisesorrelapses,asmanifestedinasignificantincreaseinsymptomseverity,asignificantdecreaseinsocialfunctioningoramajorchangeinthepatternofcaresuchashospitalisation.Theremayalsobeincreasedrisksofharm,bothtotheindividualsthemselvesandtoothers.Onlyaboutafifthofpeoplewithschizophreniaorbipolardisorderrecoverfullyafteraninitialepisode,withtheremainderathighriskofexperiencingmultipleepisodesofsevereillnessextendingovermanyyears(Wiersmaetal.,1998;MackinandYoung,2005).Therateofrelapseinpeoplewithschizophreniaisestimatedataround3.5%amonth,ormorethan40%inthecourseofayear(CsernanskyandSchuhart,2002).Bipolardisorderissimilarlycharacterisedbyhighratesofepisodicrecurrence;afteramanicepisode,thereisa50%chanceofrecurrencewithin12months(Tohenetal.,1990).

Relapseisnotonlyamajorclinicaleventbutalsoaverycostlyone.Forexample,astudyofasampleofpatientswithschizophreniainLeicesterfoundthatoverasix-monthperiodmentalhealthservicecostsforthosewhohadexperiencedarelapsewereoverfourtimeshigherthanforthosewhohadnot(Almondetal.,2011).AlsodrawingonasimilarstudyofasampleofpatientsinsouthLondon(Munroetal.,2011),itmaybeestimatedthatintoday’spricesthecosttotheNHSofacrisisepisodeamongpatientswithschizophreniaisaround£19,800.AFrenchstudyofpatientswithbipolardisordersuggestsasomewhatlowerfigureofaround£12,300forthiscondition(OliéandLévy,2002).

AccordingtoNHSreferencecostdata,mentalhealthservicesspent£188millionin2013/14oninpatientpsychiatriccareforpatientsinpsychoticcrisis(DepartmentofHealth,2015).Theaveragedailycostofthiswas£376,higherthanforanyothermentalhealthpatient

groupingorcluster.

Theveryhighcostsofacuteinpatientcarehaveencouragedthedevelopmentofanumberofcommunity-basedalternativestocrisiscare,aspartofthewidermovetowardsde-institutionalisationthathasdominatedmentalhealthpolicyandserviceplanningformanyyears.Mainlybecauseoftheavailabilityofrelevantevidence,thefocushereisontwospecificinterventions:crisisresolutionteamsandcrisishouses.

Crisis resolution teams

Crisisresolutionteams(CRTs),alsoknownas‘crisisresolutionandhometreatmentteams’,‘crisisassessmentandtreatmentteams’and‘intensivehometreatmentteams’,wereestablishedthroughouttheNHSfollowingtheirrecommendationinthe1999NationalServiceFrameworkformentalhealth.Theaimoftheseteamsistoprovideintensivetreatmentandsupportinthecommunitytothoseundergoingaseverementalhealthcrisisthatwouldotherwiseresultinhospitaladmission.AsdescribedinJohnson(2013),therolesoftheteamareto:

• Assessallpatientsbeingconsideredforadmissiontoacutepsychiatricwards,thusactingasagatekeeper;

• Initiateaprogrammeofhometreatmentwithfrequentvisits(usuallyatleastdaily)forallpatientsforwhomthisappearsafeasiblealternativetohospitaltreatment;

• Continuehometreatmentuntilthecrisishasresolvedandthentransferpatientstootherservicesforanyfurthercaretheymayneed;

• Facilitateearlydischargefromacutewardsbytransferringinpatientstointensivehometreatment.

Theseservicesareprovidedbymultidisciplinaryteamswhichonaverageinclude17staffatanoverallcostofaround£1.0millionperteam(Curtis,2014).Supportisavailable24hoursaday,sevendaysaweek.

Chapter 9: Community-based alternatives to acute inpatient care for people with severe mental illness at times of crisis

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Evidence of effectiveness

Thereissomeevidenceindicatingthat,whenimplementedwithfidelity,crisisteamsprovideeffectivesupportforpeopleexperiencingcrisesandcanresultinreducedadmissions(Andrewetal.,2012).Theevidencedemonstratesthatmodelimplementationandoutcomesvaryconsiderablyandutilisingcrisisteamstotheirfullpotentialisessential(Wheeleretal.,2015,Andrewetal.,2012).Itisimportanttonotethatthestudiesreportedareofvaryingquality,presentingachallengeindrawingfirmconclusions(NICE,2014).

Severalsystematicreviewsandindividualstudieshavefoundthatcrisisteamsreduceadmissionstoinpatientcare.ACochranereviewofeightRCTscomparedcrisisinterventionmodelswithstandardcare(Murphyetal.,2012).Relativetostandardcare,crisisinterventionsappearedtoreducerepeatadmissionstohospitalaftertheinitialcrisis,especiallyformobileteams.ThemostrecentNICEguidelineonschizophreniaandpsychosis(NICE,2014)presentsmixedresults,withsomestudiessuggestingthatcrisisteamsreduceriskofadmittanceat6,12and24-monthfollow-upwhencomparedwithstandardcare.Inasystematicreviewexaminingtheimpactofcrisisteams,itwasfoundthatineightofthestudies,usingapre-andpost-interventionstudydesign,CRTshadanimpactonreducingreadmissionsandnumbersofdaysininpatientcare(Carpenteretal.,2013).Forexample,onestudydemonstrateda24%reductioninpsychiatricadmissions,a22%reductioninmeandurationofstay,a17%reductioninMentalHealthActadmissionsanda4%fallinreadmissions.OnestudyincludedinthesystematicreviewwasarandomisedcontrolledtrialofacrisisteaminNorthIslingtonwhichfoundthatpatientsincontactwiththecrisisteamwerelesslikelytobeadmittedduringeightweeksandwithinsixmonthspost-crisis(Johnsonetal.,2005).

Inrelationtoclinicaloutcomes,theCochranereviewfoundthatatthreemonthfollow-uppeoplesupportedbycrisisteamshadabettermentalstatethanthosewhoreceivedstandardcare.Thereviewdidnotfindanydifferenceinmortalityoutcomes.

Concerningpatientsatisfaction,studiesgenerallyfoundthattherewasgreatersatisfactionwithcrisisteamsthanwithstandardcare(Murphyetal.,2012,Johnsonetal.,2005,NICE2014).TheNICEreviewfoundsomeevidencethatat6and12monthfollow-uptherewasgreatersatisfactionamongstpatientsinCRTs(2014).Johnsonandcolleagues(2005)foundthatindividualsintheinterventionarmweremoresatisfiedwithcare.

Onalesspositivenote,areportbytheHealthcareCommission(2008)foundthatCRTteamswereoftennotimplementedasintended.Overasix-monthperiod,CRTswereinvolvedin61%ofnearly40,000admissionstoacutewards.Thisvariedbetween9%and100%acrossthecountry.Amongalmost40,000discharges,only25%(range0%to70%)occurredearlywithCRTsupport.Similarly,asurveyof500admissionsbytheNationalAuditOfficeindicatedthatonly50%wereassessedbyaCRTteamandthat20%ofinpatientadmissionscouldhavebeensuitableforhometreatmentinstead(NAO,2007).

Evidence of cost- effectiveness

Theevidencesuggeststhat,whenimplementedwithfidelity,CRTscanmakesavings(Knappetal.,2014).Aprospectivenon-randomisedstudycomparedservicecostsbeforeandafterimplementationofacrisisresolutionteaminsouthIslington(McCroneetal.,2009a).MeancostsforthecohortfollowingimplementationofaCRTwere£1,738lowerthanbeforetheservice,althoughthedifferencewasnotstatisticallysignificant(McCroneetal.,2009a).

McCroneandcolleaguessubsequentlyassessedthecost-effectivenessofacrisisresolutionteamaspartofarandomisedcontrolledtrialinnorthIslington(2009a)andfoundthatmeantotalserviceusercostswere£2,520lowerforthoserandomisedintotheCRTgroup(McCroneetal.,2009b).

Crisis houses

Crisishousesofferacommunity-basedresidentialalternativetoacutepsychologicalwardsforpeopleexperiencingseverementalhealthcrises.Residentialcrisismodels

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housesfoundnosignificantdifferenceinclinicaloutcomesbetweentrialarms(Lloyd-Evansetal,2009).However,findingsdidindicatethatnocrisishousehadpooreroutcomesthanstandardcareand,wheretherewasadifferenceinoutcomes,itfavouredthecrisishouses.

Evidence of cost-effectiveness

Arandomisedcontrolledtrialofwomen’scrisishousesshowedareducedmeantotalcostof14%overthreemonthswhencomparedwithinpatientcare,althoughthedifferencewasnotstatisticallysignificant(Howardetal.,2010).Comparingfiveresidentialalternativeswithstandardcare,Sladeandcolleaguesfoundthattheformerwereonaverage22%cheaperthantraditionalservices,butagainthedifferencewasnotstatisticallysignificant(Sladeetal.,2010).


Theavailableevidenceontheeffectivenessandcost-effectivenessofcrisishousesasanalternativetoadmissionsistoolimitedtosupportarecommendationforpractice.Itis,however,possibletomakesuchaproposalinrelationtocrisisresolutionteams,asthereisgrowingevidencethatwhenimplementedasintendedtheseteamsareeffectiveinreducingadmissionsandreducinglengthofstayinhospitalwithoutanyadverseimpactonclinicaloutcomes.Theyarealsopreferredbypatients.

Despitethisfavourableverdict,spendingonCRTshasbeencutinrecentyears,withonerecentsurveyofmentalhealthtrustsfindingthatexpenditureontheseteamsfellby8.3%inrealtermsbetween2010/11and2014/15(McNicoll,2015).Moreover,thiswasdespitean18%increaseinaveragemonthlyreferrals.Basedondatacollectedinanow-discontinuedannualsurveyofinvestmentinadultmentalhealthservices(MentalHealthStrategies,2013),itisestimatedthatitwouldcost£29milliontorestorespendingtoitsrealtermslevelof2010/11and£63milliontoallowalsoforan18%increaseinreferrals.

AssumingthatcaseloadsareatthelevelspecifiedintheDepartmentofHealth’soriginal

varyconsiderablyandincludeclinicalcrisishouses,specialistcrisishouses,crisisteambeds,recoveryhousesandnon-clinicalthirdsectoralternatives(JCPMH,2014).Crisishousestendtohave24-hourstaffingbytrainedmentalhealthstaffandsupportworkers.Supportincludestreatmentplanningandimplementationandhelpwitheverydayactivities.

Evidence of effectiveness

Onlylimitedevidenceisavailableontheeffectivenessofcrisishousesandevaluatingtheirimpactiscomplicatedfurtherbythediversityofservicemodels,makingitdifficulttocomparestudiesanddrawfirmconclusions(Howardetal.,2010,Knappetal.,2014).Themainfindingsrelatetoserviceuserpreferenceforcrisishousesoveracuteinpatientcare(Howardetal.,2010;Sladeetal.,2010;LarsenandGriffiths,2013).Onestudy,adoptingapatient-preferencerandomisedcontrolledtrial,comparedcrisishousesandinpatientwardsforwomeninaseverementalhealthcrisis(Howardetal.,2010).Thisfoundgreatersatisfactionwithcareforthoseadmittedtothecrisishouse.However,itwasalsofoundthat,regardlessoftreatment,participantswhoobtainedtheirpreferredtreatmentweremoresatisfied(Howardetal.,2010).

RethinkMentalIllnessCrisisHousesprovide24-houremotionalandpracticalsupportforpeopleinmentalhealthcrises.Anationalevaluationreportedimprovedrecoveryoutcomessuchasbettermanagementofmentalhealth,identityandself-esteem,andhopeandself-careamongstindividualswithmentalhealthdiagnosesincludingschizophrenia,depression,personalitydisorder,bipolardisorderandanxiety(LarsenandGriffiths,2013).

Sladeandcolleaguescomparedfivealternatives(clinicalcrisishouses,short-staywards,crisisteambedsandtwonon-clinicalalternatives)withstandardacuteinpatientcare,andreportedasignificantimprovementinseverityandfunctioningatdischargeamongpatientsintheformergroup,40%ofwhomhadsymptomsoraformaldiagnosisofpsychosis(Sladeetal.,2010;Knappetal.,2014).Areviewof27studiesexaminingtheeffectivenessofcrisis

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implementationguidanceforCRTs(DH,2001),itisestimatedthatadditionalexpenditureof£29millionwouldsupporthometreatmentforaround8,500patientswhomightotherwisehavebeenadmittedtohospital.Netcostsavingsareputat£2,305perpatient,derivedasanaverageofthetwostudiesbyMcCroneandcolleaguescitedabove,expressedintermsoftoday’sprices.Totalcostsavingsthusequal£19.6million.Itshouldbeemphasisedthatthisisanetfigure,whichalreadytakesintoaccountthecostsofadditionalprovisiononCRTs.Ifthesecostsareaccountedforseparately,therelevantfiguresare:additionalspendingonCRTs=£29million,grosssavingsinNHScosts=£48.6million.Every£1investedinCRTsthusyieldssavingsof£1.68.Applyingthisbenefit:costratiotothespendingof£63millionneededtoaccommodatean18%increaseinreferralstoCRTs,estimatedgrosssavingswouldbe£106million.

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Scale and cost of problem

Themortalityrateamongmentalhealthserviceusersis3.6timeshigherthaninthegeneralpopulation(HSCIC,2013).Theincreasedriskislifelongandaffectsmenandwomenmoreorlessequally.Theendresultisthatpeoplewithseverementalillnessdiebetween15and20yearsearlierthanthepopulationaverage(Rethink,2013;Wahlbecketal.,2011),andthereissomeevidencethatthisgapinlifeexpectancyhas,ifanything,beenincreasinginrecentyears(Brownetal.,2010).PrematuremortalityduetoschizophreniaalonecostsUKsociety£1.4billionayear(Andrewsetal.,2012).

Althoughsuicideratesareveryhighamongpeoplewithseverementalillness,themajorityofexcessmortalityisfromdiseasesthatarethemajorcausesofdeathinthegeneralpopulation,particularlycirculatorydiseases,respiratorydiseasesandcancer(Brownetal.,2010;Leuchtetal.,2007).Thefactorscontributingtothisexcessmortalityaremanyandinterrelatedbutincludesmoking,obesity,poordiet,illicitdruguse,physicalinactivityandlong-termantipsychoticuse(RoyalCollegeofPhysicians,2013;Brownetal.,2010;Changetal.,2011).Therearealsoservice-levelchallenges,astheidentificationandtreatmentofphysicalhealthproblemsamongpeoplewithseverementalillnessrequirejointworkingbetweenprimaryandspecialistcare.

Thefocusofthisanalysisisontheeffectivenessandcost-effectivenessofinterventionsandisthereforelimitedtotwomainareasofinterventionwherethereisareasonableevidencebase:smokingcessationandweightmanagementinterventions.Whilethereareinterestingscreeningandjointworkinginitiatives(NHSEngland,2015),thereisnotyetsufficientevidencetoevaluatethese.

Smoking

Smokingratesamongpeoplewithmentalhealthproblemsarehigh.Estimatesrangefrom

around33%forthoselivinginthecommunity,whichisnearlytwicethegeneralpopulationaverage,to59%forthosecurrentlyonantipsychoticmedicationandaround70%forpeopleinpsychiatricinpatientunits(McManusetal.,2010;RoyalCollegeofPhysicians,2013;Jochelson&Majrowski,2006;Brownetal.,2010).Thereisastronglinkbetweentheseverityofmentalillnessandsmoking:peoplewithseverementalillnessaremorelikelytosmokeandtosmokemoreheavilythanthosewithmilderproblems(RoyalCollegeofPhysicians,2013).AstudyofpeoplewithschizophreniafromSouthamptonfoundthatthemortalityriskforsmokerswasdoublethatfornon-smokers,withsmoking-relateddiseaseaccountingfor70%oftheexcessmortality(Brownetal.,2010).

Theeconomiccostofsmokingamongallpeoplewithmentalhealthproblemshasbeenestimatedataround£2.34billionin2009/10intheUK(Wuetal.,2014).Some31%ofthetotal(£719million)wasspentontreatingdiseasescausedbysmoking,whileprematuremortalityaccountedforafurther34%(£797million).Becauseoftheeffectthatsmokinghasonthemetabolismofantipsychoticdrugs,smokersmayneeduptoa50%higherdoseofmedicationthannon-smokers,increasingtheNHSmedicinesbillbyatleast£10millionayear(RoyalCollegeofPhysicians,2013).Itisalsoworthnotingthatpeoplewithseverementalillnessmayspendupto40%oftheirdisposableincomeoncigarettesandtobacco(PublicHealthEngland,2015).

Obesity

Obesityisbetween1.5and4timeshigherinpeoplewithseverementalillnessthaninthegeneralpopulation(Faulkneretal.,2007).Studieshavereportedratesofobesityofupto60%forpeoplewithschizophreniaorbipolardisorder.AUSstudyof169randomlyselectedoutpatientswithseverementalillnessfoundthat50%ofthefemalesand41%ofthemaleswereobesecomparedwith27%and20%

Chapter 10: Interventions to improve the physical health of people with severe mental illness

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respectivelyinthegeneralpopulation(McElroy2009).

Obesitydoublestheriskofall-causemortality,coronaryheartdisease,strokeandtype2diabetes.Italsoincreasestheriskofsomecancers,leadstomusculoskeletalproblemsandlossoffunction,andhasnegativepsychologicalconsequences(Faulkneretal.,2007).

Antipsychoticmedicationsareassociatedwithweightgain(RethinkMentalIllness,2013)andcardio-metabolicrisksappearwithinweeksofcommencingthem(NCCMH,2014).Whiletreatmentwithsecond-generationantipsychoticsisfrequentlyinvokedasthecauseofweightgaininschizophrenia,theexplanationismulti-factorialandincludespre-treatmentandpre-morbidgeneticvulnerabilities,socioeconomicdisadvantagesandunhealthylifestyle(Manuetal.,2015).

Atthegeneralpopulationlevel,arecentstudycommissionedbytheconsultancyfirmMcKinseyhasestimatedthatobesitycoststheUKeconomynearly£47billionayear,equivalentto3.0%ofnationalincome(McKinsey,2014).Thisincludes£6billionayearontheNHScostsoftreatingconditionsdirectlyrelatedtoobesity.(Thesamestudyalsoputstheaggregatecostofsmokingat£57billionayearor3.6%ofnationalincome.)BasedontheMcKinseyfigures,averyapproximateestimateisthattheeconomiccostofobesityamongpeoplewithseverementalhealthproblemsisaround£1.9billionayear.

Effectiveness and cost-effectiveness of interventions

Smoking

Reviewsofsmokingcessationamongpeoplewithseverementalillnesshaveconsideredinterventionswhichincludebehaviouralprogrammes(individualandgrouptherapy),nicotinereplacement(patchesandinhalers)andpharmacologicaltreatments(bupropionandvarenicline).Theseinterventionscanbeappliedsinglyorincombination.ThustheNICEpublichealthguidanceonsmokingcessationevaluated12separateinterventionsinvolvingdifferentcombinationsofthevariouscomponents(NICE,2008).

Animportantfindingfromareviewofstudiesspecificallyrelatingtopeoplewithseverementalillnessisthattreatingtobaccodependenceiseffectiveandthestrategiesthatworkforthegeneralpopulationareequallyeffectiveforthosewithseverementalillness(BanhamandGilbody,2010).Thisreviewalsofoundthatifparticipantswerepsychiatricallystableatinitiationofquitattempts,smokingcessationinterventionsdidnotworsentheirmentalstate.

TherecentNICEguidelineonschizophreniaandpsychosisandarecentCochranereviewhaveassessedpharmacological(bupropionandvarenicline)andnicotinereplacementstrategies(NCCMH,2014;Tsoietal.,2010).Bothfoundthatbupropioniseffective:smokerswithschizophreniawhousedbupropiontoaidsmokingcessationhadatwoandahalftimeshigherrateofabstinenceattheendoftreatmentcomparedwithplaceboandthiswassustainedsixmonthsafterthetreatment.Tsoiandcolleaguesalsoreportednoevidencethatusingbupropionforsmokingcessationadverselyaffectedpositive,negativeordepressivesymptomscomparedwiththoseonplacebo(Tsoietal.,2010).Vareniclinewasalsoreportedtobeeffective(NCCMH,2014).

AnalysisbyNICEhasfoundthatmosttreatmentsarebothmoreeffectiveandlesscostlythandoingnothing,asthelatterhascostsassociatedwiththeday-to-daymanagementofsmoking-relatedillnessesfortheNHS(NICE,2008).ThehighestcostperQALYreportedforinterventionisstilllessthan£10,000,comfortablybelowtheNICEthresholdof£20,000-£30,000(Flacketal.,2007).Halvingtheeffectivenessoftheinterventionsstillresultsinhighlycost-effectivetreatmentwhencomparedtotheNICEthreshold(Jochelson&Majrowski,2006).

Interventionsspecifictopeoplewithseverementalillnessmaybeevenmorecost-effectivethanforthegeneralpopulation,duetothereductionincostassociatedwithreducedantipsychoticdosingandincreasedqualityoflifebecauseoftheconsequentreductioninside-effects.

Thekeyoutcomeofsmokingcessationisincreasedlifeexpectancy.LifeyearsgainedareshownfordifferentagegroupsinTable1.

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Thetwomainlimitationsoftheevidencebaseoninterventionsforobesityinpeoplewithseverementalillnessare:first,thatlittleisknownabouttheextenttowhichweightreductionsaremaintainedbeyondtheshorttomediumterm;andsecond,thatevenlessisknownaboutthecost-effectivenessofinterventions,thoughpreliminaryeconomicmodellingworksuggestspromisingresults(reportedinKnappetal.,2014).


Smokingcessationhasbeenshowntobeperhapsthesinglemosteffectiveandcost-effectiveinterventioninthewholefieldofpublichealth.Giventhefurtherevidencethattheprevalenceofsmokingisparticularlyhighamongmentalhealthserviceusersandthatinterventionsarejustaseffectiveinthisgroupasintherestofthepopulation,itisclearthatthewiderprovisionofsmokingcessationservicesforpeoplewithseverementalillnessshouldbeahighpriority.

Nationaldatashowthatin2013/14(thelatestavailableyear)around1.7millionpeopleofallageshadsomecontactwithsecondarymentalhealthservicesinEngland(HSCIC,2015).However,manyofthesehadonlyoneortwocontacts,e.g.forassessment,anditmaybemorefeasibleandrealistic,atleastinitially,totargetservicesspecificallyonthosementalhealthserviceuserswhoareon

Table 1: Years of life gained from smoking cessation (from Doll et al., 2004)

Age at quitting Year of life regained

<35 10

35-44 9

44-54 6

55-64 3

InlinewiththeRoyalCollegeofPhysiciansreport(2013),thesamebenefitmaybeassumedforpeoplewithseverementalillnessasinthegeneralpopulation.

Obesity

Some,albeitlimited,evidenceisavailableonthepreventionofweightgainorsupportingweightlossinpeoplewithseverementalillness.Bothbehaviouralandpharmacologicalapproacheshavebeenstudied.Arecentreviewoftheevidencerelatingtonon-pharmacologicalinterventionsreportedameanweightreductionof3.12kgover8to24weeks(Caemmereretal.,2012).TheNICEguidelinereportedevidenceofabeneficialeffectofbehaviouralinterventionsfocusedonpromotingbothmoderateactivityandhealthyeating(weightreductionof2.88kgattheendoftreatment),althoughtherewerenodatabeyond6months.ThesealignwithfindingsfromaCochraneReviewandprevioussystematicreviews(Faulkneretal.,2007;McElroy,2009;Manuetal.,2015),assummarisedinTable2.

Cognitive/Behavioural Interventions

Pharmacological Interventions

Preventing weight gain Mediumterm:-3.38kg

Endoftreatment:-4.87kg

Endoftreatment:

-1.16kg

Treating weight gain Mediumterm:

-1.69kg

Endoftreatment:

-3.85kg

Table 2: Evidence relating to weight management treatments (from Faulkner et al., 2007)

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theCareProgrammeApproach(CPA).Thesearegenerallypeoplewiththemostsevereproblemsand,asseen,thereisastronglinkbetweenseverityofmentalillnessandsmokingbehaviour.Altogethertherearearound358,000peopleonCPA(HSCIC,2015)andifitisfurtherassumedthat60%aresmokersandthat69%ofthesewouldliketoquit(RoyalCollegeofPhysicians,2013),thisgivesatargetpopulationofapproximately150,000people.

TheproposedinterventionisthemosteffectiveofallthoseevaluatedineconomicanalysispreparedfortheNICEguidanceonsmokingcessation(Flacketal.,2007),withanestimatedquitrateof35%.Itisamulti-componentintervention,comprisingnicotinepatchespluspharmacistcounsellingplusabehaviouralprogramme.Theunitcostoftheinterventionis£450intoday’sprices,givingatotalcostfor150,000peopleof£67.5million.

Estimatedsavingsare£100.8million,spreadoveranumberofyears,duetoreducedsmoking-relatedNHScosts.Moreprofoundly,thosesuccessfullyquittingwouldonaveragegainanincreaseinlifeexpectancyofaroundsevenyears.

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babies count: spotlight on perinatal mental health.Availableathttp://www.nspcc.org.uk/globalassets/documents/research-reports/all-babies-count-spotlight-perinatal-mental-health.pdf.

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Priorities for mental health

Published January 2016

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Priorities for mental health · and anxiety during the perinatal period 3 Treatment of conduct disorder in children up to age 10 14 4 Early intervention services for first-episode

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