Economics and Mental Health: Pain or Gain? - Martin Knapp - Altering States, Reforming the System Brisbane - June 2009
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Altering States, Reforming the System
Brisbane – June 2009
Economics and
Mental Health:
Pain or Gain?
Martin Knapp
PSSRU, London School of Economics
Institute of Psychiatry, King’s College London
NIHR School for Social Care ResearchStructure Why is economics relevant? Seven deadly economic sins: Accountancy* Neglect Greed Impatience Protectionism Myopia Paternalism Take-home messages
Why is economics relevant?
… er … just switch on the TV … Every country faces big economic challenges Consequences? Government has less money coming in (lower tax revenues etc) But more going out, since needs are greater (unemployment etc) Reactions? This is NOT the time to cut spending … … BUT we need to convince decision makers that mental health services not only improve well-being but also have economic benefits
The underlying problem is …
Scarcity
There are not enough resources
to meet all of society’s needs or
wants
So society has to choose how
to use them (i.e. to ‘ration’)… and when choosing … … we need to know … what people need and what they want what services can meet those needs what staff and other inputs are employed to deliver those services what are the costs of employing them how to raise the funds to meet those costs BUT ….
Accountancy*
Don’t just look
at the costs.
You have to
check the
outcomes too
* Don’t confuse with …… and when choosing … … we need to know: what people need and what they want what services can meet those needs what staff and other inputs are employed to deliver those services what are the costs of employing them how to raise funds to meet those costs BUT … we also need to know: what outcomes are achieved and whether those outcomes are worth the cost needed to generate them
Neglect The most important input is the one you most often overlook
Costs of dementia in Australia
Equipment
Welfare Residential
etc
payments care
2%
1% 48%
Payments to
carers
5%
Carer time Hospital
29% 4%
Other health
Mortality care
0% Patient lost Patient lost 3%
taxes earnings
2% 6%
Access Economics, report, 2003Costs of children with persistent
antisocial behaviour, London UK
Health care Social care Education
5% 0% 5%
Voluntary
2%
Benefits
43%
Family costs
45%
Romeo, Knapp & Scott, Brit J Psychiatry, 2006Greed Don’t shift the balance of care just so that you can cut spending
Psychiatric beds - Western Europe
Psychiatric hospital beds per 100000
500
Why this fall?
Better treatments
400 Human rights Austria
Belgium
Consumer preferences
Cyprus
Denmark
Community tolerance
Finland
France
300 Germany
AND potential savings?
Greece
Iceland
Ireland
Italy
Luxembourg
Malta
200 Netherlands
Norway
Portugal
Spain
Sweden
United Kingdom
100
Source: WHO
0
1970 1980 1990 2000 2010Friern Hospital closure: cost of
community care for each annual
cohort of ‘leavers’
900 Weekly costs,
1994/95 prices (£)
800
700
600
Average
hospital cost 500
= £595 400
Average cost of
Note – very 300 community care
wide cost 200 = £665 (pRisks of under-funding? Growth of
involuntary hospital admissions
250 Rates per 100,000
200 1990 2002 2006
150
100
50
0
AUS DEN ENG GER IRE ITA NET SPA SWI
Priebe et al Psychiatric Services 2008Impatience Give preventive measures time to have their full effects
Early identification and intervention
for psychosis
Psychosis - onset in late adolescence / early
adulthood. Often earlier signs
Usual response to first onset is hospital
admission; then frequent readmissions
Psychosis is also associated with:
poor educational outcomes
disrupted employment
social isolation
violent behaviour, homicide
self-harm, suicideEarly intervention teams: are they
cost-effective?
Most areas in England invested in early
intervention (EI) teams (community-based)
But it is always hard for a preventive service
to prove effectiveness and cost-effectiveness
Outcomes evidence for EI – is certainly
encouraging, but decision makers were
worried about the cost of these teams
So we constructed a ‘model’ to simulate care
pathways and costs with and without EI
And populated it with data from real
services, previous research etcCosts (over 3 yrs) of EI team and
standard care
40
28.4
Expected costs (£,000)
30
22.1
20
10
0
Standard care EI team
McCrone, Dhanasiri & Knapp, EIP, 2009 forthcomingProtectionism Think about the wider context, not just your own budget and targets
Costs of depression (adults) in
England, 2000
Total cost = £9 billion
Productivity Mortality
90% 6%
Service costs
4%
Thomas & Morris Brit J Psychiatry 2003Can better health care save money
as well as proving effective?
We know that – compared to the rest of the
population - people with depression are …
… less likely to have a job
… more likely to have sickness-related absences
… less productive at work when they are unwell
So economic impacts of depression fall widely:
on individuals and families (lost income)
on employers (lost productivity)
on the government (welfare payments; lost taxes)
Research What would happen if good treatment
was made available to all who needed it?Cost per person
Savings averaged over all
per person
people withper
= £2266 depression in over
year averaged England
all
adults aged 18-65 with depression
15000 BUT – the spending on better health
care needs to come from the health
10000
system …
… while the savings accrue mainly to
5000
other parts of government
… which needs collaboration
0
53% with evidence-based Potentially 100% with
treatment in 2000 evidence-based treatment
Service costs Incapacity benefit Lost taxes Lost productivity
Knapp, McCrone, Capdevielle, unpublished, 2008Myopia Don’t close your eyes to (often enormous) longer-term impacts
Inner London Longitudinal Study
Study of all 10-year olds in part of London in 1970
(n=1689). Led by Michael Rutter at that time
Teacher ratings, child questionnaires
Intensive study of 50% of those with psychological
problems and random 8% of the total population
At age 10:
o No problems at school, no clinical diagnosis (65)
o Emotional problems at school, only (32)
o Emotional disorder (8)
o Antisocial behaviour at school, only (61)
o Conduct disorder (16)
Followed up at age 26-28 …
Later … we calculated costs from 10 to 28 (but
original study not built for this purpose)Costs in early adulthood from
childhood conduct disorder
Costs (£)
from ages
60000 10 to 28
Criminal
justice
Benefits
40000
Relationships
Social care
Health 20000
Education
0
No problems Conduct Conduct
problems disorder
Scott, Knapp, Henderson, Maughan, BMJ 2001Paternalism Consumers can make informed (supported) choices about their lives
Self-directed support (SDS)
People eligibleBut
for state
alsosupport
concernscan take cash rather
about:
than services arranged by the state
• vulnerability/competence of consumers
In the UK today, this includes social care, housing,
• risk of exploitation/abuse
equipment, welfare payments, health (from later in
2009) • public accountability for tax funds
Why this policy?
• monitoring of quality of support
Professional support forcosts
• transaction empowerment
(brokerage etc)
Linked to citizenship agenda
Broad political appeal – all parties support it
Many consumers seem to like it
SDS is expected to generate better outcomes …
… and lower costsIndividual budget pilots in England Piloted in 13 localities – give people the option to take cash rather than services. Does it improve outcomes? Is it cost-effective? Research findings for people with mental health needs. Compared to conventional social care: IBs offered greater range and flexibility of support Quality of life was better Psychological wellbeing was slightly higher IBs appeared to be more cost-effective
Take home messages
Messages for policy makers - 1 Accountancy Policy driven only by financial considerations is always suspicious. You must know the outcome consequences. Neglect Many economic impacts are hidden. Remember that unpaid carers are precious resources. Greed Good quality care doesn’t (usually) come cheap. Don’t cut services for vulnerable or disadvantaged people just because they don’t have much voice. Impatience Prevention can work, but in the mental health area you have to give it time. There is no vaccine against schizophrenia, depression, … .
Messages for policy makers - 2 Protectionism Don’t just focus on your own budget and your own performance targets. Collaborate for the greater common good! Myopia Many people have mental health needs over most of their lives. Make sure decisions are taken from a life-course perspective. Paternalism Professionals don’t always know best. Give consumers (supported, monitored) choice and control. So … economics … Is it pain? Sure, but it can offer gains too
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