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The health economic case for investment in primary care mental health
David McDaid
PRIMHE: Examining the future strategic direction of primary mental health care, February 2011, St Pancras Novotel
LSE Health & Social Care and European Observatory on Health Systems and Policies, London School of Economics
E-mail:[email protected]
Structure
• Economics and mental health
• Examples of the economic case for mental health in primary care
• Obtaining economic information
• Implications and challenges for GP commissioning
The economic impacts of poor mental health range far and wide
Centre for Mental Health, 2010http://www.centreformentalhealth.org.uk/pdfs/Economic_and_social_costs_2010.pdf
Costs of depression (adults) in England, 2000
Day care0%
General practitioner
1%
Mortality61%
Out-patient2%
In-patient3%
Primary care medication
33%
Thomas & Morris Brit J Psychiatry 2003
Excluding ‘morbidity’ costs
Costs of depression (adults) in England, 2000
Productivity90%
Mortality6%
Service costs4%
Total cost = £9 billion
Thomas & Morris Brit J Psychiatry 2003
Costs of depression (adults) in England, 2000
Productivity90%
Mortality6%
Service costs4%
Total cost = £9 billion
Thomas & Morris Brit J Psychiatry 2003
Only measures unemployment and absenteeism; ‘presenteeism’ could double this cost
Disability Benefits GB 200722%
40%
6%8%
18%
6%
Other Mental and Behavioural Disorders
Nervous System Circulatory and Respiratory System
Musculoskeletal System Injury, Poisoning, External Causes
Source: Department of Work and Pensions, 2007
€ 3.9 billion per annum
Plus reduced tax receipts €14 billion
What do economists mean by cost effectiveness?
Economics is about choice
Budget
Choice ‘A’Choice ‘B’
Resources are always constrained;
How can we best spend public monies to maximise benefit to society
Be mindful of potential consequences for fairness and equity
Economic evaluation
The effectiveness question:
Does this intervention work?
The economic question:Is it worth it?
Two Basic Needs: (A) Costs and Outcomes; (B) 2+ Alternatives
Outcomes (e.g. Quality of Life Years (QALYs) for intervention X
Costs for intervention X
Costs for intervention Z Outcomes (e.g
Quality of Life Years (QALYs) for intervention Z
Cost per QALY circa £30,000 considered good value; But need to be mindful of budgetary impact
Medically Unexplained Symptoms:Impacts on NHS in England
• 22% of all primary care consultations • 7% of all prescriptions• 25% of all outpatient care• 8% of all inpatient bed days• 5% of A & E attendances
Source: Bermingham, Cohen, Hague & Parsonage, 2010
Health care costs of all medically unexplained symptoms in England 2009
32%
13%
3%9%
41%
2%
Primary Care Consultations Prescriptions
Hospital Outpatient Referrals Outpatient follow up
Inpatient Care Accident and Emergency
Source: Bermingham, Cohen, Hague & Parsonage, 2010
£ 2.88 billion per annum
11% of all health care expenditure for working age population
Costs beyond health care system
Cost’s £ Billions
Sub-ThresholdDisorders
Somatisation Disorder
Total
Health Care Costs
£2.05 £0.83 £2.88
Lost Employment
£4.79 £0.45 £5.24
Other Quality of Life Impacts
£8.37 £0.88 £9.25
Total £15.21 £2.16 £17.37
Economic Modelling study Objective: To evaluate the cost effectiveness of detection in
primary care followed by cognitive behavioural therapy for sub- threshold and somatoform disorders
Outcomes: Improvement in Quality of Life Scores over 3 yearsImpact on employment rates over 3 years
Impacts on use of NHS resources over 3 years
Data: Cost data from NHS sources, Bermingham study; Cost of awareness training for GPs (including need for locums) from national sources; E-learning for GPs as alternative; IAPT cost data for CBT costs. Incidence of MUS from Bermingham study
Three Year Cost Impacts
-700,000,000
-600,000,000
-500,000,000
-400,000,000
-300,000,000
-200,000,000
-100,000,000
0
100,000,000
200,000,000
Somatoform disorders (e-learning)
Somatoform disorders(face to face learning)
All MUS disorders (e-learning)
All MUS disorders (face toface_)
NHS only NHS and Employment Impacts
McDaid, Parsonage and Park, 2011
CBT for sub-threshold disorders pop coming into contact with GPs (e-learning model)
Cost component Total Costs/Savings
CBT awareness training 600,000
GP costs -114,609,037
Prescription costs -33,233,116
CBT cost 787,349,160
Outpatient consultations -27,807,096
Inpatient treatment -199,879,589
A&E Care -122,218,965
Net NHS costs 290,201,357
Productivity -513,870,616
Net NHS and productivity costs per year -223,669,259
QALYs gained 35,958
£/QALY gained (NHS) 8,071
£per QALY gained (NHS plus productivity) -6,220
CBT for somatoform disorders pop coming into contact with GPs (e-learning model)
Cost Component Total costsCBT awareness training 600,000
GP costs -135,337,749
Prescription costs -39,168,358
CBT cost 847,613,160
Outpatient consultations -45,012,443
Inpatient treatment -442,914,724
A&E Care -190,020,975
Net NHS costs -4,241,088
Productivity -634,828,662
Net NHS and productivity costs per year -639,069,750
QALYs gained 42,074
£/QALY gained (NHS) -101
£per QALY gained (NHS plus productivity) -15,189
Implications
Potentially cost effective / cost saving to NHS for severe somatoform disorder
Need to look at case for stepped care approach Examine lower cost interventions initially for sub-
threshold Consider impact on costs, effectiveness and uptake
of computerised CBT Conservative analysis Potential impacts on other family members Other service user groups that benefit from
investment in infrastructure for psychological therapies
Impact of co-morbid depression and diabetes in Great Britain
Using data from Psychiatric Morbidity Survey, compared to people with diabetes alone:
Four times more likely to have difficulty in managing medical care
Twice as likely to have consulted primary care doctor about physical health in previous year
Six times more likely to have days off from work
Four times more likely to report other impacts on work/regular activities
Das-Munshi et al 2007 Psychosomatic Medicine
Costs of health service use, by depression status
0
1000
2000
3000
4000
5000
6000
No depression Subthreshold depression Major depression
Depression treatment Diabetes treatment Other treatment
Simon et al, Gen Hosp Psychiatry, 2005
Collaborative care to manage depression in people with diabetes in primary care: costs
over 5 years
0
2000
4000
6000
8000
10000
12000
14000
Year 1 Year 2 Year 3 Year 4 Year 5
Usual care Care management
Katon et al, Diabetes Care, 2008
Compared usual primary care and a nurse depression intervention (12 months - education, behaviour activation, choice between medication and problem-solving therapy)
Requires better early recognition of co-morbidity
Potential economic benefits of collaborative care in England
2 year economic model using effectiveness data from literature review
Estimated the costs and benefits of investing in GP nurse case- manager led collaborative care following screening for depression in cases of diabetes Type II
Cost per QALY gained £3600
But significant additional initial costs to run programme
But long term substantial costs of diabetes complications avoided not included
King, Moloswanke & McDaid 2011
Obtaining Health Economic Inputs
• More challenging to obtain health economic input? More limited role of NICE on economic impact
• Potential inefficiencies in having multiple GP clusters all looking for health economic inputs
• Pooling resources – to look at economic issues?• Making use of continuing resources e.g. NICE
systematic reviews? York Economic Database• But need for even more local consideration of
budgetary issues• Local Health Economies: relationship with local
authority public health groups?
Implications for GP commissioning
• GP Commissioning could provide opportunities for local innovation and clinician led care
• Could better meet local mental health needs
• But speed of change / administrative impact potential challenging
• Safeguarding resources for primary care elements of mental health strategy?
• ‘Buy In’ from sectors that benefit from better mental health may be even more challenging with more devolution of budget holding:
To sum up• The personal, health, social and economic costs of
poor mental health in England are substantial• Opportunities for scaling up of cost effective
services at primary care level, e.g. tackling risk of co-morbidities; appropriate use of psychological therapies – building on IAPT capacity
• But local choice will need to more variation in service provision – not always helpful
• Potential challenges in obtaining budgetary and economic inputs for decision making in more fragmented system?
