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Mc daid primhe conference 2011

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Mc daid primhe conference 2011

  1. 1. 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:d.mcdaid@lse.ac.uk
  2. 2. Structure <ul><li>Economics and mental health </li></ul><ul><li>Examples of the economic case for mental health in primary care </li></ul><ul><li>Obtaining economic information </li></ul><ul><li>Implications and challenges for GP commissioning </li></ul>
  3. 3. <ul><li>The economic impacts of poor mental health range far and wide </li></ul>
  4. 4. Centre for Mental Health, 2010 http://www.centreformentalhealth.org.uk/pdfs/Economic_and_social_costs_2010.pdf
  5. 5. Costs of depression (adults) in England, 2000 Thomas & Morris Brit J Psychiatry 2003 Excluding ‘morbidity’ costs
  6. 6. Costs of depression (adults) in England, 2000 Total cost = £9 billion Thomas & Morris Brit J Psychiatry 2003
  7. 7. Costs of depression (adults) in England, 2000 Total cost = £9 billion Thomas & Morris Brit J Psychiatry 2003 Only measures unemployment and absenteeism; ‘presenteeism’ could double this cost
  8. 8. Disability Benefits GB 2007 Source: Department of Work and Pensions, 2007 € 3.9 billion per annum Plus reduced tax receipts €14 billion
  9. 9. <ul><li>What do economists mean by cost effectiveness? </li></ul>
  10. 10. 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
  11. 11. Economic evaluation The effectiveness question: Does this intervention work? The economic question: Is it worth it?
  12. 12. 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
  13. 14. Medically Unexplained Symptoms: Impacts on NHS in England <ul><li>22% of all primary care consultations </li></ul><ul><li>7% of all prescriptions </li></ul><ul><li>25% of all outpatient care </li></ul><ul><li>8% of all inpatient bed days </li></ul><ul><li>5% of A & E attendances </li></ul>Source: Bermingham, Cohen, Hague & Parsonage, 2010
  14. 15. Health care costs of all medically unexplained symptoms in England 2009 Source: Bermingham, Cohen, Hague & Parsonage, 2010 £ 2.88 billion per annum 11% of all health care expenditure for working age population
  15. 16. Costs beyond health care system £9.25 £0.88 £8.37 Other Quality of Life Impacts Total Somatisation Disorder Sub-Threshold Disorders Cost’s £ Billions £17.37 £2.16 £15.21 Total £5.24 £0.45 £4.79 Lost Employment £2.88 £0.83 £2.05 Health Care Costs
  16. 17. 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 years Impact 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
  17. 18. NHS only NHS and Employment Impacts McDaid, Parsonage and Park, 2011
  18. 19. CBT for sub-threshold disorders pop coming into contact with GPs (e-learning model) -6,220 £per QALY gained (NHS plus productivity) 8,071 £/QALY gained (NHS) 35,958 QALYs gained -223,669,259 Net NHS and productivity costs per year -513,870,616 Productivity 290,201,357 Net NHS costs -122,218,965 A&E Care -199,879,589 Inpatient treatment -27,807,096 Outpatient consultations 787,349,160 CBT cost -33,233,116 Prescription costs -114,609,037 GP costs 600,000 CBT awareness training Total Costs/Savings Cost component
  19. 20. CBT for somatoform disorders pop coming into contact with GPs (e-learning model) -15,189 £per QALY gained (NHS plus productivity) -101 £/QALY gained (NHS) 42,074 QALYs gained -639,069,750 Net NHS and productivity costs per year -634,828,662 Productivity -4,241,088 Net NHS costs -190,020,975 A&E Care -442,914,724 Inpatient treatment -45,012,443 Outpatient consultations 847,613,160 CBT cost -39,168,358 Prescription costs -135,337,749 GP costs 600,000 CBT awareness training Total costs Cost Component
  20. 21. Implications <ul><li>Potentially cost effective / cost saving to NHS for severe somatoform disorder </li></ul><ul><li>Need to look at case for stepped care approach </li></ul><ul><li>Examine lower cost interventions initially for sub-threshold </li></ul><ul><li>Consider impact on costs, effectiveness and uptake of computerised CBT </li></ul><ul><li>Conservative analysis </li></ul><ul><li>Potential impacts on other family members </li></ul><ul><li>Other service user groups that benefit from investment in infrastructure for psychological therapies </li></ul>
  21. 22. Impact of co-morbid depression and diabetes in Great Britain <ul><li>Using data from Psychiatric Morbidity Survey, compared to people with diabetes alone: </li></ul><ul><li>Four times more likely to have difficulty in managing medical care </li></ul><ul><li>Twice as likely to have consulted primary care doctor about physical health in previous year </li></ul><ul><li>Six times more likely to have days off from work </li></ul><ul><li>Four times more likely to report other impacts on work/regular activities </li></ul>Das-Munshi et al 2007 Psychosomatic Medicine
  22. 23. Costs of health service use, by depression status Simon et al, Gen Hosp Psychiatry , 2005
  23. 24. Collaborative care to manage depression in people with diabetes in primary care: costs over 5 years 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
  24. 25. Potential economic benefits of collaborative care in England <ul><li>2 year economic model using effectiveness data from literature review </li></ul><ul><li>Estimate d the costs and benefits of investing in GP nurse case- manager led collaborative care following screening for depression in cases of diabetes Type II </li></ul><ul><li>Cost per QALY gained £3600 </li></ul><ul><li>But significant additional initial costs to run programme </li></ul><ul><li>But long term substantial costs of diabetes complications avoided not included </li></ul>King, Moloswanke & McDaid 2011
  25. 26. Obtaining Health Economic Inputs <ul><li>More challenging to obtain health economic input? More limited role of NICE on economic impact </li></ul><ul><li>Potential inefficiencies in having multiple GP clusters all looking for health economic inputs </li></ul><ul><li>Pooling resources – to look at economic issues? </li></ul><ul><li>Making use of continuing resources e.g. NICE systematic reviews? York Economic Database </li></ul><ul><li>But need for even more local consideration of budgetary issues </li></ul><ul><li>Local Health Economies: relationship with local authority public health groups? </li></ul>
  26. 27. Implications for GP commissioning <ul><li>GP Commissioning could provide opportunities for local innovation and clinician led care </li></ul><ul><li>Could better meet local mental health needs </li></ul><ul><li>But speed of change / administrative impact potential challenging </li></ul><ul><li>Safeguarding resources for primary care elements of mental health strategy? </li></ul><ul><li>‘ Buy In’ from sectors that benefit from better mental health may be even more challenging with more devolution of budget holding: </li></ul>
  27. 28. To sum up <ul><li>The personal, health, social and economic costs of poor mental health in England are substantial </li></ul><ul><li>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 </li></ul><ul><li>But local choice will need to more variation in service provision – not always helpful </li></ul><ul><li>Potential challenges in obtaining budgetary and economic inputs for decision making in more fragmented system? </li></ul>

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