Between £8 billion and £13 billion of NHS spending in England is attributable to the consequences of co-morbid mental health problems among people with long-term conditions57
- Unnecessary investigation;
- Increased presentations in primary care, emergency departments and outpatient clinics;
- Increased use of medication;
- Increased, usually unscheduled, admissions with longer lengths of stay;
- In older people, increased risk of institutionalisation.
- For example, co-morbid depression is associated with a 50–75 per cent increase in health spending among diabetes patients54, and yet only half of the cases of depression in diabetes are detected.55
- At least 28 per cent of patients admitted to hospital with physical illness also have a significant mental health problem, and a further 40 per cent have sub-clinical depression or anxiety.55 This rises to at least 60 per cent for people over the age of 60.56
Co-morbid mental health problems are a major cost driver in the care of long-term conditions35:
- Associated with a 45–75 per cent increase in service costs.
- At least £1 in every £8 spent on long-term conditions is linked to poor mental health and wellbeing, meaning that between £8 billion and £13 billion of NHS spending in England
- Majority of these costs will be associated with the most complex patients whose long-term conditions are most severe or who have multiple co-morbidities.
There is considerable scope for NHS savings and health gains for patients through improving the care pathways and delivering appropriate psychological interventions for patients with diabetes and co-morbid common mental health problems.
Collaborative care for patients with Type 2 diabetes and co-morbid depression36:
- Delivered in a primary care setting to individuals with co morbid diabetes and depression.
- Estimate that the total cost of six months of collaborative care is £682, compared with £346 for usual care.
- A two-year evaluation in the United States found that, on average, collaborative care achieved an additional 115 depression-free days per individual; total medical costs were higher in year one, but there were cost savings in year two.36
- Investing in six months of collaborative care in England for patients with newly diagnosed cases of Type 2 diabetes who screen positive for depression, compared with care as usual. The costs associated with screening are not included in the baseline model. Existing data on the cost effectiveness of CBT were used to estimate the impact on healthcare and productivity losses.
- Estimated costs and savings for 119,150 new cases of Type 2 diabetes in England in 2009: assumed that 20 per cent of patients under collaborative care would receive CBT, compared with 15 per cent of the usual care group.
- Assuming 20 per cent screen positive for co-morbid depression, completing and successfully responding to collaborative care leads to an additional 117,850 depression-free days in Year 1 and 111,860 depression-free days in Year 2. Substantial additional net costs in Year 1 due to the costs of the treatment but in Year 2, net savings for the health and social care system due to lower costs in the intervention group, plus further benefits from reduced productivity losses.
- Using a lower 13 per cent rate of co-morbid diabetes and depression, total net costs in Year 1 would be more than £4.5 million, while net savings in Year 2 would be more than £450,000.
In the year following a brief cognitive behavioural intervention for patients with chronic refractory angina43
- Patients exhibited 5-10 fewer inpatient bed days associated with cardiac admissions on average, and 0.75 fewer inpatient bed days associated with myocardial infarction.
- On this basis, the study demonstrates reductions in healthcare usage of approximately £2,000 per person in the year after treatment, well in excess of the cost of psychological intervention.
Adaptive pacing therapy (APT), cognitive behaviour therapy (CBT), or graded exercise therapy (GET) for patients with chronic fatigue syndrome resulted in improvements in health-related quality of life in comparison with specialist medical care (SMC) which produced little change.
- At a threshold of £30,000 per QALY, CBT had a 62.7% likelihood of being the most cost-effective option from a healthcare perspective followed by GET at 26.8%;
- CBT had a 59.5% likelihood of being the most cost-effective option from a societal perspective.
Evaluation of the Rapid Assessment Interface and Discharge (RAID) liaison service in Birmingham demonstrated improvements in health and wellbeing and in cost savings.60-61 An independent economic evaluation was undertaken by the London School of Economics showing:
- Demonstrated total incremental savings from RAID to be in the order of £3.55 million a year, that is 14,500 bed days saved at £245 per bed day
- In comparison with the incremental cost of RAID was £0.8 million a year.
- Benefit: cost ratio is therefore in excess of 4:1, or a saving of £4 for every £1 invested which may well be an underestimate of potential cost savings.
- Additional benefits may be derived from decreased health resource usage as a result of:
- Improvements in the health and quality of life of patients,
- Improvement in the identification of mental health problems,
- The signposting of patients to more appropriate mental health pathways;
- Impact on elective admissions (evaluation only considered emergency admissions);
- Increased discharge of older people to their homes
- Decreased discharge to residential or nursing homes and hence potential savings in the social care sector.60
Commissioners are required to improve quality while at the same time increasing productivity (QIPP). Liaison services provide an excellent opportunity to do this by:
- Improving clinical outcomes
- Reducing admissions to and lengths of stay in acute settings
- Ensuring patients with co-morbid long term conditions receive better treatment while using fewer health care resources
- Treating and reducing costs for patients with PES (‘MUS’)
- Reducing psychological distress following self-harm, and reducing suicide.
Liaison services are usually commissioned by the commissioners of mental health services. However the major benefits in health gain and cost that can accrue from liaison services occur within acute services. There is therefore a case for funding of liaison services to move to become a responsibility of commissioners of acute hospital care to realise these potential cost-benefits.