Connections between health and employment: implications for cost-effectiveness
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Helsinki 28 October 2014 Martin Knapp Personal Social Services Research Unit London School of Economics and Political Science & NIHR School for Social Care Research Connections between health and employment: implications for cost- effectiveness
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Transcript of Connections between health and employment: implications for cost-effectiveness
Helsinki 28 October 2014
Martin Knapp Personal Social Services Research Unit
London School of Economics and Political Science & NIHR School for Social Care Research
Connections between health and employment:
implications for cost-effectiveness
Some of the work presented here was supported from: • Department of Health • NHS England and Rethink Mental Illness • National Institute for Health Research (NIHR) School for Social
Care Research • NIHR Health Technology Programme All views expressed in this presentation are those of the presenter, and are not necessarily those of any of the funding bodies. I have no conflicts of interest to report relevant to this presentation.
Funding, disclaimer, conflicts of interest
A. Employment & health
B. Employment, health … & economics
C. Looking for cost-effectiveness
D. Issues & challenges
Structure of my talk
Employment & health
o Social role & status
o Activity & structure
o Social networks
o Self-esteem
o Income
o Productivity
o Economic growth
o Entitlements (pension, health care)
Why employment is important …
o Social role & status
o Activity & structure
o Social networks
o Self-esteem
o Income
o Productivity
o Economic growth
o Entitlements (pension, health care)
… and links to ill-health / disability
IMPACTS OF and/or FOR ILL-HEALTH & DISABILITY
Non-availability for work
Unemployment
Absenteeism
Presenteeism
Workplace stress
Redundancy
Premature retirement
Murray et al, Lancet 2013
Mental & behavioural
disorders
Years lived with disability by cause and age, UK in 2010
Mental health problems: c.20% of population (= 10.2 million, England)
Long-term conditions: 30% of population (= 15.4 million, England)
The intersection group is 30% of people with a LTC and 46% of people with a MHP (= 4.6 million)
Naylor et al Long-Term Conditions and Mental Health, King’s Fund & CMH 2012
Between 12% and 18% of all NHS expenditure on LTCs is linked to poor mental health and wellbeing
Overlap: mental & physical ill-health
Knapp et al, Youth Mental Health: New Economic Evidence 2014
Years lived with disability by cause and age, UK in 2010 Treatment rates
by age group:
o 12-15 = 45%nb
o 16-20 = 58%
o 21-25 = 36%
o 26-45 = 54%
o 46-65 = 65%
o 66-74 = 79%
0
20
40
60
80
100
Severe disorder Moderate disorder No disorder (↘)
Mental illness & employment (10 countries)
OECD Sick on the Job, 2012
Employment, health … & economics
Examples: - Depression costs - Recession & stigma - Child mental ill-health - Unpaid care
Day care0%
General practitione
1%
Mortality61%
Out-patient2%
In-patient3%
Primary care medication
33%
Thomas & Morris Brit J Psychiatry 2003
Excluding ‘morbidity’ costs
Costs of depression for adults in England, 2000 – mortality & health care
Productivity90%
Mortality6%
Service costs4%
Total cost = £9 bn
Thomas & Morris Brit J Psychiatry 2003
Presenteeism costs (not shown) could be twice the size of absenteeism costs
Costs of depression for adults in England, 2000 – absenteeism & unemployment
0
5
10
15
20
2006 2010
% u
nem
ploy
ed
No mentalhealth problemsMental healthproblems
Recession widened the gap in unemployment rates between individuals with and without MH problems … ...especially for males and people with low education levels.
Evans-Lacko, Knapp, McCrone, Thornicroft, Mojtabai PLOS ONE 2013
All 27 EU countries
Recession, unemployment, stigma (EU)
Public attitudes played a part in this increase: Eurobarometer 2006 asked the general public questions about ‘people with psychological or emotional health problems’. Do you agree that: 1.… “they constitute a danger to others” 2.… “they are unpredictable” 3.… “they have themselves to blame” 4.… “they never recover”. We converted responses to a single overall measure of stigmatizing beliefs concerning mental illness.
Stigmatizing attitudes
0
5
10
15
20
2006 2010
% u
nem
ploy
ed
No mental healthproblems
Mental healthproblems
Evans-Lacko, Knapp, McCrone, Thornicroft, Mojtabai PLOS ONE 2013
The disadvantage facing people with mental health problems is greater in countries with higher levels of stigmatizing attitudes towards mental illness.
Stigmatizing attitudes also play out in other spheres (e.g. schools), reducing disclosure, recognition, treatment.
Recession, unemployment, stigma (EU)
Family costs45%
Education5%
Voluntary2%
Benefits43%
Social care0%
Health care5%
Total cost excluding benefits averaged £5,960 per child per year, at 2000/01 prices (benefits = £4307)
Romeo, Knapp, Scott (2009) British J Psychiatry 2009
Costs in childhood: young children with persistent antisocial behaviour
Fergusson et al J Child Psychol Psychiat 2005
Adulthood impact of childhood problems: Christchurch (NZ) Health & Devel’t Study
Mother’s IQ also significant
Breastfed also significant
Bauer et al Psychological Medicine 2014
Adjusted for child gender, mother’s age, previous depression, relationship changes (none significant).
Chances of child development problems as result of maternal depression (perinatal)
Bauer et al Psychological Medicine 2014
Cost per child exposed to perinatal depression (£, 2010/11, discounted to birth)
These studies show us that child mental health problems:
oAffect parental employment in childhood
oAffect the child’s educational attainment and later employment
oAnd are themselves sometimes the consequence of parental mental health problems (especially in perinatal period)
oBut those mental health problems are very often unrecognised and untreated
So … for child mental health problems
Public expenditure costs > £1.3 billion per year (2010)
o£300 million a year in Carer’s Allowance paid to people who have left employment because of unpaid caring
o£1 billion a year in taxes forgone on this group’s lost earnings
Total does not include additional benefits, such as Housing Benefit, to which carers who have left work may additionally be entitled.
Public expenditure costs of unpaid carers leaving employment, England
Pickard et al SSCR scoping study report 2012
Looking for cost-effectiveness
Examples: - Beating the Blues - IPS - Workplace action - Replacement care
Options include:
oPrevention – of ill-health or disability
oPrevention – of bad employment consequences of ill-health or disability
oGeneric interventions – treating ill-health or supporting disabled people – with good employment outcomes
oWorkplace-based interventions
Economics evidence could come from:
oRandomised controlled trials
oObservational and other designs
oSimulation modelling
What should the response be to these links? And will it be cost-effective?
o Computerised Cognitive Behavioural Therapy (CBT) for adults aged 18-75 with depression and/or anxiety disorder, not currently receiving face-to-face psychological therapy.
o N = 274 primary care patients; randomised controlled trial.
o Interventions: Beating the Blues (BtB) - computer sessions (8 x 50 mins) added to usual care vs. treatment as usual (TAU) alone (primary care doctor, counsellor, nurse etc.)
o Outcomes: BtB better on depression symptoms, anxiety symptoms and a measure of work and social adjustment. Also small QALY gain.
Computer-based therapy for adults with depression or anxiety (‘Beating the Blues’)
Proudfoot et al, Brit J Psychiatry 2004; McCrone et al, Brit J Psychiatry, 2004
McCrone et al, Brit J Psychiatry 2004
‘Beating the Blues’: Cost differences over 8-month follow-up period
o BtB is more costly to the health service than standard treatment …
o … but even so, the additional cost is small compared to the outcomes achieved …
o … and the cost per incremental outcome gain was low (e.g. cost per additional depression-free day = £2.50; cost per additional QALY = £2190)
o Plus BtB had strong effects on employment … and looks highly cost-effective from a wider societal perspective.
[Note: Later influence of CBT modelling study on IAPT policy; making the economic case was probably pivotal]
‘Beating the Blues’: cost-effectiveness conclusions
McCrone et al, Brit J Psychiatry, 2004; Layard, Clark, Knapp, Mayraz NIER 2007
o Individual placement and support (IPS) for people with serious mental illness (SMI) compared to good quality ‘standard’ vocational rehabilitation services.
o N = 312 people with SMI (80% schizophrenia; 17% bipolar) across six European sites: London, Ulm, Rimini, Zurich, Groningen, Sofia. [The EQOLISE trial]
o RCT; 18-month follow-up.
Individual placement and support (IPS) vs standard vocational rehabilitation
IPS = involves rapid job search based on individual preferences; placement; support from ‘job coach’ to individual and employer; small caseload (max 25) for people who want to secure ‘open/competitive’ employment.
Burns et al Lancet 2007; Knapp et al World Psychiatry 2013
EQOLISE trial in six European cities: IPS was more effective than vocational services
Burns et al Lancet 2007
Site (results using imputed costs)
Additional cost per additional 1% of
people working at least 1 day
Additional cost per additional
day worked
Overall (6 sites together)
IPS more effective and less costly
IPS more effective and less costly
London
IPS more effective and less costly
IPS more effective and less costly
Ulm
Rimini
Zurich
Groningen £2754 / 7.7% = £358 £2754 / 24 days = £114
Sofia IPS more effective and less costly
IPS more effective and less costly
EQOLISE: cost-effectiveness results
Knapp et al World Psychiatry 2013
Modelling 15 mental health interventions Each was evidence-based – known to be effective. But what was the economic case?
Measured economic impacts as widely as possible for as long as possible using secondary data.
All estimates were cautious / conservative; discounted back. Any ‘economic pay-offs’ were over and above the health and quality of life benefits to individual patients/users
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Interventions examined – promotion & prevention
NHS
Other public sector
Non-public sector
Total
Early identification and intervention as soon as mental disorder arises
Early intervention for conduct disorder
Health visitor interventions to reduce postnatal depression
Early intervention for depression in diabetes
Early intervention for medically unexplained symptoms
Early diagnosis and treatment of depression at work
Early detection of psychosis
Early intervention in psychosis
Screening for alcohol misuse
Suicide training courses provided to all GPs
Suicide prevention through bridge safety barriers
Promotion of mental health and prevention of mental disorder
Prevention of conduct disorder through social and emotional learning programmes
School-based interventions to reduce bullying
Workplace health promotion programmes
Addressing social determinants and consequences of mental disorder
Debt advice services
Befriending for older adults
Interventions examined – promotion & prevention
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Breadth of potential pay-off considered
NHS
Other public sector
Non-public sector
Total
Early identification and intervention as soon as mental disorder arises
Early intervention for conduct disorder Health, education, crime, social care
Health visitor interventions to reduce postnatal depression
Mothers’ health care and employment; only for 1 year.
Early intervention for depression in diabetes Health care, productivity gains
Early intervention for medically unexplained symptoms Health care, productivity gains
Early diagnosis and treatment of depression at work Health care, productivity gains
Early detection of psychosis Health, homicide, suicide, work
Early intervention in psychosis Health, crime, suicide, educ’n, work
Screening for alcohol misuse Health, productivity, crime
Suicide training courses provided to all GPs Self-harm, death, grief, productivity
Suicide prevention through bridge safety barriers Self-harm, death, grief, productivity
Promotion of mental health and prevention of mental disorder
Prevention of conduct disorder through social and emotional learning programmes Health, education, crime, social care
School-based interventions to reduce bullying Health, education, social care, crime
Workplace health promotion programmes Health care, productivity gains
Addressing social determinants and consequences of mental disorder
Debt advice services Health, legal, local economy, work
Befriending for older adults Health care only
Breadth of potential pay-offs in the models
o EI teams – psychiatrists, clinical psychologists, community psychiatric nurses, occupational therapists and health care assistants.
o Access available 365 days a year. Care includes low-dose atypical antipsychotics, CBT, family counselling and vocational therapies (Craig et al 2004).
Economic case?
o Net savings of £7,972 per person after 3 years, mostly to the NHS, but some through employment
o Over a 10-year period, £15 in costs can be avoided for every £1 invested.
Park et al, Early Intervention in Psychiatry 2014
Example: early intervention (EI) teams for psychosis
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Target - working-age adult population accessed through their place of employment
Multi-component health-promotion programme, including health risk appraisal and information and advice tailored to employee’s readiness to change health-related behaviours. Cost = £80 employee p.a.
Outcomes – Strong evidence from US and Australia. Some evidence in UK of reduced stress levels and absenteeism, and improved productivity (Mills et al 2007).
Economic pay-offs: o Reductions in sickness absence and presenteeism;
reduced costs of avoidable mental health problems to NHS
o Total savings = £9.69 for every £1 invested, mostly accruing to employers
McDaid et al, in Knapp et al DH report 2011; Mills et al Am J Health Promotion 2007
Workplace well-being programmes
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Economic pay-offs per £1 investment
NHS
Other public sector
Non-public sector
Total
Early identification and intervention as soon as mental disorder arises
Early intervention for conduct disorder 1.08 1.78 5.03 7.89
Health visitor interventions to reduce postnatal depression 0.40 - 0.40 0.80
Early intervention for depression in diabetes 0.19 0 0.14 0.33
Early intervention for medically unexplained symptoms 1.01 0 0.74 1.75
Early diagnosis and treatment of depression at work 0.51 - 4.52 5.03
Early detection of psychosis 2.62 0.79 6.85 10.27
Early intervention in psychosis 9.68 0.27 8.02 17.97
Screening for alcohol misuse 2.24 0.93 8.57 11.75
Suicide training courses provided to all GPs 0.08 0.05 43.86 43.99
Suicide prevention through bridge safety barriers 1.75 1.31 51.39 54.45
Promotion of mental health and prevention of mental disorder
Prevention of conduct disorder through social and emotional learning programmes 9.42 17.02 57.29 83.73
School-based interventions to reduce bullying 0 0 14.35 14.35
Workplace health promotion programmes - - 9.69 9.69
Addressing social determinants and consequences of mental disorder
Debt advice services 0.34 0.58 2.63 3.55
Befriending for older adults 0.44 - - 0.44
Economic pay-offs per £1 invested in each intervention
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
Men Women
Not using anypaid servicesUsing at least onepaid service
Employment rates of carers providing unpaid care for 10 or more hours a week, England
Carers under State Pension Age; data for 2009/10.
Pickard, King, Brimblecombe, Knapp, Journal of Social Policy forthcoming
o Carers are more likely to be in employment if the cared-for person receives paid (‘formal’) services (after controlling for key factors)
o Use of home care and help from a personal assistant are associated on their own with carers’ employment.
o Use of day care and meals-on-wheels are associated on their own with female carers’ employment
o Use of short-term breaks is associated with carers’ employment when combined with other services.
Does ‘replacement care’ help carers stay in employment? Findings from England
Pickard, King, Brimblecombe, Knapp, Journal of Social Policy forthcoming
Issues & challenges
Challenges: - Multiple, complex links - Methodological issues - Policy issues
Links run in both directions:
oIll-health / disability can cause employment problems
oPoor employment experiences can cause ill-health / disability
Policy initiatives must break into this (sometimes vicious) cycle
Links are also mediated by many things:
oIndividual characteristics – e.g. skills, preferences, resilience
oEmployment factors – e.g. employer attitudes, bullying etc.
oHealth system structure - entitlements, access, quality, etc.
oHealth professionals – attitudes, awareness etc.
oWelfare benefits – generosity, eligibility rules, etc.
oSocietal factors – e.g. stigma, attitudes, etc.
Links between health and employment
Each of these links and mediating factors is both:
- methodological complication
- and potential policy lever
The consequences of most of these links is to push up costs.
But actions to address them will also require resources.
Cost-effective strategies have been found in some areas.
o Designing robust evaluations to generate reliable findings …
o … but without making policy-makers wait years for results.
o Measuring impacts that are widely spread across sectors…
o … and that take many years to show full impact.
o Being able to attribute effects to causes – e.g. making confident long-term links in complex circumstances …
o … and then being able to provide policy-makers with accurately calibrated levers.
o Deciding on the real cost with less-than-full employment.
o Deciding on the real benefit with marginalised groups.
o … and probably many other methodological issues.
Some methodological issues
o Prevent or react? (Or what balance between them?)
o Employment-focused or generic? (Or what balance?)
o How to change negative attitudes of professionals?
o And societal attitudes and prejudices?
o Efficiency is an important goal, but not the only one …
o … e.g. generosity (say, with welfare benefits) can create the ‘wrong’ disincentives.
o Negotiating across sectors/budgets is always challenging
o Investing for the longer-term is also tough when pressures are immediate
o … and there are undoubtedly many other policy issues.
Some policy issues
