Martin Knapp

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CPHVA Torquay 31 October 2007
The Economic Consequences of Missed Opportunities

• Martin Knapp Pon-Hsiu Yeh
• PSSRU, London School of Economics
• Institute of Psychiatry, Kings College London

2
Health visitors can be effective

• Parenting skills and quality of the home
  environment
• Amelioration of child behavioural problems,
  including sleeping behaviour
• Improved intellectual development, esp. with low
  birth weight or failure to thrive
• Reduction in frequency of unintentional injury,
  and reduction in prevalence of home hazards
• Improvements in detection and management of
  postnatal depression
• Enhancement of quality of social support to
  mothers
• Improved rates of breastfeeding

Elkan et al HTA 2000
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but are they cost-effective?

• The cost for a health visitor per hour of client
  contact 72 (and is 84 if proper allowance
  made for training etc)
• The costs of referrals on to other professionals
  or services can be high
• Some (many?) families dont really need health
  visitor support but currently get it
• And some (many?) could afford to pay for it
  themselves
• And resources are scarce there is never enough
  to meet all needs or demands
• So we need to think cost-effective Is it
  worth spending money to prevent or treat?

Crunch question Is it worth it?
4

• 1

• Economics. So why is it relevant?

• Scarcity
• Rationing
• Careful choice

5

• 2

• Health visitors and postnatal depression

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Health visitors can help women with postnatal
depression

• HVs are effective in identifying PND and
  referring on to GP or others Numerous studies
  reviewed by Elkan et al. 2000
• HVs delivering psychological therapies can help
  to reduce symptoms E.g. Jane Morrells recent
  study of CBT or person-centred approach
• Preventive counselling begun antenatally for
  women at high risk, plus postnatal support and
  counselling up to 8 weeks reduces duration of
  symptoms Lynne Murrrays study in Reading

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And some evidence of short-term cost-effectiveness

• Lynne Murrays trial of preventive counselling
  and postnatal support and counselling
• significantly reduced duration of depression by
  2 weeks over 18 months
• but (non-significantly) increased health and
  social care costs by 120

Crunch question Is it worth it?
Petrou et al IJTAHC 2006
8
And some evidence of short-term cost-effectiveness

• Lynne Murrays trial of preventive counselling
  and postnatal support and counselling
• significantly reduced duration of depression by
  2 weeks over 18 months
• but (non-significantly) increased health and
  social care costs by 120
• The cost per additional depression-free day was
  1.42
• and this high probability of being seen as
  cost-effective by decision makers

Petrou et al IJTAHC 2006
9

• 3

• Depression has longer term and wider effects and
  costs

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Costs of depression (adults) in England, 2000
Excluding morbidity costs
Thomas Morris Brit J Psychiatry 2003
11
Cost of depression (all adults) in England, 2000
Total cost 9 billion
Thomas Morris Brit J Psychiatry 2003
12

• 4

• Postnatal depression harms children

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Maternal depression has harmful effects on
children 2 examples

• Lynne Murray et al (1999) ? children at age 5 did
  less well in relation to
• behaviour with mother
• behavioural disturbance at home
• content and social patterning of play at school
• Dale Hay et al (2001) ? children at age 11 did
  less well in relation to
• IQ
• attentional problems
• mathematical reasoning
• Special educational needs

Murray et al JCPP 1999 Hay et al JCPP 2001
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And these child effects are costly - persistent
antisocial behaviour
Total cost excluding benefits averaged 5960 per
child per year, at 2000/01 prices (benefits
4307)
Romeo, Knapp Scott, Brit J Psychiatry, 2006
15

• 5

• Adverse childhood effects have long-term impacts

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Example 1 the Inner London Longitudinal Study

• Study of all 10-year olds in part of London in
  1970 (Michael Rutter)
• Teacher ratings, child questionnaires
• Plus intensive further assessment of some
• At age 10
• No problems at school, no clinical diagnosis (65)
• Emotional problems at school, only (32)
• Emotional disorder (8)
• Antisocial behaviour at school, only (61)
• Conduct disorder (16)
• Followed up at age 26-28
• Later we calculated costs from 10 to 28

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Costs in early adulthood from childhood conduct
disorder
Costs () from ages 10 to 28
Scott, Knapp, Henderson, Maughan, BMJ 2001
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Example 2 the 1970 British Birth Cohort Study

• 17,198 children born in UK during 1 week in April
  1970
• Subsequent collections at ages 5, 10, 16, 26, 30
• 11,261 people successfully followed up at age 30
• Andrew Healey (PhD thesis, LSE) What is
  connection between mental health problems at age
  10 and employment and income experiences at age
  30?

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BCS70 From age 10 to age 30 (adjusting for
baseline covariates)
Healey, unpublished results, LSE, 2005
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BCS70 From age 10 to age 30 (adjusting for
baseline covariates)
Healey, unpublished results, LSE, 2005
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• 6

• What needs to be done?

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What needs to be done?

• 1. Please dont shoot the messenger
• 2. But do heed the message
• Resources are scarce
• Rationing is inevitable (weve always had it)
• Economic analysis helps it is transparent,
  structured, has a rational basis, and is now
  widely accepted as a contributor to decision
  making
• 3. Sometimes there are quick fixes
• 4. But services that aim to set in place good
  parenting cannot be judged by just their
  short-term impacts
• 5. We need long-term social and economic
  perspectives on long-term social and economic
  challenges

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m.knapp_at_lse.ac.uk
www.pssru.ac.uk
www.iop.kcl.ac.uk and search on CEMH