The cost-effectiveness of early care by dedicated teams for chronic mental health conditions: results from the Oxford-CLAHRC on Early Intervention Psychosis services in England

Abstract

Introduction: Psychosis is a common and severe mental illness, with a large health and economic impact on societies worldwide. The earlier the illness is treated the better the long term outcomes. In England, Early Intervention in Psychosis (EIP) services have been introduced over the last 15 years to address this problem and they are included in the new Access and Waiting time standard in England published in April 2015. This standard mandates that all those with first episode psychosis should be treated within an EIP service within 2 weeks. They differ from standard community care in that they provide continuity across child and adult services, cognitive behavioural therapy, family interventions, assertive community treatment and vocational and educational support for early recovery. However, evidence about the effectiveness and cost-effectiveness of EIP services in England is inconclusive and their implementation is variable. We therefore undertook a health economic evaluation of EIP services to demonstrate the costs and outcomes associated with these services.Methods: We used routinely collected data (pseudonymised physical and mental health data licensed from the HSCIC – HES and MHMDS) of 4,104 patients with psychosis to compare the costs and effects of EIP services with other community mental health teams over a 3-year period (Apr 2010 – Mar 2013) in Thames Valley. Psychosis patients were identified using a combination of ICD-10 diagnosis codes, Mental Health Payment by Results Clusters and Health of the Nation Outcome Scales. The sample consisted of 923 patients were treated under EIP service and 3,181 patients were under standard community care. The analysis included the costs of acute hospital emergency (A&E) visits, length of stay in mental health hospital ward and acute care hospital wards, and community care services. Outcomes were measured in terms of getting employed and moving to mainstream housing during the follow-up period. Generalised Estimating Equations and Generalised Linear Models were used in the analysis and Propensity Score Matching was used to correct for confounding between the compared services.Results: EIP services resulted in on average saving of £1,761 (13%) in healthcare costs (p=0.059) compared to standard community care. This annual saving is translated into £32 (32%) less A&E costs (p<0.001), £378 (11%) higher community care costs (p=0.139), £1,295 (18%) less hospitalization costs in mental health wards (p=0.038), and £811 (28%) less hospitalization costs in physical health wards (p=0.010). In the outcomes side, patients in EIP services had about twice (109%) as much probability (p<0.001) to get employed over the 3-year period than patients in other community mental health teams. Among employed patients, EIP services increased the probability for patient to move to mainstream housing during the 3-year period by 63% (p=0.002).Discussion: The findings of this study show that EIP services save costs for the NHS. Considering that there are approximately 17,000 first episodes of psychosis each year in England, EIP services could save NHS about £30 million per year. The savings are higher when reduced social care costs due to higher mainstream housing and productivity gains due to higher employment are added. Considering the ability of patients with psychosis to live independently (i.e. to have a paid job and live in mainstream housing) as an indicator of health status, EIP services are also cost-effective.The results are in line with the findings from an RCT undertaken in 110 participants (LEO study), which identified cost savings associated with EIP services although the primary outcome measure of reduced admission did not reach significance. The strengths of this current study include the large dataset and the statistical techniques to analyse panel data and to control for confounding. Future cost-effectiveness studies of EIP services should include patient health outcome measurements and detail of the interventions provided within services, to try and identify the necessary components for a successful outcome.Integrating adolescent and adult mental health services and introducing complex interventions such as EIP services into routine clinical practice can improve patient health and reduce health and social care costs to the same extent as shown in RCT. This is an important finding for health services researchers, commissioners of healthcare and healthcare professionals.Conclusion: Our study suggests that EIP services, as implemented in the NHS in England, are cost saving and likely to be cost-effective. They could save the NHS about £30 million per year.