Summary of the impact

Research on the economic case for interventions to prevent mental illness, to address mental health needs and to promote mental wellbeing has been conducted by the Personal Social Services Research Unit (PSSRU) in the LSE Health and Social Care group with demonstrable impact on government policy in England and beyond. Research has influenced preparation of the National Dementia Strategy for England and the Prime Minister's Challenge on Dementia; underpinned the establishment of the Improving Access to Psychological Therapies (IAPT) programme; and generated part of the evidence base for the emphasis in the 2011 English mental health strategy on promoting mental health and preventing mental illness. The work has also influenced discussion led by the World Health Organization (WHO) and European Parliament.

Underpinning research

Research Insights and Outputs: The Unit's work builds on a framework for economic evaluation and policy analysis developed over two decades (1) to generate empirical evidence (a) to provide a platform for policy and practice discussion and development, and (b) to establish individual and community impacts of meeting mental health needs and improving wellbeing. Three specific areas of research are highlighted.

A team led by Martin Knapp (jointly with King's College London) produced the Dementia UK report, examining care patterns for people with dementia, pointing to unacceptably wide variations across the UK, estimating and projecting numbers of people with dementia (and associated costs), and discussing implications for health, social care and related policy (2). Follow-up analyses were carried out at the request of the National Audit Office (NAO). Macro-simulation modelling projected future costs of dementia care and support as a basis for exploring policy and practice scenarios (3). The Unit costed some `Actions' recommended by the External Reference Group for the National Dementia Strategy in England, working alongside the National Clinical Director, Sube Banerjee (4).

In partnership with Richard Layard at the LSE's Centre for Economic Performance (and with some input from David Clark, Oxford University), the PSSRU evaluated the economic impacts of widening access to psychological therapies, particularly cognitive behaviour therapy (CBT) for common mental disorders (5). Analyses showed the overwhelming economic case for improving access to evidence-based therapies. Subsequent research demonstrated a strong economic case for CBT in other contexts (6).

The Unit also examined the economic case for investing in the promotion of mental health and prevention of mental disorder (with small inputs from KCL), analysing the level and distribution of costs and economic pay-offs of fifteen mental health interventions for the DH (6). Each intervention was already accepted as effective (in terms of disorder prevention, symptom alleviation or improved quality of life). The Unit's new research, conducted in close association with government officials and others, built economic models to examine whether interventions were cost-effective and affordable. Areas examined included: parenting programmes to address persistent child anti-social behaviour; early detection and early intervention for psychosis; primary care screening and brief intervention for alcohol misuse; early diagnosis and treatment of common mental disorders in the workplace; debt counselling; collaborative care for depression in individuals with diabetes; treatment of medically unexplained symptoms; and befriending of older adults. Modelling for each area showed a strong economic case for the interventions examined. For example, parenting programmes generate economic benefits over many years and sectors (better health, less crime, less substance misuse). Workplace screening and treatment is cost-beneficial for employers as well as the Exchequer. Findings on early intervention for psychosis (6) reinforced messages from previously influential PSSRU research (7) that specialist teams save the NHS and wider economy substantial sums of money, while improving health and quality of life. A parallel study commissioned by the DH examined community capacity-building initiatives, finding that community navigators, time banks and befriending schemes encourage volunteering, increase employment and meet social care needs, each generating economic benefits (8).

Key researchers: Martin Knapp (LSE since January 1996, .8 FTE), David McDaid (since January 1997, .5 FTE), Raphael Wittenberg (since January 1996, .5 FTE), Adelina Comas-Herrera (since January 1996, .8 FTE).

References to the research

Evidence of quality: References 3, 4, 5, 7 and 8 are peer-reviewed journal articles. Peer-reviewed grants awarded include: Martin Prince (KCL), Martin Knapp (LSE): Dementia in the UK, Alzheimer's Society, May 2006 — February 2007 (£30,000 overall, £3,125 to LSE).

Details of the impact

Nature of the Impact: The Dementia UK report (2) highlighted widespread problems with care arrangements for people with dementia, and set in train a process that led to the National Dementia Strategy for England (A). Dementia UK received substantial national and international media coverage (including lead story on BBC TV and radio news on launch day (February 2007)). The (then) National Clinical Director and co-author of the Strategy reflected: `In the UK, the process [of policy action] was initiated by the Alzheimer's Society commissioning an independent report from the LSE and the Institute of Psychiatry, King's College London, entitled: The Dementia UK report' (B). The new prevalence and cost projections, the evidence on care variations across the country, and the case for improving service quality were among findings of Dementia UK heavily cited by the NAO (C), prompting the Government to develop its 2009 National Strategy (A) and its 2010 regulatory impact assessment (D). Dementia UK continues to be widely cited, e.g. in the NAO's 2010 follow-up report (E), the 2010 Public Health White Paper (F) and the 2011 Mental Health Strategy (G).

The Prime Minister's Challenge on Dementia built directly on the 2009 National Strategy; in launching it, David Cameron quoted from Dementia UK (H). A recent progress report on the PM's Challenge twice cited the report (I). Outside England, the report has informed policy discussions by, for example, the World Health Organization (J). The Unit was also commissioned by the All Party Parliamentary Group on Dementia to review evidence on cost-effective dementia care; this report again cites Dementia UK (K). By bringing together robust evidence and analysis on many topics, Dementia UK highlighted practice challenges for a future that will be heavily influenced by a rapidly ageing world population, and has directly informed the development of policy.

The Unit's modelling of the economic consequences of common mental disorders and their treatment with psychological therapies (5) started in 2004 and influenced the Labour Party's decision to make access to psychological therapy (specifically CBT) a manifesto commitment in 2005. Following the General Election, this became a major plank of health policy: the Government's Improving Access to Psychological Therapies (IAPT) programme started with ten pathfinder sites in 2006/07 and was followed by 32 implementation sites in 2008/09 (with £173m invested over three years). The Unit's 2011 report on mental health promotion and mental illness prevention (6) was subsequently cited in a Coalition Government document that supported the extension of IAPT with £400m over a further four years (L). The IAPT is widely viewed as a success in greatly improving access to evidence-based psychotherapy for people with mental health needs, thereby improving their quality of life and reducing workplace absenteeism, unemployment and long-term NHS costs.

The Unit's work on costs and economic pay-offs from fifteen separate interventions (6) and on community capacity-building (8) provided key inputs to the Government's 2011 mental health strategy for England, which was intended to promote mental health and prevent mental disorder. The accompanying impact assessment (G) cited this research heavily: `The best practice examples presented in this Strategy are based on analytical work done by the London School of Economics' (p.14). The impact assessment used 9 of the 15 economic models in the Unit's report (6) and another 2 models from parallel work (8). A further DH document explored the economic case for improving efficiency and quality in mental health through the Government's new policy framework (M); 26 of 99 citations in the document were to PSSRU research. The report (6) was cited in guidance for general practitioners published by the NHS Confederation jointly with a number of mental health charities and service providers (N) and heavily cited by the Joint Commissioning Panel for Mental Health (O). Along with other work by the Unit, the 2011 programme of research was also cited in the Mental Health Strategy for Scotland 2012-2015 (P).

The Unit's research on suicide prevention (part of ref. 6) was used in the Coalition Government's suicide prevention strategy for England, which, when citing the Unit's work, noted that `suicide prevention education for GPs ... has the potential to be cost-effective if it leads to adequate subsequent treatment' (Q, p.17). The research is also reaching policy-makers internationally; e.g., it was highlighted in a WHO report to justify investing in mental health (R); the Unit was invited to present its work to European Parliamentary Committees (S); and to draft a background report for a `High Level EU/German Government Conference' on mental health promotion in workplaces (T). Across the full programme, PSSRU's research has provided strong support for introducing, expanding or protecting (in the face of budget cuts) a range of interventions that have considerable potential to improve mental health and wellbeing.

Wider Implications: At any one time, mental health problems affect at least one in six adults; for half these people the problem will last longer than one year. Consequences include enormous distress for the individuals and families concerned, damaged life chances, disproportionately high contributions to total disability burden, and huge economic impacts through lost or disrupted employment and the costs of treatment and care. The Unit's research has contributed to the development of policy frameworks and practice responses by offering robust economic evidence to help decision-makers achieve bigger and fairer impacts from available societal resources.

Sources to corroborate the impact

All Sources listed below can also be seen at https://apps.lse.ac.uk/impact/case-study/view/59

A. Department of Health (2009) Living Well with Dementia: A National Dementia Strategy. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168220/dh_094051.pdf [see pages 16, 34, 77, 94]

B. Banerjee S (2012) The macroeconomics of dementia — will the world economy get Alzheimer's disease? Archives of Medical Research, 43(8), 705-709. [quote from p.707]
http://www.sciencedirect.com/science/article/pii/S0188440912002883

C. National Audit Office (2007) Improving Services and Support for People with Dementia. London: TSO [pages 4, 6, 7, 12, 13, 14, 15, 16, 17, 18, 19, 26, 51, 54].
http://www.nao.org.uk/wp-content/uploads/2007/07/0607604.pdf

D. Department of Health (2010) Impact Assessment of National Dementia Strategy. London: DH [see pages 4, 7, 13, 16, 22 for references to PSSRU work or to figures taken from the Dementia UK report (reference 2 in section 3 above)].
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168223/dh_094055.pdf

E. National Audit Office (2010) Improving Dementia Services in England: an interim report. London: TSO [see pages 4, 5, 14, 15, 19]. http://www.nao.org.uk/wp-content/uploads/2010/01/091082.pdf

F. Secretary of State for Health (2010) Healthy Lives, Healthy People: Our Strategy for Public Health in England. CM 7985. London: TSO [see page 21].
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216096/dh_127424.pdf

G. Department of Health (2011) Impact Assessment. No health without mental health: a cross government mental health strategy for people of all ages. London: DH [all impact case studies in this document build on PSSRU research].
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf

H. David Cameron's speech to the Dementia 2012 Conference, 26 March 2012. Transcript is on No.10 website (http://www.number10.gov.uk/news/dementia-challenge/).

I. Department of Health (2012) The Prime Minister's Challenge on Dementia: Delivering major improvements in dementia care and research by 2015. A report on progress. London: DH https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215101/dh_133176.pdf [see pages, 2, 6]

J. World Health Organization (2012) Dementia: A Public Health Priority. Geneva: WHO http://www.who.int/mental_health/publications/dementia_report_2012/en/ [pp. 15, 20-21, 24]

K. All Party Parliamentary Group on Dementia (2012) Unlocking Diagnosis: the key to improving the lives of people with dementia. London [see page 22].
www.alzheimers.org.uk/site/scripts/download.php?fileID=1457

L. Department of Health (2011) Talking Therapies: A Four-Year Plan of Action. A supporting document to No Health without Mental Health. London: DH [see page 19].
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213765/dh_123985.pdf

M. Department of Health (2011) The Economic Case for Improving Efficiency and Quality in Mental Health. London: DH [26 out of a total of 99 citations are to PSSRU research].
https://www.gov.uk/government/publications/the-economic-case-for-improving-efficiency-and-quality-in-mental-health

N. Mental Health Strategic Partnership (2011). No health without mental health: a guide for general practice. London: the author [see page 2].
http://www.mentalhealth.org.uk/content/assets/PDF/105151/Web_Mental_Health_Strategic_Partnership_GPs.pdf

O. Joint Commissioning Panel for Mental Health (2012) Guidance for Commissioning Public Mental Health Services. London: JCPMH (Royal College of Psychiatrists, Royal College of General Practitioners, Association of Directors of Adult Social Services and other bodies) [pages 3, 9, 11, 12, 13, 31, and Appendix E]. http://www.rcpsych.ac.uk/pdf/jcpmh-publicmentalhealth-guide[1].pdf

P. The Scottish Government (2012) Mental Health Strategy for Scotland 2012-2015. Edinburgh: [see pages 12, 20, 46]. http://www.scotland.gov.uk/Resource/0039/00398762.pdf

Q. HM Government (2012) Preventing Suicide in England; A Cross-Government Outcomes Strategy to Save Lives. London: DH [see page 17].
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216928/Preventing-Suicide-in-England-A-cross-government-outcomes-strategy-to-save-lives.pdf

R. World Health Organization (2013) Investing in mental health: making the case for a renewed public health commitment. Geneva: WHO [see page 12].
http://apps.who.int/iris/bitstream/10665/87232/1/9789241564618_eng.pdf

S. European Parliament Environment, Public Health and Food Safety Committee (2012) Report on Mental Health in Times of Economic Crisis Workshop. Brussels: Policy Department, http://www.europarl.europa.eu/document/activities/cont/201206/20120618ATT47063/20120618ATT47063EN.pdf [see pages 29 and 31].

T. Background Document for EU Thematic Conference: Promotion of Mental Health and Wellbeing in Workplaces. Berlin: Federal Ministry of Labour and Social Affairs, Federal Ministry of Health, European Commission.
http://ec.europa.eu/health/mental_health/docs/ev_20110303_bgdoc_en.pdf