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What Do We Mean When We Say ‘Such and Such a Problem Costs the Economy £XXm per Annum’?
When we treat a disease it has a net marginal cost – we will call it A, and assume it is positive, i.e. it costs the health service more than the counter-factual. It also has a benefit, measured perhaps in Quality-Adjusted Life Years (QALYs) or Disability-Adjusted Life Years (DALYs). A cost per DALY can then be calculated. If we know the value of a QALY (£20m in England, for example), then we can calculate the expected benefit in monetary terms. In England, an intervention providing an incremental 2.5 QALYs would represent a monetary value of 2.5 x 20 = £50k – call that B. Then the Expected Net Benefit is B – A; if the intervention has net mean costs of £30k per patient, then the ENB is £20k.
What’s wrong with that? Well nothing, unless the treatment is life-saving. In that case, insofar as the new treatment is effective, some patients who would have died now survive to generate health costs in the future. So strictly speaking the downstream (discounted) cost, C, should be included, so that Expected Net Benefit is B – A – C. This is never done, perhaps because it makes the dismal science just too dismal. In the case of individual clinical treatments alternative uses of the money may involve a treatment that saves a similar proportion of life years so downstream costs can be ‘pruned’. If not, then the treatment that saves more lives gets penalised, which seems wrong even if it is logical within the paradigm. But clinical treatments are one thing, calculating the societal cost of a disease is another. Here it seems particularly wrong to ignore downstream contingent costs unless these are very remote (say over 50 years), in which case discounting takes care of them. It is common, for example, for public health academics to claim that public health interventions, such as reducing salt or sugar in the diet, would save £XX million per year. Yet these calculations exaggerate returns to society because the costs of looking after survivors are ignored in the calculations. Many public health interventions would still be a very good investment even if downstream costs were included. So there is no need to exaggerate the benefit by ignoring downstream costs contingent on earlier deaths avoided.
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On October 26 1977 the last naturally occurring case of smallpox was diagnosed, and two years later the World Health Organization declared 'Smallpox Zero', to commemorate its eradication. But who was the last person to catch smallpox in the wild?
Email CLAHRC WM your answer.
Image from World Health Organization
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Answer to our previous quiz: The Nobel Prize in Economic Sciences 2016 was awarded to Oliver Hart and Bengt Holmström for their contributions to contract theory, described as key to the understanding of the real-life contracts and institutions that hold together modern economies. Read more.
Congratulations to Alan Hargreaves, Magdalena Skrybant and Hannah Dodd who all answered correctly.
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Director's Choice - From the Journals
Nobel and Lasker Prizes
Many years ago we posted an article on autophagy – the process by which cells reutilise their basic components. We cited research showing that a borderline starvation diet is associated with greater longevity in all species where it has been tried.[1] Intense exercise is also associated with widespread health benefits and prolonged life. Autophagy provides a link between these two sets of observations, since both calorie restriction and exercise induce and accelerate autophagy. News Blog readers will therefore be interested to learn that this year’s Nobel prizes for Medicine and Physiology was awarded for the discovery of the mechanisms for autophagy, originally in yeast, by Prof Yoshinori Ohsumi.
The Lasker award for Basic Medical Research went to the three researchers, one from Oxford, who discovered molecular pathways through which changes in oxygen levels provoke a response in cells. It turns out that mechanisms to sense and respond to ambient oxygen levels are present in all cells, not just those that manufacture erythropoietin. This story is quite complex, and readers are referred to a recent article in JAMA.[2]
-- Richard Lilford, CLAHRC WM Director
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Electronic Health Record System and Adverse Outcomes
Does introducing an electronic health record system in a hospital result in an increase in adverse outcomes? Seventeen hospitals were tracked over the ‘go live’ date to see if electronic records would affect risk-adjusted mortality or readmission rates.[1] The result was null – care neither improved nor deteriorated on the end-points observed. The CLAHRC WM Director’s comment is that these end-points are not sensitive to change, since the noise to signal ratio is poor. And, of course, the range of outcomes narrow – no mention here of any stress to patients or staff, for example. Nevertheless, these results are broadly reassuring, especially as the NHS is planning a big push on electronic notes following the Wachter review.[2]
-- Richard Lilford, CLAHRC WM Director
More on e-Cigarettes
An overview of this topic in the New England Journal of Medicine caught the eye of the CLAHRC WM Director.[1] A very short summary:
- Evidence that e-cigarettes are better than other pharmacological products in assisting people with quitting is not compelling according to the authors.
- The subject is hard to pin down because there are over 400 brands each of a different chemical composition.
- Compared with tobacco smoke, e-cigarette vapour is almost certainly less toxic.
- E-cigarette vapour contains many known toxins, such as formaldehyde and acetone. So it is more toxic than air.
Should they be banned? Certainly not. Should a product warning that the health effects are unknown and there is a material risk be mandated? Certainly.
-- Richard Lilford, CLAHRC WM Director
The School, the Teacher, or the Pupil – Which is Most Important?
News Blog readers will know that the CLAHRC WM Director takes a critical look at Hattie’s monumental overview of evidence-based education in most of our posts.[1-4] Today let’s look at a fundamental question Hattie addresses in the monograph – the question of how much of the variance in educational outcomes resides in the pupil, the teacher, or the school. Not surprisingly this has been looked at many times. It is a little like separating the components of variance in the outcome of surgery according to the patient, the surgeon, and the hospital. Hattie [5] quotes a meta-analysis by Marzano who found that the lion’s share (80%) of variance in achievement was accounted for by student level variables, the smallest share (7%) by school effects, and an intermediate share by teachers (13%). Of course, as we shall see in future blogs based on Hattie’s work, this is not the end of the story. For instance, student effects include the effect on the student of previous education – i.e. previous teachers are consolidated within the student component of variance. More important still, is the effect of parents / guardians, since this is also consolidated within students in cross-sectional studies. We will look at unravelling these factors in future news blogs. In the meantime, we can say that ineffectual teachers have a negative effect on achievement, no matter how good the school, and exceptional teachers can more than compensate for a rubbish school.
-- Richard Lilford, CLAHRC WM Director
More Null Results for Arthroscopic vs. Conservative Surgery
for Degenerative Meniscal Tears
News blog readers know that that the CLAHRC WM Director concentrates on general rather than specific issues. However, we have featured articles on invasive vs. surgical therapies for meniscal cartilage injuries in the knee – justified perhaps by the high incidence of the condition and of the fact that the CLAHRC WM Director has had this surgery. Anyway, yet a further RCT has added evidence that any benefits of surgery over conservation treatment are ‘minute’.[1]
-- Richard Lilford, CLAHRC WM Director
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It's Never Too Early: Policy Implications From
Early Intervention in Youth Mental Health
Two pieces of news may have escaped your attention in recent months: the first was that in the post-Brexit cabinet re-organisations, the Secretary of State for Health, Jeremy Hunt, picked up the responsibility for mental health, which had previously been separated from the health portfolio. This resulted in barely a mention in the mainstream media and has not resulted in any perceptible changes in policy… yet.
The second piece of news was last week, and featured prominently in the Health Services Journal, but to my surprise seemed to make very little impact in the national news. Jeremy Hunt described children’s mental health services as “the biggest single area of weakness in NHS provision at present”. When you stop to consider the breadth and depth of challenges facing the NHS at present, to single out this oft overlooked area so starkly came as a surprise, albeit a welcome one.
Of course, bold statements are one thing and actions another, but there seemed to already be early seeds of policy initiatives creeping in to the detail of the statement, along with the suggestion that this was a particular area of concern for the Prime Minister Theresa May. The statement highlighted the need for early intervention for children with mental health problems and suggested closer working between Child and Adolescent Mental Health Services (CAMHS) and schools, as well as the challenges that exist within the 16-24 year old age group and the need to address this gap in service for particular conditions. Interestingly, some of these issues have also been brought to the fore in policy documents issued by the Clinton Presidential campaign in the United States.
All this bodes well for the Youth Mental Health theme of CLAHRC West Midlands. CLAHRC researchers though both this CLAHRC and the previous incarnation of CLAHRC Birmingham and Black Country have worked on a variety of projects whose research could help provide an evidence base for policy formulation. These include the redesign of youth mental health services to improve access; early intervention in first episode psychosis; the impact of schools on mental health (see also youthspace.me), and interventions within the 0-25 age range.
Professor Max Birchwood, Theme lead for the Youth Mental Health theme commented “It’s great to see this important area of health receiving national attention and mirroring many elements of the research undertaken by CLAHRC BBC and now CLAHRC WM. We look forward to playing an active role in contributing to the discussion and helping to shape future guidance and policy in this area”.
— Paul Bird, CLAHRC WM Head of Programme Delivery (Engagement)
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From Global to Local: How Patient and Public Involvement is
Shaping Mental Health Services in CLAHRC West Midlands
Each year, World Mental Health day draws attention to the many issues people with mental health issues need to overcome on a daily basis. Although there are effective treatments for mental health disorders, such as medication and therapies, it is important that people can access the right care at the right time.
There are many stigmas associated with having a mental health disorder, which impact on people disclosing that they have a problem in the first place and then accessing the right treatment as early as possible. In the UK, NICE quality guidelines, which were informed by research undertaken by CLAHRC WM, recommend that 50% of people of all ages who experience psychotic symptoms for the first time should be treated with a NICE approved care package within two weeks of a referral. However, researchers in CLAHRC WM’s Prevention and Early Intervention in Youth Mental Health theme found that young people were not always accessing the services they needed, particularly as they were making the transition from child to adult mental health services. This was due to a number of reasons, including poor help-seeking behaviour, and bottlenecks in specialist mental health services. You can read more about this research here.
Having identified a need to improve access for mental health services for young people in the region, CLAHRC WM researchers work in partnership with patient and public advisers to deliver research that is both meaningful and accessible to them. In particular, CLAHRC WM researchers work with existing patient and public groups in the region to co-design and develop services that are appropriate for the young people that will use them. These groups included the Young Person’s Advisory Group, facilitated by the Clinical Research Network, and the Youth Board (recently renamed Ripple), a group of people aged 16-25 years old, some of whom have lived experiences of mental health issues.
As with all projects within CLAHRC WM, patients and the public can work with researchers in all stages of the research cycle: from coming up with ideas of what research to do, right through to making sense of research findings and sharing these with relevant networks. Readers of the News Blog will have read about how researchers and young people worked with primary care and Child and Adolescent Mental Health Services (CAMHS) to create an effective and appropriate youth clinical service to meet local needs, reduce delays, improve transitions between services, and adopt a preventative triaged intervention model. This new service is delivered by the Forward Thinking Birmingham Partnership.
Young people working in partnership with CLAHRC WM are essential to ensuring that the services both meet the needs of the people who will use them, and are also designed in the right way. Some examples of how CLAHRC WM has involved patients and the public are:
- Designing and developing www.youthspace.me, an online resource that offers relevant, up-to-date information and advice for young people and their families on all aspects of mental health. Young people helped to design the pages, write content and ensure that the language is accessible.
- Helping to raise awareness of mental health issues through designing materials for public campaigns such as ‘Don’t Stay Silent’ and ‘Don’t turn your back on the symptoms of psychosis’.
- Celebrating the successes of the new care pathway through ‘Shout Out for Youth Mental Health’, an event held in Birmingham on 7 June 2016. Young people had an active role in planning the day and facilitating the sessions. Challenges of living with mental health disorders were brought to life through dance and poetry performances by young people, and young people’s willingness to share their experiences emphasised the need to ensure mental health services are accessible and acceptable. You can read more about the event here.
- Participating in an educational randomised controlled trial in secondary schools across Birmingham to reduce stigma and increase mental health literacy in young people.
Researchers in CLAHRC WM’s Youth Mental Health theme work with Patient and Public Advisers, Barry Clark, Keith Elder and Richard Grant, to ensure that benefits of working with patients and the public in research are maximised. Bringing a wealth of experience and knowledge, our Advisers have not only helped to shape PPI strategies within the theme, but have engaged local networks and communities about the research undertaken by CLAHRC WM in youth mental health. Working in partnership with patient and public advisers ensures that key findings from research are accessible and have impact.
One of the current projects underway in the Youth Mental Health theme is SchoolSpace, a partnership with CLAHRC WM researchers and schools to understand the factors which precede the onset of eating disorders. With growing need for schools to concern themselves with the well-being of their students, researchers in CLAHRC WM are working with schools to design effective screening tools and interventions for teachers and those who work with young people. Our PPI Advisers have worked closely with researchers to help ensure the successful development and implementation of SchoolSpace.
On World Mental Health day, some of the twitter hashtags were #timetotalk and #timetochange. CLAHRC WM researchers are doing their bit by talking and listening to people that use the services and working in partnership with them to deliver change. By working ‘with’ young people, patients and the public, rather than ‘to’ or ‘for’ them, CLAHRC WM has demonstrated the value of meaningful patient and public involvement. Not only is the research undertaken relevant: people using the service have had a key input into the way research is shaped and delivered. Involving people at every stage at the research cycle has benefits including healthy participation rates and widespread dissemination. Most importantly, partnership with patients and the public has led to outcomes that are suitable and of benefit to people using the service, resulting in better care. CLAHRC WM is doing its utmost to ensure that we are removing stigmas to mental health and enabling people to access the right treatments and therapies as soon as possible.
-- Magdalena Skrybant, PPIE Lead
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Evaluating the Implementation of the
Birmingham Symptom specific Obstetric Triage System (BSOTS)
The Birmingham Symptom specific Obstetric Triage System (BSOTS) was created in April 2012 by researchers, clinicians, patients, and the public in CLAHRC WM’s Maternity and Child Health team. Before BSOTS, there was no standardised system to assess unscheduled pregnancy-related attendances: women were seen in the order they arrived rather than according to clinical need. Triaging of patients is used effectively in Emergency Departments and, in developing BSOTS, the clinical needs of both the mother and the baby were considered.
BSOTS was first implemented in Birmingham Women’s Hospital, and early evaluations showed that the system improved safety and organisation. However, the system would need further testing across other maternity units, and three sites implemented BSOTS: New Cross (Wolverhampton), University Hospitals of North Midlands (Stoke), and Shrewsbury and Telford Hospitals.
When implementing changes, it’s valuable to ‘take stock’ and share experiences with others undergoing similar changes. On 14 October 2016, representatives from the three sites, together with researchers from both the CLAHRC WM Maternity Theme and Warwick Business School, clinicians, patients, and the public, met in the centre of Birmingham to feedback about the implementation of BSOTS. Each site had recently undertaken an audit, and feedback was provided on both successes and challenges to implementing BSOTS.
In the morning session, presentations offered insights into how each of the sites had fared in implementing the new triage system and valuable lessons learned were shared. Key findings included:
- The need to identify both clinical and management staff to champion the system.
- Training of staff is imperative to successful implementation, and who is trained and when the training is delivered needs careful consideration.
- Location and arrangement of triage environment is important.
Some examples of good practice were shared (such as a poster informing women about triage) and could be implemented in each of the sites. Each of the sites also described unexpected benefits: in implementing triage they learned more about their maternity units and how they operated, and could make changes, enabling them to run more efficiently.
Following the presentations, there was an opportunity for round table discussions, where representatives from each of the sites could share experiences and suggest ways in which barriers to successful implementation of BSOTS in each of the sites could be overcome. Members from the CLAHRC WM team were then able to work with each of the sites to draw up clear action plans, which would enable the triage system to be more successful going forward.
Guy Kawasaki, author, marketing specialist, and a former Apple employee, said ‘Ideas are easy, implementation is hard’. In the feedback day, each of the sites described challenges of implementing a new system and the need for commitment, determination, and a lot of hard work required to make it a success. However, it was clear that a maternity triage system leads to better care and examples came forward of how women had better outcomes as a result of being seen in order of clinical need.
For CLAHRC WM, the event provided a valuable opportunity to improve BSOTS, with practical suggestions that can be taken forward. CLAHRC WM is grateful to all who attended the event and looks forward to further implementation of BSOTS in more maternity units. For further information about BSOTS, contact Sara Kenyon (s.kenyon@bham.ac.uk) or Nina Johns (nina.johns@bwnft.nhs.uk).
-- Magdalena Skrybant, PPIE Lead
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World Mental Health Day
Professor Swaran Singh was recently interviewed by CCTV America to discuss World Mental Health Day (10th October), where he stated that mental health is a huge suffering, not just for individuals, but for society as a whole. There is a wide range of mental disorders, from those where normal human behaviour is exaggerated (stress, low mood), through to disorders that produce more florid symptoms (psychosis, bipolar disorder). One in four people will suffer some sort of mental illness at some point in their lives, and there is a myth that mental disorders are progressive and that there are no cures. This is not the case, however, with many effective interventions available: from talking therapies and psychotherapy through to powerful medication. For example, in the case of psychosis, nine out of ten people will respond to anti-psychotics following their first episode.
In low- to middle-income countries, the main treatment barrier is the lack of availability of medication and health care. However, in high-income countries other problems, such as the stigma attached to mental health, stop people from accessing help. Even while suffering from mental illness, people often feel some kind of personal inadequacy or failing that prevents them from disclosing their illness and/or seeking help.
-- Nathalie Maillard, CLAHRC WM Head of Programme Delivery
Mental Health in Slums
A Lancet series on the health of people who live in slums was recently published, co-authored by CLAHRC WM supported researchers. The authors discuss why slums are unhealthy places and make recommendations on how health might be improved in slum neighbourhoods and how the general field of study might be scientifically developed.
Insufficient attention has been paid to the mental health of people who live in slums, although neuropsychiatric disorders have been reported to be the leading cause of years of life lost worldwide. Living and working conditions in slum neighbourhoods mean that people are predisposed to stress, often leading to psychological disorders. Previous findings suggest that children living in slums have greater behavioural and emotional problems, although the authors note that direct literature in this area is lacking.
You can watch an interview with Dr Oyinlola Oyebode (co-author) at: youtu.be/0YnPO_qFc6A; or listen her Lancet interview at: thelancet.com/pb-assets/Lancet/stories/audio/lancet/2016/16october-slumhealth.mp3. The papers are available at: thelancet.com/series/slum-health.
-- Nathalie Maillard, CLAHRC WM Head of Programme Delivery
Job Opportunity
A job opportunity for a Research Associate with the ECLIPSE Programme (a CLAHRC-related study evaluating the implementation of cogntive remdiation into first episode services) is now open for applications. The post is a 3 year fixed-term contract located at Coventry and Warwickshire Partnership NHS Trust with a deadline of Tuesday 8 November 2016. More information can be found online.
10th Round of NIHR Fellowships
The tenth round of NIHR Fellowships is now open, with amendments to build capacity for clinical trials. The deadline for application is 20 December 2016 for post-doctoral levels and 17 January 2017 for doctoral levels. To accompany this the NIHR have also released a new version of the Clinical Trials Guide for Trainees, which includes updated guidance and new case studies.
New NIHR Funding Opportunities
New funding opportunities are available from the NIHR Public Health Research Programme:
- 16/121 Healthy diet in early years.
- 16/122 Interventions in community organisations.
- 16/123 Migrant health and wellbeing.
- 16/124 Age-friendly environments.
Deadline is 25 April 2017, and more information can be found at: nets.nihr.ac.uk/funding/phr-commissioned
RSS Feed
We have now set up an RSS feed (a format for delivering regularly changing web content) for those who wish to use an RSS reader to keep up to date with our blogs. It can be accessed at clahrcwmblog.wordpress.com/feed. There is also a link at the bottom of this page. Thanks to Dr Rachael Wood for the idea!
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Maria Livanou
 Ms Maria Livanou is a second year PhD student within the Division of Mental Health and Wellbeing at Warwick Medical School, funded by CLAHRC WM. Her research focus is on young offenders (17-19 years old) with ongoing mental health problems in transition across forensic mental health services. The overall aim of this study is to assess the transition processes and policies across all national six medium adolescent secure units in England. This project is using a mixed methods approach:
- A systematic review and meta-analysis on the prevalence of mental health problems in young offenders in detention and other settings.
- A mapping exercise to identify young offenders approaching the transition age boundary moving to adult services within a six-month period and to address processes and outcomes of transition across agencies in terms of policy, practice, and user experience.
- Case-note reviews looking retrospectively at processes and outcomes of transitions to adult services and custody the preceding year.
- Semi-structured interviews to explore health-care providers’, service users’ and their parents'/carers' (followed-up from mapping exercise) views and experiences of the transition process and infrastructure
Maria obtained a First Class Honours Degree in Forensic Psychology (summa cum laude) from John Jay College of Criminal Justice, City University of New York. She has worked as a Research Assistant for the past four years in several projects, including forensic experimental psychology (deception detection and false confessions), and in clinical psychology (suicidal behaviours in emerging adults). Her research interests are forensic child and adolescent psychiatry, transitions of young people to adult mental health services, mental health problems in this population (self-harm and suicidal behaviour), and young offenders' mental health and how to build resilience in this group to avoid recidivism. One of Maria’s projects explored the relationship between dysfunctional families, suicidal behaviour, and borderline characteristics in young individuals. She is also interested in social justice research and has been involved in an interdisciplinary project that examined LGBT Youth of Colour and their mental and physical health.
Her research outputs include:
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Re: Surgical Volumes vs. Specialisation
It’s an interesting study but what about difficulty of operation? I’ll bet that the list of comorbidities does not entirely capture this. Isn’t it axiomatic in surgery that better surgeons generally handle the more complicated and therefore risk cases?
-- Marissa Carter
Director's Reply - Yes, and I was saying that limiting one's range of cases often comes later in life, and therefore its not specialisation per se that makes the difference.
-- Richard Lilford
Re: Beyond Logic Models
Julie Reed et al.'s paper on Action Effect Method is worth a look on this topic as well. They conclude " A clear definition of what constitutes a well-articulated programme theory [logic model] is provided to guide the use of the method and assessment of the fidelity of its application." Reed et al. BMJ Qual Saf. 2014; 23: 1040-8.
-- Leon Fern
Director's Reply - Yes, thank you - it's true that a quantiative model can only be as good as the logical model it tries to explicate. So there is uncertainty about the quantities with which the model is populated and about the model itself.
-- Richard Lilford
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Buckingham SA, Taylor RS, Dalal HM, et al. Home-based versus centre-based cardiac rehabilitation: Cochrane systematic review and meta-analysis. Open Heart. 2016; 3: e000463.
Ezeh A, Oyebode O, Satterthwaite D, et al. The history, geography, and sociology of slums and the health problems of people who live in slums. Lancet. 2016. [ePub].
Fry M, McLachlan S, Purdy S, Sanders T, Kadam UT, Chew-Graham CA. The implications of living with heart failure; the impact on everyday life, family support, co-morbidities and access to healthcare: a secondary qualitative analysis. BMC Fam Pract. 2016; 17 (1):139.
Jordan RE, Adab P, Sitch A, et al. Targeted case finding for COPD versus routine practice in primary care: cluster randomised controlled trial. Lancet Resp Med. 2016;4(9):720–30.
Lilford RJ, Oyebode O, Satterthwaite D, et al. Improving the health and welfare of people who live in slums. Lancet. 2016. [ePub].
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WMS's Prof Swaran Singh, discussed solutions to mental health problems on @CCTV_America for #WorldMentalHealthDay
-- @Warwick Medical School, October 11
We're outside the Church of St Martin in the Bull Ring, talking to people about mental health today. Come and say hi! #WMHD16
-- @Forward Thinking Birmingham, October 10
"When someone is trying to talk, let's try to listen...#WorldMentalHealthDay #timetochange
-- @ShoutOutFYMH, October 10
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