CB-NSG, London 8 March 2013
Martin Knapp, Monique Ferdinand, Marija Trachtenberg
PSSRU, London School of Economics and Political Science
1
Sample of 930 people living in residential
accommodation (11 NHS trusts, 4 vol orgs, 3
private providers) in 1996
Mild CB
Moderate CB
Severe CB
750
500
250
0
Mild LD
Moderate LD
Comas et al (2001); Knapp et al (2005)
Severe LD
… what people need and what they want;
… what care and support arrangements can meet those
needs and satisfy those wants;
… what staff and other inputs are employed to deliver
the associated services;
… what are the costs of employing them; and
… where and how to raise the funds to meet those costs.
Importantly, they also want to know:
… what outcomes are achieved; and
… whether those outcomes are worth the cost that is
spent to produce them
Social care
Family
Social
context
Emply’t
Income
Resilience
Trauma
Events
Needs
for care
and
support
Housing
Education
Crim justice
Benefits
Employment
Vol sector
Income
Mortality
Different agencies and budgets
Health care
Genes
… outcomes that are
worse
Outcomes that are
better
Costs that
are higher
Costs that
are lower
5
… outcomes that are
worse
Costs that
are higher
Outcomes that are
better

A non-starter
Costs that
are lower
6
… outcomes that are
worse
Costs that
are higher
Outcomes that are
better

A non-starter

Costs that
are lower
A winner – but check
the timing and spread
of impacts
7
… outcomes that are
worse
Costs that
are higher
Outcomes that are
better

A non-starter
 A delight to

Costs that
A winner – but check
penny-pinchers;
are lower but unpopular with the timing and spread
everyone else
of impacts
8
… outcomes that are
worse
Costs that
are higher

A non-starter
 A delight to
Outcomes that are
better
??
Do the outcomes
justify the higher
costs?

Costs that
A winner – but check
penny-pinchers;
are lower but unpopular with the timing and spread
everyone else
of impacts
9
Research led by Angela Hassiotis (UCL)
Compared specialist behaviour service (added to standard
provision) with standard provision alone.
All staff in the specialist service had received training in
order to deliver treatment based on applied behaviour
analysis.
Randomised controlled trial (n=63 adults)
Outcomes better on the Aberrant Behavior Checklist 6
months after randomisation.
Costs were no different between the groups.
So  the specialist team seen to be cost-effective.
Hassiotis et al (2009, 2011)
Weekly cost, 2002/03 prices
Costs initially higher in the community than in hospital.
BUT outcomes were better (self-care skills, choice,
participation, social integration, expressed satisfaction)
Knapp et al (1992); Hallam et al (2006); Forrester-Jones et al (2012)
We are looking at the economic case for interventions to
meet the needs and respond to the preferences of people
with challenging behaviour
Part of a project funded by the NIHR School for Social
Care Research.
We did not have the time or resources to set up new
‘trials’ (or similar) collecting primary data.
Instead, we are working with existing services and
(mainly) extant information from previous research to
‘model’ the costs and benefits.
ITSBS aims to enable young people with LD and challenging behaviour
to remain within their family and community settings.
Provides:
(1) intensive support and clinical psychology input with the young
person, family, and frontline workers, and
(2) an extended short break (as required)
Success story in Ealing: 23 clients since 2009, no child with LD placed
in long-term care due to their challenging behaviour.
Multi-agency: Based within Ealing Services for Children with
Additional Needs (ESCAN); funded by the local authority; team led by
two clinical psychologists (Catherine Sholl & Caroline Reid)
Collaborative initiative: involving clinical psychology, social services
and short breaks services; plus ‘usual care’.
13
Costs:
•
0.8* FTE Clinical Psychologist *Increased to 1 FTE in March 2013
•
1 FTE Assistant Psychologist
•
Approx. 8 extended short breaks packages annually
Benefits:
•
Client remains in community, and out of residential
placements
•
Challenging behaviours reduced
•
Families report increased ability to cope
Main economic benefit = costs avoided / saved, both shortterm and longer term.
We are now estimating those costs and benefits.
14
ITSBS Intervention
C
Probability (5%)
cost
benefit
A
probability cost
Usual costs + Intervention
costs, with uptake, dropout rates applied…
Long-term care
D
Probability (95%)
cost
benefit
Stays within home
Child with
LD + CB
Usual care
B
probability cost
Treatment as usual costs
health service, social care…
C
Probability (?)
cost
benefit
Long-term care
D
Probability (?)
cost
benefit
Stays within home
A+C
Expected CostsExpected Benefits
A+D
Expected CostsExpected Benefits
B+C
Expected CostsExpected Benefits
B+D
Expected CostsExpected Benefits
Analysis and collection of extant data:
•
•
•
Length of time in ITSBS
Cost per client (i.e. contact time, short breaks, case studies)
Client Service Receipt Inventory (CSRI) to describe full care and
support patterns (and hence costs)
16
Client C:
2009-2010
Item
Unit Costs
Phase 1: Assessment
Clinical
Psychologist
(£68 per
hour)
Phase 2: Intensive
Therapy
Phase 3: Short Break
Short Break
Phase 4: Maintenance (£1876
/ Closing Case
weekly)
Total Costs
Sessions
Client 13:
2011 – 2013
Total (£) Sessions
Total
(£)
7
£476
15
£1020
86
£5 848
35
£2380
3 weeks
£5,628
n/a
£0
1
£68
7
£12, 020
£476
£3,876
17
Looked after child – ‘Median
cost’
( 14 months)
Item
Care Planning
Maintaining the
Placement
Finding Next
Placement
Review
Legal
Cost to(2012)
Local
Curtis
Looked after child – ‘High Cost’
(18.5 months)
Unit costs
Total
Unit costs
Total
£240 x 3
£720
£240 x 2
£480
£696 x 87 weeks
minus
£5,238
£55,314
£293,741
£293,741
£310
£310
£415
£415
£815 x 3
£2,445
£10,139
£10,139
£10 x 87 weeks
£843
£618.54 +£1,233
£1,851
18
Analysis and collection of extant data:
•
•
•
Length of time in ITSBS
Cost per client (i.e. contact time, short breaks, case studies)
Client Service Receipt Inventory (CSRI) to describe full care and
support patterns (and hence costs)
Find and analyse suitable comparison data
•
What would ‘treatment as usual’ have been in Ealing? Look at
patterns of placement pre-2009? Or in another London borough?
• Seek data from elsewhere to compare with that collected on the
young people in Ealing (using the Developmental Behavioural
Checklist) comparison
• Also compare data using CSRI from other studies.
19
We have a little scope for exploring other
interventions in this area.
Please do send us suggestions / comments /
information.
20
Thank you
Email us for more information
m.knapp@lse.ac.uk
m.ferdinand@lse.ac.uk
21
Adelina Comas-Herrera et al (2001) Benefit groups and resource groups for adults with
intellectual disabilities in residential accommodation, Journal of Applied Research in Intellectual
Disability, 14, 120-140.
Lesley Curtis (2012) Unit Costs of Health and Social Care 2012, Canterbury: PSSRU, University of
Kent.
Rachel Forrester-Jones et al (2012) Good friends are hard to find: the social networks of people
with mental illness 12 years after deinstitutionalisation. Journal of Mental Health, 21, 4-14.
Angela Hallam et al (2006) Service use and costs of support for people with learning disabilities
twelve years after leaving hospital, Journal of Applied Research in Intellectual Disabilities, 19, 296308.
Angela Hassiotis et al (2009) Randomized, single-blind, controlled trial of a specialist behavior
therapy team for challenging behavior in adults with intellectual disabilities. American Journal of
Psychiatry 166(11):1278-85.
Angela Hassiotis et al (2011) Applied behaviour analysis and standard treatment in intellectual
disability: 2-year outcomes. British Journal of Psychiatry 198(6), 490-1.
Martin Knapp et al (1992) Care in the Community: Challenge and Demonstration, Avebury,
Aldershot.
Martin Knapp et al (2005) Intellectual disability, challenging behaviour and cost in care
accommodation: what are the links? Health and Social Care in the Community, 13, 297-306.
22