Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.
The economic case for the prevention of mental illness. Annual Review of Public Health [PubMed] [RePEc] Published April 2019
I’m a big fan of these annual reviews in public health, partly because they provide a really useful overview of a topic and plenty of links for further reading, but mostly because what they don’t contain usually ends up being a really good back and forth in our office that ends with strategising about what we could do better, locally, to inform the delivery of services. So it was with this article, which does a pretty comprehensive job of setting out the economic case for prevention of mental illness, but also makes the case for framing arguments in an economic context using health economics evidence rather than burden of morbidity alone.
The article is structured across several domains based on where there is both quantity and quality of studies, but also makes clear that the natural history of mental health problems and the intervention opportunities to prevent them occur across the entire life course (which will please local authorities who have adopted a life-course approach to health and wellbeing). There is a short section on the barriers to implementation of programmes to prevent mental illness despite the evidence of their effectiveness. One of the suggested solutions is to make use of economic models to highlight short-, mid-, and long-term costs and benefits of prevention, which is OK as far as it goes. I think that one of the biggest barriers with this kind of evidence is the challenge of communicating it to commissioners and decision makers in local authorities, who are far less familiar with health economic methods and approaches than colleagues in health. Modelling is often viewed as a dark art that is impenetrable and difficult to trust, and you cannot fix that by developing more models. I was also surprised at the lack of discussion of the growing evidence of physical health inequalities in people with mental health conditions compared to the general population, which manifests in stark contrasts in healthy life expectancy between these groups and oftentimes differences in underlying health behaviours such as smoking, alcohol consumption and self-medication.
The health effects of Sure Start. Report by the Institute for Fiscal Studies Published 3rd June 2019
Sure Start offers families with children under the age of 5 a ‘one-stop shop’ for childcare and early education, health services, parenting support, and employment advice, with the aim of improving children’s school readiness, health, and social and emotional development. Sure Start is not a new programme and has considerable history of implementation and funding from initial targeting of deprived areas, through to universal provision via the 10-year Strategy for Childcare, with £1.8 billion of public investment. The last ten years have seen substantial cuts and rationalisation with a reduction of funding in the order of 33%. The IFS report is interesting because it stands out as one of the vanishingly small bits of evaluative evidence into the programme’s effectiveness and cost effectiveness, and because early reviews of Sure Start were contradictory in their findings about whether health benefits were being delivered.
The IFS report uses ‘big data’ in an ecological study framework that tracked, spatially and temporally, access to Sure Start centres (which varied within and between neighbourhoods and nationwide from one year to the next) and cross-referenced health data and outcomes for children and their mothers who accessed the service. Using a difference-in-differences methodology, the IFS compared the outcomes of children in the same neighbourhood with more or less access to Sure Start, after accounting for both permanent differences between neighbourhoods and nationwide differences between years.
The results suggest that Sure Start reduced the likelihood of hospital admissions for children of primary school age, and that there was a persistence to this benefit which increased with age, so a 5% reduction in probability at age 5 became an 18% reduction by age 11. For the younger kids, the admissions avoided were largely those associated with infections, whilst for older kids it was a reduction in admissions for injuries. From an inequalities standpoint, the poorest 30% of areas saw the probability of any hospitalisation fall by 11% at age 10 and 19% at age 11. Those in more affluent neighbourhoods saw smaller benefits, and those in the richest 30% of neighbourhoods saw practically no impact at all. There were no recorded benefits to maternal mental health, or to childhood obesity by age 5.
In a simple cost-benefit analysis, Sure Start was able to offset 6% of its programme costs through NHS savings. For me, this is the most disappointing aspect of the report, and perhaps the most misleading. I think it is a disservice to Sure Start that the benefits were evaluated through a very narrow resource utilisation view of ‘health’ as health care. So much of the rationale for setting up Sure Start and the policy narratives along the way have been grounded in a much wider definition of health and the view on the ground is that Sure Start has impacted many more ‘softer’ (but no less important) outcomes. I hope there will be parallel reports on the impact of Sure Start on school readiness, educational attainment, crime, adverse childhood experiences, employment and the economy. If not I worry that this evaluation from a value for money perspective could be used by Whitehall to justify further cuts.