Read the full case study for 'A coping programme for family carers of people with dementia: economic evidence' here
Martin Knapp, Klara Lorenz, Adelina Comas-Herrera, Gill Livingston, Michela Tinelli, Danielle Guy 2019

• what dementia is and how it affects people
• carer stress, how to recognise it and techniques for managing it
• how to manage difficult behaviour
• how to access support that is available for people with dementia and family carers
• maintaining skills learned and planning for the future.

Read the full case study for 'Advance care planning: economic evidence' here

• Advance care planning is an important end of life care intervention that helps people at risk of losing their mental capacity or their ability to communicate, plan for their future care and support needs, including medical treatment.
• It helps people get the treatment they want during the final stage of their life and increases their chance to die in their preferred place of death. It benefits the mental health of the person caring for them.
• Advance care planning is likely to be cost-effective. This is due to improvements in carer’s quality of life, reductions in the use of aggressive life-sustaining treatment and more people dying at their place of residence rather than in hospitals.
• Future research needs to address gaps in implementation knowledge of advance care planning.
• Implementing advance care planning effectively is challenging and requires substantial organisation and system-wide changes that are likely to be costly. Whilst there is increasing knowledge about how to implement advance care planning, there is no economic evidence about how to implement advance care planning so that it generates good value for money.

Read the full case study for 'Advocacy for parents with learning disabilities. A small-scale social care intervention: economic evidence' here (PDF)
Martin Knapp, Annette Bauer, Michela Tinelli, Danielle Guy 2019

Read the full case study for 'Annual health checks for older people with learning disabilities' here

• People with learning disabilities grow old with many more health conditions than the general population, which are less likely to be identified and treated.
• AHCs, which were introduced in 2008 as part of a national scheme, provide the tools and incentives for General Practitioners (=primary care) to check people with learning disabilities for a wide range of health conditions.
• Although AHCs have been shown to successfully improve short-term outcomes e.g. number of diagnosed health conditions, their long-term health outcomes are not known.
• AHCs are not likely to be cost-effective for older people with learning disabilities from a health and social care perspective. While findings are from an explorative modelling study and reflect a lack of evidence, it is consistent with other evidence which suggests that for health checks to lead to substantial health improvements, people identified with health problems also need to receive the appropriate follow-on care which is at the moment not always the case. Therefore, wider system changes beyond primary care are required.
• Recent efforts have been made to scale up AHCs (which are now reaching 75% of the eligible population) as well as to introduce frontrunner localities, in which primary and secondary care develop new ways of increasing access to health care for this population.

Read the full case study for 'British Red Cross (‘Support at Home’ hospital discharge scheme), a small-scale social care intervention: economic evidence' here (PDF)
Martin Knapp, Annette Bauer, Michela Tinelli, Danielle Guy 2019

Read the full case study for 'Cognitive stimulation therapy: economic evidence' here (PDF)
Annette Bauer, Martin Knapp, Adelina Comas-Herrera, Danielle Guy 2019

KEY POINTS

• Cognitive stimulation therapy (CST) helps memory and cognition of people with dementia. It involves structured group therapy sessions with themed activities. Those are typically provided over 14 sessions in seven weeks.
• Maintenance CST involves 24 additional sessions after the initial seven weeks that follow the same principles as regular cognitive stimulation therapy sessions.
• People using CST are likely to experience improvements in memory, cognition, and overall quality of life (although improvements in quality of life are less easy to establish).
• Both (standard) CST and maintenance CST for people with mild-to-moderate dementia can be cost-effective; this is particular so when offered in combination with dementia medication.
• Whilst provision of CST is recommended by NICE, and rolled out more widely, current provision remains patchy.

Read the full case study for 'Cognitive stimulation therapy: economic evidence' here

• Cognitive stimulation therapy (CST) involves structured group sessions with themed activities. Those are typically provided over 14 sessions in 7 weeks.
• Maintenance CST involves 24 additional sessions after the initial 7 weeks, following the same principles as regular CST sessions.
• People using CST are likely to experience improvements in general cognition and overall quality of life.
• Both (standard) CST and maintenance CST for people with mild-to-moderate dementia can be cost-effective; this is particularly so when offered in combination with dementia medication.
• Whilst provision of CST is recommended by NICE, and has been provided in some local services, current provision remains patchy.
• Recent economic analysis found that scaling-up CST across England would be cost-effective, providing an economic rationale for the recommended roll-out. However, questions remain about how to best deliver CST at scale as part of routine care, and whether additional support might be required to support unpaid carers.

Read the full case study for 'Employment support for autistic adults: economic evidence' here (PDF)
Martin Knapp, Valentina Iemmi, Michela Tinelli, Danielle Guy 2019

KEY POINTS

• Employment support interventions provide individualised training and workplace support for autistic adults with the aim to enable autistic people to gain and maintain employment.
• Research shows that supported employment for autistic adults can be successful. However, the research is based on a small number of small-scale studies targeting a subgroup of autistic people.
• There is also a strong economic case for supported employment from both a health and social care perspective and a broader societal perspective, which includes productivity gains (based on employment support for the general population). In addition to being cost-effective, the intervention may also be cost-reducing.
• There is a need to examine whether the outcomes of supported employment for autistic adults from current studies can be replicated on a larger scale and to a wider subgroup of autistic people.
• The Lynx Resource Centre in Weston-super-Mare and EmployAbility in Surrey are two examples of successful implementation of employment support interventions for adults with autism. The former appears to be primarily funded by the local authority and the latter by Jobcentre Plus.

Read the full case study for 'Hearing dogs for people with severe and profound hearing loss: economic evidence' here

• The severity of people’s hearing loss increases the risk for, and severity of, negative impacts on their lives which may have associated costs as well as adverse outcomes.
• Audiological and rehabilitation interventions appear to have limited impact on these outcomes. Hearing dogs are an alternative way of supporting people with hearing loss. Hearing dogs live with the recipient and are a companion as well as providing sound support.
• This study provides a significant contribution to the scant evidence base on hearing dogs. It found that hearing dogs appear to benefit recipients across a number of life domains.
• It is likely that hearing dogs are cost-effective from a public sector perspective when the charity covers the cost of producing, training and supporting the partnership between the hearing dog and the recipient.
• Future research could examine the impact of hearing dogs over a longer (more than 6 months) time horizon, examine the impact of hearing dogs on recipients’ productivity in the workplace, and also the impact on their wider network of family and friends.

Read the full case study for 'Help-at-home: economic evidence' here (PDF)
Annette Bauer, Michela Tinelli, Danielle Guy 2019

KEY POINTS

• Help-at-home schemes provide older people with access to a range of highly-valued support and can lead to health and wellbeing benefits.
• Help-at-home schemes appear to save local government and the NHS around £1500 per person per year, owing to:
  • people remaining longer in their homes, rather than moving to care homes;
  • fewer GP appointments;
  • fewer hospital admissions.
• Benefits of help-at-home schemes might also accrue to volunteers providing support (who are more likely to find jobs after gaining skills through volunteering with the schemes).
• Findings from the economic evaluation summarised here are the first to demonstrate that help-at-home schemes also have the potential to offer value for money
• Despite the support provided by help-at-home schemes some older people continue to experience loneliness, financial worries and personal care.
• Despite economic evidence that help-at-home schemes can be good value for money, many benefits are likely to depend on local infrastructures and how such schemes are run, making it hard to generalise their value.

Read the full case study for 'Home adaptations for older people' here

• About 2 million households in England include one or more people with a health condition/disability that require adaptations to their home.
• Home adaptations are permanent alterations which aim to make buildings more suitable for older people and have been identified as one of the 10 most promising prevention interventions for older adults.
• Home adaptations secure better home usability, improve independence and functional ability, and can prevent falls.
• Those who received home adaptations, and their carers, widely appreciated them as they believed they led to improvements in their health and well‐
• Delays in the provision of home adaptations may increase the risk of hospitalisation and associated costs.
• More research funded by NIHR SSCR is underway to explore whether major adaptations to bathing facilities (these adaptations usually involve the removal of a bath or inaccessible shower and replacement with a level or easy access shower) improve or maintain older people’s health, safety, quality of life, and ability to manage their personal care. It will also explore whether delayed installation has a negative effect on physical and mental health and independence, and also leads to more costs.

Read the full case study for 'Home care reablement for older people: economic evidence' here (PDF)
Annette Bauer, Michela Tinelli, Danielle Guy 2019

KEY POINTS

• Home care reablement helps older people do things themselves, enabling them to re-learn skills and recover their confidence to live at home.
• Studies have consistently shown that home care reablement leads to improved functioning and a decrease in dependence as well as reductions in ongoing home care.
• Across different age groups, home care reablement for older people also has a high probability of reducing costs when compared with standard home care.
• The National Institute for Health and Care Excellence (NICE) recommends that every older person referred to home care should be offered reablement if it is indicated that person would benefit from it.
• It is plausible that some people (e.g. those living alone) are less likely to benefit from reablement without additional support. Future research needs to focus on what populations should receive home care reablement and for how long.

Read the full case study for 'Hospital discharge and intermediate care services for people who are homeless: economic evidence' here
2022

• There is strong evidence to support the commissioning of specialist homeless hospital discharge schemes, as they are consistently more effective and cost-effective than ‘standard care’. Homeless hospital discharge schemes with direct access to specialist intermediate care (step-down beds) are more cost-effective than homeless hospital discharge schemes that have no direct access to intermediate care.
• The interviews with frontline professionals highlighted the poor current practice associated with seeing each hospital admission in isolation, the failure to provide appropriate multidisciplinary responses and to initiate safeguarding alerts where unsafe discharge occurs. In addition, patients reported situations where the combination of being a homeless person and a person that abuses drug and alcohol is a highly stigmatised condition. They also reported that when resources are stretched there is less tolerance of the challenging behaviour that can be associated with substance use.
• Local authority funding to support single homeless people has fallen dramatically in recent years in England and many of the schemes originally supported by the Homeless Hospital Discharge Fund are now reduced in scale or have closed.
• The researchers in this study developed a new toolkit containing usable evidence on the effectiveness and cost-effectiveness of the schemes originally piloted with the Homeless Hospital Discharge Fund. It also provides guidance on the multiple factors that decision-makers should consider in order to deliver consistently safe, timely transfers of care for adults who are homeless.

Read the full case study for 'Integrated housing with care and support for older people: economic evidence' here (PDF)
Michela Tinelli, Martin Knapp, Danielle Guy 2019

KEY POINTS

• Extra care housing is diverse. Key elements include self-contained accommodation, 24-hour accessible on-site care and support, some collective meal provision and a range of leisure and communal facilities on site.
• There is evidence to suggest that extra-care housing can be cost-effective.
• However, research has focused on comparison with the cost of living in a residential care home, which may not always be the relevant comparator. More research is required to examine the cohort of people in extra-care housing schemes to establish how their needs would otherwise be met.
• Most of the research evidence to date derives from schemes in England where government funding has promoted greater development of extra care. People are motivated to use extra care housing for physical and emotional security, availability of support and an accessible environment, and social contact.
• People living in extra care housing value the opportunities for friendship and social interaction. Carers value that it enables them to carry on leading an active life and enhances their relationship with their spouse.
• There is evidence that extra care housing produces health benefits and increases life expectancy. It also reduces needs for care and use of health and social care resources, which can reduce costs and generate economic value.
• The government should look at innovative ways to make sure that health, housing and social care sectors work together and support each other in planning and funding of extra care housing schemes.

Read the full case study for 'Interventions beyond medicine for dementia: economic evidence' here (PDF)
Michela Tinelli, Martin Knapp, Adelina Comas-Herrera, Danielle Guy 2019

KEY POINTS

• A series of interventions ‘beyond medicine’ are available for people living with dementia. The effectiveness in relation to cognition, independence, wellbeing and other outcomes varies across these interventions.
• The National Institute for Health and Care Excellence (NICE) developed economic models to simulate the cost-effectiveness for an average person receiving each intervention of interest, compared with usual care. The effectiveness measure was (health-related) quality-adjusted life years (QALYs).
• Individual cognitive stimulation therapy is the only cost-effective intervention for dementia. However, group cognitive stimulation therapy and group reminiscence therapy are interventions to consider for people living with mild-to-moderate dementia. Additionally, cognitive rehabilitation or occupational therapy are interventions to consider for supporting functional ability in people living with mild-to-moderate dementia.
• For other interventions the NICE committee agreed that people should be offered access to a range of activities that should be tailored to their individual preferences.

Read the full case study for 'Peer-led self-management for people with severe mental health issues. A small-scale social care intervention: economic evidence' here (PDF)
Martin Knapp, Annette Bauer, Michela Tinelli, Danielle Guy 2019

Read the full case study for 'Person-centred support for people living with dementia in care homes: economic evidence' here (PDF)
Michela Tinelli, Renee Romeo, Martin Knapp, Danielle Guy 2019

KEY POINTS

• Almost all (95%) of the average cost of care home residence (£792 per week) is accounted for by room and board charges. Hospital contacts contribute the largest proportion of the additional healthcare costs. The absence of an association between cost and needs emphasizes the importance of a more needs-based service system which could result in clinical and economic advantages.
• Person-centred, integrated, and in-reach care home services responding to the needs of individual residents may improve health outcomes and quality of life at reasonable costs.
• Interventions providing good value for money, similar to the Wellbeing and Health for People with Dementia or Enhanced Care Home Outcomes interventions are good value for money.

Read the full case study for 'Providing debt advice: economic evidence' here (PDF)
Michela Tinelli, David McDaid, Martin Knapp, Danielle Guy 2019

KEY POINTS

• Debt advice helps people manage and repay money owed or make arrangements with creditors where debt cannot be fully repaid.
• While debt advice helps individuals get back control of their finances, it can improve mental and physical wellbeing as well as overall quality of life. Wider societal benefits include lower incidence of stress-related illness and smaller likelihood of family breakdown.
• According to economic modelling, over five years, society can gain at least £2.60 from every £1 invested in face-to-face debt advice services. In addition, avoiding an episode of depression or anxiety would have an impact of additional social costs avoided up to £24–£52 million annually. The benefit in terms of reduced mental health care costs due to debt advice is between £50 and £93 million annually in UK.
• Economic modelling on debt advice includes a number of assumptions based on limited data. As such, attribution of impacts to debt advice should be considered with caution.
• Debt advice services are provided across the UK and are regulated by the Financial Conduct Authority.

Read the full case study for 'Short breaks for adults with learning disabilities and behaviour that challenges: economic evidence' here (PDF)
Martin Knapp, Marija Trachtenberg, Michela Tinelli, Danielle Guy 2019

KEY POINTS

• Although short breaks (respite care) are intended to give time off caring to carers for adults with learning disabilities and challenging behaviour, it is commonly provided as residential care intervention for the service users (rather than for the carers).
• In evaluating short breaks, the work that fed into the NICE guideline did not find any robust evidence on their effectiveness or cost-effectiveness. Other information was available to suggest that the Guideline Committee should made a recommendation for short breaks that is potentially resource-intensive.
• Additional economic analyses from a public sector perspective demonstrated that short breaks at various intensities can be considered cost-effective and potentially cost-saving.
• Since the analyses were based on assumptions rather than evidence, NICE is very cautious about using the results to guide commissioning and provision decisions. Beyond the certainty of the potential cost range of short breaks, the economic analyses produced are speculative and their validity cannot be confirmed.
• A variety of national charities currently provide short breaks and other services for those with intellectual disabilities and challenging behaviour as well as their carers.

Read the full case study for 'Signposting and navigation services for older people: economic evidence' here (PDF)
Annette Bauer, David McDaid, Michela Tinelli, Danielle Guy 2019

KEY POINTS

Health, social care and other local government services can help ‘signpost’ or facilitate links to community and voluntary organisations that can help address social isolation and loneliness.

• Signposting and navigation services are available in many areas, and may be found in GP surgeries, shopping centres and libraries. Some services even proactively identify and liaise with potentially isolated older individuals.
• Signposting and navigation services can increase access to a range of statutory and voluntary sector activities and support. They can benefit the mental wellbeing and independence of older people.
• Economic studies suggest that signposting and navigation services have the potential to achieve positive return on investments.
• However, evidence is restricted to a few small-scale studies and modelling. Further research is needed to test those findings, particularly as findings are likely to vary between different populations and subgroups of older people.

Read the full case study for 'Social prescribing' here

• In England, social prescribing schemes have been (re-)introduced as a policy tool for reducing pressure on GPs and promoted as a solution for health service-budgeting constrains; they consist of link workers integrated into primary care structures, which support people in managing their health conditions and accessing resources in the community thus addressing the social determinants of health.
• A large number of studies have investigated the impact on health and wellbeing outcomes as well as on healthcare resources; findings suggest that schemes have the potential to change health behaviour and outcomes; they can also enhance people’s self-confidence. However, not everyone accesses or benefits from social prescribing schemes; and those most vulnerable are less likely to benefit.
• There is some evidence to suggest that social prescribing schemes can reduce demand on primary and secondary care service and offset the costs of the intervention.
• Main gaps in evidence include: their relative cost-effectiveness compared to other interventions that seek to address the social determinants of health; how social prescribing schemes need to be designed and implemented in order to achieve good value for money, and which population they should target; the wider community impacts of schemes.

Read the full case study for 'Specialist nursing support (Admiral Nursing) for unpaid carers of people with dementia: economic evidence' here

• Admiral Nursing provides important support to carers of people with dementia.
• Potential benefits of Admiral Nursing include improved carer quality of life and ability to continue caring for the person with dementia.
• It is likely that Admiral Nursing can be offered to people without increasing the costs of (other) social care and health care services.

More research is needed to understand potential costs and benefits of Admiral Nursing.

Read the full case study for 'Support for unpaid carers: economic evidence' here (PDF)
Nicola Brimblecombe, Martin Knapp, Michela Tinelli, Danielle Guy 2019

KEY POINTS

• For those who provide unpaid care, particularly at higher intensities, there is substantial evidence of negative effects on employment, health and wellbeing, with associated individual and societal costs.
• There are significant gaps in the evidence with regards to interventions to support carers, outcomes and types of caring situation studied, with a lack of evidence on cost-effectiveness and few evaluations of key recent policy initiatives.
• Evidence is strongest and most consistent for formal care services for people with care needs; flexible working conditions; psychological therapy, training and education interventions; and support groups. It may be that a combination of interventions is most effective.

Read the full case study for 'Telecare for older people' here (PDF)
Michela Tinelli, Catherine Henderson, Danielle Guy, Martin Knapp 2019

KEY POINTS

Telecare is a form of assistive technology that is available in different packages according to the wide range of products featured.

• There is great policy interest in the potential of telecare to improve outcomes,including functional independence, psychological and quality of life, as well ascarer outcomes.
• There is also policy interest in whether wider use of telecare could reduce or contain use of other services and costs.
• The evidence suggests that telecare, as deployed in England at the present time,does not deliver the outcomes of effectiveness and cost-effectiveness thateveryone might have wanted.
• More research is needed to evaluate technologies in use, strengthen workforce training and share learning across settings.

Read the full case study for 'Transition into and from hospital for people with social care needs: economic evidence' here (PDF)
Annette Bauer, Michela Tinelli, Danielle Guy 2019

KEY POINTS

• Interventions that seek to improve the transition between hospital and other settings include: comprehensive geriatric assessments; specialist dementia / delirium unit; short-term early discharge home care and rehabilitation packages; early supported discharge with multidisciplinary community care; multi-professional palliative care.
• Each has been linked to some positive outcomes – although for specialist delirium/ dementia unit and for multi-professional palliative care outcomes referred to small changes in mood, satisfaction or symptom control rather than to changes in health-related quality of life.
• Early supported discharge programmes that include a rehabilitation-focused community care package are likely to be cost-effective from a combined health and social care perspective. The evidence refers to older people and people with stroke.
• Comprehensive geriatric assessment and short-term rehabilitation provided to older people in hospital units may be cost-effective from a hospital perspective, but the wider impacts are unclear.
• Multi-professional palliative care might be cost-effective; evidence refers to people with multiple sclerosis and people with breathlessness; there might cost savings for people with multiple sclerosis due to reductions in hospital and primary care.
• A specialist delirium/ dementia unit was not cost-effective based on health-related quality of life but might importantly improve experiences of people using it and their carers.
• Various national initiatives have been recently implemented to support development of innovative services to integrate care between hospitals and other settings.

Read the full case study for 'Vision rehabilitation services: Economic evidence' here

• Community-based vision rehabilitation services aim to provide early interventions by offering people in need of care and support a short period of rehabilitation before an assessment of longer-term needs is undertaken.
• Whilst local authorities have a duty to fund them, they can choose to provide them in-house or to contract them out to external agencies.
• An in-house vision rehabilitation service is more likely to be cost-effective from the perspective of the local authority i.e., when the costs of publicly-funded social care but not health care are considered. If costs to the local authority and NHS for publicly funded health and social care are both considered, then a contracted-out rehabilitation service seems more likely to be cost-effective compared to an in-house service.