Professor Eddie Kane

This brief study aimed to: assess the economic impact of the Leeds Managed Clinical Network (MCN) model using a before and after review of service use and costs in a small, representative sample of clients (N=20) examine the equivalent costs in a broadly matched sample of individuals in Sheffield where there is no dedicated personality disorder service (N=22) apply the Leeds MCN service change profile in usage and costs to the Sheffield sample highlight the key wider economic impacts of PD in society examine the potential impact in Leeds and Sheffield of these wider factors using a composite case vignette from each cohort. . A partnership of:

Multiple complex needs Significant risk of self harm or neglect Matching Criteria: Diagnosis of personality disorder or identified personality difficulties Multiple complex needs Significant risk of self harm or neglect Poor response to previous intervention Difficulty in maintaining contact with services Limited social networks Aged 18 or over A partnership of:

All services have been costed at 2009/10 price levels using published national data on unit costs, the main sources being the NHS Reference Costs produced by the Department of Health (1) and an annual compendium of unit costs in health and social care published the Personal Social Services Research Unit, University of Kent (2). In line with the methodology used in these sources, all services are costed on a ‘full cost’ basis, including appropriate allowance for building costs, administrative support, management overheads and so on A partnership of:

Number of in-patient bed-days Number of community contacts Table 1: Use of services in Leeds (annual average per client) ‘before’ ‘after’ Change Number of in-patient bed-days 39.4 12.3 - 68.8% Number of community contacts 25.6 90.7 +254.5%

Table 2: Cost of services in Leeds (annual average per client in £s at 2009/10 prices) ‘before’ ‘after’ Change In-patient bed-days £12,249 £3,715 - £8,534 Community contacts Total Costs £1,747 13,996 £3,574 7,289 +£1,827 - 6,707 A partnership of:

Annual Average Per Client Table 3: Use and cost of services in Sheffield: Annual Average Per Client Number Cost In-patient days 32.1 £9,686 Community Contacts 123.9 £4,388 Total Costs - £14,073 A partnership of:

comparing ‘before’ and ‘after’, total costs in Leeds fell by 47.9% Applying this change to total costs in Sheffield estimated at £6,741 per client. total costs per client are virtually identical in Leeds ‘before’ and Sheffield, but there is a different mix of costs between in-patient services and community contacts. Comparing ‘before’ and ‘after’ in-patient costs in Leeds fell by 69.7% while community contact costs increased by 104.6%. If these separate changes are applied to the Sheffield data, in-patient costs fall by £6,751 per client while community contact costs rise by £4,590, giving a net saving of £2,161 per client. A partnership of:

The Secure Services Commissioning Team provided information regarding out of area spend on low secure placements for individuals with personality disorder throughout this period and indicate that on average over the three years Leeds would have three clients in such placements and Sheffield seven. Given that an average annual cost of such placements is £164,000 per client this gives an average spend for Leeds of £492,000 and for Sheffield of £1,148,000. Thus Sheffield appears to spend £656,000 more per year on PD low secure out of area placements whilst having a total city wide population which is approximately two thirds the size of Leeds. A partnership of:

Wider Economic Costs A partnership of:

Unemployment According to data analysed in a recent publication by the King’s Fund (3), men with personality disorder are five times more likely to be unemployed than the national average and women with personality disorder are 2.5 times more likely. The aggregate cost of lost output in the economy associated with this higher unemployment is estimated at around £8 billion a year (England, 2009/10). Averaged over all people with personality disorder, the cost works out at nearly £9,000 a year among men and £1,600 a year among women. A partnership of:

Crime: Singleton et al’s research on psychiatric morbidity among people in prison indicates a prevalence of any type of personality disorder among male sentenced prisoners at 64%, including 49% with anti-social personality disorder. On average the lifetime economic and social costs of crime committed by someone serving a prison sentence amount to around £220,000 Based on Home Office data, the economic and social costs of violent crime, including costs to victims, amount to around £30 billion a year in England . Combining these figures, the costs of violent crime associated with any type of personality disorder work out at £14.4 billion a year and at £6.6 billion a year for anti-social personality disorder A partnership of:

Family breakdown: The adverse consequences of family breakdown may take a number of different forms and not all of these can realistically be quantified and valued in monetary terms. The largest financial cost is likely to arise if family breakdown results in children being taken into care. The unit cost of local authority foster care for children was £676 a week (over £35,000 a year) in England in 2009/10, while the cost of care in a local authority children’s home was £2,881 a week, or just under £150,000 a year A partnership of:

Implications for Leeds and Sheffield A partnership of:

NHS: both clients have had numerous psychiatric in-patient admissions (at a unit cost of c. £300 a day in an acute mental health ward and c. £600 a day in a PICU), and both have also required in-patient treatment in acute general hospitals because of severe self-harm and overdosing behaviour (at a unit cost of c. £400 a day). In addition, costs will have been incurred on a range of community-based services for both mental and physical health needs. A partnership of:

Social services: the Leeds client has four children, all of whom have been removed by social services. Depending on whether the children are in foster care or in a local authority children’s home, the combined cost for these four children is in the range £140,000 - £600,000 a year A partnership of:

Social security: both clients have been continuously unemployed for lengthy periods (11 years and 4 years respectively) and are reliant on social security benefits. The typical cost of supporting a single person on incapacity benefits, income support and housing benefit is around £8,000 a year A partnership of:

Police and other criminal justice agencies: both clients have had regular involvement with the police, albeit mainly as the victims rather than the perpetrators of crime. Thus the Sheffield client has been visited by the domestic violence police on over 100 occasions in a period of 18 months. Even on very conservative assumptions, this is likely to have entailed costs of at least £10,000 in terms of police time. It is also noted that the Leeds client has often been held by the police under Section 136 of the Mental Health Act. A partnership of:

Summary Conclusions Leeds: Is cost effective and makes measurable savings on a before and after analysis Reduces reliance of clients on high cost inpatient services Lowers the level at which contact is made with community services and thus cost Appears to reduce the numbers of cases reaching the level of complexity that require sustained inpatient intervention and high usage of crisis services Has the potential to reduce the wider economic impacts of complex cases. A partnership of:

Sheffield: When the same analysis and assumptions are applied to the Sheffield sample, potential for direct service cost savings is evident and the potential for a reduction in the adverse economic impacts equally applicable. A partnership of: