Commissioning stepped care for people with common mental health disorders
This is an extract from the commissioning guide. The complete commissioning guide is available at www.nice.org.uk/guidance/cmg41
7 The commissioning and benchmarking tool
- 7.1 Identify indicative local service requirements
- 7.2 Review current commissioned activity
- 7.3 Identify future change in capacity required
- 7.4 Model future commissioning intentions and associated costs
- 7.5 Potential savings
Use the commissioning and benchmarking tool for common mental health disorders to determine the level of service that might be needed locally and to calculate the cost of commissioning the service, as described below.
There are 4 indicative benchmark rates used in the tool:
At step 1, the indicative benchmark for people receiving services is 3.5%, or 3500 per 100,000 population aged 18 years and older per year.
At step 2, the indicative benchmark for people receiving services is 1.6%, or 1600 per 100,000 population aged 18 years and older per year.
At step 3, the indicative benchmark for people receiving services is 1.1%, or 1100 per 100,000 population aged 18 years and older per year.
At step 4 and above, the indicative benchmark for people receiving services is 0.9%, or 900 per 100,000 population aged 18 years and older per year.
The commissioning and benchmarking tool helps you to assess local service requirements using the indicative benchmarks as a starting point. With knowledge of your local population and its demographic, you can amend the benchmarks to better reflect your local circumstances. For example, if your population is significantly younger or older than the average population, or has an ethnic composition different from the national average, or has a significantly higher or lower rate of common mental health disorders (see section 4.2), you may need to provide services for relatively fewer or more people.
You may already commission a common mental health disorder service for your population. The tool provides tables that you can populate to help you calculate your total current commissioned activity and costs.
Using the indicative benchmarks provided, or your own local benchmarks, you can use the commissioning and benchmarking tool to compare the activity that you might need to commission against your current commissioned activity. This will help you to identify the future change in capacity required. Depending on your assessment, your future provision may need to be increased or decreased.
You can use the commissioning and benchmarking tool to calculate the capacity and resources needed to move towards the benchmark levels, and to model the required changes over a period of 4 years.
Use the tool to calculate the level and cost of activity you intend to commission and to consider the settings in which services for people with common mental health disorders may be provided. Where possible the tool is pre-populated with data on the potential recurrent and non-recurrent cost elements that may need to be considered in future service planning, which can be reviewed and amended to better reflect your local circumstances.
The summary section of the tool calculates unit costs per service-user analysed by each step of the stepped care pathway. There are also unit cost calculations for indirect costs such as service design and management and improving access to services. This analysis, along with the supporting costing pages included in the tool may be helpful in assisting commissioners to identify local costs of such activities which are recommended in the guidance.
Commissioning decisions should consider both the clinical and economic viability of the service, and take into account the views of local people. Commissioning plans should also take into account the costs of monitoring the quality of the services commissioned.
Savings at local level are difficult to predict and are therefore not estimated in the commissioning and benchmarking tool. This section describes the type of savings and benefits that could occur from commissioning a common mental health disorder service:
fewer inappropriate referrals to secondary mental health care services, including community mental health teams
reduced use of hospital-based services as a result of increasing access to services in the local community and in primary care
costs avoided from successful use of psychological interventions reducing the inappropriate use of medications such as antidepressants
fewer GP visits to monitor progress and response to medication
fewer GP visits, because of earlier identification
wider economic savings from improved employability of people recovering from a common mental health disorder; this would deliver savings in the form of additional tax receipts and reduced welfare benefits payments.
Primary care: costs avoided and benefits
There may be cost savings in primary care as a result of reduced use of medication such as antidepressants if people respond to psychological therapies, and resources released in terms of reduced GP visits to monitor progress and response to medication. In research carried out by the Mental Health Foundation, 60% of GPs surveyed said they would prescribe antidepressants less frequently if other options were available to them.
Early intervention is important because this reduces the chance of subsequent admission to hospital. Early psychological treatment, though expensive, can significantly reduce repeat GP visits and drug prescriptions, which are becoming a serious burden on the NHS.
Secondary care: costs avoided and benefits
Providing psychological therapies to people who can benefit from them can help commissioners deliver greater efficiencies to the local health economy. A review of 91 studies showed that implementing psychological interventions achieved average savings of 20%, including immediate gains achieved by reducing outpatient appointments and treating people with long-term conditions.
A cost-benefit analysis study for psychological therapy set out the likely cost savings achievable through completing the implementation of IAPT adult talking therapy services. This estimated that recovery from a common mental health disorder leads to reductions in healthcare use relating to GP consultations, outpatient appointments and referrals. As a result of improved access and earlier intervention there may be fewer cases of undetected common mental health disorders.
Other benefits and savings
Implementing the guidance is likely to result in benefits and savings outside the health service. The economic case for fully implementing the guidance is that it will improve employability of people who have been successfully treated. Improving access to services and providing choice and continuity of service is likely to result in people successfully completing treatment and allowing them to retain or regain employment. The effect of this is to deliver savings in the form of additional tax receipts and reduced welfare benefits payments.
 Mental Health Foundation (2005) Up and running! How exercise can help beat depression [online]. Available from www.mentalhealth.org.uk/content/assets/PDF/publications/up_running.pdf
 Layard R (2005) Mental health: Britain's biggest social problem? Paper presented at the No.10 strategy unit seminar on mental health (2005) [online]. Available from http://cep.lse.ac.uk/research/mentalhealth/
 Chiles JA, Lambert MJ, Hatch AL (1999) The impact of psychological interventions on medical cost offset: A meta-analytic review. Clinical Psychology: Science and Practice 6: 204–220. Available from http://onlinelibrary.wiley.com/doi/10.1093/clipsy.6.2.204/abstract
 Layard R, Clark D, Knapp M et al. (2007) Cost-benefit analysis of psychological therapy. In: Department of Health improving access to psychological therapies (IAPT) programme: an outline business case forthe national roll-out of local psychological therapy servicesLondon: Department of Health