Community mental health services: resources and costs

The development of community-based services for people with mental health problems has been a long-standing policy in England, but assessing the levels of provision that comprise ‘community care’ is not easy. Routinely collected data may enumerate the number of hospital beds or mental health professionals but give little information on how services are delivered, what type of support is provided and to whom, and to what effect. Such information has become increasingly important following implementation of the National Health Services and Community Care Act, 1990.

The reforms introduced by that Act have also bought care and cost issues closer together. No longer solely the province of finance personnel, costs data are also essential to inform both purchaser and provider activities. Moreover, the drive to provide evidence-based health care creates a demand for information on both the costs and the effectiveness of services.

Six broad evaluative questions are addressed in this thesis, each of which has relevance for medium- and long-term planning in mental health care. What do care services cost? What are the components and costs of clients’ care packages? How can costs data be used in the broader evaluation of mental health care? Can the resource requirements of a particular policy be predicted? What are the associations between costs and outcomes? What incentives do finance mechanisms provide?

Frameworks, methodologies and techniques derived from economics are used to evaluate available costs and resource information, to consider the role of research in filling some of the information gaps, and to examine the ways in which research results can inform mental health policy and practice.

Although considerable progress has been made to date in addressing these questions, many research techniques still require development. Furthermore, there is a broader research agenda yet to be addressed by mental health economics.

The people who have contributed to this thesis one way and another are too numerous to mention. However, I am particularly indebted to Professor Martin Knapp of the Personal Social Services Research Unit (PSSRU) for his guidance and support over the last ten years: without him this thesis would never have been started. The thesis draws upon a number of research activities undertaken while I have been employed at the PSSRU and funded by the North East Thames Regional Health Authority and the Department of Health.

My thanks are offered for the input from members of the Team for the Assessment of Psychiatric Services and the PSSRU Care in the Community Team. Rachel Dean and Amanda Dansie undertook the CSR1 interviews for the Domus and MOSTT studies. The contributions of staff and users of all the services evaluated should not be forgotten. Reference is made at various points throughout the thesis where work was undertaken with other researchers, and where relevant, details are given of the publications from which certain sections have been developed.

Thanks are also extended to Professor Bleddyn Davies as Director of the PSSRU. Cliff Netten receives high honours for editing the final version while suffering from a slipped disc and although it may be unusual for a PhD thesis to contribute so directly to a low handicap, Peter Cook’s weekend defection to the golf course has been as important as his presence and his cooking. This thesis was only finished because friends and colleagues provided emotional and practical support when my confidence and technical skills needed bolstering.