We very much welcome the publication of this report Early interventions: an economic approach to charitable giving which seeks to advise charitable funders on how they might spend their money in order to do the most good for society by supporting effective solutions for problems which carry particularly high economic and social costs. On the basis of a wide-ranging review of evidence on costs and returns, drawing extensively on work published by the Centre, the report identifies three priority areas for funding, all of which have a strong mental health component. These are: childhood conduct problems; mental health and employment; and chaotic families with multiple needs, often including mental ill health and substance misuse.
In terms of effective solutions, the report rightly highlights the critical importance of prevention and early intervention in all three priority areas. Recent work undertaken by the Centre in partnership with the London School of Economics and the Institute of Psychiatry and summarised in a report on Mental health promotion and mental illness prevention: the economic case published by the Department of Health, strongly supports this approach and indeed shows that in some cases the returns on investment in prevention and early intervention are even larger than suggested in the Barclays Wealth/NPC report. It also summarises the returns on investment that can be achieved through a range of interventions (see p.39). Those that relate directly to the three priority areas identified by Barclay’s Wealth are summarised below.
Evidence-based parenting programmes for the prevention of persistent conduct disorders in young children lead to future savings in public expenditure which exceed the costs of intervention by a factor of more than 3 to 1. Also taking into account consequences in the wider economy, every £1 invested in these programmes leads, over time, to total cost savings of more than £8. School-based social and emotional learning programmes also have very high returns through their impact on conduct problems.
Workplace screening to support the early diagnosis and treatment of depression among people in employment generates a return of £5 for every £1 invested, mainly by reducing sickness absence and ‘presenteeism’ (reduced productivity while at work). A strong economic case can also be made for workplace well-being programmes, with benefits exceeding costs by a factor of nearly 10 to 1 for well-designed interventions.
A variety of interventions may be needed to address the needs of these families. To give one or two examples, screening for alcohol misuse followed by brief advice sessions in primary care is good value for money, offering returns of up to £12 for every £1 invested. The financial distress experienced by many chaotic families is now increasingly recognised as a risk factor for depression and anxiety and there is growing evidence to show that debt advice services can be very cost-effective. Finally, parenting programmes for early conduct problems have a critical role in preventing the inter-generational transmission of family disadvantage.
The Barclays Wealth/NPC report draws on a wide range of published research but also notes that there remain important limitations in the coverage and quality of the available evidence and in the reliability of economic data in the areas discussed. We very much agree with this and would also argue that there is a crucial role for charitable donors not only in supporting the provision of evidence-based interventions but also in funding research and other studies which aim to fill some of the key gaps in the evidence base.
In some cases the main need is more high-quality research on what works. For example, in the field of mental health and employment, we need more cost-benefit studies of whole company approaches to promoting and managing mental health in the workplace, and also of employment support programmes aimed at helping unemployed or economically inactive people with mental health problems back into work, particularly the large numbers with common mental health problems such as depression.
In other areas we have reasonably good evidence on the effectiveness of interventions but know much less about how to address practical shortcomings in their delivery and implementation. For example, parenting programmes for childhood conduct disorder often have low rates of take-up and high rates of drop-out, and interventions aimed at supporting chaotic families suffer from similar problems of identifying, engaging and retaining those who would benefit most. In the light of this, the Centre has recently embarked on a major programme of implementation-focused research in relation to parenting programmes and will be reporting next year on the first phase of this work.
In general terms, implementation is an under-researched area in the field of mental health and studies which yield generalisable findings are particularly likely to be good value for money. Research and development work that has a demonstrable impact on everyday practice in any of these areas would produce returns on investment that are many times greater still.