personal social service research unit (pssru) lse health ...personal social service research unit...

Economic Analysis of the Health Champions Scheme in Hammersmith and Fulham Commissioned by Turning Point – Connected care and Hammersmith and Fulham Primary Care Trust Annette Bauer and José-Luis Fernandez

March 2012

Personal Social Service Research Unit (PSSRU) LSE Health and Social Care London School of Economics and Political Science

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1 INTRODUCTION AND STRUCTURE OF THE REPORT ............................ 3

2 AIMS AND METHODOLOGY ...................................................................... 4

3 BUDGET AND THROUGHPUT FIGURES .................................................. 6

4 ECONOMIC VALUE OF INTERVENTIONS PROVIDED BY HEALTH CHAMPIONS AND VOLUNTEERS ................................................................. 7

4.1. Physical activity interventions ....................................................................................................... 7

4.1.1. Intervention costs and reduction in health service demand ...................................................... 8

4.1.2. Economic value of quality adjusted life years gained .............................................................. 10

4.2. Healthy eating interventions ........................................................................................................ 10

4.2.1. Intervention costs and reduction in health service demand .................................................... 11


4.3. Smoking cessation advice .............................................................................................................. 12



4.4. Debt advice and signposting ......................................................................................................... 13



5 ECONOMIC VALUE OF INCREASE IN SOCIAL SUPPORT ................... 14

6 ECONOMIC VALUE OF INCREASE IN CARERS’ SUPPORT ................. 15

7 EMPLOYMENT, TRAINING AND EDUCATION RELATED COSTS AND BENEFITS ..................................................................................................... 16

7.1. Training provided as part of the Scheme .................................................................................... 16

7.2. Economic value of changes in employment ................................................................................. 17

7.3. Benefit claims ................................................................................................................................. 19

7.4. Economic value of changes in volunteering ................................................................................. 19

7.5. Economic value of changes in education ..................................................................................... 20

8 SERVICE RE-DESIGN ............................................................................... 20

9 FINDINGS, LIMITATIONS AND CONCLUSIONS ..................................... 21

APPENDIX .................................................................................................... 23

REFERENCES .............................................................................................. 25

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1 Introduction and structure of the report In 2011, the Personal Social Services Research Unit (PSSRU) at London School of Economics (LSE) was approached by Turning Point Connected Care and Hammersmith and Fulham PCT (from now on called the Commissioners) to undertake economic evaluation research of their health champion model. After a series of scoping meetings this evaluation study was carried out between May and August 2011, which assesses costs and economic benefits of the scheme retrospectively. From 2008 until 2011, the White City Estate within the neighbourhood of White City in Hammersmith and Fulham participated in the Health Champions scheme under the Well London programme. In October 2008, 40 members of the community were identified who were interested in becoming involved in the Health Champions scheme. Out of the 40 participants, 18 received the accredited health champions training provided by the Royal Society of Public Health. 17 individuals completed the course. In addition, a comprehensive training programme was accessible to all 40 community members which focused on enhancing their knowledge and skills to improve their health, to enter volunteering and to achieve better employment outcomes. Almost half (45 percent) of all participants gained employment or moved into a better paid job because of their involvement in the scheme. Almost the same proportion became involved in regular volunteering after entering the scheme. The present report analyses the economic implications of the scheme. As part of their volunteering role, health champions and other volunteers signposted individuals to services and - after receiving additional training - provided health promotion advice and supported the delivery of activities on a broad range of topics including physical activity, healthy eating, smoking cessation and mental wellbeing. At the same time as the health champion scheme was set up, the Well London programme ran locally providing a wide range of (mental) health promotion activities which health champions and volunteers referred to (see Insert 1).

Insert 1: Description of the Hammersmith and Fulham Health Champions Scheme (provided by the Commissioners)

The Well London Health Champions Project is delivered as an integral part a wider Community Engagement approach and framework in Hammersmith and Fulham which is based on the assumption that we as staff do not have the solutions but merely facilitate the process of empowering communities and patients to articulate the problems that currently exist in the system and come up with their own solutions. As a result, our principle aim has been that of building the capacity of the local community and individuals to design and develop local services so that they are able to respond effectively to the increasing demands of local health and social care needs.

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The Commissioners wanted to explore three key questions to generate conclusions about the effectiveness and cost-effectiveness of the scheme and inform future funding decisions:

1. Does the scheme support local people from marginalised groups (specifically NEET) into employment?

2. Does the scheme promote and support healthy lifestyles and appropriate use of services among at-risk groups?

3. Is the community development model cost-effective in achieving the above outcomes? This report starts by outlining the aims of the research and the methods that were used. Details on budget and throughput information are provided. The main part of the analysis is concerned with the costs and benefits of running a core set of interventions that were provided by the volunteers, namely those on physical activity, healthy eating, smoking cessation, social support and debt advice. Improved outcomes achieved by the volunteers of the health champion scheme themselves in terms of education, training and employment are presented.

2 Aims and methodology The background to the research was the Turning Point Connected Care project in Hammersmith and Fulham by which local health champions had been trained up to become community researchers to help inform better ways of delivering public services in the community including the expansion of the health champion model and a transformation of their role. Initially, the aim was to examine the economic value associated with the following service delivery options:

1) Continuation with the health champion scheme as it had been running so far.

2) Transformation of the role of the health champions and volunteers from a health promotion focussed role to a broader community activities, advocacy and signposting role.

3) A geographical expansion of the scheme beyond White City Estate. It soon became clear that information about future service planning could not be provided in the current situation of uncertainty about health service commissioning and planning. The research was thus centred on the first question of the economic pay-offs (if any) that were likely to be associated with the health champion scheme with its core elements of support provision. Questions 2 and 3 were briefly scoped based on findings from previous work carried out by PSSRU but could not be analysed. The focus of the analysis was on those elements of the champion scheme that where there was evidence available from the literature. Findings from the analysis were

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aimed at informing the future design of the scheme under consideration of available resources and commissioning priorities and plans. The analysis focused on a short-term, one year time horizon and was carried out from the perspective of the public purse. In addition, longer-term economic consequences and a wider societal impact were analysed separately where this was possible based on the available evidence. Primary data and information were generated from commissioners, project managers and volunteers involved in the scheme. The methods used were the following:

Introduction and listening visit at local partnership meeting

Presentation and initial scoping with local health commissioners

2 Semi-structured interviews with the service/ project manager and public health commissioners

3 Structured interviews with volunteers involved in the health champions scheme

Primary information that could be accessed included:

Literature provided at project start, including publications on regional and national evaluations and reports on the Health Trainer programme and Well London programme as well as on the Connected Care research.

Data on local circumstances and schemes, including statistical summaries of service use at the new local health centre.

Exemplary information from questionnaires on service use and outcomes before and after individuals became involved with the health champion scheme.

Data on throughput: the number, kind of events and activities which took place as part of the health champions scheme including number of people participating and their socio-demographic profile.

Budget and cost information.

Career development and volunteering and employment paths of individuals involved in the scheme.

For secondary data, rapid reviews of the literature were carried out to examine the evidence on the effectiveness and cost-effectiveness of interventions that were provided as part of the scheme. A second set of secondary data was reviewed on the long-term economic implications associated with outcomes. Reviews were undertaken of interventions using the following search terms: Physical activity, nutrition, social support and mental wellbeing, inequalities, deprived communities, immigration, older people, younger people, debt and finance, caring, volunteering and employment. Databases searched included LSE and PSSRU internal libraries, the Database of Abstracts of Reviews of effects (DARE), NHS Economic Evaluation Database (NHS EED), Health Technology Assessments, Cochrane library, Campbell library.

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Preference was given to high quality studies (usually randomised controlled trials) and to evidence from the United Kingdom and where available from London trials. Statistics on prevalence rates, costs and similar were generally taken from the National Office for Statistics – either at a country level or where this was available at an inner city London level. In cases where evidence from United Kingdom was not available, evidence from other countries such as the United States and Australia was considered. The costs of running the scheme were estimated on a ‘per intervention’ basis by taking local salary and cost of venue information. Where overhead costs needed to be estimated, information was taken from national sources. It was not feasible to attribute cost to the interventions from budget information because of the large number of interventions and activities that had been carried out simultaneously and a lack of records of the allocation of funding to activities.

3 Budget and throughput figures An amount of £40,000 was provided by the New Opportunities Fund and Well London programme for the first two years (End 2008 to 2010). A further £90,000 was provided by Hammersmith and Fulham PCT so that overall budget for the period from End of 2008 to 2011 was £130,000. A wide range of activities was provided by the health champions and volunteers during this time including:

Cookery classes (3-4 classes, 6wks, 2hrs/wk)

Food co-op at the local school (1 store, 12wks, 1day/wk, accessed by 200 people)

Signposting to health activities provided as part of Well London (400 referrals)

Debt advice in one-to-one sessions and signposting to statutory services

Smoking cessation service outreach and brief interventions (6wks, 1hr/wk, 16 people)

Mental wellbeing workshop for women (1 course, 8wks, 3.5hrs/wk, 20 people)

Aerobic classes (10 courses, 8wks, 4hrs/wk, 30-40 people)

Salsa classes (10 courses, 8wks, 4hrs/wk, 30-40 people)

Yoga classes (10 courses, 8 wks., 4hrs/wk, 30-40 people)

Fun trips with children (altogether 200 children participated in trips)

Football tournament (1)

Swimming scheme for young people (1x over summer holiday)

Dance classes for young people (1 course, 6wks., 40 people participating)

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Taekwondo for young people (1 course, 20-12wks.)

Chair based exercise for older disabled women people (for 6 months period, 2-3 times/month)

In addition to those health activities, a range of one-off community events were organised helping to promote these activities and getting people involved. From 2010, the provision of exercise classes was provided via social enterprises which were held and organised by volunteers including those who have become qualified health instructors through their involvement in the health champion scheme.

4 Economic value of interventions provided by health champions and volunteers

4.1. Physical activity interventions

The positive outcomes associated with exercise classes and similar interventions were based mostly on the benefits of an expected increase in physical activity levels. In addition, based on the information from interviews and questionnaires, it was established that women who participated in the exercise classes had used those as a way to build new social contacts, support networks and friendships (as often suggested in the literature). Both sets of evidence were considered in the economic analysis. There are a range of studies which show that physically active adults face a lower risk of developing certain chronic conditions compared to those physically inactive (DH 2004, NICE 2006). Conditions that can be prevented with an increase in physical activity levels above a certain threshold1 are coronary heart disease, type-2-diabetes, breast cancer, colorectal cancer, ischemic stroke and depression (WHO 2004, Finkelstein et al. 2004). The analysis used evidence on the reduction in incidence rates from Roux et al. (2009). To avoid the risk of double counting, we only looked at physical health outcomes whilst an improvement in mental wellbeing was considered by measuring the benefits of an increase in social support (see section 5).. Exercise classes provided as part of the health champion scheme included aerobics, salsa zumba, yoga, chair-based exercise and dancing classes. Based on local information, we assumed that those exercise classes (with the exception of the chair-based exercise and activities for young people) involved a group of at least 30 women who attended the full range of classes offered two to three times a week

1 The evidence for a reduction in risk of developing chronic conditions is strongest for the change

from physical inactivity to moderate physical activity levels which consisted of 30 minutes for five times a week or of 2.5 hours per week respectively (DH 2004).

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with each session lasting an hour. Women then achieved moderate physical activity levels by attending those classes alone even before considering any possible increase in activity outside of these classes. Participants were primarily from ethnic minority groups in particular from the Somali Muslim community who were more likely to live in single households and at risk of social isolation and physical inactivity (DCLG 2009). The evidence for chair-based exercise provided to older people and the activities offered to young people were not included in the analysis because the information provided did not allow a robust estimation. However, some considerations to the costs and benefits of those interventions based on the evidence from the literature are presented in the Appendix.

4.1.1. Intervention costs and reduction in health service demand

The reduction in health service demand is estimated based on NHS expenditures linked to the relevant chronic conditions. Other typical economic costs associated with physical inactivity are those of productivity losses when individuals are absent from work because of their condition. Here, productivity losses were not considered based on the assumption that the groups targeted by this scheme were less likely to be in formal employment. Based on the evidence by Roux et al. (2009), reduced incidence rates observed for physical interventions per 100,000 ranged from: 5 to 15 cases for colorectal cancer, 15 to 58 cases for breast cancer, 59 to 207 cases for type-2-diabetes, and 140 to 476 cases for cardiovascular disease. Annual treatment costs (Table 2) were applied to those reduced likelihoods of needing care. The reduction in health services demand per participant was calculated at £26 with a lower value of £12 and an upper value of £41. The costs of physical activity classes were calculating as follows: Costs of hiring a hall were £35 per hour. The cost for paying the health instructor was £25 per hour and unit costs were estimated at £36 which included managerial overheads and salary on-costs. These were calculated by applying the typical proportional overhead applied for health professionals in the PSSRU ‘Unit costs for health and social care’. The average session time was 1 hour plus 30 minutes for setting and clearing up so that overall costs of exercise classes were calculated at £107 per session. If 30 participants were assumed per session, the cost per member and session was £3.6, and circa £9 per week for attending 2.5 exercise classes per week as part of the Scheme. The intervention has been recently run by a social enterprise and participants contribute at the moment with payments of circa £5 per session. If it can be ensured that 22 or more members are participating per class, the courses may be run without the use of public resources. If the reduction in demand for mental health services from calculations in section 6 was included then the net benefit exceeded £50 per person and year at a minimum, £79 at a maximum and a midpoint of £64. With a longer term time horizon, Pringle et al. (2010) estimates the potential reduction in health services demand at up to £2,500 per person.

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Table 1: Annual risk of developing diseases in age groups 35-65 yrs Condition Annual risk Source and details

Coronary Heart disease

0.26 percent (women) 0.68 percent (men)

Coronary heart disease statistics. Morbidity, 2003 Statistics. Angina or myocardial infarction in 30-69yrs age group

Ischemic stroke

0.03-0.06 percent

The Stroke Association 2006: under 65 yrs age group (25% of strokes occur in people under 65yrs)

Lung cancer 0.05 percent European age-standardised rates calculated by the Statistical Information Team at Cancer Research UK, 2011 using data from GLOBOCAN 2008 v1.2, IARC, http://globocan.iarc.fr; Office for National Statistics, Cancer Statistics registrations: registrations of cancer diagnosed in 2008, England. 2010

Stomach cancer

0.012 percent Age-standardised rates, Office for National Statistics, Cancer Statistics registrations: Registrations of cancer diagnosed in 2007, England. Series MB1 no.38. 2010, National Statistics: London.

Oesophaegeal cancer


Breast cancer


Diabetes 0.233 percent Diabetes UK (2010): 145,000 people diagnosed with diabetes in the UK in 2008

. Table 2: Annual treatment costs for chronic conditions to the NHS

Disease Cost per patient

Sources and details

Colon/ colorectal cancer

£2,425 - Cancer Research UK: 2m living with cancer in the UK in 2008 - Parliament: £4.3bn for cancer services in the UK in 2005/06,

£4.85bn at 2010 prices

Breast cancer

£2,425 - Cancer Research UK: 2m living with cancer in the UK in 2008 - Parliament: £4.3bn for cancer services in the UK in 2005/06,

£4.85bn at 2010 prices

Diabetes £1,190 - Currie et al (2010) for primary care cost inc prescription costs at 2010 prices: £1,141

- Morgan et al 2010 for diabetes-related hospital costs at 2010 prices: £49

Cardiovascular disease

£7,702 - British Heart Foundation: circa 2.65m patients with cardiovascular disease

- Luengo-Fernandez et al 2006: 20.41bn health care expenditure in the UK for CVD (at 2010 prices)

Stroke £4,052 - Prevalence estimated at 0.0175 from O’Mahony et al 1999, citizens UK circa 62,200,000

- Saka et al 2009: Costs of direct expenditure (NHS) for stroke 0.49*9bn in UK

http://globocan.iarc.fr/

http://www.statistics.gov.uk/statbase/Product.asp?vlnk=8843








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4.1.2. Economic value of quality adjusted life years gained

In government decision making in the health field, cost-effectiveness analysis is commonly applied which puts a monetary value on the quality and length of life contributed by particular interventions. A year of perfect health has been given a willingness-to-pay threshold at the lower end of £20,000 (NICE, 2004). For the one-year time horizon, a value for improved mental wellbeing was applied based on the calculations in Section 5. Quality of life improvements associated with a reduction in depression were valued at £585. In addition, quality of life improvements associated with improved physical health were valued at less than £10 in the analysis taking a one year perspective. This was based on the reduced annual risk presented above and improved quality of life scores presented in Table 3. If quality of life improvements due to a reduced disease risk are valued over a life time and discounted to the present then exercise classes can be attributed an economic value of £148 per person receiving the class (see Appendix for calculations). Table 3: Parameters to calculate QALY gain associated with reduction in developing chronic conditions when exercising regularly - taken from NICE (2006)

Average QoL score for women (35-65 yrs) without disease

Average QoL score for women (35-65 yrs) with the disease

Diabetes 0.86 0.64

Cancer 0.86 - Colon 0.63 - Breast 0.79

CVD 0.86 0.57

4.2. Healthy eating interventions

Cookery classes were provided on a bi-annual basis and run for 6 weeks with each session lasting 2 hours. Each course was visited by on average 7 people with the aim to teach healthy cooking and to encourage socialising among participants. Cobiac and colleagues (2009) show the reduced risk of developing a number of chronic conditions when persons consume an additional portion (80 grams) of fruits and vegetables per day. In order to estimate the likelihood that cookery classes led to an 80 grams increase in the consumption of fruits and vegetables we looked at proxy indicators from evaluation studies. An evaluation carried out by the Food Standard Agency (FSA, 2008) finds an 8 per cent increase in probability that a person attending a cookery class consumes a portion more per day after the course. Another evaluation of cookery clubs in Kent showed that 12 per cent of participants reported an increase in fresh fruit and vegetables after the course. In our analysis we took

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these figures to estimate a probability since we were unable to obtain local information on outcomes. We were not able to identify appropriate trials in this area that could have provided effectiveness data. We assumed that effects on consumptions were sustained for the whole year and reduced the risk over a 5 years period. There is generally only weak evidence around the long-term sustainability of lifestyle behavioural changes in individuals although it is indicated that social support has a positive impact on sustainability (Wing et al., 1999). Cobiac and colleagues find a risk reduction for developing cardiovascular disease of 11 per cent, of 6.4 per cent for stroke, of 4.2 per cent for lung cancer, of 6.4 per cent for stomach and oesophageal and of 1 per cent for stomach cancer. Estimates for the accumulated risk for a middle aged woman to develop those conditions over a 5 years period are presented in Table 4. Table 4: Annual risks and 5-years risk of developing chronic conditions

Disease Risk over 5

years period (in %)

Source

Stomach cancer 0.06 Office for National Statistics (2007), Cancer Statistics registrations across age groups

Lung cancer 0.25 European age-standardized rates calculated by Cancer Research UK, 2011 using data from http://globocan.iarc.fr, Cancer Statistics registrations: registrations of cancer diagnosed in 2008, England. 2010

Oesophagal cancer 0.065 Office for National Statistics (2007), Cancer Statistics registrations across age groups

Cardiovascular disease

1.3 Coronary heart disease statistics. Morbidity, 2003 Statistics for angina or myocardial infarction, 30-69yrs age group

Stroke 0.23 The Stroke Association 2006, under 65yrs age group with 25 per cent of strokes in this age category


The reduction in demand for health services was generated based on the avoided costs for treating relevant chronic conditions (Table 2). If the effectiveness estimates of 8 to 12 per cent were applied then reduction in NHS expenditure was only £2. Even if it could be assumed that the intervention was 100 per cent effective i.e. all participants increased their fruit and vegetable intake by one portion per day for the period of the whole year, the annual reduction in NHS expenditure was only just above £20, whereby this is attributed to the largest extent to a reduction in costs for the treatment of cardiovascular disease. This, however, does not yet include the benefits women experience because of their increase in social support and new friendships. Including this effect increases the



http://globocan.iarc.fr/



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overall reduction in health service demand to circa £40 per participant (see Section 5). If an average attendance of 7 was assumed then the costs of the course per participant was £122. This was based on unit cost per hour of £36 for the nutritionist and cost of £35 per hour for hiring the kitchen. It is thus very unlikely that cookery classes lead to cost savings to the NHS. We need to look at quality of life improvements in the next section to understand whether the intervention is cost effective.


The economic value generated for quality adjusted life years saved over a year time was estimated at below £20. With the help of modelling techniques a five years time horizon was considered too and the discounted value of quality adjusted life years gained was circa £160. In other words, the intervention is likely to be cost effective if a longer time horizon of 5 years is taken.

4.3. Smoking cessation advice

A Health Technology Assessment was published earlier this year (Carr et al 2011) which investigated the evidence of smoking cessation interventions provided by lay health advisors and analysed the economic value of a range of interventions. We took the effectiveness data from a randomised controlled trial by Woodruff (2002) which investigates a ethnically targeted smoking cessation service provided by trained lay promoters and applied the local costs of the intervention. Costs of smoking to the public pocket were estimated by looking at the national figure of expenditure for smoking-related conditions (Allender et al 2009) and dividing it by the number of smokers in the UK. The average number of quality of life adjusted years was taken from Cromwell et al (1997) and Fiscella and Franks (1996). The likelihood of a person permanently stopping smoking because of the 6 weeks intervention was estimated at 1.2 percent. This figure is derived from a 10 percent chance that people stop smoking after the intervention, a risk of 30 percent that they relapse during the course of the year, a risk of relapsing thereafter of 50 percent and a chance of 0.3 percent that the person would have stopped even without any intervention.


Two smoking cessation advisors were paid £25 per hour and £75 per week for 3hrs of volunteering. Following the same method described earlier we estimated unit costs at £36. Each volunteer provided one session of smoking cessation advice per week. On average, a client would be seen for six weeks so that altogether circa 16

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clients received the intervention. We thus estimated the cost of the intervention at circa £650. This is likely to be a maximum amount because smoking cessation advisors used hours of their time for other face-to-face activities, for which any additional direct benefits to clients that have not been accounted here. The average annual costs for treating smoking-related conditions in the UK were £450 per smoker at 2010 prices. Based on this figure the reduction in costs for NHS treatment per person receiving the smoking cessation intervention was estimated at £122. The cost of the intervention only occurs once whilst the reduced demand on health services continues beyond the first year. A break-even point is achieved after 6 years if an interest rate of 3.5 per cent (as commonly used by the National Institute for Clinical Excellence) is assumed.


Quality of life improvements were estimated at £473 based on quality adjusted life years gained of 1.98. This figure was taken from Carr et al (2011) and relates to the years gained over a life time whereby the authors acknowledge this to be a very conservative estimate. If a life expectancy of 80 years and interest rate of 3.5 per cent is assumed, then this translates into an annual value of circa £22.

4.4. Debt advice and signposting

Although the main focus of the health champion role was on health promotion and employment, at times this brought up other personal issues such as housing and debts. Based on Pleasence and Balmer (2007) a debt problem was defined as ‘being behind in payments for mortgage, rent, credit/ store card, personal loan, hire or credit purchase, utilities, maintenance, tax or court fines and having a problem paying the money owed’. It has been shown that people with debt problems from deprived communities access the appropriate advice services at a late stage. By reaching out to the most vulnerable members of the community, the health champion scheme identified problems at an early stage so that it was assumed that negative consequences of debt problems were prevented. Advice, referrals, mediations and payment arrangements were provided by the project manager. The total number of residents who were advised during the two years project period on debts was in total 20. Altogether 23 referrals were made out of which 30 percent were concerned with tax arrears, 30 percent with utility bills, 22 percent with fines and the rest was split equally between maintenance payments (9 percent) and rent (9 percent). On average 1.15 referrals were made per person.

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Based on local information we estimated that the project manager spent on average 4.5 hrs with a person and unit costs were estimated at £52 based on local salary information and estimates for overheads and salary on-costs from PSSRU (2010) ‘Unit cost of health and social care’. The cost of the intervention was thus £234. For every referral we added the costs of visits to the Citizens Advice Bureau or Job Centre Plus which are set out with £196 by the Legal Services Commission, so that the costs per case were circa £460. Average reduction in health service demand through reduced GP visits were calculated at £22 per person based on data from two national studies, the English and Wales Civil and Social Justice Survey 2004 and the Advice Agency Client Study 2007. Both studies showed also a reduction in crisis and hospital services but number on visits were not specified so that they could not be included in the analysis. If productivity gains were included then the economic value of the intervention was estimated by us in previous research (Knapp et al., 2011) at circa £1,130 per person out of which on average £140 represented reduced government spending on benefit claims. This calculation was based on an assumption that the person’s situation would not have improved on its own in the year. There are long-term economic consequences of alleviated debt problems which were not considered in the analysis and those include a reduced risk of relationship breakdown, homelessness, moving house and disrupted education for children, and costs to courts (Williams, 2004).


Individuals living with unmanageable debt are at a 33 per cent higher risk of developing mental health problems (Skapinakis et al., 2006). Quality of life gains were valued in previous research at circa £840 (Knapp et al., 2011).

5 Economic value of increase in social support Activities provided as part of the health champion scheme such as physical exercise classes and cookery classes were used by participants to establish and sustain frequent social contacts and friendships. Based on information from interviews and questionnaires we knew that women attending cookery and physical exercise classes were more likely to be living alone and at high risk of social isolation. In a study by Rajaratnam et al. (2007) it was shown that socially isolated mothers living in deprived urban areas were more likely to report depressive symptoms (measured using the CES-D) than their counterparts who were not socially isolated.

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The average CES-D score of socially isolated women was almost identical with the cut-off point for major depression (16), whilst the average CES-D score among non-isolated women was around 9. If we assume a normal distribution of depressive symptoms then the likelihood of women who were isolated to be above the cut-off point would be circa 50 percent. The accuracy of the CES-D to identify major depression at a cut-off point of 16 was found to be 75 percent so that the risk of women who are isolated to have major depression was calculated at 37.5 percent. Prevalence of depression (CESD>=16) in US women across socio-economic and ethnic groups was found to be 24 percent (Bromberger et al 2004). The same prevalence was found in the female urban UK population (Ayuso-Mateos JL et al 2001). Thus, the additional risk of isolated women to have major depression compared with their non-isolated counterparts was 19.5 percent. Following a conservative approach, it was assumed that women who were depressed because of their social isolation moved from major to moderate depression levels. Average cost to the NHS per person living with depression were estimated at £196. This was derived from Thomas and Morris (2003) who estimated the direct treatment costs in England at £370 million. A prevalence of 2.6 million from the source was applied and this figure presented at 2010 prices. The cost savings to the NHS were estimated at £38 per participant. Quality of life benefits were calculated at £585 based on utility values from Revicki and Wood (1996) for depression and a willingness-to-pay threshold of £20,000 per quality adjusted life year gained.

6 Economic value of increase in carers’ support For England, the number of carers can be estimated at circa 10 percent with almost a fifth providing more than fifty hours of care (Census 2001, ONS). In London, people from Asian, Black and Ethnic Minorities populations make up 30 percent of all carers (Carers UK, 2007). Carers are at particular risk of physical and mental health problems (Edwards et al., 2008). Although the link between increasing caring responsibilities and the impact on productivity is not straight forward there is strong evidence on substantial strains experienced by carers who work (Arksey et al., 2002; Ipsos, 2009). Recent and previous governments have expressed a strong commitment to help carers to not become disadvantaged from career opportunities because of their caring responsibility and to maintain a good quality of life (HM Government 2010, 2008). From information gathered via interviews and questionnaires we assumed that some people who got involved with the scheme had caring responsibilities. The health champion scheme provided a range of potential benefits to carers such as improved employment conditions, reduction in financial strains, an increase in the number of breaks, new social contacts and support. For one individual we were able to obtain detailed information on her situation before and after the scheme and we used this case example to illustrate the potential economic gains for carers involved in such

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scheme. Values were applied by looking at the replacement costs of informal care and the costs associated with mental health problems. In the case study, a middle aged woman had been working on night shifts and was struggling to care for her husband who was recovering from a stroke and living with diabetes. If it was assumed that the arrangement would not have been sustainable then the involvement from the government would have been required, usually through the provision of respite care. The economic value of caring has been estimated at £18,473 per year (Buckner and Yeandle 2011). This is based on an average number of hours (2.8hrs per day) for which informal care is assumed to be replaced by formal support. The unit cost of replacement care taken here was £18 which is the official figure for cost per hour of home care to an adult in the UK provided by the NHS Information Centre in 2010. Because of her involvement in the Scheme, the female carer was able to find better paid employment in the community which allows her to look after her husband. She reported reduced stress and reduced strains on her financial situation. She was also able to build up friendships and social support networks with the other participants which she felt were like a family to her. A study by Singleton et al. (2002) found that carers who were not getting breaks from their caring responsibilities had an additional risk of 19 percent to have a mental disorder. At the same time, mental health disorders were more common amongst carers who perceived a lack of social support. Carers with a perceived lack of social support were twofold more likely to have mental health problems compared to their counterparts with social support. If average cost to the NHS per person living with depression was applied then a reduced demand of £40 per carer was calculated. We assumed that the improved employment conditions and the social support led to an improvement in depression symptoms (from moderate to mild) and quality of life improvements were valued at £1,240.

7 Employment, training and education related costs and benefits

7.1. Training provided as part of the Scheme

The accredited health champions training was provided to 17 members of the community. In addition, the following one-to-one and group based training sessions were provided to the 18 health champions and 23 other volunteers involved with the scheme.

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Group sessions Public speaking (1-day) Outreach/door knocking (1-day) First aid course (1-day) Food hygiene (1-day) Mentoring (3 months) Interview skills (2-days) IT course (10-12wks) Individualised (one-to-one) training IT Creative writing Management Parenting Public health The overall training budget was £50,000 so that an average of £1,250 was spent on training for each of the 40 volunteers. The health champions scheme provided career and employment-related benefits to those directly participating in the scheme. Relevant outcomes included:

Employment as part of the health champions scheme

Paid work as part of the connected care research

Employment within the public health field

Engagement in volunteering opportunities as part of one or more of the above

Other employment in the public, non-profit or private sector

Engagement in other volunteering opportunities

Engagement in education For individuals this may have meant that they were able to pay their bills and reduce their debts. Intangible outcomes that were reported included an increase in skills, knowledge and experience, confidence and self-esteem, happiness, reduced stress and anxiety and social contacts and support networks.

7.2. Economic value of changes in employment

12 out of 17 health champions entered the job market or got a better paid job because of their involvement with the scheme (see table 11). The employment status of the other 5 health champions did not change. The average productivity gain per person was thus estimated at circa £5,500.

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Table 11: Economic value of changes in employment among health champions Before involvement in health

champions scheme After involvement in health

champions scheme Productivity

gain/loss

HC 1 Foster Care taker full time; Estimated at weekly average reward payment of £150/child (based on information from Kent County Council), 1.5 children assumed £11,700 p.a.

Receptionist and health care assistant at the Canberra Health Centre £16,000 p.a.

£4,300

HC 2 Factory worker part time (night shift), £5.6/hr 49wks p.a. assumed £10,976 p.a.

Health trainer at Shepherds Bush Housing group full time £18,030 p.a.

£7,054

HC 3 Nurse at mental health trust, part-time (night shifts) Information taken from job descriptions: www.nurse.co.uk £12,500 p.a.

Placement health champion at local Primary care trust

-£12,500

HC 4 Unemployed Healthcare assistant £16,000 p.a.

£16,000

HC 5 Unemployed Sexual health champion 16hrs/w, £10/hr), and self –employed cooking circa £150 per month

£7,840

HC 6 Unemployed Homecare job £16,000 p.a. (estimated)

£16,000

HC 7 Unemployed Project manager employed by voluntary sector, part-time Estimated at £15,000 p.a.

£15,000

HC 8 Unemployed Smoking cessation advisor employed by social enterprise, part time (3hrs/wk, £25/hr), 49wks p.a. assumed £3,675 p.a. does not affect benefit payments

£3,675

HC 9 Unemployed Smoking cessation advisor employed by social enterprise, part-time time (3hrs/wk, £25/hr), 49wks p.a. assumed £3,675 p.a. does not affect benefit payments

£3,675

HC 10

Unemployed Youth worker £22,000 p.a. £22,000

HC 11

Unemployed Retail/ shop assistant, full time £600/month (assumed) £7,200 p.a.

£7,200

HC 12

Unemployed Connected care researcher at £10/hour, 16hrs/wk over 6 months £3,840 p.a.

£3,840

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Of the 23 volunteers who did not participate in the formal health champion scheme but in the generic training package, 6 individuals entered employment because of their involvement with the scheme. The employment outcomes for the other 17 did not change. The average productivity gains per person were estimated at £1,830. Overall, across health champions and other volunteers, average productivity gains person were £3,390. Table 12: Economic value of changes in employment among volunteers Before involvement in health

champions scheme After involvement in health

champions scheme Productivity gain/ loss

V1 Unemployed Health trainer, full-time £17,200

V2 Unemployed Health trainer, part-time £8,600

V3 Unemployed Expert patient tutor, £10/hr, Assumed were 4hrs/week, 42wks p.a., £1,680 p.a.

£1,680

V4 Unemployed Expert patient tutor, £10/hr, Assumed were 4hrs/week, 42wks £1,680 p.a. Connected care researcher at £10/hr, 16hrs/wk over 9 months £5,760

£7,440

V5 Unemployed Shop assistant, part time, £300/month

£3,600

V6 Unemployed Shop assistant part-time, £300/month

£3,600

7.3. Benefit claims

The information provided on benefit claims did not allow us to derive one true average estimate. Instead we calculated a lower threshold based on the following considerations: Most people moved from unemployment into low paid, part-time jobs whilst some moved from one salaried job to another. We conservatively assumed that benefit claims did not change for this group. For 5 people we know, however, that they moved from unemployment into a salaried job above 16 hours per week. The estimated reduction in government expenditure was £80 per week and £4,160 per year and person so that overall savings to the exchequer were calculated at £20,800 overall with an average £520 per person.

7.4. Economic value of changes in volunteering

Most of the health champions took on volunteering roles in addition to their champions role and the majority continue being involved in volunteering activities – we assumed that 75 percent were active volunteers who volunteered on average 4

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hrs per week for 42 weeks a year. Out of the other 23 volunteers, 7 (30 percent) became active volunteers who volunteer 4 hrs per week. As to how to value volunteering has been heavily debated in the literature and different approaches have been suggested. It is for example discussed that the economic value should reflect the costs that would occur if a professional would carry out the role. Since we did not have enough information about those activities we were unable to assign a monetary value for volunteering as such. There is, however, substantial evidence that shows the mental and physical health benefits to volunteers themselves such as an increase in self-esteem, social contacts and support networks. In this analysis, this was considered with the value of social support as calculated earlier.

7.5. Economic value of changes in education

We did not assign a monetary value to education in this analysis because this could have led to an overestimation of productivity outcomes. Vocational qualifications have been linked to higher wages and better employment prospects and this is (at least partially) reflected in this data. There are likely to be substantial long-term benefits. In an interview we held with a young man who was in College, he reported that he was sure that he would still be unemployment and not in any form of education without the Scheme. 16 to 18 years old persons not being in education, training and employment (NEET) are estimated to cost the State £56,301 over a life time (Coles et al 2010).

8 Service re-design As explained earlier, the original purpose for this piece of research was not only to understand the economic value of the scheme as it has been running but to also explore the costs and outcomes associated with a change in role towards a scheme that is focused on managing debt, housing support and skills and employment. From previous research (Knapp et al., 2011) undertaken of a community navigator scheme, we can generate the following conclusions about cost and benefits when members of the community are trained and employed to provide housing and debt and benefits advice. The net benefit of the housing and homelessness advice and signposting intervention was estimated at £3,380 without quality of life improvements and at £4,220 if improvements were considered. Costs savings accrued to the largest extent to the housing sector. The net benefit of debt advice was estimated at £365 before quality of life improvements were considered and £1,205 if those were included. If we take the estimates from section 7, then employment related interventions provided are worth £4,810 before quality of life improvements are considered and £5,390 when they are included.

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It is assumed that the scheme can be run by 20 volunteers who work on average 16 hours per week. Furthermore, it is assumed that their time and caseload is allocated equally between the three types of interventions. The ratio between client to client-related work is estimated at 1.5 so that every volunteer would be able to have a caseload of 8 clients per year if the average duration of the intervention was 12 weeks. Each year, 160 interventions could then be provided as part of the new Scheme and 53 of each kind. The net benefit of this new Scheme would then be £456,267 before considering quality of life improvements and £576,800 after including those.

9 Findings, limitations and conclusions In this research, we aimed to identify the economic value (net benefit) of the Health Champion Scheme in White City. We were faced with a range of barriers which limited the research. Many of them are typical for programmes in the community development field. For example, data recording was focused on processes and outputs rather than on outcomes which meant we had to base our analysis to a large extent on secondary data sets. An exception from this was the availability of detailed employment related outcomes achieved by health champions and the other volunteers. It had to be assumed that the interventions were as effective as it can be expected based on published information from trials for interventions that used the same or a similar approach. In the future, monitoring of the outcomes needs to make sure that this is really the case in practice and cost benefit results need to be adapted according to the local information. A further limitation is that we could not include all activities provided as part of the Scheme in the analysis, either because of a lack of primary or secondary data. This does not mean they are not (cost-) effective. Finally, because budget information was not available at the level required to derive unit costs we had to use a bottom-up approach for the costing of the interventions based on national data. For the reasons above it was not possible to derive a single economic value that could be attributed to the Scheme. Instead, the different net benefit estimates for each intervention or activity are summarized in Table 13. Exercise classes were delivered achieving cost savings to the Government. Those, however, were to a large extent achieved because of fees that were paid by the participating individuals which exceeded the costs of running the classes so that the Government gained from a profit. The provision of cookery classes (for which participants did not have to pay a fee) led to overall additional costs to the Government. However, interventions were still cost effective because of the quality of life improvements participants gained from new and lasting friendships and social networks. Smoking cessation interventions caused not only a negative net benefit to the Exchequer but did also not show to be cost-effective. Both findings are not surprising considering the short time scope of the analysis. Debt advice was estimated to lead to some considerable cost savings. The by far highest net benefit was, however, achieved through the employment part of the Scheme

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Table 13: per annum findings across interventions

Physical exercise

Healthy eating

Smoking cessation

Debt advice

Employment

Interventions included in the analysis

Aerobics, salsa, yoga

Cookery classes

Brief inter-vention

One-to-one support and signposting

Training to volunteers

Beneficiaries group* 1 1 1 1,2 2

COST OF INTERVENTION

Government spending

£0 £122 £650 £234 £1,250

Cost to the individual £625 £0 £0 £0 £0

ADDITIONAL USE OF STATUTORY SERVICES

Statutory benefits advice

£0 £0 £0 £196 £0

REDUCTION IN GOVERNMENT SPENDING AND PRODUCTIVITY GAINS

NHS (depression) £38 £38 £0 £22

£38

NHS (physical condition)

£26 £11 (£2-

£20) £122 £0

Benefit claims £0 £0 £0 £140 £520

Profit from user fees £175 £0 £0 £0 £0

Productivity gains £0 £0 £0 £1,186 £5,500

QUALITY OF LIFE IMPROVEMENTS

Quality of life improvement per person (mental health)

£585 £585 £0 £840 £0

Quality of life improvement per person (physical health)

£10 £20 £22 £0 £0

Net benefit (A) £239 -£73 -£530 £365 £4,808

Net benefit (B) £834 £532 -£508 £1,205 £5,393

No of participants 30 14 16 20 40

Net benefit (C) £7,170 -£1,022 -£8,480 £7,300 £192,320

Net benefit (D) £39,360 £7,448 -£8,128 £24,100 £215,720

Explanations: * Beneficiaries group 1 are the persons who receive interventions provided by the community

health champions, whilst Beneficiaries group 2 concerns the health champions themselves (A) Net benefit per person before considering quality of life improvements (B) Net benefit per person after considering quality of life improvements (C) Net benefit across the Scheme before considering quality of life improvements (D) Net benefit across the Scheme after considering quality of life improvements

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For future service planning it is important to take into account that the effectiveness of interventions will depend on the target group whereby cost-effectiveness will usually increase when people are targeted who are from high risk or certain age groups who at the same time show a certain readiness to change: For smoking cessation intervention for example, demand on health services can be substantially reduced if people stop smoking in their mid thirties or before. Employment support interventions will achieve higher cost-effectiveness if younger people are addressed who were not in education or at risk of dropping out and adults who have caring responsibilities. Cookery classes targeted at women and mothers at risk of cardiovascular disease the benefits of the intervention are likely to be higher than the ones estimated here.

Appendix

Evidence for interventions not included in the analysis Chair-based exercise for disabled, older women Although a lot of research has been carried out investigating the benefits of interventions that promote wellbeing of individuals with particular chronic conditions, only few studies exist that provide conclusive evidence of the effectiveness of universal physical activity interventions for disabled people

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(Stuifbergen et al. 2010, Wendell et al 1998,). One important evaluation barrier is the difficulty to measure changes in response to the intervention (Jette, 2003). Studies which specifically investigate the health benefits of chair-based exercise for older people show inconclusive results (Nicholson et al 1997). The effectiveness of the intervention appears to depend on a wide range of factors including the frailty of the person, whether they are institutionalised, the design of the intervention and who is providing it. For example, there can be even some negative effects if the intervention is targeted at a people with higher mobility (Lazowski et al 1999). It could not be shown that chair-based exercise is generally effective in preventing falls (Murdo et al 2000). At the same time there is good evidence that people with disability are less likely to participate in physical activity intervention and are more likely to excluded from the services provided (Sport England, 2002; Sport and People with Disability, 2001; Disability Survey 2000, 2001; Finch et al, 2000). In the case of the White City health champions scheme, the chair-based exercise classes were targeted at disabled women above 65 years who were unable to participate in the other physical activity classes. Classes were offered on a weekly basis. Whether the cost-effectiveness findings found in the previous section apply for this group is likely to depend on the kind of disability and whether the intervention encourages and enables the daily integration of physical activity into the lives of those women. We thus concluded that it would be difficult to model the physical health benefits of the interventions. If, however, the frequency of either the intervention itself or of similar opportunities for activity is increased then it is likely that similar cost effectiveness findings apply than the one generated by physical exercise classes for non-disabled women. Other positive benefits associated with the intervention could include healthier eating habits because women received a free healthy lunch during the classes. Women who met during the chair-based exercise group were known to be particularly isolated before and they were able to build up a robust social support network through the exercise group. Thus, the social support benefits analysed in section 5 apply. Young People The daily amounts of physical activity that young people need to achieve in order to generate health benefits are twice as high than those for adults (DH, 2004). It was not possible to conclude from the information provided that young people were involved in sufficient physical activities as part or because of their involvement with the scheme. If this can be ensured in the future, then government savings are likely to be similar to the ones we estimated for adults while the economic value of the intervention will be higher. Food co-op A lack of access to affordable, healthy food has been recognised as an influencing factor for differences in diet and health disparities in deprived or marginalised

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communities (Diaz-Roux, 2009). There is a lack of quantitative evidence on whether interventions are effective in addressing those determinants at a community level. Cummins et al (2005) investigate the impact of a hypermarket concept and find a small but not significant increase in fruit and vegetable consumption of 0.35 portions a day in the intervention area. They conclude that improving diet in deprived communities is not simply a matter of relocating and redeveloping food stores. Thus, we could not find a way of hypothesizing how successful food co-ops are in achieving an increase in intake of fruits and vegetables and the sustainability of the intervention. More information would be required on the frequency of people visiting the store and the change in buying more fruits and vegetables even after the closure of the stall. In addition, it was also found difficult to establish costs of food co-op without further information on who was running the co-op, the market and selling price for the fruits and vegetables including wastage, the price for renting the stall, etc. If it can be assumed that the stall can be run on a self-financed basis then even overall very small health gains would still provide a better option than not running the stall. Costs that need to be considered too are those in planning and organising the food co-op even where this done by volunteers since it is the time forgone that they cannot spend on other activities that may bring more benefits.

References Adults with a Disability and Sport National Survey 2000-2001, Headline Findings, Sport England, 2002 Arksey H, Kemp P, Glendinning C, et al (2002), Carers’ aspirations and decisions around work and retirement, Department for Work and Pensions Research Report No 290, Leeds 2005. Ayuso-Mateos JL, Vazquez-Barquero JL, Dowrick C et al (2001), Depressive disorders in Europe: prevalence figures from the ODIN study BJP October 2001 179:308-316 Buckner L and Yeandle S (2011) Valuing carers 2011 – Calculating the value of carers’ support. University Leeds and Carers UK, May 2011. Carers UK (2007), Support for Black, Asian and Minority Ethnic cares – A good practice briefing, Carers London, July 2007.

26

Carr SM, Lhussier M, Forster N, Geddes L, et al (2011), An evidence synthesis of qualitative and quantitative research on component intervention techniques, effectiveness, cost-effectiveness, equity and acceptability of different versions of health-related lifestyle advisor role in improving health, Health Technology Assessment 2011; Vol. 15: No.9, February 2011. Cromwell J, Bartosch WJ, Fiore MC, Hasselblad V, Baker T. Cost-effectiveness of the clinical practice recommendations in the AHCPR guideline for smoking cessation. JAMA 1997;278:1759–66. Cummins S, Findlay A, Petticrew M, Sparks L (2005), Healthy Cities: The Impact of Food Retail-led Regeneration on Food Access, Choice and Retail Structure, J Built Environment (31);4: 288-301 Currie, C. J., Gale, E. A. M. and Poole, C. D. (2010), Estimation of primary care treatment costs and treatment efficacy for people with Type 1 and Type 2 diabetes in the United Kingdom from 1997 to 2007. Diabetic Medicine, 27: 938–948 DCLG (2009), The Somali Muslim Community in England – Understanding Muslim Ethnic Communities, Communities and Local Government, London, April, 2009.

Diaz-Roux, A. (2009). “The Local Food Environment and Health: Where Are We and Where Do We Go Next?” Presentation at the IOM/NRC Workshop on the Public Health Effects of Food Deserts, January 26, Washington, DC.

Disability Survey 2000: survey of young people with a disability and sport', N Finch et al, University of York Social Policy Research Unit, 2001 Edwards B, Higgins DJ, Gray M, et al (2008), The nature and impact of caring for family members with a disability in Australia, Research report No. 16, 2008. Finch, C., Owen, N., & Price, R. (2001). Current injury or disability as a barrier to being more physically active. Medicine & Science in Sports & Exercise, 33(5), 778-782. Finkelstein EA, Wang G, Lee IM, et al. (2004) National and state-specific inactivity attributable medical expenditures for six diseases. Final report prepared for the Centers for Disease Control and Prevention by the Research Triangle Institute. Research Triangle Park NC: CDC and Research Triangle Institute, 2004. Fiscella K and Franks P(1996), Cost-effectiveness of the transdermal nicotine patch as an adjunct to physicians’ smoking cessation counseling. JAMA 1996;275:1247–51. HM Government (2008), Carers at the Heart of 21st-Century Families and Communities: A Caring System on Your Side. A Life of Your Own, 2008. HM Government (2010), Recognised, valued and supported: next steps for the Carers Strategy, 2010.

27

IPSOS (2009) Mori poll for the Department for Work and Pensions and Carers UK, November 2009. Jette, A M (2003), Assessing disability in studies on physical activity. American Journal of Preventive Medicine, 25, 122-128. Kahn EB, Ramsey LT, Brownson RC, et al (2002), The effectiveness of interventions to increase physical activity: a systematic review. Am J Prev Med 2002;22(4S):73–107. Knapp M, Bauer A, Perkins M, Snell T (2011), Building Community Capacity: Making an Economic case Think Local Act Personal, June 11. Lazowski DA, Ecclestone NA, Myers AM et al (1999), A randomized outcome evaluation of group exercise program s in long-term care institutions. J Gerontol A Biol Sci Med Sci. 1999 Dec;54(12):M621-8. Luengo-Fernández R, Leal J, Gray A, Petersen S, Rayner M (2006), Cardiovascular medicine: Cost of cardiovascular diseases in the United Kingdom, Heart 2006;92:1384-1389 McMurdo ME, Millar AM, Daly F (2000), A randomised controlled trial of fall prevention strategies in old people’s homes, Gerontology 46(2):83-7. Morgan CL, Peters, JR, Dixon S. and Currie CJ (2010), Estimated costs of acute hospital care for people with diabetes in the United Kingdom: a routine record linkage study in a large region. Diabetic Medicine, 27: 1066–1073 NHS Information Centre (2010), Unit cost for adults and older people receiving home care - NHS Information Centre, PSS EX1 Return for 2009-2010 NICE (2006), Costing Report – Four commonly used methods to increase physical activity, NICE Public health intervention no. 2, Issue date: May 2006, National Institute for Clinical Excellence, London, 2006. NICE (2004), Guide to the methods of technology appraisal. National Institute for Health and Clinical Excellence, London, 2004. Nicholson CM, Czernwicz S, Mandilas G, Rudolph I and Greyling MJ. 1997. The role of chair exercises following hip fracture. South African Medical Journal. 87: 1131-1138. O’Mahony PG, Thomson RG, Dobson R, et al (1999). The prevalence of stroke and associated disability. J Public Health Med 1999; 21: 166–71. Pleasence P, Buck A, Balmer N J, Williams K (2007) A Helping Hand: The Impact of Debt Advice on People’s Lives, Legal Services Research Centre, London. Rasmussen SR, Prescott E, Sorensen TIA, Sogaard J. The total lifetime health cost savings of smoking cessation to society. Eur J Public Health 2005;15:601–6.

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Saka Ö, McGuire A, Wolfe C (2009), Cost of stroke in the United Kingdom Age Ageing; 38(1): 27-32.

Singleton N, Maung NA, Cowie A, Sparks J et al (2002), Mental health of carers, A report of a survey carried out by the Social Survey Division of the Office for National Statistics on behalf of the Department of Health, London: The Stationery Office.

Skapinakis P, Weich, S et al (2006) Socio-economic position and common mental disorders. Longitudinal study in the general population in the UK. British Journal of Psychiatry 189:109-117.

Sport and People with a Disability: Aiming at Social Inclusion', Scott Porter Research and Marketing Ltd, 2001

Stuifbergen AK, Morris M, Jung JH, et al (2010), Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence, Disabil Health J 3(3):133-45. Thomas CM and Morris S (2003), Cost of depression among adults in England in 2000 BJPsych;183:514-519 Ustun TB (2004), Global burden of depressive disorders in the year 2000. British journal of psychiatry, 184 (5), p. 386. WHO (2004), A global strategy for diet, physical activity, and health. Geneva: WHO, 2004. Witham MD, Gray JM, Argo IS et al (2005), Effect of a seated exercise program to improve physical function and health status in frail patients > or = 70 years of age with heart failure. Am J Cardiol. 2005 May 1;95(9):1120-4. Williams K and Sansom A (2007) Twelve months later: does advice help? – The impact of debt advice – advice agency study, Ministry of Justice Research Summary 3. Williams T (2004), Review of Research into the Impact of Debt Advice, TPR Social Research, produced for The Legal Services Research Centre, 2004. Woodruff SI. Evaluation of a culturally appropriate smoking cessation intervention for Latinos. Tob Control 2002;11:361–7.

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