Economic Impact of an Eye Clinic Liaison Officer (ECLO) on Health, Social Care and Welfare Budgets: A Case Study

Full report

Introduction

In 2012-13 early intervention services delivered by sight loss advisers such ECLOs (Eye Clinic Liaison Officers) managed by the RNIB group of charities provide emotional and practical support to over 16,000 patients after a diagnosis of sight loss. This research focussed on a specific ECLO service in Wales, using Social Return on Investment (SROI) to estimate the value of savings attributable to the ECLO service.

The framework produced provides the next step in demonstrating the financial business case and cost-effectiveness of providing early intervention support through the ECLO role. It showsthat support at the early stages of sight loss can reduce public expenditure that can result from a lack of support to help people adapt to sight loss.

Author

Phil Sital Singh, July 2013.

Acknowledgements

This report would not have been possible without the contribution of Philippa Simkiss, Rebecca Colclough, Ansley Workman and of course ECLOs, health professionals and patients who gave their time so generously.

Methodology

Social Return on Investment

Social Return on Investment (SROI) is a methodology developed to evidence and value the outcomes created by non-profit activities, comparing it to the cost to create them. By comparing the total value of the outcomes to the total input value, a 'social return on investment' can be estimated.

Overall, the SROI process follows through six stages:

Stage / Description
Establishing Scope and Identifying Stakeholders / Identify the scope of the evaluation including which stakeholder groups will be engaged in evidence collection
Mapping Outcomes / Identifyintended outcomes intended by the intervention and which will be measured in the study
Evidencing Outcomes / Implement research methodology to gather evidence of whetherthe outcomes occurred
Valuing Outcomes / Identify and apply financial costs and proxies to place a value on the outcomes evidenced
Establishing Impact / Quantify through estimation or evidence the level of discount factors (see below) to be applied to the outcomes observed in orderto establish impact
Calculating savings and SROI / Establish the overall value of the impact generated, comparing with the overall value of the costs of the intervention

‘Impact’ inSROI

The uniqueness of SROI methodology compared to other outcomeand cost benefit methodologies is the strict definition of ‘impact’. It is calculated after applying a series of ‘discount factors’ to the outcomes observed after an intervention. Thesefactors estimate:

  • what would've happened anyway if the intervention hadn't occurred (known as deadweight)
  • how much credit can be claimed for the outcomes observed (known as attribution)
  • whether positive outcomes delivered by this intervention prevent other positive outcomes that might have been delivered elsewhere (known as displacement)
  • how long the outcomesare likely to last (known as drop-off)

Study Methodology

Scoping and Identifying Stakeholders

The study is designed around a single ECLO site in Wales. It was chosen because the ECLO service is full-time and established amongst the eye clinic staff, and therefore represents a high performing ECLO service. Stakeholders for the study were identified in consultation with the ECLO, and focussed on patients and health professionals in direct contact with or with knowledge of the ECLO role.

Mapping and Evidencing Outcomes

The aim of this study was to identify and estimate the real financial benefits and cost savings of early intervention support by an ECLO. Therefore investigation was restricted to outcomes with direct or clear indirect associations with further costs to public services. These outcomes included:

  • Increased emotional well-being
  • Increased job retention
  • Increased independence in own home
  • Increased welfare income
  • Reduced likelihood of falling
  • Increased registration
  • Increased service uptake
  • Decreased time spent by health professionals with patients

The evidence was gatheredusing a mixed quantitative and qualitative methodology. A ten-item questionnaire covering the seven patient-focussed outcomes was developed and delivered by a telephone interview. For simplicity and ease of use, each question had Yes or No answer, and a qualitative follow-up for further explanation.

All 96 RNIB Cymru ECLO clients, from services across Wales, who had agreed to take part in evaluationwere contacted.Due to the broad nature of the outcomes it is believed that the results from this sample are applicable to the particular ECLO Service in the scope of the study. Participants were called between two and three months after seeing the ECLO.

A follow-up period of two to three months was chosen to give enough time for information and referrals provided by the ECLO to be used by clients, but not so much time that the role of the ECLO in early support was forgotten.The interviews were conducted by an independent research company, Viewpoint CIC, and lasted 10-15mins. The questions can be found in Appendix 1.

Of the 96 ECLO clients contacted 66 were successfully interviewed. Of the 30 who were not, 11 could not be reached, 5 declined, 7 were unable to complete it due to difficultly hearing or other impairment, and 7 could not remember seeing the ECLO in order to comment. These results alone show the difficulty in evaluating the impact of the ECLO Service on patients.

To gather evidence of the impact on health professionals of the ECLO service selected (run by a fully trained and well established ECLO working in an eye clinic) seven qualitative interviews were planned and attempted with four ophthalmology consultants, two nurses and one optometrist. Five of these interviews were successfully completed, however the interview with one nurse and the optometrist were not completed despite multiple contact attempts to find a time to conduct the interview.

These health professionals wereasked about what they had observed about the impact of the ECLO on patients, their own working practices, and any other areas of the eye clinic function.

Valuing Outcomes and Establishing Impact

Outcome valuation was completed by reviewing the literature for direct costs e.g. social services supporting independence in the home, NHS treatment for mental health, welfare eligibility. Wales-specific cost data was not available on an individual service or treatment basis so in most cases, UK data has been used. Table 1, below, gives a summary of the information sources used.

Outcome / Cost Data / Source
Increased Home Independence / Local Authority home visits / PSSRU (2013)
Increased Mental Well-Being / NHS for ten sessions of CBT counselling / PSSRU (2013)
Increased Job Retention / Job Seeker’s Allowance (JSA) / DWP (2014)
Increased Welfare Uptake / Attendance Allowance, Disability Living Allowance and Carer’s Allowance / DWP (2014)
Reduced Fear of Falling / Estimated cost of falls / Parrott (2000), Dolan &Torgerson (1998),
Reduced Follow-Up Appointments / Cost of nurse appointments / PSSRU, 2013

Table 1: Overview of cost data for outcome valuations

In order to estimate the discount factors free-text additions in the quantitative interviews conducted for this stage of the study (n=66) and existing ECLO patient-reported impact evidence gathered by RNIB Scotland were used (n=105, three-month follow up) (RNIB, 2014).

In keeping with a conservative approach to estimating impact an additional discount factor of ‘Proxy Fit’ was applied to ensure that the cost data used does not overestimate the cost savings of the outcome evidenced in this study.

Limitations

The limitations of this research are the small sample size and mixed data sources. A larger patient sample would provide more confidence in the proportion of the patient population who report outcomes, and give more qualitative evidence from which to draw stronger estimates for the discount factors. The sample is taken from a range of ECLO Services operated by RNIB Cymru across Wales rather than the one eye clinic in which the health professional interviews were conducted. It is possible that variations exist in performance between the ECLO service selected and other ECLO services, and that these variations are hidden in these results. In addition the availability of Wales specific cost evidence would strengthen the quality of the valuations used.

Results

Overall

Figure 1: Percentage of respondents reporting each outcome

Figure 1 shows the distribution of outcomes reported by the respondents. Not all respondents answered every question. The two most frequently reported outcomes were increased confidence in remaining independent in the home, and increased emotional well-being, both with 59 per cent (or 38 of 64). The third most frequent was increased welfare income or intention to claim new welfare income with 44 per cent (29 of 66). The fourth most frequent was increased service uptake or intention to uptake services with 34 per cent (22 of 65), and fifth was reduced fear of falling with 11 per cent (7 of 65). The least frequently reported outcome was confidence in job retention (2 of 66).

Figure 2: Summary results of outcome valuation for one year

Figure 2 shows a summary of the estimated value of the outcomes for a one year period. The total estimated savings as a result of the ECLO role is £377,936 and the total estimated increased expenditure as a result of the ECLO role is £201,936. Therefore the estimated total net savings as a result of the ECLO across a one year period is £176,001.

Figure 3: Outcome by outcome savings and valuations

Figure 3 shows the estimated savings and increased expenditure as a result of the ECLO by each outcome that was valued. Reducing follow-up appointments is estimated to save £8,009 in a year, increased job retention is estimated at saving nothing in a year, reduced fear of falling is estimated at saving £17,840 in a year, increased independence in the home is estimated at saving £257,080 in a year, and increased emotional well-being is estimated at saving £95,009 in a year.

The increased government expenditure in the form of increased welfare payments to individuals is estimated at £201,936.

Figure 4: Outcomes savings by expenditure-type

Figure 4 shows that in the model 68 per cent of the savings come from social care spending (increased independence in the home) and 32 per cent from health care spending (increased emotional well-being; reduced fear of falling; reduced follow-up appointments). 100 per cent of the increased costs come from welfare budget.

Outcome by Outcome

Outcome: Emotional Well-Being
Background
People with sight loss are at a high risk of depression (Brody, Gamst, Williams et al., 2001; Rovner, Casten & Tasman, 2002; Evans, Fletcher and Wormald, 2007). Support, information and referrals at the point of diagnosis can prevent significant deterioration in mental health.
Evidence
This study found that across ECLO Services in Wales 59 per cent of respondents reported increased emotional well-being, measured by optimism about living with sight loss, after a result of the ECLO support they received. Explanatory comments included:
“I have been worrying about my situation and having someone to talk to helps.”
“Because she told me about all the support that is out there and I could get in touch when I needed to.”
“She was very helpful and I can ring her at anytime for support, which means a great deal.”
“She has been very helpful especially financially.”
The average annual number of patients for the eye clinic in this case study is 481 patients, and therefore the ECLO in this case study is estimated to increase the emotional well-being for284 patients.
Deadweight – What would’ve happened anyway?
Deadweight is best calculated through the identification of a control group. In this instance evidence was taken from another ECLO study (RNIB, 2014). A random sample of ECLO patients found that 58 per cent reported increased optimism about the future three months after ECLO support. Of these 9 per cent said that the ECLO played no part or only a small part in this change. Applying this 9 per cent estimate to this study, we estimate that of the 284 patients who reported increased emotional well-being, only 26 would’ve improved anyway.
Attribution – How much credit can the ECLO take?
To estimate attribution, qualitative comments from the patientswere assessed to indicate whether full credit was given to the ECLO. For emotional well-being 81 per cent of respondents attributed benefits solely to the ECLO.
Displacement
There is no one who is being deprived of any outcome because these patients are experiencing improved emotional well-being, and therefore the displacement is estimated at zero.
Drop-Off
The ECLO service is an on-going support mechanism within an eye clinic, and not a one-off intervention for a limited number of patients only. Therefore year on year there is no drop-off in outcomes in this model.
In fact the opposite is true. The year after the patients in this study are supported, another set of patients is supported. Therefore the model is likely significantly underestimating the long-term cumulative benefits of the intervention.
Impact
After taking into account the four discount factors, we are left with an estimation that of 481 patient per year, 284 patients are expected to experience improved emotional well-being after ECLO support, and 209 of whom are assessed as the unique impact of the ECLO.
Financial Valuation
This outcome saving was valued using the estimated cost to the NHS for ten sessions of CBT counselling: £910 (PSSRU, 2013). This seemed appropriate because the higher costs of medication and longer-term therapy may overestimate the level of poor mental health experienced by the patients.
Proxy Fit
The financial valuation is deemed to be a good fit for the costs of poor emotional well-being. This is because although ECLO support does not provide the same level of support as counselling, by providing the emotional and practical support before poor mental health develops, it is preventing the higher cost to NHS of alleviating significantly poorer mental in the future.
However although there is a strong link between sight loss and depression, it may be an overestimate to assume that every patient who sees an ECLO will suffer significantly poor emotional well-being and seek treatment. Therefore the application of this valuation is discounted by 50 per cent.
Annual Savings of ECLO Impact
All accounted for, the savings of the unique ECLO value on improved emotional well-being across one year in this eye clinic is estimated at £95,009.
Outcome: Job Retention
Background
The employment rate for blind and partially sighted people is consistently below that of the general population (Hewett & Keil, 2014) and there is evidence to suggest that the economic downturn of the last half decade had disproportionately negative effects on the employment of blind and partially sighted people (Hewett & Keil, 2013). The cost in long-term welfare expenditure of this situation is high, and the additional costs of unemployment the economy and the well-being of blind and partially sighted people of working age is vast. Job retention support and information at the point of diagnosis is an effective way to prevent the loss of existing employment, and the ECLO role can inform and signpost to this.
Evidence
This study found that 9 per cent of respondents were of working age, and of these 33 per cent reported increased confidence to retain a job they were in. Therefore the estimated incidence of this outcome is 3 per cent of a yearly reach of 481 patients, or 14 patients.
Deadweight – What would’ve happened anyway?
This factor is hard to estimate due to a lack of empirical evidence about the proportion of people who retain their jobs afterexperience ofsight loss. However RNIB’s experience of working in this area suggests that it is not common; the norm is for either individuals or employers to assume that employment must end. Therefore for this study it is estimated that only 10 per cent of patients would’ve found support to be more confident in retaining their jobs without the support of the ECLO.
Therefore applying this 10 per cent estimate to this study, we estimate that of the 14 patients who reported improved confidence in retention, only 1 would’ve improved in this way anyway.
Attribution – How much credit can the ECLO take?
To estimate attribution, qualitative comments from the patient questionnaire were assessed to indicate whether full credit was given to the ECLO. For increased confidence to retain their job, 67 per cent of respondents attributed benefits solely to the ECLO. The other 33 per cent cited other factors and services working alongside the ECLO.
Displacement
Employment is one area where displacement is relevant. A blind or partially sighted person remaining in a job can be said to deprive another unemployed worker remaining unemployed. The increased welfare costs of a newly unemployed ECLO patient is offset by the decreased welfare costs of one person moving into that employment. Therefore for this outcome displacement was estimated at 100 per cent.