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 shows that 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 / DescriptionEstablishing Scope and Identifying Stakeholders / Identify the scope of the evaluation including which stakeholder groups will be engaged in evidence collection
Mapping Outcomes / Identify intended outcomes intended by the intervention and which will be measured in the study
Evidencing Outcomes / Implement research methodology to gather evidence of whether the 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 order to 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’ in SROI
The uniqueness of SROI methodology compared to other outcome and 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. These factors 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 outcomes are 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 gathered using 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 evaluation were 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 were asked 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 / SourceIncreased 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
BackgroundPeople 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 for 284 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 patients were 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.