Read CG35 Parkinson's disease: national cost-impact report text version

Parkinson's disease: diagnosis and management in primary and secondary care

National cost-impact report

Implementing NICE clinical guideline no. 35 June 2006

Clinical Guideline 35 National cost impact report to accompany `Parkinson's disease: diagnosis and management in primary and secondary care' Issue date: June 2006 This report is an assessment of the costs of implementing the recommendations in `Parkinson's disease: diagnosis and management in primary and secondary care'. The Institute's full guidance is available from the NICE website (www.nice.org.uk/CG035NICEguideline). An abridged version of the guidance (a 'quick reference guide') is also available from the NICE website (www.nice.org.uk/CG035quickrefguide). Printed copies of the quick reference guide can be obtained from the NHS Response Line: telephone 0870 1555 455 and quote reference number N1052. Information for the public is available from the NICE website (www.nice.org.uk/CG035publicinfo) or from the NHS Response Line (quote reference number N1053).

This guidance is written in the following context This report represents the view of the Institute, which was arrived at after careful consideration of the available data and through consulting healthcare professionals. It should be read in conjunction with the NICE guideline. The report and templates are implementation tools and focus on those areas that were considered to have significant impact on resource utilisation. The cost and activity assessments in the reports are estimates based on a number of assumptions. They provide an indication of the likely impact of the principal recommendations and are not absolute figures. Assumptions used in the report are based on assessment of the national average. Local practice may be different from this, and the template can be used to estimate local impact.

National Institute for Health and Clinical Excellence MidCity Place 71 High Holborn London WC1V 6NA www.nice.org.uk Published by the National Institute for Health and Clinical Excellence June 2006 © Copyright National Institute for Health and Clinical Excellence, June 2006. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the express written permission of the National Institute for Health and Clinical Excellence.

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Contents

Executive summary .......................................................................................5 Supporting implementation Significant resource-impact recommendations Total cost impact Local costing template 1 5 5 6 6

Introduction.............................................................................................7 1.1 Supporting implementation 1.2 What is the aim of this report? 1.3 Epidemiology of PD 1.4 Models of care 7 7 8 9

2

Costing methodology .............................................................................9 2.1 Process 2.2 Scope of the cost-impact analysis 2.3 General assumptions made 2.4 Basis of unit costs 9 10 12 13

3

Cost of significant resource impact recommendations ....................14 3.1 Regular access to specialist nursing care 3.2 Physiotherapy 3.3 Occupational therapy 3.4 Speech and language therapy 3.5 Potential savings 14 16 18 20 23

4

Sensitivity analysis...............................................................................24 4.1 Methodology 4.2 Impact of sensitivity analysis on costs 24 25

5 6

Impact of guidance for commissioners ..............................................26 Conclusion ............................................................................................27 6.1 Total national cost for England 6.2 Next steps 27 27

Appendix A: Approach to costing guidelines ...........................................28 Appendix B: Calculation of therapy costs .................................................28 Appendix B: Calculation of therapy costs .................................................29 National costing report: Parkinson's disease (June 2006) Page 3 of 31

Unit costs of rehabilitative services...........................................................29 Appendix C: Results of sensitivity analysis ..............................................30 Appendix D: References .............................................................................31

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Executive summary

This costing report looks at the resource impact of implementing the NICE guideline `Parkinson's disease: diagnosis and management in primary and secondary care' in England. The costing method adopted is outlined in appendix A; it uses the most accurate data available, and was produced in conjunction with key clinicians and reviewed by clinical and financial experts.

Supporting implementation

The NICE clinical guideline on Parkinson's disease (PD) is supported by the following implementation tools available on our website www.nice.org.uk/CG035: · costing tools - a national costing report; this document - a local costing template; a simple spreadsheet that can be used to estimate the local cost of implementation · · · a slide set; key messages for local discussion implementation advice; practical suggestions on how to address potential barriers to implementation audit criteria (see appendix d of the NICE clinical guideline)

A practical guide to implementation, `How to put NICE guidance into practice: a guide to implementation for organisations', is also available to download from the NICE website. It includes advice on establishing organisational level implementation processes as well as detailed steps for people working to implement different types of guidance on the ground.

Significant resource-impact recommendations

Because of the breadth and complexity of the guideline, this report focuses on the recommendations that are considered to have the greatest impact on resources and will therefore require the most additional resources to

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implement or that will generate savings. They relate to regular access to specialist nursing care and access to therapy services.

Total cost impact

The annual revenue changes in costs and estimated savings arising from fully implementing the guideline are summarised in the table below. Summary of annual revenue changes

Annual cost Recommendations with significant resource impact £000

Increased cost of access to specialist nursing care Net cost of physiotherapy for people with PD Net cost of occupational therapy for people with PD Net cost of speech and language therapy for people with PD Cost of implementing PD guideline Estmated potential saving Total net cost of implementing the PD guideline Savings

3,623 1,054 1,820 3,709 10,206 -6,429 3,776

It is anticipated that improving access to specialist nursing care and therapy services could lead to reduced admissions and outpatient attendances providing savings that can offset the cost of improving care. These savings have also been estimated. However, importantly, savings will arise only if the improvements in access are fully implemented.

Local costing template

The local costing template produced to support this guideline enables organisations such as primary care trusts (PCTs) to replace variables with data that depict the current local position in order to estimate the local impact of implementing the guideline. A sample calculation using this template showed that the average PCT with an adult population of 145,000 could expect to incur additional costs of £29,000; estimated savings are £19,000, leading to an estimated annual net cost of £10,000. Further consideration of aspects of interest to commissioners is included in section 5 of the report.

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1 Introduction

1.1 Supporting implementation

1.1.1 The NICE clinical guideline on Parkinson's disease (PD) is supported by the following implementation tools available on our website www.nice.org.uk/CG035: · costing tools - a national costing report; this document - a local costing template; a simple spreadsheet that can used to estimate the local cost of implementation · · · a slide set; key messages for local discussion implementation advice; practical suggestions on how to address potential barriers to implementation audit criteria (see appendix d of the NICE clinical guidelines). 1.1.2 A practical guide to implementation, `How to put NICE guidance into practice: a guide to implementation for organisations', is also available to download from the NICE website. It includes advice on establishing organisational level implementation processes as well as detailed steps for people working to implement different types of guidance on the ground.

1.2 What is the aim of this report?

1.2.1 This report provides estimates of the national cost impact arising from implementing the guidance on PD in England. These estimates are based on assumptions made about current practice and predictions of how current practice may change after implementation. 1.2.2 This report aims to help organisations in England plan for the financial implications of implementing NICE guidance. 1.2.3 This report does not reproduce the NICE guideline on PD and should be read in conjunction with it (see www.nice.org.uk/CG035).

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1.3 Epidemiology of PD

1.3.1 PD is a progressive neurodegenerative condition resulting from the death of the dopamine-containing cells of the substantia nigra. The onset is insidious and people with PD classically present with the symptoms and signs associated with parkinsonism, namely slowness of movement, rigidity and rest tremor. Other presentations include difficulty walking, clumsiness and fatigue. 1.3.2 Parkinsonism can also be caused by drugs, and less common conditions than PD such as multiple cerebral infarction, and degenerative conditions such as progressive supra-nuclear palsy (PSP) and multiple system atrophy (MSA). 1.3.3 Although PD is predominantly a movement disorder, other impairments frequently develop, including psychiatric problems such as depression and dementia. Autonomic disturbances and pain (which is rarely a presenting feature of PD) may later ensue, and the condition progresses to cause significant disability and handicap with impaired quality of life for the affected person. Family and carers may also be affected indirectly. 1.3.4 As the illness progresses the person with PD usually has decreasing contact with NHS services and increasing reliance on social services. An economic report (Findlay et al. 2003) analysed the economic impact of PD and found that the direct annual cost of care for people with PD increases as the condition progresses. 1.3.5 We have used prevalence data from a report by Schrag and coworkers (Schrag et al. 2000). This survey was conducted in London but noted that there was no marked geographical variation in prevalence across the UK. This report indicates that PD occurs in 0.17% of the general population ranging from 0% in younger ages to 1.26% of those over 80 years old. We have modelled prevalence within age ranges in the cost template so that PCTs with varying age demographics can more accurately estimate their local impact (see table 2).

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1.4 Models of care

1.4.1 The models of care used in the costing model focus on the following aspects. · Regular access to specialist nursing care. · Referral of people with PD for the rehabilitative services of physiotherapy, occupational therapy, and speech and language therapy interventions. 1.4.2 The proposed model of care covers patients in hospital and in community settings. 1.4.3 In order to establish the model of care, we contacted neurologists, elderly care consultants, physiotherapists, occupational therapists and Parkinsons disease nurse specialists (PDNS) around the country. Discussions with these experts highlighted the fact that the treatment of PD varies greatly across the country. 1.4.4 Following these discussions, we created a model for diagnosis and management that was considered to be typical of existing practice in the NHS. We made assumptions about how this model may change following implementation of the guideline, including the potential cost savings that could result from a reduction in the use of some diagnostic scans, and improved access to rehabilitative services.

2 Costing methodology

2.1 Process

2.1.1 We use a structured approach for costing guidelines (see appendix A). Little information about care for patients with PD has been systematically collected, and this led to problems in building a comprehensive bottom-up model for costing. 2.1.2 To overcome this limitation, we had to make assumptions in the costing model. We developed these assumptions and tested them for reasonableness with members of the Guideline Development Group

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(GDG), other data sources where possible, and in discussions with other experts in the relevant fields. 2.1.3 Little recent, reliable data have been collected on the number of patients diagnosed with and treated for PD, and there is little quantitative information on the different elements of the current care pathway. Estimates of patients receiving care for PD and predictions of how it might change following implementation have mostly been based on expert opinion.

2.2 Scope of the cost-impact analysis

2.2.1 The guideline sets out best practice guidance for the diagnosis and management of PD in England and Wales. It covers adults older than 20 years who have a diagnosis of PD or parkinsonism. The aim of the guideline is to improve the diagnosis and management of people with idiopathic PD only. The guideline specifically covers: · · · · · · · · diagnosis and monitoring communication and education pharmacotherapy (prevention of progression) pharmacotherapy (functional disability in early disease) adjuvant pharmacotherapy non-pharmacological management neuropsychiatric conditions palliative care.

2.2.2 The guideline will help healthcare professionals to appropriately diagnose and treat people with PD who require rehabilitative and palliative care. The guideline does not cover juvenile-onset PD, pregnant women or the treatment of parkinsonism. Therefore, these issues are also outside the scope of this assessment of the implementation costs.

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2.2.3 We initially considered all the recommendations in the guideline. However, because of the breadth and complexity of the guideline, we worked with the GDG and other practitioners to identify the recommendations that would have the most significant impact on resources (see table 1). Costing work has focused on these recommendations. 2.2.4 The savings that could potentially arise from having regular access to specialist nursing and therapy services have been estimated, taking into account feedback from users. Table 1 Recommendations that have a significant impact on resources

Relevant part of recommendation Recommendation number People with Parkinson's disease should have regular access to the following: · clinical monitoring and medication adjustment · a continuing point of contact for support, including home visits, when appropriate · a reliable source of information about clinical and social matters of concern to people with PD and their carers, which may be provided by a Parkinson's Disease Nurse Specialist. Physiotherapy should be available for people with PD. Occupational therapy should be available for people with PD. Speech and language therapy should be available for people with PD. 1.9.4.1 1.9.3.1 1.9.2.1 1.9.1.1 Key priority?

2.2.5 Nine of the recommendations in the guideline have been identified as key priorities for implementation, and four of these key implementation priorities are also considered to have significant resource impact.

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2.2.6 A key recommendation relates to referring untreated patients quickly to a specialist with expertise in diagnosis. We initially considered this could have major resource implications; however, discussions with clinicians indicated resource implications are not significant. It was considered that improving regular access to specialist nurses could reduce the follow up and free up more time for initial assessment. 2.2.7 We have limited the consideration of costs to direct costs to the NHS that will arise from implementation. We have not included costs to the individual, the private sector, the not-for-profit sector or social services. Where applicable, any cost savings arising from a change in practice have been offset against the cost of implementing the change.

2.3 General assumptions made

2.3.1 The model is based on prevalence and annual incidence. (see table 2). Prevalence data was obtained from a report by Schrag and coworkers (Schrag et al. 2000). The Schrag survey was conducted in London but noted that there was no marked geographical variation in prevalence across the UK. 2.3.2 The mean age of onset for PD is about 65 years. `Young onset' of PD occurs before the age of 40 years, but this is very rare. Table 2 Prevalence of Parkinson's disease in England

Total males and females in Numbers with PD Prevalence of PD in England England 18,442,944 0.000% 0 7,630,628 0.008% 610 6,871,785 0.012% 825 6,304,946 0.109% 6,872 4,641,504 0.342% 15,874 3,566,733 0.961% 34,276 2,173,896 49,632,436 1.265% 27,500 85,957

Age group 0­29 30­39 40­49 50­59 60­69 70­79 > 80 Totals

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2.3.3 Prevalence data have been used to estimate the numbers of people with PD in England, and are the basis for calculating the follow-up costs of the rehabilitative services in this model. The initial rehabilitative service costs are based on the number of new cases annually. People with PD may need to access the different rehabilitative services throughout the lifetime of their condition. For example, a study of occupational therapy (OT) practice in Europe (Jansa 2004) found evidence suggesting that OT intervention is most often required in the intermediate and later stages of the condition. The study stated that therapists were in agreement that early referrals may result in people with PD adapting better as the condition progresses. 2.3.4 The incidence of PD we used is 0.0175% as cited in the Parkinson's disease clinical guideline from Dodel et al (1998).

2.4 Basis of unit costs

2.4.1 The way the NHS is funded has recently undergone reform with the introduction of `Payment by Results', (PbR) based on a national tariff. The national tariff will be applied to all activity for which Healthcare Resource Groups (HRGs) or other appropriate case-mix measures are available. Where a national tariff price or indicative price exists for an activity this has been used as the unit cost; this has then been inflated by the national average market forces factor. 2.4.2 For new or developing services, where there is no national average unit cost, some trusts already undertaking this activity have been asked their current unit cost.

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3 Cost of significant resource impact recommendations

3.1 Regular access to specialist nursing care

Background 3.1.1 The guideline states that people with PD should have regular access to the following: · · clinical monitoring and medication adjustment. a continuing point of contact for support, including home visits, when appropriate. · a reliable source of information about clinical and social matters of concern to people with PD and their carers. which may be provided by a Parkinson's Disease Nurse Specialist (1.9.1). 3.1.2 The model that we have based costing work on is for the regular care to be provided by a PDNS. It is important to note that although PDNS care is the model of nursing care that this report has used, other models of care are possible. Specialist nurses who have neuroscience experience and an interest in Parkinson's disease may also provide support to people with PD. 3.1.3 PDNS care has been operational in the UK for the past 10 years supported by the UK Parkinson's Disease Society. The Society has funded the majority of PD nursing posts in the NHS for the first 1 or 2 years each and has indicated that they will continue to do so until the required numbers of nurses are in post. 3.1.4 The organisation of PDNS care varies across the country depending on the organisation of PD services. PD services are generally set up around a specialist (for example, GP, consultant in elderly care, consultant neurologist) with an interest in PD, and the PDNS can be a

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key member of a multidisciplinary care team. In some areas PDNS care will substitute for some or all of existing consultant care and in others it would provide additional care. 3.1.5 The specialist nurse is important in the coordination of care for the person with PD, conducting holistic assessments of the individuals needs as well as making referrals to other health and social care professionals. The specialist nurse provides education for health and social care professionals, individuals and carers living with the condition. The majority of PDNS are employed in secondary care but operate shared care covering inpatient and community care settings. 3.1.6 Health economic studies show that most of the benefits derived from specialist nursing interventions are related to the overall patient care experience and the delivery of services such as the monitoring of medication and provision of information. It is anticipated that regular access to specialist nursing will reduce the need for hospitalisation, outpatient appointments and GP attendances, and related costs as detailed in section 3.5 below. Assumptions made 3.1.7 According to PDNS practitioners the current average caseload for a PDNS is 450 people with PD. Expert opinion advises that the recommended caseload should be about 300 people with PD per nurse specialist. Based on the current average caseload we estimate that currently there are about 191 whole-time equivalent (WTE) PDNS posts in England and based on the recommended caseload per PDNS it is estimated that an increase of 95.5 WTEs is required to bring the numbers of PD specialist nurses up to 286.5 WTE. However, as noted above, specialist care may be provided by a nurse with a special interest who is not necessarily a PDNS. Cost summary 3.1.8 We used the `Agenda for Change' pay scale midpoint of band 7 (£37,936, 2005/06 pay rates) to calculate the total cost of increasing

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the numbers of PDNS from 191 to 286.5 WTEs. The increase in cost of additional PDNS is £3.6 million. Other considerations 3.1.9 The Parkinson's Disease Society has indicated that it will continue to fund the majority of new PDNS posts for up to 2 years as part of its commitment to supporting PDNS care. If this does happen then a proportion of the estimated cost to the NHS of £3.6 million to increase the numbers of PDNS will be deferred accordingly. 3.1.10 PDNS are qualified nurses with substantial clinical experience and undertake specialist training while in the post, including non-medical prescribing. The PDNS is expected to have existing skills and experience in neurological nursing and achieve all the competencies set out in the integrated career and competency framework for nurses working in PD management (Parkinson's Disease Society, 2005). 3.1.11 As noted in 2.2.6 increased access to specialist nurses could free up other speciailists to enable quicker assessment and diagnosis. Increased access to regular specialist nursing care is also central to realising some of the savings assumed.

3.2 Physiotherapy

Background 3.2.1 The guideline recommends that physiotherapy should be available for people with PD (1.9.2). 3.2.2 The Chartered Society of Physiotherapy defines physiotherapy or physical therapy as: `A health care profession which emphasises the use of physical approaches in the promotion, maintenance and restoration of an individual's physical, psychological and social wellbeing, encompassing variations in health status'. 3.2.3 Physiotherapy primarily addresses the physical components of rehabilitation, essentially to maximise the functional capacity of a

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person. People with PD develop progressive disability and physiotherapy can enhance movement rehabilitation. Assumptions made 3.2.4 According to expert opinion, about 40% of people with PD who need physiotherapy are currently receiving it. It is estimated that about 70% of people with PD require physiotherapy and should have access to it. 3.2.5 Generally, patients receive one-to-one physiotherapy sessions with a physiotherapist as well as group physiotherapy. In some regions, education, exercise and relaxation are available in the group sessions, which are held periodically throughout the year. 3.2.6 The cost of physiotherapy for people with PD is calculated to reflect therapy for new cases annually and ongoing follow-ups in subsequent years. The cost for new cases is based on incidence data and has been calculated as £156.08 per person. This cost assumes an initial assessment of 45 minutes, followed by six one-to-one sessions of 35 minutes each and two one-to-one follow-up sessions of 35 minutes each within the first year of referral. In addition, each person attends eight multidisciplinary group sessions of 1.5 hours per session. These group sessions involve physiotherapist time (1 hour) and occupational therapist time (0.5 hours) in groups of 10 people. Carers are usually included in these sessions but costs have not been apportioned to them. 3.2.7 In subsequent years, it is estimated that on average a person with PD would have two follow-up physiotherapy sessions per year of 30 minutes each, at a cost of £25.09 annually. In practice some patients may require more or less physiotherapy time as the PD progresses. For this reason the cost calculations for the follow-up physiotherapy sessions are based on prevalence data as follow-ups can continue for the duration of the condition. 3.2.8 It is expected that physiotherapy sessions will be carried out by a trained physiotherapist on the `Agenda for Change' payscale at the midpoint of band 7, costing £37,936/year. Appendix C sets out the National costing report: Parkinson's disease (June 2006) Page 17 of 31

calculations and assumptions underpinning physiotherapy costs for people with PD. Cost summary 3.2.9 We calculated the total net cost of physiotherapy for people with PD to be £1,054 million as summarised in table 4. Table 4 Summary of physiotherapy costs for PD

Current Numbers Unit cost Initial year Each subsequent year Totals £25.09 34,383 37,857 863 1,405 60,170 66,250 1,510 2,459 25,787 28,393 647 1,054 £156.08 of people 3,474 Cost £000 542 Proposed Numbers of people 6,080 Cost £000 949 Change Numbers of people 2,606 Cost £000 407

3.3 Occupational therapy

Background 3.3.1 The guideline recommends that occupational therapy should be available for people with PD (1.9.3). 3.3.2 Occupational therapy is concerned with promoting health and wellbeing through occupation. The primary goal of occupational therapy is to enable people to participate in the practical activities of everyday life. This can be achieved by enabling people to do things that will enhance their ability to participate or by modifying their environment with aids and adaptations to better support participation. Occupational therapy assists people with PD to retain their independence for as long as possible and to develop their own coping strategies to deal with potential future problems. 3.3.3 Occupational therapy is highly individualised and so a wide variety of interventions can be used for people with PD. But generally the focus

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of occupational therapy is on the functional aspects of self-care and mobility. 3.3.4 A recent study on the level of occupational therapy for people with PD showed that the proportion of occupational therapy time devoted to patients correlated with the stage of their disease. 14% of therapy time was given to people in the early stage, 58% in the intermediate stage, and 42% in the late stage of PD (Jansa 2004).

Assumptions made 3.3.5 According to expert opinion, about 40% of people with PD who need occupational therapy are currently receiving it. It is estimated that 70% of people with PD require occupational therapy and should have access to it. 3.3.6 Generally, patients receive one-to-one occupational therapy sessions with an occupational therapist as well as group occupational therapy in groups of about 10 along with their carers. Costs have not been apportioned to carers. 3.3.7 The cost of occupational therapy for people with PD is calculated to reflect therapy for new cases annually and ongoing follow-ups in subsequent years. The cost for new cases is based on incidence data and has been calculated as £155.83 per person. This cost assumes six one-to-one sessions of 45 minutes each and two one-to-one follow-up sessions of 45 minutes each within the first year of referral. In addition, each person attends eight multidisciplinary group sessions of 1.5 hours per session. These group sessions involve physiotherapist time (1 hour) and occupational therapist time (0.5 hours). 3.3.8 In subsequent years, it is estimated that on average a person with PD would have three follow-up occupational therapy sessions per year of 45 minutes each, at a cost of £54.82 annually. The cost calculations for the follow-up occupational therapy sessions are based on prevalence

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data as follow-ups can continue for the duration of the condition, in varying proportions at different stages. 3.3.9 It is expected that occupational therapy sessions will be carried out by a trained physiotherapist on the `Agenda for Change' payscale at the top of band 6, costing £36,836/year. Appendix C sets out the calculations and assumptions underpinning occupational therapy costs for people with PD. Cost summary 3.3.10 We calculated that the total net cost of occupational therapy for people with PD to be £1,820 million as summarised in table 5. Table 5 Occupational therapy costs for people with PD

Current Numbers Unit cost Initial year Each subsequent year Totals £54.82 34,383 37,857 1,885 2,426 60,170 66,250 3,299 4,246 25,787 28,393 1,414 1,820 £155.83 of patients 3,474 Cost £000 541 Proposed Numbers of patients 6,080 Cost £000 947 Change Numbers of patients 2,606 Cost £000 406

3.4 Speech and language therapy

Background 3.4.1 The guideline recommends that speech and language therapy (SLT) should be available for people with PD. 3.4.2 Deterioration in speech is a common manifestation of PD that increases in frequency and intensity with the progression of the disease. There may also be difficulties around swallowing, eating and drinking. Speech and language therapists help people with PD to

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improve their communication ability, and also address these other related difficulties. 3.4.3 Most speech and language therapists agree that people with PD generally require speech and language therapy throughout their lifetime.

Assumptions made 3.4.4 According to expert opinion, about 20% of people with PD who need SLT are currently receiving it. It is estimated that about 70% of people with PD require SLT and should have access to it. 3.4.5 Generally, patients receive one-to-one SLT sessions with a speech and language therapist. It is expected that SLT sessions will be carried out by a trained SLT therapist on the `Agenda for Change' payscale at the top of band 6, costing £36,836/year. Appendix C sets out the calculations and assumptions underpinning SLT costs for people with PD 3.4.6 The cost of SLT for people with PD is calculated to reflect therapy for new annual cases separately from ongoing follow-ups in subsequent years. The cost for new cases is based on incidence data and has been calculated as £211.15 per person. This cost assumes 10 one-toone sessions of 45 minutes each and three one-to-one follow-up sessions of 45 minutes each within the first year of referral. 3.4.7 In subsequent years, it is estimated that on average a person with PD would have 4 follow-up SLT sessions of 45 minutes each per year, at a cost of £64.97 annually. The cost calculations for the follow-up SLT sessions are based on prevalence data as follow-ups can continue for the duration of the condition, in varying proportions at different stages.

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Cost summary 3.4.8 We calculated the total net cost of speech and language therapy for people with PD is £3,709 million, as summarised in table 6. Table 6 Speech and language therapy costs for people with PD

Current Numbers Unit cost Initial year Each subsequent year Totals 64.97 17,191 18,928 1,117 1,484 60,170 66,250 3,909 5,193 42,979 47,322 2,792 3,709 211.15 of patients 1,737 Cost £000 367 Proposed Numbers of patients 6,080 Cost £000 1,284 Change Numbers of patients 4,343 Cost £000 917

Other considerations 3.4.9 Local organisations would need to take into account the cost of post graduate training to ensure Speech and Language Therapists have the necessary specialist skills to deal with patients with PD. 3.4.10 Expert opinion suggests that the Lee Silverman Voice Training (LSVT) is very effective for people with PD. We calculated that this method of therapy would cost about £400 for each person with PD who required it. Based on new cases alone it amounts to £3.5 million pounds a year, and would be higher if existing cases are referred for LSVT. These costs were calculated on each person with PD having 16 hourly sessions with a therapist on midpoint of band 7 AfC. 3.4.11 Other considerations around LSVT are the availability of SLT therapists who are trained to deliver this form of therapy. Currently about 120 therapists nationally have been trained in a training programme that is tightly regulated and is being delivered worldwide only by the originators of the programme. It is estimated that about 1,000

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therapists would require training in the LSVT method but 30 therapists can be trained annually under the current training scheme. In addition, training costs for a therapist is about £350 plus an annual licence fee of £50. 3.4.12 With these considerations in mind local organisations are able to decide the most suitable and cost-effective way of delivering SLT to the population of people with PD.

3.5 Potential savings

Background 3.5.1 The NICE guideline recommends that people with PD should have regular access to specialisg nursing. Expert opinion suggests that in different regions PDNS care could substitute some or all of the consultant care, serve as additional care or be a combination of these. The potential saving resulting from increased specialist nursing care has been estimated on the basis that PDNS care is substituted for and not additional to consultant care. 3.5.2 It should also be noted that savings will not be immediate. They will arise when all new PDNS or other specialist nurse posts are filled and regular access to specialist nursing care and therapy services is readily available. Assumptions made 3.5.3 Hospital inpatient and outpatient figures were obtained from the `Hospital Episode Statistics' (HES) data. According to HES there were 6,313 admissions for PD in 2004/05. Expert opinion estimates that access to specialist nursing care and therapy services can reduce admissions for PD by 50% resulting in 3,157 fewer admissions. The average cost of £1,220 per admission was obtained from the 2006/07 PbR tariff.

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3.5.4 Expert opinion suggests that access to specialist nursing care and therapy services may potentially reduce outpatient attendance by 40%. A large part of outpatient attendance for people with PD is for clinical monitoring and medication adjustment. The guideline recommends that these services may be provided by specialist nurses. Outpatient attendance for PD in 2004/2005 was estimated as 62,569 which is 14% of neurology follow-up outpatient attendance (Reference costs 2005). The cost of £103 per outpatient attendance was obtained from the 2005/06 Reference costs. Cost summary 3.5.5 The above assumptions lead to an estimated potential saving of £6.4 million as shown in table 7. Table 7 Potential annual savings

Potential saving Unit cost £ % reduction in units resulting from PDNS care Reduced inpatient admissions Reduced outpatient attendances Total potential annual saving 1,220 103 50% 40% ­3,157 ­25,028 ­3,851 ­2,578 ­6,429 Annual units Estimated annual saving £000s

4 Sensitivity analysis

4.1 Methodology

4.1.1 There are a number of assumptions in the model for which no empirical evidence exists. Because of the limited data, the model developed is based mainly on discussions of typical values with NHS practitioners and is therefore subject to a degree of uncertainty. 4.1.2 As part of discussions with practitioners, we discussed possible minimum and maximum values of variables, and calculated their impact on costs across this range.

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4.1.3 It is not possible to arrive at an overall range for total cost because the minimum or maximum of individual lines would not occur simultaneously. We undertook one-way simple sensitivity analysis, altering each variable independently to identify those that have the greatest impact on the calculated total cost. 4.1.4 See appendix c for a table detailing all variables modified. The key conclusions drawn are discussed below.

4.2 Impact of sensitivity analysis on costs

Variation in the average caseload for PDNS 4.2.1 Expert opinion has advised that a PDNS currently has an average caseload of about 450 people with PD, while the recommended average caseload is about 300. To calculate the sensitivity analysis, estimates for the current average caseload were varied between 400 and 650. Using these minimum and maximum values in the costing model the total cost of implementing the guideline was found to vary between £3.1 and £6.3 million. Varying the recommended caseload independently between 250 and 400 cases resulted in implementation costs ranging from £6.2 to £1.4 million. Variation in physiotherapy 4.2.2 The value assumed in the costing model for the proportion of people with PD who currently receive physiotherapy interventions is 40%. To calculate the sensitivity analysis, the proportion of referrals was varied between 20% and 50%. Using these minimum and maximum values in the costing model the net cost of implementing the guideline was found to vary between £4.8 and £3.7 million. Speech and language therapy 4.2.3 The predicted value in the costing model for the proportion of people with PD who will receive speech and language therapy after implementation of the guideline is 70%. The sensitivity analysis was calculated by varying this value between 50% and 85%. These

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minimum and maximum values resulted in significant variation in the net cost of implementation; between £2.6 and £5.2 million. Variation in the assumptions regarding potential savings 4.2.4 The model makes certain assumptions about potential annual savings. This is based on an estimated 50% reduction in hospital admissions and a 40% reduction in outpatient attendance as a result of increased PDNS care. Using minimum and maximum levels of 25% and 80%, respectively, for reduced admissions, the total estimated savings varied between £6 million and £1.8 million.

5 Impact of guidance for commissioners

5.1.1 This document presents estimates of costs and savings across a variety of settings including primary and secondary care. `Payment by Results' in 2006/07 only covers inpatient activity commissioned from acute providers. Neurology outpatient attendance is not currently included in the Payment by Results tariff so prices would be negotiated locally. 5.1.2 Specialist nursing care is a key development in improving care for people with Parkinson's disease, and has quantifiable benefits in terms of reducing admissions and outpatient attendances. Commissioners need to take account of the recruitment and training of specialist nurses.

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6 Conclusion

6.1 Total national cost for England

6.1.1 Based on the recommendations that have significant resource impact shown in table 1 and the assumptions specified in section 3 we have calculated the cost of fully implementing the guideline to be £3,776 million, as detailed below:

Annual cost Recommendations with significant resource impact £000s

Increased cost of access to specialist nurses Net cost of physiotherapy for people with PD Net cost of occupational therapy for people with PD Net cost of speech and language therapy for people with PD Cost of implementing PD guideline Total potential saving Total net cost of implementing the PD guideline

3,623 1,054 1,820 3,709 10,206 ­6,429 3,776

6.1.2 We applied reality tests against existing data wherever possible, but this was limited by the availability of detailed data. We consider this estimate to be reasonable, given the limited detailed data regarding the care pathway. However, the costs presented are estimates and should not be taken as the full cost of implementing the guideline.

6.2 Next steps

6.2.1 The local costing template produced to support this report enables organisations such as PCTs to estimate the impact locally and replace variables with ones that depict the current local position. A sample calculation using this template showed that the average PCT with an adult population of 145,000 could expect to incur additional costs of £29,000, offset by potential annual savings of £19,000 resulting in a net cost of £10,000.

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Appendix A: Approach to costing guidelines

Guideline at first consultation stage

Identify significant recommendations and population cohorts affected through analysing the clinical pathway

Identify key cost drivers ­ gather information required and research cost behaviour

Develop costing model ­ incorporate sensitivity analysis

Draft national cost-impact report

Determine links between national cost and local implementation Develop local cost template

Internal peer review by qualified accountant within NICE

Circulate report and template to cost-impact panel and GDG for comments

Update based on feedback and any changes following consultations

Cost-impact review meeting

Final sign-off by NICE

Prepare for publication in conjunction with the guideline

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Appendix B: Calculation of therapy costs

Unit costs of rehabilitative services Physiotherapy Occupational therapy Speech and language therapy Top of band 6 £36,838 42 x 36 = 1,512 £24.36

Grade of staff (Agenda for change) Salary, including employer costs Working weeks / hours per week Hourly rate Number of individual hours of therapy given to person with PD in first year Number of group hours of therapy given to person with PD in first year Cost of therapy hours given to person with PD in first year Number of follow up hours in subsequent years Cost of therapy hours given to person with PD each subsequent year

Midpoint of band 7 £37,936 42 x 36 = 1,512 £25.09

Top of band 6 £36,838 42 x 36 = 1,512 £24.36

5.42 hours

6 hours

8.67 hours

0.8 hours

0.4 hours

no group sessions

£156.08 1 hour (2 sessions of 30 minutes each) 25.09

£155.83 2.25 hours (3 sessions of 45 minutes each) 54.82

£211.15 2.67 hours (4 sessions of 40 minutes each) 64.97

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Appendix C: Results of sensitivity analysis

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Appendix D: References

Department of Health (2006) NHS Trust reference cost schedule 2005, UK Findley L, Aujla M, Baker M, Beech C, Bowman C, Holmes J, Kingdom W, MacMahon DG, Peto V, Playfer JR (2003). Direct economic impact of Parkinson's disease: A research survey in the United Kingdom. Movement Disorders 18:1139-1189 Jansa J (2004) OT in Europe. EPDA Focus. Issue 27, summer 2004. European Parkinson's Disease Association. Brussels The Chartered Society of Physiotherapy (1996) The Curriculum Framework for qualifying programmes in Physiotherapy. London, the Chartered Society of Physiotherapy, The Council for Professions Supplementary to Medicine. Parkinson's Disease Society (2005) Competencies: an integrated career and competency framework for nurses working in Parkinson's disease management. London, UK Schrag A, Ben-Schlomo Y, Quin NP (2000). Cross sectional prevalence survey of idiopathic Parkinson's disease and parkinsonism in London. British Medical Journal 321: 21-22

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