ESTIMATING THE BENEFITS OF INVESTMENT IN ONGOING SUICIDE MORTALITY REVIEW - A COST BENEFIT ANALYSIS

Transcription

1 ESTIMATING THE BENEFITS OF INVESTMENT IN ONGOING SUICIDE MORTALITY REVIEW - A COST BENEFIT ANALYSIS A paper developed jointly by the Health Quality & Safety Commission and the New Zealand Institute for Economic Research (NZIER). December 2015

2 ESTIMATING THE BENEFITS OF INVESTMENT IN ONGOING SUICIDE MORTALITY REVIEW - A COST BENEFIT ANALYSIS This cost benefit analysis (CBA) was undertaken to assess the benefits of investment in ongoing suicide mortality review as a tool for reducing suicide rates. It was developed jointly by Health Quality & Safety Commission and the New Zealand Institute for Economic Research (NZIER). Executive Summary 1. Suicide is one of the leading causes of death in New Zealand. In 2012 it was the most common cause of death for youth, accounting for over one-third of deaths (150 deaths). The next most common cause of death for youth was motor vehicle deaths (70 deaths). 2. Rates of suicide have remained static over the last ten years despite suicide prevention activities. For Māori youth, they have increased by around 65% (90% for young Māori women) over this time. 3. Other jurisdictions have been able to make reductions of 10-20% in their numbers and rates of suicide through carefully planned prevention strategies based on in depth research and carefully targeted programmes. 4. New Zealand could do better. Improved targeting of the prevention spend, based on new insights resulting from in-depth analysis of current cross agency data, has the greatest chance of making a real difference. This approach is supported by the WHO which recommends establishment of integrated data collection systems which service to identify vulnerable groups, individuals and situations. 5. Given the relatively low level investment in suicide prevention, this is particularly important. 6. Mortality review committees operating under the NZ Public Health Act 2000, are the only agencies (apart from coroners) that can require identifiable data from other agencies. It is this power that enables mortality review committees to play a unique role in bringing together these rich datasets, linking them in ways not previously possible and identifying key patterns and possible intervention points. This knowledge can be used to develop new suicide prevention strategies and action plans (both in health and other sectors), and to help agencies and services in the redesign of their policies, procedures and services. 7. The social and economic cost of suicide and suicide attempts in any one year is estimated to cost $2.7billion. The purely economic cost is estimated to be $587,000 for each suicide. We have used the economic cost in this assessment. 8. For an investment of $760,000 annually, suicide mortality review could play a critical role in the 10-20% reduction in suicide expected from more effective targeting of suicide prevention activity over 10 years. This reduction would save between 55 and 110 lives over that time and the net savings would be between $92m and $178m. If 55 lives were saved (10% reduction), for every dollar invested, a return of around $15-$20 could be expected. For a reduction of 20% one dollar spent would result in savings of $36-$ It would require a reduction of only 1.2 suicides per year (or less than a 0.5% reduction from current levels) for an investment in an ongoing suicide mortality review function to break even. So even if suicide mortality review contributed to only a relatively small proportion of the reduction in suicide deaths, there is still a clear investment case 2

3 In conclusion, by improving our understanding of suicide, and where and when to intervene in the system, government can more effectively target investment to reduce New Zealand s high rate of suicide, which has remained largely static for the past ten years. Suicide is a significant issue in New Zealand 11. Suicide is one of the leading causes of death for Maori and non-maori males in New Zealand. In 2012 it was the most common cause of death for youth, accounting for over one-third of deaths (150 deaths). The next most common cause of death was motor vehicle deaths (70 deaths). Appendix 1 contains further information on leading causes of death. 12. The cost of suicide and attempted suicide occurring in the year is estimated to be $2.7 billion. This is based on the work of Tucker and O Dea in 2005, and updated informally updated by the Ministry of Health using CPI data to 2015 dollars. This figure includes the economic and social costs. Just the economic cost alone is estimated to be $322.3m or $587,000 per suicide. Further detail on the method of calculation is contained in Appendix Suicide numbers and rates have remained relatively steady in New Zealand over the last few years. In the later 1990s there was a drop in numbers and rates, mainly due to a drop in rates of suicide of young men. Significant effort was put into the prevention of youth suicide at this time. The graph below shows rates and numbers. Figure 1: Suicide numbers and rates in New Zealand Suicide numbers and rates Number Rate Source: Ministry of Health Suicide Facts While suicide rates have remained relatively steady since 2003, they have increased by around 65% for Māori youth in that period. The increase for young Māori women during that time is around 90%. 15. New Zealand has suicide rates very slightly above average when compared to other OECD countries. The median rate for male suicides in OECD countries for males is 16.2, and for New Zealand is And for females the OECD average is 4.5 compared to the New Zealand rate of 4.7 (Ministry of Health, 2015). 3

4 Other countries have reduced their suicide rates over recent years prevention programmes can work. 16. Other jurisdictions, such as Scotland, have achieved sustained reductions in their rates of suicide over the same time period 1 (a 19.5% reduction over 11 years from to ). Figure 2: The Scotland experience 17. In Germany, the Nuremberg Alliance against Depression, a four level community based intervention programme, comprising a variety of measure and activities for different target groups at community level, was associated with a 32.5% reduction of suicidal acts (completed and attempted suicides combined) compared to the baseline year and the control region over a three year period ( ) Documentation about these successful programmes shows that they had in-depth research programmes sitting alongside them. 19. The World Health Organization (WHO) notes that in England, the 1999 national health strategy Saving Lives: Our Healthier Nation set a target to reduce the death rate from suicide and undetermined injury by at least 20% by 2010 (WHO 2013). This was reached by The same report notes that countries that are guided by the WHO s Mental Health Action Plan can aim for a 10% reduction in the suicide rate. As part of a suicide prevention strategy, the WHO recommends establishment of integrated data collection systems which service to identify vulnerable groups, individuals and situations, noting that quality improvement depends on having data that point to where the needs for improvement exist (Preventing Suicide: A global perspective 2014) 21. There is New Zealand and international research/literature about best practice and suicide interventions that work. Mortality review is able to use that existing literature and research alongside the insights from suicide mortality review, to inform the choices that are made about more effective targeting of these interventions. Given the relatively low level investment in suicide prevention, this is particularly important (see Appendix 3) Ulrich Hegerl, Christine Rummel-Kluge et al. Alliances against depression A community based approach to target depression to prevent suicidal behaviour. Neuroscience and Biobehavioral Reviews 37 (2013)

5 The trial of a suicide mortality review mechanism 22. Action 11.1 of the New Zealand Suicide Prevention Action Plan required the Ministry of Health and Health Quality and Safety Commission to trial a suicide mortality review mechanism to improve knowledge of contributing factors and patterns of suicidal behaviour in New Zealand, and to better identify key intervention points for suicide prevention. 23. The trial was carried out between September 2013 and October 2015, with most of the research work carried out between June 2014 and June The trial: reviewed 1797 deaths between 2007 and 2011 focusing on a number of groups with high rates of suicide i.e. rangatahi Māori, mental health services users in the year prior to death and men aged (criteria for chosing these groups is outlined in appendix 4). used matched data from a wide range of government agencies used a representative range of mortality review methods. 25. It demonstrated that a suicide mortality review approach is feasible. New and useful insights into contributing factors and patterns were found. The findings of the report have been received positively to date. Informal communication from people working in the area of suicide prevention across a number of government agencies has indicated that they will use the initial findings of the report in their future planning and programme implementation, and that they look forward to some more in-depth analysis in future. The effectiveness of a suicide mortality review function - a foundation stone for suicide prevention 26. A key factor in determining whether suicide mortality review can provide the foundation stone for suicide prevention is whether it is able to identify key intervention points for suicide prevention. 27. In the short research window available, the trial identified some useful new findings, as well as reinforcing existing knowledge about suicidal behaviour. The trial s key findings have been translated into discussion on potential intervention points and have identified targeted opportunities for a range of government agencies to consider in their suicide prevention efforts. 28. Insights included the extent of multi-agency contact people had had throughout their lives and in the lead up to their deaths. For all three sub-groups, and especially rangatahi Māori and men, the nature and extent of engagement with Police and Corrections prior to and at the time of death is notable. This warrants further investigation, and suggests potential opportunities for suicide prevention. 29. The review of mental health service users also identified some important findings that point to improvements in practice that may reduce suicide rates in that sub-group. These include questioning the value of ongoing risk assessments when care is not going to plan and suicide risk increased, and greater use of a recovery model of care. 30. While this first cut at suicide mortality review has provided new findings, it has also provided glimpses of the kind of potentially powerful findings that could be expected in the longer term from the rich data collected. Some of the areas for possible further investigation are outlined in Appendix 5. 5

6 31. The Police have already requested a meeting with the Chair of the SuMRC to discuss the findings of the report and how these can inform their suicide prevention activities. They consider that the work to date has provided very useful insights and they are keen to be involved in, and help shape, future suicide mortality review work. Successes of other mortality review committees in New Zealand 32. It is also useful to look at other mortality review committees and whether the mortality review mechanism has enabled them to better identify key intervention points to reduce future deaths as well as whether deaths have reduced as a result. 33. Each year the four existing mortality review committees in New Zealand carry out mortality reviews which identify key intervention points and result in recommendations for prevention activities. The recommendations made by the committees are well respected and most are implemented by health agencies and across government over time. The committees that have been in existence for longest i.e. the Child and Youth Mortality Review Committee (CYMRC) and the Perinatal and Maternal Mortality Review Committee (PMMRC), have measured: a reduction in child and youth mortality rates of 20% over 11 years. a 25% reduction in perinatal and maternal deaths over five years and a 47% reduction in stillbirths over six years. 34. Of course these reductions cannot be solely attributed to more effective interventions resulting from mortality review insights and evidence. However, the insights/evidence base have enabled the committees to constructively engage with both the health sector and broader government agencies on more effective and better targeted prevention activities. 35. For example, based on CYMRC evidence that SUDI rates were not reducing in spite of prevention efforts, the committee worked with key stakeholders to identify the reason. As a result, changes were made to the NGO funding model and more culturallyappropriate safe sleep programmes, including the roll out of culturally-appropriate safe sleep devices, were introduced. Between 2009 and 2013 there was a reduction of deaths from SUDI from 60 down to 38, a 36% decrease (CYMRC 10 th data report). 36. A second example is the significant reduction in teenage drink-drive convictions in the year after the zero alcohol limit was brought in for the under-20s and the reduction in motor vehicle crashes in young people between 15 and 24. After finding that alcohol had been a factor in 31% of motor vehicle deaths of children and young people in New Zealand during 2007, CYMRC recommended a zero alcohol limit in its 2011 special report on alcohol related deaths. The Law Commission noted that the CYMRC evidence had been most useful in developing the zero alcohol limit legislation, as this information had not been previously been available. 37. The usefulness of mortality review as a process for improving outcomes is being recognised internationally. As an example, the recent Lancet Commission on Global Surgery draft report, Data for the sustainable development of surgical systems notes in relation to the Perioperative Mortality Review Committee that perhaps the most robust national system for collecting, reporting, and using the perioperative mortality rate is that of New Zealand It notes that the Committee s report provides sufficient information to identify specific populations that are at high risk of perioperative mortality with a view to providing safe surgical and anaesthesia care for all. The report recommends that all countries can work toward this model of systematic surgical outcomes data collection, reporting, and meaningful use. 6

7 38. There are few examples of suicide mortality review functions worldwide. However, in 2012 Scotland introduced a Scottish Suicide Information Database (ScoSID) which provides a central repository for linked information from several official sources on all probable suicide deaths in Scotland. The database covers demographic information, contact with health services and related health data, and will eventually (through inclusion of information from other data sources) provide further details relating to the suicide event and an individual s wider social circumstances. The purpose is to support epidemiology, prevention activity and policy making. The most recent report was used to support the Scottish Government suicide prevention engagement paper. The underpinning intervention logic 39. The figure below demonstrates the intervention logic that underpins this CBA. It shows how mortality review could result in more effective targeting of suicide prevention activities and reduced rates of suicide. 40. The basic premise of this intervention logic is that there are currently a number of rich, potentially interlinked data sets relating to suicide that are not being used to their fullest. In fact they are being used in a fragmented and ineffective way, if at all. This is mainly attributable to constraints around sharing identifiable data across agencies. Mortality review committees operating under the NZ Public Health Act 2000, are the only agencies (apart from coroners) that can require identifiable data from other agencies and it is this power that enables mortality review committees to play a unique role in bringing together these rich datasets, linking them in ways not previously possible and identifying key patterns and possible intervention points. Figure 3: How suicide mortality review adds value to suicide prevention Suicide mortality review which: Research which: is able, under its legislative powers, to collect and match data already collected on suicide deaths across a broad range of government activities makes better use of the data already collected adds to the evidence base on contributing factors and patterns of suicidal behaviour and potential interventions/intervention points across government agencies uses existing literature and research on best practice and interventions that work, to ensure their targeted use i.e. provides leadership and advice on effective targeting and interventions informs further research priorities adds to the evidence base on effective suicide prevention activities informs future areas for mortality review. New/revised suicide prevention strategy and action plan Use of effective programmes and bettertargeted suicide prevention activities across government DHB suicide prevention plans and cross agency work locally Improved mental health services Improved targeting of atrisk populations across government agencies Better targeted research e.g. HRC priorities Coroners reports which make comments or recommendations to prevent the occurrence of other deaths in similar circumstances. Evaluation of suicide prevention activities to assess whether they work. Reduced rates of suicide and associated savings 7

8 41. The Office of the Auditor General is currently carrying out an investigation into suicide data and whether it is being used effectively. Although still in the early stages, the investigation seems likely to support the view that better co-ordination/leadership is needed to ensure consistency of collection and best use of the data available. The cost data used in this analysis Cost of an ongoing suicide mortality review function (see Appendix 6 for more detail) 42. Total funding received by the Commission from the Ministry of Health from 1 September 2013 to 31 December 2015 (2.25 years) was $606,000. The Commission has estimated that the cost of an ongoing suicide mortality review function would be in the area of $700,000 per year. This cost is consistent with the costs of other mortality review committees (see appendix 7). 43. The cost does not include a local interagency suicide mortality review function. It is anticipated that any local interagency review functions would be the responsibility of DHBs as part of their suicide prevention activities. 44. Other costs associated with ongoing mortality review include the costs incurred by other agencies in providing matched data for the trial. We have estimated this to be a total of around $63,000 (for 13 agencies at an average of $4,800 for each agency). Cost of suicide (see Appendix 2 for more detail) 45. Work was undertaken on the cost of suicide in New Zealand by Tucker and O Dea in The Ministry of Health recently used this work as a basis to informally update the cost of suicide. Table 1: Cost of suicide in New Zealand Cost of Suicide Per Suicide Total Social and economic costs - $2.7 billion Economic costs $587,000 $322.3 million Cost of services associated with suicide (see note 1) $13,368 $7.3 million Note 1: the information on the cost of services associated with suicide includes very limited information. It does not include all full sets of possible impacts on government services e.g. information on changes to benefits or ACC payments for suicide victims or their dependents, reductions in services required by suicide victims or support services for their families. Estimating the benefits of investment in ongoing suicide mortality review 46. The scenarios below are based on an assumption that it could be possible to aim for a 10% 20% reduction in suicide rates over a ten year period if suicide prevention activities were more effectively targeted (see supporting information above). To give a sensitivity analysis, the calculations include a 5%, 10% and 20% reduction. The numbers used in the table are based on the updated 2015 economic cost of a suicide of $587,000. Economic cost was used as the cost information methodology did not enable us to separate out the social costs of suicide in a useable manner. 8

9 Table 2: Benefits of suicide mortality review % reduction in suicide 5% by year 10 10% by year 10 Cost of suicide mortality review over 10 years $7.6m (discounted is or Potential reduction in suicide 27 lives saved by year 10 $7.6 million 55 lives saved by year 10 Potential cost saving based on the economic cost of $580k per suicide over the 10 years 3 Net benefit over 10 years $46m $42m $97m $92m 20% by year 10 $7.6m 110 lives saved by year 10 $183m $178m 47. It would only require a reduction of 1.2 suicides per year (or less than a 0.5% reduction from current levels) for the investment to break even. 48. So even if suicide mortality review contributed to only a relatively small proportion of the reduction in suicide deaths, there is still a clear investment case. And given that suicide rates have been static for nearly 10 years in spite of current suicide prevention activities, the role of the insights and subsequent leadership of change from mortality review could make the critical difference. 49. The NZTA Value of Statistical Life measure could also be used to calculate the estimated benefits of the reductions in the number of suicides. In this case where a 20% reduction could be achieved over the 10 years the potential savings would be more than $1billion. Or a benefit ratio of 1:1200 So a reduction of just less than 2 suicides over the 10 year period of operation of the SuMRC would be needed in order to break even. 50. The worksheet below uses the Treasury format for agencies to describe the net present value, benefit cost ratio and return on investment for initiatives. This is based on reaching a 10% reduction in suicide numbers over the 10 year period that the Committee operates. Table 3: Key ratios Use ranges for values where appropriate Discount Rate 8% real (default) 4% real (sensitivity) Net Present Value (NPV) (note 1) $97m $124m Benefit Cost Ratio (BCR) (note 2) Return on Investment (ROI) Societal Total (note 3) Return on Investment (ROI) Government 4 (note 4) Assumes a gradual decrease in the numbers once the work of the Committee starts getting results. So 10 in each of the first two years, 20 at each of years 3-5, 30 at year 6 and 7, then 40 at year 8 and 9, then to 55 at year 10. It is based on a discounted present value to recognise that costs come over the 10 year period. An 8% discount rate has been used. 4 There is insufficient information available to assess the ROI Government as we do not have information on all government services associated with suicides, in particular benefit payments to surviving dependents, or ACC payments. 9

10 Note 1. Net Present Value (NPV): The NPV is the sum of the discounted benefits, less the sum of the discounted costs (relative to the counterfactual). This gives a dollar value representing the marginal impact on the collective living standards of all New Zealanders of the initiative, in today s dollar terms. Note 2. Benefit Cost Ratio (BCR): The BCR is the ratio of total discounted benefits to the total discounted costs. A proposal with a BCR greater than 1.0 has a positive impact, because the benefits exceed the costs. The BCR is the same as the Return on Investment Societal Total, unless there are negative impacts in addition to the fiscal cost of the initiative. All negative impacts are included in the denominator for the BCR measure. For example, the BCR measure would reduce if the private cost to people of attending was monetised for the illustrative example and therefore included in the denominator for the BCR calculation. Note 3: Return on Investment (ROI) - Societal Total: The ROI is calculated by dividing the discounted net change in wider societal impact, including benefits to government, by the discounted cost of the initiative. This can be interpreted as the impact on New Zealanders per dollar the government spends on the initiative. In this case, for every $1 the government spends on this programme, New Zealanders receive benefits of between $15.3 and $19.5. Note 4: Return on Investment (ROI) Government: The ROI is calculated by dividing the discounted net change in impact for the government by the discounted cost of the initiative. This measures the discounted net marginal (fiscal) benefits to the government. As discussed above, information was not available to make this calculation. The counterfactual 51. The Treasury Guide to Social Cost Benefit Analysis notes the importance of articulating the counterfactual - the possible alternative uses as well as the option of doing nothing. Are there alternative uses of the $700,000 that would provide similar or better results? 52. Some of the alternative uses could include: additional suicide prevention activity funding additional research activity 53. As noted previously, current investment in suicide prevention activities the past ten years has had limited impact in reducing suicide rates, with suicide numbers and rates remaining relatively steady overall. In fact, suicide rates have increased by around 65% for Māori youth in that period with the increase for young Māori women being around 90%, despite investment in Māori suicide prevention. 54. Investment of an additional $700,000 per annum in further suicide prevention programmes might make a small difference in suicide rates. But investment of the same amount in suicide mortality review, which will result in more effective targeting of the total expenditure on suicide prevention can make a greater difference. This is particularly important given the small amount of investment in suicide prevention across government ($25m per annum in 2008/09). 55. While investment in suicide prevention activities and mortality review should not be seen as either/or options, it is important that any further investment in is more effectively targeted and evidence based wherever possible to ensure that it does result in reduced rates. 56. Both research on suicide prevention and mortality review have potential to provide evidence on effective suicide prevention strategies. However, existing research has not resulted in reduced suicide rates over the past ten years. 10

11 57. Once again, research and mortality review should not be seen as an either/or option. There is potential for suicide mortality review to inform research priorities (e.g. the suicide research priorities funded by the Health Research Council) and vice versa. What would be the impact of doing nothing i.e. not establishing an on-going suicide mortality review function? 58. Given that suicide rates have not changed significantly over the past 10 years (and that the rates in some sub-groups has increased, the do nothing different option is likely to result in: no change to suicide rates gradual increases in the cost of suicide to society (through general inflation, and increases in the cost of services and wages). Feedback and review to allow reassessment of ongoing value for money 59. It is important to ensure that any new investment has feedback and review systems in place that allow it to re-assess value for money. 60. There are already good annual reports on suicide rates, the Ministry of Health s Suicide Facts which will enable ongoing monitoring of suicide rates. In addition, all mortality review committees regularly monitor the uptake of their recommendations to find out how people use the results of their work and measure the results. An ongoing suicide mortality review function would do the same. This is built into the $700,000 budget, as it is with all the mortality review committees. 11

12 Appendix 1: Leading causes of death in New Zealand The information below is from Suicide facts: Deaths and intentional self-harm hospitalisations Wellington: Ministry of Health Suicide accounted for 1.8% of all deaths in However, suicide was the cause of death for about 45% of males and females aged years. Approximately one in three deaths in males and females aged 5 24 years were due to suicide in 2012 (Figure 3). Suicide as a percentage of all deaths, by age group and sex, 2012 Source: New Zealand Mortality Collection Suicide was the most common cause of death for youth (150 deaths), accounting for over one-third of all youth deaths in 2012 (37.4% of all male youth deaths and 31.9% of female youth deaths). 5 The next most common cause of death for this age group was motor vehicle accidents (70 deaths). This equates to youth mortality rates of 23.4 per 100,000 for suicide and 10.9 per 100,000 for motor vehicle accidents. Male youth suicide rates began to rise noticeably in the early 1970s, then rose sharply from the mid-1980s, reaching a peak of 44.1 suicides per 100,000 population in Since then, the rate has trended downwards; the 2012 rate was 26.7% lower than the peak in Female youth suicide rates also showed a general increase over time and peaked in The rates have remained variable since then. The information below is from the Ministry of Health website: The tables below show that: suicide was the third leading cause of death for Māori males and the second leading cause of death for non-māori males when ranked by aged standardised mortality rates suicide was the second leading cause of premature death for Māori male and the fourth leading cause of premature death for non-māori males when ranked by years of life lost. in terms of total numbers, annual deaths from suicide are nearly the same as for breast cancer and for prostate cancer. It is higher that motor vehicle accidents and skin melanoma and around five times higher than cervical cancer. 5 These percentages have been calculated from unpublished provisional New Zealand Mortality Collection 2012 data. 12

13 Major causes of death, ranked by age-standardised mortality rates, by gender, Māori and non-māori, Māori Non-Māori Males Females Ischaemic heart disease Lung cancer Lung cancer Ischaemic heart disease Suicide Chronic obstructive pulmonary disease Diabetes Cerebrovascular disease (stroke) Motor vehicle accidents Diabetes Ischaemic heart disease Ischaemic heart disease Suicide Breast cancer Lung cancer Cerebrovascular disease (stroke) Cerebrovascular disease (stroke) Lung cancer Motor vehicle accidents Colorectal cancer Major causes of death, ranked by YLL, by gender, Māori and non-māori, Māori Non-Māori Males Females Ischaemic heart disease Lung cancer Suicide Ischaemic heart disease Lung cancer Breast cancer Motor vehicle accidents Chronic obstructive pulmonary disease Diabetes Cerebrovascular disease (stroke) Ischaemic heart disease Ischaemic heart disease Lung cancer Cerebrovascular disease (stroke) Cerebrovascular disease (stroke) Breast cancer Suicide Lung cancer Colorectal cancer Colorectal cancer 13

14 Selected causes of mortality 2012 Condition Total deaths Percentage of deaths by sex Māori rate Non-Māori rate Total rate Male Female Male Female Male Female Male Female All cancer 8, Lung cancer 1, Female breast cancer Prostate cancer Melanoma of the skin Cervical cancer Ischaemic heart disease Cerebrovascular disease 5, , Diabetes mellitus Suicide Motor vehicle accidents... = Not applicable

15 Appendix 2: The cost of suicide in New Zealand The table below summarises key information about the economic and non-economic cost of suicide and attempted suicide to New Zealand. Information about the cost of suicide Information $ Total cost Caveats/discussion Source Total economic and non-economic cost of suicide and suicide attempts to New Zealand in 2002 $1.4 billion Unofficially updated by Ministry of Health in 2015 to $2.7 billion In June 2004 $s and based on 460 suicides in Using 8% discount rate. It covers both suicides and suicide attempts and includes direct costs, economic costs, and non-economic costs. O Dea D and Tucker S The Cost of Suicide to Society. Wellington: Ministry of Health Calculation of the non- economic costs is based on a DALY calculation a combination of years of life lost for suicides, and estimated years lost to disability for attempted suicides. The Value of a Statistical Life estimates of the Land Transport Authority ($2.725m in 2004) were used in this study; it is now $3.95 million per fatality at June 2014 prices 6 Total economic cost of suicide to New Zealand in 2002 $206.2 million In June 2004 $s and based on 460 suicides in 2002 using 8% discount rate. Economic loss calculated using lost wages by age/gender using average wage rate (including adjustments for those on benefits or un-waged), plus cost of services above. O Dea D and Tucker S The Cost of Suicide to Society. Wellington: Ministry of Health Unofficially updated by Ministry of Health in 2015 to $322.3 million Using 2002 figure of cost of lost production multiplied by Reserve Bank inflation calculator between 2002Q1 and the 2012 Q1 and the 2012 number of suicides (549) Economic cost of each suicide to New Zealand in 2002 $ 448,250 As above O Dea D and Tucker S The Cost of Suicide to Society. Unofficially updated by Ministry of Health in 2015 to $587,198 Wellington: Ministry of Health 6 If adjusted to 2016 this would be $4.2 million (from The Treasury CBAx spreadsheet model (NZTA 2014) 15

16 Information $ Total cost Caveats/discussion Source Annual costs in 2002 associated with suicide excluding lost production i.e. services used in cases of suicide such as police, coroners and Victim Support 7. $4.7 million ($10,217 per suicide) Unofficially updated by Ministry of Health in 2015 to $7.3 million ($13,368 per suicide) In June 2004 $s and based on 460 suicides in Using 8% discount rate Using 2002 cost excluding lost production multiplied by Reserve Bank inflation calculator between 2002Q1 and the 2012 Q1 and the 2012 number of suicides (549) O Dea D and Tucker S The Cost of Suicide to Society. Wellington: Ministry of Health Value of statistical life Quality adjusted life years (QALY) gained per year $4,214,914 Adjusted to 2016 From The Treasury CBAx spreadsheet model (NZTA 2014) 8 $38,110 Adjusted to 2016 From The Treasury CBAx spreadsheet model (PHARMAC 2014) 9 7 This does not include changes to income support through either ACC or the benefit system in respect of the families of suicide victims e.g. widows benefits, or ACC payments for surviving spouse and dependent children; or cessation of benefits as a result of death from suicide

17 Appendix 3: Expenditure on suicide prevention activities It has not been possible to identify current spending on suicide prevention activities across government. To do this would involve significant work that was not within the scope of this cost benefit analysis. So the figures used here are based on work carried out by ACC in 2010 and relate to spending in 2008/09. Spending on suicide prevention activities Information Expenditure Caveats/discussion Source Estimated government expenditure on suicide prevention 2008/2009 $25 million made up of: MoH: $15m (58%) Corrections: $8m MSD: $1.7m MoE: $1m This includes: activities paid for out of funding streams explicitly allocated for suicide prevention activities that have a primary stated objective of preventing suicide New Zealand Injury Prevention Strategy: Estimating government expenditure on injury prevention. Published by ACC in February ACC: $1m It excludes: activity with a primary purpose that is not injury prevention related and/or where injury prevention is just one of many objectives activities that would have to be implemented even if they dropped their injury prevention focus e.g. mental health services Government expenditure on prevention as a proportion of the total social and economic cost of injuries in 2008/09 (also see table below) Motor vehicle accidents Suicide and deliberate selfharm 38.9% 1.2% Falls 0.5% Workplace injuries 6.3% There is wide variability across priority injury prevention areas New Zealand Injury Prevention Strategy: Estimating government expenditure on injury prevention. Published by ACC in February Assault 32.1% Drowning 3.4%

18 18

19 Appendix 4: Prioritisation criteria used for selecting the sub-groups for the trial The following criteria were used for selecting the subgroups for the trial. large numbers or disproportionate rates of suicide less research available (and therefore more to be learned) data already available that has yet to be analysed likelihood that interventions can be identified with potential to reduce suicide opportunity to improve equity alignment with government priorities and the priorities in the Suicide Prevention Action Plan public and/or political interest. Once a shortlist of sub-groups was identified, the options were further refined by considering where the greatest value for prevention could be expected and what types of review could be implemented within the budget, timeframe and information available. The three subgroups reviewed for the trial, rangatahi Māori, mental health services users in the year prior to death and men aged were identified using these criteria. 19

20 Appendix 5: Some options for a future work programme Any ongoing SuMRC will need to develop a work plan that is based on an overarching framework and explicit prioritisation principles developed in consultation with stakeholders including other government agencies. Some work plan ideas were identified through the feasibility study and subsequent consultation process that could be considered for a future work programme. These involved using already collected data and new data to review: suicide in other subgroups such as children under 15, Pasifika communities, rural areas, people over 65, youth with mental health issues (including around transition from child and youth to adult services) in more depth, suicide across the three subgroups for those with a Police, Corrections or CYF file with the aim of identifying new prevention initiatives in more depth, the subgroup of men aged with the aim of identifying new prevention initiatives. This might include using data and information from: o Ministry of Social Development data that could allow more exploration of the financial issues that men have experienced in the years leading up to their death. For example, benefit receipt and type (e.g., unemployment or sickness) from Work & Income and/or Inland Revenue data could provide information on financial hardship, debt write-off, outstanding tax returns, overdue student loan or child support payments, domestic maintenance payments, and audit activity. Data held by the New Zealand Insolvency and Trustee Service on bankruptcies could be explored. This is freely available online. o Ministry of Justice data to provide information on prosecutions, orders for drug and alcohol rehabilitation, fines, and orders relating to guardianship and care of children (including protection orders). o primary care providers could provide information on the use of primary care mental health services, such as engagement with GPs and referrals to counselling. o large employer organisations that use Employee Assistance Programmes could potentially provide information about other sources of counselling or support that men access anonymously through their jobs. primary care prescribing, contacts, use of analgesics and alcohol and drug use choice of methods of suicide in NZ (which are significantly different to other countries) whether mental health service use data can identify specific time points where service users are at particular risk of suicide school drop-out, non-enrolment, alternative education, kura kaupapa Māori enrolment and other educational issues attempted suicide and admissions for self-harm. This could include the role of emergency departments and emergency/crisis mental health services for people who presented with suicidal behaviours/attempts and who subsequently died by suicide and/or comparative analysis of those who died by suicide compared to those who made suicide attempts. There is potential to use the NNPAC data to look at ED and outpatient admissions in the year or two prior to death and what type of service/speciality was involved. use of social media. Further work was identified relation to collection and standardisation of data including: developing a standard for DHB reviews and reporting of suicide and collectively reviewing these centrally developing with Police and Coroners a minimum set of data to be collected when suicide is suspected 20

21 working with the Office of the Chief Coroner and Royal College of Pathologists of Australasia on standardised testing and data collection for all cases of suspected suicide. constructing a data dictionary and master data set (of thoroughly cleaned data) and/or a national suicide case register. The new Integrated Data Infrastructure (IDI) system from Statistics New Zealand will offer an opportunity to explore linked longitudinal administrative data which will provide information on education, Police victim data and incident data, charges data, sentencing data, injury data, migration, tenancy, personal and business tax, income, labour force and business data. Access to this type of information will build on the areas which have been explored in the trial and provide new insights and additional information on contributing factors and patterns in men who die by suicide. 21

22 Appendix 6: Cost of a Suicide Mortality Review Committee Total funding received by the Commission from the Ministry of Health from 1 September 2013 to 31 December 2015 (2.25 years) was $606,000. Contract duration Amount Deliverables 2013/14 $190,000 Develop implementation plan 2014/15 $260,000 Research and report 2015/16 $156,000 Maintain momentum and finalise report Total $606,000 Of the $606,000, the amount used for research, governance and secretariat support to produce the first report was $416,000. The Commission has estimated that the cost of an ongoing suicide mortality review function would be in the area of $700,000 per year. This does not include a local interagency suicide mortality review function. It is anticipated that any local interagency review functions would be the responsibility of DHBs as part of their suicide prevention activities. Budget for ongoing suicide mortality review Budget item $s Comment Governance $50,000 Committee members fees, travel and expenses, meeting expenses Data management provider $230, Responsible for collection of data, secure storage, management, processing, analysis and reporting Epidemiology and report writing $100,000 Secretariat staff salaries and expenses Publishing reports, holding $30,000 conferences/workshops Overheads $20,000 TOTAL $700,000 $270,000 Likely to include a lead coordinator, and resources for policy analysis, project management and administration, some of which will be shared across committees There may be potential to reduce the cost of ongoing suicide mortality review by around $100,000 depending on: how the new Integrated Data Infrastructure (IDI) from Statistics New Zealand database is able to be used in future economies of scale that the Commission could negotiate with the data management provider as a result of expanding their activities to cover suicide mortality and possible one or more of the other committees reductions in the cost of epidemiology and secretariat that could result from these changes. While the ongoing cost for a fully functional suicide mortality review function is between $600,000 and $700,000 per annum, the costs in year one are likely to be less, as the committee and its work ramps up to full implementation. There are multiple reasons why the cost of an ongoing suicide mortality review function is higher than the cost of the trial: 12 This is not very different to the sum paid to Otago University for doing very similar work ($215,000). 22

23 The actual cost to the various agencies involved in developing the first report (i.e., the Commission and Otago University) was greater than the funding received and these costs were carried by the agencies in the interests of doing a good job. The trial review was limited by the amount resource available e.g. there was insufficient resource to do the work required to provide denominator data and/or case-control methodology and research on protective and resiliency factors to allow the SuMRC to make stronger evidence-informed recommendations. Systems review and whanau stories, which are more costly to undertake, were only a small part of this first review. The insights that these methodologies provide are very significant and likely to play a greater role in future reviews. Development and implementation of Māori-centred approaches is likely to be more costly than conventional research methods. The trial involved minimal engagement with other government agencies. There is a need to invest in the development of strong working relationships in order to ensure the best possible understanding of wider agency data and policy and more consistent data gathering across agencies, target analysis on shared priorities, facilitate access to data and information about suicide prevention policy and services, and inform recommendations. A future suicide mortality review function would play more of a leadership role for suicide data and best practice interventions for suicide prevention both in the health sector and across agencies. The diagram below demonstrates the way that a future suicide mortality review function could operate. This is substantially different from the operation of the trial phase. National level Local level National level crossagency expert advisors group Provide understanding of wider agency data and policy More consistent data gathering across agencies national minimum dataset Target analyses on shared priorities Facilitate access to data and information about suicide prevention policy and services Inform recommendations Could potentially advise MoH on implementation of suicide prevention action plan etc (as per current interagency committee) Data management provider Collection, secure storage, management, processing, analysis, reporting SuMRC Leadership role for suicide prevention Direction and oversight of mortality review Approving reports Approving research proposals and publications Secretariat Supporting SuMRC Report writing Managing cross agency relationships including implementation of recommendations Supporting local/regional groups Managing contract Committee chairs group Other mortality review committees Local and/or regional cross agency groups that potentially: review deaths provide reports to SuMRC encourage local implementation of SuMRC recommendations are part of DHB cross-agency suicide prevention activity Other agency activities DHB serious adverse events reporting 23

24 Costs incurred by other agencies Other costs associated with ongoing mortality review, include the costs incurred by other agencies in providing matched data for the trial. The following information was provided by one of the agencies that provided data. We have used this as an average across all the agencies, acknowledging that it is a rough calculation and that it will differ for each agency depending on how much data is requested. Process Hours Hourly rate Cost Comments Providing data to the 12 $70 $840 Including consultation, clarification, research team data query design, peer review and Legal discussions and vetting researchers (only required for some agencies) Providing feedback on reports, recommendations etc. release 40 $70 $2800 May include review/clarify, log, draft contract, vetting, internal consultation etc. 17 $70 $1190 `Total 69 $70 $4830 Assuming that 13 agencies provide data each year, the total cost to other government agencies will be $62,790 (rounded to $63,000). 24

25 Appendix 7: Efficiency how do the proposed costs of an ongoing committee compare with other similar committees? Productive efficiency is about doing things well, but at least cost. The question is whether $700,000 is a reasonable cost for a suicide mortality review function? For suicide mortality review we can use the other mortality review committees as a benchmark. Benchmarking suicide mortality review against other mortality review committees Total annual cost SuMRC CYMRC FVDRC PMMRC POMRC $0.70m (est) $1.35m $0.43m $0.67m $0.43m Current 13 number of deaths per annum 565 (see note 1) Annual funding per death $1,238 $2,621 $15,357 $1,090 $86 Demographic analysis System analysis Stories Local review for feasibility study, possibly for future Possibly, but funded by DHBs X X X X (funded by DHBs) (funded by DHBs) Regional panels X X X X Note 1: Number of suicides in 2013/14. What this table tells us is that each of the committees legitimately does things differently because of the nature of their respective areas however, the funding recommended for an ongoing suicide mortality review function is not out of line with that of other committees. 13 These number may change over time so this is a point in time analysis 25