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Introduction: Dementia is a leading cause of death and disability globally. Estimating total societal costs demonstrates the wide impact of dementia and its main direct and indirect economic components.Methods: We constructed a global cost model for dementia, presenting costs as cumulated global and regional costs.Results: In 2019, the annual global societal costs of dementia were estimated at US $1313.4 billion for 55.2 million people with dementia, corresponding to US $23,796 per person with dementia. Of the total, US $213.2 billion (16%) were direct medical costs, US $448.7 billion (34%) direct social sector costs (including long-term care), and US $651.4 billion (50%) costs of informal care.Discussion: The huge costs of dementia worldwide place enormous strains on care systems and families alike. Although most people with dementia live in low- and middle-income countries, highest total and per-person costs are seen in high-income countries.

Objectives: The STrAtegies for RelaTives (START) intervention is effective and cost-effective in supporting family carers of people with dementia. It is currently not available to all eligible carers in England. What would be the impacts on service costs and carer health-related quality of life if START was provided to all eligible carers in England, currently and in future? Methods: Effectiveness and cost-effectiveness data from a previously conducted randomised controlled trial were combined with current and future projections of numbers of people with newly diagnosed dementia to estimate overall and component costs and health-related quality of life outcomes between 2015 (base year for projections) and 2040. Results: Scaling-up START requires investments increasing annually but would lead to significant savings in health and social care costs. Family carers of people with dementia would experience improvements in mental health and quality of life, with clinical effects lasting at least 6 years. Scaling up the START intervention to eligible carers was estimated to cost £9.4 million in 2020, but these costs would lead to annual savings of £68 million, and total annual quality-adjusted life year (QALY) gains of 1,247. Although the costs of START would increase to £19.8 million in 2040, savings would rise to £142.7 million and QALYs gained to 1,883. Conclusions: Scaling-up START for family carers of people with dementia in England would improve the lives of family carers and reduce public sector costs. Family carers play a vital part in dementia care; evidence-based interventions that help them to maintain this role, such as START, should be available across the country.

Introduction: Dementia is a leading cause of death and disability globally. Estimating total societal costs demonstrates the wide impact of dementia and its main direct and indirect economic components. Methods: We constructed a global cost model for dementia, presenting costs as cumulated global and regional costs. Results: In 2019, the annual global societal costs of dementia were estimated at US $1313.4 billion for 55.2 million people with dementia, corresponding to US $23,796 per person with dementia. Of the total, US $213.2 billion (16%) were direct medical costs, US $448.7 billion (34%) direct social sector costs (including long-term care), and US $651.4 billion (50%) costs of informal care. Discussion: The huge costs of dementia worldwide place enormous strains on care systems and families alike. Although most people with dementia live in low- and middle-income countries, highest total and per-person costs are seen in high-income countries. Highlights: Global economic costs of dementia were estimated to reach US $1313.4 in 2019. Sixty-one percent of people with dementia live in low-and middle-income countries, whereas 74% of the costs occur in high-income countries. The impact of informal care accounts for about 50% of the global costs. The development of a long-term care infrastructure is a great challenge for low-and middle-income countries. There is a great need for more cost studies, particularly in low- and middle-income countries. Discussions of a framework for global cost comparisons are needed.

Background Black, Asian and minority ethnicity groups may experience better health outcomes when living in areas of high own-group ethnic density-the so-called 'ethnic density' hypothesis. We tested this hypothesis for the treatment outcome of compulsory admission. Methods Data from the 2010-2011 Mental Health Minimum Dataset (N = 1 053 617) was linked to the 2011 Census and 2010 Index of Multiple Deprivation. Own-group ethnic density was calculated by dividing the number of residents per ethnic group for each lower layer super output area (LSOA) in the Census by the LSOA total population. Multilevel modelling estimated the effect of own-group ethnic density on the risk of compulsory admission by ethnic group (White British, White other, Black, Asian and mixed), accounting for patient characteristics (age and gender), area-level deprivation and population density. Results Asian and White British patients experienced a reduced risk of compulsory admission when living in the areas of high own-group ethnic density [odds ratios (OR) 0.97, 95% credible interval (CI) 0.95-0.99 and 0.94, 95% CI 0.93-0.95, respectively], whereas White minority patients were at increased risk when living in neighbourhoods of higher own-group ethnic concentration (OR 1.18, 95% CI 1.11-1.26). Higher levels of own-group ethnic density were associated with an increased risk of compulsory admission for mixed-ethnicity patients, but only when deprivation and population density were excluded from the model. Neighbourhood-level concentration of own-group ethnicity for Black patients did not influence the risk of compulsory admission. Conclusions We found only minimal support for the ethnic density hypothesis for the treatment outcome of compulsory admission to under the Mental Health Act.

While debate on how best to pay for social care in England continues, information about public attitudes on this issue is limited. We asked representative samples of the public whether care costs for older people should be met by the state, met by the service user or shared between state and user. We used an online survey of people aged 18-75 (n = 3,000) and interview survey of people aged 65 and over (n = 466). Respondents were given four vignettes (two home care, two residential care) and asked who should pay at different levels of user resources; and how much users should contribute when costs were shared. Fewer than one-fifth of the online sample and one-quarter of the interview sample considered that the state should meet the full costs whatever users' resources; considerably lower proportions believed that users should meet the full costs in all cases. Two-thirds of the online sample and half the interview sample thought costs should be shared. The proportion of costs that users should contribute was relatively low (20-50 per cent, varying by user resources). The study illustrates that public views elicited through vignettes can provide evidence to inform policy on social care funding.

Objectives: Cognitive stimulation therapy (CST) is one of the few non-pharmacological interventions for people living with dementia shown to be effective and cost-effective. What are the current and future cost and health-related quality of life implications of scaling-up CST to eligible new cases of dementia in England? Methods/design: Data from trials were combined with microsimulation and macrosimulation modelling to project future prevalence, needs and costs. Health and social costs, unpaid care costs and quality-adjusted life years (QALYs) were compared with and without scaling-up of CST and follow-on maintenance CST (MCST). Results: Scaling-up group CST requires year-on-year increases in expenditure (mainly on staff), but these would be partially offset by reductions in health and care costs. Unpaid care costs would increase. Scaling-up MCST would also require additional expenditure, but without generating savings elsewhere. There would be improvements in general cognitive functioning and health-related quality of life, summarised in terms of QALY gains. Cost per QALY for CST alone would increase from £12,596 in 2015 to £19,573 by 2040, which is below the threshold for cost-effectiveness used by the National Institute for Health and Care Excellence (NICE). Cost per QALY for CST and MCST combined would grow from £19,883 in 2015 to £30,906 by 2040, making it less likely to be recommended by NICE on cost-effectiveness grounds. Conclusions: Scaling-up CST England for people with incident dementia can improve lives in an affordable, cost-effective manner. Adding MCST also improves health-related quality of life, but the economic evidence is less compelling.

There is ongoing debate about how the funding system for social care of older people in England should best be reformed. We investigated how public attitudes to individual and state responsibility for paying for social care in later life vary with demographic and socio-economic characteristics. Four vignettes of individuals in need of home care or residential care with varying levels of savings, income and housing wealth were presented to a sample of people aged 18–75 years (n = 3000) in December 2018. Respondents were asked if care costs should be paid by the user, the state or shared. They were also asked about the best way to pay for social care in old age. Latent class analysis was used to identify sub-groups with similar preferences for paying for care, and to explore their socio-demographic characteristics. We identified five classes. The majority (Class 1, 58%) preferred that the state and the user should share social care costs. Class 2 (18%) thought that the state should pay all costs regardless of users' savings, income or housing wealth. Class 3 (15%) preferred users to pay all costs at all levels of savings, income and housing wealth, with the exception of those unable to afford the costs. Classes 4 and 5 (5% each) were characterised by different patterns of ‘don't know’ answers. Socio-economic status was higher among those proposing higher user contributions (Class 3) and lower among those with several ‘don't’ know’ responses (Classes 4 and 5). Concerns about care costs in old age were high among those proposing that the state pays all costs (Class 2) and those preferring that users pay all costs (Class 3). This study shows that public views on social care funding vary with respondents' characteristics and that proposals to reform the system need to be carefully calibrated.

Challenges are often encountered in recruiting participants into adult social care research studies, while strategies to overcome them are not widely understood or shared. This Methods Review aimed to describe the challenges in recruiting organisations and individuals for adult social care research and identify possible strategies to address them. In semi-structured interviews, 17 senior researchers in the social care field were asked about their experiences of recruitment of research participants. One of the main barriers to recruitment was variation among provider organisations, so recruitment strategies needed to be adjusted for different organisations, many of which lacked capacity for research participation. The rapidly changing nature of adult social care organisation and delivery in England also means that recruitment strategies often need to be adapted while research is in progress. Building partnerships between researchers and providers and offering financial and other incentives were suggested as mitigating strategies. In recruiting individuals, a lack of understanding of research benefit and organisations’ gatekeeping arrangements were common difficulties. Interviewees suggested: raising public awareness of adult social care research; building relationships with user/carer groups; using a variety of recruitment strategies and offering a range of participation routes. Researchers and funding bodies should allow sufficient time and resources to recruit representative samples. Researchers should share recruitment knowledge. A limitation in this review is that the individuals who participated in the review may not be representative of all adult social care researchers. This review highlights opportunities for developing recruitment in adult social care research, such as improving recruitment and participation methods; investing in research support and research capacity and increasing public engagement with adult social care research.

Objectives: To explore whether the Screen and Treat Programme to support United Kingdom citizens potentially affected by terrorist attacks in Tunisia (2015), Paris (2015) and Brussels (2016) was effective in identifying and referring people to mental health services, to examine the programme’s acceptability to users and to understand how agencies involved worked together. Methods: Individuals offered screening by the programme (n = 529) were invited to participate in the study and were sent a questionnaire. Follow-up interviews were conducted with questionnaire respondents who consented and with employees of agencies involved in the programme’s planning and delivery. Seventy-seven people affected by the attacks completed questionnaires, 35 of those were also interviewed, and 1 further person only participated in an interview. Eleven people from agencies organizing and delivering the programme and five clinician-managers were also interviewed. Results: Most service users said the attacks had a major impact on their lives. Many reported anxiety, depression, difficulty going out or travelling, sleep problems, panic attacks, flashbacks and hyper-vigilance. A third had reduced their working hours and a similar proportion had taken sick leave. Two-thirds sought help from their General Practitioner (GP) before being contacted by the programme, but almost all thought their GP had not been helpful in dealing with post-traumatic stress disorder (PTSD) or referring to appropriate care. Several people were prescribed psychotropic medication; only a few were referred to mental health professionals. Many participants used help offered by organizations external to National Health Service, with mixed experiences. Waiting times for treatment varied from no delay to a few months. Most interviewees thought the programme should have started sooner and provided more information about sources of support. Most users found treatment received via the programme helpful. Professionals involve

Background: The increasing rate of compulsory admission to psychiatric in-patient beds in England is concerning. Studying variation between places and services could be key to identifying targets for interventions to reverse this. We modelled spatial variation in compulsory admissions in England using national patient-level data, and quantified the extent to which patient, local area and service setting characteristics accounted for this variation. Methods: Cross-sectional, multilevel analysis of the 2010/11 Mental Health Minimum Data Set (MHMDS). Data were available for 1,238,188 patients, covering 64 NHS Provider Trusts (93%) and 31,865 Census Lower Super Output Areas (LSOAs) (98%). Primary outcome was compulsory admission to a mental illness bed, compared with people admitted voluntarily or receiving only community-based care. Outcomes: 7∙5% and 5∙6% of the variance in compulsory admission occurred at LSOA- and Provider Trustlevels, respectively, after adjusting for patient characteristics. Black patients were almost three times more likely to be admitted compulsorily than White patients (OR 2∙94, 95% CI 2∙90-2∙98). Compulsory admission was greater in more deprived areas (OR 1∙22, 95% CI 1∙18-1∙27) and in areas with more non-white residents (OR 1∙51, 95% CI 1∙43-1∙59), after adjusting for confounders. Interpretation: Compulsory psychiatric in-patient admission varies significantly between local areas and services, independent of patient, area and service characteristics. Compulsory admission rates appear to reflect local factors, especially socio-economic and ethnic population composition. Understanding how these condition access to and use of mental health care is likely to be important for developing interventions to reduce compulsion.

Purpose:- We evaluated the effectiveness and cost-effectiveness of a peer-led self-management intervention for people with severe mental disorders. Design/methodology/approach:- This is a one-arm longitudinal study without control group. 262 adults with (self-reported) severe mental disorders, who have used secondary mental health services and were living in the community, were evaluated at three time-points (baseline, 6 months, 12 months). Socio-demographic data were collected at baseline. Wellbeing (Warwick-Edinburgh Mental Wellbeing Scale), functional living skills (Health Promoting Lifestyle Profile II) and service use (Client Service Receipt Inventory) data were assessed over time. Findings:- Self-management for people with severe mental disorders improved well-being and health-promoting lifestyles. After an increase in the short term, costs appeared to decrease in the longer term, although this change was not statistically significant. Due to the lack of a control group, we are unable to attribute those changes to the intervention only. Nevertheless, the self-management intervention appears to warrant further attention on both wellbeing and economic grounds. Originality/value:- Self-management may facilitate recovery, helping to support people with severe mental disorders at no additional cost. Given recent emphasis on recovery, peer workers and self-management, this peer-led self-management approach for people with severe mental disorders appears to have potential.