Child Death Reviews: Scottish Government Steering Group Report

Chapter 5 Resources And Costings

Introduction

5.1 The Child Death Review Panel Steering group considered that it did not possess the expertise to address resources adequately. The group was content for the Chair and Scottish Government support staff to meet with individuals who would be able to assist. The group however was aware of the costing of the University of Dundee pilot child death review project of 2014. That report contained certain details regarding the pilot costs. The Chair, support staff and others, have taken advice and input from the Scottish Government Health Finance, eHealth and Analytics Division in connection with the details provided here. Additionally, the COSLA input to the group assisted in considering this matter.

5.2 As mentioned above, the University of Dundee Fatality Investigation and Review Studies Team ran a child death reviews pilot (referred to as Ruby Reviews) in early 2014. In An Account of the Tayside Ruby Reviews, March-April 2014, it stated that the Child Death Overview Panel (CDOP) system in England appeared to be demanding of time and resources (RCPCH, 2008) (Sidebotham et al., 2011). The CDOP system had required government seed funding and 3-year operating costs of £55.2m over its first 3 years (CDFS, 2008). A considerable proportion of these costs tended to derive from aspects of the English statutory and child protection frameworks not present in Scots law or operating arrangements. The size of CDOPs' budgets^[13] vary widely with a median value of just under £52,000 per annum but ranging from just less than £10,000 to £200,000. Only 60% of CDOPs had a designated budget.

5.3 The costings associated with the University of Dundee Ruby Review process were reviewed but they were not considered to be relevant, given the different approach developed by the Steering Group.

Potential Costings

5.4 These costings are an overview for the Child Death Review Panel system outlined in this report. The majority of the costing methodology is based on previous modelling work undertaken for the Certification of Death (Scotland) Act 2011 and provides indicative figures. Modelling centres around the composition of staff involved with managing and undertaking the review Panels. As staff costs are the biggest cost item, the composition of Panel membership and frequency of Panels significantly affects overall costs.

5.5 The proposed model for Child Death Reviews (CDRs) at present comprises of the following:

• The National Resource Centre - ideally hosted within existing public sector (NHS) infrastructure though preserving its independent position; with 3 regional offices in the North, West and East of the country - also ideally hosted within existing public sector (NHS) infrastructure though preserving its independent position.
• Total staff envisaged amount to 4 coordinators and 4 administrators in full time positions, across these 4 centres, plus one data analyst.
• Chairs of Review Panels ought to be remunerated (at senior level, paid pro rata). This resource may be transferred from other NHS resources.
• It is proposed that there would be broadly one Panel each month, in each Regional Office, and Panels would comprise of circa 10 people - compensated for travel and expenses but without additional compensation.
• The cost arising from time dedicated to Panels by members other than the Chairs would constitute an opportunity cost to their regular employer and this was discussed at paragraph 2.9. Currently, there is no provision made for compensating regular employers for this cost and the potential for compensation would need to be discussed further, but could be similar to the costs for Child Protection and Care proceedings, and Adoption and Fostering Panels.

5.6 A possible set of minimum and maximum pay ranges based on NHS Agenda for Change (AfC) pay scales, is set out below.

Staff grade assumptions	Min	Equivalent to approx.	Max	Equivalent to approx.
Coordinator	AfC band 8c, incl. on-cost full time	£77,100	Med Consultant, incl. on-cost, full time	£138,600
Admin	AfC Band 3, incl. on-cost, full time	£22,800	AfC Band 5, incl. on-cost, full time	£29,200
Local coordinators	AfC Band 5, incl. on-cost, full time	£29,200	AfC B7, incl. on-cost, full time	£45,200
Local assistants	AfC Band 3, incl. on-cost, full time	£22,800	AfC Band 5, incl. on-cost, full time	£29,200
Local reviewers	AfC band 8c, incl. on-cost, pro rata	£350	Med Consultant, incl. on-cost, pro rata	£630
Data analyst	AfC band 6, incl. on cost, full time	£37,500	AfC band 8b, incl. on cost, full time	£64,200

5.7 The table that follows provides an overview of potential cost implications. The column labelled 'Year 1' shows the costs in the first year and gives an early indication of how staff cost will play a proportionately greater role than implementation costs as the number of staff increases. The column labelled 'PC over 30 years' provides Present Costs (PC) of these cost implications over a time period of 30 years.

5.8 Ideally in a full cost benefit analysis (CBA), PC would be set against the Present Value (PV) i.e. the sum of monetised benefits, aggregated over the same time period, in order to arrive at a Net Present Value (NPV). However, as is discussed in the section on benefits below, it is very difficult in this case to estimate a representative value for benefits and only indicative values are presented.

5.9 There are a number of items in the costing model which have been based on the initial analysis for the Certification of Death (Scotland) Act 2011, such as changes to National Records of Scotland (NRS) databases and the development of a training module, and which have been updated, where possible, to the current model. They are provided as indicative costs.

Total Cost in year 1 and after 30 years	Current model costings
	Year 1	PC over 30 years
Recurring costs
Total training and replacement	£0	£0
Total Salary cost	£480,189	£9,140,768
Total Running costs	£41,178	£783,854
Total recurring	£521,367	£9,924,621
Start-up costs
Total Initial Accommodation Costs	£17,550	£17,550
Non-IT programme management	£330,000*	£330,000
IT Changes and Support	£357,000*	£357,000
Advertising/information cost	£10,000	£10,000
Development of e-learning Module	£57,500	£57,500
Total start-up	£772,050	£772,050
Total	£1,293,417	£10,696,671

* these are indicative figures based on the medical reviews of death certificates and may be less than stated

5.10 Regarding running costs - all costs are also based on previous modelling undertaken for Certification of Death (Scotland) Act 2011 and are for indicative purposes. Travel claims are based on a transport model; including relevant deaths per annum; Scottish Government mileage compensation at £0.40 per mile. There is an assumption that each Panel will incur travel expenses for each Panel member. Annual IT, telephony cost is as advised by Scottish Government IT in 2009/10.

5.11 In respect of start-up costs - item costs are as advised by Scottish Government Buildings and Maintenance, as at June 2015.

5.12 IT and support costs are also based on previous modelling undertaken for Certification of Death (Scotland) Act 2011 with system change to include change to NRS databases and forms.

5.13 The estimated cost of IT changes and support in the first year are substantial. These are driven by the complexity and scale of the system in addition to the number of different stakeholders and potential users that will need to access and use the new system. The cost estimate includes Project Management, Analysis, Developer, Testing, Hosting and Security costs which all need to be factored into developing and implementing any new system.

5.14 Please note that no estimate has been given for ongoing/longer term running costs although this can usually be estimated (as a starting point) as 10% of the implementation costs.

5.15 Other costs have been addressed as:

• Job advertising cost - these are non-linear with the number of posts included in model and can range from £2,000 -20,000 per post;
• Advertising/information cost - estimated at £10,000;
• Development of e-learning module - estimated at £57,000 - £65,000;
• Training cost of involved staff - considered to be included in on-going NHS Education for Scotland (NES) cost.

Benefits

5.16 When considering the estimated costs of Child Death Review implementation it is important to also consider potential benefits from having CDRs in place. The main anticipated benefit of CDRs would be a reduction in the future number of preventable child deaths. Child Death Reviews would influence subsequent practice and policy, with the lessons learned from the reviews.

5.17 A Lancet^[14] review on child death in high-income countries noted that "locally, a systematic approach to inquiry can lead to better understanding of how and why a child died […] a diagnosis is invaluable to a bereaved parent and might allow them to undergo counselling for future pregnancies." Further that "Child Death Reviews greatly increase understanding of how and why children die, provide a framework for detailed investigation of unexpected deaths, contribute to better accuracy in coding cause of death, provide a framework for the formal assessment of modifiable factors."

5.18 It is beneficial to give estimates of the value of prevented child deaths, to put the CDR implementation costs into perspective. There are a number of possible approaches to this, including the Value of a Prevented Fatality (VPF) approach and measuring Quality Adjusted Life Years (QALYs).

5.19 Value of a Prevented Fatality (VPF) is the approach taken by the UK Department for Transport (DfT) to monetise prevented fatalities from road and rail traffic, and is based on estimated willingness to pay, encompassing all aspects of the valuation of casualties, including the human costs, which reflect pain, grief, suffering; the direct economic costs of lost output and the medical costs associated with road accident injuries. The current estimated cost per casualty (fatality) from 2013 is £1.743m^[15].

5.20 An alternative calculation would be to assess the value of the years of life lost given average healthy life expectancy and life expectancy, using the Quality Adjusted Life Year (QALY) approach. A rough calculation using a cost per year of £60,000, healthy life expectancy of 60.8 and life expectancy of 77.1 years and taking the average number of years lost from deaths of those aged between 0-17, would give a value of life lost of about £3.681m.

5.21 There are various ranges given in the literature for the proportion of child deaths with avoidable (modifiable) factors or that were entirely preventable. Below are a number of estimates for this range:

• Lancet^[16]: A 2006 confidential enquiry into deaths of children […] identified avoidable factors in 31 (26%) deaths of 119 cases reviewed with potentially avoidable factors noted in a further 51 (43%) cases.
• Lancet^[17]: In 2009, 66,000 children younger than 5 years died in high-income countries […] up to a quarter of these deaths could be considered preventable.
• Lancet^[18]: In England, of 4061 child death reviews that were completed in 2010-11, investigators noted that 800 (20%) had modifiable factors.
• DoE^[19]: 22% of child death reviews (823 reviews) identified as having modifiable factors, a slight increase from 20% in the year ending 31 March 2011.

5.22 A Scottish Government study into The Financial Impact of Early Years Interventions in Scotland^[20] found that short term savings from investing in early years/early interventions from pre-birth to aged five suggest that there are potential net savings of up to £37.4k per annum per child in severe cases and of approximately £5.1k per annum for a child with moderate difficulties in the first 5 years of life. There are potential medium term net savings to the public sector, that can be realised 10 years after the early years period. In the longer term, a failure to effectively intervene to address the complex needs of an individual in early childhood can result in a nine fold increase in direct public costs, when compared with an individual who accesses only universal services. Interventions based on CDR learning could potentially contribute to realising these savings.

5.23 The above estimates show that, even if Child Death Reviews prevent one death a year, they may represent good value for money. If the proportions above were applicable and between 22% and 26% of deaths could be prevented, in Scotland with an estimated 322 deaths in 2013 this would equate to between 71 and 84 potentially avoidable deaths.

5.24 It is expected that Panel members will be involved from a wide range of backgrounds, and some may require to be freed from their day job for the days on which Panels take place. A full economic analysis would need to take into consideration the opportunity cost of the productive output forgone by these staff. In April 2013 the gross median weekly earning for full-time employees in Scotland was £508.30, equating to a median daily earning of about £102. Applying this to 8 Panel members not fully employed on CDRs, across 36 Panels in one year would give an opportunity cost of staff time of about £29,300.

5.25 There will, of course, also be wider costs and benefits such as the additional service need (e.g. emergency and other health services) by a child whose death was prevented. These are however extremely difficult to quantify and are not addressed at this stage.

5.26 Taking into account the points above, a national child death review process represents good value for money.