Introduction and context
IRIS (Identification and Referral to Improve Safety) is a general practice based domestic abuse training, support and referral programme for female patients aged 16 and above experiencing abuse from a current partner, ex-partner or family member. The IRIS model is an evidence based model that was tested in a randomised, controlled trial. It is centred on partnership work, with primary care and specialist third sector agencies coming together to deliver services and promote this work.
It is commissioned across areas of England, Wales, the Channel Islands and Northern Ireland. IRISi is a not-for-profit organisation that provides areas with the IRIS model, training package, updates to the training, and support.
- The estimated cost of domestic violence and abuse, including physical and mental health costs, is £ 66 billion per year (Home Office, 2019);
- Most recent research shows that the IRIS programme is sustainable and that practices with IRIS are 30 times more likely to make a referral to specialist support for their patients than those without IRIS (Panovska-Griffiths et al, 2020);
- The cost effectiveness of the model was assessed in this study and it found that the IRIS programme saved £14 for each woman aged 16 or older registered in the IRIS trained general practice (Barbosa et al, 2018); the same study shows an increase in quality of life for each woman affected by domestic abuse;
- The IRIS programme is therefore cost-effective and cost-saving from a societal perspective in the UK and cost-effective from a health service perspective (NHS perspective) (Barbosa et al, 2018).
From 2016 – 2019, five interventions were evaluated by a health economist at University College London and only IRIS was found to be both cheaper and more effective than usual care and to improve the overall quality of life. In 2019 to demonstrate the health benefits of IRIS in financial terms, an IRIS cost-effectiveness analysis tool was created to help local sites with their case for recommissioning and programme continuity. The tool looks at how the costs and quality of life improvements are related. Results can be presented from two cost perspectives: the NHS perspective and the societal perspective.
The NHS perspective takes into account change in healthcare system (NHS) costs as a result of the IRIS programme – for example: any change in how often service users visit their GP or attend A&E, or how many prescriptions they require.
The societal perspective takes a wider view considering how the IRIS programme affects costs to the healthcare system, the legal system (civil and criminal), costs of housing, social care, personal costs, costs of specialised services and loss of productivity due days lost at work. This tool was used in the recent study of six IRIS sites running in north east London for over two years. They found from an NHS perspective, IRIS was cost saving and cost effective in 4 out of 6 sites.
Net monetary benefit is a concept used in cost-benefit analysis. Essentially it monetizes QALYs [quality adjusted life years] i.e. the monetary benefit of an additional healthy year of life, using the NICE threshold. NICE considers interventions costing the NHS less than £20,000 per QALY gained as cost effective, so both cost and benefits have a monetary value. If the net monetary value is positive, it means the benefits outweigh the costs, so the intervention is good value for money. If the net monetary value is negative, costs outweigh the benefits, so the intervention is not good value for money and should not be further implemented.
This means that, based on NICE guidance, IRIS should be rolled out to all primary care staff.
An example to compare with IRIS is from the NICE recommendation for flu vaccinations (August 2018). The net monetary benefit “for increasing vaccination by 5% for adults in clinical risk groups is £4.00 per targeted person, for pregnant women is £4.50 per targeted person, and for children in clinical risks groups is £2.40 per targeted person” (pg. 51 from the guidance) from an NHS perspective. Therefore IRIS is at least 4.8 times better value for money than the annual flu jab.
HIV screening and testing is another example of something clinicians do at primary care settings, but there is no evidence to show that it is effective or cost effective. Whereas the IRIS programme is not only more effective from an NHS perspective, but also cheaper than not implementing IRIS to the public pocket, if other services such as justice, housing and social care are considered.
From a health care perspective, the cost of DVA usually falls in acute and mental health settings – so when talking about saving the NHS money, it is about savings in acute/A&E and mental health.
Where primary care settings are not seeing monetary benefits, there are 3 points to consider:
1. Funds for IRIS are coming out of the same pot of money that funds the NHS;
2. A small investment in primary care will result in a reduction of use in acute and mental health care, particularly A&E and secondary mental health; and
3. The NHS is funded by taxation i.e. it is public money. Whilst some primary care commissioning bodies may not want to pay for cost saving that will take place in acute health settings, mental health services and wider public services, the funds come from the same source – and putting public money into an intervention that works is a better use of public money than putting it into what does not.
By having an intervention at primary care level we can stop the chain of costs of DVA – not just in acute health care settings [A&E, hospital admission, ambulance services] and in mental health services, but also societal costs e.g. police time, social services, protection orders and the considerable costs of homicide investigations. From a public health perspective there are substantial savings related to preventing or identifying cases early, that fall outside of the NHS. It is therefore a good use of public money because investing at primary care level is also saving society money over time. Additionally, NICE guidance on tackling DVA clearly emphasises the need for a cross-sector approach, and not only a primary care view.
IRIS is cost-effective and saves money for society and the NHS as a whole. As such, it should be considered an effective health intervention that is worth investing in at the primary care level.