The economics of waiting time in mental health

This thesis empirically explores aspects of the economics of waiting times in the mental health context. Waiting times are of persistent policy concern as they risk poorer treatment outcomes and threaten the desired principles of timely and equitable access. The empirical applications focus on first-episode psychosis patients and early intervention in psychosis (EIP) services in the English National Health Service where policymakers recently placed new emphasis on reducing waiting times. Analyses are based on the nationally representative Mental Health and Learning Disabilities Dataset 2011 to 2015. We develop procedures to measure various dimensions of waiting times at the patient level – such as duration of untreated psychosis, inpatient waiting time, and referral-to-treatment waiting time. We apply generalised linear modelling to accommodate the heavy-tailed distribution of waiting time and use duration analysis to overcome the challenge of right-censoring. We further make use of difference-in-difference and matching techniques to evaluate the impact of the newly introduced EIP waiting time target. We found significant socioeconomic inequalities in duration of untreated psychosis. Also, hallucinations and delusions, as well as previous mental health service use, were influencing factors for patients to access services. Waiting for a care coordinator was associated with a clinically significant deterioration in patient outcomes independent of treatment intensity. The implementation of the EIP waiting time target led to an increased probability of waiting below target whereas waiting times along the distribution did not improve. However, waiting times improved already in anticipation of the policy change with little evidence of unintended effects such as re-prioritisation of patients or gaming behaviour of providers. Results of this thesis can help to inform the development of strategies to reduce inequalities in access to EIP services, and the prospective implementation of waiting time targets in other mental health service areas as well as its adaptation to other countries.