Postnatal care: routine
postnatal care of women
and their babies
Costing report
Implementing NICE guidance in
England
NICE clinical guideline no. 37
Issue date: July 2006
This costing report accompanies the clinical guideline: ‘Postnatal care: routine postnatal care
of women and their babies’ (available online at www.nice.org.uk/CG037).
Issue date: July 2006
This guidance is written in the following context
This report represents the view of the Institute, which was arrived at after careful
consideration of the available data and through consulting healthcare professionals. It should
be read in conjunction with the NICE guideline. The report and templates are implementation
tools and focus on those areas that were considered to have significant impact on resource
utilisation.
The cost and activity assessments in the reports are estimates based on a number of
assumptions. They provide an indication of the likely impact of the principal recommendations
and are not absolute figures. Assumptions used in the report are based on assessment of the
national average. Local practice may be different from this, and the template can be used to
estimate local impact.
National Institute for Health and Clinical Excellence
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71 High Holborn
London WC1V 6NA
www.nice.org.uk
© Copyright National Institute for Health and Clinical Excellence, July 2006. All rights
reserved. This material may be freely reproduced for educational and not-for-profit purposes.
No reproduction by or for commercial organisations, or for commercial purposes, is allowed
without the express written permission of the Institute.
National costing report: Routine postnatal care of women and their babies
(July 2006)
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Contents
Executive summary ....................................................................................... 4
1
2
Supporting implementation
4
Significant resource-impact recommendations
4
Total cost impact
5
Local costing template
6
Introduction ............................................................................................. 8
1.1 Supporting implementation
8
1.2 What is the aim of this report?
9
Costing methodology ............................................................................. 9
2.1 Process
3
4
5
9
2.2 Scope of the cost-impact analysis
10
2.3 Basis of unit costs
12
Cost of significant resource-impact recommendations .................... 12
3.1 A structured programme that encourages breastfeeding
12
3.2 Savings from improvements in breastfeeding rates
23
3.3 ‘Birth to five’
26
Sensitivity analysis ............................................................................... 28
4.1 Methodology
28
4.2 Impact of sensitivity analysis on costs
28
Conclusion ............................................................................................ 29
5.1 Total national cost for England
29
5.2 Next steps
31
Appendix A: Approach to costing guidelines ........................................... 33
Appendix B: Results of sensitivity analysis .............................................. 34
Appendix C: References ............................................................................. 36
National costing report: Routine postnatal care of women and their babies
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Executive summary
This costing report looks at the resource impact of implementing the NICE
guideline ‘Postnatal care: routine postnatal care of women and their babies’ in
England.
The costing method adopted is outlined in appendix A. The costing model
created using this method uses the most accurate data available, was
produced in conjunction with key clinicians, and was reviewed by clinical and
financial experts.
Supporting implementation
The NICE clinical guideline on routine postnatal care is supported by the
following implementation tools available on our website
(www.nice.org.uk/CG037):

costing tools
− a national costing report; this document
− a local costing template; a simple spreadsheet that can used to
estimate the local cost of implementation

a slide set; key messages for local discussion

implementation advice; practical suggestions on how to address potential
barriers to implementation.

audit criteria (see appendix d of the NICE clinical guideline)
A practical guide to implementation, ‘Putting NICE guidance into practice: a
guide to implementation for organisations’, is also available to download from
the NICE website. It includes advice on establishing organisational level
implementation processes as well as detailed steps for people working to
implement different types of guidance on the ground.
Significant resource-impact recommendations
Because of the breadth and complexity of the guideline, this report focuses on
recommendations that are considered to have the greatest resource impact
National costing report: Routine postnatal care of women and their babies
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and therefore require the most additional resources to implement or generate
savings. They are:

the implementation of an externally evaluated structured programme
that encourages breastfeeding,

the savings arising from an improvement in breast feeding.
This report has examined the cost of implementing the UNICEF baby friendly
initiation (BFI) which is recommended as a minimum standard by the
guideline. UNICEF BFI has been shown to improve the rates of breast feeding
through comprehensive training and coordination of breast feeding activities in
acute and community settings. Potential savings are linked to the reduction in
the incidence of certain childhood disease because of the protective effects of
breastfeeding. The conditions examined in the report include gastroenteritis,
otitis media and asthma. It should be noted that other positive effects such as
reduced admissions to emergency services and reductions in breast cancer
have been reported in the literature.
The report has also considered the impact of offering ‘Birth to five’ to all
postpartum women. Although the resource impact of this recommendation is
smaller than would normally be considered significant, ‘Birth to five’ is referred
to throughout the NICE guideline as the key source of information for mothers.
Consequently access to this document for all mothers is considered key to the
implementation of the guideline.
Total cost impact
The annual changes in revenue costs arising from full implementation of the
significant resource-impact recommendations until a steady state is reached
have been calculated. The annual costs have been found to vary from an
initial cost of £6.8 million to a potential saving of £1.1 million, due to the effect
of increasing savings and reducing training costs over time. These costs are
summarised in the table below.
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Cost of a structured
programme that
encourages breastfeeding
Cost of changes to
provision of Birth to Five
Savings from
improvements in
breastfeeding rates
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
£000s
£000s
£000s
£000s
£000s
£000s
£000s
8,575
8,176
7,227
4,362
4,781
5,008
4,362
214
211
211
211
211
214
214
-1,956
-2,948
-3,960
-4,972
-5,548
-5,596
-5,596
6,834
5,439
3,477
-400
-556
-374
-1,021
Net resource impact,
£000s
The net cost impact of the recommendations of significant resource impact is
shown in a graphical format below.
Cost impact of recommendations of significant resource
impact from the NICE post natal care guideline
Net savings across all recommendations
Net costs across all recommendations
10,000
8,000
6,000
2,000
2012/13
£000s
2011/12
£000s
2010/11
£000s
2009/10
£000s
2008/09
£000s
-2,000
2007/08
£000s
-
2006/07
£000s
Cost, £000s
4,000
-4,000
-6,000
-8,000
Time, financial years
Local costing template
The local costing template produced to support this guideline enables
organisations such as primary care trusts (PCTs) to estimate the impact
locally and replace variables with ones that depict the current local position.
Using this template the example cost to implement the guidance has been
National costing report: Routine postnatal care of women and their babies
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conducted for an ’average‘ maternity unit with 220 staff members and an
average number of births per year of 2,534. Three calculations have been
completed for this average unit based on one of the three different BFI
statuses: pre-certification; certified and accredited. Units at each of the three
statues will start from a different position and therefore the cost of
implementation will vary until a similar steady state is reached.
Currently pre-commitment
2006/ 07, 2007/ 08, 2008/ 09, 2009/ 10, 2010/ 11, 2011/ 12,
£s
£s
£s
£s
£s
£s
31,818
32,541
35,612
13,451
13,451
17,911
Cost of a structured
programme that
encourages
breastfeeding
Cost of changes to
provision of Birth to Five
Savings from
improvements in
breastfeeding rates
Total resource impact
-
897
897
4,687 -
9,374 -
28,028
24,063
Currently has certificate of commitment
Cost of a structured
33,158
26,974
programme that
encourages
breastfeeding
897
897
Cost of changes to
provision of Birth to Five
Savings from
improvements in
breastfeeding rates
Total resource impact
Currently accredited
Cost of a structured
programme that
encourages
breastfeeding
Cost of changes to
provision of Birth to Five
Savings from
improvements in
breastfeeding rates
Total resource impact
-
9,374 -
14,062 -
897
897
897
14,062 - 18,749 - 23,436 -
22,447 -
4,402 -
9,089 -
897
23,436
4,628
13,451
13,451
17,911
13,451
897
897
897
897
18,749 - 23,436 - 23,436 -
4,402 -
9,089 -
4,629 -
23,436
24,680
13,809 -
13,451
13,451
17,911
13,451
13,451
17,911
897
897
897
897
897
897
-
23,436 -
23,436 -
-
9,089 -
9,089 -
23,436 - 23,436 - 23,436 -
4,629 -
9,089 -
9,089 -
9,088
23,436
4,628
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1 Introduction
1.1 Supporting implementation
1.1.1
The NICE clinical guideline on routine postnatal care is supported
by the following implementation tools available on our website
(www.nice.org.uk/CG037):

costing tools
−
a national costing report; this document
−
a local costing template; a simple spreadsheet that can
used to estimate the local cost of implementation

a slide set; key messages for local discussion

implementation advice; practical suggestions on how to address
potential barriers to implementation.

audit criteria (see appendix d of the NICE clinical guideline)
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1.1.2
A practical guide to implementation, ‘How to put NICE guidance into
practice: a guide to implementation for organisations’, is also
available to download from the NICE website. It includes advice on
establishing organisational level implementation processes as well
as detailed steps for people working to implement different types of
guidance on the ground.
1.2 What is the aim of this report?
1.2.1
This report provides estimates of the national cost impact arising
from implementation of guidance on routine postnatal care in
England. These estimates are based on assumptions made about
current practice and predictions of how current practice might
change following implementation.
1.2.2
This report aims to help organisations in England plan for the
financial implications of implementing NICE guidance.
1.2.3
This report does not reproduce the NICE guideline on routine
postnatal care and should be read in conjunction with it (see
www.nice.org.uk/CG037).
2 Costing methodology
2.1 Process
2.1.1
We use a structured approach for costing clinical guidelines (see
appendix A).
2.1.2
Some information has been systematically collected that relates to
specific elements of postnatal care such as breastfeeding. The
available data is not sufficient for the purposes of predicting the cost
impact of this guideline and we had to make assumptions in the
costing model. We developed these assumptions and tested them
for reasonableness with members of the Guideline Development
Group (GDG) and key clinical practitioners in the NHS.
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2.2 Scope of the cost-impact analysis
2.2.1
Postnatal care is primarily about the provision of a supportive
environment in which a woman, her baby and the wider family can
begin their new life together. It is not the management of a condition
or an acute situation. The postnatal care guideline aims to identify
the essential ‘core care’ which every woman and her baby should
receive, as appropriate to their needs, during the first 6−8 weeks
after birth, based on the best evidence available.
2.2.2
It does not cover interventions that may be needed by a healthy
woman or her healthy baby beyond that associated with core
postnatal care. Nor does the guideline cover the management of
complications arising in the woman or her baby before, during or
after the birth, existing pregnancy and/or non-pregnancy-related
acute or chronic diseases or conditions, or any aspect of
antepartum or intrapartum care, including procedures immediately
following the birth. Therefore, these issues are also outside the
scope of this assessment of the implementation costs.
2.2.3
Because of the breadth and complexity of the guideline, we worked
with the GDG and other professionals to identify the
recommendations that would have the most significant resource
impact (see table 1). Costing work has focused on these
recommendations.
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Table 1 Recommendations with a significant resource impact
High-cost recommendations
Recommendation Key
number
priority?
1.3.3

A structure programme that encourages
breast feeding
All maternity care providers (whether working in
hospital or in primary care) should implement an
externally evaluated structured programme that
encourages breastfeeding, using the Baby
Friendly Initiative as a minimum standard.
Breastfeeding support should be made available
1.3.1
regardless of the location of care.
All healthcare providers should have a written
1.3.2
breastfeeding policy that is communicated to all
staff and parents. Each provider should identify a
lead healthcare professional responsible for
implementing this policy.
Birth to Five
The Department of Health booklet ‘Birth to five’,
1.2.2
which is a guide to parenthood and the first 5
years of a child's life, should be given to all
women within 3 days of birth (if it has not been
received antenatally).
2.2.4
Seven of the recommendations in the guideline have been identified
as key priorities for implementation and one of these is also among
the four recommendations considered to have significant resource
impact. Other key recommendations for implementation not
included in this cost assessment outlined information that should be
shared with mothers to be and proposals for documentation that
should accompany the mother.
2.2.5
We have limited the consideration of costs and savings to direct
costs to the NHS that will arise from implementation. We have not
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included consequences for the individual, the private sector or the
not-for-profit sector. Where applicable, any cost savings arising
from a change in practice have been offset against the cost of
implementing the change.
2.3 Basis of unit costs
2.3.1
The way the NHS is funded has changed following the introduction
of Payment by Results, based on a national tariff. The national tariff
will be applied to all activity for which Healthcare Resource Groups
(HRGs) or other appropriate case-mix measures are available.
However, none of the recommendations assessed in this report
involve interventions or healthcare activities that are included within
a national tariff.
2.3.2
The full guideline includes a health economic evaluation that has
assessed the cost impact of implementing the UNICEF Baby
Friendly Initiative (BFI). Whenever possible we have followed the
approach taken by this comprehensive evaluation and have
attempted to use similar assumptions in a manner that is consistent
with the evaluation.
2.3.3
When necessary we have calculated appropriate unit costs based
on a bottom-up cost assessment of the activity required to
implement the recommendations.
3 Cost of significant resource-impact
recommendations
3.1 A structured programme that encourages breastfeeding
Background
3.1.1
The guideline recommends that all maternity care providers
(whether working in hospital and or in primary care) should
implement an externally evaluated structured programme that
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encourages breastfeeding, using the BFI (www.babyfriendly.org.uk)
as a minimum standard (NICE 1.3.3). Breastfeeding support should
be made available regardless of the location of care (NICE 1.3.1).
3.1.2
All healthcare providers (hospitals and community) should have a
written breastfeeding policy that is communicated to all staff and
parents. Each provider should identify a lead healthcare
professional responsible for implementing this policy (NICE 1.3.2).
3.1.3
The guideline does not specify which externally evaluated
structured programme should be implemented, but does suggest
that the UNICEF BFI should be a minimum standard. We have
therefore based our assessment on the costs incurred
implementing the UNICEF BFI.
3.1.4
There are two main Baby Friendly awards: the certificate of
commitment and full baby friendly accreditation. The certificate of
commitment recognises that a trust is working to bring its practices
into line with the required BFI standards and that it is working
towards assessment and full accreditation. Full accreditation means
that a trust has fully implemented the BFI and has been
successfully assessed against standard criteria. For the purpose of
this costing exercise we will use the BFI award status to classify
maternity units and community trusts into three categories: precertification; certificate of commitment; and accredited.
3.1.5
On the basis of information from the BFI website (UNICEF UK
2006) the current status of all maternity units in England can be
classified in the following manner (see table 2, below).
Table 2 Number of units and current BFI status, England
Current BFI Award Status
Pre-certification
Certificate of Commitment
Accredited
Number of
maternity
units
124
94
21
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3.1.6
The cost incurred over time in order to implement BFI will vary
depending on a trust’s current BFI status. BFI has been found to
significantly increase the rate of breastfeeding. Several potential
savings have been identified based on the evidence that
breastfeeding promotes health benefits for both infant and mother
and that these health benefits lead to reduced healthcare costs.
The cost impact of implementing an externally evaluated structured
programme such as BFI should equal the cost incurred to ensure all
units are accredited less the potential savings from improvements in
breastfeeding rates.
Assumptions made
3.1.7
We have found that three main cost elements are incurred when
implementing BFI. These are:

UNICEF BFI fees for work planning and assessment

training costs, and

employment costs for a breastfeeding coordinator.
UNICEF BFI fees
3.1.8
UNICEF BFI fees are incurred as a trust progresses towards BFI
accreditation and undergoes re-assessment. Table 3 outlines the
fees that are required and indicates when the fees might be
incurred against a plausible implementation timeline. We have
assumed that it takes 3 years from a decision to implement BFI to
reach a situation where full assessment and accreditation is
possible.
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Table 3 UNICEF BFI fees incurred against an implementation timeline
Year on
BFI
Year 1
UNICEF
Description of activity
BFI fee, £
720 Initial BFI work plan
Year 2
Assumption for cost model
Pre certificate of commitment
trusts will start at this point
Trusts with a certificate of
commitment will start at this
point
0
Year 3
6,720 Initial assessment fee and follow-up
visit fee
Year 4
0
Accredited units will start at
this point
Year 5
0
Year 6
4,460 Re-assessment fee and follow-up
visit fee (required by 50% of units)
The costs incurred between year 4 to 6 will be repeated every 3 years
3.1.9
The table also indicates how far along the timeline we assume precertification, certified and accredited trusts will have progressed. So
pre-certification trusts will currently be at year 1 on the
implementation timeline and will incur all costs from year 1 onwards
as they progress towards accreditation. Trusts that currently have a
certificate of commitment will start at year 2 and trusts that are
accredited will start at year 4.
3.1.10
Table 4 gives the total UNICEF BFI fees for all trusts between
2006/07 and 2013/14 based on the current status of trusts and on
the implementation timeline outlined above.
Table 4 UNICEF BFI fees between 2005/07 and 2013/14 for all trusts in
England
Current BFI
Award Status
Accredited
Certificate of
Commitment
Pre-certification
Total
Number of
maternity
units
2006/
07
UNICEF BFI fees incurred over time, £000s
2007/ 2008/ 2009/ 2010/ 2011/ 2012/
08
09
10
11
12
13
2013/
14
21
94
0.0
0.0
0.0
631.7
93.7
0.0
0.0
0.0
0.0 419.2
93.7
0.0
0.0
0.0
0.0
419.2
124
239
89.3
89.3
0.0
631.7
833.3
926.9
0.0
0.0
0.0 419.2
553.0
646.7
0.0
0.0
0.0
419.2
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Training costs
3.1.11
BFI requires that all healthcare staff who provide primary care for
mothers and babies should be trained in the skills necessary to
implement the breastfeeding policy in order to be accredited. It is
suggested that the training should cover the BFI ten steps or sevenpoint plan and it is recommended that it should be at least 18 hours
in duration, including a minimum of 3 hours of supervised clinical
experience.
3.1.12
In-house training provision is the approach taken by the majority of
infant breastfeeding coordinators who were contacted in the course
of this assessment. We have therefore assessed the cost of training
based on a programme of initial and update training that is provided
’in house‘ by members of staff that have been appropriately trained
in breastfeeding management and education.
3.1.13
We have assumed that each trust will require at least two trained
trainers and that these trainers will need to attend the UNICEF BFI
3-day course in breastfeeding management and the UNICEF
course on delivering in-house breast feeding education. We have
assumed that the two trainers will normally include a breastfeeding
coordinator or equivalent employed at band 6 point 27 (£31,686
including on-costs) and a health visitor or equivalent employed at
band 5 point 21 (£25,582 including on-costs).
3.1.14
We have assumed that training will be a key part of these trainers
role and that therefore they will not require replacement costs to
ensure that their clinical work is covered. Consequently the cost to
train one trainer is £575. Table 5 gives values for each of the
constituent cost elements of trainer training fees.
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Table 5 Cost to train an individual trainer to be able to offer in-house
breastfeeding education
Assumption
UNICEF UK Baby Friendly Initiative three-day
Course in Breastfeeding Management, £
Length, days
Accomodation costs
Total cost of breastfeeding management
course
3.1.15
Value
£240
3
£210
£450
Delivering in-house breastfeeding education
course, £
Length of training, days
Total cost of delivering in-house
breastfeeding education course
£125
Total trainer training costs
£575
1
£125
Many units will already have trained trainers. For the purpose of this
assessment we have assumed that accredited units and units with
a certificate of commitment have sufficient numbers of trainers and
that units that are pre-certification have no sufficiently trained
trainers. When trainers leave they will need to be replaced and we
assume that all new trainers employed because of turnover will
require additional trainer training. We have assumed that turnover
for trainers will be 6.3% per year. This figure is based on estimates
of annual turnover used in a Midwifery Workforce model
constructed by the workforce review team (Healthcare workforce
2006).
3.1.16
On the basis of these assumptions the number of trainers required
for pre-commitment units is 248 and the cost of training this number
of trainers is £148,000. A 6.3% turnover rate among trainers from
certificated and accredited units would mean that in the first year
following the publication of the guideline an additional 15 trainers
would need to be trained at a cost of £8,635. This means that in the
first year following implementation the total trainer training cost will
be £151,225.
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3.1.17
In subsequent years we have assumed that the only additional
trainer training required would be due to turnover among trainers in
all units. This means that 31 new trainers would require training
every year at a cost of £17,825.
3.1.18
The total cost of running the breastfeeding education courses can
be calculated based on two elements: replacement costs to ensure
that cover is available to allow the member of staff to attend the
course and the cost of providing the trainer. If the trainers are
already employed by the trust the costs of providing a trainer
represents an opportunity cost. If the additional trainer time is
required to complete the training it will be a direct cost to the trust.
3.1.19
Training will cover a wide variety of professional groups, including
midwives, nurses, health visitors and healthcare assistants. We
have assumed that the average salary of the staff attending this
training will be band 5 point 21 (mid point). This means that a daily
replacement cost for each member of staff attending this training
will be £127.
3.1.20
We have identified that units and trusts run initial and update
training courses that vary in terms of content and duration. We have
assumed that initial training will take on average 2 days and that all
staff will need to attend this training once. Notably, certain members
of staff, typically doctors, currently receive shorter courses of initial
training of as little as 2 hours. We have assumed that all staff will
receive 2 days initial training but the option to allocate some staff
members to a shorter initial training session and calculate costs on
this basis is available on the costing template that accompanies this
report.
3.1.21
Many organisations provide annual update training that is much
shorter in duration and that is often included as part of the corporate
mandatory training programme. We have assumed that update
training will take 2 hours and that all members of staff who have
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already attended update training will need to attend these
programmes annually. Where update training is included in the
corporate training programme there will effectively be no cost. We
assume that training will be delivered by two trainers to groups of
16 staff members. The assumptions and units for initial and update
training are outlined in table 6.
Table 6 Assumptions and unit costs for initial and update training
Numbers of staff per session
Duration, hours
Duration, days
Replacement costs per person
Total member of staff replacement costs
Total trainer costs
Cost per member of staff trained
3.1.22
2 day initial 2 hour initial 1 hour update
training
training
training
16
16
16
2
1
2
0.267
0.133
£127
£127
£127
£4,058
£541
£271
£573
£76
£38
£289
£39
£19
Continual initial training will be required to train new members of
staff that join trusts because of turnover. We have assumed that
turnover for all members of staff will be 6.3% per year as discussed
in 3.1.15.
3.1.23
It is clear from contacting breastfeeding coordinators across the
country that the current levels of BFI breastfeeding training varies
considerably. Similarly, the actual number of staff to be trained will
vary depending on the size of the unit and the scope of the BFI
implementation project. It is clear that some BFI implementation
projects are intending to train a large number of community and
primary care staff, including staff in general practice. The number of
staff being trained in a particular unit does not appear to have a
direct correlation with the number of births delivered.
3.1.24
For the purpose for completing this national cost assessment we
are assuming that trusts with the same BFI status have successfully
trained the same proportion of staff members and that the average
number of staff being trained per unit is 220. This is slightly higher
than the number of staff per unit used in the health economic
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evaluation. We assume that this number includes community
midwives and health visitors that work in coordination with a
particular unit however the costs for training these community staff
will be borne by the appropriate trust.
3.1.25
We do not expect all members of staff who require initial training in
pre-certification units to receive training in the same year. On the
basis of estimates from the UNICEF BFI programme and from
breastfeeding coordinators around the country it appears to take
between 2 and 3 years to complete initial training for all staff. If we
assume that the average initial training programme takes 2.5 years
to complete, then approximately 40% of staff can be given initial
training in 1 year.
3.1.26
Following a survey of maternity units from around the country, we
have assumed that trusts will start from the situations outlined in
table 7 below and deliver initial training to a maximum of 40% of
staff members per year and offer update training to all who require it
every year. This would continue until a steady state is reached
where the only initial training offered in all units is because of staff
turnover.
Table 7 Proportion and number of staff requiring initial training based on
the Baby Friendly Initiative (BFI) status of a particular unit
Current BFI
Award Status
Pre-certification
Certificate of
Commitment
Accredited
3.1.27
Number of
Proportion of staff who
Number of staff
maternity
have already received
still to receive
units
initial training
initial training
124
0%
10,912
94
21
45%
94%
8,272
291
Following this training programme, the numbers of staff who require
each type of training and the associated costs over time are shown
in table 8 below. Costs have been shown over four years as it will
take this period of time to reach a steady state.
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Table 8 Proportion and numbers of staff requiring initial and update
training and associated training costs over time for England
Units that are
currently precertification
Initial
training
Update
training
Units that
Initial
currently have training
a certificate of
commitment
Update
training
Units that
Initial
currently have training
full
accreditation Update
training
All units
% trained in period
Staff trained
Costs, £000s
% trained in period
Staff trained in period
Costs, £000s
% trained in period
Staff trained
Costs, £000s
% trained in period
Staff trained in period
Costs, £000s
% trained in period
Staff trained
Costs, £000s
% trained in period
Staff trained in period
Costs, £000s
Total cost of all initial
training, £000s
Total cost of all
update training, £000s
Total training costs,
£000s
3.1.28
2006/ 07
40%
10,912
3,158
0%
0
0
40%
8,272
2,394
45%
9,306
180
6%
291
84
94%
4,343
84
2007/ 08 2008/ 09
40%
33%
10,912
8,893
3,158
2,574
34%
67%
9,193
18,387
177
355
21%
6%
4,405
1,303
1,275
377
79%
94%
16,275
19,377
314
374
6%
6%
291
291
84
84
94%
94%
4,329
4,329
84
84
2009/ 10
6%
1,719
497
94%
25,561
493
6%
1,303
377
94%
19,377
374
6%
291
84
94%
4,329
84
5,636
4,517
3,035
959
263
575
812
951
5,900
5,092
3,847
1,909
This table illustrates that the total annual training costs for England
will start at £5.9 million because a large proportion of staff still
require initial training. However, within 4 years training costs will
drop to a steady state of £1.9 million, which represents annual
update training for all but new starters.
Coordinators
3.1.29
To successfully implement a programme like UNICEF BFI,
appropriate policies must be formulated and implemented, training
and educational materials need to be created and distributed, and
practice needs to be regularly audited. We have assumed that a
dedicated coordinator will be required to perform these non-training
activities.
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3.1.30
A survey of units and trusts currently implementing BFI suggests
that the not all organisations have a designated coordinator to
conduct the required non-training BFI activities. Where designated
coordinators were employed by units or trusts, there was no
uniformity in the time spent conducting non-training activities. Our
survey suggests that coordinators or staff who can devote part of
their working week to this kind of role are present in 77% of units.
The survey also suggests that, on average, these members of staff
are able to devote 19 hours per week to these kinds of activities.
3.1.31
We have assumed that a breastfeeding coordinator will be
employed at band 6 point 27 (£31,686 including on-costs). There is
no guidance on how much time a coordinator would need to spend
working on non-training BFI activities. The health economic
evaluation assumed that 25 hours per week would be required for
the average unit and we have used this assumption to asses the
cost impact of this recommendation (see table 9, below).
Table 9 Cost impact of changes to the non-training BFI activities,
England
Current
Hours per week spent
working on non-training
BFI activities per unit
Time spent working on
non-training BFI activities
per unit, WTE
Pro rata annual salary
cost
Proportion of units with a
coordinator
Total number of units
with a coordinator
Total salary costs, £mil
Proposed
Change
19
25
6
0.51
0.67
0.16
18,665
24,559
5,894
77%
100%
23%
184
239
55
3.43
5.87
2.43
Cost summary
3.1.32
The net cost of implementing a structured programme that
encourages breastfeeding, using BFI as a minimum standard, is
summarised in table 10.
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Table 10 Net cost impact of implementing a structured programme that
encourages breastfeeding
Change in coordinator salary
costs for non-training
activities
BFI fees
Initial training costs
Update training costs
Trainer training costs
Net cost
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
£000s
£000s
£000s
£000s
£000s
£000s
£000s
2,435
2,435
2,435
2,435
2,435
2,435
2,435
89
5,636
263
151
632
4,517
575
18
927
3,035
812
18
0
959
951
18
419
959
951
18
647
959
951
18
0
959
951
18
8,575
8,176
7,227
4,362
4,781
5,008
4,362
3.2 Savings from improvements in breastfeeding rates
Background
3.2.1
The health economic evaluation with the guidance suggests that the
implementation of a programme such as BFI can lead to substantial
improvements in the initiation rate of breastfeeding. Improvements
are not uniform but the evaluation assumes that a 10%
improvement in initiation rates is a realistic target. We assume that
this maximum level of improvement will only occur once a unit is
accredited but that some improvements in the rate of breastfeeding
will be seen annually as a unit progresses towards accreditation.
Assumptions made
3.2.2
Potential savings are linked to the reduction in the incidence of
certain childhood disease because of the protective effects of
breastfeeding. On the basis of medical literature we assume that an
increase in the number of babies that breastfeed will lead to a
reduction in healthcare expenditure because of avoided cases of
otitis media, gastroenteritis and asthma. On the basis of an annual
birth rate of 605,634 a 10% improvement in breastfeeding would
mean that 60,563 additional babies would be breastfed.
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3.2.3
Potential savings from cases of otitis media avoided are based on
the finding that the incidence of 25% for breastfed infants and 53%
for bottle-fed infants (Weimer J 2001). Although acute otitis media
can result in admission to hospital for a surgical procedure, we
assume that in the majority of cases treatment would consist of
assessment, treatment with antibiotics and follow-up in primary
care. The unit cost for the treatment of otitis media is £30. A 10%
increase in breastfeeding could lead to about 17,000 cases of otitis
media being avoided at a saving of £509,000.
3.2.4
Potential savings from cases of gastroenteritis avoided are based
on the observation that the rate of hospital admission for
gastroenteritis of breastfed infants is 1.4% and the rate of hospital
admission for gastroenteritis of bottle-fed infants is 7.8% (Howie et
al. 1990; Department of Health 1995). The national tariff cost for an
episode of infectious or non-infectious gastroenteritis (HRG P26) is
£915 for an elective episode and £662 for an emergency episode.
The weighted average cost based on the proportion of elective and
emergency cases seen in 2003/2004 (HES) is £675. A 10%
increase in breastfeeding could lead to almost 3900 cases of
gastroenteritis being avoided, at a saving of £2.6 million.
3.2.5
This cost varies from the findings of the health economic evaluation.
The health economic evaluation used a figure for potential savings
from a Department of Health document from 1995 updated to a
2005 cost based on inflation. The figured quoted in this document
was based on a treatment episode with a 4-day length of stay,
which resulted in a unit cost of around £1300 per case of
gastroenteritis treated. The national tariff for HRG P26 suggests
that the average length of stay for treatments within this HRG is
now 2 days.
3.2.6
Potential savings from cases of asthma avoided are based on the
observation that breastfed infants are 25% less likely to develop
asthma than bottle-fed infants (Oddy et al. 1999). If we assume a
National costing report: Routine postnatal care of women and their babies
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10% annual incidence of asthma in children, then we effectively
avoid 2.5% of cases through improvements in breastfeeding. The
annual cost of treating asthma £1,425. A 10% increase in
breastfeeding could lead to over 1500 cases of asthma being
avoided, at a saving of £2.6 million.
3.2.7
An increase in the number of breastfed babies will also result in a
reduction in the use of formula and teats in hospital. The health
economic evaluation used a unit cost based on teats and formula
milk for immediate neonatal spending of £1.69 per baby. This
information was based on macro level costing data from County
Antrim. A 10% increase in breastfeeding could lead to a reduction in
the cost of teats and formula of £102,000.
3.2.8
It should be noted that other studies have suggested that breast
feeding can lead to a reductions in morbidity in other areas of care
such as breast cancer and reductions in admissions to accident and
emergency departments. Consequently it may be possible to
identify and realise savings from other areas of care through an
increase in breast feeding.
Cost summary
3.2.9
The net saving from improvements in breastfeeding is summarised
in table 11.
National costing report: Routine postnatal care of women and their babies
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Table 11 Net saving of improvements in breastfeeding
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
Additional babies
breastfeeding
Cumulative improvement in
breastfeeding
Saving from cases of otitis
media avoided
Saving from cases of
gastroenteritis avoided
Saving from cases of asthma
avoided
Saving from reduced use of
formula and teats
Net saving
3.2.10
21,134
31,622
42,478
53,334
59,509
60,416
60,416
3%
£000s
5%
£000s
7%
£000s
9%
£000s
10%
£000s
10%
£000s
10%
£000s
178
266
357
448
500
507
507
913
1,366
1,835
2,304
2,571
2,610
2,610
829
1,263
1,697
2,130
2,377
2,377
2,377
36
53
72
90
100
102
102
1,956
2,948
3,960
4,972
5,548
5,596
5,596
As shown in the table above, the saving varies from £1.9 million to
£5.6 million.
3.3 ‘Birth to five’
Background
3.3.1
The Department of Health booklet ‘Birth to five’, which is a guide to
parenthood and the first 5 years of a child's life, should be given to
all women within 3 days of birth (if it has not been received
antenatally) (NICE 1.2.2).
Assumptions made
3.3.2
We have assumed that currently hard copies of ‘Birth to five’ are
offered and accepted by all first-time mothers. It is clear that
practice does vary across the country and that some professionals
do offer ‘Birth to five’ to all women. We assume that in the future
hard copies of ‘Birth to five’ will be offered and accepted by all
postpartum mothers.
3.3.3
Communications with the Department of Health team responsible
for the production of ‘Birth to five’ suggest that the unit cost for the
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production, storage and dissemination of one copy of ‘Birth to five’
is £0.61.
3.3.4
The Government Actuary's Department (2004) states that between
2004 and 2006 there were 605,634 births per year. Mothers giving
birth to multiple babies at one time will only need one copy of the
document. However, the annual number of multiple births is small
enough for its effect to be ignored (Office for National Statistics
2004). Information on the proportion of women giving birth for the
first time is not routinely collected for all mothers. Information on the
number of previous live-born children is only collected for mothers
who are registered as being married at the time of birth (Office for
National Statistics 2004, table 4.1). In 2004, approximately 42% of
all mothers who were registered as married at the time of birth had
had no live-born babies previously. If we apply this percentage to all
annual live births between 2004 and 2006, there are approximately
254,000 first-time mothers.
Cost summary
3.3.5
The net cost of offering ‘Birth to five’ to all postpartum women is
summarised in table 12.
Table 12 Cost of changes to the provision of ‘Birth to five’ for England
2006
Birth to Five
3.3.6
Unit cost Current Current Proposed Proposed Change,
Change
numbers cost,
numbers cost,
numbers costs,
£000s
£000s
£000s
£0.61 254,366
155
605,634
369
351,268
214
The change in cost to implement the proposed level of provision of
‘Birth to five’ will vary slightly over time as the birth rate changes.
However, based on the Government Actuary's Department
predicted changes in birth rate, these changes will be negligible.
3.3.7
‘Birth to five’ is also available freely to all via the Department of
Health website and it is reasonable to expect that some mothers will
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access the information in ‘Birth to five’ via the online version. This
will reduce the costs associated with the implementation of this
recommendation.
4 Sensitivity analysis
4.1 Methodology
4.1.1
There are a number of assumptions in the model for which no
empirical evidence exists. Because of the limited data, the model
developed is based mainly on discussions of typical values with
NHS healthcare professionals and is therefore subject to a degree
of uncertainty.
4.1.2
As part of discussions with practitioners, we discussed possible
minimum and maximum values of variables, and calculated their
impact on costs across this range.
4.1.3
Wherever possible we have used the national tariff 2006/07 plus
market forces factor to determine cost. We used the variation of
costs for the 25th and 75th percentiles from reference costs
compared with the reference cost national average as a guide to
inform the maximum and minimum range of costs.
4.1.4
It is not possible to arrive at an overall range for total cost because
the minimum or maximum of individual lines would not occur
simultaneously. We undertook one-way simple sensitivity analysis,
altering each variable independently to identify those that have
greatest impact on the calculated total cost.
4.1.5
A table detailing all variables modified is shown in appendix C, and
the key conclusions drawn are discussed below.
4.2 Impact of sensitivity analysis on costs
Percentage of staff in all units requiring initial training
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4.2.1
The assumptions used in the cost assessment mean that 37% of all
staff in all units will receive initial training in the first year following
the launch of this guidance. When this figure is varied using 27%
and 47% as a minimum and maximum respectively, the first year
costs vary from £4.4 million to £7.4 million. Given the relatively large
cost of initial training, the model is particularly sensitive to the
proportion of staff receiving initial training.
Duration of initial training
4.2.2
The model suggests that initial training will take 2 days. When this
figure is varied using 1.5 and 2 days as a minimum and maximum
respectively, the first year costs vary from £4.2 million to £7 million.
Given the relatively large cost of initial training, the model is
particularly sensitive to the duration of any initial training being
provided.
Replacement costs for initial training
4.2.3
The model suggests that an average replacement cost for all
members of staff attending initial training is £128. This figure is
based on a band 5 point 21 annual salary plus on costs. When the
top and bottom points on band 5, point 17 and point 25 respectively,
are used as a minimum and maximum, the first year costs vary from
£4.8 million to £6.8 million. Given the relatively large cost of initial
training, the model is particularly sensitive to any variation in
replacement costs for staff attending initial training.
5 Conclusion
5.1 Total national cost for England
5.1.1
Using the significant resource-impact recommendations shown in
table 1 and assumptions specified in section 3 we have calculated
that the annual cost impact of fully implementing the guideline will
vary over time from an initial cost of £6.4 million to a potential
saving of £1.4 million. The change over time is due to the effect of
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increasing savings and reducing training costs. Table 13 shows the
breakdown of cost of each significant resource-impact
recommendation.
Table 13 Total cost impact of significant resource impact
recommendations for England over time
2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
£000s
£000s
£000s
£000s
£000s
£000s
£000s
Structured programme that encourages breastfeeding
2,435
2,435
2,435
2,435
2,435
2,435
2,435
Change in coordinator salary
costs for non-training
activities
BFI fees
89
632
927
0
419
647
0
Initial training costs
5,636
4,517
3,035
959
959
959
959
Update training costs
263
575
812
951
951
951
951
Trainer training costs
151
18
18
18
18
18
18
Cost of a structured
8,575
8,176
7,227
4,362
4,781
5,008
4,362
programme that
encourages breastfeeding
Savings from improvements in breastfeeding rates
Saving from cases of otitis
-178
-266
-357
-448
-500
-507
-507
media avoided
Saving from cases of
-913 -1,366 -1,835
-2,304
-2,571 -2,610
-2,610
gastroenteritis avoided
Saving from cases of asthma
-829 -1,263 -1,697
-2,130
-2,377 -2,377
-2,377
avoided
Saving from reduced use of
-36
-53
-72
-90
-100
-102
-102
formula and teats
Savings from
-1,956 -2,948 -3,960
-4,972
-5,548 -5,596
-5,596
improvements in
breastfeeding rates
Cost of changes to
provision of Birth to Five
Net resource impact,
£000s
214
211
211
211
211
214
214
6,834
5,439
3,477
-400
-556
-374
-1,021
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5.1.2
We applied reality tests against existing data wherever possible, but
this was limited by the availability of detailed data. We consider this
assessment to be reasonable, given the limited detailed data
regarding diagnosis and treatment paths and the time available.
However, the costs presented are estimates and should not be
taken as the full cost of implementing the guideline.
5.2 Next steps
5.2.1
The local costing template produced to support this guideline
enables organisations such as primary care trusts (PCTs) to
estimate the impact locally and replace variables with ones that
depict the current local position. Using this template the example
cost to implement the guidance has been conducted for an
’average‘ maternity unit with 220 staff members and an average
number of births per year of 2,534. Three calculations have been
completed for this average unit based on one of the three different
BFI statuses: pre-certification; certified and accredited. The costs
over time using the standard assumptions are given in table 14
below.
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Table 14 Total cost impact of significant resource impact
recommendations over time for an average pre-commitment, certificated
and accredited unit
Currently pre-commitment
2006/ 07, 2007/ 08, 2008/ 09, 2009/ 10, 2010/ 11, 2011/ 12,
£s
£s
£s
£s
£s
£s
31,818
32,541
35,612
13,451
13,451
17,911
Cost of a structured
programme that
encourages
breastfeeding
Cost of changes to
provision of Birth to Five
Savings from
improvements in
breastfeeding rates
Total resource impact
-
897
897
4,687 -
9,374 -
28,028
24,063
Currently has certificate of commitment
Cost of a structured
33,158
26,974
programme that
encourages
breastfeeding
897
897
Cost of changes to
provision of Birth to Five
Savings from
improvements in
breastfeeding rates
Total resource impact
Currently accredited
Cost of a structured
programme that
encourages
breastfeeding
Cost of changes to
provision of Birth to Five
Savings from
improvements in
breastfeeding rates
Total resource impact
5.2.2
-
9,374 -
14,062 -
897
897
897
14,062 - 18,749 - 23,436 -
22,447 -
4,402 -
9,089 -
897
23,436
4,628
13,451
13,451
17,911
13,451
897
897
897
897
18,749 - 23,436 - 23,436 -
4,402 -
9,089 -
4,629 -
23,436
24,680
13,809 -
13,451
13,451
17,911
13,451
13,451
17,911
897
897
897
897
897
897
-
23,436 -
23,436 -
-
9,089 -
9,089 -
23,436 - 23,436 - 23,436 -
4,629 -
9,089 -
9,089 -
9,088
23,436
4,628
Use the local template to calculate the cost of implementing this
guidance in your area.
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Appendix A: Approach to costing guidelines
Guideline at first consultation stage
Identify significant recommendations and
population cohorts affected through analysing
the clinical pathway
Identify key cost drivers – gather information
required and research cost behaviour
Develop costing model – incorporating
sensitivity analysis
Draft national cost-impact
report
Internal peer review by
qualified accountant
within NICE
Determine links between national
cost and local implementation
Develop local cost template
Circulate report and template to cost-impact panel and
GDG for comments
Update based on feedback and any changes following
consultations
Cost-impact review meeting
Final sign off by NICE
Prepare for publication in conjunction with guideline
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Appendix B: Results of sensitivity analysis
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Appendix C: References
Department of Health (1995) Breastfeeding: Good practice guidance to the
NHS. London: Stationery Office.
Department of Health (2000) Infant feeding survey 2000.
www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsStatistics/P
ublicationsStatisticsArticle/fs/en?CONTENT_ID=4079223&chk=UpJ4Sr
[accessed 22 February 2006]
Government Actuary's Department (2004) 2004-based principal projections.
www.gad.gov.uk/Population/2004/england/wengsumcc.xls [accessed 30 May
2006]
Healthcare workforce (2006) Midwifery workforce model.
www.healthcareworkforce.org.uk/C5/Nursing%20and%20Midwifery/Project%2
0Documentation/2005%20Midwifery.xls [accessed 4 June 2006].
Howie PW, Forsyth JS, Ogston SA et al. (1990) Protective effect of breast
feeding against infection. British Medical Journal 300: 11−6.
Oddy WH, Holt PG, Sly PD et al. (1999) Association between breastfeeding
and asthma in 6 year old children: findings of a prospective birth cohort study.
British Medical Journal 319: 815−9.
Office for National Statistics (2004) Review of the Registrar General on births
and patterns of family building in England and Wales, 2004. London: Office for
National Statistics.
UNICEF UK (2006) Baby Friendly Initiative − Baby Friendly progress of all UK
maternity units. www.babyfriendly.org.uk/htables/all_hospitals_acc_status.asp
[accessed 22 February 2006].
Weimer J (2001) The economic effects of breastfeeding: a review and
analysis. Washington DC: ERS Food Assistance and Nutrition Research
Report, no.13.
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