Mental Health Payment by Results (PbR)

1. Mental Health Payment by Results (PbR)

2. Outline • Why move to PbR? • What is the mental health currency? • Care clusters • How does clustering work • Assessment • Transition protocols • Care packages • Pricing • Implementation timeline • Local commissioner update • Local trust update

3. Why does MH commissioning need to change? • Quality, efficiency and the cost of MH care have been variable across the country, and with little flexibility or patient choice. • Economic context makes it all the more important to ensure we get the best value for every single pound of tax payer money we spend. We need a framework that will enable us to do just that. • Providers in MH are fed up with acute providers taking all the money and being left as a soft target. • Commissioners need to demonstrate more value from substantial MH investment.

4. Why move to PbR? • Facilitate patient choice • Enable diversity of provision • Introduce some of the benefits of a market without having to negotiate the cost. Reward quality more! • Promote efficiency at higher cost trusts (because they have to reduce costs to a national tariff level) and there is more standardisation of pathways • Refocus discussions between commissioner and provider

5. The Mental Health Currency • The mental currency is care clusters – the tariff is based on the packages of care and interventions that go with it. • A key issue for mental health and PbR is that in many cases diagnosis and severity of the illness do not predict resource use accurately.

6. What is in the currency? • All mental health care should be covered by the clusters. • The clusters are designed to be setting independent, on the premise that people should be treated in the least restrictive care setting possible. • They should cover care provided by social care staff of integrated services (Section 75 agreements).

7. Care clusters – some characteristics • The care clusters are based primarily on the needs and characteristics of a service user. • Expected diagnoses are given for each cluster, but the same diagnosis can appear in multiple clusters. • The clusters are mutually exclusive in that a service user can only be allocated to one cluster at a time. • Clinicians allocate patients to clusters using the Mental Health Clustering Tool (MHCT)

8. Description of clusters

9. Decision tree for clustering

10. MH PbR vs acute PbR • Care clusters are needs based but clinically relevant (Acute PbR uses HRGs, based on diagnosis (ICD-10)* and procedures (OPCS-4)** • Clusters are different from Acute HRGs • Currently only 21 clusters (c/f approx. 1,500 HRGs) • Clusters cover extended periods of time (HRGs cover short term, completed episodes of care) • Clusters are determined at the beginning of the process (HRGs are determined at the end of treatment – finished consultant episodes) • Clusters embody a review / transition process (HRGs have no equivalent) • Nobody has yet successfully implemented an MH PbR process (Acute PbR has been working since 2003/4) * International Statistical Classification of Diseases and Related Health Problems 10th Revision ** Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision)

11. How will PbR work? • MH providers will be paid for actual patients they see and treat (X patients x £Y for each cluster) • Payment initially based on a local tariff (possibility of moving to a national tariff) • Tariff will use 20 clusters to reflect patient complexity • This will expand over time as the system becomes more refined • PbR initially encompasses Adult and Older Adult services only • Projects are underway to extend MH PbR to CAMHS, LD, Forensics, IAPT, Alcohol services, Quality and Outcomes

12. How does clustering work? • Part1 – 11 HoNOS items and 1 SARN item related to severity of problems during 2 weeks prior to assessment (HoNOS scale 1 is not used for clustering) • Part2 – 5 SARN items consider problems from a ‘historical’ perspective: these may not have been experienced during the two weeks prior to assessment • This then also gives a baselines from which to measure outcomes later at transition points agreed nationally

13. How does clustering work? (cont’d) • Step 1 - Routine screening assessment process to score the patient’s needs using MHCT (will suggest the closest fit – maybe more than one possible cluster); or • Step 2 - Decision tree - to decide if the presenting needs are “A,B,C” (“super clusters) This will then narrow down the list of possible clusters. • Step 3 - Look at the grids - which one is the most appropriate? • red: level of need which must score • orange: expected scores - • yellow : may score • Final clustering decision is based on clinical judgement applying the guidance

15. What is the Initial Assessment • It relates to new referrals and ‘one-off’ assessment services, rather than to re-assessments of existing service users • The initial assessment can be triggered in a number of ways • E.g. GP referral or self referral and others • These initial assessments can be classified in three ways a) Assessed not clustered b) Assessed, clustered c) Assessment ‘service’ N.B: Great potential to print money – so prior approval rules important to be developed, particularly if GPs want telephone advice with Consultants etc.

16. Duration of Initial Assessment • The assessment is completed when the individual is either allocated to a cluster, not allocated, or the provision of the one-off service has concluded. • An initial assessment will take no more than two community or outpatient sessions or two inpatient days NB: The Initial Assessment is not necessarily a full diagnostic assessment – it is principally for the purpose of clustering the patient.

17. Transition Protocols • Use of the MHCT is appropriate only on initial assessment • At review, Transition Protocols must be used • These describe different criteria to be used to determine whether a patient should change clusters or not NB: a change of cluster will mean a change of care package

18. Concepts included in the Care Transition Protocols • Indicative episode of care • The length of time service users typically need to be in receipt of a specific package of care • Indicative episode refers to current understanding of reasonable practice • Variations will occur around this duration • Cluster review interval • Review interval refers to the maximum time that should elapse between scheduled clinical reviews • Review intervals are appropriate to the cluster rather than being a universal standard

20. Care packages • The clusters do not define the appropriate interventions and treatments to meet an individual’s characteristics • Exact format of care packages to be decided locally • Providers have the flexibility to develop innovative approaches to care • Care packages can be tailored to an individual’s requirements (support the personalisation agenda)

21. Care packages (cont’d) • Content of care packages should reflect NICE guidance • Content and format will vary due to location • Guidance on care packages content www.mednetconsult.co.uk/imhsec

22. Care packages (cont’d)

23. Pricing issues • Local vs regional vs national • Cost per day per cluster • Cost per cluster episode • Cost for assessments • Top-ups/additional payments • How cost becomes price • Payment for outcomes

24. Main critical risks and issues • Volatility of expenditure • Savings required at a time of major change • Data collection requirements • Variation in the accuracy of clustering and the quality of clustering data • Clarity around costing • New standard contract • Both commissioners and providers must work on this together

26. Expanding the scope • Current scope WAA & OP (50-75%) • Forensic MH (1% NHS spend) • IAPT • CAMHS • Alcohol and Drugs • Learning Disability

27. Lots more to do • Develop the guidance further – 3 year plan • Improve communications • Improve data quality • Social care, PHB’s, SDS • Outcomes • Competing priorities & economic pressures

28. Benefits • Greater focus on the individual and their needs • Transparency – common language • Developing benchmarking • Increased knowledge and awareness of what is offered/provided – choice • Opportunity to establish an outcomes focus

29. Add local commissioner update here: • PbR technical group • Development of service specs • Data schedules and collection • Engagement with CCGs

30. Add local trust update here: Clustering • progress so far • next steps

31. Add local trust update here Care packages development • progress so far • next steps

32. Add local trust update here Costing • progress so far • next steps

33. Issues to consider • Governance structure • Rebasing – ‘price per cluster per organisation’ • Care packages • Non-PbR activity

34. Next steps • How do you want to move forward from here?