Care clusters and packages in mental health in the West Midlands Michael Clark

1. Care clusters and packagesin mental health in the West MidlandsMichael Clark

2. Overview in the West Midlands • The SHA has brokered an agreement with all commissioners and mental health provider trusts across the region; • To develop two joined pieces of work in mental health and learning disabilities: • Productivity Improvement Programme (PIP) - successful in acute and community care over the last 3 years to help map services, understand how staff work, and redesign services to free staff to better help patients. • Care clusters and packages - to put in place common assessments and the care clusters and packages model. • Regionally this gives us a strong position to better understand our services, improve the way they work for staff and patients.

3. Twin Track Approach Provider Focus Provider/Commissioner Focus Productivity and Improvement Programme Yorkshire Care Pathway Programme Directory of Services MH/LD Benchmarking Tool Rostering Assessment Reference Cost Benchmarking Tool Time to Care Diary Card completion • Yorkshire Care Pathway Launch and Training • Assessment and allocation to pathways • Collection and Analysis of PAS data in pathways Cost Activity Workforce Synthesis Recommendations Action Plans Local Cost Shadow tariff Tariff Service Level Economics Tool

4. Our values underpinning this Supporting clinical decision making High consistency of care; quality and equality of access, experience and outcomes Personalisation and recovery More transparent model of finance and commissioning More efficient systems of care Better data for system and care planning Greater accountability throughout the system Stronger local mental health systems

5. Objectives of the programme Working through the programme will enable each MH Provider to: Undertake a rigorous and insightful analysis and benchmarking of workforce productivity of MH/LD services Assess current levels of productivity and identified areas for improving productivity and reducing costs while maintaining standards in key quality and performance indicators; Focus on developing MH Trust capacity to manage and improve service line economics focusing on pathways of care On the basis of needs, allocate users to care clusters and packages, supported by an electronic assessment tool Consistently report activity information by service user Analyse PAS downloads in order to compare distribution across pathways and quality of care

6. Objectives of the programme (contd) Working through the programme will enable each MH Provider and Commissioner to: Develop a shared ‘language’ using YcPs Identify local costs of delivery pathways and define local shadow tariff Develop West Midlands tariff for MH services (2011)

7. Yorkshire Care Pathways/clusters • 21 care pathways for all people who use adult mental health services • Grouped on the basis of similar needs • All new referrals are assessed using a needs assessment tool -based on HoNOS, with additional questions • Pathways tested in Yorkshire and two West Midlands Mental Health Trusts. Key points: • the pathways made clinical sense - face validity • Consistent and high degree of allocation to the clusters • Good basis for continuing development work • Additionally, there is an electronic decision support algorithm which suggests a pathway but allows clinicians to override this (97% concordance)

8. Rate the most severe problem as: 0. No problem 1. Minor problem requiring no action 2. Mild problem but definitely present 3. Moderately severe problem 4. Severe to very severe problem 9. Unknown HONOS The Health of the Nation Outcome Scale (HONOS) is an outcomes measurement tool for use in mental health care. The scales rate severity of problems experienced by the patient during the 2 weeks prior to the date of the rating. The scales are: 1. Overactive, aggressive, disruptive or agitated behaviour (current) 2. Non-accidental self-injury 3. Problem drinking or drug-taking 4. Cognitive problems 5. Physical illness or disability problems 6. Problems associated with hallucinations and delusions 7. Problems with depressed mood 8. Other mental and behavioural problems 9. Problems with relationships 10. Problems with activities of daily living 11. Problems with living conditions 12. Problems with occupation and activities Additional Questions Rate each according to the most severe occurrences still relevant to the care plan. 13. Overactive, aggressive, disruptive or agitated behaviour (historical) 14. Repeat self-injury (historical) Child protection risk (historical) Engagement (historical) Vulnerability (historical) Strong Unreasonable Beliefs (historical)

9. Further Questions Tickbox answers A1. Does this presenting need relate to non-psychotic, psychotic or organic? A2. Does your client have a history of psychotic illness that is now controlled? A3. Has your client been known to the service for less than one year? A4. Is your client having an acute psychotic episode? A5. Have they been known to the service for a long time?

10. Summary of clusters and pathways model

11. Summary of clusters and pathways model Working-aged Adults and Older People with Mental Health Problems Non-Psychotic Psychotic Organic a.Mild/Mod/ Severe b. very severe & complex c.Substance misuse a.First episode b. ongoing/ recurrent c. Psychotic crisis d. Very severe engagement a.Cognitive impairment 10 9 14 15 18 19 20 21 1 2 3 4 5 6 7 8 11 12 13 16 17

12. Benefits of using pathways • For user: • Clear what basis starting from • Upfront information of what services will be provided by who and when • For clinicians: • Support clinical decision making and care planning • Easier to ‘slot in’ evidence • Allows analysis and comparison of clinical practice • Development of outcomes measures • Good practice pathways to work towards • For provider organisations: • Detailed understanding of current model of service delivery • Facilitates service redesign • Improved dialogue with commissioners, transparency of work and costs • For commissioners: • Focus on pathways of care and greater transparency of service model • Improved dialogue with providers

13. Risks of not developing the work Variations in practice and outcomes Someone else defines the work for us Lack of clarity and transparency in services Unhelpful for service users Unhelpful for services Unhelpful for commissioners Mental health systems unable to articulate a strong case in relation to acute care Pressures on public sector spending

14. Current state of development • Regional steering group to oversee work • Training pack being rollout across the West Midlands • IT development to support the work • Local project leads and support in place • Beginning of PIP work, mapping local services

15. Further development work This is a developmental process Need to ensure the model is: clinically meaningful and workable is generalisable is robust and stable Need to maintain and extend the regional consensus Develop it for benchmarking across services and quality improvement

16. Further development work (contd) Development of care pathways and packages to reflect our context and shared values Refinement of clusters as necessary Extend the approach to learning disabilities and CAMHS Refinement of assessment and allocation process as necessary Development of (local) tariff Ensure consistency with other areas e.g. social care, Darzi and IAPT Development of quality and outcomes frameworks for the pathways

17. Quality and outcomes framework

18. Towards Payment By Results? Background Reforming NHS Financial Flows (DH 2002) - announced Payment by Results (PBR) - to bring transparency and incentives to the system Terminology Currency - the things/units being contracted for e.g. hip operations Tariff - the amount paid for each unit of currency (£) PBR introduced into acute care in 2003/4 and extended since High Quality Care for All (DH 2008:41) - ‘In 2008/09, over 60 per cent of the average hospital’s income is through Payment by Result.’ Continue to refine the system - redefine HRGs, payment systems and quality improvement

19. Background Mental health to date not covered by PBR Yorkshire model of Care clusters, pathways and packages developed January 2009 DH letter - “committed to making a currency available for use nationally in 2010/11.” June 2009 - further DH letter and guidance on preparing for PBR in mental health