Payment by Results for Dementia

1. Payment by Results for Dementia Peter Howitt – 06/10/09 Project Lead for Mental Health PbR Development Peter.howitt@dh.gsi.gov.uk

2. Mental Health PbR – The Context • Payment by Results (PbR) was introduced for the acute sector in 2003/04 • At its simplest, PbR is just a list of prices: • Price x Activity = Providers’ (e.g. hospitals) income • PbR does not affect the total amount of money available, but it does provide a clear and transparent method of funding, where the money follows the patient/service user Price X Activity = Income

3. Mental Health PbR – The Commitment • Mental Health identified as no.1 priority for inclusion in PbR from the Options for the Future of PbR consultation. • High Quality Care For All published end of June 2008. Set out plan to have a national mental health currency available for use in 2010/11 (chapter 4 para 23).

4. Currencies or Prices? • When people talk about Payment by Results they often get currencies and prices/tariffs confused. • Currencies = the unit for which payment is made e.g. Healthcare Resource Groups, Outpatient Attendances, Complexity-adjusted year of care for Cystic Fibrosis. • Price/tariff = Set price for a given currency unit. • Our focus is initially on developing a currency to be used across mental health services in England. This will allow benchmarking, comparability and transparency. Can’t do. National Price National Price National Currency National Currency No Currency

5. The Currency Methodology • The Care Pathways and Packages approach, developed initially by six mental health trusts in the North East and Yorkshire and Humber SHAs, is the currency we are developing. • Needs further refinement, wider validation etc, but it is the basis for future work. • Users assessed with a standard assessment tool derived from HoNOS. • Allocated to empirically derived care clusters/groups[1] • These clusters are expected to be the currency unit so that you would commission for 10 people in cluster 1, 20 people in cluster 2 etc. [1] Methodology set out in Clinical Decision Support Tool: A rational needs-based approach to making clinical decisions, Journal of Mental Health, February 2008, 33-48

6. DECISION TREE (RELATIONSHIP OF CARE CLUSTERS TO EACH OTHER) Working-aged Adults and Older People with Mental Health Problems C Organic A Non-Psychotic B Psychosis a Mild/ Moderate/ Severe b Very Severe and complex c Substance misuse a First Episode b Ongoing or recurrent c Psychotic crisis d Very Severe engagement a Cognitive impairment 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

7. Dementia Clusters - Low

8. Dementia Clusters - Moderate

9. Dementia Clusters - High

10. Dementia Clusters – High Physical/Engagement

11. Describing the elements of a currency

12. Meeting Service Users’ Needs • Providers can develop responses to the needs of people in particular clusters using NICE guidance, Policy Implementation Guidance etc. • Because payment is for meeting an individual’s needs, then there is the opportunity for innovative approaches if agreed by service user and clinician e.g. green prescription rather than anti-depressants. • From commissioner’s perspective the means of treating a service user does not matter.

13. 2009/10 Financial Year Series of conferences and events to continue to raise profile of mental health PbR. Links made with related policies e.g. dementia strategy. Publication of revised cluster booklet with agreed assessment tool, latest version of the clusters and cluster time durations. Summer Autumn Dec March Evaluation of HoNOS PbR and SARN assessment tools looking at their ability to allocate to clusters, useability and inter-rater reliability. Data Set Change Notice issued to bring required additional data items into Mental Health Minimum Data Set.

14. Timescales • 2010/11 – Currencies available for use. Likely to be used in shadow form. • Beyond this commitment, our timescales are subject to review, but our assumptions are: • 2011/2012 – All health economies should be using the currencies in some form and be establishing local prices. • 2013/2014 – The earliest possible date for a national tariff for mental health (if evidence from the use of a national currency presents a compelling case for a national price).

15. We have a nationally co-ordinated, but locally driven, programme in place • Key: • Original Care Pathways and Package Trusts • PbR Payment Development Sites: • Mental Health • Liaison MH Services • Learning Disability • London Project • Other interested Trusts

16. An increasing SHA focus….. • Broadly two approaches – SHA-wide or not SHA-Wide Organisation-led • Care Pathways and Packages Project - North East and Yorkshire and Humber • West Midlands Productivity Improvement Programme and Care Pathways Project • London Mental Health Currency Development Programme • North West PbR Mental Health Development Group • East Midlands PbR work • East of England • South West • South Central • South East Coast

17. Quality and Outcomes • Approach does incorporate quality and outcomes: • For lower clusters completion of courses of treatment and movement out of mental health system. • Increased transparency will allow more comparison. • Incorporates HoNOS – internationally recognised outcome measure so can see reduction in severity. • Need to link to other ways of rewarding quality e.g. Commissioning for Quality and Innovation (CQUIN) scheme. • Still potential to have quality measures tailored to the 21 clusters. Quality measures should be more than just clinical – also look at social and wellbeing indicators. E.g. potential measure for cluster could be % return to part time employment. • Have agreed to a joint programme of work with CP&PP to focus on these measures.

18. Any Questions Further details on our web page:http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NHSFinancialReforms/DH_4137762

19. PBR and the National Dementia Strategy • PbR care clusters model has been built up over a long period of time (from 2000) before the National Dementia Strategy existed. • Two do fit – probably an issue about aligning the language e.g. one dementia pathway, four care clusters that are probably stages on that pathway.

20. PbR’s fit with the National Dementia Strategy’s Objectives • Objective 1: Improving public and professional awareness and understanding of dementia – Outside scope of PbR • Objective 2: Good quality early diagnosis and intervention for all – there is an early intervention/first episode psychosis cluster (cluster 10). Do we need something similar for dementia? • Objective 3: Good-quality information for those with diagnosed dementia and their carers – some elements included in the clusters. • Objective 4: Enabling easy access to care, support and advice following diagnosis through dementia advisers – outside of the scope of PbR. • Objective 5: Development of structured peer support and learning networks – could be covered by clusters (especially 18 and 19). • Objective 6: Improved community personal support services – depends on how comprehensive the clusters are in including social care. • Objective 7: Implementing the Carer’s Strategy – Looking to include additional item in assessment on carers.

21. PbR’s fit with the National Dementia Strategy’s Objectives • Objective 8: Improved Quality of Care for people with dementia in general hospitals – work on recognising liaison services in payment. • Objective 9: Improved intermediate care for people with dementia outside the scope of mental health PbR. • Objective 10: Considering the potential for housing support, housing-related services and telecare to support people with dementia and their carers. • Objective 11: Living well with dementia in care homes – outside of PbR. • Objective 12: Improved end of life care for people with dementia – probably see dementia as a complicating factor for an end of life payment mechanism. • Objective 13: An informed and effective workforce for people with dementia – PbR clusters help identify dementia workers. • Objective 14: A joint commissioning strategy for dementia – supported by the clusters.