Care Pathways

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Payment by Results (PbR) in Mental
Health Presentation to CPAA Quarterly meeting
Peter Howitt 23/0909 Project Lead for Mental
Health PbR Development Peter.howitt_at_dh.gsi.gov.uk
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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
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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).

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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.

Cant do.
National Price
National Price
National Currency
No Currency
National Currency
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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/groups1
• 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
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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
a First Episode
c Substance misuse
b Ongoing or recurrent
c Psychotic crisis
d Very Severe engagement
a Cognitive impairment
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Example Care Cluster and Assessment Scores
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Cluster Periods and Transitions
Important ongoing work to define expected time
periods in each cluster and transition protocols
between clusters.
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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 individuals
  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 commissioners perspective the means of
  treating a service user does not matter.

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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.

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What is the Scope of the National Project?
Although not included in national project people
are looking locally at all these areas.
Line not always clear? PICU, some low secure,
specialist (e.g. acquired brain injury, eating
disorders).
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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

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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

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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).

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North West PbR MH Development Group
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PbR and links with Care Programme Approach 1

• It makes sense to align cluster time periods with
  CPA reviews, where possible.
• Clustering will occur at first assessment, review
  and at significant pathway changes.
• PbR covers wider scope than just those on CPA,
  but clusters recognise factors that mean CPA is
  required such as unsettled accommodation, history
  of violence or self-harm and dual diagnosis.
• Parenting and caring responsibilities partly
  considered through safeguarding children and
  vulnerable adults additional item.

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PbR and links with Care Programme Approach 2

• Allocation involving HoNOS fits with CPA. CPA
  guidance states It is expected that for people
  on (new) CPA HoNOS ratings will be completed at
  significant points of change within the care
  pathway and at any event, at least once a year.
• PbR allocation, like CPA needs to consider fit
  with social care service user led assessments.

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What can you do to prepare for Mental Health PbR?

• Check PbR website for more detail e.g. Practical
  Guide.
• Find out if your Trust have work ongoing to
  prepare for mental health PbR.
• Get involved in SHA wide project, where they
  exist.

http//www.dh.gov.uk/en/Managingyourorganisation/F
inanceandplanning/NHSFinancialReforms/DH_4137762
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Any Questions
And a question for you what, if any, additional
links need to be made between mental health PbR
and the Care Programme Approach?