Feature / A common language

A new national currency may have been released, but work is ongoing to realise the ambitions for mental health payment by results. The Department of Health’s Adebayo Adekaiyaoja provides an update.

When payment by results (PBR) was introduced for acute trusts in 2003/04, it was always intended that it would expand to include more services. That included mental health services, which account for 11% of the NHS budget and employ thousands of staff in mental health trusts and other providers.

In a Department of Health consultation on the Options for the future of payment by results in 2007, mental health was identified as the number one priority for inclusion in any expansion. Providers were concerned that if mental health services were outside the scope of PBR, they would be vulnerable to disinvestment when money is tight – a situation we are now entering. Commissioners, meanwhile, wanted to be able to understand what they were getting for millions of pounds of funding.

However, attempts to develop a patient-level funding system for mental health have proved challenging internationally as diagnosis does not tend to determine resource usage, treatment is often long term and conditions are generally chronic in nature.

Fortunately, the NHS in Yorkshire and Humber had come up with an approach of grouping mental health service users into 21 different ‘care clusters’, based on their needs or characteristics. This had the potential to be the basis of a funding system.

Adopting this work nationally, the Department made a commitment in High quality care for all to make a national mental health currency available for use in 2010/11. (By ‘currency’, we mean a common set of units for payment for mental health services – the currency for the acute sector is the healthcare resource groups – HRGs). The clusters as a currency are very different from HRGs, as they pay for a service user’s needs over a period of time, rather than for each individual intervention such as a day case or outpatient procedure.

Progress report

The original concept came from the NHS, so development of mental health PBR has been very much a joint project between the Department and frontline services. The original developers of the clusters, the Care Pathways and Packages Project – a collaboration of providers, commissioners and the strategic health authorities in Yorkshire and the North East – have been heavily involved in refining and improving the work.

The project has now blossomed into a genuinely national endeavour as there has been significant input from other parts of the country, such as the West Midlands and London. The national project focuses on co-ordinating and bringing together this excellent local work.

As a result, significant progress has been made, most notably achieving the High quality care for all commitment (which was restated in the 2010/11 operating framework) of a national currency available for use by publishing a suite of documents in February. These included:

• A Clustering booklet for mental health PBR (2010/11), outlining the care clusters and the mental health clustering tool that helps mental health professionals determine which cluster a service user matches against
• The Payment by results guidance 2010/11, section 9 of which relates to mental health and looks at operational issues in using the currencies
• A revised version of The practical guide to preparing for mental health PBR, which sets out 10 actions that can be taken locally to prepare for the introduction of the new currency.

National policy documents are all very well, but not much use if data cannot be captured locally. So another crucial step for the project has been to have the care clusters and the mental health clustering tool approved as information standards. The Information Standards Board has published two information standards notices (the new

name for a data set change notice) on 30 April. They are available at the ISB website at www.isb.nhs.uk/isn and require IT suppliers to ensure this information can be captured by 1 April 2011 at the very latest.

Future direction

Although we are now entering the implementation phase, there is still development work to do. The clusters will be improved and refined over time. Charged with this task is the Mental Health PBR Product Review Group (PRG), which brings together local projects to achieve national consistency. The PRG has recently established five sub-groups:

• Quality and outcomes
• Costing
• Mental health clustering tool (MHCT)
• Transition and algorithm
• Forensic and challenging behaviour.

The groups will be involved in detailed work to support specific work areas of the mental health PBR development project. For instance, the forensic and challenging behaviour sub-group is looking to apply the cluster methodology to secure services and community forensic teams – the clusters are currently used for mainstream adult and older people’s mental health services.

A key component for the future development of mental health PBR is costing. The costing sub-group members are producing costing data for the clusters during 2010 at the level of individual service users. This work, informed by the mental health clinical costing standards, will help examine the resource homogeneity of the clusters. It may lead to sub-divisions of clusters, or the establishment of outlier payments for service users with higher or additional needs. This work will be carried out over this summer and autumn to inform the clusters for 2011.

The quality and outcomes sub-group is working to establish outcome measures and quality indicators for the care clusters. The aim is to have agreed outcome measures and quality indicators for the care clusters by March 2011 that would then be ready for mandating and full use in 2013/14. The approach will build upon data and tools now in use, and will be developed further to identify gaps where new indicators are needed.

This development process will mean that for the next few years there will be refinements and improvements to the care clusters and the clustering tool. However, changes will build on the existing work, rather than being a significant departure.

While development work continues, the timescale for implementation – with all service users needing to be clustered by the end of 2011 and contracting done using currencies and local prices in 2012/13 – means there is much to do now. One key issue is training to support use of the clustering tool. The Department has been working with the care packages and pathways project and the Royal College of Psychiatrists to develop training. Details on this should be available soon.

Another significant implementation step will be to collect reference costs on a cluster basis. Therefore the 2010/11 reference costs (submitted summer 2011) will be returned using the clusters. This will ensure finance managers are using the same common language as their clinical and informatics colleagues.

It also establishes the national cost collection that will enable the development of a national tariff to be considered. We have suggested this should not take place before 2013/14, as we will need to have robust cost information. We must also ensure we can account for issues such as differing levels of integration with social care among mental health services round the country. Going earlier would risk us getting the price wrong and destabilising care.

Mental health PBR will bring significant benefits, from helping to tackle the quality, innovation, productivity and prevention (QIPP) challenge to offering a framework for the implementation of mental health policy. For the first time, it will provide a common language and the national currencies mean we will be able to compare care offered in different parts of the country and the associated costs.

It goes without saying that 2010/11 will be a crucial preparatory year as we strive to fully implement mental health PBR. The more work that is done now, the greater the chance of a successful transition to per service user funding in mental health.