Comment / Improving value in mental health services

Having spent 15 years in acute hospitals before joining Kent and Medway NHS and Social Care Partnership Trust (KMPT), it was a real eye opener for me moving into the mental health sector.

I remember the monthly catch up call with NHS Improvement on just my second day in the job.  I was asked: what do you think is driving the deficit at KMPT? Thank you Carla Moody – nothing like being eased in gently by the regulator!  It was a perfectly legitimate question. What was driving the deficit? And how do we look to improve value? (This issue is discussed further in a new briefing – Mental health value challenge, published by the HFMA Healthcare Costing for Value Institute.)

We had an underlying overspend of £11m per annum and we were a very traditional organisation that reported actual expenditure versus budget and never looked at income versus expenditure for services. I knew this was something I needed to change immediately, if we were going to get engagement from the operational and clinical teams to address the underlying deficit.

Understanding costs is a key component in understanding value. We had a really good patient-level costing system, but sadly the outputs of this were not widely shared across the organisation. And the operational and clinical teams had no idea whether their services made a loss or broke even.

I encouraged the team to develop service-line reporting (SLR) as soon as possible – building on the solid platform of our patient-level costing system.  Within three months we had the first SLR report to share with the organisation. We could see what the financial performance was for each care group, split by the relevant service lines. It would be an iterative process once we had the engagement, but it was a good starting point to provoke debate.

This provided me, the executive team and the board with a much better understanding of our financial position. And it also enabled me to develop a plan with the chief operating officer regarding which areas we needed to look at first, at pace!

The trust is structured into four clinical care groups: forensics and specialist services; older adults: community recovery; and acute.  Each care group is responsible for specific services, which may be inpatient-based or community-based depending on the service the trust is providing. The services within each group are then delivered by a range of multi-disciplinary teams spread across the whole county of Kent and Medway.

One care group was actually driving nearly half of the trust deficit. Using the information we had, we were able to compare team level information across the county, but also across two of our main hospital sites. We compared the costs of running each team internally, but also benchmarked our prices with our peers (income and expenditure).

This was undertaken jointly with finance, operational and clinical teams. A number of reasons were identified for the group deficit. In one particular case the bed price we received (income) was considerably lower compared to our peers with an impact of £1m per year.

Costs on one site were also considerably higher than the other site for providing exactly the same services. This enabled finance colleagues to challenge the care group and start to understand the potential drivers of this.

The result was a care group that had a far better understanding of its cost base and a robust recurrent cost improvement plan (CIP), something the group had struggled to produce for a number of years. To date, the group’s recurrent CIP has been £1.5m.   

We have also looked at various pathways in KMPT. One particular area of focus was the cluster 18 pathway, which is the memory assessment service – a pathway that appeared to lose KMPT £1m a year, based on the income we are receiving for the service and our cost base.

We worked with the relevant care group and a lead clinician to look at the team level data, analysing the number of clinical contacts undertaken by each team.

There appeared to be unwarranted variation across the 11 teams covering the county and so we scrutinised their cost base, and the whole-time equivalents (WTE) to understand this. Each team was different. However, a particular focus was the length of time it took to undertake an initial assessment, which varied between teams from 30 minutes to two hours. 

The lead clinician drove this work and made a number of key changes to standardise the time for an assessment and embedded new practices.  It is surprising what robust data and hard facts can highlight for our services. The variation between the teams was very surprising, but the information helped to focus on what could be done to support the clinical lead in his main aim of delivering excellent patient care and outcomes.

The power of SLR should never be underestimated in an organisation; it positively encourages clinicians to join in the important discussions regarding finance. It has been an interesting journey so far. 

There is still more to do, there always will be. But we have reduced the underlying deficit to £5m from £11m in the past two years. The next major step in the move to addressing value is to improve our understanding of outcomes, using patient reported outcome measures.

We have a clear plan and one that will be delivered jointly by finance and the operational and clinical teams, I am confident of that!

Mental Health Value Challenge – how can we maximise the use of resources in mental health to provide the best possible outcomes for service users? is available for download from the HFMA website