Comment / Mental health QIPP and the domino effect

Unrealistic and simplistic QIPP targets for mental health services could be paid for in other parts of the health system unless we take a system-wide approach to planning, argues Ros Francké

The NHS faces unprecedented challenges in finding productivity savings of £20bn in the next four years. We are no strangers to efficiency, but this is different. Without the real and significant growth in income of recent years, we now need – to quote David Flory – to deliver efficiency like never before.

All parts of the health economy have to contribute, but it is vital that planning is across whole systems. We need to understand the appropriate contribution each sector can make and appreciate the inter-connections. We must avoid cuts in one sector leading to increased costs in another.

The HFMA Mental Health Special Interest Group has discussed concerns about the quality, innovation, productivity and prevention (QIPP) models being used in some areas. The current QIPP models  look at growth and demand in a way that mental health providers – still largely on block contracts – find it difficult to engage with. The formula employed tends to look at drivers in the acute sector. The danger is  these models miss the valuable economy-wide contributions that can be made by relatively small investments in mental health services.

For acute trusts, last year’s tariff uplift was challenging. But their income still flexes with increased activity, even within emergency admissions (albeit at a marginal rate). But for mental health providers, increases in demand are often simply not recognised in block contracts. Just reducing a block contract to ensure a contribution to the health economy’s financial  targets is not the answer. Instead we need to recognise what extra value commissioners are receiving for the same contract price, year-on-year that is not costing the health system any more.

Mental health providers have already been delivering significant levels of efficiency and productivity improvement. For instance, many have made huge improvements in reducing inpatient admissions and have developed supporting community services to ensure recovery and reablement for service users.

This community service approach by mental health organisations can make a huge contribution to the overall QIPP challenge. For example, evidence shows that community drug and alcohol services can reduce demands on acute services. They help avoid emergency admissions and enable swifter discharge of those admitted for alcohol- or drug-related issues.

Now initiatives such as alcohol liaison workers could deliver the desired impact but still not take an acute provider over a tipping point where inpatient costs can be taken out of the system. This can be overcome by assessing the critical mass of inpatient capacity no longer required and how a bundle of initiatives (supporting dementia care, say) can support this transition. What we must avoid is the reduced demand from these initiatives being eaten up by latent unmet demand elsewhere in the system.

An expansion of these services – and primary care mental services – would be beneficial in many areas. But cutting services to meet unrealistic QIPP targets will end up being paid for in the acute sector.

The key will be strong leadership from primary care trusts in assisting the emerging GP consortia developing this agenda. The proposed national mental health currency, based on clusters of service users with similar care needs, is a chance  for providers and commissioners to gain understanding of activity, casemix and spending within mental health services.

But even ahead of the currency, mental health organisations must engage with commissioners to improve understanding and ensure QIPP programmes are realistic, thought through, and deliver the right service and cost outcomes across the whole economy.

The contribution of integrated mental health and community services organisations to QIPP will also be interesting. This bringing together of a critical mass of community-based service may offer greater potential to avoid costs in other sectors, improve patient outcome and be a more powerful agent for change.