Feature / Sowing the seeds

Imagine a world where you were referred by your GP to a secondary care mental health service and had one relatively simple assessment at the beginning of the referral in which both your health and social care needs were reviewed.

What if, at the end of the assessment, you were offered a number of evidence-based treatments – including those that are medically based, a range of practical and talking therapies and evidence-based treatments addressing biological, psychological and social needs? You knew how long the treatment was likely to last, what the success rate was, and the point at which progress would be reviewed.

Your social care needs around housing or employment would have been identified in the same assessment, and if you should have access to a personal budget you would be made aware of this.

At the same time, you were given choices about your care package – about who, where and when your care was delivered. Your own outcome would be measured and fed back to you at the end of your care.

Imagine a world for clinicians and providers, where they are clear about the range of people their service sees and the treatment options available for each group of people. They can plan and deliver training to staff to enhance their skills and enable them to use the clinical skills they have to best advantage. Imagine clinicians and providers getting routine feedback on the outcomes they achieve – and being able to map the flows of people coming into and exiting mental health systems while understanding the different costs associated with delivering these treatments.

And imagine a world for commissioners, where the focus is on the types of treatments people are given instead of struggling through block or cost per activity contracts; where their driver is clinical and service user outcomes; they receive information that gives them confidence in understanding what is being delivered; and the task is to review, rethink and redesign pathways followed.

This may be imaginary today, but ongoing developments to understand people’s needs within care clusters and to move to a tariff based on this may make it a reality in the next few years.

Mental health services are on a journey of developing and implementing care clusters and moving to tariff. All service users will be clustered by 31 December 2011, and mental health payment by results (PBR) will be introduced in 2012/13. 

The Department of Health has a comprehensive programme of work ongoing, and the strategic health authority mental health leads are launching a readiness review to assess how far we have progressed and what further work needs to be done.

The clusters should be the foundation for a three- to five-year programme of development in mental health provision, which will support a rethinking and redesigning of local plans. This will enable all stakeholders to use better information that will enable joint working to make the best use of mental health resources and skills in the future.

Northern initiative

The breakthrough in creating a currency for mental health was developed by clinicians working in Yorkshire and Humber and the North East – now known as the Care Pathways and Packages Project (CPP). They recognised that to gain a broad understanding of the needs of people who used secondary care mental health services, they needed to build on simple clinical diagnoses and create a system that reflected the needs of the service user.  

The problem in mental health is that simple diagnoses are often not very helpful in predicting service response or in determining need. For example, with something like a diagnosis of depression, this could refer to a person who has a sub-clinical passing phase of mild depression, or could refer to a person with a lifetime of severe depression, who might need hospitalisation and at worst might be a suicide risk. The classic diagnoses are not strong enough at identifying service user needs or resources required. 

The CPP team proposed that the needs of most people in mental health services could be captured within one of 21 care clusters. So, for example, cluster one would include people who had a definite but minor problem of depressed mood or anxiety. In cluster 10 there would be people who present for the first time with psychotic problems, and in cluster 17 there would be people with moderate to severe psychosis, with unstable and chaotic lives and hard to engage with services.

Assessment is made using the mental health clustering tool. This is largely based on the Health of the Nation Outcome Scales, which have been the standard psychiatric assessment for over a decade, combined with some additional questions. The tool captures the full range of a person’s needs so we can develop a collaborative plan for care.

Many areas are developing electronic algorithms to support the clinicians in robustly and accurately allocating people to clusters, and a national algorithm is under development.

The clusters are based on service user needs, and focused on periods of care rather than individual contacts.

After decades of debate in the mental health sector about diagnosis, it all seems too simple to allocate people to one of 21 clusters, so the model has been tested in a large number of sites across the country. But while nothing is ever perfect, the response has been both clear and consistent – clinicians have found the clusters to be robust, practical and useful.

A robust set of clusters opens the door to a whole new way of understanding and managing mental health services. Providers using the clusters are enhancing their understanding of their services and using the information to question different emerging patterns, and giving feedback to practitioners that in turn is generating greater clarity and focus on the interventions offered.

Cluster co-operation

Across the country, services are using the National Institute for Health and Clinical Excellence guidance and the evidence base to develop clear programmes around what should be offered to service users in the different clusters. This will enable and enhance the delivery of effective, evidence-based mental health services.

This analysis also offers a framework for assessing staff skills and training needs. Too often staff in mental health services have been offered training, only to return to base to find their work patterns do not enable them to use the new skills. The clusters provide a framework for the use of these new skills.

The clusters also offer the framework for the routine monitoring of outcomes for every service user, and to feed back on a routine basis to clinicians.

In addition, some providers have already used the cluster data to review how people flow into and out of services, and how they flow through the system. It is common to find duplication and lack of service focus, and this opens up a big opportunity for improving services, improving quality and demonstrating outcomes potentially at lower cost.

The strategic health authorities mental health leads group has worked – through the NHS Confederation – to commission a rapid review of readiness for the delivery of clusters and tariff. The key focus of this is to:

• Assess commissioner and provider readiness to implement the currencies, building on work already done, such as the HFMA survey – click here. 
• Understand the progress already made.
• Identify the ‘hearts and minds’ issues in implementation.
• Look at what good practice can be shared across the country, and how best to do this.
• Recommend further action needed to ensure successful delivery of the programme and ensure the potential gains from this initiative are realised in practice.

There are major challenges as well as opportunities in implementing the clusters and moving to a mental health tariff. These include the following:

• Information systems and IT – the full implementation of care clusters moving to a tariff require significant investment in IT systems and a level of detail about activity previously uncollected.
• Costing – providers across the country are developing and checking costing approaches to accurately reflect what they do and what they might do. However, as it aims to calculate a cost per cluster, this is more complex than simply costing a bed day.
• Commissioner and provider relationships – as a developing process this will require a significant degree of sharing between commissioner and provider. This is difficult in the rapidly evolving landscape, and especially with the current pressure on resources.
• Putting users at the centre – this is a great opportunity to move forward in enabling users and carers to understand and navigate through the system.
• Working with social care – key drivers within social care are personalisation and resource allocation tools. The resource allocation system and the care funding calculator are social care approaches to understanding or allocating costs. Work has commenced to bring these alongside the care clusters – which potentially offer a way to enhance a coming together of cost analysis across sectors – but, once again, this will require further work in order to deliver a workable model.

Patient choice

In addition personalisation will be supported by enabling user choice, and there is potential to convert a care cluster into a personal budget, though this is yet to be put into practice.

There is a tight deadline to meet the Department delivery dates, but there has already been significant progress across the country. The readiness review creates the opportunity to enhance learning and sharing. However, if we are to reap the many potential benefits that the cluster and tariff hold, we need to see this as the beginning of a journey, not the end.