News / Well paced progress

An erroneous media report declaring the premature death of the new mental health payment system in September created consternation among the mental health community. Trust finance practitioners were straight on the phone to double-check there was no truth in the story. These were quickly followed by numerous further calls to reassure local stakeholders, including GPs and commissioners, that the system remained in place.

Last month's 2014/15 national tariff payment system: a consultation notice underlined the point. Far from wielding an axe at the new cluster-based currency, Monitor and NHS England outlined their expectations on how clusters should be used in local contracts for 2014/15.

As the incorrect news story had rightly stated, there will be no national tariff in 2014/15. But no one in mental health was expecting one. After all, Monitor and NHS England's engagement paper at the start of the summer had already indicated the extent of the planned changes. And, in line with developments across the acute sector too, Monitor and NHS England appear to have decided the 'payment by results' term is unhelpful. They want to talk about a tariff payment system that provides rules for all secondary care activity, whether covered by national or local prices.

But the cluster-based payment system remains the approach of choice for adult mental health services. And that has to be a good thing if speakers at an HFMA Mental Health Finance faculty discussion forum in October are to be believed.

In fact, talk of national tariffs is seen as a distraction by finance practitioners in the sector. At one time, national tariffs were seen as the main point of developing mental health payment by results – providing a link between funding and the services provided and some protection against the erosion of mental health budgets. Instead the focus from speaker after speaker was on the benefits already being achieved in terms of improved understanding of what is actually being delivered to service users and what should be delivered.

Improved data

'We already have much better data than we have had,' said James Duncan, finance director of Northumberland, Tyne and Wear NHS Foundation Trust and chairman of the Department of Health's mental health payment systems finance group. 'We’re light years ahead of where we've been. In the past, we have not known what is going on and taken decisions at the margins. And that leads to disjointed systems.'

He added that the NHS was on a journey with the new mental health currency, but that the direction of travel was right. 'We have got to get to a point where we are sharing good-quality data and are focused on better outcomes for service users,' he said.

Simon Hunt, assistant finance director at Cumbria Partnership NHS Foundation Trust, told the delegates, who represented all English mental health trusts, that the new system was providing a 'truer picture of service need' and 'real evidence for commissioning discussions'. In many areas, the need to develop pathways has led to standard approaches being put in place across whole health economies, providing assurance to service users that they are getting the right treatment, irrespective of postcode. And there was widespread positive feedback about the way the currency and system development had driven clinical, and in some cases, service user and carer, engagement.

Pippa Ross-Smith, deputy finance director at Avon and Wiltshire Partnership NHS Trust, said this greater understanding – of service provision, service user need, staffing requirements and outcomes – was really 'what the whole journey is about'.

The next steps in the journey – at least those needed to meet national requirements – were set out in the tariff consultation notice and the accompanying non-mandatory Draft guidance on mental health currencies and payment. The limited mandatory requirements in the formal tariff notice include continued use of the 21 clusters as the currencies for adult mental health (although one is currently blank). Initial assessments are treated as a separate currency outside the clusters.

In one sentence, the consultation notice mandates the currencies for payment purposes and then allows for risk sharing mechanisms. Given these risk sharing mechanisms range from the continued use of block contracts to payments varying with activity within agreed limits, this amounts to a strong push towards the use of activity-driven contracts based on clusters.

Mr Duncan said this was a sensible approach and added that the suggested caps (±2%) and collars (±5%) offered a good way forward. ‘There is no point moving to cost and volume (contracts) if the data quality is not good enough,’ he said. ‘There is simply no point in destabilising a commissioner or a provider. First, we need to understand what the data is telling us. So [the approach set out in the tariff notice] is about sensible steps forward, with the thresholds recommended to keep the system as stable as possible.’

The non-mandatory guidance recommends the use of cluster days as the detailed contract currency, with separate prices for non-admitted and admitted care. These prices should be identified alongside activity levels and assessment prices in the finance and activity schedules, which should also indicate the integrated cluster price. The guidance continues to suggest that cluster prices should be set at CCG level, with a uniform price across all of a provider's commissioners an option 'where locally agreed'.

Quality indicators

The other significant mandatory requirement is the continued use of quality indicators, agreed for each care cluster and monitored on a quarterly basis. With a growing focus on outcomes, these quality metrics are seen as an integral part of the new payment system – the key to it not being a simple driver of activity. ‘There is more prominence given to quality and outcomes than last year,’ Mr Duncan said. ‘If you concentrate on one thing this year, it should be this.’

Testing is continuing on the HONOS-based four-factor model consultant rated outcome measure, (CROM), with the Health and Social Care Information Centre due to start reporting this measure from April. But providers and commissioners are also urged to use patient reported outcome measures (PROMs) and patient rated experience measures (PREMs) too.

Mr Duncan admitted the metrics weren’t perfect but that waiting for perfection was not an option. ‘We’ve got to see this as a journey,’ he said. ‘These are the best metrics we’ve come to so far. We’ve got to start using them, then improve them [as we go].’

But he acknowledged that initially incentives and penalties around the metrics should be linked to ‘improvement trajectories’ rather than hard targets. And in terms of the four-factor model, he warned that use of the full assessment tool at the outset and review was vital to demonstrate improvement. ‘If you haven’t used the full tool at the beginning, you won’t be recording a user’s full needs,’ he said – making it difficult to demonstrate improvement.

The West Midlands has already started to explore a more sophisticated approach to assessing and reporting outcomes. Steve Byng, payment by results implementation lead at Dudley and Walsall Mental Health Partnership NHS Trust, told the forum that a good outcome varied among the different service users across the 21 clusters.

 ‘A user in cluster 5, who is severely depressed – you might expect to get better and be discharged,’ he said. ‘But for a user in another cluster, it might be more about maintenance.’ And good outcomes for a service user in the latter stages of a degenerative condition such as dementia will be completely different.

The West Midlands regional quality and outcomes group has developed a matrix that analyses where improvement might realistically be expected and mapped this to the four-factor model to provide a more granular understanding of assessment scores. It is exploring how this tool can be used in practice.

Paul Stefanoski, chairman of the HFMA’s MH Finance faculty and deputy chief executive at Black Country Partnership NHS Foundation Trust, underlined the importance of improved data as the foundation for using clusters to both understand services better and as the basis for payment.

He said Monitor’s permissive approach, with limited mandatory requirements, provided an opportunity for mental health practitioners to have a real influence on the system’s development. But the flip side of this was that health economies needed to make real progress.

‘The cluster-based mental health payment system is not dead,’ he said ‘But what we don’t know is exactly what it will look like in three to four years’ time. We can – and should – have a real role in shaping this system. We are all at different stages in our own journeys towards using clusters, but there is lots we can do aside from what we have to do as part of the tariff requirements. We can already see some of the benefits, but the potential prize – a real understanding of our services and a real focus on better outcomes for service users – is much greater.’