Mental health: achieving the right focus

The long-term plan prioritises a widely supported expansion of mental health services. Management information will play a key role in delivering these goals, but it needs to be the right data and timescales need to take account of significant service pressures. Steve Brown reports

The NHS long-term plan renews a commitment to pursue the most ambitious transformation of mental healthcare England has ever seen. Mental health clinicians and leaders fully support the ambitions set out in the plan. However, despite a promised increase of £2.3bn in real terms for mental health by 2023/24, mental health bodies face significant challenges in meeting the plan’s goals.

They say it is vital that everything they do is focused on delivering these goals – including delivering a major boost to children and young people’s services and community mental healthcare, expanding access to IAPT services and providing comprehensive crisis care.

Data and management information will be key to the sector’s success. However, practitioners say the sector needs to be collecting the right data, the requirements need to be achievable and the collection needs to be affordable.

According to Suzanne Robinson, chair of the HFMA’s Mental Health Finance Steering Group, the debate has long centred on the implementation of clustering. But it is much wider than that.

‘It can get confusing,’ she says. ‘Clustering, the mental health service data set (MHSDS), the Model Hospital, the mental health investment standard (MHIS), outcomes measures (such as the Health of the Nation Outcome Scales, HoNoS) patient-level costing, reference costs… the list goes on. Which one adds most value? And how do we prioritise where we direct our resources? It can often depend on who you ask.’

A task and finish group led by NHS England and NHS Improvement has been looking at tariff development, which is underpinned by having good data. The group has been looking at current uptake and trying to understand why there hasn’t been universal appetite for this and possible alternative designs that could be adopted.

Finance practitioners and clinicians at an HFMA workshop in July discussed the different data and information sources available and how the sector should navigate these to provide a clear roadmap to implement an agreed way forward. The session was framed around five principles. The data and information framework:

• Needs to be simple
• Needs to be clinically engaging
• Needs to be meaningful for commissioner and providers
• Must deliver value for money from any investment in infrastructure
• Must utilise the expertise of highly skilled costing practitioners and information specialists.

Cluster focus

One area receiving attention is the currency built around mental health clusters. Introduced around 2012, the 21 clusters group patients by their characteristics and requirements, rather than the individual interventions they receive or their diagnosis. Providers have had to submit cluster-based costs for much of the last decade as part of their reference cost submissions.

The original key driver for the cluster currency was to support the development of a payment system amid concerns that the lack of a link between payment and activity was disadvantaging the mental health sector. In some providers, use of clusters has been embedded well – with clusters providing the initial way to separate out different pathways and explore variation within them. But this is not the case everywhere.

One deputy medical director at the workshop said clustering at his trust was seen as a bureaucratic exercise – with a system based on diagnosis and condition complexity likely to have more resonance with clinicians. However, there appears to be broader acceptance of the HoNoS scales that are used as a core part of the clustering process.

A finance director said clusters were not being universally used and were not well understood outside mental health secondary care. To really be useful in developing mental health services, GPs and social care would need to be familiar with their use, he said. The fact that this wasn’t the case undermined moves to system working and integrated care.

Practitioners said the world had moved on from activity-based payment approaches. With capitated budgets now seen as the future, was a payment currency even relevant?

Recognising that the current currency approach is not working as well as it could for the sector, NHS England and NHS Improvement have been reviewing the suitability of clusters. As part of this review, the organisations have looked at a number of options to develop a currency model that suits service delivery and incentivises high-quality care. This has included a review of existing local approaches.

One trust has been implementing a system where clinicians assign patients to condition-specific pathways. Cluster allocation has been standardised through use of an algorithm and clusters are used to understand patient severity and risk. Another provider has developed a needs-based currency approach, grouping patients based on their team/setting and their needs and engagement with their care.

The review has noted that all the local approaches work well when the organisation is committed to them and use the information that underpins the currency model for other purposes. This includes the clusters. NHS England and NHS Improvement plan further testing to identify the most appropriate approach.

For many finance practitioners at the HFMA workshop, the need for a national currency is inextricably tied up with payment by results and the context has changed. If integrated care systems develop as many commentators suggest they should, the service could be moving towards capitated budgets covering whole populations rather than paying for individual episodes of care.

Helen Todman, NHS England and NHS Improvement mental health infrastructure programme manager, says there is a consensus at the centre on the need for a currency. ‘A national currency model supports effective investment, by improving the transparency of funding flows through the mental health payment system, which works alongside the mental health investment standard (MHIS) to ensure that long-term plan priorities have sufficient investment,’ she says.

And she insists that whatever payment system is used – locally or nationally – needs to be informed by a currency (see box). ‘We have to have a currency as a building block for any funding system,’ she says, ‘whether that is blended payment or population-based.’

A currency also enables services to demonstrate how much safe and effective care costs, she adds. ‘Currency allows understanding of whether services are delivering value to patients; by providing comparison between the cost of service delivery with quality, safety and effectiveness for specific patient groups,’ she says.

Costing – and in particular the move to patient-level costing – is one of the other issues challenging mental health finance managers. There are different views around the introduction of patient-level costing for mental health providers. Some organisations have been pursuing patient-level costing for years, despite typically having fewer resources dedicated to costing than acute providers.

North Staffordshire Combined Healthcare NHS Trust implemented patient-level costing in 2015 and has been an early implementer of the new national costing standards. Its work was recognised with the HFMA Costing Award in 2016.

But not all mental health trusts have made this sort of progress and some managers at the workshop said it was hard to make a business case locally for the investment of time and money needed to meet next year’s mandatory patient-level cost submission deadline. (Acute trusts faced their first mandatory collection this year.)

Ms Robinson says the sector is committed to ensuring all services add value and make a difference and that it maximises the value of the mental health pound. ‘But there is concern that clustering and a tariff-based system may not answer this question from a system perspective, at least not in the short/medium term,’ she says.

It was highlighted that a huge amount of detailed data is needed to deliver a patient-level cost submission. Some at the workshop said this was difficult to deliver with current information systems and would provide uncertain benefits – especially given the existence of other benchmarking tools such as the Model Hospital. (The plan is for the Model Hospital to draw information direct from patient-level cost data, but it currently uses a bespoke collection for workforce cost submission.)

For some, the key issue is timescale and prioritising the initiatives that will best support the delivery of the long-term plan goals.

‘There may be more value in focusing in the short term on the key data sets,’ says Ms Robinson, although there is some recognition around the service that the overall goal of developing a deeper understanding of patient costs is valuable. And the demanding deadlines for patient-level costing have encouraged some trusts to make steps towards being compliant, even if many are still some way off being able to produce meaningful patient-level costs.

Mental health trusts are often less well advanced in terms of costing than acute colleagues, a position created by the introduction of tariff-based systems in the acute sector many years ago. This has driven up the data quality for acute trusts, but there are questionmarks around the affordability of the framework for mental health trusts. Ms Robinson believes there is a danger that next year’s costing submission could end up as a tick-box exercise producing data of little value.

One finance director at the workshop was concerned there would be no return on patient-level costing if it was just an annual submission that disappeared into a central black hole. It has to add value. Simply cranking the handle to make the submission would consume all a typical mental health trust costing team’s time, when these teams could be more usefully supporting clinical teams to improve service costs, he said.

Improving transparency

Ms Robinson believes improving transparency around the mental health investment standard (MHIS) should be top of the agenda. This should focus on helping to demonstrate that the standard is being met and that additional investment from the forward view and the long-term plan is reaching its intended areas. Beyond that, she says, agreeing a common, well-defined set of service lines would improve the sector’s ability to compare and contrast and provide better assurance across systems (and multiple providers) that they are making a difference.

There is broad support for the goals set out for mental health in the NHS long-term plan. Management information will be vital in helping to deliver these goals and demonstrating their achievement. But the clear message from July’s HFMA workshop was that current initiatives should be working together to ensure they support these goals. And timescales must take into account the sector’s starting point and existing pressures.

The HFMA Mental Health Finance Faculty is working with NHS England and NHS Improvement to set out some principles and key milestones that might support a clearer roadmap for mental health providers to work to on their costing journey.