Delivering a more effective mental health investment standard

by Suzanne Robinson and David Chandler

20 November 2020

The mental health investment standard (MHIS) aims to drive commissioners’ investment in mental health services at a faster rate than their overall increase in allocation. But it is an issue that frequently divides local health economies, where ‘commissioners just don’t understand’ and ‘providers just don’t get it’.

While it is a blunt tool, finance practitioners from both the provider and commissioning communities have come together to recommend ways to sharpen its performance and make it a useful mechanism for supporting a shared goal of improving services.

The MHIS seeks to address the historic under funding of mental health services through mandating increased spending in this area by clinical commissioning groups, year on year. This spend can be in many different areas that meet the definitions in the standard, including on prescribing and continuing healthcare (CHC). The majority of CCGs meet their MHIS and this is independently reviewed each year.

NHS mental health providers can see that their local CCG is meeting the MHIS for their area, but they might only see a proportionally smaller level of investment in their services. There is frustration that CCGs can meet the standard through prescribing and CHC spend and not by investing in their local services. But this frustration is felt by commissioners too.

Both prescribing and CHC are volatile areas of spend and CCGs need to hold back some money until later in the year in case it is needed to meet unavoidable expenditure. This is money that could have been invested into improving local services earlier in the year, but instead has had to be held in reserve for some unknown future problem. Even if this money is subsequently released for providers, trusts will not have been able to plan for its use.

Another problem is the way that the current MHIS is measured by comparing levels of investment year on year. If a CCG invests more than required in one year, then that has to be exceeded in the following year, regardless of how significant that extra investment was. With limited resources, CCGs have to be aware of how expenditure in one year could adversely impact their ability to invest in future periods.

It is issues such as this that brought together the HFMA’s Mental Health and Commissioning Networks to develop solutions to the perverse incentives of the MHIS. The aim of the MHIS is supported by everybody, regardless of organisation, and the problems are universally recognised. Some fairly small changes could have a significant impact on the effectiveness of the MHIS and really improve mental health services for patients.

Together the two groups have developed a number of recommendations that we believe will make the MHIS more effective. These have been shared with NHS England and NHS Improvement to support them as they develop the financial regime for the coming years. You can read more about the background to these issues and the association’s recommendations for change in a new briefing – Development of the mental health investment standard – published this week.

For example, if MHIS investment was measured over a three-year period, then CCGs could pump prime services and support improvements without being concerned about making future years difficult. Removing prescribing and CHC from the MHIS would take away the volatility and enable more informed decisions to be made about where to spend funding to improve services.

NHS England and NHS Improvement recognise that the MHIS is not perfect. Spending more money on mental health doesn’t necessarily mean that you are spending it well. And even if year-on-year spend increases, some areas are still severely underfunded when it comes to mental health. While it is difficult, it is essential that quality and outcome measures are added to the assessment of the MHIS. We need to know that the extra money is making a difference and that it is being invested in the right place.

When it comes to delivering high quality care that makes a difference to people’s lives, it doesn’t matter whether you are a provider or a commissioner; you want to spend that money well and you want to spend it in the right place. Working together through the HFMA gives the finance community a voice. It puts aside our differences and it shows what is possible when we talk to each other. As we all move towards ever closer system working, breaking down those boundaries and finding the common ground, is more important than ever.

HFMA briefing: Development of the mental health investment standard