Comment / Staying on track with the cluster system

According to some reports, payment by results is not fit for purpose. This is a view I can sympathise with, given that the purpose of the system has changed substantially over the past decade. There is undeniably a need to look at different approaches, but there is still going to be some form of tariff-based system for most services – and mental health services need to be part of this.

As Paul Briddock commented last month (Healthcare Finance September 2013), the payment system must support delivery of greater integration, pathway change and whole system working. Greater links with outcomes have to make sense. And we are likely to need different models for different services.

Mental health is one area where we need to let the current work play out. We are only in the early stages of adopting a new cluster-based currency, albeit with local prices. We are nowhere near a national tariff-based system. But we are testing ways in which we can get quality and outcomes embedded into the architecture of the system.

We also have the benefit of the acute sector experience. There has been a move away from simple activity-based payments for acute care, but this has required bolt-on adjustments for outcomes (readmission rules) and quality (best practice tariffs). In mental health, we have the advantage of trying to build these in from the outset.

For many aspects, the mental health community is being left to determine the detail. For a sector more accustomed to implementation than design, this marks new territory. But with Monitor and NHS England looking to build future currency and tariff development on local experimentation, it is something we will all have to become more comfortable with.

Mental health PBR guidance for this year talks about quality indicators and outcome measures being ‘an integral part of the currency model’. Trusts have already been given seven quality indicators to report on, but these still feel like organisational-level measures. The future power of any tariff model will come from indicators more directly focused on care at an individual service user level. The ongoing work to develop PROMs (patient reported outcome measures), PREMs (patient reported experience measures) and CROMs (clinician rated outcome measures) is fundamental.

I do not expect there to eventually be a perfect ‘answer’, applicable in all circumstances and relevant for all individuals. But given competing demands and the economic environment we are operating in, mental health services need a methodology for justifying investment in terms of outcomes. Today’s balancing act is to maintain momentum and a real sense of year-on-year movement while acknowledging that actual services still need to be developed and innovation pursued in the meantime.

While this development takes shape, trusts need to ensure their information and costing systems can respond effectively and efficiently to the additional demands placed on them. Whatever the end-game is, robust information about each part of the needs-resources-outcomes triumvirate will be required.

I believe the mental health approach that’s being developed is consistent with Monitor’s and NHS England’s longer term goals for payment systems. Media reports in September  of ‘dropping’ mental health PBR on the back of uncertainty surrounding the existing system are just plain wrong.

Dropping the ‘payment by results’ name, on the other hand, makes sense, given its links with simple activity-based funding. I believe that, for once, mental health is ahead of the game. It would be a shame to squander this advantage.

Paul Stefanoski is chair of the HFMA Mental Health Finance Faculty and finance director of Black Country Partnership NHS FT