Feature / Beyond payment

As payment by results in mental health takes a significant stride forward in 2013/14, Steve Brown finds finance practitioners focused on the new currency’s ability to improve understanding around local services.

Mental health finance practitioners have long called for a national tariff for mental health services. They saw it as offering some protection for funding. With payment related to activity in the acute sector, and rising levels of acute demand, mental health organisations feared their budgets would be squeezed.

In 2013/14 the NHS takes a giant stride towards a national tariff. There are published indicative costs for the new mental health clusters, the currency introduced last year.

The costs are there to be used as comparators and not to set contract prices. But they are a clear indicator of how a tariff could look. And while contracts will not be at national tariff prices, all contracts in 2013/14 do have to be agreed on the basis of clusters, with local prices agreed based on cluster activity and current contract value.

So it is interesting that just as the service takes this step towards a possible future national tariff, practitioners at the HFMA Mental Health Finance conference in London during March seemed less focused on the urgent need for a mandatory price list.

That, however, does not equate to a disinterest in the new currency. Far from it. In the more advanced organisations, there are reports that the new currency – and the clinical engagement created around it – is providing the mental health service with an opportunity to understand exactly what it does.

Alongside this, clinicians and managers are looking to standardise pathways, manage caseload and develop meaningful outcome measures. For the time being, this is where the value is for the sector – not an early move to national prices.

In some mental health providers, PBR and the use of clusters remains a finance initiative. But it must enter the clinical domain to succeed. Northumberland Tyne and Wear NHS Foundation Trust finance director James Duncan told the conference he was seeing signs of traction at his trust. ‘Some clinicians are wary of clustering but when we talk about how we redesign services, it tends to click,’ he said. ‘It’s a way of having a common language.’ 

Mr Duncan said the work around clustering – assigning patients to clusters, observing review periods and developing packages of care to be provided to users in each cluster –had been an eye-opening experience. It had given the trust a much better understanding of what it was currently doing.

He said this was a vital starting point for the challenge facing all organisations across the health service of taking significant cost out.

‘We need to take the cost out and we know we can’t do it by just taking slices off, as that would lead to unsafe services,’ he said.

Transformation call

As with other sectors, transformation is the only solution – finding better ways to care for patients and users. The development of packages of care to support clusters is an opportunity to deliver exactly what is required – clinically designed, standardised pathways.

Perhaps what is missing currently – and not just in mental health – is a real link with service user outcomes. But here too there is progress. The Department of Health will be testing a number of quality indicators and outcome measures in 2013/14. Seven indicators have been published and trusts are required to agree between one and three of these for each cluster (see PBR in 2013/14 box overleaf). Alongside this, work is continuing on clinician-rated outcome measures, patient-rated outcome measures and patient-rated experience measures (CROMs, PROMs and PREMs).

Mr Duncan said outcome measures – those being developed nationally and local indicators agreed with commissioners – were a work in progress. But he said it was important to start somewhere.

Having defined and agreed cluster-specific care packages, the Northumberland trust has been analysing the skills needed to deliver these services alongside the skills it already has in place across its teams.

There are big challenges ahead – improving clustering and getting it embedded in clinical practice and how clinicians use the Health of the Nation Outcome Scales four-factor model, for example . In general it knows it needs to make significant improvements in the time its community teams spend with patients. It also needs more granular data to understand the care it is delivering, but do this without creating a massive system of bureaucracy.

Information is perhaps the overriding issue relating to the new currency. ‘Data quality is the key concern,’ Paul Stefanoski, chair of the HFMA’s faculty MH Finance and finance director of Black Country Partnership NHS Foundation Trust told Healthcare Finance. ‘It’s improving but it is nowhere near there yet’.

It is something the Department is acutely aware of as well. Its PBR guidance for 2013/14 said that some providers were still not submitting complete data records set out in the mandatory mental health minimum data set.

Recording diagnosis is one area of great variability. Incomplete records will this year be highlighted on a monthly basis. It also flagged the importance of accurate clustering (supported by new clinical algorithms) and the need to improve costing (the subject of a recent audit exercise).

If data is the big challenge, clinical engagement is perhaps the major benefit from the work around clustering. Garry Nixon, care pathways project lead at Berkshire Healthcare NHS Foundation Trust, said the trust was clear: ‘Never mind PBR, we’d want to do this anyway.’

While early clinical involvement was perhaps driven by a desire to challenge relative funding between localities, those involved have quickly recognised the wider benefits.

Dr Virginia Goncalves, a consultant psychiatrist, took an early lead on clustering and care packages work at the trust.

She told the conference she quickly came to see care packages as a way of describing the basic components of care to support the provision of a consistent level of service.

There were some also specific issues that could be tackled. Discharge criteria, for example, were seen as a way of managing a caseload that was characterised by growing referrals but few discharges.

Mr Stefanoski summarised the views of many at the conference. ‘We have a framework to develop something really powerful, but we need time to do it properly,’ he said. ‘We don’t want to move to tariff too quickly because we run the risk of freezing the numerous imperfections that would be in it at that time. But we also don’t want to carry on indefinitely. It’s a judgement – do the benefits outweigh the risks?’

Steady progress

The 2013/14 PBR package is the last one to be issued by the Department as it transfers responsibility for pricing to Monitor and the NHS Commissioning Board. But the mood music coming from the two new bodies suggests there is no appetite to overaccelerate progress towards a mental health national tariff. Monitor, for example, has talked about wanting to support the development of improved activity and costing data in mental health – vital precursors in any moves to national prices.

We await a soon-to-be published pricing strategy, but the expectation around mental health is for an approach based on stability and steady progress.

That steady progress should be built on greater sharing of experience across the sector, according to Mr Stefanoski. He described  PBR as being built of a ‘myriad of different dynamics and issues’ – issues relating to clinical engagement, commissioning, finance, data quality, outcomes and pathway redesign.

‘Mental health trusts have majored on different aspects,’ he said. ‘But no one has got it all right. We need to understand what is going on and join all the best bits to get to where we want to get to. Moving forward has to be about sharing local experience and best practice.’