Feature / Herts and minds

The new cluster-based currency and payment system for mental health may present big implementation challenges but the system offers opportunities that are worth the effort, argue Paul Ronald and Christina Walters

Questions are being asked about the future of payment by results for the acute sector. Alongside anecdotal reports of health economies setting aside aspects of the payment regime to suit local circumstances and funding availability, we have also seen more considered concerns beginning to emerge. The King’s Fund, for example, recently concluded that PBR in its current form was ‘not fit for purpose’.

Its report How can payment systems help to deliver better care? last November acknowledged that PBR was ‘broadly suited to those services such as elective care where a choice of provider is available and where the services concerned are relatively easy to define’. But elsewhere a range of different approaches might be needed.

Given this mood music, to outsiders the Department of Health’s commitment to the staged introduction of PBR for mental health organisations from 2013/14 may seem strange. But for Hertfordshire Partnership NHS Foundation Trust, and many others in the sector, the overall goals of the new payment system make perfect sense.

The current financial environment and the structural upheaval on the commissioning side of healthcare provide a challenging context. On top of continuing to deliver services and drive up quality, mental health providers – alongside other health providers – need to challenge historical practices and service configurations and consider wholesale system change. Given this agenda, the current workload relating to the new mental health currency and payment system could be seen as a distraction. It is certainly true that current tasks – assigning clusters to service users, reworking costing systems and ramping up data quality – are time-consuming.

So is the journey worth it? Our perspective in Hertfordshire is ‘yes’. While we accept this view is not universally held, we see PBR – with some sensible tweaks – as an opportunity to provide enormous benefits to the service users and families we serve.

Mental health differs greatly from the acute system in many ways including the way care is delivered. As a consequence the move towards a payment system in mental health has been a slow, drawn out process.

The approach to mental health PBR has its origins in a model of holistic needs-based care clusters describing common needs and problems of groups of patients. It was developed from a ‘bio-psycho-social’ model – which roughly translated means a system that understands and assesses a patient’s wider needs. The model is not universally accepted, with some clinicians advocating a purely medical model based on initial diagnosis.

Diagnosis and procedure driven models of PBR, as in acute settings, mean payment will be based on what the medical diagnosis predicts is needed or, more importantly, what it should cost. However, the prevailing view in mental health is that diagnosis is not an accurate predictor of cost. The broader approach to understanding patient needs – based on the cluster model – provides clinical benefits (in assessing patients, clinicians are guided to decide what problems the individual is having and what care could be offered) and so is potentially a better predictor of cost.

How does it work?

The first step is to find a common way of summarising the wider needs of the patient and classifying them in a clinically meaningful but systematic way. Mental health services now have the Mental Health Clustering Tool and a system of ‘care clusters’ to enable groups of cases to be identified. A cluster does not link to a unique diagnosis of illness but will include a number of different diagnostic codes within its descriptions. And each care cluster – there are 21 defined – then becomes the unit of currency by which transactions are made.

The second stage is to determine the range of healthcare – described in care packages – an individual might be offered to meet their needs. Any organisation on track to meet mental health implementation will have begun to develop packages of care. The earliest examples linked to this system were produced in 2007 (by South West Yorkshire Partnership NHS Foundation Trust) and many similar versions have been in circulation since.

They provide guidance for the clinical teams, backed up by clinical evidence to describe what and how to meet the needs of someone whose needs are described by a care cluster. Flexibility and clinical judgement are factored in and as we head towards using clusters as a currency for payment we have to also keep an eye on affordability.

The final requirement is therefore to understand the cost of the packages of care – what they translate to in terms of clinical hours spent, and all associated costs – and translate costs into a tariff.

Why is it needed?

Hertfordshire Partnership is a successful mental health trust. With an excellent reputation for service quality and a strong financial track record, the trust is progressing an ambitious programme of capital investment and service transformation. Yet we believe there is much we can do better. In particular:

• While the trust is profitable and will fully meet its Monitor targets, our knowledge of the costs of individual services is limited. Individual service line contribution and an understanding of the marginal cost of our services are not developed.
• While we have very supportive relationships with our commissioners, the lack of transparency in the make-up or costs of our services is a growing issue as they review their current investments.
• Our information systems are limited and the depth and richness of our information is poor. Data quality is mixed and not universally seen as a priority.
• Details of productivity and case load management is unreliable. This does not facilitate comparisons across teams and between individual practitioners.

This is likely to be a common position across most mental health trusts, a position that suffers by comparison to acute trusts. Liverpool Heart and Chest Hospital NHS Foundation Trust, for example, runs a well-developed service line management system enabled by PBR to address the above ambitions.

The care packages and pathways approach to structuring mental healthcare is the underpinning framework for the PBR mechanism. Implemented within community and inpatient settings it will start to structure a process to ensure the right people get the right care at the right time. And it will take us closer to our specific goals.

We may have some way to go to deliver patient-level costing, but using a packages and pathways approach lends itself to a level of transparency and acuity that we have previously lacked. As each mental health provider adopts and implements a comparable and more consistent way of understanding its service offer, its data and the trust income derived this way, we move towards associating the key words ‘packages’, ‘pathways’ and ‘outcomes’ with tariff.

This approach also gives commissioners and service users a clear understanding of the treatments available, as well as being provided with a level of transparency never achieved within the acute sector model. Further, the outcomes of delivering care are the measures we can use to tell us the money is well spent and the care provided is achieving its purpose.

National work is under way to develop meaningful, validated outcome measures that link to clusters. While very different from understanding the number of bed days or finished consultant episodes, the principles are the same – we are looking to clearly show the link between understanding the needs of the patient and offering an affordable package of care that gives value for money, does what it says on the tin and only draws the money through the system in response to need.

In information terms, the changes brought about by transforming both clinical and financial systems will drive data quality improvements. This will enable more informed operational and strategic decision-making by commissioners and providers. And commissioners will have more opportunity to use and scrutinise the mental health minimum data set published by the Information Centre for Health and Social Care.

In Hertfordshire, understanding the financial value of each per cent of unclustered activity has brought a real focus to data completeness.

Improved activity data linked to revenue and unit costs also provides the building blocks for reporting systems to compare data across service lines, teams and individual clinicians. This facilitates meaningful evidence-based information on clinical variation and a real opportunity to drive improvements. While this is also the claim in the acute sector, the use of care pathways provides, in our view, a much greater chance of success.

Challenges

Even after several years, limited understanding and incorrect assumptions about mental health PBR are being articulated. There is a lot to change and resistance to some of the changes required. Elements such as clinical engagement, the adoption of new technologies and systems and the creation of a culture of transparency are huge challenges. But if we walk away from them we will not address the deficiencies we have identified. We need to see the opportunities, not just the challenges.

We must also address commissioner concerns about potential increases in costs. We believe the financial climate, use of contract caps, capitation limits and other controls will protect against this. Yet providers need to work with commissioners to reassure them and to ensure both sides understand the new system.

Mental health PBR may share a name with the acute model, but it is only a distant cousin – often speaking a different language. It perhaps already delivers one of the different payment systems the King’s Fund is calling for. It may have taken a long time to get to this point, but it is well placed to take the best elements of the acute experience and produce a tariff that will support many of the issues the sector has to tackle.

Paul Ronald is deputy director of finance at Hertfordshire Partnership NHS FT; Christina Walters is systems development programme manager at South West Yorkshire Partnership NHS FT and provides consultancy support to PBR implementation at Hertfordshire