WORKING TOGETHER TOWARDS
INTEGRATION
PAYMENT BY RESULTS (PbR)
WORKSHOP
Why Payment By results (PbR)?
• Increase the link between payment and
quality of care and drive integration of
services
• Support the expansion of a more
transparent rules based funding system
• ‘Incentivise best clinical practice and
improve outcomes’*
* Operating Framework NHS 2012-13
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Mental Health PbR is different to
acute PbR
• The currency of Acute PbR is the
Healthcare Resource Group (HRG).
• HRG uses ICD10 codes and other
classification systems .
• Mental Health PbR uses Care Clusters
instead of HRG.
• Mental Health PbR does not use the ICD10. Instead, professionals rate service
users using the Mental Health Clustering
Tool.
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Current system
• Before PbR most (PCTs) had simple ‘block
contracts’– effectively a fixed amount of
money for the year ahead.
• Many of the risks in the system were
carried by providers. i.e. rising activity
levels would increase provider costs,
without any extra income
• Block contracts were generally based on
historical patterns of care and reflected
local costs of providing care.
4
New system - Care clusters
• The Care Clusters are based primarily on
the needs and characteristics of a service
user
• Clinicians allocate a patient to one of 21
care clusters
• The clusters are mutually exclusive in that
a service user can only be allocated to one
cluster at a time.
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What’s not included in 2012/13
• Improving Access to Psychological Services
(IAPT)
• Child and Adolescent MH services (CAMHS)
• Forensic and secure services
• Specialist services (incl. deaf, eating
disorder, neuropsychiatry, learning disability,
addiction services, alcohol)
• MH services under a GP contract (and
others)
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Decision Tree- Care Clusters
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The Mental Health Clustering tool
• The MHCT incorporates items from the
Health of the Nations Outcome Scales
(HoNOS) and The Summary of
Assessments of Risk and Need (SARN).
• Part 1 – 12 items HoNOS related to
severity of problems
• Part 2 – SARN consider problems from a
‘historical perspective’
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How does it work?
Step 1
Routine screening assessment
process scores the patient’s needs
using MHCT
Step 2
Decision tree - to decide if the
presenting needs are A,B,C
Then decide which of the next level. This will
narrow down the list of possible clusters.
Step 3
Look at the grids - which one is the
most appropriate
red: level of need which must score
orange: expected scores
yellow : may score
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Service delivery
• Assessments – funded separately and can
be classified in three ways
a) Assessed, not clustered
b) Assessed, clustered
c) Assessment ‘service’
• Care pathway – 21 care clusters
• Care Transition protocols – move within
super cluster or discharge
• There is one transition protocol for all MH
Providers
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Different from Wonderland - Clusters
as Contract Currency
• Commissioners will be paying providers on
the basis of x people in cluster 1, x people in
cluster 2 and so on.
• Payment would be for all elements of care
service user receives, both direct (therapies)
and indirect (care co-ordination).
• Clusters should cover care provided as part
of the section 75 arrangements
• Person/needs focused as opposed to
service focused
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Strategic Challenges
• Timescales
• Risk of focus on detail and challenges
• Commissioning and governance changes.
All of the above will divert attention away
from potential of PbR to deliver quality
services which focus on ability and
reablement and offer choice.
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Delivering QIPP via PbR
If PbR is implemented correctly, PbR will…
• Offer a real understanding of how services
are configured and delivered
• Provide a means to systematically
measure quality information that allows
data reporting and benchmarking
• Inform decisions about commissioning and
de–commissioning
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Using PbR to incentivise quality care
If PbR is implemented correctly, PbR will…
• Enable payment for a cluster of care with
data on the outcomes
• Potentially encourage providers and
clinicians to innovate with pathway
development which delivers better outcomes
at the same cost
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PbR and Personalisation
• ‘Personalisation is generally understood to
mean a culture in which citizens are able
to shape the services they need, with
choice and control, so that support fits the
way they wish to live their lives’
• ‘The link between personalisation and PbR
is vital if the ambition to offer people real
choices and achieve more cost effective
joined up commissioning and provision is
to be realised’*
*Getting it together for MH Care: Payment by results, personalisation and whole system working, NDTi, Dec 2011
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Local Challenges
• The quality of data - poor data quality
means that trusts will not have a robust
currency by April 2012
• Data interpretation
• Robust costing mechanism - inaccurate
tariff risk destabilising providers and
commissioners
• Significant variation of funded services
between boroughs – price per cluster per
trust for 2013-14
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London programme 2012-13
• London Currencies Development Board
(LCDB) - chaired by Wendy Wallace
• London Health Programmes (LHP)
o Commissioner steering group – chaired
by Stuart Saw
o Programme approach
o Engaged stakeholders
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Work streams
Commissioners
• Costing and contracts
o Service specs, care clusters
o Template for information scheduling and reporting
• LA and 3rd sector
• Transition to CCGs
Providers
• Training on transition protocols
• Data quality
• One price per cluster
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Work streams cont…
Jointly commissioners and providers
• Cost per cluster per trust 2013/14
• Develop specs and care clusters
• Information and reporting schedules
Nationally
• Outcome metrics
• Expand PbR (IAPT and Forensics in
2013/14)
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Mental health PbR timeline
Commissioning Implementation
by providers
DH
Costing & Implement
contracts HoNOS PbR Mandate
2009
2010
2011
2012
April 2012:
Introductory year
Jan 2009: DH
mandates MH PbR
2010: MHCT
and transition
protocols
released
April 2013:
Go live
Feb 2012:
31 Dec 2011:
All patients Final guidance
released
clustered
April 2013:
•Initial data
shared
•Contracts
signed off
Dec 2011:
MOU agreed
June 2009:
Implementation
starts
2013
Feb 2012:
Training
for
transition
protocols
Dec 2011:
Joint
working
initiated
April 2012:
•Commissioning
using PbR