Mental Health Payment by
Results (PbR)
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Outline
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Why move to PbR?
What is the mental health currency?
Care clusters
How does clustering work
Assessment
Transition protocols
Care packages
Pricing
Implementation timeline
Local commissioner update
Local trust update
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Why does MH commissioning need
to change?
• Quality, efficiency and the cost of MH care have
been variable across the country, and with little
flexibility or patient choice.
• Economic context makes it all the more important
to ensure we get the best value for every single
pound of tax payer money we spend. We need a
framework that will enable us to do just that.
• Providers in MH are fed up with acute providers
taking all the money and being left as a soft target.
• Commissioners need to demonstrate more value
from substantial MH investment.
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Why move to PbR?
• Facilitate patient choice
• Enable diversity of provision
• Introduce some of the benefits of a market without
having to negotiate the cost. Reward quality more!
• Promote efficiency at higher cost trusts (because
they have to reduce costs to a national tariff level)
and there is more standardisation of pathways
• Refocus discussions between commissioner and
provider
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The Mental Health Currency
• The mental currency is care clusters – the
tariff is based on the packages of care and
interventions that go with it.
• A key issue for mental health and PbR is
that in many cases diagnosis and severity
of the illness do not predict resource use
accurately.
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What is in the currency?
• All mental health care should be covered by
the clusters.
• The clusters are designed to be setting
independent, on the premise that people
should be treated in the least restrictive care
setting possible.
• They should cover care provided by social
care staff of integrated services (Section 75
agreements).
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Care clusters – some
characteristics
• The care clusters are based primarily on the
needs and characteristics of a service user.
• Expected diagnoses are given for each
cluster, but the same diagnosis can appear in
multiple clusters.
• The clusters are mutually exclusive in that a
service user can only be allocated to one
cluster at a time.
• Clinicians allocate patients to clusters using
the Mental Health Clustering Tool (MHCT)
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Description of clusters
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Decision tree for clustering
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MH PbR vs acute PbR
• Care clusters are needs based but clinically relevant
(Acute PbR uses HRGs, based on diagnosis (ICD-10)*
and procedures (OPCS-4)**
• Clusters are different from Acute HRGs
– Currently only 21 clusters (c/f approx. 1,500 HRGs)
– Clusters cover extended periods of time (HRGs cover
short term, completed episodes of care)
– Clusters are determined at the beginning of the
process (HRGs are determined at the end of
treatment – finished consultant episodes)
– Clusters embody a review / transition process (HRGs
have no equivalent)
– Nobody has yet successfully implemented an MH
PbR process (Acute PbR has been working since
2003/4)
* International Statistical Classification of Diseases and Related Health Problems 10th Revision
** Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision)
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How will PbR work?
• MH providers will be paid for actual patients they see
and treat (X patients x £Y for each cluster)
• Payment initially based on a local tariff (possibility of
moving to a national tariff)
• Tariff will use 20 clusters to reflect patient complexity
• This will expand over time as the system becomes
more refined
– PbR initially encompasses Adult and Older Adult services
only
– Projects are underway to extend MH PbR to CAMHS, LD,
Forensics, IAPT, Alcohol services, Quality and Outcomes
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How does clustering work?
• Part1 – 11 HoNOS items and 1 SARN item related
to severity of problems during 2 weeks prior to
assessment (HoNOS scale 1 is not used for
clustering)
• Part2 – 5 SARN items consider problems from a
‘historical’ perspective: these may not have been
experienced during the two weeks prior to
assessment
• This then also gives a baselines from which to
measure outcomes later at transition points
agreed nationally
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How does clustering work? (cont’d)
• Step 1 - Routine screening assessment process to score the
patient’s needs using MHCT (will suggest the closest fit –
maybe more than one possible cluster); or
• Step 2 - Decision tree - to decide if the presenting needs are
“A,B,C” (“super clusters)
This will then 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
• Final clustering decision is based on clinical judgement
applying the guidance
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What is the Initial Assessment
• It relates to new referrals and ‘one-off’ assessment
services, rather than to re-assessments of existing
service users
• The initial assessment can be triggered in a number
of ways
– E.g. GP referral or self referral and others
• These initial assessments can be classified in three
ways
a) Assessed not clustered
b) Assessed, clustered
c) Assessment ‘service’
N.B: Great potential to print money – so prior approval rules
important to be developed, particularly if GPs want telephone
advice with Consultants etc.
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Duration of Initial Assessment
• The assessment is completed when the
individual is either allocated to a cluster, not
allocated, or the provision of the one-off
service has concluded.
• An initial assessment will take no more than
two community or outpatient sessions or two
inpatient days
NB: The Initial Assessment is not necessarily a full
diagnostic assessment – it is principally for the
purpose of clustering the patient.
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Transition Protocols
• Use of the MHCT is appropriate only on
initial assessment
• At review, Transition Protocols must be
used
• These describe different criteria to be used
to determine whether a patient should
change clusters or not
NB: a change of cluster will mean a change of care
package
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Concepts included in the Care
Transition Protocols
• Indicative episode of care
– The length of time service users typically need to
be in receipt of a specific package of care
– Indicative episode refers to current understanding
of reasonable practice
– Variations will occur around this duration
• Cluster review interval
– Review interval refers to the maximum time that
should elapse between scheduled clinical reviews
– Review intervals are appropriate to the cluster
rather than being a universal standard
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Care packages
• The clusters do not define the appropriate
interventions and treatments to meet an
individual’s characteristics
• Exact format of care packages to be decided
locally
• Providers have the flexibility to develop
innovative approaches to care
• Care packages can be tailored to an
individual’s requirements (support the
personalisation agenda)
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Care packages (cont’d)
• Content of care packages should reflect
NICE guidance
• Content and format will vary due to
location
• Guidance on care packages content
www.mednetconsult.co.uk/imhsec
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Care packages (cont’d)
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Pricing issues
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Local vs regional vs national
Cost per day per cluster
Cost per cluster episode
Cost for assessments
Top-ups/additional payments
How cost becomes price
Payment for outcomes
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Main critical risks and issues
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Volatility of expenditure
Savings required at a time of major change
Data collection requirements
Variation in the accuracy of clustering and the
quality of clustering data
• Clarity around costing
• New standard contract
• Both commissioners and providers must work
on this together
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2010/11
2011/12
Mental health
currencies
(clusters &
clustering tool)
made available
for use
All eligible
patients to have
been clustered
2012/13
Transition
protocols to be
implemented
Algorithm to
become
available for use
Care packages
to be developed
for each cluster
2013/14
2015/16
Care packages
to form the
basis of contract
service
specifications
Earliest date for
national tariffs
to be introduced
(and only if
sufficiently
robust data
available)
Local tariffs to
be implemented
Local prices to
be developed
(average cluster
cost per day)
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Expanding the scope
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Current scope WAA & OP (50-75%)
Forensic MH (1% NHS spend)
IAPT
CAMHS
Alcohol and Drugs
Learning Disability
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Lots more to do
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Develop the guidance further – 3 year plan
Improve communications
Improve data quality
Social care, PHB’s, SDS
Outcomes
Competing priorities & economic
pressures
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Benefits
• Greater focus on the individual and their
needs
• Transparency – common language
• Developing benchmarking
• Increased knowledge and awareness of
what is offered/provided – choice
• Opportunity to establish an outcomes
focus
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Add local commissioner update here:
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PbR technical group
Development of service specs
Data schedules and collection
Engagement with CCGs
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Add local trust update here:
Clustering
• progress so far
• next steps
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Add local trust update here
Care packages development
• progress so far
• next steps
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Add local trust update here
Costing
• progress so far
• next steps
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Issues to consider
• Governance structure
• Rebasing – ‘price per cluster per
organisation’
• Care packages
• Non-PbR activity
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Next steps
• How do you want to move forward from
here?
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