Outcomes Based Commissioning (OBC) overview
Oxfordshire Clinical Commissioning Group’s (OCCG’s) aim is to secure improved outcomes and value for money for patients and the public. In March 2012, OCCG decided to change how it commissions (buys) some health and social care services by introducing a more outcomes orientated approach to commissioning and contracting. The CCG decided to work in the following three areas to introduce outcome based commissioning contracts for
2013/14:
• Frail Elderly
• Maternity
• Mental Health
This document asks for your views on how OCCG is planning to introduce Outcomes Based
Commissioning (OBC) for the Mental Health (MH) services it buys.
How do we buy Mental Health (MH) services now?
Current contracts identify some outcomes and quality measures; however the actual payment for providers is generally linked to activity. For example we measure services by, how often is the service available; how many people are seen; how many days of hospital care are delivered, etc.
How will OBC change the way we buy MH services?
OBC will incentivise providers to achieve the outcomes that matter most both clinically and to patients rather than paying them for how much work they do. This is a substantial change for health and social care commissioning.
The Better Mental Health in Oxfordshire (BMHO) strategy has 3 broad ambitions and OCCG wishes to explore how OBC could support the delivery of these:

To keep people well
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To ensure that when people become unwell they can get better, quicker
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To ensure that people can get access to high quality, responsive services
How will OBC apply to different people’s needs?
We need to identify which groups of people, and which money and current services we would include within OBC at this stage. We can only properly build the care around the individual if we have thought about his/her needs, and the type of service that s/he would need to achieve better outcomes. We need to find a way of grouping people according to their needs so that we can build a contract that works both for the individual and at a system wide level.
We have decided to build on the nationally driven development of mental health contracting via payment by results (PbR). The model for delivering this is called “clustering”. Broadly the mental health clusters work by grouping people in terms of needs, ranging from less intensive, milder needs to more severe, higher needs.
OCCG, Oxford Health NHS Foundation Trust, Oxfordshire County Council and representatives from the voluntary sector have been looking at the different groups of people with mental illness currently supported by the mental health pooled commissioning budget and the services that they use, to try and identify who and what should be considered within
OBC.
You will find more detail on what is being proposed in Appendix A – ‘The scope of this work’.
If you would like to comment on the outcome measures proposed for mental health services there is an opportunity to do so in the survey referred to on page 4.
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What would be different under OBC?
There are some key differences in how we would commission services under OBC:
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The contracts with providers would be based on those outcomes that help people living with mental illness keep well and move towards recovery, whilst at the same time ensuring that an individual’s care needs are met
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Service user will be at the centre of care so that personalised care planning and services will be integrated and built around individual needs: there would be one plan for each person that would describe how they should achieve the outcomes that will support her/his well-being and recovery

Providers work better together in a way where they share responsibility for delivering the outcomes and achieve a high level of integration
What is the difference between quality and outcomes?
In the conversations we have had with people to date we have recognised that we need to clarify the difference between quality and outcomes.
• Quality is the essential element in determining if someone’s care is safe, effective and was a positive experience, which might include things like how long you had to wait for a service, attitude of the staff, choice of appointment time and place etc.
• An outcome is what you want to get out of that service to be able to fulfil your personal goals and clinical improvement and live as independent a life as possible.
This document asks you to think about the outcomes that are important to you.
What you have told us so far:
In January 2013 OCCG ran an engagement event across a number of health subjects related to OBC, including mental health, which gave us an initial sense of what people thought was important:
Outcomes for people with anxiety and depression
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Appropriate and timely diagnosis
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Service users re-engage and are active in the community
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Service users build and maintain quality relationships
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Service users understand their condition
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Individual treatments developed by user involvement
Outcomes for people with psychosis
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Service users attain employment
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Service users attain stable housing
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Service users have improved financial management
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Service users have improved physical health
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Service users avoid inpatient admission
Subsequently in March 2013 we ran a focused workshop with service users and carers who had attended the earlier event to look in detail at mental health outcomes and more priorities were shared; these are attached as Appendix A.
Your views on the proposed outcomes
A group of clinicians, social workers and mental health practitioners have looked at what has been said so far and worked up the following suggested outcomes that we would like to test as part of this engagement.
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What we have done is try to identify;
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The high level outcome th at will tell us that someone’s MH is improving and moving towards recovery and well-being
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Why these are important to people in Oxfordshire and how they link to national priorities
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Some suggestions about how we might measure these broad outcomes
1. People with severe mental illness will have good physical health
People with severe mental illness die younger than the rest of population.
Physical ill-health can be a barrier to recovery and well-being; “psychosis made me ill, but it was the weight I put on while on medication that stopped me getting better”
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Reviews of physical state, mapped into care plans
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Health checks in primary care
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Increase in physical exercise
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Harm minimisation: reduction in risky behaviours
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Local mortality rate
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% of people in clusters in paid employment
The measure/expectation will be tailored to the cluster
2. People with severe mental illness (in clusters
4-17 1 ) will be in paid employment
3. People with severe mental illness will be in settled, independent accommodation that supports their recovery and wellbeing
Employment has been identified as a key tool for supporting recovery and as a measure of “improved functional ability”.
This is both a national and local priority. It also addresses equality issue for people with severe, disabling mental illness
Stable housing is a key indicator both for the opportunity to move towards recovery and well-being, but also of people’s ability to manage their own care needs
4. People with severe mental illness will move towards recovery and wellbeing through improved
MH as assessed by clinicians using the Cluster tool
“How do the professionals think you are doing?”
Recovery and wellbeing presumes that people are able to live with less intensive support and from a clinical perspective move towards managing their own care with the support of their GP
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% of people moving to less intensive accommodation within the supported to independent living (SIL) pathway
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% of people successfully managing independent accommodation
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Reduction in amber/red ratings in cluster score
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% of people with their care needs reviewed
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Number of people moving down and up the cluster levels
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Numbers of people stepped down to “no significant MH problems” and discharged to primary care
1 See Glossary for cluster descriptions
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5. People with severe mental illness will achieve their personal goals in relation to recovery and well-being
6. Carers of people with severe mental illness (in clusters 4-17) will be supported in their caring role
“How do you think you are doing?” to be “owned” by the service user. of relationships, a sense of hope and ambition, and identifying and enable the service user to move towards the other outcomes here around physical health, work,
For recovery to be sustained it has
Recovery is a complicated concept that incorporates a range of features including sense of wellbeing, quality progressing along the steps that will independence and clinical recovery.
For some people stability will be the initial goal, and for others their goal will be meaningful activity or work.
How well supported do carers feel?
Carers often are the principle source of support for the person with severe mental illness and the back stop when things go wrong. Carers do this willingly, without complaint and are committed to the well-being and recovery of the person they care for. Carers who are supported are better able to support good outcomes for the person they care for.
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Service users have selfdefined & self-reported social inclusion measures
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Service user report level of inclusion meets their expectations
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% of service users satisfied with support to achieve their goals
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% people with a personal recovery plan
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Measures in relation to community engagement; reducing reliance on services; controlling own support; sustaining personal relationships; self-esteem
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% of people achieving their goals as set out in their plan
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% of carers feeling involved in care planning
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%of carers able to find information and support
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% of carers satisfied with support from providers
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% of carers satisfied with the support the person they care for has received
Questions for stakeholders about these outcomes:
An on-line survey, two stakeholder meetings and focus groups will be organised to get feedback on the work done so far; so that we can establish:
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Do people agree with these outcomes? Are there others we have missed?
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Are some outcomes more important than others?
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Do people agree with the suggested measures?
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Anything else that is important to people that should be added.
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Appendix A
Focused workshop feedback - OBC Mental Health – March 2013
What is Important to service users and carers

Quick and timely access to psychological services for SMI

Doing normal things
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Building meaningful relationships
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Having a meaningful life
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Building social life and social skills
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Bespoke recovery pathway
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Using expertise- people with lived experience around design and delivery of services
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Choice in supported housing
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Choice overall
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Respite/ crisis / recovery house
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Least restrictive solutions
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Family therapy
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Timely intervention when unwell
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Access to community resources – non-stigmatised
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Learning to manage self and symptoms
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Knowledge of what is there
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Access to GP – physical health and cover advocacy
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Dedicated mental health lead in GP surgeries
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Good physical health
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Accommodation
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Finances
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Food/nutrition
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Hospital bed when acutely unwell
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Diagnosis: accurate and timely
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Access to service in a crisis
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Personalised and meaningful activities
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Enjoyment
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Inclusion: considerate – external to mental health, anti-stigmatised
 Access to carers’ assessments and review
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Speak in private to medical staff
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Up-to-date and timely information, medication, benefits, rights and diagnosis
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Respite – funds
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Timely notice of meetings/appointments
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Peer support
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Best quality medication
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Knowledgeable and accessible care coordinators
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Second opinion
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Find and/or retain employment over the longer term
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Glossary:
• OCCG …………….. Oxfordshire Clinical Commissioning Group
• CCG ………………. Clinical Commissioning Group
• OBC ………………. Outcomes Based Commissioning
• MH ……………….... Mental Health
• PbR ………………... Payment by Results
• Care Cluster ……... We have decided to build on the nationally driven development of mental health contracting via payment by results (PbR). The model for delivering this is called “clustering”. They are made up of 21 groupings and are a way of classifying individuals using mental health services. Broadly the clusters work from less intensive, milder needs to more severe, higher needs: o Clusters 1-3 are largely for people with mild to moderate anxiety and depression who would normally be supported in primary care. Some people might be still under the care of secondary mental health services as part of their recovery pathway o Clusters 4-8 are for more severe anxiety and depression. Cluster 8 would include some people with personality disorders. Anyone cluster 4 and above would normally be using secondary mental health services. o Cluster 9 is vacant o Clusters 10-17 cover psychosis, including early intervention and crisis. o Clusters 18-21 cover organic illness, such as dementia
• Co-morbid ………. more than one medical condition being present at the same time
• SIL ……………… Supported to Independent Living
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