2Outline Why move to PbR? What is the mental health currency? Care clustersHow does clustering workAssessmentTransition protocolsCare packagesPricingImplementation timelineLocal commissioner updateLocal trust update
3Why 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.
4Why move to PbR? Facilitate patient choice Enable diversity of provisionIntroduce 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 pathwaysRefocus discussions between commissioner and provider
5The 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.
6What 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).
7Care 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)
10MH PbR vs acute PbRCare 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 HRGsCurrently 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)
11How 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 complexityThis will expand over time as the system becomes more refinedPbR initially encompasses Adult and Older Adult services onlyProjects are underway to extend MH PbR to CAMHS, LD, Forensics, IAPT, Alcohol services, Quality and Outcomes
12How 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 assessmentThis then also gives a baselines from which to measure outcomes later at transition points agreed nationally
13How 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); orStep 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 scoreorange: expected scores -yellow : may scoreFinal clustering decision is based on clinical judgement applying the guidance
15What is the Initial Assessment It relates to new referrals and ‘one-off’ assessment services, rather than to re-assessments of existing service usersThe initial assessment can be triggered in a number of waysE.g. GP referral or self referral and othersThese initial assessments can be classified in three waysa) Assessed not clusteredb) Assessed, clusteredc) 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.
16Duration 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 daysNB: The Initial Assessment is not necessarily a full diagnostic assessment – it is principally for the purpose of clustering the patient.
17Transition ProtocolsUse of the MHCT is appropriate only on initial assessmentAt review, Transition Protocols must be usedThese describe different criteria to be used to determine whether a patient should change clusters or notNB: a change of cluster will mean a change of care package
18Concepts included in the Care Transition Protocols Indicative episode of careThe length of time service users typically need to be in receipt of a specific package of careIndicative episode refers to current understanding of reasonable practiceVariations will occur around this durationCluster review intervalReview interval refers to the maximum time that should elapse between scheduled clinical reviewsReview intervals are appropriate to the cluster rather than being a universal standard
20Care packagesThe clusters do not define the appropriate interventions and treatments to meet an individual’s characteristicsExact format of care packages to be decided locallyProviders have the flexibility to develop innovative approaches to careCare packages can be tailored to an individual’s requirements (support the personalisation agenda)
21Care packages (cont’d) Content of care packages should reflect NICE guidanceContent and format will vary due to locationGuidance on care packages content
23Pricing issues Local vs regional vs national Cost per day per cluster Cost per cluster episodeCost for assessmentsTop-ups/additional paymentsHow cost becomes pricePayment for outcomes
24Main critical risks and issues Volatility of expenditureSavings required at a time of major changeData collection requirementsVariation in the accuracy of clustering and the quality of clustering dataClarity around costingNew standard contractBoth commissioners and providers must work on this together
252010/11Mental health currencies (clusters & clustering tool) made available for use2011/12All eligible patients to have been clustered2012/13Transition protocols to be implementedAlgorithm to become available for useCare packages to be developed for each clusterLocal prices to be developed (average cluster cost per day)2013/14Care packages to form the basis of contract service specificationsLocal tariffs to be implemented2015/16Earliest date for national tariffs to be introduced (and only if sufficiently robust data available)
26Expanding the scope Current scope WAA & OP (50-75%) Forensic MH (1% NHS spend)IAPTCAMHSAlcohol and DrugsLearning Disability
27Lots more to do Develop the guidance further – 3 year plan Improve communicationsImprove data qualitySocial care, PHB’s, SDSOutcomesCompeting priorities & economic pressures
28Benefits Greater focus on the individual and their needs Transparency – common languageDeveloping benchmarkingIncreased knowledge and awareness of what is offered/provided – choiceOpportunity to establish an outcomes focus
29Add local commissioner update here: PbR technical groupDevelopment of service specsData schedules and collectionEngagement with CCGs
30Add local trust update here: Clusteringprogress so farnext steps
31Add local trust update here Care packages developmentprogress so farnext steps
32Add local trust update here Costingprogress so farnext steps
33Issues to consider Governance structure Rebasing – ‘price per cluster per organisation’Care packagesNon-PbR activity
34Next stepsHow do you want to move forward from here?