1. Introduction to Payment by Results (PbR) for Mental Health Peter Howitt, Head of Expanding the Scope of PbR Mental Health Information: NHS Trust Forum, 26 April 2010 peter.howitt@dh.gsi.gov.uk

2. Mental Health PbR Development 2 Mental Health Currency Published – 22 Feb  Mental Health Clustering Booklet – contains the care clusters and the clustering tool that supports allocation of service users to the clusters.  Section 9 of PbR guidance on mental health – acknowledges still lots of questions.  Updated Practical Guide to Preparing for Mental Health PbR  Draft Care Transition Protocols (look at issue of re-clustering and how needs change due to treatment). Commitment to make currency available for use in 2010/11 fulfilled.

3. Mental Health PbR Development 3 Timetable Clarified - 1 April  A Dear Colleague letter from Bruce Calderwood (Director, Mental Health Policy) and Bob Alexander (Director, NHS Finance) has clarified the timetable.  2010/11 – The clusters are available for use. Reference costs are returned on a cluster basis.  2011/12 –  All service users accessing mental health care (post GP or other referral) that have traditionally been labelled working age (including early intervention services from age 14) and older people’s services, should be allocated to a cluster by 31 December 2011.  Local prices should be agreed for use in 2012/13 and this will require understanding of local costs per cluster  2012/13 – The clusters (with local prices) become mandatory for contracting and payment purposes.  2013/2014 – The earliest possible date for a national tariff for mental health (if evidence from the use of a national currency presents a compelling case for a national price).

4. Mental Health PbR Development 4 Currencies or Prices?  When people talk about Payment by Results they often get currencies and prices/tariffs confused.  Currencies = the unit for which payment is made e.g. Healthcare Resource Groups, Outpatient Attendances, Complexity-adjusted year of care for Cystic Fibrosis.  Price/tariff = Set price for a given currency unit.  Our focus is initially on developing a currency to be used across mental health services in England. This will allow benchmarking, comparability and transparency. No Currency National Currency National Price Can’t do.

5. Mental Health PbR Development 5 The Currency Methodology  The Care Pathways and Packages approach, developed initially by six mental health trusts in the North East and Yorkshire and Humber SHAs, is the currency that has been developed.  Although the currencies will be available for use in 2010-11, its development will be an on- going process.  Further refinement, wider validation etc is envisaged.

6. Mental Health PbR Development 6 Care Pathways & Packages Approach  Users assessed with a standard assessment tool derived from HoNOS.  Allocated to empirically derived care clusters/groups[1]  These clusters are expected to be the currency unit so that you would commission for 10 people in cluster 1, 20 people in cluster 2 etc.  Different from acute (physical) PbR – paying for needs/characteristics over a period of time. Shares risk between commissioner and provider.  Payment would be for all elements of care service suer receives, both direct (e.g. therapies) and indirect (e.g. care co-ordination). [1] Methodology set out in Clinical Decision Support Tool: A rational needs- based approach to making clinical decisions, Journal of Mental Health, February 2008, 33-48

7. Mental Health PbR Development 7 What is the Scope of the National Project and the clusters? In (covered by the clusters) In (not yet clear if/how clusters can be made applicable) Out (at present) Specialist Mental Health Services (post-GP) for working age adults and older people Improving Access to Psychological Therapies Secure Services CAMHS Learning disability Although not included in the national project, people are looking locally at these areas

8. Mental Health PbR Development 8 Mental Health Care Clusters

9. Mental Health PbR Development 9 Mental Health Clustering Tool (MHCT)  Nationally agreed and utilised tool for allocation to Care Clusters in 2010/11  Tool incorporates HoNOS with additional items  Item 1 (Overactive, Aggressive, Disruptive or Agitated Behaviour) not used for Clustering purposes  Items marked (H) are historical. Other items are current (within the last two weeks)  Historical items to be identified alphabetically rather than numerically for distinguishing purposes

10. Mental Health PbR Development 10 Data items within the Mental Health Clustering Tool HoNOS 1 OVERACTIVE, AGGRESSIVE, DISRUPTIVE OR AGITATED BEHAVIOUR* 2 NON ACCIDENTAL SELF-INJURY 3 PROBLEM DRINKING OR DRUG-TAKING 4 COGNITIVE PROBLEMS 5 PHYSICAL ILLNESS OR DISABILITY PROBLEMS 6 PROBLEMS ASSOCIATED WITH HALLUCINATIONS AND DELUSIONS 7 PROBLEMS WITH DEPRESSED MOOD 8 OTHER MENTAL HEALTH AND BEHAVIOURAL DISORDERS 9 PROBLEMS WITH RELATIONSHIPS 10 ACTIVITIES OF DAILY LIVING 11 LIVING CONDITIONS 12 PROBLEMS WITH OCCUPATION AND ACTIVITIES Summary Assessment of Characteristics (SAC) 13 STRONG UNREASONABLE BELIEFS A AGITATED BEHAVIOUR / EXPANSIVE MOOD (H) B REPEAT SELF HARM (H) CSAFEGUARDING CHILDREN & VULNERABLE ADULTS (H) DENGAGEMENT (H) EVULNERABILITY (H)

11. Mental Health PbR Development 11 Importance of Information  For this to work, we need MHCT ratings and a care cluster for each service user.  This is a significant leap in the quality of individual information available for mental health service users.  It is happening at the same time as many providers are moving systems.  There are considerable challenges e.g. linking social care held information with NHS held information.  We need to consider whether information will have to become more timely i.e. more like the acute trust situation.

12. Mental Health PbR Development 12 Development and Implementation – Entering a New Phase Development We are here. Implementation will start in April 2010 with use of clusters (although funding not yet attached). Development will be highly iterative, with annual updates as we implement. Implementation 2010

13. Mental Health PbR Development 13 London MH Currency Development Programme National co-ordination of local implementation and development.

14. Mental Health PbR Development 14 Product Review Group and Sub-Groups Product Review Group Quality and Outcomes sub-group Chair: Liz Lightbown /David Daniel Costing sub-group Chair: Peter Howitt Algorithm and Transitions sub-group Chair: Lawrence Moulin (W Mids) Mental Health Clustering Tool sub- group Chair: Norfolk and Waveney Sub-groups report into PRG. They will be a standing item on the PRG agenda and periodically a sub-group area will be the main focus of a PRG meeting. Secure sub- group Chair: TBC

15. Mental Health PbR Development 15 Other issues to address in 2010  Future-proofing the cluster numbering.  Link between IAPT Minimum Data Set information and clusters.  Personalisation agenda and social care.  Training to support mental health professionals in using the approach.  Technical issues around elements included within cluster such as first assessment.

16. Mental Health PbR Development 16 Mental Health PbR sits at the centre of improved mental health services Mental Health PbR Quality Indicators Reduction of variation in mental health services Service Organisation and SLM Delivery of national policies e.g. New Horizons Enhanced personalisat- ion and choice Value for money/QIPP Diverse provision Improved, comparable data Impacts across an organisation – not simply finance.

17. Mental Health PbR Development 17 Any Questions For more information see: http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/NH SFinancialReforms/DH_4137762