1. Mental Health PbR Implementation Experience in Oxleas NHS FT Dr Pratima Singh Darzi Fellow and PbR Clinical lead 8th April 2011

2. Aim of session PbR Implementation in Oxleas so far Clustering Care Package Development process Opportunities Engagement Tips on what not to do Questions at the end please

3. PbR? New way of funding mental health services from April 2012 Move away from annual block contracts-> care provided to each person accessing (using) MH service National currency and local tariffs Emphasis on Quality and Outcomes

4. Use as much as you like,it all costs the same. No incentive for saving Average bills Pay in advance Pay for what you use/get Less usage=£ Metered bills Pay after use Payment by results aims: Retrospective payments for the services actually delivered and outcomes achieved for patients. Incentive if you do it better, quicker= Innovation Opportunity to standardise some aspects of care via care packages Block contracts: Paid for numbers / activity Targets for providers Penalty for breaches Little incentive for innovation and doing things differently

5. 5 White paper confirmed Govt support for PbR in MH with emphasis on outcomes MENTAL HEALTH STRATGY THEMES- Patient choice and control (personalisation) Outcomes and quality Reducing inequality and tackling stigma Improving efficiency (QIPP) in the context of a challenging financial climate

6. The Payment by Result methodology in theory What are the needs of our service users? How can we assess them in a standardised way? MHCT What is the most useful way of profiling our service users based on their needs? Clusters 3. What are the care packages that we should offer to service users in each of the needs ‘clusters’? Local care packages for each cluster 5. How should we cost each of the care packages and how should the care provided be paid for? Tariffs 4. What should the quality and outcome indicators be for each of the care packages? Nationally decided / mandated & agreed locally with commissioners 1. What are the needs of our service users? How can we assess them in a standardised way? MHCT 2. What is the most useful way of profiling our service users based on their common needs? 21 PbR Clusters

7. Do 21 Cluster= resource utilisation? Care packages? One care package for everyone in that cluster if needs are indeed similar Demonstration of outcomes achieved for each cluster (Nationally mandated) MHCT as the standardised needs assessment tool Local Cost tariffs Egs show most use average costs

8. MHCT A set of 18 ITEMS based on the original 12 item HoNOS tool and 6 additional items to create MHCT Each item is based on the same 5-point scales which are completed in a few minutes by mental health professionals after routine assessments, CPA reviews etc The addition of the 6 items to develop the PbR version is designed to create a clinical assessment tool Severity scale- General rule applies to call 18 scales 0 = no problem 1 = minor problem requiring no action 2 = mild problems but definitely present 3 = problem of moderate severity 4 = severe to very severe problem 9= not known Training ! Training! Training!

9. When to cluster? To ensure clustering becomes a routine part of the patient pathway, ensure a process is in place to cluster: The point of referral Planned CPA or other formal reviews Significant change in need/ Any other point where a change in planned care is deemed necessary Eg Unplanned reviews, urgent admissions etc Word of caution about over simplification…..

11. 21 Needs-Based Clusters 1. Common Mental Health Problems (Low Severity) 2. Common Mental Health problems (Low Severity with Greater Need) 3. Non-Psychotic (Moderate Severity) 4. Non-Psychotic (Severe) 5. Non-Psychotic (Very Severe) 6. Non-Psychotic Disorders of Overvalued Ideas 7. Enduring Non-Psychotic Disorders (High Disability) 8. Non-Psychotic Chaotic and Challenging Disorders 9. Blank 10. First Episode Psychosis 11. Ongoing or Recurrent Psychosis (Low Symptoms) 12. Ongoing or Recurrent Psychosis (High Disability) 13. Ongoing or Recurrent Psychosis (High Symptom and Disability) 14. Psychotic Crisis 15. Severe Psychotic Depression 16. Dual Diagnosis 17. Psychosis and Affective Disorder Difficult to Engage ---------------------------------------------------------------------------------------------------------------------------- 18. Cognitive Impairment (Low need) 19. Cognitive Impairment or Complex Dementia (Moderate Need) 20. Cognitive Impairment or Complex Dementia (High need) 21. Cognitive Impairment or Complex Dementia (high physical or engagement)

12. Approach and experience of Oxleas

13. 13 Nationally co-ordinated work Product Review Group Quality and Outcome s sub- group Chair: Carole Green /David Daniel Costing sub- group Chair: Kay Ward Algorithm and Transitions sub-group Chair: Kay ward Mental Health Clustering Tool sub- group Chair: Sam Pittam- Smith London Representatives are Wendy Wallace, Martin Baggaley (SLAM) and Sophie Donnellan (Oxleas) Secure sub- group Chair: Ged Nolan/ Carole Green NEW: CAMHS sub- group Chair: ? PS SD RP JC et al

14. MHCT V2 Launched Data for Cluster 0 not included since Dec 10

15. Trustwide view in Feb 2011

16. Spread of clusters in the trust and Boroughs Far greater than anticipated What do we make of these low 7 & 8 numbers? Psychosis numbers more in line with others with highest numbers in 11 Cluster 16 underused even when clear diagnosis

17. Eg: Audit of Clusters 1-3 in Oxleas 1 Nov 10 – 31 Jan 11 ( n =686)

18. Points of Clustering In 1- 3 Note: Oxleas have an internal target of 100 % new referrals

19. When to cluster? To ensure clustering becomes a routine part of the patient pathway, ensure a process is in place to cluster: The point of referral Planned CPA or other formal reviews Significant change in need/ Any other point where a change in planned care is deemed necessary Eg Unplanned reviews, urgent admissions etc Word of caution about over simplification…..

20. Clustering teams in 1-3

21. 7.Problems with depressed mood 0No problem associated with depressed mood during the period rated. 1Gloomy; or minor changes in mood. 2Mild but definite depression and distress (e.g. feelings of guilt; loss of self-esteem). 3Depression with inappropriate self-blame; preoccupied with feelings of guilt. 4Severe or very severe depression, with guilt or self- accusation. 8.Other mental and behavioural problems 0 No evidence of any of these problems during period rated. 1Minor problems only. 2A problem is clinically present at a mild level (e.g. patient has a degree of control). 3Occasional severe attack or distress, with loss of control (e.g. has to avoid anxiety provoking situations altogether, call in a neighbour to help, etc.) i.e. moderately severe level of problem. 4Severe problem dominates most activities. Eg: MHCT nuances Item 7 and 8 in MHCT

22. Cluster Definitions, limitations and risks Cluster 1 Cluster 2 Cluster 3 Cluster4

23. ScoreQ 7 – MoodQ 8 - Other Cluster 14 n=193343%32% 2 155%66% 0 Cluster 24 n=136357%48% 2 142%51% 0 Cluster 34 n=357345%37% 254%61% 1 0 Red= incorrect scores for this cluster

24. Care Package questions What is the best possible care that can be provided in the current resources? Best practice aspirations- what are current areas of best practise? Gaps Resources needed to provide such a package Misfits/ outliers- what to include what to leave out? Commissioners engagement- what will they need to see? How can this meaningfully be managed?

25. PbR Care Package Development Care Package Development group. Monthly meetings with MDT input Developed composite care manual with professional interventions for 4-17 Completed 18-21 on same lines Ongoing development of Care pathways with NICE guidelines Care pathways incorporating NICE RiO care plan library for Cluster care plans

27. Current care in PbR Clusters-Audit 6 pts per cluster randomly selected from this time period, 2 from each borough (N= 126) 6 months care: 1 Feb 2010 - 31st July 2010 Data was pulled from RiO and manually collected from RiO records. Manually cross checked to get comprehensive understanding of pathway and care received in Oxleas. Clinicians contacted to cross check where unexpected entries, clustering found. Quantitative: Contacts, Nature of contacts (face to face, t/c, DNA), range of MDT input, quality of data input Qualitative: Other elements of care such as access to services, social inclusion activities, carer support etc

28. Multi-professional interventions captured in contacts: Nursing, Medical, HTT, inpt, Care coordinator, Psychology, OT, SW, Amph Basic Information and record keeping: Cluster number, Pri and Sec diagnosis, CPA level, Core assmt, Risk assmt Other: Use of MHA Out of Oxleas referral /Care Social inclusion activity And other case contingent specific care Nature of contact: Face to face, Telephone, DNA, Carer (RiO, Diary, Progress notes) Crisis episode requiring HTT or Inpt: LOS days Care Received in 6 months METHODOLOGY OF CURRENT CARE AUDIT ( Feb- Jul 2010)

29. Manual Cluster Allocation Cross-check with MHCT Booklet Variation byNumber/126 % No Cluster can be allocated due to given scores 32.3% No Variation 7660.3% ± 1 Cluster1814.2% ± 2 Clusters97.1% ± 3 Clusters32.3% ± 4 Clusters43.1% ± 5 Clusters75.5% ± 6 Clusters43.1% ± 7 Clusters10.7% n = 126 Variation = 46/126 (36.50%)

30. Cluster NoNumber of Incorrect ClustersPercentage 1583.3% 25 3233.3% 4350% 5116.6% 61 7350% 8466.6% 96100% 10116.6% 11233.3% 12233.3% 13116.6% 14233.3% 15116.6% 16466.6% 17350% 18233.3% 19116.6% 20116.6% 2100%

31. Variation by Cluster by MHCT Scores (Pri Check n= 50/126 ) Greatest variation in clustering are in clusters where we have unexpected numbers in Oxleas 1-2, 7-8, 16 (Sec check: N= 19/126 ) Common reasons: Incorrect super cluster, Algorithm confusion/ compliance, Mistake in Cluster 6 Overvalued ideas, Too many 9

32. Main Diagnosis n=109 /126(86.5%) PSYCHOSISPSYCHOSIS DEMENTIADEMENTIA DEPRESSIONDEPRESSION ADJUSTADJUST ANXIETYANXIETY BIPOLARBIPOLAR NONENONE DRUGDRUG NO MI PD

33. Secondary Diagnosis n=50/126 (39.6%) Personality disorder Common but very low trust number in Cluster 8

34. CPA across Clusters

35. Nature of contacts Carer = 0.7 %

36. Medical Contacts across Clusters

37. Occupational Therapy Contact n=38/126 (30.15%) SuperclusterNumberRangeMean Non psychotic11/541-376.45 Psychotic27/481-309.81 Organic0/24--

38. Psychology Input N= 40/126 (31.7%)

39. Social Inclusion Activity Per Cluster n = 19/126 (15%)

40. Correct clustering of patient according to needs What is evidenced based care for this patient? What services/resourses are needed to provide this? What are the gaps? Where is the variation? How is this information captured? Recorded? Reported? Steps in care package development

41. Key considerations… Training Pace of implementation very rapid Significant opportunities Clinical engagement is key for an eveolving care package development Commissioner engagement in PbR process

42. Thankyou. Questions?