This post is one in a series on Payment by Results in mental health, written for both professional and personal reasons. The full series is introduced and linked to here, including a post with all references in it.
In theory, PbR should support personalisation and the introduction of personal health budgets. Early on in the process of introducing Payment by Results, some of those responsible for its implementation were positive that the clustering process gave them new information about the people they were treating, leading to a better understanding of where quality and outcome improvements could be made. Similarly, the currency model is focused on paying for individuals, not individual services, and so means that delivery may be provided by different organisations, such as those in the voluntary and independent sector, rather than “just” NHS providers (DH, 2013:18).
In the early days of PbR in mental health, it was noted that implementation needed to support the adoption of best practice in the delivery of outcomes, as set out in No Health Without Mental Health. Similarly, ADASS amongst others noted that PbR in mental health needed to take a whole-systems approach to mental health needs, or otherwise risk “unwittingly undermine some of the innovative partnerships, services and associated health and social care outcomes for people” (ADASS, 2009).
The potential was clear:
“The Care Pathways and Packages approach that is being used for mental health Payment by results has the potential for embedding personalisation into mental health services. By focussing on individual needs it potentially lends itself to commissioning for outcomes and this will be developed further. The “results” should ultimately be more personalised services and improved outcomes.” (ADASS, 2009)
However, people have felt unclear how PbR fits with personalisation and some concerns about PbR have been expressed about whether or not it will be a systems change that will in practice lead to real improvements, choice and control for people (King’s Fund, 2009).
These worries have included whether PbR may perpetuate a medical model of mental health rather than taking into account a range of social care outcomes. Similarly, by taking a deficit approach to mental health – through, for example, using HoNOS measures – the tools of PbR may not be geared towards promoting recovery-based approaches and increasing social inclusion (ADASS, 2011). The language currently used in the PbR Clusters and the allocation tool tends to focus on symptoms and problems” (NDTi, 2012:13). This is a concern echoed by the Royal College of Psychiatrist:
“The College recognises that social, economic and cultural influences will have a large impact on outcomes… Likewise, the College’s determination to support recovery principles and service user empowerment emphasises a focus on patients’ strengths and skills which are currently absent from the care clusters.” (RCP, 2012)
There is a concern that the Care Pathways and Packages approach reflected in the PbR currencies focuses on intervention and treatment (ADASS, 2009) and so potentially misses the opportunity for PbR to be an:
“added ingredient to make it possible to achieve a culture that embraces personalisation, recovery and a whole systems approach, with person-centred integrated planning, easily accessible personal budgets for health and social care, whole system creative commissioning in partnership with people and communities and recognising the contribution they make, and a personalised PbR system that will reward recovery and inclusion as well as activity and efficiency.” (RCP, 2012)
Currently, PbR is felt to be more about contracting, rather than commissioning mental health services (MHN, 2011b:15). For it to be successful it needs to evolve from “being an essentially ‘payment by activity’ model, to becoming a true ‘payment by results’ approach” (RCP, 2012:8).
Clearly, PbR in mental health is still a work in progress, and its impact on personalisation will be more apparent as PbR, and the framework to measure outcomes, begins to be further developed and implemented (ADASS, 2011).
As NDTi notes in its paper on PbR in mental health and personalisation:
“As with any development in public services, raising key questions in the development stage may avoid the danger of disappearing down a rabbit hole of systems development without coming up to see that on the surface nothing much has changed, and the burrowers have lost sight of important values and principles.” (NDTi, 2012:15)
As such, it is important to check the extent of understanding of those developing and delivering PbR in mental health care about personalisation in practice, and the culture, attitude and systems changes that it brings, and not leave this to chance (NDTi, 2012:13).