Immediate (or relatively immediate), permanent accommodation is provided to service users directly from the streets, without the requirement of assessed housing readiness
No preconditions of treatment access or engagement are made (housing first, not treatment first)
Comprehensive support services are offered and brought to the service user
A harm-reduction approach is taken to dependency issues and abstinence is not required. However, the support agency must be prepared to support residents’ commitments to recovery
Support can ‘float away’ or return as needs arise and the housing is maintained even if the resident leaves the programme, for example through imprisonment or hospital admission.
In the US, a four-year study found that the Housing First approach led to 88% housing retention rate, compared to a 47% retention rate for treatment first models. A shorter UK study of nine housing services (pdf) has found a range of excellent outcomes, too, including housing retention, improved mental and physical health, some reductions in drug and alcohol use, some positive evidence of social integration, and some reductions in anti-social behaviour.
It’s interesting to me the parallels between the housing first model (get people a house, then support them) and the Individual Placement & Support employment model for people with mental health problems (get people a job, then support them).
This is intriguing stuff, and I’ll be keeping a lookout for more on this.
For what they’re worth, here are some reflections of my own.
First, a point of disagreement: I’m not keen on talking about “bullshit jobs”. For me, this has a bit of the ring of the Taxpayers’ Alliance and general public sector skepticism abut it. Though there are undoubtedly some such jobs, any complex environment needs a variety of people with a range of skills to help that whole work together; resulting jobs won’t always be roles that work directly with people or that have the most descriptive job titles. For me, it’s ensuring we regularly challenge ourselves over what different jobs contribute to people’s lives, rather than what their function in feeding a machine might be.
Bureaucracies perform an ongoing con trick on people who have to engage with them. They are explicitly designed to be inhuman, so that actual people engaging with these bureaucracies are set up to fail. And people administering bureaucracies still have as much arbitrary power as they ever did, except that it is now cloaked and not to be challenged (except within the nonsensical terms of the bureaucracy itself). And everyone knows this, including (especially) people administering these bureaucracies, but there is a collective complicity within bureaucracies that does not allow this fact to be spoken.
This is exactly right. Chatting with someone the other day, they said that bureaucracies don’t exist in some perfect vacuum: they exist within and themselves contribute to a cultural context that brings norms, values, beliefs and cultures with it, and as a result behaviours and approaches that are ridiculous. As Chris goes on to note:
[I]t’s only in such totalizing inhuman systems that people have to be told to act with ‘candour’ or that we really need ‘empathy’ in the workforce.
The fact that this has to happen shows that bureaucracies are in no way, and could never be, neutral.
Finally, the discussion of violence – literal and symbolic – made me stop in my tracks. Of course this is what the health and social care system sometimes does. The idea that a general member of the population may be made to leave their home or physically restrained/attacked is abhorred if, say, the police do it; but it’s both absolutely typical for people with learning disabilities or mental health problems and systematically under-reported. Placing these actions within a ‘care’ system doesn’t change what it is: violence, and things we would in no other circumstances accept.
I’m personally glad Chris finished on notes of hope in #justiceforLB and human rights. The characteristic these share is that neither is located within any system or bureaucracy. The challenge they offer from beyond a bureaucracy’s borders can hopefully remind people who work inside those boundaries that they, too, are human, and not beholden to what the bureaucracy says.
 – The title of Chris’s post is “The four staplers of the apocalypse”. If there was an award for the best blogpost titles, Chris would be on the shortlist.
 – Chris often worries about the length of his posts. I don’t think he should.
Piecing together various bits of news (BBC, Mind) it seems some of this funding will also go on supporting pregnant women and new mothers with their mental health (i.e. perinatal mental health services) and doubling funding for veterans’ mental health services.
Let’s answer our first self-posed question: what is this worth?
In this context, £250m a year doesn’t seem so much, though any money is, of course, welcome.
What about our second question: what will this money be spent on?
Inevitably, given its provenance ahead of the Budget, details of how this money will be spent are unclear. The intention, though, seems to be for it to go on “early intervention schemes to stop children developing serious and potential fatal mental illnesses”. Such early intervention is to include therapy sessions, family support work, better training for clinicians and the development of help via websites and online apps.
This is better than I expected, though we should raise a word of warning: given the almost universal focus on children’s inpatient beds it will be hard for providers to not funnel this money into more inpatient beds. We should keep a close eye on where this money goes.
One suggestion I’d like to see is that at least some of the money should be ear-marked for use as Personal Health Budgets, including as part of the Integrated Personal Commissioning programme. Both the PHBs and IPC programmes have explicit focus on mental health and children and young people, and we know that this route leads to more control and more flexible solutions that can meet individual needs. We also know it can join up fragmented systems, and is likely to divert money away from institutionally biased provision.
Money is a blunt tool. Even if it’s questionable whether the amount of money being pledged to something is worth much, we should also ask how it will be spent and ensure it’s used not just to prop up more of what went before. The money to be pledged in the Budget on children’s mental health is a particularly acute case in point.
 – The Lib Dem press release also says funding will go to “extend access to services for children under five and those with autism and learning disabilities”, which is strange to say the least.
 – I think it is worth noting just how difficult it is to get hold of spending figures on children’s mental health. The Health Select Committee’s recent report on children’s mental health services noted (paragraph 15 here http://www.publications.parliament.uk/pa/cm201415/cmselect/cmhealth/342/342.pdf (pdf)) there is a “lack of information about service provision, including demand, access and expenditure” and that the best source of such information is currently voluntary. The spending figures found by Young Minds took an FOI request!
Most discussion about health and social care is about how much money there is(n’t) in the system. Relatively little attention is given to how the money in health and social care flows through that system.
This post shares some extended thoughts on what we know about the payment system in health, how this has been applied to mental health and how, despite potential perils, we can use current and future payment system changes and extensions into social care to support personalisation.
It is a bit dense in places, but it hopefully gives a useful grounding in the payment system for those who’d like to know a bit more about it and the opportunities (and difficulties) it presents. The post is broken up into 3 parts: (1) How the health payment system works; (2) How the health payment system has been extended into mental health; and (3) The perils and opportunities of moving a health payment system into social care.
I. The health payment system
To understand how a system works a good rule of thumb is to follow the money. In large parts of the health service this is pretty easy to do because of the payment/tariff system (which used to be known as “Payment by Results”).
The core building blocks of the payment system are currencies and tariffs. The currency defines the unit of healthcare for which a payment is made (i.e. the ‘what’, such as a hip replacement or cataract operation) and the tariff defines ‘how much’ for each currency (i.e. what will be paid).
Thus, for any person receiving any treatment in certain settings, the following basic process is followed:
Treatment is coded using separate classification systems for diagnoses and interventions
Grouping of treatment – a Healthcare Resource Grouping (HRG) is allocated based on clinical codes and other patient data
Tariff – The tariff price depends on HRG and type of admission, and there are a variety of tariff adjustments made
Payment – standard monthly payments are made in advance, based on activity plan. Actual activity transmitted from provider to commissioners adjusts these payments up or down
In its introduction to the payment system (from 2013) the Department of Health produced this useful diagram to explain the broad principles of how the payment system applied to Mrs Smith having twins, Mr Jones having an emergency hip replacement and how much their treatment costs.
To get to this point the payment system in health has evolved a lot since it was first introduced in 2003/4. That year this type of payment system made up around £100m of health spending (some 0.2% of relevant commissioner allocations); by 2011/12 it made up £28.9bn of health spending (32.4% of relevant commissioner allocations).
II. Extending the health payment system into mental health
What if, though, we apply similar principles to areas where definitions or boundaries aren’t so easy to come across: mental health and social care?
In mental health, a lot of effort has already been made in this direction. All of the various mental health problems that people can have are divided up into 21 ‘clusters’ – a way of grouping people with mental health problems according to their needs, based on descriptions of characteristics of people who are assumed to have similar mental health support needs, and the level of resource needed to meet these needs. In mental health, these ‘clusters’ are the currency (i.e. the ‘what’, or the equivalent of hip replacements etc.).
If this were to follow the twins / hip replacement example, we would then allocate an amount of money to the treatment of someone in a particular cluster and all would, we hope, be sorted. In mental health, though, there are a whole range of other factors that affect what is or isn’t included in someone’s treatment. These factors include (but are not limited to):
Mental health episodes are more difficult to define and diagnoses are less clear-cut
There is less clinical consensus on optimal care pathways, making cost variations more pronounced. Even if there was a consensus on pathways, mental health support is not consistently available across the country, including where some types of support simply aren’t available
Interrelationships with physical health are complex, with mental health problems having a substantial impact on health conditions
Mental health problems typically imposes costs and benefits in non-health sectors
There are shortcomings in both the availability and quality of activity data for mental health, which make very difficult the development of robust remuneration
The evidence base for mental health interventions is far less developed than for traditional health interventions
The money that meets different elements of the support comes from different sources, most notably health and social care pots of money.
What this list of factors means is that the pathway and the payment are much harder to determine in mental health.
Efforts have been underway since 2010/11 to both define the typical pathways associated with each cluster and the prices that might be attached to them. Progress is very mixed, though: clustering people with mental health problems is required by central government, but payment isn’t yet compulsory – local areas can develop their own ways of arranging payment. Furthermore, the extent to which the new payment system in mental health has changed the nature of activity and the differences it has made in people’s lives is a moot point. A recent survey by the Healthcare Financial Management Association (HFMA) (pdf) shared the views of health finance managers on progress regarding the mental health payment system. Findings included:
84% reported commissioner understanding of the mental health payment system to be very poor, poor or fair
60% reported cluster-based activity as having “no” financial impact
70% reported that they still operated under a block contract with commissioners with a shadow tariff.
III. The opportunities and perils of moving a health payment system into social care
As it is in mental health, so the picture would be (even) more complicated in social care.
It isn’t yet the case that formal segmentation of the care population (to create ‘currencies’ and ‘clusters’), associated care pathways and prices have been developed. What we are starting to see, though, is a more concerted effort to define what we might typically expect from a social care pathway; this is mainly been driven through the NICE Collaborating Centre for Social Care (guidelines are being produced, for example, on the topics of home care and reablement). The drive to integration will also bring social care far more, perhaps fundamentally, under the aegis of agencies like Monitor and NHS England, who are jointly responsible for the payment system in health. CQC is, of course, already a joint regulatory body that operates across both health and social care.
In my personal view, and drawing on the experience in mental health, there are both perils and opportunities of bringing a health-type payment system into social care.
The biggest peril is that social care could be the less richer for such a payment system. This lost richness would be made up of a more medical focus in social care, painting a more black and white picture of people than the complexity and range of social care represents. Health is making attempts to shift away from this viewpoint (see, for example, the Coalition for Collaborative Care, Co4CC), but the experience in mental health suggests the practice of anything other than medical thinking related to payment systems is very hard to do.
There are, though, 4 positive opportunities we can take from any current or future attempts to develop currencies and payments in social care.
Such a payment system begins to bridge the gaps (professional, language etc.) people from different professional backgrounds bring. Health and social care professionals start from very different technical positions, though aren’t different in what they seek to do for and with the people they support. Thinking about pathways and payments and trying to put them in place enables people across the piece to come together for a common goal, starting from where they currently respectively are
Building standard national mechanisms won’t, I think, work. But providing a strong requirement to develop a local model, backed up by excellent guidance, support, encouragement and sharing of learning can help areas to create strong local health and social care economies through their common work to develop (if not produce) pathways and payments
Attempts to build the picture will show where evidence is most needed in social care (and health). I am by no means advocating the unrealistic position that we should only spend money on models/interventions/supports backed up by ‘gold-standard’ evidence; but I am saying that knowing where more appropriate evidence is needed will help us to ensure more of what is available through social care is as effective as it can be in supporting people
Perhaps the most exciting opportunity is that developing payments systems like this does much of the heavy lifting in identifying how much money is associated with the care and support of an individual. Even more exciting is the idea that such information would incorporate both health and social care provision. Once the amount is known it is then easier for an individual to take that resource as a Personal Budget / Personal Health Budget, with all the benefits we know are associated with this. After such work, the natural foundations for things like Integrated Personal Commissioning are then in place.
These are 4 reasons I could get behind.
Reforms in health and social care aren’t always renowned for their subtlety. What I’ve therefore endeavoured to do in this post is show how there are always opportunities in reforms – in this case, the payment system, with its currencies and tariffs – that can be used to support a whole range of ends. Here, following the money provides a chance to bring health and social care people together and do much of the heavy lifting that personalisation through, for example personalised payment mechanisms, requires. Though this isn’t without its perils, as the experience in mental health shows, the opportunities aren’t too bad either.
Last year, Outside the Box ran a series of great events on what the new Self-Directed Support Act (2014) might mean for mental health in Scotland. The events brought together a range of people from across the mental health system: people who use services, families, carers and representative organisations; social workers; team managers; commissioners and providers. As a result, the conversations were rich and engaging.
One thing that struck me during people’s discussions was that very few people thought the health and social care system was working for people with mental health problems as it was. This feeling wasn’t limited to just social care outcomes and people’s mental health themselves: it included what opportunities people with mental health problems had in areas of life like housing, employment and fairly accessing welfare support.
The question before everyone was clear: how do we make things better? The Self-Directed Support Act 2014 is a major part of the answer. The Act aims to empower people to have control and responsibility over how their care and support is arranged, including offering people different choices for organising their care. (You can find out more information about the Act on the Getting There website.)
Henry Ford famously said: “If you always do what you’ve always done, you’ll always get what you’ve always got.” The Act is therefore a really good chance to do something differently. A really interesting question for everyone with an interest in the mental health system to ask themselves is: what can they do differently as a result of the new SDS Act?
Here are a few suggestions (you can find more in this practice paper on the Getting There website):
For people who use services, this could mean finding out more about the Self-Directed Support Act so you know what your rights are and how to access the support available to live the life you want.
For a frontline practitioner, this could mean working in partnership with a person rather than thinking of them as someone to assess and put in place a package for. This could include thinking together beyond the usual menu of ‘traditional’ services people might access.
For team managers, it could mean creating regular opportunities for their team members to talk about the good things they’ve done as a result of self-directed support, or to talk about the challenges this new way of working brings and enabling people to support each other to address those challenges.
For people who commission services, it could mean knowing how much money was spent on what types of mental health support and then explicitly aiming to change this over the next 3 years, responding to the different choices that people make.
The pressure and constraints that currently exist in the mental health system sometimes lead people to think they can’t do anything themselves to make things better – it’s “beyond their control”. The places that make the most progress are those where as many people as possible take the opportunity to do something different in their part of the system and give it a go – no matter how small a change they personally make. Let’s all of us use the opportunity of the Self-Directed Support Act to help improve the lives of people with mental health problems.
Today is Time to Talk day, when people are being encouraged to by taking 5 minutes out of their day to have a conversation about mental health.
Time to Talk day is one of the major points of the year for the Time to Change campaign – England’s biggest programme to challenge mental health stigma and discrimination. Time to Change has done a terrific job since it started in 2007 and has had a demonstrable, considerable effect on people’s attitudes towards mental health.
I’m fully supportive of the Time to Change campaign.
One thing I struggle with, though, is seeing politicians – particularly Ministers – blithely adding their support to such campaigns.
The reason, you see, is this:
The red box shows real-terms spending on mental health has decreased year-on-year since 2009/10  – from £1.32billion in 2009/10 to £1.10billion in 2013/14.
Now, I understand the difficulties that politicians, including Ministers, have in discharging their public duties. They want to use their position to promote good campaigns, or to provide direction to something they hope will bring along the public, and this often involves talking about things that aren’t necessarily being talked about.
But when the reality of their actions is so far away from their warm words – as documented in mental health virtually every week over the last 4.5 years, and as symbolised by the real-terms cut in mental health budgets – it becomes pretty hard to swallow.
It’s certainly #timetotalk about #mentalhealth: to highlight the gap between politicians’ and Ministers’ talk and action. For them it’s far less #timetotalk and much more #timetoact.
A significant component of the personalisation agenda fundamentally challenges and changes where money goes as a result of the different choices people make about achieving what they want. This is rightly so, for “if you always do what you’ve always done, you’ll always get what you’ve always got.”
We know some pretty good numbers about how much money is spent in the social care system through Direct Payments. They show that the scale of spend through Direct Payments against all social care expenditure is growing, but small.
Does this mean that personalisation has failed? No. But what does it mean?
There have undoubtedly been compromises and manifestations of what was originally intended, meaning personalisation hasn’t always translated into what it was hoped and intended it would. For example, resource allocation systems and panel processes have become unwelcome norms. (We should remember that money was only ever one aspect of personalisation.)
But in any change that fundamentally disrupts, or has the potential to disrupt the status quo, other forces – invisible or not – will always play their role. These include organisations who benefit most from the status quo and have literally vested interests in maintaining it. This is, I think, one of the more powerful reasons why personalisation in mental health is still taking hold rather than taken hold, as seen through the Direct Payment numbers.
In mental health the status quo is a particular challenge because the overwhelming destination of money is in the health system. For health organisations dealing with mental health it tends to be more a question of how much money they’ll get rather than whether they’ll get it.
Organisations generally exist in order to protect what they are currently doing. The personalisation agenda in mental health is thus a fundamental challenge to health organisations and the status quo. How do we therefore bridge the chasm of effecting the change personalisation seeks to achieve by working with and through health organisations?
Rather than just mechanisms and processes, we need to think explicitly and tactically. We need to speak in a language that others will understand, and recognise their existing, actual starting point and create a path from that point to where we want things to be in the future.
Start where you are. Use what you have. Do what you can – Arthur Ashe (via @areynolds67)
To change the status quo you need a variety of approaches. Policy and legislation through government have their role. So does compulsion through regulation. Peer or public pressure is another, as is the drive to maintain existing levels of business.
A useful tactical way to change the status quo is to align agendas.
I’ve often talked about the public policy idea of the Advocacy Coalition Framework. Here, people with often very different perspectives share a common goal and form a coalition through which they advocate for particular outcomes. They align their agendas. Changes in the treatment of domestic violence are a good example of a successful Advocacy Coalition approach, bringing together feminists and the police as unlikely allies.
Another way of thinking of this is by imagining being George Clooney’s character in Up In The Air. He specialises in making people redundant, but how he frames it is not as an opportunity to carry on doing what’s always been done, but to take the opportunity to do something different. Despite it being painful, and a process that doesn’t always work for everyone, what Clooney’s character does is align one set of objectives – the company’s, wishing to make people redundant – with another – the person’s, wanting to make a different future.
What if we apply this to personalisation in, say, the area of mental health? I think it can be strongly argued that personalisation is a solution to two existing problems that health organisations (and others) are grappling with: Section 117 aftercare and out-of-area placements.
Without going into the details here, key elements of the personalisation agenda, if done properly, would directly address causes or effects of problems related to S117 aftercare or out-of-area placements. Personalised funding, integrated at the level of the individual, with a clear plan that matches assessed need with outcomes and choice over how best to achieve those outcomes, helps to address a myriad of S117 aftercare problems. Good market development in an area, that enables supporting people at the right level at the right time, with good information and a focus on maintaining meaningful networks important to the person, directly addresses many of the problems of out-of-area placements.
By tactically aligning agendas through choosing to address issues around S117 aftercare and out-of-area placements using personalisation, there is an opportunity to normalise personalisation. This approach takes account of where health organisations currently are, but gives them a different set of tools for addressing the problems they face which has the added benefit of showing them personalisation works. It is undoubtedly tactical, and may well involve an element of compromise, but I’d strongly suggest it would help with where we want to get when it comes to personalisation.
 – Remember when NHS England imposed a 1.8% deflator on non-acute health services, including mental health, compared to a 1.5% deflator for acute services? The equivalent cut to local authority social care services – also covering mental health – has been 26% to date since 2010/11. For more details see LGA’s Adult social care funding: 2014 state of the nation report
Mark draws out nicely the difference between stuff that’s complicated and stuff that’s complex.
Complicated is something like putting a man on the moon:
There was a clear objective – success was easily measured. The laws of physics pertained and sending a rocket to the moon did not change those laws. Effect can be predicted from cause. It is possible to make big, long-term plans and be reasonably certain of achieving them – London 2012, Channel Tunnel, Crossrail etc.
Complexity, however, is a different beast:
Dealing with something like poverty is complex. Poverty is hard to define meaningfully. It is difficult to measure improvement. It is subject to changeable human behaviour and action is persistently met with unintended re-action. Effect can be deduced from cause, but only in retrospect.
In complicated problems, Mark notes that the “build” mindset works, whereas in complex situations it’s the “grow” approach that works best.
The bit of Mark’s analysis that hit home for me was this:
The problem is not in plans, people or methods – it’s in mindset. Trying to build things that really need to be grown just won’t work – no matter how they are managed.
He also notes that we shouldn’t necessarily just abandon “programmatic approaches” but ensure we understand when complexity is at play and change our approach accordingly.
His thinking is mainly applied to IT infrastructure, but the applicability of this thought to social care or mental health is clear.
Both are significant systems with large amounts of money, buildings, providers, commissioners, wider stakeholders and, most importantly, users and families. Neither are particularly well-defined or have a particularly clear idea of what their end goal is (for mental health: better mental health of the population? More cost-effective services? More people with mental health problems in work? Less stigma? For social care: more money? More integration? Less integration? More care homes? More community provision?). And, goodness me, human behavior and action within the mental health and social care systems is changeable!
Indeed, I’ve always thought the mental health and social care systems are a bit like a Jackson Pollock painting:
To this end, it’s always been clear that the mental health and social care systems are complex. But plans to try and improve them have always tended to rely on top-down, “build” solutions.
Whilst equally not calling for the abandonment of good programmatic approaches in social care and mental health, what we do need to do is recognise the complexity at play and update our approaches accordingly. In these cases, such adaptations include: (1) distributing power amongst all stakeholders through all aspects of co-production; (2) putting people at the centre of their care and support, through personalised approaches and money more directly in their hands through Personal Budgets; and (3) creating a more equal playing field for a wider variety of providers based in across a range of settings.
If people like Mark are clear the “grow” mentality needed by complexity applies to the (supposedly) deterministic world it’s easy (but wrong) to assume government IT is, then it’s pretty obvious that the equivalent “grow” approach is needed for the future of the mental health and social care systems.
There was an endless stream of responses to Robin Williams’s suicide last week. I found the most dispiriting of these to be from organisations who found the comedian’s death just happened to substantiate everything they’d uniquely been arguing needs to change and, oh by the way, they’re in the best position to lead that change.
As someone who works in and around mental health, I couldn’t help but feel that most of the reactions, what they said and the motivations for publishing them showed why mental health in the UK is in the mess it’s in in the first place.
The best response I saw was from a friend on Twitter who said the following:
I am going to refrain from ranting but all these ‘if you’re depressed seek help’ messages are all well & good. But let’s look at the ‘help’: If you live in any kind of city you can wait months for an appointment to talk to a therapist.
Then you’ll get a limited number of sessions. So what help are we urging people to seek exactly? Oh, your GP will happily give you drugs indefinitely. Now piss off.
This was a straightforward response that I found refreshing in its honesty.
That I found it the best reaction possibly says more about me than it does about anything else, but nevertheless I wanted to make sure it was a reaction shared.