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.
One considerable concern regarding PbR in mental health is the possibility that a person may, during reassessment using the Mental Health Clustering Tool, have a lower recorded score because they are receiving effective treatment, but that if this treatment is stopped – by being discharged or allocation to a lower cluster – their needs may grow.
To specifically address this possibility, the Mental Health Clustering Booklet includes what are known as “Draft Care Transition Protocols”. These should be considered by the relevant clinician(s) before the final result of the MHCT score is recorded (DH, 2011b:6).
National / local tariff
In PbR in acute care there is a set national tariff, with a Market Forces Factor (MFF) index applied to reflect local variations.
A national tariff for PbR in mental health, however, does not exist. The commitment in Equity and Excellence: Liberating the NHS is for there to be clusters as the currency but with local prices, and that tariffs will be agreed locally between commissioners and providers.
Nevertheless, and though reaffirming the fact that a national tariff is not being introduced for PbR in mental health, some indicative cluster costs were published by DH (DH, 2012a:7), which are based on costs derived from 2011/12 data.
The future decision as to whether there will be a national tariff will fall to Monitor and NHS England (DH, 2012a:7). In preparation for this, Monitor is looking to base tariffs on costs submitted by organisations using the PLICS3 system and drawing on the Healthcare Financial Management Association’s mental health clinical costing standards (DH, 2012a:6).
Within clusters, the payment for each care cluster is generally an average payemtn. However, since variation of costs within clusters is not understood in great detail, there are likely to be requirements for top-up payments or alternative funding arrangements in addition to any average cluster payment (DH, 2011b:13).
Very closely related to the question of determining a tariff (be it local or national) is the issue of data and its quality to inform developments and decisions. Any payment system needs to be underpinned by high-quality data and analysis, and risks a lack of compliance and/or unintended consequences if this isn’t in place (King’s Fund, 2012:vi).
There are concerns with data within the current system of PbR in mental health. Issues include:
- Completion rates for collecting HoNOS scores are low, even though they should be collected as part of the mental health minimum data set (MHMDS)
- Inconsistency in whether users are correctly allocated to clusters
- Inconsistency in the use of care transition protocols
- IT systems may not be well-enough developed to support the recording of assessment scores and cluster allocations (DH, 2010:14).
This picture is likely to become more complicated, since some quality metrics are being mandated in 2013/14, including:
- Cluster caseloads (%age clustered)
- Cluster caseloads (Client Numbers)
- Adherence to cluster reviews periods
- Adherence to Care Transition Protocols” (DH, 2013:17).
There is also a growing expectation that patient experience measures, such as PROMS, will feature in PbR data and its use (DH, 2013:17).
To address questions of data and its robustness, a significant project has been commissioned from Capita by the Audit Commission to explore the issue (DH, 2012a:6).
Link of Payment by Results in mental health to social care
It was noted early in the development of PbR in mental health that “the costs of social care and other provision should be identified and factored into the PbR work.” (ADASS, 2009:3).
The Department of Health moved in this direction: the costs of social care staff directly employed by a mental health provider or under formal Section 75 arrangements should be included in cluster costs (DH, 2011b:13). However, the same guidance noted that “non-NHS costs should [be] deducted to arrive at the cluster care price” and that “[t]he funding of interactions with social care will be subject to further national work” (DH, 2011b:13).
Though the scale of such a piece of work isn’t underestimated (see, for example, King’s Fund, 2012:40), there is confusion amongst health commissioners and providers about how to deal with social care in mental health PbR (MHN, 2011a:3).