NDTi

With the NHS developing mental health ‘care clusters’ in response to the shift to payment by results, and the Government also demanding the implementation of personalisation (which is a clear priority for local government), there is a real danger that these two policies are not ‘talking to one another’ and the mental health PbR systems will be developed in a way that runs counter to the aspirations of PbR. NDTi have produced a discussion document to help promote debate about how to avoid this happening and we would welcome your thoughts and contributions.

You can see the document at www.ndti.org.uk/who-were-concerned-with/mental-health/payment-by-results-and-personalisation-in-mental-health-services/ and it is also attached to this post.

We have already been discussing this issue with a number of interested parties, including SCIE, Think Local Act Personal and the SHAs. After allowing a period of time for people to comment, we will consider with those colleagues and others, how best to take this agenda forward.

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Kind regards
Kate Linsky

NDTi
Head of Development - Mental Health

A few thoughts to kick this conversation off.

We are keen to encourage this conversation because both policies (PbR and personalisation) are important and can contribute towards better outcomes for people. Outcomes is the key word here. Just delivering on processes is not, in itself, good enough.

Personalisation could be argued as being fundamentally concerned with three things (i) giving people more choice and control over their services (ii) services therefore behaving in different ways towards the person (iii) people being able to use public resources and services to build ‘social capital’. The resultant life outcomes for individuals should, inter alia, mean fewer demands being placed upon mental health and other health and social care services.

For PbR and personalisation to be working together in harmony, it is therefore important that the PbR mechanisms contribute toward these changes. Now, I readily admit I am no PbR expert (others at NDTi who are working on this know far more than I do), but I do have difficulty in seeing how a PbR process that is constructed around clinically defined pathways is - on its own - going to do this. This is not to say that the clinically defined pathways are not the appropriate way forward - but on their own they are not enough. They need to be associated with mechanisms that evidence that the clinical interventions have resulted in improved social capital and personal control and autonomy. At the moment, people in the field who encouraged us to promote this debate say this element is missing and our reviews of documentation concur with that.

How to achieve this synergy is the key question and is the core of what we are hoping people can contribute ideas around in this Forum discussion.

Rob Greig

PbR clustering will achieve a vast range of outcomes.  Included in these are:-

-Clustering individual according to diagnostic categories on the basis that they fit a ‘type’
-Reinforcing the notion that diagnostic categories are credible, valid and reliable categories, which are by definition discrete
-Implying that there are care packages that are typically appropriate for and desired by people who share common symptomatology.  Assumed here is that care packages are interventions that relate to symptoms or diagnostic categories of clusters rather than to individuals.

Regardless of symptoms and common presentations each person has had a different life experience, a different set of triggers and a different way of experiencing their mental health problem and what they feel about it.  Take an example.  Two women who experienced childhood sexual abuse may self harm, have a diagnosis of borderline personality disorder and may both benefit from impulse management support and counseling.  The may however be different in their understandings of their experiences.  One may feel violated by a system that pathologises them and the other may feel safe and supported in knowing that they are not maladapted but ill.

In theory PbR should allow a provider to be financially rewarded for meeting the needs of individuals creatively but the big challenge is that the costs of interventions will vary significantly depending on the kind of support being provided.  Significant variations within clusters defeats the objective of creating clusters.  Another way of saying this would be that allowing too much individuality, too much freedom to choose and define is anti clustering and anti PbR. Or perhaps the best way of saying it would be that personalised approaches are anti PbR.  I don’t know.  Would welcome views.

Generally personalisation has not gained the traction for citizens who use mental health services that it has for other citizens accessing social care services.  This taken with the more limited penetration of the principles under-pinning personalisation in the NHS generally and its mental health provision specifically, places citizens with mental health issues in a sub-optimal position when it comes to having choice and control over the services they receive.

‘Getting it together for mental health care’ clearly illustrates that personalisation, Payment by Results (PbR) and the recovery approach could come together as a ‘perfect storm’ to give citizens using mental health services real opportunity to exert choice and control over the services provided to support them.

Evidence from citizen-led solutions in other areas of service provision regularly show improved outcomes for citizens, as well as financial savings to the public purse.

The move to PbR is requiring significant resource to implement - at a time when as much value needs to be extracted from the public purse as possible.  It therefore follows that if PbR can also be used as a mechanism to improve choice and control for citizens and progress other government agendas - implementing personalisation and the recovery approach - that such opportunities must be taken.

‘Getting it together for mental health care’ presents a clear challenge to the present rationale underpinning the arrangements for support to citizens with mental health issues - a challenge that should be faced and answered to improve the life chances of a group of citizens who historically have often been failed by services and wider society.

I think PbR in Mental Health offers us some great opportunities; the big question is whether we can deliver them. I have to declare I’m very involved in this work regionally and nationally, so I am biased!
The key thing is not the money side of PbR, the key point is that PbR and the work around it can make things clear and transparent, and when they are clear and transparent it opens doors to challenge and choice.
So if you approach a mental health service tomorrow:
- Will you know how you can actually access services, (and more importantly how you get out of them)?
- Will you be offered an assessment which brings together both health and social care?
- At the end of the assessment will you be offered a ‘menu’ of support, which will include medication, talking therapies, support around housing and work if appropriate?
- Will you be told about the success rates of the different options of support on offer?
- Will you be able to choose your own pathway through your own menu, choosing different parts of the menu to be delivered by different providers?
- Will you be asked at the end of your time using services for your own measure of your outcome, and this used to improve services and to share with other people who use the services?
The PbR programme is driving work in all these areas right now, a clear and defined beginning and end of care and the long periods some people seem stuck in services is being discussed across England, Norfolk and Suffolk are working on a joint health and social care assessment, the draft menu of support is already available online, and work on user measured outcomes is ongoing both in local areas and nationally, and the use of Recovery Star routinely.
Will this all come together in the next few years and deliver the revolution we want in individual control over the services we receive?  It is a real challenge, but in the end it is really up to all of us.
Lawrence Moulin

Having read through the NDTi document a second time I think it is quite helpful to the debate but possibly in its brevity minimalised some of the key issues?

I would have liked more emphasis on some of the findings from the “Puzzles and Possibilities” scoping exercise May 2010 - namely that PbR cannot succeed without the LA and so there is a need for a high level joint strategic leadership in order to avoid duplicated care. It rightly highlights the medical language in PbR and that it can be interpreted as concentrating on health needs with a fear that holistic needs may not be all met especially in the more complex cases.

I also like Simon Duffys point (a man who has done much work on this) that the integration of PbR and personalisation is not rocket science especially if there is political will and in his paper “resource allocation in MH” he proposes a model where PbR incorporates FAC (Hartlepool are I believe pilotting such). He also suggests that the Recovery Star is used as an outcome measure which in its holistic nature might help move the ethos to a genuinely integrated view of need and be more acceptable to local authorities

A point which appears not be covered is how this may affect already integrated health and social care teams. What if a social worker has the expertise to care co-ordinate both the health and social needs of a person within a particular cluster? (the existing practice in integrated teams) Does that mean that the Trust will not get payment for such? Our local commissioners could not answer this but in the financial climate for a foundation trust the threat of losing such potential streams of income is understandably a genuine stress on integrated working from a Trusts perspective?

Certainly if these two policy initiatives are not developed in tandum as is suggested further stains on integrated working will be the result and in many areas we are already seeing increasing separations?

craig wilson

I am Care Co-ordinator/social worker in City CMHT in South seconded to local Trust. Social approaches to mental health care are definetely having a harder time than ever! Medical model dominant with patients risk asssessments full of unnecessary and unchecked observations on their behaviour more so with the advent of new computer systems. Patient appointments needing ‘validating’ as each contact is ‘worth £250 for the trust’! This for me works against all notions of doing brief crisis work with patients to ennable them to stay out of a system that labels them with diagnostic categories. This is not creative. Local support agencies under pressure. Housing departments too under pressure to evict vulnurable individuals with mental health problems who “can’t sustain tenancies” and therefore won’t be given another one! SDS helpful but the paperwork is difficult to manage particularly when you don’t have access to computer systems to make necessary changes to care plans etc as they arise. I believe that if I didn’t have my large caseload I would still be usefully employed doing all the other things that are required of me! My small GP orientated team has now been subsumed by a large team consisting primarily of doctors and nurses. Very little secondary psychology for patients so this is not really a resource. Colleagues and myself not risk managed as we were in smaller teams. Managerial priorities and systems dictate the work. I spend treble the time I did before in front of a computer which is bad for my health and I do not have a desk so more of my own identity is lost (and possibly social work with its value base and advocacy role) Social work should be about challenging unhealthy systems but often because that means the individual doing the challenging is seen as a threat they are bullied. NHS? a bullying culture.. county council for me more democratic and supportive.. It seems staff are another disposable community. Uncared for unsupported staff leads to less ability to support distressed patients and families. One word about responsibility. Personalisation and choice is fine but what if the patient is not willing to take advice for example prefers to be a patient with a diagnosis so ‘things are done to them’ rather than taking the risk of effecting change through psychological approaches? Good support is not always about giving the patient ‘what they want’. For me the emphasis should be on what is healthy in terms of intervention and support. Supporting people to take risks involved in breaking negative patterns. Also carers are not always caring! People can become patients with mental health labels when they are part of a bigger family dynamic that makes them into the ‘problem’...Big institutions such as the NHS and County Council are not individually focussed. They have become corporate with the day to day work marginalised creating a strange dichotomy between the smart appearance of the HR staff and the Managers office and front line staff. The status and pay awarded to doctors who are involved briefly with the patient and prescribe are indefensible in line with taxpayers funding. The huge pay awarded to NHS trust high level Managers is an appalling indictment when services are so stretched and resources so limited. Vulnurable patients are not able to articulate their views. Community psychiatry is not at its best. Society more under pressure due to economic situation is less willing to take kindly towards the vulnurable particularly the mentally ill. Sorry to drift from point to point just my end of a long challenging day’s ramblings!

I read ‘Getting it together for mental health’ with great interest. I am very familiar with this debate and the challenges it raises. Together with the additional challenges of a meaningful quality and outcomes framework to underpin the assurances needed for mental health PbR, I agree a greater emphasis on personalisation within the development is absolutely essential going forward.

My role is within the Trust where the model of clusters and care packages were developed, and we continue to focus on the future functionality of the model, starting with the clinical system, working up to the information functions and lastly the resources and financial system functions.  Those with long memories will recall that the PbR mechanism for mental health is using the methodology of clusters, care packages and pathways which was already being developed, and not that the clinical methodology was developed in response to PbR!

Having read the issues the raised in the other posts, I wanted to take the opportunity to reiterate some fundamental points which people might find helpful.

The cluster descriptions are not based on diagnostic (ICD-10) catergories. The descriptions are based on common features of people with similar needs, irrespective of their diagnosis. The diagnosis is actually less relevant than the needs of the person, and those familiar with the descriptions will know that the some diagnostic codes appear in many different clusters.

There are no national care packages for each cluster nor is there any need for some. Others may disagree, but I would ask if taking a nationally-led approach of one care packages per cluster lends itself to personalisation?  NICE and other nationally-recognised and evidence-based guidance has shaped those developed in our and other Trusts). Our Trust’s care packages are informative guidance for clinicians and not prescriptive. They have and will change over time, to reflect improvements to care and changes in needs of the individuals receiving care from our services. Only by continuously evaluating ‘what works well’ over time, using meaningful outcomes, will we be able to establish ‘what a good service looks like. The care packages provide those first steps to establishing consistency in good practice but maintaining responsiveness to the personalised approach.

If embedding the culture of personalisation within mental health PbR ever feels that is on the ‘too hard to do’ pile, then it is possible we are approaching it too much from the top down, policy driven angle. To get a perfect fit, I agree with others, we must work together. But I strongly suggest as we do that, we focus together on the delivery of care layer first and not the financial layer.

Christina Walters
South West Yorkshire Partnership NHS Foundation Trust

As a mental health service user, PBR, and clustering are actually very threatening processes. At a time when all NHS services and funding are being marketised and fragmented, this restructuring is being done purely for funding purposes - so that tariffs can be set “either locally or nationally”.  There must be good reasons why no other mental health service in the world runs PBR - not even the US insurance-based model. To me, it seems a largely pointless exercise to group people together in 21 different categories based on similar levels of “need” (subjectively measured by different workers, using the HONOS scale?)  - where before, clinicians were trusted to make diagnoses of individuals as users and we spent years fighting for individual care plans and rights…now we will be in a general cluster “pathway of care”. But there is no new money for funding - so what new services can be offered?
I see this as a re-structuring with a view to making mental health services easier and more attractive to the private sector - just as academies and free schools have with the education sector. 21 low cost, easy to fund and manage “pathways of care”, it will be like the McDonalds of mental health, you will just have to fit the service on offer and not expect to be treated as an individual anymore. In the region where I live, Serco have already put in a joint bid to run children’s services with a nearby mental health Foundation Trust.  From this position Serco are well placed strategically to move into adult mental health care.
Personalisation hasn’t taken off with users for good reasons - it is hard to manage , it conflicts with benefits, very few councils offer it to mental health service users and there just aren’t the services available to purchase.