1. Payment by Results in Mental
Health – An Update
Ashok Roy
Coventry & Warwickshire Partnership Trust
ashok.roy@covwarkpt.nhs.uk
2. Structure
• General principles
• Clusters and care pathways
• Cost, price, tariff
• Service redesign
• Operational issues
• Financial issues
• Take home message
• Test
4. Components of PBR
• Activity based funding: Payment by volume of work
done
• Healthcare resource groups: Groupings of individual
cases which are clinically similar and require similar
amounts of resource for their treatment
• Payment according to a national tariff: Payment
fixed based on average cost of treating that type of
patient across NHS
5. Justification of PBR
• Negotiations focussed on access and quality and
not on price
• Removal of link between price (tariff) and cost
incurred may promote greater efficiency and activity
• Information systems will need to improve to develop
better performance measures (appropriateness,
effectiveness, outcomes)
• May promote choice and a wider variety of providers
6. Lessons from Mental Health 1
• Adjustments for treatment variables needed (e.g.
setting, age, comorbidity etc)
• Condition assessed by enhanced HoNOS
• Diagnosis did not predict cost
• High cost variation for community based treatment
• Provider characteristics explained cost variation
better than patient characteristics
7. Lessons from Mental Health 2
• Highly demanding in terms of data
requirements for collecting and coding
information
• Possible to develop clusters based on
shared need which are the basis of care
packages for the individual
9. WHAT IS IN A
CARE PATHWAY
Needs ClustersNeeds Clusters
Interventions
Outcomes
10.
11. Non psychotic (mild, moderate, severe)
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)
12. Non psychotic (very severe and
complex)
5. Non psychotic disorders (very severe)
6. Non psychotic disorder of over-valued
ideas
7. Enduring non psychotic disorders (high
disability)
8. Non psychotic chaotic and challenging
disorders
22. Currencies and Care Transition Points
Period
start
Period end
Unscheduled
Review
Periodic
Review
Period end
Period
start
Cluster
2
Care Transition
Points
Cluster
10
30. Care Clusters
• To promote consistency in practice
• To collect needs-related data for clinical decision
making
• To aid commissioning
• To enhance service development
• To spread best practice
• To encourage consistency in delivery of care
• To help inform decisions about configuration of services
31. Priorities
• Integrate Care Clusters into existing business
processes of Trust
• Clarify transition from one care cluster to
another
• Allocate clusters to existing caseloads
• Focus on data quality and outcomes
• Continue work on LD clusters
33. Department of Health Timescales for
Mental Health PbR
• 2010/11 – clusters available for use. Reference costs returned on cluster
basis
• 2011/12 –
• all service users accessing Mental Health care (post GP or other
referral) traditionally labelled working age (including EIS from age 14)
and older people’s services, should be allocated to a cluster by 31st
December 2011
• local prices should be agreed for use in 2012/13 and this will require
understanding of local costs per cluster
• 2012/13 – clusters (with local prices) become mandatory for contracting
and payment purposes
• 2013/14 – earliest possible date for national tariff for mental health (if
evidence from use of national currency presents compelling case for a
national price
34. Payment by Results (PbR)
Analysis of activity for those patients allocated to Cluster 1
0
20
40
60
80
100
120
140
03/1887
Patient
Activity
SMS IP Alcohol
SMS Eating Disorders
Community
SMS Alcohol OP Review
OP OP Review
OP IP Organic
OP Day Care
OP CMHT
Adult OP Review
Adult OP Other
Adult OP New
Adult IP PICU
Adult IP Acute
Adult EIS
Adult Day Care
35. Payment by Results (PbR) - Challenges
• 2010/11 reference cost submission
• Obtaining sufficient activity data
• Ensuring national consistency
• Developing business rules
• Information system resourcing
• Organisational awareness
National and Local
Local
36. Payment by Results (PbR) – Risks
• Centralised currency setting not reflect all service inputs
• Tariff not capture all patient activity - duration
• Use of reference costs means averages of averages
• Information systems can’t capture intervention codes
• Local work not fit with national process
• Potential for non recovery of CWPT costs
National
and Local
Local
37. Payment by Results (PbR) –
Priorities
• Reference Cost submission
• Increase activity capture
• Glossary of terminology
• Overlay operational areas to ‘what we know’ about Care Clusters
• Shadow contracts on Care Cluster basis
• Development of local prices
38. Take Home Message
• We are the front line
• We carry out the clinical activity
• We spend the money
• We provide quality
• We can be more efficient and productive
• Lets lead the way
• Lets have a coherent message
