people lives communities people lives communities

Mental health payment systems

and personalisation

NDTi webinar
16 October 2014
people lives communities
Welcome and introductions
What question is a new payment system the
answer to?
Does personalisation work?
Where are we with the payment system in MH?
Whats needed to put this into place?
What else is going on?
Discussion
Overview
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Who you are
Where youre from
What your role is
Welcome and introductions
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Real-terms spending decreased for last two
years - 1% cut in 2011/12 and a further 1% cut in
2012/13
MH providers subjected to 20% bigger cut than
acute providers from 1 April 2014
Only around 1/3 of people with a MH problem
receive any kind of formal support.

What Q are we A? (1a)
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What Q are we A? (1b)
people lives communities
NHS Care Plan (in England):
54% definitely had views taken into account
42% said plan definitely set out their goals
Of these, 44% said NHS MH services definitely helped
them start achieving these goals
Choice and control in Scotland
People using Direct Payments as a proxy for this
37% people with physical/sensory impairments
24% people with learning disabilities
19% frail older people
5% people with mental health conditions
What Q are we A? (2)
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What Q are we A? (3)
Employment for people with a MH problem
Non-disabled people is approx. 79%
Disabled people is approx. 48%
Depression is approx. 26%
Other forms of mental health conditions (e.g.
phobias) was 13%
Only 8% of adults with serious mental health
problems in employment
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Put it another way
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Evidence personalisation works
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Evidence personalisation works
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70%+ of people with mental health problems:
Being as independent as they want
Getting the support they want
Being supported with dignity and respect
60%+ of people with mental health problems:
Physical health
Mental wellbeing
Control over important things
Control over support
Less than 10% reported a negative impact on
any area of their life

Evidence personalisation works
people lives communities
West Sussex:
DPs process that supported discharges from
residential care
Encouraging evidence that residential care
admissions reduced
Florida:
People spent significantly less time in psychiatric
inpatient and criminal justice settings
People spent significantly higher number of days in
the community (compared to inpatient or forensic
settings) than in the year before
Similar findings in other places

Evidence personalisation works
people lives communities
Health system: PbR represents 60% of acute
hospital income (29bn) and one-third of primary
care trust budgets
Mental health identified for further roll-out
2012/13 was a key year
2 fundamental features:
Currency the unit of care for which a payment is
made
Tariffs the prices to be paid for each currency
PbR introduction
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Clusters are the currency groupings based on
common characteristics such as level of need /
similar resources
21 care clusters under 3 main headings
Mental Health Clustering Tool
Tariff
Indicative national tariff
Local tariff agreed locally between commissioners
and providers
PbR in MH overview
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Covers both hospital and community care
Episodes are more difficult to define
Diagnoses are less clear-cut
Less consensus on optimal care pathways
Complex interrelationship between mental and
physical health
Data
Provision of MH service varies considerably
PbR in MH differences
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Clustering provides
new information
Better understanding
of quality and o/c
Individuals, not
services
Delivery beyond just
NHS providers
Supports introduction
of PHBs and IPC
PbR and Personalisation theory
Medical model / deficit
approach
Focuses on (defined)
interventions and
treatments
Payment by Activity
Whole system?
Complementary?
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Whats the national picture?
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Whats the national picture?
people lives communities
Whats the national picture?
people lives communities
Whats the national picture?
people lives communities
Whats the national picture?
people lives communities
Whats the national picture?
people lives communities
hfma survey
Commissioner understanding: 84% very poor fair
Open and regular dialogue w commissioners: 95%
Open and regular dialogue w service users: 40%
Cluster activity financial impact: 60% none
Contract type: 70% block with shadow tariff
No provider is using nationally specified currencies
with local prices as the primary basis for contracts
Range of opinions on the future

Whats the national picture?
people lives communities
Discussion paper
How PbR and Personalisation being understood and
implemented together
Seminar (with TLAP and SCIE)
Opportunities and challenges of PbR and
Personalisation
Lack of good practice examples that can be shared
NHS Confederation MH Network commissioned
a practice paper
Snapshot of how working in practice
Emerging approaches
Payment system & personalisation
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5 areas (identified by SHA MH leads)
Suffolk, Lambeth, Worcs, Northants, Stockport
In each area the project looked at:
What has worked well
The difficulties encountered on the way
Critical success factors
Pitfalls to avoid
Caveat
Around 1 day in each area
Designed to be a snapshot
Method
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Creative, whole systems approach to
commissioning, contracting and service design
Recognition that traditional approaches undermine
collaborative working
Understanding that PbR puts pressure on VCS providers
but limited ways of addressing this (including social
investment)
Most attention is on systems change and more attention is
needed on market development
Financial pressure isnt yet leading to new approaches
Those with biggest picture view have more chance to be
successful
What we found (1)
people lives communities
Systems and culture change to support right PbR
Leadership, vision and commitment
Especially in solving issues
Joint capacity in commissioners and providers
Good communication, that especially avoids conflicting
messages (e.g. choice versus block contract vacancies)
Involvement of all right stakeholders effective
mechanisms to do this
Two approaches:
Think then do
JDI
On balance, JDI
What we found (2)
people lives communities
Partnership and integration
No evidence that one form of joint arrangements is
better than another
Different stages of development affect joint working
E.g. where RAS is well-developed more difficult to
unpick
but could well be worth it
Bridge differences in language
E.g. RAS and PbR are both about allocating resources
Not sufficient understanding or communication of
Care Transition Protocols beyond clinicians
What we found (3)
people lives communities
Inclusive and streamlined approach to
development
It takes a considerable amount of time and
effort from a wide range of people
Commissioners need to lead conflict of
interest for providers
Balancing cost and quality is very difficult
Not enough focus on outcomes or impact
that PbR can have on peoples lives and
experiences
What we found (4)
people lives communities
From health assessment to FACS eligibility
with 25% up-down discretion PbR as
opportunity to improve RAS for MH PBs
Strong engagement of business support and IT
staff
Integrated health and social care budgets
provide a good platform for developing joint
assessment and local tariffs
Personal Health Budgets are more generally a
positive development for PbR and
personalisation
Practice highlights (1)
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Stockports alliance contract
Comprehensive coproductive approach
including involvement of practitioners
Significant engagement with voluntary sector
organisations
CQUINS used to introduce enhanced primary
care services
Beginnings of a Payment by Recovery project
with Experts by Experience monitoring PbR
process

Practice highlights (2)
people lives communities
Lessons difficult to disentangle from issues
more widely in MH
Payment system an opportunity for those
who do things really well to do something
else really well
Some have grasp of what needs to be done
Still putting it into practice
Juggernaut of Payment Systems (incl in
MH) continues irrespective
Overall reflections (1)
people lives communities
Social care involvement not very much
Need to equip social care colleagues
Provider engagement
Overwhelmingly MH provider trusts
Very strong incentive to be involved
VCS?
Whats a cluster?
Less Payment System and personalisation
more what can Payment System can learn
from personalisation?

Overall reflections (2)
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Contact
Rich Watts, MH Programme Lead
T: 01225 789135
E: rich.watts@ndti.org.uk
Twitter: @rich_w