• National policy committee proposes radical reform to specialised mental health payment systems
  • Mental health programme of care board said current occupied bed day payment system was “problematic”
  • It proposes a new three-part system aimed to providing more specialised care in the community

NHS England is considering a radical overhaul of the way specialised mental health services are paid for including a greater emphasis on rewarding providers for shifting care into the community, according to internal documents obtained by HSJ.

A paper, written for NHS England’s mental health programme of care board, which advises NHS England on commissioning policy for the sector, has set out a vision for the way tier four child and adolescent mental health services and adult secure mental health services should be paid for.

The document, obtained under the Freedom of Information Act, could see providers being paid a fixed amount for a set number of beds, with further payments for each specialised care episode and a top-up fee for reducing specialised inpatient care days.

The new model would be based on:

  • Inpatient capacity payments to maintain an agreed number of beds, irrespective of occupancy, with value set by security level;
  • A fixed fee per patient episode, where specialised care episodes for non-secure patients can be delivered in the community; and
  • A community outreach top-up fee paid for achieving a reduction in the number of specialised inpatient care-days.

Tier four CAMHS and adult secure services are commissioned by NHS England, with an expected spend of £1.9bn in 2017-18.

The new proposals were put to the programme of care board at a meeting in November last year ahead of implementation by April 2019. However, NHS England has not said whether it accepted the proposals.

The paper said the current payment system was “problematic” as it was tied to occupied bed days which “inhibits” adequate funding of community-based mental health care.

The document added: “There is potential for reimbursement reform to support a substantial shift of care out of inpatient settings, contributing both to patient recovery and to the efficiency of use of mental health funding.

“The aim is to implement a reformed reimbursement system where contracts are varied for the service review, and then systematically from contract renewal in April 2019.”

The board report proposes a three-part payment system for CAMHS, but said it was being designed in “tandem for both CAMHS tier four and adult patients”.

It added that the community top-up was ”an essential part of the model – focusing effort on delivering speedy restoration of patients to their community, which is an important outcome for almost all patients. It is envisaged that the benchmark for inpatient stays against which the [top-up] is paid would decline over time according to outcomes achieved across the country.”

But it added that the top up would need to be funded through a reduction of the number of specialised beds, while increased care in the community will free up inpatient beds for adult care which can be used to “enhance access to specialised beds for patients currently warehoused in locked rehab beds”.

The document said these proposals will need a lead provider or accountable care system to take responsibility for the specialised patient pathway.

This could see responsibility for crisis stabilisation services handed to clinical commissioning groups on an STP footprint and create a financial case for them to invest in services to pre-empt crises.

The report said this will require a permanent funding adjustment, but this will be offset by the reduction in specialised inpatient bed use for patients with a short-term crisis.

An NHS England spokesman said: “The NHS nationally spends nearly £2bn on specialised mental health care each year, so it’s right that we consider alternative methods of funding care which deliver better outcomes for patients, and the best possible value for taxpayers.”