Dr Daniel Harwood says introducing payment by results to mental health services will propel psychiatry into the 21st century

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There are widespread concerns that long-term non-specific supportive interventions are harmful as they can foster dependence and encourage unhelpful behaviours

There are already national tariffs for admission, inpatient care, outpatient attendance and some procedures, and the government is rolling out this approach to mental health and other community services.

Instead of the traditional block funding of mental health service providers, from April 2013 providers will be paid according to what they do. To start, payment will be made on the basis of activity but eventually service providers’ income will be linked to clinical outcomes.

How is it going to work?

At the first assessment by the specialist clinician, or shortly thereafter, each patient will be assigned a “care cluster” using the mental health clustering tool (a version of the Health of the Nation Outcomes Scales).

‘Services will not be paid unless they implement payment by results, so it is a “must-do”’

The 20 care clusters group together psychiatric disorders that have similar levels of severity and risk and share similar treatments. Commissioners will pay the provider for delivery of a menu of treatments or care pathway linked to a cluster.

Care pathways for each cluster are agreed locally but are expected to conform to national good practice standards, such as NICE guidance. Each care cluster has agreed clinical outcome measures that are validated assessment tools.

There is much excellent practice in adult community mental health teams. But staff often have large caseloads and much of their work is routine; monitoring medication, supporting vulnerable people with personality disorders and substance misuse problems, and managing crisis. Some of this work is evidence-based.

Major shift

However, there is a significant amount that is not. There are widespread concerns that long-term non-specific supportive interventions are harmful as they can foster dependence and encourage unhelpful behaviours.

If providers of mental health services are to be financially sustainable and patients are to receive effective treatments, payment by results has to involve a major shift towards using evidence-based treatments in the context of a culture that expects patients to be active participants in their recovery.

There will need to be a renewed emphasis on accurate assessment and diagnosis, clinical care will be need to be standardised, with all practitioners using the same assessment tools and risk assessments. Recovery and discharge will be the norm, rather than support and monitoring.

Why is it worth doing?

Services will not be paid unless they implement payment by results, so it is a “must-do”. As well as improving the clarity of funding arrangements for providers, payment by results has huge potential benefits in improving quality of clinical care. Staff will have to be more precise in defining what they do, and will be asked to provide interventions of proven efficacy.

Routine use of clinical outcome measures will facilitate the benchmarking of services, and will provide information needed for performance management; identifying strengths and weaknesses of staff by comparing clinical outcomes for the same intervention in different staff.

Commissioners are less likely to withdraw funding from a service if the provider can prove it is making a difference to patients. Patients in a particular cluster will know what treatments they can expect and how they will be assessed to check the treatments are effective.

Five key drivers to make it work

Give the staff as much responsibility as possible in implementing payment by results. The Department of Health is telling trusts what they have to do and there is only a limited room for manoeuvre. This is why it is crucial that clinicians are empowered to make payment by results work in their locality. Clinical teams should lead in defining cluster care pathways, and in designing appropriate risk assessment and care planning documentation.

‘Payment by results could be the tonic psychiatry needs to move into the modern world’

Clinicians can audit their services, collecting outcome measures and benchmarking these against other services. The more you can get clinicians involved the smoother the process will be. It is then easier to push through the inevitable “must do’s”.  

In our trust we have designated “clinical leads” from all disciplines who are working closely with their team leaders to provide the clinical steer for this complex project.

Involve service users. Most patients and carers will probably not want to know the detail of the move to payment by results but they will want to know about how the service is going to change and what they might notice as a result. It is important for there to be a communications strategy with different groups of patients using the service. In our service the clustering guidance and care pathways are being discussed at service users’ forums. Patients have generally welcomed the clarity that the new model provides.

Good communication. Under payment by results a patients’ involvement with specialist services tends to be brief and focused on specific interventions. Patients will need to be signposted to other providers for care or support after the specialist treatment has ended. So clear communication and shared care pathways with other agencies are more crucial than ever. Patients and carers must have a copy of their plan with clear contingency and details of who to contact if problems arise.

The central role of the team leader. The team leader plays a crucial role in making payment by results work. He or she is the person who ensures practitioners have completed their care plans and outcome measures and that patients are assigned to the correct cluster. Team leaders need a good system of caseload management that challenges practitioners and ensures they are not veering off the path. Team leaders will need a lot of support, through meetings with their peers and from their line manager. They need to be set simple achievable targets for the implementation of payment by results. For example, on the quality of care clustering, and performance management of his or her team.

Get paid for everything you do. Agreements must be made with commissioners to cover the funding of teaching, training, liaison and consultation work, which do not strictly speaking fall under the remit of care cluster interventions, but none the less are vital in supporting good clinical care. Similarly, some essential activities, such as assessments, which do not result in a specific treatment, fall “out of tariff” under payment by results.

Mental health service practitioners are tired with frequent reconfigurations and changes of emphasis demanded by successive governments. However, payment by results looks like it is here to stay. Implemented sensibly, with clinicians leading, and with effective treatments and an emphasis on recovery at its core, payment by results could be the tonic that psychiatry needs to move into the modern world.

Dr Daniel Harwood is a consultant psychiatrist and lead clinician in dementia for the Isle of Wight Trust memory service.