WORKING TOGETHER TOWARDS INTEGRATION

PAYMENT BY RESULTS (PbR)WORKSHOP

Why Payment By results (PbR)?

• Increase the link between payment and quality of care and drive integration of services

• Support the expansion of a more transparent rules based funding system

• ‘Incentivise best clinical practice and improve outcomes’*

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* Operating Framework NHS 2012-13

Mental Health PbR is different to acute PbR

• The currency of Acute PbR is the Healthcare Resource Group (HRG).

• HRG uses ICD10 codes and other classification systems .

• Mental Health PbR uses Care Clusters instead of HRG.

• Mental Health PbR does not use the ICD-10. Instead, professionals rate service users using the Mental Health Clustering Tool.

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Current system • Before PbR most (PCTs) had simple ‘block

contracts’– effectively a fixed amount of money for the year ahead.

• Many of the risks in the system were carried by providers. i.e. rising activity levels would increase provider costs, without any extra income

• Block contracts were generally based on historical patterns of care and reflected local costs of providing care.

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New system - Care clusters

• The Care Clusters are based primarily on the needs and characteristics of a service user

• Clinicians allocate a patient to one of 21 care clusters

• The clusters are mutually exclusive in that a service user can only be allocated to one cluster at a time.

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What’s not included in 2012/13

• Improving Access to Psychological Services (IAPT)

• Child and Adolescent MH services (CAMHS)• Forensic and secure services• Specialist services (incl. deaf, eating

disorder, neuropsychiatry, learning disability, addiction services, alcohol)

• MH services under a GP contract (and others)

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Decision Tree- Care Clusters

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The Mental Health Clustering tool

• The MHCT incorporates items from the Health of the Nations Outcome Scales (HoNOS) and The Summary of Assessments of Risk and Need (SARN).

• Part 1 – 12 items HoNOS related to severity of problems

• Part 2 – SARN consider problems from a ‘historical perspective’

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How does it work? Step 1 Routine screening assessment process

scores the patient’s needs using MHCTStep 2 Decision tree - to decide if the presenting needs

are A,B,CThen decide which of the next level. This will narrow

down the list of possible clusters. Step 3 Look at the grids - which one is the most

appropriatered: level of need which must score orange: expected scores yellow : may score

Final clustering decision is based on clinical judgement applying the guidance 9

Service delivery • Assessments – funded separately and can

be classified in three ways a) Assessed, not clusteredb) Assessed, clusteredc) Assessment ‘service’

• Care pathway – 21 care clusters• Care Transition protocols – move within

super cluster or discharge• There is one transition protocol for all MH

Providers10

Different from Wonderland - Clusters as Contract Currency

• Commissioners will be paying providers on the basis of x people in cluster 1, x people in cluster 2 and so on.

• Payment would be for all elements of care service user receives, both direct (therapies) and indirect (care co-ordination).

• Clusters should cover care provided as part of the section 75 arrangements

• Person/needs focused as opposed to service focused 11

Strategic Challenges

• Timescales • Risk of focus on detail and challenges• Commissioning and governance changes.

All of the above will divert attention away from potential of PbR to deliver quality

services which focus on ability and reablement and offer choice.

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Delivering QIPP via PbR

If PbR is implemented correctly, PbR will… • Offer a real understanding of how services

are configured and delivered• Provide a means to systematically

measure quality information that allows data reporting and benchmarking

• Inform decisions about commissioning and de–commissioning

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Using PbR to incentivise quality care

If PbR is implemented correctly, PbR will… • Enable payment for a cluster of care with

data on the outcomes• Potentially encourage providers and

clinicians to innovate with pathway development which delivers better outcomes at the same cost

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PbR and Personalisation • ‘Personalisation is generally understood to

mean a culture in which citizens are able to shape the services they need, with choice and control, so that support fits the way they wish to live their lives’

• ‘The link between personalisation and PbR is vital if the ambition to offer people real choices and achieve more cost effective joined up commissioning and provision is to be realised’*

15*Getting it together for MH Care: Payment by results, personalisation and whole system working, NDTi, Dec 2011

Local Challenges • The quality of data - poor data quality

means that trusts will not have a robust currency by April 2012

• Data interpretation• Robust costing mechanism - inaccurate

tariff risk destabilising providers and commissioners

• Significant variation of funded services between boroughs – price per cluster per trust for 2013-14

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London programme 2012-13• London Currencies Development Board

(LCDB) - chaired by Wendy Wallace

• London Health Programmes (LHP)oCommissioner steering group – chaired

by Stuart SawoProgramme approach oEngaged stakeholders

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Work streamsCommissioners• Costing and contracts

o Service specs, care clusterso Template for information scheduling and reporting

• LA and 3rd sector• Transition to CCGs

Providers• Training on transition protocols• Data quality• One price per cluster 18

Work streams cont…

Jointly commissioners and providers• Cost per cluster per trust 2013/14• Develop specs and care clusters• Information and reporting schedules

Nationally• Outcome metrics• Expand PbR (IAPT and Forensics in

2013/14)19

Jan 2009: DH mandates MH PbR

Mental health PbR timeline

April 2012: Introductory year

April 2013: Go live

2010: MHCT and transition

protocols released

31 Dec 2011: All patients clustered

Feb 2012: Final guidance

released

Dec 2011: MOU agreed

April 2013: •Initial data

shared•Contracts signed off

June 2009: Implementation

startsDec 2011:

Joint workinginitiated

April 2012:•Commissioning

using PbR

Feb 2012: Training

for transition protocols