This time last year adult mental health services in England started road testing ‘clustering’ in assessments – an early version of the government’s Payment by Results (PbR) approach to funding mental health care.
As care coordinators gear up for the second year of clustering, we’ve published a piece looking back at frontline social workers’ verdicts on the first year of implementation. PbR is a complex policy so, to accompany that article, here are five key points on the theory behind it and some of the concerns.
1. PbR for mental health is a more complex beast than its acute-medicine incarnation where, in an often-used example, it can be easily applied to the process of a hip replacement (a procedure in which costs are relatively stable and relate mostly to one discrete instance of care).
2. In terms of mental health, the set-up entails assessing service users into one of 21 clusters; for example ‘(6) non-psychotic disorders of overvalued ideas’ or ‘(19) Cognitive impairment or dementia (low need)’.
Within these a 1-4 scale indicates the seriousness of the condition, and clusters are pegged to various maximum review periods ranging from four weeks to annual.
Each cluster is linked to a care package – under PbR this is what commissioners pay for, as opposed to the traditional ‘block contracts’ that are commonly used to fund care. The theory is that resources follow the patient.
3. Many have expressed bewilderment at the system. Others also argue that ‘payment by activity’ sums the process up far better than ‘payment by results’, because PbR currencies relate first of all to packages of care rather than the outcomes they produce.
4. Some social workers are worried about private providers muscling in and creaming off easy-to-treat (and therefore profitable) clusters, leaving the remnants of mental health trusts to cope with individuals suffering from slow-changing conditions such as personality disorders.
5. Different parts of the country are at very different stages of implementing PbR for mental health, owing in part to variances in the readiness of providers and commissioners.
At the moment care packages and tariffs are set locally. Introducing a national tariff, which the Department of Health believes would support the delivery of more consistent services, is in the pipeline but has been deemed too challenging an objective to meet during 2013-14.