For the past year many social workers in England’s adult mental health services have been road testing a new framework for assessing client need and coordinating care packages.
The new framework is an early version of the government’s payment by results (PbR) scheme for mental health services. It is a complex policy (see our quick guide here) but, very broadly, a ‘clustering’ system introduced in 2012/13 sees social workers and other ‘care coordinators’ charged with assigning each person they assess to one of 21 ‘care clusters’.
These clusters group psychiatric disorders with similar levels of severity, for example ‘non-psychotic chaotic and challenging disorders’, and are linked to care packages.
Commissioners pay providers for the care package that is linked to the patient’s cluster. The theory is that resources follow the patient, rather than the indeterminate block contracts for mental health care that currently dominate.
For now, the level of payment for care packages is set locally but the Department of Health hopes to introduce a national tariff in coming years.
Ministers, who have made PbR a key plank of the coalition’s mental health strategy, say the approach drives up quality and personalised care. But critics argue that the framework, long established in acute medicine, is too blunt to apply to the complex world of mental health.
So how have adults’ social workers trialling PbR found the first 12 months of applying a system that ministers intend to extend to both children’s and forensic mental health services in coming years?
Twitter user @444BlackCat is an experienced social worker and Approved Mental Health Professional (AMHP) who works in an integrated team. He says that the health-driven PbR agenda can clash with social care priorities: “health have got their targets, we’ve got our own – the two don’t seem to fit.”
@444BlackCat feels senior managers at his NHS trust have little enthusiasm for PbR. “The message is, ‘we know it’s rubbish, but we’ve got to do it because it’s how we’re going to be funded’,” he says.
The main impact of the system to date has been a sense of confusion and an increase in paperwork, rather than any tangible benefit to service users, he says.
“I’ve had three lots of training: each time it’s been different,” @444blackcat explains. “The clusters don’t fit individuals, so you have to put people in boxes that make no clinical sense. You’ve got a rigidity that means you can’t get a full picture of someone.”
The sense of incomplete information brought about by piloting clustering ahead of full PbR implementation (which could happen as soon as 2014) is something @444blackcat and his peer The Masked AMHP, a mental health social worker and blogger who has written about PbR, repeatedly cite as a major source of frustration.
“We’re still unclear as to what the real purpose of the clustering will be and how applicable it will be to the people we’re seeing,” says The Masked AMHP.
He explains that at present assessments, treatment and support continue much as they did before – with clustering forming an extra level of process – but says his team “don’t know how close to the eventual packages of care what we’re doing will be”.
An awkward fit with social work values?
Social care leaders recognise the concerns. Ruth Allen, chair of The College of Social Work’s mental health faculty says that social workers who are care coordinators are spending additional time on “diagnostically driven” clustering.
“It’s counterintuitive in relation to modern social work, which is personalised and all about assessing and self assessing, thinking about what people want their journey of support to be like and how you can help them achieve that,” says Allen.
Allen acknowledges that the “everything having its price tag” nature of PbR isn’t necessarily a negative scenario just because it hasn’t been part of social workers’ traditional value base, but says that the system has to be kept in check.
“The danger is, if it overrides the human relationship element of supporting people on their recovery journey then services won’t be effective,” says Allen.
Faye Wilson, chair of the British Association of Social Workers’ mental health forum, is concerned that PbR will fragment care and drive a further wedge between health and social care.
“It creates silos,” says Wilson. “The most important thing for social workers, and for service users and other professionals, is that in mental health people don’t divide between health and social care needs.”
PbR and personalisation
Some social workers, including The Masked AMHP, are sceptical about whether the health-driven PbR can successfully work alongside the social care-led drive for personalisation in mental health care.
But Ann Sheridan, head of social work and social care at Central and North West London NHS Foundation Trust, insists that research carried out in her area shows the two systems aren’t mutually exclusive.
“Both are based around allocating resources,” she says. “That’s something powerful, at this time of wanting to save money and look at outcomes, despite the fact that they may seem to come from different extremes.”
For Sheridan, much of the negativity around PbR stems from language and cultural barriers between health and social care professionals. From this month, her trust will be initiating a project attempting to create a deep integration between PbR and personalisation.
“It’s unfortunate the Department of Health doesn’t think more at a strategic level before it rolls out these agendas, over where they could integrate more, [but] where that’s not happening we have an obligation to make it work for people who use the service,” says Sheridan.
The way forward?
Stephen Dalton, chief executive of the NHS Confederation’s Mental Health Network, is another urging that maintaining this focus should take precedence over simply picking out PbR’s faults.
Dalton admits to having his own doubts, but argues that some of the complaints voiced by frontline staff are likely to be down to local failures in how PbR has been interpreted, rather than structural flaws in the system.
Dalton also believes PbR may be the most effective means of revealing shifts in demand on different services – another frequent gripe among frontline staff – as well as showing taxpayers where money is going.
“The central question is,” he adds, “even if you responded to people’s anxieties and said, ‘We’re not going to have PbR because it’s not working out the way we wanted it to’, what system are you going to have instead?”
Others remain convinced, however, that alternative models are viable – and should be test-driven more fully before PbR becomes the default.
BASW’s Wilson advocates exploring the Year of Care strategy, a more holistic way of packaging care that has been trialled in support of long-term conditions such as diabetes, and is extremely wary of the proposed rollout of PbR to children’s services.
“More than anything, CAMHS should be integrated. It makes no sense to over-medicalise it,” says Wilson.
“[The DoH] needs to work with local authorities to find a truly health and social care needs-based approach that also incorporates personalisation rather than operating parallel systems. Otherwise the people to lose out are service users.”