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Keywords:

  • Healthcare payment system;
  • Resource allocation;
  • Clustering;
  • CAMHS

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References

Payment by Results (PbR) is a healthcare payment system in England only, already in place for elective secondary care, which has started in Adult Mental Health and is being developed for CAMHS. The approach taken for Mental Health PbR is to allocate service users to groups which are similar in resource usage, called clusters. A choice of care packages and a mechanism for reviews linked with outcome measures all aim to facilitate innovative, efficient and effective management of mental health needs linked to a transparent payment system.

Most of us have heard about Payment by Results (PbR) and may be aware of what is going on in our organisations from colleagues in Adult Mental Health. This article describes the progress with extending PbR into CAMHS. As this is very much work in progress, the information below is correct at the time of writing (July 2012) and subject to change. For up to date information, please contact the author.

Background

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References

Payment by Results was introduced into elective secondary care in England in 2003/04. The Government is committed to extending PbR to support choice, efficiency and incentivise best practice.

Work on Adult Mental Health PbR started in 2003. Many challenges were recognised – problems tend to be long term and do not fall into discrete categories. International casemix systems in mental health are very limited (Mason & Goddard, 2009). Trials of PbR (or casemix) in Australia and New Zealand have not been taken forward. Learning from the Netherlands and United States indicate that risks for provider financial instability can be minimised by gradual, iterative implementation.

From 2008, the Department of Health (DH) in England commissioned a group initially based in Yorkshire & Humberside – the Care Pathways and Project Consortium – to develop a national system for adults (http://www.cppconsortium.nhs.uk). In 2011, DH extended work into CAMHS, with the aim to develop a system that works for young people and their families and promotes creative and effective services.

The anatomy of PbR

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References

Payment is not for results, but for care involving outcomes monitoring.

The currency (unit of payment) in physical medicine is ‘healthcare resource groups’. Mental health uses ‘clusters’, which are groupings with similar needs, requiring similar resources (resource homogeneity). A clustering tool helps clinicians' allocation of service users to the best fit cluster. The tool does not override clinical decision-making. For Working Age Adult MH PbR, this is the Mental Health Clustering Tool (Department of Health, 2012). The price for a given currency is called the tariff.

Working in a clustering system

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References

At the initial appointment, the clinician gathers information to allocate the person to a cluster. A choice of care packages is then offered, which will be based on NICE guidance or best practice with locally agreed adaptations.

Reviews with outcome monitoring occur at defined intervals, with reallocation to a different cluster (and new care package) discharge or continuation. Significant change in needs may prompt a review. Payment is linked to review periods and commissioning is for a certain number of clients in a certain cluster. All elements of care both direct and indirect are included.

CAMHS PbR

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References

CAMHS PbR work started at the end of 2011. A Project team was appointed, supported by a range of advisory and decision-making groups including a CAMHS Expert Advisory Group, which the author chairs. Their first task was to review all the local work around England and link closely with stakeholders, Adult Mental Health PbR and government departments.

Scope

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References

CAMHS PbR will be independent of setting; apply to all NHS Trusts, the Independent Sector and Third Sector; cover Tiers 2–4, learning disability, forensic and dual diagnosis. It will be consistent with Adult PbR and CYP-IAPT. Non-mental health learning disability services, GP services, primary substance misuse and addiction are excluded.

Development of clusters

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References

The first task is to develop the currency clusters suitable for CAMHS. How can we categorise young people into meaningful groupings? The human condition is complex and does not fit neatly into boxes, especially in relation to mental health. A review of current NICE guidelines by the Project Team revealed patterns for similar levels of need, irrespective of diagnosis. This led to consultation on an initial cluster proposal that took into account of complexity factors outside the mental health problems, which impact on the care needed.

Data modelling work was undertaken over the summer of 2012 to determine whether these clusters were supported by real data on real young people seen in CAMHS. Several retrospective large datasets were interrogated, including the CORC dataset (CAMHS Outcomes Research Consortium) and others from clinical services, with consequent revision of the proposed clusters. At the time of writing, the revised clusters have not yet been agreed.

Adult services use 21 clusters, developed for adult needs. Work will be done to ensure mapping across from CAMHS clusters to adult clusters is easy to do and be informed by careful transition planning and protocols.

Next steps

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References

Prospective data will be used to further examine the robustness of the proposed clusters. Subject to DH agreement, future work plans include piloting in CAMHS in Autumn 2012. Subsequent work will include producing a clustering tool, tariff and quality measures.

Acknowledgement

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References

This article was invited by the Editors of the journal; the author has disclosed that she is the Chair of the CAMHS Expert Advisory Group advising the Department of Health in England on PbR, but has no additional potential conflicts of interest.

References

  1. Top of page
  2. Abstract
  3. Background
  4. The anatomy of PbR
  5. Working in a clustering system
  6. CAMHS PbR
  7. Scope
  8. Development of clusters
  9. Next steps
  10. Acknowledgement
  11. References