22.09.10
Beggars in the market
Whatever might be said about the rest of the NHS, we do have very good secondary mental health services. But the NHS is changing radically and Dr Martin Elphick believes the business processes of mental health services are not well enough prepared for the competitive health market
The quality of British services compared to other countries must owe something to our combination of affluence and national organisation. Many other countries with aspirations to develop state welfare have lacked the resources to progress from asylums to enlightened community care. Elsewhere, if there is money but a weak state system then piecemeal development has tended to favour those at either end of the severity scale - those who can pay or seem to be dangerous.
It is hard to attribute our success to sustained political interest, despite mental problems costing the country an estimated 3-4% of its gross domestic product. There have been remarkable changes – where I work there has been a reduction from over 1,500 hospital beds to just 43 (about 3%) within two decades - but those seem to have been driven more by factors like the improvement of medication and the deterioration of the buildings than by policy.
On a local scale, too, day to day necessities have the most impact on the model of care. Senior managers have very little information deriving from the care process, so care teams have a lot of freedom to prioritise between patients. From time to time things go wrong but mostly they just go on.
But there are new challenges . For a start, overall mental health funding levels are at risk, partly because the ‘block contract’ funding system that we still work under has been replaced in most of the NHS by a tariff-based approach - Payment by Results. PbR enables acute trusts to precisely enumerate their need for funds. As a result mental health services, which have no comparable way to argue their case, have become a soft target for budget balancing.
Block contracts have further disadvantages within trusts. Because commissioners do not demand comparative data from treatment settings serving differing groups of patients, resources are allocated without the benefit of information on who is being treated or how. It is not possible to relate quality data to financial information, so there is no mechanism through which to use financial pressure to improve care. Our performance indicators are two steps removed from patient outcomes and can only be used as a blunt instrument.
There is no chance either of improving equity of access in a system that treats all mental health problems, and all the people with them, as though they were the same.
Why don’t we just join the PbR mechanism like everyone else? There have been several DH projects aimed at establishing a tariff-based mental health funding mechanism. The difficulty is that even cases with the same diagnosis are very different and we have no standard classification of interventions. Those are the usual criteria used for defining ‘costing currencies’ (aka casemix groupings). Last year, a group of mainly northern mental health trusts trusts described a number of ‘care packages’ – common combinations of interventions – to which most adult cases could be assigned. But the next phase of work, understanding the variability of costs within each package, is critical. Mental healthcare has not yet been successfully bagged up and priced anywhere else in the world, so establishing a mental health variant of PbR is at best a long way off.
We need to find a parallel means of maintaining budgets and quality.
Why have we not done more already? The mental health sector is poised uncomfortably halfway in and halfway out of the information age. Lack of investment has been associated with a negative cycle in which the DH and its arm’s length authorities have claimed that clinicians are resistant to change; and that mental health practice can’t be quantified anyway. Sure enough, collecting invalid data is unpopular, and the resulting information of poor quality.
It is possible to develop computer systems that serve both management and direct care requirements but implementation is forever about to happen. It has been frustrating to be repeatedly asked to explain what we need by successive teams from the National Programme for IT when they have already teamed up with suppliers who only sell systems designed for the acute and primary care sectors. Adaptation for our business model would cost more than NPfIT has left over once they have done whatever it is they do. Now, three or four years on, most mental health trusts are retracing their steps to specialist suppliers who provide better value for money - if we are allowed any.
How will the new market work for mental health? The new model contract for foundation trusts provides a framework for three-year contracts between commissioners and providers. Commissioners will supposedly assess the mental health needs of their flock, describing and judiciously costing those needs so that the providers will be able to do what is required. Should any unforeseen mental health needs befall the population during the three years, the providers will have to assemble a new case. But in reality there is almost no information upon which to base those arguments or refine the contracts and hence no leverage within the business mechanism.
We will be in competition for finite budgets with rival providers who do have those advantages. Mental health trusts will face competition from four directions. First, the NHS acute and primary care sectors seeking a greater share of budget to expand their current fields of work. Second, other NHS mental health trusts in straight competition for mental health work. Third, acute and primary trusts offering easily defined mental health services. Fourth, the independent sector. Easily costed services are going that way already such as psychological therapies to primary care, liaison services to acute trusts, and medium secure units to independent providers.
For people needing only a short episode of care the fragmentation of mental health services between providers may not matter. For complex long term cases however - those whom the NHS has managed well compared to other countries - it could be a disaster. Most mental health trusts are already introducing the ‘functional model’ – teams within the same trust working as a sort of assembly line, passing patients on as their needs change. But the new structure of services will mean that patients with the most complex needs will be simultaneously treated by different providers as well as serially treated by different functional teams. If it is done safely, communication costs will be extravagant. But multiple providers multiply the dangers of vulnerable people falling through the care net. That seems to me to be the biggest risk.
We are already disadvantaged by effective exclusion from PbR, a lack of valid information and IT infrastructure. But a lot of the background work to overcome that has already been done – it just needs to be pulled together into a national strategy. Clinicians, individually and collectively, would applaud a programme that addressed their real responsibilities.
So what is the DH policy? There is none. There is no funding. There is one project manager appointed to help trusts to spend their own money developing their PbR mechanisms ‘along the lines of the Northern PbR Project’. There is no mental health team within the central NPfIT. In other words, central funding is only going to acute and primary care trusts, our competitors. There is no plan to approve an intervention or condition classification. No plan to improve commissioner’s abilities to assess needs or quality of life. No policy on clinical outcomes. No intention to measure severity thresholds. I gather that the CEOs of mental health trusts have politely requested that this decision be reviewed and I gather that the Royal College of Psychiatrists supports them.
What is the answer? We need a nationally led business and information strategy for mental health and social care. We need to be clear whether it will be an NHS initiative, or a DH initiative including independent providers. It must be kept in harness with mutually dependent NHS programmes such as Pay for Quality (Advancing Care), and the review of the Care Programme Approach. Without a managed programme, and without the means to argue our case, the mental health community will be no more than beggars in the health marketplace.
Dr Martin Elphick is a consultant psychiatrist and chairman of the Royal College of Psychiatrists working party on Payment by Results
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