Mental health payment systems

Mental health payment systems, formerly known as Payment by Results (PbR), aim to provide a transparent, rules-based system for paying mental health service providers. It is intended to reward efficiency, support patient choice and diversity. Payment is intended to be linked to activity and adjusted for casemix to ensure a fair and consistent basis for provider funding rather than relying on historic budgets and the negotiating skills of individual managers.

The information presented here is adapted from fully referenced source material at Emotional Wellbeing.

Payment-by-Results is used to allocate funding for health services throughout the UK but not yet in mental health. PbR has been prioritised for extension to mental health services.

Whilst this is very important to improve quality and cost control, it is also recognised as very challenging. The method being used is to group all patients into care clusters based on profiles derived from an adaptation of the Health of the Nation outcome scale (HoNOS). These clusters were developed to represent different levels of need in patients with Organic, Psychotic and Non-psychotic conditions.

The care cluster approach involves clinicians assessing the clinical need of patients using secondary mental healthcare services. Patients are then allocated into one of 21 clusters depending on their care needs.

Guidance initially specified that all patients are to be ‘clustered’ by the end of 2011 with local tariffs to be developed and ready for use by April 2012 with a view to a National tariff being introduced from April 2013. Following a review of the readiness of providers and commissioners the Department of Health concluded that it is not yet possible to introduce a national tariff in 2013-14 without significant risks.

The most recent guidance, Mental health PbR: guidance for 2013 to 2014, published by the Department of Health includes a set of indicative cluster costs and proposes quality and outcome measures. It aims to ensure that all contracts are rebased on the basis of the mental health cluster by providing a methodology which sets out an approach for how this can be done.

A key complementary element is linking clusters to care pathways (see Care Cluster Website) to ensure that the nature and quality of services provided is specified and progressively improved.

Projects to develop PbR for other areas including learning disability, forensic services and CAMHS are underway.

In adults and older people, clusters have been developed to represent stages in care pathways:

1: Common Mental Health Problems (low severity)
2: Common Mental Health Problems (low severity with greater need)
3: Non-Psychotic (Moderate Severity)
4: Non-Psychotic (Severe)
5: Non-Psychotic (very severe)
6: Non-Psychotic Disorders of overvalued ideas
7: Enduring Non-Psychotic Disorders (high disability)
8: Non-Psychotic Chaotic and Challenging Disorders

10: First Episode in Psychosis
11: Ongoing Recurrent Psychosis (low symptoms)
12: Ongoing or Recurrent Psychosis (high disability)
13: Ongoing or Recurrent Psychosis (high symptom and disability)
14: Psychotic Crisis
15: Severe Psychotic Depression
16: Dual Diagnosis
17: Psychosis and Affective Disorder Difficult to Engage

Memory difficulties
18: Cognitive impairment (low need)
19: Cognitive impairment or Dementia Complicated (Moderate need)
20: Cognitive impairment or Dementia Complicated (High need)
21: Cognitive impairment or Dementia (High physical or engagement needs)

Useful resources

Relevant projects