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Payment by results: unleashing the potential of mental health services

Submitted by on 26 Jul 2011 – 11:30

Prof. Philip SugarmanProf. Philip Sugarman, Chief Executive of St Andrew’s

The UK’s largest mental health charity, argues that the country’s mental health system leads the world in many respects, but it must be reconfigured radically to meet the Government’s aspirations for better outcomes.

In the UK both the practice of psychiatry, and the infrastructure of mental healthcare, have been at the cutting edge of European developments for many years.  The move to community care has been managed in the UK as well as anywhere in the world, and the range of services and professional expertise has continued to develop.  Current infrastructure includes hospital and community provision, from national specialist units, through local psychiatric facilities, to targeted support services, able to meet the needs of a diverse range of people. Public sector services are complemented by substantial private residential provision and charitable community support, in a mixed market which could be a model for other countries (Sugarman & Kakabadse 2011).

Despite all this progress, the total cost of mental disorder to society in the UK is estimated at over £100billion per annum (Centre for Mental Health 2010), of which mental health and specialist social care spend accounts for £13billion (Laing & Buisson 2009).  These services address only a fraction of the need that family doctors see, not to mention people untreated amongst the homeless and the prison population.  Specialist hospitals and community services are costly, as many individuals stay too long, whilst length of stay in acute mental health facilities is typically too short, with poor and costly outcomes such as frequent readmission. This is a major concern for both mental health professionals and service users (e.g. Bhugra 2011, MIND 2011).  Common complaints are that the system is bedevilled by budget silos and boundaries of specialism and catchment area, with slow decision making and waiting lists, whilst any open, responsive service is immediately overwhelmed.

There is a clear need for change in the governance and management in the sector. Radical plans to change the commissioning of public healthcare have been amended, with the emerging involvement of both family doctors and clinicians (e.g. Royal College of Psychiatrists 2011).  This should link with the recent high level Government strategy “No Health without Mental Health” (Department of Health 2011), which focuses on prevention and wellbeing, personalisation of services, and outcomes.  Policy makers and professionals are at last talking seriously about ways to organise truly collaborative mental health care.  Given the reality of the public balance sheet, the best that can be hoped for is that current expenditure levels are maintained – which leaves the major question– how can Government spending in mental health be made more effective?

The core problem is – there is no ‘business’ incentive to move patients on successfully, and to take on the most needy.  Providers should efficiently escalate and de-escalate the response to need, rather than concentrating on those who happen to be captured by services. The system would work better if services were rewarded for responding more dynamically to the needs of the population.

The solution is indicated by the Department of Health’s “Payment by Results” programme, for which it is piloting mental health treatment tariffs, built on defined conditions, levels of severity and problem clusters. However there is a danger in a complex categorisation of mental health into neat boxes, rather too like the problem it aims to solve. We should be more radical, focusing less on processes, and more clearly on patient outcomes, as urged in “No Health without Mental Health”.  Services should be rewarded with payments that link to individual treatment outcomes, in line with current thinking on personalised budgets.

But how would this work? Mental health is so complex, we have to be daring in keeping it simple. A commissioner or case worker, such as a family doctor or social worker, who holds a budget, would contact two or three reputed service providers. They would ask them to assess a person and answer a simple question.  What would be the guaranteed total cost to achieve the key recovery milestones with this individual?  This would elicit a variety of guarantees on length of stay, reducing cost over time, and payment linked to (e.g.) stepping down to the next level of service, or returning to home or work, all of which are currently emerging concepts in the increasingly competitive mental health sector. The purchaser should choose the most credible treatment package, which also had a strong, built-in financial motivation for the provider to treat the patient quickly and successfully.

The temptation is to over-define outcomes contractually, rather than simply invite the provider to take this risk, and trust commissioners to honour the spirit, in order to build collaborative relationships with quality providers. Commissioners must have wide discretion to make partial payments, where they believe treatment has been partially effective, especially where they wish to purchase further care. They should have guidance and training, but ultimately must be trusted with their budgets.  This may sound radical and simplistic, but is little different from GPs now buying a series of counselling sessions, or a social worker or service user buying home support, with each party trusting the quality of input and undisputed payment of bills.  

The challenge in mental health is – can we accept the failings of our current over-managed approach, and be creative and adventurous in our determination to unleash the potential of current services to provide massively more effective care?  For the benefit of service users and society at large, and for the UK to remain a leader in mental health, policy makers need to rise to this challenge.

Bhugra D (2011). Mental health services in crisis.

Centre for Mental Health (2010). The economic and social costs of mental health problems in 2009/10. Centre for Mental Health.

Department of Health (2011). No health without mental health.

Laing & Buisson (2009). Mental health and specialist care services. UK market report 2010/11

Fifth edition. Laing & Buisson, London.

MIND (2011). Care in crisis.

Royal College of Psychiatrists (2011).  The Joint Commissioning Panel for Mental Health.

Sugarman P & Kakabadse A (2011). Guest editorial.  Governance, choice and the global market for mental health. International Psychiatry 8, 53-54.