A pathfinder GP consortium in Kingston, Surrey, is pioneering outcomes-based tariffs for mental health services including substance misuse and access to psychological therapies. Joint mental health commissioning manager Sylvie Yeo and consortium chair Dr Charles Alessi explain.
Last year, when Kingston in Surrey became a pathfinder consortium, we started looking at the existing PCT contracts held by NHS Kingston as part of our preparation for taking over budgets. Until then, we hadn't had that much insight into the way the PCT worked. However, GPs had felt for some time that the system regarding substance misuse wasn't working as well as it could have. In general, services didn't seem to be that responsive to patients' needs and access times and acceptance rates into services were sometimes unsatisfactory.
We are now at the point where we have established clusters to categorise patients and identified the outcomes we wish providers to achieve. Our pathfinder funding is being used to pay consultancy Mental Health Strategies to develop a tariff that rewards these outcomes. We are determined to keep the tariff simple and it will reward providers most when patients achieve the best outcomes.
Starting point
We started a process of engagement with patient groups, GPs and other stakeholders to find out what they wanted to change.
We were also mindful of the Borough of Kingston-upon-Thames Drug Misuse Needs Assessment Report 2009/10, which showed there was limited movement within the treatment system and no evidence of joint care co-ordination for service users accessing more than one service. Services appeared to be working in isolation, resulting in gaps and duplication in service provision.
We identified three main challenges:
• expediency was too often a problem because of services having a ‘full' caseload
• some patients were slipping through the net because of the fragmented way in which providers worked and their criteria for accepting patients
• there was little incentive for providers to discharge patients in a designated time frame.
GPs commented that they felt mental health services were ‘exclusive' rather than inclusive. We quickly realised that the way forward was to base the system around outcomes – what the patient needed – and then work out how best to get there.
Defining outcomes
In line with wider Government policy and National Treatment Agency indicators, we're moving towards a recovery and abstinence model. So far, we've produced a project initiation document that sets out the basis for the tariff and will allow us to work out what payments should be attached to which services. Primary outcome targets of the service – which we plan to launch in October – will include:
• freedom from dependence on drugs or alcohol
• abstinence from all drugs and alcohol
• controlled or low-risk use of alcohol or drugs and medically assisted recovery using substitution or other medications.
These primary outcomes will have the greatest reward under the Payment by Results (PbR) model currently being developed.
Secondary outcome metrics will include
• blood-borne viruses
• reduction in crime and re-offending
• prevention of drug-related deaths
• sustained employment or full-time education
• the ability to access and sustain suitable accommodation
• improvement in mental and physical health wellbeing
• improved relationships with family members, partners and friends
• the capacity to be a caring and effective parent.
The tariff will be time limited so there will be no incentive to keep patients rather than discharging them back to primary care.
Part of ensuring objectives are met will include using patient-reported outcome measures (PROMs). We're determined that the tariff will be as simple as we can make it so that everyone understands it. It will be a case of +1 if a patient is back at work, 0 if a patient is still off.
Clustering patients
The basis for payment and the care patients receive will be based around a cluster model. Patients will be put into a cluster based on their condition and needs.
Mental Health Strategies has developed the clusters for us. These are based on the work being done by central Government to develop a PbR tariff for mental health. The clusters help overcome two fundamental problems in mental health: patients falling through the net or not being accepted by individual providers.
In the past, GPs might have referred a patient for alcohol misuse to then be told by the provider that the number of units being consumed per week was not enough to meet their criteria.
Patients with dual diagnosis often get overlooked in mental health, but there is a cluster for this particular group of patients. Under the old system, a patient might have a substance misuse problem but they are, in fact, using to mask a serious mental illness. The GP could refer to either mental health services or the drug misuse team.
But the community mental health team will not treat patients who are still using substances and the drug misuse team will not accept patients with underlying serious mental health problems. The next stage of our programme will be to do a caseload review with all our providers to determine what patients would fall into which cluster.
Changing provision
The GP will refer patients in the way they have always done. The change will be in how providers tailor their services to meet the needs of that cluster of patients. Once we have determined the number of patients in each cluster and the payment tariff, we will be speaking to providers about how they wish to be involved in the clusters.
In some cases, there might be a central provider that subcontracts services to other providers to achieve the outcomes we require. Another option would be to tender for an external organisation to co-ordinate the care for a particular cluster.
We are confident the cluster approach will get providers working together to deliver care and engaging with other organisations such as social care and the third sector to truly ensure patients' needs are met. We expect providers to take more responsibility for what that patient needs and the eventual outcome. The main providers might see patients 20% less than before because the patients get what they need from another strand of care, such as a support group or a voluntary mentor.
We have a local mental health implementation team including GPs, housing providers and community groups, which meets every six weeks.
It will take a good six months running the new framework in shadow form until we can really talk about outcomes. In any case, the framework is applicable to other service areas. Part of it is generic. With a bit of substitution and lateral thinking, we've got a model.
The initiative is going to make our finances go so much further. For example, say a patient is detained under the mental health act in a secure hospital but no longer requires that level of care – previously there was no incentive for them to be repatriated. But now, we have a range of support and can release up to £175,000 per patient a year.
This has been a hard nut to crack, but we think we're nearly there in Kingston. And it demonstrates the value of clinical commissioning. Interestingly, mental health is one of the service areas that critics of commissioning said GPs wouldn't want to take on. This is evidence that GP commissioners really are interested in tackling the difficult things.
Dr Charles Alessi is a GP in Kingston, Surrey, and NAPC executive member
Sylvie Yeo is head of non-acute commissioning and joint mental health commissioning manager at Royal Borough of Kingston/NHS Kingston
Creating outcomes-based mental health tariffs Cluster groups
