Are specialist psychiatric services losing the PbR race?: commentary on… clustering in mental health payment by results

Summary

Payment by results (PbR) is a payment platform for healthcare services. Introduced to acute physical healthcare services in England in 2003–2004, the system has continued to expand and is currently being implemented in acute mental health services. Owing to the variations and complexities of the patients who access specialist psychiatric services, existing clusters do not always accurately capture their needs. The development of PbR tools specific to psychiatric subspecialties is ongoing, but might not be available in the short term. The funding of acute mental health services through PbR might have funding implications for specialist services such as psychiatry of intellectual disability.

There is very little guidance available on payment by results (PbR) and David Yeomans’ excellent critical summary (Yeomans 2014: this issue) is a timely addition to existing literature on the topic. Although many clinicians would actively want to avoid diverting their time away from patient care to update themselves on PbR, they need to be aware of the intricacies of the system because of the direct impact of PbR on the financial sustainability of services. But there may be undesirable consequences to specialist services due to a delayed roll-out of PbR to these (Radhakrishnan 2012).

Background

When PbR was introduced in the acute sector, there were concerns that commissioners would disinvest in mental health services since these were not being funded at the time through PbR (Jacobs 2014). This concern is also quoted as one of the key reasons that should persuade psychiatric specialties to adopt PbR swiftly to balance the disadvantage. But is there a potential risk that this scenario will be enacted among psychiatric services themselves if use of PbR in acute mental health services leads to disinvestment in subspecialties? For instance, would my specialty, the psychiatry of intellectual disability, and other subspecialties that are funded by clinical commissioning groups (CCGs) lose out because PbR tools for these services are still being developed? As mentioned by Yeomans, gaming is even more of a risk in mental health PbR owing to lack of administrative support (clinical coders) and reliance on clinical staff to administer the Mental Health Clustering Tool.

IT investment

There will be a need for significant investment to improve training and IT structures within trusts to ensure that the nuances of specialist care needs are accurately captured: without this, these services would risk underfunding. As a clinician, it is not clear to me whether the finalised tariffs will include such training and IT setup costs. If these costs are not included in the tariffs, the lack of additional funding would make it difficult for organisations to invest in developing and/or improving their training and IT programmes. This could have a bigger impact on small voluntary/charity organisations that do not have such systems already or the resources to put them in place.

Is PbR fit for purpose?

With the ever-increasing demand on the time of clinicians in psychiatric subspecialties and the constantly shrinking size of their teams, PbR is perceived by some as a cumbersome and bureaucratic process that does not directly benefit patients. A system that has not achieved its goals in the acute sector might equally be less beneficial to psychiatry (British Medical Association 2012). It is to be noted that Monitor, the sector regulator for health services in England, is questioning the national tariffs and the future viability of the payment system, which does not incentivise outcomes but merely rewards activity. The mandatory roll-out of tariffs planned for mental health services in 2014–2015 has been dropped by Monitor (Lintern 2013). The future relevance of this system to mental health services is uncertain. The uncertainty faced by psychiatric subspecialties if the system is implemented in acute mental healthcare is equally a cause for concern.