Mental Health PbR & Clustering – a clinician's perspective

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25 Νοε 2013 (πριν από 3 χρόνια και 6 μήνες)

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Mental Health PbR &
Clustering


a clinician’s
perspective

Dr Mo Zoha

Consultant Psychiatrist

St Charles Hospital

& CNWL Clinical Effectiveness Lead

Overview


Cover the basics of the proposed
methodology for mental health PBR


Clustering


what is it and how are patients
clustered?


Care packages


how will they be determined?


What are the clinical benefits and
drawbacks of implementing MH PbR?


Questions

Assessing & treating
patients in mental health
services


GP


Primary care liaison service


Secondary
services


Secondary services increasingly provide a SPOE,
staffed by a multidisciplinary team consisting of
psychiatrists, social workers & CPNs


Assessments undertaken by members of MDT who
may use a semi
-
structured assessment form,
following which a care plan is agreed with the
patient


Question: Following this process, do patients
always end up with the most appropriate care plan,
addressing all of their needs?

Clustering


Clustering is a method of undertaking a detailed
assessment of the needs of each patient and then
using the results of this assessment to allocate
them to a needs
-
based “cluster”



This approach was pioneered in SW Yorkshire by
clinicians (CPPP) whose intention was to ensure all
patients in their service were in receipt of the most
appropriate care package, based on their needs



Clustering



>90% of mental health patients can be
reliably allocated to one of 21 clusters
defined by CPPP


This clinically
-
derived approach has been
adopted by the Department of Health as the
template for implementation of Payment by
Results


Using a needs assessment is a better
predictor of service utilisation compared
with other methods eg diagnosis



How to cluster


Huge number of standardised rating
scales exist to assess aspects of
mental health


eg >1000 outcome
measurement tools exist


CPPP decided to use HoNOS (Health of
the Nation Outcome Scales) as their
assessment tool

What is HoNOS?


HoNOS was developed in 1990s by RCPsych


HoNOS (Wing et al) is

acceptable, reliable
& useful both clinically and for the planning
of mental health services

.


HoNOS recording part of the MHMDS, but
HoNOS scoring was not widely implemented


Recent increased focus on demonstrating
clinical effectiveness eg by measuring
clinical outcomes. This has led to a
widespread increase in HoNOS
implementation.

HoNOS Features







Is short, simple and useful to mental health
professionals


Provides an overview of clinical and social
problems


Has a variety of uses for mental health
professionals, administrators and researchers


Is sensitive to improvement, deterioration or
lack of change




Health of the Nations Outcome Scales (HoNOS)
©

Royal College of Psychiatrists

What does HoNOS do?


Translates a clinical encounter into a
numerical score, allowing changes to
be easily tracked & analysed.


Measures 4 main problem areas:


Behavioural difficulties


Physical & cognitive impairments


Symptom severity


Social problems

Using HoNOS


HoNOS is a useful rating scale for comparing a
patient’s presentation at different points in time


However HoNOS is NOT an assessment tool, it is an
outcome measure, designed to provide a rating of
current mental health


Because a cross
-
sectional tool is a poor predictor of
overall service utilisation, CPPP started to modify
HoNOS to make it into a needs assessment


eg Question 1 in HoNOS asks about current levels of
aggression, the new question asked about ANY history of
aggression (in the context of mental disorder)


This became HoNOS+ / SARN


Politics


HoNOS is copyright of the RCPsych and is
used internationally. Used for benchmarking
etc.


There is an inter
-
governmental agreement
not to amend HoNOS!


After a 2 year+ wrangle and pilots,
eventually HoNOS PbR was accepted as the
new Mental Health Clustering Tool (MHCT).
It consists of the original 12 items of HoNOS
and adds 6 new questions taken from SARN

Health of the Nation Outcome Scales (HoNOS)
© Royal College of Psychiatrists 1996

13







Rate 9 if Not Known




3. Problem
-
drinking or drug
-
taking


Do not include aggressive/destructive behaviour due to alcohol or
drug use, rated at Scale 1.


Do not include physical illness or disability due to alcohol or drug
use, rated at Scale 5.


0

No problem of this kind during the period rated.

1

Some over
-
indulgence but within social norm.

2


Loss of control of drinking or drug
-
taking, but not seriously
addicted.

3

Marked craving or dependence on alcohol or drugs with frequent
loss of control; risk taking under the influence.

4

Incapacitated by alcohol/drug problem.




17. Engagement (historical)


Rate the individual’s motivation and understanding of their
problems, acceptance of their care/treatment and ability to
relate to care staff.


Include the ability, willingness or motivation to engage in
their care/ treatment appropriately, agreeing personal goals,
attending appointments. Dependency issues.


Do not include Cognitive issues as in scale 4, severity of
illness or failure to comply due to practical reasons.

17. Engagement (historical)

0

Has ability to engage / disengage appropriately with services. Has
good understanding of problems and care plan.

1

Some reluctance to engage or slight risk of dependency. Has
understanding of own problems.

2

Occasional difficulties in engagement i.e. missed appointments or
contacting services between appointments inappropriately. Some
understanding of own problems.

3

Contacts services inappropriately. Has little understanding of own
problems. Unreliable attendance at appointments.

Or attendance depends on prompting or support.

4

Contacts multiple agencies i.e. GP, A & E etc, constantly. Little or no
understanding of own problems. Fails to comply with planned care.
Rarely attends appointments. Refuses service input.

Or Attendance and compliance dependent on intensive prompting
and support.


Rate 9 if not known

How to cluster


Clinical opinion (gold standard) v summary
needs assessment tool


Problems with both approaches?


After assessing a patient, complete a MHCT
score and enter the score into the clustering
algorithm (currently an online tool)


The algorithm generates a cluster, which
the clinician is asked to confirm



0

1

2

3

4

9

1) Overactive, aggressive, disruptive behaviour

X

2) Non
-
Accidental Self
-
Injury

X

3) Problem Drinking or Drug
-
taking

X

4) Cognitive Problems

X

5) Physical Illness or Disability

X

6) Hallucinations and Delusions

X

7) Depressed Mood

X

8) Other Mental & Behavioural Problems

X

9) Relationships

X

10) Activities of daily living

X

11) Living conditions

X

12) Occupation and activities

X

13) Strong Unreasonable Beliefs

X

14) Agitated behaviour/expansive mood

X

15) Repeat Self
-
Harm

X

16) Safeguarding children and vulnerable dependent
adults

X

17) Engagement

X

18) Vulnerability

X

Assessment Results


Your initial Recommendation

13) Ongoing or Recurrent Psychosis (high symptom and disability)


Algorithm recommendations

Primary recommendation: 14) Psychotic Crisis

This is a strong match at 83.3%

Secondary recommendation: 13) Ongoing or Recurrent Psychosis

(high symptom and disability)

This is a strong match at 81.0%

Tertiary recommendation: 15) Severe Psychotic Depression

This is a strong match at 76.3%


Final cluster agreed for assessment

13) Ongoing or Recurrent Psychosis (high symptom and disability)



What are the clusters?


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.

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



18.
Cognitive Impairment (low need)



19.

Cognitive Impairment (moderate Need)




20.

Cognitive Impairment (high need with functional
complications)



21.
Cognitive Impairment (high need with physical
complications)

Cluster Description

1

Common Mental Health Problems (Low Severity)

This group has definite but minor problems of depressed mood, anxiety or other disorder but they
do not present with any psychotic symptoms.

2

Common Mental Health problems

(Low severity with greater need)

This group has definite but minor problems of depressed mood, anxiety or other disorder but not
with any psychotic symptoms. They may have already received care associated with cluster 1 and
require more specific intervention or previously been successfully treated at a higher level but are
representing with low level symptoms.

3

Non Psychotic (Moderate Severity)

Moderate problems involving depressed mood, anxiety or other disorder.

(Not including psychosis)

4

Non
-
Psychotic (Severe)

This group is characterised by severe depression and/or anxiety and/or other and increasing
complexity of needs. They may experience disruption to function in everyday life and there is an
increasing likelihood of significant risks.

5

Non
-
psychotic Disorders (Very Severe)

This group will be severely depressed and/or anxious and/or other. They will not present with
hallucinations or delusions but may have some unreasonable beliefs. They may often be at high
risk for suicide and they may present safeguarding issues and have severe disruption to everyday
living.

CDST Clusters Effective from 1 April 10

Cluster Description

6

Non
-
Psychotic Disorder of Over
-
valued Ideas

Moderate to very severe disorders that are difficult to treat. This may include treatment resistant
eating disorder, OCD etc, where extreme beliefs are strongly held, some personality disorders and
enduring depression.

7

Enduring Non
-
Psychotic Disorders (High Disability)

This group suffers from moderate to severe disorders that are very disabling. They will have
received treatment for a number of years and although they may have improvement in positive
symptoms considerable disability remains that is likely to affect role functioning in many ways.

8

Non
-
Psychotic Chaotic and Challenging Disorders

This group will have a wide range of symptoms and chaotic and challenging lifestyles. They are
characterised by moderate to very severe repeat deliberate self
-
harm and/or other impulsive
behaviour and chaotic, over dependent engagement and often hostile with services.

10

First Episode Psychosis

This group will be presenting to the service for the first time with mild to severe psychotic
phenomena. They may also have depressed mood and/or anxiety or other behaviours. Drinking
or drug
-
taking may be present but
will
not be the only problem.

Cluster Description

11

Ongoing Recurrent Psychosis (Low symptoms)

This group has a history of psychotic symptoms that are currently controlled and causing minor
problems if any at all. They are currently experiencing a period of recovery where they are capable
of full or near functioning. However, there may be impairment in self
-
esteem and efficacy and
vulnerability to life.

12

Ongoing or Recurrent Psychosis (High Disability)

This group have a history of psychotic symptoms with a significant disability with major impact on
role functioning. They are likely to be vulnerable to abuse or exploitation.

13

Ongoing or Recurrent Psychosis

(High symptoms and disability)

This group will have a history of psychotic symptoms which are not controlled. They will present
with moderate to severe psychotic symptoms and some anxiety or depression. They have a
significant disability with major impact on role functioning.

14

Psychotic Crisis

They will be experiencing an acute psychotic episode with severe symptoms that cause severe
disruption to role functioning. They may present as vulnerable and a risk to others or themselves.

15

Severe Psychotic Depression

This group will be suffering from an acute episode of moderate to severe depressive symptoms.
Hallucinations and delusions will be present. It is likely that this group will present a risk of suicide
and have disruption in many areas of their lives.

16

Dual Diagnosis

This group has enduring, moderate to severe psychotic or affective symptoms with unstable,
chaotic lifestyles
and co
-
existing
substance misuse. They may present a risk to self and others
and engage poorly with services. Role functioning is often globally impaired.

Cluster Description

17

Psychosis and Affective Disorder


Difficult to Engage

This group has moderate to severe psychotic symptoms with unstable, chaotic lifestyles. There may
be some problems with drugs or alcohol not severe enough to warrant dual diagnosis care. This group
have a history of non
-
concordance, are vulnerable and engage poorly with services.

18

Cognitive Impairment (Low Need)

People who may be in the early stages of dementia (or who may have an organic brain disorder
affecting their cognitive function) who have some memory problems, or other low level cognitive
impairment but who are still managing to cope reasonably well. Underlying reversible physical causes
have been ruled out.

19

Cognitive Impairment or Dementia Complicated (Moderate Need)
People who have problems with
their memory, and/or other aspects of cognitive functioning resulting in moderate problems looking
after themselves and maintaining social relationships. Probable risk of self
-
neglect or harm to others
and may be experiencing some anxiety or depression.

20

Cognitive Impairment or Dementia Complicated

(High Need)
People with dementia who are having significant problems in looking after themselves
and whose behaviour may challenge their carers or services. They may have high levels of anxiety or
depression, psychotic symptoms or significant problems such as aggression or agitation. They may not
be aware of their problems. They are likely to be at high risk of self
-
neglect or harm to others, and
there may be a significant risk of their care arrangements breaking down.

21

Cognitive Impairment or Dementia (High Physical or Engagement)

People with cognitive impairment or dementia who are having significant problems in looking after
themselves, and whose physical condition is becoming increasingly frail, they may not be aware of
their problems and there may be a significant risk of their care arrangements breaking down.


1

Common mental health problems (low severity)


8 weeks


2

Common mental health problems




12 weeks


3

Non
-
psychotic (moderate severity)




4 months


4

Non
-
psychotic (severe)





6 months


5

Non
-
psychotic (very severe)




6 months


6
Non
-
psychotic disorders of overvalued Ideas



6 months


7
Enduring non
-
psychotic disorders (high disability)


Annual


8
Non
-
psychotic chaotic and challenging disorders


Annual


10

First episode in psychosis





Annual


11

Ongoing recurrent psychosis (low symptoms)



Annual


12

Ongoing or recurrent psychosis (high disability)


Annual


13

Ongoing or recurrent psychosis (high symptom and disability)

Annual


14

Psychotic crisis






4 weeks


15

Severe psychotic depression




4 weeks


16

Dual diagnosis (substance abuse and mental illness)


6 months


17

Psychosis and affective disorder difficult to engage


6 months


18

Cognitive impairment (low need)




6 months


19

Cognitive impairment or dementia (moderate need)


6 months


20

Cognitive impairment or dementia (high need)



6 months


21

Cognitive impairment or dementia (high physical or engagement)

6 months



Care packages


How does clustering help ensure
patients receive the best care package
for their difficulties?


Each cluster has a needs
-
based profile
which forms the basis of “core” and
“essential” interventions

Needs
-
based profiles

0
1
2
3
4
H1
H2a
H2b
H3
H4
H5
H6a
H6b
H7
H8
H9
H10
H11
H12
H13
H14
H15

Care Group 3

Non
-
Psychotic (moderate severity)

0
1
2
3
4
H1
H2a
H2b
H3
H4
H5
H6a
H6b
H7
H8
H9
H10
H11
H12
H13
H14
H15

Care Group 17

Psychosis and Affective Disorder


Difficult to Engage

Example of a care package



Care Cluster 16: Dual Diagnosis


Description: This group has enduring,
moderate to severe psychotic or affective
symptoms with unstable, chaotic lifestyles
and co
-
existing

substance misuse. They may
present a risk to self and others and engage
poorly with services. Role functioning is
often globally impaired.



Impairment:

Physical illness may be
present as a result of substance misuse and
possibly cognitively impaired as a
consequence of psychotic features or
substance misuse. Global impairment of role
functioning likely

Care Cluster 16: Dual
Diagnosis


Diagnoses:
Likely to include (F10
-
F19)
Mental and behavioural disorders due to
psychoactive substance use & (F20
-
F29)
Schizophrenia, schizotypal and delusional
disorders, Bi
-
Polar Disorder


Risks:

Moderate to severe risk to others
due to violent and aggressive behaviour.
Likely to engage poorly with services. Some
risk of accidental death


Course:
Long
-
term


No

Item description

Score

0

1

2

3

4

7

Hallucinations and
Delusions

10

Strong Unreasonable
Beliefs

8

Depressed mood

9

Other Disorders

4

Substance Misuse

5

Cognitive Problems

6

Physical
Illness/Disability

11

Personal Relationships

12

Activities of daily living

13

Living conditions

14

Participation

1

Agitative Behaviour

2

Suicide

3

Repeat Self
-
Harm

15

Safeguarding Children

16

Engagement

17

Vulnerability

Expected to score

Unlikely to feature

Issue for some

Care Package 16

Element
Number

Skills Group

Skills Level

Core Elements

1a

Care Coordination

6

1b

Care Co
-

ordination

( Support )

3

2

Medical Interventions

7/8

Essential Elements

1

Nursing Interventions

5

2a

Functional Therapies

5/6

2b

Occupational
Interventions
support

3/4

3

Psychological
Therapies

7/8

4

Accommodation

5

5

Pharmacy

CARE PACKAGE FOR DUAL DIAGNOSIS

Core Element 1a: Care Coordination

Aim

Activities

Skill/level

Contact

Resource

Maintain appropriate
contact

Management of crisis

Reduce risk of harm to
self

Reduce risk of harm to
others

Significant reduction of
symptoms

Prevention of
worsening of
condition

Prevention of relapse

Management of crisis

1)

Assessment

a)

mental health state

c)

other complicating
factors

d)

risk

f)

screening

3)

Enabling

f)

service intervention

8)

Care
Coordination

a)

care planning

b)

coordination

c)

liaison

d)

Write contingency
plans

e)

Write crisis plans

f)

alert others and
request action

g)

take direct action

h)

risk assessment

i)

risk monitoring

j)

write risk plans

Minimum

Level 6

Drugs
agency/Prima
ry care +

Qualified MH
practitioner(s
killed in
withdrawal,
harm
minimisation,
social
inclusion,
substitute
prescribing)

Up to

At least twice
weekly (2
hours per
visit, 2 people
if risk)

Administration

Community
based

Transport

Drug agency

Pharmacy
Services

Probation

Supervision

Core Element 1b: Care Co
-
ordination Support

Aim

Activities

Skill/level

Contact

Resource

Maintain appropriate
contact

Management of crisis

Reduce risk of harm to
self

Reduce risk of harm to
others

Significant reduction of
symptoms

Prevention of
worsening of
condition

Prevention of relapse

Management of crisis

3)

Enabling

a) Represent clients
interests

b)

Promoting
independence

c)

Provision of
information

d)

Treatment
adherence

e)

Assertive
engagement

Level 3

Minimum

2 Hours per
week

Administration

Community
based

Transport

Supervision

Core Element 2: Medical Interventions

Aim

Activities

Skill/level

Contact

Resource

Reduce risk of harm to self

Prevention of worsening of
condition

Prevention of relapse

1
)

Assessment

a)

mental health state

b)

role functioning

c)

other complicating factors

d)

risk

e)

care concordance

f)

physical health state

g)

diagnosing / formulating

2)

Monitoring

a)

mental health state

c)

other complicating factors

d)

risk

e)

care concordance

f)

physical health state

g)

treatment

h)

level of engagement

4

Therapeutic
interventions

a)

medical treatment
(Prescribe Medication)

g)

detox/ substance
management

3)

Enabling

c)

provision of information

d)

treatment adherence

e)

assertive engagement

f)

service intervention

Level 7 or 8
Psychiatrist

Delegate to level 6

or

Specialist GP

or

Level 6 / 7

Non medical
prescriber

( all activities )

Regular review


must have skills
in morbidity and
physical health
issues

Can be weekly

At the request of care
coordinator

Administration

Depots

Medication

Clozaril (regular
tests and
transport)

may need to be
admitted for
this as
monitoring is
very intensive

Supervision

Level 6/7 Pharmacy

Pharmacy Services

Community/home
based

Supervised
consumption

Essential Element 2a: Occupational Interventions

Aim

Activities

Skill/level

Contact

Resource

Maximise social role
functioning

Return to provide
best level of
functioning

Significant
improvement in
quality of life

)

Assessment

b)

role functioning

Level 5/6

Qualified MH
practitioner



Initially twice
weekly

Step down

Administration

Community
based

Transport

Sports

Housing

DSS

Probation
services

Vocational
services

Non
-
statutory
provision

Core Element 2b: Occupational Interventions ( Support )

Aim

Activities

Skill/level

Contact

Resource

Maximise social role
functioning

Return to provide best
level of functioning

Significant
improvement in
quality of life

2)

Monitoring

b)

role functioning

h)

level of engagement

3)

Enabling

b)

increasing
confidence /
independence

e)

assertive
engagement

4)

Therapeutic
interventions

d)

coping skills

f)

Physical Health
Therapy

5)

Role support

a)

training

b)

informal counselling

c)

emotional

d)

practical

e)

social

9)

Social participation

a)

employment

b)

education

c)

recreation

d)

activities of daily
living

e)

relationships


Level 3/4

Up to Daily

Administration

Community
based

Transport

Sports

Housing

DSS

Probation
services

Vocational
services

Non
-
statutory
provision

Essential Element 3: Psychological Therapies

Aim

Activities

Skill/level

Contact

Resource

Significant
reductions of
symptoms

Prevention of
relapse

Better adjustment to
situation

Reduce risk of harm
to self

Reduce risk of harm
to others

1)

Assessment

a)

mental heath
state

c)

other
complicating
factors

d)

risk

g)

diagnosing/form
ulating

4)

Therapeutic
interventions

b)

Structured
Psychological
Therapy

c)

Group
Psychological
Therapy

d)

coping skills

e)

Family/ Couples
Therapy



Level 7 or 8

Advanced or
Consultant
qualified
practitioner
with
training and
experience
with
Patient/
Service
User group
and in
appropriate
types of
therapy(ie
CBT,DBT,
CAT,
Psychodyna
mic.)

Weekly with
flexibility

Over 10
sessions
greater than
six months
in duration

Over 16
sessions
greater than
nine months


( Bi
-

Polar )

Administration

Drug Agency

Clinical benefits of
clustering


Ensure each patient receives the most appropriate
care package to address their problems


Help prepare us for PBR


Help inform future service redesign


Help us gain a better understanding of our caseload


What is the needs profile for each team/
directorate/ the trust?


Are our teams providing the most appropriate,
evidence
-
based interventions for our patients?



What did the London PbR
pilot tell us?


What did clinicians think about the
proposed model for MH PbR?


CNWL’s involvement


Participated in a MH PbR pilot in 2009


Attend the adult and older adult PbR
project boards

London PbR pilot

Designed to evaluate whether HoNOS PbR is “fit for purpose” as the
clustering tool for mental health PbR

Questions to be answered by the pilot:


-
Can clinicians allocate > 90% of their cases to one of the 21 clusters?


-
Is there inter
-
rater reliability of > 80%?


-
Is the tool appropriate across care pathway stages?


-
Is the tool easy to use?


Pilot data collection period: mid
-
July until the end of September



Pilot sample (per trust): 200 assessments + cluster allocation
decisions



CNWL was one of 5 London MH trusts that signed up to take
part in the pilot.

London PbR pilot
-

results


CNWL clinicians clustered over 500
patients using HoNOS PbR.


What did the pilot tell us about the
tool?


What did the pilot tell us about our
patients?

Evaluating the tool


93% of all patients could be clustered
into one of the 21 clusters


60% agreement between the HoNOS
PbR algorithm & clinician opinion

Evaluation Results

1.

Cluster allocation and analysis


MET



Over 90% of service users allocated to a cluster
using both tools.

2.

Inter
-
rater Reliability Workshops


NOT MET


Average allocation of vignettes to “correct”
clusters at 52% for SARN and 46% for HoNOS
PbR. Average ICC 0.49 (moderate relationship).

3.

Ease of Use Survey


MET


Majority of respondents said <15 minutes (75%
for HoNOS PbR and 66% for SARN). Majority
agreed fit for purpose and adequately captured
needs.

What did the pilot tell us
about our patients?



Our own analysis provided the following
information:


Clustering information for one of our AOTs (how
many fitted into the AOT clusters?)


Clustering information for one of our EIPTs
(what clusters do EIPT patients progress to?


For 300 K&C patients, how were they clustered,
broken down by:


North v South


CPA patients v outpatient (lead professional) only care

Advantages of proposed
PbR methodology

For patients:


Clustering should lead to more appropriate
and more detailed care packages


not just
reliant on who does the initial assessment


Better quality, more holistic assessments.


Clearly defined aims and activities for each
intervention


Clarity for patients as to the care they will
receive (and a framework for choice?)

Advantages of proposed
PbR methodology

For services (& therefore patients):


Allocation of patients to one of 20
empirically and clinically derived care groups
with clear inclusion / exclusion criteria.


Development of detailed, minimum
-
standard
care packages for each clinical cluster


Analysis of clusters delivers a better
understanding of caseload


What is the needs profile for each team/
directorate/ the trust?


Are our teams providing the most
appropriate, evidence
-
based interventions
for our patients?

Disadvantages of proposed
PbR methodology


“It’s all about money”


“Can not reduce mental health problems to
an algorithm”


Proposed care packages will be too
expensive (
but can help form the basis of
future discussions with commissioners
)


Enforced subspecialisation/ functionalisation


the “death of psychiatry”!


“Lack of evidence base”





Can we use PbR
methodology to improve the
quality of our services?


A commissioner can expect to have:


a clear understanding of the number and
nature of service users being treated


a transparent framework on which to
align outcome measures


the opportunity to have meaningful
discussions with providers about the
service response to each care cluster.

Questions


How will services and commissioners
(& LA, third sector, patient groups)
define care packages for each cluster?


How do commissioners envisage
moving forward with mental health
PbR?