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Katie brennan - integrated approach for mental health services

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Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning …

Better outcomes, better value: integrating physical and mental health into clinical practice and commissioning


Tuesday 24 June 2014: 15 Hatfields, Chadwick Court, London

Published in: Healthcare, Health & Medicine
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  • Key question for Monitor and NHSE’s pricing function

    What are the preferred long run payment design options to deliver proactive co-ordination of care across multiple providers and settings to support sustainable delivery of better quality care for vulnerable, multi-morbid and older patients?

    What are the associated incentives of different payment systems?
    What does the evidence say?
    What approach is suitable and implementable in the NHS?
    How can we transition to the preferred option? What can be done for 15/16?


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    • 1. Towards a joint long term payment strategy: enabling an integrated approach for mental health services Katie Brennan Pricing Development Lead 24 June 2014 GOV.UK/monitor
    • 2. Aims for this session 1. Provide context for the long term payment system design 2. Share some emerging thinking 3. Set out our next steps
    • 3. We want the national payment system to do more for patients …evidenced based approach to both mental and physical health 4 July 2014 3 At a high level we are aiming for the payment system to support: • Improved outcomes for patients • More efficient use of scarce resources • Best possible placement of risk Which requires supporting changes to existing patterns of services, in particular to deliver the 6 characteristics identified in the NHSE planning guidance: New national urgent & emergency care system Improved access to wider primary care Integrated care, especially for elderly and LTCs Centralised specialised services Productivity step- change for elective care Engaged patients and supported self-care
    • 4. Within a very challenging financial climate 30 12 4 2 5 7 Gap by 2021/22 Improve current services Right care, right setting Innovate new services Wage freeze to 2014/15 Remaining challenge £bn p.a Monitor’s Closing the Gap report identifies three improvement opportunities: • Improve ‘as is’: provider efficiency, look again at low value interventions • Right care, right setting: patient self-care, integrated care, shift activity to low cost settings • New models: telemedicine, greater specialisation ... but a £7 bn gap still remains.
    • 5. 5 BASE PRICE ACCOMPANYING INCENTIVES CURRENCY + + Core Elements of a Payment Approach • How is demand risk dealt with? o Gain / risk share o Marginal rates o Caps / collars • How is performance risk dealt with? (quality/ outcome measures) • Episode of care (HRG/DRG) • Defined care pathway • Capitation (full or partial) • Block (all activity) • What is the basis for calculating the price (actual costs vs. efficient costs)? • How are payments shared between multiple providers? Design Options / Questions • Core elements can be set at different levels • May vary by sector, location Pricing is a key component to enabling a more patient centred approach to care
    • 6. The design of payments is only one element that needs to be in place to improve outcomes… 6 Planningand FinancialArchitecture Determine Commissioning Model Decide Contracting Approach PatientFacing/Care Interventions Identify Patient Population Determine Services In/Out of Scope Design Service Delivery Approach Design Payment / Incentives Approach Establish Leadership & Shared Purpose Identify Key Outcomes to be improved Linked Data Transactional Capabilities Workforce Skills Evaluation CULTURE CORE ENABLERS CARE CONTRACTS
    • 7. ... Tightening rules for local price-setting, to ensure incentives are equally sharp ... Changing the role of national prices – only mandating where necessary ...Making information more important to support local action e.g., bench- marking To be credible, our regulatory stance will need to use the full range of our tool kit, through... Improving Cost and Quality Data Setting Mandatory Prices Constraining Prices & Contracts Setting Reference Prices & Contracts Assessing Value for Money TOOL KIT FOR PAYMENT REGULATION LESS INTERVENTIONIST Determining Allowed Revenues MORE INTERVENTIONIST Arbitrating where Local Pricing fails ...And making our regulation more predictable with longer national tariff cycles, added rigour to price calculations and fully exposing our regulatory judgement to the sector. ...Supporting evaluation of new payment approaches, by allowing local innovation
    • 8. Aims for this session 1. Provide context for the long term payment system design 2. Share some emerging thinking 3. Set out our next steps
    • 9. Address lack of information Framework of rules Incentivise behaviour change REGULATORY LEVERS Raising the quality of data that underpins the payment system Adopting a regulatory stance is credible Introducing different payment approaches for different types of care needs POTENTIAL GOALS? Creating an enabling environment toward positive behaviour change Our proposed vision for payment reform – regulatory levers extend beyond price…
    • 10. Multiple Needs Significant Risk Factors Mostly Healthy Population People with multiple long-term or significant risk factors – may need… • Care coordination & planning • Self-management tools • Single care record for all • Multi-disciplinary care • Psychosocial wellbeing support for recovery A population who might be at low risk or healthy – may need… • Prompt first response services • Emergency care for trauma • Planned care for routine diagnostics and treatments Patients with rare and complex conditions – may need… • Access to specialised expertise and equipment Specialised Needs Different people have different care needs, which payment design must account for
    • 11. 11 NHS England’s characteristics of care raise important questions for payment design Engaged People Can payment incentivise self- care? Can payment incentivise greater use of remote urgent advice and safe, sustainable emergency care centres? Can payment incentivise services designed and managed to remove error and increase productivity? Can payment incentivise coordinated care for the 25% with frailty factors or multiple long-term conditions? Can payment incentivise concentration of specialised care and links to research and teaching? Modern Integrated Care & Wider Primary Care A new national urgent & emergency care system Step-change in productivity for elective care Centralised specialised services
    • 12. 12 Which arguably also apply when designing payments for mental health services.... Users in control What is the role for self- management, personal health budgets and choice? Can payment incentivise sustained provision of rapid response mental health services? Can payment incentivise adoption of best practice that promote sustained recovery in most appropriate settings? Could these include physical health care settings? Can payment incentivise coordinated care for users with multiple and ongoing needs, improving outcomes and reducing premature mortality? Can payment incentivise provision of efficient secure mental health care, and effective recovery pathways? Integrated mental, physical and social care Crisis response teams and liaison psychiatry Delivering cost effective interventions Forensic, secure and high cost mental health beds
    • 13. Aims for this session 1. Provide context for the long term payment system design 2. Share some emerging thinking 3. Set out our next steps
    • 14. We are also considering what we can do in the 2015/16 national tariff, given the particularly challenging financial context 4 July 2014 14 2014/15: • Introducing new regulatory regime • Creating stability in national prices • Freeing LHEs to use local variations • Bringing transparency to actual behaviours • Establishing local modifications for structural issues 2015/16: • Improving rigour of national price-setting method (e.g., input costs, efficiency factor) • Transition towards long-term system by testing new payment designs (e.g., UEC, integrated care) • Helping close the financial gap 2016/17: • Continued improvements to rigour, especially costing data • Rolling out priority long-term payment redesigns • Enabling widespread service change in line with 5 year commissioning and provider strategies
    • 15. 15 There are opportunities to engage with us on policy formation Dec 13 Jan 14 Feb 14 Mar 14 Apr 14 May 14 Jun 14 Jul 14 Aug 14 Sep 14 Oct 14 Nov 14 Dec 14 Dec 2013 Publish planning guidance Apr 2014 • Publish15/16 NT method paper for engagement July 2014 Launch 15/16 TED and stakeholder engagement Autumn/late 2014 • Publish final Monitor/NHSE long-run strategy • Publish NT notice for statutory consultation • Publish LT strategy for engagement Feb 2014 • Launch crowd- sourcing • Publish our 2014 Forward Look The long-term strategy will be accompanied by a number of supporting documents on specific areas, including: enabling long-term conditions care coordination, delivering Keogh’s urgent & emergency care networks, aligning incentives, options for multi-year tariff cycles, and, based on today’s discussions, next steps for mental health.
    • 16. More information: http://monitor.gov.uk/regulating-health-care- providers-commissioners/regulating-prices-nhs- funded-care Katie Brennan katie.brennan@monitor.gov.uk

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