Payment by Results (PbR)

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Payment by Results (PbR)

Post by eponymous85 » Thu Apr 14, 2011 9:15 am

Mental health services have traditionally tended to be paid for by block funding. In short, "here's a lump of money and go do some good with it". There are also more specific contracts where it is clearer to see where money has come from and for what it is being used; this is called Payment by Results or PbR.

At a basic level, a formula to understand PbR is: price (aka tariff) x activity = income.

So, far so good - you get paid for what you do, seems simple enough. However, the question of defining the what is a bit more tricky. For payments to work, the Department of Health has been devising national 'tariffs' (i.e. a nationally agreed price) for national 'currencies' (i.e. nationally agreed units of activity for which payment is made, e.g. outpatient appointments, or care for someone with dementia).

In practice, this has led to the development of 'clusters' of patient groups sharing similar presentations. I believe there are currently 20 clusters (+ a blank cluster, number 9), covering three main areas:

Non-Psychotic (1-9). 1-4 cover the mild/moderate/severe range; 5-8 are very severe and complex; 9 is blank whilst they work out what to put there.
Psychosis (10-17). 10 is First Episode; 11-13 Ongoing or Recurrent; 14-15 Psychotic Crisis; 16-17 Very Severe Engagement.
Organic (18-21). These relate to Cognitive Impairment / Dementia.

The thinking is you can define a price (the tariff) for how much it should cost to provide care (the currency) for, say, someone experiencing a First Episode of Psychosis (Care Cluster 10) by working out what might be normally offered to someone with that presentation. There's a nice little scoring matrix to see if you have put someone in the right cluster and then off they trundle to get your Care Cluster 10 services.

Now, here's the thing: if you don't spend as much as the national tariff for the cluster that your patient/client is in, you get to keep the extra money (that is you the service, unfortunately no NHS staff bonus payments). However, if you spend 'too much' by providing lots of expensive services and treatments then the Trust/provider has to make up the difference from elsewhere.

The categories are not particularly diagnosis heavy, and in some qualified psychologists' experience they seem fit for purpose - it did seem to be possible to categorise everyone. That doesn't necessarily mean that we should, or that it would work, but there does not seem to be much wrong with the categories themselves.

Within an IAPT service, PbR arrangements are that the service will get paid for a change down in severity range, so in depression say if a client is within the severe range on the PHQ-9, when they start treatment and are in the moderate range when they complete treatment, payment can be awarded. Currently 'recovery rates' across the whole service are part of the formula on which IAPT services receive funding. It is not the only measure. But this does mean that if the service user does really well in treatment say moving from the severe range to the mild range, that client would not have 'recovered' well enough to meet the criteria for this part of the funding formula. So in the current formula if you discharge when the person scores 6 (mild range) on the PHQ-9, they won't be added into the formula, but if they scored 5 they would.

There are issues with using a basic measure like the PHQ-9 so wholeheartedly that you allocate payment on it. It is very open to interpretation as it is based on subjective ratings. Some have suggested an alternative; using percentage drop of score, not on the actual rating number as not everyone rates it the same way (one person's 5 may be another person's 8)

The NHS is increasingly moving to commissioning services on this basis, making services 'activity led'. This can present real problems for professions like psychology, who in some specialities do lots of indirect working. Whatever work you do (whether seeing a client for face to face therapy, or providing consultation for a staff team, or working with carers), there needs to be a tariff for it and a way of logging the activity or the service will not get paid. Services now bid for contracts based on what 'activity' they can provide at what price. On the surface this seems like a good idea - an effective service is one that is doing what it is paid for efficiently. However, the danger is that this can make services target driven rather than quality driven. This has caused serious problems before, such as the Mid Staffordshire Trustwho concentrated so much on achieving Foundation Trust status that the standard of care slipped dramatically.

Put in the context of the 'free market economy' paradigm being promoted in the current NHS, there is an additional danger that quality of care will be driven down by services winning contracts based on being the cheapest and promising the most activity. This does not necessarily lead to the best care; it can result in cutting corners and overworking staff. Trusts can also be heavily fined for not meeting their targets (for example, they are contracted to provide an A&E service that moves people on after 4 hours). If these targets are rudimentary and inflexible, it can cause real problems for standards of care (in the above example, not everyone will be stable enough to be discharged or admitted to another ward in 4 hours, yet if this is not done the Trust will be fined thousands of pounds). This presents significant challenges to NHS clinicians trying to work safely and ethically, and balancing their clinical responsibilities with political and administrative demands.

with thanks to, russ, Dr. Dot and LIWY for their contributions

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