Payment by Results for Specialist Alcohol Services Don Lavoie Alcohol Policy Team

What is ‘Payment by Results’? A system in which PCTs pay providers for the number and complexity of patients treated, using a price list – the national tariff – for all activity within the scope of PbR. Covers admitted patient care, outpatients and A&E Introduced in Previously Block contracts were awarded to provide services with prices based on historic local costs and negotiating skills. Now Under PbR, commissioners pay providers; (NHS trusts, Foundation Trusts and the independent sector) a national tariff or price for the number and complexity of patients seen. Provider income = activity x price

Three Tiers of Payment (A) National currencies with national prices: Depends on services being sufficiently standardised to support the use of national currencies and is appropriate to encourage contestability at national level, or to focus local contract negotiations on quality and outcomes. (B) National currencies with local prices: Appropriate where there is sufficient standardisation of services across different local areas. Appropriate where there is standardised data collection and information flows based on national definitions. Often a transitional stage in the development of a national tariff. (C) Local currencies with local prices: Appropriate where there is significant diversity amongst services at local level - where services are provided in very different ways and to widely differing individuals.

The Future Development of PbR This has been spelt out in a Revised NHS Operating Framework and the White Paper Liberating the NHS.

PbR Going Forward Coalition Government committed to introducing Payment by Results (PbR) across healthcare and beyond (e.g welfare, Children’s Centres). Desire for PbR to be linked more to the patient pathway and to be focussed on outcomes The White Paper Equity and Excellence: Liberating the NHS, made a number of commitments around expanding the scope of PbR, including restating the timetable of 2012/13 for the introduction of PbR payments for adult MH services.

Mental Health PbR development history When PbR was introduced for acute physical services in 2005/06 work had already begun on mental health. Six Mental Health Trusts in the North East and Yorkshire and Humber regions came up with an approach of grouping service users in a clinically meaningful way. This was adopted as a national way forward in Autumn Development work continued around the country leading to a first set of agreed currency units (the care clusters), an allocation/assessment tool (the Mental Health Clustering Tool) and draft guidance in February 2010.

Planned future work in mental health Costing: Major strand of work is to determine cost per service user per cluster – has revealed that this level of detail lacking in most mental health providers. Costing work may inform understanding of costs of alcohol services. Care Packages: Care package response is left to local determination to allow for innovation and flexibility (may want to be more prescriptive for alcohol). Quality and Outcomes Measures: Seeking to define quality and outcome measures for each of the care clusters.

Mental Health PbR: Lessons Learned 1.PbR is not simply a financial initiative – has the potential to drive how care is given and its quality. 2.Works need to involve professionals who deliver services – will require a culture change in the information they collect and record. 3.Information systems take time to adapt to meet your needs. 4.Locally led development is good, but it is important to define where national consistency is needed and how agreement will be reached.

Background to PbR for Specialist Alcohol Services The Department of Health is establishing a project to develop a ‘Payment by Results’ (PbR) approach for Specialist Alcohol Services. The main purpose of the project is to create an opportunity to develop national currencies and tariffs that can be used as the basis for contracting and paying for specialist alcohol services in England. Alcohol PbR is seen as a natural progression from mental health PbR as specialist alcohol treatment is often delivered through NHS Mental Health Trust contracts. Where alcohol misuse is a complicating factor in mental health need, it is already included in mental health PbR

Specific Objectives To agree an approach for needs based clusters of patients. To agree standard individual needs assessment tool(s). To identify good practice in needs based packages of care. To agree an individual outcome measure for alcohol services. To cost up both good and existing practice. To ensure that an amended National Alcohol Treatment Monitoring Service (NATMS) data set is fit for the purpose of specialist alcohol services PbR. To successfully pilot local approaches to PbR for specialist alcohol services and extract the nationally applicable learning. To determine how reimbursement will occur e.g. will it be through utilising PbR-SUS (Secondary Uses Service) or another mechanism.

Project Scope The focus of the Alcohol PbR approach will be on men and women of working age. The project will include services in the community that are traditionally described as both primary and secondary care, with the exception of exclusions (detailed in PID). The customers of the project will be alcohol commissioners (whether practice-based, at PCT level or more specialised) and specialist alcohol service providers (NHS Trusts, Foundation Trusts, Independent Sector and Third Sector).

Products 1.National tool for classification for needs based clusters 2.Nationally utilised individual needs assessment tools 3.Best practice needs based packages 4.Individual outcome measure 5.Appropriate Minimum Data Set 6.Costing of best practice packages 7.Indicative tariffs (unit costs)

Project governance

Timescales The introduction of the currencies and tariffs developed will take place from April 2013 The project is anticipated to run between Oct 2010 to Summer the project will need to be in place to oversee and get feedback from first few months of implementation