1. Equity and Excellence: Liberating the NHS

2. White Paper outline An NHS that puts patients and the public first… …which focuses on improving healthcare outcomes… …with more autonomy for professionals, and more accountability to patients … …with reduced bureaucracy and improved efficiency… …leading to an NHS that achieves healthcare outcomes that are among the best in the world

3. White Paper outline An NHS that puts patients and the public first… …which focuses on improving healthcare outcomes… …with more autonomy for professionals, and more accountability to patients and the public… …with reduced bureaucracy and improved efficiency… …leading to an NHS that achieves healthcare outcomes that are among the best in the world Shared decision-making An “information revolution” Greater patient choice Public/consumer voice through HealthWatch

4. White Paper outline An NHS that puts patients and the public first… …with more autonomy for professionals, and more accountability to patients and the public… …with reduced bureaucracy and improved efficiency… …leading to an NHS that achieves healthcare outcomes that are among the best in the world NHS Outcomes Framework Backed by clinically-evidenced NICE quality standards Money to follow the patient, with incentives for quality …which focuses on improving healthcare outcomes…

5. White Paper outline An NHS that puts patients and the public first… …with more autonomy for professionals, and more accountability to patients and the public… …with reduced bureaucracy and improved efficiency… …leading to an NHS that achieves healthcare outcomes that are among the best in the world GP-led commissioning, supported by new NHS Commissioning Board More autonomy for providers; all providers regulated on a consistent basis Stronger role for local authorities, to boost local democratic legitimacy …which focuses on improving healthcare outcomes…

6. White Paper outline An NHS that puts patients and the public first… …with more autonomy for professionals, and more accountability to patients and the public… …with reduced bureaucracy and improved efficiency… …leading to an NHS that achieves healthcare outcomes that are among the best in the world Major cut in management costs, to reinvest in front-line services Abolition of Strategic Health Authorities, Primary Care Trusts and some arm’s- length bodies …which focuses on improving healthcare outcomes…

7. Before Policy: Implementation: NHS Public healthSocial care Department of Health Public healthNHS Social care After

8. The new system Department of Health Public health service NHSSocial care NHS Commissioning Board Monitor (economic regulator) Care Quality Commission Providers GP commissioning consortia Local authorities

9. Policy Context Equity and Excellence White Paper - towards GP- led commissioning and outcomes The Outcomes Framework The Public Health White Paper Quality Innovation Productivity & Prevention (QIPP) agenda Mental Health Strategy – 2010 IAPT and talking therapies

10. GP Commissioning What we know: Its going to happen No (very little) central guidance Variable size of groups Every practice will be involved in a consortium 80% of NHS expenditure will be devolved for commissioning Consortia can use private commissioners to commission on their own behalf Consortia will commission mental health services

11. GP Commissioning What we don’t know: Will there be a similar governance structure for all consortia? What levers will there be to influence the commissioning plans? What role will the public and users of services have in commissioning plans? What role will the Local Authority have in commissioning plans? What role will third sector organisations have? …..

12. GP Commissioning… …is not PCT commissioning writ small Doctor to Doctor contact

13. Mental Health Adult services –IAPT –CMHTs –In-patient services –Specialist Teams Older people services Children’s services Forensic Services Links to Social Services

14. What should MH Trusts be doing now? Identify local GP leaders Support the development of local networks Encourage the clinician to clinician contact Embark on a charm offensive

15. Mental Health Emphasis on Outcomes Traditionally difficult to measure outcomes in mental health How to annoy a chief executive of a mental health trust “ How many patients did you make better in the last quarter?”

16. Why outcomes? From a commissioner perspective: –It is outcomes that matter –Don’t need to get involved with process or clinical detail From a provider perspective: –Less intrusion from commissioners in day to day running of services –Greater focus on outcome, less on process –Greater opportunity for innovation

17. Outcomes should… be simple to administer, the data underpinning the currency should be easily obtainable not provide perverse incentives reflect the needs of the individual (the individual receives a high quality service) reflect the needs of the population (the currency does not discriminate against hard to reach populations) acknowledge the range of complexity of particular disorders, from the very mild disorder, to those with much more complex and severe disorder. include outcomes which reflect best clinical practice include outcomes which reflect the views and experiences of the person receiving the care ensure outcomes are not be limited to just clinical/medical outcomes but where appropriate, social, employment or vocational outcomes 17

18. Four Domains Access –Population based block payment Recovery/improvement –Individually based payment Employment/vocation –Individually based payment Choice and satisfaction –Individually based payment Balance to be determined locally 18

19. Access Population access – proportion of at risk population attending IAPT services Disorder specific – allows payment to reflect that all common mental health disorders are treated Vulnerable groups – age, sex, ethnicity, gender specific etc To be determined locally 19

20. Improvement/reco very Designing a tariff that is just based on recovery has problems: A large number of patients that showed improvement (but not recovery) would not merit an outcome based payment The quantity of care and level of training of staff to deliver improvement/recovery for somebody with a longer term more severe disorder is much greater than for somebody with a mild short lived disorder A solely recovery based tariff would encourage the provider to concentrate on those with mild and short lived disorder, at the expense of those with more complex, and longer lasting disorders. This is a perverse incentive that any tariff should seek to avoid 20

21. A Tiered Approach We propose a tiered approach to outcomes, Built on the PHQ-9 and GAD-7 Both questionnaires are completed by all patients Includes the ADSMs score

22. Improvement/Recovery RecoveryTier 1Tier 2Tier 3 PHQ-90 – 910 – 1415 – 1920 - 27 GAD-70 – 78 – 1011 – 1515 - 21 NoneMildModerateMod Severe Severe PHQ-90 – 45 – 910 – 1415 – 1920 – 27 GAD-70 – 45 – 1011 – 1515 - 21 Current definitions of recovery Proposed tiers for currency use ONLY

23. Improvement/Recovery RecoveryTier 1Tier 2Tier 3 PHQ-90123 GAD-70123 RecoveryTier 1Tier 2Tier 3 PHQ-90123 GAD-70123 Total0246 Tariff Allocation Tariff Points

24. Improvement/Recovery Change in tariff points (between first assessment and last assessment) Tariff units earned by provider, per patient 2 or 11 4 or 32 6 or 53

25. Employment/Vocation Based on change of employment or vocation status, between beginning and end of contact with services Includes subjective (patient reported) opinion on change in intention in relation to work/vocation Developed into a unit calculation

26. Patient Choice and Satisfaction YesNO Were you given the option to choose from the range of therapies and treatment approaches offered by the service*? Were you offered information in a way that enabled you to make an informed decision about your treatment? Were you satisfied with the overall experience of using this service? Were you given the opportunity to feel involved in decisions about your treatment? Do you feel that your therapist considered and valued your background, beliefs and lifestyle * NICE recommends only CBT for some anxiety disorders; this question applies to people with other mental health problems

27. Outcomes Based on the balance between 4 domains Data for the 4 domains already being collected Balance between the 4 domains decided by local stakeholders –This is how people who use the services and the general public get involved in commissioning

28. Summary There is lots that we don’t know –(and others don’t know as well) Which provides the opportunity to design in, what we think is important How can we influence GP commissioners? What impact will outcome led commissioning have?

29. Thank you