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Audit of Mental Health Trust PbR implementation

Author: Mike Stedman & Kate O’Regan

Published: Online Res report  [please request more information]

The state of readiness PbR evaluation into a large urban mental health Trust was undertaken to determine a case study around operational challenges for PbR in this sector. The evaluation process incorporated both quantitative methods (data validation) and qualitative approaches (through a series of semi-structured interviews with senior internal stakeholders).

There was significant evidence of a good deal of progress being made in the implementation of PbR with an acknowledgement that there remains much work to do on what is a long journey. More specifically the trust has established robust governance and performance systems aligned to service lines. Work on the development of costings has commenced. A significant challenge remains in relation to staff engagement and buy in as well as the perennial problem of data quality.  

The data validation analysis revealed that only 38% of patients are allocated to the correct cluster when the Department of Health (DH) algorithm is applied to the HoNOS score. The clusters that patients should have been allocated to are included in the analysis. What this means in reality is that many patients are allocated to the wrong cluster at the initial point of assessment and that this presents a range of problems as a stable foundation is not in place to support further work in embedding a PbR system. The key recommendation is that the trust finds a technical solution to the utilisation of the DH algorithm (which is not being currently used). This will enable further auditing of inter-rater reliability and cluster assurance to take place. The data validation process also provided evidence that the trust is “under clustering” i.e. allocating patients to lower clusters. If this trend continues there is the risk that the trust will not be sufficiently remunerated for the complexity of the work it undertakes, as well as a potential risk to quality with patients not receiving optimum treatment.

Through its internal auditing systems the trust reported a compliance rate of over 70% with reassessment points (as stipulated by the CPPP rules). Out of the patient records that could be tested, the analysis indicated a compliance rate of 46%. It is likely that the trust is performing well in this area when benchmarked against comparators. Transitions between clusters and service lines were highlighted as a key local challenge.   

Packages of care (PoC) are being developed in each service line against best practice guidance. These are being seen as offering “gold standard” treatment and concern was expressed that these interventions are not affordable within current funding arrangements. Further agreement and sign off of the PoC that can be provided affordably is required with commissioners. The implementation of PbR requires system-wide thinking across a local health economy, specifically in relation to the management of the primary care interface, patient flows and care pathways across sectors. Further work needs to take place in this area as part of the PbR implementation process.  

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