care clusters and packages in mental health in the west midlands michael clark n.
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Care clusters and packages in mental health in the West Midlands Michael Clark. Overview in the West Midlands. The SHA has brokered an agreement with all commissioners and mental health provider trusts across the region;

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overview in the west midlands
Overview in the West Midlands
  • The SHA has brokered an agreement with all commissioners and mental health provider trusts across the region;
  • To develop two joined pieces of work in mental health and learning disabilities:
    • Productivity Improvement Programme (PIP) - successful in acute and community care over the last 3 years to help map services, understand how staff work, and redesign services to free staff to better help patients.
    • Care clusters and packages - to put in place common assessments and the care clusters and packages model.
  • Regionally this gives us a strong position to better understand our services, improve the way they work for staff and patients.
twin track approach
Twin Track Approach

Provider Focus

Provider/Commissioner Focus

Productivity and Improvement Programme

Yorkshire Care Pathway Programme

Directory of Services

MH/LD Benchmarking Tool

Rostering Assessment

Reference Cost Benchmarking Tool

Time to Care

Diary Card completion

  • Yorkshire Care Pathway Launch and Training
  • Assessment and allocation to pathways
  • Collection and Analysis of PAS data in pathways




Synthesis Recommendations

Action Plans

Local Cost

Shadow tariff


Service Level Economics Tool

our values underpinning this
Our values underpinning this

Supporting clinical decision making

High consistency of care; quality and equality of access, experience and outcomes

Personalisation and recovery

More transparent model of finance and commissioning

More efficient systems of care

Better data for system and care planning

Greater accountability throughout the system

Stronger local mental health systems

objectives of the programme
Objectives of the programme

Working through the programme will enable each MH Provider to:

Undertake a rigorous and insightful analysis and benchmarking of workforce productivity of MH/LD services

Assess current levels of productivity and identified areas for improving productivity and reducing costs while maintaining standards in key quality and performance indicators;

Focus on developing MH Trust capacity to manage and improve service line economics focusing on pathways of care

On the basis of needs, allocate users to care clusters and packages, supported by an electronic assessment tool

Consistently report activity information by service user

Analyse PAS downloads in order to compare distribution across pathways and quality of care

objectives of the programme contd
Objectives of the programme (contd)

Working through the programme will enable each MH Provider and Commissioner to:

Develop a shared ‘language’ using YcPs

Identify local costs of delivery pathways and define local shadow tariff

Develop West Midlands tariff for MH services (2011)

yorkshire care pathways clusters
Yorkshire Care Pathways/clusters
  • 21 care pathways for all people who use adult mental health services
  • Grouped on the basis of similar needs
  • All new referrals are assessed using a needs assessment tool -based on HoNOS, with additional questions
  • Pathways tested in Yorkshire and two West Midlands Mental Health Trusts. Key points:
    • the pathways made clinical sense - face validity
    • Consistent and high degree of allocation to the clusters
    • Good basis for continuing development work
  • Additionally, there is an electronic decision support algorithm which suggests a pathway but allows clinicians to override this (97% concordance)

Rate the most severe problem as:

0. No problem

1. Minor problem requiring no action

2. Mild problem but definitely present

3. Moderately severe problem

4. Severe to very severe problem

9. Unknown


The Health of the Nation Outcome Scale (HONOS) is an outcomes measurement tool for use in mental health care. The scales rate severity of problems experienced by the patient during the 2 weeks prior to the date of the rating. The scales are:

1. Overactive, aggressive, disruptive or agitated behaviour (current)

2. Non-accidental self-injury

3. Problem drinking or drug-taking

4. Cognitive problems

5. Physical illness or disability problems

6. Problems associated with hallucinations and delusions

7. Problems with depressed mood

8. Other mental and behavioural problems

9. Problems with relationships

10. Problems with activities of daily living

11. Problems with living conditions

12. Problems with occupation and activities

Additional Questions

Rate each according to the most severe occurrences still relevant to the care plan.

13. Overactive, aggressive, disruptive or agitated behaviour (historical)

14. Repeat self-injury (historical)

Child protection risk (historical)

Engagement (historical)

Vulnerability (historical)

Strong Unreasonable Beliefs (historical)


Further Questions

Tickbox answers

A1. Does this presenting need relate to non-psychotic, psychotic or organic?

A2. Does your client have a history of psychotic illness that is now controlled?

A3. Has your client been known to the service for less than one year?

A4. Is your client having an acute psychotic episode?

A5. Have they been known to the service for a long time?


Summary of clusters and pathways model

Working-aged Adults and Older People with Mental Health Problems








severe & complex

c.Substance misuse

a.First episode

b. ongoing/ recurrent


Psychotic crisis


Very severe engagement

a.Cognitive impairment






















benefits of using pathways
Benefits of using pathways
  • For user:
    • Clear what basis starting from
    • Upfront information of what services will be provided by who and when
  • For clinicians:
    • Support clinical decision making and care planning
    • Easier to ‘slot in’ evidence
    • Allows analysis and comparison of clinical practice
    • Development of outcomes measures
    • Good practice pathways to work towards
  • For provider organisations:
    • Detailed understanding of current model of service delivery
    • Facilitates service redesign
    • Improved dialogue with commissioners, transparency of work and costs
  • For commissioners:
    • Focus on pathways of care and greater transparency of service model
    • Improved dialogue with providers
risks of not developing the work
Risks of not developing the work

Variations in practice and outcomes

Someone else defines the work for us

Lack of clarity and transparency in services

Unhelpful for service users

Unhelpful for services

Unhelpful for commissioners

Mental health systems unable to articulate a strong case in relation to acute care

Pressures on public sector spending

current state of development
Current state of development
  • Regional steering group to oversee work
  • Training pack being rollout across the West Midlands
  • IT development to support the work
  • Local project leads and support in place
  • Beginning of PIP work, mapping local services
further development work
Further development work

This is a developmental process

Need to ensure the model is:

clinically meaningful and workable

is generalisable

is robust and stable

Need to maintain and extend the regional consensus

Develop it for benchmarking across services and quality improvement

further development work contd
Further development work (contd)

Development of care pathways and packages to reflect our context and shared values

Refinement of clusters as necessary

Extend the approach to learning disabilities and CAMHS

Refinement of assessment and allocation process as necessary

Development of (local) tariff

Ensure consistency with other areas e.g. social care, Darzi and IAPT

Development of quality and outcomes frameworks for the pathways

towards payment by results background
Towards Payment By Results? Background

Reforming NHS Financial Flows (DH 2002) - announced Payment by Results (PBR) - to bring transparency and incentives to the system


Currency - the things/units being contracted for e.g. hip operations

Tariff - the amount paid for each unit of currency (£)

PBR introduced into acute care in 2003/4 and extended since

High Quality Care for All (DH 2008:41) - ‘In 2008/09, over 60 per cent of the average hospital’s income is through Payment by Result.’

Continue to refine the system - redefine HRGs, payment systems and quality improvement


Mental health to date not covered by PBR

Yorkshire model of Care clusters, pathways and packages developed

January 2009 DH letter - “committed to making a currency available for use nationally in 2010/11.”

June 2009 - further DH letter and guidance on preparing for PBR in mental health