The improvement of mental health is now a key government priority. Currently, one in six adults in the UK has a mental health disorder, greater than the number of people with coronary heart disease. It is estimated that mental health problems cost the UK £77 billion a year and mental health care expenditure is the biggest single share of programmed expenditure in the NHS.
Mental health performance has been given increasing attention following the National Service Framework (NSF) for Mental Health which set standards for service provision within a performance measurement framework. Measuring the performance of mental health services is a major challenge - there are difficulties in obtaining good quality data, and in understanding the different elements of and defining the boundaries of service provision. Furthermore, many of the impacts of mental health go well beyond economic consequences – poor mental health has seriously marginalizing social consequences for individuals. These problems are compounded by deeply rooted stigma, fear, prejudice and discrimination. Fundamental human rights can also be affected as mental health is almost unique in its potential for compulsory detainment and treatment of individuals. As a result of these challenges, there is a long-standing and wide gap in the evidence base related to mental health care system performance.
CHE’s research in the area of mental health has been contributing to filling this gap. Our research has focused on outcomes, finance (Payment by Results), resource allocation and performance.
The NHS collects mandatory Patient Reported Outcome Measures (PROMs) from all acute hospital Trusts before and after certain elective procedures. The change in health status provides an indication of the outcome or quality of care delivered.
The development of PROMs is particularly relevant to mental health services because of the extent to which mental health will be required to follow the footsteps of the acute health services in England in future years in terms of mandatory PROMs. We investigated the potential roll-out of PROMS to mental health services.
One outcome measure, HoNOS (the Health of the Nation Outcome Scales), has already been mandated for use by mental healthcare providers in England. HoNOS was developed for people with severe and enduring mental illness and is not a patient-report or self-report measure, but rather is completed by a member of the clinical team. This 12-item outcome measure forms part of the Mental Health Minimum Dataset (MHMDS), the collection of which is mandatory. As a minimum, HoNOS is recommended for use for all patients with more complex needs, with at least one measurement taken per year. Despite this, we found that only around a half of all providers complete HoNOS returns in the MHMDS and coverage is less than 10% among those that do. In addition, the collection of repeat measures on individual patients is almost non-existent, making measurement of changes in health status impossible and only allowing HoNOS to provide a measure as a snapshot of patient severity or casemix, rather than as an outcome.
We also examined the feasibility of incorporating patient outcomes in mental health into a productivity measure. We examined which outcome measures have the widest coverage in mental health, which are routinely collected, the practical issues about collecting these outcome measures, and whether they can be converted into a generic measure.
Barriers to routine outcome measurement ( excerpts from interviews with managers, clinical staff, policy makers, commissioners and service users ):
(Its like)…“pouring valuable clinical information into a black hole.”
“Only about 5% of patients will receive a second rating at time T2. This is because they (clinicians) feel they should be completing them, though they can’t see it as useful if they’re only completing them at T1.”
“… people are afraid of others viewing their outcome measures – you want a culture where people aren’t afraid. We’re a long way off that.”
“One can’t even get ones caseload on the electronic system, so there is no belief that one could get nicely labelled graphs of routine outcome measures.”
The role of commissioners in increasing the use of outcomes is… “probably around zero.”
If PbR were a driver (we’d)… “surf this wave, however evil it might be.”
The use of casemix-based funding mechanisms is increasing internationally. This funding approach potentially offers incentives for a range of diverse objectives, including improvements in efficiency, quality of care and patient choice. However, to date, the application of this approach to mental health care has been limited and there is no long-term experience to inform policy and practice.
In England, the Department of Health plans to extend the scope of Payment by Results to mental health. The Care Pathways and Packages Clusters comprise a set of 21 ‘care clusters’ that together form ‘currencies’, or units for contracting and commissioning mental health services. Each cluster defines a package of care for a group of service users who are relatively similar in their care needs and therefore resource requirements. The currencies are being refined and tested at several sites in England. In addition, costing exercises are underway to investigate the resource implications of the currencies.
Our report examines the international literature on payment mechanisms for mental healthcare services. These approaches are described and critiqued, drawing on relevant theoretical and empirical research to explore the strengths and weaknesses of payment mechanisms. Implications for the proposed Care Pathways and Packages Clusters are explored and recommendations are outlined.
Weighted capitation formulae have been used in England since the 1970s to distribute NHS resources between health care organisations. They are currently used to distribute resources between PCTs and to inform practice budget-setting under Practice Based Commissioning. Under these formulae, more resources are directed to organisations that are expected to commission a larger volume of services and to commission services delivered in high cost areas.
Larger volumes of services are expected to be commissioned by organisations that serve larger populations, older populations, and populations with worse health and more socioeconomic deprivation. For the current formula, the effects of these factors on funding needs are estimated separately for different types of health care. The information on these factors should be rich, robust and as up-to-date as possible. This report describes the work we have undertaken to update the needs elements of the formulae for (i) the health service needs of people with severe and enduring mental health problems and (ii) prescribing by general practices.
Street A. Should GPs hold budgets to purchase hospital services? Revista Espanola de Economia de la Salud. 2007;6(2):88-92. Download from Economia de la Salud
The RAMP formula has been applied to PCTs. See:
As part of the Quality and Outcomes Framework (QOF), quality indicators for mental health have been routinely measured in primary care. The QOF offers financial rewards to GP practices for good quality care, including payments for treating people with serious mental illness such as schizophrenia, bipolar disorder and psychoses. For example, QOF indicators require GPs to closely monitor the dosage of particular medicines; to ensure that people with serious mental illness have a comprehensive care plan; and to undertake annual reviews including physical health checks.
The NIHR SDO programme has commissioned us to investigate whether better primary care is associated with a reduction in emergency (unplanned) admissions for people with serious mental illness. Effective primary care can have an important preventive role, and better quality of primary care should therefore be associated with lower emergency admission rates.
The rate of emergency hospital admissions is an important indicator of the level of GP care received by patients. Admissions in these circumstances for mental health sufferers are costly and cause dissatisfaction amongst service users and carers. Even when admitted for the treatment of a physical condition, people with mental health problems tend to stay in hospital for much longer than average.
Previous research on the effectiveness of the QOF has focused on physical conditions, such as diabetes, for which improvements in the quality of care given by GPs can reduce both illness and emergency admissions. However, the link between quality of care and emergency admissions has not been investigated for people with mental health problems.
Our study investigates whether better quality of primary care, as measured by the QOF indicators, is linked to lower levels of emergency admissions for people with mental health problems. These individuals can be admitted to hospital for treatment for their mental health problems or for physical problems and we will analyse both. Our analysis will also estimate the impact of potential improvements in the QOF on subsequent mental health resource use in secondary care.
Crisis Resolution and Home Treatment (CRHT) teams were introduced in England in 2000/01 to provide intensive home-based care for patients in crisis as an alternative to hospital treatment, allowing for a reduction in inpatient admissions. The policy drive to introduce CRHTs and potentially take away resources from existing Community Mental Health Teams was in part driven by early and geographically limited evidence on the effectiveness of CRHTs in reducing admissions. Contrary to previous results however, and using national data with a more robust difference-in-difference methodology, we find that the CRHT policy has had no significant effect in reducing admissions.
Results show the proportionate difference in admissions for PCTs with CRHTs relative to the rest of England comparator group for two years prior to the introduction of CRHTs and four years after their introduction. Zero represents the comparator group and if confidence intervals overlap zero, the proportionate change in admissions is not significant relative to the comparator group. These show lower admissions for the CRHT group across all years, however these differences are insignificant. In addition, the confidence intervals for each year are aligned (they overlap from one year to the next) suggesting that the differences over time are also not significant. Thus the policy intervention of introducing CRHT teams in 2000/01 was not responsible for a change in PCT behaviour with regard to reducing admissions; these were already lower for PCTs with CRHT teams, although not significantly. There has been no significant difference between admissions for PCTs with and without CRHT teams, either before or after the policy introduction. If anything the difference in difference has been diminishing over time.
The figure shows the proportionate difference in admissions between PCTs with and without crisis resolution and home treatment (CRHT) teams and the rest of England comparator.