Provocation for innovation 1: Payment by Results – outcome measures – getting data – arranging payment

On 14th of April 2016, Mark Brown (@markoneinfour) ran a mental health minihack at Marmalade, the fringe of the Skoll World Forum in Oxford.  In preparation he prepared three provocations to put to attendees for areas where it would be possible to innovate in mental health as actors coming from outside of the established publically funded system of mental health treatment and support.

Attendees were told to apply their knowledge and experience to addressing these presenting issues.

Below is the first of these provocations. (The second  ’In mental health communication is flakey’ can be found here, and the third ‘ Provocation for innovation 3: Frugal innovation – making good stuff happen with eff-all cash’ can be found here)

Provocation 1: Payment by Results – outcome measures – getting data – arranging payment

Roughly speaking, the three areas where it is possible to help people with mental health difficulties to live lives where they can do what they want and need to do centre on

  • Treatment

  • Care

  • Enablement (either augmentation of the individual or alteration to the conditions of their life, surroundings or the workings of the society in which they live)

Helping and supporting people with mental health difficulty is an area where it can sometimes be difficult to assess impact.  Unlike other areas of health, it can be more difficult to see the relationship between activity and outcome.  In surgery it is possible to look at operations carried out versus recovery rates.  In mental health ‘recovery’ is a more challenging idea and one that is more difficult to measure.

The effectiveness of interventions or services in mental health is often judged either by a proxy measure, which are often imperfect, or by self submitted information about the effect the intervention has had.

What people such as charitable funders, governments and investors are prepared to pay for is what it is possible to measure.  To measure things that happen inside people’s heads and in their lives is often considered to be difficult.

Public services, including the provision of mental health support or treatment, are increasingly moving toward a Payment by Results model.  This has led to concerns both from professionals and from people with mental health difficulties who may or may not use services.

The concerns include:

  • Collection of data is difficult, time consuming or challenging for providers

  • Collection of data involves prying further into the personal lives of people using a service than those people are comfortable

  • Data is not robust and does not really reflect results

  • Data does not give a clear enough picture of what is happening to make changes in the way that a service is delivered or in the way in which it is paid for

There are also concerns that any process of measuring impact will transform the service into something that measures its clients progress against the required or intended impacts rather than measuring the ability of the organisation to deliver the results intended.  In mental health, tools such as the Recovery Star have shifted from measuring activity to being an activity in themselves where the measurement tool becomes a goal setting tool instead.  The tools intended to measure impact of services are often used to measure the progress of individuals.

Mental health is also struggling to work out methods of paying for individual activities or services.  Personalised services, while in theory possible, are often tied up mires about contracting, managing and payment.  Personal health budgets or personal care budgets are intended to make it possible for eligible people to commission or contract support or care that they choose but currently have a high level of bureaucracy involved.  There is, at present, no strong methods of managing the contracting, payment and funding of small blocks of personalised care and support.

At present the NHS takes the majority of all government spending on mental health.  Charitable funding is not to the level of other areas of health, despite mental health difficulty being a significant area of expenditure.  At present investors find it difficult to know what they would be investing in were they to invest in mental health .

Presenting problems

How might impact be measured in mental health in a way that will drive both delivery and efficiency?

How might a payment by results model be developed that actually fits mental health?

How might mechanisms be developed to enable more efficient use of personal budgets?

How might investors structure investment in mental health in a way that does not short change people with mental health difficulties and how might investees evidence impact of that investment?

Mark Brown is development director of Social Spider CIC.  He is @markoneinfour on twitter.

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