Thursday, 27 September 2012

Clustering and Payment by Results: The End of Service User Centred Mental Health Care?

Most mental health service users will be completely unaware that when they are assessed by Community Mental Health Teams or in hospital their mental health problems and symptoms are now subjected to an arcane system known as Clustering.

The Department of Health issued guidelines in October 2011 (a link is here) which proudly announced:

“2012-13 is the introductory year for what is a major change in the way that mental health care is currently funded, a shift from block grants to PbR currencies which are associated with individual service users and their interactions with mental health services.”

(PbR, by the way, stands for Payment by Results. Payment by Results is the new way in which local NHS Trusts will be funded by the GP consortia that are due to replace PCTs in 2013.)

It is the preliminary stage in “introducing the mental health care clusters as the contract currency for 2012-13 with local prices. This means that prices will be agreed between commissioners and providers, and are not set at a national level.”

Mental Health Professionals working within the NHS are now expected to assign everyone they assess to a specific “cluster”, using the Mental Health Clustering Tool. This tool has 18 scales. Examples include “Non-accidental self injury”, “Problems associated with hallucinations and delusions”, and “Depressed mood and ideation”. The assessor has to assign a score between 0 (no problem) and 4 (severe to very severe problem). Depending on these scores, the assessor can then assign each service user to a cluster.

A cluster is not a diagnosis but rather a description of an individual’s mental health problems and its impact on their ability to manage daily living. Someone presenting with moderate depression, for example, might be assigned to Cluster 3, which is defined as “Non Psychotic (Moderate Severity)”. Someone with chronic schizophrenia might be assigned to Cluster 7, “Enduring Non-psychotic Disorders (High Disability)”. Someone with a borderline or emotionally unstable personality disorder might be assigned to Cluster 8: “Non-Psychotic Chaotic and Challenging Behaviours”. 

I wrote about Clustering in the Guardian back in January of this year (link here). At the time of writing that article I was still quite new to clustering. Now, I have over a year’s experience of clustering service users in Charwood Community Mental Health Team where I am based. I have also been on further training.

So far, it has become clear that it is very difficult to use this assessment tool in any sort of meaningful way. The point of clustering is apparently to assign service users to the care or treatment package that best meets their identified needs. However, unless these care packages are known, it is almost impossible to know which cluster to assign to a specific individual. And these care packages themselves have not yet been defined, which the training course admitted.

It’s a bit like being on one of those TV cookery competitions, and being given a pile of ingredients but without being told what dish you’re supposed to be preparing.

I apologise if this post has appeared a little dry and boring so far. Imagine what it’s like for mental health professionals trying to apply clustering to their assessments. Unfortunately, even though inserting sharp objects into one’s own rectum might appear a preferable pastime to using the Mental Health Clustering Tool, it is now not only a compulsory requirement, but it will also have a profound effect on the funding of mental health trusts.

And this, of course, is what clustering is really about. It actually has little to do with actually trying to identify the needs of service users, and then providing care and treatment according to those needs. That is the old, unfashionable, “needs led” approach.

Over 20 years ago, when Charwood CMHT was first created, the team spent a considerable time trying to identify what a CMHT was for. It was, of course, to try to meet the needs of people with severe and enduring mental health problems, as well as those in acute distress where there was a severe risk to that person or their ability to function. Our services were therefore developed to try to meet the needs of those individual service users.

One example of this was the identification that many people presenting to the CMHT with depression, self harming and suicidal behaviours had significant histories of childhood abuse. If all we did was give them some antidepressants and some supportive contact until the crisis was over and then discharge them, we realised that these people would keep coming back. So we started to develop specialist counselling within the team that was designed to address their underlying problems. If the reasons for a person’s low mood or urges to self harm were dealt with and resolved, then not only would they feel much better, but they would also be less likely to relapse.

Over the intervening years, there have been many changes to the shape and organisation of community mental health care. 20 years ago, the CMHT was part of Charwood District Health Authority. Then it became Charwood Health Partnerships Trust. Then it became a Mental Health Foundation Trust.

Other teams were created: the Early Intervention in Psychosis Team, the Assertive Outreach Team, the Crisis Resolution and Home Treatment Team. Some of those changes made our job a little easier; some made it more difficult. But despite those difficulties, we always tried to keep the needs of the service user at the centre of what we did. We didn’t always succeed in this, but we always tried.

Clustering and Payment by Results, while giving lip service to the concept of service user led service provision, in fact does nothing of the sort. The “customer” is not the service user. Under this new model, the service user, or rather their cluster, explicitly becomes a unit of currency. So mental health services become a market place in which this currency can be spent.

The real “customers” in all this are the new GP consortia. With their cluster currency, they can shop around, looking for the best deals. The potential implications of all this are that interested businesses can cherry pick certain treatment packages.

Many Tesco stores have pharmacies and even dentists. What’s to stop them offering cut price treatment packages for Cluster 3 (Non-Psychotic, Moderate Severity) or even Cluster 11 (Ongoing Recurrent Psychosis, Low Symptoms)?

CMHT’s could simply become places where people are assessed and sorted, a bit like an egg grading production line, before being farmed off to any of a range of private or voluntary organisations offering the cheapest prices.

But how many of these organisations would see the commercial potential in Cluster 14 (Psychotic Crisis)? And what about Cluster 8, Non-Psychotic Chaotic and Challenging Disorders – after all, people with personality disorders aren’t very rewarding to work with are they? They’re difficult and challenging, take a long time to treat, and above all can be very expensive in terms of services. They’ll probably be left for what’s left of NHS mental health services to pick up.

Is this really what the changes in the NHS are all about: a means of privatising the NHS by stealth, using the GP’s as unwitting stooges, and at the same time cutting back on funds? Ultimately, these “currencies” are nothing more than Monopoly money; the Government can and will control their actual value.

And despite the Government maintaining that NHS spending is increasing, in spite of the evidence of cutbacks that people working in the NHS are faced with every day, the actual evidence is that, certainly in mental health, funding has decreased. The Observer on Sunday 27.09.12. stated: “After inflation, expenditure fell by 1% in 2011-12, dropping by £65m to £6.63bn, according to reports published by the department of health. Older people's mental health was hit hardest, seeing a real-terms spending decrease of 3.1% to £2.83bn in 2011-12.”

Phew! Perhaps a bit radical for the Masked AMHP! The trouble is, I’ve endured and survived so many changes to service provision over the 35+ years I’ve worked in social care. I fear that this is one change too many.

Friday, 21 September 2012

Origins 5: Death in Charwood

Part 5 of an occasional series about my early years as a social worker in the 1970’s.

Within a few months of starting as an unqualified social worker in Charwood Area Social Services Department it was decided that I could take part in the Area on call rota.

Charwood provided a local out of hours emergency service. Every social worker in the team had to be on the rota. This meant that about once a fortnight I was on call during a week night. About every three months I had to cover a whole weekend, from the end of the day on Friday until the following Monday morning. Being the late 1970’s, there was no such thing as a mobile phone or even a pager, so your home number was placed on the office answer phone and you could not leave home as long as you were on duty – unless, of course, you had to respond to an emergency.

I was on call one cold February Saturday when Robina phoned.

Robina was an elderly woman who was well known to Charwood Social Services Dept. When her husband died, she fell to pieces and her behaviour became disinhibited and erratic. She developed a somewhat cavalier attitude to continence, and was frequently incontinent of urine and faeces. I had on one occasion had to visit her at home, and discovered that, if she was taken short while in bed, she would simply scoop up the excrement and place it on the windowsill. The windowsill consequently contained a neat line of turds in varying stages of decomposition.

Robina lived in a village a few miles out of Charwood, and liked to go to Charwood market on a Saturday. However, she was banned from using the local bus because of her incontinence. Her solution to this was to hitchhike into Charwood. She had a unique method of doing this, which consisted of lying in the middle of the road with her voluminous dress over her head. When a concerned driver stopped to investigate, she would leap up and ask for a lift into town.

When I look back at what I have just written, it seems apparent to me that if a social services department was confronted with this situation in the present day, Robina would probably end up either being detained under the Mental Health Act, or being placed in residential care using the Mental Capacity Act.

However, back then, it seemed quite natural to tolerate this sort of behaviour, and although Charwood SSD was involved with her, intervention was focused on keeping her in the cottage in which she had lived for the previous 50 years, and she had a home help who would keep an eye on her and ensure that she had regular meals.

Charwood SSD had a number of clients, especially in the outlying villages, who could probably best be described as eccentric, but who were generally tolerated within their community. The main object of intervention was to preserve them in their own homes for as long as was feasible.

“Hello, it’s Robina here. I’ve just been to see Cyril. He’s awful ill. I don’t know what to do.” Robina went on to tell me that Cyril lived in Charwood. He was an elderly man who lived alone. I decided that I would have to go out and investigate. Robina couldn’t be left to handle this on her own.

I found Cyril’s address. It was at the end of a terrace of ancient cottages in the older part of Charwood. The door wasn’t locked so I went straight in. It was like walking into a Dickens novel. The cottage was quite literally a “2 up, 2 down”. The front door opened directly into what might have been a living room, except that it had no furniture. The only things in the room was a wooden stump with an axe, and a pile of split logs. A rickety staircase led up from the corner of the room.

I went through into the next room, which was a kitchen/parlour. This contained a stone sink with a cold tap above it. Beside it was the back door into the small garden. There was an ancient Victorian kitchen range which appeared to provide the only source of heating and cooking for the cottage. It had gone out, and the room was bitterly cold. In a corner was a small table with a wooden chair on which Robina was sitting.

It was very dim in the room, but when I looked around for a light switch, I realised that Cyril had no electricity in the house, and never had had. I could not even find a candle or an oil lamp.

The only other furniture in the room was a battered armchair in which Cyril was slumped. He was only partially clothed. It was apparent to me from a single glance that he was in a bad way. He appeared to be conscious, with his eyes staring, and was breathing shallowly. However, he was quite unable to respond to any questions.

I looked around for something to cover him up with. There was nothing in the kitchen, so I went upstairs. There was no furniture at all in the landing bedroom. In what must be Cyril’s bedroom there was only an old brass bedstead with a bare mattress, which was piled high with old coats. I took one of the coats and attempted to cover him up with it.

“Is he all right?” Robina asked me.

“No, he isn’t, Robina. I’ll call the doctor and get him to have a look at him. You wait here while I go to a phone box.”

I went down to the nearest phone box and rang the on call doctor, who was one of the surgery’s GP’s. This was back in the days when GP practices covered their own patients with a rota of GP’s attached to the practice. He said he’d come right out.

I returned to Cyril’s house and told Robina what I had done. Then I waited for the GP, confident that he would examine him and then probably arrange for an ambulance to admit him to hospital.

The doctor arrived, looking rather grumpy. He gave Cyril a very cursory examination, which did not even appear to include checking his pulse, heart or temperature.

Then he stood up and said to me, “There’s nothing much wrong with this chap. He just needs feeding up in the local old people’s home.”

I was aghast. Cyril was clearly immobile, and to my eyes appeared to have had a stroke or some similar serious health crisis. No care home would have him in this condition. I told the GP this.

“That’s not my problem,” the GP replied when I pointed this out. “There are no hospital beds, and he can’t stay here, can he? With that, he left.

“What’s going to happen now?” Robina asked me.

“I don’t know, Robina. I don’t know. I’m going to have to leave now and try and sort something out. Can you keep an eye on him?”

This was way out of my experience zone. I went to the local authority old people’s home in Charwood and spoke to the manager. She confirmed that Cyril was in no condition to be admitted to them. I used their phone to ring my own manager. She did her best to reassure me, and said she make a few calls and get it sorted.

I waited at the home for half an hour or so until my manager rang me back.

“I’ve spoken to a doctor on the geriatric ward at Charwood Hospital and he’s happy to admit him. I’ve called an ambulance and they’ll be there any minute.”

Much relieved, I returned to Cyril’s house.

Robina was still sitting beside Cyril with his hand in hers.

“Hello, Robina, it’s all sorted out. Cyril’s going to hospital. The ambulance will be here any minute. How is he?”

She looked up at me.

“I think he’s dead,” she said.

I had a close look at Cyril. His eyes were staring sightlessly. He was not breathing. She was right.

The ambulance arrived.

The crew took one look at Cyril.

“He’s dead,” one of them said.

“I know that,” I replied.

“He’s not one for us,” he said. “I’ll call the police and let them know.” They left.

Everyone was leaving.

I went back to the phone box and called the GP again.

“Oh, it’s you again, is it?” he said. “What is it now?”

“You know that old man who you said just needed feeding up in an old people’s home?”

“Yes, what about him?”

“Well, he’s dead.”

There was a brief silence. Then: “Oh shit,” the doctor said. “I’ll come straight out.”

 When I got back to Cyril’s house, the police and a police hearse had arrived. The GP came soon after and formally certified Cyril as dead. He studiously avoided eye contact with me and left rather quickly.

As the hearse crew zipped Cyril into a body bag and carried him out to the hearse, I comforted Robina, who was crying.

“He was a good friend, Cyril was,” she said. Then she looked around the room, Spying a box of eggs on the table, she took a few out of the box and put them into her shopping bag.

“Cyril won’t miss these, will he?” she asked me.

“No, he won’t, Robina. You may as well have them.”

She saw a pile of split logs ready to go on the fire, and slipped a few of them into her shopping bag too, with predictable results.

“Let me take you home,” I said.

“A lift, oh good, with such a nice young man,” Robina replied, and smiled at me.