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.


  1. Great post. I think PbR, clustering and some of the reorganisations which have followed this change pose one of the greatest threats to integrated working.
    After years of extending integrated mental health work, including an increasing number of partnership agreements, more and more local authorities are pulling their staff out of integrated services, returning to separate mental health social work teams in order to deliver the social care agenda.
    I believe the organisational changes which have come with PbR are at least partly responsible for this.
    As mentioned in the post, the focus is on fitting all mental health service users/patients into a relatively small number of groups, or 'clusters' which will inform the money coming into the trust for each patient and identify the sort of services the person will need, based on the cluster.
    Now this seems to me to come into real conflict with the concept of personalisation, where service users are given increased freedom to choose how to spend their budgets, based on their own individual preferences and strengths.
    PbR expectations are also leading to many trusts reorganising their services along 'service lines', with changes from geographically based to functional directorates, creating many new boundaries within a geographical area.
    This is a recipe for internal disputes, confusion and reluctance to take responsibility for patients who are linked to more than one service. When the professionals in the service are struggling to understand how to make it work, what hope for the people who need the help and support?

    1. CMHT's were supposed to provide a seamless integrated multidisciplinary service, which was able to reduce duplication. We're going the other way, which has to be less efficient. Where are the "efficiency savings" therefore supposed to come from?

  2. I'm not advocating "dis-integration", as I think the multi-disciplinary nature of CMHTs (as they were known before service lines) provides an opportunity for all professionals to work closely in partnership with the client/patient.
    But the increasing obsession with NHS performance indicators is coming at the expense of the social care agenda, so much so that a significant number of local authorities have decided that enough is enough, pulling their social workers out of the integrated service.
    I personally think it's a retrograde step, but at the same time have an increasing anxiety about the ability to maintain the social care input in organisations which are becoming more and more focused on NHS imperatives.
    Only this week I have been involved with a referral for a MHA assessment with a person very well known to services, who had experienced a sudden relapse over a few weeks. Not one of the four possible 'service lines' who could have responded, did so, insisting that others were responsible and visiting the person wasn't their pigeon.
    Finished up with a MHA assessment this morning and the person being detained in hospital. No one who knew the person had seen them during the period of their relapse.

  3. I had training two weeks ago with an individual who was closely tied to meetings with PCT Commissioners.
    She told us that in our area, if someone is clustered as 8, then reclustered 8 again on another 2 consecutive times, the PCT would not pay for a 4th time as the CMHT would be seen as having failed the service user because according to the NHS, three years is an adequate time to receive DBT and to recover.
    So that means everyone with Emotionally unstable Personality Disorder will have three years tops under a CMHT.
    We're being told to 'discharge, discharge, discharge' because if the person is reassessed and taken back, the CMHT gets paid everytime the person gets to come back to the CMHT

  4. Please can you tell me is this normal. I became ill over a period of time, then saw a crisis team then got sent for outpatient apointments. I was placed in care cluster 11 (although I did not know this at the time ) and apart from medicine was given no supportive treatment at all. After a couple of outpatient appointments I stopped going to them because I asked for more support ( I did not know what had happened to me) and was completely ignored. I was very depressed during this time and I did not start to feel better till one and half years later. Is care cluster 11 a way to dump people and not support them? Does the NHS receive payment per person for this cluster but then not have to spend it on supporting them? Since I was very depressed I keep thinking if I had been in a different care cluster I would have got some support.

  5. A very interesting and informative article. The only part I struggled with was the derogatory statements towards those living with personality disorders. I felt that though on the whole the article was in support of not categorising and labelling vulnerable people for institutional reasons, this comment showed a lack of depth in recovery focus. People with personality disorders are not a homogeneous group. They can have hope of change, growth and recovery and this "double stigma" can be a hugely limiting factor in this process. For people who have often undergone horrific trauma and victimisation this stigmatisation by mental health professionals, the very people supposed to be helping can be incredibly painful. I know many professionals maintain compassion and humanity and I'm not doubting this is true when working directly with service users, but I feel its also important to be watchful of this when talking with colleagues to create a culture of hope, positivity and transparency.

    1. I have always approached people with personality disorders with the greatest respect, and hoped that was reflected in this post. The "derogatory" comments relating to personality disorder were meant to be ironic, pointing out that if clusters were essentially sold off to the highest bidder for treatment, people with personality disorders might be left with a poorer service, as the reality is that their problems are often difficult to resolve, and need better and specialist approaches and consistent care and treatment, rather than left to the open market.