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.