www.england.nhs.uk

• Andy Wright, IAPT Clinical Advisor, Rebecca Campbell, Quality Improvement Manager and Sarah Boul, Quality Improvement Lead

• andywright1@nhs.net, rebecca.campbell6@nhs.net and sarah.boul@nhs.net

• Twitter: @YHSCN_MHDN #yhmentalhealth

• July 2017

Yorkshire and the Humber

Mental Health Network

IAPT PBR Workshop

20 July 2017

www.england.nhs.uk

@YHSCN_MHDN

#yhmentalhealth

Housekeeping:

www.england.nhs.uk

Yorkshire and the Humber

Mental Health Network

Welcome, Introductions and

Aim of the Workshop

Andy Wright, IAPT Advisor,

Yorkshire and the Humber Clinical Networks

www.england.nhs.uk

IAPT Payment Implementing an

outcomes-based payment

approach for IAPT

Sue Nowak | Head of Pricing Development

Pricing Team, Strategic Finance, NHS England

s.nowak@nhs.net | 0113 824 9353

Robert Melnitschuk | Pricing Development Manager

Pricing Team, Strategic Finance, NHS England

robert.melnitschuk@nhs.net | 07730 37 53 45

20 July 2017

www.england.nhs.uk

Strategic context Five Year Forward View for Mental Health

• Recommended payment system that will increase transparency in the payment system and support improvements by linking payment to quality and outcome measures

Increased transparency

• “…the continued use of unaccountable, ill-defined, block contracts by mental health commissioners is detrimental to patient access to mental health services” IMHSA Policy Paper…”

Move towards commissioning based on quality and patient outcomes rather than historical service provision.

• “…payment mechanisms that enable person-centred approaches to care and parity between physical and mental health. Payment agreements for mental health services are to be transparent, consider the needs of patients and ensure accountability…”

Enhancing quality through allocative efficiency

• Using the payment system to incentivise adoption of practice that promotes sustained recovery, in the most appropriate setting

5

www.england.nhs.uk

2017/19 national tariff and IAPT payment

6

From April 2017 commissioners and providers should be

shadow testing an outcomes-based payment approach

By April 2018 commissioners and providers should have

implemented an outcomes-based payment approach

Local pricing rule 8 requires:

• the adoption an outcomes-based payment approach

• use of the 10 national outcome measures collected in the

IAPT data set

www.england.nhs.uk

• Transparent

• Framework for commissioner-provider discussions

• Support improved quality and outcomes

• For service users, providers and local systems

• Appropriate incentives

• Recognises activity, case-complexity and

outcomes

IAPT payment approach key principles

7

www.england.nhs.uk

• Nature of the payment approach

• Share learning between areas

• Outcome measures information

• Thresholds

• IAPT payment and outcomes tool

• Delivery, testing and expansion

• Non-mandatory prices – useful?

8

Updating the guidance

www.england.nhs.uk

National IAPT payment approach

Aims:

1. To reimburse providers for the costs of providing evidence-based

episodes of treatment

2. To reward providers for performing well against agreed quality and

outcome measures

Total IAPT payment per

episode Assessment

Cluster-based episode of treatment

Basic service price component

Outcomes component

9

www.england.nhs.uk

• Local prices for an assessment and a cluster-based

episode of treatment

Basic service price (activity)

10

www.england.nhs.uk 11

Intensity of treatment by cluster

www.england.nhs.uk 12

Costs by cluster

Cluster weighted average cost £619.94

www.england.nhs.uk

Cluster 1

£x

Cluster 2

£y

Cluster 3

£z

Cluster-based episode of treatment

price

• Commissioners and providers should agree cluster prices to cover the

efficient costs of delivering evidence-based IAPT episodes of treatment

• Price levels can also be adjusted to incentivise activity in relation to

people with a specific complexity of need in response to local priorities.

Cluster 4

£p

www.england.nhs.uk

Performance price (outcomes)

• Locally weighted 10 national quality and outcome

measures linked to payment

14

www.england.nhs.uk

Value of the outcomes component

15

• Our guidance with NHS Improvement recommends the value of the

outcomes component being set at a minimum of 5% of contract value

initially.

Activity component

95%

Outcomes component

5%

www.england.nhs.uk

• Local pricing rule 8 requires the use of the 10 national measures:

1. Waiting times (Access)

2. Black, Asian and minority ethnic (BAME) (Access)

3. Over 65s (Access)

4. Specific anxieties (Access)

5. Self-referral (Access)

6. Clinical outcomes

7. Reduced disability and improved wellbeing

8. Employment outcomes

9. Satisfaction (Patient experience)

10. Choice of therapy (Patient experience).

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10 national quality and outcome

measures

www.england.nhs.uk

Cluster 2

£y

Cluster 3

£z

Quality and outcome weightings

17

• Commissioners and providers should agree quality and outcome

measures weightings in line with local priorities

www.england.nhs.uk

High level operational flowchart

18

Monthly

activity and

outcomes

data

Monthly

submission

to IAPT

minimum

dataset

Monthly

payment

calculation

Quarterly

reconciliation

Business

rules ie risk-

sharing

mechanism

Monthly

payment

Quality and

outcomes

measures

Finance envelope

(monthly plan)

Annual activity

(monthly plan)

Prices and quality

and outcomes

thresholds (set

annually)

Assessment Price

Quality and

outcome

measures

Relative outcome

weightings

Annual activity and

finance plans

Cluster based

episode of

treatment prices

www.england.nhs.uk

• Shadow testing in 2017/18

• Bringing together payment approach and

contracting

• IAPT service model

• Use of care clusters

• Stepped pathway shared between providers

• Data quality

• Price Setting

• Gain/loss share

Implementation considerations

19

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Step 12: Understand the root cause of

any differences.

From the comparison work in Step 11,

ensure that the cause of all differences

are understood. Step 5: Create an output to test!

For testing to begin, there needs to be

something to test! This should be an early

iteration of the new payment model.

1. Planning / Design 2. Simulation 3. Shadow

4. Live

Step 1: Define the aim of the testing

project and the overall scope.

This should be informed by the initial

proposals to form a new care model.

Step 2: Agree on a new payment model.

Given the new care model, identify the

payment approach which will best deliver

the aims. Local payment leads, NHS

England or NHS Improvement can all help

with this decision.

Step 3: Identify the key stakeholders to

be involved and those who will make

decisions based on the model’s

performance during testing.

Who is leading the testing and who is

setting the agenda for it.

Step 4: Agree on the areas to assess.

Be clear on what answers are required

from testing. This will provide steer on

what areas will need to be assessed.

Know what constitutes success and

failure.

Step 6: Process historical data through

the new payment model.

This is a practical step which will start to

confirm or refute some of the

expectations formed during the design of

the new payment model. It won’t wholly

reflect reality, but it will give a good

indication about performance.

Step 7: Will it be physically possible to

implement the new payment model.

Termed ‘Infrastructure Capability’ in the

guidance. This is when testing should be

carried out to gauge whether the

resources and physical infrastructure are

in place to enable the new payment

model to perform.

Step 8: Make further adjustments and

refinements to the new payment model.

Collate the results for Step 6 & 7 and

evaluate them. Do they suggest that any

amendments are needed.

Step 9: Process current, live data

through the new payment model.

The main step. Parallel running of the

current and proposed payment models

- using the same inputs - to better

assess any differences between them.

Step 10: Consider all the potential new

arrangements.

Assume the new payment model is in

use. Discuss what changes there may

be and act out or role-play the

situations which may arise.

Step 11: Make comparisons with the

existing payment model.

Collate all the new information and

compare it to existing processes.

Step 13: Continue to test the new

payment model while it is in use.

This promotes continual testing and the

allowance for further modifications to the

new payment model if required. There

may be initial teething problems which

further testing can help resolve.

Step 14: Refine and begin a ‘version 2’ if

needed.

If Step 13 provides evidence that changes

are required, put in place plans to action

these. Have discussions about next steps

and whether further iterations of the new

payment model may be needed.

Step 15: The old model is retained as

back-up.

It might be prudent to retain the old

model in some form in case it is needed.

Unforeseen circumstances may cause

issues with the new payment model and

the old model can be a useful ‘safety net’.

A general framework for

Shadow Testing

20

www.england.nhs.uk

• Local Implementation via Cloud Architecture –

Microsoft Azure

• Reduced burden of infrastructure for providers

• Dedicated Resource

• Ready Access

• N3 not necessary

Deployment of IAPT Currency Tool –

Interim State

21

www.england.nhs.uk

National implementation via integration with Data Flow

at HSCIC Bureau Services Portal (Exeter)

• Embedded in National Infrastructure

• Allows for pre-deadline testing of provider data

submissions

• N3 connection needed

Deployment of IAPT Currency Tool –

End State

22

www.england.nhs.uk

• 2017/19 national tariff published requires areas to implement an

outcome-based payment approach by April 2018

• Payment approach should use the 10 national outcome and

quality measures, but there may also be metrics which are locally

important

• NHS England and Improvement have published guidance on an

outcomes-based payment approach which has two components:

1. Activity

2. Outcomes

• NHS Digital have been commissioned to provide a tool to support

implementation

• We can provide other resources which will help you to shadow

the impacts of a new payment approach in 2017/18

Summary

23

www.england.nhs.uk

24

Questions?

www.england.nhs.uk

Quick Comfort Break

10 minutes only please!

IAPT Tariff Tool

presented by Kit Hadley-Day

Information Design Consultant

IAPT Tariff Tool

• Who am I?

• What has happened so far?

• The Tool

• The Data

• Implementation

• Getting ready for the tool

• Questions

27

What is the National Casemix Office

• Responsible for creating the Hospital Resource

Groups used for costing and pricing the activities

performed in hospitals

• Produce the freely available grouping software used

throughout the physical acute service

• Provide ‘Patients to Pound notes’ costing and tariff

modelling and analysis

• For more information visit the website

http://content.digital.nhs.uk/casemix

28

Project History

• Tool has been in development for several years

• Issues with funding and developer resource has

caused delays

• Recent collaboration between Birmingham CrossCity

CCG, NHS England and NCO has provided focus and

highlighted required changes to the tool

• These changes have been rapidly developed to make

the tool comply with the published outcomes-based

payment for IAPT services guidance

29

What is the IAPT Tariff Tool

• Developed in collaboration between NHS England

and the National Casemix Office

• It is driven from the current IAPT data set (version 1.5)

• Consistent with guidance on an outcomes-based

payment approach for IAPT services covering:

– Activity component (assessment and episode of treatment)

– Outcomes component (10 national quality and outcomes

measures)

30

Current Data Collection

31

• Eight tables containing

• Appointment data

• Patient data

• Referral data

• Assessment Data

• Treatment Data

• Submitted via the Exeter Portal

Building the Input

• Tool input is a flat file built from the existing 1.5

dataset after it is processed by Exeter

• NCO Input file is currently produced by the NHS

Digital Mental Health Team, as the internal asset

owners

• It is produced to a specification containing business

rules on how source tables should be linked and

resolving any ‘fuzzy’ connections

32

Outputs

• Appointment level output

– This contains all the data that was submitted to the tool along with additional fields, derived by the tool, to help understand how the model has been applied to individual records

• Pathway level output

– This contains the summary information for each completed period of care (pathway)

– Details of the targets for the model, if they have been achieved and the final tariff calculations and outcomes

33

Tool Implementation

• User assurance cloud service, currently in development.

This is a beta service with limited numbers of users to

get feedback on the model and tool functionality

• Full cloud service accessed through the Exeter Portal to

be made available to whole service as soon as

information governance and cyber security testing is

completed

• Integration into the current flow of the IAPT data set,

currently being developed in Exeter

34

Cloud Service

• User data made available after final processing by

Exeter – no need to upload your own data

• Users will have the ability to change any of the tariffs

and targets that drive the model to allow for

meaningful analysis of the impacts of contract

negotiations

• Produces outputs in formats ready to be uploaded into

a database or analysed in Excel

35

Exeter Implementation

• Integrates the tool logic into the current national data

flow

• Will automatically apply the current agreed targets and

tariffs to data as part of final processing

• Outputs will be available via the Exeter Portal besides

the currently created extracts

36

Time Line for delivery

• Test Cloud – This should be available from the beginning of August to

‘Trailblazers’ who have agreed to early access to the tool for evaluation purposes, we expect this to be about fifty users. This will be populated with synthetic data

• Full Cloud Service – This service should be on line and open to the whole service by

the end of the year, all efforts are being made to make this available as soon as possible

• Exeter Integration – This is aimed to be available from the beginning of the next

financial year.

37

Preparing for the Tool

• Data quality is vital to ensure accurate reimbursement

calculations

• The tool requires a fairly large amount of reference

data to accurately define the terms of the model, this

data will need to be collected in advance of the

system go live.

• Become an early adopter, feedback from the service is

vital to improving the tool.

38

Any Questions

?

39

www.england.nhs.uk

Time for some lunch?

Back in 1 hour please!

www.england.nhs.uk

Yorkshire and the Humber

Mental Health Network

Provider Presentation: IAPT as an AQP

Andy Sainty, Service Manager – Humber NHS

Foundation Trust Emotional Wellbeing Services

(IAPT)

IAPT as an AQP

Spoiler ALERT!

Block Contract paid for 12 Therapists (9 wte)

Long Waiting Lists

Unable to fund further staff

Present

IAPT as an AQP

Current State

Moved from Block Contract to AQP Tariff 1st April 2014 (21+ tariff values) Commissioned to provide 7 service lines Population size of just over 333,000* Geographical patch just under 10002 miles - mainly rural Provide to more than 1 CCG under separate contracts* Under AQP we now have over 60 Therapists

Service Lines & Tariffs

Service Delivery • NICE Stepped Care Model - fully compliant with IAPT model • Currently 60/40 split between 3rd Party and Self Referrals but Self Referrals

increasing monthly

• 49 Main venues across East Riding + Group Venues

• Mode of Delivery - Face to Face/Telephone/Online

Cluster 0 - 21

IAPT as an AQP

HOW?

Capacity & Demand Theory

Demand is all the requests and referrals coming in from all sources

Capacity is the resources available to do the work. This includes all

equipment (rooms) and the staff hours available to treat or patients.

Activity is all the work done. It is the actual clinical work carried out by

clinical staff.

Natural variation: Is not within our control but can often be predicted

• Differences in presentation that patients present with • The socio-economic or demographic differences between patients • Seasonal variation • Staff skills

Artificial variation: A large part of artificial variation is within our control

• The way we schedule services • The working hours of staff and how staff leave is planned • The order in which we see and treat patients • How much work we group and deal with in ‘batches’ • How we manage waiting lists

Normal Variation : There are ups and downs in new referrals (demand)

and in our available capacity but in most cases they are predictable.

The model helps you to: • Understand your demand and also the variation in demand • Understand your current service • Understand the core capacity you genuinely have available to see patients and the ad hoc / flexible capacity you rely on to deliver the service The model will provide: • An estimate of the capacity you need to meet your demand • An estimate of the backlog that may need to be cleared to sustainably deliver national and locally agreed waiting times standards

CCG Access Rates*

• Previously commissioned for less than 10% and have worked on increasing this over last two years.

• Currently meeting 15% on regular basis (14 patients short of 15% at last published data from NHS England) and target is 18.6% from 1st April 2017

Referrals (not including Direct Access)

Waiting Times

Outcomes

DNA Average 6.7% for 2015/16

Patient Satisfaction >= 95% and closer to 100% if anomalies* are removed

Waiting Times 6 & 18 Week Standard

• Multiple access points • E-Referral • Telephone • Fax/Letter • Short Text code • Direct access to Groups

• App available via Android/iTunes for patients to enter OM’s – more therapy time • Groups – SC/LAS/LAHA/BA/Worry/Panic/Sleep • Pathways from

• DWP • Dual Diagnosis Services • LTC – bespoke groups for CoPD/Respiratory/Stroke/CVD/Diabetes • Secondary care • Perinatal

• Online appointment booking – coming soon

Basics

Challenges • AQP – no guarantee of income revenue • Capacity/Demand • Choice & venue – costs • Organisational Risk - Waiting Lists if no capacity from other

providers • Training • Diversity • Marketing – bus story • Recruitment – but not retention • Do more for less culture

Research www.iaptprn.com

Involved in various research projects • ETR/LRI • Stress Control • TDS • ReQol • Others applied for but going through ethics

BROKERAGE MODEL?

Future

www.england.nhs.uk

Yorkshire and the Humber

Mental Health Network

Questions and Answers

www.england.nhs.uk

Discussion and Action Planning

1. What are the main challenges for

implementing PBR in IAPT services?

2. What are the key next steps and actions

for you and your organisation?

3. What support do you need to deliver on

your next steps and actions?

www.england.nhs.uk

Yorkshire and the Humber

Mental Health Network

Closing Remarks and Next Steps

Andy Wright, IAPT Advisor,

Yorkshire and the Humber Clinical Networks

www.england.nhs.uk

Yorkshire and the Humber

Mental Health Network

Thank you for Attending!

Please remember to fill out your

evaluation forms!