The evidence is compelling that advanced analytics leads to improved care for people experiencing mental ill health. Working together, CF and the Wider Devon STP used our unique analytical toolkit to analyse how resource is currently consumed, expose variation in effectiveness and efficiency, leading to a more joined up approach to providing care.
- Analyses population needs, outcomes and complexity in-depth
- STPs encompass different geographies and environments, where demographic characteristics and hence health needs differ. One size does not fit all. The analysis defines localities according to similar characteristics. In Devon, six localities were identified
- An outcomes index capturing long term wellbeing and recovery for people experiencing mental ill health
- A complexity index tailored to Devon’s specific characteristics. The index adds further understanding of what drives mental health needs / resource consumption, and how to best organise care
Triangulating complexity, spend and outcomes enables identification of difference in practice and value for money (slides 6 and 7). In Devon, for example, this highlighted where areas of similar levels of complexity had markedly different outcomes, and hence where models of care could be improved through drawing on existing local successful models.
- Breaks down core CCG mental health spend on different services; and goes into more detail for the largest consumers of resource, the average spend for each type of patient and the impact of co-morbidity on commissioner spend. Devon used this to focus on high spend areas where the potential for improvement was greatest:
- Patients were broken out by supercluster and severity, to reveal relative resource consumption. In Devon, it revealed that 1% of patients accounted for 30% of occupied bed days
- The costs of care for each group were estimated, based on the calculation of an average spend per type of patient e.g. a patient with severe mental illness and detained under the mental health act costs ~£27,000/ year
- Exposure of how co-morbidity between physical and mental health correlates with spend
- Assessment of the quality of services, using a bespoke clinical standards survey co-designed with local clinicians. This highlighted key areas where services were not meeting current standards and guidelines.
Taken together, Devon could now identify opportunities to improve outcomes while increasing the effectiveness of their mental health spend.
The business case
We at CF are passionate about using analytics to help the NHS identify, plan and then implement the solutions that transform care. We sought a partner from the NHS who shared the belief that analytics could initiate this change, and so we joined forces with the Devon STP. Together we invested time to create the tools to unlock the benefits that we knew were there.
Mental health, an area that has lagged in applying robust analytics to spearhead transformational change, is a priority for both of us. Developing an objective picture of current spend and provision is complex, as the many different mental health conditions require different types of care and treatment, and so the tool has had to be sufficiently sophisticated to reflect that complexity. Our targeted analysis provides that clarity, identifies where improvements can be made, draws on a broad evidence base of best practice models of care to quantify potential opportunities, and provides the foundations for deploying resource and budget differently to improve health and wellbeing.
By bringing together the data on mental health in a structured fashion, we tested whether mental health was underfunded, shifting the focus to improving care. By comparing to peer CCGs with similar levels of complexity, Devon CCGs agreed to protect the growth in allocation earmarked for mental health.
The analysis identified the steps that are now being taken to reduce variability, increase reliability and thereby improve the efficacy of spend by £6.4m-8.4m, equivalent to 4-5% of mental health spend, over and above 2% provider efficiency. It also identified £18m of potential cost benefits that could accrue to the wider health system in Devon by investing in mental health. Supporting slide 11 is an example – the saving in acute settings identified for dementia patients through reducing spend per head to the median is equivalent to 28% of the incremental acute spend for someone with dementia (over and above the acute spend for a patient in good mental health).
The analysis of spend by service user can also be used to quantify the funding streams necessary to support accountable care.
Supporting the NHS
Improving the health and wellbeing of people with mental health problems is both a national and local priority for the NHS. It is one of the nine ‘must do’s’ in the 2017-19 Operational Planning and Contracting Guidance. The Five Year Forward View commits to an equal response to mental health and physical health, including achieving parity of esteem by 2020. Implementing the Five Year Forward View for Mental Health requires a movement to accountable payment approaches in mental health, linking payment to quality and outcomes.
Locally, Devon believes that mental health should have equal priority with physical health and that everyone who needs mental health care should get the right support, at the right time.
Our product supports delivery against all of these priorities, by quantifying:
- The level of funding necessary to achieve parity of esteem
- The level of resource needed to treat a locally defined population, which in turn supports the development of capitated budgets for accountable care
- Investment required to deliver the Five Year Forward View for Mental Health
- The cost of physical and mental health co-morbidities in the current system, and opportunities to reduce these while improving outcomes.
Devon CCGs are now commissioning new ways of funding mental health, moving away from poorly defined historic block contracts towards a funding model based on the needs of the population. The analysis informs better planning, advances a local accountable care system, including potentially establishing an accountable care organisation for mental health.
Value for money
CF and Devon developed a set of replicable analytical tools that will help other systems unlock benefits. The work helped make the Devon system more economic, efficient and effective by:
- Demonstrating how improving health and wellbeing increases the effectiveness of spend, by investing in accommodation and employment;
- Evidencing how more proactive care can reduce exacerbations and costs, by, for example, intervening early with patients experiencing psychosis, leading to c.£4,000 in reduced costs per patient;
- Highlighting resource currently spent on Out of Area placements and inpatient admissions under the Mental Health Act. Devon is now exploring a community based model of care to reduce costs and preserve people’s links to their support networks and local community; and
- Demonstrating the system-wide benefits that can be released through appropriate treatment of physical and mental health co-morbidities e.g. for dementia patients, targeted intervention can reduce length of stay in acute hospitals and reduce the primary care cost associated with medically unexplained symptoms.
Quantifying the opportunities above, the work identified savings of up to:
- £2m from improving health and wellbeing;
- £4.4m from treating dementia more proactively;
- £3.1m from treatment depression and anxiety more proactively;
- £5.4m from community care rather using the MHA to admit; and
- £2.2m from standardising the secure care pathway.
The product demonstrates value for money by providing a robust platform for an invest to save model at scale in mental health. Replicated across the NHS, this could release up to £822m net savings.
Devon STP leaders had long believed that improving mental health services would save money across the system, but had been unable to demonstrate this robustly. The concept – understanding the actual needs of local populations, and identifying good practice to meet these – was shared and we agreed to work collaboratively to invest in an analytical approach that would be transformational for Devon, and with the potential for roll-out across the wider NHS.
SRO was Melanie Walker, chief executive of Devon Partnership Trust. A steering group, comprising local commissioners, providers, third sector and, most importantly, people with lived experience, oversaw the work, supported by finance and clinical groups. Each convened local stakeholders, ensuring appropriate leadership, input, and ownership.
- Mental health clinical leads and public health representatives co-designed the tool that assessed clinical standards;
- Survey responses from 230 people with lived experience and two 50 stakeholder strong workshops informed the six major opportunities identified;
- The voluntary sector emphasised the role of employment and housing, which became the health and wellbeing opportunity;
- Input from NHS commissioners, providers and local authorities led to Plymouth and Torbay becoming distinct localities.
Local NHS leaders picked up and executed the final conclusions, in particular how investing in mental health services will improve the health of the population and benefit the wider health and care system. In parallel, Devon Partnership Trust now has a road map for developing accountable care, building on their experience as lead provider for forensic services in the South West.