Mental health funding FOI responses update

I asked Treasury:

Blame for insufficient mental healthcare funding has been passed around between Department of Health, NHS England, and individual Clinical Commissioning Groups (CCGs), however, the source of funding is the Treasury. Although CCGs and other mediating organisations make decisions about how much funding mental health receives, this is as a proportion of budgets decided at Treasury level. Any budgetary planning at Treasury level must therefore take mental health into consideration, alongside other areas of healthcare.

I am writing to request:

(i) names of individuals at Treasury and above, including advisors by official name or function, who are responsible for decisions made in relation to mental health care budgets;

(ii) documentation on budgetary decisions made, including evidence of how, in calculating the total health budget, mental health needs have been taken into consideration.

To (i) they said they don’t hold the information. To (ii) they said they do, but wouldn’t share it, citing Section 35 of the FOI act.

(Full response here.)

I asked the Department of Health:

CCGs and other mediating organisations make decisions about how much funding mental health receives, but this is as a proportion of budgets decided at Treasury level. Any budgetary planning at Treasury level must therefore take mental health into consideration, alongside other areas of healthcare.

I am writing to inquire about advice provided by Department of Health to Treasury on mental health budgets.

1. Who in DH provides this advice?

2. What advice has been provided to inform the most recent budget allocation for health?

They also confirmed that they held relevant information but refused to share it, citing s35(1)(a).

(Full response here.)

I asked NHS England the same question:

[…] I am writing to inquire about advice provided by NHS England to Treasury on mental health budgets.

1. Who in NHSE provides this advice?

2. What advice has been provided to inform the most recent budget allocation for health?

They provided a response.

1. Who in NHSE provides this advice?

Paul Baumann, Chief Financial Officer for NHS England, has responsibility for the organisation’s budgets including providing advice on these budgets. NHS England is an Arm’s Length Body (ALB) of the Department of Health (DH), much of the advice the Treasury would receive on Mental Health would be coordinated by the Department.

2. What advice has been provided to inform the most recent budget allocation for health?

NHS England’s view of the overall funding requirements of the NHS were set out in financial analysis conducted for the Call to Action (July 2013) [see, especially, the technical annex] and the Five Year Forward View (October 2014), which have been shared with DH and Her Majesty’s Treasury.

This analysis projects “do-nothing” expenditure using assumptions about the three main drivers associated with current health care demand and costs: demographic growth, non-demographic growth (e.g. technological development and medical advances) and health cost inflation. Historic trends for these drivers were reviewed and an estimation of future pressures developed for six service level ‘assumption sets’: Acute, Mental Health, Specialised Services, Primary Care, Prescribing and non-activity based costs. This high level analysis thus includes assumptions related to cost and demand growth for mental health services as part of the overall modelling.

Detailed analysis and costing is completed by NHS England on specific initiatives, the output of these models are used to inform budget announcements and the planning guidance information. These costings are developed by the Medical Directorate and Finance Directorate working together.

(Link to response here.)

An argument against payment-by-outcomes for mental health

I have just seen a report on Payment by Results (PbR) for the adult Improving Access to Psychological Therapies (IAPT) programme and have concerns about the approach. The conclusion of the summary is that “the system appears feasible and the currency appears to be fit for purpose” which seems to suggest that the approach is going ahead.

This IAPT PbR proposal is outcomes based, so that the more improvement shown by service users, as partly determined by patient-reported outcome measures (PROMs), the more money service providers would receive. This is a worry as there is evidence that linking measures to targets has a tendency to cause the measures to stop measuring what it is hoped that they measure. For instance targets on ambulance response times have led to statistically unlikely spikes at exactly the target, suggesting times have been changed [1]. A national phonics screen has a statistically unlikely spike just at the cutoff score, suggesting that teachers have rounded marks up where they fell just below [2]. The effect has been around for such a long time that it has a name, Goodhart’s law: “Any observed statistical regularity will tend to collapse once pressure is placed upon it for control purposes” [3]. Faced with funding cuts, how many NHS managers will be forced to “game” performance-based payment systems to ensure their service survives?

PROMs have been criticised by therapists for leading to an “administratively created reality” [5] and being clinically unhelpful, perhaps even damaging. However, evidence is building that feeding back results from PROMs to clinicians is helpful for improving care [4]. It would be very sad indeed if this useful tool were destroyed by payment systems, just as many mental health practitioners — and more importantly, service users — are seeing the benefits. Linking outcomes algorithmically to finances at all seems to be a bad idea in general — it’s especially bad when PROMs are just beginning to be trusted in routine practice.

References

[1] G. Bevan and C. Hood, “What’s measured is what matters: targets and gaming in the English public health care system,” Public Adm., vol. 84, no. 3, pp. 517–538, 2006.

[2] L. Townley and D. Gotts, “Topic Note: 2012 Phonics Screening Check Research report,” 2013.

[3] C. A. E. Goodhart, “Monetary relationships: A view from Threadneedle Street.” 1975.

[4] C. Knaup, M. Koesters, D. Schoefer, T. Becker, and B. Puschner, “Effect of feedback of treatment outcome in specialist mental healthcare: meta-analysis.,” Br. J. Psychiatry, vol. 195, no. 1, pp. 15–22, Jul. 2009.

[5] J. McLeod, “An administratively created reality: Some problems with the use of self-report questionnaire measures of adjustment in counselling/psychotherapy outcome research,” Couns. Psychother. Res., vol. 1, no. 3, pp. 215–226, Dec. 2001.