The Independent Mental Health Services Alliance (IMHSA) welcomes the extension of the choice framework to mental health services. We are of the view that in order to realise parity of esteem in mental health, patients accessing mental health services must be given the same opportunity to choose their provider as those with physical health needs. However, we are disappointed the interim guidance has not been adapted to incorporate concerns raised by IMHSA in the draft guidance consultation phase. The guidance remains unusable for the majority of independent sector (IS) providers, providing secure inpatient care services, and therefore prohibits patients having a meaningful choice on what care they receive. NHS England must urgently address the use of rolling block contracts and adapt the guidance to account for the governance arrangements of non-NHS providers.   

 

Do the interim guidance and FAQs provide you with the information you need to effectively implement patient choice of provider in mental health? If not, what needs changing or adding?

Rolling block contracts

The use of rolling block contracts prevents implementation of patient choice and a fair playing field for providers.  In circumstances where CCGs commission block contracts from NHS providers, there is no incentive to implement a patient choice agenda and accordingly this limits patients’ choice. As a consequence, IMHSA believes that the end of all block contracts arrangements for mental health services is vital to the choice agenda.

Within its Fair Playing Field Review undertaken in 2012, Monitor highlighted how a diversity of NHS providers would be an important lever for improving patient care and how greater patient choice in health services would benefit patients by driving the provision of better services and benefit the NHS by stimulating greater productivity and efficiency amongst providers in a locality.   These goals were embodied within the National Health Service (Procurement, Patient Choice and Competition) Regulations 2013 (“the Regulations”) which introduced a statutory requirement for commissioners to act in a transparent and proportionate way and to treat providers equally and in a non-discriminatory way including by not treating a provider or type of provider more favourably than any other provider, in particular on the basis of ownership.

In practice, the new statutory requirements are often not being met in respect of the commissioning of mental health services. Despite NHS England’s guidance pointing out that, under legislation, it is not sufficient for a CCG to do nothing more than re-contract with existing qualified providers, there remains a high prevalence of rolling block contracts with incumbent providers of mental health services.  The lack of transparency is compounded whenever a commissioner does not publish the details of the contracts it has awarded in this manner.

IMHSA members consider that these contracts prevent a diversity of provision to facilitate choice for patients. For as long as these contracts remain, service users are not being given the ability to choose from the range of provision that does exist.

Governance arrangements

The interim guidance fails to outline any governance arrangements on how mental health services are commissioned to enable the choice agenda. Despite the 1st April start; there is a lack of infrastructure to govern how the independent sector will be involved. Where independent organisations promote inpatient services, there is a regulatory framework in place to ensure quality and effective clinical practices. Organisations are subject to several strands of regulation and services can be measured as safe and effective. However, a similar regulatory infrastructure does not exist for independent practitioners who operate outpatient services. Therefore, significant consideration needs to be given to ensure that the same robust quality governance is approved to outpatient services.

Conflicts of interest

Our understanding is that in some circumstances there is a form of secondary commissioning within the mental health sector that could lead to conflicts of interest. In order to deliver reasonable patient choice, the new guidance must be clear in reaffirming the Regulations regarding conflicts of interest.  

Complexity

The definition of when Choice is mandated under the current guidance is confusing and needs to be made far clearer for service users and carers. There is complexity in framing what Choice is. For example, a patient’s first interaction is defined differently depending on the situation. It needs to be made clear when Choice is actually appropriate. If the mental health system is unable to define what an appropriate choice is then this agenda will be difficult to deliver.

 

Is the guidance presented in a way useful to quickly finding the information you need? If not, what needs changing?

The work NHS England has proposed to improve the information to help patients choose is a positive step. Service users should have access to a wide variety of key indicators aside from financial measures to inform choice and enable providers to fairly compete.

 

Does the further programme of work outlined here cover all of the right areas for embedding the right to choice in mental health? If not, what needs changing or adding?

Appropriate patients and delivering integrated care

Further definition is required on what constitutes an ‘appropriate patient’ and the extent of the choice offered to deliver integrated care. IMHSA is of the view that many patients with mental health needs would be considered inappropriate as they may need an integrated multi agency approach to meet their needs. This integrated approach may include housing and employment support and social care following an outpatient appointment. As these aspects cannot be delivered through the framework and integrated care is therefore not on offer, patients with mental illness are not able to access the full range of choice given to acute patients. In addition, should a patient require sectioning or have a dual diagnosis, there is no guidance for providers or commissioners on how to embed the choice agenda in placing the patient in an appropriate level of security and care. Clearer guidance on ‘what if?’ is urgently needed before providers can feel confident using this framework.

The continued use of block contracts needs to be address to allow the NHS Mandate commitment to Choice to be introduced in a meaningful way within mental health. The continued use of block contracts in secondary mental health services and established care pathways will mean that the recently published guidance with respect to Choice in mental health is unlikely to make any meaningful or transformational change. These mandate requirements could be introduced very quickly as the contractual and governance processes are already in place within the secure pathway. This is one of the few easily defined Mandate commitments on mental health and could be rolled out widely by end of 2014/early 2015.

Financial risk and a competitive offering

We expect a low volume of patients to be included in this scheme. However, there is also a cost involved with regard to setting up infrastructure to ensure that it is effective. The low volume of patients combined with the set up costs may make the scheme prohibitively high. As a result some providers may be excluded.

Whilst IMHSA wholeheartedly welcomes Choice in mental health the current guidance fails on the Choice agenda and substantial work is required in order for the independent sector to be in a position to participate. It is disappointing that from April 1st, mental health patients will still be unable to choose between the full range of high quality services available to them.

We would welcome the opportunity to support NHS England in developing the choice framework for secure and inpatient care mental health services.