The big national health “system” story of the past week has been the surprise announcement of a voluntary tariff. This is one part of a solution put forward by NHS England and Monitor to resolve the current impasse, which arose from an objection mechanism to the proposals being triggered by those it affects—providers of NHS care.
As we all know, the annual setting of the tariff, and the process of balancing what can be afforded with what providers of NHS care need to be paid to stay afloat, is always a big deal. But this year it has been bigger than ever. Although this detail in the NHS’s arcane internal processes will pass most patients by, the quality and availability of their care could be profoundly affected by it.
In the discussion of this issue our focus is nearly always on providers of acute care: hospitals large and small, urban and rural. They are the ones who are paid directly through the tariff. But, and it’s a big but, the efficiency requirements and other incentives and penalties included in the package impact on all providers, including mental health trusts.
As a mental health trust chief executive or chair, you could be forgiven for thinking that achieving parity of esteem between mental and physical health hasn’t really been factored into the recent tariff announcements. Nor has the tariff really been triangulated with other developments or behaviours, such as NHS England’s guidance to local commissioners to implement the new mental health access targets and clinical commissioning groups’ own approach to allocating their budgets for the coming year.
Before the tariff announcement there was disquiet about how these two latter issues would play out. The guidance published by NHS England on implementing the new access standards is hugely important. It’s a tangible sign that the “if it’s measured, it matters” mantra is being followed through, with firm indications of how commissioners should ensure that early intervention in psychosis, liaison psychiatry, and access to talking therapies can be delivered to quality and accessed within a reasonable timescale.
These parity standards are a delivery challenge that needs to be tackled speedily, effectively, and with adequate investment. Yet much of the activity to be contracted is subject to local pricing—a process of local negotiation between commissioners and providers. This relies on a full understanding of the nature of the service to be delivered, and an understanding that this spending needs to be prioritised.
We are hearing very mixed reports about how CCGs are responding. It is worrying that a number of trusts are telling us that their CCGs aren’t prepared to make an allocation for mental health services until they know what their acute spend is likely to be: the access targets stand on their own and what they cost to deliver must be decided—irrespective of spending in other areas. There is not and should not be a dependency between the two. And it is clear that many trusts are not being offered the additional mental health investment, which was a clearly worded element of the December 2014 planning guidance “Forward View into Action.” Worryingly for patients, this could see very different services being available not just in different parts of the country, but between adjacent neighbourhoods.
Then we get the updated tariff proposals or, as the advert says, “now for the science bit.” A mental health provider is impacted by the tariff efficiency factor in terms of the price paid for its services, but as it operates on a mainly block contract basis it is not in a position to protect itself in any way against fluctuating—and mainly increasing—demand.
Monitor and NHS England have put two offers on the table. Either the enhanced tariff option (the voluntary tariff), which lowers the efficiency factor from 3.8% to 3.5%, offers commissioning for quality and innovation (CQUIN ) payments, and commits to a 0.35% tariff adjustment to the good to deliver the early intervention in psychosis access target. For acute providers there are a number of other offers, including changes to the marginal rates being applied to both emergency and specialised services. Or there is a rollover tariff, which means that for mental health trusts choosing this option, the 14/15 payment rules should remain in place until formally superseded by a new tariff; there will be no CQUIN payments; and no tariff adjustment for the mental health access targets.
On the face of it, it seems that the enhanced offer should be the route to take. However the devil, as always, is in the process as well as the detail. Calculation of many of the payments is dependent on commissioners and providers having agreed a baseline cost, which if not already set, is now vulnerable to negative adjustments in light of the impact of the voluntary tariff.
For mental health providers much of the detail isn’t yet known, not only about the impact of the proposals, but also how wider commitments will be fulfilled: How will mental health trusts access their share of the money for new talking therapy targets, which is to be held and distributed nationally’? How will the additional funding for liaison psychiatry be distributed? And how will the early intervention on psychosis tariff adjustment really work, and will it apply to the whole contract or just parts of it?
Fundamentally, there is a point of principle and practice here: the tariff proposals are made on the basis that CCGs are passing on to mental health providers the enhanced investment they have received after the autumn statement to deliver on the commitment to parity of esteem, as outlined in the guidance. We haven’t seen that yet.
If time was on everyone’s side, these questions would be food for thought—for working through, modelling, and consultation. But providers need to make their decisions by 4 March.
Saffron Cordery is director of policy and strategy at NHS Providers.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.