Electronic Letters to:
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eLetters: Electronic letters published:
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Payment by Result
- Norbert Andersch (27 October 2008)
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The potential fragmentation of services as a result of PBR
- Sanjay Khurmi, Dr Bal Powar (3 December 2008)
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Norbert Andersch, Consultant Psychiatrist South London & Maudsley
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norbert.andersch{at}slam.nhs.uk Norbert Andersch
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Subject: correspondence: payment by result and mental health services / psych bulletin oct 08 p.361-63 Dear Colleagues, 'Payment by results' has been on the agenda in the US and various European Countries since the early 1980s. The article by John Jacques bluntly ignores comprehensive research efforts & distinctive results from those countries; thus only reflecting a more general approach in the recent English debate on this specific problem in psychiatry. Even on the internet there is quite a lot of research and memoranda about diagnosis related pay in psychiatry in the US from the mid 80's to the early 90's.The DRG (Diagnoses Related Group) system has clearly failed in US-psychiatry & was subsequently stopped - even more as European researchers & trials came to the same (negative) results. It has now more or less vanished from the professional discourse in Germany/Swiss/France&Scandinavian countries. A slightly different model from Hungary which reimbursed DRGs for the acute phase of treatment suggesting a day related cost rewards for subsequent rehab periods was also discontinued. The general outcome is that there are no directly patient-related criteria (diagnostic or otherwise selected attributes) collectable which would bring up a predictable validity with regards to the demands in personal (professional) resources, length of stay and final costs. Due to the variability of symptomatic features proper evaluated categories cannot be established. Moreover: DRG's in psychiatry have led to system-related inconsistencies in the programmed treatments and might have resulted in disadvantages for patients, actually undermining the overall task to reestablish patients' mental health. There is at present a lively discussion in Germany whether 'standardized treatment pathways' might lead to different results. There are trials running in LKB Hamburg on a 'Standardized Treatment-Plan: Schizophrenia', but contesting questions remain who to include into these treatment periods. In Germany a pragmatic "solution" has been agreed on since 1991: while in all other medical specialties payment has been linked to DRG-like criteria, psychiatric departments are reimbursed via the 'Pflegesatzverordnung'. This scheme describes groups of patients - and this goes well across different diagnoses - who require a similar length of stay and are in need of comparable numbers of professional staff - thus ending up spending comparable amounts of money for inpatient treatment. This regulation also applies to patients on psychosomatic and psychotherapeutic wards. No one is really happy with this compromise and most hospitals feel disadvantaged and pressured by the approach but all recent local and regional research efforts looking at other cost-related factors could not come up with a better solution, and: trials continue...... Reading again through US & European experiences between 1980 and 2005 Colleagues in the NHS would be well advised to do the same and to join a 'debate in progress' instead of trying to reinvent the wheel. Norbert Andersch Consultant Psychiatrist, SLaM 27/29 Camberwell Rd London SE5 0EZ norbert.andersch@slam.nhs.uk |
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Sanjay Khurmi, Psychiatrist Birmingham and solihull mental health trust, Dr Bal Powar
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skhurmi{at}hotmail.com Sanjay Khurmi, et al.
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After reading John Jaques article (Psychiatric bulletin 2008) on Payment By Results we wished to expand on another potential drawback. The tariff will lead to certain services and treatments becoming more profitable than others, due to greater profit margins. For example outpatient treatment of a patient with anxiety could generate potentially more money than outpatient treatment of a patient with anorexia. As Foundation Trusts are now working in a competitive open market, the primary aim for a Foundation Trust (FT) must be to “keep its head above water”. Tariffs will further encourage managers and chief executives to focus on financial viability. There have already been concerns that FT are promoting profit making services at the expense of others (Health Service Journal 2006). Whilst this is an obvious consequence of a free market, the NHS aims to provide a good local level of service for all patients (NSF 1999). Without clear and strong commissioning guidelines, there could be an increase in fragmentation of provision and quality of local psychiatric services. This could have negative consequences for both our patients’ and their families. Department of Health 1999 National service framework for mental health: modern standards and service models standard 5 Health Service Journal 6th of April 2006 J. Jaques (2008) Psychiatric bulletin. Payment by results and mental health services. 32, 361-363 |
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