How clustering is used to decide which mental health staff you see

Mental Healthy investigates how patients are allocated

By Ian Birch

A nationwide programme called “mental health clustering” is being rolled out across NHS mental health trusts to save money as part of government cutbacks.

Psychiatrist with female patientIt’s already been implemented fully in some areas such as my local NHS Trust.   What it means for you me, in practice, is that, for example, I face losing nearly all of my care team by the end of this year as they are forced to downgrade me on a points system, similar to those used by the Department for Work and Pensions for benefits,  and reallocate me to a new team – with the aim to discharge me altogether.  Currently there are four options – red, amber, green and discharge to GP.   Traffic lighting is an initiative of Lancashire Care NHS Foundation Trust, other Trusts may choose to cluster differently. . The “red team” is for the most unwell patients who require possibly regular home treatment or are in hospital.

They have their own consultants and CPNs and care coordinators.  When someone recovers enough to be downgraded to the “amber team”, they lose all of the continuity with their mental health workers and are allocated a new consultant, a new care coordinator, new support workers, new CPNs and so on.  Eventually, patients will be downgraded to the “green team” – no psychiatrist, two CPNs instead of care coordinators, and the only regular contact with services is every two months with a support worker. 

Should patients relapse, the theory is that the NHS Crisis Team or the team themselves will re-grade upwards, and, once again, the patient will lose all contact with his or her current team and be reallocated to previous or new staff.  Eventually, the aim is to discharge patients completely to the care of their GPs: many of whom have highly inadequate mental health training or lack the confidence to deal with mental health problems – despite one third of consultations being about a mental health issue.

Charity Rethink Mental Illness is so concerned about the lack of continuity of care that its Schizophrenia Commission currently includes it in its patient questionnaire.   Other mental health charities also believe that it’s detrimental to patient care and wellbeing.

How is "clustering" defined by the NHS/Dept of Health?

So how does the NHS define “clustering” in mental health?  Let’s look at its official definition:

“The Mental Health Clustering Tool is a dataset of 18 scales captured for each service user receiving mental health services in order to support Payment by Results. 12 of the scales are identical to those recorded in the Health of the Nation Outcome Scales (HoNOS (Working age adults)) assessment. The other six, known as the Summary Assessment of Characteristics (SAC), consider problems from a historical perspective. These will be problems that occur in episodic or unpredictable ways. Whilst they may not have been experienced by the individual during the two weeks prior to the rating date, clinical judgement would suggest that there is still a cause for concern that cannot be disregarded.

“The Mental Health Clustering Tool is used by clinicians to support their decision to allocate a service user to a care cluster. The care clusters are intended to be used as the national currency for Payment by Results (PbR) in mental health. The information standard for Mental Health Care Clusters is defined in ISB 1509/2010.”

Criteria used to decide which teams patients are allocated to

How does this work in practice? Well let’s look at the NHS explanation of how it works first then some examples.   The NHS website says:

Summary of rating information

  • Rate each scale in order from 1 to 16, followed by A to E in part 2.
  • Do not include information rated in an earlier scale except for scale 10 which is an overall rating.
  • Rate the MOST SEVERE problem that occurred
  • All scales follow the format:
  • 0 = no problem
  • 1 = minor problem requiring no action
  • 2 = mild problem but definitely present
  • 3 = moderately severe problem
  • 4 = severe to very severe problem
  • Rate 9 if Not Known but be aware that this is likely to make accurate clustering impractical.

The document addes: “N.B. The first data item (current rating of Overactive, aggressive, disruptive or agitated behaviour) is not used in the clustering process, hence does not appear on the cluster profiles. All other ratings are used.”

So let’s take the example of criteria number 2, because this is a critical indicator of whether someone will receive red/amber care or face discharge to the green “recovery” team.  Clinicians are asked to rate whether, over the past two weeks, and also historically, a patient has any risk of “non-accidental self-injury”.   They are then asked to rate patients on a scale of 1-4 as follows:

  • 0 No problem of this kind during the period rated.
  • 1 Fleeting thoughts about ending it all but little risk during the period rated; no self-harm.
  • 2 Mild risk during the period rated; includes non-hazardous self-harm (eg wrist-scratching).
  • 3 Moderate to serious risk of deliberate self-harm during the period rated; includes preparatory acts (eg collecting tablets).
  • 4 Serious suicidal attempt and/or serious deliberate self-injury during the period rated.
  • Rate 9 if Not Known”

Another highly significant category for many with severe mental illnesses such as schizophrenia and bipolar is that of “problems associated with delusions or hallucinations”.  Again, a score out of four must be allocated, depending on current and historical symptoms:

  • 0 No evidence of hallucinations or delusions during the period rated.
  • 1 Somewhat odd or eccentric beliefs not in keeping with cultural norms.
  • 2 Delusions or hallucinations (eg voices, visions) are present, but there is little distress to patient or manifestation in bizarre behaviour, ie clinically present but mild.
  • 3 Marked preoccupation with delusions or hallucinations, causing much distress and/or manifested in obviously bizarre behaviour, ie
  • moderately severe clinical problem.
  • 4 Mental state and behaviour is seriously and adversely affected by delusions or hallucinations, with severe impact on patient.
  • Rate 9 if Not Known

What does this mean in practice if you’re under services?

Well the first thing to do is not to panic!   Your NHS staff will discuss fully with you any re-grading and implications before making any decision and you should be invited, if on the Care Programme Approach, to review your care plan.  At my local NHS Trust, I have just completed a crisis plan and advance directive to stay on the NHS Crisis Team’s timeline so that when I move into the green “recovery team” and if I am one day discharged to primary care then I will still have all of my wishes and those of my current team available to access and I have been promised that I can still access the NHS Crisis Team helpline out of hours if I need them even if I am discharged to my GP.  Similarly I have been promised that I will be able to call the NHS duty worker even if I am discharged if I need “reassurance” about my mental health or grading upwards again to services.

Not that this does reassure me one bit, you understand.   I have a fantastic care coordinator who is really kind and understanding and treats me as an equal, a brilliant consultant psychiatrist whom I rarely see but works also for a nationally-famous private psychiatric hospital, a kind occupational therapist, and I’ve had a lot of input from a kind and gifted CBT therapist and various support workers.  If you read my Mental Healthy blog regularly you will know my diagnosis and my opinions on how people with severe mental illnesses should be afforded every opportunity to make personal recoveries and to be socially included – but never at the expense of continuity of care or of personal safety or quality of life.

External Links:

http://www.cppconsortium.nhs.uk/admin/files/1299679285Highlighted%20Mental%20Health%20Clustering%20Tool%202%200.pdf

Your rating: None Average: 6.5 (2 votes)