Mental Health Matters: At your own risk

With more money flowing into mental health and increased scrutiny of commissioners’ spending habits, a closer look at the national spec comm budget will be on the cards.

Almost a third of NHS England’s £1.9bn specialised commissioning budget has already been transferred to providers through the new care models.

Although we’re yet to see the national evaluation of this, the word is that it will be largely positive and could lead to the rest being transferred shortly.

Transforming Care budgets could also come into the mix, which would be an interesting one considering the lack of success in fulfilling the programme so far. Providers would surely have to shoulder the risk of non-delivery with any new budget responsibility.

Taking on the risk

There is an acknowledgement among many senior mental health leaders that NHS England’s central awareness of what its specialised commissioning teams are spending regionally is somewhat lacking.

To quote one chief: “Some of the figures are not very good.”

While this may be manageable when spending at a national level, it becomes a problem when you’re trying to unpick and delegate individual budgets. This could mean when the budget is transferred locally, it may not match the required activity levels, leaving providers holding the baby.

It is also worth noting that as specialised commissioning is not held to the mental health investment standard, we don’t know for certain whether this budget has been receiving even the inflationary budget uplifts.

To ensure they don’t take on more than they can chew, future providers will want to ensure any transfer of specialised budgets also comes with an agreement for NHS England to meet any future financial risk and covers those inflationary increases.

The greyness

The potential risks will be more complicated when it comes to patients with extremely complex mental health needs for whom there are only a few inpatient units around the country.

But reducing the current complexity in the commissioning of these beds – by having providers manage the budgets – could make for a smoother and quicker discharge.

The new chief executive of St Andrews Healthcare, a third sector which deals with some of the country’s most complex patients, said she was “really surprised by [how] fragmented the commissioning system is and how grey the rules are around where specialist commissioning responsibilities stop, and local commissioning responsibilities start”.

Katie Fisher, who has previously worked in the NHS acute sector, added: “Of the patients we [St Andrews] have delayed here, and we have a considerable number… I would say the single most common reason by quite a long way is this greyness around where does the responsibility between NHS England specialist commissioning stop and where does responsibility from a local commissioner start.”

When the responsibility falls on a CCG to commission a bed for a patient with very specialist needs, which they may only experience every few years, they’re often “not going to be able to provide a really timely comprehensive, best in practice response”, while NHS England’s spec comm teams, who have the experience, “are often not resourced to do so”, she said.

This “greyness” has the potential to leave patients languishing in an inpatient bed while commissioners wrangle over who is responsible for funding their ongoing care.