Secure care accounts for almost one-fifth of NHS spending on mental health services in England. They include the three high secure hospitals as well as about 7,000 beds in medium and low secure units and a handful of community forensic services.
When the Commissioning Board takes over responsibility for specialised services in April 2013, commissioning secure care will be a major part of its remit. Getting this right will be a huge challenge and needs careful attention now to design a system without the blockages that beset it today.
People awaiting transfer from prison to hospital in a crisis are still having to wait for weeks and sometimes months for a secure hospital bed: a move that outside prison would normally be expedited within a few hours. And there is growing evidence that many patients spend considerably longer in hospital than they need because of difficulties in arranging discharges back to prison or into the community.
The encouraging news is that the way secure services are commissioned is already changing. While full-fledged payment by results is unlikely to emerge for another two years, this year the Department of Health is offering CQUIN incentives to providers that use the new clustering tool for secure care in order to begin the journey.
Payment by results systems do not in themselves guarantee improvements in service quality or outcomes for service users. Indeed in some cases they can disadvantage some groups of people, and we need to be watchful of this throughout the NHS. Nonetheless, these first steps towards PBR for secure services are to be welcomed.
Currently, secure services are commissioned using block contracts, top-sliced from PCT budgets and managed by specialised commissioning groups at a regional level. With beds purchased in advance, at a cost of £150,000 a year for low secure and more for the higher tiers of security, the system militates against the commissioning of timely and effective pathways through services, particularly when it comes to move-on accommodation and community-based services for those who no longer require inpatient care. This is exacerbated further by a lack of robust outcome measures, a high level of risk aversion in decision-making and an absence of clear guidance on the role and purpose of low and medium secure services. The result is a system that is high-cost with little evidence of value for money.
The potential for secure care to boost the life chances of some of the most vulnerable people in our society is considerable. Many service providers are exploring ways of adapting the Recovery approach to their environment. Others are developing move-on accommodation or integrating prison and secure care teams to facilitate faster transfers in a crisis.
To achieve consistent progress across the country, however, the Commissioning Board will have to get a grip on secure care commissioning as an early priority. It will need to redesign the system to pay providers for the outcomes they achieve, backed up with robust information drawn from service users’ experiences and clear guidance about the respective roles and expectations of medium secure, low secure and community services. This will take time to achieve, but concerted action now could help to create a system that is better at managing cost, speeding up admission and discharge, and creating good outcomes.