Evaluating the implementation of Payment by
Results in mental health services: a case study of Nottingham.
PhD thesis, University of Nottingham.
The aim of this study is to evaluate the implementation of the Payment by Results (PbR) policy in mental health in England through the identification of the driving factors that have caused the delayed implementation of the system. Payment by Results, the English version of Diagnosis Related Groups, is a prospective payment system under which the nationally-fixed prices are set against the clinically-classified groups in which patients share similar health care needs. First introduced in acute services in 2003/04, PbR was expected to control healthcare costs, increase providers’ efficiency and improve the quality of service delivery in the market-based healthcare system. An expansion of PbR to mental health was initially planned to come into effect by 2013, but at the time of writing (October 2015) it had yet to become the definitive framework of funding for the NHS secondary mental health services.
In light of the debate on the feasibility of implementing this policy in mental health, this study has adopted a mixed-methods approach to conduct a three-stage analysis of the PbR policy. Firstly, through the theoretical analysis of the initiation of the PbR policy, this study has revealed that the policy was poorly initiated due to the mismatches between the market theory and public services in the current context. Secondly, through the investigation of the design of PbR, this study has argued that the policy was poorly formulated due to the conceptual and the constructional drawbacks of the Mental Health Clustering Tool (MHCT) classification system as well as the inappropriateness of applying the “standardisation-to the-average” principle to the cost calculation. In the fieldwork stage, this study has carried out 12 semi-structured interviews and online surveys to explore the implementation phase of the policy-making process. The divergent, and even conflicting perspectives obtained among the three interest groups have pointed to the fact that the policy was poorly executed, and it suffered from “bad luck” (Hogwood and Gunn, 1984) as a result from the political context of austerity.
Through the comparison of the implementation of PbR in mental health with that in acute services this study has highlighted the importance of the external context to the success of any policy. It has also argued that one size does not fit all systems since the PbR payment system may be able to serve the purposes in acute services, but it does not fit mental health services. In this respect, this study reminds policymakers to consider the potential trade-offs between the political objectives and the inevitable consequences. As a policy evaluation, based on the experiences drawn from the failure of implementing PbR in mental health, this study has suggested that policy should be consistent, and policy should be tested prior to full implementation.
Thesis (University of Nottingham only)
||Diagnosis related groups, Mental health services, England
||R Medicine > RA Public aspects of medicine
||UK Campuses > Faculty of Social Sciences, Law and Education > School of Sociology and Social Policy
||15 Oct 2016 06:40
||16 Oct 2016 02:43
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