Carrots and Sticks on Opposite Sides of the Atlantic: Integration Incentives for People With Serious Mental Illness in England

In the United Kingdom, as in the United States, clinical and financial concerns have focused attention on integrating general medical and behavioral health care. A significant proportion of adults with behavioral disorders have co-occurring general medical conditions (1,2). People with behavioral health problems die ten to 20 years earlier than the general population, typically of medical conditions such as cardiac disorders, cancers, and strokes (3). Also, people with behavioral health conditions, particularly those with serious mental illnesses, tend to be high utilizers of care (4).

These concerns have led policy makers to seek integrated care solutions that can improve health outcomes and patient experience while reducing costs (the “triple aim”). Most efforts have focused on embedding behavioral health care into primary care—as in the collaborative care model (5). Integration efforts for people with serious mental illness, who are likely to be treated in specialist behavioral health settings, are less well developed.

The United States and the United Kingdom have benefited from each other’s experience in the past. For example, the collaborative care model, developed in the United States, was inspired by research on common mental disorders in the United Kingdom (6), and further inspired U.K. research on collaborative care, although models have yet to be widely adopted here (7,8). To facilitate a similar cross-national policy dialogue on care integration for people with serious mental illness, we compare large-scale efforts in England and the United States.

Behavioral Health Care in the English NHS

The U.K. population is guaranteed universal access to health care through the National Health Service (NHS); care is funded wholly through taxation and is free at the point of delivery. Almost 100% of the population has access to a general practitioner (GP). GPs assess and treat most behavioral health problems. They serve as gatekeepers to specialty care for patients with more complex conditions. Although the NHS operates throughout the United Kingdom, its administration is carried out separately by the four devolved nations: England, Scotland, Northern Ireland, and Wales. This column focuses on England, where recent reforms have given GPs the additional responsibility of commissioning specialist services through 211 clinical commissioning groups (CCGs). CCGs are locally organized networks of GPs that manage a risk-adjusted budget granted through a central organization—NHS England. They use these funds to purchase specialty services, including mental health services, to meet local needs.

Specialty mental health care is provided by a mix of not-for-profit, for-profit, and local government organizations—but predominantly through statutory NHS Mental Health Trusts (MHTs). MHTs are public-sector, specialist organizations providing “cradle-to-grave” inpatient, outpatient, and community services for behavioral health disorders. MHTs are separated from general medical health trusts through different funding, administrative and clinical structures, which leads to fragmentation of care pathways and poorer outcomes in both settings. For example, it would be unusual for dedicated mental health facilities to be situated in a general medical hospital.

The 56 MHTs are geographically expansive and often cover millions of people, compared with the 211 locally organized CCGs. Therefore, MHTs must negotiate reimbursement with several CCGs for most of their funding. Each MHT is commissioned to provide child and adult inpatient and community services for each CCG. More specialized services, such as forensic psychiatry, perinatal psychiatry, and eating disorder treatment, are usually commissioned across CCGs.

Behavioral health services are financed principally through capitated budgets, often based on historical spending rather than linked to need or quality. Therefore, as need increases, more care must be provided for the same total reimbursement. This can disadvantage MHTs compared with general medical providers, who are paid for activity and volume. Thus MHTs (and general medical providers) are moving toward outcome-based funding.

Approaches in England and the United States

England has adopted a pay-for-performance (P4P) incentive that rewards providers for achieving agreed standards of medical care for people with serious mental illness. We compare this arrangement with a direct, grant-funded mechanism in the United States to embed primary care services in behavioral health settings. [A table in an online supplement provides more details.]

CQUIN in England.

Commissioning for quality and innovation (CQUIN) is a payment framework that enables CCGs to reward excellence by linking a proportion of a service’s income to achievement of a national quality improvement target. Most CQUIN targets are set locally from a menu of centrally agreed goals, but there are four national indicators, each worth at least 1% of an MHT’s annual income, which can be increased further to 2.5% by local CCGs.

One national target covers the 20,000 adults with psychotic illnesses in psychiatric inpatient beds and the 5,000 in community-based early intervention in psychosis services (EIS). The target requires 90% of this population to have comprehensive cardiometabolic risk assessments, as judged by documented smoking status, lifestyle advice, BMI, blood pressure, glucose regulation, and blood lipids. These need to be completed at the start of an episode in EIS or on hospital admission. When indicated, individuals with abnormal results must receive appropriate treatment by specialist medical or primary care services, either “in house” or, more commonly, through affiliated providers.

CCGs can either withhold payment or request a proportionate return depending on the level of achievement (thus screening and appropriate follow-up for only 50% of the target population would reduce annual income by 75% of the total CQUIN amount). Each MHT has several eligible services (adult inpatient and community EIS) spread between a number of CCGs, leading to potential variability in achievement. However, poor achievement or unwarranted variability (as funding does not increase above the 90% screening threshold) would constitute a decrease in the MHT’s total income. Therefore, it is in the MHT’s interest to ensure that CQUIN targets are uniformly attained. Achievement of the general medical CQUIN is assessed through a record audit conducted by the Royal College of Psychiatrists and commissioned by NHS England. Results are shared with CCGs but have not yet been made publicly available.

GPs have a separate P4P mechanism (the Quality and Outcomes Framework) that rewards similar cardiometabolic monitoring for people with serious mental illness in primary care (9). The CQUIN is seen as a mechanism to link general medical health monitoring in primary care and specialist settings (10). It aims to foster closer working relationships between primary care and specialist behavioral health providers through sharing of diagnoses and treatment plans rather than a predetermined model of care. Good performance depends on concerted action and agreed pathways of care between providers.

PBHCI grants in the United States.

The Primary and Behavioral Health Care Integration (PBHCI) program is a federally administered grant provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) and intended to improve the general medical health of people with serious mental illness. It provides $400,000 per year for four years to specialist behavioral health clinics to allow them to provide primary care services. The initiative began in 2009 and had awarded 189 grants by 2015, with an average of 250 enrollees per grantee. The program has four core features: screening for and treatment of general medical conditions, developing a registry or tracking system for all primary care needs, case management, and prevention and well-being support services.

Early assessment by the RAND Corporation suggested that the scheme has been successful in building integrated multidisciplinary teams and making available a much greater array of primary care to those in the program compared with those not in the program (11). More recent evaluations have suggested that the grant improves some general medical outcomes but not all (12) and may reduce hospitalization costs in clinics where integration has been established longer (13).

Comparing the approaches.

Both the United States and England have used financial incentives to attempt to motivate providers to integrate care for people with serious mental illness. Whereas the United States has made new money available for implementation of integrated care in behavioral health settings (“carrot”), England has used a disincentive to ensure that providers carry out general medical screening and referral (“stick”). It is difficult to accurately calculate the amount of funding represented by the general medical CQUIN, but the minimum 1% of all English MHTs’ income is estimated to be $165 million annually. This covers about 25,000 patients with psychotic disorders. SAMHSA awarded $40 million to 60 PBHCI grantees in 2015, covering about 15,000 enrollees.

Whereas the PBHCI grant produces new services according to a preconceived model, the CQUIN incentivizes existing services to improve care in a more sustainable manner on a national scale. Although SAMHSA has recently started requiring successful applicants to develop sustainability proposals, grantees have found it difficult to maintain integration efforts beyond the grant. The grant is a start-up fund to implement a package of integrated care, which should be replaced through other funding mechanisms—for example, Medicaid Health Homes or the recently proposed Certified Community Behavioral Health Centers. Thus sustainability depends largely on the availability of other federal, state, or local funding streams. In contrast, CQUIN funding is awarded on a rolling annual basis and mandated centrally. However, it is potential money (that is, the threat of income being withheld) rather than actual funding to put integration structures and processes in place. Nevertheless, funding is tied to achievement of outcomes in the CQUIN, whereas PBHCI grants are not awarded for achieving high-quality care. Instead, funding is based on addressing an identified need.

Both programs have led to key improvements, including raising national awareness, local and regional training programs, enablement of electronic health records, formation of best-practice networks, and significant engagement with local communities.

Conclusions

In its principal approach to improving the general medical health of people with serious mental illness, the NHS has focused on strengthening the care that such consumers should be receiving on a national scale. It can do this not only because NHS is a single-payer system but also because of its robust primary care provision and because a good degree of collaboration between primary and behavioral health care already exists.

The United States in many ways has needed to stimulate this collaboration and access, so that PBHCI grantees are required to colocate primary care services before holistic care can be provided. This has led SAMHSA to advocate comprehensive integration between different services, as opposed to the CQUIN, which, as an incentive for innovation among primary and behavioral health providers, is not prescriptive and geared toward sustainable change.

A move toward value-based care may hold the potential for more sustainable and robust integration, and in this ambition are opportunities for both countries to learn from the other’s experiences. The United States could learn from England’s experience with a P4P system in behavioral health settings; but in the drive toward implementation, it is often forgotten that integration on its own is insufficient. Both countries have so far overlooked integration with substance use disorder services and social services. The United States must also ensure that it expands provision and availability of primary care services, even when integration occurs in behavioral health settings. Conversely, England might learn which specific features of integration from the PBHCI program it should consider incentivizing—for example, whether to focus on colocation rather than coordination or identifying which populations will gain most from case management. England needs to improve how it monitors quality and make these results transparent. In this way, England and the United States can continue to learn from each other in the future.