Introduction
This programme covers the full range of mental and behavioural disorders, including personality, mood, behaviour, and psychosis. Particular challenges are mental health of prisoners and young offenders, self harm and suicide, drug and alcohol misuse, child psychiatry, and mental health in older age. Nationally and locally, this is the biggest single programme in terms of its budget.
Questions for each programme budget category
Consider constructing a list or grid like the table below. This table uses examples developed from Norwich Primary Care Trust (PCT). The table is divided into aims, objectives, actions, and costs.
Patients and clinicians should be involved at every level. The tables, as they evolve, should be published—for example, on the PCT's website—so that everyone can see their development.
General questions to think about:
- What are the main health issues in each programme?
- Who are the major players (including patients every time, and often non-NHS agencies) and how will they be engaged?
- What are the programme's broad aims and specific objectives? Try to make the objectives ‘SMART’ (specific, measurable, ambitious, realistic, and time-bound).
- Set objectives at each stage in the patient pathway—for example: protecting good health; getting a rapid diagnosis and assessment; going for full cure; supporting chronic illness where cure is not possible; easing the passing (a well managed death).
- What are the main unmet needs and any striking inequalities?
- What are the programme inputs (programme budget) at present?
- What outputs are being generated?
- What outcomes are being generated?
- What ideas can be generated for starting and stopping programme activities to get a better fit between resources and objectives. (Start by looking within programmes before looking between programmes.)
Programme budgeting for mental health
| Aims | Objectives | Action: stopping or starting | Value (£) +/– |
| TIPS: These should draw on national service frameworks or strategies where they exist. They should be limited in number, but there should be least five that cover the steps in the patient pathway . | TIPS: These should be drawn directly from the aims. There will usually be more than one objective for each aim. Objectives should be SMART. | TIPS: These should be drawn from the objectives. There may be more than one and they should relate to disinvestment (cutting back on some areas) and new investment. All these suggested actions should be formulated by a marginal analysis advisory group and tested for changes in cost and benefit at the margin. | TIPS: Every action should be costed whether that means cash releasing (saving), cash neutral or cash requiring. The discipline is to keep the total in the cost column within the programme budget set by the PCT. |
| 1. Promote positive mental health and prevent relapse | Reduce the higher than expected rates of self-harm and suicide in the PCT | Further liaison between mental health providers on admissions related to self-harm and alcohol and drug misuse (e.g., from Norwich PCT) Encourage activities to promote mental health and self-esteem, and personal coping strategies with voluntary agencies. These will use arts and other cultural facilities (e.g., of Norwich PCT activity) | - |
| 2. Alleviate symptoms when mental illness does occur | Reduce social isolation through group activities | Continue campaigns to break down stigma | - |
| - | Reduce the current high levels of prescribing of antidepressant medicines | Make more use of alternatives to medication and hospital admissions—for example, through physical exercise, arts activities, talking therapies Audit use of NICE guidance | - |
| 3. Restore patients to their maximum potential as functioning members of society | Bring average rates of admission and length of stay down to peer PCT norms | Work with educational providers and employers to help people with mental health problems achieve employment and fulfil their academic potential | - |
| 4. Relieve pressure on carers | Reduce the number of expensive out of NHS and out of county placements when equally good outcomes can be achieved locally | Provide support for carers; develop local initiatives with assistance from voluntary agencies | - |
Author
Dr Peter Brambleby
Dr Peter Brambleby has a clinical background in child health and 20 years’ experience in public health, including five years as Director of Public Health in the former Norwich PCT. He currently serves on the National Programme Budgeting Project Board and related working groups. He has a long-standing interest in trying to match health needs to health spending, and to getting public and clinical engagement in that process. From 1 July 2007, Peter will be the Director of Public Health at North Yorkshire and York PCT.