Frequently asked questions for independent review of Mental Health Investment Standard (MHIS)

The MHIS category guidance (see NHS England » Mental Health Investment Standard (MHIS): Categories of Mental Health expenditure) for prescribing was intended to make clear that CNS Stimulants and drugs should be included in the MHIS if and only if they are used for mental health conditions. However, we know that this has caused confusion for some ICBs and on reviewing the guidance we can see how some ICBs may have considered it as direction to include CNS stimulants.

For the ongoing independent review of 21/22, best practice is to include only CNS drugs which are being used to treat mental health conditions. Given the confusion, in 21/22 only, if ICBs are unable to split CNS stimulants and drugs used for mental health from those used for ADHD and ICBs have included the whole value of CNS stimulants and drugs in previous years they may continue to do so.

From 2022/23 onwards, if CNS stimulants and drugs cannot be identified as being spent for mental health (e.g. through a clinical estimate of a percentage of the total) then CNS stimulants and drugs should be excluded entirely from the MHIS. ICBs will have the opportunity to update their historical MHIS reporting and MHIS targets for 22/23 and 23/24 in autumn of 2023, ahead of the independent review of 22/23 spend.

Julian Kelly and Claire Murdoch wrote to all CCGs following the independent review of 2018/19 MHIS statements in July 2020 to say that the split of a block contract between MHIS and non-MHIS elements must be calculated each year. While previously best practice, this principle will apply for 2020/21 and onwards.

The “Mental Health Financial Planning 2019/20 – Additional Guidance” published in January 2019 set out that “CCGs should endeavour to provide robust, accurate data and to liaise with providers wherever necessary to ensure that apportionments are reasonable and consistent with reported activity levels.” We therefore would expect that where a contemporary split between MHIS and non-MHIS spend is not available, the CCG and provider would have discussed the split to be used to ensure that it was a fair reflection of current spend and reflected any significant changes to the balance of MHIS and non-MHIS services between 2019/20 and the year for which the split was calculated.

Where patients have multiple diagnoses and one or more of them is out of scope of the Mental Health Investment Standard, clinical judgement should be applied to determine what proportion of the spend is in scope of the Standard. This is particularly relevant in looking at Continuing Health Care or s117 spend.

In some cases it may be possible to distinguish on the basis of services provided (e.g. changing dressings or changing a colostomy bag are clearly outside the scope of the MHIS). More complex cases may require a relevant clinician to provide an estimate of the proportion of spend which relates to mental health need. If applying this principle would result in an inconsistency with previous approaches, please contact NHS E&I via your region to discuss.

A CCG is expected to check that data supplied by a third party for the MHIS is reasonable – e.g. that it appears to reflect any significant changes since previous years and that any significant variances have been investigated and explained. The CCG is not expected to have done a detailed review of the third party’s records.

Some drugs are prescribed for both mental health and non-mental health purposes. It is not reasonable either to exclude these drugs entirely from the MHIS or to include them completely. We think that best practice is that CCGs consult with a relevant clinician to make an estimate of the split between mental health and non-mental health uses of the drug in question.

The review of the 2019/20 expenditure should be completed and the reports ready to be published by 28 February 2021. Any request to extend this deadline due to COVID pressures should be raised through regional teams for national agreement.

Independent reporting accountants are not expected to challenge clinical judgments made by appropriate individuals.