September 2009
Promoting an outcomes culture in New Zealand's mental health services
New Zealand – like many other countries – has been actively working on developing an outcomes culture within its mental health services for the past few years. As I will indicate later this commendable objective has not made all the gains we might have wanted. I will signal in this article how we might reignite the outcomes project and refocus our endeavours on promoting an outcomes culture within New Zealand once again.
It needs to be said at the outset that outcomes have always been important in mental health services. At the most basic level they have been interested in the proposition: are people actually getting better? Traditionally this was seen as a matter of clinical judgement but increasingly the subjective view of the people using services has achieved prominence. The use of measurements, which would provide evidence for the proposition, have unfortunately been more of a hit and miss affair. While some individual clinicians and services have attempted to provide evidence of outcomes measurement there has been no systematic attempt until quite recently.
In the UK in the mid-nineties the Health of the Nation Outcomes Scale (HoNOS) was developed as a measurement tool which could provide a systematic measurement of outcomes across the UK. This measure was adopted by other countires such as Australia and New Zealand. One of the outstanding issues in New Zealand is the introduction of a service user self-rated outcome measure, as a way of balancing the clinician perspective. We are still awaiting the roll out of a national tool in this area.
The introduction of the HoNOS family of measures as part of the MH-SMART [Mental Health Standard Measures of Assessment and Recovery initiative] suite of measures in 2005 has had a mixed reception. Many clinicians remain unconvinced of the clinical utility of the measures and this has meant they have not made outcome measures an integral part of the clinical interview experience for service users.
Given the limited (though significant) achievements to date, a new approach to promoting an outcomes culture is needed. This new approach is one which primarily needs to demonstrate the clinical utility of outcomes measurement.
Adopting this new focus, there are four main ways by which we can promote an outcomes culture in New Zealand’s mental health services.
Firstly, we can promote an outcomes culture by demonstrating that an outcomes culture improves recovery.
Secondly, we can show that an outcomes culture assists clinicians to do a better job.
Thirdly, we can show that an outcomes culture makes it easier to distinguish good from bad services.
Fourthly, we can show how an outcomes culture leads to better use of information more generally.
There has been a gathering body of evidence (Lambert et al 2001, 2005, Miller and Duncan 2004, Anker et al 2009 and Willis et al 2009) that feeding back outcomes information to people using services improves their recovery outcomes. This is no minor matter because what it means is that feeding back outcomes measurement is itself a therapeutic activity. Many clinicians remain of the view that outcomes measurement is simply a collection exercise for the Ministry. It must be said that while this is not true, those of us involved in promoting outcomes have not done a particularly good job in marketing it as a therapeutic activity. Perhaps our score card in this area should read ‘could do better’.
Gathering and using outcomes information assists clinicians to do a better job. It does this by providing feedback to clinicians on their performance as clinicians. Clinicians informally already have a good idea on whether they are doing a good job but this is usually based not on outcomes measurement but their feelings with regards to their performance, a notoriously highly subjective area. Intuitive feelings about performance alone are simply not enough.
Without an outcomes culture we will never be able to distinguish the quality of services, since – other than anecdotally – we won’t know who is doing a good job and who isn’t. The use of aggregated outcomes data tied to key performance indicators will provide a way of benchmarking individual clinicians, services and regions.
Promoting an outcomes culture with its emphasis upon outcomes information will, hopefully, assist individuals and services to develop a greater appreciation of information more generally. This will translate into better decision making by clinicians and less reliance on intuition as the final arbiter.
Promoting an outcomes culture is not new, given we have been trying to do this systematically for the past four years in New Zealand. However, we probably need a new spirit and emphasis in our use of outcomes information. The past few years, up until quite recently, have seen a strong emphasis upon collecting outcomes information. This was a necessary first step to ensuring that we had this information. But, while necessary, it would never be sufficient. We needed to show how the information could be really useful. This proved and is proving more difficult than most people expected.
References
Anker, M., Duncan, B. and Sparks, J. (2009) . Using client feedback to improve couple theory outcomes: A randomised clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693-705.
Lambert, M J., Harmon, C., Slade, K., Whipple. J L. and Hawkins, E J. (2005). Providing feedback to psychotherapists on their patients progress: clinical results and practice suggestions. Journal of Clinical Psychology 6, 165-174.
Lambert, M J., Whipple, J L., Smart, D., Vermeersch, D., Nielson, A. and Hawkins, E. (2001) . The effects of providing therapists with feedback on patient progress during psychotherapy: are outcomes enhanced? Psychotherapy Research 11, 49-68.
Miller, S., Duncan, B. and Sparks, J. (2004). The Heroic client: A revolutionary way to improve effectiveness through client directed, outcome informed therapy. USA: Jossey-Bass, John Wiley.
Willis, A., Deane, F P. and Coombs, T. (2009). Improving clinicians attitudes toward providing feedback on routine outcome assessments. International Journal of Mental Health Nursing 18, 211-215.
Page last updated: 17 September 2009