Care clusters and mental health Payment by Results

The key to doing routine mental health outcomes well ¹ is to make them relevant, meaningful and available to practitioners, service users and managers. The Health of the Nation Outcome Scales (HoNOS) is now a front-runner for a general outcome measure since it is required for Payment by Results, a new contracting system for mental healthcare in the UK. Only one HoNOS rating is currently required in order to allocate patients to Payment by Results care clusters, so managers have little incentive to take the extra step and mandate more than one HoNOS rating to assess the effectiveness of interventions. The simplest way to introduce outcome measurement with HoNOS would be to mandate at least two ratings, one at the outset of an intervention and one at the close. A benchmark for this approach has been set by the Priory Group for HoNOS outcomes of in-patient stays (www.priorygroup.com/Personal-Site/About-Priory/About-Us/Healthcare-Outcomes/General-Psychiatry.aspx). Psychological therapists are ahead of the curve, since many already use a commercial outcomes tool (e.g. Clinical Outcomes in Routine Evaluation, CORE; www.coreims.co.uk) in their work to monitor treatment progress, to support reflection and to aid supervision. They also involve patients, who make their own ratings on a standard questionnaire. They have made outcomes relevant and meaningful. Could their experience help develop HoNOS as an outcome tool? The HoNOS could be put to work supporting practitioners. For example, HoNOS could inform referral and assessment systems, by helping select between primary and secondary care services. If no individual HoNOS item rating is greater than 2 (mild), then secondary services may not be indicated. Individual scale scores could also indicate priorities for interventions: a high score on ‘hallucinations and delusions’ and a low score on ‘living conditions’ could suggest a focus on treatment over accommodation (and vice versa). The HoNOS total and individual scale scores would also indicate progress and could be used in supervision. The HoNOS scores that fall below predetermined thresholds may indicate readiness for discharge. These could even be agreed as goals with patients. Co-producing HoNOS with service users and carers could balance the perspective of HoNOS as a clinician-rated measure. Getting all practitioners on board will need vision and effort. Gilbody et al ² found that psychiatrists were not very interested in recording standardised outcomes. Feedback is crucial to engagement. Trusts should invest time to design their information systems so that they report person-centred outcomes directly to practitioners and teams in a meaningful format. Simply reporting outcome returns centrally would miss a huge opportunity to engage clinicians with outcomes, but still burden them with data collection. Outcomes information will create new challenges, for example the apparent ability to compare the effectiveness of teams and individual practitioners. For some, this could be intensely motivating or intimidating. The introduction of standard outcome measures should be done thoughtfully with ongoing input from service users, practitioners, managers and academics; or as Macdonald & Elphick put it: well.