Embedding value in mental health services

Dr Rumina Taylor [pictured below, right] shares an update on work to improve outcomes for patients accessing mental health services.  

What is the value based healthcare approach and how can it improve patient outcomes? 

A value based healthcare approach aims to deliver excellent and consistent health outcomes that matter to patients and their families, across the entire pathway of care, while making best use of the resources available. This approach prioritises patient experience and ensures that the mental, physical and psychosocial needs of people are treated as one.

When organisations do incorporate concepts of value, this does appear to translate into better, safer care, and sharing outcomes drives up quality. 

Despite increased interest in achieving value in mental health services, delivering this has been difficult and rarely done in practice. This is because many patients use mental health services for years and receive treatment for more than one condition, which makes deciding when care starts and ends challenging.

Another issue is that routine outcome measures are not used in many UK mental health settings, although work is taking place to change this such as through the development of standard frameworks (including by International Consortium for Health Outcomes (ICHOM)).  

In addition, providers within the UK healthcare system are commonly paid based on block contracts and therefore there is often little or no reward for effective clinical outcomes, which can result in these measures being overlooked.  

One key area of care where we have been working to implement value based healthcare is depression. Depression affects around 20% of those over 65 years of age living in the community and 22% of older adults cite mental health as one of their primary concerns as they age. Depression in older adults also substantially (27%) increases the risk of other health comorbidities such as coronary heart disease and stroke.  

The Psychological Medicine and Older Adults Directorate at South London and Maudsley NHS Foundation Trust has been working to improve value within their depression pathway by better understanding the key factors that influence patient “flow” through healthcare services. This data was gathered to help identify and improve outcomes that matter most to service users, their families and carers.

The Directorate started by developing pathway maps for a range of conditions and then linking outcome measures to each pathway. This complemented the Trust-wide Changing Lives strategy to:

• deliver the best value by working in partnership with people and communities;
• attract and retain the best people; and
• maximise ability to innovate.

Introducing value based healthcare in this pathway 

Our project – recently presented as a poster at the ICHOM Virtual Congress – shared the methodology for collecting and analysing patient data and understanding cost of service delivery, helping us understand key drivers of patient behaviour between pathways.  

We looked at patients with depression, mapped their journey of care and the associated resources used, and then analysed two questionnaires completed by clinicians and patients: Health of the Nation Outcome Scales 65+, (HoNOS), and Hospital Anxiety and Depression Scale (HADS). These measures, despite being different from tools used in the ICHOM standard set, still provide an assessment of symptoms and functioning that is in line with ICHOM recommendations. 

We considered ICHOM standards, but it was decided to use the HADS and HoNOS measures as they are well validated in an older adult population and were already established within the clinical pathway. We also conducted a series of interviews with patients and clinicians to define the outcomes that matter to them. 

Our interviews showed that patients wanted to be asked about the history and causes of their depression, whilst staff wanted feedback from managers about outcomes and more guidance on when to complete assessments. The assessment tools also had different benefits; clinicians said the HoNOS was more helpful for holistic assessment but the HADS was better for informing treatment. 

Lessons 

Overall, our project found that South London and Maudsley NHS Foundation Trust’s capability for treating those with complex depression is good. We found that the HoNOS appeared to be offering better value when compared to the HADS, though staff uptake of the HADS was limited. The standardised measure integrated within patient notes offered by the HoNOS method offered a better completion rate than the paper-based method offered by HADS.  

We found that patients’ depression improved by 81% across all diagnoses, with improvements also reported in functioning. More severe depression was associated with increased resources and a greater number of illness episodes, but not more time within the pathway. Those with recurrent depression required higher costs, a greater number of illness episodes, and long treatment times. Care was provided by community rather than inpatient services. 

Nonetheless, it was difficult to draw firm conclusions as to the relationship between the HoNOS, costs, and diagnosis. It would have perhaps been better to look at one type of depression diagnosis at a time with larger sample sizes. 

We have highlighted the importance of feedback mechanisms to staff; the necessity to identify patient and clinician reported outcomes and gain their reflections on the utility of chosen measures. 

The project also identified some questions for future study:  

1. How do we facilitate consistent outcome completion across pathways?
2. How do we communicate with staff on assessment administration? 
3. How do we integrate outcome measurement most effectively with existing systems? 
4. How do we make decisions on value and impact for recurrent depression treatment pathways?  

This initial pilot identified a way to use value based healthcare methodology within mental health. By doing this, we can start to truly understand outcomes that matter to patients and staff, and the resources required to deliver these.  

Value based evaluation has the potential to enable us to identify and support older people who may be living with depression and redirect those who would benefit from accessing services to the most appropriate professional across the full pathway of care. 

Learn more about value based healthcare at King's Health Partners.

Dr Rumina Taylor, value based healthcare Mind & Body Lead at King’s Health Partners, and the Psychological Medicine and Older Adults Directorate from the South London and Maudsley NHS Foundation Trust.