1. How can commissioner’s
decisions be based upon quality and outcomes measures as well as
levels of activity?
At present there is limited
information for commissioning[1].
The mental wellbeing of the
whole population is the most valid criterion of success (see for
instance ‘A New Vision for Mental Health’), but it is
ambitious in terms of information collection and use. It
cannot be inferred from statistics collected within provider
organisations. The results of whole population surveys and needs
estimations should be used where possible to determine local
prevention and promotion strategy as well as the commissioning of
therapeutic and recovery services. Ideally that implies the
need for joint commissioning by responsible agencies and a broader
mental health strategy than is currently employed.
Funding decisions on statutory
care services may be linked through direct or indirect mechanisms
to quality measures:
Direct: Some proposals have been
made for ‘automatic’ systems in which a percentage of the potential
funding for each service is held back by commissioners and
selectively released to reward those providers meeting targets for
a specified range of quality measures (NHSNW, 2008). There
appears to be little experience of that technique globally outside
the acute sector. ‘Best practice tariffs’ are promised in
England by Lord Darzi’s review (DoH, 2008) but it is not certain
yet how those might work for mental health. As is the case for
performance targets in general, the main dangers arise from placing
undue emphasis upon some criteria to the detriment of other aspects
of the service; or from removing supportive funding from providers
who are already struggling with a local obstacle.
The balanced scorecard approach
to be used in the Scottish benchmarking project includes a number
of mandatory performance indicators as well as some for local
selection (Scottish Government, 2008).
Indirect: Commissioners
might of course take into consideration any number of quality
measures when they use their discretion to decide upon one
organisation or another to provide a service. And they can
subsequently agree with that provider to use any range of quality
measures for subsequent monitoring. It is also intended in the
policies for England that a similar principle of devolved choice
should enable practice commissioners and individual patients to
make choices between providers, based upon freely available
information (DH, 2008). For these mechanisms to be effective,
information on a range of quality measures needs to be very easily
accessible, and easy to interpret. That is not the case presently.
There is a risk that subgroups of the population with less access
to information, or less ability to make complex choices, will be
disadvantaged.
Local decisions as to
which quality and outcome measures will be used should
encourage local issues to be addressed, although there may be a
temptation to choose easily available, cheaper methods. On
the other hand, the argument in favour of standard measures is that
each commissioning body should be able to compare quality between
rival providers; and providers will frequently be working across
commissioning boundaries – they will not wish to provide different
measures for each commissioner. National minimum sets of
quality and outcome measures therefore seem to be required, with
options for local additions (DH, 2008). An authoritative
source from which quality measures can be selected for different
purposes seems to be required, together with the means to collect
the data at a local level.
CSIP (the Care Services
Improvement Partnership) is currently producing a compendium of
mental health outcome measures covering a range of settings and
intended purposes (CSIP 2008).
The College Research and
Training Unit is the leading national authority on quality
assessment of MH services in the UK. The CRTU website has
details of each of its projects and programmes including that of
the CCQI (College Centre for Quality Improvement).
There has been a long history of
difficulties in sustaining the collection of clinical outcomes
data. It is generally agreed that there are statistically
reliable and valid measures of different types, but clinicians who
have to make and record the assessments often remain
unmotivated. That could be improved by providing them with
regular access to the analysis of their own results, and the means
to change their service model accordingly.
Commissioners should insist upon
the presentation of quality and outcomes information from
providers, separately by team, intervention type, care pathway,
problem or client group, etc.
National bodies should agree a
national set of common quality measures as well as a validated
additional set for optional local use.
Related
questions:
Sources:
CSIP Routine
Outcome Measures Website
CSIP Commissioning toolkits
Dept of Health (2008) "High Quality Care for All: NHS Next Stage
Review Final Report."
E-journal article on CQUIN (Commissioning for Higher Quality and
Innovation):
Jacques J (2008) Payment by Results and Mental
Health Services. Psychiatric Bulletin, 32 (10),
361-363
NHSNW Advancing Quality
Website (2008)
Public Finance (2008) E-Journal article on funding and
quality:
Royal College of Psychiatrists - College Centre for Quality
Improvement
Scottish
Government (2008) Mental Health Project Final Report: National
Benchmarking Project Report 2.
The Future Vision Coalition (2008) A New Vision for Mental
Health: