17.
Do we need a classification
or list of mental health interventions?
Surprisingly, there is currently no means for
systematically collecting information on what methods of treatment
or management are used in NHS and Social Care facilities.
Such information would provide a valuable insight into the
availability of different types of therapeutic effort across teams
and service types. In combination with data on problems and
needs, levels of activity, and outcomes measures, it would
contribute to the evidence base for evaluating what is effective in
local practice rather than in general principle.
The two core classifications used in the NHS
are of health conditions (the International Classification of
Diseases version 10 (ICD-10) and of interventions (or ‘procedures’
– the OPCS -4). Unfortunately, OPCS contains very few mental
health items. The inclusion of new procedures in later
versions of OPCS has only been allowed when they are proven to be
needed for implementation of the Payment by Results
programme. Since PBR is only just being accepted for mental
health services in England, and since its development has in turn
been inhibited by the lack of an interventions classification,
progress on both fronts has been inescapably slow! In any
case, inclusion of only those interventions needed for PBR would
not necessarily cover the whole range of provision in mental
healthcare. In the immediate future, therefore, we cannot
look to the OPCS to provide a classification.
There is no international classification of MH
interventions, but the development of an Australian MH Intervention
Classification (initially for use mainly in inpatient facilities)
was presented to the WHO Collaborating Centres for the Family of
Classifications in 2006/7. A draft version is available on the
website (se below).
An ideal classification should be a
comprehensive set of mutually exclusive categories. It is
widely assumed to be very difficult, if not impossible, to define
such a set for mental health that would cover all settings both in
health and social care. The difficulty is due to the range of
different types of problem to be addressed, as well as the problem
of defining exactly what goes on in any particular
interaction. Each type of therapy can often be carried out in
various types of setting which can greatly affect its execution and
results. For those reasons, it may be better to give up the
idea of a classification as defined above and with it the
aspiration that everything that happens in a mental health unit
could be assigned to a clearly defined category. It follows
that it may never be possible to reliably compare the total
‘intervention mix’ of two similar MH teams, in the way that
surgical units can compare the numbers of different procedures on
their operating lists using OPCS.
However there is still great value in using a
standard list of those interventions that are amenable to
definition (the rule being that ‘you know whether you have done it
or not’). Collecting data in which staff record each time
they provide such an intervention (the lumps in the therapeutic
soup) may tell us nothing about the valuable input that goes on
during the periods of indefinable activity (the liquid). But
the proportion and quality of the definable activity can
be validly compared to activity of the same type in other distant
teams using activity and outcomes measures. In fact,
outcomes data are only useful when you know for certain what you
are measuring the outcome of.
A draft list of MH interventions was prepared
some years ago by Ruth Page of the then NHS Information Authority
as part of the MH Information Strategy for England, but it has not
been tested or approved.
A seemingly alternative approach to an
interventions list or classification is to identify a smaller
number of higher level care packages, care clusters or care
pathways. These approaches are similar to each other in the
respect that service users or their data are allocated to broad
composite groupings, generally on the basis of a needs assessment
(eg ‘crisis care’, or ‘continuing care of serious and enduring
mental illness’). This provides a method for breaking down
big heterogeneous caseloads into groupings with good face validity,
but whether there is still too much variability remaining within
each group to prevent valid comparisons between various service
settings has not yet been established. Care packages are
currently proposed as the care currency for the Payment by Results
programme, though they have not yet been approved by the
Information Standards Board and are not intended to be a
building-block level classification of indivisible categories of
intervention.
Related
Questions:
Sources:
Australian
Institute of Health and Welfare. Mental Health Information
Strategy Sub-committee
Department of Health (2007). The National Interventions
Classification (from the Payment by Results website)
Information Centre for Health and Social Care (2003). Draft MH
interventions list by Ruth Page.
Information
Centre for Health and Social Care (2004). National Interventions
Classifications – Frequently asked questions
NHS Connecting For Health (2009). The official website for
OPCS.
World
Health Organisation (1992). International Classification of
Diseases (v 10) Chapter F. Online list of codes.
World Health Organisation Collaborating Centres (2006). The
Australian Mental Health Interventions Classification.