Outcome-based providing and commissioning: pathways and standards

Abstract

Attribution-NonCommercial-NoDerivatives licence (http:// creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of Cambridge University Press must be obtained for commercial re-use or in order to create a derivative work. Aims and method Implementation of evidence-based psychosocial interventions in accordance with National Institute of Health and Care Excellence guidelines and quality standards has been incomplete. This project involved allocation of adults under mental health services to six guideline categories, completion of a clinician-and patient-rated outcome measure, and individual assessment against clinical standards. Results In the first 3 months of the project, 5048 patients were allocated to a pathway and 3734 (73%) were assessed against at least one of the relevant standards. All were assessed using the Health of the Nation Outcome Scales (91-93% of scales completed) and 1866 (36%) completed the patient-rated outcome measure, DIALOG. Clinical implications Clinicians will allocate patients to pathways, complete outcome measures and assess against standards, providing data to guide practice, service design and costing of mental health systems with supporting technology to assist data entry and presentation. This has the potential to provide much improved and readily accessible information about individual outcomes and standards for people with mental health problems and those working with them. It could also provide a method for payment for services which directly support good clinical practice. Declaration of interest None. Over the past two decades, the National Institute for Health and Care Excellence (NICE) has developed guidelines for broad mental health categories 1 and quality standards. 2 However, systematic implementation of these has not occurred despite general agreement and a national direction that this should happen. Clinicians have developed and evaluated pathways 3 based on broad categories for use by clinicians in Southern Health NHS Foundation Trust, which are available to patients and other service users. These developments have received strong support from clinicians, managers, patients, carers and local commissioners. A key factor to aid implementation has been the recognition that the primary pathway being followed by each patient needs to be identified. Second, clinical-and patient-rated outcome measures need to be implemented and, third, each patient needs to be assessed against the standards set by NICE and the Pathways groups and Trust Medicines Management Procedures. It was also recognised that this would provide essential information to develop a clinically meaningful costing system. Clinical and needs profiles could be developed from the pathway allocation and the clinical measure used (Health of the Nation Outcome Scales; HoNOS) to form groups for costing, e.g. as clusters, and for accounting for comorbidity using weighting factors such as comorbid symptoms, risk ratings, physical health scoring or social measures from DIALOG.