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South London and Maudsley NHS Trust, Reay House, 108 Landor Road, Stockwell, London SW9 9NT
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Abstract |
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Clinicians are often required, by managers, to provide information that does not appear relevant to clinical practice. Rooted in compromise, an outcome-based information model that supports practice and also provides information for managers was developed. A 9-month pilot project at three sites in South-East London took place to test the feasibility of this model in real clinical settings.
RESULTS
Accurate data were reliably collected. Clinicians at participating sites agreed the model produced potentially useful information and, on condition that support is provided, continue to collect data voluntarily.
CLINICAL IMPLICATIONS
This is not an exclusively clinical model. However, because it also fulfils management needs there is a better chance that clinicians will get the support they need.
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Introduction |
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This paper describes an attempt to overcome this information deadlock through a compromise in terms of what is collected and for whom.
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Method |
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In very broad terms, a patient-based model to investigate ‘what works best with whom?’ was constructed. This meant describing and categorising three axes of information: the underlying problem or need of the patient; the intervention or what is done; and the clinical outcome — does the patient get better?
To categorise ‘problem’, full ICD—10 diagnosis was considered infeasible as it can be difficult to collect the necessary information (Glover et al, 1997). Categories were based on ICD—10 (World Health Organization, 1992) but those that all clinicians can apply were therefore used. In analysis these categories were collapsed into ICD—10 chapter headings.
To measure severity, and ultimately outcome, Health of the Nation Outcome Scale (HoNOS) (Wing et al, 1996) and its variant HoNOS for elderly people (HoNOS65+) (Allen et al, 1999; Burns et al, 1999) were selected because they form part of the mental health minimum data-set and are consequently recommended in the National Service Framework (Department of Health, 1999).
In categorising interventions, a detailed description can be open to variations in interpretation in different parts of the service (Carthew & Page, 1999). A practical list of generic intervention categories applicable across the whole service was developed, focusing primarily on intensity (Clifford, 1993).
Two older adult sites — a community mental health team and acute ward — and an adult case-management team took part in a 9-month pilot. Each site was already routinely recording HoNOS/HoNOS65+. During the pilot, problem and intervention were routinely recorded as part of established HoNOS assessments. Two specific hypotheses were tested:
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Results |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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=0.87, P<0.001, n=67) and
older-adult cases (=0.79, P<0.001, n=161).
Were contacts predicted accurately?
There was a positive correlation between the number of contacts predicted
and those recorded electronically (r=0.79, P<0.001,
n=22) and in case notes (r=0.59, P<0.001,
n=29).
Did the model produce evidence with the potential to inform
practice?
By the end of the pilot period reports indicating which patients had
best/worst outcomes and how these were related to the intensity of
intervention was being generated. For example, at one site 15 clients with an
organic mental disorder (F0; World Health
Organization, 1992) had been referred and discharged during the
pilot period. HoNOS65+ scores showed eight had improved and seven
deteriorated. Apparently related to intensity of intervention, the
‘improved’ group had received more than double the amount of
contacts than the ‘deteriorated’ group
(fig. 1).
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Why is one client offered more contacts than another? Mean HoNOS65+ scores at referral showed that the ‘high contact’/‘better outcome’ group had presented with greater severity. However, at discharge, rather than converging, the score differential for these two groups increased. The ‘deteriorated’ group ended up worse off than the others had been at referral. The ‘improved’ group ended up better off than the others had been at referral.
This result begged an obvious question — paradoxically, for clients with an organic disorder is it better to be worse at referral? Within the team, heated debate ensued. They concluded, sample-size aside, that independent variables such as age, onset etc. needed investigation before validly answering this question.
After similar reports, clinicians at all sites agreed the information was ‘potentially’ useful. Rather than providing firm conclusions it has the potential to highlight relevant questions and direct evidence-based debate about best-practice. As a concrete representation of this, participants volunteered to continue data collection after the pilot period was over. However, continued data collection was contingent on two explicit conditions:
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Discussion |
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The second of these is not a surprise. Evident from the focus on intensity of intervention — of more interest to commissioners than clinicians — this model is rooted in compromise. Ironically though, perhaps the strength of the model lies in this compromise. Based on past experience many are cynical that the kind of support recommended for long-term collection will ever be delivered. However, in this case, there is a direct and practical incentive for commissioners, managers and therefore information departments to provide exactly the kind of support required — namely, they want this information as well. As direct evidence of this in practice, both the local health authority and the NHS information authority continue to directly fund this project, even though it is now focused on providing the kinds of support (e.g. feedback and training) and development (e.g. of intervention categories) requested by clinicians.
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Conclusion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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Acknowledgments |
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References |
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TopAbstractIntroductionMethodResultsDiscussionConclusionReferences |
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BURNS, A., BEEVOR, A., LELLIOTT, P., et al
(1999) Health of the Nation Outcome Scales for elderly people
(HoNOS65+). British Journal of Psychiatry,
174,
424-427.
CARTHEW, R. & PAGE, R. (1999) Mental health groups: providing the framework to ask the right questions: the development of patient and care groups for Mental Health Services. In The Fourth National Casemix Conference, Casemix into the Millennium. Winchester: The NHS Information Authority.
CLIFFORD, P. (1993) The FACE Project: Final Report to the Department of Health. London: Quality Development Unit.
DEPARTMENT OF HEALTH (1997) The New NHS: Modern, Dependable. London: HMSO.
DEPARTMENT OF HEALTH (1999) National Service Framework for Mental Health. London: Department of Health.
GLOVER, G., KNIGHT, S., MELZER, D., et al (1997) The development of a new minimum data set for specialist mental health care. Health Trends, 29, 48-51.
WING, J., CURTIS, R. & BEEVOR, A. (1996) HoNOS: Brief Report on Research & Development. London: Royal College of Psychiatrists College Research Unit.
WORLD HEALTH ORGANIZATION (1992) The ICD—10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: WHO.
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
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