Tag Archives: NHS

Professor Ruth McDonald ~ Paying for Performance in the NHS – is it good for our health?

In the olden days, we used to trust public servants to do their best for the people they served. Nowadays things are a little different, especially in the NHS. Policy makers are increasingly resorting to ‘Pay for Performance’ (PfP) in an effort to drive up the quality of care delivered to patients. The Commissioning for Quality and Innovation Payment Framework, or CQUIN as it is known, makes a proportion of income conditional on the achievement of quality improvement and innovation goals. This was increased from 0.5 to 1.5% in the second year of the scheme and this year the percentage was increased to 2.5%. David Nicholson, the NHS Chief Executive said recently that he wants to see this rise to 4 or 5%, presumably due to fears that the 2.5% isn’t having the desired effect.

The question asked by a lot of people is ‘do PfP schemes work’? But this is the wrong question, since it fails to recognise that these initiatives are all different. What we need to do is to look at the features of the individual schemes – how they are designed and implemented and in what context – and assess impact to work out how and to what extent a scheme works.

Our recent evaluation of the Advancing Quality (AQ) scheme in the NHS North West found that it saved almost 900 lives. The bonus payments were a drop in the ocean compared with CQUIN, which suggests that whilst it’s helpful to offer carrots, there are other motives afoot here. Perhaps NHS staff are only too ready, willing and able to improve services, but what they need sometimes is a little help. In this case, help took a number of forms including standardised data definitions and bespoke software. But aside from these technical aspects, collaborative events brought together staff from all 24 participating organisations to share their learning and work through common problems. In addition to shared learning, the development of this AQ ‘community’ appears to have been really important in providing emotional support for what has been (make no bones about it!) a gruelling and often uphill struggle for the staff involved. As our study shows, ‘PfP’ can produce desired results, yet  what motivated the front line NHS staff in our study was not ‘rational’ calculation of efforts versus rewards, but an ability and desire to  work together in a supported way, to do what they all felt was the right thing for patients. AQ has now broadened its scope to include all of the mental health Trusts in the region so we’re watching with interest to see if the initial success can be replicated as the programme expands.

Much of the thinking on incentives has traditionally been dominated by economists who take a rather one dimensional view of human beings. And economic rationality has often been seen as contrary to emotion. But an obsession with finding the magic percentage which proves to be a tipping point is the wrong way to go here (David Nicholson, please take note). What’s needed is for policy makers and evaluators to begin to adopt a less impoverished view of human behaviour – recognising the importance of emotion in improvement initiatives would be a good place to start.

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Professor Ruth McDonald
Chair in Health Innovation and Learning
Business School
University of Nottingham


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Dr Simon Clarke ~ Living in Glass-Walled Asylums: The Schizophrenia Commission Report

Last week the Schizophrenia Commission, headed by the mental health charity Rethink, released its report into the current state of care in the UK for people diagnosed with Schizophrenia. It made predictably depressing reading. Amongst other things, employment rates for people diagnosed with schizophrenia are less than 7%. The life expectancy rates are 15-20 years lower than the general population due to physical health-related problems. These health problems are often associated with weight gain, side-effects from powerful anti-psychotic medications. A huge proportion – 87% – of service users report experiences of stigma and discrimination, whilst the cost of schizophrenia to the economy was estimated at around £11.8 billion.

Perhaps even more depressing was report’s findings into the current state of mental healthcare in the UK for people diagnosed with schizophrenia. Mainstream psychiatric care was described as “a broken and demoralised system that does not deliver the quality of treatment that is needed”, in which service users “feel shuttled from one team to another as if on a factory production line”. Inpatient wards are often “frightening places where the overwhelmed nurses are unable to provide basic care and support” and in some cases “so anti-therapeutic that when people relapse and are in need of a period of care and respite, they are unwilling to be admitted voluntarily”. Too often, “medication is prioritised at the expense of the psychological interventions and social rehabilitation” and genuine service innovations like Early Intervention is Psychosis (EIP) teams are “vulnerable to service cuts”. The net result of all this is that psychiatric care “adds greatly to their distress and worsens the outcomes for what can already be a devastating illness”.

As someone who has experienced psychosis, been sectioned, diagnosed with schizophrenia, spent time in an alternative therapeutic community, qualified as a clinical psychologist and worked for two years in an EIP service in London, I can relate to much of this. I found my inpatient stays traumatic and demoralizing. As a result of medication I put on four stone of weight in 6 months. I used cannabis to cope, which of course led to more long-term problems. Thankfully I was helped by an alternative therapeutic community; the love and kindness showed by people in the community helped repair some of the damage from my experience as a psychiatric service user. Supportive but challenging relationships were key, as in fact they always are (Pilgrim et al., 2009).

So before we become self-satisfied with smug complacency about having better attitudes towards severe mental illness than wider society, perhaps we should get our own, crisis, house in order. Attitudes amongst mental health staff can still reflect negative, and inaccurate, expectations of people diagnosed with schizophrenia; in one study for example (Nordt et al., 2006), psychiatrists’ attitudes were more negative than the general population. Health professionals with past or present experience of mental health difficulties are often less likely to disclose their problems to colleagues than people outside the health service (Hinshaw, 2008).

When I was working at a large, well-known mental health research institution a senior colleague once told me, “you only got the job because of your psychiatric history, not because you are a good researcher”. When, whilst working at another NHS Trust, a confused visitor looking for an A & E department was told by a receptionist, “No, no love you’ve got it wrong; this is not a real hospital, this is a hospital for mental people”. The receptionist helpfully added a circular motion beside his head to illustrate what he meant by ‘mental’, just in case the flummoxed visitor (and, presumably, the patients and carers waiting in reception) didn’t understand.

Those in glass houses…

Posted by:
Dr Simon Clarke
Clinical Research Psychologist
Nottinghamshire Healthcare NHS Trust

The Schizophrenia Commission Report (2012): http://www.schizophreniacommission.org.uk/the-report/.

Hinshaw, S.P. (2008) Breaking the Silence: Mental Health Professionals Disclose Their Personal and Family Experiences of Mental Illness. New York: Oxford University Press.

Nordt, C., Rossler, W. & Lauber, C. (2006) Attitudes of Mental Health Professionals Toward People With Schizophrenia and Major Depression. Schizophrenia Bulletin 32(4): 709–714.

Pilgrim, D., Rogers, A. and Bentall, R. (2009) The Centrality of Personal Relationships in the Creation and Amelioration Mental Health Problems: the current interdisciplinary case. Health: an interdisciplinary journal for the social study of health, illness and medicine 13(2): pp.235-254.

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Dr Hugh Middleton ~ Mental health care: working together to reach full potential

Dr Hugh Middleton (Consultant Psychiatrist Nottinghamshire Healthcare NHS Trust and the University of Nottingham’s School of Sociology and Social Policy) writes on how research is identifying success stories and offering new strategies for collaboration:

To précis, mental health professionals need to work together if they are to fulfil their potential and deliver the best possible patient care, a new report has revealed (ref. below).

Hospital soap operas, everyday experience and what we hear about the “state of the NHS” all draw attention to strife between those who “do” health care and those who manage them, so it is good to see publication of some fresh research that tries to rise above this. October 10th saw publication of the final report from a three-year investigation of multi-disciplinary team working in mental health. Numerous investigators were involved, including Dr Hugh Middleton and other participating organisations (e.g. Nottinghamshire Healthcare NHS Trust).

Healthcare professionals must work together as effective teams if they are to provide the best possible patient care. This is important for mental health services where quality includes consistency and a reassuring sense of being known and understood. Providing these and at the same time working in shifts, so that the service is available beyond office hours, is difficult without great team processes.

Previous research shows that many multi-professional teams fail to perform to their full potential, as they are not clear about their objectives, disagree about goals, their leadership and how to work together; or they find themselves trying unsuccessfully to meet the conflicting demands of senior managers from different disciplines. The Healthcare Commission has discovered that as many as half of all NHS staff may work in dysfunctional teams, which can jeopardise patient care and undermine staff well-being.

The overall aim of this research was to explore such issues in more focused detail amongst teams providing NHS mental health services. A variety of settings were investigated. Service users, their families and friends, a range of mental health practitioners and service managers were all consulted in the course of developing a novel measure of community mental health team effectiveness. Some 1500 practitioners from 120 teams took part in a survey which estimated how effective such teams were, and reported upon what it was like to work in them.

There were strong associations between team effectiveness, measured on a scale which reflects service users’ views of good and bad practice, and the quality of team working. This was assessed using the Aston Team Performance Inventory, a well-established measure of team working. Particular success in providing good quality mental healthcare was found amongst teams that had a clear sense of purpose, welcomed participation in creative problem solving and were well led in a style that encouraged reflective practice.

Alongside this survey the investigators also observed a number of team meetings and interviewed 114 service staff, 31 service users and 13 users’ informal carers. This qualitative research enabled enquiry into the interactions that lie behind numbers derived from the survey. In terms of what matters to service users it revealed disparities between what they find important, such as relationship, flexibility, availability, consistency and understanding, and requirements of the organisational settings from which care is provided.

Of service users, in the words of one community mental health team manager:

“… they don’t really want to see the paperwork and they don’t really want to see the risk assessment, don’t really want to see the care plan, sometimes they’ll talk to us about the care plan but they don’t want copies of it … a care plan doesn’t mean anything to them in that sort of sense but I think we do keep trying to engage with them … “

In relation to creativity, in the words of a support worker:

“So there may be some patients who would really, really benefit from you say taking them for a day at the seaside, because that was what they remembered their parents doing for them when they were little and that would mean so much for them to do that. We obviously can’t do that, and time is probably our most valuable resource really”

These are readily dismissed as intuitive and predictable findings. Perhaps unsurprisingly they relate good clinical mental health outcomes to team creativity, task focus, participation, supportive leadership and interest in true relationship. On the other hand they are also timely and novel. They identify clear relationships between organisational determinants of the practitioner’s context and well-being, and the outcome of their clinical activities. It will require further studies to establish whether such interactions are also present in healthcare settings that are possibly less dependent upon practitioners carrying out “emotional work”, but an element of that is present in all health care settings. What this research demonstrates is that the success with which “emotional work” is conducted, in part reflects the practitioner’s emotional well-being and that is in the hands of those who manage and commission health care. There are connections between the management of health services and the service user’s experience which are not simply reflections of business efficiency, but provide the creative commissioner or manager with more sophisticated opportunities to influence real outcomes.

Reference:  West M, Alimo-Metcalfe B, Dawson J, El Ansari W, Glasby J, Hardy G, et al. Effectiveness of Multi-Professional Team Working (MPTW) in Mental Health Care. Final report. NIHR Service Delivery and Organisation programme; 2012.

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Dr Rex Haigh ~ Has CBT killed the human spirit?

The following post is written by Dr Rex Haigh, blogger for Struggling to Be Human: what we’re up against, originally posted on 17 June 2012 entitled ‘Has CBT killed the human spirit?‘.

Much as psychoanalysis set the cultural tone for our understanding and conduct of relationships for most of the twentieth century, cognitive behavioural therapy (CBT) has been leading us into a much less forgiving place for the last twenty years or so.

CBT Circle

In the world of psychotherapy, CBT has numerous siblings and cousins: most with three letter abbreviations to make a multiflavoured soup of ‘alphabetti spaghetti therapies’. Two flavours of the month are Dialectical Behaviour Therapy (DBT)  and Menatlisation Based Therapy (MBT). DBT, with its trendy ‘mindfulness’ plus new age and hippy edge, give its authoritarianism a warm fuzzy feeling; mentalisation has considerable weight of respectability afforded to it by years of attachment research in the experimental psychology departments of prominent universities – and charismatic professors with superstar status to market it. There are many other manualised and packaged ‘new therapies’, easily findable with your favourite search engine. But my overwhelming feeling is that they are all missing the point, and engaged in a pointless horse race with celebrity status prizes for the academics who reduce the interventions to dumbed-down therapy cookbooks, and then make sure everybody is following the recipes with multivariate statistical analyses backed up by powerful regulators like NICE. To me, this all seems like a very elaborate, somewhat sinister and ruthlessly inexorable way of taking the essential human qualities of the therapeutic relationship out of the picture.


It feels like these ways of working are all fashions of the moment – holding onto the coat tails of …of what? That is the big puzzle. All sorts of vaguely pejorative words and phrases get bandied about by malcontents like myself – without understanding the precise definitions – such as reductionism, materialism, biogenic dogmatism, logical positivism, determinism, behaviourism, scientism, alienating modernity, market managerialism. The best one I’ve seen lately is instrumental rationality: “A specific form of rationality focusing on the most efficient or cost-effective means to achieve a specific end, but not in itself reflecting on the value of that end”.

At its root, at least from where I stand at the moment, seems to be the need for certainty – and the fear of chaos that would ensue were we not able to measure, predict and control everything in our working lives. It is interesting indeed that complexity – what we have to deal with on multiple levels in our work every day – is only a step away from chaos, and indeed ‘creative chaos’ is an important ingredient of therapeutic communities, and perhaps all group therapies. Along with ‘therapeutic ordinariness’ and Keats’ Negative Capability (being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason) we seem to be in the world of the romantic poets, postmodernists, and idealists – dealing with moral philosophy, semiotics and aesthetics. Truth and love and beauty, maybe, rather than rigour and technique and effectiveness.

I would maintain anywhere that we need all of both sets of values in the world of the complex and often chaotic systems that determine human development, and we confront daily in psychotherapeutic work. We need multivariate regressions, p-values and confidence intervals for instrumental reasons – but they should be our tools rather than our purpose. Perhaps complexity and chaos theories could provide a conceptual, and even mathematical, bridge between these two worlds.

After an ill-tempered social meeting with two senior colleagues, and months of fighting the ‘corporate machine’ in my day job I think these considerations have wider relevance – in academia, public policy and health service management. What links them may be the impossibility of allowing any human being working in these systems to trust another – an no longer allowing people to hold that uncertainty, rather than algorithms and risk registers.

Universities are now run by financial considerations where the security of grant income subordinates everything else: they have to ‘play it safe’. We end up with students mounting legal challenges when they do not agree with the results when their work is marked, and researchers who produce numerous programmes, projects and papers with very little real value – and only need to show that their strategy does not cause any risk to the projected income stream.

In public policy, it is utterly unacceptable for anybody in the civil service to admit any failing – however small – that might reflect ill on their political masters. When we have a colossal failing – such as the absence of anything that is genuinely psychotherapeutic in the statutory structures of the whole of a country’s mental health system – then the conspiracy of silence is utterly deafening…

In the corporate world of NHS Foundation Trusts, a similarly sanitised version of reality is all that is allowed to be released for public consumption. When everybody knows that real cuts are being made, it cannot be spoken – even in letters to medical colleagues. Presumably it would be a ‘reputation risk’ for the truth to be acknowledged.

But this ugly truth – of the way we are so often not allowed to relate to each other as human beings any more – might even go to the core of the current global malaise. I met an economics undergraduate the other day, and he was explaining to me the depth of mathematical and statistical techniques that he is struggling to learn. The bursting of ‘debt bubble’, from which we are all now suffering, was built on sophisticated algorithms which allowed financial risk to be packaged and sold at lightning speed, with no intervening human thought about sustainability, or feeling that something morally wrong was being done. Is it not this chicanery, and the political systems which underpin it, that need to be exposed and dismantled?

The answer, I hope, is in the philosophy of greencare. Not particularly in the details of therapeutic horticulture, animal assisted interventions or care farming, but in the better use of land, air, soil, water, sunshine and each other for our mental health; the realisation that we need to live sustainably in a finite world; that mental health care is not scalable like an industrial process; and that it’s only relationships between each other that really matter.

Posted by:
Dr Rex Haigh FRCPsych

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Chris Sampson: Generic benefit measurement – the key to better mental health research

The NHS can’t afford to fund every new medical treatment. Budgets are limited. Resources are finite. It’s a boring fact of life, from which people like me – economists – benefit. In recent years the UK has championed the provision of cost-effective healthcare. The efficiency of the NHS owes no small thanks to NICE, which evaluates health technologies for all kinds of conditions. To do so they need to be able to compare these technologies with each other. The general consensus amongst health economists, and the approach adopted by NICE, is to use quality-adjusted life years (QALYs). QALYs are required by the NICE reference case and we have excellent tools such as the EQ-5D to capture these. The use of QALYs as an outcome is almost ubiquitous in the evaluation of health technologies. So much so that they have come to define cost-effectiveness. The area in which their use and study appears most limited is in mental health research. Herein lies a problem: from the decision-makers perspective, not knowing whether an intervention is cost-effective isn’t all that different from knowing that it isn’t.

Generic preference-based measures

Health technologies are competing for the same pot of NHS money and are therefore pitted against each other, regardless of dissimilarities in the conditions they treat. We therefore need an outcome measure that is relevant to all conditions; from baldness to bunions; abdominal pain to Zellweger syndrome. We need an outcome measure that is ‘generic’. For economists (and to some extent decision-makers), preferences are paramount. A hypothetical change in an individual’s health only matters if they (or, in practice, the public) actually assign any value to this health change. As such, the last few decades have witnessed the rise of generic preference-based measures. The EQ-5D is the most well-know of these, but others do exist. These measures enable researchers to calculate the benefits of an intervention in terms of quality and length of life – combined in to one number. Decision-makers are then presented with an illuminating ‘cost-per-QALY’ of an intervention. Such a minimalist result is of great value in funding decisions. Unfortunately, in many cases, economic evaluations in mental health are not armed with this figure. This is no doubt detrimental to future provision and research.

Condition-specific preference-based measures

Mental health researchers’ apparent unawareness of generic preference-based measures is justifiable. The EQ-5D, for example, only includes a single question relating to mental health. There are also greater methodological problems with using generic preference-based measures in mental health; are public values representative of patients’ preferences; can severe patients understand the questions; are ‘general’ questions even relevant? There are certainly pros and cons to using a measure like the EQ-5D in mental health research1.

Fortunately there’s a happy medium that still allows for the calculation of QALYs and, therefore, the generic valuation of mental health technologies. Condition-specific preference-based measures. These measures capture changes in an individual’s quality of life based on dimensions relevant to specific conditions. The development of a preference-based measure involves two stages: development of the classification system (questionnaire) and the elicitation of values. Unfortunately most existing measures have only completed the first stage. Nonetheless, measures do exist and I implore you to research them further, get involved in their development and include them in your studies. There are measures under development that are specific to particular mental health problems, such as DEMQOL: a quality of life measure for individuals with dementia2. Some of the most promising work relates to the development of preference-based measures that are specific to mental health but general across disorders. This work includes development of a preference-based measure from the CORE-OM3,4.

Where next?

Unfortunately these measures are almost solely employed and researched by economists. Researchers involved in the evaluation of interventions for mental health need to champion these measures, as economists alone cannot. If you’re a researcher, why not try to include fledgling preference-based measures (both general and condition-specific) in your studies, and aid their development. Cost-effectiveness is often an ‘unknown’ in mental health. This is no longer acceptable. If mental health research and care is to obtain the funding it needs, then researchers will have to bend to accommodate these methods and engage with economists. If you do nothing else please read this5, then read this6, and do not forget to read this7. The long-term benefits could be huge.

Posted by:

Chris Sampson
Health economist
University of Nottingham
E: chris.sampson@nottingham.ac.uk


1 Brazier, J., 2010. Is the EQ-5D fit for purpose in mental health? The British Journal of Psychiatry, 197(5), pp.348-9.

2 Mulhern, B., Smith, S.C., Rowen, D., Brazier, J.E., Knapp, M., Lamping, D.L., Loftus, V., Young, T.A., Howard, R.J. and Banerjee, S. (2010) Improving the measurement of QALYs in dementia: Developing patient- and carer-reported health state classification systems using Rasch analysis. Discussion Paper. (Unpublished)

3 Mavranezouli, I., Brazier, J.E., Young, T.A. and Barkham, M. (2011) Using Rasch analysis to form plausible health states amenable to valuation: the development of CORE-6D from CORE-OM in order to elicit preferences for common mental health problems. Quality of Life Research, 20 (3). pp. 321-333. ISSN 1573-2649

4 Mavranezouli, I, Brazier, JE, Rowen, D and Barkham, M (2011) Estimating a preference-based index from the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM): valuation of CORE-6D. Discussion Paper. (Unpublished)

5 Brazier, J., 2008. Measuring and valuing mental health for use in economic evaluation. Journal of health services research & policy, 13 Suppl 3, pp.70-5.

6 Jacobs, R., 2009. Investigating Patient Outcome Measures in Mental Health. CHE Research Paper 48, Centre For Health Economics: York

7 Chisholm, D., Healey, A. & Knapp, M., 1997. QALYs and mental health care. Social psychiatry and psychiatric epidemiology, 32(2), pp.68-75.

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