Thursday, 9 October 2014

The drawbacks of mental health targets

I see the Guardian is impressed with Nick Clegg's speech.  They didn't like everything - how could they? - but they were right that it was a speech of confidence from a leader, as they said, "at ease with himself".

I think this was right.  It was impressively delivered and it was a powerful case, uncompromising in some respects.  Even for someone like me who is instinctively nervous about 'split the difference' messages.  I'm not sure the case for a middle way could have been put better.

But then it was more than that.  The final line of the speech put this most starkly:

"The only party who says no matter who you are, no matter where you are from, we will do everything in our power to help you shine..."

That is the message of Liberalism in all ages and it was good to hear it.  But there was a story at the heart of the speech - the targets for mental health waiting times - and it has got a good deal of publicity.  It certainly is important given the appalling state of mental health services, but I am sceptical about the use of targets and seems worth saying so now.

I fully accept that, when the rest of the NHS has targets for waiting times, then any service which doesn't will get corroded.  It is a kind of beggar-my-neighbour approach.  I'm even prepared to except the idea, from the King of Blairite Targets Michael Barber, that very poor services need a shock dose of targets to start with.

But you only have to see what contractual targets are already doing to talking therapies in the NHS to realise there is a problem.  A recent report by Chester University set out some of the effects of the combination of Any Qualified Provider and Payment By Results (PbR) on psychological therapies.  They found that the combination of tariff structure “produces widespread perverse incentives for providers and perverse outcomes for patients.” 

These were that:
  • The tariff and PbR becomes a factor in the decision to take patients on, and the type of treatment to offer them.
  • There is a destabilisation and some deterioration in service and a destabilisation of provider organisations affecting their viability. 
  • The pressure of mechanistic throughput of patients affects decision-making and quality. 
  • There are financial incentives to misuse measurement scales within therapy to improve measured outcomes and trigger payments, when these measurement scales were not designed or validated as a payment method. 
There was already “severe strain” among providers in the Any Qualified Provider areas for talking therapies, and it meant that they were taking on work against their professional judgement.

One anonymous large provider had been threatened with insolvency because the tariffs had been set too low and commissioners had been forced to recommission the service, at great expense.  It is true that the new arrangements had reduced the waiting list, but that had been a factor in the gaming by providers – with less demand, they were being forced to rely on the throughput of patients who might not really have needed the service.

One provider told the report authors:

“There is a distinct danger that I am aware of. In stepped care, if a client has only one session it is considered as no therapy and no payment. If it is two sessions, the therapy is considered completed and therefore the provider can claim a flat rate. It makes a slightly perverse model where some rogue organisation might be able to get a sizeable fee just by offering two sessions and claiming a flat fee. There’s a bit of a joke in some circles that ‘oh, all I need to do is deliver my two sessions’.”

On the other hand, so many providers were unable to meet the requirements of commissioning or could not afford the tariffs. Patients were also being rejected because they did not fit the ‘recovery model’, the timescale set down before therapies were supposed to be effective.

I understand that announcing waiting time targets for mental health has huge political and symbolic significance.  But it won't solve the basic problem, and we may find it gets in the way - as all these forms of administration-by-numbers tend to do.

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