Bringing Value Based Healthcare to a mental health pathway

Dr Rumina Taylor, Value Based Healthcare Mind & Body Lead at King's Health Partners, talks through her work enabling staff, service users and carers to lead system changes in improving quality and outcomes.

Almost two years ago, Dr Rumina Taylor blogged about ways of encouraging people to lead the kind of system changes that improve outcomes for patients. In this blog, Rumina provides an update on her work and future plans. 

I have been at King’s Health Partners now for almost two years! In that time, I have been working with the Psychological Medicine and Older Adults Directorate (PMOA) to improve value within their depression pathway. The PMOA is part of the South London and Maudsley NHS Foundation Trust. The work we have been doing supports the trust’s ‘Changing Lives’ strategy to deliver on value and support best quality outcomes. Our project specifically aimed to identify ways to extract data and cost information in order to understand key factors that influence patient flow and ultimately improve outcomes that matter to service users, their families and carers. The first phase of this work is now complete, so it is a great time for me to provide an update as to how we have got on with implementing Value Based Healthcare in a mental health care pathway. 

Why depression in older adults? 

Depression affects around 20% of people over 65 years-of-age living in the community and 22% of older adults cite mental health as one of their primary concerns as they age. Depression in older adults substantially (27%) increases risk of coronary heart disease and stroke over ten years, even after adjustment for traditional risk factors, such as disability, antidepressant use and dementia. Older people can often respond well to treatments such as medication and psychological therapies, and in some cases respond better than people in other age groups. 

What did we do? 

In order to understand a service user’s journey and related costs through the depression pathway, we looked at patients with depression from two community mental health teams, who had previously been under the care of the South London and Maudsley NHS Foundation Trust. We mapped their journey of care, associated resources such as costs, and looked at two key questionnaires they completed whilst being treated for depression: 

  1. The Health of the Nation Outcome Scales 65+ (HoNOS), a clinician rated measure with 12 scales assessing behaviour, symptoms, physical and cognitive impairment, and social functioning
  2. The Hospital Anxiety and Depression Scale (HADS), a patient reported 14-item questionnaire designed to assess anxiety and depression symptoms. 

To optimise value within the NHS, we need to really understand outcomes and resources across the full pathway of care. This means talking to service users and staff about health outcomes that matter to them. Therefore, in addition to mapping the pathway, we conducted interviews with current service users with depression and care professionals working in mental health teams to define the outcomes that matter to them. 

What did we find? 

Data from 72 service users with a depression diagnosis who had completed their treatment were included. Their average age was 75, and the majority of the group were female. Most people had received a recurrent or moderate depression diagnosis. The majority of participants described their ethnicity as British, although there was a wide distribution of ethnicity. 

Service user’s depression got better as they moved through the care pathway and 81% improved across all diagnoses. Improvements were also reported in relationships, daily living skills, and engagement with occupation and activities. 

As expected, more severe depression diagnoses were associated with increased resources and a greater number of illness episodes, but not necessarily more time within the care pathway. Interestingly, those with recurrent depression were also found to need on average higher resources, have a greater number of illness episodes, and long times within the care pathway. However, service user care for recurrent presentations was predominately provided by community, rather than inpatient services, and there was greater use of liaison and home treatment services.  

When we met with staff and service users, we asked them about the questionnaire assessments used in the depression pathway. Service users fed back that both measures routinely used were relevant to their experiences and provided a good overall picture of their needs. They felt it was important to be asked about the history and potential causes of their depression in addition to the questionnaires, so their care team could gain a full understanding of their experiences.  

Care professionals fed back the importance of holistic assessment and said the HoNOS was more helpful in supporting them to achieve this. They described the HADS as good for informing treatment and valued it as it was completed by service users themselves. Staff were keen to get more feedback from their managers about the outcomes the teams were achieving. They requested more specific guidance about the best times to complete assessments and questionnaires with service users. There were also practical suggestions to make collecting outcome measures easier, such as fully integrating them within the patient notes system.  

What does it all mean? 

This initial pilot identified a way to use Value Based Healthcare methodology within mental health. By doing this, we can try to truly understand outcomes that matter to service users and staff, and the resources required to deliver those outcomes. This has the potential to enable us to identify and support older people who may be living with depression, and redirect those who would benefit from accessing care to the most appropriate professional across the full pathway of care. Understanding how to improve outcomes for a population as a whole, not just those who manage to access services, is critical as it ensures equity, reduces inequalities and increases long-term value. 

Some of our initial learning concludes that we need to explore: 

  • How to develop a consistent protocol for the completion of outcome measures
  • How to foster more transparent communication with staff regarding the administration of assessments and findings 
  • How PMOA can further integrate outcomes. For example, through staff training and providing feedback on outcome measures, which is crucial, and prompts within the patient notes system.  

We are planning on continuing our work on value with PMOA, so watch this space! 

Learn more about Value Based Healthcare at King's Health Partners.