Billy Boland: Broken legs—the holy grail of outcome measures in mental health

Outcomes in mental health are getting a lot of attention of late. A troublesome concept for us; how do we measure what we do? Measurement is central to quality improvement (QI), as QI is all about change. In order to consider whether the work we are doing is having an impact, we need an indicator. Otherwise how would we know if anything was happening?

I find myself talking about broken legs when I’m explaining the challenge, though to be fair, it’s a while since I’ve seen one of them. The analogy is that a broken leg is either broken or it isn’t. Most people (including the patient) can agree whether it’s broken. The treatment is clear, the course of recovery is predictable, and it is obvious when no further treatment or care is required.

Ok, Ok, so I’m aware that this is a massive over simplification. But contrast it with mental health problems. Where is the cut off between misery and depression? Where does “normal” anxiety end and an anxiety disorder begin? How do you describe the range of challenges someone with a personality disorder faces?

The way we are trying to tackle this (and how we are being guided by NHS England) is similar to how other branches of medicine are approaching it; in using PROMS (Patient reported outcome measures), PREMS (Patient reported experience measures) and CROMS (Clinician reported outcome measures). Some infrastructure is already present for us to be able to do some of this e.g. We already use the Friends and Family Test in mental health services in England—a type of PREM. We even use a CROM—the Health of the Nation Outcome Scale (HoNOS) as part of our arrangements with commissioners. This is used as part of the national “care cluster currency” in the NHS in England, and data must be submitted by all providers for working age and older adults to NHS Digital as part of the mental health dataset.

However, as yet there is no universal national PROM, and one might see why. Given the diversity of issues we tackle in mental health, it is a huge challenge to find a one size fits all tool that can cover the whole population. And the need for agreement is pressing.

It is no coincidence that the five year forward view for mental health saw specific investment go to areas that are relatively further ahead when it comes to evidencing what they do. Services such as early intervention in psychosis services have done well in making compelling cases for investment, and notably have a number of nationally agreed PROMS (including the DIALOG and Process of Recovery Questionnaire (QPR)). Other mental health services are playing catch up, but there is hope. For example, the National Collaborating Centre for Mental Health has been commissioned by NICE to develop community mental health service pathway guidance, and they are expecting to make some recommendations about outcomes including PROMs towards the end of the year.

There’s a long road ahead. Once our range of outcomes are agreed, we need to mobilise to make sure we measure them regularly and reliably, record them in a way that is accessible, and be able to make use of them meaningfully. We’ve a lot to learn from broken legs that have gone before, but patients and carers deserve that we get this right.

Billy Boland is consultant psychiatrist in community psychiatry, Hertfordshire Partnership University NHS Foundation Trust, Deputy Medical Director, Hertfordshire Partnership University NHS Foundation Trust, and Vice Chair (elected), Faculty of General Adult Psychiatry, Royal College of Psychiatrists.

Competing interests: Vice chair role at RCPsych as the faculty has been collaborating within the college to produce recommendations around outcomes.