Management by geographic area or management specialised by disorder?: A mixed methods evaluation of effects of an organisational intervention on secondary mental health care for common mental disorder

Alexander David Tulloch; B Soper; A Görzig; Sophie Pettit; L Koeser; C Polling; A Watson; Mizanur  Khondoker; Diana Rose; Paul Richard McCrone; A Tylee; Graham Thornicroft

doi:10.3310/hsdr04090

Management by geographic area or management specialised by disorder? A mixed methods evaluation of effects of an organisational intervention on secondary mental health care for common mental disorder

Alexander David Tulloch, B Soper, A Görzig, Sophie Pettit, L Koeser, C Polling, A Watson, Mizanur Khondoker, Diana Rose, Paul Richard McCrone, A Tylee, Graham Thornicroft

Centre for Health Economics

Research output: Contribution to journal › Article › peer-review

Abstract

Objectives:We aimed (1) to understand the CAG programme using realistic evaluation and (2) to assess whether or not it led to changes in activity and health-care quality.Methods:Qualitative analysis was based on interviews and project documents. Quantitative analyses were based on electronic patient records and compared care in community mental health teams (CMHTs) and psychotherapy teams before and after CAG implementation. Analyses of activity covered caseload, counts of new episodes, episode length and number of contacts per episode. We also looked at CMHT costs. Analyses of effectiveness covered processes (pharmacological and psychological treatment of depression in CMHTs) and outcomes (effect on the Health of the Nation Outcome Scales total score or the Clinical Outcomes in Routine Evaluation 10-item version total score). Analyses of safety examined the rates of self-harm among current or recent CMHT patients. Patient centredness was represented by waiting time.Results:The first core component of SLaM’s CAG programme was the CAG restructuring itself. The second was the promotion of care pathways; interpreted as ‘high level pathways’, these schematised processes of referral, assessment, treatment, reassessment and discharge, but abstracted from the details of treatment. The three mechanisms of the CAG restructuring were increasing oversight, making teams fit the template of team types defined for each CAG (‘CAG compliance’) and changing financial accounts by grouping services in new ways; these mechanisms resulted in further reconfigurations. The use of high-level pathways supported service redesign and performance management. In CMHTs and psychotherapy teams activity tended to decrease, but this was probably not because of the CAG programme. CMHT costs were largely unchanged. There was no evidence that the CAG programme altered effectiveness or safety. Effects on waiting times varied but these were reduced in some cases. Overall, therefore, the CAG programme appeared to have had few effects on quality. We attributed this to the limited effect of the programme on individual treatment.Conclusions:SLaM’s CAG programme had clear effects on service reconfiguration at team level, with high-level pathways changing the ways that managers conceptualised their work. However, our quantitative work indicated no clear effects on quality. Thinking about how to use care pathways in ways that complement ‘high-level’ pathways by supporting the delivery of evidence-based treatments is a strategy that could help SLaM and other providers. Future research should look at the genesis of organisational change and how this is altered through implementation; it should also look at the effectiveness of care pathways in mental health services.

Original language	English
Journal	Health Services and Delivery Research
Volume	4
Issue number	9
DOIs	https://doi.org/10.3310/hsdr04090
Publication status	Published - Mar 2016

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10.3310/hsdr04090

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Tulloch, A. D., Soper, B., Görzig, A., Pettit, S., Koeser, L., Polling, C., Watson, A., Khondoker, M., Rose, D., McCrone, P. R., Tylee, A., & Thornicroft, G. (2016). Management by geographic area or management specialised by disorder? A mixed methods evaluation of effects of an organisational intervention on secondary mental health care for common mental disorder. Health Services and Delivery Research , 4(9). https://doi.org/10.3310/hsdr04090

@article{c4b88be80c474364ae2acaf2b0f7e26a,

title = "Management by geographic area or management specialised by disorder?: A mixed methods evaluation of effects of an organisational intervention on secondary mental health care for common mental disorder",

abstract = "Objectives:We aimed (1) to understand the CAG programme using realistic evaluation and (2) to assess whether or not it led to changes in activity and health-care quality.Methods:Qualitative analysis was based on interviews and project documents. Quantitative analyses were based on electronic patient records and compared care in community mental health teams (CMHTs) and psychotherapy teams before and after CAG implementation. Analyses of activity covered caseload, counts of new episodes, episode length and number of contacts per episode. We also looked at CMHT costs. Analyses of effectiveness covered processes (pharmacological and psychological treatment of depression in CMHTs) and outcomes (effect on the Health of the Nation Outcome Scales total score or the Clinical Outcomes in Routine Evaluation 10-item version total score). Analyses of safety examined the rates of self-harm among current or recent CMHT patients. Patient centredness was represented by waiting time.Results:The first core component of SLaM{\textquoteright}s CAG programme was the CAG restructuring itself. The second was the promotion of care pathways; interpreted as {\textquoteleft}high level pathways{\textquoteright}, these schematised processes of referral, assessment, treatment, reassessment and discharge, but abstracted from the details of treatment. The three mechanisms of the CAG restructuring were increasing oversight, making teams fit the template of team types defined for each CAG ({\textquoteleft}CAG compliance{\textquoteright}) and changing financial accounts by grouping services in new ways; these mechanisms resulted in further reconfigurations. The use of high-level pathways supported service redesign and performance management. In CMHTs and psychotherapy teams activity tended to decrease, but this was probably not because of the CAG programme. CMHT costs were largely unchanged. There was no evidence that the CAG programme altered effectiveness or safety. Effects on waiting times varied but these were reduced in some cases. Overall, therefore, the CAG programme appeared to have had few effects on quality. We attributed this to the limited effect of the programme on individual treatment.Conclusions:SLaM{\textquoteright}s CAG programme had clear effects on service reconfiguration at team level, with high-level pathways changing the ways that managers conceptualised their work. However, our quantitative work indicated no clear effects on quality. Thinking about how to use care pathways in ways that complement {\textquoteleft}high-level{\textquoteright} pathways by supporting the delivery of evidence-based treatments is a strategy that could help SLaM and other providers. Future research should look at the genesis of organisational change and how this is altered through implementation; it should also look at the effectiveness of care pathways in mental health services.",

author = "Tulloch, {Alexander David} and B Soper and A G{\"o}rzig and Sophie Pettit and L Koeser and C Polling and A Watson and Mizanur Khondoker and Diana Rose and McCrone, {Paul Richard} and A Tylee and Graham Thornicroft",

year = "2016",

month = mar,

doi = "10.3310/hsdr04090",

language = "English",

volume = "4",

journal = "Health Services and Delivery Research ",

issn = "2050-4349",

publisher = "NIHR Journals Library",

number = "9",

}

Tulloch, AD, Soper, B, Görzig, A, Pettit, S, Koeser, L, Polling, C, Watson, A, Khondoker, M, Rose, D, McCrone, PR, Tylee, A & Thornicroft, G 2016, 'Management by geographic area or management specialised by disorder? A mixed methods evaluation of effects of an organisational intervention on secondary mental health care for common mental disorder', Health Services and Delivery Research , vol. 4, no. 9. https://doi.org/10.3310/hsdr04090

Management by geographic area or management specialised by disorder? A mixed methods evaluation of effects of an organisational intervention on secondary mental health care for common mental disorder. / Tulloch, Alexander David; Soper, B; Görzig, A et al.
In: Health Services and Delivery Research , Vol. 4, No. 9, 03.2016.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Management by geographic area or management specialised by disorder?

T2 - A mixed methods evaluation of effects of an organisational intervention on secondary mental health care for common mental disorder

AU - Tulloch, Alexander David

AU - Soper, B

AU - Görzig, A

AU - Pettit, Sophie

AU - Koeser, L

AU - Polling, C

AU - Watson, A

AU - Khondoker, Mizanur

AU - Rose, Diana

AU - McCrone, Paul Richard

AU - Tylee, A

AU - Thornicroft, Graham

PY - 2016/3

Y1 - 2016/3

N2 - Objectives:We aimed (1) to understand the CAG programme using realistic evaluation and (2) to assess whether or not it led to changes in activity and health-care quality.Methods:Qualitative analysis was based on interviews and project documents. Quantitative analyses were based on electronic patient records and compared care in community mental health teams (CMHTs) and psychotherapy teams before and after CAG implementation. Analyses of activity covered caseload, counts of new episodes, episode length and number of contacts per episode. We also looked at CMHT costs. Analyses of effectiveness covered processes (pharmacological and psychological treatment of depression in CMHTs) and outcomes (effect on the Health of the Nation Outcome Scales total score or the Clinical Outcomes in Routine Evaluation 10-item version total score). Analyses of safety examined the rates of self-harm among current or recent CMHT patients. Patient centredness was represented by waiting time.Results:The first core component of SLaM’s CAG programme was the CAG restructuring itself. The second was the promotion of care pathways; interpreted as ‘high level pathways’, these schematised processes of referral, assessment, treatment, reassessment and discharge, but abstracted from the details of treatment. The three mechanisms of the CAG restructuring were increasing oversight, making teams fit the template of team types defined for each CAG (‘CAG compliance’) and changing financial accounts by grouping services in new ways; these mechanisms resulted in further reconfigurations. The use of high-level pathways supported service redesign and performance management. In CMHTs and psychotherapy teams activity tended to decrease, but this was probably not because of the CAG programme. CMHT costs were largely unchanged. There was no evidence that the CAG programme altered effectiveness or safety. Effects on waiting times varied but these were reduced in some cases. Overall, therefore, the CAG programme appeared to have had few effects on quality. We attributed this to the limited effect of the programme on individual treatment.Conclusions:SLaM’s CAG programme had clear effects on service reconfiguration at team level, with high-level pathways changing the ways that managers conceptualised their work. However, our quantitative work indicated no clear effects on quality. Thinking about how to use care pathways in ways that complement ‘high-level’ pathways by supporting the delivery of evidence-based treatments is a strategy that could help SLaM and other providers. Future research should look at the genesis of organisational change and how this is altered through implementation; it should also look at the effectiveness of care pathways in mental health services.

AB - Objectives:We aimed (1) to understand the CAG programme using realistic evaluation and (2) to assess whether or not it led to changes in activity and health-care quality.Methods:Qualitative analysis was based on interviews and project documents. Quantitative analyses were based on electronic patient records and compared care in community mental health teams (CMHTs) and psychotherapy teams before and after CAG implementation. Analyses of activity covered caseload, counts of new episodes, episode length and number of contacts per episode. We also looked at CMHT costs. Analyses of effectiveness covered processes (pharmacological and psychological treatment of depression in CMHTs) and outcomes (effect on the Health of the Nation Outcome Scales total score or the Clinical Outcomes in Routine Evaluation 10-item version total score). Analyses of safety examined the rates of self-harm among current or recent CMHT patients. Patient centredness was represented by waiting time.Results:The first core component of SLaM’s CAG programme was the CAG restructuring itself. The second was the promotion of care pathways; interpreted as ‘high level pathways’, these schematised processes of referral, assessment, treatment, reassessment and discharge, but abstracted from the details of treatment. The three mechanisms of the CAG restructuring were increasing oversight, making teams fit the template of team types defined for each CAG (‘CAG compliance’) and changing financial accounts by grouping services in new ways; these mechanisms resulted in further reconfigurations. The use of high-level pathways supported service redesign and performance management. In CMHTs and psychotherapy teams activity tended to decrease, but this was probably not because of the CAG programme. CMHT costs were largely unchanged. There was no evidence that the CAG programme altered effectiveness or safety. Effects on waiting times varied but these were reduced in some cases. Overall, therefore, the CAG programme appeared to have had few effects on quality. We attributed this to the limited effect of the programme on individual treatment.Conclusions:SLaM’s CAG programme had clear effects on service reconfiguration at team level, with high-level pathways changing the ways that managers conceptualised their work. However, our quantitative work indicated no clear effects on quality. Thinking about how to use care pathways in ways that complement ‘high-level’ pathways by supporting the delivery of evidence-based treatments is a strategy that could help SLaM and other providers. Future research should look at the genesis of organisational change and how this is altered through implementation; it should also look at the effectiveness of care pathways in mental health services.

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DO - 10.3310/hsdr04090

M3 - Article

SN - 2050-4349

VL - 4

JO - Health Services and Delivery Research

JF - Health Services and Delivery Research

IS - 9

ER -