The emphasis on health outcomes and information systems to support service quality improvement has been gaining momentum in the wider health sector for several years. Increasing focus is being given to the responsibility of health care providers to use outcome measures to contribute to the ongoing review and development of clinical practice as well as to inform health service planning, policy development and the broader community.
Within the mental health field, the regular assessment of consumer outcomes has been a priority of the National Mental Health Strategy since it was first agreed by Health Ministers in 1992. The National Mental Health Policy includes as one of its original objectives:
"To institute regular review of client outcomes of services provided to persons with serious mental health problems and mental disorders as a central component of mental health service delivery." 9
The concept was simple but ambitious in the context of the poor status of information in mental health services in the early 1990s. Most services did not routinely collect basic clinical and service delivery data nor have systems capable of timely analysis and reporting of such data to inform clinical care. Simple and reliable instruments for measuring consumer outcomes were not available at the commencement of the Strategy, nor was a set of candidate measures evident. Perhaps more significantly, there were few precedents to follow as no other country had established routine consumer outcome measures comprehensively across their publicly funded mental health services.
In response, a research and development program was initiated early in the Strategy to identify measures of outcome that were feasible for use in routine clinical practice with adult consumers, resulting in the selection of a small set of standard measures that were put to trial.10,11 Similar work was undertaken in relation to outcome measures for use in child and adolescent mental health services.12
Implementation of the selected measures in public sector mental health services commenced under the Second National Mental Health Plan and was a central objective of the 'first edition' statement of national mental health information priorities released in 1999. All States and Territories prepared comprehensive Information Development Plans to guide their implementation activities. A summary of the outcome measures selected for use in public sector services is shown in table 1.
Recognising the complexity of the work required and its national significance, the Australian Government contributed substantial funding to assist States and Territories to implement their plans and support a range of related quality and safety initiatives in specialist mental health care. This was made available through bilaterally negotiated 'Information Development Agreements'.
Implementation of the 'simple concept' articulated in 1992 has taken the mental health sector into a period of major industry re-development and involved all public mental health services. By June 2003:
- approximately 57% of Australian public mental health services had commenced the process of consumer outcome measurement (figure 2);
- an estimated 10,000 clinicians had participated in training sessions for the collection and use of outcome information, representing approximately 60% of the public sector mental health workforce;
- information systems in all States and Territories had been overhauled, or commenced the upgrade process, to accommodate the new requirements (see section 2.8); and
- States and Territories began the process of pooling data at the national level, contributing approximately 70,000 de-identified records for which outcome data had been collected.
Table 1: Consumer outcome measures introduced in public sector mental health servicesTable 1 is presented as text in this HTML version for accessibility reasons. It is presented as a table in the PDF version.
Clinician-rated outcome measurement scales:
- Health of the Nation Outcome Scales (HoNOS) - used to measure outcomes for adults
- Health of the Nation Outcome Scales for Older People (HoNOS 65+) - used to measure outcomes for older people
- Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA) - used to measure outcomes for children and adolescents
- Life Skills Profile (abbreviated version) (LSP-16) - used to measure outcomes for adults and older people
- Mental Health Inventory (MHI), Behaviour & Symptom Identification Scale (BASIS-32), Kessler-10 (K10)* - used to measure outcomes for adults and older people
- Strengths & Difficulties Questionnaire (SDQ) - used to measure outcomes for children and adolescents
Figure 2: National progress of services routinely collecting mental health outcomes
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Text version of figure 2National progress of services routinely collecting mental health outcomes:
- December 2000 - 0%
- June 2001 - 3%
- December 2001 - 12%
- June 2002 - 21%
- December 2002 - 27%
- June 2003 - 57%
9 Australian Health Ministers (1992). National Mental Health Policy. Australian Government Publishing Service, Canberra.
10 Andrews G, Peters L and Teeson M (1994). The Measurement of Consumer Outcome in Mental Health: A Report to the National Mental Health Information Strategy Committee. Australian Government Publishing Service, Canberra.
11 Stedman T, Yellowlees P, Mellsop G, Clarke R and Drake S (1997). Measuring Consumer Outcomes in Mental Health: Field Testing of Selected Measures of Consumer Outcomes in Mental Health. Department of Health and Aged Care, Canberra.
12 Bickman L, Nurcombe B, Townsend C, Belle M, Schut J and Karver M (1999). Consumer Measurement Systems for Child and Adolescent Mental Health. Department of Health and Aged Care, Canberra.