Rethinking Clinical Audit

Psychotherapy Services in the NHS

Rachael Davenhill, Matthew Patrick, Rachael Davenhill, Matthew Patrick

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781317725206
• Edition: 1
• Topic: Geschichte
• Subtopic: Britische Geschichte der Neuzeit

Clinical audit can be a powerful tool for change, but is often perceived as externally-imposed time-wasting. Focusing on applications of clinical audit in psychoanalytic psychotherapy NHS services, the authors examine why audit is resented, how it can be 'reconstructed' as a useful tool for clinicals, and provide real-life examples of good practice. More than a simple 'how-to', this book provides new rnderstanding of a persistent problem in health-care organisations and will be of interest to all mental health staff, trainees and service managers.

Chapter 1

Psychotherapy services, healthcare policy and clinical audit

Glenys Parry

The policy context

The policy context for clinical audit in psychotherapy is rich and varied. To understand it we need to review briefly the historical and current role of psychotherapy in health services, the influence of macroeconomic factors and recent policy developments on evidence-based health care and clinical effectiveness.

The major advances in psychotherapeutic treatments over the last forty years have been fostered by the National Health Service (NHS) and, in turn, are reflected in NHS services. However, psychological therapies predate the NHS. Earliest psychological treatments were largely psychoanalytic and, before the Second World War, were available to only a relative few, mainly in London. With the birth of the NHS in 1946, these treatments were made available to NHS patients in London through the Tavistock Clinic, which began to treat NHS patients in 1948. Psychoanalytic treatments continued to be developed in the UK and child psychoanalytic therapy was offered to children through the creation of NHS-funded child psychotherapist posts. The emergence of behaviourism as a theoretical force in the 1940s also had a profound influence on psychological treatments, as during the 1950s and 1960s theories of learning derived from animal experimentation were applied to humans, bringing experimental methods to human psychological processes. By the 1960s behavioural treatments were available in many mental health services throughout Britain. Then the so-called ‘cognitive revolution’ in academic psychology during the 1960s was followed by a new emphasis on cognitive processes in therapy. The application of specific cognitive techniques to depression and anxiety now extends to other neurotic disorders, personality disorders, psychosis, functional syndromes and physical illness. During the early 1970s the gulf between psychoanalysis and behaviourism was filled with an explosion of ‘new’ therapies, based variously on ‘humanistic’, ‘experiential’, ‘constructivist’ and ‘existential’ approaches. These were largely developed outside the NHS, in the self-styled ‘human potential movement’, although they have had an important influence within NHS services. Client-centred counselling, in particular, continues to be practised within the NHS, mainly within primary care. As cognitive behavioural therapies became more widely practised during the 1970s and 1980s, the field of psychoanalytic therapy continued to develop in parallel, with briefer, focal psychodynamic treatments, psychoanalytic groups, therapeutic communities and systemic family therapies becoming available within the NHS.

With an ever greater number of therapies being applied to a wider range of problems during the 1980s, many NHS professionals used a range of clinical techniques quite pragmatically, rather than training within a particular school. Recently, interest in pan-theoretical and integrationist therapies has burgeoned, for example through cognitive analytic therapy. In addition to psychological therapies developed and practised by specialists, the influence of these approaches has been widely felt within generic mental health professional practice, for example psychiatry and mental health nursing. Psychological therapies commonly conducted within mental health services by these professions include cognitive behavioural approaches, eclectic approaches, counselling and psychosocial interventions. These services have developed alongside a more general appreciation of the psychological aspects of physical health, and increasing public and media awareness of ‘talking therapies’.

Despite the proliferation of therapeutic work within mental health services, until recently there was no formal Department of Health policy recognition that psychological therapies are widely practised within the NHS, and, although specialist services remain small and relatively poorly resourced, the overall provision of psychological therapies in the broader sense represents a significant public funding investment. Pressure on NHS funding in successive years has been experienced by NHS staff as threatening the basis of their services, and, indeed, funding to some services has been cut. These cost pressures need to be understood in a broader fiscal context.

Internationally, the costs of health care have increased and will continue to do so, as available health technologies proliferate and public expectations of better health services rise. Public demand for health interventions as they become available has outstripped health investment from direct taxation. Although the UK spends relatively little on health care – as a proportion of gross domestic product (GDP) – compared with other European countries or the US, the rate of growth of costs in the health sector is comparable, with similar results. Those responsible for third-party payment in health care – whether payment by government revenue, health insurance or employers – in the UK and elsewhere are concerned with (some might say preoccupied by) cost containment. The issue of which interventions for which conditions should be funded from public revenue through direct taxation is not likely to diminish, and will continue to influence the psychotherapies.

There has been a parallel concern to base health policy and management decisions on evidence of clinical effectiveness and to promote better standards of healthcare interventions (Muir Gray 1997). This concern arose first within hospital medicine, when wide variations in practice and outcomes were observed between physicians, leading to doubts about the reliability of procedures for medical decision-making. The resulting movement in evidence based medicine (EBM) aimed to help doctors make rational clinical decisions on the best available evidence and has now developed into a considerable industry, with a proliferation of books, journals, World Wide Web (WWW) pages, CD-ROMs and Internet discussion groups dedicated to pursuing this aim (Sackett et al. 1997). EBM has also generated considerable debate, with critics of EBM attacking the movement as arrogant, platitudinous, biased in its claims, and committing two cardinal sins against clinical medicine, ‘the barely concealed view that scientific data are an adequate basis for clinical decision making and the conviction that there can be absolute authority to identify and recommend the “best external evidence”’ (Miles et al. 1997).

Evidence based health care takes the logic of EBM into broader multidisciplinary practice, into community health care, general practice and purchasing decisions. It evaluates the effectiveness of healthcare interventions through a rigorous programme of health services research, conducted to high scientific standards, then disseminates the results of research in intelligible and useful forms to the organizations and individuals who need to know. The point is to use the results of research to change clinical practice and the provision of health care.

‘Managed care’ initiatives, particularly in the USA, have attempted to address both cost and effectiveness concerns through the greater use of clinical practice guidelines and reimbursement decisions to change clinician behaviour (Schwartz and Brennan 1997). These initiatives are controversial: concern has been expressed by some clinicians that they damage the relationship between clinician and patient and can paradoxically lower standards of care, whereas others have accommodated to them and have changed their clinical practices in response (Austad and Berman 1991). The debate suggests that some moves to contain costs leave many clinicians suspicious of demands for evidence based practice, and it generates adversarial processes between funders, clinicians and researchers.

Within the UK, the NHS has so far avoided the approach of making funding dependent on compliance with care protocols. However, there is an explicit commitment to drive policy and make commissioning decisions on the basis of research evidence of what is clinically and cost-effective. This includes assessing evidence of need for a service or an intervention (basically defined in terms of people’s capacity to benefit) and the measurable health gain for a given investment of revenue, sometimes expressed in terms of cost/utility ratios, or £/quality-adjusted life-year (QALY). This is a prospect which often provokes strong feelings. Some people argue that, ethically, some generic measures of health benefit in relation to cost are essential in an equitable and transparent allocation of limited resources. Others, equally appalled at the prospect, are also equally convinced that there are no such easy utilitarian solutions to complex issues of power and value in the use of resources.

There has been growing investment within the NHS in health service research and development (R&D), with greater emphasis on specifying research priorities on the basis of health service needs and then commissioning research to meet these, with relatively less funding for ‘curiosity-driven’ research. NHS research is supported in several ways: central commissioning (including a health technology assessment programme), local commissioning through Regional Offices, indirect support through the health services research initiatives of the Medical Research Council, and direct funding of Trusts’ research support costs (Culyer 1994).

The Department of Health review of strategic policy in NHS psychotherapy services

The policy drive towards a knowledge-based healthcare system has, as yet, hardly influenced the provision of psychotherapies. However, the policy framework for such developments has recently been established. In 1996 the Department of Health published its first formal statement on good practice in psychotherapy services, having undertaken a review of these services in the NHS in England (Department of Health 1996). This strategic policy review included consultation within the NHS, with professional associations and with organizations representing consumers. It found that the unitary term ‘psychotherapy’ is often unhelpful and misleading, being used to mean entirely different things in different contexts. There is a need to specify which type of NHS provision is referred to, and a simple framework was proposed describing three types of psychotherapy delivery: type A refers to psychological treatments integral to wider mental healthcare programmes; type B refers to eclectic psychological therapies and counselling; and type C is formal psychotherapy based on a single theoretical approach.

The key policy messages from this review can be summarized briefly. Psychological treatments are an important part of mainstream mental health care, one of two main classes of treatment. If well conducted and appropriate for the presenting problem, there is evidence that they can be clinically effective. Within the NHS, demand for these therapies outstrips supply, and there are long waiting lists. However, the review also found evidence of poorly targeted, inappropriate interventions, ineffective organization, and poorly coordinated services, leading to wasted resources.

The current policy framework sets out five aims for NHS psychotherapy services. There should be comprehensive provision to meet needs of people for all three types of therapy services. Services should be coordinated, for example better links between primary and secondary care and brokerage assessment for treatment of choice to avoid sequential assessment. Services should be user-friendly and accessible, taking into account the preferences and social circumstances of service users and providing good information to patients. Psychotherapy should be safe, minimizing the risk of harm to patients through therapist incompetence or inappropriate treatment. Finally, psychotherapy services should be clinically and cost-effective, based on best research and clinical evidence of what is likely to be most helpful.

There are several implications of this for NHS Trusts and psychological therapists working in the NHS. The policy direction is towards a more systematic approach between different services within a Health District, e.g. psychology services, psychodynamic therapy, cognitive behavioural therapy, primary-care counselling, with agreed joint guidelines on criteria for referral and cross-referral, shared core assessment and audit processes, including agreement on which outcomes measures should be routinely used.

Placing psychotherapies on the mainstream mental health policy agenda, if indeed achievable, is more likely to have long-term than short-term effects. The desired consequences would include increased legitimacy for psychotherapy provision within the NHS and an improved mandate for practice, training, audit and research. It is too soon to judge whether this will happen or, if it does, whether it will have a beneficial effect on revenue flows for these activities, but early signs are encouraging, at least within research and clinical effectiveness.

Psychological and psychotherapeutic topics are at last emerging within a number of government- and charity-funded initiatives. A Cochrane Collaboration in neuroses has been established to build a systematically reviewed database of controlled trials, using rigorous search criteria and including psychotherapy research. The NHS Executive Health Technology Assessment Programme has funded research into the efficacy of counselling and is likely to fund further psychotherapy-related work. The Wessex Regional Development Evaluation Committee appraises systematic cost-effectiveness reviews on behalf of health authorities, and has recently examined therapeutic communities for personality disorder and cognitive behavioural therapy for chronic fatigue syndrome. A psychotherapy research initiative has been launched by the Mental Health Foundation, funding research into a common core battery of outcome measures for psychotherapy and work on therapeutic competence in transference interpretation. The Department of Health has recently funded the British Psychological Society Centre for Outcomes Research Evaluation to develop national clinical practice guidelines for treatment-of-choice decisions in psychotherapy and counselling. The implementation of the Culyer Report (Culyer 1994) in providing research support funding to NHS Trusts also offers opportunities for psychotherapy developments.

The Department of Health review does not recommend a list of ‘validated therapies’ to service commissioners and, indeed, recommends caution in basing funding decisions solely on the existing base of research evidence in this field. It notes that there is a notable absence of outcome research on some widely practised therapies and also that the weaknesses of psychotherapy research in relation to external validity are severe. Furthermore, research compares treatments within diagnostic groups, whereas other factors will govern the clinical choice of therapy, such as the patient’s capacity to form a therapeutic alliance or to tolerate anxiety, or the level of social support available to them. Outcome measurement in this research continues to be problematic, for example in relation to levels of functioning or quality of life, and, although well-designed group comparisons can yield results which are generally true, the specific applicability of these findings to the individual case remains a matter for clinical judgement. A review of research findings on the efficacy of psychotherapy was commissioned as part of this work and published separately (Roth and Fonagy 1996).

Instead of ‘prescriptive’ commissioning, an alternative way of fostering evidence based psychotherapies was recommended in the review and is also summarized by Roth et al. (1996). Clinical audit plays a significant role here, but forms part of a wider strategy. This strategy recommends single-case studies and case-series evaluation of innovative practice prior to formal research. Research findings are then incorporated into clinical practice guidelines and other influences on psychotherapists’ clinical decision-making. Research and clinical consensus, sometimes formalized in guidelines, can be used as the basis for setting audit standards and benchmarking outcomes. These activities should also influence education and training in the psychotherapies.

The recommended approach depends on psychotherapists being able to achieve a level of consensus on standardized practices and to specify them more clearly. It can be argued that the current absence of consensus in this field damages the credibility of psychotherapy as an evidence based, replicable form of treatment in mental health. The task of achieving consensus may not be as impracticable as is sometimes thought; for example, when psychotherapists move from arguing abstractions to formulating single cases, significant levels of agreement can be obtained (Persons et al. 1991). Psychotherapeutic formulation in routine clinical practice has also been shown to have considerable validity in terms of formal research instruments (Bennett and Parry 1997).

Standardized practice, clinical practice guidelines, therapy protocols, etc. should not be used prescriptively. Psychotherapists are wary of the concept of clinical protocols and guidelines, seeing them as a threat to clinical freedom, but clinical guidelines can be used to benchmark best practice and as an aid to clinical judgement. They should be informed by service-evaluation evidence, formal research findings and clinical consensus. Research evidence is incorporated into standard clinical practice through these protocols, but it is the prerogative of the clinician to make a judgement in the individual case, on the basis of assessment an...