Indicator 23: Mental health outcomes for people who receive treatment from state and territory services and the private hospital system

Key messages:

• Around three quarters of consumers admitted to state and territory public sector mental health inpatient services improve significantly, just under one quarter show no change, and a small percentage deteriorate. This pattern also holds true in private psychiatric hospital units.
• In state and territory community services, the picture depends on the nature of the episode of care. Fifty per cent of those who receive relatively short term care and are then discharged improve significantly, 42% show no change, and 8% deteriorate. Twenty six per cent of those who receive longer term, ongoing care show significant improvement, 58% show no change, and 15% deteriorate.
• This picture is complex and requires careful interpretation in light of the goals of care within each setting and for each type of episode and the limitations of the measurement process. Further work needs to be done to determine what outcomes are consistent with a service system offering 'best practice' care across the board.

The ultimate arbiter of success of the mental health service system is whether it leads to improved outcomes for consumers. Improving the quality and effectiveness of mental health services has been firmly on the agenda in Australia since the inception of the National Mental Health Strategy in 1992.

One of the specific objectives of the original National Mental Health Policy, released in the first year of the Strategy, was 'to institute regular review of ... outcomes of services provided to persons with serious mental health problems and mental disorders as a central component of mental health service delivery.' Since that time, Australia has invested heavily in establishing a standardised system for the routine monitoring of consumer outcomes that has been the focus of extensive activity in state and territory mental health services and the private hospital sector, with support from the Australian Government. The goal has been to develop standard measures of consumers' clinical status and functioning and apply these at entry to and exit from care to enable change to be measured. For consumers who require longer term care, the measures are applied at review points every three months. A number of different measures are used, some of which are completed by clinicians and some of which are completed by consumers themselves. These repeated assessments allow changes in consumers' clinical status to be monitored over time from different perspectives. The approach taken by Australia to developing a comprehensive system of outcome measurement is well regarded internationally.

Today, 85% of state and territory public sector inpatient and community mental health services collect data that can be used to assess outcomes, as do 98% of private hospitals. Over 12,000 clinicians have received training in the use of outcome measures. Systems have also been established to enable pooling and analysis of information at the national level, and to provide feedback and support to clinical staff in assessing the progress of individual consumers (see Australian Mental Health Outcomes and Classification Network website at www.amhocn.org). Top of page

One of the key measures used to assess change is the Health of the Nation Outcome Scales (HoNOS), and its equivalents for children and adolescents (HoNOSCA) and older people (HoNOS65+). All three comprise items that collectively cover the main types of problems that may be experienced by people with a mental illness. Each item is rated from 0 (no problem) to 4 (very severe problem), resulting in individual item scores, subscale scores and a total score.

Figure 67 uses the most current data from the HoNOS family of measures to indicate the proportions of consumers who show significant improvement, no significant change and significant deterioration during episodes of care in different mental health care settings.

The picture is complex, and can be summarised as follows:

• For people admitted to state and territory managed psychiatric inpatient units (Group C in Figure 67), approximately three quarters (72%) have a significant reduction in the symptoms that precipitated their hospitalisation. Notwithstanding the changes in symptoms for this group, most remain symptomatic at discharge, pointing to the need for continuing care in the community. For a small percentage (4%), their clinical condition is worse at discharge than at admission. About one in four (23%) are discharged with no significant change in their condition.
• Similar patterns are evident for consumers admitted to private psychiatric hospital units (Group D in Figure 67). Seventy two percent show significant improvement, 24% show no significant change, and 4% show significant deterioration.
• In state and territory community services, the picture is more complicated. This is because consumers in the community are more diverse than those in inpatient settings in terms of their conditions, needs and trajectories of recovery. Some receive relatively short term care in the community, entering and exiting care within the year (Group B in Figure 67). Fifty per cent of this group experience significant improvement, 42% experience no change, and 8% deteriorate.
• A second group of consumers of state and territory community care are in longer term, ongoing care (Group A in Figure 67). This group, representing a significant proportion of people treated by state and territory community mental health services, are affected by illnesses that are persistent or episodic in nature. More than half of this group (58%) experience no significant change in their clinical condition, compared with approximately one quarter (26%) who improve and 15% who experience clinical deterioration. An important caveat to understand for this group is that, for many, 'no clinical change' can be a good result because it indicates that the person has maintained their current level and not experienced a worsening of symptoms. Top of page

These results are both complex and challenging to policy makers who prefer to distil health outcome indicators into a single message. The data suggest that consumers of state and territory and private hospital sector mental health care have a range of clinical outcomes that require careful interpretation. It makes sense that the proportion of people who show significant improvement is greatest in acute inpatient episodes. Those who are admitted to these settings in both the state and territory and private hospitals are often very unwell, but their symptoms can often be treated quite effectively and reasonably quickly. It also makes sense that those who have relatively short episodes of care with state and territory community mental health services are less likely to show significant improvement than their counterparts in inpatient care, with many demonstrating no change. Many of these people will only be seen in the community, or will be discharged from inpatient units to community care once their symptoms have begun to abate. Either way, their level of severity at the beginning of the episode is lower than that of those admitted to inpatient settings, which means that they may have less room to demonstrate improvement. The observed pattern for those in ongoing community care is also intuitively sensible. This group is mixed - for some the focus of care is further reductions in symptoms and increases in functioning, but for others the focus is more about helping the person maintain their current state of wellness and averting deterioration. The finding that some people improve but that many remain stable is arguably consistent with these treatment goals.

The picture derived from Australia's investment in routine outcome measurement represents 'work in progress' that is both imperfect and incomplete. Further work needs to be done to determine what outcomes are consistent with a service system offering 'best practice' care across the board. The main outcome measurement tools being used describe the condition of the consumer from the clinician's perspective and do not address the 'lived experience' from the consumer's viewpoint. Although consumer rated measures are included in Australia's approach to outcome measurement, uptake by public sector services has been poor to date. Additionally, there are many technical and conceptual issues that are the source of extensive debate. Foremost among these is the fact that the outcome measures are imprecise measurement tools. There is also concern that the approach used to report outcomes separates a consumer's care into segments (hospital versus community) rather than tracking the person's overall outcomes across treatment settings.

Continued government collaboration will be required to support the further development of the national approach to measuring and reporting
on mental health consumer outcomes.

Figure 67: Clinical outcomes for people receiving various types of mental health care, 2010-11^a

^a Totals do not always add to 100% due to rounding.

Text version of figure 67

	Significant improvement (%)	No significant change (%)	Significant deterioration (%)
Public sector: People in ongoing community care	26	58	15
Public sector: People discharged from community care	50	42	8
Public sector: People discharged from hospital	72	23	4
Private sector: People discharged from hospital	72	24	4

Note:

• Data for "public sector: people in ongoing community care" are based on the difference between first and last clinical ratings made in the year for people in longer term, ongoing community care.
• Data for the other categories are based on the difference in clinical ratings at admission and discharge from hospital or community care.
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