The purpose of the standardised treatment packages in mental health care is to save time and provide help to more patients. But do they lead to better help?
Expectations, glossy paper and a shiny bow. The package of measures that the Directorate of Health gave to the mental healthcare service in the autumn of 2018 shone with lofty goals, such as increased user participation, user satisfaction and involvement of the patients’ families (1). The package was officially opened on New Year’s Day 2019. At the end of January 2020, the first evaluation report from SINTEF was published (2).
The treatment packages for mental health and addiction were intended to meet a need for more consistent and coordinated services (1, p. 1) and were inspired by the patient pathways in cancer care and similar Danish assessment models for mental disorders. In Denmark, psychiatric assessment and treatment packages were introduced as early as in 2013 (3). Pre-defined amounts of consultation time were key to these. For example, the basic assessment package in child and adolescent psychiatry allowed for up to 6.5 hours of assessment distributed over 3–6 services (4). If the symptoms were complex and the diagnosis was challenging, the assessment period could be extended.
In 2015, Danish doctors advised the Norwegian health authorities against using specific time indicators when establishing the psychiatric treatment packages (5). In their experience, this simply did not work. Among other things, the treatment resources turned out to be so small that the stipulated hours foreseen in each package could not possibly be achieved. This experience was available before the scheme was implemented in Norway, but nevertheless, clinicians are now working against the clock in the new treatment packages for mental health care.
Experience from Denmark shows that those psychiatric patients in most need of help are also least likely to be allocated to the treatment package intended to help them (6). Moreover, it can be challenging to apply specialist competence optimally within the framework of the package (7). When Danish therapists were interviewed about their experience from the introduction of the national psychiatric care packages, a repeated challenge they reported was the lack of time to make good clinical assessments, and that this could result in treatment that did not match real needs (8).
SINTEF’s ongoing evaluation of the Norwegian treatment packages for mental health and addiction is intended to provide knowledge on the experience of the patients and service providers, and whether these packages fulfil their intention (9). A one-year report on the service providers’ experience was available in late January 2020 (2). Not unexpectedly, it can be described as somewhat disheartening. The report covers all treatment packages in mental health care, for both children and adults. SINTEF concludes that if the packages turn into an excessively rigid system, there is a risk of overlooking special needs among users.
The report reveals that approximately 60 % of therapists in child and adolescent mental health care feel that the treatment packages do little or nothing to help establish more coherent or coordinated patient pathways (2). Barely 5 % believe that the packages fulfil their intentions. In the view of the health authorities, this indicates further requirements and obligations to be imposed on the health trusts (9). But is this really the best solution? The red numbers say nothing about the reason why we were beaten by the clock.
The treatment packages use progress codes to monitor goal achievement. One key indicator to be coded is the duration, which is not to exceed a specified limit. For example, the maximum time allocated for a basic assessment and diagnosis of mental disorders in children and adolescents amounts to 42 calendar days. The initial meeting with the patient, feedback to the GP, the clinical decision on diagnosis and evaluation of the effect of the therapy are other elements that must be coded. Whether the diagnosis is correct, however, or whether the treatment is effective appear to be irrelevant.
Since the treatment package only asks whether the effect evaluation has been undertaken, the treatment may have no effect without giving rise to red numbers
In theory, the numbers may light up bright green while an inattentive young person starts taking methylphenidate for a hyperkinetic disorder that he or she does not have. And since the treatment package only asks whether the effect evaluation has been undertaken, the treatment may have no effect without giving rise to red numbers. Seeking to ensure user participation and predictability and enhancing service quality are commendable, but then the system which is introduced also needs to measure quality.
When seeking to stop uncontrolled cell division in cancers, quality involves measuring the patient pathway time with an intention of shortening it. During a consultation with a person with a mental disorder, on the other hand, it would be unprofessional to look at your watch instead of your patient. The package has been opened, but we did not get what we wished for.