In our view, the purpose of psychiatric service evaluation is to establish how far these services meet their pre-identified aims. This means that a clear statement of the service aims should be prepared well in advance of starting an evaluation. In terms of the matrix model shown in TableJ., service aims can be located at three levels: national, local, and individual. Planners are primarily concerned with the first two, while clinicians limit their scope to the latter. Both commit categorical errors. The local-level approach alone runs the risk of disregarding the extent to which organizational arrangements do actually lead to improved outcomes for individual patients. The individual level approach alone, on the other hand, cannot address vital local issues, such as ensuring access to all those needing care in the whole population. One of the few examples of explicit service goals that have been set at the national level are the Health of the Nation targets for the United Kingdom, which are shown in Table 2.
Table 1 Overview of the matrix model, with examples of key issues in the outcome phase i Tc ridu« ¡it frtnl s.i-it w ty i: Intui )S£ by ite r"' 111 ftf ifflOOO ¡nfbttcn r 1 Wto nfl Mrt ftflJ
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Table 2 National mental health targets for the United Kingdom
In other words, we are proposing that the desired purposes of psychiatric services can be classified into two categories:
1. the provision of effective treatments to individuals, according to the standards of evidence-based medicine;
2. the fulfilment of principles which are regarded, according to both scientific evidence and clinical experience, as central to the adequate provision of psychiatric care.
The nine principles we have identified for this purpose are autonomy, continuity, effectiveness, accessibility, comprehensiveness, equity, accountability, co-ordination, and efficiency. From their initials, these principles may be termed 'the three ACEs' (see T.able..5 of Chapter 7.5 for their definitions).
Another common error, made by both planners and clinicians, is to consider outcomes of both service provision and treatments as separate from inputs and processes. In other words, in terms of service evaluation, it will often be necessary to measure outcomes in relation to particular types of service, inputs, and processes.
The distinction and balance between inputs, processes, and outcomes within mental health services are far from clear-cut for three reasons. (7) First, there is no consensus on the definitions of these terms, and their use in the literature is widely variable. A consequence is that the three temporal phases are often used in a confused way so that processes (such as the numbers of admissions) are employed as if they were outcome variables. Second, these three categories of variables are interconnected and need to be seen as different aspects of the wider, dynamic mental health care system. In fact, patients will often want acceptable care processes and outcomes, so that attention to outcomes alone will miss a part of what is valued by the recipients of care. Third, the paradigm that best fits the tripartite sequence of input, process, and outcome, is one of an acute episode of illness and its consequent medical care, such as an uncomplicated infection or a straightforward surgical intervention such as an appendectomy. This is because the acute-illness paradigm assumes the following:
1. clear start- and endpoints for the episode;
2. outcomes are directly related to treatment inputs and to the processes of their delivery (or, as Donabedian put it, outcomes are the states or conditions attributable to antecedent health care);
3. outcome is simply the difference (or health gain) between health status at time 1 and at time 2.
However, many mental disorders, particularly those treated by specialist mental health services, are chronic, relapsing, and remitting conditions, which do not fit a simple acute-illness paradigm.
Although the purpose of evaluation can be seen as a method to assess whether services are meeting their stated aims, in practice it is common that psychiatric services do not make explicit statements of purpose. Indeed, they may simultaneously attempt to fulfil multiple incompatible purposes, such as providing a comprehensive service to everyone with a mental disorder within a local area, and targeting those most severely disabled by mental illness.
Thus, when evaluation shows that service aims are unmet or only partially met, then actions should follow which are intended to move the services closer to their intended goals. This means that the results of evaluation should be primarily used for the improvement of the service in which data were obtained, as well as in other similar services. The production of scientific publications, government reports, and training materials should only be seen as secondary aims. (5) A pragmatic list of reasons why an evaluation of psychiatric services is actually conducted is shown in Table...3.
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Table 3 Pragmatic reasons why psychiatric service evaluation is conducted
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