Management by geographical area or management specialised by disorder? A mixed-methods evaluation of the effects of an organisational intervention on secondary mental health care for common mental disorder

Background: In 2010, South London and Maudsley NHS Foundation Trust (SLaM) established a programme replacing the borough directorates responsible for adult mental health services with three Clinical Academic Groups (CAGs), each of which took on a subset of adult services straddling all four boroughs. Care pathways were also introduced. We studied the Mood Anxiety and Personality CAG, which took on assessment and treatment teams and psychotherapy services. Objectives: We aimed (1) to understand the CAG programme using realistic evaluation and (2) to assess whether or not it led to changes in activity and health-care quality. Methods: Qualitative analysis was based on interviews and project documents. Quantitative analyses were based on electronic patient records and compared care in community mental health teams (CMHTs) and psychotherapy teams before and after CAG implementation. Analyses of activity covered caseload, counts of new episodes, episode length and number of contacts per episode. We also looked at CMHT costs. Analyses of effectiveness covered processes (pharmacological and psychological treatment of depression in CMHTs) and outcomes (effect on the Health of the Nation Outcome Scales total score or the Clinical Outcomes in Routine Evaluation 10-item version total score). Analyses of safety examined the rates of self-harm among current or recent CMHT patients. Patient centredness was represented by waiting time. Results: The first core component of SLaM’s CAG programme was the CAG restructuring itself. The second was the promotion of care pathways; interpreted as ‘high level pathways’, these schematised processes of referral, assessment, treatment, reassessment and discharge, but abstracted from the details of treatment. The three mechanisms of the CAG restructuring were increasing oversight, making teams fit the template of team types defined for each CAG (‘CAG compliance’) and changing financial accounts by grouping services in new ways; these mechanisms resulted in further reconfigurations. The use of high-level pathways supported service redesign and performance management. In CMHTs and psychotherapy teams activity tended to decrease, but this was probably not because of the CAG programme. CMHT costs were largely unchanged. There was no evidence that the CAG programme altered effectiveness or safety. Effects on waiting times varied but these were reduced in some cases. Overall, therefore, the CAG programme appeared to have had few effects on quality. We attributed this to the limited effect of the programme on individual treatment. Conclusions: SLaM’s CAG programme had clear effects on service reconfiguration at team level, with high-level pathways changing the ways that managers conceptualised their work. However, our quantitative work indicated no clear effects on quality. Thinking about how to use care pathways in ways that complement ‘high-level’ pathways by supporting the delivery of evidence-based treatments is a strategy that could help SLaM and other providers. Future research should look at the genesis of organisational change and how this is altered through implementation; it should also look at the effectiveness of care pathways in mental health services. Funding: The research was supported by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and was performed using infrastructure provided by the NIHR South London and Maudsley and Institute of Psychiatry Biomedical Research Centre