February 2010

Inputs, outputs and outcomes

This column is not yet another justification for using outcomes in mental health services. Frankly I think the case for demonstrating the use of outcomes within mental health services has been well made already. This column, by contrast, is more interested in the relationship - or lack of relationship - between inputs, outputs and outcomes.

Imagine, if you will, that the mental health service is a big box, a box into which we cannot see. At one end we have lots of things coming into the box: buildings, resources, people and - for sure - money, quite a lot of money. At the other end, coming out of the box, we have lots of outputs: the number of referrals, discharges, admissions, seclusions, contacts and the like. Almost magically the inputs are transformed into outputs it would seem. We can see the inputs coming into the box and we can see the outputs going out of the box but what goes on inside the box is largely impossible to see, from the perspective of outcomes. What goes on inside the box refers to the outcomes from the inputs that we are putting into the box. In other words, what difference are all those inputs making? It also refers to the outputs from the box, in the sense that presently outputs have no obvious relationship with outcomes.

Imagine, if you can, another big box, the same as before, only this time a box we can see into. At one end, as before, we have inputs and at the other, as before, we have outputs. This time however we can see the linkage inside the box between the inputs and the outputs and the outcomes. What might those linkages look like as we peer into the box?

I think we would see how inputs connect to outcomes more directly. We would see how staff numbers and professional disciplines relate to outputs and we would then have some kind of feedback - based on outcomes - for the inputs that are needed. It all sounds very obvious, so why has the non transparent box had such a good run? I think there are four main reasons.

1. Some people think all you need is inputs and outputs. In some industries - making cans of baked beans for example - this would probably be true. In mental health we need to know more than this. Indeed the whole purpose of mental health care is to focus on the outcomes for service users.
2. Some people (hopefully not the same people as for 1 above) genuinely get confused between outputs and outcomes. Usually once the misunderstanding is corrected, they accept the need for outcomes.
   
   
3. Some people want to focus on results and this, they think, means focusing on outputs. Unfortunately focusing on outputs gives us only some of the results and arguably the least important.
   
   
4. Some people are frightened, for whatever reason, that focusing on the transparency of the box will result in questions being asked, by people in authority, about their performance as an individual, a team, a service, a region and nationally. I can only say, accountability brings some responsibility for how we are spending taxpayer money.

Inputs, outcomes and outputs are connected very closely in mental health services but for a long time we have had an obsession with inputs and outputs, and outcomes have largely been ignored as a Cinderella concern. Hopefully now we can finally get to peer into the box with the PRIMHD outcome reports, all of that will change. I don’t think there is any way of getting the lid back on this particular box even if we wanted to!

Page last updated: 12 February 2010