Training is necessary, but not sufficient
Most clinicians working in mental health are trained in evidence-based therapies. These are often talking therapies that have been proven effective for most people through research studies such as clinical trials.
But internationally there is often a gap between what clinicians are trained to do and what they actually do at the bedside or in the therapy room.
Large studies of treatments in general healthcare across multiple conditions and age ranges have shown that only about 60 per cent of healthcare is currently aligned with evidence-based guidelines. According to this research, 30 per cent is “waste, duplication or of low value” and 10 per cent is actually harmful.
In Aotearoa, there are countless examples of this “know-do” gap. Many mental health services deliver therapies based on dialectical behaviour therapy to help young people and adults improve their emotional regulation. But few deliver these in the way they were designed.
National autism guidelines have been available for almost two decades, but adherence is patchy because of clinicians’ doubts about their usefulness. Finally, despite parent-child interaction therapy being an effective treatment for childhood conduct problems, the usability and acceptability of some parts, especially use of “time out”, may be off-putting for clinicians.
As clinicians working within mental health services, we have seen that good people are trying to do good things for those in need. Thanks to many decades of research, there’s substantial knowledge about what works for improving mental health.
There will always be a need to develop and adapt therapies, but a central challenge is better implementation of those we already have.
Better implementation of proven therapies
Implementation science is a relatively new field. It studies methods to enhance the adoption, implementation and sustained delivery of evidence-based practices to improve the quality of routine care.
Rather than asking tired clinicians to do more, implementation science can identify the influences on clinician behaviour and target supports accordingly. Implementation science teaches us that providing guidelines or training in evidence-based therapy is necessary, but often not enough to achieve quality care.
Complex factors such as a clinician’s belief in their own capability, attitudes, intentions and emotions can have a powerful influence on how well they implement therapies. So can team or service-related factors such as leadership, wider organisational culture and climate, policy, priorities and resourcing.
To improve implementation of evidence-based therapies, it’s essential to first understand and prioritise the enablers and barriers clinicians experience in their daily work. Next, it’s important to carefully choose implementation supports or strategies to address these barriers.
In our research, clinicians trained in parent-child interaction therapy often lacked necessary equipment.
International examples of implementation support come from a large project that provides more than 70 strategies to improve care. These include identifying local opinion leaders or quality champions, auditing care delivery, providing supervision and feedback to clinicians, and creating professional learning collaborations.
Quality in action
In Aotearoa New Zealand, we see encouraging examples of better implementation already underway. Health New Zealand-Te Whatu Ora is rolling out national clinical networks, including one dedicated to mental health. Their aim is to promote national standards for care quality in partnership with whānau, consumers and local communities.
Beyond mental health, apparently simple solutions such as surgical checklists have been shown to substantially improve quality, even in resource-limited settings.
Exciting initiatives in neighbouring health fields can also inform implementation in mental health. A new equity-focused implementation framework based on Te Tiriti o Waitangi but designed to support mainstream services provides guidance for implementation planning, monitoring and evaluation.
People deserve access to effective mental healthcare. Unless we urgently prioritise its quality, we are at risk of developing an ill-equipped workforce that turns over rapidly, or creating a situation where fully staffed teams deliver low-value care.
Given we’re living in resource-constrained times, we must ensure care is the best it can be. Service leaders, funders and policymakers must urgently consider how we can best equip existing and new staff to deliver quality care, based on insights from implementation science.
It cannot be postponed until services are fully staffed and waiting lists have disappeared.
