A Dutch health insurer is changing the way it pays for treatment for some forms of depression, so that invoices will be paid on results and not the number of sessions. Will this lead to the delivery of more effective therapy, or simply encourage the various players to ‘game’ the system? We explore the pros and cons.

Dutch health insurer Menzis is one of the biggest health insurance providers in Holland. According to a recent article is has about 15% of the market and treats around 35,000 patients with depression a year.

Recently Menzis has concluded agreements with 18 large mental health provider organisations to accept a new method of funding based on results rather than the number of sessions provided. The new system will apply to treatment for non-chronic cases of depression in which therapy lasts less than a year.

Detail about the new funding arrangement is sparse, but the implication is that provider organisations will only be paid for those cases for which they are able to show a demonstrable improvement in depressive symptoms. As far as I understand, if the provider can demonstrate better outcomes than those specified in the contract then Menzis saves money, and this is split with the provider as a reward for providing effective care in the most efficient way.

Coming to a place near you?

Could it happen here? Almost certainly, and to some extent it already is. It just may not have reached you yet. Given all the noise over Payment by Results (PBR) and outcome-based commissioning in recent years I’m surprised that this kind of development hasn’t come along much sooner.

PBR has never really been driven by outcomes. Rather, it is a system of paying NHS healthcare providers a standard national price or tariff for each patient seen or treated. Outcome-based commissioning (OBC), however, is shaping up to be an altogether different beast. Delivering the Five Year Forward View for Mental Health: Developing quality and outcomes measures [i]  makes the direction of travel for the NHS in England explicit:


The Five Year Forward View for Mental Health is clear that there must be a move to

payment approaches which have transparency around quality and outcomes, and

these should be in place by 2017/18 for adult mental health services.

Delivering the Five Year Forward View for Mental Health: Developing quality and outcomes measures

In the UK I suspect that the effects of OBC are likely to be felt first and most powerfully within the NHS and services commissioned by Clinical Commissioning Groups (CCG’s) or health and local authority commissioning partnerships. I find it inconceivable that they will be limited to these areas.

Let’s game out a couple of possible scenarios, shall we?

You work as an affiliate for an Employee Assistance Programme (EAP).

You work (as I currently do), for an EAP that requires that you ensure that clients routinely complete a global distress measure at the start and end of their counselling. The EAP holds that data centrally and has done so for years, but you’ve no idea what use, if any, it is put to. You’ve never had any feedback about the forms that you’ve submitted over the years.

Unknown to you, the EAP starts to explore its historical data and discovers that some of its affiliates seem to consistently achieve higher levels of improvement with their clients and start to prioritise those affiliates when making referrals. You may or may not be one of those affiliates.

You are employed by a third sector agency contracted by the local CCG

You’re employed by a third sector organisation as part of IAPT provision that has been commissioned within the past two years by the CCG. The contract requires session by session use of GAD7 and PHQ9. Clients complete paper measures which are input into an online system by an administrator. You have no access to that system.

As part of your annual appraisal you’ve been told that your improvement rates are in the bottom 25% for therapists in the service. Your manager has made it clear that your performance needs to improve, and how you do this is down to you and your supervisor.

I’ve experienced elements of both of these scenarios as either practitioner or consultant. I imagine that you’ll have your own experiences of how our world is becoming more demanding of evidence. Please feel free to share those below.

The writing is on the wall, but what’s it saying?

If counselling has learned anything from the experience of how the rollout of IAPT impacted our profession, it should be that, suitably prepared, we can turn threats into opportunities. It wasn’t inevitable that so many well-established primary care counselling services be swept aside in the 2000’s.

Neither is it inevitable that a system of payment by outcomes should represent an existential threat. If we’re not prepared, however, it almost certainly will. Setting our faces against these kinds of developments isn’t going to end well unless we are prepared only to work in private practice.

I want us all to have a little more faith in what we do and be prepared to put ourselves to the test. It is a fact that as therapists we are not all equal in impact. It’s a fact that we seem to routinely over-estimate our ability relative to others in our field, and struggle to predict early on which clients are going to benefit and which will not. It’s also a fact that we can also become more effective, but we won’t do that by chance.

In the title of this blog I posed the question of whether we should be fearful of systems of payment based on results, or more accurately, on outcomes. The answer depends on two critical factors:

Whether the specified results or outcomes are ones which are consistent with our philosophy, values and practice.

In other words, whether we can sign up to them, even if we might not describe them as they appear in a contract document. For example, while you might struggle with ‘recovery’ being an aim of your therapy, you may be less likely to take issue with the aim of helping a client achieve significant reductions in their symptoms of anxiety or depression.

2. Whether we (as therapists or services) have access to the systems that are being used to determine our performance

In both the scenarios above, the therapist’s only relationship with the data is as paper measures used with clients. It could be worse: in scenario 2 the client could complete measures in a waiting room prior to being seen by the therapist. The point is that in each case the therapist does not have access to their aggregate data, not any information about their performance relative to others or the service mean.

If my performance is being judged, then I want full access to the system that is going to be used as the basis for that judgment. I want to be able to challenge or put into context any conclusions that may be drawn from my data. More than that, however, I want to be the first to know how I’m doing.

As the Dutch example and the process of OBC in the UK shows, the writing is indeed on the wall. If we really have confidence that what we do makes a difference, however, we shouldn’t be anxious about trying to evidence that. If you’re not already engaged in that process already, I strongly suggest you make a start and don’t wait to be told.

Getting started is no more complicated than these three steps:

Learn what the numbers that come from outcome measures actually mean, and what’s meant by terms like clinical cut-off, clinical change, reliable change, recovery, no reliable change and deterioration. (I’ll be covering all of these in forthcoming blogs).

Start experimenting with measures in your own practice if you don’t already. Our last two blogs will help you get started. The first is here

Aim to develop baselines for your unplanned ending and improvement rates for a 12-month period and update every quarter so you have a sense in which direction you’re heading. I recently put my own dropout figures on the line here

Related blogs

Introducing measures into working with clients


Dropout: what’s normal and what’s it costing us?


Self-assessment bias in psychotherapy


Wake up and smell the evidence (which clients are going to benefit?)


We thrive on feedback, so please let us know what you think about what you’ve read in the comment section below. Only the name you use to identify yourself will be shown publicly. Thank you!

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Posted by:Barry McInnes

2 replies on “Payment by outcomes. Should we be afraid?

  1. Working with depression is very difficult, particularly when the playing field is frequently ploughed up by frequent changes in the client’s medication, and hoops the client is expected to jump through by inhuman resources.

    I have two depressed clients at present who are not making improvements (based on their outcome measure scores). One has been attending for over a year, one for four months. Both of them have insisted that they wish to continue working with me (they are both private clients) – one says I’m the only one he can have these kind of conversations with, and the other says that he feels much better through coming to see me even though the outcome score doesn’t alter significantly. I use ORS at each session, and CORE-OM every sixth session. One of these clients actually has a CORE-10 scale at home, which he uses more frequently to check how he is responding to medication changes etc.

    I might be tempted to adopt a tick-box culture, and after the client has had an exceptionally good week make that my final session, and then end therapy. Or give it a few weeks and cut my losses.

    Has anyone else noticed the startling results of new research on the effects of psilocybin for drug resistant depression? https://www.nhs.uk/news/mental-health/magic-mushrooms-may-help-reset-depressive-brains-study-claims/ . We should start paying our politicians and lawmakers by outcomes.

    1. Hi David and thanks for your post.

      I agree with you that working with depressed clients can be a challenge, especially when there are factors external to the therapy that impact on a client’s mood, including medication and navigating the expectations of employers.

      Your comment about the tick box culture is exactly the kind of way in which we might be tempted to terminate the therapy process completely if we feel it’s the only we we’ll be paid. I hope that we’ll not be tempted in this way, but the temptation would be understandable.

      A couple of thought son your clients. I wonder what contract/goals you’re currently working towards? I sometimes find that some degree of renegotiating the focus after a period of no change can be helpful. Second, I wonder what their scores are saying about how distressed they are i.e. how far over the clinical cut-offs for the measures you’re using. One closing thought – might there be an investment of any kind in not improving? For example, might being depressed be a core part of their self-definition?

      I hadn’t seen the research on psilocybin, but despite the limitations of the trial it does look both interesting and of potential promise – thanks for that.

      I hope those thoughts are helpful and thanks again.

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