important to systematically solicit for these concerns and address them in one to one and team meetings. Some examples of feedback from staff are illustrated in Box 1. It has also been useful to listen out for


the more subjugated stories of enthusiasm for the measures and interest in seeing what they might contribute – organisational life is always multi-storied (Box 2). It has been important to repeatedly


emphasise the trans-theoretical nature of these measures – the department is comprised of highly skilled, creative, experienced clinicians who are used to a high level of autonomy in their practice, and being clear that the measures will not signifi cantly change the models and practices they use has been important in engaging colleagues in their use. We both learnt quickly to avoid words such


as ‘effi ciency’ and ‘targets’ when we were presenting these ideas in the department and always emphasised the idiographic over the normative functions of the measures (Sparks & Duncan, 2018) – by idiographic we mean the contribution the feedback from the measures can make to our therapeutic relationships through foregrounding the voice of the client at every step in the therapy process. This emphasis, however, has its own hazards: if we position the use of the measures as the ethical choice and as aligned with a concern for social justice, we simultaneously position those who do not use them as unethical and unconcerned with the privileging of the voices of the marginalised and vulnerable. We have sought to guard against this unhelpful polarity (Campbell & Groenbaek, 2006) through appeals to professional autonomy – it remains at each practitioner’s discretion whether they use the measures with all the clients they see, though they remain accountable for the exercise of this discretion. It has also been important to address the


very real concern colleagues have had that the scores might be “taken down in evidence and used against them” – writing into the outcomes policy that the scores will never be used in performance management. We were aware too of some emerging fi ndings from the literature: • that previous services had experienced high levels of resistance to the mandatory use of these measures resulting in the loss of 40% of the staff team(!) • that the outcome data from services using the measures were becoming less impressive over time (Miller, 2015), particularly as it was rolled out as


Context 170, August 2020


“The measures help maintain focus on change. Provide really useful feedback on what is helpful and unhelpful that I am doing in session. Facilitate discussion about what is not going well, why, and what might be helpful.”


“Helps me be less defensive if things are not going well.”


“Regular conversations about how therapy is going. Opportunity for patient to track change beyond subjective sense of how therapy has been going. Another way for me to see how therapy is helpful.”


“Helps facilitate discussion about how sessions are helping or not and off er some concrete way of knowing this together. Helps clients to see how far they have come and can be affi rming for them. Having outcome data even when folk become unwell and stop attending (usually palliative).”


“I love it. Keeps me on track and helped me to ask those questions that I usually wouldn’t ask” “It’s like a Fitbit for therapy!”


Box 2


mandatory rather than the initial literature which was based on services where there was considerable enthusiasm for the measures It was apparent to us that if clinicians used


the measures begrudgingly, they would be unlikely to embed them in their practice and have the collaborative conversations the measures are designed to prompt – in short if the measures remained a solely paper exercise they would be unlikely to be of benefi t to anyone. Accordingly, and infl uenced by the notion of the “Coalition of the Willing” (Kings Fund), we started with a few enthusiasts, in the hope that others would become infected with our enthusiasm, become intrigued and join the coalition. To a large extent this has happened, though some staff remain to be convinced, often citing particular aspects of their particular practice that obviates the use of the measures. This has constituted a change in


departmental culture, from a tradition of


managers trusting clinicians are doing a good job to something much more transparent and accountable. The prospect of one’s clinical outcomes being not only systematically measured but then available for all to see has, for some, been anxiety provoking and resisted. It has been important to acknowledge how threatening such a degree of openness and accountability can be and, albeit from a position of greater power, to model such openness by sharing our outcomes and therapeutic-alliance data “warts ‘n’ all”. Emotionally, leaders can be experienced as


siblings who have risen above their station, who think they are better than everyone else; in being so open about my perfectly reasonable, but in the context of the wider department, quite unexceptional, outcomes I (Rob) have tried to counter these feelings. This shift has also entailed challenging a


dominant discourse around the sanctity of the therapeutic hour – something that should not be disrupted by something


“Excellent graded approach, slowly gathering momentum”


“Emphasising value for clinical work as compared to demonstrating our value externally helped reduce anxiety about change”


“CPD sessions (led by Rob) explaining evidence base and personal experiences helped increase enthusiasm”


“Not being expected to do it with everyone helped as it felt like a personal clinical decision rather than a top-down management decision”


Box 3 39


Refl exive positioning as a tool for organisational change: Systemic approaches to implementing outcome measurement


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