Does box-ticking ensure good care by Dieneke Hubbeling

Managers in the NHS nowadays assume that good health care consists of many boxes being ticked on an electronic patient note system. 

As a mental health professional, I am instructed to ask specific questions.  For example, every service user not known to the trust is asked: ‘Are you renting your house?’ and, if the answer is yes, there is a mandatory follow-up question: ‘Do you rent it from a private landlord, from the council or a housing association?’.  Of course, I also must enter the answers on the computer. Managers do check whether it is done, and they also compare individual practitioners and teams on performance criteria derived from the electronic note system, in other words how many boxes are ticked by each mental health practitioner and by teams.  The question is whether this checking really improves care. 

I have been informed that managers in the NHS are told by commissioners that they must check whether all the necessary boxes have been ticked.  Apparently, if they do not produce the performance data, commissioners may decide to put a service up for tender and let the care be provided by a third-party provider.  This has happened quite frequently especially for addiction and IAPT services (Improved Access Psychological Therapies). 

But do you really receive the best possible care, if all the boxes are ticked And is the care you receive always bad, if only a few boxes are ticked?  In my view there is an analogy with identifying good paintings. 

Komar and Melamid were interested in identifying most wanted paintingsThey arranged surveys in various countries and asked participants which elements of paintings they preferred. In the Netherlands in 1996 they surveyed 949 participantsThe preferred colours were blue (31%), green (19%) and red (13%) and the Dutch people in 1996 preferred an abstract painting.  Combining all the findings gave a picture consisting of red, green and blue parts, which can be seen on their website ( This picture is not a nice painting.  Other Dutch paintings such as The Night Watch by Rembrandt or, if one prefers abstract paintings, various works by Mondriaan are actually much nicer to look at.

To my knowledge no similar study has been done in the United Kingdom, but Komar and Melamid did organise a survey in the USA in 1993 with 1001 participants.  This resulted in the favourite colour being blue (44%) and a preference for realistic paintings with historical figures.  Combining all the results gave picture with George Washington in the middle, which can also be seen at Komar and Melamid’s website.  Again, the overall picture is not particularly appealing 

 Combining preferred elements does not necessarily give a good painting. 

Maybe people will say that this is entirely predictable.  It is an overall judgement whether a painting is good, some specific elements can be dreadful, and the overall painting can still be very good.  However, when it comes to mental health care the assumption seems to be that it consists of a number of specific elements and nothing more. 

I often wonder whether the need to include the pantheon of most wanted RiO elements such as social inclusion data (is somebody living in rented accommodation or not), HoNOS (Health of the Nation Outcome Scale) score2 and clustering, smoking cessation data, the myriad of questions in the risk assessment, even if not obviously relevant, is really offering good care to service users?  

In the Komar and Melamid study participants were asked which elements they considered important in a nice painting. The situation in mental health is even worse.  Service users have not even been asked about the items which need to be covered in an initial assessment.  It is highly unlikely that a question such as ‘Do you live in rented accommodation?’would be selected by service users 

This process of checking whether certain boxes are ticked must stop. It is not only that questions are often irrelevant; it also leaves less time to talk about what really mattersOne should only allow maximum 5 minutes to check boxes and the content of the mandatory questions should be agreed by service users.  

Dieneke Hubbeling works as a consultant psychiatrist for the NHS in London  

This is a sample article from the Winter 2019 issue of Asylum magazine

(Volume 26, Number 4)

To read more . . . subscribe to Asylum magazine.