Mental health legislation needs to point to the future.
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Abstract:
The forum article by Professor Xie[1] raises the broad issue of whether mental health legislation in China needs to respond to the existing realities of the community mental health services system. Given the lack of community mental health resources in China, the burden of caring for persons with mental illnesses has traditionally been borne by families and by psychiatric hospitals. As China introduces its first national mental health legislation the concern is that it is premature to introduce legislative changes that the current community mental health service system is ill-prepared to implement. Professor Xie suggests that the extent and direction of the change to current practices proposed in the mental health legislation could have a negative impact on access to much needed services because it raises the threshold for involuntary treatment too high and increases the opportunities for challenging the decision to admit and treat. In our view there are two issues which need to be considered separately – the criteria for involuntary admission and treatment, and who is authorized to decide whether or not the criteria are met.Keywords:
Mental Health Act
Externality
Mentally ill
Mental Health Care
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Dignity
Center (category theory)
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BACKGROUND: the structural problems of the mental health system in the UK have been analyzed by a number of authors over the past several years as the "reforms" of the health and social service systems have continued (Kavanagh and Knapp, 1995; Mechanic, 1995). In a recent article, Hadley and Goldman (1995) suggest that one possible solution to some of these issues may be the creation of a local mental health authority. Such an authority would consolidate the funding, authority and responsibility in a single entity. We believe this model, which is typical of many local public mental health systems in the US, is at least part of the solution to the current problem of financial and service fragmentation of the current system in the UK. The numerous "reforms" of the health and social service systems (which include the Community Care Act, the development of the Internal Market, GP fundholding and the purchaser-provider split) were not designed for the care of the mentally ill (Han, 1996). These policy changes in the design of health and social services have created a complicated and difficult context in which services must be delivered. Too many agencies play a significant role in the delivery and management of mental health services. Health authorities, social service agencies and GP fundholders are direct and indirect funders of the system while community care trusts, social service agencies and GPs are service providers (Hadley, 1996a). RESULTS AND A PROPOSAL: We believe that the development of local mental health authorities may be part of the solution to the structural and economic problems of the current system in the UK. It is not the answer to limited resources or limited skills, but can create a new structure, which will permit and encourage the cooperation and innovation that is now possible only with unusual effort. Local mental health authorities have a number of crucial characteristics, but, most importantly, they refocus the system on the provision of care to the seriously mentally ill. This is the expressed priority of government, advocates and providers, alike.These new entities could be created at either the purchaser or provider level or, as exists in a number of jurisdictions in the US, at both levels, where a single purchaser may be responsible for multiple consolidated providers. This combination is now the emerging model for innovative services in the US. In the UK, the development of a local mental health authority at the purchaser and/or provider level might be relatively simple. Although the creation of a statutory authority would require primary legislation and is therefore probably not a short-term solution, there appears to be a variety of administrative options that would have the same effect. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The creation of a local mental health authority may be a necessary first step towards the development of a coordinated and comprehensive system of care. It seems likely that there is currently more "political" support for the development of a purchaser model but the development of a sophisticated purchsaer is also likely to take considerable time and effort. Although all the structural and policy problems of the mental health system in the UK will not all be solved by local mental health authorities, they may be beneficial if responsibility for mental illness care is to be centralized and fragmentation is to be reduced. Without making structural changes, the best efforts by clinicians, policymakers and managers are most likely to be in vain. Without a clear point of ultimate purchasing and service responsibility, the fragmentation and inefficiency of the current system will remain (Hadley et al., 1996).
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Advocates for political and legislative changes to the American health system posit that getting more (or all) people insured will resolve the inequalities in health care. That overlooks the disparity in the present system between mental and other health problems. Compromised and dated attempts by Congress and state lawmakers to create mental health parity made insignificant changes in access to care for those with mental illness. This unprotected class has all the qualifications for recognition as suspect (or semi-suspect) but the Supreme Court has not regarded it so. Fear, stereotyping and lack of information has historically and contemporaneously led to discriminatory treatment and the embrace of policies and practices that have a tragically disparate impact upon the emotionally unwell. Insurers and benefit plan sponsors can discriminate without economic justification. Civil Rights laws aimed at protecting the disabled are better suited to problems connected with physical disabilities. Definitions and accommodations needed for the mentally ill have not been advanced in decades of litigation. However, if the data in this research is credible, mental health parity is economically efficient, both in reducing other health care costs and in maximizing the utility of an employee with untreated problems.
Parity (physics)
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After a decade of robust growth in spending, Dutch mental healthcare is on a more stricter budgetary path since 2012. High prevalence of illness and limited spending, imply the need for efficient mental healthcare delivery.
AIM: To advise how mental health care can be managed more efficiently. There will also have to be more differentiation between mild and serious psychiatric illnesses.
METHOD: Review of academic articles and policy studies.
RESULTS: With regard to the treatment of fairly common disorders, more attention needs to be given to integrated basic care and e-health. Employers and stakeholders can perhaps play a role in financing some of these services. Severe mental disorders can be handled more often on an integrated ambulatory basis setting than only in a hospital setting, while scaling down inpatient capacity. These steps would represent a major transition and would require spending cuts and a change in the provider 'landscape'.
CONCLUSION: Sustainable mental healthcare is inseparably linked to an agenda that provides value for money and it implies a major transition. However, in principle, it should be possible to fit these changes into the current system of governance. More attention needs to be given to coordination between the various domains, and to a reduction in administrative costs. Reimbursement methods should align e-health, collaborative care, case-management and best-practice pathways.
AIM: To advise how mental health care can be managed more efficiently. There will also have to be more differentiation between mild and serious psychiatric illnesses.
METHOD: Review of academic articles and policy studies.
RESULTS: With regard to the treatment of fairly common disorders, more attention needs to be given to integrated basic care and e-health. Employers and stakeholders can perhaps play a role in financing some of these services. Severe mental disorders can be handled more often on an integrated ambulatory basis setting than only in a hospital setting, while scaling down inpatient capacity. These steps would represent a major transition and would require spending cuts and a change in the provider 'landscape'.
CONCLUSION: Sustainable mental healthcare is inseparably linked to an agenda that provides value for money and it implies a major transition. However, in principle, it should be possible to fit these changes into the current system of governance. More attention needs to be given to coordination between the various domains, and to a reduction in administrative costs. Reimbursement methods should align e-health, collaborative care, case-management and best-practice pathways.
Reimbursement
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Staying mentally well should be given the same priority by NHS policymakers as keeping physically fit, says an independent think tank based in the United kingdom, the Institute for Public Policy Research. In a report published this week, the institute set out its vision of what mental health services should look like in 2025. It suggests that by then, people with mental health problems will have access to local drop-in services and that public stigma around mental health will have declined. In addition, every neighbourhood will have access workers, …
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For the past 50 years, federal legislation has been a key force in shaping the delivery of public mental health services. This article describes and summarizes recent relevant federal legislative initiatives and analyzes their potential in providing support, either explicit or implicit, for community-based mental health care for adults in the United States. These legislative mandates and options can be a source of optimism and ammunition for advocates and change agents as they continue to work vigorously to improve the mental health services system.
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This article reviews the forces leading to the current emphases on managed mental health systems. Rapidly escalating costs, especially for inpatient care, and associated concerns for quality and patient outcomes, have led third-party payers and employers to demand more eifective cost and quality controls. The article describes and illustrates methodologies for managing mental health costs, and reviews issues related to evaluating the impact of managed care on costs and quality of patient care. This special section is a testament to the fact that managed care is beginning to affect the practice of professional psychologists, and more important, that this trend is likely to continue. To practice effectively within such an environment, psychologists need to understand the forces promoting the growth of managed care and the ways they stand to be affected by and potentially to benefit from this major shift in the way mental health and substance abuse treatment services will be delivered in the future (Bloom, 1990). Although professional psychologists have not been primarily responsible for creating the cost trends that have stimulated managed care in mental health, they, like all other professionals, will be affected. It will not suffice to proclaim professional innocence, although professional sophistication on the issues may have some positive effects. This article has four major purposes: (a) to review national trends in general health care costs and in health service delivery systems reacting to these cost trends; (b) to review comparable trends in mental health, drug, and alcohol treatment costs and service delivery systems that echo those in the general health system; (c) to make the case that managed care in the mental health industry arises as a marketplace response to concerns for service cost, quality, and accessibility on the part of employers and insurers; and (d) to describe a general framework for understanding the structure of managed mental health care, while pointing to opportunities for psychologists who have cost-effective services to offer in a cost- and quality-competitive market.
Mental Health Care
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With standards to guide treatment largely absent and a highly debilitated, stigmatized, and isolated clientele, it is hardly surprising that mental health providers have historically been effectively immune from professional liability claims. Recent developments, as described in this article, suggest that this immunity is eroding.This evolution creates a conundrum for the courts and society. Providing mental health treatment has never been highly prestigious or particularly financially rewarding, making it difficult to recruit and retain qualified practitioners, notwithstanding that they serve a vulnerable population who at times are in desperate need of their services. Simultaneously, however, society is increasingly recognizing how crucial it is to enhance the quality of mental health services, with the tort system providing one vehicle by which this quality may be improved.This article examines a number of areas in which professional liability claims pertaining to mental health care can be expected to increase. On the one hand this represents a triumph. It indicates that clients are sufficiently recovered, empowered, and supported that they can pursue claims against mental health providers for inadequate care. However, mental health care in this country continues to be under-funded, under-supported, and under-appreciated. To the extent that its providers feel that the delivery of this care has become too onerous, it may drive them away from the field and make critically needed services even less available. Individuals with a mental illness, too, will likely be torn between applauding the enhanced acceptance of claims of inadequate mental health services and a fear that the already limited pool of qualified care providers will be further diminished.The debate about the impact of medical malpractice liability on the practice of medicine and whether it improves or impedes the quality of health care has raged for over a century-and-a-half in this country and continues today. The emergence of this parallel debate with regard to mental health care calls for greater attention to when and why its practitioners are likely to be exposed to professional liability, an effort undertaken herein.
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Thornicroft et al have provided a service to the mental health community worldwide by summarising their combined experiences in developing community orientated mental health services in England and Italy over the past 30 years. The challenges they identify go a long way to explaining why mental health reform is often piecemeal and incomplete, sometimes leaving the system more fragmented than it was before reform was embarked upon. This has certainly been the case in Australia, where mental health reforms, whilst occurring in the context of a well articulated and universally agreed national mental health policy 1, have been differentially implemented in the various state and territory jurisdictions. Even within such jurisdictions there is inconsistency with respect to how community care is provided. Within Australia, the state of Victoria has arguably undertaken the most comprehensive and rapid restructuring of mental health services, closing all its psychiatric hospitals within the decade of the 1990s. This rapid deinstitutionalisation was hugely successful in shifting the locus of mental health care into the community, along with a shift of resources. For example, between 1993 and 2003, expenditure on mental inpatient facilities in Victoria was reduced by AU$ 184 million, with a growth in spending on community based care of some AU$ 323 million 2. Each of the urban area mental health services provides services to around 250,000 people. Each has a small number of acute inpatient beds (around 20; average length of stay 10–14 days) co-located with general hospitals, but also has access to 20 bed continuing care units for longer-stay rehabilitation (length of stay from 3 months to 2 years) and various other facilities provided either solely by, or in partnership with, non-government organizations. Community health services are configured uniformly, with acute crisis work being performed by a crisis and assessment team, longer-term care by a continuing care team, and intensive case management by a multidisciplinary mobile support and treatment team. Thus, both in terms of emphasis of dollar allocation, as well as staffing and overall service provision, Victoria has delivered on the imperative to shift mental health care into the community. However, we have been struck by the dissonance that has arisen between many mental health professionals who are convinced that services are much better than they were, and many in the community (including consumers and particularly carers) who are convinced they are worse. One explanation for this phenomenon is the changing expectation of the community in response to the benefits of community psychiatry having been oversold by its vigorous and sometimes zealot proponents. These advocates (perhaps more in the past than at present) appear to be working on certain assumptions about the nature of mental health and its amenability to treatment. We 3 have recently published a summary of these premises and the reality that decades of experiences with deinstitutionalisation has subsequently generated about them. They are as follows: — Psychotropic drugs, particularly the newer atypical antipsychotics, will deal effectively with most psychotic symptoms and reduce markedly consequent disability. – Insight into the need for treatment will be enhanced, so that adherence to treatment will improve. – Intensive case management (or assertive community treatment) will only be required for brief periods, and have lasting gains for individuals. – Substance abuse will not increase in the psychiatrically ill population. – Stigma against the mentally ill in the community at large will decrease. – The justice system will be more tolerant of mentally ill people who run foul of the law. – Mentally ill patients will be adequately serviced by available accommodation options as well as adequately dealt with by the general health system in regard to their physical health. – Effective community services will substantially reduce if not eliminate the need for acute and (more specifically) chronic beds. – Demand for psychiatric service will remain stable over time. – The costs of community services can be constrained by limiting services to the low prevalence disorders (or those with "severe mental illness"). Anyone who has lived through the full implementation of a comprehensive mental health reform program will recognise that many of these premises are substantially misguided. This does not mean that community care for the vast majority of psychiatric patients is impossible, or that we should reverse the process of deinstitutionalisation. But we would argue that further reforms need to be more cognisant of the reality and tragedy of mental illness, and that there is no panacea. We need to keep on trying new ways of enhancing community care to the betterment of the health of our patients, rather than continually restructuring service delivery models. Much more needs to be done to reduce community stigma against people with illnesses such as schizophrenia, and concerted approaches adopted more effectively to reintegrate these individuals into mainstream living. Lack of suitable accommodation and very low work participation rates are particular barriers in this regard. It is true that mental health systems, perhaps more obviously than general health systems, are under-funded for what they are expected to achieve. This is certainly the case even in an affluent country such as ours. But significant gains have been made, and our profession should expend energy on building on those gains rather than seeking to dismantle them. Thus, we would contend that any approach to improving the mental health of the population needs to take particular heed of the strength of the challenges articulated by Thornicroft et al, namely to acknowledge that there is no right way but that each community society and nation needs to put the necessary elements for care together in a package that makes sense for them. We would add the imperative to ensure ongoing evaluation of the effectiveness of service interventions, and continuing to listen to all the main stakeholders, not least staff within services, and patients and carers themselves.
Restructuring
Inpatient care
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