Richard H. Beinecke DPA, ACSW Suffolk University Department of Public Management Boston, MA

SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

APHA 2004

Comparing the American and English Experiences of Creating Quality Mental Health Systems Based on Crossing the Quality Chasm and the Report of

the President's New Freedom Commission

Richard H. Beinecke DPA, ACSW Suffolk University Department of Public Management

Boston, MA

American Public Health Association, Washington DC

November 9, 2004


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Agenda

The UK Mental Health System (very briefly)

The IOM and President’s Commission Reports Highlights

Comparisons of US and UK Systems


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THE UK MENTAL HEALTH SYSTEM


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THE UK MENTAL HEALTH SYSTEM Organization

NHS (Dept. of Health)

28 Strategic Health Authorities (planning)

Primary Care Trusts ("commission" and fund services)


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Organization

Care Trusts, Mental Health Trusts, NHS Trusts (NHS hospitals), Ambulance Trusts

Provide or contract for services with nfps or private organizations.

NIMHE (Modernisation Agency)

LITS (Local Implementation Teams)


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Focus on SMI (much less for mild or moderate problems)

Care coordinator; health and social care assessed; no discharge without appropriate aftercare; consultation with patient, carer, and others; care plan; regular review

Care Programme Approach (CPA): Goal - "safety-net" of review.

Key Elements


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Range of Services (acute/emergency care; rehabilitation and continuing care; day care; home-based and community care)

Primary Care

Inpatient Units

Key Elements


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Early Intervention Teams

Community Mental Health Teams ("mainstay")

Crisis Resolution Teams

Assertive Outreach Teams

CBT (Cognitive Behavioral Therapy)

Specialist Teams


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National Health Service Framework

Centre on Evidence Based Care

Evidence Based Practice

Cochrane Collaborative

Minervation

NeLH (National electronic Library for Health)


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National Health Service Framework

CRD (Centre for Reviews and Dissemination)

Dare

NICE (National Institute for Clinical Excellence)

CHAI (Commission for Healthcare Audit and Inspection)


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• 1971 Better Services for the Mentally Ill

• 1983 Mental Health Act

• 1991 The Health of the Nation

• 1991 Care Programme approach

• 1998 Our Healthier Nation

Recent Key Documents


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• 1998Modernising Mental Health Services

• 1999 Mental Health National Services Framework

• 2000 NHS Plan

• 2001Prison Mental Health Strategy



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• 2001 Older People's National Service Framework

• 2002 2003-2006 NHS Priorities(mental health one of top three)

• 2002 National Suicide Prevention Strategy for England



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• 2003 NIMHE (National Institute for Mental

Health)• 2002 2003-2006 NHS Priorities(mental health one of

top three)


• 2002 CAMHS (Children's and Young People's Mental Health Services)

• 2002 A Sign of the Times (mental health for

people who are deaf)


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• 2003 Money for Mental Health (Sainsbury Centre)

• 2003 Tackling Health Inequalities

• 2004 Children's National Service Framework


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State programs, e.g. Massachusetts – large scale public managed care – are the closest systems in the US to UK and Europe.

Staff model HMOs (e.g. Kaiser, Harvard Pilgrim) are also close, but serve mainly privately insured members.

Models that are most similar:



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David Kingdon - University of Southampton (2003)

Major changes in services in the last decade have occurred.

Therapeutic advances are gradually being implemented.

The range of services is widening.

CONCLUSIONS

But development is patchy and we need more resources.



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TWO MAJOR US REPORTS


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“The President’s New Freedom Commission on Mental Health – Achieving the Promise: Transforming Mental Health Care in America” (July 22, 2003)

Institute of Medicine (IOM): “Crossing the Quality Chasm” (2001)

MAJOR US REPORTS


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Key IOM Points

Quality Aims: Care should be safe, effective, patient centered, timely, efficient, and equitable.


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Four priority areas:

1. Applying evidence to health care delivery

3. Aligning payment policies with quality improvement

2. Using information technology

4. Preparing the workforce

Key IOM Points


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Commission Goals

1. Americans Understand that Mental Health is essential to General Health

2. Mental Health Care Is Consumer and Family Driven

3. Disparities in Mental Health Services Are Eliminated


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Commission Goals

4. Early Mental Health Screening, Assessment, and Referral to services Are Common Practice

5. Excellent Mental Health Care Is Delivered and Research Is Accelerated

6. Technology Is Used to Access Mental Health Care and

Information


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COMPARISONS OF US AND UK SYSTEMS


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What We Have In Common


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Developed countries are more alike than different, while major differences between us and developing countries. Many opportunities for learning from each other and collaboration.


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Mix of incomes.

Increasing diversity.

People with similar serious and more moderate problems.


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Thus, treatments and needs should be similar.

Live in urban, suburban, rural areas with somewhat different needs.


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Need for good medical care, mental health/sa care, wide mix of social services, employment etc.

Need to assist people throughout the life cycle: children and families, adults, elders (growing concern). Similar medication needs.


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Neither are simple, unified systems, very complex. But movements towards managed and organized systems of care.

Many people treated by primary care providers or providers as gatekeepers, need to improve this care.


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• Deinstitutionalization. Hospital usually is the least preferred location for care if other alternatives are appropriate. Need active, skilled, and effective treatment if in hospital, good community and home care, a continuum of care.


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Both have shortages of residential and other community services.

Same basic needs from providers, e.g. knowledgeable person, who cares about us, will listen to us, will advocate for us. More important than any particular talk therapies.


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Prison care is an emerging issue.

The recovery paradigm instead of illness model.

Better understanding of neurology and “mind/body and need to address both; i.e., treating the whole person.


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Future revolution in genetics, understanding of genetics and the environment, and appropriate provision of these services.

Integration of care, case management. But problems in the separation of mental health, primary care, substance abuse treatment, social services; public and private provider collaboration.


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What We Have in Common

Growing family (carer) and consumer movements and need (still far from being met) to involve them as well as providers in policy making and administration at all levels, peer care, research and evaluation.

The problems of stigma, barriers that it creates, and educational campaigns.


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Movement towards good information and systems, outcomes and evidence based practice, performance measurement and implementation of these including financial incentives that support these.


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Administrator and clinical staffing and recruitment problems, workforce development, aging of leaders, current knowledge in curricula, need for continuing education of existing clinical staff, management and leadership training.


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Not enough funding.

Need for community empowerment and skills in facilitating it, team building, modernization support.

Caring, committed, hard working professionals at all levels.


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Differences


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Differences Dual public and private systems in the US since

no universal coverage, no NHS.

States prime managers of public health care, not the Federal government, although with much Federal as well as state money.

Both countries have separate social service systems, but in UK managed by appointed local authorities, in US by states.


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Differences

Services in US provided by thousands of private agencies, non-profit or for profit. Smaller but growing voluntary sector in the UK.

Primary care doctors are gatekeepers in both systems, but direct access to specialist care much more common in the US.


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Differences

UK doctors much better trained and used more for mental health services.

US has more strongly biomedical model for understanding mental health, but...


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Differences

Much closer relationships in the UK between primary care, specialist care, substance abuse and mental health, social services, although integration is still a problem. Case management )care programme) emerging in both countries, but individual case management more common in the US.


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Differences

Harm and violence reduction focus in the UK, recovery models not yet as prevalent. Focus on "access to service" more than "access to recovery."

Most public care in the UK for SMI, little (or very long waits) for people with less serious problems, unlike US where more common to treat all fairly quickly.


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Differences

Acute hospital care in the UK generally behind the US, less active treatment, more warehousing, less respect for hospital staff, often poor facilities.

More continuity between hospital and community psychiatry in the UK, but frequently less effective aftercare planning.


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Differences

Almost no home care in the US, much home care and "carer" (family) support in UK.

Much less individual and group therapy in the UK. CBT and assertive outreach more common in the UK with SMI.


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Differences

Many individual and private practitioners in the US, few in UK.

Less focus in UK on work, housing, though recognize the need.


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Differences

While both countries emphasize drug more than alcohol treatment, substance abuse treatment in UK generally lags behind US, little care coordination, and less effective treatment for people with dual diagnoses. Substance abuse residential as good as the US. UK ahead of the US on "harm reduction" ("early client engagement")


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Differences

Social workers are primary line clinical and managerial staff in US, while psychologists and nurses have a greater role in the UK.


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Differences

Nationally organized evidence based care much more advanced in the UK in mental health (but not substance abuse) with more research, protocols, systems to disseminate the information, expectations that practice will be evidence based, training and teaching in schools. Just starting in the US. But still major implementation problems in both countries.


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Differences

Much more movement to outcomes measurement in the US and linkage to service utilization and cost data.

Contracting, performance management, and management information systems/data collection more advanced in US. Less regulation and paperwork in the UK.


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Differences

Users and carers growing in influence in both countries. More user run services in the US, and users creating policy and research at all levels in the UK.

Broader definition for detention in the UK ("in the interests of health" vs. "danger to self or others"). Community detention a big national law reform issue now in the UK.

Richard H. Beinecke DPA, ACSW Suffolk University Department of Public Management Boston, MA

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