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

1. 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 SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

2. Agenda • The UK Mental Health System (very briefly) • The IOM and President’s Commission Reports Highlights • Comparisons of US and UK Systems SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

3. THE UK MENTAL HEALTH SYSTEM SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

4. THE UK MENTAL HEALTH SYSTEM Organization • NHS (Dept. of Health) • 28 Strategic Health Authorities (planning) • Primary Care Trusts ("commission" and fund services) SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

5. THE UK MENTAL HEALTH SYSTEM 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) SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

6. THE UK MENTAL HEALTH SYSTEM Key Elements • Focus on SMI (much less for mild or moderate problems) • Care Programme Approach (CPA): Goal - "safety-net" of review. • Care coordinator; health and social care assessed; no discharge without appropriate aftercare; consultation with patient, carer, and others; care plan; regular review SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

7. THE UK MENTAL HEALTH SYSTEM Key Elements • Range of Services (acute/emergency care; rehabilitation and continuing care; day care; home-based and community care) • Primary Care • Inpatient Units SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

8. THE UK MENTAL HEALTH SYSTEM Specialist Teams • Community Mental Health Teams ("mainstay") • Early Intervention Teams • Crisis Resolution Teams • Assertive Outreach Teams • CBT (Cognitive Behavioral Therapy) SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

9. National Health Service Framework Evidence Based Practice • Centre on Evidence Based Care • Cochrane Collaborative • Minervation • NeLH (National electronic Library for Health) SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

10. National Health Service Framework • CRD (Centre for Reviews and Dissemination) Dare • NICE (National Institute for Clinical Excellence) • CHAI (Commission for Healthcare Audit and Inspection) SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

11. THE UK MENTAL HEALTH SYSTEM Recent Key Documents • 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 SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

12. THE UK MENTAL HEALTH SYSTEM Recent Key Documents • 1998 Modernising Mental Health Services • 1999 Mental Health National Services Framework • 2000 NHS Plan • 2001Prison Mental Health Strategy SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

13. THE UK MENTAL HEALTH SYSTEM Recent Key Documents • 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 SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

14. THE UK MENTAL HEALTH SYSTEM Recent Key Documents • 2002 CAMHS (Children's and Young People's Mental • Health Services) • 2002 A Sign of the Times (mental health for • people who are deaf) • 2003 NIMHE (National Institute for Mental • Health) • 2002 2003-2006 NHS Priorities(mental health one of top three) SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

15. THE UK MENTAL HEALTH SYSTEM Recent Key Documents • 2003 Money for Mental Health (Sainsbury Centre) • 2003 Tackling Health Inequalities • 2004 Children's National Service Framework SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

16. THE UK MENTAL HEALTH SYSTEM Models that are most similar: • 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

17. THE UK MENTAL HEALTH SYSTEM CONCLUSIONS 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. • But development is patchy and we need more resources. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

18. TWO MAJOR US REPORTS SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

19. MAJOR US REPORTS • Institute of Medicine (IOM): “Crossing the Quality Chasm” (2001) • “The President’s New Freedom Commission on Mental Health – Achieving the Promise: Transforming Mental Health Care in America” (July 22, 2003) SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

20. Key IOM Points • Quality Aims: Care should be safe, effective, patient centered, timely, efficient, and equitable. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

21. Key IOM Points Four priority areas: • Applying evidence to health care delivery • Using information technology • Aligning payment policies with quality improvement • Preparing the workforce SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

22. Commission Goals 1.  Americans Understand that Mental Health is essential to General Health • Mental Health Care Is Consumer and Family • Driven   3. Disparities in Mental Health Services Are Eliminated SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

23. 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 SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

24. COMPARISONS OF US AND UK SYSTEMS SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

25. What We Have In Common SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

26. What We Have In Common • Developed countries are more alike than different, while major differences between us and developing countries. Many opportunities for learning from each other and collaboration. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

27. What We Have In Common • People with similar serious and more moderate problems. • Mix of incomes. • Increasing diversity. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

28. What We Have In Common • Thus, treatments and needs should be similar. • Live in urban, suburban, rural areas with somewhat different needs. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

29. What We Have In Common • 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

30. What We Have In Common • 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

31. What We Have In Common • 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

32. What We Have In Common • 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

33. What We Have In Common • 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

34. What We Have In Common • 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

35. 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

36. What We Have in Common • Movement towards good information and systems, outcomes and evidence based practice, performance measurement and implementation of these including financial incentives that support these. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

37. What We Have in Common • 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

38. What We Have in Common • Not enough funding. • Need for community empowerment and skills in facilitating it, team building, modernization support. • Caring, committed, hard working professionals at all levels. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

39. Differences SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

40. 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

41. 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

42. Differences • US has more strongly biomedical model for understanding mental health, but... • UK doctors much better trained and used more for mental health services. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

43. 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

44. 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

45. 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

46. 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

47. Differences • Many individual and private practitioners in the US, few in UK. • Less focus in UK on work, housing, though recognize the need. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

48. 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") SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

49. Differences • Social workers are primary line clinical and managerial staff in US, while psychologists and nurses have a greater role in the UK. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT

50. 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. SUFFOLK UNIVERSITY CENTER FOR PUBLIC MANAGEMENT