The Patient Protection and Affordable Care Act of the ACA aims to increase access to care, improve the quality of care, and lower total health care costs.
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View 3 excerpts, cites background. Faith-based organizations and the Affordable Care Act: Reducing Latino mental health care disparities. Psychological services. Severe and persistent mental illnesses are among the most pressing health and social problems in contemporary America. Recent estimates suggest that more than three million people in the U. The impact of national health care reform on adults with severe mental disorders. The American journal of psychiatry. Medicare's bundled payment pilot for acute and postacute care: analysis and recommendations on where to begin.
Moving beyond parity--mental health and addiction care under the ACA. The New England journal of medicine. Enactment of the Mental Health Parity and Addiction Equity Act in improved insurance coverage for mental health and addiction treatment.
Now, the Affordable Care Act could affect the financing … Expand. Comparison of ACT and standard case management for delivering integrated treatment for co-occurring disorders. Psychiatric services. Long-term cost effects of collaborative care for late-life depression. The American journal of managed care. Economic considerations associated with assertive community treatment and supported employment for people with severe mental illness. A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness.
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Yet the drive to take the health service into the 21st century and become an economically viable and sustainable endeavour has also highlighted another deep-seated problem within the NHS: How to ensure vulnerable groups are cared for effectively, particularly with shifting demographics. The focus of this article is that of the mentally ill, and it will consider how this group fares under the changes introduced by the HSCA Prior to the enactment of the HSCA , the needs associated with mental health conditions 5 had already been explicitly acknowledged as a priority.
These mental health objectives are expected to map onto the broader NHS changes under the HSCA by virtue of explicit recognition within the legislation that mental ill health will be given parity alongside other physical health needs. The vulnerable, whether the mentally ill, the elderly or those who are mentally incapacitated, are particularly at risk as they are often not in a position to protect their own rights.
Instead, reliance is placed upon those around them and the systems they are placed within to do this for them. In the wake of the HSCA , it is necessary to reflect upon whether the Act offers hope to those made vulnerable through mental ill health, or whether it instead fails them, and if so, why?
This article explores this question with reference to three key policy drivers within the legislation and is structured accordingly. In the first instance, the article examines the HSCA from the mental health perspective, in terms of how the restructured commissioning process operates and how it maps on to the mental health framework.
Attention is then given to three issues: First, whether parity between mental and physical health can in all reality have life beyond political rhetoric; second, what impact driving up efficiency within the NHS, in terms of commissioning decisions, will have upon patients with mental health conditions and third, the extent to which the personalisation agenda can be meaningfully applied within the mental health context.
These issues are considered with reference to broader policy influences within the mental health law and policy landscape. Whilst the fundamental restructuring of the NHS has been the subject of recent attention with the enactment of the HSCA , mental health has also been under the spotlight of reform in the past few years. The Mental Health Act 12 sought to respond to the challenges posed by changing psychiatric practices and the policy shift from hospital-based treatment to care in the community.
Hospital care is now reserved largely for those requiring acute or intensive psychiatric care. In parallel with the introduction of the Mental Health Act , modifications have been made to the Mental Health Act Code of Practice to reflect the legislative amendments. Whilst the Code is not legally binding, decision-makers are required to justify any departures from its guidance in their decision-making. It is often here where the legislative framework fails the mentally vulnerable.
The HSCA has been heralded as the most extensive and radical reorganisation of the NHS to date 19 and has been accompanied by significant levels of political rhetoric, speculation and controversy.
These objectives are incontrovertible; however, many of the mechanisms that the legislation introduces to achieve these aims have generated concern amongst service users, clinicians and service providers alike. The changes introduced by the Act are far reaching and for those with chronic and enduring conditions, of which all mental health conditions would likely be labelled, the HSCA can be expected to wield significant weight in treatment and care planning as it becomes fully operational in the months to come.
Several key elements of the legislation guide its implementation: ensuring a patient-centred NHS; promoting and supporting a clinician-led service and transferring the emphasis of measurement to clinical outcomes. The question remains whether any one of these principles will dominate during the implementation process, and if so, which it will be.
The persistent concern amongst many professional and user groups 22 alike has been and continues to be that the political desire to make financial savings and improve the cost-effectiveness of the NHS may prove to be the overarching driver.
In all likelihood, this will encourage providers to be more active in lucrative areas of health care. Mental health care and associated social care provision is generally seen as an unprofitable field, with long-term and often complex care and support required by individuals.
This enables the private sector to have direct access to the central operations of the NHS, in terms of both planning and provision. Commissioning of services for mental health care and treatment services will be conducted and guided by Clinical Commissioning Groups CCGs , 30 which are introduced by the HSCA , in a similar fashion as for all other services. CCGs will also have a general duty to improve the quality of the services they provide or commission. Primary medical services which include acute inpatient psychiatric care and secure psychiatric units are to be commissioned by NHS England.
The focus on quality improvement goes beyond the old duty that primary care trusts PCTs had under NHS Act , which was to improve the quality of health care services apropos existing published standards. Instead, the duty under the HSCA explicitly recognises the need to consider treatment and care outcomes and the patient experience.
CCGs are also required to endorse a patient-centred approach 33 by encouraging patient involvement through shared decision-making. The implementation of this duty will be facilitated by new guidance to be published by NHS England.
How viable the balancing exercise of enabling patient choice within the mental health field will be remains to be seen. The creation of patient choice relies not only upon CCG behaviour endorsing and facilitating patient choice, but the providers of these services must actually exist — in mental health, the fulfilment of identified need has often presented challenges, as service provider limitations are routine.
At a broader level, concern surrounds the impact this duty to facilitate patient choice may have on the market. Patient choice is often determined through a plethora of motivating factors, not least the common desire to be close to family and friends. For many, access to psychological services is a central wish, with drug therapy being a necessity of last resort. Additional choice may inevitably be at the expense of effective integration.
Despite this, under the Act, CCGs have a duty to promote service integration. This entails the integration of health services with health-related and social care services.
The political motivation behind this duty is to improve efficiency of service provision and to reduce unnecessary costs. Nonetheless, from the patient perspective, this offers an avenue for improvements in quality of life, particularly for those who need longer term support in the community.
For the mentally vulnerable, effective integration of services is often particularly important, improving the implementation of treatment plans, medication compliance and ongoing community-based support. The difficulty with this duty is that as yet no guidance has been supplied to aid CCGs in the process of achieving good integration amongst and between these various services. Furthermore, mental health provision is littered with countless examples of joint working failures and inadequate communication throughout the health and social care system.
Indeed, the ideal of achieving seamless provision is far removed from the reality for many patients, and it is often this which leads to the disjointed care that is received 39 and the gaps in provision where patients fall through the net. The required establishment of Health and Wellbeing Boards 40 by each local authority may reduce the perennial problems surrounding joint working. Boards can extend their membership to reflect particular area needs; this may allow a local service to be developed for local needs.
The Board is also required to take account of affiliated services with social care, such as, housing and education and to recognise that these services have a direct influence on the broader well-being of individuals. It is uncertain whether this will directly improve service provision, but the Cross-Government Mental Health Strategy 42 pins its hopes on the shift towards localism and local care decision-making under the Act. The restructuring of the NHS and the changes created by the HSCA to the commissioning process will take time to grow accustomed to.
From a mental health perspective, the HSCA offers real potential to see mental health brought from the margins of provision to feature much more prominently. It creates the possibility for a conceptual reconfiguration of health to emerge, introducing explicitly the need for parity between mental and physical health.
Indeed, this duty to promote health parity could create the impetus for a paradigmatic shift within health and social care provision, but just how successful the implementation of this will be remains to be seen as the high-level commitment to health parity is only one of several key objectives within the legislation.
Devolution of budgets down to CCGs may provide opportunities for mental health to feature more prominently within the commissioning process; yet there are concerns that mental health needs may continue to be overlooked by CCGs when pressure to commission services efficiently whilst also increasing patient choice presents significant tensions for CCGs to overcome. We will now turn to consider three drivers within the Act, exploring whether they are feasible within the mental health context or whether the legislation will prove to be detrimental to those with mental health needs.
First, attention will be given to the commitment to achieving parity of physical and mental health within the health care system, followed by a consideration of how the desire to increase efficiency may influence commissioning decisions within the mental health arena and finally, consideration will be given to the move towards expanding patient choice and personalisation within the health care market.
Mental health conditions are now to be recognised as a clear equality issue 46 and the NHS Equality Delivery System 47 will be primed to help those providing NHS services to respond properly to it. Clearly, making improvements for mental health provision is dependent upon good implementation. CCGs will be expected to demonstrate to NHS England that they have sufficient planned capacity and an ability to commission for improved health outcomes in mental health.
Owing to this shift in attitude, and indeed, reconfiguration of the conception of health within the legislation, the neglected and under-resourced mental health service may be a thing of the past.
The drive to improve access to psychological therapies for patients with mental health conditions is an example of this attitudinal shift and is a welcome move. The newly restructured system of health and social care is in its infancy, and it is still too early to say whether the steps taken to achieve parity will bear fruit. Likewise, how the vulnerable will be able to protect their rights in this new health and social care environment is unknown, but it seems likely that CCGs, if motivated by market-driven policies, could lose sight of the particular needs of these vulnerable groups.
In many ways, achieving parity is a deep-seated cultural issue and goes far deeper than surface-level implementation. Achieving parity needs fundamental attitudinal change at institutional, organisational and individual levels. For mental health, the best hope for this change exists within the Mental Health Implementation Framework 57 where explicit mention is made of the need to promote research into mental health and to recognise, support and strengthen academic career paths in this field.
Whilst parity of mental and physical health is a clear commitment within the HSCA , the introduction of competition principles will also facilitate efficiency savings. Mental health needs are often complex, requiring the input of a variety of different agencies and service providers. Not only can providing for this complex diet of needs be difficult, it can be expensive. Both the cost and complexity of provision in mental health has been a persistent source of difficulty in the past and where tragic failures in care have occurred; investigations have often presented a catalogue of challenges surrounding the coordination and adequate funding of care.
Two separate issues in the commissioning process for mental health services exist: First, the level of clinical expertise that exists and second, whether CCGs have sufficient management experience to meet the need for equal distribution and coverage of services. These two areas raise doubts about how efficient and effective commissioning decisions will be carried out.
If pockets of poor management do emerge, 67 then mental health provision may be adversely affected. Whether the HSCA will improve this is uncertain. Management inadequacies and failures to identify needs by CCGs may not be detected as there remains some doubt about how the new NHS structure and regulatory bodies will scrutinize and oversee activities.
The challenges facing CCGs are unlikely to reassure patients in the short term; for mental health patients, these concerns may simply be more acute, given the complexity of typical mental health care needs which tend to stretch over a number of agencies and providers, often featuring periods of both acute need and stable chronicity. The standard and effectiveness of care received will all too often depend upon a strong framework of planned and integrated systems or pathways of care from a well-coordinated network of providers.
CCGs are going to have to ensure sufficient awareness is present within the strategic planning process to take account of this, and if they do not, health conditions, including most mental health conditions, that require a complex health and social care response may suffer. The position of the already vulnerable could simply be compromised further.
Personalisation is a central tenet of the restructured NHS. The personalisation agenda seeks to move the health and social care framework away from crisis management, 74 relying upon patients identifying personal needs and making appropriate care choices to meet these needs.
To implement the personalisation agenda, the social care system, in particular, will need to be sufficiently capacious to enable patient choice to be fully achievable. This means that CCGs have to take seriously the need to make and implement local commissioning decisions in a way that will enable genuine choices to be made. Commissioning will need to be multilayered and from a variety of providers; it will need to be possible to manipulate services so that tailor-made packages of care can be created for individual patients.
In addition to the actual availability of services, steps must be taken to facilitate patients in the decision-making process. For some time, 79 self-directed support has been an operational feature of care in the community. The idea is founded upon flexibility, choice and control of social care funding and focuses upon giving eligible people an annual budget to spend on their own care, 80 based upon self-designed care plans.
In practice, patients are encouraged to work with clinicians and social care staff to facilitate implementation. For those who need it, assistance in devising a care plan reflective of individual need is an essential element of the process; particularly as individual budgets are increasingly being used as a vehicle to combine several funding streams that many mental health patients may need to access in the community.
Payment for local authority adult social care falls within the remit for individual budgets and include integrated community equipment services, disabled facilities grants, Supporting People for housing-related support, Access to Work and the Independent Living Fund. However, to enable mental health patients and other chronic patients with complex social care needs to benefit from this, better integration of services and a collective willingness to embrace choice needs to be fostered.
How successful the personalisation agenda and its implementation under the HSCA is, is perhaps best judged by assessing the benefits to patients that have flowed from this agenda. Existing research already indicates that the injection of choice and control over care options can be very positive for patients and carers alike. Other associated and recurrent problems exist within the mental health system, placing further strain on the achievement of the personalisation agenda.
For example, staffing shortages and service scarcities often result in extensive waiting times and inadequate response rates. The HSCA represents a significant departure from a culture of public service provision that we have become accustomed to, but does it fail the vulnerable, notably those with mental health care needs?
The need to drive efficiency up, whilst also tailoring health and social care to individual patients is, perhaps, an impossible dilemma.
How mental health provision will fare in this new and uncharted landscape remains open; but, inevitably, it will face its own set of problems in the months to come. Does the Act fail the mentally vulnerable? Time will tell, though the tensions that exist between three of the key policy drivers within the legislation, the focus of this article, suggest that where there are pressure points and the vulnerable may ultimately experience the greatest detriment.
Competition principles within the health and social care system may drive efficiency up. However, they cannot be responsive to the more nuanced needs of patients with chronic conditions, particularly where care needs bridge both health and social care and are often required for lengthy periods of time.
Perhaps, the brightest ray of hope should be the recognition that parity between mental and physical health will be a clear objective. In mental health, it is the implementation stage that frequently presents the most significant challenge for decision-makers, with limitations in staffing, funding and social care placements creating bottlenecks in the system.
Unless these practical hurdles can be overcome, the desire to forge a new and fairer culture within health and social care, where parity between mental and physical health is the accepted benchmark, will be a very difficult one to attain. The HSCA offers a very real opportunity to enable mental health to be mainstreamed into core public health priorities. It can only be hoped that there are those prepared and willing to fight to ensure the needs of vulnerable groups, such as those with mental health conditions, are met and protected and that faith in the achievement of health and social care equality endures.
The author thanks Prof Robert Thomas and Prof Christopher Newdick for their insightful comments on an earlier draft of this article. Funding: This work was supported by a British Academy Mid-Career Research Fellowship, for which the author wishes to express her thanks. See also, T. For a more detailed consideration of the foundations of the NHS in , see, M. Singleton, R. Bumpstead, M. Lee and H. McManus, H.
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