Education And Debate

Effect of recent health and social service policy reforms on Britain's mental health system

BMJ 1995; 311 doi: (Published 09 December 1995) Cite this as: BMJ 1995;311:1556
  1. Trevor R Hadley, directora,
  2. Howard Goldman, directorb
  1. Center for Mental Health Policy and Services Research, University of Pennsylvania, Room 717, 3600 Market Street, Philadelphia, PA 19104-2648, USA
  2. Mental Health Policy Studies, Department of Psychiatry, University of Maryland, 645 West Redwood Street, Baltimore, MD 21201, USA
  1. Correspondence to: Dr Hadley.

    The introduction of new policies in health and social services in Britain has changed the way community care is provided to seriously mentally ill people. Britain is creating the same problems that have existed in the United States, whereby clinicians struggle to provide services in an environment with multiple payers and perverse incentives. A simple system in Britain has been replaced with complicated organisational and financial structures that require almost impossible feats by local health and social service staff to coordinate care for patients for whom continuity of care is critical for their survival in the community and their wellbeing. Seriously mentally ill people are in the middle of these complicated problems. The creation of a local mental health authority that could be held responsible for community care, as exists in some American states, may be one solution.

    Viewed from an American policy perspective, the structure of mental health services in England was relatively simple before the recent NHS and social services reforms. Central government controlled the NHS and was responsible for the funding, operation, and management of the mental health services (mainly hospital based). Local government social services departments provided a limited amount of community care for mentally ill patients, mainly housing and social work support. Historically, this was always a hospitalcommunity divide. In the 1980s important reforms were made to both the NHS and social services. These reforms were largely aimed at changing the management arrangements for delivering general health care in the NHS and at reforming the community care of elderly people provided by social services. Little thought was apparently given to how the reforms would affect the care of mentally ill people.

    We believe that these changes, each of which on their own might have been valuable, have combined to damage provision of care, at least …

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