There are many variations in the way governments attempt to address the needs of their populations. The United Kingdom and the United States provide two examples.
The centralized administration of health services in the United Kingdom has been modified under a series of reforms to devolve considerable authority and responsibility for administering health care to local bodies. Psychiatric services fall mostly under the purview of district health authorities ( DHAs). The DHAs are designated as the purchasers of services. Hospitals, practitioners, health service trusts, and other agencies are the providers who contract with the DHA. Within each district a number of sectors or catchment areas are defined.
The principle upon which the system is designed is that of needs-led planning. (39 Each DHA is mandated, under the provisions of the National Health Service and Community Care Act 1990, to make an assessment of the needs of its area population as a basis for allocating resources. The method for accomplishing this was not stipulated in the legislation, but most DHAs have used formulas based on social indices such as the UPA-8 as indicators of need and for the development of contracts with providers in the area. This model is clearly based on a concept of need—defined epidemiologically and estimated by the professionals who manage the system. The planner is, in theory, able to discern where special needs exist, so that the purchaser can contract with providers to address those needs. The purchaser can also propose innovations and contract with providers to implement them.
In the United States, the central planning approach is giving way to increasing reliance on market forces to meet needs. Exponents of this view maintain that even within public-funded service systems, a market is the most equitable and efficient mechanism to allocate resources; that consumers or purchasers of care will only be prepared to pay for services that are beneficial and only to the extent that they are needed. Unmet needs create demand and a willingness to pay a fair price, and in an open market it is believed that providers will step in to meet the demand. The advantage, in theory, is that overprovision is reduced to a minimum and the most cost-efficient approaches will displace less efficient methods. The consumer can select those services that best meet his or her needs and preferences. Consumers thus, in theory, have a major role in determining which programmes succeed and which fail.
The marketplace model assumes that all consumers are cognizant of what their needs are and are able to take the initiative to seek out the services they need. These assumptions are often not valid in the health-care arena, particularly in mental health. Thus the pure market approach needs to be modified, for example by the promulgation of regulations to ensure that providers meet certain standards and address certain needs. Mental health authorities are set up by state governments with oversight responsibility to protect the interests of consumers. These regulatory bodies are to ensure quality of care and promote fairness. They are required to make estimates of prevalence of serious mental illness, as described above, and thus implicitly make judgements about needs. Where market systems are set up, public mental health authorities may act to ensure that within the marketplace at least the most apparent needs of individuals are being met. For example, most systems recognize that individuals may have a need for emergency care when they (the individuals) perceive such a need. Payers may be required to pay for emergency care without preauthorization. Case managers may be employed to ensure that individual consumers obtain access to the services they need. The marketplace theory holds that consumers will demand that a service be provided if it is truly needed and that payers will then be obliged to provide it.
Whether a marketplace model can be successful in meeting the needs of people with mental illnesses remains to be seen. There is insufficient experience at this juncture to determine whether or not patients' needs are being better met than under older systems based on central planning, grant funding, and unmanaged fee for service reimbursement.
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