The Ailing Welfare Service: Reforms of Health and Social Care Needs Proper Scrutiny

Change is part of a humans’ existence therefore, it is unavoidable and timeless. This concept is interrelated and insensitive to current occurrences within the wider welfare institutions in the UK’s health and social care sectors in particular. At present, health and social services are yet again undergoing a painstaking restructuring that is creating psychological and physical stresses to the entire workforce and consumers. This trajectory is building uncertain future due to continuous re-organizations, change of emphasis and redirections of care delivery to the general public. Ironically, people are not sure where their future and loyalty lies as changes in the system is triggering great worries to all concerned.

On reflection, health and social services went through a huge conscientious change in 1990s (The NHS and Community Care Act), that reconfigured the welfare systems to what many practitioners and managers thought would be a modern establishment. However, the New Labour government in 1997 to 2010 changed the prospect and redesigned it to new approaches such as personalization of services (Direct payments, Cash for Care and Personal Budgets) that transformed services delivery within the sectors. Change can make or break staff commitment, maximization of services, profitability or industrial disputes between the management and employees, this owing to mishaps within industrial relations’ policies and protocols.

Changing organizational cultures as well as philosophy and employee’s terms of reference requires effective governance and scrutiny in order to ensure health and social care reforms work for the benefits of all. The key to making the reforms work as planned would be to safeguard effective analysis of all new policy directives and structures. It is now questionable whether the “New Ways of Working” is capable of changing the fabrics and structures of the welfare services in the UK. The main themes of the overhauls are to reduce costs/budgets, staffing and improving quality and standards of services.

Decision making in some departments or services are proving to be irrational because costs are escalating, standards declining and waiting lists for assessment increasing across many social services departments. Most quality newspapers affirm that the coalition may have done everything they could to start implementing health and social care modifications before being properly examined. But, without careful considerations and good governance the plans would be an unmitigated disaster. That notwithstanding, the speed of restructuring and reallocation of services have produced an unsettling atmosphere for most health/social care workers and managers. The government’ itinerary to continue with reforms and their failure to allow time for study or to win the professional’s backing for these radical plans have been challenging to the wider community of experts and the public at large.

Considering the clamor amongst practitioners and clinicians, the question is, would the governments’ defiant be regarded as democratic or dictetorism? In contrast, it is believed that democracy means “government for the people and by the people”. If that is the case, the coalition would have itself to be blamed for any criticisms regarding their actions. The dismantling of the (PCT) Primary Care Trusts throughout the country in the next two or three years could be termed as political vandalism of tax payer’s money and good governance.

Similarly, most strategic health and local government authorities have expressed concerns regarding cutbacks on their budget, which could have huge ramifications to services for older people and other vulnerable groups such as people with disabilities and mental health. This has also been widely highlighted by a large proportion of the professional bodies such as the Nursing and Midwifery Council, British Medical Association and BBC 2 News Night in particular. The criticisms of the government is now without seasoning because health and social care organizations needs to double their expected cuts in order to remain afloat.

The growth of older people and their increasing demand for care is now unprecedented and becoming a threat to the welfare service and public services. This is despite extraordinary support from informal caregivers who are believed to have saved the government over eleven (£11bn) billion pounds a year. That notwithstanding, change is needed to reduce duplications within the system therefore, what is desirable now is a long term strategic alliance between all stakeholders (the national and local governments, health and social care and family members etc.). This would guarantee and strengthen collaborative services and minimization of costs and wastage within the sectors involved. Yet, judging from the current state of the economy both the macro and micro variable, it is certain that change is foreseeable in order to meet the challenges presented by the turmoil in the financial market and escalation of cost to maintain health and social care.

However, the difficulty in planning, management and administration of the ageing universal service in the UK has been made a lot harder as a result of disproportionately deep cuts to local authorities. The Big Society agenda indicated that the government should devolve responsibilities to the community, individuals, families and the third sector. By all assumptions, this would ensure that service users’ care would continue while restructuring is in progress. In hindsight, the key to making the reforms work would be to safeguard effective control and scrutiny of all the workflow patterns and services delivery. Practically, this has proved overwhelming for the organizations and management as details of the shake-up is superficial in terms of economics and socio-politics in line with social policy in the UK.

Presently, the government seems unconcerned and flustered regarding the “House of Common’s” health select committee’s proposal that councillors should be appointed to have seats on the boards of GPs consortia. On reflection, the quality and capacity of the representatives of some voluntary bodies such as: patients/service user’s liaison body and the local involvement network agencies could be inconsistent and lacking because of clinical and financial expertise. Thus, as a scrutiny committee, it would in practice be problematic to work closely with Health Watch, as well as with the health and wellbeing boards.

Financing to Support Coordination of Behavioral Health and Primary Care Services

In October 2003, the Health Resources and Services Administration issued Program Information Notice (PIN) 2004-05 regarding Medicaid Reimbursement for Behavioral Health Services. The PIN requires Medicaid agencies to reimburse Federally Qualified Health Centers and Regional Health Centers for behavioral health services provided by a physician, physician assistant, nurse practitioner, clinical psychologist, or clinical social worker, whether or not those services are included in the state Medicaid plan. The PIN clarifies that “FQHC/RHC providers must be practicing within the scope of their practice under the state law.”

What might PIN 2004-05 mean for the Medicaid population? Categorically eligible Medicaid beneficiaries (e.g., TANF, aged/blind/disabled) may or may not be able to easily gain access to public mental health services, depending on definitions of target populations and medical necessity, which vary from state to state.

In states with public mental health systems that focus on populations with serious mental illness and serious emotional disturbance, PIN 2004-05 creates an opportunity for other Medicaid populations, with higher physical health and lower behavioral health risks, to obtain behavioral health services through a CHC. This is consistent with the HRSA initiative to reduce health disparities and create behavioral health capacity in CHCs. PIN 2004-05 helps to assure that safety net populations are served.

But what does PIN 2004-05 mean in terms of financing and the behavioral health services now provided to populations with serious mental illness? The answer varies from state to state because of differing Medicaid models. This variability requires every community partnership between a CHC and a CMHC to assess their specific financing and policy environment in order to identify a business model that will support integration activities. Such partnerships must develop policy direction that addresses the need for greater access to behavioral health services for the Medicaid population, without disadvantaging any populations now served by the public mental health system.

Learning from Pilot Sites:

“Depression in Primary Care: Linking Clinical and System Strategies” is a Robert Wood Johnson Foundation national program to increase the effectiveness of depression treatment in primary care settings. The program charged its eight demonstration sites with addressing financial and structural issues as well as implementing clinical models. A special issue of Administration and Policy in Mental Health and Mental Health Services Research contains a series of resulting papers, some of which speak directly to the financial and policy barriers in the system.

The pilots reveal the commitment of sites around the country that continue to patch together funding because they believe in the integration approach. For example, in Washington State there is a partnership between the CMHC and the Federally Qualified Health Center, where the CMHC’s clinicians in the FQHC sites are financed by an annual golf tournament – hardly a sustainable model. The IMPACT trials, Depression in Primary Care project, state Medicaid pilot sites, and an Aetna project all identify similar components for financing: