Governance, choice and the global market for mental health.

The provision of health services to vulnerable members of the population should be regarded as one of the prime duties of government. However, it will be apparent to any reader of International Psychiatry that access to effective mental healthcare varies widely across the world, an impression powerfully reinforced for those who have the chance to visit and work in countries facing different developmental challenges. On World Mental Health Day 2010, the Secretary-General of the United Nations called for this shortfall to be remedied (United Nations, 2010). With the globalisation of knowledge and culture affecting every facet of life across national boundaries, it is worth reviewing how such changes could influence the development of mental healthcare across the planet.

There is some agreement that the improvement of mental health services depends on resourcing, service infrastructure and government policy (Thornicroft, 2002; Jenkins, 2003). The current focus is on scaling up global resourcing in mental health (World Health Organization, 2010). Of course, different infrastructures may be appropriate for different challenges, including levels of resourcing. The country profiles in International Psychiatry set out overviews of facilities, services and professionals, and give creative examples of how targeted intervention has brought benefit. For some years advice has been available to governments on policy models for rolling out community mental health services (e.g. World Health Organization, 2010).

The value of inter-country cooperation and teaching (including the less formal transmission of knowledge) is undoubted, especially when they foster an accurate understanding of cultural diversity and local conditions. The World Psychiatric Association and the World Health Organization are key in the sharing of expertise, including the evidence base for treatments and infrastructure models. However, the success of such initiatives depends crucially on both resourcing and government planning (Lancet, 2010).

In some well-resourced high-income countries, a diverse market of providers has developed, often unplanned, but meeting a great deal of need, and enabling comparisons of efficiency and of outcome for service users. This is one way in which the concept of choice in mental health is gaining ground (Sugarman et al, 2010). Taking the UK as an example, annual expenditure on mental health, across state-funded health and social care services, currently runs at around £21 billion (Centre for Mental Health, 2010), covering an infrastructure of hospitals, care homes and extensive community mental health services. While most of this is provided directly by the state-run National Health Service and local authorities, in recent years the commercial sector has made an increasing investment in care homes and hospitals, now funded by the public purse at around £8 billion annually (Laing & Buisson, 2010).

There is great value in this diversity of players in mental health, not least because it has started to highlight what is needed, what works, the relative strengths and weaknesses of provider models, and the role of government in commissioning services in an open market. In the UK there are at present interesting tensions between public and private providers (Pollock et al, 2010). The voluntary (‘third’) sector in the UK is also an important mental health service provider, especially strong in innovative forms of community support, and at its most effective when it brings together commercial-style efficiency with public healthcare values. In addition, provider charities often campaign for improved resourcing and awareness of mental health, and are closely linked with the wider mental health knowledge sector, which includes universities, professional bodies and think-tanks.

In an age when knowledge can be shared so easily, and when successful industries roll out models of healthcare across the world, from pharmaceutical companies to hospital corporations, there is an emerging alternative to governments in lower-income countries importing information and advice, setting policy and also running service programmes directly. They have the option of a conscious policy decision to exercise choice in selecting providers and their models of care, and to concentrate on an effective model of service commissioning. The coalition government in the UK is now extending this market-based approach with a policy of ‘any willing provider’, which emphasises commissioner and patient choice (Department of Health, 2010).

At present there is very little systematic information available on the market diversity of mental health providers in countries across the world. In addition to public services, there are of course private hospitals (taking wealthier patients), charitable institutions (filling some gaps in provision) and scattered examples of public purchasing of mental health services from independent providers. Community support is generally publicly run, but families still take a predominant role in most societies, especially in those with less well developed services. Of course, cultural factors greatly affect models of service governance, including the balance between older, leaner forms of management led by medical and nursing staff, and more modern, general-management-led styles. There is also great variation in the subculture of psychiatry and mental health work by country, including divergent patterns and quality of care and administration, visible between, for example, Europe East and West, the Far East and North America (Gijswijt-Hofstra et al, 2005). Some of this service diversity is no doubt also seen within countries, offering some basis for choice.

Developments in the UK suggest that a market based on provider diversity could offer an alternative to total state provision, allowing governments to focus on their aspirations for the population and on the assurance of outcomes for service users. This may be most effective and efficient for middle-income countries with adequate but not abundant resources. Calling on a spread of mental health service providers is likely to be equally attractive to those fast developing countries that intend to build infrastructure quickly. Rather than investing directly, the creation of a market attracting new providers with international experience may be a partial answer to the common plea to scale up investment in services. Such providers could vary from commercial corporations to charities, cooperatives and state-sponsored foundations, as well as expatriate mental health professionals training abroad. Government policy to move away from the default of state provision towards state commissioning, with an inclusive approach to providers, both for-profit and not-for-profit enterprises, could bring a mix of investment in infrastructure as well as a long-term focus on service development and outcomes.

Effective service commissioning requires a coherent policy approach to healthcare quality governance. Amid an abundant recent literature on healthcare governance, there is little on the specific topic of mental healthcare governance. It is, however, possible to develop contemporary concepts in mental health – such as rights, risk, rehabilitation and recovery (e.g. Sugarman & Kakabadse, 2008) – into a governance model which turns on reporting to purchasing commissioners adverse events, organisational learning, therapeutic activity and patient outcomes, as required by the current framework in England and Wales. Other key elements of the market are an intelligence- and inspection-based industry regulator, and transparent public sector accounting, so that the true cost to government of state-run services is available for comparison.

The advent of competition in global healthcare raises fears for vulnerable groups, but it also offers a healthy challenge to monopoly state provision of services, which risks inefficiency and ineffectiveness in delivering outcomes. Such competition requires a planned regulatory and commissioning environment, which has the interests of the patient at heart. Governments which concentrate on the creation of a socially managed market, and on effective mental healthcare governance, may be able to realise major benefits for the most vulnerable groups in the population. By planning now to harness the power of globalisation of markets and information, the vision of improved care through choice for patients could become a reality.

Declaration of interest

Philip Sugarman is Chief Executive Officer of St Andrew’s Healthcare, the largest provider of charity sector services to the UK National Health Service, and a trustee of the Royal College of Psychiatrists.