As we contemplate the next Administration, the following quote, which I came across in the May 2008 issue of Psychiatric Services, is worth considering:
Public mental health policy attempts to provide maximally effective services in the context of limited resources, promulgate clear service standards in the context of scientific uncertainty, and work to harmonize frequently conflicting needs and objectives of multiple stakeholders (patients, families, providers, other payers, general citizenry, and so forth).. . .
Choosing which services to provide in a public mental health system is always a matter of balancing clinical effectiveness, cost, and political will. Political will has never been sufficient to support the full cost of all that we believe to be clinically effective, and therefore difficult choices are always necessary.
(Joseph J. Parks, M.D., Alan Q. Radke, M.D. and Rajiv Tandon, M.D.: Impact of the CATIE Findings on State Mental Health Policy. Psychiatric Services 59:534-536, May 2008.)
This may be stating the obvious, but as we work to rebuild our shattered public mental health system, we will need to return to basic principles.
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Many of the elements of the reform have merit. I would like to comment on the design flaw I feel has lead to the diaster for people in need of effective, quality services. As long as paraprofessionals are the designated entry point and clinical home, the experts in the field cannot lead and have no decision making power in the field. On the other hand, if psychiatrists, psychologists, and other licensed clinicians are the entry; the consumer can expect, at the very least, an appropriate assessment of clincal need,medical necessity, and a plan. These clinicians are accustomed to clinical responsibility and accountability. The State does not need to create an elaborate system of accountability. Licensing boards already take care of many of these tasks. North Carolina is not using existing systems of clinical managemnt.
The mental health system needs professional leadership. Services, such as community support, then become one of many specialized tools in treatment, but not clinical decision makers, not the "driver of the service".
North Carolina is in a system crisis in terms of money and manpower. Rather than rebuild public clinics to assure clinical coverage, why not establish a reasonable rate structure so that professionals can lead and direct services. The use of paraprofessionals as the entry and clinical home is a devastating design flaw that must change.
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