- Factors That Influence Policy Drivers In Health And Social Care Center
- Identify And Explain The Factors Which Influence Policy Drivers In Health And Social Care
Abstract
Although the National Health Service (NHS) is regarded as a national treasure, it is no longer immune from the colossal financial pressures brought about by global recession. Economic sustainability has largely driven the reform process leading to the Health and Social Care Act (HSCA) 2012, however; other considerations have also played a role in the journey to turn the health and social care service into an institution which is fit for the 21st-century needs. This article examines the impact of the HSCA 2012 on those made vulnerable through mental ill health. It then considers three issues: First, whether parity between mental and physical health can have life beyond political rhetoric; second, what impact driving up efficiency within the NHS will have upon mental health patients; and finally, the extent to which the personalisation agenda can be meaningfully applied within the mental health context.
Introduction
Over the last 60 years, the National Health Service (NHS) has become an intrinsic feature of the United Kingdom, not only underpinning the nation’s health but exemplifying some of its core values and beliefs that are still widely held today.1 The NHS was founded upon three core principles: to meet the needs of everyone; to remain free at the point of delivery and that access to the NHS be based on clinical need, rather than ability to pay.2 These principles remain a fundamental part of the NHS – yet as the years have passed, there is broad agreement that modernisation of the NHS has become a necessity.3 With costs soaring and demand rising exponentially; with the need for improvements and technological developments remaining an unremitting drain on the NHS coffers and the current economic climate making protected, ring-fenced NHS budgets unsustainable in the years to come, proactive steps to reform the NHS have been taken in the shape of the Health and Social Care Act (HSCA) 2012.4 Modernisation has been driven by the demands placed upon a 60-year-old health service provider. Yet the drive to take the health service into the 21st century and become an economically viable and sustainable endeavour has also highlighted another deep-seated problem within the NHS: How to ensure vulnerable groups are cared for effectively, particularly with shifting demographics. The focus of this article is that of the mentally ill, and it will consider how this group fares under the changes introduced by the HSCA 2012.
Prior to the enactment of the HSCA 2012, the needs associated with mental health conditions5 had already been explicitly acknowledged as a priority.6 Since then, a new mental health outcomes strategy was published in February 2011, No Health Without Mental Health: A Cross-Government Mental Health Outcomes Strategy for People of All Ages,7 followed by an implementation framework, published in July 2012.8 The strategy aims to provide better mental health for all and to increase the number of people recovering from mental health conditions, whilst the implementation framework focuses on the provision of strong outcomes monitoring. These mental health objectives are expected to map onto the broader NHS changes under the HSCA 2012 by virtue of explicit recognition within the legislation that mental ill health will be given parity alongside other physical health needs.9 The consolidation of these steps by the HSCA 2012 is fundamental in ensuring mental health conditions are effectively recognised and responded to.10 Achieving this will not be easy in a climate where the global burden of disease is rising, and mental health and behavioural disorders in particular account for an increasing proportion of this.11 Provision for the mentally ill has always been stretched, struggling under the weight of systemic neglect and a lack of resources. The vulnerable, whether the mentally ill, the elderly or those who are mentally incapacitated, are particularly at risk as they are often not in a position to protect their own rights. Instead, reliance is placed upon those around them and the systems they are placed within to do this for them.
In the wake of the HSCA 2012, it is necessary to reflect upon whether the 2012 Act offers hope to those made vulnerable through mental ill health, or whether it instead fails them, and if so, why? This article explores this question with reference to three key policy drivers within the legislation and is structured accordingly. In the first instance, the article examines the HSCA 2012 from the mental health perspective, in terms of how the restructured commissioning process operates and how it maps on to the mental health framework. Attention is then given to three issues: First, whether parity between mental and physical health can in all reality have life beyond political rhetoric; second, what impact driving up efficiency within the NHS, in terms of commissioning decisions, will have upon patients with mental health conditions and third, the extent to which the personalisation agenda can be meaningfully applied within the mental health context. These issues are considered with reference to broader policy influences within the mental health law and policy landscape.
The HSCA 2012 – the mental health perspective
Whilst the fundamental restructuring of the NHS has been the subject of recent attention with the enactment of the HSCA 2012, mental health has also been under the spotlight of reform in the past few years. The Mental Health Act 200712 sought to respond to the challenges posed by changing psychiatric practices and the policy shift from hospital-based treatment to care in the community.13 Over the last two decades, reliance on hospital-based care has diminished and has been replaced by the community as the dominant care environment. Hospital care is now reserved largely for those requiring acute or intensive psychiatric care.14 To some extent resources have followed this changing pattern of care, but inevitably, service provision and delivery has been affected by the gradual shift in the mental health landscape.15
In parallel with the introduction of the Mental Health Act 2007, modifications have been made to the Mental Health Act Code of Practice to reflect the legislative amendments. Whilst the Code is not legally binding, decision-makers are required to justify any departures from its guidance in their decision-making.16 The amended Code features principles which are designed to promote patients’ interests and guide decision-making under the Act.17 These principles are first, the purpose principle, whereby decisions under the Act must be made to minimise the undesirable effects of mental disorder; second, the least restriction principle, where decision-makers should keep to a minimum the restrictions they impose on the patient’s liberty; third, the respect principle, whereby recognition and respect should be given to the diverse needs, values and circumstances of each patient; fourth, the participation principle that encourages patients’ involvement and finally, the effectiveness, efficiency and equity principle that focuses upon optimal decision-making using available resources in the most efficient way possible.18 In many ways, the essence of these principles can also be found within the HSCA 2012. However, whilst these principles promote universally recognised values and provide an opportunity to foster better care, their literal interpretation may not always ‘fit’ the actual process of implementation. It is often here where the legislative framework fails the mentally vulnerable. Ineffective implementation of core values within both ‘hard’ and ‘soft’ legal instruments is, perhaps, the largest source of damage for vulnerable groups and will be reflected upon throughout this article.
The HSCA 2012 has been heralded as the most extensive and radical reorganisation of the NHS to date19 and has been accompanied by significant levels of political rhetoric, speculation and controversy.20 The legislation had two key objectives: To improve the quality of care and outcomes for patients and to reposition the mode of provision so that health service provision becomes more patient-centred and facilitates choice. These objectives are incontrovertible; however, many of the mechanisms that the legislation introduces to achieve these aims have generated concern amongst service users, clinicians and service providers alike. The changes introduced by the Act are far reaching and for those with chronic and enduring conditions, of which all mental health conditions would likely be labelled, the HSCA 2012 can be expected to wield significant weight in treatment and care planning as it becomes fully operational in the months to come.
Several key elements of the legislation guide its implementation: ensuring a patient-centred NHS; promoting and supporting a clinician-led service and transferring the emphasis of measurement to clinical outcomes.21 However, it is conceivable that these principles have the potential to conflict with significant consequences and may have lasting implications upon the quality of delivered care. The question remains whether any one of these principles will dominate during the implementation process, and if so, which it will be. The persistent concern amongst many professional and user groups22 alike has been and continues to be that the political desire to make financial savings and improve the cost-effectiveness of the NHS may prove to be the overarching driver.23 A related concern is that the legislation represents an inevitable shift away from the ideology of universal provision, a mainstay of the old NHS,24 towards a stronger endorsement of expanding private sector involvement and a gradual privatisation of the health service.25 The reinforcement of competition principles within the health care system is likely to have a detrimental impact on the mentally vulnerable as the Act opens up private sector involvement, making the process of commissioning outside of the NHS structure easier and more cost-effective. In all likelihood, this will encourage providers to be more active in lucrative areas of health care. Mental health care and associated social care provision is generally seen as an unprofitable field, with long-term and often complex care and support required by individuals. The 2012 Act’s market-based approach may prove to be particularly damaging for the mentally ill, with resources being allocated away from the needs of this group and short-term care measures, such as acute inpatient provision, being given greater attention than the longer term health and social care needs of individuals in the community. The Act also introduces a change to one of the central NHS tenets:26 No longer will services be exclusively operated via the NHS and its partners; instead, ‘any willing provider’ could supply services. This enables the private sector to have direct access to the central operations of the NHS, in terms of both planning and provision. Although this allows for ‘any willing provider’ and thus goes beyond the private sector, social enterprises may find it difficult to compete against organisations in the private sector who can afford to undercut in the race to acquire a commissioning contract.27 Currently, the role of third sector organisations in mental health care is much more prominent and is, indeed, essential, particularly in relation to social care provision; however, whether this will continue remains open to speculation.28 If third sector organisations do struggle in this new provider landscape, the mentally ill will inevitably suffer as the tailored, personal provision currently offered by many small organisations and charities is likely to be curtailed as they battle to compete.29
Commissioning of services for mental health care and treatment services will be conducted and guided by Clinical Commissioning Groups (CCGs),30 which are introduced by the HSCA 2012, in a similar fashion as for all other services. The guiding principles31 under the HSCA 2012 will be influential in how CCGs conduct their activities. In the first instance, CCGs have a duty to promote the NHS Constitution32 and ensure patients, staff and the public are aware of the NHS Constitution and their NHS constitutional rights. CCGs will also have a general duty to improve the quality of the services they provide or commission. Primary medical services (which include acute inpatient psychiatric care and secure psychiatric units) are to be commissioned by NHS England. The focus on quality improvement goes beyond the old duty that primary care trusts (PCTs) had under NHS Act 2006, which was to improve the quality of health care services apropos existing published standards. Instead, the duty under the HSCA 2012 explicitly recognises the need to consider treatment and care outcomes and the patient experience. CCGs are also required to endorse a patient-centred approach33 by encouraging patient involvement through shared decision-making. The implementation of this duty will be facilitated by new guidance to be published by NHS England.34 As part of the focus upon patient-centred provision, CCGs will now also have to operate with a view to commissioning services from more than one provider as the 2012 Act also introduces a duty to enable patient choice.
How viable the balancing exercise of enabling patient choice within the mental health field will be remains to be seen. The creation of patient choice relies not only upon CCG behaviour endorsing and facilitating patient choice, but the providers of these services must actually exist – in mental health, the fulfilment of identified need has often presented challenges, as service provider limitations are routine. At a broader level, concern surrounds the impact this duty to facilitate patient choice may have on the market.35 Encouraging CCGs to commission several alternative treatments from different providers may lead to more providers having a smaller market share and greater fragmentation within the health and social care service sector might result.36 Quite how the commissioning process can effectively achieve efficiency through competition whilst also increasing patient choice is difficult to understand; or at least, it is possible to foresee challenges and tensions developing in the attainment of this aim. Patient choice is often determined through a plethora of motivating factors, not least the common desire to be close to family and friends. For many, access to psychological services is a central wish, with drug therapy being a necessity of last resort. However, as we will see later in this article, drug therapy is often deemed to offer a front-line response to patients’ mental health needs by general practitioners (GPs), and psychological services are limited in availability.37 CCGs will be restricted by these practical limitations, but they will also be under a duty to ensure service commissioning is subject to tender under the National Health Service (Procurement, Patient Choice and Competition) Regulations 2013.38 If the framework of health and social care does crumble under the weight of these different legislative objectives, those with mental health conditions may be particularly vulnerable as a fragmented health and social care service will not be beneficial to them. Additional choice may inevitably be at the expense of effective integration.
Despite this, under the 2012 Act, CCGs have a duty to promote service integration. This entails the integration of health services with health-related and social care services. The political motivation behind this duty is to improve efficiency of service provision and to reduce unnecessary costs. Nonetheless, from the patient perspective, this offers an avenue for improvements in quality of life, particularly for those who need longer term support in the community. For the mentally vulnerable, effective integration of services is often particularly important, improving the implementation of treatment plans, medication compliance and ongoing community-based support. The difficulty with this duty is that as yet no guidance has been supplied to aid CCGs in the process of achieving good integration amongst and between these various services. Furthermore, mental health provision is littered with countless examples of joint working failures and inadequate communication throughout the health and social care system. Indeed, the ideal of achieving seamless provision is far removed from the reality for many patients, and it is often this which leads to the disjointed care that is received39 and the gaps in provision where patients fall through the net.
The required establishment of Health and Wellbeing Boards40 by each local authority may reduce the perennial problems surrounding joint working.41 Collaboration between the Board members will afford the opportunity to assess local health and social care needs, agree on spending priorities and encourage CCGs to work with seamless, joined up provision in mind. Boards can extend their membership to reflect particular area needs; this may allow a local service to be developed for local needs. The Board is also required to take account of affiliated services with social care, such as, housing and education and to recognise that these services have a direct influence on the broader well-being of individuals. It is uncertain whether this will directly improve service provision, but the Cross-Government Mental Health Strategy42 pins its hopes on the shift towards localism and local care decision-making under the 2012 Act. The Mental Health Strategy Implementation Framework43 suggests that it is this focus on local needs which ‘can deliver the vision of improved mental health and wellbeing’.44
The restructuring of the NHS and the changes created by the HSCA 2012 to the commissioning process will take time to grow accustomed to. From a mental health perspective, the HSCA 2012 offers real potential to see mental health brought from the margins of provision to feature much more prominently. It creates the possibility for a conceptual reconfiguration of health to emerge, introducing explicitly the need for parity between mental and physical health. Indeed, this duty to promote health parity could create the impetus for a paradigmatic shift within health and social care provision, but just how successful the implementation of this will be remains to be seen as the high-level commitment to health parity is only one of several key objectives within the 2012 legislation. Devolution of budgets down to CCGs may provide opportunities for mental health to feature more prominently within the commissioning process; yet there are concerns that mental health needs may continue to be overlooked by CCGs when pressure to commission services efficiently whilst also increasing patient choice presents significant tensions for CCGs to overcome.
We will now turn to consider three drivers within the 2012 Act, exploring whether they are feasible within the mental health context or whether the legislation will prove to be detrimental to those with mental health needs. First, attention will be given to the commitment to achieving parity of physical and mental health within the health care system, followed by a consideration of how the desire to increase efficiency may influence commissioning decisions within the mental health arena and finally, consideration will be given to the move towards expanding patient choice and personalisation within the health care market.
Parity between mental and physical health in the commissioning process: More than political rhetoric?
The Government’s draft mandate to NHS England is explicit in its message: Direct recognition is to be given to the need to place mental health on the same footing as physical health.45 This is a significant step forward and should be welcomed. Mental health conditions are now to be recognised as a clear equality issue46 and the NHS Equality Delivery System47 will be primed to help those providing NHS services to respond properly to it.48 Perhaps of greatest importance is the Government’s recognition in the Mental Health Implementation Framework49 that achieving parity between physical and mental health is an absolute goal,50 where more still needs to be done to ensure all organisations (both public and private) ‘meet their equality and inequality obligations in relation to mental health’.51 Steps are being taken to create a framework to measure outcomes and overall progress within mental health,52 so that improvement strategies can be created and implemented when clear underperformance is identified.
Clearly, making improvements for mental health provision is dependent upon good implementation. CCGs will be expected to demonstrate to NHS England that they have sufficient planned capacity and an ability to commission for improved health outcomes in mental health. Owing to this shift in attitude, and indeed, reconfiguration of the conception of health within the legislation, the neglected and under-resourced mental health service may be a thing of the past. The drive to improve access to psychological therapies for patients with mental health conditions is an example of this attitudinal shift and is a welcome move.53 The rhetoric of achieving parity between mental and physical health is, in many ways, politically driven, though the evidence suggests that greater effort to improve mental health is needed; mental ill health is a leading cause of suffering, economic loss and social problems and accounts for over 15% of the disease burden in developed countries.54 In the European Union at least 83 million people (27%) suffer from mental health problems (16.7 million in the United Kingdom),55 with depression being the most common (8–12% of the adult population).56
The newly restructured system of health and social care is in its infancy, and it is still too early to say whether the steps taken to achieve parity will bear fruit. Likewise, how the vulnerable will be able to protect their rights in this new health and social care environment is unknown, but it seems likely that CCGs, if motivated by market-driven policies, could lose sight of the particular needs of these vulnerable groups. In many ways, achieving parity is a deep-seated cultural issue and goes far deeper than surface-level implementation. Achieving parity needs fundamental attitudinal change at institutional, organisational and individual levels. For mental health, the best hope for this change exists within the Mental Health Implementation Framework57 where explicit mention is made of the need to promote research into mental health and to recognise, support and strengthen academic career paths in this field.58 It is only by consolidating capacity, instilling aspiration and professional motivation within the mental health care framework (both research and practice pathways) that the cultural transformation can begin to emerge.
Efficiency: The impact on mental health patients
Whilst parity of mental and physical health is a clear commitment within the HSCA 2012, the introduction of competition principles will also facilitate efficiency savings. Mental health needs are often complex, requiring the input of a variety of different agencies and service providers. Not only can providing for this complex diet of needs be difficult, it can be expensive. Both the cost and complexity of provision in mental health has been a persistent source of difficulty in the past and where tragic failures in care have occurred; investigations have often presented a catalogue of challenges surrounding the coordination and adequate funding of care.59 Inevitably, establishing and identifying patient need and having the resources in place to meet it are not always achievable, and it is at this point that these system failures have often occurred.60 The mental health care framework has very limited scope to be able to deal with increases in demand, and, traditionally, this is where the third sector has often been sought to plug the gap.61 It is quite possible that without any form of overarching regional oversight, a task that PCTs undertook prior to the 2012 Act, the commissioning process may become fragmented and uncoordinated, and ultimately, gaps in some areas may be difficult to fill as patient needs may not be recognised in the round.62
Two separate issues in the commissioning process for mental health services exist: First, the level of clinical expertise that exists and second, whether CCGs have sufficient management experience to meet the need for equal distribution and coverage of services. These two areas raise doubts about how efficient and effective commissioning decisions will be carried out. In the first instance, there are doubts concerning GPs’ broad clinical knowledge and expertise to identify and evaluate patient mental health needs. For many GPs, the initial response to patients presenting with mid to mild mental health conditions is to prescribe medication, rather than ‘approach treatment holistically and refer patients to psychological therapies, peer-to-peer support networks or community-based services’.63 GPs often rely heavily upon drug therapy as the first response to symptomatic presentation in patients,64 which adds to the sense that GPs lack the depth of knowledge necessary. This is supported by recent research which reported that 30% of patients found their GP was unaware of services to support mental health recovery beyond medication.65 Second, it is predicted that CCGs may have inadequate management expertise and from this, optimal commissioning decisions will be less likely to occur.66 Given the sheer scale of care and social support needs that patients with mental health conditions often need, if CCGs lack membership that reflects the level of experience needed to recognise this, adequate mental health care provision is likely to be inadequate.
If pockets of poor management do emerge,67 then mental health provision may be adversely affected. Often mental health provision is not the focus, with greater attention being given to physical health needs; yet mental health conditions account for 23% of the total burden of disease; but in terms of NHS expenditure, only 13% of health expenditure is currently directed towards psychiatric and related services.68 Such underinvestment is not new and despite funds being channelled through PCTs at a regional level to recognised areas of need prior to the HSCA 2012, resource shortfalls have been commonplace. Mental health did not gain the moniker of the ‘Cinderella’ service without good reason and has been struggling under the weight of systemic neglect for a considerable time.69 Unfortunately, mental health care must compete with all other health and social care needs, of which most are far more evident and have a more tangible quality about them. Whether the HSCA 2012 will improve this is uncertain. Management inadequacies and failures to identify needs by CCGs may not be detected as there remains some doubt about how the new NHS structure and regulatory bodies will scrutinize and oversee activities. The organisational reconfiguration reflects the mood of the Government to reduce bureaucracy and complexity in the health and social care framework, to improve efficiency and to redeploy functions through bodies that are independent or at least operating at arm’s length of the Government.70 Time will tell how these national bodies will work together in practice though as ‘it is … [just not yet] … clear how these national bodies will interact or how they will provide coordinated and consistent governance of the NHS’.71
The challenges facing CCGs are unlikely to reassure patients in the short term; for mental health patients, these concerns may simply be more acute, given the complexity of typical mental health care needs which tend to stretch over a number of agencies and providers, often featuring periods of both acute need and stable chronicity. The standard and effectiveness of care received will all too often depend upon a strong framework of planned and integrated systems or pathways of care from a well-coordinated network of providers. CCGs are going to have to ensure sufficient awareness is present within the strategic planning process to take account of this, and if they do not, health conditions, including most mental health conditions, that require a complex health and social care response may suffer. The position of the already vulnerable could simply be compromised further.
Personalisation: Mapping the agenda on to the mental health framework
Personalisation is a central tenet of the restructured NHS. It refers to a social care approach where every person in need of care and treatment will have ‘choice and control over the shape of that support in all care settings’.72 Personalisation is characterised by shifting the power dynamic within the provider–user relationship. Greater emphasis is placed upon self-directed support and personal budgetary control combined with a move away from the notion that provision should follow a ‘one-size-fits-all’ approach.73
The personalisation agenda seeks to move the health and social care framework away from crisis management,74 relying upon patients identifying personal needs and making appropriate care choices to meet these needs.75 For this to be possible, adequate information and transparency within the system is essential. To implement the personalisation agenda, the social care system, in particular, will need to be sufficiently capacious to enable patient choice to be fully achievable. This means that CCGs have to take seriously the need to make and implement local commissioning decisions in a way that will enable genuine choices to be made. Commissioning will need to be multilayered and from a variety of providers; it will need to be possible to manipulate services so that tailor-made packages of care can be created for individual patients. In addition to the actual availability of services, steps must be taken to facilitate patients in the decision-making process. All patients, irrespective of age, capacity or support needs, should be aided as far as possible to ensure treatment and care choices are modified and are reflective of the patient’s wishes.76
Within mental health, the essence of personalisation has been grounded in the mental health ‘recovery approach’.77 This approach is focused upon the mental health patient being afforded the opportunity to determine his own life and to be offered the support required to be able to live as independently as possible.78 Some patients with mental health conditions have already experienced personalisation. For some time,79 self-directed support has been an operational feature of care in the community. The idea is founded upon flexibility, choice and control of social care funding and focuses upon giving eligible people an annual budget to spend on their own care,80 based upon self-designed care plans.81 For many, creating a care plan and then organising providers to meet these identified needs is a challenging task to undertake alone. In practice, patients are encouraged to work with clinicians and social care staff to facilitate implementation.82 When a plan has been formulated, social care support can be obtained from a variety of sources, including statutory social services, the private sector, the voluntary sector, community groups, neighbours, family and friends. For those who need it, assistance in devising a care plan reflective of individual need is an essential element of the process; particularly as individual budgets are increasingly being used as a vehicle to combine several funding streams that many mental health patients may need to access in the community. Payment for local authority adult social care falls within the remit for individual budgets and include integrated community equipment services, disabled facilities grants, Supporting People for housing-related support, Access to Work and the Independent Living Fund.83 Glendinning’s84 research into the effectiveness of pilot schemes conducted by the Individual Budgets Evaluation Network demonstrates some promising results for patients, whereby clear benefits can be achieved through greater choice and control over funding. However, to enable mental health patients and other chronic patients with complex social care needs to benefit from this, better integration of services and a collective willingness to embrace choice needs to be fostered.85
How successful the personalisation agenda and its implementation under the HSCA 2012 is, is perhaps best judged by assessing the benefits to patients that have flowed from this agenda. Existing research already indicates that the injection of choice and control over care options can be very positive for patients and carers alike.86 However, there is also evidence suggesting some groups may not be experiencing these benefits, notably, patients with mental health conditions, patients with dementia and other capacity-reducing conditions.87 Bureaucracy and cuts in social care spending are exacerbating the situation; patients who require significant levels of support in this process may find their experience of the personalisation agenda hampered. Other associated and recurrent problems exist within the mental health system, placing further strain on the achievement of the personalisation agenda. For example, staffing shortages and service scarcities often result in extensive waiting times and inadequate response rates.88 As such, staffing challenges and the need for extra support by mental health patients to benefit from the personalisation agenda may in reality make this policy a largely spurious one with little practical substance.
Conclusion
The HSCA 2012 represents a significant departure from a culture of public service provision that we have become accustomed to, but does it fail the vulnerable, notably those with mental health care needs? The need to drive efficiency up, whilst also tailoring health and social care to individual patients is, perhaps, an impossible dilemma.89 Making systems responsive to individual need also raises the spectre of cost and waste; meeting the 2012 Act’s expectations will be an exacting challenge and not for the faint-hearted. How mental health provision will fare in this new and uncharted landscape remains open; but, inevitably, it will face its own set of problems in the months to come. Does the 2012 Act fail the mentally vulnerable? Time will tell, though the tensions that exist between three of the key policy drivers within the legislation, the focus of this article, suggest that where there are pressure points and the vulnerable may ultimately experience the greatest detriment. Competition principles within the health and social care system may drive efficiency up. However, they cannot be responsive to the more nuanced needs of patients with chronic conditions, particularly where care needs bridge both health and social care and are often required for lengthy periods of time.
Perhaps, the brightest ray of hope should be the recognition that parity between mental and physical health will be a clear objective.90 As with so many of these things, effective policy needs to be translated into a workable and user-friendly legal framework that can then be implemented. In mental health, it is the implementation stage that frequently presents the most significant challenge for decision-makers, with limitations in staffing, funding and social care placements creating bottlenecks in the system. Unless these practical hurdles can be overcome, the desire to forge a new and fairer culture within health and social care, where parity between mental and physical health is the accepted benchmark, will be a very difficult one to attain.
The HSCA 2012 offers a very real opportunity to enable mental health to be mainstreamed into core public health priorities. But, this relies upon a determination reminiscent of Aneurin Bevan, ‘The NHS will last as long as there are folk left with the faith to fight for it’. It can only be hoped that there are those prepared and willing to fight to ensure the needs of vulnerable groups, such as those with mental health conditions, are met and protected and that faith in the achievement of health and social care equality endures.
Acknowledgements
The author thanks Prof Robert Thomas and Prof Christopher Newdick for their insightful comments on an earlier draft of this article.
Funding: This work was supported by a British Academy Mid-Career Research Fellowship, for which the author wishes to express her thanks.
1For a detailed discussion of the creation and foundation of the NHS, see, N. Timmins, The Five Giants: A Biography of the Welfare State (London, UK: HarperCollins, 2001).
2Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx (accessed 2 August 2013). See also, T. Delamothe, ‘Founding Principles’, British Medical Journal, 336 (2008), p. 1216. For a more detailed consideration of the foundations of the NHS in 1948, see, M. Powell, ‘Granny’s Footsteps, Fractures and the Principles of the NHS’, Critical Social Policy 16 (1996), p. 27.
3For example, A.C. Enthoven, & M. Eccles, ‘A Promising Start, But Fundamental Reform is Needed’, British Medical Journal 320 (2000), pp. 1329–1331.
4There is little doubt that the NHS is facing considerable challenges today. If the NHS ‘[was]…performing at world-class levels, the NHS could save 5,000 more lives from cancer, and 2,000 more lives from respiratory diseases each year. Our population is aging, while the cost of advances in treatments and medicines add around £600 million of funding pressure to the NHS budget every year’, Department of Health, Pausing, Listening, Reflecting, Improving, Available at: http://healthandcare.dh.gov.uk/pausing-listening-reflecting-improving/ (accessed 20 August 2013).
5Throughout this article the term ‘mental health condition’ is used to describe all mental disorders or illnesses that meet generally accepted criteria for clinical diagnosis.
6See, Department of Health, Modernising Health and Social Services: National Priorities Guidance 1999/00–2001/02 (London, UK: Department of Health, 1998); Department of Health, Saving Lives: Our Healthier Nation, Cm 4386 (London, UK: HMSO, 5 July 1999); Department of Health, National Service Framework for Mental Health: Modern Standards and Service Models (London, UK: TSO, 8 February 2007).
7Department of Health, No Health Without Mental Health A Cross-Government Mental Health Outcomes Strategy for People of All Ages (London, UK: TSO, February 2011). Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213761/dh_124058.pdf (accessed 2 August 2013).
8See, Centre for Mental Health, Department of Health, Mind, NHS Confederation Mental Health Network, Rethink Mental Illness, Turning Point, No Health Without Mental Health: Implementation Framework, 24 July 2012. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156084/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf.pdf (accessed 25 July 2013).
9See, Department of Health, The Mandate: A Mandate From the Government to the NHS Commissioning Board: April 2013 to March 2015 (London, UK: Department of Health, November 2012).
10Different data sets highlight the need to recognise mental ill health as a fundamental concern, for example, see, N. Singleton, R. Bumpstead, M. O’Brien, A. Lee and H. Meltzer Psychiatric Morbidity Among Adults Living in Private Households, 2000 (London, UK: TSO, 2001); Royal College of Psychiatrists, Mental Health and Work (London, UK: Royal College of Psychiatrists, 2008); S. McManus, H. Meltzer, T. Brugha, P. Bebbington and R. Jenkins, Adult Psychiatric Morbidity in England 2007: Results of a Household Survey (London, UK: National Centre for Social Research, 2009).
11See, C. Murray, et al., ‘UK Health Performance: Findings of the Global Burden of Disease Study 2010’, The Lancet, 381(9871) (2013), pp. 997–1020.
12See, Report of the Expert Committee, Review of the Mental Health Act 1983 (London, UK: Department of Health, 1999); HM Government, Reforming the Mental Health Act: Part I: The New Legal Framework (London, UK: TSO, 2000), Cm 5016-I; see also, J.M. Laing, ‘Rights Versus Risk? Reform of the Mental Health Act 1983’ Medical Law Review 8(2) (2000), pp. 210–250; J. Peay, ‘Reform of the Mental Health Act 1983: Squandering and Opportunity?’, Journal of Mental Health Law 3 (2000), pp. 5–15.
13D. Pilgrim, ‘New ‘Mental Health’ Legislation for England and Wales: Some Aspects of Consensus and Conflict’, Journal of Social Policy 36(1) (2007), pp. 79–95.
14Inpatient facilities are now often not a place for therapeutic intervention, but instead are ‘crisis stabilisation centres’, see, A. Hill, ‘Mental Health Services in Crisis Over Staff Shortages: Exclusive: Royal College of Psychiatrists Warns Society will be Overwhelmed if Ministers Fail to Fill Gap’, The Guardian, Monday 20 June 2011.
15G. Thornicroft and M. Tansella, ‘Components of a Modern Mental Health Service: A Pragmatic Balance of Community and Hospital Care. Overview of Systematic Evidence’, The British Journal of Psychiatry 185 (2004), pp. 283–290; P. Tyrer and S. Johnson, ‘Has the Closure of Psychiatric Beds Gone Too Far? Yes’, British Medical Journal 343 (2011), p. d7457; G. Thornicrift and M. Tansella, ‘The Balanced Care Model: The Case for Both Hospital and Community-Based Mental Healthcare’, The British Journal of Psychiatry 202 (2013), pp. 246–248.
16R (Munjaz) v Mersey Care NHS Trust [2005] UKHL 58.
17In 1998, the Richardson Committee proposed that the new mental health legislation should be rooted in legislative principles, see, Report of the Expert Committee, Review of the Mental Health Act 1983 (London, UK: Department of Health, 1999). Instead, the guiding principles can be found in the Code of Practice, instead of on the face of the Mental Health Act 2007 (see, House of Lords, House of Commons Joint Pre-Parliamentary Scrutiny Committee Report on the Draft Mental Health Bill (HL Paper 79(1), HC Paper 95(1), Session 2004–2005, at para 64. For an in-depth discussion, see, P. Fennell Mental Health: The New Law (Bristol: Jordans Publishing, 2007), p. 37.
18Department of Health, Code of Practice: Mental Health Act 1983 (London, UK: The Stationery Office, 2008) at paras 1.2–1.6.
19By July 2010, the White Paper, Equity and Excellence: Liberating the NHS, Cm. 7881, was published. Although progress of the Health and Social Care Bill was slowed with a ‘listening exercise’ between April and May 2011 for the Government to hear and take account of concerns raised about the Bill, the Bill received Royal Assent on the 27 March 2012.
20N. Timmins, Never Again? The Story of the Health and Social Care Act 2012: A Study in Coalition Government and Policy Making (London, UK: The King’s Fund and the Institute for Government, 2012). See also, R. Taylor, God Bless the NHS (London, UK: Faber & Faber, 2013).
Red Dead Redemption 2 Guns All Rockstar has given us is about each one: • Shootout and Team Shootout – Classic gunfight modes with unlimited lives. Compete to rack up the most kills before the timer runs out.
21See, Department of Health, Equity and Excellence: Liberating the NHS, Cm. 7881 (London, UK: TSO, 2010).
22See, D. Redding, ‘NHS Reforms: What do They Mean for Patients?’ Guardian Professional, Tuesday 3 April 2012.
23Exponential spending on the NHS has occurred since it was established in 1948. In 2010/11, government expenditure was £121bn, see, R. Harker, NHS Funding and Expenditure (London, UK: House of Commons Library, SN/SG/724, 3 April 2012). See also, C. Naylor, M. Parsonage, D. McDaid, M. Knapp, M. Fossey and A. Galea, Long-Term Conditions and Mental Health. The Cost of Co-morbidities (London, UK: The King’s Fund, 2012).
24E. Speed and J. Gabe, ‘The Health and Social Care Act for England 2012: The Extension of ‘New Professionalism’’, Critical Social Policy 33(3) (2013), pp. 564–574.
25Currently, it is estimated that £1 of every £20 spent in the NHS goes to a non-NHS provider, see, Q&A: The NHS Shake-Up, 1 March 2013, Available at: http://www.bbc.co.uk/news/health-12177084 (accessed 25 July 2013).
26R. Page, ‘The Attack on the British Welfare State-More Real Than Imagined? A Leveller’s Tale’, Critical Social Policy 15(44–45) (1995), pp. 220–228.
27N. Curry, C. Mundle, F. Sheil and L. Weaks, The Voluntary and Community Sector in Health: Implications of the Proposed NHS Reforms (London, UK: The King’s Fund, 2011).
28N. Glover Thomas and W. Barr, ‘Re-Examining the Benefits of Charitable Involvement in Housing the Mentally Vulnerable’, Northern Ireland Legal Quarterly 59(2) (2008), pp. 177–200; N. Glover Thomas and W. Barr, ‘Enabling or Disabling? Increasing Involvement of Charities in Social Housing’, The Conveyancer and Property Lawyer 3 (2009), pp. 209–235.
29Opening up markets creates considerable barriers to market entry by social enterprises as high capital costs can often only be found by large providers. As social enterprises are usually quite small (and so, there is a greater risk of failure to deliver the contract owing to shortages of funds) and there is no longer preferential treatment given to social enterprises, it is likely that in the health sector where social enterprises are competing with large NHS providers and private organisations, their involvement may diminish. See further, M. Brown and D. Floyd, Better Mental Health in a Bigger Society? (London, UK: The Mental Health Providers Forum, 2011).
30CCGs are clinically led groups that include all of the general practitioner (GP) groups in their geographical area and have the aim of giving GPs and other clinicians the power to influence commissioning decisions for their patients.
31Same as fn 19.
32Section 3 of the Health and Social Care Act 2012 inserts a new section 1B into the NHS Act 2006, placing a duty on the Secretary of State to have regard to the NHS Constitution. Section 14P imposes a duty upon CCGs both to act in the exercise of its functions with a view to ensuring health services are provided in a way that promotes the NHS Constitution.
33For a broader discussion, see A. Coulter, ‘Do Patients Want a Choice and Does it Work?’, British Medical Journal 341 (2010), p. c4989; Care Quality Commission, National NHS Patient Survey Programme: Survey of Adult Inpatients 2010; Survey of Adult Outpatients 2009; Maternity Survey 2010; Survey of Local Health Services 2008. Available at: www.nhssurveys.org (accessed 31 August 2013); N. Richards and A. Coulter, Is the NHS Becoming More Patient-Centred? (London, UK: Picker Institute Europe, Department of Health, 2007).
34NHS England, Developing the NHS Commissioning Board (London, UK: TSO, 2011), p. 9.
35The National Health Service (Procurement, Patient Choice and Competition) Regulations 2013, No. 257, impose a requirement on the NHS Commissioning Board and clinical commissioning groups to protect patients’ rights to make choices and to prevent anti-competitive behaviour.
36Care Quality Commission, The State of Health Care and Adult Social Care in England in 2011/12 (London, UK: TSO, 2012).
37Cf. fn 64.
38Same as fn. 35.
39C. Ham and N. Walsh, Making Integrated Care Happen. Lessons From Experience (London, UK: The King’s Fund, 2013).
40These Boards will take on their statutory functions from April 2013. See, Department of Health A Short Guide to Health and Wellbeing Boards. Available at: http://healthandcare.dh.gov.uk/hwb-guide/ (accessed 28 February 2012).
41R. Humphries, A. Galea, L. Sonola and C. Mundle, Health and Wellbeing Boards: System Leaders or Talking Shops? (London, UK: The King’s Fund, 2012).
42See, N. Glover Thomas, ‘Joint Working; Reality or Rhetoric in Housing the Mentally Vulnerable?’ Journal of Social Welfare and Family Law 29(3–4) (2007), p. 217.
43Centre for Mental Health, Department of Health, Mind, NHS Confederation Mental Health Network, Rethink Mental Illness, Turning Point No Health Without Mental Health: Implementation Framework. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156084/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf. Briefing paper available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/137645/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf.
44‘Centre for Mental Health, Department of Health’ p. 5.
Factors That Influence Policy Drivers In Health And Social Care Center
45The first NHS Mandate was published on 13 November 2012. It sets out the Government’s ambitions for the health service until 2014 and reaffirms its commitment to an NHS that remains comprehensive and universal. Available at: http://mandate.dh.gov.uk/
46An integral principle running through No Health Without Mental Health: Implementation Framework, is the acknowledgement that groups protected by the Equality Act 2010 need to be identified and protected. These groups are defined by the characteristics: age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex and sexual orientation. Parity of physical and mental health has been formally recognised as an important objective within health provision for many years prior to the HSCA 2012. This was acknowledged in the House of Lords Committee Stage debate where Baroness Hollins (Crossbench) moved an amendment to replace the word ‘illness’ within the Health and Social Care Bill with the words ‘physical and mental illness’. Lord Howe noted that the term illness is defined in Section 275 of the National Health Service Act 2006 as including mental disorder within the meaning of the Mental Health Act 1983. He went on to note that ‘references to the prevention, diagnosis and treatment of illness would already apply to both physical and mental illnesses without the need for those additional words’ (HL Hansard, 2 November 2011, col 1293).
47The Equality Delivery System for the NHS was introduced in August 2011.
48NHS services must explicitly consider the particular needs of the most vulnerable groups, and within this, mental health needs must be directly responded to.
49Centre for Mental Health, Department of Health, Mind, NHS Confederation Mental Health Network, Rethink Mental Illness, Turning Point No Health Without Mental Health: Implementation Framework. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156084/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf. Briefing paper available at: http://www.nhsconfed.org/Publications/Documents/mhn-briefing-247.pdf (accessed 17 January 2014).
50Section 1 Health and Social Care Act 2012 emphasises the importance of mental health alongside physical health as it amends Section 1 of the NHS Act 2006, which contains the Secretary of State’s duty to promote a comprehensive health service designed to secure improvement in the physical and mental health of the people of England, and in the prevention, diagnosis and treatment of mental and physical illness.
51‘Health and Social Care Act’ fn 49, p 8.
52‘Health and Social Care Act’ fn 49. The mental health framework introduces a new mental health dashboard, which will provide a picture of overall progress towards implementing the mental health strategy.
53Improving Access to Psychological Therapies (IAPT) is an NHS programme being rolled out across England offering interventions approved by the National Institute of Health and Clinical Excellence (NICE) for treating people with depression and anxiety disorders. The programme’s second phase is marked by the publication of Talking Therapies: a four year plan of action in February 2011. The plan aims to expand the scope of the programme to other groups, including, children and young people, people with long-term physical conditions and medically unexplained symptoms or severe mental illness. In the 2010 Spending Review, the Government committed an additional £400 million over the next 4 years to 2014/15, and confirmed support for the IAPT programme, which was originally launched in October 2008.
54M. Prince, V. Patel, S. Saxena, M. Maj, J. Maselko, M. Phillips and A. Rahman. ‘No Health Without Mental Health’, Lancet 370 (2007), pp. 859–877.
55H. Wittchen and F. Jacobi, ‘Size and Burden of Mental Disorders in Europe: A Critical Appraisal of 27 Studies’, European Neuropsychopharmacology 15(14) (2005), pp. 357–376.
56T. Ustun, J. Ayuso–Mateos, S. Chatterji, C. Mathers and C. Murray, ‘Global Burden of Depressive Disorders in the Year 2000’, British Journal of Psychiatry 184 (2004), pp. 386–392.
57Centre for Mental Health, Department of Health, Mind, NHS Confederation Mental Health Network, Rethink Mental Illness, Turning Point, No Health Without Mental Health: Implementation Framework, 24 July 2012. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/156084/No-Health-Without-Mental-Health-Implementation-Framework-Report-accessible-version.pdf (accessed 17 January 2014).
58E. Cyhlarova, A. McCulloch, P. McGuffin and T. Wykes, Economic Burden of Mental Illness Cannot be Tackled Without Research Investment (London, UK: Mental Health Foundation, 2010).
59J. Ritchie, The Report of the Inquiry Into the Care and Treatment of Christopher Clunis (London, UK: Stationary Office, 1994); J. Coid, ‘The Christopher Clunis Enquiry’, Psychiatric Bulletin 18 (1994), pp. 449–452. See also, J. Manthorpe and N. Stanley, The Age of the Inquiry: Learning and Blaming in Health and Social Care (Oxford, UK: Routledge, 2004), chapter 7; N. Glover Thomas, ‘Joint Working; Reality or Rhetoric in Housing the Mentally Vulnerable?’, Journal of Social Welfare and Family Law, 29(3–4) (2007), pp. 217–233 and N. Glover-Thomas, An Investigation into Initial Institutional and Individual Responses to the Mental Health Act 2007: Its Impact on Perceived Patient Risk Profiles and Responding Decision-Making, Mersey Care NHS Trust Final Research Report, March 2011, pp. 1–158.
60For example, the National Inquiry found in July 2013 that there were ‘1,508 suicides in patients under crisis resolution/home treatment teams (CR/HT), 12% of the total sample, an average of 137 deaths per year. Since 2006, there have been 150-200 suicides per year under CR/HT’. It was also noted that ‘since 2006 there have been more patient suicides under CR/HT than in in-patient care, reflecting a change in the nature of acute care [my emphasis]. In the last 3 years over twice as many suicides have occurred under CR/HT’; see, L. Appleby, N. Kapur, J. Shaw, I.M. Hunt, D. While, S. Flynn, K. Windfuhr and A. Williams. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report: England, Northern Ireland, Scotland and Wales (Manchester, UK: National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Centre for Mental Health and Risk, July 2013), p. 31.
61N. Glover Thomas and W. Barr, ‘Re-examining the Benefits of Charitable Involvement in Housing the Mentally Vulnerable, Northern Ireland Legal Quarterly 59(2) (2008), pp. 177–200; N. Glover Thomas and W. Barr, ‘Enabling or Disabling? Increasing Involvement of Charities in Social Housing’, The Conveyancer and Property Lawyer 3 (2009), pp. 209–235.
62R. Millar, I. Snelling and H. Brown, Liberating the NHS: Orders of Change? Policy paper 11, Birmingham, UK: Health Services Management Centre, University of Birmingham, 2011.
63All Party Parliamentary Group on Mental Health, Health and Social Care Reform: Making it work for mental health, 2011, p 8. Available at: http://www.mind.org.uk/assets/0001/8974/APPGMH_Report_Health_and_Social_Care_Reform_Making_it_work_for_Mental_Health.pdf (accessed 25 July 2013).
64For example, ‘GPs prescribe soaring numbers of drugs for depression’, The Telegraph, Thursday 09 May 2013; Spence, D, ‘Are antidepressants overprescribed? Yes’, British Medical Journal, 2013, p. 346.
65In an unpublished survey conducted by Mind in May 2011, of 1,237 mental health service users, 358 (28.9 per cent) of participants reported that their GP was unaware of services to support mental health recovery. Available at: http://www.mind.org.uk/news/5247_as_gps_leave_mental_health_patients_in_the_dark_mind_hits_the_road_to_champion_local_services#research (accessed 25 July 2013).
66A. O’Dowd, ‘GP Consortiums Will Need First Class Management Support, says Nuffield Trust’, British Medical Journal 342 (2011), p. 342. Available at: http://www.bmj.com/content/342/bmj.d337 (accessed 17 January 2014).
67Care Quality Commission, The State of Health Care and Adult Social Care in England in 2011/12 (London, UK: TSO, 2012).
68The Centre for Economic Performance’s Mental Health Policy Group, How Mental Illness Loses Out in the NHS (London, UK: Mental Health Policy Group, 2012).
69For in interesting discussion, see, J. Adams, ‘Challenge and Change in a Cinderella Service’: A History of Fulbourn Hospital, Cambridgeshire, 1953–1995, PhD thesis, The Open University, 2009.
70See, Department of Health, Liberating the NHS: Report of the Arm’s- length body review (July 2010) Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117691 (accessed 3 August 2013).
71K. Walshe & C. Ham, ‘Can the Government’s Proposals for NHS Reform be Made to Work?’, British Medical Journal 342 (2011), p. d2038.
72J. Dunning, ‘Expert Guide to Personalisation’, Community Care. Available at: http://www.communitycare.co.uk/articles/25/07/2012/109083/personalisation.htm (accessed 25 July 2012).
73A personal budget focuses upon providing ongoing social care support. See, Association of Directors of Adult Social Services Making Progress with Putting People First: Self- Directed Support (London, UK: DH/ADASS/IDeA/LGA, 2009a).
74Department of Health, Caring for Our Future: Reforming Care and Support, Cm 8378 (London, UK: TSO, 2012).
75R. Forster and J. Gabe, ‘Voice or Choice? Patient and Public Involvement in the National Health Service in England under New Labour’, International Journal of Health Services 38(2) (2008), pp. 333–356. See also, M. Fotaki, M. Roland, A. Boyd, R. McDonald, R. Scheaff and L. Smith, ‘What Benefits Will Choice Bring to Patients? Literature Review and Assessment of Implications’, Journal of Health Services Research & Policy 13(3) (2008), pp. 178–184.
76S. Carr, Personalisation: A Rough Guide (London, UK: Social Care Institute for Excellence, 2012), p. 2.
77See, L. Davidson, ‘Recovery, Self Management and the Expert Patient: Changing the Culture of Mental Health from a UK Perspective’, Journal of Mental Health 14(1) (2005), pp. 25–35.
78S. Carr, ‘Personalisation: An Introduction for Mental Health Social Workers’, in P. Gilbert, ed., The Value of Everything: Social Work and its Importance in the Field of Mental Health (London, UK: Jessica Kingsley, 2010).
79Department of Health, Independence, Choice and Risk: A Guide to Best Practice in Supported Decision-Making Executive Summary (London, UK: Department of Health, 2007). See also, Department of Health, Putting People First – Working to Make it Happen: Adult Social Care Workforce Strategy – Interim Statement (London, UK: Department of Health, 2008).
80In March 2012, the Association of Directors of Adult Social Services Personal Budgets Survey showed that the total number of personal budgets delivered by local authorities across England is estimated to be 432,349, which is an increase of 38% in 2010–2011. The amount spent on personal budgets in 2011–2012 was nearly £2.6 billion some 15% of all direct spend on adult care and support services, ADASS, Personal Budgets Survey March 2012: Results (London, UK: ADASS/Judgement Framework, 2012).
81ADASS, Making Progress with Putting People First: Self- Directed Support (London, UK: DH/ADASS/IDeA/LGA, 2009), see pages 3–4; See also, ADASS, Personalisation and the Law: Implementing Putting People First in the Current Legal Framework (London, DH/ADASS, 2009).
82See, Putting People First Consortium Advice Note (January 2010): Personal Budgets: Council Commissioned Services (London, UK: Department of Health, 2010); Putting People First Consortium, Briefing Note (January 2010): Personal Budgets: Managed Services (London, UK: Department of Health, 2010); Putting People First Consortium The Future of Social Work in Adult Social Services in England: Statement (London, UK: Putting People First consortium, 2010).
83Social Care Institute for Excellence (in collaboration with the AMHP National Leads Network and the Social Care Strategic Network for mental health), Personalisation Briefing: Implications for Community Mental Health Services (London, UK: SCIE, 2009).
84C. Glendinning, The National Evaluation of the Individual Budgets Pilot Programme (York, UK: SPRU, University of York, 2008); C. Glendinning, H. Arksey, K. Jones, N. Moran, A. Netten and P. Rabiee, The Individual Budgets Pilot Projects: Impact and Outcomes for Carers (York, UK: Social Policy Research Unit, 2009).
85N. Moran, C. Glendinning, M. Stevens, J. Manthorpe, S. Jacobs, M. Wilberforce, M. Knapp, D. Challis, J-L. Fernadez, K. Jones and A. Netten. ‘Joining Up Government by Integrating Funding Streams? The Experiences of the Individual Budget Pilot Projects for Older and Disabled People in England’, International Journal of Public Administration 34(4) (2011), pp. 232–243.
86C. Glendinning, The National Evaluation of the Individual Budgets Pilot Programme (York, UK: SPRU, University of York, 2008).
87Association of Directors of Adult Social Services, Personal Budgets Survey March 2011, Available at: http://www.thinklocalactpersonal.org.uk/_library/ADASS_Personal_Budgets_Survey_March_2011_-Summary_of_Results_9.6.11_3.pdf; Think Local, Act Personal Partnership, Personal Budgets Outcome Evaluation Tool (Poet) Survey, June 2011. Available at: www.thinklocalactpersonal.org.uk (accessed 23 June 2013).
88See for example, R. Kakuma, H. Minas, N. van Ginneken, M. Dal Poz, K. Desiraju, J. Morris, S. Saxena and R. Scheffler. ‘Human Resources for Mental Health Care: Current Situation and Strategies for Action’, The Lancet 378(9803) (2011), pp. 1654–1663; G. Aarons and A. Sawitzky, Organizational Climate Partially Mediates the Effect of Culture on Work Attitudes and Staff Turnover in Mental Health Services, Administration and Policy in Mental Health and Mental Health Services Research 33(3) (2006), pp. 289–301.
89A. Woolridge, A. Morrissey and P. Phillips, ‘The Development of Strategic and Tactical Tools, Using Systems Analysis, for Waste Management in Large Complex Organisations: A Case Study in UK Healthcare Waste’, Resources, Conservation and Recycling 44(2) (2005), pp. 115–137.
90P. Cunningham, ‘Beyond Parity: Primary Care Physicians’ Perspectives on Access to Mental Health Care’, Health Affairs 28(3) (2009), pp. 490–501.
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Patterns of ill health in the UK are monitored through the use of statistics. The UK National Statistic organisation is responsible for producing these statistics in order to illustrate and identify patterns of ill health within the UK. Government statistical departments play a vital role in identifying and monitoring patterns of ill health in the UK, of which include:
The Department of Health
Health and Safety Executive
NHS Information Centre for Health and Social Care
Statistics can be collected from records such as birth certificates, the death register and hospital admissions records.
Records can be used for further analysis in order to gain more specific information, for example the weight of a new-born baby, or the reason an individual was admitted into hospital. The government has made the use of having these records available a legal requirement so that the statistics may be available when they are required. Statistics can be collected through the use of surveys, i.e. the national census of which is held every 10 years in the UK by the government.
The national census survey has been in place since 1801 and takes into account each individual within a household. It is able to provide an outline of the UK which enables us to compare geographical areas. However statistics are not always accurate for what they represent, as there will always be information on illness which may not be reported therefore the statistics can only provide a general idea on what health in England is actually like.
Patterns of ill health can also be identified through other means, such as using reports; one such example includes the Black Report which took place back in 1980, and discovered that there were gross inequalities in health during that time period. The Black Report illustrated that the death rate of men in the lowest social class was two times higher than that of the death rate of men in the highest social class; therefore the gap in inequality was increasing rather than decreasing as it was expected to do so.
At present there are an extensive amount of various patterns of ill health within the UK today. Patterns of ill health can vary depending on their geographical locations in England.
Acheson Report (1998) – The Acheson Report was an independent study commissioned by the new Labour government in 1997, under the advisement of former Chief Medical Officer for England and Wales Sir Donald Acheson in regard to the state of health inequalities in the UK. It was a comprehensive survey about those in society who were described as being at a disadvantage. The findings provided by Acheson mirrored the previous findings in the Black Report back in 1980 which stated that the main cause of the inequalities to health was poverty. The report concluded that in order to improve the health of the nation the gap between the higher and lower classes in society in the UK needed to be reduced.
Our Healthy Nation (1999) – Our Healthy Nation was an action plan established to tackle poor health within the UK by setting attainable targets in areas where peoples health is at most risk of which include cancer, coronary heart disease, stroke, accidents and mental illness. Our Healthy Nation believe that social, economic and environmental factors are what leads to poor health, and that by making healthier choices to not only their health but their families’ health, they would make a huge difference. They believed that people can improve their own health through physical activity, better diet and stopping smoking, but in order to do so, individuals and their families need to be properly informed about the risks they taken when making their decisions.
Health inequality is seen throughout the UK and affects the most disadvantaged who suffer the most from poor health. By the government addressing inequality with a range of initiatives regarding to education, welfare to work, housing, neighbourhoods, transport and the environment would thereby improve the overall quality of health. As well as tackling important issues in regards to sexual health, drugs, alcohol, food safety, communicable diseases etc.
Tackling Health Inequalities: a Programme for Action (2003) – A Programme for Action sets out targets in order to tackle heath inequalities in the UK and is used in order to establish the foundations that are required in order to reduce the gap in infant mortality across the social groups, and to raise life expectancy in the most disadvantaged areas in the UK. The programme is also used to address the short-term consequences of avoidable health in the UK as well as its long term causes. Its main priority is to address the inequalities which are found across different geographical areas, between genders and different ethnic communities along with different social and economic groups.
Tackling health inequalities on a local level have already improved due to the help of front-line practitioners that were working in tandem with community groups and non-government organisations.
Choosing Health: Making healthy choices easier (2004) – The White Paper Choosing Health: making healthier choices easier lays out the government’s plan of action in order to undertake a variety of public health challenges which range from smoking, obesity, drinking to mental and sexual health. For example labelling the amount of fat, sugar and salt there is in food in order to broaden the public’s awareness on how it affects their health and the impact it has on their lives. This has made a substantial impact due to the amount of media coverage it has gotten in the past. (P4) (M2): Explain the main factors affecting current patterns of health in the UK –
There are a variety of factors that affect current patterns and trends of ill health in the UK, as each factor has a significant impact on an individual’s health. These factors include: Socio-economic, Education, Residing in a rural area, Pollution, Sexuality, genetics, Culture and Diet.
Factor
Effect
Socio-economic
Social class – Social class is a term defined by an individual’s status within the social hierarchy of today’s society. A person’s status within the hierarchy depends on how much wealth the individual has, and how successful they are. The most commonly recognised of the social classes within the UK are the lower class, middle class, and upper class. An individual’s geographical location (where they come from and/or live in) is a contributing factor as to where they are placed in the social hierarchy.
The gap between the upper class and lower class in the UK is very slim due to the fact that most of the individuals living in the UK fall into the category of the middle class. In today’s society however, there are still signs of inequality; this can be shown through using statistics to show that individuals born in a lower class area are more likely to have worse health prospects than those born in an upper class geographical area.
Individuals born into a lower social class are more likely to face more problems in terms of their day to day life than those born into a less deprived geographical location. The day to day problems make it exceedingly difficult for individuals to stay healthy due to the fact that they may have very little income or enough time in order to feed themselves and their family’s healthy meals. In some cases people in the lower social class may not have enough money to allow them to take time off work or off caring for their family in order to use the healthcare services made available to them as effectively as they could, compared to those who live in a richer geographical area. People who live in poorer areas are more likely to suffer from mental health illnesses due to depression than those in the upper class due to the amount of depravation they face on a daily basis, for example unemployment.
Housing – ‘There is a correlation between poor housing and ill health and previous attempts to address the situation of poor housing that causes ill health have failed. For example individuals who suffer from ill health and live in poor quality housing due to low income. The highest risks to an individual include: cold, damp and mouldy conditions. The first study was conducted in 1986 by a man named Martin et al, in an area of North Edinburgh in which the resident were concerned about the dampness and its effects on their health. Through all the data collected, there was no clear evidence that suggested that the damp was causing health problems.
A separate study was undertaken by the Council of Environmental Health Officers and also found that there was no substantial difference between those living in damp housing, compared to those living in non-damp homes. However defective housing was associated with ill health among children. It was 85% more likely for children in damp housing to experience aches, pains, nerves, diarrhoea, headaches and respiratory problems over the course of two months, compared to the 60% of children residing in non-damp housing. Children in homes that had visible mould had higher rates of vomiting, and sore throats.
Evidence for adults living in damp housing had decidedly mixed results, however several studies have been able to link damp and mould to symptoms similar to that which were experienced by the children. The prevalence of illness increases with the levels of dampness in the homes.
Another example of poor housing includes the levels of overcrowding and living in high rise flats in association with various psychological conditions such as depression, although there are other outside influences such as social and economic influences which can add to the detrition of the individual’s mental health. The rates of anxiety and depression are gradually increasing due to the number of housing problems.
Education
The better educated the individual, the more likely they are to have better health and knowledge on health, and this includes:
The individual would be more knowledgeable about the health care services available to them; therefore it would increase their likelihood of being able to use them more efficiently. There is a greater chance of having a well-paid job, if the individual is better educated, of which increases their chances of a better quality of life – thereby improving their mental health. Overall improvement of health due to their improved quality of life, as they are able to afford healthier food leading to living a healthier lifestyle. The individual would be more informed on what is considered healthier to do/eat and what is not. This knowledge would allow them to make more informed decisions on eating, the consumption of alcohol, smoking cigarettes and exercising in general.
Easy driver pro license activation serial key crack. Residing in a Rural Area
Living in a rural area has its merits and its faults for an individual in regards to their mental and physical health. Rural areas are the complete opposite to urban areas, the case being that rural areas do not have as many buildings but instead consist mostly of large areas of land otherwise known as the countryside. Living in a rural area can have a positive impact on an individual’s health, this includes:
Levels of pollution are considerably lower compared to urban areas such as towns, which are much denser with pollutants for example cars and planes. Those who live in rural areas are less likely to develop breathing difficulties, of which is one such example. The open spaces in rural areas provides those residing there uplifting views, this would have a positive effect on their mental health. These open spaces are also able to provide a good place for exercise. Individuals are less likely to become a victim of an assault compared to those living in urban area where it is considerably more populated, due to the fact there are far less people living in a rural area.
Negative effects on an individual’s health include:
Individuals living in rural areas are more likely to end up feeling isolated due to the fact that there is a smaller number of people living there, in this case it can affect their mental health which may lead to death by suicide. It can be difficult to access health care services for those who live in rural areas as they may live too far away from any hospitals and GP surgeries. In addition healthcare services may have to travel for a long period of time in in order to reach those who live in rural area because of the distance they must travel. This can lead to an increase in death rates caused by accidents. There is a higher risk of road traffic collisions in rural areas opposed to those in urban areas.
Road traffic collisions which occur in a rural area compared to that of an urban area, are more likely to lead to a fatality as the speed limit in rural areas are significantly higher than in urban areas. Collisions occur more frequently in rural areas as public transport is not as good as it could be, therefore leads more people to drink and drive because they cannot take the bus or a train. This is another reason as to why road traffic collisions have a higher mortality rate in rural areas, due to the amount of people who travel in a single vehicle due to the lack of public transport.
Pollution
Pollution occurs when the environment is harmed by pollutants in the forms of gas, liquid, light and sound.
Gas pollutants: Toxins released from cigarettes and aeroplanes Liquid pollutants: Toxic waste or pesticides used by farmers to increase crop growth. Light/Sound pollutants: Street lights and vehicles
Pollution has a negative impact on the environment and in turn can have a harmful effect on an individual’s physical health. The severity of the harm to a person’s health can depend on amount of exposure they have had, and much harm the pollutants can cause. Some individuals can be more sensitive to pollution than others, such as babies, pregnant women, the elderly and people with health problems.
Low levels of pollution can cause minor effects to an individual’s physical condition, such as irritation to the eyes and throat. However even low concentrations of pollution can have a lasting effect on a person’s health if they are exposed to it on a regular basis. Pregnant women how have been exposed to continuous low concentration of pollution have a greater risk of their child being born with asthma.
Exposure to high concentration levels of pollution on a short term basis can prove extremely damaging and in some cases can even be fatal. In London in 1952, the great “Smog Disaster” caused a total of four thousand people to die over the course of a few days due to the high concentration of pollution.
Living in a big city where there is a lot of noise and light pollution can have detrimental effect to an individual’s mental health, and can lead them to becoming depressed.
Sexuality
A person’s sexuality defines what gender they are and what their sexual orientation is. What sexuality an individual is cannot only affect their physical health but also have a significant impact on their mental health as well. Physically being sexually active whether they are homosexual or heterosexual does have its risks, of which include STD’s, HIV and unwanted pregnancies.
However mentally being homosexual can prove hard to come to terms with for some individuals due to discrimination and prejudice homosexual individuals receive from society.
The stress of coming out to friends and family can be too great of a pressure for some individuals that they end up suffering from depression. However society in England in this day and age, homosexuality is widely accepted. In some cases homosexuality is not always as accepted and this can be the case in religious families where homosexuality is considered a sin. If their sexuality is not accepted this can lead to some individuals ending up homeless and feeling rejected by society. Young gay men have the highest rate of suicide due to feeling rejected from society.
Genetics
Cystic Fibrosis – Cystic Fibrosis is a genetic disorder that is caused by a recessive allele. Both parents need to be carrying the recessive allele in order for the child to be born with the disorder. There is a 1 in 4 chance of the child being born with Cystic Fibrosis if a couple with allele decide to a baby. Cystic Fibrosis affects the internal organs of the body clogging them up with mucus, which can make it hard for the individual to breathe. Cystic Fibrosis is a progressive disorder with no current cure, and an individual’s average life expectancy with the disease is 31. There are measures in place in order to help the individual to stay healthy for as long as possible, despite the fact that there is no cure at present. Treatments include a healthy diet, exercising, physiotherapy and medicine treatment.
The result of the mucus clogging up the lungs, the individual can find that it is difficult to breathe and eat properly and this can have an impact on how they live and go about their day-to-day life. Cystic Fibrosis is a major factor which can affect the patterns and trends of ill health in the UK. In the future it is expected that over 2 million people in the UK will carry the gene.
Thalassemia- Is a group of inherited disorders where part of the blood otherwise known as haemoglobin is abnormal. This means that the red blood cells that are affected are unable to function properly, this can cause anaemia.
In thalassemia the production of haemoglobin is abnormal, of which can lead to anaemia due to the reduction of oxygen being carried around the body. The symptoms include feeling tired, breathless, drowsy and faint.
If thalassemia is left untreated, it can cause a variety of complications of which include: organ damage, restricted growth, liver disease, heart failure and death.
Thalassemia is a condition inherited from your parents, however there is now known reason as to what causes the genetic mutations of which are associated with thalassemia.
Thalassemia can be diagnosed through a series of blood tests and DNA tests in order to determine the type of thalassemia. Pregnant women for example have a routine check-up to look to see if they have an inherited disorder such as sickle cell anaemia.
Treatments for the disorder can include bone marrow transplants and cord blood transplantations. However the procedures can cause a variety of complications and are not suitable for everyone.
Culture
Culture is a term generally used to describe a person’s ethnicity, diet and religion. Culture comes hand in hand with rules and traditions which are enforced by the family, of which can influence an individual’s health. In some cases culture can affect an individual’s health, as if the individual has been taught that blood transfusions are wrong and that they should not accept a blood transfusion even at the cost of their own life then they are more likely to stick to that belief and die when it could have been prevented. Once again referring back to homosexuality and how it can lead to the individual being rejected by their family. However culture can prove beneficial to an individual’s health, for example those who follow a traditional Japanese diet are the most likely to live the longest out of all other national diets due to how healthy the diet is. The Japanese diet is mostly comprised of fish, rice and vegetables.
These examples indicate just how much culture can affect the patterns of ill health, as they show just how much culture can be detrimental and beneficial to an individual’s health mentally and physically.
Diet
Diet is a major contributing factor affecting health today. Poor diet can lead to type 2 diabetes, coronary heart disease, malnutrition, obesity, cancer, high blood pressure and strokes. Obesity is not only a concern in the UK but is also a concern throughout the world. The World Health Organisation (WHO) predicts that 2.3 billion overweight adults in the world by 2015 and that over 700 million of them will be obese. Large groups of teenagers (mostly females) who suffer from eating disorders which can lead them to suffering from malnutrition.
(M2) (D1): Discuss the factors likely to influence current and future patterns of health in the UK –
How factors are likely to influence current and future health patterns of health in the UK. For example how factors such as an individual’s diet can affect current patterns of health such as life expectancy.
Factor
Influence
Socio-economic
Social class is a key influence of life expectancy. The higher the individual’s social status, the wealthier means the better overall quality of life they have. Individual’s with a better quality of life are more likely to live longer than those with a poorer quality of life, due to the fact that they are more likely to eat healthier and are less likely to vulnerable and become a victim of crime and be more mentally stable than those of a lower social class, as their lives are not as stressful therefore they have les to worry about.
For example the argument that males which are born into a setting where their quality of life is of a good standard due to the fact that their parents are professionals compared to individuals born into a family where their quality of life is not as good as their parents are not as skilled. This theory can be backed up through the use of statistics from 2007:
However the gap between the social classes should start to become smaller in the future, as it has been doing throughout the years due to the fact that equality has improved exponentially in the UK.
Education
An individual is more likely to be successful in life and have a good career and quality of life rather than doing unskilled manual labour if they are well educated. Compared to those who are not well educated therefore are less likely to be successful in life and are more likely to get poorly paid jobs, leading to a lower quality of life of which can have a significant to their health as they will be unable to afford to eat as healthily compared to those in well-paid jobs.
This claim that professionals are more likely to live longer compared to unskilled manual workers can be backed up through the use of statistics previously used in social class:
National Statistics – “Males in the professional class had a life expectancy at birth of 80.0, compared with 72.7 years for those in the manual unskilled class”.
Identify And Explain The Factors Which Influence Policy Drivers In Health And Social Care
Residing in a Rural Area
Living in a rural area can have an overall negative influence on an individual’s health due to the fact that it is exceedingly difficult to access health services, along with increased risk of road traffic collisions are much more common and in most cases prove to be fatal. These effects can influence the life expectancy of individuals born in rural areas in a negative way.
Through the use of the National Statistics report, the average life expectancy for individuals who live in London is 2 years higher than for those residing in a rural area. However the same statistics also state that the life expectancy in rural areas is on the increase and will continue to do so in the future. http://www.ons.gov.uk/ons/dcp171778_238743.pdf
Pollution
Pollution can affect patterns of life expectancy due to the fact that it can increase the chances of the individual developing problems and breather disorders, for example asthma. During 2009 the NHS reported that a study which was conducted in the USA had found that individuals living in polluted areas are expected to live 10 months less than those who lived in non-polluted areas, like the countryside for example as the air is cleaner. www.nhs.uk/ news/2009/01January/Pages/Pollutionandlifeexpectancy.aspx
Genetics
As previously stated, Cystic Fibrosis is a progressive disorder which at present has no cure and an individual’s average life expectancy with the disorder is 31, this can affect the patterns of health as an estimated 7,500 people have the disorder and 2 million people carry the gene. Although there may be no cure there are treatments, and new treatments are constantly being researched and the current treatments continually improved. Due to the vast improvement in treatments and the research of other treatments, the life expectancy for those with Cystic Fibrosis is likely to continue to rise, as it has been doing over the last few years. According to www.disabled-world.com the life expectancy for individuals who had the disorder back in the 1980’s was just 14 years old. This illustrates how much the life expectancy rate for someone with the disorder has improved immensely.
Culture
Due to the different traditions and beliefs of different individuals, people may live longer than others due to their health lifestyles because that is the way they believe they should live. Ethnic groups come under the topic of culture and across the UK there are differences in equality based on a person’s ethnicity. Since the Black Report was first published, the gap that was between the white British population and the ethnic minorities has decreased dramatically, however there are still un-equalities between the groups. White British people are expected to live around 2 years longer than those in the ethnic minority according to statistics taken from the government. The statistics state that on average white British people are expected to live to 77.7 years of age compared to people in the ethnic minority, who on average are expected to live to 75.5 years of age. www.lancashire.gov.uk
Diet
It is well known that a healthy diet can increase a person’s lifespan. This can be backed up from mass media (news reports) stating the positive aspects of healthy eating and the negative effects of an unhealthy diet. In one such report it states how a good healthy diet can increase an individual’s lifespan and reduce the risks of developing cancer, cardiovascular disease, diabetes etc. www.livestrong.com/article/479611-organic-diet-life-expectancy
By eating unhealthy foods on a regular basis for a long period of time, the individual is more likely to become obese. Obesity is a killer and is currently on the rise. Obesity can cause arthritis, diabetes, cancer, coronary heart disease and high blood pressure. 60.8% of adults within the UK are estimated to be overweight according to the report by the BBC, and that the problem of obesity is on the rise and in 15 years it could affect 75% of the population in the UK. www.bbc.co.uk/health/physical_health/conditions/obesity.shtml
(D1) Evaluate the influence of government on factors that contribute to the current patterns of health and illness in the UK –
Over the course of the last 50 years in the UK the government (England, Wales, Northern Ireland and Scotland) have made a great effort in order to improve the overall health of the general population in the UK. This has been achieved through the use of making the general population more aware of the dangers to their health and what they are along with they can do in order to improve it, thereby making better informed decisions in regards to their health when it comes to things such as diet, road safety (driving), exercise, smoking and education.
The greatest influence that the government has had on the population in general on patterns of health over the last 50 years has been to increase the awareness on the negative effects smoking can have on a person’s health. The ill effects of smoking were originally discovered in 1961 and from that point onwards the government have worked continuously in order to stop people from smoking in order to prevent individuals from dying. The first government initiative was put into place in 1971 which led to manufactures agreeing to display on their packaging compulsory anti-smoking adverts, such as “smoking kills”. This new initiative made a significant impact on raising people’s awareness in the UK about the damaging effects smoking can cause to their health.
Adverts promoting smoking were officially band in 2002 through the use of another government initiative; known as “The Tobacco Advertising and Smoking Bill 2001” Smoking has dropped significantly since 1948 which is proof enough that the government initiatives have had a positive impact on
patterns of health and ill health in the UK.
The government have been campaigning to make driving safer in the UK. Driving under the influence of alcohol increases the chance of an individual having a road accident. Nhk 2038 bcas rar. The government has taken measures to prevent situations like this from occurring by releasing health campaigns in order to tackle drink drivers over the past couple of years in order to decrease the rates of road traffic collisions in the UK or to even prevent them completely. However the government have not just been attempting to raise awareness about the effects of drink driving but also putting in place stricter measures for offenders so that people are deterred even more from driving whilst they are under the influence of alcohol.
At present the maximum penalty for being caught drinking and driving is a ?5000 fine, a ban on the individual’s driving licence and 6 months imprisonment. If the individual causes a road collision whilst they are under the influence of alcohol and cause a fatality, they can be sentenced to a maximum of 14 years in prison. Apart from the initiatives in place to prevent drinking and driving, there have been other government initiatives used in order to stop people from using their phones when they are driving, to wear their seatbelt whilst they are driving and to prevent road rage by raising awareness.
In the 21st century obesity within the UK was starting to become a major concern, after the issue of smoking had been dealt with. In order to get a handle on the growing problem of obesity, the prime minister at the time released a new piece of legislation otherwise known as “Choosing Health: Making healthy choices easier”. This piece of legislation was designed with the purpose to motivate people, improve emotional well-being and to make healthy choices easier for individuals to make in the UK. By making a healthier nation the government aimed to prevent individuals from becoming obese and in turn developing other various health problems as result, of which include type 2diabetes and coronary heart disease. However it is too early to tell whether this piece of legislation has had any real positive impact on the patterns of health and trends of health in the UK. On the other hand, this legislation has sparked other health campaigns to form from other government organisations such as the NHS.
A future health campaign is being set up targeted at the prevention of accidents especially in the workplace. The campaign is being released to tackle accidents that are currently a top cause of ill health and death in the UK. The campaign is aiming to raise awareness, so that individuals may take precautions and actions to prevent accidents from occurring, such as slips, trips and falls.
In conclusion I believe that the government has had a positive influence on the state of the population’s health in the UK thanks to their use of initiatives such as new legislation and health campaigns. The government’s most positive influences on patterns of health in the UK have been on smoking, driving and obesity. However I believe that the government needs to focus more on the current alcohol epidemic currently spreading across the UK, of which at present the government has not really done much about. Hospital admissions due to alcohol have cost the NHS billions, and if something is not done about it the admissions could be costing ?3.7 billion by 2015 according to the BBC. Besides the rise in hospital admissions, deaths due to alcohol related liver disease has also been on the rise. I think that the government should focus more on alcohol campaigns before the issue with alcohol becomes a major problem.
References
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LIVESTRONG.COM, (2013). Health Benefits of Organic Foods Vs. Processed Foods | LIVESTRONG.COM. [online] Available at: http://www.livestrong.com/article/258734-health-benefits-of-organic-foods-vs-processed-food/ [Accessed 22 Oct. 2014].
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