Planning, commissioning and audit

At present, much of healthcare is planned, audited and commissioned on the basis of diagnosis. The supposed reliance on diagnosis to plan and commission care is a mainstay of the arguments that diagnosis is necessary. However, it doesn't have to be that way. For individuals, as I shall explain below, individual care plans can be - and in fact frequently are - developed without recourse to diagnosis. And it simply isn't necessary for planning purposes either. I am constantly proud of the UK's National Health Service, a comprehensive system ensuring world-class healthcare available to all, free at the point of need and predicated on the principles of universal and equitable provision. Other nations are less fortunate, and still rely heavily on either commercial provision or on services funded through insurance. In these latter schemes, diagnosis is often important in gaining access to services, and services therefore suffer. In the UK, diagnostic information - incidence and prevalence - are important, but not of overwhelming significance. As we'll see in Chapter 8, services are currently commissioned on the basis of a wide range of parameters, in liaison with local authority social services through the joint Health and Wellbeing Boards. These parameters include prevalence statistics - which in turn rely on diagnosis - but are not dominated by them. This means that we can easily imagine a system for the commissioning of services that would not be predicated on diagnosis. In other settings - in education, in social services, in criminal justice services - we do not rely on diagnosis. That doesn't mean that such services are aimless or random. Instead, well-developed systems of service commissioning are in place, based upon the identification of problems and the evidence-base for available services.

We do, of course, need to know the extent of the problems that we have to address, and the scale of the response needed. We need to know how many psychological therapists, how many psychologists, how many psychiatrists to employ. We need to know what type of residential services to commission, and how many people will be needed to staff them. We need to know the extent of the problems; how many working days are lost each year to emotional problems, how many children are finding it difficult to attend to their school work (and who might need the help of educational psychologists). Commissioners and planners of services need answers to questions that are unrelated to diagnosis. They need to know how many people experience certain problems, the economic costs associated with those problems, and the recommended interventions. It is a perfectly valid question to ask how many employment advisors are needed in our mental health services, but knowing how many people have a certain diagnosis doesn't tell us that. Once again, we need information about specific problems, specific needs and specific circumstances, not diagnoses, to plan for care.

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