Different contexts, different challenges

The article by Thornicroft et al on the challenges in improving community mental health care emphasizes staff-related problems – staff anxiety about change, staff concern regarding lack of structure in a non-institutional setting, staff’s difficulty in visualizing new developments, staff opposition to change, staff creating system rigidity and inter-team barriers, and low staff morale. Only three out of the ten challenges they cite relate to non-staff issues: neighbors’ opposition to the location of new programs, policymakers’ deception, and the need for user feedback. This is not the constellation of problems which routinely confront program developers in the US. American administrators face challenges primarily from the structure imposed by government and the health insurance industry. The European challenges arise from a number of sources which are not common in the US. Firstly, because the US psychiatric institutional care system was almost entirely destroyed in the 1960s and 1970s before the community mental health system was well established, few hospital staff transferred to employment in the community mental health system. As a result, US community staff were, in general, not psychiatric nurses with an institutional background, but social workers and psychologists with no hospital experience. The demand for retraining, therefore, was not as acute as in Europe, where deinstitutionalization proceeded at a more leisurely pace and staff were transferred from one treatment environment to another. Secondly, in contrast to Britain and Italy, the US community mental health workforce is largely non-unionized, and worker concerns have not been taken as seriously as in Europe. Finally, US community mental health agencies are often not governmental bodies but independent non-profit entities. As such, they are not bound by governmental personnel policies and pay scales, but can operate more fluidly with respect to staff hiring and firing, training, and incentives. Many of these agencies have been able to develop a flat administrative structure, with few layers of administration between the staff who provide services and the director of the agency. This type of structure enhances communication and reduces problems with staff morale. In contrast, a major challenge faced by program developers in the US is system fragmentation. There is enormous variation in the different American states’ organization, funding and delivery of ser- vices, and no broad national policies govern system activities. Funding sources are highly fragmented. At least 42 different federal programs assist people with serious mental illness, most of which were never designed to serve this population. These programs are weakly administered by state and local programs, resulting in lack of coordination of health, mental health, vocational, housing and other services 1. Efforts to coordinate services through a centralized mental health authority have been unsuccessful 2. It should be recognized that system fragmentation can provide opportunities for entrepreneurialism and inventiveness which are rarely available in Europe. Pockets of excellent service delivery can be developed where administrators are effective in combining funding streams and in creating collaborative relationships with other agencies. On the other hand, when local managers are not competent, there is no centralized bureaucratic system to make up for their deficiencies. In consequence, the quality of service provision may vary dramatically from one district to another. Fragmentation also results from the existence of multiple points of entry into care. A patient may be evaluated in one hospital emergency room and denied treatment, but may approach another emergency room on the same day and be admitted to hospital care. On one occasion he or she may be treated in one hospital; on the next occasion it may well be another. Transfer of information about the client from one hospital to another is made difficult by confidentiality law. At discharge from hospital, moreover, there is often difficulty in locating a community agency willing to provide ongoing community care. A second challenge in the US is represented by competing models of care. Governmental and private health insurance programs impose a medical model which requires proof of “medical necessity” before funding can be approved – a standard which usually excludes reimbursement for vocational and psychosocial rehabilitation. A third challenge concerns interagency cooperation. It is difficult to build cooperative programs between different community agencies to aid an identified at-risk group. For example, children and adolescents at risk of out-of-home placement (in foster care or a juvenile detention facility) are best served by collaborative programs involving mental health, criminal justice and social service agencies. The management and funding of these various agencies are in discrete “silos”, which makes obtaining the necessary collaboration and sharing of funds a difficult task 3. The state-level bureaucracy for an entity such as youth corrections may not be capable of adapting to the requirements of a collaborative enterprise developing at a county level. In addition, the lack of contiguity between the geographic districts for law enforcement, health, social services and local government can be a major problem. Cooperation between police and mental health crisis services is another area in which the provision of optimal services for people with acute psychiatric disturbance is often frustrated. It is clear that the challenges facing program developers are context-related, an observation which underlines one of Thornicroft et al’s conclusions: it is not likely that one will learn the right answer for one’s own service area by visiting model programs in another, remote part of the world.