Experience base and system context in mental health care reform
Authors: THOMAS BECKER, REINHOLD KILIAN
Journal: World Psychiatry (2008)

Thornicroft et al offer a cogent account of the experience base for implementing better mental health care in the community. They describe ten key challenges in the process of change, from “anxiety and uncertainty” to the “maintenance of morale”, and discuss whether there is always “a right answer” in the process. Their perspective is highly relevant as it focuses on people or groups of people who initiate and maintain change. In this commentary, we focus on structural factors affecting mental health service change and on cross-national variation to complement this perspective. A recent editorial 1 pointed out that, in spite of a tendency for homogenisation of different systems of care in Europe, “…a long road remains to be made in order to achieve a real homogeneity between mental health services in different countries composing the European mosaic”, partly due to the gap between acquisition of knowledge and application. According to de Girolamo et al 2, the Italian mental health reform led to the establishment of a broad network of facilities meeting diverse care needs, but efforts are required to improve care quality and develop a more integrated care system. For England, another country with a tax-based national health service 3, Glover 4 stated that mental health care is undergoing significant change as a result of major government initiatives, with new types of (specialist community) service being introduced quickly and others being scaled down. There are also accounts of current mental health care and service change in two countries with health insurance-based care systems 3, namely France and Germany. Against the background of a current high density of psychiatrists in the country, Verdoux 5, in her paper on France, described a structural crisis due to the reduction in public health budgets and an expected 30% decrease in the number of psychiatrists, while numerous national programmes aimed at renovating the care system have not kept their promises. As regards Germany, Salize et al 6, against the background of psychiatric reform and substantial achievement in integrating two mental health care systems following re-unification, described an ongoing struggle, in a well-resourced service system 3, to adapt to changing administrative set-ups, legal frameworks, financial constraints and privatisation of some mental health provider trusts. The authors concluded that the system is facing a serious challenge in defending service improvements achieved during the last 35 years. One way of looking at these national accounts of mental health systems is to emphasise the contrast between systems with a strong central public health perspective and (some) central control over guiding principles of mental health care (Italy, UK), on the one hand, and health insurance-based systems (France, Germany) with a lack of central control of mental health care, on the other. These latter systems often lack the power to implement key elements of service set-up across regions. Thornicroft spelled out that community care “is a service delivery vehicle. It can allow treatment to be offered to a patient, but is not the treatment itself. This distinction is important, as the actual ingredients of treatment have been insufficiently emphasised” 7. Also, a recent review of the literature on “assessing the content of mental health services” 8 came to the conclusion that measures providing a greater depth of information about the nature of interventions are needed. Thus, apart from the impact of health and social service constraints on mental health service change, it is this uncertainty on what makes mental health care “work” that suggests additional caution when we discuss the ups-and-downs of mental health care reform. On another note, Thornicroft et al highlight the importance of resources and “ring-fencing” of mental health budgets, and there is no doubt that this is a key issue. However, some cross-national studies indicate that there is not always a clear-cut relationship between funding level and patient outcome 9. On the basis of health economic analyses, some authors suggest that the cost-effectiveness of psychiatric services could be significantly improved by shifting resources from the current mix of interventions to evidence-based optimal treatment strategies 10–13. Nonetheless, as mentioned by Thornicroft et al, the shift of resources from less effective to more effective types of intervention is often difficult, due to inflexible reimbursement systems or admission practices. This carries the risk that initiatives to make the system more cost-effective might end up in a cost-minimisation policy. One way of tackling the risks of a simple cost-minimisation perspective would be to combine the proposition of this commentary, namely that historic and structural constraints shape service change, with the proposition in Thornicroft et al's paper that it is essential to build an enthusiastic workforce devoted to a range of guiding principles, their implementation and evaluation. One key challenge, in the broader health and social care system, is to insist on the importance of mental health, the ethics base, and user and carer values in promoting social inclusion. In the broader context, the set of guiding principles shared by protagonists concerns the social care system as a whole. The general concepts of social inclusion, social choice and human rights inform both the mental health care agenda and the societal project of non-discrimination of people struggling with deficits.