The reform and expansion of mental health care (MHC) systems is a key health policy target worldwide. Evidence informed policy aims to make use of a wide range of relevant data, taking into account past experience and local culture and context.
To discuss the organisation, provision and financing of MHC in Spain visa vis the goals of recent psychiatric reforms.
We draw upon existing literature, reports and empirical data from regional and national health plans, as well as European reports pertinent to Spain. In addition we have made use of iterative discussion by an expert panel on the features of Spanish MHC services, namely its history, characteristics and determinants in comparison to reforms in other European health systems.
In contrast to most other European health systems, the Spanish case reveals that political regional devolution leads to a greater heterogeneity in MHC systems, with some of the 17 autonomous communities (ACs) or region states that make up the country moving more rapidly to full de-institutionalisation alongside coverage expansion and policy innovation. There remains a lack of specific earmarked budgets for MHC at a time of under-funding. There has been an imbalance in MHC reforms, with more focus on the principles underpinning the process of de-institutionalisation and less on the actual development of alternative community based mental health services. Moreover there has been a lack of monitoring of the reform process. Common to other countries, attempts to develop a more informed evidence policy have been hampered by a dislocation between the production of research evidence and the timing of actual policy reform implementation.
Much of the focus of policy attention is on how to improve coordination within and across sectors, tackle socioeconomic inequalities and thus reduce the gap between perceived and observed need while monitoring any trends suggesting trans-institutionalisation. Other issues include developing and strengthening services to meet the needs of new migrants, as well as those of the rural population. There is also a growing recognition of the need to strengthen the evidence base both through research capacity and mechanisms to encourage the use of health economic information as one key component in the assessment of the system.
The evolution of MHC in Spain may be regarded as a useful contextual case study for other countries embarking on reform, including some in Eastern Europe and Latin America. Spain is an example of a country that has undergone substantial economic and democratic transition in a short time frame; it has seen significant economic growth in some areas and has experienced mass immigration. While it is too early to judge the effectiveness of reforms in Spain, work to date clearly indicates some of the challenges that have to be overcome. These include better harmonisation and integration between health and social care, and more attention paid to the development or monitoring mechanisms to assess progress in reform implementation and better identify any widening of geographical disparities.
"Therefore any intervention provided at a primary care centre will be available for the whole population of the related health area. The characteristics of the Spanish primary care system and the mental health system have been described elsewhere (Borkan et al., 2010; Salvador-Carulla et al., 2010). Furthermore, the programme is aligned – in its objectives and in its development – with the current priorities and strategies for addressing mental healthcare and chronicity established in Europe (Nolte and McKee, 2008; Busse et al., 2010) and with the Spanish healthcare system (Ministry of Health, Social Services and Equality, 2011; Orozco-Beltrán and Ollero Baturone, 2011). "
[Show abstract][Hide abstract] ABSTRACT: Background
Collaborative care programmes lead to better outcomes in the management of depression. A programme of this nature has demonstrated its effectiveness in primary care in Spain. Our objective was to evaluate the cost-effectiveness of this programme compared to usual care.
A bottom-up cost-effectiveness analysis was conducted within a randomized controlled trial (2007–2010). The intervention consisted of a collaborative care programme with clinical, educational and organizational procedures. Outcomes were monitored over a 12 months period. Primary outcomes were incremental cost-effectiveness ratios (ICER): mean differences in costs divided by quality-adjusted life years (QALY) and mean differences in costs divided by depression-free days (DFD). Analyses were performed from a healthcare system perspective (considering healthcare costs) and from a society perspective (including healthcare costs plus loss of productivity costs).
Three hundred and thirty-eight adult patients with major depression were assessed at baseline. Only patients with complete data were included in the primary analysis (166 in the intervention group and 126 in the control group). From a healthcare perspective, the average incremental cost of the programme compared to usual care was €182.53 (p<0.001). Incremental effectiveness was 0.045 QALY (p=0.017) and 40.09 DFD (p=0.011). ICERs were €4,056/QALY and €4.55/DFD. These estimates and their uncertainty are graphically represented in the cost-effectiveness plane.
The amount of 13.6% of patients with incomplete data may have introduced a bias. Available data about non-healthcare costs were limited, although they may represent most of the total cost of depression.
The intervention yields better outcomes than usual care with a modest increase in costs, resulting in favourable ICERs. This supports the recommendation for its implementation.
"This fact was related to the direct involvement of the Spanish MH national and regional agencies in the use of the instrument for evidence-informed planning. Services from other sectors and other countries were added to the database, mental health is regarded as a paradigm of complex care including health, social, education, work and crime and justice services , and Spain has a high diversity of health and social care systems in its 17 regions . Therefore, to be fully generalizable, our results should be completed by studies comparing different countries and carried out in different health sectors. "
[Show abstract][Hide abstract] ABSTRACT: Background
The harmonization of European health systems brings with it a need for tools to allow the standardized collection of information about medical care. A common coding system and standards for the description of services are needed to allow local data to be incorporated into evidence-informed policy, and to permit equity and mobility to be assessed. The aim of this project has been to design such a classification and a related tool for the coding of services for Long Term Care (DESDE-LTC), based on the European Service Mapping Schedule (ESMS).
The development of DESDE-LTC followed an iterative process using nominal groups in 6 European countries. 54 researchers and stakeholders in health and social services contributed to this process. In order to classify services, we use the minimal organization unit or “Basic Stable Input of Care” (BSIC), coded by its principal function or “Main Type of Care” (MTC). The evaluation of the tool included an analysis of feasibility, consistency, ontology, inter-rater reliability, Boolean Factor Analysis, and a preliminary impact analysis (screening, scoping and appraisal).
DESDE-LTC includes an alpha-numerical coding system, a glossary and an assessment instrument for mapping and counting LTC. It shows high feasibility, consistency, inter-rater reliability and face, content and construct validity. DESDE-LTC is ontologically consistent. It is regarded by experts as useful and relevant for evidence-informed decision making.
DESDE-LTC contributes to establishing a common terminology, taxonomy and coding of LTC services in a European context, and a standard procedure for data collection and international comparison.
BMC Health Services Research 06/2013; 13(1):218. DOI:10.1186/1472-6963-13-218 · 1.71 Impact Factor
"Problems with coordination of services have also been described with psychiatric reforms in other European countries [18,19,22,23]. In Norway during the ten year National Plan for Mental Health, there was significant growth and development of primary care in relation to mental health. "
[Show abstract][Hide abstract] ABSTRACT: Over the last three decades significant efforts have been made in many European countries to move away from a mental health system dominated by institutional care towards one whereby the main emphasis is on providing care and support within the community. Although the time of starting the reforms, their pace, the political context, and the exact objectives varies substantially across Europe, practically all countries have been undergoing such major reforms aimed at establishing services in the community to replace institutional based care. Each country makes its own decisions about the necessary mental health services taking into account a range of factors including population needs, level of resources, flexibility and coordination of organizational structures, as well as local culture. These factors become an integral element of a national mental health policy and action plan, closely linked with national public health strategies.
Greece has been modernizing an outdated mental health system, which was based on institutional care, over the last 20 years, by developing community-based mental health care. This article describes the methodology used for the evaluation of the Psychargos programme of the mental health reforms in Greece. Various forms of community-based mental health services have been developed including supported living facilities, community mental health centres and employment opportunities.
International Journal of Mental Health Systems 03/2013; 7(1):11. DOI:10.1186/1752-4458-7-11 · 1.06 Impact Factor
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