Graham Thornicroft and Michele Tansella have written an altogether remarkable monograph. The Mental Health Matrix is lucid, written in such simple and spare language as to make its concepts transparent, free of cant and of special pleading. For all these reasons, it should have a profound impact on the provision of mental health services; that is, if it is read by the practitioners, the policy makers and the politicians who need to understand its basic principles. Thornicroft and Tansella present no new data; what they provide are new ways to determine what data are needed across domains and to assess available data to permit evidence-based, integrated conclusions.

Amidst the clamour of cost-containment, they have managed to do the unique. They highlight the importance of a population-based approach to mental illness, because of its health benefits, at the same time that they make the care of the individual patient the focus for clinical planning. In the United States, at least (and I suspect, this is not solely an American disease), ‘population medicine’ is a slogan often used to rationalise cost control by limiting services that might have benefited individual patients.Such rhetoric is absent from this volume. Better care can be less expensive care when ineffective high cost procedures and episodic interventions are replaced by integrated services, but the goal must be the provision of care that benefits patients rather than investors or managers (or mental health workers!).

The aim of this chapter is to describe a stepwise approach toward an evidence base for planning or re-forming mental health services. In section 10.1 we describe this pathway in terms of the background epidemiological information which can support service development. In section 10.2 we discuss the different components of a mental health system of care, both with respect to their categories and their capacities. In section 10.3, we discuss how local service utilisation data can contribute to the evidence base that should inform planning decisions.

Although we present in this section an approach to assessing the need for mental health services, these estimates cannot be properly interpreted without first considering overall health and social care needs of the population in question. This is because it is misleading to discuss mental health needs without consideration of wider family and other social networks. Further, the specialist mental health services do not operate alone, but rather function at a whole series of interfaces with other social and health care agencies, all of which are under the influence of the wider social, political and cultural climate.

To illustrate this point, we shall refer to a enquiry carried out by Mueller (1973) in which he contacted 18 leading social psychiatrists in six countries asking for their views on the ideal psychiatric service for a population of 100000. However, reflecting the socio-political climate of the time, Franco Basaglia, in reply, refused to give figures on that basis. He criticized the way the question was put, and underlined the need for extensive background information about each particular area before any estimate of local service needs can be made. His objection would be seen as self-evident now.

Brief historical overview of Danish psychiatry

In Denmark organised psychiatric treatment dates back to the beginning of the nineteenth century, with the establishment of the first asylum, now Sct. Hans Hospital, which opened in a former manor house in Roskilde southwest of Copenhagen, serving the capital, Copenhagen. In 1852 the asylum idea had gained much ground, and a new asylum was established north of Aarhus, the second largest town in Denmark. The asylum was built for the purpose and was designed by one of the leading Danish architects. It is my opinion that the ideas behind the asylums were far more epochmaking and visionary compared with the organisation, practice, knowledge and attitudes dominating in the mid-1800s than anything else which has been seen in psychiatric organisation since then. The asylum model dominated in Denmark until the Second World War.

Denmark had a psychiatric law (1938) and a social reform (1933),however, without a radical change in the concept of treatment. In Denmark this period was marked by the same progress within treatment as the rest of Europe, progress that I will not mention here, but a specifically new way of thinking which resulted in an important treatment facility, namely home care. Long-term patients from the psychiatric hospitals lived with private families, often farmers, under the inspection of the hospitals. This model faded out in the 1960s and the 1970s.

The asylum model was still in use in the post-war period when we in Denmark, in parallel with the beginning of the psychopharmacological era at the end of the 1950s, started establishing psychiatric departments at the general hospitals.

This volume represents a watershed in writing about the mental illness services, in that the authors are proposing a model that brings together a public health concern with the health of populations, with an insistence on remembering that services must also be judged by their effectiveness in dealing with disorders at a patient level. It was all there before they wrote it, but no-one has previously put it together so elegantly. Space and time arefairly obvious dimensions to choose for a model; what they have achieved is to produce a simple model that neatly serves as a framework for comparisons between different services, and illuminates the way in which planning at different levels of the model relates to events at other levels.It is especially ingenious to use the ‘time’ dimension to indicate time with respect to the treatment of illnesses, rather than merely indicating the historical passage of time. This gives the whole model greater power, which the authors have exploited brilliantly. Nothing will ever be quite the same again; it is a book certain to be widely read and quoted.

One point needs further clarification. Models can be predictive, they can be explanatory, they can be heuristic, or they can be descriptive. In Chapter 17 misgivings are expressed from the Nordic countries that the model is not specific, which implies that no predictions follow from it. First and foremost, this is a descriptive model,which helps to ensure that like is compared with like, by carefully disentangling the nine divisions in the proposed matrix.

Part III will deal with health care measures and indicators which we consider in the phases of the temporal dimension: input, process and outcome.We shall use the term ‘measures'to denote direct assessments,and ‘indicators’ as indirect assessments (or reasonable proxies) that summarise information relevant to a particular phenomenon. Like other instruments used for health services evaluation, such measures and indicators should have adequate validity, reliability, sensitivity and specificity (Jenkins, 1990). Since direct measures are difficult to collect, indirect proxy variables are more common and such performance indicators have been defined as ‘operationally- defined indirect measures of selected aspects of a system which give some indication of how far it conforms to its intended purpose’(Glover & Kamis-Gould,1996).

The distinction and balance between inputs, processes and outcomes within mental health services are far from clear-cut for three reasons. First, there is no consensus on the definitions of these terms, and their use in the literature is widely variable. The consequence of this is that it is often the case that the three temporal phases are used in a confused way so that processes (such as numbers of admissions) are used as if they were outcome variables. Second, these three categories of variables are inter-connected and need to be seen as different aspects of the wider,dynamic mental health care system. In this case, outcomes cannot be considered in isolation, and in fact patients will often want acceptable care processes andoutcomes, so that attention to outcomes alone will miss a part of what is valued by the recipients of care.

Defining the process phase

The Concise Oxford Dictionary defines process as ‘a course of action or proceeding, especially a series of stages in manufacture or some other operation’ or as ‘ the progress or course of something.’

We define as process ‘those activities which take place to deliver mental health services’.

In relation to the theme of this book, the process phase therefore refers to a wide range of clinically related procedures which occur in the mental health service system. In fact, we consider the process of care as the shell within which the active ingredients of treatment (inputs) are delivered to patients.

The distinction between inputs and processes is important but is often not clear cut. On one hand, it should be recognised that these processes are the vehicle for the delivery of care, and are not the substance of the treatment itself (Shepherd & Sartorius, 1989). On the other hand, these processes (non-specific contextual factors) also contribute indirectly towards patient outcomes, through many psychological mechanisms. For example, increased patient satisfaction with services may improve consequent treatment adherence. We therefore see the content of specific treatments (inputs) as of primary importance, and the process of care as a second order issue. The balance between these two sets of factors will vary. In situations where there is a limited knowledge base about what are the effective treatments for a particular clinical condition, or where known effective treatments are simply not available in a given local area, then process issues tend to assume greater relative importance.

The central role of human resources

This book is written for the range of people who are interested in improving mental health services, and this particular chapter will probably be of more interest to clinicians than to administrators and planners. Having already discussed in the last two chapters how to establish the overall needs for information and services, our aim here is to suggest how the staff who constitute the service can be directly involved in formulating plans and putting them into practice. Our main guiding theme is the question: how can the human resources in any existing mental health service best be deployed for the benefit of patients? We take again as our frame of reference the public health approach, which we have outlined in somewhat idealised terms in Chapter 10. In this chapter we shall concentrate upon more pragmatic and day-to-day issues, and in effect we shall base our comments upon the evidence of our experience, rather than the evidence of research. This is simply because there is a striking poverty of relevant research.

To a much greater extent than most other areas of medicine and health sciences, mental health services rely almost entirely upon human technology rather than upon instrumental technology, both for diagnosis and for therapy. For example, the best way to validate a questionnaire as a screening instrument is still by comparison with a clinical interview. In spite of the progress made recently in biological markers, none are yet available as clinical tests for the diagnosis of mental disorders. In terms of treatment, it is clear that the human factor is also central to how far, for example, patients comply with prescribed medication.

Defining the country / regional level

By country we mean the level with a shared government at which mental health laws are established, any relevant minimum clinical standards are set, overall policy is formulated and which is often the level at which the training of professionals is organised. In some countries different regions or states, while sharing some regulations, may formulate their own policy directives and clinical practice guidelines, particularly in countries with a more federal or decentralised political structure.The issues relevant at this country / regional level can be considered in the following three domains: social and political,economic,and professional.

Social and political domains

In the social and political domain, there is the balance that exists in each country, on one hand between concerns for the duty of care to individual patients and the degree of importance attached to their civil liberties, and on the other hand the legitimate expectations of the wider public that mentally ill individuals should receive prompt and proper treatment and care and also that the wider community should be protected from disturbance and harm from patients.

To simplify the complex interactions which take place within the social and political domain, we think that it is useful to consider three aspects within this domain: perceptions by the public, perceptions by politicians, and their policy and legal consequences.Although we portray this as a linear association in Table 4.1, these are recursive pathways, and the chaining effects can be considered to start from any point.

Defining the planning process

In Chapter 10 we outlined two ways of describing mental health services which are located in a particular area: the segmental approach (which considers separately each service component, treatment facility or programme) and the system approach which underlines the contribution that each programme gives to the wider system of care at the local level, and which explicitly considers the inter-relationships between the different services. We have also stressed the point that the selection of one of these two approaches for describing services is closely related to the actual organisation of services in each particular site being described.

In this chapter we shall deal with the planning of mental health services, defined in Table 13.1, using both the evidence and the ethical bases which have been discussed in the previous two chapters. It is often difficult to know whether values or evidence should be given first consideration. Here we propose to reverse the usual order (which is first evidence and later, maybe,ethics!),for the simple reason that even the choice of which evidence is to be collected and used is influenced by value judgements.We address planning for general adult services at the local level, and for simplicity we refer mainly to planning which is limited by a fixed resource input, and the task then becomes one of considering alternative ways in which to shape services for the best outcomes.We recognise that resource inputs may also vary, both to increase or decrease the total resources available.

Defining the patient level

By patient level we refer to the therapeutic domain which may include treatment,care and support for individual patients, or for groups of patients, who share common characteristics or problems, as well as interventions for the members of their wider social networks, including their families and carers. This level is traditionally considered to be the only proper territory of the clinician. As we have already argued, the practice, as well as the outcome, of clinical psychiatry strongly depends upon the characteristics of the other two geographical levels,and it is therefore important for clinicians to be aware of how processes at these higher levels may positively or negatively influence their clinical work. This may especially be the case for clinicians who tend to concentrate their attention solely upon the patient level.

The significance of the patient level

In this chapter we shall introduce the key elements (shown in Table 6.1) which are intended, when used together, to create the framework for clinical interventions at the patient level. As far as the first element is concerned, choosing the most effective clinical interventions, information on the evidence for treatments for individual patients is outside the scope of this book,and we refer the reader to the extensive relevant literature (see for example: Sartorius et al., 1993; Murray et al., 1997).

Introduction

Best Practices in Reforming Mental Health Services has just been launched by Health & Welfare Canada, the Federal Ministry of Health (Health & Welfare Canada, 1997). Since the beginning of the 1990s, many of the ten provincial governments, all responsible for the planning, financing and governance of health and social services, have produced new mental health policies, with particular regard to severely mentally ill patients. Indeed, as with many industrialised countries, Canadian planners consider that we have entered an era of transformation for services in need of a reform. These documents talk about moving and ensuring proper care in the community and indicate the main service components at the patient, local and provincial levels.

But are we witnessing a social reform? Can it not be argued that this is just another phase in the pursuit of further deinstitutionalisation and development of community care? The deinstitutionalisation and community care movement started three to four decades ago. Consider how in most industrialised countries there has been a steady decline of psychiatric hospitals’ population (but no country has done without these facilities), the development of general hospital psychiatric services, of ambulatory outpatient and rehabilitation services. The movement has been fuelled,as indicated in Chapter 2, by social forces: humanitarian, clinical and economic (see also Lesage & Tansella, 1993). Humanitarian concerns have fostered the view that people with disabilities, physical or mental, shall not be segregated and shall live as normal a life as possible in their community.

From colonial rivalries to a national mental health strategy

Historical development of mental health services in Australia

This history is entwined with the impact of European (British) invasion and settlement, initially in 1788, to form penal colonies to alleviate the overcrowding of English jails. As European settlement in Australia expanded, the colonisers tried to come to terms with this remote vast landscape, and fought with the original Aboriginal inhabitants over land and resources. This resulted in fear and isolation for Europeans, and widespread, deadly epidemics and determined attempts at extermination, seriously endangering the indigenous peoples. People of European stock were, therefore, seen as vulnerable to ‘bush madness’, ‘moral insanity’, ‘sunstroke’ and ‘intemperance’, the latter being due to binge drinking and adulterated alcohol. Aboriginal peoples have been subjected to dispossession and ‘spirit-breaking’: largely undocumented emotional traumas through massacres, forced removal from their parents (‘the lost generations’), traditional lands, culture and language, amounting to genocide (Rosen, 1994,Wilson, 1997).

Initially, people with mental illness were confined in irons on ships and in jails alongside troublesome convicts. It was some years before the first suicide was recorded: ‘When life is cheap suicide is rare’ (Dax, 1989). No separate provision was made until 1811, with the first small institution for the ‘insane' opening in Castle Hill, New South Wales, (NSW) accommodating 20 people. Two small asylums were opened in Van Dieman's Land, now Tasmania,in 1824.The first large asylum at Tarban Creek, NSW,was opened in 1838 (later named Gladesville Hospital, which finally ceased operating as an in-patient psychiatric facility in 1997).

Guiding principles at the international level

We argue in this book that the twin foundations for planning community mental health services are the evidence base and the ethical base. In Chapter 10 we discussed one side of the coin,the evidence base for such planning. The aim of this chapter is to discuss the main principles which should form the ethical base of mental health services. Principles are important because they necessarily guide and shape both aspects of the general organization and specific daily service activities. Even if these ethical issues are not made explicit in planning and service delivery, they will exert a profound influence on clinical practice.We believe that good clinical practice will be the manifestation of a sound ethical base. Indeed it is good practice to make this ethical framework explicit early in a planning cycle, so that the infrastructure of values that underpins any project can be debated by the relevant constituent interest groups at an early stage. It is our experience that if this is not done, then value conflicts will occur later, and may slow, limit or even undermine the viability of the work.

In relation to the matrix model, we shall suggest in this chapter, that each service should produce a written statement of the principles which are meant to guide the clinical activities of all staff. This process will often mean the adaptation and reconfirmation of previously produced declarations at the national or international levels for local use.

Defining the local level

By local level we mean the catchment area for which an integrated system of care for general adult mental health services can be provided. The population size will vary between countries and regions, but is generally between 50 000 to 250 000 total residents. In some countries the scale of the local level is smaller where a single generic team is the main service provider (as in South-Verona in Italy), whereas in other settings (for example in Victoria in Australia) the main unit of organisation driving the whole service is the 24-hour Crisis Assessment Team, leading to a larger-scale ‘local level'of about a quarter of a million population.

Where local services are organised on the basis of catchment areas at the local level, these are often called sectors. The concept of the sector has permeated community mental health service development. Following the emergence of the first sectors in France in 1947, by 1961 over 300 had been established. In the USA the Community Mental Health Centres Act (1963) introduced the principle of a catchment area for each CMHC, and by 1975, 40% of the population had sectorised services. In Europe, throughout the 1970s sector development grew but sizes varied between countries (Lindholm, 1983). Germany has sector sizes in the range of 250 000, the Netherlands around 300 000, while the areas for the Scandinavian countries are smaller with Denmark averaging 60–120 000, Finland 100 000, Norway 40 000,and Sweden 25–50 000. Of all countries, however, Italy has most comprehensively adapted the concept by virtue of Law 180, passed in 1978,which established sectors in the range of 50–200 000 population. A further range of factors can also affect the choice of sector size and they are shown in Table 5.1.