Psychiatric and Mental Health Plan 2005-2008

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Abstract

The French government decided in 2005 to introduce a psychiatric and mental health care plan for the period 2005-2008 with four aims: 1) to improve the mental care supply; 2) to improve the involvement of patients, their families and health professionals in policy decisions concerning mental health care and to address challenges linked to stigma and discrimination; 3)to improve quality of care and research in this area; 4) to implement programs for specific disorders or population groups.

Purpose of health policy or idea

After ten years of public audit, evaluation and reporting, a common vision and diagnosis on the challenges and problems faced by psychiatric and mental health care delivery emerged between the stakeholders: the organisation of psychiatric and mental health care in France is quite original with the specificity of the French deinstitutionalization process: the slow development of a community based mental health care system was decisive, innovative but uncompleted (see below "Origins of health policy idea").

The current French government appear to act on this recurring diagnosis by introducing the "psychiatric and mental health plan 2005-2008" and proposing to move from a structure-and-service-based-approach to a global approach taking into account community needs. This perennial plan (2005-2008) was first presented in February 2005 to mental health care actors for consultation (representatives of health professionals, associations of patients and families) and then amended for presentation to the Council of Ministers in April 2005.

This plan is declined in four axes:

1. Breaking the compartmentalization in the delivery of psychiatric and mental health care :

• To improve promotion, prevention and education by: promoting activities towards specific population groups (in particular, children and teenagers) and communication campaigns towards general practitioners as well as using the media to sensibilise the entire population;
• To improve the provision of care for mentally ill by: breaking the isolation of general practitioners in this area (improving the coordination with network, continuing medical education, implementation of guidelines); encouraging the development and diversification of alternatives to inpatient treatment and reinforcing hospital front door facilities; adapting hospital inpatient facilities for children or adolescents (increasing bed facilities, cooperation between paediatric and psychiatric services and between health care and social, educational, juridical fields) and for adults (improvement of response to emergency and crisis, bringing closer somatic and psychiatric services, encouragement of cooperation between hospitals, improving the physical facilities of hospitals with a freeze on inpatient bed closure);
• To improve socio-medical support by: developing state and local level new structures for supporting social and medical services for all adult handicapped (Services d'accompagnement médico-social pour adultes handicaps, SAMSAH); increasing the number of adequate accommodation or housing and working places for handicapped person (Maisons d'accueil specialise, MAS, and Foyers d'accueil médicalisé, FAM)as well as supporting the development of Support Groups lead by patient or family associations (Groupe d'entraide mutuel or "club", GEM).

2. Involving patients, their families and professionals:

• To reinforce patients' and their family and relatives rights by: improving their involvement in policy decisions on the provision and regulation of psychiatric and mental health care (participation to public bodies); providing financial support to associations representing patients and their families; tackling issues associated with stigma, discrimination and basic rights of the population with psychiatric and mental health disorders (i.e. compulsory admissions, isolation and physical contention measures); and encouraging the elaboration and dissemination of evidence based practice.  
• To improve the practice of mental health professionals by reinforcing initial and continuing medical education (especially for nurses); and supporting the development of mental health care supply by increasing considerably the investment.

3. Improving the quality of care and research:

• To improve clinical practice and drug utilisation by: elaborating, diffusing and implementing evidence based guidelines;
• To improve the data on psychiatric and mental health care activity;
• To develop clinical and epidemiological research in psychiatry (i.e. creation of a Scientist Interest Groups which can promote the information diffusion and guide research in psychiatric and mental health epidemiology).

4. Introducing targeted programs for specific diseases or groups

The government decided to implement a number of targeted programs for specific diseases or population groups. The major subjects tackled are the following:

• depression and suicide: through a mass-media campaign, screening, research, development of social and medical care facilities;
• prisoners : impoving the diversification and coordination of care, the development of new secure hospital facilities;
• children and adolescents: improving screening programs, GPs continuing medical education, the development of social support facilities,
• homeless people (reinforcement of mobile mental health crisis team),
• elderly people.

This plan represents, including both the investment and running costs, a total amount of 287.5 million euros for the period 2005-2008 and another 223.5 million euros for the period 2005-2010. Most part of this money come from reallocation of resources or from a special fund which supports since 2003 all hospital care investment (called Fonds pour la modernisation des établissements de santé publics et privés, FMESPP, which is grant of 327 millions euros for 2006). The creation of new secure hospital facilities for prisoners is financed by some specific subsidies coming from the FMESPP about 26.5 million euros for the period 2005-2008.

Main points

Main objectives

The main objectives of this plan are:

• to improve supply complementarities;
• to involve patients, families and professionals in decision making and to promote non-stigmatization;
• to improve quality of care and research;
• to tackle specific diseases or the problems of specific groups by implementing targeted programs.

Type of incentives

The financial plan for 2005-2008 for psychiatric and mental health care strategy included: new resources, specific loans and resource re-allocation.

Groups affected

State (government, parliament and central or local administration), Institutions and professionals providing psychiatric and mental health care, Patients, family and their representatives

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

not relevant.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

After ten years public audit, evaluation and reporting - there is now consensus by the state, sickness fund and professionals bodies that the French psychiatric and mental health care system has unquestionable strengths but it also has acute weaknesses:

(1) The mental health status of French population does not compare favourably relative to the situation in other EU countries (cf. the study by Kovess "State of Mental Health in European Union", European Commission, 2004, which compares mental health status of the population in Europe). France has a bad score for positive mental health (8th rank on 11); high proportion of population with psychological distress (3rd rank on 11) and depressive or anxiety disorders (6th rank on 6); high rate of death form suicide both for male and female (respectively 14th and 15th ranks on 15). Moreover the consumption (in DDD/1000 inhabitants) of psychotropic drugs (antidepressants, anxiolytics and hypnotics) is highest in France. Some specific population groups have over risk such as young adults (18-24 years old) for depressive disorders, elderly for suicide, unemployed for psychological distress.

(2) Psychiatric and mental health care supply is considered as very extensive (in terms of psychiatrists density and hospital beds capacity) and organized in an innovative way, especially in public hospitalization. The sector organisation (SO) for psychiatric and mental health care, called sectorisation psychiatrique or de secteur psychiatrique, started more than 40 years ago (in 1960).

In France the psychiatric and mental health care sector is organised seperately for adults and children/adolescents, for a geographically defined area in which a wide range of comprehensive hospital and community services - covering prevention, acute care, post-care and rehabilitation - are coordinated for a relatively small defined population (one adult sector for 70.000 adults inhabitants in average). The sector organisation network includes service facilities (inpatient and outpatient hospitalisation, ambulatory care, rehabilitation) and health professionals (psychiatrists, psychologists, psychiatric nurses,) who work in cooperation with local policy representatives, associations, private physicians, social care workers, educational workers and the justice.

While the de-institutionalisation policy was similar to other countries, the process and schedule of its implementation was very specific in France. French de-institutionalisation policy was characterised by a soft-revolution (rather then a hard one) supporting incremental changes (slow development of alternative care in the community before, any hospital and bed closure), which was certainly innovative and (in one sense conservative too), and which is still unfinished.

(3) Despite the existence of a common organizational framework, there is a gap between the theory and practice and with the founding principles. We observe:

• Geographical disparities in financial and human resources allocated and equipment capacity, as well as a structural imbalance between the hospital care and ambulatory and community care on one hand, adult and children/adolescent care on the other. These are the sources of inequities in access to psychiatric and mental health care.
•  Available resources are decreasing as demand rise and new missions are given to physiatric care.
• Compartmentalization: within the mental health care system (between general practitioners and psychiatrists; between health care system front door structures, PS front door structures and population); between mental health care, social care, educational, juridical, systems; source of lack of coordination and complementarity.
• Inadequate hospitalization: it is estimated that about 13.000 patients are not adequately hospitalised. Also, lack of necessary bed facilities is pointed out for children and adolescents.

(4) The proportion of health budget dedicated to mental health care in France is amongst the lowest in EU (less than 6% as in Spain, Portugal, Latvia, Czech, Slovakia ; cf. European commission green paper: "Improving the mental health of the population. Towards a strategy on mental health for the European Union", Brussels, 2005). Thus the general and rather consensual idea is that the psychiatric and mental health care sector organisation suffering from inadequate resources(rather than excess).

Initiators of idea/main actors

• Government

Approach of idea

The approach of the idea is described as:
renewed: To complete psychiatric and mental health sector organisation in order to tend towards a more comprehensive and community based supply.

Stakeholder positions

On the whole, the psychiatric and mental health plan 2005-2008 have been well received and supported, both by hospitals and by the representatives of health professionals working in this area (Association Française de Psychiatrie (AFP), Syndicat des psychiatres français (SPF), Fédération Hospitalière de France (FHF), Conférence des présidents de CME de CHS, Fédération Française de Psychiatrie (FFP)) as well as the associations representing the patients and their family (Union Nationale des Amis et Familles de Malades Mentaux (UNAFAM), Fédération Nationale des Associations de Patients et ex-Patients en Psychiatrie (FNAP-Psy), Fédération d'Aide à la Santé Mentale Croix-Marine (FASM Croix-Marine)).

First of all, the process of consultation (which began in February 2005), before the plan is finalized for the Ministries Council in April, was very well received. Second, there is a large consensus regarding the four principle axes of this plan. The development of socio-medical facilities is particularly demanded.



But hospitals, health professionals and patient or family associations express their doubts on the functioning of this plan:

• The amount dedicated to finance the plan is too low to be credible. On a total amount of 1.5 billion euros, there is only 65 million euros of real new resources, the rest are to be created by loans and through self-financing or resource re-allocation. All the stakeholders call for a dedicated financial envelop for psychiatry and mental health.
• Insufficient number of new socio-medical facilities (about 3000 places) regarding the number of patients potentially expected (about 10.000 patients are estimated to be hospitalised inappropriately);
• Gap between the political speech and the actual text regarding the reaffirmation of sector organisation as the principal unit of planning. Public hospitals are worried about the supply of psychiatric and mental health care;
• Lack of guarantees concerning the coordination between central administration and local representatives, who have the responsability for the financing and implementation of most measures of the plan;
• The appropriateness of the hospital bed closure moratorium, which can be seen as a security drift and remind the old ages of asylum if this is not linked to the development of alternatives to inpatient facilities.

Actors and positions

Government
State (government, parliament, administration)	very supportive		strongly opposed
Hospitals and professionnals	very supportive		strongly opposed
Patients, family and their representatives	very supportive		strongly opposed

Influences in policy making and legislation

Most of this plan, which is registered in the project of Financing of Social Security Project Act 2006, is still in progress and conditioned to the adoption of the circular or the decree.

Legislative outcome

pending

Actors and influence

Government
State (government, parliament, administration)	very strong		none
Hospitals and professionnals	very strong		none
Patients, family and their representatives	very strong		none

Positions and Influences at a glance

Adoption and implementation

Implementation, monitoring and evaluation, of this plan will be followed by a special comitee combining the central authorities ( of health; hospitalisation; social security; research and statistical institutions, etc.) and local administration (Regional hospital, health and social authorities)  and a special body, under the state supervision (Health and Social Ministries), the National Mission of Mental Health Support (Mission Nationale d'Appui en Santé Mentale, MNASM).

Until now, the following (draft) legislation and regulations have been adopted (see website of MNASM) :

• Draft Financing of Social Security Act 2006,
• Circular regarding the constitution of the technical committee and the local (regional) coordination between administations (social, health and hospitalisation) (22th July 2005),
• Socio-medical  facilities (places in SAMSAH, MAS, MAF): creation, mission and functionning, financement, circular of the national ceiling for health insurance expenditure (22th March 2005), decree (11th March 2005) and head of administration letters (hospitalisation and social administration) to local administrative authorities and councils (region, department) regarding their financial duties,
• Circular regarding financing and support to mutual group of support (30th August 2005).

Monitoring and evaluation

See adoption and implementation.

Expected outcome

References

Sources of Information

Regarding this reform:

Ministère de la santé et des Solidarités: « Plan psychiatrie et santé mentale 2005-2008 », avril 2004. Available at:  www.sante.gouv.fr/htm/dossiers/sante_mentale/plan_2005-2008.pdf

Regarding diagnosis on the challenges and problems faced by French psychiatric and mental health care:

• Gérard Massé (1992): « Intégration de la psychiatrie dans le système général de santé ».
• Joly P. (1997): « Prévention et soins des maladies mentales: bilan et perspectives », Avis et Rapport du Conseil Economique et Social.
• Guy Nicolas, Michèle Duret (1998): « rapport sur l'adéquation entre les besoins et les effectifs en anesthésie-réanimation, gynécologie-obstétrique, psychiatrie et radiologie ».
• Guilmin A. (DREES), Parayre C. et Boisguérin B. (DGS), avec la collaboration de Niel X., Bonnafous E. (DHOS) et Gallot A-M. (DGS), (2000): « Bilan de la sectorisation psychiatrique ».
• Jean-Luc Roelandt et Eric Piel (2001): « De la psychiatrie vers la santé mentale ».
• DGS (2002):  « L'évolution des métiers en santé mentale : recommandations relatives aux modalités de prise en charge de la souffrance psychique jusqu'au trouble mental caractérisé ».
• DHOS (2002): « Recommendations d'organisation et de fonctionnement de l'offre soins en psychiatrie pour répondre aux besoins en santé mentale »,
• Jean-Luc Roelandt (2002): «La démocratie sanitaire dans le champ de la santé mentale».
• Clery-Mellin P., Kovess V. et Pascal J-C (2003):  « Plan d'actions pour le développement de la psychiatrie et la promotion de la santé mentale », rapport de la mission Clery-Mellin remis au Ministre de la Santé, de la famille et des personnes handicapées.
• Kovess V., Lopez A., Penochet J-C. (2001):  « Psychiatrie, années 2000: organisation, évaluation et accréditation ».
• Coldefy M., Bousquet F., Rotbart G. (2002): « Une typologie des secteurs de psychiatrie générale en 1999. DREES, Études et Résultats n°163.
• Kovess "State of Mental Health in European Union", European Commision, 2004.

Author/s and/or contributors to this survey

Julien Mousquès (IRDES)

Suggested citation for this online article

Julien Mousquès (IRDES). "Psychiatric and Mental Health Plan 2005-2008". Health Policy Monitor, October 2005. Available at http://www.hpm.org/survey/fr/a6/1