Impact of the workforce allocation on the technical performance of mental health services: the collective case of Helsinki-Uusimaa (Finland).

BACKGROUND: Long-term mental health (MH) policies in Finland aimed at investing in community care and promoting reforms have led to a reduction in the number of psychiatric hospital beds. However, most resources are still allocated to hospital and community residential services due to various social, economic and political factors. Despite previous research focussing on the number and cost of these services, no study has evaluated the emerging patterns of use, their technical performance and the relationship with the workforce structure. OBJECTIVE: The purpose of this study was to observe the patterns of use and their technical performance (efficiency) of the main types of care of MH services in the Helsinki-Uusimaa region (Finland), and to analyse the potential relationship between technical performance and the corresponding workforce structure. METHODS: The sample included acute hospital residential care, non-hospital residential care and outpatient care services. The analysis was conducted using regression analysis, Monte Carlo simulation, fuzzy inference and data envelopment analysis. RESULTS: The analysis showed a statistically significant linear relationship between the number of service users and the length of stay, number of beds in non-hospital residential care and number of contacts in outpatient care services. The three service types displayed a similar pattern of technical performance, with high relative technical efficiency on average and a low probability of being efficient. The most efficient acute hospital and outpatient care services integrated multidisciplinary teams, while psychiatrists and nurses characterized non-hospital residential care. CONCLUSIONS: The results indicated that the number of resources and utilization variables were linearly related to the number of users and that the relative technical efficiency of the services was similar across all types. This suggests homogenous MH management with small variations based on workforce allocation. Therefore, the distribution of workforce capacity should be considered in the development of effective policies and interventions in the southern Finnish MH system.

Patterns of Mental Health Care in Remote Areas: Kimberley (Australia), Nunavik (Canada), and Lapland (Finland): Modèles de soins de santé mentale dans les régions éloignées: Kimberley (Australie), Nunavik (Canada) et Laponie (Finlande).

OBJECTIVE: Mental health (MH) care in remote areas is frequently scarce and fragmented and difficult to compare objectively with other areas even in the same country. This study aimed to analyze the adult MH service provision in 3 remote areas of Organization for Economic Cooperation and Development countries in the world. METHODS: We used an internationally agreed set of systems indicators, terminology, and classification of services (Description and Evaluation of Services and DirectoriEs for Long Term Care). This instrument provided a standard description of MH care provision in the Kimberley region (Australia), Nunavik (Canada), and Lapland (Finland), areas characterized by an extremely low population density and high relative rates of Indigenous peoples. RESULTS: All areas showed high rates of deprivation within their national contexts. MH services were mostly provided by the public sector supplemented by nonprofit organizations. This study found a higher provision per inhabitant of community residential care in Nunavik in relation to the other areas; higher provision of community outreach services in the Kimberley; and a lack of day services except in Lapland. Specific cultural-based services for the Indigenous population were identified only in the Kimberley. MH care in Lapland was self-sufficient, and its care pattern was similar to other Finnish areas, while the Kimberley and Nunavik differed from the standard pattern of care in their respective countries and relied partly on services located outside their boundaries for treating severe cases. CONCLUSION: We found common challenges in these remote areas but a huge diversity in the patterns of MH care. The implementation of care interventions should be locally tailored considering both the environmental characteristics and the existing pattern of service provision.

Identifying Local and Centralized Mental Health Services-The Development of a New Categorizing Variable.

The challenges of mental health and substance abuse services (MHS) require shifting of the balance of resources from institutional care to community care. In order to track progress, an instrument that can describe these attributes of MHS is needed. We created a coding variable in the European Service Mapping Schedule-Revised (ESMS-R) mapping tool using a modified Delphi panel that classified MHS into centralized, local services with gatekeeping and local services without gatekeeping. For feasibility and validity, we tested the variable on a dataset comprising MHS in Southern Finland, covering a population of 2.3 million people. There were differences in the characteristics of services between our study regions. In our data, 41% were classified as centralized, 37% as local without gatekeeping and 22% as local services with gatekeeping. The proportion of resources allocated to local services varied from 20% to 43%. Reclassifying ESMS-R is an easy way to compare the important local vs. centralized balance of MHS systems globally, where such data exists. Further international studies comparing systems and validating this approach are needed.

A Comparison of Mental Health Care Systems in Northern and Southern Europe: A Service Mapping Study.

Mental health services (MHS) have gone through vast changes during the last decades, shifting from hospital to community-based care. Developing the optimal balance and use of resources requires standard comparisons of mental health care systems across countries. This study aimed to compare the structure, personnel resource allocation, and the productivity of the MHS in two benchmark health districts in a Nordic welfare state and a southern European, family-centered country. The study is part of the REFINEMENT (Research on Financing Systems' Effect on the Quality of Mental Health Care) project. The study areas were the Helsinki and Uusimaa region in Finland and the Girona region in Spain. The MHS were mapped by using the DESDE-LTC (Description and Evaluation of Services and Directories for Long Term Care) tool. There were 6.7 times more personnel resources in the MHS in Helsinki and Uusimaa than in Girona. The resource allocation was more residential-service-oriented in Helsinki and Uusimaa. The difference in mental health personnel resources is not explained by the respective differences in the need for MHS among the population. It is important to make a standard comparison of the MHS for supporting policymaking and to ensure equal access to care across European countries.

Regional Correlates of Psychiatric Inpatient Treatment.

Current reforms of mental health and substance abuse services (MHS) emphasize community-based care and the downsizing of psychiatric hospitals. Reductions in acute and semi-acute hospital beds are achieved through shortened stays or by avoiding hospitalization. Understanding the factors that drive the current inpatient treatment provision is essential. We investigated how the MHS service structure (diversity of services and balance of personnel resources) and indicators of service need (mental health index, education, single household, and alcohol sales) correlated with acute and semi-acute inpatient treatment provision. The European Service Mapping Schedule-Revised (ESMS-R) tool was used to classify the adult MHS structure in southern Finland (population 1.8 million, 18+ years). The diversity of MHS in terms of range of outpatient and day care services or the overall personnel resourcing in inpatient or outpatient services was not associated with the inpatient treatment provision. In the univariate analyses, sold alcohol was associated with the inpatient treatment provision, while in the multivariate modeling, only a general index for mental health needs was associated with greater hospitalization. In the dehospitalization process, direct resource re-allocation and substituting of inpatient treatment with outpatient care per se is likely insufficient, since inpatient treatment is linked to contextual factors in the population and the health care system. Mental health services reforms require both strategic planning of service system as a whole and detailed understanding of effects of societal components.

How size matters: exploring the association between quality of mental health services and catchment area size.

BACKGROUND: The diversity of mental health and substance abuse services (MHS) available to service users is seen as an indicator of the quality of the service system. In most countries MHS are provided by a mix of public, private and third sector providers. In Finland, officially, the municipalities are responsible for organizing the services needed, but the real extent and roles of private and third sector service providers are not known. Our previous study showed that the catchment area population size was strongly associated with diversity of mental health services. It is not known whether this was due to some types of services or some provider types being more sensitive to the size effect than others. The aim of this study was to investigate the association between area population size and diversity of mental health services, i.e. which types of services and which service providers' contributions are sensitive to population size. METHODS: To map and classify services, we used the ESMS-R. The diversity of services was defined as the count of main types of care. Providers were classified as public, private or third sectors. RESULTS: The diversity of outpatient, residential and voluntary services correlated positively with catchment area population size. The strongest positive correlation between the size of population and services available was found in third sector activities followed by public providers, but no correlation was found for diversity of private services. The third sector and public corporations each provided 44 % of the service units. Third sector providers produced all self-help services and most of the day care services. Third sector and private companies provided a significant part (59 %) of the residential care service units. CONCLUSIONS: Significant positive correlations were found between size of catchment area population and diversity of residential, outpatient and voluntary services, indicating that these services concentrate on areas with larger population bases. The third sector seems to significantly complement the public sector in providing different services. Thus the third sector be needs to be functionally integrated with other MHS services to achieve a diversified and integrated service system.

Size matters - determinants of modern, community-oriented mental health services.

Governances, structures and contents of mental health services are being reformed across countries. There is a need for data to support those changes. The aim of this study was to explore the quality, i.e., diversity and community orientation, and quantity, i.e., personnel resources, of mental health and substance abuse services (MHS) and evaluate correlation between population needs and quality and quantity of MHS. The European Service Mapping Schedule-Revised (ESMS-R) was used to classify mental health and substance abuse services in southern Finland. Municipal-level aggregate data, local data on unemployment rate, length of education, age of retirement, proportion of single households, alcohol sales and a composite mental health index were used as indicators of population mental health needs. Population size correlated strongly with service diversity, explaining 84% of the variance. Personnel resources did not associate with diversity or community orientation. The indicators of mental health services need did not have the expected association with quality and quantity of services. In terms of service organization, the results may support larger population bases, at least 150,000 adult inhabitants, when aiming for higher diversity.

Does primary care mental health resourcing affect the use and costs of secondary psychiatric services?

Collaborative care models for treatment of depression and anxiety disorders in primary care have been shown to be effective. The aim of this study was to investigate at the municipal level to what extent investment in mental health personnel at primary care health centres in the study area is reflected in the costs and use of secondary psychiatric services. Furthermore, we analysed whether the service provision and use of secondary psychiatric care correlates with the socioeconomic indicators of need. We found significant variation in the amount of mental health personnel provided at the health centres, uncorrelated with the indicators of need nor with the costs of secondary psychiatric care. The amount of mental health nurses at the health centres correlated inversely with the number of secondary psychiatric outpatient visits, whereas its relation to inpatient days and admission was positive. The costs of secondary psychiatric care correlated with level of psychiatric morbidity and socioeconomic indicators of need. The results suggest that when aiming at equal access of care and cost-efficiency, the primary and secondary care should be organized and planned with integrative collaboration.