[Psychiatric reform needs good planning-a national, federal, and regional responsibility]. / Psychiatriereform braucht gute Planung ­ Bund, Länder und Kommunen tragen dafür Verantwortung.

While the German mental health system is extensive and well differentiated, at the same time it is fragmented and lacks coordination. Services do not necessarily follow regional demand. They are not sufficiently integrated into the local social infrastructure. Competition and market mechanisms obstruct cooperation in regional networks. Service management proposed by the 1975 German psychiatric reform ("enquete") has proven to be dysfunctional.This article explores the question of what is necessary to allocate available resources for treatment and care according to modern service concepts and both ethical and professional standards adequately.Based on several years of observation and of playing an active part on the national, federal, and local level, this paper presents concepts of coordination and planning of community mental health services over the last 40 years. As a result, four topics of mental health service planning are presented: individual need for support, institutional quality development, regional networking, and political frameworks.More than ever, psychiatric reform is in need of good planning. A suggested concept integrates the following: (1) good planning of individual assistance, (2) organizational development of mental health services, (3) cooperation in regional networks, and (4) a political framework. Thus, national, federal, and regional activities should be sustainably aligned. We recommend a working group integrating national, federal, and regional policy makers - backed by a trialogic expert advisory board.

Hannover study on long-stay hospitalization - part II: Characteristics and care conditions of long-stay hospitalization in cases of chronic mental illness.

BACKGROUND: Long-stay hospitalization is often a consequence of insufficient care structures. This article examines the characteristics and care conditions of long-stay hospitalization (LSH) in an urban area in Germany. METHODS: Extensive data of patients in the urban catchment area of the Medical School of Hannover, capital of Lower Saxony, were evaluated during a 10 years period. RESULTS AND CONCLUSION: Community psychiatric efforts certainly help to reduce long-stay hospitalization, but cannot fully prevent it. Reference figures are given for comparable urbanized areas: consequently 500 chronically mentally ill persons per 100.000 inhabitants must be expected, 20% of which must be considered as long stay hospitalized according to a given definition. We estimate 250 places per 100.000 inhabitants to be required for institutionalised outpatient care, further 30 places for day clinic and full-time in-patient treatment and 40 places for residential home treatment. We suggest these results as a guidance for psychiatric planning in comparable communities.

How does mental health care perform in respect to service users' expectations? Evaluating inpatient and outpatient care in Germany with the WHO responsiveness concept.

BACKGROUND: Health systems increasingly try to make their services more responsive to users' expectations. In the context of the World Health Report 2000, WHO developed the concept of health system responsiveness as a performance parameter. Responsiveness relates to the system's ability to respond to service users' legitimate expectations of non-medical aspects. We used this concept in an effort to evaluate the performance of mental health care in a catchment area in Germany. METHODS: In accordance with the method WHO used for its responsiveness survey, responsiveness for inpatient and outpatient mental health care was evaluated by a standardised questionnaire. Responsiveness was assessed in the following domains: attention, dignity, clear communication, autonomy, confidentiality, basic amenities, choice of health care provider, continuity, and access to social support. Users with complex mental health care needs (i.e., requiring social and medical services or inpatient care) were recruited consecutively within the mental health services provided in the catchment area of the Hanover Medical School. RESULTS: 221 persons were recruited in outpatient care and 91 in inpatient care. Inpatient service users reported poor responsiveness (22%) more often than outpatients did (15%); however this was significant only for the domains dignity and communication. The best performing domains were confidentiality and dignity; the worst performing were choice, autonomy and basic amenities (only inpatient care). Autonomy was rated as the most important domain, followed by attention and communication. Responsiveness within outpatient care was rated worse by people who had less money and were less well educated. Inpatient responsiveness was rated better by those with a higher level of education and also by those who were not so well educated. 23% of participants reported having been discriminated against in mental health care during the past 6 months. The results are similar to prior responsiveness surveys with regard to the overall better performance of outpatient care. Where results differ, this can best be explained by certain characteristics that are applicable to mental health care and also by the users with complex needs. The expectations of attention and autonomy, including participation in the treatment process, are not met satisfactorily in inpatient and outpatient care. CONCLUSION: Responsiveness as a health system performance parameter provides a refined picture of inpatient and outpatient mental health care. Reforms to the services provided should be orientated around domains that are high in importance, but low in performance. Measuring responsiveness could provide well-grounded guidance for further development of mental health care systems towards becoming better patient-orientated and providing patients with more respect.

Hannover study on long-stay hospitalization - part I: prediction of long-stay hospitalisation in cases of chronic mental illness.

BACKGROUND: The problem of long-stay hospitalization is still a pressing issue. In this study we examined the possibility of detecting and characterising the group at risk of long-stay hospitalization in advance. METHODS: This study examines the data of patients in the urban catchment area of the Medical University of Hannover, capital of Lower Saxony, Germany, during a period of 10 years. RESULTS AND CONCLUSION: The introduced "psychosocial risk-score", calculated at the first institutional contact, was able to predict the risk of long-term hospitalization. Characteristics of social disintegration, especially with regard to employment status, are of particular importance.