Summary and conclusions of the SINTEF report A23879
By: Project Manager Solveig Osborg
The report has descriptive presentations and analyses of man-year efforts within municipal psychiatric health work during the years 2007-2011. The country’s municipalities reported a total of 11 940 man-years within psychiatric health work on the local level in 2011. Of these, 9 326 (78 %) was connected to services for adults, while 2 614 (22 %) was connected to services for children and young people. During this period, a marginal decline of man-years in the municipalities could be observed on a national level, but there was great variation from one municipality to the next. This is the fifth report in the series and the basis for the data has been presented in the Directive IS-24.
The report follows the development of resource input in the municipalities (psychiatric health work) and it also draws parallels to the number of man-years in the specialist health care service (mental health care) each year from 2007-2011. Thus, we are able to see the development according to the intentions set out by the Coordination Reform concerning the transfer of resources and competence from the specialist health service to the municipalities. On a general basis, there is a high degree of stability in the figures from 2007 to 2011 within the area of services to people with mental disorders and psychological distress, both in the municipalities and in the specialist health service.
At the same time there is great variation in the resource input in different areas of health enterprises, both municipally in the catchment area and in mental health care. In some areas the number of man-years in mental health care is high, but low in municipal psychiatric health work, while other areas have the exact opposite correlation between man-years in the municipal - and specialist health care service. Presumably, the greatest potential in the Coordination Reform lies in areas where the number of man-years in the specialist health care service is large in proportion to the number of municipal man-years.
For the first time there are also chart illustrations detailing the man-year input, both in the municipalities and in the specialist health care service. The geographical variation is evident.
In addition to the presentation of man-year statistics and analyses of municipal variations, the report contains a few qualitative topics which are key issues in services directed to people with mental disorders and psychological distress:
- The GP’s role in municipal psychiatric health work
- Challenges facing municipal psychiatric health work at the commencement of 2012
The GP’s role in municipal psychiatric health work
This section of the report includes a review of the key research findings in the evaluation of the regular general practitioner reform (RPG reform) and the evaluation of the psychiatric health Action Plan. There has been little research on the GP’s role in psychiatric health work following this. Briefly put, in 2006 it was believed to be a great potential for improvement in the services of GPs, as well as in the cooperation with other services concerning people with mental disorders. Neither the patients, the GP’s nor collaborative health care services felt that the general practitioner scheme had offered much in terms of changes. The GP lacked involvement in the report and follow-up of people with psychological disorders and focused on performing his or her primary medical duties. There was a wish for greater accessibility and flexibility in the general practitioner scheme. Based on these findings certain measures were suggested in order to help improve the municipal health services for people with serious disorders. Among the measures were collaboration, increased competence and the division of role assessment between the services. The conclusion was that the larger municipalities benefitted most from improved cooperation, while increased competence was of higher importance in the smaller municipalities.
The research also emphasized the need for a good relation based on more allocated time and better communication between the GP and the patient.
In order to obtain information about the GP’s current status, we asked managers/professionals in psychiatric health work describe the GP’s actual contributions to psychiatric health work in their municipality. 90 % of the municipalities have answered (both brief and lengthy descriptions), and a systematic review of the replies offers a different picture than the status in 2006. The primary impression is that most representatives from psychiatric health work in the municipalities who have described the GP’s daily contribution to their work, have a good cooperation with their GPs. Not many of them complain of the GP’s involvement, accessibility and competence compared to earlier research findings. Even though the qualitative basis for the data is not adequately representative of the development of cooperation concerning people with mental disorders and psychological distress in the municipalities; the findings indicate that the GPs are well informed about this group of patients and that they contribute extensively to the psychiatric health work in the municipalities.
In the 2011 reports a new scope to the GP’s efforts in municipal psychiatric health work has emerged, view report chapter 1.3. In the 2012 reports we will map the extent of the GP’s referrals to psychiatric health work and ask direct questions about the collaboration with the GP’s and its development these past few years. We will also look into whether or not there are any municipal characteristics to observe in regards to how involved the GP gets in individual cases, developmental service work, accessibility, perceived competence of the GP and so on. Through a more quantitative categorization rather than open-ended questions, we will obtain answers more easy to analyze in terms of municipal characteristics. The chief municipal medical officer will be requested to join the assessment of these questions.
Challenges facing the municipal services to people with mental disorders and psychological distress at the commencement of 2012
Due to the changes in municipal services following the implementation of the Coordination Reform it was prudent to do research into what the experts in psychiatric health work felt were the greatest challenges. Strong incentives were set in motion in 2012 to make the municipalities accept somatic patients from the hospitals. Simultaneously, according to the Coordination Reform and the Norwegian Public Health Act, the municipalities are supposed to prioritize preventive work. We asked the managers/experts within municipal psychiatric health work to describe the most important challenges facing each municipality in terms of academic discipline, users, structure, legislation, and so on.
It is a comprehensive research basis with both brief and lengthier descriptions from approximately 90 % of the municipalities. We reviewed all the replies and labeled them with codes according to topic. It was all in all close to 40 codes, which was reduced to 20 in the next round. These, again, were assembled in some primary categories and further analyzed. We can see the following main features:
The users/patients – an increase in demand and high-demanding user groups
Many municipalities experience a strong increase in demand for their services and they report of particular challenges connected to the following user/patient groups:
- People with both substance use disorder and psychological dysfunction (ROP)
- People with serious or complex disorders who the municipalities want the specialist health care services to help or keep for a longer period of time
- Young people with extremely complex needs
- People incapable of accepting services (bad patients who refuse assistance from the specialist health care services and who do not meet the criteria for being forcibly committed to a psychiatric ward, people who are too ill to seek help)
- Socially deprived families, where poverty and social inequality is enforced by health issues
- Refugees, asylum seekers and residents from countries devastated by war
- Children and adolescents (the transition from primary and secondary school to high school, behavioral problems, etc., adolescents who falling between excisting services)
Although many municipalities report of a numeral increase in various user groups, this is not enough foundation to establish which user group is increasing most in the municipalities. As of yet there is no sufficient national basic data to keep tabs on the development of this group of users in the municipalities.
The challenges of the quality of service offered
Many municipalities also report of challenges concerning the quality of the service offered. Even though many people feel that good changes have been made to the services offered to people with psychiatric disorders following the National psychiatric health Action Plan; the municipalities are still facing relatively big challenges connected to the quality of the services offered on a day-to-day basis. Some people refer directly to the quality-term, while others speak more indirectly about the actual shortcomings in the service offered:
- Poor housing situation (reports of an increased need for 24-hour care homes, other housing with or close by 24-hour staffing assistance, residential services to people with ROP disorders, shared house)
- Poor collaboration with and a lack of understanding of the legislation, roles and responsibilities of the specialist health care services
- Difficult to achieve good user involvement
- Difficult to assemble an adequate day care – and activity service and a meaningful everyday life
- Lack of skilled competence concerning ROP disorders
- Lack of tools for mapping the development of good plans of action for multiple groups
- Lack of resources to keep up with the increase in demand
There exists great disparity in how much the different municipalities have succeeded in these areas, but most of the municipalities are to a small or large extent seemingly challenged by providing adequate quality of service. Particularly the final issue, the lack of resources, is a recurrent issue in many of the municipalities.
The coordination dilemma
Moreover, many municipalities point to the overall problems with regard to the coordination with the specialist health care services, where several issues are perceived as obstacles. This is, for instance, that the specialist health care services discharge several users with serious disorders to the municipalities, expecting them to have specialist knowledge. Furthermore, a lack of information and flow of information from mental health care to the municipalities, the disappearance of 24-hour stay accommodation (consistent with figures from the specialist health care services), and the problem of achieving a viable and equal collaboration with the specialist health care services, et cetera. The consequences of the somatic services financing scheme is mentioned specifically, but also the general strain of collaboration and division of labour assignments. In next year’s form we will also map closely the quality of the collaboration with mental health care, both patient-oriented and on the system level. Finally, the therapists in the specialist health care services will be questioned about their knowledge of the municipal services. Particular focus will be on identifying potential geographical variation. Both open-ended and check box questions are included in order to get plentiful of information.
The need for advanced/other competence
Many municipalities report a need for further competence within the services offered. In some municipalities this might be for a psychiatric nurse, while others could benefit from people with further training in psychiatric health work. The majority of the municipalities report a demand for trained psychologists. There are several reasons for the municipal use for employing psychologists, we will especially mention:
- Survey and treatment of children, adolescents and adults
- Guidance and assistance in interdisciplinary teams
For all intents and purposes, the need for psychologists in the municipalities is increasing in several places for different reasons. A few of the reasons are:
- The users’ need for treatment becomes greater as they are discharged earlier from the specialist health care services
- A disagreement with the specialist health care services exists concerning needs assessment; the municipality wants to bolster competence in arguing against them
- Several people point out an increased need for psychologists due to the fact that the municipalities are meant to be handling the early diagnosis in order to commence early follow-up and good preventive work.
In addition to the shortage of psychologists, several municipalities and especially the smaller ones, report of an overly heterogeneous user group, making it challenging to offer adequate competence in all areas. A broad specter of various compounded needs from the users is to be met. Several municipalities report the primary problem as obtaining and retaining competence. There is a wish for more regional summits held by The Norwegian Directorate of Health, where the desired topics of debate are better information about the expectations following the Coordination Reform, improvement in the understanding of the legislative amendments, as well as current key facilities and means (such as tools for categorization, courses offered about the use of guidance counselors, et cetera).
The wish for more focus on preventive work
Shifting the use of resources from treatment to preventive work is crucial in light of the Coordination Reform. From 1 January 2012, the Act concerning public health (the Norwegian Public Health Act) will also delegate large public health assignments to the municipalities. The municipalities prioritize preventive work, and the psychiatric health services feel the weight of their responsibility keenly. At the same time, achieving this shift of resources from treatment to prevention is a difficult task to succeed in. The saying is that it is easier to eliminate positions in preventive work than it is to remove permanent employees in care facilities. Moreover, it is harder to defend the man-years due to the problem with obtaining documented results.
Early intervention in cases regarding children and young people is considered an excessively important preventive task, but considering the sheer number of users with serious disorders and need for extensive aid, the shift is not easy to achieve. On a general basis, the argument of resources is often seen in light of the difficulties prioritizing preventive work.
Challenges facing small municipalities
Over 50 % of the country’s municipalities exceed 5000 inhabitants. This means that several municipalities face challenges which are not crucial matters of relevance in greater municipalities. We have gathered all the contributions coming from the municipalities in an attempt to arrange them according to some key points:
- The combination of a large area and few inhabitants is a challenge for chances of expansion, as well as travel time, et cetera
- Small units and small academic environments pose a challenge in all ways, recruitment difficulties and vulnerability
- Too few to assemble adequate 24-hour services
- Challenges connected to assembling a viable service to people with serious disorders
- The long distance to the specialist health care services places a large strain on small municipalities
- Could be a challenge for users to live in small, transparent municipalities
- Challenges connected to start and offer activity services/variation within a small municipality
- Small municipalities can have limited chances of applying preventive measures
A lack of resources
A scant financial framework is a recurrent issue in most of the challenges facing the municipal services assigned to deal with people with psychiatric disorders. The comments are primarily about the following circumstances:
- Many and complex work tasks divided between too few employees
- A lack of resources concerning registered needs and requirements from the population
- An expanding user group, but no expansion in resources
- The work is difficult to measure and thus can easily become an expense during budget negotiations
- A failing municipal economy leads to cutbacks
Conclusion
The scarcity of resources makes it harder to make preventive work a priority in municipal psychiatric health work. This corresponds with the municipalities having to use its resources on very sick patients who are only briefly allowed to stay in the specialist health care services. There are no earmarked funds for preventive work, and there is a shortage of psychologists able to diagnose early on. Moreover, it is difficult to render visible the on-going activity, so the measures suffer harsh cutbacks at the next budget cut.
Considering the zero increase in resource input measured with the number of man-years from 2008-2012, it is highly likely that the services will face economic challenges, while at the same time face a powerful increase in demand and high-demanding user groups in need of extensive services. This provides a poor basis for making preventive work an area of commitment. Most likely certain funds should be earmarked for preventive work should the municipalities be able to make this work a priority. The municipal employees who observe the great needs of the users often find that they need to fight for their right to keep current resources. Moreover, that they are losing the battle of the resources in favor of the increasing needs of elderly care and the robust financial incentives set forth in the Coordination Reform to make municipalities place priority on patients in the somatic care who are ready to be discharged.
View municipal psychiatric health work