Advantages and disadvantages of the local community level for planning

We need to consider first the scale at which local planning should take place. In terms of a geographically defined 'community', for example, the size of such a local population will vary between countries and regions, but is generally between 50 000 and 250 000 of the total residents. In some countries the scale of the local level is smaller where a single team is the main service provider (as in South Verona, Italy), whereas in other settings (e.g. Victoria, Australia) the main unit of organization 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 arranged on the basis of catchment areas at the local level, these are often called sectors, which can be considered the smallest practical unit for local planning. The concept of the sector has permeated community mental health service development. Following the emergence of the first sectors in France in 1947, over 300 had been established by 1961. In the United States, the Community Mental Health Centres Act (1963) introduced the principle of a catchment area for each centre, and by 1975 40 per cent of the population had sectorized services. In Europe, throughout the 1970s sector development grew but sizes varied between countries.(3) 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 60 000 to 120 000, Finland 100 000, Norway 40 000, and Sweden 25 000 to 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 50 000 to 200 000 population. A further range of factors can also affect the choice of sector size, and they are shown in Box..!.

In terms of advantages of planning at the local level, the first reason for this emphasis is that it is usually the best level at which to consider the components of the general adult mental health system, their organization, and their integration with each other.

Second, the local level is usually the most relevant scale at which to formulate a service strategy or plan, which will also take into account interfaces with other types of local service (such as old age, forensic, learning disabilities, and substance misuse services, general health services, and a range of non-clinical services including social service and housing departments, patient representative groups, local politicians, local newspapers and radio stations, and family, carer, and voluntary groups).

Third, knowing the sociodemographic characteristics of each local area can guide assessment of needs for services and assist the siting of facilities, by using specific population indicators, including both direct census variables and composite scores of social deprivation.

A fourth consideration is that an emphasis on the local level can reverse the trend which formerly forced the deportation of patients away from their homes and their local communities—this was a characteristic of the period during which institutions were built for large catchment areas. Instead of removing patients to remote sites, services must move to the patients' local area. Further benefits of planning and delivering services at the local level are shown in Box.2. In addition, there are some key characteristics of service delivery, such as accessibility, co-ordination, and continuity of care, that we consider to be more achievable within the local context.

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