Service Utilisation Data

Event-based data on clinical contacts by levels of care [in-patient, out-patient etc], numbers of events and rates per 10,000 population per year

Selective assessment of all data from A, B and C relevant for Individual-based data on both clinical contacts (as above) and on treatment episodes across service planning different levels of care per year

Setting a medium-term time scale for service plans (3- 5 years) Data on outcomes and costs of different clinical contacts (disaggregated for sub-groups of patients) with which to establish substitutability and complementarity of service components in Identify highest priority service needs (both met and unmet) terms of cost-effectiveness

Identification of highest priority unmet social needs and information from relevant authorities

Plan:

(a)new service functions and necessary facilities

(b)extension of capacity of current services

(c)disinvestment from lower priority services propose collection of new data necessary for the next planning cycle

Reproduced with permission from G. Thornicroft and M. Tansella (1999). The mental health matrix; a manual to improve services. Cambridge University Press.

After an initial section dealing with the overall area characteristics, this instrument allows the completion of a 'service mapping tree', and then a 'service counting tree'. Although still at the pilot stage, and still to be fully standardized, it allows considerable promise for mental health service description in the future.

In comparing these three systems of classification, it is important to note that the WHO system and the ESMS may be complementary in that they record different aspects of the service system, but both are relatively complex and the most recent versions have not yet been fully tested in practice. We therefore consider that the Spectrum of Care is a suitable classification for those who seek a clear and simple structure for clinical and planning purposes

A fourth system is our proposed scheme for a Basic Services Profile, which shows the basic services we consider to be the essential elements in any system of careA) This profile (see Table...4) is intended to be usable in a wide range of service patterns at different stages of development.

Having established a system to categorize local services, the question of service capacity arises. There is considerable debate about the numbers of psychiatric treatment and care places that are necessary.'2!22ยป

Strathdee and Thornicroft(4) have set targets for service provision based on likely prevalences of mental illness nationally. These targets assume that community residential places and day care largely replace facilities for long-term patients in asylums. Wing (23) provides figures for targets for day provision by mental health services, which again take account of the prevalence of severe mental illness in the community. The capacities given in T.able.,5, for example, are intended to apply to a whole service where each of the other service components are present in the required capacities. The table also shows the results of a revised version (24) which has been used in London as a basis for comparison with the actual provision of services to allow estimates of over- and underprovision.

Table 5 Estimated need and actual provision of general adult mental health services (aged 15-64 only), (inpatient and residential care): places per 250 000 population, estimated for England in 1992-1996

Recent experience suggests that figures of this sort may be of only limited use. They can be used for local comparisons between similar areas, but they become progressively less useful at the higher geographical levels. They are also open to misunderstanding or to misuse. If this approach is misapplied, for example by being used to calculate inpatient bed numbers alone in the absence of other related categories, then it will produce misleading results.

There is a strong relationship between service provision and service use, and it is somewhat similar to the economic relationship between supply and demand. It appears, first, that where psychiatric beds are available then they are filled, whatever the quantity of provision. (24) Second, the categories of service used are usually entirely governed by the types of service available locally. If, for example, home-treatment services are not provided in a given area, then the options available to staff when assessing a patient in crisis are normally restricted to inpatient or day-hospital admission. (25) In this way supply, in turn, also shapes demand in that the family of a patient in crisis may demand an admission, since in their experience this is the only option that can help. Third, the use of the services provided depends to a large extent upon the system turnover, or, in the case of beds for example, the average length of stay. In other words, both structural and dynamic aspects need to be considered simultaneously.

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