Definitions of Nine Principles for Planning Mental Health Services the Three ACEs

1. Autonomy is 'a patient characteristic consisting of the ability to make independent decisions and choices, despite the presence of symptoms or disabilities.' Services should aim to promote autonomy by the delivery of effective treatment and care.

2. Continuity is the ability of the relevant services to offer interventions, at the patient or at the local level, (i) which refers to the coherence of interventions over a shorter time period, both within and between teams (cross-sectional continuity), or (ii) which are an uninterrupted series of contacts over a longer time period (longitudinal continuity).

3. Effectiveness at the patient level is 'the proven, intended benefits of treatments provided in real life situations.' At the local level, it is 'the proven, intended benefits of services provided in real life situations'.

4. Accessibility is 'a service characteristic, experienced by users and their carers, which enables them to receive care where and when it is needed'.

5. Comprehensiveness is 'a service characteristic with two dimensions. By horizontal comprehensiveness we mean how far a service extends across the whole range of severity of mental illnesses, and across a wide range of patient characteristics. By vertical comprehensiveness we mean the availability of the basic components of care, and their use by prioritised groups of patients.

6. Equity is 'the fair distribution of resources.' The rationale used to prioritise between competing needs, and the methods used to calculate the allocation of resources, should be made explicit.

7. Accountability is 'a function which consists of complex, dynamic relationships between mental health services and patients, their families and the wider public, who all have legitimate expectations of how the service should act responsibly'.

8. Co-ordination is 'a service characteristic which is manifested by coherent treatment plans for individual patients. Each plan should have clear goals and should include interventions which are needed and effective: no more and no less. Cross-sectional co-ordination is the co-ordination of information and services within an episode of care [both within and between services], as opposed to longitudinal co-ordination, which refers to the interlinkages between staff and between agencies over a longer period of treatment, often spanning several episodes'.

9. Efficiency is 'a service characteristic, which minimises the inputs needed to achieve a given level of outcomes, or which maximises the outcomes for a given level of inputs'.

In our view the system approach also has advantages in terms of accountability, which will be shaped by the information available to patients and their consequent expectations of the service. While both the service component and the system views can allow lines of accountability to individual patients to develop, only the latter also allows the possibility of a wider accountability to be given to a population as a whole.

Co-ordination is the primary intended advantage of the system over the service component approach. In our view, the degree to which this principle is enacted makes the biggest difference to the results of planning. Planning on the basis of service components alone always runs the risk of fixing one local difficulty at the price of displacing it to another part of the system—for example, the question of where patients with personality disorders are seen.

In parallel, there may be considerable gains for efficiency in that a system view can take account of any duplication between services, and can also seek to ensure that the most efficient service inputs can be given to patients—for example, more appropriate and less expensive supported residential care for disabled and longer-term patients, rather than inefficient placements in acute inpatient units. In this case a distinction needs to be recognized between the efficiency of individual service components, for example in terms of fast patient turnover, and efficiency of the system as a whole, which may best be served by longer lengths of stay in some forms of residential care to reduce the likelihood of expensive readmission to hospital.

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Breaking Bulimia

We have all been there: turning to the refrigerator if feeling lonely or bored or indulging in seconds or thirds if strained. But if you suffer from bulimia, the from time to time urge to overeat is more like an obsession.

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