Establishing the service principles

The initial step refers to establishing the service principles. Although we place these as the foundation stone for planning, the explicit identification of such principles is usually excluded from the entire process. Even when values are considered, most often at an early stage of planning, they remain without consequence for three reasons. First, those involved may assume that their colleagues share common ground and that such agreement goes without saying. Second, they may tacitly acknowledge substantial differences in core values within the planning group, and reckon that better progress will be made by avoiding than by addressing these differences. Third, planners may judge that discussion about underlying values is not sufficiently important to take up scarce planning time. In our opinion all three views, although common, are mistaken and will lead to the re-emergence of disagreements later in the planning process, when value differences become displaced on to operational matters.

As mentioned above, we can distinguish two fundamentally different approaches to planning: (i) mental health service component planning, and (ii) mental health system planning. The first type of planning is segmental, in the sense that it takes the needs of individual institutions or particular types of patients one at a time without putting these needs into a general framework with the other services available in the same area. On the other hand, system planning is often population-based and aims to organize, for defined populations, a system of care that underlines the connections between different components, and the relationships with other health as well as social and private services in the same area. In other words, the system approach to planning is the practical consequence of taking a public health approach to assessing the mental health needs of a population.

The strength of the segmental approach is that it allows more specific and detailed planning for the separate service components. The weakness of this approach is that it does not provide a framework with which to understand interactions between these components. It cannot explain, for example, how the lack of provision of long-term residential care can mean that acute beds are inappropriately used for new long-term patients, leaving no capacity for acute crisis care.

Whatever the overall approach adopted, those who plan services in each local area may wish to produce an explicit statement of the principles that have been selected to guide practical action. It has become common in many organizations to frame this statement of principles within a 'mission statement' or as the 'aims and objectives', or the scope of the service. However phrased, this initial step will clearly set out the fundamental values intended to be realized by the operation of the service.

We have previously identified and defined nine principles intended to be most relevant to specialist mental health services at the local level. (5) This selection of principles, shown in B.o.x.4 with their definitions, has also been made to minimize conceptual overlapping between the nine principles, namely autonomy, continuity, effectiveness, accessibility, comprehensiveness, equity, accountability, co-ordination, and efficiency (and which, from their initials, may be termed 'the three ACEs').

Table.2 shows the relationship between the two overall models of service planning and the nine guiding principles, indicating the relative strengths of the two approaches.

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Table 2 Principles for community mental health services in relation to the strengths of the segmental and system approaches to planning

Individual facilities, planned using the segmental approach, will often attract patients from a wider geographical reference population, and therefore will reduce the ability of the service to offer a locally accessible provision to people unable to travel, or unable for other reasons to gain entry to remote resources. The 'service component' approach therefore acts to limit horizontal comprehensiveness. For instance, if the service is privately operated, as is often the case in segmentally organized services, this goal can be influenced by cost issues. In contrast, the 'system approach' tends to promote horizontal comprehensiveness, which is mainly regulated by two boundaries: the geographical catchment area definition, and the priority treatment groups defined by policy or by practice. As far as vertical comprehensiveness is concerned, the difference between the two approaches to service planning is even more pronounced. The service component approach tends to provide one type of care only, while the system approach explicitly seeks to interlink the different multiple levels of care which are delivered at any one time.

If equity is defined as the fair distribution of resources, then we consider that the service component approach is a much more limited frame of reference, in that it will attempt to distribute staff time and expertise only between patients in contact with that particular service. The system approach, by comparison, takes as the frame of reference all morbid individuals within a given geographical area or reference population, and allows explicit consideration of how patients simultaneously use different service components as parts of a larger package of care. To this extent the system view seeks to be inclusive for the needs of all those needing care, rather than only those who happen at any time to be in contact with a particular service component.

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