Factors in the Local Area

• Significant geographical structures

• Inherent community structures

• Presence of building sites or development

Source: Modified from Strathdee and Thornicroft ( )

There are also disadvantages to planning mental health services at the local level. It may not be cost effective to develop expertise and facilities for low prevalence disorders, which can receive better quality care at a higher regional or supraregional level. For example, services for eating disorders or for forensic patients may be better provided in specialist centres at the regional level to the populations of combined local catchment areas. On the other hand, where such subspecialist services exist there may be a secondary effect that local catchment areas lose expertise to treat such conditions.

Another concern related to the provision of local services is that the quality and capacity of services in different, even adjoining, local areas may vary enormously. Such inequalities are best addressed a priori by co-ordinating the planning of local services at the regional or country level, and by methods of updating the distribution of health resources from time to time, explicitly taking into account not only overall population needs, but also other specific local factors, such as the composition of each local service in terms of case load and severity.

An additional issue is that local catchment area services may offer less freedom of choice to patients and referrers. As far as patients are concerned this is an overemphasized problem, since a well-organized local service can usually respect the wish of a patient to change clinician by a reallocation within the same clinical team. In addition, it is occasionally necessary deliberately to refer a patient to a team serving another catchment area—for example, if the patient is a member of staff in the local health services, or if a complex family includes more than one patient, and treatment will be clarified by providing distinct treatment to each patient in separate settings. In this case, catchment area boundaries are better seen as somewhat fluid and pliable rather than as rigid and insurmountable.

A further local concern is the degree to which the boundaries of the key agencies that deliver services to the mentally ill are coincident. The three most important boundaries are those for the mental health services, for primary health-care services, and for social services. The main point is that most organizational issues become far easier if these boundaries are coterminous. In terms of both planning and research, it is invaluable to have geographically defined service catchment areas which exactly coincide with local government and census boundaries, so that the relevant base population data can be easily obtained.

On a more cautionary note, in some particular areas the local level, as we conceptualize it here, may not exist in terms of the organization of services. Most European countries have an administrative infrastructure that organizes health, social, and other public services for defined geographical areas. On the other hand, health systems with a greater degree of deregulation, such as seen in most parts of the United States, may more weakly reflect the public health approach, without which a meaningful and efficient integration of services, which we consider to be the central purpose of the local level, becomes extremely difficult to achieve. For the reasons given in this chapter, we are drawn to the conclusion that locality is the central organizing theme for the efficient planning, organization, and delivery of mental health treatment and care.

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