Mental health services as a hydraulic system

For the reasons we have indicated in the previous section, we prefer the system to the service component (segmental) approach to planning. One useful metaphor for visualizing the system approach is to see a mental health service in hydraulic terms. In other words, we can conceive of the way mental health services as a whole operate as, in some ways, similar to a closed system containing fluid, such as a central heating system. In these terms we can draw parallels between the fixed 'pressure of morbidity' and the water pressure, between the flows of patients between the different service components and the flow of water between the chambers of the fluid system, and the effects in terms of back-pressure of closing or restricting access to any one key compartment.

We therefore argue that the totality of mental health service components should be considered as a series of interrelated elements, in which the behaviour of each affects (directly or indirectly) all the others. Such a view allows us to speak of the volume and the capacity of components and of the whole system (for both under-and overcapacity), to calculate rates of flow between components, to build in control taps and safety valves for periods of expected and unexpected excess pressure, and to make allowance for overflow capacity in times of excess volume, for the 'leakage' of some patients out the system (when patients may be inappropriately lost to contact with services). Such a metaphor also allows us to consider the need for routine and emergency maintenance to avoid system breakdowns, and to build in sentinel events or alarm systems to warn of incipient system failures. While not wishing to overstretch this parallel, we do find that such a view helps to illuminate links between service components.

This hydraulic model can produce a more balanced consideration of questions, which at first sight require a component-level answer, such as 'how many beds?'(see above and Wing(21i). If a local mental health service usually has all its beds fully or overoccupied, and has great difficulty identifying beds for patients needing admission, a response framed in terms of service components alone will simply point to the need for more beds or more efficient use of current beds. A system view, by comparison, would take account of flows of patients into and out of beds, and the thresholds and delays for such transitions, and may point to the need to establish more highly staffed long-term hostels for long-term disabled patients who may be inappropriately placed in acute psychiatric beds.

Our emphasis in this chapter has been on the primacy of the local level within the geographical dimension of the matrix model, (D and leads us to make explicit that the work of mental health services is more similar to primary care than most other specialist health services. This is so because what they have in common is not only a responsibility for a given (and usually geographically defined) patient population, but also a longitudinal perspective in assessing and treating patients (which hospital specialists with a typically cross-sectional or episodic approach will be unable to develop). Moreover, they will both adopt a clinical perspective that regards treatment and rehabilitation as a continuum rather than as conceptually and practically distinct. As some other areas of medicine, such as rheumatology, metabolic diseases, or geriatrics, develop systems of service for patients with chronic or relapsing and remitting conditions, we expect that these skills will become more widespread in future.

Finally, our focus in this chapter has been upon the planning and provision of mental health services for a local community. We have described methods to establish systems for delivering effective treatment and care. An important distinction is necessary between these systems as vehicles for treatment delivery and the active treatments themselves. A properly planned system of care is only the envelope within which appropriate interventions, as described elsewhere in this book, can be efficiently offered to patients.

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