Planning and resourcing specialist services

Before planning future service developments, it is crucial to assess the existing specialist services, their distribution relative to the population, their balance, and their current pattern of use. Where large asylums exist, they tend to be in poor repair, with inadequate resources for maintaining the fabric of the building, staffing, treatment, and rehabilitation. Policy needs to consider the future of such asylums which research has shown encourage institutionalization and the accumulation of significant social handicap. There is an inevitable tension between putting resources into developing a range of local services in each locality, however defined, and continuing to put adequate resources into the asylum until it can close. In essence it is necessary to provide double running costs for a period of time until there is sufficient service infrastructure in each locality so that the asylum can be closed. In practice most governments do not budget for double running costs and this leads in many countries to the existence of mental hospitals which are in a far worse state of repair than the general hospitals, with worse staffing, training, and morale. It is therefore essential for policy to address the mechanics, timescale, and resourcing of the transition period and to build in adequate monitoring of progress. (4)

From the point of view of good outcomes, people with severe mental illness should be cared for as close to home is as compatible with the health and safety of the individual and the safety of the public, in as least restrictive an environment as possible, and with due regard to their rights as a human being and respect for their dignity, religion, and culture. The precise service structure and configuration needs to be determined in the context of local needs, culture, and resources. It is particularly important to emphasize rehabilitation back into the normal pattern of daily activities of the rest of the population.

Where patients are cared for in places other than their own homes, it is essential for the government to set a system of quality assurance to ensure that some basic standards are met.(4Z>

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