The public health context for psychiatric service evaluation

The strategies and methods of evaluation are constrained by the types of psychiatric services that exist in any particular area. In turn, the configuration of these services reflects the overall conceptual approach used for their planning and implementation. One such conceptual framework is the public health approach, the historical origins of which, according to Eisenberg,(8) are rooted in the work of Virchow who proposed the reform of medicine on the basis of four principles.

1. The health of the people is a matter of direct social concern.

2. Social and economic conditions have an important effect on health and disease, and these relations must be the subject of scientific investigation.

3. The measures taken to promote health and to contain disease must be social as well as medical.

4. Medical statistics will be our standard of measurement.

Therefore the public health approach is primarily concerned with the health of populations. As applied to psychiatry, it means that the mental health of individuals is integrally linked with the wider social and economic health of their communities. Moreover, a consequence of adopting a public health orientation in planning mental health care is that the service components (such as a community mental health team, an inpatient unit, or an outpatient department) are viewed not only as separate elements, but also as parts of a wider service system. Such a system aims to provide care to all those in need within an entire local population. An alternative way to plan is to provide a range of independent service components for separate patient groups according, for example, to diagnostic or financial eligibility criteria, without reference to the population-based levels of need for such services.

Therefore we can distinguish mental health system planning from mental health service component planning. The first type is not only population based but also underlines the connections between different components within the mental health service, as well as the interfaces with other forms of health and social care. By contrast, the second view is segmental, in the sense that it considers individual institutions, or particular groups of patients, one at a time, without putting these in the wider framework of the other services available in the same area.

When services are planned only as separate components, an important consequence is that the characteristics of the patients treated are not representative of all those within the local area who may be suitable for treatment. The inclusion and exclusion criteria are usually implicit. The effect of such clinical selection bias is to limit the generalizability of the results of evaluation conducted upon these segmental services and patient groups; this point is expanded upon later in this chapter.

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