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How the goals of high quality, equity, efficiency and better care in the field of mental health can be achieved by adequate mixes of financing systems (tax, social and private health insurance and out of pocket payments, etc.) and by adequate provider payment mechanisms?
To answer these goals, REFINEMENT standardized the comparison methodologies of different systems of provision, financing and performance assessment of mental health care in European countries' mental health and social services.
The REFINEMENT project was conducted by an experienced team of mental health service researchers, health economists, public health specialists and social care experts from 9 European countries:
- University of Verona (Italy),
- Ludwig Boltzmann Gesellschaft (Austria),
- London School of Economics and Political Science (UK),
- Terveyden ja hyvinvoinnin laitos (Finland),
- Asociacion Cientifica Psicost (Spain),
- Stiftelsen Sintef (Norway),
- University of Tartu (Estonia),
- Université Paris XII - Val de Marne (France),
- and Institutul de Prognoza Economica (Romania).
Mental Health has been recognized as a key priority area and goal for Europe as stated by the European Commission in June 2008 through the publication of the European Pact on Mental Health and Well-being.
In view of this the REFINEMENT project has conducted (for a total of 36 months) the first ever comparative and comprehensive overview of links between the financing of mental health care and the outcomes of mental health services in Europe. Four bespoke, interlocking tools have been designed to provide advice on what information to collect and which questions to ask. Any mental health system will in part be influenced by the way in which it is financed, as well as the way in which service providers are paid.
These issues are dealt with by the FINCENTO tool, while the REMAST tool is used to map out the organisational structure of mental health services, both at a national and regional level and then in great detail for a smaller geographical area. Understanding the pathways of care that individuals follow within a mental health system can also help in understanding the impacts of different financial incentives and disincentives, as well as better understanding issues around continuity of care.
The REPATO tool looks at these issues. It may be a way, for instance, of identifying the extent of use of inpatient services. The level of focus on inpatient specialist care in terms of its quality and appropriateness can then be considered.
A fourth tool, REQUALIT, focuses specifically on quality issues. It consists of a detailed list of quality indicators against which the quality of care provided by a mental health system can be judged. The ability of the system to safeguard human rights and to fully engage mental health service users in decisions on care to be received can, for instance, be considered. Broader issues concerning the way in which issues such as discrimination and social exclusion are dealt with by a country can also be examined with this tool.
The four tools are contained in the frame of a Decision Support Toolkit (DST), the DST identifies some of the key questions that need to be asked in order to assess performance, and in particular how the financing and funding of a mental health system may be correlated with its organisational structure, pathways of care and quality. The DST also provides a step by step guide to developing questions, collecting information and then interpreting findings. While the information, if collected comprehensively, may seem daunting, advances in information communication technology and data processing systems will allow for more sophisticated approaches to performance assessment to be undertaken even when time and human resource availability may be tight.
European policy-makers and providers of care will be able to use the results and any subsequent analyses to understand the complexity of financing the mental health care system including primary and social care services. While we focus on performance assessment of mental health systems for adults of working age, the principles outlined here will generally be applicable for policy makers wishing to assess the performance of other types of mental health system, for instance child and adolescent mental health services. The principles and approach to data collection and analysis can also apply to other complex elements of health and social care systems, for instance looking at approaches to manage chronic physical health problems such as diabetes, poor musculoskeletal health and cardiovascular disease.
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