Size matters - determinants of modern, community-oriented mental health services

Int. J. Environ. Res. Public Health 2014, 11, 8456-8474; doi:10.3390/ijerph110808456 International Journal of Environmental Research and Public Health ISSN 1660-4601 www.mdpi.com/journal/ijerph Article Size Matters — Determinants of Modern, Community-Oriented Mental Health Services Taina Ala-Nikkola 1,2,3,*, Sami Pirkola 1,2,4, Raija Kontio 5, Grigori Joffe 1, Maiju Pankakoski 2, Maili Malin 2, Minna Sadeniemi 2,6, Minna Kaila 3 and Kristian Wahlbeck 2 1Department of Psychiatry, University Hospital Region, Hospital District of Helsinki and Uusimaa, Välskärinkatu 12, FI-00029 HUS, Finland; E-Mails: [email protected] (S.P.); [email protected] (G.J.) 2Department of Mental Health and Substance Abuse Service, National Institute for Health and Welfare, Mannerheimintie 170, FI-00270 Helsinki, Finland; E-Mails: [email protected] (M.P.); [email protected] (M.M.); [email protected] (M.S.); [email protected] (K.W.) 3Hjelt Institute, Medical Faculty, University of Helsinki, FI-000014 Helsinki, Finland; E-Mail: [email protected] 4 School of Health Sciences, University of Tampere, Medisiinarinkatu 3, FI-33014 Tampere, Finland; E-Mail: [email protected] 5Department of Psychiatry, Hyvinkää Hospital Region, Hospital District of Helsinki and Uusimaa, Vanha Valtatie 198, FI-04500 Kellokoski, Finland; E-Mail: [email protected] 6Department of Psychiatry, Porvoo Health Care Area, Hospital District of Helsinki and Uusimaa, Kaivokatu 37, FI-06100 Porvoo, Finland; E-Mail: [email protected] *Author to whom correspondence should be addressed; E-Mail: [email protected]; Tel.: +35-850-345-8130; Fax: +35-894-716-3600. Received: 17 June 2014; in revised form: 4 August 2014 / Accepted: 8 August 2014 / Published: 19 August 2014 Abstract: Governances, structures and contents of mental health services are being reformed across countries. There is a need for data to support those changes. The aim of this study was to explore the quality, i.e., diversity and community orientation, and quantity, i.e., personnel resources, of mental health and substance abuse services (MHS) and evaluate correlation between population needs and quality and quantity of MHS. The European Service Mapping Schedule—Revised (ESMS-R) was used to classify mental health and substance abuse services in southern Finland. Municipal-level aggregate data, OPEN ACCESS Int. J. Environ. Res. Public Health 2014, 11 8457 local data on unemployment rate, length of education, age of retirement, proportion of single households, alcohol sales and a composite mental health index were used as indicators of population mental health needs. Population size correlated strongly with service diversity, explaining 84% of the variance. Personnel resources did not associate with diversity or community orientation. The indicators of mental health services need did not have the expected association with quality and quantity of services. In terms of service organization, the results may support larger population bases, at least 150,000 adult inhabitants, when aiming for higher diversity. Keywords: mental health services; community mental health services; catchment area 1. Introduction Mental health and substance abuse services (MHS, including mental health and substance abuse services, regardless of their integration or separation) are undergoing governance, structural and content reform in Finland as well as elsewhere. In Finland, municipalities are responsible for arranging public health care and social services for their residents and governmental steering is limited. Municipal health care is basically funded by taxes. For specialized health care, including specialized mental health care, municipalities form hospital districts. Finland is divided into 20 hospital districts. The primary care health centres have a gatekeeper role, and access to elective specialized care is usually by referral from primary care. As a general rule, smaller municipalities rely more heavily on the hospital district for provision of specialized mental health services, while some bigger (such as Helsinki, the capital city) municipalities tend to provide specialized mental care in their own health care organizations [1]. The autonomy of municipalities in organizing public services leads to heterogeneity between municipalities, depending on geographical area and the stage of psychiatric service reform toward community-based care [2,3]. This kind of geographical heterogeneity in provision of MHS and its implications for access to adequate treatment has been previously reported by Rocha et al. [4], who noted that in Spain heterogeneity causes individual and regional inequalities in access to adequate treatment and available resources. The MHS reform in Finland aims at patient-centered community-based outpatient services, while further limiting the use of institutional hospital-based services [5,6]. This deinstitutionalization process; i.e., restructuring and downsizing of psychiatric inpatient care, has been successful, as deemed by a decrease in suicides immediately or within one year post discharge [7]. In fact, well developed community mental health services in the municipalities have been associated with a lower level of suicides [3]. Overall, there has been an increased life expectancy for people with schizophrenia, other psychoses, mood disorders and neurotic disorders [8,9], but not for people with substance use disorders [9,10]. Currently despite the policy aim to prioritize community care, most MHS resources in southern Finland are still invested in hospital and non-hospital residential services, and low threshold outpatient services are relatively scarce [11]. Overall, both international [12] and national [3,7] data Int. J. Environ. Res. Public Health 2014, 11 8458 support the advantages, quality and effectiveness of more community-oriented, and multifaceted service structure. Current mental health policies prioritize MHS which: (1) are balanced regarding communityand hospital-based care; (2) are based on well-developed community MHS; (3) appreciate and emphasize mobility and flexibility and (4) are characterized by abundant differentiation and diversity of service types [12–14]. Countryand global-level data about MHS resources, policy and development indicate a high degree of variability of MHS systems, even in countries within the same income categories. MHS provision patterns and structures are dependent on specific local circumstances such as general health care, income level, population density and state of MHS policy development [4,15,16]. When evaluating mental health services, assessment of local services should take into account local needs and resources [17]. The European Service Mapping Schedule (ESMS) is an instrument designed to investigate MHS structures, describe their major characteristics, provision of services and resource allocation [18–20]. It aims to find key elements and benchmark references for better and more differentiated MHS development, which allows for systematic and standardized comparisons of MHS. This Finnish study is part of the nine country European REFINEMENT (REsearch on FINancing systems’ Effect on the quality of MENTal health care) project. The overarching aim of the project is to look at the relationship between different models of health care financing systems, and the extent to which mental health services can meet the goals of high quality, equity, efficiency and better long-term health outcomes [21,22]. The Finnish subproject focuses on the performance of Finnish MHS utilizing analyses of care pathways [11]. In this study we set out to analyse data on MHS service provision structure and volume with aggregate municipal-level indicators and to explore associations between needs of services and service provision. The aims were to evaluate: (1) MHS quality, using two indicators of quality: diversity and community orientation; (2) MHS quantity, using allocated personnel resources and (3) correlation between population needs and quality and quantity of MHS. 2. Methods 2.1. The Study Area The study area included three hospital districts, those of Helsinki and Uusimaa, Kymenlaakso and Etelä-Karjala, owned and governed by 56 municipalities, altogether in the southernmost part of Finland. The total population in the study area is 1.8 million people, with 1.4 million adults (aged ≥ 18 years). The study area consists of nine non-overlapping catchment areas: Länsi-Uusimaa (Area 1), Lohja (Area 2), Hyvinkää (Area 3), Porvoo (Area 4), Helsinki (Area 5), Jorvi (Area 6), Peijas (Area 7), Kymenlaakso (Area 8) and Etelä-Karjala (Area 9). All catchment areas have a general hospital. Psychiatric hospital care is to some extent integrated in the general hospitals, but many areas still have separate, free-standing psychiatric hospitals. The total adult population size varied within areas from approximately 45,000 to (Area 1) to 500,000 inhabitants (Area 5). The study area is rather representative of the whole of Finland, because it covers about 30 per cent of the total country Int. J. Environ. Res. Public Health 2014, 11 8459 population. However, the study area is much more densely populated (174 inhabitants per square kilometers) than the country in total (16 inhabitants per square kilometers). 2.2. Data Collection Data collection was performed with the revised European Service Mapping Schedule (ESMS-R) tool [23]. An earlier version of the ESMS has been used previously in Finland [3] and it has been evaluated as a valid instrument in a European context [17,24,25]. In ESMS-R, mental health services are classified into 89 different Main Types of Care (MTC). The MTC is the main descriptor of the generic care function (e.g., mobile team or acute hospital care), provided by a Basic Stable Input of Care (BSIC). In practice, BSIC is the organizational unit providing the MTC. The operational description of a BSIC is based on organization, staff, premises and target population [26]. Information for classifying the MHS was collected in 2011–2012 systematically by three researchers, who received special training for use of the ESMS-R. Coding reliability was supported by a standardized handbook [23] as well as a systematic mapping procedure, case-based mapping training and assessment of inter-rater reliability by vignettes. Data were collected using public data sources, as well as interviews with health and social care representatives of municipalities and private care providers. The mapping covers all municipalities in the study area, and includes all services within the scope of the municipalities’ obligation to arrange adult population MHS in primary care, secondary care, tertiary care level, social and substance abuse services. Only services for adults with mental health problems and substance abuse problems were included in the mapping; i.e., services for general health problems were excluded. Primary health care employees specialized in adult mental health care, such as psychiatrists, psychologists and psychiatric nurses in municipal health centres, were included. The mapped MTC were allocated to one of the six main branches of ESMS-R: (1) information for care (I); (2) accessibility to care (A); (3) self-help and voluntary help (S) (4) outpatient care (O); (5) day care (D) and (6) residential care (R) [23] (Figure 1). Figure 1. The European service mapping schedule (ESMS-R) mapping tree [23,26]. Int. J. Environ. Res. Public Health 2014, 11 8460 2.3. Measures 2.3.1. Diversity and Community Orientation The count of different MTC codes was used to indicate the diversity of services, which was considered a quality indicator. The ratio of personnel in community-based services; i.e., outpatient and day care services vs. residential care, was used to indicate the community orientation, which was the second quality indicator used. The quantity of resources was expressed as amount of personnel in full-time equivalents (FTE) per 1000 inhabitants. The community orientation of MHS was evaluated by calculating a community-based service ratio by counting FTE of outpatient (O) and organized day care services (D) and dividing the count by the residential FTE. The self-help and voluntary (S) services were not included, as they did not have any FTE resources, only voluntary personnel. 2.3.2. Mental Health Needs Several background variables were used to depict population mental health needs (Table 1). These are national and commonly used statistics that are supposed to indicate mental health needs. The Mental health index (MHI) was calculated for each catchment area using three years data on the number of suicides and suicide attempts, the number of persons eligible for special reimbursement for antipsychotic medication, and the number of persons on disability pension due to mental disorders (18–64 years old). The indicator describes through three dimensions the prevalence of mental health problems as a proportion to the population of the same age. Each of the three dimensions represents one third of the total weight of the disease group in the morbidity index. The MHI of Finland was given the value 100 and other areas or municipalities are compared with that baseline index. An MHI smaller than 100 indicate a better state of mental health than the average and a higher value indicates a worse state of mental health [27]. Adult population size was used because only adult MHS was mapped. The quantity and quality of MHS provision were expected to associate within MHI and other background variables as indicators of populations needs. Other background variables used were: years of education after primary school (education), average age of retirement, unemployment rate, ratio of single households and alcohol sales. These are established socioeconomic variables linked to mental health and were used to further explore differences in mental health needs between areas. Background information was collected from the Finnish Statistics and Indicator Bank ―Sotkanet‖ using statistics data from 2011 [28]. 2.4. Data Analysis The nonparametric tests for independent samples (Mann Whitney Test) were used to test differences between areas due to non-normal distribution and a small number of units of analysis. Spearman correlations were used to investigate the association between the different indicators of population needs and quality and quantity variables: the number of different MTC codes (diversity), total FTE per 1000 inhabitants (quantity) and community-based service FTE ratio (community orientation). Int. J. Environ. Res. Public Health 2014, 11 8461 Table 1. Background variables of catchment areas *. Catchment area Länsi-Uusimaa Lohja Hyvinkää Porvoo Helsinki Jorvi Peijas Kymen-laakso Etelä-Karjala Weighted Mean SD Finland Area number 1 2 3 4 5 6 7 8 9 Population (≥18 year) 35,316 70,192 138,973 74,079 497,814 227,605 185,984 141,085 107,612 164,295 138,626 4,202,852 Mental health index (not age adjusted) 82 84.5 72.1 73.5 83.9 65.9 78 110.8 104.7 83.4 13.1 100 Education ** 3 3.2 3.5 3.3 4.1 4.6 3.4 3 3 3.4 0.6 3.4 Average age of retirement 60.2 59 58.6 59.3 59.3 58.9 58.9 58.4 58.8 59 0.5 58.7 Unemployment % 7.2 7.1 6 7.1 7.5 5.5 8 12.2 11.8 7.8 2.4 9.4 Single households (%) 40.1 34.8 34.2 35.2 49 34.4 38.1 43.9 43.6 41.5 5.3 41.2 Alcohol, sold (100%/ltr/inhabi-tant) 8.8 8 7.3 7.2 9.4 6.3 8.1 8.6 9.4 8.3 1 8.2 * Data Statistics Finland© THL, SOTKAnet Statistics and Indicator Bank 2005–2013; ** Approximate education years (Scale 0–X) after primary school (in Finland approximaly 9 years education). Int. J. Environ. Res. Public Health 2014, 11 8462 Scatterplots were used to explore and illustrate the associations between indicators of quality and quantity of services. Linear regression modelling was used to investigate the amount of variance in service quality and quantity explained by different indicators of population mental health need. Regression models were also adjusted for background variables, one by one (data not shown). The SPSS Statistics software version 21 was used for the analyses. 3. Results 3.1. Characteristics of the Catchment Areas There were differences between the catchment areas (Table 1). The mean MHI was 82.8 (SD 13.8), indicating that in the study area as a whole, mental health needs may be lower than the national average (100). In two areas; i.e., Kymenlaakso and Etelä-Karjala (8 and 9), MHI was higher (110.8 and 104.7) than the national average. Those areas encompass old paper industry cities, which have suffered from global and national economic turmoil, also indicated by their higher than average unemployment rate. Also higher than average unemployment rates were found in the same areas (8 and 9). A lower than national average (3.4) length of education was found in five areas. The proportion of single households was higher than mean in three areas. The highest alcohol sale was located in Helsinki capital city area (5) and in Etelä-Karjala area (9). Altogether, indicators of higher level of service needs seemed to cluster in Areas 8, 9 (Kymenlaakso and Etelä-Karjala) and to some extent in Area 5 (Helsinki). 3.2. Diversity Figure 2a,b present the scatterplots and regression lines between the diversity and size of adult population of the areas and mental health index. The size of population explained 84% of the variance in service diversity, shown by the regression coefficient r2 (Figure 2a). Table 2 summarizes the collected quantity and quality data of services; number of services (BSIC), allocated resources (FTE), number of different MTCs and community orientation indicators. The association between service diversity and population size of the catchment area was significant (r = 0.86, p = 0.003 (Table 3)). There was no statistically significant association between diversity and MHI. Number of service units (BSIC) (N = 726) by main branches of ESMS-R varied widely related to size of areas (Table 2). Totally 56 different types of services (MTC) were recognized; i.e., 62% of all 89 possible types. As an example, Acute hospital care facilities (R3) are units without 24-hours physician cover in a registered hospital, and Outpatient acute non-mobile health related care (O3.1) provide specific care for a defined specific population group on a non-mobile basis [23]. The count of different services available in the catchment areas varied from 13 to 38 (mean 22.8, SD 7.5). There were no services mapped to accessibility to care (A) services which are more common in long-term disability services [26]. Information for care (I) services was found in five catchment areas corresponding to <0.5% of total FTE and 1.6% of (14/726) total number of units (BSIC). Int. J. Environ. Res. Public Health 2014, 11 8463 Figure 2. Diversity of services (MTC N = 89) association with size of population (a) and mental health index (b) (MHI national average 100). Linear regression lines and coefficients (r2) are shown. (a) (b) Int. J. Environ. Res. Public Health 2014, 11 8464 The different MTC count varied from 13 to 16 in the three smallest areas (less than 100,000 adults). Medium-sized catchment areas’ (100,000–150,000 adults) variation were 23–26 MTC. In areas with the largest population (180,000–500,000 adults) the range varied from 23 to 38 MTC. Table 2. The number of different Main type of care (MTC) * by main branch of ESMS-R (diversity), resource allocation (FTE **) and community orientation of services. Catchment area Länsi-Uusimaa Lohja Hyvinkää Porvoo Helsinki Jorvi Peijas Kymen-laakso Etelä-Karjala Total Mean SD Area number 1 2 3 4 5 6 7 8 9 Quantity of services (Number of BSIC by ESMS-R main branches and resource allocation (FTE) I Information for care - 1 - - 6 1 4 2 0 14 2.33 2.3 D Day care 6 3 10 7 29 9 10 16 16 106 11.8 7.7 S Self-help and voluntary care 4 9 24 9 29 15 11 23 18 142 15.8 8.3 O Outpatient care 6 11 19 12 55 19 22 31 19 194 21.6 14 R Residential care 7 16 41 15 72 25 30 44 20 270 30 20 Number of service units/BSIC 23 40 94 43 191 69 77 116 73 726 80.6 50 Day care (D) FTE 20.7 13 49.2 18.4 134.5 24.5 14 30 65.2 369 41.1 39 Outpatient care (O) FTE 44.6 49.3 131.9 48.2 563.9 198.7 173 128.3 90.11 1428 159 162 Residential care (R) FTE 113 179.2 396.7 130.2 983.0 252.9 283.5 397.4 176.5 2912 324 268 Total FTE 178.3 242.5 577.7 196.7 1701.4 479.1 477.5 557.7 331.7 4741 527 466 Total FTE/1000 adults 5.1 3.5 4.2 2.7 3.4 2.1 2.6 4.0 3.1 3.2 3.4 0.7 Quality of services (Number of different MTC by ESMS-R main branches (diversity) and community orientation) Number of different MTC 16 16 26 13 38 27 23 24 23 56 22.8 7.5 Community-based services =FTE D + O 65.3 62.3 181.1 66.58 420 223.2 187 158.3 155.3 1519 164 101 Community-based services =FTE D + O/1000 adult 1.85 0.89 1.3 0.9 0.84 0.98 1.01 1.12 1.44 1.03 1.13 0.3 Community orientation ratio *** 0.58 0.35 0.46 0.51 0.43 0.88 0.66 0.4 0.88 0.52 0.58 0.2 * European Service Mapping Schedule-Revised mapping tree’s main branch codes [23]: Accessibility (not found), Information for care, Day care, Self-help and voluntary care, Outpatient care and Residential care are main branches of Main types of Care (MTC). Totally 89 different MTC are possible on ESMS-R [23]; ** FTE, allocated full-time equivalents as personnel resources (located on units/ BSIC) on D, O and R services; *** Community orientation= community-based care (D+O) FTE/ residential care FTE ratio. Int. J. Environ. Res. Public Health 2014, 11 8471 bias in the count of MTC, if units in smaller catchment areas more often provide more than one type of care. Individual units may also be able to differentiate and offer diversity of services, in case of well-trained teams. 5. Conclusions and Recommendations This study demonstrates that the size of catchment area enables increased MHS diversity, which appears to be non-dependent on per capita personnel resources in the services. In our urban and semi-urban public service setting, large differences in community orientation and total allocated staff resources do not seem to be determined by service needs. A recommendation could be that areas with low community ratio continue to reallocate resources to community-oriented services and reduce residential care. Diversity, on the other hand, may possibly require large population bases—in this study up to at least 150,000 inhabitants, but possibly even up to 500,000. Acknowledgements The research leading to these results has received funding from the European Union Seventh Framework Programme under grant agreement n° 261459 (REFINEMENT Project). The contents of this publication are the sole responsibility of the REFINEMENT Group and can in no way be taken to reflect the views of the European Union. This research has received funding from Helsinki and Uusimaa Hospital Districts Research and Development grants. Matthew Grainger has kindly revised the English language of this article. Author Contributions Taina Ala-Nikkola: Study conception, design, analysis and interpretation of data and drafting manuscript, Sami Pirkola and Kristian Wahlbeck: Study conception, design, analysis and critical revision. Raija Kontio; Grigori Joffe; Maili Malin; Minna Kaila; Minna Sadeniemi: Critical revision. Maiju Pankakoski: Statistical analysis and Critical revision. Conflicts of Interest The authors declare no conflicts of interest. References 1. Lehtinen, V.; Taipale, V.; Wahlbeck, K.; Pirkola, S. Mental Health Work and Psychiatric Care. In Health in Finland; Koskinen, S., Aromaa, A., Huttunen, J., Teperi, J., Eds.; KTL, Stakes: Helsinki, Finland, 2006. 2. Harjajärvi, M.; Pirkola, S.; Wahlbeck, K. Aikuisten Mielenterveyspalvelut Muutoksessa. In Merttu — Tutkimuksen Palvelukatsaus, Acta No. 187; Kuntaliitto: Helsinki, Finland, 2006. 3. Pirkola, S.; Sund, R.; Sailas, E.; Wahlbeck, K. Community mental-health services and suicide rate in Finland: A nationwide small-area analysis. 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