Letters

Published: 30/09/2004, Volume II4, No. 5925 Page 25

Italy's mental health services are superior to ours on everything from training to time spent with clients. John Mahoney thinks we can close the gap

Some years ago I spent a short time working in mental health services in Trieste, an industrial city in northern Italy. Trieste has developed what I would consider an extremely comprehensive mental healthcare system.

When I visited again recently with a group of clinicians, managers and service users from English mental health services, I was equally impressed. Trieste has one of the lowest rates of compulsory admission anywhere in the Western world. In fact, they consider a compulsory admission as a failure of the service.

Services in Trieste work in areas with a population of approximately 60,000. Each area has local inpatient beds, a broad range of accommodation and day services and community mental health teams that operate from 8am-8pm seven days a week. There is the capacity to respond to crises around the clock and provide individualised care packages to those most in need.

Every area also has programmes providing work for people with mental illness.Mental health services allocate up to 5 per cent of their budget for grants to local employers to provide training for people with mental illness.

Within services themselves, well over 80 per cent of staff time is spent in direct client contact. The administrative systems used to record and monitor client progress are simple, yet extremely effective. For example, the local mental health team records any significant concerns about clients in a diary and meets every lunchtime to review the diary and arrange who will go out to visit clients.

The group from England was struck by the stark contrast of this simple approach to the increasingly cluttered and overly bureaucratic care planning system it has become used to.

Only about 15 per cent of qualified staff time in inpatient units in England is spent in direct contact with service users. The situation is only slightly better in community services. There, about 50 per cent of qualified staff 's time is spent on completing assessments and the form-filling involved in the various aspects of the care programme approach (CPA) process - a situation I am sure that ministers never intended.

The CPA, introduced in 1991, requires that everyone seen by specialist mental health services should have a risk assessment and care plan drawn up and be allocated a named mental health worker to co-ordinate their care and regularly review their needs. The principles are sound, but implementation is problematic.

Mental health professionals, including most psychiatrists, tell us that implementing CPA in its current form is a huge waste of their time and can in fact be a significant barrier to good patient care.

What's really going to change the experience of mental health service users in this country is freeing up front line staff so they can provide the quality and depth of care that they would like to.

By streamlining CPA and performance management I think we could release much of the£2bn of staff time currently invested in bureaucracy and effectively double service user contact.

Let's really shift the balance of power to the front line.

John Mahoney is director of the National Institute of Mental Health in England (eastern region).