CONVERGENCES AND DIVERSITY IN HEALTH POLICY AND PRACTICE IN EUROPE
SMT Sponsor: Dr Sandra Payne / Author: Teresa OwenDate: 14/02/06 / Version: 4
For SMT on: 23/05/06 / Approved at SMT
Summary: This report summarises the proceedings of a conference on Mental Health and the Promotion of Well Being in France and Wales, held on 11th & 12th October 2005 in Wrexham.
It was the latest in a series of exchanges between the National School of Public Health in Rennes, and representatives of the health and social care community in Wales, hosted by the NPHS.
SMT is asked to note the report, and to support the ongoing link with Rennes.
Relevant Previous SMT Papers: Comparing Public Health Policy: Lessons from Brittany and Wales Ref no. SMT 06-05 SP1 VI / Ref. No: SMT 05-06 SP1
Proposed Publication/Distribution if Approved:
· NPHS E-bulletin
· Attendees at the conference
CONVERGENCES AND DIVERSITY IN HEALTH POLICY AND PRACTICE IN EUROPE
Mental Health and the
Promotion of Well Being
in France and Wales.
11th & 12th October 2005
Background
The National Public Health Service (NPHS) for Wales and the Ecole Nationale de la Santé Publique (ENSP), Rennes maintain a link established initially back in the late 1990’s. This link has resulted in an ongoing programme of annual exchange visits between the 2 regions.
In 2005, a visiting team from Rennes visited the Wrexham Medical Institute to discuss mental health and the promotion of well being from a French and Welsh perspective. This report details highlights of the lively and informative discussions, both philosophical and practical, and suggests possible next steps for further developing the Welsh/French link. The presentations are summarised below and it should be noted that where possible on day one, presentations were paired – resulting in a menu of Welsh and French delights!
In addition, the report contains:
· A proposal for collaboration and cooperation put forward by the ENSP side (Appendix I)
· The evaluation results (Appendix II)
· The list of participants from Wales and France (Appendix III)
· The programme for the two days (Appendix IV).
Purpose of Visit
To explore the similarities and differences in Mental Health practice between France and Wales.
Highlights from the presentations on the 11th October 2005
Peter Stevenson, Local Public Health Director, Wrexham, welcomed guests from both France and Wales to the Medical Institute in Wrexham. He set the scene by summarising the nature of the ongoing links between the two regions, and the schedule for the 2 days consisting of presentations, discussions and informal networking on the theme of mental health and well-being. Electronic e-mail address lists were also shared with participants to encourage further networking. Peter Stevenson thanked all those involved with the organisation of the events. Particular thanks were given to Jeff Evans, Director of the Institute of Health Studies, North East Wales Institute (NEWI) who was acting as joint chairperson for the two day event.
Presentation 1: Introduction and Overview of Mental Health and Mental Health Services Including NSF Strategy, Mental Health Action Plan and the Mental Health Profile for Wales
Phil Chick, Mental Health Development Manager/Director of Mental Health (NPHS/WAG (Welsh Assembly Government))
Phil Chick provided a brief profile of the general health status of the people of Wales. He highlighted some of the major challenges ahead including the ageing profile of the population and the high levels of limiting long term illness. He then provided an overview of mental health and mental health services in Wales. This was put into context with an overview of the changing mental health policy in Wales (and the UK), alongside the historical context. In chronological order, Phil started with a description of the 1950’s where public concern started to focus on conditions in institutions and emergent new therapies. The introduction of the 2001 mental health strategy in Wales was also described, based on a vision of equality of provision across Wales and both effective and efficient services. By 2003 an Adult Mental Health National Service Framework was in place based on 8 standards and 44 key actions.
The excellent timing of the current conference was also highlighted, since the new revised National Service Framework (NSF) for adult mental health in Wales, entitled ‘Raising the Standard’ had been launched the previous day, the 10th October, Mental Health Day 2005. (A document which reiterates the standards and provides an action plan for the next 10 years across Wales). The rationale behind the NSF review was also discussed, and was a consequence of:
· the lack of clear priorities for the service,
· numerous relevant policies, reports and documents such as the ‘Wanless review’ and ‘Designed for Life’
· changes to the NHS mental health commissioning processes, and
· a desire to introduce a better patient pathway from GP to hospital.
The “Mental Health Action Plan” was highlighted as a key development, led by the WAG with support from the NPHS. Also noted was the NPHS development of a number of evidence based policies for WAG (personality disorder framework, an eating disorder model and a suicide prevention paper); and also a mental health profile which will be an important development for mental health services in Wales and as such will be a ‘live’ document in need of constant updating.
During the question and answer session, the discussion focused on the new targets for mental health services in Wales as set out in the updated NSF. It was suggested that there is still a ‘long way to go’, and that the service continues to be under pressure. Mr Chick also noted that since mental health was now regarded as a genuine priority, then there should be more action and mobilisation in parallel with a more rigorous quest for ‘added value’.
Presentation 2: Overview of French Mental Health Services with Special Reference to Suicide and Health Inequalities
Alain Jourdain, Senior Lecturer in Health and Social Policy and Planning, National School of Public Health, Rennes; and Gwenola Levasseur, Professor in General Practice, Faculty of Medicine, University of Rennes.
Alain Jourdain provided an historical overview of mental health services and issues in France since the 2nd World War, highlighting the 1970’s as a time of debate on disability care and 1990, 1996 and 2003 as times of change with numerous hospital reforms. He also compared the French mental health resources with other European countries (Germany, Italy, and Belgium) and suggested that on the whole the French situation was relatively good for the professionals but that the service users did not fare so well. In terms of psychiatric services, the emphasis in France tends towards therapy with less focus placed on drugs and drug therapy.
The current data on mental health and well being across Europe was also summarised:
· Positive mental health (SF36) - better in Spain and Netherlands
- not so good in France and Italy
· Trends in male suicides - rate is decreasing in France
· Sale of antidepressants - high level in France
· Alcohol consumption - high but decreasing
Gwenola Levasseur went on to discuss mental health care in the general practice setting at the current time. She described the General Practitioners (GPs) as the first step onto the care pathway, but noted the problems with the current pathway, such as the number of depressive conditions not being recognised as such and diagnostic tools not used very much. She also highlighted the tension at the interface between GPs and Specialists which resulted from geographical inequalities, inadequate co-ordination and the blurred role boundaries.
The mental health plan for France and the current situation were also described. Here there was only a weak tendency to refer patients onwards appropriately, a lack of participation in mental health care, and inequalities in psychological service availability.
The Mental Health Plan was launched in June 2005 and consisted of both information and plans based on 8 domains.
Version: 4 / Date: 14.2.06 / Status: FINALAuthor: Teresa Owen / Page: 1 of 24
National Public Health Service for Wales / Convergences and Diversity in Health Policy and Practice in Europe
(1) Services
(2) Social care
(3) Patient and family
(4) Training of professionals
(5) Quality
(6) Information services
(7) Clinical research
(8) Specific programmes
Version: 4 / Date: 14.2.06 / Status: FINALAuthor: Teresa Owen / Page: 1 of 24
National Public Health Service for Wales / Convergences and Diversity in Health Policy and Practice in Europe
The lively question and answer session centred on 2 main issues:
· The number of beds/institutions in France and Wales – This proved interesting as crude data on bed numbers for mental health patients was shared, highlighting a five to six times higher number of beds in France, and all were in agreement that this was possibly an area for further exploration using real data and comparable statistics. The participants reflected on the maturity of the mental health services in the two countries.
· The risk issue – The differences in policy drivers across the two countries were shared and a consensus that Wales’ policies are currently driven by ‘risk aversion’, whereas in France, risk is not such a big issue.
Other areas discussed in this session included the users’ perspective in both countries, and the care pathway approach.
Presentation 3: Mental Health Promotion and Prevention
Jackie James, Principal Public Health Development Specialist, National Public Health Service for Wales
Jackie James started by providing an alternative title for her presentation: ‘Promoting mental health and well being in Wales – strategies, structures and context’. She went on to discuss the ‘Ottowa’ Charter and the central nature of mental health and well being, noting that if we have no mental health, then we have no health – and this concept applies at both an individual and population level.
Next she described the current agenda in Wales where mental health is seen very positively, and where the current public health approach in Wales aims to tackle the root causes. There is a need to improve everyone’s health i.e. a public health approach by decreasing risk factors and increasing protective factors. These can occur at 3 levels:
(1) Individual level
(2) Societal level
(3) Structural level
In terms of the strategic context in Wales, Jackie described the:
· Numerous strategies/papers (which have appeared since devolution) which have tended to stress the positive aspects of Wales.
· HSCWB (Health, Social Care and Well Being) Strategies – where health boards and local authorities come together with a partnership board, to address local issues.
· The role of the NPHS – established in 2003 as a national service but deployed across counties to improve the health agenda.
· Health Challenge Wales – a ‘branding’ used by the Welsh Assembly Government to increase the profile of ‘improving health’.
Some of the NPHS activities were described next, including the numerous generic initiatives which may support the mental health agenda ‘coincidently’. The Welsh Assembly Government mental health promotion action plan was being devised with support from the NPHS, based on a review of the evidence base for effectiveness. The NPHS were also considering drafting some ‘How to’ guides relating to mental health promotion issues.
The subsequent question and answer session focused on the ambitious nature of the activities and the clear need for ‘joined’ up approaches, better networking and mapping of current activity. In terms of action, local government needs to be active, and the WLGA (Welsh Local Government Association) has shown initial interest in this area.
Presentation 4: Promoting Mental Health Well Being in France
Jeanine Pommier, Doctor and Lecturer in Health Promotion, National School of Public Health, Rennes.
In a thought-provoking presentation, Jeanine Pommier used some interesting black and white slides to emphasise the lack of visibility of mental health promotion in France at the current time. She described the current situation where mental health is still mainly about the absence of mental illness and where the treatment of mental illness is still the priority. Therefore, preventative interventions with groups at high risk were not highly developed nor prioritised.
Jeanine then introduced the notion of ‘mal-être’, which is often discussed in France. Although not directly translatable she described it as feeling unwell, mental health strain or social distress. She highlighted 4 main issues with ‘mal-être’:
(1) No structure to deal with it
(2) What do you do for people who are suffering but have no illness
(3) Psychiatrists only focus on the illness
(4) Social workers try to help but see it as someone else’s role – but whom?
Therefore the new French mental health agenda is trying to deal with the problem of ‘mal-être’.
The current mental health programmes in France were also described, but the scarcity of national programmes was highlighted. Most activities happening at a regional level (e.g. the regions can decide on their own priorities/programmes and there is no global approach). It is the NGOs who have the most positive mental health approach; but unfortunately these interventions do not always match up with the regional priorities. Meanwhile the lay sector tends to concentrate on mental illness and not on positive mental health.
Four hypotheses were put forward for the current lack of health promotion in the field of mental health:
(1) Health promotion may not be a well understood concept (In France, the emphasis is on health education, not health promotion)
(2) Capacity issues in mental health promotion
(3) Mental health promotion had not shown benefits
(4) The role of mental health professionals in the ‘promotion’ aspect was not sufficient.
Jeanine finished by highlighting the ‘positive’ approach now required in France, and already underway. She noted that improvements in housing and workplace policies were all helping the mental health agenda (perhaps unknowingly), and therefore public health input was timely.
The varied question and answer session started by focussing on the Ottowa charter and the more recent Bangkok charter on health promotion, which focused on the importance of government level interventions, the need for a raised awareness by the private sector of the impact on health, and a general raising of awareness regarding health policies. The discussion then moved on to the ways to get other sectors/individuals onboard the well being agenda and the need for a greater ‘win-win’ approach by all involved, and a need for both top down and bottom up approaches to improving health. There was also a discourse around the long term benefits of health promotion and prevention activities, and then the need for better definitions of health and illness and the need for stabilisation within mental health systems.