The economic consequences of deinstitutionalisation of mental health services: lessons from a systematic review of European experience

Abstract

What is known about this topic Understanding the economic consequences of deinstitutionalisation is fundamentally important. What this paper adds dThe evidence base on the economics of deinstitutionalisation is modest and uneven across countries. There are strong economic arguments for closing psychiatric hospitals in favour of community-based arrangements, but rebalancing care will not generate great savings. There are also many challenges. Decision-makers should plan a dynamic community-based system to match the needs of people moving from institutions, and must take the long view. AbstractMany European mental health systems are undergoing change as community-centred care replaces large-scale institutions. We review empirical evidence from three countries (UK, Germany, Italy) that have made good progress with this rebalancing of care. We focus particularly on the economic consequences of deinstitutionalisation. A systematic literature review was conducted using a broad search strategy in accordance with established guidelines. We searched the International Bibliography of the Social Sciences, Health Management Information Consortium, British Nursing Index and PUBMED ⁄ Medline to 2008. The on-line search was supplemented by advice and assistance from contacts with government departments, European Commission, professional networks and known local experts. Community-based models of care are not inherently more costly than institutions, once account is taken of individuals' needs and the quality of care. New community-based care arrangements could be more expensive than long-stay hospital care but may still be seen as more cost-effective because, when properly set up and managed, they deliver better outcomes. Understanding the economic consequences of deinstitutionalisation is fundamental to success. Local stakeholders and budget controllers need to be aware of the underlying policy and operational plan. Joint planning and commissioning or devolving certain powers and responsibilities to care managers may aid development of effective and cost-effective care. People's needs, preferences and circumstances vary, and so their service requirements and support costs also vary, opening up the possibility for purposive targeting of services on needs to improve the ability of a care system to improve well-being from constrained resources. As the institutional ⁄ community balance shifts, strategic planning should also ensure that the new care arrangements address the specific contexts of different patient groups. Decision-makers have to plan a dynamic communitybased system to match the needs of people moving from institutions, and must take the long view.

Costs and cost–effectiveness of HIV community services: quantity and quality of studies published 1986–2011

“…Conversely, the view that comprehensive community services are necessarily more expensive may not be true either: "Community-based models of care are not inherently more costly than institutions, once account is taken of individuals' needs and the quality of care. New community-based care arrangements could be more expensive than longstay hospital care but may still be seen as more cost effective because, when properly set up and managed, they deliver better outcomes" [93] .…”

Insights from the clinical assurance of service reconfiguration in the NHS: the drivers of reconfiguration and the evidence that underpins it – a mixed-methods study

“…188 Moving services into the community does not generate cost savings, although these services may be more cost-effective in the long term. [188][189][190] The quality of care provided by community mental health teams appears to be closely related to levels of expenditure and 'community-based models of care are largely equivalent in cost to the services that they replace'. 188 This transformation in service delivery led to a reduction in bed numbers of over 60% between 1987 and 2010; 189 however, there was little evidence supporting the centralisation or colocation of inpatient mental health services on the basis of cost.…”

Health economic evaluation of community-based psychiatric interventions

“…Die ersten systematischen Konzepte einer gesundheitsökonomischen Analyse psychiatrischer Reformprozesse wurden während der 1980er Jahre in England entwickelt [18]. Eingebettet waren diese Konzepte in die Arbeiten des Teams for the Assessment of Psychiatric Services (TAPS) [20], welches 1985 gegründet wurde, um die Auswirkungen der Schließung zweier psychiatrischer Großkrankenhäuser wissenschaftlich zu untersuchen.…”

“…Der Beitrag erhebt dabei nicht den Anspruch auf Vollständigkeit im Sinne eines systematischen Reviews, greift aber soweit wie möglich auf Ergebnisse aktueller systematischer Übersichtsarbeiten zurück [18,19,28].…”