Nezbytné kroky reformy psychiatrické péče v ČR Cyril Höschl www.hoschl.cz National Institute of Mental Health & Charles University, 3rd Medical Faculty, Prague M NI H Praha, 11.4.2017
Co je psychiatrická péče? Nejdříve musíme vědět, co vlastně reformujeme Psychiatrická péče jako systém služeb péče o duševní zdraví, které jsou vykonávané profesionálními pracovníky, a který je ovlivněn politikou, legislativou a zdroji. Systém služeb péče o duševní zdraví se skládá ze služeb zaměřených na: Mental health prevention & promotion Early intervention Treatment (& relapse prevention) Kompetence a schopnosti profesionálních pracovníků jsou ovlivněny vzděláním Politická rozhodnutí, legislativa a investování zdrojů mohou být jen tak dobré, nakolik je dobrá evidence, která je podporuje 13.4.2017 NÁRODNÍ ÚSTAV DUŠEVNÍHO ZDRAVÍ
History of psychiatry in CEE Western influence Eastern influence Syndromological approach Psychological approach Out-patient oriented service International Classification of Mental Disorder (ICD-1999), Evidence-based medicine Stigma problems awareness and deinstitutialization Decentralised care Nozological approach Biological approach In-patient oriented service Russian school (Post-Kraepelin psychiatry) Specific methods of treatment Institutionalization Semashko Health Care System Дмитрий Крупченко 2017 N.A. Semashko
Institutional nature of Mental Health Care 1. Ambivalence: Awareness of changes necessity Stability of current system 2. Weakness of primary & community care 3. Lack of intersectoral collaborations Dlouhý, 2014
WHO Service Organization Pyramid for an Optimal Mix of Services for Mental Health Frequency of needs Quantity of services needed WHO recommendations Psychiatric services in general hospital Long stay facilities and specialised psychiatric services Community Mental health services Primary care Mental Health Services Costs Informal Community Care Self-Care
WHO Service Organization Pyramid for an Optimal Mix of Services for Mental Health Frequency of needs Psychiatric services in general hospital Quantity of current services in Eastern Europe Long stay facilities and specialised psychiatric services Community Mental health services Primary care Mental Health Services Costs Informal Community Care Self-Care
Czech mental health care system and its reform Before 1989 Biological orientation, social problems officially did not exist, people with severe mental health problems excluded into large psychiatric hospitals After 1989 Replacement of taxation based system by public health insurance Development of patient-oriented advocacy groups Increasing attention to human rights Deinstitutionalization and destigmatization major issues Slow progress, lack of enthusiasm of many stakeholders, development of community based services still limited Höschl C, Winkler P and Pěč O. (2012) The state of psychiatry in the Czech Republic. International Review of Psychiatry 24: 278-285. Dlouhy M. (2014) Mental health policy in Eastern Europe: a comparative analysis of seven mental health systems. BMC health services research 14: 42-42.
Czech mental health care system and its reform Dobřany Mental Hospital 1.200 beds
New revolutionary tool for visualization and analysis of data. Sociomaps are complex graphs that resemble a landscape. Your abilities to move in space, for which you are trained from early childhood, will help you to interpret the complex relationships encoded in Sociomap. Sociomap enables to visualize, explore and analyze the structure and dynamics of a system and to present it in a way, which is easy to understand. Bahbouh R., Höschl C.jr & QED group
Number of states: 34 Albania, Austria, Azerbaijan, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, Georgia, Germany, Greece, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Luxembourg, Malta, Moldova, Montenegro, Netherlands, Norway, Romania, Russian federation, Serbia, Slovakia, Spain, Switzerland, United kingdom, Uzbekistan Bahbouh R., Höschl C.jr & QED group
Number of states: 34 Albania, Austria, Azerbaijan, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech republic, Denmark, Estonia, Finland, Georgia, Germany, Greece, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Luxembourg, Malta, Moldova, Montenegro, Netherlands, Norway, Romania, Russian federation, Serbia, Slovakia, Spain, Switzerland, United kingdom, Uzbekistan Winkler P., Höschlová E. et al. 2013; Bahbouh R., Höschl C.jr & QED group
United kingdom Switzerland Denmark Israel Italy Norway Netherlands Belgium Spain Estonia Hungary Ireland Croatia Bosnia and Herzegovina Slovakia Moldova Albania Austria Montenegro Bulgaria Latvia Czech republic Romania Lithuania Georgia Greece Azerbaijan Malta Luxembourg Germany Mental Health Care systems across Europe Positions (distances): Mutual similarity in Community-based rehabilitation Community-based crisis care d. d.in daytime Community-based crisis care d.24hours a day Assertive outreach Home treatment Community-based early oiintervention Elevation: GDP per capita (2011) Winkler P. et al. 2013
Czech mental health care system and its reform Reform Strategy of mental health care reform published in 2013 Aims: To improve quality of life of people with mental health problems To re-structure the system of services (deinstitutionalization) Empowerment of families, inclusion into decision- and policymaking processes To develop community mental health centres To decrease stigmatisation Implementation plan being worked out Challenges: opposition, lack of leadership, limited knowledge base, limited socioeconomic data
Reformní projekty Projekt MERRPS Metodika pro Evidenci Respektující Rozvoj Psychiatrické Péče Projekt Analytická základna (snad bude?) Zatím nic (!) Projekt Destigmatizace Projekt Deinstitucionalizace Projekt Multidisciplinarita Projekty CDZ 1, 2, 3 Pracovníci Vzdělání Politika, legislativa, zdroje, evidence Služby Prevence a podpora zdraví Časná intervence Léčba lůžková & komunitní (prevence relapsu) 13.4.2017 NÁRODNÍ ÚSTAV DUŠEVNÍHO ZDRAVÍ
Nezbytné kroky Zajistit, aby reformní projekty dávaly smysl dohromady Architektura nebyla vytvořena, ad hoc vznikají různé odborné rady, poradní skupiny, diskusní skupiny atd., které nemají definovaný statut, kompetence atp. Zajistit, aby komponenty v jednotlivých projektech byly co nejvíce evidence-based a napojené na mezinárodní struktury a organizace Zatím jsou některé projekty velmi vágně definované Adresovat nové výzvy, dostat na palubu nové lidi např. nové vedení WHO (Daniel Chisholm nebyl z nějakého důvodu pozván na tento kulatý stůl) Zajistit vznik a realizaci projektů, které doposud nebyly vytvořeny Vzdělávání, prevence, Early Intervention, School Interventions, Suicide prevention atd. mnoho chybí a některé cílové skupiny nejsou vůbec podchyceny Zajistit, aby se projekty opravdu realizovaly Zajistit udržitelnost změn Podchytit hrozby Lidé jsou demotivovaní, proces trvá příliš dlouho, je netransparentní, projekty jsou vágně definované a lidem nesrozumitelné velká nejistota mezi profesionály (lékaři, sestry, komunitní pracovníci), nejsou vůbec jasné kompetence a zodpovědnosti za reformu atd. atp. 13.4.2017 NÁRODNÍ ÚSTAV DUŠEVNÍHO ZDRAVÍ
Main barriers Lack of leadership & capacity Weakness of service users and advocacy organisations Stigma among decision- and policy-makers Unawareness of changes necessity Insufficiency of finances allocation Stability & rigidity of current system
Main future directions Development of primary care and services in community Developing rehabilitation, psychotherapy, employmentassistance Addressing stigma Promoting human rights perspective Empowerment of service users Promoting evidence-based treatment & research activity
Nezbytné kroky reformy psychiatrické péče v ČR Cyril Höschl www.hoschl.cz National Institute of Mental Health & Charles University, 3rd Medical Faculty, Prague M NI H Praha, 11.4.2017