Mental health represents a major challenge for the national health care system. Broadly speaking, more than 10% of the French population (i.e. 8 million insured people) are affected, with this diverse group covering both patients suffering from psychiatric conditions (2.5 million insured people) and those taking long-term psychotropic treatment (5.6 million insured persons). In total, more than one GDP point (22 billion euros) was allocated in 2019 to this type of care, far ahead of cancer and cardiovascular diseases.
Out of the 2.5 million insured people suffering from psychiatric conditions, most received follow-up care as outpatients (2.1 million patients), while 420,000 patients were treated in hospital on a full- or part-time basis. These patients treated in hospital are followed up in public or private for-profit or not-for-profit organizations.
Analysis of the stakeholders in hospital psychiatric practice highlights the significant burden of public hospitalization.
Despite a slight decrease in its capacity since the beginning of the decade, the public sector provides three-quarters of this treatment. This major stakeholder comprises three distinct components, which are not particularly well organized. The public institutions of mental health (EPSMs), established as a result of the law of 1838 which made it obligatory for each département (“départements” are second-tier administrative subdivisions of France, below the regions) to have an insane asylum, represented two-thirds of public hospitalization beds in 2019. The remaining third of the capacity is split between integrated psychiatric services within general hospitals and psychiatric departments within university hospitals (CHU). Lastly, in addition to these purely public capacities, there are non-profit private health institutions (ESPIC) with smaller capacities (nearly 13,000 beds and sites, including all types of care), whose operating and financing methods are largely similar to those of public establishments.
Expanding capacity in the private for-profit sector is focused on full-time hospitalization of patients with less serious conditions than those treated in the public sector. This recent expansion of capacity in the private for-profit sector, which is still a minority player, has triggered a shift in the concentration of organizations within three groups.
Although hospital practice is essentially provided by public institutions, this is almost exclusively the case for the continuity of care and involuntary treatment (IT), thus causing major organizational tensions.
This situation is the result of the discrepancy between the medical and care resources crisis – the resolution of which calls for measures to make the roles more attractive and retain staff, particularly in the field of child psychiatry – and the growth in the volume of active patient cases specific to emergencies and IT. However, the innovative cooperation between the public and private sectors seen in some areas indicates a sharing of responsibilities that the mission advocates and should be more routinely encouraged when the healthcare authorization system is reformed.
The healthcare authorizations reform, for which the mission expects the publication of regulations before the end of 2022, could be supplemented by an option given to the Regional Health Agencies (ARS) to make the granting or renewal of an authorization conditional on participation in care activities that are in short supply in the territory, as specified on a national or regional list. This new authorization system could make all the stakeholders holding an authorization contribute to the treatment service. This reform could also add more value by defining minimum standards for non-hospital care.
Emergency departments are a key point of initial access to psychiatric treatment, but suffer from a lack of staff resources, which is compounded in many areas by a lack of strategic and operational regulation. It would therefore seem appropriate to start work on the planning of psychiatric emergency departments in the next Regional Health Projects (PRS). In addition, in very heavily populated cities or départements, the mission suggests identifying the department likely to be appointed by the ARS to undertake operational regulation. Lastly, in order to facilitate the provision of out-of-hours care, the mission encourages collaboration between private practitioners and emergency services.
With regard to IT, something that distinguishes psychiatry from other medical specialties, the mission notes that this is a hospital admission route for one in three patients. The assumption that this route will be used to overcome difficulties accessing treatment should be assessed. It is therefore recommended that a dedicated mission conduct territorial analysis of the determining factors of IC (context of initiating it, precise methods of care, patients involved, etc.).
As a contributor to the backlog of active patient cases, IC also constitutes an acute point of tension for the medical community. The surrounding legal framework, which regularly evolves in order to reconcile the need to provide care that respects constitutionally guaranteed rights and freedoms, comes with extra administrative tasks that are sometimes perceived by the medical community as a sign of mistrust in their practice. During its investigations, the mission noticed a wide variety in the layout of isolation rooms. It suggests, as recommended by the Controller-General of Places of Deprivation of Liberty (CGLPL) in 2019, and before the reform of authorizations in psychiatry, to define precise specifications in order to protect the rights of patients and healthcare professionals. The mission also observed fairly widespread use of CCTV (closed-circuit television) devices in isolation rooms and, on one occasion, in a standard hospital room. As the law stands, the use of these devices does not comply with constitutional and conventional case law. In the present case, the mission communicated its observations to the relevant regional health agency (ARS) so that this practice could be stopped immediately, which has since been done. Beyond this situation, the mission thinks that a distinction should be made between the case of isolation rooms and that of standard rooms. In the first instance, it recommends initiating a legal assessment in the near future to determine whether it is possible to install CCTV in these rooms, and if so, the statutory provisions necessary to reconcile this practice while respecting the fundamental rights and freedoms of patients. With regard to standard hospital rooms, the mission recommends that the ARS and all the directors of the institutions be reminded immediately that installing CCTV systems in these rooms is not allowed.
Consequently, pending the reform of authorizations which will clarify the technical conditions of involuntary treatment and recourse to isolation, it seems essential that clear information be given to the ARS and to health institutions in order to put an end to possible illegal practices, in particular for patients in voluntary treatment.
Despite France placing in the top half of OECD countries in terms of the number of beds and psychiatrists, these capacities should not conceal the genuine difficulties in accessing psychiatric and somatic treatment.
There are three factors, which are cumulative in certain regions, that contribute to this situation : insufficient gradation of treatment services, a lack of treatment capacity before and after hospitalization, and the availability of a model for allocating resources that no longer aligns with the healthcare needs of territories.
Firstly, and given the impact of current inequalities in terms of lost opportunities for patients, the mission considers that expanding the gradation system of care is a priority. To this end, it recommends reducing the time it takes for patients to gain access to treatment, and creating specifications for the medico-psychological centers (CMPs) setting out the technical conditions in terms of opening hours, holding walk-in clinics and referring initial treatment requests. It also suggests experimenting with the delegation of tasks between psychiatrists and nursing staff within the CMPs, as this reallocation of duties to non-doctors could also help reduce waiting times.
Relieving some of the difficulties in accessing primary mental health treatment also implies improving the involvement of general practitioners and psychologists so that they can, as far as possible, provide the first line of access to treatment. Rolling out reimbursement for treatment from a psychologist is part of this system. Its expansion by more closely associating general practitioners to the organization of the sector would constitute a further step. This avenue involves initial and continuing training, but also organizing support by advanced practice nurses (APNs) and the CMPs when necessary.
Firstly, the mission found that there is still work to be done in terms of access to somatic treatment for the population with mental health problems. In fact, despite a high prevalence of somatic comorbidities, it is more difficult for the population with severe mental disorders to access somatic treatment. By whatever means necessary, we must seek to articulate somatic and psychiatric treatment offerings. To do this, the mission recommends analyzing and assessing the link between the proximity of somatic and psychiatric services and better access to somatic treatment in order to draw conclusions about the relevant organizational impact (integration of psychiatric services within general hospitals, integration of general practitioners within EPSMs). It also recommends, like for elderly patients with long term illnesses (LTIs) or patients with autism spectrum disorders, recognizing the specificity of ongoing treatment for patients with severe psychological disorders along with the cost impact of general medicine.
Secondly, the mission notes that shortcomings in prevention and in the provision of suitable adapted places to live for certain patients lead to disrupted treatment programs. Upstream, increasing prevention means improving local outpatient services such as outreach, particularly for the most vulnerable populations, and home visits for patients at risk of a disruption in care. The mission recommends starting work on defining the specifications for mobile teams and home visits and to consider tailored financing methods. Downstream, inadequate preparation for discharge from hospital and the lack of suitable places to live in some areas lead to patients being kept in hospital, sometimes unnecessarily. Preparing for discharge from the point of admission will be a requirement for all psychiatric care facilities from 2024 onwards and should make it possible to improve this stage. However, the backlog of cases and unsuitability of the existing downstream care offering requires investment in the development of new capacities and the continuation of developments already underway in the field of inclusive housing. The mission believes that people with mental disabilities linked to severe psychological disorders could be considered as priority beneficiaries. Furthermore, the mission deems it necessary to undertake a thorough investigation into the elderly and psychotic patients and their access conditions to residential centers for the dependent elderly (EHPADs).
In the absence of dedicated capacities, long-term hospitalizations disrupt the flow of hospital capacities. This long-standing trend substantiated by a minority of patients (less than 1% of patients representing a quarter of hospital days) is a time-consuming obsession for hospitals. The mission recommends investigating the relevance of developing a follow-up and rehabilitation care offering in the light of the needs and current practices of certain institutions, which seem to be very similar.
Thirdly, while the mission acknowledges that the financing reform rolled out since January 2022 is a significant improvement on the previous system, which led to the coexistence of dual public/private systems, both of which were out of touch with territorial needs, it notes that there is room for improvement in this new model. Admittedly, as it stands, the limitations of mental health epidemiology and knowledge of psychiatric activity data complicate regulation of the treatment offering. However, following the example of some regions (Hauts-de-France, Occitanie), other regions could be encouraged to support epidemiological and research studies in mental health in their territories. Most importantly, at national level, the French National Public Health Agency (SPF) could be given the task of creating psychiatric epidemiology indicators. Creating these indicators is in fact an essential step to reach the objective of reducing territorial inequalities. This new financing model, which applies to both the public and private sectors, should take full effect in 2026. On top of the many decisions that the ARSs will have to make in 2022 (parameters for distributing the population-based allocation under the psychiatric financing reforms, list of specific regional activities, etc.) and on which recommendations are made, the mission believes that the financial model needs to address social problems more often as health issues in order to reduce inequalities and prevent any possible eviction effects, particularly for complex or vulnerable patients. To help achieve this, it would be useful for the distribution of regional population allocations to take into account indicators of the first line of care and its actual accessibility, as well as health data that could be linked to the number of LTIs for certain diagnoses of severe psychological disorders. Similarly, the active patient case allocation should be expanded with an incremental allocation method for the benefit of certain categories of patients, i.e. the most vulnerable, and for certain types of treatment, in particular outpatient care, which already exists for child psychiatry. In the end, it seems essential to link population-based allocations and active patient case allocations in order to guarantee that the financial resources allocated correspond to the care actually provided.
Lastly, based on in-depth discussions with four ARSs and the responses to the questionnaire sent to them, the mission considers it absolutely critical to strengthen their support, which has already started with the mobilization of teams of the French National Performance Support Agency for Health and Medico-social Institutions (ANAP). The series of reforms that these teams must implement against the backdrop of the pandemic and the crises in different segments of treatment services do not facilitate their involvement in a new regulation of a segment of treatment services which, until now, only mobilized them for involuntary treatment, as it was largely financed on the basis of a general operating allocation,.
ABBREVIATIONS & ACRONYMS
|ARS||Agence régionale de santé||Regional Health Agency|
|ANAP||Agence Nationale d’Appui à la Performance des établissements de santé et médico-sociaux||French National Performance Support Agency for Health and Medico-social Institutions|
|CMP||Centre médico-psychologique||Medico-psychological center|
|CHU||Centre hospitalier universitaire||University hospital|
|EHPAD||Établissement d’hébergement pour personnes âgées dépendantes||Residential center for the dependent elderly|
|EPSM||Etablissement public de santé mentale||Public institution of mental health|
|ESPIC||Etablissement de santé privé d’intérêt collectif||Non-profit private health institution|
|APN||Infirmier de pratique avancée||Advanced practice nurse|
|OECD||Organisation de coopération et de développement||Organisation for Economic Co-operation and Development|
|PRS||Projet régional de santé||Regional Health Project|