Mental health policy and practice across Europe: an overview

Financing and funding 77
provided in the Italian and Spanish sites. Differences were found within as
well as across countries and among sites with similar levels of resources. In
this study home visits were commonly suggested in the Irish and Portuguese
sites but there were differences in use across the French centres in the study
(Kovess et al. 2005).
What these and many other studies demonstrate is the breadth of economic
impact. Evidence from some English studies provides illustrations. Thomas and
Morris (2003) calculated the broad costs for depression, finding that the impact
on employment (and hence on national productivity), expressed in cost terms,
was 23 times larger than the costs falling to the health service. This is an enormous
‘hidden’ impact. Sizeable ‘hidden’ costs are not unique to depression.
In a study of children with persistent antisocial behaviour in London, only
5 per cent of the total cost was carried by the health service, the remainder
falling to schools (special educational needs), social care agencies, community
voluntary organizations, families (disrupted parental employment, household
damage) and the welfare system (disability and similar transfer payments)
(Romeo et al. 2006). Another study found that adults, who as children had a
conduct disorder, generated costs for a range of agencies that were significantly
higher than the costs for a non-morbid control group; most noticeable were the
criminal justice system costs, which were 18 times greater (Scott et al. 2001).
Crime costs are another important consideration when looking at the social
impact of addictions. A few years ago, for every GBP£1 of health service expenditure
spent on people referred for addiction treatment, it was calculated that
another GBP£3 is incurred by the criminal justice system and GBP£10 by the
victims of crimes (Healey et al. 1998). In old age, mental health problems can
often lead to expensive admissions to nursing homes, but a big impact is often
felt in the family. Although it is difficult to put a figure on the opportunity costs
of informal care, there is no doubt that they are high and often overlooked in
policy and practice discussions (McDaid 2001). Overall, therefore, it is clear that
the lion’s share of the broad social costs of mental illness will often fall outside
the health sector.
Silo budgeting
As countries come to rely less on psychiatric inpatient facilities and more on
community-based options, the balance of expenditure ought to shift away from
health care (as conventionally and narrowly defined) to other areas (especially
social welfare and housing). Similarly, as a country’s overall commitment
to mental health grows – and with it the better recognition of the diversity and
multiplicity of individual needs – so again we might expect the balance between
health and non-health expenditures to alter. In order to effect change there
might therefore be a need to shift funds from one budget to another. But
professional rivalry, myopic budget protection, performance assessment regimes
or simple stultifying bureaucracy could mean that one agency is unwilling or
unable to spend more of their own resources in order for another agency
or service to achieve savings or for the broader system overall to achieve
effectiveness or cost-effectiveness improvements.