Mental health policy and practice across Europe: an overview

216 Mental health policy and practice
Mental health policy and primary care
The WHO Atlas survey of mental health resources worldwide defined mental
health policies as ‘a specifically written document of the government or Ministry
of Health containing the goals for improving the mental health situation of
the country, the priorities among those goals and the main directions for attaining
them’. 1 Policies provide a common vision and plan for all programmes
and services related to mental health, and avoid inefficiency and fragmentation.
The Atlas survey found that 67 per cent of European countries had a mental
health policy (WHO 2001a).
One key policy recommended by the WHO World Health Report 2001 concerned
the importance of providing treatment for mental health problems in
primary care (WHO 2001b). Primary health care was defined by the Alma Ata
declaration as ‘essential health care based on practical, scientifically sound and
socially acceptable methods and technology made universally accessible to
individuals and families in the community through their full participation and
at a cost that the community and country can afford to maintain at every stage
of their development in the spirit of self-reliance and self-determination’.
Descriptions of the core content of primary care vary (Starfield 1992; Fry and
Horder 1994), but key aspects include:
• first contact care, with direct patient access;
• care characterized by patient-centredness, family orientation, and continuity;
• a role in the coordination of care; and
• a ‘gatekeeping’ function in relation to access to specialist care.
The structure of health care systems in Europe varies widely, and the degree
to which particular systems can be characterized as ‘primary care-led’ varies
(Boerma et al. 1993; Fry and Horder 1994; Saltman et al. 2006). There is some
evidence that the degree of primary care focus in a health care system (especially
the gatekeeping role) is a key driver of the cost-effectiveness and efficiency of
health care provision (Starfield 1992).
Mental health care in primary care is defined as ‘the provision of basic preventive
and curative mental health care at the first point of contact of entry into the
health care system’. Usually this means that care is provided by a non-specialist
primary care clinician, such as a general practitioner (GP) or nurse, who can
refer complex cases to a more specialized mental health professional (Boerma
and Verhaak 1999; WHO 2001a). The Atlas survey found that 96 per cent of
European countries identified mental health activity in primary care, and 62 per
cent reported training facilities, although implementation was highly variable
among countries (WHO 2001a). In particular, a number of countries in central
and eastern Europe still have the overwhelming majority of resources for mental
health tied up in long-stay institutions, with little role for primary care practitioners.
For instance, in Lithuania more than 70 per cent of state expenditure for
mental health services was allocated to such institutions in 2003 (Murauskiene
2003).