Mental health policy and practice across Europe: an overview

Policy in former eastern bloc countries 419
deinstitutionalization initiative in the Lithuanian capital, Vilnius, launched in
2003, to restructure a municipal mental hospital on Vasaros Street. The Vasaros
project became possible as a result of unusual circumstances. A young, energetic
hospital director decided to invest time in upgrading the hospital and opened it
up to reforms. A young mayor understood the need to improve the quality of
health care services in his city. Vasaros Hospital, unlike most other mental
institutions in this part of Europe, had the opportunity to be established within
the city centre. Finally, the Dutch Ministry of Foreign Affairs agreed to finance
the development plan.
The project’s objective was to develop a network of coordinated services with
a seamless transition between them as clients’ needs might dictate. In addition,
three new modules of specialist psychiatric care were designed for implementation:
crisis intervention, assertive community treatment and specialized services
for eating disorders. Financially, the project envisaged municipal investment to
upgrade premises and add new buildings. In addition, the project provided for
the systematic involvement, throughout all stages, of both relatives and service
users in the hospital’s management, and a patients’ council was established to
undertake this task. Finally, there were negotiations with health insurance
companies to provide adequate reimbursement for new services not covered
by existing regulations. This was the key issue in sustaining the quality of the
costly new services in an organizational culture that fails to provide for quality
assurance.
The project met with opposition from two sides. Firstly, the site on which
Vasaros was built was considered to be a prime location and a target for urban
redevelopment. Secondly, the project was considered a threat by a group of
psychiatrists and officials who favoured institution-based psychiatry and who
– with regard to psychiatric hospitals – adhered to the concept of ‘the bigger
the better’. They countered the proposals by suggesting instead that Vasaros
close all inpatient wards and run only outpatient services. They did so while
being fully aware that only inpatient psychiatric services could be adequately
reimbursed under Lithuania’s health insurance laws (outpatient services being
funded only in primary care centres via a capitation system). In fact, the
opponents of the Vasaros project were advocating that the Vilnius Republican
Psychiatric Hospital in Naujoji Vilnia, a suburb of Vilnius, be given a monopoly
in providing mental health services. This hospital, a classical example of a large
national psychiatric hospital with special privileged status under the direct
authority of the Ministry of Health, was facing its own institutional anxieties.
To prevent potential closure in the event that Lithuania’s new mental health
policies should gain momentum in the future, pressure was placed on the
Ministry of Health to give this hospital a monopoly over inpatient psychiatric
services for the whole of the Vilnius region which has a catchment area of
around 1 million inhabitants.
By the end of 2003 a stalemate had been reached: the Minister of Health
decreed that Vasaros Hospital should be affiliated to Naujoji Vilnia, with the
clear intention of closing the small hospital at Vasaros and concentrating all
inpatient psychiatric services, without any possibility of having a choice in
inpatient treatment, in Naujoji Vilnia. In response, the mayor of Vilnius publicly
protested, emphasizing the need for a modern vision of mental health