Mental health policy and practice across Europe: an overview

64 Mental health policy and practice
Chapter 8). One of the organizational challenges in this complex ‘de facto mental
health system’ (Regier et al. 1978) is to ensure that those services and agencies
are appropriately coordinated. Without effective coordination there will probably
be wasteful overlaps and, more commonly, yawning gaps in the spectrum
of support. Even in the best health systems there are people who ‘fall through
the net’.
Consequently, ‘mental health services’, as narrowly defined and as conventionally
viewed, actually sit in the middle of a complex, dynamic multiservice,
multi-budget world. When we use a term such as ‘mental health system’
we therefore need to remember that many resources – indeed, an increasing
proportion of resources – are not actually in the health care system as conventionally
defined but are provided by social welfare, housing, employment,
criminal justice, education and other systems. Countries will differ in their
service and agency definitions, responsibilities and arrangements, and consequently
in their inter-agency boundaries. One of the biggest challenges
in trying to establish effective and cost-effective mental health promotion,
community-based care and rehabilitation is managing these organizational and
inter-professional interfaces and the various incentives and disincentives that
characterize them.
A mixed economy
Multiple provider sectors
Some of the services used by people with mental health problems are provided
by or located within the state (public) sector, some by private (commercial) or
non-governmental (civil society) entities, and some by families or through
informal community arrangements. This multiplicity of sectors and services –
what we can call the mixed economy of provision – is characteristic of all mental
health systems in Europe. Even formal mental health promotion strategies,
which tend to be dominated by the state (locally, regionally or nationally), as
are other public health initiatives, still need inputs from employers and local
communities (the ‘social capital’ effect). Treatment and rehabilitation services
may be dominated by the public sector, both quantitatively and strategically,
but non-governmental organizations are often also major providers of day and
residential care in some countries. They are certainly key providers of advocacy
services through user and family groups. Private businesses may provide residential
and some specialist psychiatric care; for example, psychotherapy is
widely offered by private practitioners. Patterns of provision vary from country
to country. In central and eastern Europe, for instance, the public sector has
historically dominated service provision; the absence of civil society structures
over the last half century has meant that emerging voluntary sector activities
remain weak (see Chapter 17).
Another source of provision, still quite marginal today but growing in
importance, has arisen from non-contributory, directly-funded employer programmes.
Some companies in Europe are themselves funding, and in some
cases also providing, on-site mental health support for their staff and families,