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Functional versus integrated mental healthcare

The aim of the EU-funded COFI project was to answer the question of whether continuity or specialisation of care is associated with more favourable treatment outcomes for those suffering from a mental illness.
Functional versus integrated mental healthcare
Mental health disorders affect 38.2 % of the EU population. To reduce this burden, European countries are looking to improve the organisation of mental health care with often radical reforms. Despite their differences, all of these reforms focus on one central and controversial issue: should mental health care systems be functional or integrated?

COFI project coordinator and professor at Queen Mary University of London Stefan Priebe explains.

Can you briefly explain the difference between a functional system and an integrated one?

Whereas in functional systems different clinicians and teams (i.e., specialisation of care) are responsible for in-patient and out-patient care, in integrated systems the same clinician(s) are responsible for both the in-patient and out-patient care of a given patient (i.e., continuity of care). Although the difference between the two approaches has far reaching policy implications, surprisingly, there has been no sound research evidence to inform the debate.

Which is where the EU-funded COFI project comes in?

Yes. The aim of the COFI (Comparing policy framework, structure, effectiveness and cost-effectiveness of functional and integrated systems of mental health care) project was to answer the question of whether continuity or specialisation of care is associated with more favourable treatment outcomes for those suffering from a mental illness. To find out, we conducted studies in five countries (Belgium, Germany, Italy, Poland and the United Kingdom) where both approaches were used in routine care. Doing so meant we could avoid a confusion of country with approach. We recruited patients when they were first admitted to the hospital and followed up with them over a one-year period. Using this natural experiment approach, we were able to successfully investigate outcomes in real-world scenarios as opposed to experimental studies.

So, which system is associated with more favourable health and social outcomes?

Actually, what we found is that the approach to care – whether it be continuity or specialisation – has no significant impact on any clinical or social outcomes for patients one year after being admitted to a psychiatric hospital. This result was not only consistently found for the whole sample, it also holds true for different subgroups – including subgroups by country, diagnosis, age and whether or not the person had previously been admitted.

That being said, patients receiving continuity of care did report being more satisfied with their in-patient treatment, most likely because they are able to meet a clinician they already know and who is familiar with their problems.

Patients and clinicians also identified advantages and disadvantages for each approach, with advantages of one approach mirroring the disadvantages of the other. For example, with continuity of care, we found that many patients appreciate having an ongoing, trustful relationship where they do not have to tell their oftentimes stressful story each time they are treated by a different service. With specialisation, however, patients reported feeling that their clinician was focused on the specific service they were being treated in and they often appreciated having a new start with a new clinician following the crisis that led to the hospital admission.

These views on the advantages and disadvantages were consistent between patients and clinicians and across the different countries. Furthermore, anticipated and experienced discrimination was apparent for all patients, regardless of diagnostic group. This was particularly pronounced for patients with a primary diagnosis of schizophrenia and related disorders and anxiety and somatoform disorders.

Overall, despite being a hotly contested topic, our research concluded that regardless of whether patients are treated by the same or different psychiatrists across in- and out-patient care has no significant impact on any of their outcomes, at least as measured at the one-year follow-up.

What are the key takeaways of the project?

Based on our findings, we have made several important recommendations for treating mental illness. For example, if the aim of the treatment is to improve long-term outcomes for patients, costly reorganisations of mental health care systems should not focus on changing from integrated to functional care or vice versa. However, if the aim is to improve the patient’s experience of in-patient treatment, then integrated care may be preferable.

Furthermore, although both approaches have strengths and weaknesses, organisational considerations in the local context and preferences of patients and clinicians may favour one of the two approaches. Patient preferences are particularly important when there is a choice between the two systems in the same service. In this case, potential advantages and disadvantages of each system should be considered.

I would like to point out that, to my knowledge, the COFI project is the largest prospective study conducted with psychiatric in-patients. Recruiting and interviewing more than 7 000 patients with mental disorders within the first days of admission to acute hospital treatment and obtaining follow-up data on more than 5 000 is quite the achievement itself. This is also a study where the value of the work conducted in five centres across Europe is clearly greater than the sum of its parts. Showing that similar results are found in countries with different traditions and different systems of health and social care significantly strengthens our conclusions.

What will the project’s legacy be?

Many studies end with the conclusion that more research is needed, but not this one. COFI managed to answer one very important question that has dominated debates on mental health service organisation across Europe. The answer may not be popular with ardent supporters of either approach, but it is clear and scientifically sound.

Interestingly, one legacy might be that policy makers are more cautious with investing much time, energy and money into changing the organisation of mental health care from continuity to specialisation of care or vice versa. Thus, the legacy may be the avoidance of useless change rather than more change. It will certainly be interesting to see to what extent policy makers take our empirical and conclusive findings on board and consider them in future planning for the organisation of mental health care.

On a wider level, COFI raises questions about the effects of mental health service organisation in general. It suggests that more emphasis should be put on the content of treatments than on the overall organisation of services, as each approach comes with specific advantages and disadvantages.

Source: Interview from Research*eu magazine n. 76

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