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Financing systems’ effects on the Quality of Mental health care in Europe

Final Report Summary - REFINEMENT (Financing systems’ effects on the Quality of Mental health care in Europe)

Executive Summary:
How the goals of high quality, equity, efficiency and better care in the field of mental health can be achieved by adequate mixes of financing systems (tax, social and private health insurance and out of pocket payments, etc.) and by adequate provider payment mechanisms?
To answer these goals, REFINEMENT standardized the comparison methodologies of different systems of provision, financing and performance assessment of mental health care in European countries’ mental health and social services.
The REFINEMENT project was conducted by an experienced team of mental health service researchers, health economists, public health specialists and social care experts from 9 European countries [University of Verona (Italy), Ludwig Boltzmann Gesellschaft (Austria), London School of Economics and Political Science (UK), Terveyden ja hyvinvoinnin laitos (Finland), Asociacion Cientifica Psicost (Spain), Stiftelsen Sintef (Norway), University of Tartu (Estonia), Université Paris XII - Val de Marne (France) and Institutul de Prognoza Economica (Romania)].
Mental Health has been recognized as a key priority area and goal for Europe as stated by the European Commission in June 2008 through the publication of the European Pact on Mental Health and Well-being. In view of this the REFINEMENT project has conducted (for a total of 36 months) the first ever comparative and comprehensive overview of links between the financing of mental health care and the outcomes of mental health services in Europe.
Four bespoke, interlocking tools have been designed to provide advice on what information to collect and which questions to ask. Any mental health system will in part be influenced by the way in which it is financed, as well as the way in which service providers are paid. These issues are dealt with by the FINCENTO tool, while the REMAST tool is used to map out the organisational structure of mental health services, both at a national and regional level and then in great detail for a smaller geographical area.
Understanding the pathways of care that individuals follow within a mental health system can also help in understanding the impacts of different financial incentives and disincentives, as well as better understanding issues around continuity of care. The REPATO tool looks at these issues. It may be a way, for instance, of identifying the extent of use of inpatient services. The level of focus on inpatient specialist care in terms of its quality and appropriateness can then be considered.
A fourth tool, REQUALIT, focuses specifically on quality issues. It consists of a detailed list of quality indicators against which the quality of care provided by a mental health system can be judged. The ability of the system to safeguard human rights and to fully engage mental health service users in decisions on care to be received can, for instance, be considered. Broader issues concerning the way in which issues such as discrimination and social exclusion are dealt with by a country can also be examined with this tool.
The four tools are contained in the frame of a Decision Support Toolkit (DST), the DST identifies some of the key questions that need to be asked in order to assess performance, and in particular how the financing and funding of a mental health system may be correlated with its organisational structure, pathways of care and quality. The DST also provides a step by step guide to developing questions, collecting information and then interpreting findings. While the information, if collected comprehensively, may seem daunting, advances in information communication technology and data processing systems will allow for more sophisticated approaches to performance assessment to be undertaken even when time and human resource availability may be tight.
European policy-makers and providers of care will be able to use the results and any subsequent analyses to understand the complexity of financing the mental health care system including primary and social care services. While we focus on performance assessment of mental health systems
for adults of working age, the principles outlined here will generally be applicable for policy makers wishing to assess the performance of other types of mental health system, for instance child and adolescent mental health services. The principles and approach to data collection and analysis can also apply to other complex elements of health and social care systems, for instance looking at approaches to manage chronic physical health problems such as diabetes, poor musculoskeletal health and cardiovascular disease.

Project Context and Objectives:
The REFINEMENT (REsearch on FINancing systems’ Effect on the quality of MENTal health care) project arises from the necessity to evaluate the different and elaborate systems of both providing, financing and performance assessment of Mental Health Care in Europe (Smith, 2009) throughout a standardized definition of their services. The project was financed for 3 years by the European Commission within the 7th Framework Programme (No. 261459) and started in January 2011, lead by the Research Unit “Psychiatric Case Register, Economics & Geography of Mental Health” coordinated by Professor Francesco Amaddeo from the Department of Public Health and Community Medicine at the University of Verona (Italy). REFINEMENT conducted the first ever comparative and comprehensive overview of links between the financing of Mental Health care in Europe and the outcomes of Mental Health services thanks to an experienced team of Mental Health service researchers, public health specialists and health economists. The project covers, in terms of funding models and interfaces with social care services, a representative range of health care systems across Europe. These systems are at very different stages in their development - especially after the shift from institution to community based mental health care (Thornicroft and Tansella, 2009) - ranging from heavily hospital reliant systems in Romania through different balances between community and institutional care found in countries including Austria, the UK and Norway to the highly community centered system of Italy. For such a reason, the nine partner countries of the project represent a significant example of the variegated Mental Health Care and financing systems in Europe. These nine countries are: Italy (University of Verona - project coordinator), Austria (Ludwig Boltzmann Gesellschaft), United Kingdom (London School of Economics and Political Science), Finland (Terveyden ja Hyvinvoinnin Laitos), Spain (Asociacion Cientifica Psicost), Norway (Stiftelsen Sintef), Estonia (University of Tartu), France (Université Paris XII – Val de Marne) and Romania (Institutul de Prognoza Economica).
In order to reach its aims, the REFINEMENT was organized in 9 work packages: three administrative work-packages on management (WP1), evaluation (WP2) and dissemination (WP3) and six technical and scientific work-packages concerned with the analysis of the financing of health and social care systems (WP4), functional and dysfunctional financial incentives (WP5), the mapping services for Mental Health care (WP6), the pathways of care (WP7), the quality of Mental Health care and met/unmet needs (WP8) and, finally, the building of Decision Support Toolkit for Mental Health care financing (WP9).
In this sense, a set of four tools have been developed to map and describe the peculiarities of Mental Health care systems (methods of revenue collection, pooling of funds, allocation to service purchasers and mechanisms for the payment of service providers, provision of services, pathways of care and performances assessment) in a comparable way across the nine partner countries.
Any mental health system will in part be influenced by the way in which it is financed, as well as the way in which service providers are paid. These issues are dealt with by the FINCENTO tool, while the REMAST tool is used to map out the organisational structure of mental health services, both at a national and regional level and then in great detail for a smaller geographical area.
Understanding the pathways of care that individuals follow within a mental health system can also help in understanding the impacts of different financial incentives, as well as better understanding issues around continuity of care. The REPATO tool looks at these issues. It may be a way, for instance, of identifying the extent of use of inpatient services. The level of focus on inpatient specialist care in terms of its quality and appropriateness can then be considered.
A fourth tool, REQUALIT, focuses specifically on quality issues. It consists of a detailed list of quality indicators against which the quality of care provided by a mental health system can be judged.

FINCENTO: Financial incentives and disincentives.
The problem of financing today’s health care (including Mental Health Care) does not only consist in the rising costs as such, but also in how the flow of funds between the different players is regulated. The providers of care play an important role for providing equitable and efficient health care. One task to be performed by the REFINEMENT project was to analyse the payment mechanisms to providers, identify incentive mechanisms in these payment mechanisms, and describe their known or potential effects on the quality of mental health care. As a theoretical background for performing this task we have chosen the so-called “principal-agent model” which is briefly discussed below.
The principal-agent model (or “principal agent problem” or “agency dilemma”, as it has been called in economics), relates to the situation that one party (the “principal”) hires another party (the “agent”) to perform a specific task for the principal. The situation arises, because the “agent” has more information for performing the task than the “principal”, in other words, because a situation of “information asymmetry” exists (1). Given that each of the two parties has its specific self-interest, the problem is how to motivate the "agent" to act in the best interests of the "principal" rather than in his or her own interests.
This is a typical situation in health care, were an ill-informed patient asks a medical expert to act in the patient’s interest (Arrow, 1963). In modern health care systems where the providers of medical services are paid by a “third party” (insurance or tax fund), the same asymmetry applies to the relationship between the payer and the provider. The provider of medical services is in the more powerful position in each of these two relationships. The different types of payment mechanisms of the provider and the inbuilt or explicitly designed financial incentives and disincentives can be understood as counteracting this asymmetry of information and power in order to achieve cost-effective and high quality health care.
The assumption that the medical service providers could make use of their better knowledge in order to increase their profit (e.g. by providing unnecessary or better paid services), has, over the last decades, led to the introduction a whole range of provider payment mechanisms which have all implicit or explicit incentives to better reflect the interest of the principals (i.e. the patient and the third party payer). Some of these incentives and disincentives are contractual and intended, e.g. to affect provider treatment decisions (Christianson et al. 2007; Chaix-Couturier et al. 2000). Others have emerged as unintended consequences of changes in funding systems introduced for other purposes.
The FINCENTO - Part A aimed at eliciting information on financing and funding of key health and social care/welfare services used by people with mental health needs. The FINCENTO – Part B intended to identify financial incentives/disincentives in provider payment mechanisms and user charges. It did not deal with incentives in collecting, pooling and allocating funds.
In FINCENTO B, the REFINEMENT partner countries were required to find examples of financial incentives related to three main service types (primary care, specialised mental health outpatient care, inpatient care - the latter could be both psychiatric and non psychiatric hospitals/institutions) which provide care to people with mental health needs and record them in detail in the specific forms provided in a separate file.
The information obtained by using FINCENTO B was intended to supplement the FINCENTO A description of financing mechanisms for mental health care for each partner country and thereby expand the array of independent variables of the “financing system” whose influence on the quality of mental health care was to be explored across the partner countries in the REFINEMENT project.
However, experience from piloting showed that it was not possible to describe these incentives for each partner country in a complete and comprehensive way. As an alternative we have therefore chosen to ask the participating countries to identify and describe in some detail examples of financial incentives. It was not necessary (but of course not excluded) that the examples refer to the current situation in a country. Often examples from the past (which had been abandoned) might be more telling since there was probably a reason why they were replaced. Also, plans might exist to introduce new financial incentives, and also there the motives as to why and which incentives are planned might be of interest.

REMAST: Organizational structure of Mental Health and Social Services.
In order to analyze the different care systems and their correlated outcomes, it is actually necessary to ensure that researchers, service planners and policy makers in different regions, countries and at the European level, compare ‘like with like’ and adequately use the data from different services systems. Past studies and project have already tried to compare in a standardized way different mental health services (De Jong, 2000; De Jong et al., 1995). For example, the European Psychiatric Care Assessment Team (EPCAT) developed the European Service Mapping Schedule (ESMS) to describe Mental Health services for the population of a catchment area provided by public sector health and social service agencies, voluntary sector and private sector providers (Johnson et al., 2000). This instrument classifies provision in a “service mapping tree” on the basis of operationalised definitions of Mental Health services and it also documents the associated levels of services provision in order to compare services in catchment areas across different countries (Becker et al., 2002). A further development of this approach has been the creation of a new instrument called ‘Description and Evaluation of Services and Directories in Europe’ (DESDE) which also includes long term care and disability services and which is now used in sixteen European countries (Salvador-Carulla et al., 2006). What has been missing from these service mapping instruments to date – including the WHO’s Assessment Instrument for Mental Health Services (WHO-AIMS) (WHO, 2005) - has been a common comparison of primary care, general health and social care services that may be used to support people with Mental Health needs. For such a reason, the REFINEMENT project has developed its own tool (the REMAST, with its revised version REMAST 2.0) applying a multilevel description which has only previously been made in the European EPSILON study in respect solely of specialists services for people with schizophrenia (Becker et al., 2002).
Finally, in order to provide a further visually comparative description of the services, the REFINEMENT project also analyzes the socio-economics characteristics of the study areas and the spatial dimension of Mental Health care delivered by health and social services by means of Geographical Information System (GIS); to date such a type of studies have only been conducted on single services at a local level (Curtis, 2007).
For example, in recent years there has been an evident decrease in the provision of mental health care by hospital-based acute services. Hospitals still play an important role within the mental health care system accounting for a substantial proportion of the health care budget. In comparison with the work by Priebe and colleagues (2008), the REFINEMENT project presented new insights also in poorest European countries like Estonia and Romania. Moreover it provided updated information about other European countries. On the other hand, provision of mobile services is an essential feature of psychiatric care and crisis interventions teams represent an important element of the whole mental health system (Allen, 1999). Quick and adequate interventions in emergency situations are fundamental to assist psychiatric patients in critical clinical conditions and should prevent any further mental health deterioration or risk in acute patients. Especially in geographical areas which are poor in mental health structures, mobile teams can be of decisive help. When necessary, mobile teams can provide cost-effective psychiatric emergency services that are favorably perceived by consumers and police officers (Scott, 2000). Data collected within the European REFINEMENT project were used to describe the distribution and utilization of both these types of mental health care services.


REPATO: Pathways of care.
Based on a systematic mapping of the literature, the REPATO tool was developed to identify the typical and most relevant pathways of mental health care and to identify system and service related factors, which could predict differences in service utilization patterns between the REFINEMENT partner countries (Austria, England, Finland, France, Italy, Norway, Romania, Estonia and Spain). The REPATO allowed three approaches to provide the requested information: (a) analyses of existing data, (b) review of empirical findings and (c) expert interviews. The following three major research topics were defined:
1. Pathways on the interface between primary and specialized mental health care.
Special attention was paid to the distribution of cases between the local primary and secondary levels of care (e.g. referral rates by general practitioners to mental health specialists; proportions of referrals from different sources to mental health services, etc.) and on the extent, to which general practitioners treat service users with psychiatric disorders themselves or refer them to psychiatric care (or may be follow a “shared care paradigm”).
2. Continuity of mental health care (and its opposite, disengagement or dropout)
We collected information on the extent, to which the discrete elements in the care pathways of individuals are linked and coordinated and the stability of service user‐provider relationships over time is ensured. Additionally we focused on interruptions and discontinuations of care pathways, demonstrated by the extent of dropout from mental health treatment.
3. Psychiatric hospital readmissions
Various data on readmissions after acute psychiatric hospitalizations were collected. As after hospital discharge the responsibility for prevention of readmission passes gradually from the hospital to the community provider/s, we differentiated between earlier and later readmissions and could relate our findings more precisely to hospital- vs. community-related variables.

REQUALIT: Quality of care indicators.
According to the Health Care Quality Indicator (HCQI) Project of the Organization for Economic Cooperation and Development (OECD), quality of care can be defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Institute of Medicine, 1990; OECD, 2004; Kelley and Hurst, 2006). Several countries have implemented projects and initiatives to define and evaluate quality of care in health and mental health systems (OECD, 2012) to tackle growing cost containment pressure, concerns about patients’ treatment choice and rights, and demands of transparency. Interest in this field is raising also due to advances in information technology systems monitoring the performance and utilization of services.
A number of authors have defined quality of health care by describing the concept according to a set of dimensions and using different indicators. Despite the growing interest around these issues, there is a lack of agreement on the dimensions and measures which should be used as indicators of quality of care in mental health (Hermann et al., 2006). This is also due to the differences in organization of health care systems, in policy priorities and in data sources available among countries. To summarize the main literature in this field, it is commonly recognised that:
- quality of care can be considered as a multidimensional construction;
- indicators can be considered as proxy measures for dimensions of quality of care; the same indicators can be considered as measures for different dimensions of quality because they are neither comprehensive nor mutually exclusive;
- a whole, balanced and tailored set of indicators is required as it will influence the health care policies to be adopted.
Finally, looking at the existing projects, OECD (2012) indicated gaps in some areas of Mental Health Care quality assessment such as psychotherapeutic treatments, equity, accessibility and safety issue, and social services.
The dimensions of quality of care can be combined into a matrix with the input, process and outcome levels as suggested in Thornicroft and Tansella model (1999; 2009). REQUALIT tool contains a set of indicators which represented, as broadly as possible, a combination of phase levels and quality dimensions, which take into account different integrated and connected features of the mental health system.
To conclude, in order to respond to diverse mental health needs, mental health care takes place in a variety of settings throughout the health and social care system. The main services involved in the system are: primary care, general hospitals, psychiatric hospitals for inpatient, community services for outpatient, social services and public service agencies, forensic hospitals, services for vulnerable groups such as old age services, drug and alcohol services or child and adolescent services. REQUALIT considers indicators of quality of care across the range of mental health services, but, in order to maximize the comparability of results among the heterogeneity of the countries, only the categories of services included in the mapping procedure (REMAST) have been considered: primary care, outpatient services, community care and inpatient services. Specific indicators for general hospitals, forensic hospitals and services for vulnerable groups were not included; anyway, in identifying the indicators, REQUALIT integrates data from health and social care derived from REMAST.
The selection of the indicators reported in the REQUALIT tool was initially based on two strategies: 1) a hand search for indicators in portals and organizational websites, representing relevant international organisations on health and mental health quality evaluation; 2) a search for indicators in published papers on electronic databases (Medline, Cinhal, Psycarticles, Psycinfo).

Scope of the project is to contribute to exchange information on current financing models and to identify innovative financial and non-financial incentives that influence the performance of the mental health system.

The REFINEMENT project aims at comparing and standardizing the different and elaborate systems of both financing and performance assessment of Mental Health care in Europe. To achieve the goals of high quality, equity, efficiency and better long term care mixes of tax, social health insurance, private health insurance and out of pocket payments are utilized. The REFINEMENT project analyses these mixed forms of payment to produce a comprehensive overview of links between the financing of Mental Health care in Europe and the outcomes of Mental Health services.
Project Results:
Increasingly countries in Europe are moving towards elaborate systems of performance assessment. Many factors have contributed to this shift. Health systems have come under intense cost containment pressures; patients expect to make more informed decisions about their treatment choices; and there have been growing demands for increased oversight and transparency in the health professions and health service institutions. At the same time advances in information technology systems have made easier to collect, process and disseminate data linked to performance.
The REFINEMENT project answers the necessity to compare and standardize the different and elaborate systems of both financing and performance assessment of Mental Health care in 9 European countries.
Refinement is organized in 9 work packages: management (WP1), evaluation (WP2) and dissemination (WP3), and technical work-packages concerned with the analysis of the financing of health and social care systems (WP4), functional and dysfunctional financial incentives (WP5), the mapping services for mental health care (WP6), the pathways of care (WP7), the quality of mental health care and met/unmet needs (WP8) and, finally, the building of the best practice models of mental health care financing (WP9).

The project has been conducted by an experienced team of health economists, mental health service researchers, public health specialists and social care experts from 9 European countries: Italy (University of Verona - project coordinator), Austria (Ludwig Boltzmann Gesellschaft), UK (London School of Economics and Political Science), Finland (Terveyden ja Hyvinvoinnin Laitos), Spain (Asociacion Cientifica Psicost), Norway (Stiftelsen Sintef), Estonia (University of Tartu), France (Université Paris XII – Val de Marne) and Romania (Institutul de Prognoza Economica).

REFINEMENT is structured in six key areas:
• Analysis of the Financing of Health and Social Care Systems
• Functional and Dysfunctional Financial Incentives
• Mapping Services for Mental Health Care
• Identifying and Interpreting Pathways of Care
• Quality of Mental Health Care and Met-Unmet Needs
• Building Best Practice Models of Mental Health Care Financing

The REFINEMENT TOOLKIT is a DECISION SUPPORT TOOLKIT comprising:
• A Manual: the instructions and guidelines to use the REFINEMENT TOOLS
• 4 TOOLS:
1) FINCENTO: financing and payment mechanisms
2) REMAST: mapping of services
3) REPATO: pathways to care
4) REQUALIT: indicators of the quality of care

• A Glossary: all the terms and definitions comprised in the Manual and Tools.
The tools can be used either singularly or together.


REMAST: Organizational structure of Mental Health and Social Services (for details and references see Deliverable D6.1).
The REMAST Tool is compounded of a battery of checklists/inventories, instruments and indexes. Its modular structure allows for future incorporation of other components relevant for mental health system assessment. It contains five main sections: (A) Population Data ; B) Verona SES Index; (C) Mental Health System Checklist describing policies and organization of mental health care through selected WHO-AIMS 2.2 items (WHO, 2005); (D) the Mental Health Services Inventory allowing the mental health services of a selected Study Area to be classified according to the ESMS/DESDE approach (Johnson et al, 2000; Salvador-Carulla et al., 2006) using the DESDE-LTC instrument for providing detailed descriptions of the coding and characteristics of services, including their utilization and staffing (Salvador-Carulla et al., 2013); and (E) Geographical Data: the description of geographical context of the Study Area.

Population Data
In order to provide a socio-demographic description of both the Study and the Macro Areas, number of inhabitants are requested for each Area by distinguishing males and females in different age groups (total population; 0-17 years; 18-64 years; 65 years and more). The reference year of the available data is also required together with the NUTS code when applicable.

Verona SES Index
This includes 16 items drawn from the Verona Socio-Economic Status (SES) index The socio-economic status (SES) deprivation index is an indicator of the resources individuals, households, groups or areas have at their disposal and which affect their power and life opportunities. The construction of such indicator may vary across areas and time periods, depending on which variables affect social ranking in the society (Tello et al, 2005). For the purpose of our study, we have identified a set of variables that could be found across all countries. These include family composition (single-parent families, individuals divorced or widowed), employment (workers employed in industry and services respectively, unemployment rate); education (individuals with Tertiary qualification on people aged 15 or older); household size (average number of people per household; Households made up by 1 person and by 5 or more people respectively); age composition (ageing index, dependency ratio, individuals below 5 years old). Other variables (rented accommodation, population density and immigrants) were also included.

Mental Health System Checklist (MHSC)
General information on Mental Health Policy; Mental Health Plan; Monitoring and Training on Human Rights; and Organizational Integration of Mental Health Services are provided through the administration of selected items from the WHO-AIMS 2.2 (WHO, 2005). Of the 6 recommendations (or domains of interest) developed in the WHO-AIMS 2.2 two were included in this Checklist: the “Policy And Legislative Framework” and the “Mental Health Services”. Of the 28 original facets in which the recommendations are divided, 4 are included (3 for the “Policy And Legislative Framework” and 1 for the “Mental Health Services”). Finally, of the total 156 items of the WHO-AIMS 2.2 ten are included (8 for the “Policy And Legislative Framework” and 2 for the “Mental Health Services”). The ten items are open questions (2) and “yes/no/unknown/not applicable” items (8). An Observations Box has been added for the “Policy And Legislative Framework” recommendation in order to provide more detailed information on the current Mental Health Policies and Plans. Data are requested at local, regional and national level. Generally, all information should be available through institutions at national level and rarely facilities are to be contacted to get data directly from them. Data source should be indicated in the box on the first page of this section. The organization of the mental health system is described with a focus on the integration of mental health services and communities, and the innovation in legislation for mental health care.

Mental Health Service Inventory (MHSI)
The Mental Health Services Inventory section is aimed at describing all Mental Health Care services of the Study Area providing health and social Care to people with a psychiatric disorder. When possible, as to get a complete overview of the services available for the residents, also those specialized services which are located outside the Study Area but which serve the patients of the Study Area are included, excluding primary care and social care services. The Services Inventory follows the ESMS/DESDE approach to service assessment (Johnson et al, 2000; Salvador-Carulla et al, 2006; Salvador-Carulla et al, 2013). It is composed of a User Manual with all the instructions and the Services Inventory File to be compiled online. The compilation of the file will provide information on the general context of each service, its ecological setting, distribution and utilization.

Five types of information are required for each service: Service basic information (4 items); Location and Geographical information about the service (3); Useful information and contacts (4); Service Data (12); and Evaluator information (3). The Service Data information allows for a detailed description of each service through the collection of data on staff, availability and contacts. Each of these five categories includes specific questions to answer with numbers, acronyms or short sentences. Definitions of technical terms are provided in the Refinement Glossary (www.refinement.eu). The core of the Services Inventory is represented by a validated tool on its own, the "Description and Evaluation of Services and Directories in Europe for Long-Term Care" (DESDE-LTC) that provides the information needed to complete the MHSI.
DESDE-LTC is the extended version of the European Service Mapping Schedule (ESMS-I) for the assessment of services in long-term care (Johnson et al, 2000). It increased the original 32 codes to 91 to allow for coding services in other sectors (education, employment, crime and justice), other specific groups (child and adolescents, elderly, drug addiction) and other health targets (disability and long term chronic care). The feasibility, reliability and validity of both ESMS-I and DESDE-LTC have been previously described (Johnson et al, 2000, Salvador-Carulla et al, 2000, Salvador-Carulla et al, 2006; Salvador-Carulla et al, 2013). These instruments have been used in over 13 countries to provide regional, national and international comparisons of Mental Health Systems and Long-term care (Salvador-Carulla et al, 2013). DESDE-LTC is intended to provide: a) a compilation of a standardised inventory of long term care services (including mental health); b) recording of changes that have occurred in service availability; c) establishing and comparing the structure and supply of long-term care services in different catchment areas, d) measuring and comparing the levels of provision/ availability and utilisation of the main types of care (MTC) between different catchment areas using an international coding system that allows semantic interoperability. DESDE-LTC uses a tree system or the classification of services in a defined catchment area according to the main care structure/activity offered as well as their level of availability (section B) and utilization (section C).

Geographical Data
Geographical Data together with the geocodification of services allow through Geographic Information Systems (GIS) the creation of an Atlas of mental health maps in a static version (see attached file: Refinement_Atlas of Mental Health Care.pdf) and in an interactive web-based version (http://www.psychiatry.univr.it/refinement/atlas/atlas.html). The Atlas of mental health includes:
a) Mapping of the main social and demographic indicators relevant to mental health care in the Study Areas by analysing available social and demographic datasets (e.g. deprivation index, dependency index, people living alone rate, unemployment rate). Information collected with the SES Index, the Services Inventory and the Geographical Data can be combined to provide a detailed description of both mapped services and the Study Areas. The SES Index provides information on the level of deprivation of each Study Area where services are located. Geographical Data can be combined with SES Index results to explore the relationship between social disadvantage and the quantity of services available. Analyzing the social and demographic characteristics of service areas may reveal populations with unmet needs.
b) Mapping of service provision (care availability, placement capacity, workforce capacity and accessibility) in each Study Area according to their Main Type of Care. Rates and ratios on services availability (opening hours and days), and places (e.g. beds) describe the utilization of the services of each Study Area. For instance, the ratio between the number of beds in mapped services and the adult population of each area multiplied by 100,000 is calculated and represented in the Atlas (see attached file: Refinement_Atlas of Mental Health Care.pdf).
c) Mapping of utilization of mental health related services in each Study Area by analysing available datasets (for instance, hospital discharge rates, mean length of stay, mean outpatient visits from the Mental Health Service Inventory). They also include rates and ratios of contacts with outpatient care and admissions to residential care beds and day care places.
Mapping of the workforce. The staff was measured in Full Time Equivalents and
presented as multi-professional groups composed of different types of workers by BSICs.

Procedure
The REMAST study was jointly coordinated by the University of Verona (Italy) and PSICOST and Loyola University (Spain) within the REFINEMET group. Prior to the study, the study areas suggested by every national partner where revised and agreed by the group. A formal partnership with the official agencies was established with the Mental Health unit at the Department of Health in Catalonia (Spain) and with the Department of Health in Finland. Additionally officers from the units of mental health of Bizkaia and Gipuzkoa (Basque Country, Spain) participated as observers. Data collected in the 8 Refinement Study Areas refer to the years from 2008 to 2011.

Step 1 –Training and Codification: First the DESDE-LTC approach to service assessment was presented and discussed by the Refinement group. Taking into account the problems identified in the accuracy and reliability on the data collection of services and the high level of training required to complete DESDE-LTC identified in previous studies (Salvador-Carulla et al, 2013), an online course and training material was made available to the researchers of the 9 project partners (www.desdeproject.eu) . In addition two face-to-face training courses were provided by PSICOST in Helsinki and Verona. In all 19 researchers from all Refinement centres except for France and Romania attended the additional course. At the end of the training researchers rated 12 case vignettes showing 14 MTCs. A multi-judge reliability analysis was made using the Cicchetti Index (Cicchetti et al, 1995) to assess the level of inter-evaluator agreement, averaged across the 19 evaluators and the average level of paired agreement of each individual evaluator with each of the remaining 18 evaluators.

Step 2 - Contact with the services to gather information: The services of the study areas which fulfilled the selection criteria were identified and described together with social and demographic characteristics and other relevant context information into an ad hoc database from the following sources: Mental Health Information Systems (e.g. social insurance and administrative databases, psychiatric case registers); datasets from institutes for statistics; Social Care questionnaires adapted from Health Care ones; interviews to both medical and administrative staff; previous reports; and official and reliable websites. The information registered in every service included: a) Service basic information (e.g. name, type of service, description of governance). b) Location and geographical information about the service (e.g. service of reference, service area). c) Service data (e.g. opening days and hours, staffing, management, economic information, legal system, user profile, number of users, number of contacts or admissions, number of days in hospital or residential structure, number of available beds or places, links with other services). d) Additional information (name of coder, date, number observations and problems registered in the data collection).

Step 3 - Codification of the services. The health-related services providing care for people with mental disorders were coded using the DESDE-LTC classification system, according to their principal MTC. Missing data and non-congruencies were identified by the core group and a second review of the data was made in October 2012. Data cleaning , additional reviews and updates followed to create the final dataset by September 2013 with a total of 748 observations. The territorial comparison was carried out using the principal MTC of every BSIC and the total number of MTCs identified in every area. Ideally a service corresponds to one BSIC that could be described by one MTC. However several MTCs can be identified in a single BSIC, and several BSICs can be recognised in a single service as we have identified in previous studies (Salvador-Carulla et al, 2013).

Step 4 – Counting of the workforce. As for the staff members, “physicians”, “psychologists”, “nurses”, “social workers” and “occupational therapists” were counted using ‘Full Time Equivalents” (FET) per every BSIC and its principal MTC. The category “other workers” was applied to all those health workers whose job is not classified in the other five definitions. For instance, voluntary staff is included in this percentage.

Step 5- Geographical analysis:
The geographical description of the catchment areas encompassed different geographical divisions (e.g. Census, Local Government, LHD Medicare Locals, Primary Care, Housing, etc.). The distribution of mental health services was described through Geographical Information Systems (GIS) technology in all countries where integrated spatial data were available (Austria, Italy, Spain, England, Norway, Finland, France, Romania). In all REFINEMENT countries it was possible to get information on mental health services access, utilization and the populations living in the services area.

Traditional methods to measure spatial accessibility to health care includes provider-to-population ratios, travel impedance to nearest provider, average travel impedance to provider and gravity models that provide a measure that accounts for both proximity and availability. The spatial analysis in the REMAST makes use of catchment area analysis using drive time isochrones maps, for each of the 8 Refinement countries, to analyse the potential accessibility and ability to travel of the population to mental health services. The catchment area for a health care provider is the geographical area that contains the bulk of served population. Understanding service areas is important for health care providers because it ties the client population to a particular area or set of communities. This area can be examined to see if all populations are being adequately served and to access the diversity of population health needs. Based on this analysis, it is possible to determine how many inhabitants live within one hour driving distance from a hospital or how many people have to drive longer than e.g. ninety minutes to reach any hospital.

Another approach to estimate the spatial accessibility is the enhanced two-step floating catchment area (E2SFCA) whose application needs three main parameters: the supply, the demand and the computation of accessibility measures. The supply is represented by mental health services. All the addresses of the services mapped in the REMAST were geocoded using the Google Geocoding API (V3) and integrated into a GIS software. The demand is represented by the potential pshychiatric clinics users (represented by the population size and location data, obtained from GEOSTAT 1A). Finally the distance between the supply and the demand locations as for the previous method has been calculated using the street networks dataset from OpenStreetMap. The travel time between each mental health services and population location can be calculated using the Origin-Destination cost matrix function of ArcGIS Network Analyst Extension.

Building on previous research (Luo and Qi, 2009), the E2SFCA method consists of applying weights to differentiate travel time zones, accounting for distance decay. In order to differentiate accessibility within a catchment, multiple travel time zones within each catchment are obtained using the ArcGIS Network Analyst and assigned with different weights according to the Gaussian function (Kwan, 1998; Wang, 2007).

Hospital-based acute services
According to the DESDE-LTC classification, all hospital-based acute services categorized as MD-R1 and MD-R2 were included, where MD stands for services specifically addressed to mental health care and R stands for Residential services. All mapped services were in fact firstly classified as either MD (Mental Disorder) or MG (Generic Medical Users) according to the type of care provided. The distinction between MD and MG was considered also for mobile services (see following section).
The codes R1 and R2 refer to acute facilities where users are admitted because of a crisis, a deterioration of their physical or mental state, behavior or social functioning which is related to their health condition. In these services, admissions are usually available within 24 hours and users usually retain their own accommodation during the admission. All R1 and R2 services belong to a hospital setting and a 24-hour physician cover is provided. More specifically, R1 services provide continuous surveillance for 24 hours a day and special isolation measures can be applied. Users are admitted in these facilities because they are considered to be too dangerous to themselves or others to be managed adequately in non-secure facilities, or because of a specific legal judgment which states that for reasons of safety they must be admitted to these particular facilities rather than to the local generic facilities. R2 services have the same characteristics of R1 facilities but their users usually retain their own accommodation during the admission. Moreover, R2 facilities provide regular care (medium intensity) of surveillance and/or security for in-patient admission. For example, hospital units where routinely admissions from a specific catchment area included are coded as R2, as well as acute units from general hospitals, psychiatric hospitals and other specialist hospitals.
For both R1 and R2 facilities, the following data were collected: service basic information (e.g. name, type of service); location and geographical information about the service (e.g. service of reference, service area); useful info and contacts (e.g. local definition of the service, sector); service data (e.g. opening days, opening hours, staffing, system management, economic information, legal system, user profile, number of users, number of contacts or admissions, number of day in hospital or residential structure, number of available beds or places, links with other services); and evaluator information (name and contacts, observations). Forensic services were excluded from the mapping.
In order to provide a clear picture of the availability and efficiency of hospital services for mental health care, mental health beds were counted. These are beds maintained for continuous use by patients with mental disorders. In detail, the highest number of acute hospital services was reported in Finland (n=22) while in Spain only 1 hospital service was mapped. The highest bed rate per 100,000 adult inhabitants was registered in France (63.38) whereas the lowest one in Spain (7.01). Beds rates are similar instead across the Study Areas of Austria, England, Finland and Norway. Acute beds were mapped for both units/wards and institutions, thus including also non-acute beds as part of the same hospital/institution. This may influence how the system works and hence bed rates, AloS etc.
Secondly, data on staff number and working hours were collected, by considering firstly the single professional figures (doctors, psychologists, nurses, social workers, occupational therapists and other health workers) and then by grouping them in 4 multi-professional teams (Team 1 = Doctor+ Psychologist + Nurse + Social Worker or Occupational Therapist; Team 2 = Doctor + Nurse; Team 3 = Doctor + Psychologist + Nurse; Team 4 = Doctor + Psychologist + Social Worker or Occupational Therapist). Data on staff were collected using Full Time Equivalents (FTE). FTE is a unit to measure the amount of the workforce per unit of time, thus allowing comparisons across services or systems with different average numbers of weekly working hours per employee. FTE at the individual level is often used to measure a worker's involvement in a project, while, in an organization, it may be used to track cost reductions. A FTE of 1 refers to a full-time worker, while a FTE of 0.5 signals a half-time worker.
Finally, geographical information about these services were collected through a Geographical Information System (GIS) in order to describe the density of hospital services in the Study Area and verify their distances from other mental health services and from the most inhabited areas.
As for the density of acute hospital units for 1000 square Km it is interesting to note that the Norwegian Study Area is 18 times bigger than the Italian one, thus showing an evident difference in the distribution of the services in these two Study Areas.

Mobile services
Out of the 9 countries included in the REFINEMENT project, three (Austria, Estonia, Romania) were excluded from these analyses since they did not provide the information on the mobile services because they were not publicly available. Mobile services were identified by a specific code, according to the DESDE-LTC. The codes O1, O2, 05, and O6 and O7 referred to all mobile services, with the codes O1 and O2 referring specifically to acute services, and O5 and O6 to non-acute ones and O7 to low intensity mobile services. The DESDE-LTC instrument defines mobile services as those facilities where user contacts occur in a range of settings including users’ homes, as judged most appropriate by professionals and users. For a service to be classified as mobile, at least 50% of contacts should take place away from the premises where the service is based. Moreover, according to the DESD-LTC definitions, acute mobile services are those facilities where users are regularly admitted because of a crisis (deterioration in physical or mental state, behavior or social functioning which is related to his or her condition) for alleviating this deterioration. The admission to the acute program is usually available within 72 hours. Non-acute mobile services are all the other mobile services not meeting these criteria.
A total of 184 mobile services were mapped: 114 mental health oriented services (Mental Disorder - MD) and 70 services for general health (Medicine General - MG), according to the distinction provided by the DESDE-LTC instrument. In all countries but Norway and France, mobile services were mostly MD instead of MG. In England, Finland and Spain no MG services were mapped. However, missing rates were not reported since not in all countries it was possible to identify available services. For instance, in the sole Norwegian Study Area, in two municipalities (Osen and Midtre-Gauldal), services could not be mapped and were thus not included in the global analyses.
Other workers are all those health workers whose job is not classified as “doctors”, “psychologists”, “nurses”, “social workers” or “occupational therapists”. For instance, voluntary staff is included in this percentage. On the total workforce, the highest percentage of nurses is reported in Finland (70.74%). Interestingly, occupational therapists are the least employed type of staff in all countries: they are employed only in England (8%), Norway (1.16%) and France (3.64%).
As for the number of opening days and hours, the averages have been calculated considering all services (e.g. for Verona 6.375 is the average of opening days per week of all 8 MD services, 6.33 for all 3 MG services and 6.36 for both MD and MG services).

FINCENTO: Financial incentives and disincentives (for details and references see Deliverable D5.1)

PRIMARY CARE

Austria
The dominant type of primary health care in Austria are self-employed single handed primary care physicians, around half of them having a contract with one or several of the 19 Social Health Insurance Funds (SHI). Social Health Insurance (SHI) is obligatory in Austria, and also the membership of the 19 SHI Funds cannot be chosen freely, but depends on the profession or on the place of employment.
The primary care physician is paid by Social Health Insurance Funds a) by a flat rate for all patient visits over a defined time period (as a rule 3 months, some SHI Funds one month) and according to FFS-catalogues. However, there are 19 different Social Health Insurance Funds with a) different items in the FFS catalogue and b) different amounts of remuneration for the flat rate per patient per time period for comparable health care activities. In the FFS-items of the majority of Social Health Insurance Funds there are no user charges for the patient, however, in some Health Insurance Funds (e.g. for civil servants) patients have to pay user charges (usually 20% of the tariff-catalogue price). Self-employed primary care physicians working in group practices are only an occasional phenomenon.
Around 40% of the single handed practitioners have no contract with the Social Health Insurance and patients are billed by the doctor. However, if the patient is insured with one of the 19 Social Health Insurances (which 99% of the Austrian population is) the patient can hand in the bill to his/her Social Health Insurance Fund and will be reimbursed 80% of the tariff-catalogue-price, regardless of how high the doctor’s bill was. This obviously also applies to a substantial degree to the above mentioned tariffs, however, since patient contribution can be quite high it is assumed that the use of the second type of general practitioner is probably restricted to more affluent patients.

United Kingdom
Self-employed primary health care physicians in group practices are the dominant subtype of primary care service providers in England. About 25% of GPs work on a salary basis in GP practices or in small private companies. Self-employed primary health care physicians working in single handed practices also exist, but such services are not common. Primary health care practitioners are private for profit and are paid from 2013 by Clinical Commissioning Groups. Before that time other local commissioning bodies, Primary Care Trusts, were the contractors and payers. The main contractual payment mechanism for self-employed primary care physicians in group practices or single handed is risk adjusted capitation. Function payments (e.g. bonus for non-contractual services or out of hours care) also add to GP income. Currently target payments, which are defined by the Quality and Outcome Framework (QOF), account for up to 25% of the income of a practice. No user charges apply in primary health care services for NHS services and primary health care physicians have a strict gate-keeping function for access to secondary care, with the exception of access to the “Individual Access to Psychological Therapies” programme where individuals can self-refer themselves directly for psychological evaluation and support.

Finland
Primary care is mainly provided in Municipality Health Centres by employed professionals. Shortage of physicians has forced many municipalities to buy workforce from private staffing agencies. In these cases there is a contractual agreement between the municipality and the staffing agency, who acts as the employer for the physicians and other health care personnel. The legal owners and payers of these Health Centres are the municipalities and usually there is therefore no payer provider split. Some large municipalities have introduced a payer-provider split within the municipality, i.e. municipal purchasing decisions have been separated from management of municipal provision of health and social services. The Municipal Health Centre has a budget. Primary care physicians are employed and as such salaried (67% of their income on average) but also receive fee-for-service (26%) and function payment (5%). (The percentages may vary across physicians). Patients have to pay user charges, with some exceptions (e.g. children under the age of 18 are exempt from user charges).
The gate-keeping system was rated as soft, which means in that case partly, as in practice, patients often access secondary care via the emergency departments of hospitals. Moreover, patients can access secondary care via private care and occupational health care.
The employed population (over one third of the total population) can use occupational health care which is provided often by private for profit organisations. These occupational health care providers are paid by patients’ employers. The providers pay contracted physicians by fee-for-service per visit or by salary. There are no user charges for patients.
Self-employed physicians, rarely single handed, mostly in group practices, work on a private for profit basis are paid by the patient and are free to determine their fee for their service. The group practices are increasingly owned by national or multinational health service chains. Patients can apply for partial reimbursement (in 2012, the reimbursement was approximately 22% of the physician’s actual fee on average) from the National Health Insurance. During each year, approximately 30% of the population receives reimbursement for visits to a physician.

France
Primary care is mainly provided by self-employed primary care physicians who belong to the so called Sector 1 scheme (92%). 60% of the Sector 1 physicians work singlehanded and 40% in group practices. Sector 1 means that physicians apply the statutory tariffs set out in the national agreement convention with the National Union of Health Insurance Funds (UNCAM). 8% of the self-employed primary health care physicians working single handed or in group practices belong to Sector 2. Sector 2 means that they are allowed to practice extra billing. Doctors who opt out for Sector 2 relinquish some of the social and fiscal advantages normally accorded to doctors under the Sector 1 agreement.
The main mechanism of payment is fee for service, with a fixed consultation fee to which additional fees for specific activities performed during the consultation can be added. Target payments account for a small amount of the physicians’ income (not more than 10%). In case of treatment of chronically ill patients under the so called ADL-scheme (affection de longue durée) physicians are paid with an extra flat rate per year. For mental health, long term psychiatric conditions (patients suffering for at least one year from psychotic disorders, mood disorders, intellectual deficiencies or severe personality disorders) are included in the ADL scheme. In most cases, self-employed professionals are paid directly by patients at the time of the provision of the service; the SHI system usually only reimburses the patient at a later stage and usually only partially. The patients have to co-pay (except if they belong to the ADL-scheme). They can opt for voluntary health insurance to cover this co-payment.
If patients have decided to have a gatekeeper doctor (“medecin traitant - MT”), i.e. have decided for the preferred doctor scheme (which is considered as soft gatekeeping), they have to co-pay 30% of the FFS-tariff-catalogue price after referral to a specialist (including psychiatrists). In case they were not referred within the preferred doctor scheme, patients have to co-pay 70% of the billed amount. Patients attending Sector 2 physicians generally have higher co-payments, as Sector 2 physicians can charge up to 19,1% of the official tariff.
(Psychiatrists can always be accessed without referral by 16-25 year old patients and patients under the ALD scheme for chronic mental disorders, in which case the regular reimbursement (70%) applies.)

Italy
Primary care is mainly provided by self-employed single handed primary care physicians who work private for profit; occasionally primary care physicians are self employed in a group practice. The National Health Service (SSN) is the payer and the main payment mechanism is risk adjusted capitation (by age). There is a limit on the amount of patients that GPs can have on their list. The ceiling is 1200 persons (up to 1500 in some cases). Additionally fee-for-service is provided for specific services (e.g. treating diabetes, influenza vaccination) and target payments are used for incentivising specific tasks (e.g. for using drugs whose patents have expired). The income generated by targets is below 10% of a GPs total income. Patients have to co-pay only for very few services and gatekeeping exists, but does not apply to mental health services, which can be accessed directly by patients.

Norway
Self-employed primary care physicians working in group practices are the dominant primary care service providers. Self-employed primary care physicians working single handed are an occasional subtype of primary care providers. Both types of primary health care providers are paid by the municipalities and co-paid by the state. They are private entities with a contract to work in the public system. Only 3% are completely private businesses. Self-employed primary care physicians receive a capitation from the municipality (introduced 2001) which makes up about 25-35% of their income. Fee-for-service presents about 65-75% of their income. The patient pays part of the FFS tariff out of pocket until he/she reaches a ceiling, the other part is paid by the state (National Insurance Scheme of the central government/ administered by Norwegian Health Economics Administration (HELFO), which is a department in the Norwegian Directorate of Health which is a subordinate agency of the Ministry of Health and Care Services).
Municipal health centres (with employed primary health care physicians) are an occasional occurring subtype of primary health care. These centres receive a budget from the municipality. In this case FFS is paid by the state to the municipality, the same tariffs as for self-employed primary care physicians apply. Patients pay a share of the FFS tariff out of pocket. In Norway strict gatekeeping for access to secondary care applies.

Romania
Single handed self-employed primary care physicians are the main and dominant service providers, self-employed primary care physicians working in group practices are also common. As private for profit organisations GPs are paid by the National Health Insurance House CNAS. The main payment mechanism is a risk adjusted capitation and fee-for service. At the time of data collection in November 2012 the capitation part accounted for 90% and the fee-for-service for 10% of a physician’s income. Patients do not have to pay user charges in primary care services. Primary care physicians act as gatekeepers for access to secondary care.

Spain
In Spain the dominant type of primary health care services are health centres, called CAPs and the legal owner of the services in 80% is the public/government and in 20% the health centres can be considered as semi-public. Concerning provider-payer-split the situation varies in different regions in Spain. E.g. in Catalonia provision and funding are split in two different agencies.
The main payment mechanism in primary health care is a global budget. Additionally the providers can receive target payments, which can add up to 15% of the total amount of payment. The providers sign a purchase contract with the Regional Health Authority. The contract specifies a global budget to provide services or specific programs related to mental health, and also a variable budget linked to specific objectives (targets) which can be selected from a priority basket. Staff in health centres is employed. In Spain there exists a strict gate keeping system to secondary care. In health centres patients do not have to pay user charges. Self-employed physicians, either single handed or in group practices, are rare and are mainly relevant for patients with private insurance or for civil servants who are insured by the MUFACE insurance system, which is a type of obligatory health insurance; civil servants can choose to attend health centres or self-employed physicians.

SPECIALISED MENTAL HEALTH OUTPATIENT CARE

Austria
Psychiatric ambulatory care is provided mainly on the one hand by single handed self-employed psychiatrists either with a contract with the Social Health Insurance Funds (SHI) or with no such contract, and on the other hand by outpatient services of community mental health centres.
Single handed self-employed psychiatrists with a contract with the Social Health Insurance Funds receive a flat rate per patient for a certain period of time (which makes up around one third of their income) and fee-for-service according to the FFS-catalogue of the Social Health Insurance Funds. There are 19 different Social Health Insurance Funds with different FFS tariffs and different flat rates. In case psychiatrists have no contract with the SHI the patient is billed and gets reimbursement for 80% of the FFS tariff. However, as the billed amount is usually higher than the FFS-tariff patients’ user charges can be quite high.
Community mental health centres receive a budget and staff is employed. Rather severely mentally ill patients attend this subtype of service, while less severely ill are rather treated by the single handed psychiatrists. Psychiatric outpatient services of hospitals are less common.
Self-employed psychotherapists work on an FFS per session basis, and two models can be found, a) services provided by psychotherapists who are members of an association that holds a contract with SHI with volume limit or b) patients are billed and receive a reimbursement from the SHI of €21.

United Kingdom
In England psychiatric ambulatory care in outpatient services of hospitals or in mental health centres is comparatively rare. The stepped care philosophy stipulates that the GP is supposed to take care of the less severely ill/less complex patients. Moreover, people with more severe mental health needs should be transferred back to the care of the GP as soon as possible. Multidisciplinary community mental health teams as a mobile service going to a patient’s home or another community setting (e.g. local church hall, library or office), are the main/dominant type of specialised outpatient care. The community mental health teams provide assessment and care to people with mental health problems and support primary care services.
The main payment mechanism of the three subtypes is a budget that is allocated to the so called (regional) “mental health trust”, and around 2,5% can be earned by CQUIN “Commissioning for Quality and Innovation (CQUIN) Payment Framework“ (see below). The “mental health trust” defines the targets and then pays the additional money if targets are met. The budget will be replaced by payment by results from 2013 (although this is called payment by results it can be considered as an activity based payment). There will be 21 clinically defined mental health clusters based on need, not diagnosis which will represent the currency for the mental health payment by results. There are no user charges for patients in psychiatric ambulant or mobile care.

Finland
Psychiatric ambulatory care is mainly provided in outpatient services of a community mental health/psychiatric centre. In addition outpatient services of a hospital are common. Outpatient services of a community mental health/psychiatric centre services are owned by single municipalities or by joint municipalities, i.e. hospital districts. The municipality either provides the services itself or it purchases them from the hospital district. In the latter case a contract between the municipality and the hospital district defines the budget and amount of services. The most common method of municipalities’ payment for an outpatient visit is a prospectively defined fixed fee per visit. Expert opinions differ whether there is a real provider-payer split in outpatient services of a hospital.
There are no user charges for patients in specialised mental outpatient care. Psychiatric ambulatory care provided by private psychiatrists, psychologists and psychotherapists (either single handed or in group practices) is an occasional service-subtype used by rather less severely ill patients, who are billed and reimbursed about 25% of the doctor’s fee by the NHI on average (National Health Insurance).

France
In France there are two dominant subtypes of ambulant outpatient care:
(1) Self-employed single handed psychiatrists belonging to the Sector 1 scheme (in 2008
70,9% of the self-employed single handed psychiatrists belonged to Sector 1). Sector 1 means that psychiatrists apply the statutory tariffs set out in the national agreement convention with the National Union of Health Insurance Funds (UNCAM). Sector 2 means that they are allowed to practice extra billing. The main mechanism of payment is fee for service. In case of treatment of chronically ill patients under the so called ADLscheme (affection de longue durée) physicians are paid with an extra flat rate per year on top of the fee for service rates. Four mental health long term psychiatric conditions (patients suffering for at least one year from psychotic disorders, mood disorders, intellectual deficiencies or severe personality disorders) are included in the ADL scheme. In most cases, self-employed professionals are paid directly by patients at the time of the provision of the service; the SHI (Social Health Insurance) system usually only reimburses the patient at a later stage and usually only partially. If patients belong to the ADL-scheme they do not have to co-pay. Patients attending Sector 2 physicians generally have higher co-payments, as Sector 2 physicians can charge above of the official tariff.
(2) Community mental health centres (Centres-Medico Psychologiques - CMP) receive a budget allocated by the Ministry of Health (MoH). Patients attending mental health centres do not have to contribute out-of-pocket payment. Psychologists or psychotherapist services have to be paid by the patient and are private-private services, some exceptions exist, e.g. a network of healthcare professionals provides psychotherapy to patients identified by a commission as in need of treatment. A specific financial agreement with the SHI exists for this.

Italy
The main subtype of psychiatric ambulatory care is the publicly owned community mental health centre. Publicly owned standalone outpatient services and outpatient services of a hospital also exist. The services are contracted and paid by the National Health Service with a global budget, which is negotiated each year on the basis of a historical budget. Staff can earn a bonus by performance related targets.
Self-employed psychiatrists working single handed or in group practices are not very frequent, the same applies for self-employed psychologists/psychotherapists. Psychiatrists and Psychologists working on their own practice bill the patients.

Norway
In Norway there are two main subtype of psychiatric ambulatory care. The District Psychiatric Centre (DPS) and the Municipal Mental Health Services. The Municipal Mental Health Services are important in the Norwegian system and provide services that are at least partly found in mental health centres in other countries including psychiatric nurses and social workers and provide both office-based and mobile/home services.
Some municipalities are also organising ACT-teams in cooperation with a DPS. There is no provider-payer-split for the Municipal Mental Health Services and they receive a budget. In the 2013-budget of the Ministry of Health and Care Services about 800 mill NOK was earmarked for mental health in the municipalities.
Outpatient services are also found in hospitals. All organisations with employed staff are publicly owned. Outpatient services of hospitals and, primarily, DPS may be geographically standalone. The DPS and hospital services are however part of larger Hospital trusts receiving a global budget from the Regional Health Authority they belong to (there are four Regional Health Authorities - RHAs). In addition they receive fee-for-service payment from the state (National Insurance Scheme of the central government/administered by Norwegian Health Economics Administration (HELFO), which is a department in the Norwegian Directorate of Health which is a subordinate agency of the Ministry of Health and Care Services).
Single handed self-employed psychiatrists are common in urban areas. Psychologists and psychotherapists are also a common subtype; group practices among those professionals occasionally exist. Contracted self-employed specialists receive a FFS from HELFO in addition to an operating subsidy (grant) from the RHA with which they contract. The size of the grant is within certain limits in a nationally negotiated scale. FFS in mental health services with employed staff constitute of two different types of tariffs. One is activity independent, based on the number of outpatient personnel (rate per hour patient related outpatient work per year that is performed by approved personnel). The other one is activity dependent rates (e.g. consultations, tests). Municipal co-payment is not yet introduced for secondary mental health care provision, as is the case for non-surgical physical health patients, but an introduction of such municipal co-payment is considered. The time frame for implementation is not yet decided.
Patients have to pay user charges in all types of psychiatric ambulatory care, except for Municipal Mental Health Services. No specific patient types are selected in District Psychiatric Services and for Municipal Mental Health Services. Outpatient services of hospitals treat rather severely ill patients. In the private-for-profit services of psychiatrists, psychologists and psychotherapists rather less severely ill patients are treated.

Romania
Psychiatric ambulatory care is provided mainly on one hand by single handed self employed psychiatrists and on the other hand by community mental health centres and outpatient services of a hospital. Single handed self-employed psychiatrists work private-for-profit and get paid from the National Health Insurance House (CNAS) on an FFS basis. The same applies to psychiatrists in group practices.
Community mental health centres, outpatient services of a hospital and standalone outpatient services are publicly owned. They receive a global budget for the salary of their staff from the Ministry of Health. Community mental health centres rather serve severely ill patients, while the self-employed professionals rather work with less severely ill patients. Patients have to pay user charges.

Spain
In Spain the main subtype of psychiatric ambulatory care are community mental health centres, either owned publicly or semi-publicly or privately not for profit. Each Autonomous Community has developed different patterns of legal ownership of services, e.g. Andalucía and Cantabria have only publicly owned providers. The payer is the Regional Health Authority (e.g. in Catalonia: CatSalut). A payer-provider split does not always exist. The same applies to the outpatient services of a hospital, but such services exist only occasionally. Both subtypes of services are paid by a global budget and additionally target payments can supplement the income of the provider. Patients do not have to pay user charges, and rather severely ill patients attend these services. All other subtypes exist only occasionally and are paid according to fee-for-service tariffs either by the patient or by private insurances. Private insurance schemes are increasingly relevant in Spain, e.g. up to 20% of the population are covered by private insurance in Catalonia.

INPATIENT CARE

Austria
In Austria three main types of specialised inpatient mental health care exist: (1) standalone psychiatric hospitals for acute care, which are publicly owned, (2) psychiatric departments in general, non-university hospitals, either with public or private providers, and (3) psychiatric departments in university hospitals, which are publicly owned. The payers for all three subtypes are the Regional (=provincial) Hospital Funds (there are nine Funds; each of them pooling contributions from Social Health Insurance and taxes in a complicated mix). The payment mechanism is DRG/ABF – which is in Austria a system based on defined medical procedures and diagnoses related groups.
The principles are the same for paying for patients with a psychiatric disorder as for those with a physical disorder. The DRG model is an instrument for standardised grouping and scoring of inpatient hospital stays across the whole country. It includes the concrete definitions for all procedure-oriented case flat rates (LDF points), for supplementary points for intensive care and for all special areas and special cases. The Austrian DRG system is intended to assure a better transparency of the procedures performed and has contributed to a reduction in the annual rates of increase in hospital costs.
Since the provincial fund is fixed and reimbursement of hospitals is calculated in points, whose monetary value is only determined at the end of the year (by dividing the predetermined budget of the fund through all points accrued from all hospitals in a province) costs are contained (there are mechanisms in place to compensate hospitals for deficits in some provinces, which in some sense devaluate the DRG system). This represents a different incentive-structure than DRG-systems with fixed monetary values for a point. Patients have to pay user charges (around €10 per day).
Stand-alone psychiatric hospitals providing chronic care are rare and they are paid on a per diem basis by the Regional Social Care Funds. It is no clear why some of these chronic care institutions have hospital status, while the majority of patients with chronic disorders are in social care homes, which are also paid on a per diem basis by the Regional Social Care Fund.

United Kingdom
In England at the time this report was written changes in payment mechanism in inpatient care (as well as in outpatient care) were ongoing. Payment by Results (PbR) – (considered as an activity based funding/ABF) for mental health services for adults and older people is currently being phased since the beginning of the financial year in April 2012. There will be 21 clusters, based on need not diagnosis, which will represent the currency for the mental health PbR. The tariffs are associated with Healthcare Resource Group (HRG) use. An HRG is a casemix group. Different patient treatments within a cluster of both diagnosis and procedure, which are deemed to have consumed the same level of resources, are assigned to an HRG. Prices in the national tariff have been set on the basis of the average cost, providing a particular procedure, using data gathered from all NHS hospitals.
In future all contracts for the coming financial years will be negotiated on this basis, however, in contrast to PbR for physical health, prices for each mental health cluster will initially be agreed locally rather than based on a national tariff. The clusters will become the primary contract currency used in the standard mental health contract. This means that commissioners will be paying providers on the basis of x people in cluster 1, y people in cluster 2 and so on. From the financial year April 2013 - March 2014 national tariffs for clusters are supposed to be in place. However any decision on whether to move to a national tariff for each cluster will be dependent on having a clear evidence base to support that move.
The main subtypes of inpatient care are psychiatric departments in general hospitals. Most of these hospitals will have medical students and trainee doctors and will have formal links (or be part of a university), but there is no separate university hospital system in England. In some parts of the country there will be small standalone psychiatric units typically with no more than 10-20 beds providing some acute inpatient services and longer term care for a small number of service users. 97% of services are provided by the NHS, but there are a small number of private service providers who have a significant share of the complex case and addictive disorder beds in England.
There are some other specialist services, including stand-alone units for people with addictive disorders and mother and baby units for women with post natal depression and other mental health problems.
The Mental health trusts will be the legal owners of most psychiatric units; they are also the commissioners of these services so there is often no purchaser provider split. They may also own hospitals that also provide services for other groups of non-mental health related service users, such as older people. Psychiatric units in general hospitals will be most likely be part of separate NHS Foundation Trusts which enter into contract with Mental Health Foundation Trusts. The non-statutory sector is a significant provider of places in secure and intensive care units. In respect of complex care, 34% of secure (low and medium) and psychiatric intensive care unit (PICU) services (2,533 beds) were provided by the non-statutory sector in England in 2011. In two strategic health authority regions over half of the investment was reported to be placed with non statutory providers - East Midlands (58%) and the West Midlands (51%). The region with the lowest proportionate investment with non-statutory providers was London Strategic Health Authority (10%).
It should also be noted that a minority of hospitals and specialist health care facilities in England have been built under the terms of the Private Finance Initiative. These facilities are owned by the Private Sector which has entered into long term leasing contracts with the NHS. At the end of the term of the lease the hospital is still owned by the private sector.
Performance related payments in the Commissioning for Quality and Innovation (CQUIN) payment framework can be earned by hospitals. How the CQUIN is determined will vary from locality to locality and some CQUIN frameworks will put little focus on mental health. The CQUIN applies to specialised inpatient and outpatient care (see also the example for England in the section on specialised outpatient care in this report). The payment achieved by the CQUIN targets cannot be more than 2,5% of the contract value.
Where independent sector providers are used (most likely for secure services and eating disorders) detailed specific contracts were common and have stipulated the level of activity that may be funded by the commissioning body. They usually also set out risk sharing protocols for any excess use of services over and above these levels. There may also be ‘named patient contracts’ which set out in detail the level of services and contract requirements for an individual service user with complex needs.

Finland
In Finland common types of inpatient care are stand-alone psychiatric hospitals providing acute care or chronic care and psychiatric departments in general non university hospitals. Occasionally psychiatric departments in university hospitals and state mental hospitals exist. With the exception of the two state mental hospitals, all types of inpatient care are publicly owned by the municipalities. Similar to outpatient care, hospital inpatient care is financed by municipalities according to the amount and type of services utilised by the municipalities’ inhabitants. However, the many different types of pricing for non-psychiatric inpatient care (DRG, package pricing, case-based, etc.) have not been extended to psychiatric inpatient care so far. Per diem payment, which has been the common way of paying for hospital inpatient care in Finland for a long time, is still the prevailing payment mechanism in psychiatric inpatient care.
Patients have to pay user charges (but less for psychiatric care as compared to non psychiatric care).

France
In France stand-alone psychiatric hospitals providing acute and chronic care are the main/dominant subtype of specialised psychiatric inpatient care. Also psychiatric departments in general hospitals and in university hospitals can be found. In the case of stand-alone psychiatric hospitals providing acute and chronic care these are in around 80% publicly owned, in 20% they are private. The psychiatric departments in general hospitals can be publicly or privately owned, and are publicly owned in university hospitals. The public providers are financed by a global budget dedicated by the Ministry of Health. In case of private-for-profit-providers, per diems are the main payment mechanism. Patients have to pay user charges.

Italy
The main/dominant subtype of specialised inpatient mental health care is a psychiatric department in a general, non-university hospital. Other occasionally occurring subtypes are psychiatric departments in university hospitals, psychiatric beds in psychiatric centres/ mental health centres and private inpatient facilities. The National Health Service (SSN) pays for psychiatric departments in general hospital and in university hospitals. University departments work under a trust between NHS and University. The main payment mechanism in all subtypes of mental health inpatient care is DRG, and there are no user charges for the patients. In public hospitals or hospital departments staff can increase their salaries by achieving targets.

Norway
In Norway the secondary health care services are organised in Health enterprises (Hospital Trusts), each with a separate catchment area. All Hospital Trusts have hospital services and district psychiatric centres (DPC). The hospital organisations (departments) in a trust may be located at one or several locations, which may be geographically co-located with the somatic part of the Hospital Trust (general hospital) or not (stand-alone). No mental hospitals are stand-alone organisationally; the standalone hospitals are departments of a Hospital Trust (general hospital). Some Hospital Trusts are university hospitals.
The main subtypes of inpatient mental health care are psychiatric beds in psychiatric centres/mental health centres (DPS – District Psychiatric Centres). The common subtypes of inpatient mental health care are stand-alone psychiatric hospitals providing acute and chronic care, psychiatric departments in general hospitals and in university hospitals. All subtypes are publicly owned and within the responsibility of the Regional Health Authorities (RHA). The payment mechanism in all subtypes is a global budget. Patients do not have to pay user charges.

Romania
Psychiatric departments in general hospitals are the main/dominant type of inpatient psychiatric care in Romania. Stand-alone psychiatric hospitals for chronic care and psychiatric departments in university hospitals are common. Occasionally stand-alone psychiatric hospitals for acute care exist. All subtypes of inpatient care are publicly owned and the payer is the Health Insurance House (CNAS). Stand-alone psychiatric hospitals for acute care are paid per flat rate per hospital episode. This payment mechanism also applies to one subtype of stand-alone psychiatric hospitals providing chronic care, another subtype receiving per diems. Psychiatric departments in general hospitals and in university hospitals are paid on a DRG basis. Patients have to pay user charges for all subtypes. Psychiatric departments in general hospitals and in university hospitals deal with rather less severely ill patients. In stand-alone psychiatric hospitals providing chronic or acute care all type of patients can be found.

Spain
In Spain common subtypes of inpatient psychiatric care are psychiatric departments in general hospitals and in university hospitals and psychiatric beds in psychiatric centres/mental health centres. Stand-alone psychiatric hospitals for acute and chronic care exist only occasionally. The legal owners of the hospitals or health centres can be public, semi-public or private not for profit. The payer is the Regional Health Authority (e.g. in Catalonia this is CatSalut). All subtypes are paid by a global budget – which is the main payment mechanism - and target payments are part of the contractual agreements. All services, except stand-alone psychiatric hospitals for chronic care also get additional payment on a fee-for-service basis (FFS is around 6-7% of the annual income). There are no out-of-pocket payments for patients.


REPATO: Pathways of care (for details and references see Deliverable D7.1).

Based on a systematic mapping of the literature, the REPATO tool was developed to identify the typical and most relevant pathways of mental health care and to identify system and service related factors, which could predict differences in service utilization patterns between the REFINEMENT partner countries (Austria, England, Finland, France, Italy, Norway, Romania, and Spain). The REPATO allowed three approaches to provide the requested information: (a) analyses of existing data, (b) review of empirical findings and (c) expert interviews. The following three major research topics were defined:
1. Pathways on the interface between primary and specialized mental health care
Special attention was paid to the distribution of cases between the local primary and secondary levels of care (e.g. referral rates by general practitioners to mental health specialists; proportions of referrals from different sources to mental health services, etc.) and on the extent, to which general practitioners treat service users with psychiatric disorders themselves or refer them to psychiatric care (or may be follow a “shared care paradigm”).
2. Continuity of mental health care (and its opposite, disengagement or dropout)
We collected information on the extent, to which the discrete elements in the care pathways of individuals are linked and coordinated and the stability of service user‐provider relationships over time is ensured. Additionally we focused on interruptions and discontinuations of care pathways, demonstrated by the extent of dropout from mental health treatment.
3. Psychiatric hospital readmissions
Various data on readmissions after acute psychiatric hospitalizations were collected. As after hospital discharge the responsibility for prevention of readmission passes gradually from the hospital to the community provider/s, we differentiated between earlier and later readmissions and could relate our findings more precisely to hospital- vs. Community-related variables.

Pathways on the interface between primary and specialized mental health care.
In all countries, a primary care service (GP) is the service type that is typically and most commonly utilized to make an initial outpatient contact with health services in case of a mental health problem.
Concerning the most frequent subsequent (following initial outpatient contact) service utilization pattern for outpatient mental health treatment, differences between the REFINEMENT countries were reported: in half of the countries (ENG, FIN, ITA and ROM), a combined treatment from primary care (GP) and specialized mental health services (e.g. self‐employed psychiatrist or psychologist, community mental health centre) is the predominant subsequent service utilization pattern; three countries (AUT, NOR, SPA) reported, that not only the initial, but also the subsequent outpatient treatment for mental health problems is primarily performed only within primary care, respectively by a GP; in FRA, individuals with mental disorders are followed up either by a GP or by a mental health professional. Co‐treatment by primary and specialized mental health services over time is rare.
Except AUT, all countries reported differences between service users with a severe mental illness and those with a common mental illness in the sense that the former are more often referred to specialist care.

The most relevant outpatient mental health service types, to which individuals with mental health problems are referred by their GPs, are:
- Self‐employed psychiatrists in private practice: AUT, FRA, ITA, NOR, ROM
- Psychotherapists and/or psychologists: AUT, FIN, FRA, ITA, NOR
- (Community) mental health centre / Ambulatory care centre (CMP) / District psychiatric centre (DPS): AUT, FRA, ITA, NOR, ROM, SPA
- Psychiatric outpatient clinic / hospital unit: FIN, NOR, RO
Mental health professionals in primary care (depression nurse / primary care community mental health team): FIN, NOR
- Access and Assessment Team, community mental health teams (incl. specialist CMHTs), health care professionals: ENG

The majority of the REFINEMENT countries reported, that individuals with a mental disorder are often (FIN, FRA, ITA, SPA: around 40% of service users) or even very often (AUT, ENG, NOR: 80‐90% of service users) treated exclusively by a GP and do not utilize any kind of specialized psychiatric outpatient treatment.
In ROM this mental health treatment pattern occurs only sometimes. In all countries patients with a severe mental illness are more likely to be (additionally) treated by mental health specialists.

Continuity of mental health care.
Although continuity of care is commonly regarded as a central characteristic of high quality care in longer term mental disorders, there is still no common understanding of the concept of continuity of care. In fact, a wide range of definitions which emphasize differing features exists (e.g. Burns et al. 2009, Adair et al. 2003, Haggerty et al. 2003).
With the REPATO questionnaire we primarily collected information on the continuity of follow‐up care after psychiatric hospitalization and on the continuity/discontinuity of outpatient mental health care and in the present report we describe the similarities and differences we found in the participating REFINEMENT countries.
Particular emphasis was placed on:
a) The extent to which the discrete elements in the care pathways of individuals are linked and coordinated and mental health care fulfils the quality criterion of continuity as well as the extent of common pathway discontinuations and interruptions – as indicated by treatment dropouts;
b) Influences of regional (e.g. financing and regulatory mechanisms), organizational (service characteristics) and individual (service user and treatment characteristics) variables on continuity of mental health care.

The four REFINEMENT countries which were able to provide data on outpatient follow‐up care after discharge from acute psychiatric hospitalization (AUT, ITA, NOR, SPA) can be divided in two groups.
In two countries (ITA, SPA) a high proportion of acute psychiatric hospitalizations is followed by outpatient mental health service contacts, namely about one third within one week, about 60% within one month and more than 80% within the first half year after hospital discharge. For the sub‐population of service users with severe mental illness (schizophrenia or bipolar disorder) the percentages are even significantly higher.
In the remaining two countries (AUT, NOR), psychiatric outpatient follow‐up care is utilized to a much lesser degree: only a very moderate proportion of acute psychiatric hospitalizations – just about one third – is followed by outpatient mental health service contacts within the first half year after hospital discharge, thereof less than 10% within one week, and not more than 20% within one month. For the sub‐population of service users with severe mental illness (schizophrenia or bipolar disorder) the percentages are nearly equal or even lower.
In ENG, a study (Department of Health, 2013: Quarterly Mental Health Community Teams Activity data for 2012‐13 Quarter 3) showed that community mental health team follow‐up for patients on CPA (care programme approach for people with severe mental illness) was 98%.
In accordance with the results presented above, the REFINEMENT regions can also be grouped by the average number of days between acute psychiatric hospital discharge and first aftercare visit. While in countries with a high follow‐up rate (ITA, SPA) the average interval between discharge and first outpatient contact is rather short (<50 days), for service users with severe mental illness (schizophrenia or bipolar disorder) it is even shorter (<40 days). In contrast, psychiatric inpatients in AUT and NOR need on average more than 130 days until they utilize outpatient follow‐up care.
The proportion of psychiatric outpatient service users who had no psychiatric outpatient service contact for at least 6 consecutive months ranges from 3% (SPA) to 62% (AUT).
While new psychiatric service users (those with first‐ever contact or first contact since at least one year) significantly drop out more often from psychiatric outpatient care, the drop‐out rates of service users with severe mental illness (schizophrenia or bipolar disorder) are much lower than those of the overall population of psychiatric outpatient service users.

Psychiatric hospital readmissions.
Readmission rates (proportions of all acute psychiatric admissions) were calculated for the intervals of 7, 30, 90 and 180 days and within each category separate calculations for service users with severe mental illness (schizophrenia or bipolar disorder) were made. In all sub‐groups remarkable variations between the REFINEMENT regions could be found. Some countries showed disproportionately high increases of readmission rates over time. In general, service users with severe mental illnesses have higher readmission rates.
Readmissions rates within 7 days vary between 1,1% (ROM) and 11,3% (AUT); for the sub‐population of service users with severe mental illness (schizophrenia or bipolar disorder) the proportions range from 1,7% (ROM) to 18,9% (FRA). The REFINEMENT regions can be divided into those with relatively high (9‐14%: AUT, FRA, ITA) and relatively low (1‐4%: FIN, NOR, ROM, SPA) overall readmission rates within 7 days.
Readmissions rates within 30 days vary between 5,6% (ROM) and 21,8% (FRA); for the sub‐population of service users with severe mental illness (schizophrenia or bipolar disorder) the proportions range from 6,6% (ROM) to 32,5% (FRA). Three categories of REFINEMENT regions can be identified: one with either relatively high (≥20%: FRA, ITA), one with rather moderate (10‐20%: AUT, FIN) and another with relatively low (≤10%: NOR, ROM, SPA) overall readmission rates within 30 days. In general, service users with severe mental illnesses have higher readmission rates.
Readmissions rates within 90 days vary between 12,7% (SPA[m]) and 39,4% (FIN[s]); for the sub‐population of service users with severe mental illness (schizophrenia or bipolar disorder) the proportions range from 15,3% (SPA) to 45,4% (FIN). Two categories of REFINEMENT regions can be identified: one with relatively high (>25%: AUT, FIN, FRA, ITA) and another with relatively low (<20%: NOR, ROM, SPA) overall readmission rates within 90 days. In general, service users with severe mental illnesses have higher readmission rates.
Readmissions rates within 180 days vary between 15,2% (SPA) and 49,7% (FIN); for the sub‐population of service users with severe mental illness (schizophrenia or bipolar disorder) the proportions range from 17,4% (SPA) to 56,9% (FIN). Again, three categories of REFINEMENT regions can be identified: one with either relatively high (>35%: FIN, FRA, ITA), one with rather moderate (25‐35%: AUT, NOR, ROM) and another with relatively low (≤20%: SPA) overall readmission rates within 180 days.
The average number of days between discharge from acute index hospitalizations and first acute psychiatric readmission7 varies between 253 (AUT) and 317 (SPA); for the sub‐population of service users with severe mental illness (schizophrenia or bipolar disorder) the figures range from 233 (AUT, FRA) to 304 (SPA). These results are in accordance with the readmission rates: the lower the readmission rates (especially those within a short timely distance from hospital discharge), the more days lie on an average between hospital discharges and readmissions.
On average, service users with an acute psychiatric hospitalization had up to 2,1 acute psychiatric readmissions within 180 days from their index hospital discharge. The lowest number (1,7) was found in SPA and FRA. In most countries service users with severe mental illnesses have a higher average number of readmissions.
In general, of all service users who had an acute psychiatric readmission (within 180 days after discharge from acute psychiatric index hospitalization), at least 78% (and up to 92%) had also utilized psychiatric outpatient services within this time period. For the sub‐population of service users with severe mental illness (schizophrenia or bipolar disorder) these percentages are even higher (82%‐95%). A remarkable exception is AUT, where only just over one third of service users with an acute psychiatric readmission had one or more psychiatric outpatient service contacts within 180 days after index discharge. This may to a certain degree be explained by the fact that only outpatient contacts with health insurance funded self‐employed psychiatrists are included.

REQUALIT: Quality of care indicators (for details and references see Deliverable D8.1)
Suicide Rate.
Suicide is a serious public health problem and an international health priority. According to WHO, European countries should reduce existing rates by at least a further one-third by the year 2020 (WHO, 1998). Indeed, suicide is a major cause of premature deaths in Europe: 12 of 1000 EU citizens die prematurely due to suicide. In 2006, about 59 000 Europeans in the 27 EU Member States completed a suicide. Risk groups for suicide are above all people with mental disorders, including substance use disorders: 90% of those who die by suicide are suffering from a psychiatric disorder at the time of death, mostly with mood disorders like depression, but also with alcohol use disorders (Wahlbeck & Mäkinen, 2008).
Looking to the overall suicide, the higher rates were in France (23.4 per 100,000 inhabitants), followed by Finland (20.2) Austria (18.9) and Norway (14.8). A lower rate of suicide resulted in Italy (6.8) and Spain (9.2). This trend seems stable also if we consider the rates for male and female alone. This confirms the literature results for Mediterranean countries, which resulted to be the area in Europe with lowest rates. A low rate resulted also in England (10.4) confirming the literature results. According to literature, males presented in all countries a higher level of suicides.

Length of Stay.
According to Key Performance Indicator Framework for New Zealand Mental Health and Addiction Services (2010), the evaluation of length of stay (LoS) provides some information on the extent to which mental health systems support persons with mental illness in the least restrictive environment. LoS indicator is an indicator of continuity of care that, together with the other continuity of care indicators, gives a more complete understanding of an organisation’s overall model of service delivery. Length of Stay ranges from 51 days in UK to about 11 days in Austria and Romania.
As external regulations could influence the LoS, we asked to REFINEMENT partners to describe the presence of these regulations in each study area. In Italy and Austria a threshold LoS is defined for every diagnosis-related group (DRG). This type of regulation does not exist in France and in Finland where there is no DRG system in psychiatry. In Finland, acute in-patient psychiatric care is funded using daily rates, which are not related to the diagnosis or any other patient characteristic. There are no financial incentives to reduce length of stay. On the other hand, due to a lack of definite payer-provider split in Finland (the providers are owned by the municipalities who pay them), the impact of hospital-level financial incentives would probably be negligible. The long average length of stay in Finland most probably reflects primarily clinical tradition and a hospital-based mental health care system.

Involuntary Admission.
Reports of the rates of involuntary admissions across Europe are then necessary for the analysis of the current utilization of this type of treatment. To the best of our knowledge, statistics on involuntary admission are rarely published on an international scale, with the exception of a few studies like the report of Salize and collaborator (2002), especially as far as cross-country comparisons are concerned.
In recent years, the Council of Europe has highlighted the necessity to rethink the legal regulations across EU countries for the involuntary admission of patients in psychiatric institutions and the coercive treatment which seem to affect severely their rights and freedom (Health & Consumer Protection Directorate General of the European Commission, 2005). Currently, the rates of involuntary admissions of people with mental illnesses are widely considered to be an indicator for the legal framework of mental health care across Europe (Salize and Dressing, 2004), and they are used also as an indicator of performance of quality of mental health care for the appropriateness of care in many international health systems. The high number of involuntary admissions of people with mental disorders constitutes in fact a major public health issue (Lay et al., 2012), and one basic objective of the reforms of commitment statues is to reduce the frequency of involuntary admission to mental health care (Harding and Curran, 1979).
The percentage of involuntary admission on the total number of admissions in the REFINEMENT countries range from 30% in Spain to 7% in Italy. While the higher rates of involuntary admissions per 100,000 inhabitants were found in France (166.7) Finland (152.5) Norway (144.9) and Austria (119.8). The raters were lower in Italy (19.6) England (38.9) and Spain (42.4).

Outcome Assessment
An outcome in mental health care is defined as “the effect on a patient’s health status attributable to an intervention by a health professional or health service” (Andrews and Peters, 1994). Measuring outcomes is a crucial element of assessing productivity, which may be defined as the value of health outputs in relation to the value of health inputs (Jacobs, 2009). Aggregate patient-reported outcome measures (PROMs) can potentially be used by managers, regulators and commissioners in contexts such as professional quality assurance and audit and funders’ assessments of the performance and value for money of services that they provide (Fitzpatrick, 2009).
Summarizing the results, differences emerged among REFINEMENT countries for the assessment of outcomes measures. Functioning and symptoms assessment seems to be the most regularly assessed. Nevertheless only in England outcome evaluation (using HoNOS) is connected to the payment system. Quality of life is the domain of outcome less covered by routine assessment procedures.

Satisfaction
Satisfaction is an indicator of the extent to which services and supports meet the needs of users and families, and is considered a key dimension of service quality. Satisfaction reflects both the user’s subjective assessment of quality of care and expectations for it. Persons who use health services are viewed as an appropriate source of information on quality of care and quality improvement. User satisfaction evaluation may be seen as a measure of responsiveness, as suggested for example in the Australia framework (NMHWG Information Strategy Committee Performance Indicator Drafting Group, 2005) According to this statement, the Canadian framework (2001) reported how the appraisals of mental health consumers/families are an important source of information regarding users’ experiences with services, service providers, and service coordination.
In Austria macro area, given the absence of any regulation, satisfaction assessment is performed but not routinely in many services (e.g. community care services; employment services, day care services and residential facilities). One of the main providers of community mental health care in the study area has developed its own questionnaire, which covers the areas of quality of service, quality of life, case management, complaint management, overall satisfaction, and asked its users. Moreover, longitudinal assessment of satisfaction every 6 months using an ad hoc questionnaire is reported in Landeskliniken Holding (public provider company of all hospitals in macro area of Austria). In both cases the results are used to improve services. For example, the Landeskliniken Holding awards those departments which are rated best by the patients, and the results are also used for finding possibilities to improve the services and are part of the quality management.
In France, the Inspector of Health and Social Affairs (IGAS) in 2007 described a situation in France where the French legislation emphasizes the rights of patients - in all health establishments, including psychiatry - expressing their satisfaction and suggested that user evaluation of services is mandatory for all health establishments, including psychiatry, through the court order of April 24th 1996. Nevertheless, there is no centralized, national data collection from this evaluation. Traditionally, complaints and feedback from patients regarding their treatment are given directly to the service provider or in some cases to the Regional Health Authorities, but the valuable information that the patients provide on the perceived quality of care is thereby lost. Also, the frequency and methods of measuring patient satisfaction vary greatly between hospitals and regions. IGAS presented a project, “Coordination pour la mesure de la performance et l’amélioration de la qualité hospitalière (COMPAQH)”, initiated by the French Institute for Medical Research (INSERM) and the General Directory of Health Care Supply (DGOS), that aims to elaborate a set of indicators measuring the performance of establishments and user satisfaction. A pilot study was conducted where 36 health establishments participated, out of which 4 were psychiatric institutions. According to hopital.fr and General Directorate of Health Supply (DGOS), patient satisfaction with services was measured and assessed frequently in 2011 and 2012. However, it does not concern patients hospitalized at psychiatric hospitals. The programs already implemented for health establishments and the legal framework show that there is a will and a plan to expand assessment of user satisfaction to psychiatry in the future.
In Finland, in the HUS hospital district level (study area), the results of the customer satisfaction surveys are used annually as a performance indicator of the inpatient treatment. A customer satisfaction survey, which is intended for users who have received service at HUS, is completed upon discharge. The survey is anonymous and responses will be directed to the unit's feedback handler. Evaluated areas are experiences of treatment, of care received, of care personnel, of received information, of care environment, with an option for adding additional free text comments. The Board of Psychiatric care in the HUS area inspects these results annually. The results at whole HUS level are presented in the annual financial statements and public report split by units - inpatient psychiatric care is presented separately. Feedback provided is used to plan and develop operations, and to improve user experience of care and service provision. It is noteworthy that the regular user satisfaction evaluation is not based on a study area initiative and that there is no national regulation for a mandatory user satisfaction evaluation.
In Romania and Italy study areas, evaluation of satisfaction is not mandatory, and satisfaction with care is not assessed regularly neither for patients nor for carers. In Italy study area satisfaction is evaluated only during specific research project but not routinely.
In Norway in the steering documents from the Ministry of Health to the Regional Health Enterprises for 2013, user experience measurements are mandatory for somatic inpatient care, but not for psychiatric inpatient care. However, in psychiatric services the user perspective has a great priority in all policy documents and the services must have user forums and users shall be heard in the decision-making process, both at an individual level and at system level (representation). Nevertheless, in mental health departments this is not systematically performed, but different units are on regular basis selected for user satisfaction measurement, using ad hoc surveys given to patients when they are attending the service. In the Municipality Health and Care Services, regular (every two years) user satisfaction surveys, including users receiving home care or live in institutions, are performed. The national system KOSTRA (Municipality-State-Reporting) monitor whether municipalities have developed a system for user satisfaction-measurement. In the study area 18 out of 25 municipalities are registered having such a system in 2011. In the municipality of Trondheim, user satisfaction surveys are also performed in services for persons with mental health problems. However, not all units are included on a regular basis, even if surveys are performed on a regular basis. Different Specialist Mental Health care units at St.Olavs Hospital and in Trondheim use a method called "User asking User", a dialogue-based evaluation method (e.g. group meetings and interviews). The results are reported and used in dialogue with service providers. Through KS (The Norwegian Association of Local and Regional Authorities), Municipalities can participate in a network with other municipalities called "Bedre kommune "(better municipality); the aim is to systematize the development on many areas of the municipal service system, also Mental Health Services. Results from Performance Measurements - User satisfaction Measurement is part of this - are published on the web and you can choose Municipalities to compare with.
In Spain, Customer service and quality Division, Catalan Health Service (CatSalut), Deparment of Health of the Government of Catalonia since 2003 has developed a Satisfaction Survey Plan for the users insured with CatSalut (PLAENSA©). The goal is to improve the user satisfaction with the public health. They have developed surveys for each service line: Acute in General Hospital, Primary Care, Outpatient Mental Health Centers, Psychiatric Acute Inpatient Units, and time-limited and Long stay Units (MILLE). All surveys are correctly validated and are collected through telephone and face-to-face interviews. The study of expectations and perceptions of the families of the people attended in services of social and medical care and mental health is done in focal groups and interviews. In an initial phase, at the end of 2004, and once the results of the first edition of the PLAENSA© were available, CatSalut sent each service provider unit its specific results compared with the average for Catalonia. This allowed the differences to be compared by line of service, territory and service provider unit. This was the starting point from which the Client Care and Quality Department, together with the Health Services Assessment Department, those responsible for the CatSalut health regions and the health service providers, started an ambitious project called Improving the perceived quality of health services, which responded to one of the strategic lines of CatSalut, understanding quality as the path towards excellence.
In England, there are many ways in which data on service user satisfaction are collected. For people receiving mental health services in the community, the Community Mental Health Survey respondents are asked to rate the overall care they received from mental health services in the last 12 months; it looks also at the involvement of family and friends and at their satisfaction. In the 2012 survey over 15,000 participants aged 18 years and more were asked about their experiences with care or treatment for mental health condition, including services provided under the Care Programme Approach (CPA). Patient Opinions on mental health services are also collected via the NHS Choice website. Satisfaction is also evaluated by Care Quality Commission Care (CQC). For the CQC Mental Health Act annual report inspectors visit facilities, talk to residents and staff and prepare reports which may require action if standards of care and support are not appropriate. This inspection reports the presence of actions to change practice in residential facilities. The community mental health survey is also used to benchmark services against the national average.
On the contrary, carers’ satisfaction is not evaluated in all countries apart from England and Spain where the assessment in longitudinal and regular (assessment but not routine in Finland).

Availability of Early Intervention
Chronic illnesses, including mental and behavioral disorders, are the leading cause of disability in the 18-24 age group (Chambers and Murphy, 2011). Adolescence and young adulthood are critical periods for the onset of mental health problems, and almost 50% of syndromes emerge by age 14, with 75% of disorders having their onset before 24 years of age (Kessler et al., 2005). A specific focus on prevention and early intervention is necessary in order to reduce youth and adult mental health difficulties in the long term (Burns et al., 2002; McGorry et al., 2006 ). Indeed, the early years in the development and onset of serious mental illness are critical, since illness often strikes when young people are forming social roles, personal identity, relationships and independence (McGorry et al., 1996). There is mounting evidence that duration of untreated illness is associated with poorer outcomes and early intervention is considered as best practice (Canadian Federal/Provincial/Territorial Advisory Network on Mental Health, 2001). Canadian Framework (2001) considers among others the presence of early intervention also as an indicator of accessibility.
In England, early detection services are being introduced; one example is Outreach and Support in South London (OASIS), a service of early detection (ED) for people with an at-risk mental state (ARMS) for psychosis. Clients who meet ARMS criteria are provided with an intervention package that comprised information about their symptoms, practical and social support, and the offer of cognitive behaviour therapy (CBT) and medication (a low-dose antipsychotic or an antidepressant). Assertive Outreach for early psychosis services also exist, and should be available in all localities, although this may not always be the case. In part of London one team, the Lambeth Early Onset (LEO) Team was established on the principles of assertive outreach, providing an extended hours service by including weekends and public holidays. Evidence-based interventions adapted to the needs of people with early psychosis include low dose atypical anti-psychotic regimens, cognitive behaviour therapy based on manualised protocols, and family counselling and vocational strategies based on established protocols. Adherence to the assertive outreach model and to these treatment protocols are ensured through supervision of cognitive behaviour therapy, medication prescribing, family support, and the assertive outreach model. In Hampshire (part of the study area) early intervention is part of the role of the Community Treatment Teams. These teams are comprised of psychiatrists, clinical psychologists, nurse practitioners, social work practitioners, occupational therapy practitioners, carer support workers, and support workers / support time recovery workers. Between October and December 2012, 144 new cases of psychosis were served by early intervention teams.
In Italy, a research programme with relevant effects also in services practice - Genetics Endophenotypes and Treatment: Understanding early Psychosis (GET-UP)- is financed by the Italian Ministry of Health and conducted by the Academic Hospital of Verona (study area). The Psychosis early Intervention and Assessment of Needs and Outcome (PIANO) trial is part of this larger research program, which aims to compare the effectiveness of a multi-component psychosocial intervention versus treatment as usual (TAU), in a large epidemiologically-based cohort of patients with first-episode psychosis and their family members, recruited from all public community mental health centers located in two entire regions of Italy (Veneto – Refinement macro area - and Emilia Romagna), and in the cities of Florence, Milan and Bolzano. Patients in the experimental group will receive TAU plus: 1) cognitive behavioral therapy sessions, 2) psycho-educational sessions for family members, and 3) case management. Another aim of the initiative is to activate a virtuous circle to foster the dissemination of early prevention and intervention practices not only for psychoses, but also in other mental disorders.
In Spain, the Master Plan for Mental health and Addictions of Catalonia (macro area) promoted the creation of early care Programs for psychosis linked to mental health centres for adults. The program is designed to early detect patients with signs of high risk of psychosis and/or with a first psychotic episode, and provide comprehensive care and intensive treatment during the first five years. Target population is 14-35 years. An Implementation Guide about the incipient psychosis Specific Care Program was developed and published; also, 13 pilot programs were developed in Catalonia. One of them was developed in the study area, and meant the creation of two early intervention teams for psychosis in the MHC of Girona-Pla de l'Estanyand Blanes. These teams are multi-professional teams composed by psychiatrist, clinical psychologist, nurse and social worker; all of them are exclusively involved in early psychosis program. Finally, the Center for Child Development and Early Care is a service focused on disorders of early child development and risky situations that might cause them. The service provides a set of actions in nature preventive screening, diagnostic and therapeutic intervention, made with interdisciplinary and trans-disciplinary methodology, and extending in a broad sense, from the moment of conception until the child meets six years, including, therefore, the prenatal period, perinatal, postnatal and early childhood. This service is aimed at children with developmental disorders or who are at risk of developing them, with a history of biological, psychological or social risk, or family difficulties.
In Norway, in 1997 a Low Threshold Detection Team (OT) was established at Stavanger University Hospital, Division of Psychiatry. This team was established in connection with the start of the TIPS study (1997-2000). One of the main objectives of the TIPS study was to see if one could change people's help-seeking behaviour in relation to initial psychosis. TIPS introduced a system for systematic information and educational campaigns. Information about the project was provided through newspaper ads, brochures, advertising on local television, aimed at the population in general as well as private institutions, teachers and pupils in secondary schools, contact with primary care physicians, and other first-line personnel. When the study ended, they continued to have a low threshold detection team aimed at first-episode psychosis. At the first onset of psychosis, the team are able to start treatment and further investigation without undue delay. They are close to the Emergency ward which allows for voluntary admission if they wish. If outpatient treatment is considered most appropriate, an outpatient treatment is set up within 1 week.
Moreover, the Health Directorate offers a grant scheme that aims to strengthen the knowledge on mental health in schools through a focus on learning, increased skills, early intervention and collaboration between key agencies for children and adolescents. The health enterprises have Patient Education Resource Centres (Lærings,- og mestringssenter) LMS. The Centres also give information to relatives, and there are a special service/course offered to children of persons with mental disorders.
In France and Finland, no such specific early psychosis interventions exist, but there are some initiatives to be considered.
In Finland, early intervention is promoted on the policy level by the National Plan of Mental Health and Substance Abuse Work Plan promotes prevention and early intervention in mental disorders and substance abuse, through the provision of continuing education for occupational health personnel and the development of reimbursement practices of the Social Insurance Institution of Finland (Kela). In the study area, the JERI Project aims at providing young people (13–22-years) with preventive services in schools and at home. The JERI Project is based on collaboration between the young person, his or her family, primary care workers and specialised psychiatric staff. The project aims at reducing remittance to specialised mental health care.
In France, early detection programs exist at local/regional levels for early detection of substance/alcohol abuse and mental health problems in children/teenagers. Nevertheless, they are region-specific and based on a region’s set of priorities. Moreover it is part of the job of occupational health care professionals to screen for work-related mental health issues in all employees. Finally, the “expert centers” for schizophrenia, bipolar disorders, persistent depression and autism contribute to the early detection and intervention of those disorders.
In Austria an early intervention programme - European Alliance Against Depression (EAAD) -exist in macro area for depression. The EAAD is based on the concepts and materials developed in the context of the Nuremberg Alliance Against Depression, a comprehensive intervention project which was conducted in the framework of the German Research Network on Depression and Suicidality (Kompetenznetz “Depression, Suizidalität”) in 2001 and 2002. Moreover, also if with a quite different aim, “KIPKE” gives information about the illness of the parent that children can understand (especially on restrictions and behaviour due to the illness), supporting children and adolescents in terms of establishing a person they trust, crisis management, taking the feeling of fear and guilt and too much responsibility, and giving advice for leisure time activities and social contacts.
Finally, in Romania early interventions do not exist in the study area.


Potential Impact:
REFINEMENT has improved the health system research capacity in describing the characteristics of mental health and social services, the financing systems of mental health care (including incentives and disincentives) and the quality of mental health care in nine European countries with different health care systems. This description has be done using new tools (FINCENTO, REMAST, REPATO, REQUALIT) bespoken and tested in 9 European countries, they should ultimately allow to collect comparable longitudinal data on various financing systems, services’ organisations and provide the basis for a better understanding of their effects on quality of mental health care.
The contribute of REFIENEMENT Tools on a better scientific understanding of these effects will have a considerable impact on health system research and health policy, generally.
In particular, in some partner countries (Finland and Spain) the result of REFINEMENT analyses have already had an impact on services’ organisation (see attached files: WP3 REFINEMENT Dissemination Report.pdf and REFINEMENT_Finlad_Policy_Practice.pdf).
The Tools developed should also improve the capacity of researchers to analyze the effects of social, economic, health care and policy changes on current and future health. Each tool can be used separately to describe one of the 4 areas of mental health care covered: financing, organisation, pathways and quality.

FINCENTO allows to collect information about financial incentives /disincentives in the field of mental health care and it is based on answers to a structured questionnaire by eight REFINEMENT countries (Austria, England, Finland, France, Italy, Norway, Romania and Spain). It provides an astonishingly motley picture of concepts behind financial incentives for improving mental health care, but also of unintended consequences. We have tried to bring some structure to the provided examples, although this has to be imperfect.
Two caveats apply. First, it has to be kept in mind that partner countries were asked to provide “examples” and not a “systematic description” of such incentives in the field of mental health care. For better understanding the examples it is useful to make oneself familiar with the pattern of services (REFINEMENT Report on Atlas of Mental Health Care; Deliverable 6.1) and with the financing mechanisms for mental health care in a specific country (REFINEMENT Report on differences in health system financing; Deliverable 4.1).
Second, out of practical reasons the examples had to be provided separately for three selected types of services: Primary care, specialized psychiatric outpatient care and inpatient care (the latter both psychiatric and non-psychiatric hospitals/institutions, but they all had to relate to care provided to patients with mental health problems in these settings). So, while the task was to identify incentives for a specific type of service, quite a few of the reported examples were related not to one type of these services only but to several, showing the trend to incentivize continuity of care, shared care and cooperation across service types. This is an interesting development in a financing and services landscape which has been characterized for a long time by fragmentation and difficulties for patients to move from one treatment modality (e.g. inpatient care) to another (e.g. outpatient care).
As stated above the analyses are by no way comprehensive, since it was open for the partners which examples they reported. Within the REFINEMENT project an important function of collecting these examples on financial incentives and disincentives was to obtain in-put for designing a comprehensive and practicable decision support tool for improving the quality of mental health care (Deliverable 9.1).

REMAST provides a tool for performing a detailed service mapping within a study area. It is especially useful for getting a good overview and comparison of services structures and resources for systems where the initial information and data are limited.
The REMAST Tool allows a good-quality common description of key features of mental health service provision, including those provided by primary and social care services, and enables researchers, service planners and policy makers in different regions, countries and at the European level to compare ‘like with like’ and to allow adequate use of data from different service systems. REMAST also allows collection of the data necessary to make an assessment of the spatial distribution of services in selected study areas. The tool was built using the experience of previous developed and validated international instruments: the European Services Mapping Schedule (ESMS), the Description and Evaluation of Services and Directories in Europe (DESDE) and the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS).

REPATO provides a tool for collecting information to identify and assess patterns of service utilisation within and between different settings. REPATO asks, in a structured way, relevant questions to describe pathways of care for adults with mental health needs within and between selected major general and specialist care settings for a specific country, region or otherwise defined geographical area.

REQUALIT provides a structured guide to collect and interpret indicators of the quality of mental health system inputs, processes and outputs. It give a basis to describe the outcome of mental health care in terms of quality of care and relate variations in outcomes to variations in the financing systems.
There are many potential uses of quality indicators including: benchmarking, performance management and quality improvement; consumer information; and provider payment. Quality indicators can be used for benchmarking purposes at both a national and an international level. Public reporting of quality metrics engages providers and organizations to improve performance and enhance their reputation.
REQUALIT contributed in the challenge of measuring quality of care together with other international organisations and projects, like the OECD HCQI project, the Mental Health Systems in OECD countries indicator benchmarking club, the International Initiative for Mental Health Leadership (IIMHL) - Clinical Leads project, the Nordic Indicator Project, the SIEP-DIRECT Project (DIscrepancies between Routine practice and Evidence in psychiatric Community Treatments provided to people with Schizophrenia), and the QuISMI (Quality Indicators in Severe Mental Illness).

Together the separate tools enable analyses of the links between the financing and quality of mental health care services.

REFINEMENT has improved our empirical understanding of the effects of different methods of financing the health care system and improve the capacity of researchers to analyze the effects of social and policy changes as they occur in the future.
Moreover, patterns of pathways of persons with mental disorders through the mental health, the general health and the social cares system, and relate variations in patterns to variations in financing systems have been described (see Deliverable 9.1 Decision Support Toolkit, Appendix), allowing a better comprehension of practice models and identifying the effective ingredients of financing systems which are conducive to good quality of mental health care.

The Decision Support Toolkit, and the four tools integrated in it, will promote integration and excellence of European research in health systems, and in particular for examining financing differences across countries and regions. This evidence base, and the instruments and methodology upon which it is based, will help – together with the results of other European projects - to create a common European framework to empower decision makers to better manage and reform health care systems.

REFINEMENT’s strength originates from the close collaboration between researchers expert in the mental health services evaluation (UNIVR, LGB, PSICOST, THL) and financial experts (LSE, SINTEF) who shared the knowledge and expertise necessary to undertake such a challenging project. REFINEMENT gathered a consortium of thus far independent researchers, which share the same visions and goals. The various strategies provided by these experts allowed for a new strategic approach to financial systems. By following this road, REFINEMENT contributed to a new understanding of both the differences between various methods of financing health care and their impact on the patients’ pathways of care. Interest on the REFINEMENT’s results has already been expressed both by researchers, policy makers and health economists.

European policy-makers and providers of care will be able to use the results and any subsequent analyses to understand the complexity of financing the mental health care system including primary and social care services. While we focus on performance assessment of mental health systems for adults of working age, the principles outlined here will generally be applicable for policy makers wishing to assess the performance of other types of mental health system, for instance child and adolescent mental health services. The principles and approach to data collection and analysis can also apply to other complex elements of health and social care systems, for instance looking at approaches to manage chronic physical health problems such as diabetes, poor musculoskeletal health and cardiovascular disease.

A synthesis of main outcome and results was presented in Brussels at the Workshop on "Public Mental Health Research – Bridging the Gap between Evidence and Policy" SDR1 and 2, CDMA, Brussels, 22 January 2014 (see attached abstract and presentation).


List of Websites:

Website: www.refinementproject.eu
Twitter: @REFINEMENT_MHC

Coordinator address:
Professor Francesco Amaddeo
Department of Public Health and Community Medicine
Section of Psychiatry
Ospedale Policlinico "G.B. Rossi"
P.le L.A. Scuro, 10, 37134 Verona (Italy)

Tel. +39 045 812 4900 (secretary)
Tel. +39 045 812 4929 (direct)
FAX +39 045 812 4889
E-mail: francesco.amaddeo@univr.it
Web site: http://www.psychiatry.univr.it


final1-executive-publishable-summary.pdf