Leçons britanniques d’un transfert de ressources : le système de dotation par patient

Les « dots » ou système de dotation par patient peuvent être définies comme des sommes globales ou des subventions récurrentes, que les autorités de la santé se donnent entre elles ou versent aux autorités locales ou aux organismes sans but lucratif, pour les soins prodigués dans la communauté, plutôt que dans un hôpital, aux personnes souffrant de troubles mentaux graves et persistants. Cet article décrit comment les dots et d'autres processus ont été élaborés en Angleterre afin d'encourager la fermeture d'hôpitaux psychiatriques. Le contexte de ce financement des soins (avant les réformes engendrées par le National Health Service et le Community Care Act de 1990) montre certaines similitudes avec les dispositions en cours au Québec. Les auteurs résument une évaluation au long cours du programme de redéploiement dans deux hôpitaux psychiatriques de Londres qui ont fermé, afin d'examiner le type de services utilisés dans la communauté par d'anciens patients de ces hôpitaux et comparer les coûts de l'hôpital à ceux des soins communautaires. Après avoir quitté l'hôpital, les patients doivent recourir à d'autres services sociaux et de santé ; tout développement des soins communautaires pour ces patients doit à tout le moins refléter ceux fournis en milieu hospitalier. On examine dans quelle mesure la dotation par patient peut être appliquée au Québec pour réduire davantage les séjours de longue durée dans les hôpitaux. À certains égards, les systèmes britanniques et québécois se ressemblent, mais il existe aussi des différences organisationnelles et politiques. Il ne serait pas raisonnable de transférer en bloc le système anglais au Québec, mais d'importants aspects de son implantation et de ses procédures peuvent servir à guider le développement de mécanismes de financement au Québec en vue du transfert de ressources de l'hôpital vers des services dans la communauté.Dowries can be defined as lump sum payments or continuing grants which health authorities make between themselves and to local authorities or voluntary organisations in respect of people with severe mental disorders to be cared for in the community instead of in hospital. This paper has three aims. First to describe how dowries and other processes were set up to encourage the closure of two psychiatric hospitals in England. The broader financing context for mental health care (prior to the reforms in England engendered by the NHS and Community Care Act, 1990) is also described and shows some similarities to the current arrangements in Québec. Second, we abstract some information from a longrunning evaluation of the reprovision programme to look at the type of services used in the community by former long-stay patients of these two hospitals and the comparative costs of hospital and community-based care. After leaving hospital, former patients require considerable inputs from other health and social care services ; any development of community care for these patients should at the least mirror the facilities provided on the hospital campus. The final aim of this paper is to examine the extent to which this English system of budget reallocation (" dowries ") can be employed in Québec to further reduce long-stay hospital provision. There are many similarities between the health and social care systems of the two countries but there are also organisational and political differences. It is not sensible, therefore, to transfer the English budget reallocation to Québec wholesale, but we suggest that there are important process and implementation issues which can guide the development of financing mechanisms in Québec

A case study: the costs of residential care for people with intellectual disability and dementia

Background People with intellectual disabilities have a shorter life expectancy but health care improvements mean that they are living longer, with the associated health difficulties. Research into ways of supporting people with intellectual disabilities who are ageing and need end of life care is short supply, and few services are provided.Method This research is a single case study that included observations, interviews with standardised questionnaires and focus groups for staff. This Discussion Paper focuses on estimating the comprehensive costs of a specialised residential facility using a standard, well-established approach.Results At £1,422 per resident week (2013 prices) our estimated cost for supporting residents at Leesdown House are likely to be slightly higher that the placement fees paid by local health trusts and social services departments. Any difference would allow the service to build up a small ‘cushion’ of funds on which to rely during periods of lower occupancy. Additional services and volunteer costs account for a further £55 per resident week.Conclusion Cost information alone should never drive care policy. However, the resources absorbed by Leesdown House generated positive results for residents’ quality of life and opportunities to make choices for themselves. This service may provide a solution to the gap in specialist service provision

Increasing access to psychological therapies – looking beyond the workforce question

While improving access to psychological therapies requires a greater number of trained professionals able to provide evidence-based treatments, it also requires services to respond more flexibly to the needs of people likely to benefit from the treatments they offer. CBT workshops are an example of innovative, evidence-based treatments that – in addition to providing clinical benefits – provide easy access through self-referral and convenient weekend sessions, while reducing costs to the NHS

Can psycho-educational workshops help stem the tide of depression? Several randomised controlled trials suggest that they are an accessible and cost-effective option.

Depression is on the rise: It alone is currently responsible for 6% of the total burden of disease in Europe (Ustun et al. 2004) and is expected to be the second highest cause of disease burden worldwide by 2020 (World Health Organization 2008)

Support for adoption placements: the first six months

Adoption can provide stability and improved outcomes for looked after children, but the support needs of adoptive families range from financial support to managing difficult behaviours and attachment problems. This study looks at the use of services and associated costs over a six-month period through data collected from nineteen adoptive parents six months after a child (average age twenty-three months) had been placed with them for adoption and at the patterns of service needs, usefulness of services and satisfaction with services, supplemented with data from twenty-seven families who were interviewed about their experience of post-adoption support. In line with previous research findings, the core element of support was provided by social workers and over a third of families received financial support from social service departments. Involvement of specialist services such as mental health professionals and educational support was low, probably because of the children’s young age. Satisfaction with the support provided by social workers varied and depended on their relationship with the parents. The mean public sector cost of services was £2,842 (range £980–£6,270) and most costs were borne by children’s social services. These support costs compare favourably with other placement options such as children’s homes or foster-care