6 August 2010

An innovative model of mental health support in the community in one Italian city could work in New Zealand says Pact CEO Louise Carr.

Along with fellow ARC Group members, Wellink CEO Virginia McEwan and Walsh Trust chief executive Rob Warriner, Louise visited Trieste, a city which delivers clinical services for mental health patients in a distributed community based setting rather than a centralised hospital.

The Trieste Model

The Trieste model arose as a result of deinstitutionalisation about 30 years ago. The city has four mental health centres that each serve a population of about 60,000 people. Each has a multi-disciplinary team of psychiatrists, nurses, social workers and occupational therapists. Two centres have eight beds and two have six beds. The average length of stay in the beds is about two weeks.

Organisations similar to Pact also provide residential support for people aimed at people who need longer-term support and who don’t have natural support systems.

There are just six beds in a traditional hospital setting, but these are used only for acute and crisis situations.

"People are only in hospital setting for short term," Louise says. "They’ll either be admitted to one of the beds in the community-based centres or else they go back to their own homes."

When people become unwell they are intensively supported in their own home.

"The number of people under compulsory treatment orders has dropped. The number of people who offend has dropped and suicides have dropped. When somebody’s unwell, they stick with them and stay beside them and they help them get through it. As soon as they can they get them back home again."

Reclaiming the institution

The old mental health institution – San Giovanni – has been "reclaimed" and is now used to house the director general of mental health and all the administrative functions.

"It looks more like an art gallery – white, bright, airy with sculptures around the place. It didn’t feel like a hospital or an office. It was more like a home-like setting."

San Giovanni also houses the University Psychiatric Clinic and co-operatives (ie social enterprises) and associations (including theatre and music groups which are open to the wider community, not just mental health clients).

"They had a tailoring shop and they were recycling jeans and clothes from op shops – making them into other clothes, artwork and bean bags to sell. They had industrial machines and a tailor and people with mental health issues actively working there."

San Giovanni also houses a 24-hour radio station and a cafe run by mental health clients.

"They have reclaimed the institution, but they live in their own houses out in the community. The staff have stayed, the clients have left. They are quite proud of it. Part of the healing is to get people who didn’t have a great time in institutions to come back in, reclaim it and see they can move on from where they were then because the place has moved on."

The director of mental health is a psychiatrist, who designates where funding from the central government goes.

"He’s got the community centres but he also funds all the NGOs (non-government organisations) and the associations and cooperatives."

The people who work in the community centres also work in the community.

"If someone comes in there to a bed they’ll only be there until they’re settled and then they’ll go home and the mental health nurse may go home with them and support them in their houses."

Community involvement

Another aspect that impressed Louise is the involvement of the wider community.

"Part of their work is encouraging their communities around that person to continue to support the person. If something’s going wrong often those people will feel free to ring them up and say so-and-so is not very good."

She says the centres have an ethos of encouraging people back out into the wider network of supports.

"So in any one day the department, through all of these organisations, could be supporting up to 500 people in all the different co-ops and associations that are happening around the community."

Louise was also interested to see that people do not get discharged from the service.

"You can come in to the centre and say ‘I’m not feeling well, I need help.’ You don’t need an appointment – you just walk in. So every day either a psychiatrist or psychologist who has a free day operates a triage process at the reception area and they deal with people who come and go on any given day."

A model for New Zealand?

Louise believes the model could work in New Zealand.

"To a certain extent we deinstitutionalised people into the community but we didn’t quite finish the process."

While Trieste has six in-patient beds for a population of 240,000, Dunedin has many times that number at Wakari Hospital, for a population of about 120,000.

"I think the time has come to ask why do we continue to do what we do? The Trieste model appears to be a more cost-effective and person-responsive way of dealing with the issues. What you do is keep the person connected to their community. Their community support doesn’t breakdown whereas if you’ve got a person in a hospital for long periods of time their support network may break down around them. They might lose their flat, they might lose their job, their family might drift away from them."

She says the way we deliver care for people in New Zealand can be more compartmentalised and fragmented.

In Dunedin, there is an acute team that works together but if people go to a long-stay bed they work with another group of people. And then when you get discharged you work with another team of community mental health nurses and you’ll be working with an organisation like Pact. So the same people are not working with you all the time."

She believes there could be four centres in Otago/Southland – two in Dunedin, one in Invercargill and one in Central Otago. The roles of people who work in a hospital setting would still be there but they would work far more in the community.

"It’s not a replacement of services - it’s a different configuration."

Discussion paper

The Arc Group is preparing a discussion paper on the idea to share with mental health professionals, district health boards, the Ministry of Health and the National Health Board.

"We think the debate is urgent before DHBs consider reinvesting large chunks of capital in building more hospital-based, in-patient services."

Louise says it would not necessarily change the way Pact operates but it would change the wider mental health community in which Pact works.

"It could only benefit the clients. I’d go as far to say that Blueprint, while well intentioned at the time, resulted in a strait-jacket being put on the ability for community services to be responsive to the needs of people. As a result of that more and more people tend to stay in Wakari because there’s nowhere to go out in the community while they still need quite intense support. This is a good alternative to combine the work NGOs can do and the work clinicians can do in the community if we all work as one team or in close alliance."