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Rome Twenty years on, Italy's psychiatric reform remains controversial
DISPATCHES
LONDON
Labour’s health plan under attack
hey were billed by ministers as “a middle way”, but the healthservice reforms set out last December by the UK government were always more revolutionary than evolutionary. Now, 6 months on, the initial euphoria with which the proposals were greeted is evaporating in the face of the sheer pace and scale of the changes that are to start next April. Labour inherited a health service that had undergone 6 years of organisational change and was in no mood for more radical reorganisation. Hence the ministerial soft sell: a middle way between the previous government’s sharp-elbowed competitive internal market and the old Labour model of central control and command. But at the heart of the government’s 10-year plan was a radical idea to create a primary-care-led service under which general practitioners (GPs), who currently control 20% of hospital budgets, would eventually be in charge of 90% of health funds. To achieve this, all GPs, rather than the current 50% who are fundholders, would be involved in the commissioning or provision of services. A graduated four-step programme would allow GPs to move from being advisors to their local health authorities through a purchasing stage to finally become full “primary-caregroup” (PCG) providers. The present pattern of 3500 fundholders plus 100 health authorities buying services from 400 trusts would be replaced by 500 PCGs—each of about 50 GPs and 100 000 patients.
T
ROME
Ministers believe this will achieve a £1-billion (US$1·6-billion) saving on bureaucracy over 5 years. What is worrying health-service professionals is the lack of guidance on basic details—who will be in charge of PCGs, how will they be appointed, &c—as well as doubts over GPs’ ability to agree spending priorities, plan health policies for populations, or given their historic role as independent contractors, their readiness to be “managed”.
“Ministers believe this would achieve a £1-billion saving on bureaucracy over 5 years” Resistance has been mounting. A survey of fundholders in March urged ministers to delay the reforms by a year. Fundholders might have been expected to oppose but policy specialists followed suit. A King’s Fund analysis of 52 “total purchasing” pilots, set up by the previous government but seen as a close prototype for PCGs, found the most successful schemes were much smaller than 100 000. Pilots serving 30 000 patients provided the best medical service. And none of the large multipractice projects was a high achiever. Finance officers weighed in— warning ministers that another big reorganisation is a high-risk strategy when one in four health authorities faces a deficit. A tight year in a stable organisation is manageable; a tight
year in turbulence is not. Ministers responded with an extra £22 million but GPs were not appeased. The British Medical Association, which initially welcomed the plan, has been forced by its grassroots members to be more critical. It has asked for clarification on five key issues by the end of this week: PCGs would not inherit health-authority debts; GPs would not be forced to ration care; budgets for practice costs would be distinct from patient-care budgets; patient care would be unaffected if groups overspend; and GPs would retain freedom to prescribe. The NHS Confederation, representing health authorities and managers, published a report this week after one of the biggest consultation exercises ever: 17 regional workshops attended by 3000 GPs, community nurses, and practice managers. The report expressed concern at the short time scale and lack of start-up funds. It urged smaller groupings than 100 000 patients but noted that smaller PCGs would mean higher management costs. Achievement of city-wide health strategies was questioned. Leeds, for example, would have 5 PCGs. How would they coordinate strategies? The report concluded that an evidence-based medical service needed evidencebased management and evidencebased policy-making. In short: too much current policy is being made on the hoof. Malcolm Dean
Twenty years on, Italy’s psychiatric reform remains controversial
A
3-metre-tall blue horse took part this week in celebrations in Rome of the 20th anniversary of the abolition of asylums. The horse, an icon of the anti-asylum movement, was built by inmates of the psychiatric hospital in Trieste run by Franco Basaglia, who spearheaded the change in law. But the reform is still shrouded in controversy. The only institutions that celebrated the event belong to the ideological lineage that advocated de-institutionalisation of mental care in the 1960s and 1970s. Basaglia, supported by influential political factions and favoured by the social climate, championed the opposition to the segregation of psychiatric patients in asylums. His starting point was a “therapeutic
THE LANCET • Vol 351 • May 23, 1998
community” set up in 1961 in Gorizia and modelled on one established by Maxwell Jones in Melrose, UK. In 1977, he closed Trieste’s asylum of 1200 inmates and replaced it with urban “mental health centres” and an acute psychiatric service in the city hospital. Despite the reform, nationwide adoption of his model has been slow and piecemeal, with uneven results. An effective, public alternative to the questionable ethics and ineffectiveness of asylums is not yet ubiquitous in Italy. Supporters assert that the reform restored dignity and civil rights to the mentally ill and removed the iatrogenic psychiatric morbidity caused by chronic confinement. A lack of will and funds to apply the law has been
blamed for the poor results. Critics deplore the peculiarity of Basaglia’s clinical work, claiming that “he treated institutions, not patients”. They assert that the reform shifted the burden of mental care to families, that suicide rates have increased among psychiatric patients, that hospitalisation in private institutions has blossomed (a discrimination against the poor), that the number of “homeless” people has grown, and that compliance with treatment has fallen. I wonder what Marcus Aurelius’ 1800-year-old bronze stallion in Rome’s Piazza del Campidoglio thought of Basaglia’s 25-year-old blue papier mâché horse? Bruno Simini
1565
LONDON
Labour’s health plan under attack
hey were billed by ministers as “a middle way”, but the healthservice reforms set out last December by the UK government were always more revolutionary than evolutionary. Now, 6 months on, the initial euphoria with which the proposals were greeted is evaporating in the face of the sheer pace and scale of the changes that are to start next April. Labour inherited a health service that had undergone 6 years of organisational change and was in no mood for more radical reorganisation. Hence the ministerial soft sell: a middle way between the previous government’s sharp-elbowed competitive internal market and the old Labour model of central control and command. But at the heart of the government’s 10-year plan was a radical idea to create a primary-care-led service under which general practitioners (GPs), who currently control 20% of hospital budgets, would eventually be in charge of 90% of health funds. To achieve this, all GPs, rather than the current 50% who are fundholders, would be involved in the commissioning or provision of services. A graduated four-step programme would allow GPs to move from being advisors to their local health authorities through a purchasing stage to finally become full “primary-caregroup” (PCG) providers. The present pattern of 3500 fundholders plus 100 health authorities buying services from 400 trusts would be replaced by 500 PCGs—each of about 50 GPs and 100 000 patients.
T
ROME
Ministers believe this will achieve a £1-billion (US$1·6-billion) saving on bureaucracy over 5 years. What is worrying health-service professionals is the lack of guidance on basic details—who will be in charge of PCGs, how will they be appointed, &c—as well as doubts over GPs’ ability to agree spending priorities, plan health policies for populations, or given their historic role as independent contractors, their readiness to be “managed”.
“Ministers believe this would achieve a £1-billion saving on bureaucracy over 5 years” Resistance has been mounting. A survey of fundholders in March urged ministers to delay the reforms by a year. Fundholders might have been expected to oppose but policy specialists followed suit. A King’s Fund analysis of 52 “total purchasing” pilots, set up by the previous government but seen as a close prototype for PCGs, found the most successful schemes were much smaller than 100 000. Pilots serving 30 000 patients provided the best medical service. And none of the large multipractice projects was a high achiever. Finance officers weighed in— warning ministers that another big reorganisation is a high-risk strategy when one in four health authorities faces a deficit. A tight year in a stable organisation is manageable; a tight
year in turbulence is not. Ministers responded with an extra £22 million but GPs were not appeased. The British Medical Association, which initially welcomed the plan, has been forced by its grassroots members to be more critical. It has asked for clarification on five key issues by the end of this week: PCGs would not inherit health-authority debts; GPs would not be forced to ration care; budgets for practice costs would be distinct from patient-care budgets; patient care would be unaffected if groups overspend; and GPs would retain freedom to prescribe. The NHS Confederation, representing health authorities and managers, published a report this week after one of the biggest consultation exercises ever: 17 regional workshops attended by 3000 GPs, community nurses, and practice managers. The report expressed concern at the short time scale and lack of start-up funds. It urged smaller groupings than 100 000 patients but noted that smaller PCGs would mean higher management costs. Achievement of city-wide health strategies was questioned. Leeds, for example, would have 5 PCGs. How would they coordinate strategies? The report concluded that an evidence-based medical service needed evidencebased management and evidencebased policy-making. In short: too much current policy is being made on the hoof. Malcolm Dean
Twenty years on, Italy’s psychiatric reform remains controversial
A
3-metre-tall blue horse took part this week in celebrations in Rome of the 20th anniversary of the abolition of asylums. The horse, an icon of the anti-asylum movement, was built by inmates of the psychiatric hospital in Trieste run by Franco Basaglia, who spearheaded the change in law. But the reform is still shrouded in controversy. The only institutions that celebrated the event belong to the ideological lineage that advocated de-institutionalisation of mental care in the 1960s and 1970s. Basaglia, supported by influential political factions and favoured by the social climate, championed the opposition to the segregation of psychiatric patients in asylums. His starting point was a “therapeutic
THE LANCET • Vol 351 • May 23, 1998
community” set up in 1961 in Gorizia and modelled on one established by Maxwell Jones in Melrose, UK. In 1977, he closed Trieste’s asylum of 1200 inmates and replaced it with urban “mental health centres” and an acute psychiatric service in the city hospital. Despite the reform, nationwide adoption of his model has been slow and piecemeal, with uneven results. An effective, public alternative to the questionable ethics and ineffectiveness of asylums is not yet ubiquitous in Italy. Supporters assert that the reform restored dignity and civil rights to the mentally ill and removed the iatrogenic psychiatric morbidity caused by chronic confinement. A lack of will and funds to apply the law has been
blamed for the poor results. Critics deplore the peculiarity of Basaglia’s clinical work, claiming that “he treated institutions, not patients”. They assert that the reform shifted the burden of mental care to families, that suicide rates have increased among psychiatric patients, that hospitalisation in private institutions has blossomed (a discrimination against the poor), that the number of “homeless” people has grown, and that compliance with treatment has fallen. I wonder what Marcus Aurelius’ 1800-year-old bronze stallion in Rome’s Piazza del Campidoglio thought of Basaglia’s 25-year-old blue papier mâché horse? Bruno Simini
1565