Portuguese National Mental Health Plan (2007–2016) Executive Summary

I. Introduction

1. Mental health: a public health priority

Latest epidemiological research shows that psychiatric disorders and mental health problems have become one of the main causes for disability in present‐day societies. The burden of mental disorders such as depression, alcohol addiction and schizophrenia has been seriously underestimated in the past, due to the fact that traditional approaches only considered mortality figures, ignoring the number of years lived with the disability caused by the illness. Of the ten main causes of disability, five are psychiatric disorders.

Also, according to the American Academy of Childhood and Adolescent Psychiatry and the European Region of the World Health Organization (WHO), one in five children exhibits evidence of mental health problems, and the tendency is rising.

Besides people who demonstrate a diagnosable disorder, many have mental health problems that can be considered ‘subliminal’, meaning they do not meet the diagnostic criteria for psychiatric disorders, but these people are also suffering, and should therefore benefit from intervention.

Based on the assessment of mental health reforms undertaken in many countries and on data from cost‐effectiveness studies, the WHO and other international organisations believe that mental health services should be organised in accordance with the following principles:

• accessibility

• sectorisation – services must be responsible for a sector (catchment area), of a size such that it is possible to ensure basic care without people having to move significantly from their place of residence (estimated dimension between 200 000 and 300 000 inhabitants)

• comprehensiveness – services must integrate a range of units and programmes, including inpatient units at general hospitals, to ensure an effective response to the different needs for care of the population

• co‐ordination

• participation of users, family members and key community agents

• integration of mental health in primary health care

• intersectoral cooperation

• accountability.

2. Mental health in Portugal

Although scarce, existing data suggest that the prevalence of mental health problems in Portugal does not significantly differ from that encountered in European countries of similar characteristics, while the most vulnerable groups (women, the poor, the elderly) seem to exhibit a higher risk than in the rest of Europe.

Analysis of mental health system development in Portugal reveals some positive aspects through recent decades. It was one of the first European countries to adopt a national law (1963) in accordance with the principles of sectorisation, which enabled the creation of mental health centres in every district and the appearance of various important movements, such as social psychiatry and integration of mental health in primary care.

New mental health legislation approved in the 1990s (Law No. 36/98 and Law Decree No. 35/99) reinforced this capital, in accordance with the principles recommended by major international organisations in the area of mental health service organisation.

The creation of decentralised services was a development that had a very positive impact on the improvement of accessibility and quality of care, enabling responses closer to the population and a greater interaction with health centres and other community agencies. Nationwide coverage for these services is still far from complete, but comparing the current situation with that of 30 years ago, important steps have been taken.

Another positive aspect was the development of psychosocial rehabilitation programmes and structures, created at the end of the 1990s as part of the European Union's (EU's) Horizon 2020 initiative (Dispatch 407/98) and of supported employment legislation. Although of limited scope, these programmes represented a significant break with the prior situation, in which residences in the community and social firms for the seriously mentally ill were entirely non‐existent in Portugal. Despite these indubitably positive aspects, lack of planning and consistent support for the improvement of mental health services explains why Portugal is lagging behind considerably in this field in relation to other European countries. Existing data and analysis of results from research undertaken as part of this report reveal that mental health services suffer serious deficiencies in terms of accessibility, equity and quality of care.

In fact:

• The number of people in contact with public services (168 389 people in 2005) shows that only a small proportion of those with mental health problems have access to public specialised mental health services. Even when we assume that only people with mental illnesses of some severity attend mental health services—which we know is not the case – the number of contacts (1.7% of the population) is still extremely low in relation to what would be expected (at least 5–8% of the population suffers a moderate to severe psychiatric disorder every year).

• The majority of resources continue to be concentrated in Lisbon, Oporto and Coimbra. Services created in various parts of the country, with excellent facilities, only operate partially, and in some cases there are units still to be opened as it has not possible to secure staff for them, as staff have been concentrated in hospitals in major urban centres.

• The distribution of psychiatrists between psychiatric hospitals and psychiatric and mental health departments in general hospitals continues to be very unbalanced (2.6 and 1.1 doctors respectively per 25 000 inhabitants). This situation is even more difficult to justify given that only 24% of the total patients were treated in psychiatric hospitals and 71% of outpatient visits were carried out in general hospitals.

• Hospitalisation continues to consume the majority of resources (83%), while all scientific evidence shows that interventions in the community, closer to people, are much more effective and preferred by patients and their families. An inevitable consequence of this distribution of resources is the reduced development of community registered services in Portugal.

• Many local mental health services continue to be reduced to hospitalisation, outpatient clinics and, sometimes, day hospital services as there are no community mental healthcare teams, with integrated case management, crisis intervention and programmes for families.

• A preference for resorting to emergency services and the difficulties reported in getting access to outpatient facilities suggest the existence of problems in terms of accessibility to specialised care. For its part, the interval between discharge and subsequent follow‐up, associated to the proportion of readmission of hospital cases without any outpatient contact, suggest the existence of problems in the continuity of care.

• Concerning the structure of mental health teams, most services continue to rely on a small number of psychologists, nurses, social workers, occupational therapists and other non‐medical professionals.

• The quality of services, according to the assessment made with the WHO evaluation tools, lies at a level below reasonable. Compared with inpatient units, the level of quality of outpatient services is even worse.

• The most critical areas in quality of services are those relating to human resources (provision, distribution, interdisciplinary composition of the staff) and to administrative organisation.

The modest level of resources available for mental health in Portugal is certainly one of the factors to have hampered the development and improvement of services in this sector. Unlike what happens in other countries, users and family associations have never had an active voice in Portuguese society. A public health perspective and evaluative culture have always been fragile in the mental health field in Portugal. As a result of that, resources allocated to mental health are unquestionably low if we look at the real burden of mental illness. The analysis of available data reveals that both financial resources and human resources are distributed in a very unbalanced manner between the various regions of the country, between psychiatric hospitals and general hospital departments and between inpatient and outpatient units.

The management and financing model of the services has represented another fundamental restraint on the development of mental health services. Placing the management and financing of local services in general hospitals, and limiting the financial autonomy of mental health departments, has impeded any consistent attempt to develop comprehensive services in the community. On the other hand, psychiatric hospitals have been able to develop without any obligation to observe the objectives attributed to them by mental health law. With regard to facilities belonging to religious orders, a model of interaction and financial compensation that is neither clear nor rational has prevailed.

In summary, the existing management and financing model is an entirely antiquated one which encourages the dysfunction of the system and hinders any attempt to develop more effective mental health services.

An analysis of the situation in Portugal should also consider other points that merit special mention:

• reduced participation of patients and families

• low number of scientific publications in mental health

• limited response to the needs of vulnerable groups

• scarcity of promotion/prevention programmes.

There are many difficulties and insufficiencies that should be given due consideration. However, there are also at present some opportunities that could help to overcome many of these difficulties, including: the new National Integrated Continuous Care Network (aiming at the creation of facilities by collaboration between the health and social sectors); the development of new family health units; and the creation of mental health units in new general hospitals under construction or in the planning stages.

Some measures planned for the coming years could also help overcome the difficulties identified in research. This point is particularly important: the increase in research capacity in psychiatry and mental health, particularly in epidemiological and services research, is an extremely effective factor in the development of a public health culture, and for the constitution of a critical mass, essential for the improvement of mental health care.

Finally, opportunities offered through international cooperation should be used. The WHO, which has already made a valuable contribution in the preparation of this plan, can provide technical cooperation in its implementation and assessment. The EU, for its part, following the approval of the Helsinki Declaration and of the Green Paper on mental health, will certainly be able to make important contributions to the development of reforms and to help integrate Portugal into the modernisation movement of mental health services currently under way on a European level.

II. Vision, values and principles

1. Vision

To ensure the entire Portuguese population has access to services capable of promoting mental health, providing mental health care of good quality, and facilitating the reintegration and recovery of people with mental health problems.

2. Values and principles

The Portuguese National Mental Health Plan (the Plan) is guided by the following values and principles (see Table 1):

Table 1.

Values and principles

Values	Principles
Mental health inseparable from health in general	Mental health services should be integrated into the general health system
	People with mental disorders who need to be hospitalised should be treated in general hospitals
Human rights	People with mental disorders should have all of their rights respected, including the right to adequate care, a home and employment, as well as protection against any form of discrimination
Care in the community	Care should be provided in the least restrictive environment possible
	The decision to hospitalise should only be taken when all alternatives of treatment in the community have been exhausted
Care co‐ordination and integration	Services in each catchment area should be co‐ordinated and integrated, so as to facilitate continuity of care
Comprehensiveness	Services in each catchment area should include a varied range of facilities and programmes, so as to be able to respond to the essential mental healthcare needs of the population
Community participation	People with mental disorders should be involved and participate in the planning and development of the services they benefit from Family members of the mentally ill should be considered as important partners in care provision, and encouraged to participate in this provision and to receive the necessary training and education
Protection of especially vulnerable groups	The needs of especially vulnerable groups (e.g. children, adolescents, women, the elderly and the disabled) should be taken into consideration
Accessibility and equity	Services should be open to everyone, irrespective of age, class, place of residence or social and economic situation
Recovery	Mental health service should create conditions that favour self‐determination and the quest for a right path by people suffering from mental health problems

III. Objectives

The Plan aims to achieve the following objectives:

• ensure equal access to quality care for everyone with mental health problems in the country, including those belonging to especially vulnerable groups

• promote and protect human rights of people with mental health problems

• reduce the burden of mental disorders and contribute to the promotion of mental health of the population

• promote the decentralisation of mental health services, so as to enable care provision closer to people and to facilitate greater participation by communities, patients and their families

• promote the integration of mental health care into the general health system.

IV. Areas of strategic action

1. Organisation of adult mental health services

Law No. 36/98, dated 24 July 1998, and Law Decree No.35/99, dated 5 February 1999, give a detailed description of the organisation model of mental health services in Portugal.

In this context it is understood, with relation to service organisation, that to define strategies that promote the realisation of the organisation as proposed by law is of prime importance.

This realisation poses four major challenges:

1. to complete the national network of local mental health services (LMHS) and promote the improvement of care provided by these services

2. to develop services and programmes for the recovery and deinstitutionalisation of the severely mentally ill (SMI)

3. to develop regional mental health services (RMHS) that are required to complement local services in specific areas

4. to restructure psychiatric hospitals and develop alternative services in the community.

These different components are, naturally, dependent upon each other, with the result that strategies for their implementation should be considered together. There is no use in completing the national network of local services if the improvement of care provided by these services is not promoted at the same time, helping them to develop integrated programmes in the community. We cannot develop recovery and deinstitutionalisation if there are no teams in the community to help the mentally ill and their families. Finally, we cannot develop new services closer to people if the majority of resources are still concentrated in inpatient treatment.

1.1. Development and improvement of the National Network of LMHSs

The restructuring of services, in this specific section, requires the development of two interrelated strategies:

1. a strategy aiming to transfer care still dependent on psychiatric hospitals to new mental health departments (MHDs), so as to complete the LMHS network

2. a strategy aiming to promote the development, in these services, of community mental health teams (CMHTs) or community mental health units (CMHUs).

This strategy should include the development and assessment throughout the country's regions of pilot services designed to test the effectiveness of CMHTs or CMHUs; these pilot services should have the following characteristics:

OBJECTIVES

To provide care to the population of a given catchment area, including:

1. integrated case management programmes for the SMI

2. treatment of common mental disorders in collaboration with primary care

3. mental health programmes for the elderly

4. prevention programmes for depression and suicide.

COMPOSITION

Multidisciplinary teams, with significant participation from nurses and other non‐medical professionals.

FINANCING AND SALARIES

1. Financing based on contractual principles, taking into consideration population size and characteristics.

2. Development of a new payment model for professionals including additional incentives related to productivity, as well as bonuses related to the complexity and quality of work developed.

By 2016, every local mental health service should be assured by general hospital MHDs. To achieve this, local services that are currently still dependent on psychiatric hospitals should be gradually transferred to general hospitals, in accordance with the phasing and measures outlined for each health district (see Annex 1). At the same time, CMHTs/CMHUs will be set up in different LMHSs. All existing MHDs not in full operation will be subject to particular and urgent attention, so as to be able to carry out their functions properly.

1.2. Recovery and deinstitutionalisation of the SMI

The approach to community mental health places increasing emphasis on keeping patients in their respective residential communities, while promoting independence and social integration, instead of confining them, more or less permanently, in psychiatric institutions.

The recent development of the National Integrated Continuous Care Network will enable the development of specific integrated continuous care responses in terms of mental health (these will be separately outlined).

The general aim of these responses, the joint responsibility of the Ministry of Labour and Social Solidarity and the Ministry of Health, will be the provision of integrated continuous care to the SMI who cannot live independently.

Specific integrated continuous care responses in terms of mental health represent a specialised segment of the National Integrated Continuous Care Network, created by Decree Law No. 101/2006 (dated June 2006), and governed by the principles therein defined, with the necessary changes to be defined in a separate document planned for the area of mental health.

In accordance with this document, the provision of integrated continuous mental health care is assured by:

• residential units of different types (maximum support, intermediate support and minimum support)

• social integration units (day centres)

• home support teams.

1.3. Regional mental health services

In accordance to the model foreseen by law, specific mental health services should be developed at the regional level when, for reasons of high specialisation or resource distribution, it is not possible or justifiable to have these services at a local level. In a context coloured by lack of resources, it must be ensured that the development of these units does not compromise the response to more pressing needs, such as care of the SMI. It is also vital to ensure the creation of more specialised services is undertaken in the most appropriate of institutional settings for collaboration with other specialities – teaching and research.

In this context, the following units will be created in the next five years:

• regional inpatient services for forensic patients and for ‘difficult to place patients’ in the following institutions: Hospital Júlio de Matos, Hospital Sobral Cid and Hospital Magalhães Lemos

• three treatment units for eating disorders, in general hospitals yet to be decided, in the Lisbon, Centre and North regions.

1.4. Psychiatric hospitals

All available scientific evidence has shown that shifting from psychiatric hospitals to a network of services based in the community is the strategy that best ensures improvement in the quality of mental health care.

As stated in the Rede de Referenciação de Psiquiatria e Saúde Mental (Psychiatric and Mental Health Reference Network), ¹ published by the Portuguese Health Authority in 2004:

the international trend, especially in EU and North American countries, has involved reducing the number of psychiatric hospitals, through the reduction of capacity and through the gradual closure or conversion to other health or social areas.

The WHO, in the World Health Report of 2001 (dedicated to mental health), ² advises developed countries to:

• close psychiatric hospitals

• develop alternative residences

• develop care in the community and

• provide individual care to the SMI in the community.

In the European Mental Health Declaration, signed by the Portuguese government in Helsinki in 2005, ³ the Ministries of Health of the European Union pledged, among other matters, to ‘develop services based in the community that substitute care provided in large institutions for the seriously mentally ill’.

Portuguese mental health legislation includes clear provisions on the role of psychiatric hospitals in the transition phase during which the new services are being developed. To ensure the correct implementation of these legal provisions, the activities are to be developed in accordance with the following principles:

• the main criteria to consider in psychiatric hospital restructuring strategies are;

  1. the priority needs for care of the population
  2. the scientific evidence available as to the effectiveness of different intervention models and
  3. advocating for the rights of the mentally ill;

     • the changes to be made should facilitate the creation of local mental health services based in the community and of inpatient units in general hospitals, as well as the psychosocial integration of people with mental health problems
     • no service can be closed until another has been created to replace it
     • patients and family members should be involved in the changes to be made from the outset.

2. Organisation of child and adolescent mental health services

For Portugal it is vital to develop services and programmes that enable responses to the needs for care of children and adolescents in accordance with the following aims:

• promoting child and juvenile mental health in the population

• improving care provision, favouring and implementing interaction between child–juvenile mental health services and other structures related to health, education, social services and family legislation.

2.1. Development and improvement of services

The organisation of child and adolescent mental health services should enable care provision on three levels: primary healthcare specialised services on a local level and specialised services on a regional level. The specific measures for each of these levels, as well as other measures in more general terms, include:

A. FOR PRIMARY HEALTH CARE

Care provision at this level is assured by childhood mental health teams, comprising health centre and family health unit professionals, with consultancy from a child and adolescent psychiatrist from the specialised local service, which has the following functions:

• screening, assessment and attending to less serious cases (children/families at risk or with mild psychopathology)

• collaboration and partnership with other community agencies (for example, social services, schools, kindergartens, protection commissions for children and adolescents at risk, early intervention teams, institutions for housing children at risk, addiction rehabilitation centres and local psychosocial intervention projects).

B. SPECIALISED CARE AT THE LOCAL LEVEL

Care at the local level, provided by specialised Child and Adolescent Mental Health services/units within general hospitals is developed and improved through actions that include:

• the programming of new Child and Adolescent Mental Health Services/Units in every central and district hospital, including new hospitals in the planning or construction phase, so as to the cover the entire geographic area of the country

• the establishment of a multidisciplinary team within a maximum period of six months after the commencement of the first child and adolescent psychiatrist

• participation of the head of child and adolescent mental health department in the governing body of the local MHD

• definition of adequate spaces, with conditions of privacy, for attending to children/adolescents and their families

• priority development of interchange actions with the community.

C. AT THE REGIONAL LEVEL

The child and adolescent mental health departments at the regional level, located in Lisbon, Oporto and Coimbra, assure, besides what they already provide in terms of local services, the following facilities:

• emergency services

• inpatient units with suitable conditions and human resources for the specific needs of these patients

• centres for intervention in specific areas for more complex conditions, and specialised units for age groups such as infancy and adolescence

• research units connected to universities.

D. SERVICES FOR SPECIAL SITUATIONS

Services for special situations, for children with very specific needs who require to be treated in specialised structures, for example: autistic children; children of mentally ill parents; abused children; seriously mentally ill children.

2.2. Training

• Implement courses of child and adolescent mental health in medical and nursing schools.

• Ensure the training of an adequate number of child and adolescent psychiatry residents.

• Implement child and adolescent mental health training for health professionals, as well as professionals working in education, social security and court services for minors.

2.3. Other measures

Besides the close relationship already mentioned with primary health care, there should also be the development of interchange between child–youth mental health services and:

• paediatrics services

• adult psychiatry, alcoholism and drug abuse support services

• social services

• court services for families and minors

• implementation of internationally recognised prevention programmes directed to areas and groups at various risks

• promotion of the organisation of day hospitals and areas in operation and the creation of new structures of these kinds in specialised services

• development of existing hospital units, creating independent spaces for the hospitalisation of children and adolescents

• creation, in collaboration with the Justice, Social Security and other government departments, of facilities to respond to the needs of children and adolescents with serious psychiatric problems and no family support.

3. Mental health and primary care

The promotion of the integration of mental health care in primary care implies that:

1. the scope of primary care responsibility and that of specialised psychiatric care responsibility (i.e. acute psychosis, depression with risk of suicide, refractory anxiety, drug addiction, personality disorder) should be clearly defined

2. a transversal project should be created that includes the following areas:

   • in‐service training programme
   • improvement of referral and return information
   • full training in community mental health for all residents in psychiatry
   • inclusion in LMHS programmes of regular collaborative activities with primary care
   • regular monitoring of population's mental health (suicide rates, patterns of psychiatric drug prescription)
   • monitoring of patient satisfaction with services.

4. Cooperation between sectors

4.1. Psychosocial rehabilitation activities

The areas of professional and residential rehabilitation and of social participation must be developed outside health services and integrated into the community. They therefore require other resources and methods and presuppose a sharing of responsibilities between mental health and other sectors.

Integrated continuous care responses are an important instrument in regulating the joint involvement of health and social security areas, enabling the assurance of residential and occupational support to people with SMI that cause disability or dependence. This new network must be linked with the National Support Network for Members or Former Members of the Portuguese Armed Forces with Chronic Psychological Disorders.

Access for the mentally ill to responses traditionally directed towards the disabled should be actively encouraged, as in certain areas of psychosocial rehabilitation the models used can be the same.

It is important to take advantage of the review of active employment policies that is under way, to develop mechanisms that allow the promotion of employment for the mentally ill as a means to get them back into the work market.

Residential support in independent housing requires negotiations with the Institute of Urban Habitation and Rehabilitation, with local authorities and the respective housing services, in conjunction with units providing home support in the mental health area.

In the area of childhood and adolescence it is vital to promote cooperation between mental health services and social security services, and in particular the Commissions for the Protection of Children and Adolescents at Risk.

4.2. Prevention and promotion activities

Based on the document of the European Network for Mental Health Promotion and Mental Disorder Prevention ⁴ the following strategies are encouraged:

• Programmes for early childhood, including prenatal counselling, early intervention, parental training, prevention of domestic violence and infant abuse, family interventions and conflict resolution.

• Education programmes on mental health at school age, teacher awareness, prevention of youth violence, counselling for children and adolescents with specific problems, prevention of drug abuse, personal and social development programmes, prevention of suicide and eating disorders.

• Employment and mental health promotion policies in the workplace, reduction and management of work and unemployment related stress factors, reduction of absenteeism cause by psychiatric illness.

• Prevention programmes for depression, anxiety and suicide, telephone help lines for isolated people, restriction of access to means of suicide.

• Policies for fighting poverty and social exclusion, support measures for families at social risk or families with multiple problems and for the homeless, impact assessment of social policies in mental health and policies for the fight against stigma.

• Awareness and information in diverse sectors, such as primary care, schools, recreational centres, workplaces, television programmes, the internet and the media in general.

4.3. Prevention and treatment of problems associated with alcohol and drug abuse

The Regional Alcoholism Centres were recently integrated into the Portuguese Institute for Drugs and Addiction (IPDT), hence the need remains for cooperation on a local scale with mental health services, particularly those which include alcohol abuse treatment units.

In the short term the responsibilities of those involved in this area will be defined, along with the principles that should govern cooperation between mental health services and IPDT services.

In a sense, considering the frequency with which emergency situations related to substance abuse are treated in psychiatric emergency services, and given the lack of psychiatrists in mental health services, the involvement of IPDT psychiatrists will be promoted in psychiatric emergency service provision.

4.4. Care for vulnerable groups (homeless people and victims of violence, among others)

The need to ensure specific mental health care to especially vulnerable groups is now accepted around the world. Amongst these groups the homeless and victims of violence are of particular interest, besides the situation already referred to of children and the elderly.

With relation to the homeless, and taking advantage of experiments already developed among us, mental health programmes specific to this population will be developed in responsible teams by the LMHSs where the homeless generally live. In a first phase, the development of a pilot project is planned, which may be extended following evaluation.

As for the problem of domestic violence, it is the jurisdiction of the Commission for Citizenship and Gender Equality (CIG) to ensure the co‐ordination needed between ministries in the fight against domestic violence, and to promote public discussion of this subject.

The importance of building a network between every public and private organisation dealing with domestic violence should be stressed, so that standard minimum service rules can be established. For these objectives to be achieved, the LMHSs should develop projects within the domestic violence area.

4.5. With the Ministry of Justice

In relation to forensic patients, psychiatric care is assured by three services (Lisbon, Oporto and Coimbra), with its future operation to be defined under negotiations under way between the Ministries of Justice and Health.

Mental healthcare provision to people in prison is part these negotiations between the Ministries of Justice and Health. To propose solutions to these problems, a Mental Health/Justice working group is to be created, dedicated to:

1. psychiatry and mental healthcare provision for convicted forensic patients and the mentally ill currently in prison

2. the elaboration of forensic psychiatric reports

3. judicially determined care provision for the mentally ill, especially children and adolescents.

5. Legislation of mental health and human rights

Portuguese legislation is relatively up to date as it contemplates the generality of the most relevant issues in the area of mental health and respects, where pertinent, the latest international recommendations. The creation of new mental health law does not, however, seem to be justified, rather there is a need for the regulation of some aspects of its application, in particular in terms of asset and pension management of people resident in psychiatric hospitals.

6. Financing and management

Mental health services in Portugal have an unsuitable management and financing system that is not favourable to the development of care in the community. The introduction of major changes in the management and financing system of mental health services is an absolute priority for the future.

The establishment of a national mental health budget represents a fundamental measure for the implementation of the reforms outlined in the Plan.

The establishment of a finance model based on principles of contract work is another priority. This financing model takes into account the specifics of mental health care, so that it is not centred merely on production areas prevalent in general hospitals (hospitalisation, consultations, day hospital attendance and emergencies), which is insufficient to reflect the activities developed by mental health services in reality.

As the law establishes, MHDs should become real ‘responsibility centres’ with a budget linked to a contractual programme.

Finally, new forms of service management should be developed and assessed, so as to enable improved involvement and responsibility of various groups of professionals and non‐governmental organisations.

7. Information system

Information brings significant advantages to fundamental decision making in complex areas that require increasingly high quality standards. Taking this into account, an information system will be developed that provides the most appropriate means to support decision taking and action within the mental health area, and to provide an overview at policy level.

The information system will serve not only to aid decision making, monitoring and assessment processes, but also to provide a base for the study and understanding of mental health in Portugal.

8. Quality assurance

The concept of quality and its associated dimensions (quality assessment, quality assurance, continuous quality improvement) currently occupy a strategic position in the planning of mental health services.

It is therefore necessary to significantly increase the implementation and assessment of quality assurance processes in the country's mental health services.

For this objective to be achieved a quality assessment process in psychiatry and mental health services will be developed and implemented in accordance with the following steps:

• identification of quality improvement policies

• development of normative documents

• development of accreditation procedures (assessed by external agents)

• monitoring of mental health services (assessed by internal agents)

• integration of assessment procedures and quality assurance into service routines

• constant review of mechanisms of quality

• dissemination of good practice.

The development of this process takes into consideration the various levels and agents involved in planning and care provision, since it is not possible to assess quality through a single or isolated perspective.

Taking into account the multiplicity of levels, dimensions and indicators (structure, process and outcomes), the development and implementation of the quality assessment process implies a selection of options, including:

i. The assessment model

A simple and flexible system of service monitoring will be developed at the same time as an assessment system on a national scale.

ii. The assessment agent

Independent of internal (routine) monitoring procedures, assessment by external agents should be carried out regularly, as recommended by the WHO.

iii. The scope of assessment

In accordance with current scientific knowledge, the assessment should include not only structure and process variables, but also outcome variables. This implies the use of common methodologies and data collection in various services in the country.

iv. The selection of indicators

This represents one of the most sensitive and problematic areas in quality assessment of mental health, having to interconnect with the existing information systems of the National Health Service and with central and regional bodies of the Ministry of Health.

v. Patient and family satisfaction

Assessment of patient and family satisfaction should be an integral part of any quality assessment process.

9. Human resources

Investment in human resources will be decisive in the success of the mental healthcare reforms to be started on the approval of this Plan. The model of work organisation in almost all of the services continues to be excessively centred on doctors and on hospital interventions. The involvement of other professionals (psychologists, nurses, social workers, occupational therapists etc.) has increased, but it is still very far from what would be considered crucial for the appropriate operation of modern mental health teams.

To overcome these difficulties, measures are to be taken to redefine the ratios recommended for each professional group, taking into consideration the work characteristics of mental health teams nowadays, which point to greater involvement of nurses, psychologists, social workers, occupational therapists and other professions relevant to mental health.

The future needs for the various professional groups are then carefully estimated using approved ratios. The training and contractual strategies for professionals of various disciplines can only be planned using this estimate as a base. Measures are also put into effect that, on the one hand, ease the in‐service training of professionals, and on the other, promote the introduction of changes in pre‐ and postgraduate training in mental health.

A fairer distribution of available human resources between major centres and outlying areas can only be achieved through a combination of various kinds of measures. Most importantly it is vital that the cycle created in the past, in which more professionals were being admitted without criteria to some services in Oporto, Coimbra and Lisbon, is stopped. To put an end to this cycle, on the one hand the entrance of new professionals into Oporto, Coimbra and Lisbon is restricted to situations in which these new professionals are clearly linked to local community health teams, and on the other, mechanisms that facilitate the placement of professionals in services outside the three main cities of the country are created.

10. Cooperation with the social sector (religious orders, misericórdias)

Religious orders have represented, within Portugal's mental healthcare system, a major proportion of available responses. Their interaction with National Health Service services is regulated through an agreement which has been in operation for over two decades, and which needs to be updated.

A review of this agreement will therefore be undertaken, taking into account legislation governing agreements with the social sector, and in particular the provision that regulates the different integrated continuous mental healthcare responses, thus more clearly differentiating acute illness care from that of long duration (continuous care) and making the relation to cooperative assistance clearer, through the definition of referral rules between public services and establishments dependent on religious order institutions.

The new agreement will also define the model of financing used in established programmes, adjusted to the type of patients and type of care.

Conditions have also been created so that these institutions can be integrated into the process of reconfiguration of the assistance model, ensuring that they have access to the programmes of deinstitutionalisation being developed.

Besides religious orders, the Santa Casa da Misericórdia do Porto, which took over the running of the Hospital do Conde de Ferreira, giving continuity to almost a century of activity, has also been a partner in this area of care provision.

The initiatives needed are thus developed for a new protocol model to be developed that obeys the principles defined for the religious orders and which reframes the cooperation that has existed with these institutions.

11. Research

Although the majority of research is carried out in an academic environment, the practice of research is an area that should be encouraged, broadened to encompass non‐academic contexts and extended/made available to the largest number possible of psychiatry and mental health professionals.

To this end, action has been taken in terms of regular dissemination of scientific activity, financing of research projects and training in clinical and service evaluation research, as well as the promotion of research experience during the residence in psychiatry.

V. Implementation and assessment

Experience gained, as much in Portugal as in other nations, shows that the main reason why processes of improving mental health care do not achieve the planned objectives has to do with difficulties of implementation. Indeed, the implementation of mental health service reforms today is a complex process, involving important changes in terms of facilities, distribution and training of human resources, development of new work methods and assignment of financial resources, amongst others.

In accordance with WHO recommendations on this subject, first of all the existence must be assured of a body that assumes responsibility for the co‐ordination of the plan's execution and which possesses the necessary technical know‐how, as well the necessary decision‐making capacity to successfully direct a process of reform that implies major structural changes.

The need for this co‐ordination was proposed by the National Commission for the Restructuring of the Mental Health Services, which included in its recommendations the creation of a co‐ordinating body for the implementation of the Mental Health Plan, within the scope of the Ministry of Health, and equally the existence, in each Regional Health Authority, of a unit or team with the necessary technical expertise to co‐ordinate the actions on a regional scale.

Thus, the development of the Plan is intended to fall within the scope of the High Commission for Health, as well as a national co‐ordinator being nominated.

The dissemination and discussion of the Plan among everyone who is involved in mental health care, especially those within the National Health Service, is essential for the promotion of full involvement in the implementation of the Plan, to which end a programme of conferences and meetings is planned.

The success of the Plan's implementation also depends on the capacity for leadership of those who have responsibility for care organisation in the Regional Health Authorities and for the management of mental health services and programmes, so that a national training programme in organisation and improvement of mental health care can be promoted for managers, with the collaboration of training centres competent in this field.

The development of pilot projects is another strategy of proved effectiveness in the implementation of service reforms. Experiments of this kind are promoted in areas of greatest innovation, such as projects for CMHTs and CMHUs, and continuous care projects.

To complement monitoring and internal assessment, an external assessment of the reform, to be carried out in collaboration with the WHO, is planned for 2007 to 2012.