PRESS RELEASE
On 16 February 202
1
PUBLIC ENTITIES AND POLICIES
CAREER PATHS IN THE ORGANISATION
OF PSYCHIATRIC CARE
In conjunction with the regional audit chambers, the Court has sought, from
the
numerous
data
available
and
site
inspections
and
checks,
to
describe
and understand the distribution and allocation of resources between the different types of
patients concerned by mental health and psychiatric care (from simple ailments to more
serious psychiatric disorders).
The main observation
is that the provision of care is diverse, poorly graduated and
insufficiently coordinated. To remedy this, the Court makes seven recommendations, aimed
in particular at defining a more coherent care policy and returning to the practice of inclusive
care initiated in the 1960s, with a view to improving the quality of support
and patient’s dignity.
In the absence of a graduated approach, there is a risk of a loss of efficiency in
care
The different types of disorders, whether they are mild, moderate or severe, should in
principle correspond to different levels of care in the primary care system (attending
physicians and psychologists) and in the “second line” system (psychiatry), whose care must
remain specialised. It is important to review access to these different levels and the
procedures for moving from one level to another, in order to reserve the most specialised care
for those who need it and to redirect the primary care system towards psychological care that
would rely, as appropriate, on psychiatry. This is not the case today: at least one-third of the
interviews in medical-psychological centres, for example, are carried out with patients who
should
come under primary care.
This situation leads to a loss of efficiency, but also of effectiveness, in the management of the
most severe cases, which is reflected in a high proportion of rapid rehospitalisations, a large
proportion of patients hospitalised for long periods and a lack of sufficient follow-up at home.
Finally, the proportion of psychiatric admissions from emergency departments is high,
whereas it should be low – the precursors of a crisis are generally progressive.
Traditional levers that are rarely involved
In principle, the supervisory authorities have powerful levers for structuring hospital activities,
including mental health and psychiatry. However, these levers do not appear to be very
operational in the latter field. Indeed:
the obligations of minimum care content, in return for activity authorisations, are non-
existent for public psychiatric establishments and private health establishments of
collective interest which are part of the public service, and are very limited for the private
for-profit sector. However, experience shows that these legal tools could be used, among
other things, to make multidisciplinary coordination and patient monitoring mandatory;
the task of admitting patients to care without consent is entrusted to institutions
designated on a historical basis, without the obligation for them to present a plan to
reduce recourse to this type of care, even though the constraint undermines the
“therapeutic alliance” which is valuable in this area;
lastly, the sector’s tasks are assigned to establishments which are not required to submit
a plan for the territorial deployment of care beforehand: responsibility for building
graduated and coherent pathways is thus granted without any commitment from
the
establishments and without any monitoring by the regional health agencies (ARS).
A stack of tools without sufficient coherence and indispensable national
trade-offs
The need to build graduated and coordinated care pathways has led to the implementation of
a toolbox, defined by the 2016 law on the modernisation of the healthcare system and
adjusted by the law of 24 July 2019. This toolbox includes territorial mental health projects,
territorial psychiatric communities, the mobilisation of mechanisms applicable to other care
sectors, such as territorial hospital groups or local health contracts. Although it is still too early
to draw up an assessment, an undeniable consultation dynamic has been observed. However,
it is possible that this is running out of steam due to the lack of monitoring tools.
In addition, other measures appear necessary at a national level. For example, access to
medical-psychological centres, which are often saturated due to their lack of focus on priority
groups, should be filtered out through prior guidance or consultation with a front-line
professional. The experimentation undertaken in four departments should also be extended,
allowing psychotherapies carried out by independent psychologists, on the prescription of the
attending physicians, to be taken care of by the National Health Insurance Fund (
Caisse
nationale d’assurance maladie
). A third development would be to reorganise the activities of
the psychiatric sectors, particularly by encouraging the mobility of teams and their refocusing
on patients suffering from the most complex disorders.