C
OUR DES
C
OMPTES
Organisation of psychiatric care:
Effects of the “Psychiatry
and mental health” plan
2005-2010
December 2011
Disclaimer
Summary
of the
Public thematic report
T
his summary is designed to aid the understanding and use of
the Cour des Comptes report.
Only the report is legally binding on the Cour des Comptes.
The responses of government departments, councils and other
organisations concerned are appended to the report.
Contents
3
Summary
of the Public Thematic Report by the
Cour des comptes
Introduction
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
1
The unnecessary weight of full hospitalisation
. . . .
7
2
“Health-Justice” scheme: unfinished progress
. . .
11
3
Insufficient supervision, adversely affecting key
objectives
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13
4
Territorial organisation
. . . . . . . . . . . . . . . . . . . .
17
Conclusion
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
19
Recommendations
. . . . . . . . . . . . . . . . . . . . . .
22
Introduction
5
Summary
of the Public Thematic Report by the
Cour des comptes
P
sychological disorders are the third most frequent form of pathologies in France,
following cancers and cardiovascular diseases. Psychiatric care is funded more than
a million times a year in France, costing the French national health insurance system alone
approximately €13 billion per year and representing approximately 7% of its total
expenditure.
An additional, undefined amount is paid by other health insurance schemes, and,
mainly in the case of social and medico-social care, notably by the State and the local
authorities. The total economic and social cost of these pathologies is estimated at some
€107 billion per year in France, which is similar to the amount seen in England for
example.
Many reports have been written on this major public health issue in recent years, with
generally similar recommendations. The French public authorities first introduced their
“psychiatry and mental health” plan in 2005. The plan follows five main strategic lines
divided into 12 operational objectives, broken down into 33 measures leading to
196 actions.
In 2011, the Cour des Comptes conducted a detailed survey with the aim of produc-
ing a status report and making the appropriate recommendations. This survey was limit-
ed to all forms of psychiatric care except those relating to Alzheimer’s disease, other forms
of dementia and developmental disorders such as the various forms of autism.
Approximately 40 psychiatric or penitentiary establishments and regional health
boards were visited in eleven regions.
Throughout the survey, the Cour des Comptes remained in contact with the High
Council of Public Health (HCSP), which itself produced a report evaluating the plan’s
implementation from a more medical point of view.
No legal definition of the public service role of psychiatry
A central finding is that the plan’s implementation has been hindered by the lack of
clarity regarding the geographical coordination of hospital and extra-hospital services; the
legal basis of “psychiatric sectorisation” has, at the same time, gradually blurred. The
regional health plans currently under development by the regional health boards will prob-
ably improve this situation, but this public service role was omitted from the “HPST” law
of 2009 in spite of the plan. One of the Cour’s principal recommendations (the list is
appended to this summary) is that this role should be established.
In his reply appended to the report, the French Minister of Labour, Employment and
Health accepts this recommendation and says that he will meet the specialist professionals
in order to do define this role.
7
Summary
of the Public Thematic Report by the
Cour des comptes
Cour des comptes
1
The unnecessary weight of
full hospitalisation
This chapter examines the plan’s
impact upon the medical care and cours-
es of treatment of patients, notably
regarding the appropriate relationship
between the players. This relationship is
crucial both in order to ensure the rele-
vance and the quality of care and in
order to prevent and reduce interrup-
tions in the courses of treatment. The
care available is divided between full
hospitalisation, hospitalisation alterna-
tives and outpatient medical care pro-
vided by community extra-hospital
establishments, combined with commu-
nity practitioner consultations.
The number of hospital beds has
continued to drop:
Number of beds
2001
2005
2010
Psychiatry
61,920
58,580
57,410
General
59,840
56,500
55,240
Children and
adolescents
2,080
2,080
2,170
The fact that the beds available for
full hospitalisation are apparently all
filled is, however, mainly due to their use
in inappropriate cases. The objective of
encouraging extra-hospital care and
freeing up some full-hospitalisation
beds has not been achieved, although
some progress has been made in this
respect.
As the opinions of psychiatric care
professionals are sometimes divided by
competitive undercurrents, there is in
fact no consensus regarding the ‘fair
use’ of this form of medical care. The
highly consensual way in which the plan
has been drafted has hardly fostered
agreement on this point.
Far from “decompartmentalising”
(1)
hospitalisation, certain measures or
announcements after the plan was
launched have heightened differences
and misunderstandings instead, particu-
larly concerning security and hospitali-
sation without consent. While remark-
able progress has been made in some
areas, some difficult situations remain.
The Cour des Comptes has reported
that some patients have been hospi-
talised unnecessarily, transferred unex-
pectedly as the establishment concerned
_______________
(1) The HCSP published the results of a related study conducted on its behalf by the CREDOC studies and
research institute in 2011.
The unnecessary weight of
full hospitalisation
8
Summary
of the Public Thematic Report by the Cour des comptes
was full or had their care interrupted as
a result of moving home, particularly in
the case of people with no job security
or prisoners. Alternatives to hospitalisa-
tion are still insufficient, and communi-
cation with the medico-social care bod-
ies still shows some weaknesses. Care is
highly likely to be less effective in these
situations, and it is frequently costly.
Increase in staffing
The staffing situation must be quali-
fied. The changes in medical-care estab-
lishment staff numbers are unclear: as
the assessment methods have changed,
the following data regarding the begin-
ning and the end of the plan are barely
comparable.
Human
resources
nevertheless
increased under the plan, particularly in
the extra-hospital environment. Their
estimated full-time equivalent (FTE) is
as follows:
2005
2010
Salaried physicians
7,800
8,500
Medical care
96,000
97,400
Education & welfare
6,300
7,100
TOTAL
110,100
113,000
Hospital
1,300
1,550
Private practice
1,230
1,310
On 1 January 2011, there were
13,645 psychiatrists in metropolitan
France, taking all forms of practice as a
whole (39.5% in private or mixed prac-
tice, and 60.5% salaried), more than a
third of whom work in the Ile-de-
France region.
In addition, there were
142 general practitioners able to provide
psychiatric care, 96 of whom are
salaried.
Whereas equal access to medical
care is only possible if psychiatric care
resources
are
properly
distributed
throughout France, 80% of all psychia-
trists practise in towns with more than
50,000 inhabitants.
Psychiatric vacancies are difficult to
fill in rural regions. The planned
measures to attract psychiatrists to settle
in
such
regions
have
not
been
implemented.
The plan has, in general, not
addressed the problem of vacancies,
representing one in five budget items
(1,155 on 1 January 2009, a rate similar
to most other medical specialisations).
The report contains a dozen maps
illustrating the disparities between
regions or departments.
The geographical disparity in the
number of private-practice psychiatrists
per 100,000 inhabitants increased slight-
ly between 2000 and 2010, with ten
times more practitioners in some areas
than in others.
The unnecessary weight of
full hospitalisation
9
Summary
of the Public Thematic Report by the
Cour des comptes
The same can be said of the psychiatrists employed by health care establish-
ments. The number of such psychiatrists per 100,000 inhabitants were as follows as
at 1 January 2010:
No. per
100,000 inhabitants
No. per
100,000 inhabitants
Source:
Cour des Comptes, adapted from DRRES, ADELL Directory
Source:
Cour des Comptes, adapted from DRRES, ADELL Directory
The unnecessary weight of
full hospitalisation
10
Summary
of the Public Thematic Report by the Cour des comptes
Additional training for nurses has
mainly been provided through junior
staff member mentoring. This measure
has cost €46.7 million (as at mid-2011)
and has been extended until the end of
2012 in order to make full use of the
€75 million allocated to it.
Similarly, the measures designed to
extend the length of psychiatrists’ train-
ing to five years or to create a Masters
degree in psychiatric research have not
yet been implemented.
The measures intended to create a
qualification for nursing training insti-
tutes and to restructure their courses
have been abandoned.
11
Summary
of the Public Thematic Report by the
Cour des comptes
Cour des comptes
2
“Health-Justice” scheme:
unfinished progress
This chapter of the report analyses
the main scheme devoted to a specific
population.
The
“Health-Justice”
scheme
(2)
is directed towards the prison
population. Up to 40% of the approxi-
mately 65,000 prisoners in France
receive care for psychiatric or addiction
problems.
The combination of mental disor-
ders and precariousness frequently
makes both social and work rehabilita-
tion and the stabilisation of medical
conditions more difficult.
Any mistake is likely to result in the
person being reincarcerated and their
pathology worsening.
The twelve planned measures were
implemented only partially, late or to an
unknown extent. In 2010, the 173
French prisons concerned had the full-
time equivalent of 157 psychiatrists
organised into 26 Regional Medico-
Psychiatric
Departments
(SMPR).
Between 2005 and 2008, they received
only €5 million of additional operating
funding under the plan. On the other
hand, €134.5 million (five times more
than planned) was allocated to invest-
ments, mainly relating to security.
More Specially-Equipped Hospital
Units (UHSA) than expected have
therefore been funded. Each UHSA is
built and managed within a psychiatric
establishment, in compliance with both
hospital and prison standards. Its exter-
nal security is provided by the prison
authorities.
Only one such unit had entered use
by the end of 2010; the other 16, which
generally contain 60 beds, will do so by
the end of 2019.
It was necessary to give precedence
to improving the premises, the renova-
tion of which is a gradual process, and
to securing them. On the other hand,
less attention has been paid to ensuring
that the courses of therapy are opti-
mised, uninterrupted and lead to the
patient’s social rehabilitation.
Coordination difficulties still exist at
several levels. The rapid social rehabili-
tation of some patients due for release is
not possible, and some remain this way
for some time.
Each year, some 8% of all consulta-
tions in prisons are cancelled at the last
moment, either due to the patients or
because staff responsible for internal
transfers of detainees are not available.
__________________
(2) The French act of 5 July 2011 on the rights and protection of persons receiving psychiatric care was pub-
lished after the Cour’s survey was carried out; as a result, its implementation is not analysed.
“Health-Justice” scheme:
unfinished progress
12
Summary
of the Public Thematic Report by the Cour des comptes
The resulting underutilisation is the full-
time equivalent of dozens of psychia-
trists.
This rate is as high as 54% in the
Limousin region and 28% in the Nord-
Pas-de-Calais region.
According to the
prison authorities, the schedules of psy-
chiatric staff are not always appropriate.
This is costly and adversely affects the
care provided.
For the prison rehabilitation and
probation service, the social stigmatisa-
tion of those awaiting trial, detainees
and ex-detainees is worsened through
“real difficulties (…) as a result, they
cannot find stable accommodation,
notably so that their medical care can be
continued,” emphasises the Ministry of
Justice.
As the reports of the Controller-
General of Places of Deprivation of
Liberty make clear, the many instances
of unsanitary conditions, promiscuity
and staff and training shortages must be
remedied.
A credible strategy that balances the
sometimes conflicting requirements
regarding personal protection and civil
liberties has therefore been lacking.
The Ministry of Justice’s strategic
action plan 2010-2014 specifies actions
that are more significant and better
structured. In view of the objective of
providing prison accommodation for
80,000 detainees in 2017, the psychiatric
care facilities will be even more inade-
quate in the medium term if the time
available for consultations is not opti-
mised and the post-prison follow-up
resources and their effectiveness are not
improved.
In his reply, the French Minister of Justice
has announced measures that implement the
resulting recommendations.
Lack of internal audits and measures to combat fraud
The French Inspector-General for Social Affairs has written approximately twenty
reports on psychiatric establishments since 2005. The lack of audits within the Ministry
until 2010, on the other hand, has reduced its ability to monitor the plan’s effectiveness,
the associated risks and the reliability of the statistics.
In 2009, a check revealed that, in one region, each of the three most active
psychiatrists had been reimbursed for an average of 63 consultations per day, whereas
the national average was 11.5. No suitable indicators existed for detecting such abuses
until now, but cases of medication-related fraud were punished. The French national
health insurance fund (CNAM) has planned a battery of checks.
13
Summary
of the Public Thematic Report by the
Cour des comptes
Cour des comptes
3
Insufficient supervision,
adversely affecting key
objectives
This chapter analyses the plan’s
method of supervision and its conse-
quences, notably regarding its major
objectives of increasing staffing, mod-
ernising real estate and increasing
research.
The plan’s supervision, which was
initially sound, fell apart in the middle of
2007. This affected the distribution,
control
and
monitoring
of
new
resources—human, investment and
research—even more because their
funding was uneven. Whereas consider-
able funding was allocated to security,
funds for job creation were barely
noticeable and highly inadequate for
research.
As many of the financial and statis-
tical data are still provisional and being
checked, a comprehensive report has
not yet been produced. There are there-
fore still no indicators for monitoring
the four psychiatric objectives of the
2004 law relating to public health policy,
to which the plan relates.
The annual collection of data has
been significantly improved, however,
thanks to IT investments funded under
the plan.
Subject to these considerable reser-
vations, three aspects of the plan’s
financial contribution can be sum-
marised as follows:
Subsidies amounting to €540 mil-
lion were paid in financial years 2005 to
2008, of which €36 million was paid by
the State while the remainder was paid
by the French national health insurance
fund (CNAM);
Since 2009, the national health
insurance funde has paid €229 million
per year to continue the plan’s actions;
Up to €1.8 billion will be allocated
to real-estate and security investment
between 2005 and 2017.
Half of the security-related invest-
ment will be funded by the French
national health insurance system (via the
‘FMESPP’ public and private health-
care establishment modernisation fund),
while the other half will be funded by
the establishments themselves, either
through internal reallocation or loans.
These three main aspects represent-
ed an annual increase of less than 2% of
the resources, with regard to the €13 bil-
lion per year allocated to psychiatry by
the French compulsory health insurance
system.
This increase is less for psychiatry
than for medicine, surgery, and obstet-
rics over the period of the plan; the
plan’s measures therefore seem to be
funded through reallocation and not
through additional funds.
Insufficient supervision,
adversely affecting key objectives
14
Summary
of the Public Thematic Report by the Cour des comptes
Major real-estate programme, but late
Under the plan, 329 actions were scheduled for implementation by 2017 to com-
pensate for shortcomings in the real-estate field, more than half of which have yet
to be carried out:
Year of entering use
No. of actions
2005
1
2006
7
2007
19
2008
31
2009
39
2010
18
2011
91
2012
26
2013-2014
12
Later
58
Date unknown
27
Total
329
Abandoned projects
25
At this stage, these funded actions,
which carried out among the hundreds
of urgent necessary upgrades, have kept
establishments, the condition of which
varies greatly, in operational condition
(sometimes after the deadline). The cost
price per square metre was highly con-
sistent.
In a third of the projects funded in
this way, half of the funding was allocat-
ed to the former “specialist hospital
centres” (CHS), which were the oldest
establishments and were often highly
dilapidated in areas.
The extra-hospital investment has,
for its part, been restricted to 12% of
the total.
This level is less than was
required by the change strategy promot-
ing
“decompartmentalisation”,
i.e.
transparent services leading to better
social rehabilitation.
Insufficient supervision,
adversely affecting key objectives
15
Summary
of the Public Thematic Report by the
Cour des comptes
Considerable effort has therefore
been made to improve the quality and
the security of the psychiatric hospital
facilities, but it has not been possible to
bring them up to the same level as the
other healthcare facilities in every case.
This modernisation, which has
focused too much on the full-hospitali-
sation units, has not been guided by a
clear, appropriate strategy as insufficient
attention has been paid to redirecting
the methods of medical care towards
eliminating or reducing the period of
hospitalisation.
The French Minister of Labour and
Health’s reply announces a forthcoming inven-
tory of hospital assets, along with measures to
improve the implementation and the monitoring
of real-estate related actions.
Psychiatric research remains the “poor
relation” of health research. Insufficient epi-
demiological research, in particular, is carried
out. The negative view stated in the plan as far
back as 2005 regarding these issues still holds
true.
The plan classified the human and
social sciences field of research as being
among those “that were underdevel-
oped and require top-priority support”,
but it specified and demanded nothing
to remedy this weakness.
Solely the hospital programmes for
clinical research (PHRC) have received
new resources, which have been reallo-
cated from other sectors: the national
health insurance system has provided
(mostly outside the plan) €12.3 million
to 46 teams between 2006 and 2009
(more than one-third of which was for
the “AP-HP” public hospital system of
Paris and Sainte-Anne Hospital), and
€3.4 million to 42 regional teams.
The French National Agency for
Research has launched a call for a “neu-
rological disease and psychiatry” project
for 2008-2010, created a “mental health
and addictions” working group and, for
the first time, a “mental health and
addiction” (SAMENTA) programme.
17
Summary
of the Public Thematic Report by the
Cour des comptes
Cour des comptes
4
Territorial organisation
Chapter IV, lastly, covers the territo-
rial organisation of psychiatric care: the
“sectorisation” of psychiatry. This par-
ticular method of organising psychiatric
care, which has been in use for half a
century, has been gradually falling into
disuse and resulted in a worrying lack of
clarity regarding the organisational
framework into which psychiatric care
must now fit.
The plan’s implementation has been
set against a national strategy consisting
in eliminating sectorisation and, with no
credible sectoral organisation in the
field, its natural continuation, resulting
in extremely harmful confusion.
The 107 health-care territories could
include a community level to ensure the
sustainability of the sectors’ achieve-
ments and overcome the sectors’ weak-
nesses. This would help to ensure
greater consistency in medical care facil-
ities, based on benchmarks if not on
standards.
At this stage, however, the plan has
not resulted in sufficient growth in
extra-hospital resources or a propor-
tional reduction in full-hospitalisation
capacity.
If this central objective is to be
achieved, the French regional healthcare
agencies (ARS) must plan their outpa-
tient or part-time hospitalisation capaci-
ty according to the requirements, taking
into account the poorly-defined public
and private medical care providers, so
that all patients are guaranteed of a
range of community medical care.
At the end of 2011, the regional
healthcare agencies defined their region-
al strategic health plans to comply with
the organisational structures (medical
care, prevention and medico-social care)
and territorial health projects resulting
from the work of the territory confer-
ences. The various players’ roles and
modes of action should therefore be
redefined and clarified as a matter of
urgency.
The particular characteristics of
psychiatry, which include the need to
provide early medical care as well as to
cater for the medico-social aspect and,
in many cases, the need for social reha-
bilitation, therefore mean that a new
public service role specific to the pro-
fession must be defined.
The
French
Minister
of
Higher
Education’s reply states various methods by
which his department “will build on the Cour
des Comptes’ report in order to further support
this discipline and increase the excellence of
French research in this area.”
19
Summary
of the Public Thematic Report by the
Cour des comptes
Conclusion
T
he “psychiatry and mental health” plan, the core subject of the Cour’s investigation, has
unquestionably played a catalytic role in the field. In 2009, the French Ministry of
Health assessed to what extent the plan’s 33 measures and 196 actions had been implemented. A
quarter of the actions did not focus on specific areas; their heterogeneity and that of the services pro-
vided did not allow meaningful national indicators to be produced.
No table contained information on the degree to which three-quarters of the other actions had
been implemented, which varied greatly. The plan was therefore adversely affected by the methodol-
ogy required by public health plan management being very poorly controlled. Under these conditions,
it is difficult to weight the degree to which the plan has been implemented. The Cour nevertheless
tried to weight the 33 measures in the following table.
This table also repeats that the objectives were all stated in terms of resources, and not of ther-
apeutic results, as these can usually only be evaluated in the medium and long term.
The evaluation report produced by the High Council of Public Health (HCSP) in parallel
with the Cour’s survey confirms the Cour’s observations and provides other case studies and assess-
ments within its areas of specialisation.
With regard to the highly critical observation made in the plan in April 2005, real progress
has certainly helped to significantly improve the situation, which was notable for the continued lack
of alternative structures both upstream and downstream of hospitalisation.
Quite a few actions appear unfinished, however, and quite a few major inflection points are
uncompleted.
As a result, more than 10,000 people remain in acute psychiatric care whereas their actual
state of health would allow them to be more independent if they were provided with suitable med-
ical care.
Psychiatric care must therefore be restructured around a more selective set of priorities and
measures so that everyone can be treated with the dignity to which they entitled when they receive
care in France, in accordance with the expectations of the patients, their families and medical care
professionals.
It is now a matter of reorganising the medical care by increasing the coordination of commu-
nity services while still maintaining the benefits of the care’s sectorisation.
A policy of more actively redeploying hospital resources to extra-hospital structures must there-
fore be adopted.
This policy must take into account the national health insurance system’s financial disequilib-
rium, which offers very little margin for manœuvre when allocating new resources.
The French Minister of Labour, Employment and Health’s reply includes the announcement
of a new plan relating to psychiatry and mental health and states that this plan, which is already
under discussion, “can greatly draw on the Cour’s chosen fields of improvement.”
Conclusion
20
Summary
of the Public Thematic Report by the Cour des comptes
21
Summary
of the Public Thematic Report by the
Cour des comptes
Recommendations
The 23 operational recommenda-
tions made by the Cour are intended to
implement the four main strategic
fields of improvement suggested in
this report:
Firstly, a public service role
directed towards all areas of psychiatry
(instead of only hospitalisation with-
out consent, as at present) should be
defined and implemented;
This definition should retain the
achievements of sectorisation and
clarify the strategy. Such a role, and the
contractual relationship it involves
with its players, would make it easier to
reorganise and structure the medical
care offering. The “sector”, provided it
evolves, remains more of a solution
than a problem.
Secondly, more effort should be
made to reduce the geographical dis-
parities, through redeployment due to
the national health insurance system’s
financial constraints, by giving a higher
priority to the community alternatives.
Thirdly, a reform of psychiatric
care funding should be drafted and
implemented. The plan’s progress in
the fields of computerisation and sta-
tistics should now enable this reform
to be implemented without delay, ben-
efiting the extra-hospital structures;
Lastly, the efficiency and efficac-
ity of the medical care can only be
increased if greater efforts are made in
the research and epidemiological
fields.
List of recommendations
22
Summary
of the Public Thematic Report by the Cour des comptes
Medical care
1. Continue to develop and
widen the extra-hospital healthcare,
medico-social care and social care
offering, mainly so that the independ-
ence and social rehabilitation of
patients are improved;
2. Evaluate
performance,
notably in terms of the waiting time
for obtaining a specialist medical opin-
ion or being admitted into a centre,
and in terms of the fit-to-need of
inappropriate full hospitalisation;
3. Add responsibility for locat-
ing, analysing and locally correcting
any medical care interruptions and
waiting times, regardless of their cause,
to psychiatry’s public service role;
4. Ensure that the establish-
ments’ organisational and internal
management methods are revised so
that it is easier to distinguish between
the resources allocated to hospital and
extra-hospital structures and reduce
the degree of fungibility between the
two;
5.
Enhance the organisation and
sustainability of emergency psychiatric
services;
6.
Harmonise the design, distri-
bution and use of units for difficult
patients;
7. Reform the funding of psy-
chiatry via the national health insur-
ance system, so that it is based on tar-
iffs that take into account the psychi-
atric care’s characteristics.
“Health-Justice” scheme
8.
Publish the circulars concern-
ing coordination between the prison
authorities and the health-care profes-
sionals, taking into account article D.90
of the Code of Criminal Procedure in
the health-justice protocols, and har-
monise their implementation;
9. Develop standards and indi-
cators for the care of patients under a
court order, including at the post-penal
stage, consolidating its medical and
social coordination as provided for in
the strategic action plan 2010-2014;
10. Ensure that all prison facili-
ties in which medical care is provided
meet the hospital standards introduced
in 2011;
11. Improve the management of
consultation time in prisons.
Supervision
12. Ensure better coordination
of psychiatric policy at an inter-minis-
terial level, particularly between the
Ministries of Justice and Health,
including for patients under a court
order, together with its follow-up
based on reliable indicators;
13. Strengthen the supervision
and national and regional monitoring
of psychiatry;
14. Consolidate the funding and
management of the French National
Mission for Mental Health Support
(MNASM) in accordance with the cur-
rent regulations.
Recommendations
23
Summary
of the Public Thematic Report by the
Cour des comptes
Indicators
15. Develop the epidemiological
and statistical data sources so that psy-
chiatric public-health indicators can be
implemented, based on more rapid and
better-coordinated data use, without
identifying objectives with no tools for
follow-up.
Funding
16. Make a clear distinction
between durable non-renewable credit
measures and new measures, and those
funded through redeployment in the
public health plans and their reports.
Human resources
17. Implement a medium-term
initial and continuous training plan for
all psychiatric players;
18. Increase the mentoring of
newly-hired staff, offering the appro-
priate incentives;
19. Reduce the pay differentials
between hospital and private practice
(repeated recommendation).
Investment
20. Ensure that all establishments
and departments welcoming the men-
tally ill comply with the national stan-
dards, including those within the prison
system;
21. Prohibit the full payment of
investment subsidies prior to comple-
tion, and ensure that their balance is
paid solely when the subsidised equip-
ment actually enters use.
Research
22. Ensure that all psychiatric
research is coordinated at the cross-dis-
ciplinary level.
Territorial organisation
23. Define a psychiatry-specific
community public service role in the
French public health code, ensuring
that all benefits of the sectoral policy
are maintained;
24. Determine the conditions
governing how each of the various
potential psychiatric activities is autho-
rised and operates;
25. Set up a consistent hierarchy
linking the community care offering
and the specialised bodies serving larg-
er areas;
26. Generalise the mental health
local councils, grouping together all
psychiatric and general practice players
and their partners, including the local
authorities, for a given territory.