Salisbury, TT; (2013) Improving care in longer term mental health facilities: International differences in quality and service user experiences of care. Doctoral thesis , UCL (University College London).

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Abstract

Background Although mental health problems are highly prevalent across the world, relatively little is spent on mental health care and a large number of individuals with mental health problems go untreated. The World Health Organization has pressed for countries to increase mental health expenditure and deinstitutionalisation of care in the hope of improved care. However, there is limited evidence regarding the relationships between national characteristics of mental health care provision and quality of care. Aim The aim of this study was to evaluate, in a European sample, the association between national mental health expenditure and the deinstitutionalisation of care and 1) the quality of longer term psychiatric and social care and; 2) service user ratings of care. Method Facility managers were interviewed using the Quality Indicator for Rehabilitative Care (QuIRC). Service users in each facility provided ratings of autonomy, life satisfaction, experience of care and therapeutic milieu. Mental health expenditure and deinstitutionalisation were measured using national mental health budgets and a novel quantitative tool, respectively. Multilevel models were developed to evaluate relationships between expenditure, deinstitutionalisation, quality of care and service user ratings of care. Results Increased mental health expenditure and deinstitutionalisation were significantly, positively associated with all QuIRC domains, except social interface. Increased expenditure and deinstitutionalisation were also significantly associated with more positive service user ratings of autonomy and experience of care. No associations with service user ratings of life satisfaction or therapeutic milieu were found. Conclusions Results suggest that financial investment in and deinstitutionalisation of longer term mental health care are integral to the provision of higher quality care. Lack of available data on country-level variables and the cross-sectional nature of the study design limit generalisability. Future work should include a variety of national, facility and service user variables in order to build more robust models with improved generalisability.

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