Preparation for the approval and implementation of a PRR is being done, where health has an extremely important weight and where mental health has an unambiguous priority.
It was also agreed that this investment, to be more than circumstantial, must have a structural effect, that is, it must be an engine for the necessary change. Changes resulting from the new investment should be directed towards solving persistent problems in the performance of mental and mental health services.
However, in a global analysis of the chapter on health, it becomes clear that the NHS will be the sole target for allocating health funds, as if this only constitutes the entire national health services system.
If we look at the reality and the role of institutions providing care in psychiatry and mental health, the unwillingness to see everyone takes on serious contours. The Directorate General of Health (DGS) National Plan of Mental Health (PNSM), drawn up in 2007, does not recognize the functioning of non-governmental entities, mental and mental health care providers, as partner entities, specifically IPSS.
The hospitable institutes – Irmãs Hospitaleiras do Sagrado Coração de Jesus and S. João de Deus Institute – with an intervention in the context of specialist detention and in the rehabilitation itself, which they pioneered in Portugal, are outside of the PNSM.
Today, 14 years after PNSM was implemented, and given the effects of a year of the pandemic, the shortcomings of the scope of mental and mental health services are clearly visible. People with mental illness are especially sacrificed, especially those with chronic and disabling mental illness. This is the issue of most concern because it is so distant from political rhetoric and priorities.
The discussion should not focus on whether there is too much or too little. What is urgent is to ensure that sectors of the population with special needs and very little weight in party and media agendas see their needs recognized, health and other services are guaranteed so that they can live their lives properly with both. She is, can and wants to be.
This mission should be everyone’s responsibility, from the state that creates, organizes and guarantees quality, along with entities that provide health care, which are long-qualified and available to become partners in this mission that must include everyone with distinction and innovation.
There is a lack of countless plans and projects issued by responsible government agencies, which consequently from the opinion of people with mental illnesses and their families, which had no weight in decision-making. It is essential to hear patients and their families about the difficulties, limitations and options and thus determine the type of services and professionals who need them. Not all mental illnesses are the same. They take different forms that pose different degrees of difficulty and limitations to patients. This reality must be taken into account in the aforementioned plans, projects and investments.
The involvement of entities from different sectors, services and structures, from an integrated and detailed perspective, remains in a bold position on true partnership. All partners responsible for providing specialized healthcare in the field of psychiatry and mental health, together with the NHS, must be taken into account in the process of restructuring the various levels of response in the clinical and rehabilitation fields.
The host institutes operate in the country with recognized technical and scientific expertise, and have a network of geographically executed services, distinct and qualified intervention teams, which are necessary for national coverage in providing these services to the population. It should also be noted that they provide healthcare at real costs of providing care that are lower than those borne by the public sector.
For all these reasons, the mental health plan, drawn up in 2007, cannot serve as a guide for what we need to do now. The assumptions and realities of mental health services at that time, with a large number of patients in psychiatric institutions, changed profoundly. Most psychiatric hospitals have closed and an investment that is in line with needs, while establishing community-based structures, has not been guaranteed. From the 2007 plan, what we can conclude is that in addition to very little achievement, the changes made have added to the problems.
Looking at this PRR and just getting PNSM 2007 off the stairs and wanting to implement it is a surefire recipe for a new failure. It is necessary to conduct an intelligent analysis of what has been achieved, with the ambition to solve the age-old problems of lack of means and resources.
Learning lessons from what happened in the past is essential in order to adopt better solutions for the future. Placing a person with a long-term mental illness in an apartment building in the community and having a team to visit them every 15 days is not enough, and in some circumstances, it constitutes neglect.
Sure, there are people with mental illness who could be included in an entire community project. But when we talk about a person suffering from a serious mental illness for life, which limits him even in exercising his rights, there are other factors and he is keen to take care of them. In most cases tested since 2007, the legal mechanisms for integrating into active life were nothing more than ink on paper. Protected work is only on paper, and at certain stages a person with mental illness may be weak and unable to search for what is most protective of them.
Without the necessary resources and means, there are no effective responses to the needs of these people.
We are talking about financial and legislative resources, as the rehabilitation structures recommended in the Integrated Continuing Care Network in Mental Health are not and cannot be in the technical requirements for the physical structure, specific to the structures of the public national network of continuing care. In fact, it will be (or is) “nonsense” in the recommended institutional rehabilitation and abolition principle. Or are we effectively “entering” what is society?
We all have to realize that creating a healthcare network with specialized clinical and social support means a pool of human resources (community teams), which can fund the implementation of PRR, but to comply with one of the central principles of PRR, a Resilience, We will have to obtain assurance that the state, through various governments, will accept permanently bearing this sum, which is a significant amount.
But in the field of mental health, there are always people with clinically unstable severe mental illness who are unable to “take them out of institutions”, due to the need for permanent clinical monitoring.
All the documentary production that has been developed in detail about the restructuring of psychiatric and mental health services, says nothing about these populations who are thus left without weight in decision-making and place in investments.
Many of these people are held in hospitable institutions, and some are in psychiatric units in general hospitals and elsewhere.
In hospital institutes, these patients are located in units with different characteristics, from a high degree of independence to a state of high dependency, always according to their needs, which differ according to the stage of the disease in which they find themselves. They are patients with a high degree of complexity of care, which requires the monitoring of properly prepared technical and clinical teams.
Host institutes have successfully created housing structures for people with mental illness which, with the development of models of mental health care, are good examples that are heading in the right direction in terms of good practice.
At the moment, according to official figures, there are approximately 400 people in the country residing in public hospitals, in psychiatric units, who will be the target of the institutional abolition process. We bear a great responsibility towards them and we cannot repeat mistakes that were made in the past.
We all expect an effective and effective mental health response, and this may be the defining moment to do so, but consider the model, structures, resources and, above all, what best responds to the needs of people with mental illness. And their families.
Let us dare to think of a new paradigm, which is comprehensive and intersectoral, with disparate structures, expressed in a network, where answers are determined by needs. Mental health has many aspects, differing in degree and severity. Therefore, it is not possible to adopt strict criteria such as “institutionalization” or “de-institutionalization”. The method is care and rehabilitation, through various specialized interventions, where respect for rights, appropriate therapeutic and rehabilitative environments, hospital or community are guaranteed.
It is up to the state to establish measures for job inclusion, when this is the appropriate pathway for the patient.
The new plan must be based on three pillars: curative, rehabilitative and integrated.
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