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This edition of Healthcare Review – OnlineTM is the first in a two-part series focussed on mental health services.
Mental illness constitutes a major component of the morbidity, costs and health burden for society. From a background of institutionally-based care, there has been a significant shift towards mental health service delivery in the community.
The focus in the series is equally on the provision of mental health services themselves and on the lessons gleaned within the sector that are applicable elsewhere in the wider health care arena.
There is an increasing commitment internationally to integration in mental health. Numerous integration initiatives abound, generally with an aim to increase the quality, appropriateness, cost-effectiveness, sensitivity, and accessibility of services. As a result, the mental health arena has provided an important learning ground for the application of integrated care principles in general.
Exposure to the process of service integration will be the focus of the next edition in this series.
In this edition, Dr Arya, Clinical Director of Mental Health Services at MidCentral Health in Palmerston North, New Zealand, presents two papers that summarise important general principles collated as a result of his experience in the Mid Central mental health service in New Zealand.
The Mid Central mental health service holds the contract to provide comprehensive mental health care to a population of approximately 160,000 in New Zealand’s central North Island. The service provides all aspects of mental health care including inpatient care, community care, crisis care, general hospital liaison, child, adolescent and family services, alcohol and drug services and Maori mental health services.
In his paper "On A Question Of Informed Consent", Dr Arya considers the questions of why is it important to have informed consent and how much and what should be disclosed.
Informed consent is associated with respect for an individual’s autonomy and dignity. Our society recognises the right of individuals to make their own decisions based on their own values. The failure to inform or involve a patient in medical decision-making is thus a failure to respect the patient as a person who can reason and choose. Only when it can be clearly shown that a person is incapable of reasoning rationally or of autonomic choice, can informed consent be waived.
Dr Arya discusses the implications of failing to provide information about a procedure or treatment within the legal system in New Zealand as well as in the US and Canada He considers the important issue of who can consent, with special consideration given to consent in relation to children and the intellectually disabled, and the process of evaluating competency to give informed consent. He reviews circumstances that are exceptions to consent and concludes by reviewing the process of how to obtain informed consent.
In the paper "A Framework for Continuous Quality Improvement in Health Care Organisations", Dr Arya discusses the concept of quality improvement and the importance of system improvement when aiming to improve service quality. He highlights leader commitment to quality improvement and the development of a "quality culture" as essential prerequisites for undertaking quality improvement initiatives.
Dr Arya suggests ground rules for implementing a quality improvement programme including adoption of a philosophy of change and support for quality-driven systems at all levels within the organisation. He goes on to identify practical strategies for organisations aiming to improve the quality of their services. Examples include implementation of processes to support customer advocacy and provision of training and education to ensure that staff members have the competencies required to implement planned quality improvement initiatives.
Readers may also wish to refer to earlier papers on quality management systems published in Healthcare Review - Online from Professor John Øvretveit, Professor of Health Policy and Management at the Nordic School of Public Health in Goteborg, Sweden. His January 2001 paper "Evaluating Quality and Quality Measures for Comparison" overviews different quality evaluation and indicator schemes, based on the experiences of quality specialists and leaders in the Nordic countries who have applied various schemes in public hospitals and health care services. This paper further expands the concept of an evidence base for use in quality programme development, which Professor Øvretveit introduced in his July 1998 paper "The Convergence of Evidence-based Health Care and Quality Improvement".
The subsequent edition in this series will focus on integration of mental health services and lessons for the wider health care system from this experience.
Dr Margaret Tobin, Director, Mental Health Services, South Australia, will present a paper reviewing lessons from the structure she implemented in Area Mental Health for South Eastern Sydney, in her role as Director for that service, and more recent service development work in South Australia.
Dr Dinesh Arya will review his experience with restructuring the Mid Central Mental Health Service in New Zealand, where continuity of care for consumers and minimal duplication of service were key components of the vision for the service.
