Managing mental health service provision in the decentralized, multi-layered health and social care system of Germany.
BACKGROUND
The effective coordination of mental health service provision is a requirement for successfully reforming mental health care from a hospital-focused system towards a more decentralized, community-oriented one. Implementing such coordination is particularly challenging in a decentralized, multi-layered health and social care system such as exists in Germany.


OBJECTIVE
(i) To investigate the coordination and planning of mental health service provision performed at and between the local, Länder and federal political levels in Germany; (ii) to outline the disparities in coordination and planning of mental health service provision that exist between the different political levels and locate key-authorities; (iii) to determine whether a decentralized, multi-layered health and social system such as Germany's allows for adequate coordination.


METHODS
(i) Analysis of mental health legislation and policy documents; (ii) guided interviews with officers and consultants of the government units responsible for mental health affairs of the 16 Länder and the federal Ministry of Health and Social Security; (iii) submission of results to the interviewed experts for verification.


RESULTS
Multi-professional boards and posts for coordinating and planning mental health services are widely implemented on local state and federal level in Germany. Most of them operate without being required by legislation. The sickness and pension funds are represented in less than half of the boards on state level. Boards on local and on state level are mainly concerned with coordinating social mental health care and have little influence on medical mental health care. Mental health policy documents exist federally and in most Länder. All but one of the mental health legislations of the Länder (present in 12 out of the 16 Länder) also considers regulations concerning coordinating and planning mental heath services. The key-authorities for mental-health policy, legislation and service implementation is with the 16 Länder. The federal government however plays an important frame setting role. Actual service provision is a local responsibility.


CONCLUSIONS
Since the beginning of mental health reforms 25 years ago and in particular in recent years, structures for the coordination and planning of mental health service provision have been established countrywide at local, Länder and federal levels. However, there are hardly any structures that connect the Länder and local levels and act as a source of independent quality assurance. The coordination boards at the Länder level include almost all the parties involved in mental health care, with the exception of sickness and pension funds that are, for the most part, absent. Thus the coordination boards are mainly restricted to governing social services in mental health care. Despite this, the countrywide establishment of diverse boards for the structured coordination of mental health service provision can be regarded in itself as a success, although little is known of the processes and impact of this framework. There are, however, indications that coordination is still restricted to the traditional interfaces and dividing lines of the mental health care system, which they seem unable to overcome. IMPLICATION FOR HEALTH POLICIES: The reform of mental health service provision towards a more community-orientated approach requires sophisticated coordination. The countrywide establishment of structures for the coordination and planning of mental health service provision has been largely possible in Germany. It does, however, require further analysis, since coordination beyond the traditional boundaries seems unlikely. Therefore, incentives are needed in order to encourage "adequate coordination" as well as integration with other parts of the mental health care system.
Bramesfeld
Anke
A
Health Policy Working Group, Department for Epidemiology, Social Medicine and Health System Research, Hanover Medical School, Hanover, Germany. Bramesfeld.anke@mh-hannover.de
Wismar
Matthias
M
Mosebach
Kai
K
D003156:Community Mental Health Services / Q000458:organization & administration*; D017598:Efficiency, Organizational; D005858:Germany; D018166:Health Care Reform / Q000458:organization & administration; D006285:Health Planning / Q000458:organization & administration; D006801:Humans; D009937:Organizational Objectives; D011057:Politics