9th Annual ESPAnet Conference Sustainability and transformation in European Social Policy

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Universitat de València - ERI POLIBIENESTAR.

Edificio Institutos-Campus de Tarongers. Calle Serpis, 29. 46022. Valencia.

Phone: (+34) 96.162.54.12– C.I.F. Q4618001-D Email: espanet2011@uv.es

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9th Annual ESPAnet Conference

Sustainability and transformation in European Social Policy

Valencia, 8-10 September 2011

Stream 21: European health systems and health inequalities

Stream convenors: Annalisa Ornaghi and Mara Tognetti (University of Milan – Bicocca)

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Considérations sur l’évolution de la politique de santé mentale en France Docteur Bernard Allemandou

L’analyse du système de santé mentale est chose complexe car elle doit tenir compte de l’évolution du contexte sociétal et des réformes de l’action publique.

L’intégration/inclusion de la psychiatrie au modèle médical dominant avec le déni de sa spécificité se traduit par une situation difficilement supportable pour de nombreux malades mentaux.

En France, malgré des intentions de l’administration centrale (création des Agences Régionales de santé) le clivage administratif et institutionnel entre le médical et le social se traduit par l’abandon de malades au sein de la cité.

Le modèle de la sectorisation de la politique de santé mentale à la française, pensée dès 1960 et réalisée à partir de 1972 n’a pas tenu ses promesses et est aujourd’hui dans une impasse totale. Selon de nombreux témoignages « En France, la psychiatrie est en crise ».

Entre les intentions affichées par l’OMS : un peu de soins intensifs (des hospitalisations rares et courtes), et beaucoup de soins en milieu de vie normal (soin communautaire), en maintenant les personnes dans leur milieu de vie ou dans un milieu de vie adapté, et la réalité des pratiques existent des écarts tels qu’on est en pleine utopie.

Cette utopie neobureaucratique [Lyse Demailly] s’appuie sur une logique de rationalité budgétaire visant au contrôle et à la standardisation des pratiques (diagnostic idéal, fiable, rapide, standardisé, permettant de prédire le comportement des patients) avec un mode d'organisation industriel et à limiter l'autonomie des professionnels et leur place dans la régulation de l'action publique.

La politique de santé mentale ne pourra s’orienter vers une démocratie sanitaire que dans la mesure où elle sera influencée par de petits collectifs et les grandes associations (UNAFAM, FNAPSY) qui contribuent à dénoncer fortement les violences institutionnelles et l'inhumanité de certains soins ou de certaines situations.

Docteur Bernard Allemandou Psychiatre

Directeur scientifique de la revue Sociologie Santé

Ex professeur associé à l’Université Victor Segalen de Bordeaux bernard.allemandou@numericable.fr

8 rue du Général Bordas 33400 Talence

06 85 53 17 19

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21 European Health systems and health inequalities Tognetti, Mara Omaghi, Annalisa

IX Annual ESPAnet Conference 2011

Reflections about the evolution of the mental health policy in France

The analysis of the mental health system is a complex thing since it must take into account the evolution of the social environment and of the public policy reforms.

The inclusion of psychiatry into the prevailing health model regardless to its own specificity results in a situation hard to bear for a lot of mentally ill people.

In France, despite the purposes of the central administration which created the Local Health Agencies, the administrative and institutional divide between the health and the social fields turns into a lack of treatment for the mentally sick within the city.

The « sectorisation» model of the French health mental policy, contemplating since 1960 and implementing since 1972, hasn’t been as successful as it should have been and has come to a complete standstill today.

According to a great amount of witnesses: « In France, psychiatry experiences a crisis ».

There are such differences between the purposes declared by the World Health Organization – a bit of intensive care (some unusual and short-term hospitalizations) and a lot of homecare (community care) to maintain people into their own homes or into an adapted place of life- and the reality of the practices, that we are living in utopia.

This « neobureaucratical » utopia, according to Lyse Demailly’s expression, leans on a budget control logic aiming at the control and the standardization of the practices (an ideal, reliable, prompt and standardized diagnosis in order to predict patients’ behavior.) It also sets up a model of industrial organization which restricts the professionals’ freedom of acting and their position in the public policy regulation.

The mental health policy could only move toward a healthy democracy as long as it will be affected by small groups and bigger associations (UNAFAM, FNAPSY), which contribute to strongly denounce the institutional violences and the inhumanity of some treatments or some situations where treatments are wanting.

Doctor Bernard Allemandou Psychiatrist

Scientific director of the review « Sociologie Santé »

Former teacher at the “Université Victor Segalen, Bordeaux 2”

bernard.allemandou@numericable.fr 8 rue du Général Bordas

33400 Talence

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21 European Health systems and health inequalities Tognetti, Mara Omaghi, Annalisa

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Reflections about the evolution of the mental health policy in France

Doctor Bernard Allemandou

I. Evolution of the social policies

1.1. The revenu minimum d'insertion

The revenu minimum d'insertion (RMI) was created in France the 1st December of 1988. The RMI is a social welfare which aims at helping the integration of the most helpless into the labour market.

Since June the 1st 2009, the RMI and the Allocation de parent isolé (API) had been

replaced by the Revenu de Solidarité Active (RSA) which, similarly, ensures a

minimum income. It also concerns workers with low income. In December 2010, 1.35

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million people were receiving the basic RSA, i.e. without the additional activity income.

¹

The question raised in all the evaluations of the RMI was about the existing link between integration and health: to what extend health problems are responsible for integration difficulties, or do the integration difficulties bring about health problems? Numerous studies converged to reveal this link between social insecurity and the lack of integration, for instance the findings of the study of the Centre de Recherche pour l’Etude et l’Observation des

Conditions de Vie² :

« Without any surprise, strong links have been proved between health status and social difficulties. The RMI beneficiaries have a weaker health condition than the rest of the French population. A clustering shows that almost half of the RMI beneficiaries out of our sample have got health issues to deal with, whether they experience disquiet, a confirmed sickness, or whether they hold or no their social situation responsible for their health condition. »

Graphic II

attribuant ou non leur situation sanitaire à leur situation sociale.»

1 Le montant du RSA socle au 01/01/2011 est de 467 € pour une personne seule sans enfants, 840 € pour une personne seule avec deux enfants, 980 € pour un couple avec deux enfants.

2 CHAUFFAUT Delphine, DAVID Elodie, GUILLOUX Sophie, OLM Christine, Les dispositifs d’insertion face aux problèmes de santé, CREDOC, Cahier de Recherche, n° 208, novembre 2004

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1.2. The universal health care coverage and the complementary health care

Ten years after the RMI Act, one of the features of the evolution of the social policies in France has been to make fighting against exclusion the top priority (the fight against exclusion Act was passed July the 29th 1998).

We think that the main problem of people suffering from precarity is not to have access to new rights but to actually have access to existing basic rights.

The essential of the directives consisted in creating the conditions and the processes through which could be utmost ensured this access to rights in every areas for the people that society’s transformations have weaken the most.

Ten years after the implementation of this Act, the outcomes of the evaluations made are rather negative concerning the consequences of the Act, which could be explained by the growth’s decrease since 2001 and by the deterioration of the budgetary environment.

Nevertheless, we can point out a positive effect: an improvement in the care access of the people in need thanks to:



the Couverture Maladie Universelle (CMU) – a basic universal health care coverage created by the July 27th 1999 Act, which allows access to health insurance for all people living in France on a steady and regular basis for more than 3 months and who are not eligible to health insurance on other regard,



the CMU complémentaire (CMU-C), a complementary free health insurance which takes care of what is not covered by compulsory health insurances allowed on financial criteria.

³

The CMu-C and the aide complémentaire santé (ACS) allow 5 million people to have access to complementary health care. Yet, without this complementary health care, the access to health care becomes difficult, or impossible for the helpless.⁴ However, the map below points out the importance of the territorial inequalities.

3 La CMU permet à 1 500 000 personnes d’avoir une couverture santé de base et la CMU-C permet à 5 millions de personnes d’accéder à une complémentaire santé. Or, sans cette complémentaire santé, c’est l’accès aux soins lui-même qui devient difficile, sinon impossible, pour les plus démunis : Evaluation de la loi CMU, rapport n° IV juillet 2009, réalisé en application de l’article 34 de la loi n°9 9-641 du 27 juillet 1999. Au 31 décembre 2008, si l’on retient les effectifs des principaux régimes (CNAMTS, RSI, MSA), pour la métropole, les effectifs CMU-C au 31 décembre 2008 étaient de 3 557 916 bénéficiaires, soit 5,7 % de la population.

4 Evaluation de la loi CMU, rapport n° IV juillet 2009, réalisé en application de l’article 34 de la loi n°9 9-641 du 27 juillet 1999. Au 31 décembre 2008, la CMU de base concernait 1 500 000 personnes.

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Inégalités territoriales de la CMU-C

Si l’on retient les effectifs des principaux régimes (CNAMTS, RSI, MSA), pour la métropole,

les effectifs CMU-C au 31 décembre 2008 sont de 3 557 916 bénéficiaires, soit 5,7 % de la population.

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Among the beneficiaries of the CMU-C, many are suffering from mental troubles, sleep

troubles, or from nervous system diseases. This specificity can be found in the medications’ use:

they use 2,3 more psychiatric medications and 6,76 more nervous system medications.⁵

Thus appears obviously the fact that health problems are an integral part of integration and exclusion problems faced by the helpless, and that, among the health issues, mental health problems are the most knotty ones for the social workers responsible of the assistance system.

But how come the social issues of the most helpless make the mental health problems raised whereas they should normally be taken care of by the mental health policy established in France since 1972, a.k.a. “sectorisation” policy?

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2. The evolution of the mental health policy

In France, the organization of psychiatry leans on the principle of “sectorisation” since 1970.

Based on the notions of accessibility and the continuity of care, the “sectorisation” aims at promote various and community care, adapted to the patients needs whether if it is an integral, partial or emergency hospitalization. In practice, each French department is divided in specific geographical areas, of about 70 000 inhabitants.

Fifty years after the instauration of this « sectorisation » policy in France, the psychiatric areas, the basic units of public mental health offer, are marked with strong disparities. They concerned as well the means – staff, equipments and financial resources – as the implication in reaching the targets of the « sectorisation » policy.⁶

Document 1

5 Questions d’économie de la santé n° 130 – mars 2008 – IRDES

6 COLDEFY Magali, LE FUR Philippe, LUCAS-GABRIELLI Véronique, MOUSQUÈS Julien,

« Cinquante ans de sectorisation psychiatrique en France : des inégalités persistantes de moyens et d’organisation », Questions d’économie et de santé, IRDES, n°145, août 2009.

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Alain Milon, senator, rapporteur of the study about the status of psychiatry in France, from the parliamentary bureau of the evaluation of the mental health policies, states that « psychiatry, which should be the basis of the mental health policy, is not able to ensure to provide health care to the patients. It finds itself today both neglected: by the patients first, and by caregivers then because the stigmatization of the sick reflect on them. »⁷

This worrying assessment follows many stances mentioning the crisis situation of the French psychiatry.

In order to analyze this political failure, we must ask ourselves about the relevance of the design of governance applied to mental health.

The governance of the central administration concerning health leans on a budget control logic aiming at the control and the standardization of the practices (an ideal, reliable, prompt and standardized diagnosis in order to predict patients’ behavior.) It also sets up a model of

industrial organization which restricts the professionals’ freedom of acting and their position in the public policy regulation. It is described as a « neobureaucritical » utopia, according to Lyse Demailly.⁸

Thus the feature of the mental health policy led since the Hospital Reform Act in 1970 was to include psychiatry into the medical model and to regard psychiatry as any other medical specialty, denying its own specificity. General hospitals and psychiatric hospitals have been included in one conceptual model, regarding them as some care-producing institutions subjected to production’s expectations: quality, innovation, mobility, evaluation.

Even if one of the positive effects was the change from a reality of imprisonment to a care conception, two major obstacles appeared:

7 Rapport sur l’état de la psychiatrie en France, 28 mai 2009, Office parlementaire d’évaluation des politiques de santé.

8 DEMAILLY Lise, Le soin en santé mentale en France : mutations et tensions in Les politiques de psychiatrie et santé mentale : entre incertitudes et perspectives à paraître in Revue Sociologie Santé, n° 34, octobre 2011.

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1) the management conception focused on the hospital administration was a main restraint to the design of the sectorisation public policy.

⁹

Between 1985 and 2005, about 30 000 beds and places were suppressed in psychiatry¹⁰.

Graphic III

Depuis la mise en place de la politique de secteur suppression de 60 000 lits en psychiatrie Source : www.ecosante.fr Données : Drees, SAE

So today the main problem of the staff in the psychiatric services is to « find a bed » to admit a patient who shows a pathology requiring a hospitalization.

The resources allocated to the field didn’t allow to make up for the diminution of the number of beds. Consequently, this transferred to the family of the patient the responsibility of his care or made many of the sick people alone and lonely in the city, without a house nor a job…

What makes the parliamentary report says that French psychiatry’s particularity is « the extent of the lack of care providing ».

2) the hospital, as a technological excellence unit of a scientific medicine, associated with some budget control regards, responds from now on to the pattern : emergency – diagnosis – short- term hospitalization, which is not adapted to the mentally ill whose sickness doesn’t show up and doesn’t evolve like any other somatic disease. This results in psychiatry in: ambulatory care, diagnosis and hospitalization without consent, i.e. being discharged only on financial motivations, with a treatment for the patient inside the Centre Médico Psychologique of the area, which is desperately short of means, because no shift is provided by private psychiatry.

Thus the implementation of the notion of short-term care inside the hospital doesn’t seem to match with the living issue of some sick people.

9 « La décision politique de confier la gestion du secteur psychiatrique à l’hôpital, en 1986, est une date historique de remise en cause des principes de la sectorisation, comme de toute autre forme de véritable psychiatrie communautaire. » in PIEL, ROELANDT, Rapport de mission « De la psychiatrie vers la santé mentale », juillet 2001.

10 Rapport du Centre national de l’expertise hospitalière. 306 000 patients ont été suivis à temps complet dans les secteurs de psychiatrie générale en 2000, soit 27% du total des patients en psychiatrie.

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3) the lack of governance related to the professionals in mental health.

The growing inadequacy of the medical demography and the failures in the territorial repartition make the coordination of the actions difficult.

MAP II

Etat des lieux de la situation française, lundi 13 février 2006, Ministère de la Santé et des Solidarités

MAP III

Etat des lieux de la situation française, lundi 13 février 2006, Ministère de la Santé et des Solidarités

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Currently, the number of places missing in public psychiatric hospitals is about 700. Therefore we need, to set up the project of a community psychiatry inspired by the WHO, a profession of public urban psychiatrists, whose position and career must be officially appointed to some mental health centers and care centers, places without hospitals so that they can become practitioners of the mental troubles on a area given.

The existing divide between an urban private psychiatry and a public psychiatry, one practicing professional fees, and the other one free of fees, creates in practice a division in among patients according to the social group and the severity of the pathology¹¹.

The decree of March the 23rd 1992 creating a common basis of formation for the nurses meant the suppression of the degree of psychiatric nurse. Seventeen years after this reform, the loss in terms of quality of psychiatric care is obvious.

To this problems of governance may be added the prevalence of a biomedical model of a hospital psychiatry at odds with psychogenetic and sociogenetic criteria.

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Suggestions

The psychiatric care system doesn’t succeed since it is inadequate for the chronically mentally ill and for the persons suffering from social insecurity and exclusion who present mental pathologies, and because of the persistent barriers between care system and social sector.

There is a specific demand from the person suffering from social insecurity who normally don’t ask for psychological assistance, for whom precisely the difficulties to access to care is a criteria of insecurity, and for whom confirmed psychological and physiopathological troubles can’t be understood and treated as usual.

The care accessibility’s inequalities, the patients’ mistreatment (in the hospitals, in specialized centers, in jail…), the ordinary social violence towards the depressed and the disabled persons of all sort, the authority abuses of legally or not constituted states, the transfer of the psychiatric

11 D’après le CNEH, la répartition des psychiatres entre la ville et l’hôpital est équilibrée, puisque 47,3 % des psychiatres exercent en ville. La répartition territoriale des psychiatres est à l’image de celle des autres médecins, avec une prédominance marquée des centres urbains et une disparité forte entre trente départements disposant d’un psychiatre pour 3 333 habitants et un groupe de treize départements qui ne comptent qu’un psychiatre pour 8 473 habitants. L’effectif des psychiatres qui était de 8814 en 1985 s’élevait à 13 663 en 2009. (Cette augmentation suit celle de l’ensemble des spécialistes).

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centers into the medico-social field, are nowadays stressed more thanks to the action of family’s association than to the professionals.¹²

If we want to help these people, we must think about a new direction for the mental health policy. In fact, the design of the public health policies must be based on the recognition of the social demand and not on a rational and budgetary way of thinking which leans only on economics and statistic notions of epidemiology.

Two prior conditions must be fulfilled:

1) To reconsider the theoretical direction of the mental health care, starting from the recognition of a psychosocial clinical medicine at the crossroads of mental health and social link.¹³ This clinical medicine is defined as the recognition of the psychic suffering when it shows up in a social place, at the time of the loss of the « social objects » (job, money, housing mainly). The clinical forms of expression of the suffering lean on the loss of the social objects and on the forms of helping and assistance that respond to it.

The reflection launched about the « housing first » project is currently in experimentation.

Document 2

12 DEMAILLY Lise, Sociologie des troubles mentaux, Paris, La Découverte, 2011, 126 p.

13 FURTOS Jean, LAHLOU Jalil et LAVAL Christian, Points de vue et rôle des acteurs de la clinique psychosociale, Recherche action, DDASS du Rhône, FNARS, décembre 1999, p.40.

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2) To reconsider an intervention strategy of the care system taking into account the fact that the demand for psychiatric care of the most helpless is relayed by the social workers and their organizations.¹⁴

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14ALLEMANDOU Bernard, « Réseau santé mentale-précarité : de la demande sociale à la demande de soin », in Revue Sociologie Santé, Les réseaux de soins, 20 ans après, n°29, décembre 2008, pp167-192.