Healthcare ecosystems research in mental health: a scoping review of methods to describe the context of local care delivery

An effective approach to tackling complex health policy challenges. Using a clinical microsystems approach and rethinking codesign

That people with serious mental illness have poor physical health and face a significant life expectancy gap compared with the general population is well known. Despite considerable policy focus in some countries, the gap in life expectancy remains. Tackling complex and persistent health problems such as this requires a systems-based approach, recognising the complexity of interacting components and their effects on the problem and on each other and applying collaborative analysis, design and implementation by those with knowledge of and expertise in the problem and the context. This paper describes the methods used to develop the Australian Being Equally Well National Policy Roadmap for better physical health care and longer lives for people with severe mental illness. Whilst recognising that high rates of physical health comorbidities are caused by many factors including lifestyle, access to high-quality healthcare and medication side effects, the work was focused on what could be done within Australian primary care to improve the physical health of this cohort. A Clinical Microsystem Approach was applied to synthesise clinical evidence with professional and lived experience, and an innovative policy development process was established, creating trust across all system levels. Participants with different kinds of knowledge and experience worked in discrete groups according to their professional or expert role whilst also being supported to participate in an intensive cross-collaboration. The potential value of this methodology for tackling other complex problems in health policy is discussed.

Patterns of service provision in child and adolescent mental health care in Australia

Standard description of local care provision is essential for evidence-informed planning. This study aimed to map and compare the availability and diversity of current mental health service provision for children and adolescents in Australia. We used a standardised service classification instrument, the Description and Evaluation of Services and DirectoriEs (DESDE) tool, to describe service availability in eight urban and two rural health districts in Australia. The pattern of care was compared with that available for other age groups in Australia. Outpatient care was found to be the most common type of service provision, comprising 212 (81.2%) of all services identified. Hospital care (acute and non-acute) was more available in urban than in rural areas (20 services [9.7%] vs 1 [1.8%]). The level of diversity in the types of care available for children and adolescents was lower than that for the general adult population, but slightly higher than that for older people in the same areas. Standardised comparison of the pattern of care across regions reduces ambiguity in service description and classification, enables gap analysis and can inform policy and planning.

Mental health service diversity and work disability: associations of mental health service system characteristics and mood disorder disability pensioning in Finland

PURPOSE

Public mental health services (MHS) are crucial in preventing psychiatric disability pensions (DP). We studied the associations between mood disorder DP risk and the characteristics of Finnish municipalities' MHS provision using the ESMS-R mapping tool and Finnish population registers, based on first-time granted mood disorder DPs between 2010 and 2015.

METHODS

The final data set included 13,783 first-time mood disorder DP recipients and 1088 mental health service units in 104 municipalities. We focused on five different MHS types: all MHS, outpatient care provision, local services without and with gatekeeping, and centralized services. Three factors for each MHS type were studied: service resources, richness, and diversity index. Negative binomial regression models were used in the analysis.

RESULTS

In all the municipalities, higher service richness and diversity regarding all MHS, outpatient care and local services with gatekeeping were associated with a lower DP risk. In urban municipalities, service richness was mainly associated with lower DP risk, and in semi-urban municipalities service diversity and resources were primarily associated with lower DP risk in outpatient care and local services with gatekeeping. In rural municipalities, DP risk indicated no association with MHS factors.

CONCLUSION

The organization and structure of MHS play a role in psychiatric disability pensioning. MHS richness and diversity are associated with lower mood disorder DP in specific societal contexts indicating their role as quality indicators for regional MHS. The diversity of service provision should be accounted for in MHS planning to offer services matching population needs.

Barriers and facilitators to the implementation of digital technologies in mental health systems: a qualitative systematic review to inform a policy framework

BACKGROUND

Despite the potential for improved population mental health and wellbeing, the integration of mental health digital interventions has been difficult to achieve. In this qualitative systematic review, we aimed to identify barriers and facilitators to the implementation of digital technologies in mental healthcare systems, and map these to an implementation framework to inform policy development.

METHODS

We searched Medline, Embase, Scopus, PsycInfo, Web of Science, and Google Scholar for primary research articles published between January 2010 and 2022. Studies were considered eligible if they reported barriers and/or facilitators to the integration of any digital mental healthcare technologies. Data were extracted using EPPI-Reviewer Web and analysed thematically via inductive and deductive cycles.

RESULTS

Of 12,525 references identified initially, 81 studies were included in the final analysis. Barriers and facilitators were grouped within an implementation (evidence-practice gap) framework across six domains, organised by four levels of mental healthcare systems. Broadly, implementation was hindered by the perception of digital technologies as impersonal tools that add additional burden of care onto both providers and patients, and change relational power asymmetries; an absence of resources; and regulatory complexities that impede access to universal coverage. Facilitators included person-cantered approaches that consider patients' intersectional features e.g., gender, class, disability, illness severity; evidence-based training for providers; collaboration among colleagues; appropriate investment in human and financial resources; and policy reforms that tackle universal access to digital health.

CONCLUSION

It is important to consider the complex and interrelated nature of barriers across different domains and levels of the mental health system. To facilitate the equitable, sustainable, and long-term digital transition of mental health systems, policymakers should consider a systemic approach to collaboration between public and private sectors to inform evidence-based planning and strengthen mental health systems.

PROTOCOL REGISTRATION

The protocol is registered on PROSPERO, CRD42021276838.

The Integrated Atlas of Dementia Care in the Australian Capital Territory: A Collective Case Study of Local Service Provision

Background

This study evaluates the dementia care system in a local area and aimed to include all specialised services designed to provide health and social services to people with dementia or age-related cognitive impairment, as well as general services with a high or very high proportion of clients with dementia.

Methods

The study used an internationally standardised service classification instrument called Description and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC) to identify and describe all services providing care to people with dementia in the Australian Capital Territory (ACT).

Results

A total of 47 service providers were eligible for inclusion. Basic information about the services was collected from their websites, and further information was obtained through interviews with the service providers. Of the 107 services offered by the 47 eligible providers, 27% (n = 29) were specialised services and 73% (n = 78) were general services. Most of the services were residential or outpatient, with a target population mostly of people aged 65 or older, and 50 years or older in the case of Aboriginal and Torres Strait Islander Australians. There were government supports available for most types of care through various programmes.

Conclusions

Dementia care in the ACT relies heavily on general services. More widespread use of standardised methods of service classification in dementia will facilitate comparison with other local areas, allow for monitoring of changes over time, permit comparison with services provided for other health conditions and support evidence-informed local planning.

Assessing unConventional Evidence (ACE) tool: development and content of a tool to assess the strengths and limitations of 'unconventional' source materials

BACKGROUND

When deciding whether to implement an intervention, decision-makers typically have questions on feasibility and acceptability and on factors affecting implementation. Descriptions of programme implementation and of policies and systems are rich sources of information for these questions. However, this information is often not based on empirical data collected using explicit methods. To use the information in unconventional source materials in syntheses or other decision support products, we need methods of assessing their strengths and limitations. This paper describes the development and content of the Assessing unConventional Evidence (ACE) tool, a new tool to assess the strengths and limitations of these sources.

METHODS

We developed the ACE tool in four stages: first, we examined existing tools to identify potentially relevant assessment criteria. Second, we drew on these criteria and team discussions to create a first draft of the tool. Third, we obtained feedback on the draft from potential users and methodologists, and through piloting the tool in evidence syntheses. Finally, we used this feedback to iteratively refine the assessment criteria and to improve our guidance for undertaking the assessment.

RESULTS

The tool is made up of 11 criteria including the purpose and context of the source; the completeness of the information presented; and the extent to which evidence is provided to support the findings made. Users are asked to indicate whether each of the criteria have been addressed. On the basis of their judgements for each criterion, users then make an overall assessment of the limitations of the source, ranging from no or very minor concerns to serious concerns. These assessments can then facilitate appropriate use of the evidence in decision support products.

CONCLUSIONS

Through focussing on unconventional source materials, the ACE tool fills an important gap in the range of tools for assessing the strengths and limitations of policy-relevant evidence and supporting evidence-informed decision-making.

Patterns of mental health services and mood disorder disability pensions: a standard comparison of Finland's three largest hospital districts

INTRODUCTION

Mental disorders are one of the most common and disabling health conditions worldwide. There is however no consensus on the best practice of system level mental health services (MHS) provision, in order to prevent e.g. mood disorder disability pensions (DPs). We analyzed the MHS provision between Finland's three largest hospital districts Helsinki and Uusimaa (HUS), Southwest Finland and Pirkanmaa, with known differences in mood disorder DP risk but presumably equal rates of mood disorder prevalence.

METHODS

We used public MHS data analyzed with the standardized DEscription and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC) mapping tool, focusing on all MHS, outpatient care provision, local services without and with gatekeeping, and centralized services. We also collected demographic data based on the European Socio-Demographic Schedule (ESDS). As a novel approach, the Gini-Simpson Diversity Index (GSDI) was calculated for the districts.

RESULTS

Evident differences were observed regarding the districts' MHS factors. As the hospital district with lower DP risk, HUS was characterized by the highest level of regional socioeconomic prosperity as well as high service richness and diversity. With a nationally average DP risk, Southwest Finland had the highest number of MHS personnel in full-time equivalents (FTE) per 100 000 inhabitants. Pirkanmaa, with a higher DP risk, had overall the lowest service richness and the lowest FTE of the three districts in all MHS, outpatient care and local services with gatekeeping.

CONCLUSIONS

Our findings indicate that greater richness and diversity of MHS, especially in outpatient and community-based settings, may serve as indicators of a balanced, high-quality service system that is more effective in preventing mood disorder DP and meeting the different needs of the population. In addition, the need for sufficient resourcing in all MHS and outpatient services is indicated. We suggest using diversity indices to complement the measuring and reporting of regional service variation.

Measuring the intensity of mental healthcare: development of the Mental Healthcare Intensity Scale (MHIS)

BACKGROUND

There are considerable differences among mental healthcare services, and especially in developed countries there are a substantial number of different services available. The intensity of mental healthcare has been an important variable in research studies (e.g. cohort studies or randomized controlled trials), yet it is difficult to measure or quantify, in part due to the fact that the intensity of mental healthcare results from a combination of several factors of a mental health service. In this article we describe the development of an instrument to measure the intensity of mental healthcare that is easy and fast to use in repeated measurements.

METHODS

The Mental Healthcare Intensity Scale was developed in four stages. First, categories of care were formulated by using focus group interviews. Second, the fit among the categories was improved, and the results were discussed with a sample of the focus group participants. Third, the categories of care were ranked using the Segmented String Relative Rankings algorithm. Finally, the Mental Healthcare Intensity Scale was validated as a coherent classification instrument.

RESULTS

15 categories of care were formulated and were ranked on each of 12 different intensities of care. The Mental Healthcare Intensity Scale is a versatile questionnaire that takes 2-to-3 min to complete and yields a single variable that can be used in statistical analysis.

CONCLUSIONS

The Mental Healthcare Intensity Scale is an instrument that can potentially be used in cohort studies and trials to measure the intensity of mental healthcare as a predictor of outcome. Further study into the psychometric characteristics of the Mental Healthcare Intensity Scale is needed.

Standardized Systematic Description of Provision of Care for Multiple Sclerosis at a Local Level: A Demonstration Study

BACKGROUND

This study evaluates and describes the pattern of services provided for people living with multiple sclerosis (MS) in a local area as a starting point for a more global assessment.

METHODS

A health care ecosystem approach has been followed using an internationally standardized service classification instrument-the Description and Evaluation of Services and DirectoriEs for Long Term Care (DESDE-LTC)-to identify and describe all services providing care to people with MS in the Australian Capital Territory, Australia. Available services were classified according to the target population into those specifically dedicated to people living with MS and those providing general neurologic services, both public and private, and across both social and health sectors.

RESULTS

A limited range of services was available. There were no local facilities providing or coordinating multidisciplinary integrated care specific to people with MS. Subspecialty services specific to MS were limited in number (6 of the 28 services), and use of specialist services provided in neighboring states was frequently reported. Overall, very few services were provided outside the core health sector (4%).

CONCLUSIONS

The provision of care to people living with MS in the Australian Capital Territory is fragmented and relies heavily on generic neurology services in the public and private sectors. More widespread use of the DESDE-LTC as a standardized method of service classification in MS will facilitate comparison with other local areas, allow monitoring of changes over time, and permit comparison with services provided for other health conditions (eg, dementia, mental disorders).

Regional evolution of psychosocial services in Australia before and after the implementation of the National Disability Insurance Scheme

OBJECTIVES

This paper compares the evolution of the psychosocial sector in two Australian regions pre and post introduction of the National Disability Insurance Scheme - a major reform to the financing, planning and provision of disability services in Australia, intended to create greater competition and efficiency in the market, and more choice for service users.

METHODS

We used a standardised service classification instrument based on a health ecosystems approach to assess service availability and diversity of psychosocial services provided by non-government organisations in two Primary Health Network regions.

RESULTS

We identified very different evolutionary pathways in the two regions. Service availability increased in Western Sydney but decreased in the Australian Capital Territory. The diversity of services available did not increase in either Primary Health Network 4 years after the reform. Many services were experiencing ongoing funding uncertainty.

CONCLUSION

Assumptions of increased efficiency through organisational scaling up, and a greater diversity in range of service availability were not borne out.

IMPLICATIONS

This study shows the urgent need for evaluation of the effects of the NDIS on the provision of psychosocial care in Australia. Four years after the implementation of the NDIS at vast expense key objectives not been met for consumers or for the system as a whole, and an environment of uncertainty has been created for providers. It demonstrates the importance of standardised service mapping to monitor the effects of major reforms on mental health care as well as the need for a focus at the local level.

Patient- and Community-Oriented Primary Care Approaches for Health in Rural, Remote and Resource-Dependent Places: Insights for Eco-Social Praxis

Accelerating ecological and societal changes require re-imagining the role of primary care and public health to address eco-social concerns in rural and remote places. In this narrative review, we searched literatures on: community-oriented primary care, patient-oriented research engagement, public health and primary care synergies, and primary care addressing social determinants of health. Our analysis was guided by questions oriented to utility for addressing concerns of social-ecological systems in rural, remote contexts characterized by a high degree of reliance on resource extraction and development (e.g., forestry, mining, oil and gas, fisheries, agriculture, ranching and/or renewables). We describe a range of useful frameworks, processes and tools that are oriented toward bolstering the resilience and engagement of both primary care and public health, though few explicitly incorporated considerations of eco-social approaches to health or broader eco-social context(s). In synthesizing the existing evidence base for integration between primary care and public health, the results signal that for community-oriented primary care and related frameworks to be useful in rural and remote community settings, practitioners are required to grapple with complexity, durable relationships, sustainable resources, holistic approaches to clinician training, Indigenous perspectives, and governance.

Barriers and facilitators to the integration of digital technologies in mental health systems: A protocol for a qualitative systematic review

INTRODUCTION

Digital technology has the potential to improve health outcomes and health system performance in fragmented and under-funded mental health systems. Despite this potential, the integration of digital technology tools into mental health systems has been relatively poor. This is a protocol for a synthesis of qualitative evidence that will aim to determine the barriers and facilitators to integrating digital technologies in mental health systems and classify them in contextual domains at individual, organisational and system levels.

METHODS AND ANALYSIS

The methodological framework for systematic review of qualitative evidence described in Lockwood et al. will be applied to this review. A draft search strategy was developed in collaboration with an experienced senior health research librarian. A systematic search of Medline, Embase, Scopus, PsycInfo, Web of Science and Google Scholar, as well as hand searching of reference lists and reviews will identify relevant studies for inclusion. Study selection will be carried out independently by two authors, with discrepancies resolved by consensus. The quality of selected studies will be assessed using JBI Critical Appraisal Checklist for Qualitative Research. Data will be charted using JBI QUARI Data Extraction Tool for Qualitative Research. Findings will be defined and classified both deductively in a priori conceptual framework and inductively by a thematic analysis. Results will be reported based on the Enhancing transparency in reporting the synthesis of qualitative research. The level of confidence of the findings will be assessed using GRADE-CERQual.

ETHICS AND DISSEMINATION

This study does not require ethics approval. The systematic review will inform policy and practices around improving the integration of digital technologies into mental health care systems.

A new bottom-up method for the standard analysis and comparison of workforce capacity in mental healthcare planning: Demonstration study in the Australian Capital Territory

The aims of this study are to evaluate and describe mental health workforce and capacity, and to describe the relationship between workforce capacity and patterns of care in local areas. We conducted a comparative demonstration study of the applicability of an internationally validated standardised service classification instrument—the Description and Evaluation of Services and Directories—DESDE-LTC) using the emerging mental health ecosystems research (MHESR) approach. Using DESDE-LTC as the framework, and drawing from international occupation classifications, the workforce was classified according to characteristics including the type of care provided and professional background. Our reference area was the Australian Capital Territory, which we compared with two other urban districts in Australia (Sydney and South East Sydney) and three benchmark international health districts (Helsinki-Uusima (Finland), Verona (Italy) and Gipuzkoa (Spain)). We also compared our data with national level data where available. The Australian and Finnish regions had a larger and more highly skilled workforce than the southern European regions. The pattern of workforce availability and profile varied, even within the same country, at the local level. We found significant differences between regional rates of identified rates of psychiatrists and psychologists, and national averages. Using a standardised classification instrument at the local level, and our occupational groupings, we were able to assess the available workforce and provide information relevant to planners about the actual capacity of the system. Data obtained at local level is critical to providing planners with reliable data to inform their decision making.

Using Geospatial Analysis to Inform Development of a Place-Based Integrated Care Initiative: The Healthy Homes and Neighbourhoods Experience

INTRODUCTION

Disadvantaged families experience many barriers to accessing health and social care. The Healthy Homes and Neighbourhoods (HHAN) Integrated Care Initiative was developed to address these barriers, and ensure families have their complex needs met and are kept safe and connected to society.

DESCRIPTION

A spatial epidemiology approach was taken, as part of the HHAN feasibility phase, to identify the geographical distribution of the "most vulnerable" families in Sydney Local Health District (SLHD). A literature review was conducted to identify indicators of family stress and disadvantage, and cluster and hotspot analyses were undertaken. Hotspots of family stress and disadvantage were mapped for SLHD and used to identify areas for HHAN place-based delivery, and for collaborative co-design.

DISCUSSION

The HHAN initiative called for consideration of context and the undertaking of collaborative design with communities. The spatial analysis provided a more accurate picture of family stress and disadvantage than previously available and provided a tool that could be used during consultation and planning activities.

CONCLUSION

When planning place-based integrated care initiatives, spatial analysis of small geographic scales can allow identification of areas of concentrated or complex disadvantage that may be masked when analysis is performed on larger areas, allowing for targeted, place-based delivery of programs to those most in need.

A Semiautomated Classification System for Producing Service Directories in Social and Health Care (DESDE-AND): Maturity Assessment Study

BACKGROUND

DESDE-LTC (Description and Evaluation of Services and DirectoriEs for Long-Term Care) is an international classification system that allows standardized coding and comparisons between different territories and care sectors, such as health and social care, in defined geographic areas. We adapted DESDE-LTC into a computer tool (DESDE-AND) for compiling a directory of care services in Andalucia, Spain.

OBJECTIVE

The aim of this study was to evaluate the maturity of DESDE-AND. A secondary objective of this study is to show the practicality of a new combined set of standard evaluation tools for measuring the maturity of health technology products.

METHODS

A system for semiautomated coding of service provision has been co-designed. A panel of 23 domain experts and a group of 68 end users participated in its maturity assessment that included its technology readiness level (TRL), usability, validity, adoption (Adoption Impact Ladder [AIL]), and overall degree of maturity [implementation maturity model [IMM]). We piloted the prototype in an urban environment (Seville, Spain).

RESULTS

The prototype was demonstrated in an operational environment (TRL 7). Sixty-eight different care services were coded, generating fact sheets for each service and its geolocation map. The observed agreement was 90%, with moderate reliability. The tool was partially adopted by the regional government of Andalucia (Spain), reaching a level 5 in adoption (AIL) and a level 4 in maturity (IMM) and is ready for full implementation.

CONCLUSIONS

DESDE-AND is a usable and manageable system for coding and compiling service directories and it can be used as a core module of decision support systems to guide planning in complex cross-sectoral areas such as combined social and health care.

Patterns of Mental Health Care in Remote Areas: Kimberley (Australia), Nunavik (Canada), and Lapland (Finland): Modèles de soins de santé mentale dans les régions éloignées: Kimberley (Australie), Nunavik (Canada) et Laponie (Finlande)

OBJECTIVE

Mental health (MH) care in remote areas is frequently scarce and fragmented and difficult to compare objectively with other areas even in the same country. This study aimed to analyze the adult MH service provision in 3 remote areas of Organization for Economic Cooperation and Development countries in the world.

METHODS

We used an internationally agreed set of systems indicators, terminology, and classification of services (Description and Evaluation of Services and DirectoriEs for Long Term Care). This instrument provided a standard description of MH care provision in the Kimberley region (Australia), Nunavik (Canada), and Lapland (Finland), areas characterized by an extremely low population density and high relative rates of Indigenous peoples.

RESULTS

All areas showed high rates of deprivation within their national contexts. MH services were mostly provided by the public sector supplemented by nonprofit organizations. This study found a higher provision per inhabitant of community residential care in Nunavik in relation to the other areas; higher provision of community outreach services in the Kimberley; and a lack of day services except in Lapland. Specific cultural-based services for the Indigenous population were identified only in the Kimberley. MH care in Lapland was self-sufficient, and its care pattern was similar to other Finnish areas, while the Kimberley and Nunavik differed from the standard pattern of care in their respective countries and relied partly on services located outside their boundaries for treating severe cases.

CONCLUSION

We found common challenges in these remote areas but a huge diversity in the patterns of MH care. The implementation of care interventions should be locally tailored considering both the environmental characteristics and the existing pattern of service provision.

[Everything is on the map: Integrated Mental Health Atlases as support tools for service planning. SESPAS Report 2020]

OBJECTIVE

This article reviews the usability of the Integrated Atlases of Mental Health as a decision support tool for service planning following a health ecosystem research approach.

METHOD

This study describes the types of atlases and the procedure for their development. Atlases carried out in Spain are presented and their impact in mental health service planning is assessed. Atlases comprise information on the local characteristics of the health care system, geographical availability of resources collected with the DESDE-LTC instrument and their use. Atlases use geographic information systems and other visualisation tools. Atlases follow a bottom-up collaborative approach involving decision-makers from planning agencies for their development and external validation.

RESULTS

Since 2005, Integrated Atlases of Mental Health have been developed for nine regions in Spain comprising over 65% of the Spanish inhabitants. The impact on service planning has been unequal for the different regions. Catalonia, Biscay and Gipuzkoa, and Andalusia reach the highest impact. In these areas, health advisors have been actively involved in their co-design and implementation in service planning.

CONCLUSIONS

Atlases allow detecting care gaps and duplications in care provision; monitoring changes of the system over time, and carrying out national and international comparisons, efficiency modelling and benchmarking. The knowledge provided by atlases could be incorporated to decision support systems in order to support an efficient mental health service planning based on evidence-informed policy.

[On the roller coaster: An abridged history of mental health planning in Spain. SESPAS Report 2020]

Effective mental health change in Spain started in 1985 with the Report of the Ministerial Commission for the Psychiatric Reform that recommended integrating psychiatric care into the general health system, providing care in the patient's context and for specific diagnoses. The SESPAS 2002 Report carried out an analysis of this reform and recommended the creation of a permanent ministerial commission, the design of a national map of socio-sanitary mental health services, the creation of a coordination and promotion agency for and carrying out a financial analysis of resource provision and research. Since 2004, the Technical Committee for the Mental Health Strategy boosted the elaboration of a theoretical and normative framework that unfortunately did not lead to a road map for the improvement of the system. After 2011, during the financial crisis, the Ministry of Health lost the opportunity to lead a second phase of change of the mental health care, which was evidence-based: no key technical reports were published nor was an action plan based on data developed. Currently, the 1985 community mental health model is still the general framework of mental health care with the addition of aspects related to the recovery model and the balance of care model. Significant progress has been made in developing care systems assessment methods and data-based models that could advance mental health planning. The gap between general health attention and mental health care has increased and the expected reform of the mental health system will not take place in the near future.

The future of community psychiatry and community mental health services

PURPOSE OF REVIEW

The aim of this article is to provide a framework and analysis of a series of critical components to inform the future design, development, sustaining, and monitoring of community mental health services.

RECENT FINDINGS

Many mental health services remain too hospital-centric, often without adequate outreach services. On the basis of outcome evidence, we need to shift the balance of mental health services from hospital-centered with community outreach when convenient for staff, to community-centered and mobile, with in-reach to hospital only when necessary. Too few training programs those with emphasize the macroskills of public advocacy, working with service users, families, social movements, and the media to improve mental health and wellbeing of regional and local communities.

SUMMARY

We should adopt a health ecosystems approach to mental healthcare and training, encompassing nano to macrolevels of service in every region. Catchment mental health services should be rebuilt as community-centric mental health services, integrating all community and inpatient components, but led and integrated from community sites. Community psychiatrists and mental health professionals of the future will need to be well trained in the nano to macroskills required to take responsibility for the mental health and wellbeing of their catchment communities and to provide leadership in service-planning, management, and continuing revision on the basis of rigorous evaluation. These approaches should be the core of all training in psychiatry and all mental health professions prior to any subspecialization.

Experts' perceptions on the use of visual analytics for complex mental healthcare planning: an exploratory study

BACKGROUND

Health experts including planners and policy-makers face complex decisions in diverse and constantly changing healthcare systems. Visual analytics may play a critical role in supporting analysis of complex healthcare data and decision-making. The purpose of this study was to examine the real-world experience that experts in mental healthcare planning have with visual analytics tools, investigate how well current visualisation techniques meet their needs, and suggest priorities for the future development of visual analytics tools of practical benefit to mental healthcare policy and decision-making.

METHODS

Health expert experience was assessed by an online exploratory survey consisting of a mix of multiple choice and open-ended questions. Health experts were sampled from an international pool of policy-makers, health agency directors, and researchers with extensive and direct experience of using visual analytics tools for complex mental healthcare systems planning. We invited them to the survey, and the experts' responses were analysed using statistical and text mining approaches.

RESULTS

The forty respondents who took part in the study recognised the complexity of healthcare systems data, but had most experience with and preference for relatively simple and familiar visualisations such as bar charts, scatter plots, and geographical maps. Sixty-five percent rated visual analytics as important to their field for evidence-informed decision-making processes. Fifty-five percent indicated that more advanced visual analytics tools were needed for their data analysis, and 67.5% stated their willingness to learn new tools. This was reflected in text mining and qualitative synthesis of open-ended responses.

CONCLUSIONS

This exploratory research provides readers with the first self-report insight into expert experience with visual analytics in mental healthcare systems research and policy. In spite of the awareness of their importance for complex healthcare planning, the majority of experts use simple, readily available visualisation tools. We conclude that co-creation and co-development strategies will be required to support advanced visual analytics tools and skills, which will become essential in the future of healthcare.

Building the foundation for comprehensive suicide prevention - based on intention and planning in a social-ecological context

National suicide prevention programmes that have been successful in reducing rates or keeping them low have been intentional, with collective alignment of local, regional and national priorities. Prevention efforts must begin well before individuals become suicidal, complementing readily available clinical services that address the needs of acutely distressed persons. These efforts, which focus on the antecedent risks and vulnerabilities of key populations, have the potential to diminish premature mortality from multiple causes, even as reducing suicide is the outcome of primary interest. In this commentary, I consider four key challenges that must be confronted in order to develop effective, broadly reaching systemic strategies that, at once, can be adapted locally while being implemented nationally - challenges that are framed in a social-ecological context. They involve defining the scope of the problem, meeting essential data needs, developing and modelling measurable implementation strategies and building prevention efforts based on shared culture and values.

Standardised description of health and social care: A systematic review of use of the ESMS/DESDE (European Service Mapping Schedule/Description and Evaluation of Services and DirectoriEs)

BACKGROUND

Evidence-informed planning and interpretation of research results both require standardised description of local care delivery context. Such context analysis descriptions should be comparable across regions and countries to allow benchmarking and organizational learning, and for research findings to be interpreted in context. The European Service Mapping Schedule (ESMS) is a classification of adult mental health services that was later adapted for the assessment of health and social systems research (Description and Evaluation of Services and DirectoriEs - DESDE). The aim of the study was to review the diffusion and use of the ESMS/DESDE system in health and social care and its impact in health policy and decision-making.

METHOD

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (1997-2018).

RESULTS

Out of 155 papers mentioning ESMS/DESDE, 71 have used it for service research and planning. The classification has been translated into eight languages and has been used by seven international research networks. Since 2000, it has originated 11 instruments for health system research with extensive analysis of their metric properties. The ESMS/DESDE coding system has been used in 585 catchment areas in 34 countries for description of services delivery at local, regional and national levels.

CONCLUSIONS

The ESMS/DESDE system provides a common terminology, a classification of care services, and a set of tools allowing a variety of aims to be addressed in healthcare and health systems research. It facilitates comparisons across and within countries for evidence-informed planning.