Community care in Slovenia

COMMUNITY CARE IN SLOVENIA

Vesna Švab, izr. prof., dr. sc., dr. med., spec. psihiater
Medicinska fakulteta Ljubljana, Zavod za zdravstveno zavarovanje
vesna.svab@mf.uni-lj.si

   There is no community psychiatry in Slovenia. Psychiatric care is organised in psychiatric hospitals and outpatient clinics. The number of beds has been reduced to 0.8/1000 inhabitants. The average length of hospitalisation is between 45 and 60 days. Outpatient clinics at this phase provide everybody in need with psychiatric treatment, but the quality of this work is regarding growing needs (26% rise in no. of visits in two years time) is probably reduced. Regarding the number of beds in hospitals it is obvious that the majority of patients stay in the community. Community services are developed in last 10 years as non-government and actually social services that provide care for socially threatened group of patients.

   In Slovenia large psychiatric hospitals with long term patients actually never existed. Regarding number of beds, most of the patients live in community. They are replaced from hospitals to asylums or old-peoples homes and by increasing the burden of care of families. Adequate complementary services in the community have not been developed until the 1992 when some NGO mental health services developed. Before that there was as well as in west quite strong anti-psychiatric movement, but it did not succeed as in neighbouring Italy. In the 90s non-government organisations and also some social ones provided various forms of community support systems. Slika1 relatives groups, employment and vocational rehabilitation, day centres, group homes, education programs: which could improve satisfaction of patients and lessen family burden, and they are also leading the antidiscrimination movement in our country. These services are social in their nature and they are scarcely connected with psychiatry or general practice

We proved with a research that in these services vulnerable group of patients are gathered: with little family support and with poor economic resources.

Slovenia is renewing old psychiatric institutions into more modern and neat ones and there is no political intention to reduce number of hospital beds or to develop community psychiatry.

Reasons for this situation:

   We actually don’t know what are the needs for community services in our country: How many people need employment and what sort of it, what are the needs for day care and housing. It is obvious that many patients wait to be accepted to group homes and that there is lack of supported employment services especially those for well paid jobs. There is also expressed need for support at peoples homes.

  When delegation from WHO came to our country they asked us what are the reasons for reluctance to develop community psychiatry and we didn’t know the actual answer. Psychiatrists are not interested in this kind of work except from rare ones. One of the hypothesis was that the strong development of psychotherapy is redirecting their attention from social psychiatry. But the most probable reasons are the following:

• Community rehabilitation services are financed irregularly,
• staff education, users and relatives– we have good programs working but only international funds;
• we are working on anti-discrimination of users and relatives, but we are not articulate and loud enough: there is not enough political power,
• community services are weakly connected and disparaged by purchasers and recognition of their work is systematically avoided people in power in the Ministry of health.
• We are recognised in local communities that provide us with some funds but we are not able to answer to their needs: especially for helping or supporting people in their living environments.
• very little communication with outpatient clinics and other community agencies

   I believe that in Slovenia there is a need to develop some policy in the field of mental health, except from providing adequate hospital living environments. There are many good (quality and comprehensiveness and continuity) programs in this country that could provide adequate care and higher quality of life for patients in community, that the government fails to acknowledge in spite of research evidence. These patients' social needs are at least partly met in these services.

Regarding the characteristics of the group, their poverty, lack of family support and regarding their more prominent cognitive disorder we assume that the services to be developed are:

Employment schemes

Family support with education

But this is quite vague. We actually don’t know what are the needs for community services in our country:
How many people need employment and what sort of it, what are the needs for day care and housing. It is obvious that many patients wait to be accepted to group homes and that there is lack of supported employment services especially those for well paid jobs. There is also expressed need for support at peoples homes.

   The number of psychiatrists in this country is low and they have to much work to do in hospitals. The growth of the private practice has just reduced the number of available professionals to patients with severe mental disorders and we believe that this condition is worsening.

   One of the options is to involve family practitioners in community care, but they report that their workload is too high to be able to develop such services. About general practice – there are some initiatives from general practitioners and community nurses to specialise some of these nurses to become community psychiatric nurses: so the attitude is changing.

 Community services are thus not supported very fruitfully from psychiatry even though some connection is trying to be established through some hypomanic individuals.