Municipal health and social services for adults with mental disorders
In 2007 the Norwegian Board of Health Supervision in the Counties and the County Governors carried out countrywide supervision of health and social services for adults with mental disorders. This involved 68 municipalities and urban districts throughout the country. In 44 of these municipalities, nonconformities (breaches of laws or regulations) were detected. No nonconformities were detected in the other 24 municipalities, but in eleven municipalities observations were made – this means that the supervision authority commented about areas identified as having potential for improvement. In thirteen municipalities, no nonconformities were detected and no observations were made.
During the last few years, the municipalities have been given increasing responsibility for taking care of people with serious mental disorders, and for providing services for them so that they can manage to live in their own homes. This is a complex, non-homogenous group of clients, who have a wide range of needs. The clients with the most serious mental disorders may have long-term illness, and the severity of their illness may vary over time. In addition, some of these clients have alcohol and drug problems. Many of them have extensive needs for services and may require comprehensive support and follow-up 24 hours a day. For example, they may require daily activities, help and support in the home, and sheltered employment, in addition to treatment and follow-up from primary and specialized health services.
There is great variation in the way in which Norwegian municipalities have organized and developed their services. However, most of the municipalities have specific services for people with mental disorders, with personnel who have special responsibility for assessing these clients and providing services for them. Particularly in large municipalities, many different services and people are involved in providing care for each individual client. This is also the case in the municipalities that were included in supervision.
The aim of supervision was to investigate whether municipalities provide health and social services for adults 18 years of age and older who have serious mental disorders, in accordance with statutory requirements. Specific areas for supervision were: whether services were adequate and available for all the people who needed them, whether services were adapted to the individual needs of the clients, and whether the different services were coordinated so that the total service was comprehensive. Other specific areas for supervision were: whether the municipalities fulfilled the statutory requirements for client participation, individual adaptation of services, coordination of services, and provision of services of sound professional standards, throughout the whole continuum of care – from the beginning when the need for care is identified and assessed, through planning, implementing, following up and adjusting services and measures.
Since supervision involved many aspects of a complex area, the supervision teams may have focussed on different aspects. Based on their previous knowledge of the municipalities, the teams may have made an assessment about which areas the danger for deficiencies occurring was greatest, and given priority to these areas.
Assessment and planning of services
The more complex clients’ needs are, the greater the demands for assessment and planning. But the risk for services not being based on sound assessment of individual needs is also greater. Clients with the most comprehensive needs have the most to loose if they are not given an adequate assessment, or if they do not receive adequate services. Assessment of clients shall be made within reasonable time, and decisions that have been made shall be clearly documented. It is important that all relevant information is collected for making an assessment and for planning which services to provide. A thorough assessment of the client’s needs, wishes and suggestions is essential, in order to provide services that the client can gain the maximum benefit from.
In one out of four of the municipalities where supervision was carried out nonconformities were detected or observations were made about the way in which needs for services were assessed. There were several examples in which applications and requests for services were not assessed within reasonable time. In some municipalities, responsibility was unclear, tasks were not clearly allocated, and staff were unsure about who had responsibility for making assessments, what should be assessed, and how this should be done. In such a situation, decisions about service provision may not be based on the real needs of the client. In several municipalities, information and documentation was not collected from other units and services. There is then a danger that different units and services can make different assessments, without these assessments being coordinated. Without a complete picture of the client’s needs for services, it is difficult to formulate clear goals for care, and to give clients the possibility to have an influence.
Inadequate service provision
Based on the reports from this supervision, there is reason to believe that in many places the services offered are determined to a large extent by available resources rather than by clients’ needs. For example, in many municipalities follow up was not offered outside normal working hours, and in some municipalities there were no contingency plans to deal with crisis situations in the evenings, at night, at weekends, or on public holidays. In some places, counselling services provided by psychiatric nurses were cancelled for long periods during holiday times, and no alternative service was offered.
Coordinated and stable service provision
order for the different services to be comprehensive, the different service providers must communicate with each other, they must coordinate the services, and they must cooperate with each other. The greater the number of services required, the greater the need for practical adaptation of the services offered. This is the case because these services are organized in different units, they are regulated by different legislation, and they are provided by many different types of professionals (for example milieu therapist, accommodation consultant, home help, district nurse, psychiatric nurse, general practitioner). Without clear management and clearly defined delegation of tasks, responsibility and authority, there is a high risk that deficiencies may occur. The consequences of deficiencies are most serious for clients who have the most comprehensive needs, and who need services over long periods of time. There is a risk that they do not receive all the services they require, or that different measures pull in different directions.
In one out of three of the municipalities where supervision was carried out, the arrangements for coordination of service provision were so inadequate that the supervision authorities either confirmed that there was a nonconformity (failure to meet statutory requirements) or observations were made (comments were given about the need to improve the arrangements).
In some municipalities the different services had inadequate knowledge about the services and measures provided by others, and there were different views about how tasks should be distributed between the different units. Thus it was difficult to establish a common understanding among the units about clients’ needs, about who does what, and about the aims of service provision.
Exchange of information necessary for providing services was also found to be inadequate in many municipalities. In several municipalities, the different services not only had their own patient records, but they also had different systems for documenting information about clients, and they had different assessments about what information was important to record and archive. Some of the personnel in sheltered accommodation had limited information about the residents. Some of the district nurses lacked important information about the clients they had responsibility for. Not everyone knew what the opening times of the mental health unit were. Some general practitioners had not been given all the information and documentation that they required. In order to ensure that services are adequate all the time, service providers need to have access to information within the limits of confidentiality, they must be able to identify the need for changes in service provision, and that they must be able to act accordingly.
The purpose of individual plans is to ensure that the needs of each client for services are seen in relation to each other, that services are comprehensive and adapted to the individual, and that responsibility for following up the client over time is clearly allocated. In other words, individual plans should prevent the type of deficiencies that were detected in many municipalities.
In almost half of the municipalities where supervision was carried out, the supervision authorities made observations about areas with potential for improvement, and in many municipalities they found nonconformities in relation to individual plans. In many municipalities there is a long way to go before the right of clients to have an individual plan is met, and before these plans function as intended. Not everyone with the right to have a plan had a plan, some clients had plans that were inadequate, some had plans that were out of date, and others had plans that had not been followed up. Some of the leaders did not manage the services adequately, and they did not appoint coordinators with adequate responsibility and authority to follow up the work. In some municipalities, the function of coordinator was regarded as a voluntary task.
“The staff were unsure about who had responsibility for making assessments, what should be assessed, and how this should be done.”
“Without clear management and clearly defined delegation of tasks, responsibility and authority, there is a high risk that deficiencies may occur.”
- Report from the Norwegian Board of Health Supervision 3/2008
- Guidelines for supervision.