Devolution and policy reform

The regional devolution of welfare state responsibilities is theoretically an institutional device to accommodate heterogeneous preferences and needs (Oates, Reference Oates1993). Generally, it opens the way to the development of different social policies, and therefore for experimentation in exchange for departing from the principle of uniformity in the provision of care. Models of devolution differ in the institutional legacies that affect the distribution of political and fiscal powers. Thus, the distribution of fiscal resources can be inspired by principles of fiscal equivalence (Olson, 1969) whereby governments’ fiscal capacity should adjust to the characteristics of each jurisdiction to provide incentives to perform efficiently. Similarly, these principles are to be balanced out with the need for regional cohesion.

One of the main concerns resulting from devolution lies in its potential effects in curtailing welfare development in the form of a ‘race to the bottom’. However, evidence suggests that when decentralisation of spending authority is not accompanied by similar levels of decentralisation of revenue authority, but funded through revenue-sharing and intergovernmental grant schemes, overall spending is more likely to expand (Rodden, Reference Rodden2003, Costa-Font and Rico, Reference Costa-Font and Rico2006). However, the answer to another, possibly more significant, question for social policy analysts – how a devolved form of welfare governance translates into policy reform initiative – is unknown. Particularly relevant is reform of neglected packages, where support or capacity might be region specific.

We contend that policy reform builds on the identification of opportunities and instruments to overcome formal and informal constraints that might frustrate policy proposals. Formal constraints to reform include autocratic procedures as well as legislative and decision-making processes which can slow down reform and even veto policies that don't command a country-wide majority. Similarly, informal constraints to welfare development include stigma associated with some policy areas, including mental health. Other constraints can involve cost-containment pressures and social movements, such as the anti-psychiatry movement in some European countries. Finally, the fragmentation of service provision also acted as a constraint on policy development in comparison with other welfare packages. The third sectorFootnote ³ has long played a major role in mental health practice, but has not been well integrated with public services. One consequence had been spectacular institutional fragmentation, especially when regulation was in the hands of underfunded and uncoordinated local authorities (Ferrara, Reference Ferrara1996).

Against these constraints, devolution is arguably one device at hand to water down policy reform constraints by tempering the requirements for majority support where opportunities for reform arise at a regional level. Increasing awareness of mental health as an issue is acknowledged regionally, which creates the preconditions for institutions to further develop policy and practice.

Context: health care devolution in Spain

Emerging from a fragmented, though mandatory social security system, the 1986 General Health Care Act re-founded the Spanish National Health System (NHS) along the lines of a tax funded and politically decentralised model of health care provision. The objectives of the health system were driven towards both health promotion and illness prevention. Entitlement to health care was extended to all residents, with equality of access and a reduction in social and geographical variations, along with defining more implicitly its efficiency goals. Access to health care was defined to be free at the point of use for all residents (including undocumented migrants), with user co-payments restricted to pharmaceuticals primarily. The health care package has been defined as ‘comprehensive’ by analysts (Lopez-Casasnovas et al., Reference Lopez-Casasnovas, Costa-Font and Planas2005) although, in addition to mental health, coverage for some services, such as long-term care and dental services, remains limited and still varies according to region-specific demands (due to differences in policy priorities). Simultaneously, health and social care have, alongside education, been key packages of a process of welfare state decentralisation (Costa-Font and Pons-Novell, Reference Costa-Font and Pons-Novell2007; Lopez-Casanovas et al., Reference Lopez-Casasnovas, Costa-Font and Planas2005).

The regional devolution of health care responsibilities took place in two waves. A first wave ranged from 1980 to 2001 and granted health care responsibilities to seven region states (autonomous communities). Then a second wave after 2001 extended the same responsibilities to all remaining ten regions. Each regional government has a specific statutory law that covers the provision of publicly financed health and social care. Both regional governments and local authorities are financed by tax revenues that are vertically assigned through block grants allocated on an unadjusted capitation system. Regional health and social care services are subject to (unenforced) cooperation and coordination through the Inter-territorial Council of Regional Ministries of Health and Social Care. The budget retained by the national Ministry of Health is restricted mainly to quality control, surveillance and safety, alongside health promotion and consumer protection. All in all, welfare devolution was introduced in less than two decades, so that, whilst in 1981 only 13 per cent of public expenditures were sub-central, by 1999 this had increased to 49 per cent – although tax revenues were kept centralised and devolved tax revenues barely accounted for 11 per cent of total revenues in 2003.

Mental health reform

Prior to the mid 1980s, a substantial proportion of mental health care was provided outside the National Health System, by the private sector albeit with some funding from local and provincial authorities (Vasquez-Barquero and Garcia, Reference Vasquez-Barquero and Garcia1999). Public mental health services when available were highly fragmented, dominated by residential care (Salvador-Carulla et al., Reference Salvador-Carulla, Garrido, McDaid and Haro2006) often organise in collaboration with non-governmental organisations (NGOs) and religious groups. Service coordination was limited.

The first steps to mental health care reform were taken in 1983 with the establishment of a Ministerial Commission on mental health. Reforms intended to modernise the mental health care network were announced by this Commission in 1985 (Ministerio de Sanidad y Consumo, 1985), and implemented alongside general health system reform in the General Health Act of 1986. These reforms had a number objectives, both explicit and implicit: (a) guaranteeing that support for people with mental health problems would be provided within the general network of health care services and specifically within primary care; (b) redefining the therapeutic meaning of psychiatric hospitalisation, which thus lost its pre-eminence in psychiatry; (c) providing adequate community services and social support to make it possible to rehabilitate and resettle long-stay psychiatric residents in the community; (d) bringing about changes in the community to prevent the marginalisation of these individuals; and (e) guaranteeing the civil rights of people with mental health problems.

Mental health care was better integrated within the national health system and within primary care; service charges other than for psychoanalysis and hypnosis were reimbursed within the general health care package. For instance, in 1986 in the newly created Andalusian health care service, primary care began to serve as a gate-keeping system for specialist care. Mental health needs were also better integrated with other specialist services provided by the Andalusian health service. Subsequently, this process was replicated in some other regions and eventually extended countrywide. A specific set of Diagnosis Related Groups (DRG) tariffs for mental disorders was also added to the national DRG system, which was used to help reimburse health care facilities for the services provided.

Among the consequences of this mental health care reform process was further impetus for de-institutionalisation. This implied a shift from a system based on old asylums to one centred on care in the community, as in some other western countries. As illustrated in Figure 1, the number of beds in psychiatric hospitals has continued to steadily decline. By 2006, there were 46.59 psychiatric beds per 100,000 population (WHO, 2009), one of the lower rates in the European Union. There has also been a shift away from specialist psychiatric long-stay units to psychiatric wards located in general hospitals.

Figure 1.

Psychiatric beds per 100,000 population Spain 1980–2006

Source: WHO Europe, Health for All Database, January 2009.

One reason for this reduction in long-stay beds has been the mainstreaming of mental health within general health and social care systems, which have long relied on a mixture of out-patient, in-patient and residential facilities, as well as multidisciplinary teams of health and social care professionals. Workforce regulation and accreditation criteria were completely reformed, and a cadre of new social care professionals created, including social workers who progressively became entitled to the same level of professional standing as health care workers. Another consequence of mental health reform was the creation of a national training programme for psychiatrists, along with the development of a network of mental health units to provide out-patient services upon GP referral, covering the same Health Areas envisaged for general health care, serving between 200,000 and 250,000 inhabitants. By 1994, about 550 mental health centres had been set up and they have continued to progressively expand; this has contributed to the relatively high rates of consultation that are found today in Spain.

These reforms also help explain the expansion in the number of psychiatrists, from 3.9 per 100,000 in 1982 to 5.12 per 100,000 by 1994; in addition, a network of new mental health care professionals began to emerge, including psychiatric nurses, neurologists and psychologists. The early reforms of the 1980s really only addressed the needs of a small number of people with severe mental health problems, namely those with psychosis who had been hospitalised, rather than tackling the broader exclusion of people living with mental health problems (Salvador-Carulla et al. Reference Salvador-Carulla, Tibaldi, Johnson, Scala, Romero and Munizza2005). Therefore, wider reforms were needed, which required public support.

A subsequent wave of reforms took place in 1995 (Royal Decree 63/1995). Significant developments included defining diagnostic and follow-up treatments, namely drug treatment and group or family psychotherapy, as well as the conditions for hospitalisation. A national therapeutic essential drug catalogue, including drugs for mental disorders, was published.

Much more recently, in 2006, a law on the ‘Promotion of Personal Autonomy and the Assistance for Dependent People’ defined social care as a personal right for people with severe disabilities, including mental illness. In parallel, some regional governments have passed similar social care regulations; this process has been complemented by the development of new coordination and financing mechanisms for health and social care at the regional level.

What impact have these reforms had? One way of evaluating success is to look at data from the 2006 Eurobarometer survey of the general public on service utilisation in Spain and the EU overall. Table 1 reveals that, whilst Spaniards on average used relatively less general practitioner (GP) services for mental disorders than other Europeans, their use was roughly the same when the sample was restricted to those with a mental disorder. Whilst they were on average less likely to use a pharmacist's advice, they appeared to be more likely to visit a psychiatrist. Rates of contact with therapists and psychoanalysts were similar to those in other countries; however, there were lower rates of psychotherapy and higher rates of nursing care. Clearly, greater contact with mental health care reflects increasing activity, though it does not say much on the effects on efficiency and productivity in tackling need.

TABLE 1.

Percentage of mental health care use in Spain compared to EU average (2006)

Question: In the last twelve months did you seek help from a professional in respect to a psychological or emotional health problem?

Source: Eurobarometer, 64.4 2006.

Finally, and consistent with other European countries, reforms have increased the use of pharmaceutical interventions within the mental health system. Indeed, the use of antidepressants in Spain, such as paroxetine, doubled in only eight years from 1997 to 2004, while sales of all antidepressants almost tripled from €169 to €447 million in the same period (Girona-Brumos et al., Reference Girona-Brumós, Ribera-Montaña, Juárez-Giménez and Laluela-Broto2006). Therefore, up to a certain point, reforms in mental health care have opened up opportunities for greater influence by the pharmaceutical industry in the way countries tackle mental neglect (Rose, Reference Rose, Knapp, McDaid, Mossialos and Thornicroft2007).

Prejudices

As we argue in this paper, the regional devolution of health care responsibilities, rather than being a dilutant, has in fact triggered an escalating awareness of the need for reform. Differences in the priorities attached to mental health across Spain reflected in differences in social values and views as to whether mental health should be largely an individual or family responsibility. Those regions that had already made mental health reform a priority no longer had to wait for countrywide agreement and were able to proceed with change. The downside, of course, was that traditionally less progressive regions were then more likely to lag behind in reform. Thus, the implementation of reforms has been geographically uneven, and generally has taken place in regions that have embraced health care responsibilities as compared to those regions were health care has remained as a centralised responsibility.

In the health system generally, due to cross regional learning and voluntary cooperation, geographical inequalities in services appear to have levelled out (Lopez-Casanovas, Reference Lopez-Casasnovas, Costa-Font and Planas2005). In the case of mental health, however, significant differences between the autonomous communities in expenditures on mental health remain: estimates for specific autonomous communities range from just 1.5 per cent in Extremadura to 9.4 per cent in Catalonia (Gisbert et al., Reference Gisbert, Brosa and Bohigas2007; Salvador-Carulla, Reference Salvador-Carulla2008). Whether those regions that have prioritised mental health will act as catalysts for others to follow, as in other areas of health, remains to be seen. However, empirical evidence reveals that devolution has acted as a catalyst for mental health policy development in Andalucia, the Basque Country, Catalonia, Galicia and recently in Madrid, Castilla Leon, Murcia and especially in Extremadura once health care responsibilities were finally devolved after 2002. These regions have been at the forefront of policy developments, which in turn have begun to spill over to other parts of the country. All have developed regional health plans after devolution specifying mental health targets. However, this development comes at the cost of less central command and the expectation that greater cooperation and policy learning will instead take place.

Another key concern with devolution is in its effects on the mixed economy of care. As already noted, mental health care services exhibit a higher reliance on both private inputs and informal care by families, who effectively are the main social care providers for people living in the community. However, reform has integrated both private and community support in the mental health package. The mental care package was updated in 2006 (Royal Decree 1030/2006) to include both primary and specialised care, including both treatment and preventive services, and to formalise the consolidation of a communitarian model of mental health care. This was a first step towards integration, given the coordination between levels of care (primary and specialist), alongside health and social care dimensions.Footnote ⁵ However, an explicit definition of the limits of mental health care provision has yet to be agreed. This has to do not only with the heterogeneity of social care needs, but principally with other more structural features that constrain reform, mainly the still limited political visibility of reform which decentralisation helps to curb. Yet, still to date the percentage of individuals that use primary mental health care is lower than in most European countries (Sicras Mainar et al., Reference Sicras Mainar, Rejas Guitierrez, Navarro Artieda, Serrat Tarrés, Blanca Tamayo and Díazs Crespo2007).