The German mental health care system differs significantly from the system in the UK. There is no central organisation with overall responsibility as in the National Health Service (NHS), and the government is not entitled to prescribe details of policy or set specific targets. It can only determine the legal framework, define general goals and, with difficulties, influence the spending level. Responsibilities for mental health care, as for other fields of health care, are shared between federal authorities, the 16 states (Länder), local authorities, and semi-statutory organisations, which govern out-patient health care provided by psychiatrists in office-based practices. Virtually every citizen is health-insured and there is free access to health care for those who have no insurance coverage, in which case social services usually cover the costs. Social services also directly fund various services in the community. The fragmented system can be difficult to comprehend. However, many of the challenges are similar to those in other countries, and policy makers and practitioners elsewhere might be interested to know some of the lessons learnt in the German system.

After the second world war, in-patient mental health care was provided in understaffed asylums with low staff morale. Following the murder of people with mental illness by the Nazi regime and the resulting large-scale depopulation of the asylums, patient numbers increased again, although they remained much lower than the UK figures at that time (Reference HäFNER and KrankeHäfner, 2001). Asylums were not adequately equipped either for acute treatment or longterm rehabilitative care. In the 1970s, significantly later than in England and the USA, a major reform movement aimed to improve mental health care, and funding for inpatient and out-patient services subsequently increased. The most important milestone was a national enquiry into mental health care, i.e. the Psychiatrie-Enquete (1975). Its recommendations for reforms were endorsed unanimously by the German Bundestag (Reference Bauer, Kunze and VoncranachBauer et al, 2001) and welcomed by the public and the media (Reference Schmiedebach, Beddies and SchulzSchmiedebach et al, 2000). They demanded the integration of psychiatric in-patient care into general hospitals and the establishment of in-patient and out-patient services including day services and residential facilities close to where patients live. The Psychiatrie-Enquete initiated a comprehensive reform process replacing custodial care in asylums, with new and much better funded services. Häfner (Reference HäFNER and Kranke2001) described this period as a ‘humanitarian turning point’ in Germany. However, the Psychiatrie-Enquete did not address the structural problems of a highly fragmented health and social care system (DGPPN, 1997; Bundesministerium, 1999; Reference Bauer, Kunze and VoncranachBauer et al, 2001).

As compared with other Western European countries, Germany has a relatively well-funded health service. More than 10% of gross domestic product is spent on health care as compared with slightly less than 7% in England and Wales (Organisation for Economic Cooperation and Development, 2002). The numbers of psychiatrists and of psychiatric beds per population are in the European middle range. Many components of modern mental health care have been widely established. This includes day hospitals, day centres, work rehabilitation services, counselling, residential services of varying intensity and even small multi-disciplinary out-patient services with an outreach function for patients with severe and chronic mental illnesses, which are attached to in-patient units (‘Institutsambulanz’). However, there are no community mental health teams, and no agency has overall responsibility for community mental health care in a given catchment area. The principles of community-based care might be endorsed by many mental health professionals, but practice is variable and integration of care remains problematic. There is no substantial barrier between primary and secondary care and patients can directly access psychiatrists in office-based practice and receive specialised treatment whenever they feel the need (Reference Bauer, Kunze and VoncranachBauer et al, 2001). However, this might be changed in the near future to reduce the costs of the system. Most out-patients are on the case-loads of office-based psychiatrists who are paid on a fee-for-performance basis in a strictly regulated market with a semi-statutory professional organisation exerting stringent control and negotiating fees with health insurance organisations. On average, there is one psychiatrist in office practice per 16 300 population. Additionally, there is one psychotherapist with a medical or psychological qualification working in office practice for less than 5000 population.

This paper describes two major initiatives beginning in 1990 and 1997, i.e. the staffing directive for psychiatric hospital services and the guidelines for commissioning community services for chronic mentally ill. The APK (Aktion Psychisch Kranke, i.e. Action Mentally Ill), a non-governmental, non-profit organisation was founded in 1971 and is funded by the German Ministry of Health. The organisation works at the interface between mental health professionals and federal policy, and has organised various influential expert commissions including the aforementioned Psychiatrie-Enquete.

The federal directive on staffing of psychiatric hospital services (‘Psych-PV’)

In general, psychiatric asylums in Germany were not closed but downsized and better equipped for acute treatment. In addition, further psychiatric in-patient units were established in general district hospitals. The former function of asylums in long-term care was transferred to residential and other services in the community. From 1980-2000 the number of psychiatric hospitals, i.e. former asylums, decreased by only 4% (to 202). However, their size decreased drastically by two-thirds, bringing the bed ratio down to 0.4/1000 population. Within the same period, psychiatric units in general hospitals about doubled their number to 220 with their bed ratio increasing to 0.26/1000. Including old age and addiction services, there are on average 0.66 psychiatric beds per 1000 population with significant regional variation.

The federal staffing directive for in-patient and day care was passed in 1990 (Reference Kunze and KaltenbachKunze & Kaltenbach, 2003). Previous standards for staffing levels in mental hospitals dated back to 1969 and were very low. They applied only to medical and nursing staff and failed to include other professional groups. Staffing indices had been defined as average staff numbers per bed irrespective of the condition and needs of the patients. As a result, hospitals were reluctant to discharge long-stay patients who required little care but, through fixed per-day funding, helped to fund the treatment of the acutely ill.

Guidelines for commissioning of services for people with severe and enduring mental illness in the community

As in other Western industrialised countries, in Germany during the 1970s and 1980s long-term hospitalised patients, including many with dementia or mental retardation, moved to nursing homes or sheltered living in the community (Reference KunzeKunze, 1985). Currently, the population of people with mental illness in sheltered homes is approximately equivalent to numbers of beds in psychiatric inpatient services (Reference BrillBrill, 2000). There is little empirical evidence on the effects of these changes on the patients concerned (Reference Rössler and SalizeRössler & Salize, 1996; Reference Priebe, Hoffmann and IsermanPriebe et al, 2002).

Conclusions

More than 10 years after the publication of the federal directive on staffing in in-patient mental health services, it is clear that it has been very beneficial to specify the type of input that should be provided for defined subgroups of in-patients. It has helped to establish staffing levels and secure reasonable funding. The specification of hospital treatment in the Psych-PV has provided commissioners and providers with a rational algorithm for their negotiations. There is good evidence that this has led to a substantial increase in multidisciplinary staff in hospitals and has made a major difference to the quality of in-patient care. However, cost pressures have had a negative impact on the implementation of the Psych-PV. Many psychiatrists are now concerned that the current funding system might be replaced by ‘diagnosis-related groups’. This funding system will apply to all hospital services other than in mental health by 2004, and, if expanded to mental health, might lead to a substantial setback (Reference FritzeFritze, 2003; Reference KruckenbergKruckenberg, 2003).

The guidelines for commissioning community mental health care have similarities with the care programme approach (CPA) in the UK. On a clinical level, the CPA in the UK is certainly better established, further advanced and probably more effective than the, so far, tentative German approach. The CPA, however, does not need to take direct decisions on funding in a health care system characterised by fragmentation and competition of various public, voluntary and private-for-profit providers. The implementation projects might help to clarify whether and, if so, to what extent, the fragmented system of institutional care in Germany can be overcome so that people with severe and chronic illnesses can ‘make the best use of [their] residual capacities in as normal a social context as possible’ (Reference BennettBennett, 1983).

The comparison of the German system of community mental health care with the situation in the UK shows overall higher spending levels and better resourced services in Germany. This spending might have helped to avoid some of the adverse effects of deinstitutionalisation described in other countries (Reference Bachrach and LeffBachrach, 1997; Reference Munk-JørgensonMunk-Jørgenson, 1999). Spending levels alone, however, appear not to guarantee an effective organisational structure of care, in particular for patients with severe and chronic mental illnesses. The German experience outlined in this paper also demonstrates that positive reforms can happen in mental health care without top-down prescribed plans on how to deliver services, but that the mechanism of funding arrangements is often a limiting factor. These mechanisms can be more important for how practice develops than scientific evidence or the ‘ philosophy’ of mental health professionals. In conjunction with the economic interest of providers and insurance companies, they appear to make the system more rigid rather than more flexible. By contrast, the public funding through the NHS does not provide financial incentives for individual clinical decisions and certainly has significant benefits, one of which is that there is no need for a complicated and time-consuming decision-making process on funding for every care component.