The social health insurance system and healthcare expenditure

Luxembourg operates a compulsory social health insurance system with a single payer, the Caisse Nationale de Santé (CNS), that covers three schemes: healthcare, sickness leave and long-term care insurance. The CNS determines overall hospital budgets, negotiates with service providers and monitors the quality of the health services.

Luxembourg's strong economic performance as well as its population and employment growth have had a positive impact on the public financing of healthcare. In addition, over 200 000 cross-border workers commute daily from neighbouring countries, representing a significant minority (45%) of the labour force and more than one-third of those are insured by the CNS. As these non-residents mostly utilise healthcare services in their country of residence, where service costs tend to be lower than those in Luxembourg, they contribute to the subsidisation of the health services for the resident population.³

Public financing of the health service is based on a system of shared contributions: 40% is paid by the state, with the rest shared between the insured population and employers. Overall, about 84% of health spending is publicly funded, with the remainder paid directly ‘out of pocket’ by households either as co-payment for various services or via top-up voluntary health insurance. In 2017, the latest year for which figures are available, Luxembourg spent €3575 per capita on healthcare, well above the EU average of €2884. Mental health services are allocated 13.4% of the total health expenditure.³

Prevalence of mental illness

To date, data on the prevalence of mental illness in Luxembourg have not been consistently collected. Information obtained as part of the European Health Examination Survey suggests that there is a considerable disease burden due to depression, with migration being a risk factor.^{Reference Ruiz-Castella4} Alcohol and substance use disorders are also thought to be common^{3,Reference Véronique and Marie-Lise5} and rates of binge drinking among adults are among the highest in the EU. The suicide rate in Luxembourg is quoted as 11.3 per 100 000, in line with neighbouring countries.⁶

Workforce

Luxembourg has a relatively low number of doctors (3 per 1000 population, compared with an EU average of 3.6 per 1000) and a rapidly ageing medical workforce. It is also one of the few countries in the EU without a medical school. As a result, Luxembourg is heavily dependent on foreign-trained doctors. At the time of writing, the University of Luxembourg offers the first year of medical education, with medical students switching to universities in other countries for their undergraduate clinical training. A 3-year Bachelor degree programme in medicine, in collaboration with selected universities in other countries, will commence in September 2021. Postgraduate medical training is currently restricted to general practice, but the plan is to develop training schemes to include neurology and oncology.³ In 2018 there were 21.5 psychiatrists per 100 000 population, placing Luxembourg in the upper middle range in the EU.⁷ Many psychiatrists work exclusively in out-patient consulting rooms, although some are employed by hospitals and provide in-patient services.

Evolution of mental healthcare provision

Historically, psychiatry in Luxembourg has been marked by different orientations, reflecting at least in part the various psychiatric traditions in the countries in which the psychiatrists trained. Agreement on nosology, even within the same hospital, used to be difficult, with language barriers contributing further to the divide.^{Reference Meisch8} Some of this diversity is still played out now. For example, at the Centre Hospitalier Neuro-Psychiatrique (Neuropsychiatric Hospital) (CHNP), the country's largest psychiatric hospital, owing to differing language competencies among psychiatrists, internal and external training opportunities are offered separately to German- and French-speaking clinicians. At a national level there is, however, an association for all psychiatrists which helps to bridge the gap.

As in other countries, guidelines are a point of reference for clinical decisions and are considered useful for the implementation of evidence-based practice. International guidelines can vary significantly in their recommendations.^{Reference Gaebel9} In Luxembourg, national recommendations for evidence-based practice are generally lacking and clinicians therefore tend to refer to guidelines from the country in which they trained, further contributing to the challenges of a cohesive approach.

The evolution of mental healthcare in Luxembourg mirrors that in other European countries: with a trend towards deinstitutionalisation that began during the 1990s there has been a move away from in-patient care towards community-based treatment facilities, and an increasing emphasis on the contributions of multidisciplinary teams.^{Reference Shorter10} In 1990 Luxembourg had the highest per capita number of psychiatric beds in Europe (2.2 per 1000), largely concentrated in the former state psychiatric hospital. Since then, significant efforts have gone into decentralising psychiatric hospital services and developing regional psychiatric services (short-stay in-patient and out-patient facilities within general hospitals), day hospitals and increased psychiatric provision in primary healthcare settings, all with the aim of promoting community reintegration. At the same time, preventive and positive mental health promotion programmes, as well as programmes targeting the reduction of stigma, have been launched. A report commissioned by the Health Programme of the EU highlighted the positive aspects of Luxembourg's well-resourced mental health services, which offer patient choice, but noted the relative lack of governance and service integration and the over-reliance on a non-national workforce.^{Reference Samele, Frew and Urquia11}

Current psychiatric services

As in many other high-income countries, the funding and provision of mental health services come from both health and social care budgets, with the voluntary sector also playing a role. Most hospitals offer differentiated mental health services for adults and children.

In-patient and ‘day hospital’ general adult psychiatry services are located within large general hospitals and are aimed predominantly at patients requiring acute admission and interventions of relatively short duration. Specialist rehabilitation services targeting patients requiring longer in-patient hospital stays and follow-up are located in the country's oldest psychiatric hospital, the CHNP, which has now become a public institution. This former asylum houses specialist units, including rehabilitation-focused wards for those with chronic severe mental illness, predominantly psychosis and mood disorders, a psychogeriatrics unit, in-patient substance misuse services and a home treatment team. Luxembourg's forensic psychiatry service is also located at the CHNP and provides in-patient care and out-patient follow-up as well as an in-reach mental health service to the country's prisons. In addition to a busy out-patient child and adolescent psychiatric service, the CHNP houses an in-patient unit for the longer-term treatment of minors who are at risk of harm to themselves or others and provides a liaison psychiatry service to the secure care service for under-18s. Acute child and adolescent psychiatric in-patient and day services are provided across two general hospitals.

Health promotion and prevention programmes exist and include crisis helplines, early years support, and school medical and psychological services. Support services for the elderly and specialist services for people with autism and neurodevelopmental disorders have been commissioned. Specific programmes targeting well-being at work and aiming to minimise occupational mental health problems have been launched in recent years. Several not-for-profit organisations offer supported living facilities and/or provide daytime activities and vocational training opportunities for people with chronic psychiatric illnesses.

Summary

Luxembourg has relatively well-resourced, publicly financed mental health services that have evolved from predominantly in-patient-based treatment models to comprise a range of community treatment options as well as preventive services. Luxembourg is heavily influenced by its neighbouring countries and the diversity thus created is an asset but can also make integrated and joined-up approaches to evidence-based practice more difficult. External reviews have praised the well-resourced mental health services but highlighted the need for improved governance and service integration.