‘Citizen Psychiatry’ – East Lille mental health service network – France

The Eastern Lille mental health service network (59G21 France operates with a sectorised mental health system. For adult services the country is divided into approximately 850 sectors, each with a population of about 70,000. The East Lille sector has the number 59G21 and only serves adults. Six suburban towns are included in this sector: Faches-Thumesnil, Hellemmes-Lille, Lesquin, Lezennes, Mons-en-Barœul and Ronchin.) has been transformed over the past three decades with a primary aim of avoiding resorting to traditional hospitalisation (Submission 19A). The change was co-ordinated at EPSM Lille métropole, a mental health centre in the towns of Faches Thumesnil, Ronchin, Lesquin, Hellemmes, Mons en Baroeul, and Lezennes.

The WHO (2021, p.161) Guidance on community mental health services describe the network as follows:

The mental health network of East Lille promotes the concept of “citizen psychiatry”. Serving a population of 88 000 in the south-east region of the Lille metropolitan area, the network has been built over 40 years of mental health system reorganization and reform. The East Lille network demonstrates that a shift from inpatient care to diversified, community-based interventions for people with mental health conditions and psychosocial disabilities can be achieved with an investment comparable to that of more conventional mental health services. The approach supports respect of human rights of individuals who use mental health services, and their empowerment – even while operating in a more restrictive national legal context.

The Public Mental Health Institution Lille Métropole (Etablissement Public de Santé Mentale Lille Métropole (EPSM)) plays a central role in administering the network, including regional oversight and planning mechanisms (World Health Organization, 2021, p.161).

The Submission (19A) suggests several themes that underly the network, including: human rights, and a belief that mental health conditions do not impeded someone exercising those rights; a commitment to not conflate mental health care with suppression of violence and risk; the need for society, and thus mental health services, to adapt to people’s needs, and not the other way around; commitment to closing medical and social institutions that effectively exclude residents from their communities; a commitment to fighting stigma and discrimination based on mental health conditions, including challenging stereotypes about dangerousness and lack of capacity.

The formal services in the network engage as a partner with other stakeholders, including people who use the service and their families, NGOs, elected officers in the municipalities, and others who are involved in the mental health field.

Within this broad initiative, two key components of the program are the Coordination Territoriale du Parcours de Rétablissement (‘Territorial Coordination of the Recovery Path’) and ‘Availability, Reactivity, Outreach’

 Territorial Coordination of the Recovery Path

This component involves ‘integrating the entire health system into the city, via a network involving all interested partners: users, carers, families and elected representatives’ (Roelandt et al., 2010).

With nearly 70 outpatient care systems, the service provides the population with prevention, diagnostic, care and monitoring services and equipment for adults, adolescents and children. Medico-Psychological Centres (CMP) or Mental Health Centres (CSM) constitute the entry point of the system. These centres organize prevention, diagnostic, outpatient care and intervention actions at home. The initiative reportedly involves a system of community care that keeps affected people as close as possible to their homes, residences, families and communities (Submission 19A). The policy and program arrangements link together health, political and social organisations and agencies: including general practitioners and health actors, elected representatives, associations and user representatives, social and medico-social actors, and social landlords. All of these elements are based on ‘local mental health councils’ which bring together all the partners (Submission 19A).

This multi-service arrangement reportedly helps to provide consistent support that assists a person wherever they are in her or his trajectory through a mental health crises, rather than creating strict divisions between the kind of support a service offers. As an example, a person may, at different times, spend time at an inpatient unit, draw on intensive home crisis unit, undertake assertive community treatment and outpatient consultations, or use a ‘leisure support service’. All these services are staffed by the same professional group – comprised of peer helpers, psychologists and psychiatrists – and they exchange information regularly.

The various options are designed to respect self-determination and avoid coercive care, particularly through emergency room visits or coercive measures that appear in services outside the East Lille Public Psychiatry service network. Broadening the range of care options allows for closer access to people's wishes, and reportedly improves engagement with the support being offered (Submission 19A).

Since 2014, the EPSM explicitly adopted a ‘recovery-oriented’ approach, with each worker trained to adhere to a charter of commitment to recovery-oriented care. This reportedly makes service culture consistent across the various services provided. Service users are encouraged to create advance directives (see p.64 for examples) and recovery plans to assist services to adhere to their wishes during crises. At the meta level, it is the coordination via the local mental health council that enables the mobilisation of partner services to advocate for people's rights and guarantee them the best possible health and social support. The council also offers prevention and information on mental health, crisis and post-crisis care, and support for people in difficulty in their daily lives. Reportedly, outreach and coordination with frontline actors helps to build trust and improve access to care by reducing coercive practices (Submission 19A).

The inpatient units are actively working on reducing the need for restraint and on alternatives to hospitalisation.

The intensive crisis unit takes care of 15 users, for an average of 14.6 days, and is available 24/7, with a presence from 8am to 10am and a nightly telephone service.

Outpatient consultations and crisis support use recovery and crisis prevention plans (based on the model of advanced directives), which make it possible to coordinate the user's care pathway according to her/his values and wishes in all the structures she/he encounters. These plans are formulated with the person, their relatives, but also in conjunction with their GP or other partners if the person so wishes.

Access to peer support is guaranteed by hiring peer health mediators (see below ‘Section E(b)(iii) Médiateur de santé pairs’ p.68). At the organisational level, elected user representatives participating in the development of the service also ‘provides a measure of health democracy’ (Submission 19A).

Twice-daily telephone coordination between the departments (9am and 8.45pm) is essential to the service, with a dedicated permanent medical on-call service. Every morning, a call is made to emergency services to find out if anyone in crisis has turned up in the area, so that the service might anticipate the necessary interventions. Availability and reactivity are also of paramount importance, especially to avoid the aggravation of situations and the coercive interventions that may result. To this end, the service offers:

  • assessment of new applications within 48 hours
  • emergency management in outpatient settings and at home
  • intensive followup at home
  • the development of outreach by being a force for proposing care for people in difficulty
  • longterm follow-up for people with psychosocial disability; and
  • the management of psychiatric hospitalisations. (Submission 19A)

Increased coordination with the GP is carried out, through meetings, telephone calls if necessary, and a consultation letter sent at each meeting with the user.

Finally, through the service's partnerships, its staff provide advocacy for individuals, promoting their rights, including by demanding resources, housing, access to health, and so on.

i. ‘Availability, reactivity, outreach’

The second key component of the EPSM approach is a mobile emergency unit, the ‘Intensive Service Integrated in the City’ (Soins Intensifs Intégrés dans la Cité) (SIIC), which has operated for 15 years and is the largest mobile team in France in terms of the number of people it supports. SIIC has two distinct missions:

  • Permanent access to care (24 hours a day, 7 days a week): medical oncall duty and telephone duty and coordination with local organisations; and
  • Capability for intensive support for 15 situations at any one time that may be of a crisis nature or in need of intensive contact.

The medical on-call activity is carried out in coordination between the on-call doctor and the SIIC team. It aims to ensure a fast and adapted response to urgent situations to allow a person’s entry into the care system. The service includes emergency interventions in the home in case of crisis situations, which remain the responsibility of the SIIC service rather than generic emergency services (like police or ambulances).

The decision about a person entering services is a medical one, and the ‘procedures are defined in dialogue between the user, her/his relatives, the team and the doctor’ (Submission 19B). The SIIC is a service designed to respond to exceptional crisis situations. It should also enable users to develop autonomous crisis management tools

In addition, a Service Médico-Psychologique de Proximité (SMPP) operates, which offers two dedicated ambulatory EPSM services (World Health Organization, 2021, p.161). The SMPP services are composed of a multi-professional team (doctors, nurses, social workers, psychologists, psychiatrists, peer health mediators, secretaries) who work in close collaboration to guarantee quality care by adapting to the needs of the population. According to the WHO review of the SMPP:

A person is referred to an SMPP by their general practitioner. Referral is followed by an assessment of both mental and physical health needs within 48 hours. Each assessment is then discussed by a multidisciplinary team, which identifies care and support needs. Consultations take place at a range of venues, such as a social and support centre for youths where they can directly access the SMPP without a doctor’s referral. There is no waiting list, and the service can also undertake home consultations.

The concept of a ‘care pathway’ is the basis for the SMPP partnering with other local services. The pathway must meet the needs of people living with mental health conditions and psychosocial disabilities, and their carers and families, and to do so with attention to their local area. To achieve this, a partnership between SMPP and the local towns is essential. Consultations can take place in diverse local venues (the local mission, a swimming pool, a social service centre, an addiction support centre, a community health centre, and so on). Two multidisciplinary meetings are held each week to orientate new requests according to the needs of the users and to refine the adequacy of the diagnosis and the care offer. The aim of SMPP is to engage a person in a cooperative relationship to promote recovery.

Three other key elements of the East Lille mental health services network are:

  • An approach of ‘recoveryoriented empowerment’
  • The development of crisis prevention and management plans, and
  • ‘Alternatives to Seclusion and Restraint’

Each will be discussed briefly below.

‘Recovery Oriented Empowerment’

Recovery-oriented care (ROC), which was a model or approach to care integrated into the 59G21 service in 2014, is aimed at helping the user to live better with his or her condition or disability and to retain opportunities for a rich family, professional and social life (Submission 19H). This approach is based on a partnership model: ‘It respects the individual's right to be in the driver's seat but also recognises the value of having professional co-driver(s) and natural support(s)’ (Submission 19H). ROC is meant to enable users to lead their recovery, and focus on overcoming the alienation and marginalisation confronting people with mental health conditions and psychosocial disabilities. Three ‘levels of alienation’ are described:

  • Level 1 in relation to the illness and symptoms;
  • Level 2 in relation to the representation of oneself as a sick person, i.e. ‘internalised stigma’;
  • Level 3 regarding alienation generated by the organisation of society and its ability (or inability) to include people with mental health conditions and psychosocial disability (Submission 19H).

In more practical terms, ROC as it is practiced in the East Lille network is comprised of the following actions:

Integration of experiential knowledge (that is, involvement of ‘experts by experience’) in the training of professionals, which:

  • imprves the knowledge of health and social associations
  • maintains hpe about the evolution of a person’s troubles
  • fsters more horizontal care-giver/carer relationships (i.e. seeks to mitigate power assymetries between care givers and receivers
  • Integrates peer health mediatrs into professional teams (there were 5 in 2020)

Development of health democracy

  • the creatin of participatory spaces and tools
  • quarterly user frum facilitated by a peer health mediator and spokespersons
  • regular ‘talking t users’ meetings facilitated by peer health mediators
  • suggestin/complaint sheet on the consultation sites
  • a mechanism fr service users to report undesirable events to management
  • QualityRights evaluatin carried out by the WHO, and integration of recommendations into the cluster project (see World Health Organization, 2021, p.161-63).

Election of the centres’ user spokespersons

  • electin of 3 spokespersons for the centres service users;
  • participatin of spokespersons with a strong involvement in the cluster's steering committee, organisational meetings and working groups;
  • participatin of a user spokesperson in the QualityRights training course.

Additional tools for recovery orientation used at 59G21 include: formal recovery-oriented training for management; the creation of a ‘Recovery Charter’ that staff members sign as a commitment to the process; service-level commitment to employ peer-to-peer mediators and the development of appropriate workplace adjustments for those workers where needed; and the creation of the crisis prevention plan as a tool (detailed in the next sub-section).

 ‘Crisis prevention and management plan’

The Crisis Prevention and Management Plan, or simply the ‘Crisis Plan’, is effectively an advance planning tool (Submission 19G). (For a fuller discussion of advance planning methods, see p.64). A Crisis Plan is meant to serve as a relapse prevention method, to be written during or after a person experiences hospitalisation or intensive outreach. The user, family and friends or health professionals can then use the crisis plan each time warning signs of a crisis appear. The Crisis Plan is a dynamic ‘recovery oriented’ tool to help people become aware of their strengths and resources, to help them identify the triggers of and warning signs of ill-health and crisis, and finally to enable them to give advance directives on the actions and attitudes that will enable them to avoid or manage the crisis.

These directives also make it possible to reduce the challenge of caring. By being aware of the user's crisis plan, the professionals, family and support persons know what to do to best respect the user's rights, needs and desires if he or she experiences a period of crisis. The first person concerned is the user herself/himself who makes her/his crisis plan, but it also concerns all the people she/he considers involved in his recovery process who may provide assistance with the plan if the person chooses. This is reportedly a very common practice in the 59G21 service and in other services of EPSM Lille-Métropole. Other services within France that take a recovery-oriented approach have developed similar tools. See for example, the ‘GPS’ program used in Ile-de-France, which is described at p.65 of this report.

‘Alternatives to Seclusion and Restraint’

As described above, the entire healthcare pathway at EPSM is designed to promote access to care in ways that preserve autonomy, and therefore avoid restrictions on freedom. It is ‘exceptional’ for a user to be placed in restraint at the central clinic that forms part of the 59G21 service network (the Jérôme Bosch [JB] clinic).

The JB Clinic has 10 hospital beds and 2 rooms have a companion bed for those wishing to have the company of a trusted person or accompaniment during their time at the clinic. A person’s support network is engaged by the service to help with negotiation, safety and avoiding conflict.

The average length of hospitalisation in 2019 was 6.5 days. Upon admission, according to the WHO (2021, p.162) review of the service, ‘both written and verbal information about an individual’s rights and obligations is provided’.

Restraint is viewed as a dysfunction which is the subject of an adverse event report, and is generally perceived as an act of abuse (Document 19I). Reportedly, in 2019, there was only one instance of restraint (which lasted 3h); in 2020, there were reportedly zero instances. The JB clinic does not have any seclusion rooms.

The theme of freedom is particularly important to the 59G21 service. The goal of the program is ‘zero seclusion/isolation, zero restraint’ (Submission 19I). The practices aim to defuse situations of violence before, during and after a crisis. Reportedly, ‘situations of violence are less frequent, as long as rights are respected and restrictions are minimal, discussed and justified’ (Submission 19I). The choice to leave the doors open helps to combat the impression of being shut in.

The features of the EPSM and 59G21 service above, are considered to be pre-requisites to avoid and limit hospitalisation. Other features of the alternatives to seclusion and restraint approach include the following:

  • professionals receive specific "OMEGA" training that enables them to identify the risk of a crisis ‘upstream’ and to defuse it if necessary (98% of staff had received the training in 2020);
  • violence prevention and management plan is worked on with the user from the moment of admission and throughout his or her stay;
  • a carer is permanently and individually present, if necessary;
  • all staff members benefit from the input of the peer staff members who provide a more experiential view of the complex situations. Access to peer support is seen as essential in the approach to recoveryoriented care, to instil hope in users and carers, and change the cultures of professionals (Submission 19I);
  • staffing levels are adjusted in line with the potential level of risk, including the possibility of constant presence and supervision with a person if necessary;
  • ‘prevention agents’ are occasionally called in to provide relief in certain situations. The presence of these agents is beneficial and reassuring for both other users and professionals. The prevention agents are security professionals who intervene on an ad hoc basis to accompany the person on a constant basis, 24 hours a day for as long as the situation requires. In 2019, the number of users requiring a prevention worker was 20, which occurred over 138 days.

If a person is placed under restraint (which occurs very rarely as noted above), a restraint protocol is adhered to and a post-event analysis is carried out with the user and the team. An Undesirable Event Sheet is drawn up to better understand what went wrong. An interdisciplinary feedback meeting, based on the situation, leads to recommendations.

The bedrooms are individual and respect privacy and confidentiality. Rooms are equipped with TV sets. The space and equipment promote well-being (‘psychomotricity room, hydrotherapy, activity area, calming room, computer room’). The architecture of the clinic favours circulation, it includes open spaces with free access to the outside garden. The control of these spaces is essential to meet the safety needs of all. The clinic offer areas for wandering and personal accompaniment, a source of calm without deprivation of liberty. The clinic has an aromatherapy system throughout the entire structure, diffusing soothing essences day and night.

The continuous availability of psychiatrists to adjust care is essential, as this ensures that the teams are not left in a closed system. Regarding peer support, there are measures for support persons to advocate for users' rights, including any constraints associated with hospitalisation.

Summarising the impact and achievements of the East Lille mental health network

According to the World Health Organisation (2021, p.163) the important achievement of this network can be summarised by noting ‘the steadily decreasing rate of hospital admissions, from 497 admissions in 2002 to 341 admissions in 2018, despite the considerable increase in the number of people receiving care in the network over the same period, from 1677 people in 2002 to 3518 people per year in 2018’. Further:

The average length of stay at the in-patient unit also decreased from 26 days to seven days over the same period. An independent assessment team conducted a who QualityRights evaluation in September 2018 across all of East Lille’s mental health services. Three of the potential five themes were fully achieved:

  • the enjoyment of the highest attainable standard of physical and mental health,
  • freedom from coercion, violence and abuse, and
  • the right to live independently in the community.

The remaining two themes: (iv) the right to an adequate standard of living and v) the right to legal capacity and personal liberty and security, were partially achieved. The existing French legal framework was found to be an important barrier for the full achievement of these latter two themes.

Other signs of success, according to WHO (2021, p.164) include the low rates of expenditure on hospitalisation relative to the rest of mental health services (28.5%) compared to 61% nationwide in France, as well as lower costs for mental health services in East Lille compared to surrounding metropolitan areas—costs which have been decreasing steadily from 2013–2017, from €3131 to €2915 per year (as at June 2021).