Sanatatea Mentala si Uniunea Europeana

Din pacate, n-am gasit si un material in lima romana, voi incerca sa gasesc.Deschid topicul cu speranta ca toti sa intelegem ca sanatatea mentala este o problema de sanatate publica majora si ca nu poate fi rezolvata decat intr-un spatiu largit, cu contributia multor actori implicati in sanatate.
REPORT AND RECOMMENDATIONS OF THE EU CONSULTATIVE PLATFORM
ON MENTAL HEALTH
RESPONSE TO THE EC GREEN PAPER
COM (2005) 484
IMPROVING THE MENTAL HEALTH OF THE POPULATION: TOWARDS A STRATEGY ON MENTAL HEALTH FOR THE EUROPEAN UNION
CONTENTS
1. Introduction...............................................2
2. Priorities...................................................4
3. Recommendations......................................5
4. Conclusions..............................................17
Appendix 1: Participants.................................18
Appendix 2: Consultation meeting reports...........19
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Report and Recommendations
of the EU Consultative Platform on Mental Health 2006
1. Introduction
1.1 Following the 2005 WHO Ministerial Conference on Mental Health, the European Commission (EC) was called upon (Helsinki Declaration, 14/01/05) to support the implementation of the Declaration on the basis of its competences.
By the end of that year, a Green Paper COM (2005) 484 had been published and a consultation process established. This set up, by a launch led by Commissioner Kyprianou in November 2005,
􀂾 A forum for a dialogue with member states
􀂾 An interface between relevant stakeholders with expertise in policy and research
􀂾 A Platform involving a variety of actors to promote cross-sectoral cooperation and consensus.
1.2 The Platform remit, initially in its consultation phase by 31 May 2006 which this Report covers, will be to "analyse key mental health aspects, identify evidence-based practice, develop recommendations for action, also at Community level, and identify best practice for promoting the social inclusion of people with mental ill health and disability and for protecting their fundamental rights and dignity, all of which can be fed into the dialogue with member states."
The Platform met at three consultation events organised by the EC:
"¢ 16-17 January in Luxembourg (Promotion Prevention)
"¢ 16-17 March in Vienna (Rights Inclusion)
"¢ 18-19 May in Luxembourg (Research Information)
plus an informal meeting in Brussels in February organised by EuroHealthNet, which provided Kasia Jurczak as Rapporteur and Clive Needle as Chair for the platform consultation process.
Some sessions were conducted jointly with the Interface group and chaired by Kristian Wahlbeck with Jordi Alonso as Rapporteur; Nicoline Tamsma of EHMA kindly acted as Rapporteur at the concluding session.
1.3 Other participating organisations have also organised consultative meetings and submitted reports, and EU institutions such as the European Parliament have held hearings and meetings which have contributed to views in this report as well as their own processes.
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1.4 The Commission indicated its particular interest in views on the following questions:
1. How relevant is the mental health of the population for the EU"™s strategic policy objectives?
2. Would the development of a comprehensive EU strategy on mental health add value to the existing and envisaged actions, and are adequate priorities proposed?
3. Are proposed initiatives appropriate to support the coordination between member states, to promote the integration of mental health into health and non-health policies and stakeholder action, and to better liaise research and policy on mental health aspects?
The reports of the official meetings are appended. They have been submitted together with minutes and plenary presentations to the Commission, and are available with other relevant documents on its website http://ec.europa.eu/health/ph_determinants/life_style/mental_health
Most participants have also submitted separate responses to the Green Paper and it is understood they will be collated in an EC report.
But the official EC process was necessarily limited for internal reasons. A number of contributions have also been made on wider issues of importance concerning process and strategy priorities. The purpose of this paper is to bring together those comments and put them into the context of the EU competences to act.
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2. Priorities
2.1 In terms of policy priorities, the basis has already been established and was essentially backed by participants. These recommendations do not seek to duplicate those provisions. It does however call for tangible actions to replace words, and for a stronger approach to partnership working than has hitherto been demonstrated in some cases.
Ministers of health have endorsed the WHO Mental Health Action Plan for Europe. They "support its implementation in accordance with each country"™s needs and resources".
2.2 The priorities were set out as
i. Foster awareness of the importance of mental well being
ii. Collectively tackle stigma, discrimination and inequality, and empower and support people with mental health problems and their families to be actively engaged in this process;
iii. Design and implement comprehensive, integrated and efficient mental health systems that cover promotion, prevention, treatment and rehabilitation, care and recovery;
iv. Address the need for a competent workforce, effective in all those areas;
v. Recognise the experience and knowledge of service users and carers as an important basis for planning and developing services.
2.3 Twelve areas for action were set out for countries to reflect on in their own strategies and plans to determine what will be delivered over the next five and ten years:
1. Promote mental well being for all
2. Demonstrate the centrality of mental health
3. Tackle stigma and discrimination
4. Promote activities sensitive to vulnerable life stages
5. Prevent mental health problems and suicides
6. Ensure access to good primary care for mental health problems
7. Offer effective care in community based services for people with severe mental health problems
8. Establish partnerships across sectors
9.a sufficient and competent workforce
10. Establish good mental health information
11. Provide fair and adequate funding
12. Evaluate effectiveness and generate new evidence
The milestones set out were within the period from 2005 to 2010. Building on that, the Platform makes the following recommendations:
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3. Recommendations
3.1 Leadership from the EC
Commissioner Kyprianou and his services have acted strongly in publishing a Green Paper on mental health within a year of the Helsinki Declaration, and launching a consultative process. The 2010 milestone coincides with the timeframe for the embracing EU Lisbon strategy and the end of the term of office for the current EU Commission.
So the first recommendation is that the pace of initiative should be maintained. By the Lisbon review and Parliamentary process to scrutinise appointments of new Commissioners (2009-10), the Commission should have brought forward:
"¢ A strategic framework communication to Council and Parliament proposing comprehensive, funded actions to support improvement of mental health and well being in all EU policies and programmes;
"¢ A Commission Coordinating Group for Mental Health Well Being at senior level to address the need for cross directorate and multi agency actions and evaluation, led by the Commissioner and DG for Public Health.
"¢ Support for Council Recommendations to take forward a consensus on a mental health and wellbeing strategy for the EU;
"¢ A minimum of one in a series of formal periodic EC Reports subject to EU inter-institutional scrutiny on the state of mental health and well being in the EU;
"¢ A sustainable advisory EU Platform on mental health and well being, with a careful balance of professional, public and policy maker expertise.
3.2 An EU Vision
That process should be based upon a strong vision of the EU role in partnership with other international bodies, member states and stakeholders.
It would be unfair to call the Green Paper suggestions complacent given its strong premise, but its subsequent description of relatively modest, project based, variable quality and sometimes unevaluated actions is disproportionate to the scale of the problem and the instruments potentially available at EU level. Actions should match words.
If Ministerial declarations mean anything, the political will to act has been established at Helsinki.
The follow up communication to the Green Paper should begin with a clear statement of purpose.
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The Platform recommends that statement comprises:
" The mental health of the European population is a resource for the attainment of some of the EU"™s strategic policy objectives, such as to put Europe back on the path to long term prosperity, to sustain Europe"™s commitment to solidarity and social justice, and to bring tangible practical benefits to the quality of life for European citizens.
The EU will fulfil its role to promote mental health and well-being and protect the health of its citizens as established in the EU Treaty Article 2:
.... to promote throughout the Community a harmonious, balanced and sustainable development of economic activities, a high level of employment and of social protection, equality between men and women, sustainable and non-inflationary growth, a high degree of competitiveness and convergence of economic performance, a high level of protection and improvement of the quality of the environment, the raising of the standard of living and quality of life, and economic and social cohesion and solidarity among Member States
Treaty Article 13:
...may take appropriate action to combat discrimination based on sex, racial or ethnic origin, religion or belief, disability, age or sexual orientation
And Treaty Article 152:
A high level of human health protection shall be ensured in the definition and implementation of all Community policies and activities."
If that is carried out with urgency in real terms, there is no need to provide further rhetorical vision statements, just act on the unanimous text agreed by all EU member state heads of government.
3.3 Competences
The sections in the Green Paper indicating willingness to apply Community policies and financial instruments in pursuit of this clear purpose are welcome and generally appropriate, but far from sufficient and exclusive. The examples given need considerable expansion.
An early purpose of the Platform in 2007 should be to draw up and disseminate, for example via the new EU Health Portal, a matrix of policy competences relevant to achieving the above purpose, and of actions in progress.
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This would (a) help to overcome the widespread lack of awareness of the EU role in this field, and (b) be an important basis for future prioritisation, policymaking and accountability.
This would then be useful to the recommended Coordinating Group, as there was evidence during the consultation process that not all EC directorates give sufficient priority to the impact of mental health within their competences.
3.4 Platform Role
Equally it was clear in the consultative period that insufficient awareness exists among many stakeholders of the potential role and limitations of the EC. The establishment of a sustainable multi stakeholder Platform is a useful suggestion, which is welcomed, and the potential remit set out is largely appropriate.
However, the process used toit has not been sufficiently transparent, which does not bode well for its operations. While effective organisation is crucial and the EC does have the right to establish its advisory bodies, it would be beneficial to build on the goodwill of the Green Paper consultation process to involve stakeholders.
Therefore before the publication of further communications taking forward the strategy, and in synergy with the inter-institutional process to determine the Public Health Action Programme 2007-13, the EC should consult stakeholders
(a) On the operational design of the Platform with a particular focus on accountability and sustainability;
(b) On its remit and scope;
(c) On its work plan and agenda for the short and medium term period.
3.5 Member State commitments
At that stage the issue of how to operate the "dialogue" with member states should be addressed. Clearly the remit of the Platform needs to be linked to providing evidence-based approaches that will address the realities of the Helsinki Declaration "to support its implementation in accordance with each country"™s needs and resources".
But if member states should expect stakeholders to fulfil their responsibilities in that respect, governments should also commit to multi agency engagement and recognise they are unable to address the burden of the mental health problems alone.
One of the lessons of the Helsinki / Green Paper process is that countries acting alone have made variable progress, but the scale and range of the problem generally continues to increase.
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The Platform would like to see EC support for two measures of practical improvement:
(a) One way forward could be support for linked national platforms. National consultations on the Green paper have been reported as variable.
The Platform recommends that the EC works with member states to integrate mental health and well being into developing national stakeholder platforms on public health and care themes.
These bodies can contribute to the future work of the EU Platform in a more broad based way.
(b) The Platform was pleased to invite a representative from sub national (regional) authorities, who often have significant responsibilities of implementation and policy making within all of the roles envisaged for the EU and WHO. It is essential that such bodies are properly represented in the future strategy.
Two steps are necessary: that sub national bodies determine clearly what is the relevant representative body or bodies and channels; and that the EC makes clear provision for their involvement.
3.6 Stakeholder participation
The experience of the consultative phase of the Platform in involvement of stakeholders has been mixed. There are lessons to consider for the advisory phase envisaged in the Green paper.
(a)Non-health sectors
It was not easy to involve non-health organisations, particularly from the employment/economic/social/media policy sectors. It became clear leading actors do not yet regard mental well being as crucial, let alone the EU role.
This can be changed by the establishment of the interactive matrix recommended above to demonstrate policy impacts, and a stronger approach to information and dissemination recommended in consultative meeting events.
The EC should lead on this, by ensuring a meaningful pre-permanent Platform event in Brussels (where the relevant bodies are based) to set out needs and aims and encourage participation.
After that, the quality of outcomes will determine future collaborations. But it is essential that non-health sectors are engaged to help achieve the aims of Article 152 and the Lisbon structural indicators.
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(b)For Profit sectors
The participation of for profit sectors is always controversial to some degree, and the involvement of vested interests of all kinds should be carefully organised in this field where promotion, prevention, rights, information and research actions and funding have major implications.
It is essential that all stages of the EU policymaking process are transparent and that there is clear synergy with the Better Regulation initiative regarding stakeholder consultation. Specifically, the contribution of pharmaceutical associations and other industry sectors caused some concern from some participants at the outset, but has been constructive during this consultation phase, and should be continued.
The role of industry is specifically stated as it brings an important dimension that was not fully explored during the consultative phase. This includes not only prevention and treatments, but also market, consumer, employment and workplace health dimensions of the EU competences.
(c)Patients/Users/Advocacy groups
Efforts were made to involve fair representation from all relevant perspectives. The EU Patient Platform and the EU Social Platform plus Mental Health Europe and the European Public Health Alliance were Platform members, potentially linking to a large number of international and national organisations.
Views have been expressed however, that the practical conditions of the consultation were not conducive for participation by organisations with most limited funds. This meant that some perspectives were not discussed, for example the role of complementary and other therapeutic interventions.
The Platform notes that the EC is limited by its financial regulations and has indicated willingness to provide core funding to certain NGOs in the Proposal for a Public Health Programme 2007-13, and expects that an inclusive approach will be taken in policy making approaches.
It is imperative that the needs and views of former, current and potential patients and users are properly taken into account.
(d)Transparency
If an advisory Platform is established, it should be an absolute requirement for financial interests of all participants to be disclosed, and declarations of interest to be required in advance of discussions on policy and funding. This would not be exclusive but would be transparent, and good models exist.
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This should extend to the professional sector. If the interface approach is to be merged with other stakeholders, it is clear that debates will include sensitive subjects, including research priorities and professional practices. In the consultative phase the contribution of expertise from professionals was generally useful, but not balanced by patient/consumer/citizen/social partner representation. This should be addressed at the outset of the permanent platform.
(e) Commitment
Lessons are emerging from other EC platforms of the value of real commitments to actions by participants, rather than seats around a discussion table.
Although regulatory sanctions are unlikely to apply in the field of mental health, at least in initial developments, it will be beneficial to insist on certain scheduled requirements by all participants to:
(a) Contribute information from their "hinterland" - profession, non-health sector, civil society, patient group, industry etc;
(b) Disseminate information about EU activities to those wider stakeholders;
(c) Implement relevant actions arising from progress at EU levels or within the WHO Action Plan;
and for the EC to publish those commitments and actions collectively, and make continued participation - and fair funding - dependant on fulfilment.
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Therefore the first recommendations have dealt with processes. The remaining recommendations focus on strategy and policy priorities. The outcomes of the three consultation meetings are not duplicated: they are either appended or available on the EC web pages. The following comments arise from separate or subsequent discussions with Platform participants.
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3.7 Scope
The scope of the EU role is potentially wider than prescribed in the Green Paper. Recognising the rights of member states to within Article 152 to organise national health and care systems, and elsewhere in the treaty to organise justice or other regulatory frameworks, does not negate or obviate the obligations of the EC to act in terms of terms of Articles 2, 13 and the public health provisions of Article 152.
Clearly this must be done sensitively. But the frequent call of member state authorities for "consensus", while welcome generally, should not stifle innovation
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and progress, nor should it exclude civil society and other stakeholder agencies. An ineffective consensus helps no-one.
One purpose of the matrix proposed in Recommendation 3 (above) would be to establish which instruments
(a) Exist and are being well applied, so good practice can be spread;
(b) Exist but are not well implemented
(c) Require amendment or updating to be effective
(d) Could be introduced.
To take items cited in the Green Paper as examples:
"¢ The Platform understands that existing Directives on discrimination in the field of employment and in the Community generally are far from fully implemented in certain states. That must be done.
"¢ The new Research Framework FP VII offers clear opportunities, but FPVI needs transparent evaluation and clear public health priorities.
"¢ ICT tools can be extended to improve patient information in many ways. More than that, Treaty Articles on discrimination should be applied to new, traditional and broadcast media to address stigma and exclusion. What action is taken compared to anti racism efforts, when perceived mental disorders are a common form of abuse? Is the proposal for an amended TV Without Frontiers Directive better for mental health? The Platform was not able to examine relevant officials in that Directorate, but they should be engaged. How is the EC helping states and NGOs grappling with potentially harmful websites?
"¢ The need for implementation of mental health and well being objectives within regional, cohesion, structural and social policies and programmes has already been alluded to. This was difficult to achieve in recent national negotiations and should be part of the mid term review by the EC.
"¢ The DAPHNE programme is cited as important because "violence can cause mental health problems". That is too narrow. While the EC competence on justice systems and crime prevention is sensitive, the next strategic stage should include far more significant attention to the realities of discrimination and stigma that many people in Europe suffer in terms of violence and abuse in many settings. Much can be done, but it became clear during the consultation that realistic aims have to be based on EC competences and clearer understanding is needed of these and the role of other human rights agencies including the Council of Europe.
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"¢ To conclude the EU consultation on mental health and well being without seriously addressing the core economic role and competence is puzzling. While the Lisbon process is mentioned, the economic burden of mental ill-health as set out, and the opportunities that improved mental-wellbeing offers to the citizens of the world"™s largest single market, is not given sufficient priority. The benefits of improved public health should be the focus, rather the cost burden of disorders, although it is appreciated that negative images sometimes attract the attention of policymakers.
"¢ The freedom offered by the EU for people to improve their quality of life with reduced barriers gives a clear imperative to examine economic strategies and market operations to ensure that their impact on mental well being is fully factored. The forthcoming alcohol strategy communication (the EC Report on the situation regarding alcohol and health was published too late to be included in the consultation, but clearly indicates major synergies are needed with mental health strategies) is a good example where that will be vital and expected, but in other aspects is that true?
"¢ For example, projects using EC co-funding have established clear lessons for mental well being from former industrial communities needing regeneration, or from rural communities suffering from animal diseases or land use change. Accessible advice is needed not just for business or for institutional patients, but for citizens, families, carers and potential patients crossing borders. Those should be incorporated into key single market and other instruments within the Lisbon framework.
"¢ The other aspect barely mentioned is trade, for example in pharmaceutical products, run on market bases and regulated within a clinical trials, consumer information and medical evaluation framework at EU levels. Developments in those areas are well known, often sensitive and certainly within the mental health remit of the EC and should be included in the scope of future processes.
These few examples are the tip of an iceberg. That is not intended as a threatening statement to subsidiarity.
The Platform Recommendation is simply that a genuinely inclusive strategy is applied within the terms of the Treaty obligations of the EC, as already agreed by governments, at a sensible pace according to institutional capacities.
Therefore there is a vital monitoring and implementation role for DG SANCO and the EC Coordinating Group proposed in Recommendation 3.1(above).
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3.8 Public Health
Turning to the specific health competence, the generally progressive approach of DG SANCO is praiseworthy. From support for Presidency developments, to project co-funding, to stimulation of cooperative bodies such as the Working Party on Mental Health, the EC has sought to "push the envelope" for mental health development within its capacities.
The reality is that supportive and cooperative measures such as that make a valid contribution, but the financial scope pales against the scale of the need in member states. So what can be done?
"¢ Ensure mental health integration in existing approaches
The consultation process has shown renewed backing for the EC role in promotion and prevention, information and research. That is underlined as set out in consultation records and submissions.
Associated processes, notably the Working Group on Health Care Systems and the Open Method of Coordination on Long Term care (in the context of demographic change) should unequivocally integrate mental health and well being indicators, impact assessments, needs and approaches within their work plans and benchmarking.
Those processes, together with other EC forums, such as the NGO and Patients Forum, the EC network of competent national authorities, the Action Programme Committee, the Expert Group on Health Inequalities etc, should integrate work carefully with any newly established Mental Health Platform.
"¢ Establish clear definitions and concepts
One useful priority should be to ensure better understanding. Although the EC has already worked on glossaries, it is recommended that more is done in that respect. It is clear that counting hospital beds is irrelevant if they have mixed purposes; it was also clear that there were different psychosocial uses of "inclusion" and "stigma" to those understood in public health or non-health circumstances. Whether that is more the role of WHO than the EC is for discussion within the welcome partnership that has underpinned the consultation process.
"¢ Co-morbidity and integration.
It is understandable that mental health advocates should do just that: advocate forcefully for greater attention to mental health. The case is compelling and there is justification for the argument that the sector has received modest attention compared to smoking prevention, communicable diseases and obesity. Mental Report Recommendations of
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health advocates are well aware that the complexity of the situation and solutions contribute to uncertainties about appropriate actions.
But it is important that the consultation process has not suggested separate strands of EC work. That vertical approach was changed after the evaluation, consultation and review that brought the current public health action programme, and was confirmed in the 2004-6 revision process leading to the current proposals for a new programme 2007-13.
Those proposals, still to be determined by co-decision, are likely to continue horizontal strands with relevant cross cutting themes on gender, equity and age. That is appropriate for the complex approaches needed for mental health, provided the work on determinants is strengthened as far as capacities allow.
Evidence of co morbidities is persuasive, and it is important not only for other branches of public health, health promotion and disease prevention to cooperate closely with mental health specialists, but vice versa. It is not helpful for comparisons to be made with proportions of funding available for cancer research; it is relevant to draw attention to the small proportion of medical research funds devoted to public health and the research - policy - practice cycle. Mental and physical health must be seen at EU levels as two sides of the same coin.
While the EC can stimulate, the real competence to implement the Helsinki Declaration Action Plan components and to take on its challenges lies in multi-agency actions within member states. The priorities that ministers have agreed there should closely match Council Recommendations that should be brought forward, decisions of the member state bodies mentioned earlier and in EC actions in international contexts, such as WTO and G8 negotiations. And that being the case, the EU priorities are clear and should achieve consensus.
3.9 Civil and human rights
The part of the consultation that demonstrated how wide some gaps remain concerned rights, inclusion, stigma and discrimination. Again the consultative meeting records contain some useful pointers, but there is also scepticism about how much can be achieved realistically within the EU context, which is more limited than some participants initially realised.
The EU Charter of Fundamental Rights contains certain helpful clauses, especially if incorporated within whatever emerges from the stalled Constitutional Treaty ratifications. But the Green Paper"™s hopes for the anticipated Fundamental Rights Agency are not shared by many informed organisations working in the field.
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Neither does the "change of paradigm" rightly sought, particularly through the balanced care model of mental health services, elicit much optimism among participants with experience of realities.
It could be argued that the EU economic requirements are potentially helpful to the process of deinstitutionalisation given health system capacities in some states that seek to meet Euro zone criteria by the Lisbon review.
But given the needs of balanced care models, that could result in greater problems for community health systems. There is certainly a need for work on cost effectiveness and evidence to be stepped up to support policy-making decisions in those contexts. A firmer impetus is needed to back good intentions.
Too much change in health system provision in the EU has been wrought from states via the courts. The Working Group on Health Care Systems and OMC process could encourage a more structured development.
But this is an area where the EC Coordinating Group could play a significant role in stimulating Directorates - and member states - who were less than fully engaged in the Green Paper consultation process to realise the ethical, social and economic benefits of actions set out in the Helsinki Action Plan and to play their part in addressing the challenges.
The first opportunity for a rational debate lead by a proposal from the EC will come in the anticipated Health and Care Services Directive. Naturally, mental health and well being considerations are expected to be a major component of that proposal and will be a first test of whether the EC and member states will jointly take forward the Helsinki Action Plan. This must be a Platform agenda item.
Training, awareness raising and quality standards for professionals should be an important component of that Directive. But that should not only apply to health professionals.
It is strongly recommended that the whole EC engages with member states (via OMC and other processes) to improve comprehensive training and awareness of mental health and well being issues, rights and values in care, education, justice, social protection, employment and other relevant public, voluntary and private service sectors.
That is one of the most important aspects insufficiently addressed in the Green Paper, and should be a priority item for more specific recommendations by the advisory Platform.
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3.10 Targets
The final group of recommendations concerns the most important part of the jigsaw: people.
"¢ Carers
It became clear during the consultation that the role of carers has been seriously underestimated in economic, social and moral terms in the Green Paper, and should be re-stated with greater emphasis. Given the scale of the burden, it is clear that the fabric of many communities depends on fragile social capital, hard pressed networks or individual stoicism in the face of vast obstacles.
That contradicts Article 2 provisions, and needs to be addressed by serious multi agency attention to social protection measures, workplace and community measures to combat exclusion, and the role of the "third sector" - however described - NGOs, civil society, mutualités, cooperatives, voluntary agencies.
"¢ Groups
Descriptions of priority groups proved problematical. The Green Paper refers to "groups at risk", "migrants and other marginalised groups" and "vulnerable groups". While that is understandable in the context of the description of some important projects working in key settings, a strategic approach is needed that avoids stigmas, and not one that falls into the "target trap", familiar to politicians, of including everybody except white middle aged men as target groups.
Clearly age, gender and equity are crucial as in public health generally. Clearly the actions of a multi national body must focus on people migrating across borders or from ethnic minorities, which is strongly emphasised as a need. The question the strategy must address is how best to do that, and for the sake of clarity the encompassing term recommended by the consultative Platform is to focus on "vulnerable individuals in communities and settings".
"¢ Patients and Users
Section 6(c) above indicates specific needs to ensure inclusivity of users and patients, and that certain perspectives may not have been fully addressed during consultation. The publication "The Red Paper"™"™ has been submitted subsequently and separately by organisations representing users. It contains recommendations that go beyond the Platform remit and therefore cannot be contained in this report.
It is, however, recommended that these are taken fully into account by all stakeholders and institutions, that every effort is made to ensure all authentic views are properly included, and that the valid needs and aims of all EU citizens contribute to equitable strategic formulation for mental health and well being.
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4. Conclusions
The above (3.1 to 3.10) ten concise groups of recommendations cover process and priorities needed to enter into the next phase of EU/EC engagement in response to the WHO Europe Ministerial Declaration and Action Plan of January 2005. They should be read in conjunction with records of the three official consultation meetings organised by the EC from January to May 2006, which contain detailed recommendations on specific approaches.
That period coincides with the attempted ratifications and subsequent reflection process for the proposed EU Constitutional Treaty, which offers some potential improvements for health systems and determinants approaches but some disappointments for social cohesion. Taken with the mid term review of the Lisbon process and in the context of successive enlargements, this is a time of fundamental introspection and revision for the EU.
Page One, Point One of the Green Paper Introduction states exactly what is needed: The mental health of the European population is a resource for the attainment of some of the EU"™s strategic policy objectives, such as to put Europe back on the path to long term prosperity, to sustain Europe"™s commitment to solidarity and social justice, and to bring tangible practical benefits to the quality of life for European citizens."
The consultative platform agrees.
But also member states have recently determined to reduce important relevant EU budgets in financial perspectives 2007 -2013, including public health and research, which could have practically supported such worthy aims.
Therefore the EU institutions, and others to whom this is addressed, are recommended and urged to apply the instruments available to them, so that within an achievable schedule, if they are truly representative of the citizens of Europe, more of them benefit from mental health and well being, and the fine words of the EU Treaties, the EU Green Paper on Mental Health, and the WHO Ministerial Declaration on Mental Health are translated into meaningful action.
If that is done, it will be an important contribution to achieving those core EU objectives currently exercising heads of state and government.
There is no health without mental health; there is no European Union without health.
Clive Needle
Chair
EU Consultative Platform on Mental Health
May 2006.
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Appendix 1: Participants
The Chair and organisers are grateful to the following participants, and all others who contributed to the Platform consultation process:
􀂾 ADHD Europe
􀂾 AGE Europe
􀂾 CPME - Comité Permanent des Medicins Européens
􀂾 CSR Europe
􀂾 Development Centre for Mental Health
􀂾 EFPIA - European Federation of Pharmaceutical Industries Associations
􀂾 EUREGHA - EU Regions for Health Association
􀂾 EU HOPE
􀂾 Eurocare - European Alcohol Policy Alliance
􀂾 EuroHealthNet
􀂾 European Brain Council
􀂾 European Disability Forum
􀂾 European Federation of Associations of Families of People with Mental Illness
􀂾 European Health Management Association
􀂾 European Network of Education Councils
􀂾 European Network of Users Survivors of Psychiatry
􀂾 European Network of Workplace Health Promotion
􀂾 European Public Health Alliance
􀂾 European Public Service Association
􀂾 European School Student Unions
􀂾 European Youth Forum
􀂾 FEANTSA
􀂾 GAMIAN-Europe
􀂾 International Organisation for Migration
􀂾 International Lesbian and Gay Association
􀂾 IUHPE
􀂾 Mental Health Europe - Santé Mental Europe
􀂾 Mentality
􀂾 Mental Disability Advocacy Centre
􀂾 Open Society Institute
􀂾 Platform of European Social NGOs
􀂾 Platform of EU Patients Organisations
NB: all above participants reserve the right to submit opinions to
the Green Paper and other EC consultations separately from
this collective Report Recommendations.
The Platform thanks the services of the European Commission and WHO Europe for information, encouragement and organisational support.
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Appendix 2: Reports of joint consultative meetings
First Thematic Meeting
Luxembourg 16 -17 January 2006
1. General Statements
The Platform has emphasized the importance of appropriate terminology when addressing mental health. First, the reference should be made in a positive way that is promoting good/positive mental health. As the concepts differ between the European languages, it would be helpful to have standardized reference of terminology in the official EU languages.
Mental health should also be seen as reflected on the spectrum, as it is not a bi-polar variable: healthy vs. ill.
2. Other policy areas for which mental health is relevant
Promotion of positive mental health and prevention of disorder can benefit actions of stakeholders from other policy areas.
"¢ Migration
Unfavourable living and working conditions, can negatively impact mental wellbeing of the migrant population. On the other hand, increased labour migration can undermine the job security of some members of the host society and have negative impact on their health. Lastly, the migrants from other cultural backgrounds have different understanding of mental health. The medical and care sectors should take account of that.
"¢ Employment
Europe has been experiencing changes in form of employment, resulting in increased pressure on individual and volatility of employment. Positive mental health promotion could contribute to diminishing of stress at the workplace.
"¢ Productivity and Employability
Investment in positive mental health in children and adolescents, will impact the development of their self-esteem and coping skills. In the labour market of present times persons equipped with those skills are more likely to succeed (or be more employable) and add to the productivity growth.
"¢ Social Cohesion
Positive mental health, leading to greater social participation - in the social networks and the labour market would positively contribute to increased social cohesion - one of the Union"™s strategic objectives.
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In order to successfully take action in relation to promotion of mental health in other policy areas at the European level, appropriate legal basis should be referred to; for example, Art.13 for anti-discrimination policies.
3. Delivering in the settings
As mental health is relevant to the work of other sectors, the concept of positive mental health should be addressed in other settings such as education, services for the migrants, family therapists or police. The issues should be presented in the language specific and understood by the given sector/setting.
In that way, the use of term "Vulnerable groups", which by many was received as a form of negative labelling, could be avoided.
4. Actions at the EC-Level
"¢ Intersectoral task force - different commission services to be involved, especially Social, education and JAI to use their mandate to promote and further mental health agenda
"¢ European Strategy on mental health is strongly encouraged.
5. Further Actions
"¢ Networks and Stakeholder Platforms
Inclusion of relevant networks (EU-level, but also WHO-related) working on the issue of mental health to disseminate and mainstream evidence-based practices.
"¢ Further research
Future research on the subject of mental health should in a uniform fashion collect data from EU-28, thus including New Member States and Candidate Countries.
Rapporteur: Kasia Jurczak
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EU Platform Informal Consultation Meeting
8th March 2006, Brussels
Chair: Clive Needle.
The format was round table, the purpose to allow EU organisations not part of the core Platform to contribute to the consultation on key issues.
I: Issues in Social Inclusion and Human Rights
"¢ Programmes raising the level of awareness of Mental Health disorders in school environments and employment settings would be important in reducing stigma related to mental health problem. Therefore teachers and employers need to be trained on how to recognise the disorder and how to fight with stigma.
"¢ Stigma originates from as early on as the act of labelling and treating a mental disorder (e.g. asking provoking questions, such as, is this a fabricated condition?).
"¢ We could use celebrities as role-models in campaigns raising awareness of mental illness and tackling stigma (e.g. as with a successful initiative by a New Zealand rugby player).
"¢ The good-quality training of a broad range of health care professionals, especially GPs and nurses who are often the first point of contact for those with mental ill-health. In reality, some people with mental health problems are not diagnosed nor receive any appropriate treatment. Lack of proper diagnosis or access to treatment raises inequality issues.
"¢ Many health promotion agencies have an impact on mental health policies but are not necessarily experts in the matter. It is important to make them aware that contributions towards improving of mental health can be done through other areas of activities, such as diet, physical activities or alcohol consumption.
"¢ Exchange of good practice in the field of mental health promotion and prevention is very difficult due to different social and cultural norms. We should call for the EU to facilitate that process.
"¢ Young people are a particularly vulnerable group prone to acquiring mental health problems. Problems include: peer pressure, bullying and identity formation (including sexual orientation and gender identity).
"¢ The consequence of mental health problems for employment opportunities is tremendous. Issues include stigma and reintegration with colleagues and provision of adequate working conditions. While there are provisions for workers with physical disabilities, those with mental health problems have difficulties getting special treatment. Employment support is also needed as well as support in employment (e.g. modified work schedules - prescribed by whom? Psychiatrists?) The Employment Equality directive does not apply to job-seekers and is also not powerful enough to prevent the mentally-ill being
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dismissed at work (the burden is still too much on the individual). In case employment is not possible due to severity of the condition, support in the form of unemployment or disability benefits should be adequate and easy to administer.
"¢ Mental health problems in groups difficult to reach, such as homeless or migrants are also important. Provision of treatment and/or adequate housing is essential here.
"¢ The issue of de-institutionalisation should be reinforced in the Green Paper. The European Commission should use the opportunity of accession negotiations with Bulgaria and Romania for enforcing termination of unlawful and unnecessary institutionalisations and degrading conditions of treatment (cot beds, chains, malnutrition).
"¢ Consequently emphasis on personalised community care should be promoted. Although at the outset this option can be more costly, in the long term care in the community becomes more cost effective. Staff previously employed in the institutions could possibly be re-trained and employed in the personal community services.
"¢ In a debate about how to enact a human rights-based approach it was suggested that it might be helpful to differentiate between basic and secondary rights.
II. Potential, specific EU roles and mandates:
"¢ The EU has the potential for supporting health screening programmes (or for making recommendations), for example, impacting on integrating general health screening into psychiatric clinics - the mentally ill are more at risk of developing and neglecting their general health problems - as well as integrating mental health care into general health care.
"¢ Importantly, to generate data exchange (as well as research), such as on best practices.
"¢ Ensuring enforcement of Article 13 of TEU regarding discrimination
"¢ The Employment Equality directive (coming into action now) contains guidelines on reasonably accommodating the disabled. It appears not to work so well in practice (it is not well-enforced) but legal proceedings ought to be possible against Member States.
"¢ A possible idea for supporting EU-level harmonisation for positive discrimination could be favours and incentives for employers. The Employment, Social Affairs and Equal Opportunities directorate needs to co-ordinate the many disparate elements of supported employment and pre-employment needs and incentives.
"¢ The EU Criminal Justice system could co-ordinate research on practices in the Member States.
"¢ With the view of respecting human rights of people with mental health problems, the EU Fundamental Rights Agency gives hope. It should be Report Recommendations of
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established by 1 January 2007, but its role will be limited. The problem is that Member States are only accountable when they have to apply EU law.
"¢ The European Charter of Patients"™ Rights feeds into the EU Charter. (The European Patients"™ Forum was invited but was not present at today"™s meeting).
III. Important specific lacunae in the Green Paper:
"¢ In Annex 7 of the green paper "˜Employers"™ and "˜Youth Networks"™ should be
included under the heading "Protective factors" - in other words, these should become protective factors - whilst "˜Youth"™ should also be included under the heading "Risk factors".
"¢ Annex 2 of the green paper omits some mental (neurological and neuro-psychiatric) disorders and disabilities, including ADHD (Attention Deficit Hyper-activity Disorder). The option is either to not specify any names of disorders or otherwise (and preferably), to produce a full list of all mental disorders.
"¢ The green paper needs to mention risk of acquiring mental health problems that is linked to important life-stages and age. Therefore the green paper should also include the elderly.
"¢ The use of structural funds for the needs of mental health care could be mentioned.
"¢ The widely understood and widely experienced category of stress should be included (which is also not mentioned in Annex 2).
"¢ There is a potential case for the Helsinki Declaration to be re-annexed to the green paper or otherwise more explicitly paraphrased within it.
"¢ There is a lack of focus around treatment and recovery.
Reported by: Anna Wood, Kasia Jurczak
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Second Thematic Meeting
Vienna, 16-17 March 2006
General consideration
The group sessions in this Second Thematic Meeting were held jointly by the European Platform for Mental Health and the Research/Policy interface subgroup. The groups were asked to address two major issues: social exclusion and human rights of individuals with mental ill health. For each topic, they were asked to describe the situation at the EC and MS level, to identify future actions to improve the situation, and to identify the specific ways the EU can undertake or support these actions. This report provides a separate summary for each topic.
Group session 1:
Social Exclusion of people with disabilities at the EC and Member States levels
1. The situation of social exclusion in Europe
Social exclusion is not a marginal problem, but affecting millions. It is related to the success in combating poverty and also taboos around mental illness. Social inclusion is among the basic needs of all human beings and includes having some power and social recognition, participation. Participation requires being able to do it, but also invitation by others, peers support. The need for social inclusion is not unique to mentally-ill. But mental ill health leads to stigma exclusion. Actually, social exclusion is a major public health risk.
A summary of the situation could be characterised by the following traits:
􀂃 Social exclusion in Europe is no trivial, it affects millions (the Green Paper should describe this more thoroughly).
􀂃 Part of the human nature is to participate in society (power). Exclusion is against nature.
􀂃 Need for social inclusion is not unique to mentally-ill.
􀂃 But mental ill health leads to stigma exclusion.
􀂃 A circular process is in place: marginalisation, stigmatisation, and mental ill health.
􀂃 Social exclusion is a major public health risk.
2. Which further actions can promote social inclusion?
Positive mental health should be promoted from the very beginning of the life cycle. Social inclusion would help improving mental health. The aims are to
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reinforce these three levels: re-inclusion, non exclusion, and empowerment.. This support is necessary in schools, workplaces and the community. And there is need to go beyond words ("walk the talk").
We need to make sure that the anti-disability discrimination legislation covers the mentally-ill. Current legislation may exacerbate stigma and discrimination (e.g., preventing people from voting). These potential problems should be reviewed and modification proposed. The Green Paper should highlight the move from long-term institutionalisation towards community-based services, as part of a vision: having mentally-ill included, not excluded.
A more specific list of considerations is as follows:
􀂃 Participation includes invitation (peers, society).
􀂃 It requires resources, including economic.
􀂃 Need to promote re-inclusion, non-exclusion and empowerment.
􀂃 Need to promote education of individuals with disabilities at all governance levels.
􀂃 Need to educate professionals (health and other areas) to deal with diversity.
􀂃 Promoting mental health from the very beginning of the life cycle would help.
􀂃 Users should get organised.
􀂃 NGOs need to have a clear role in inclusion promotion.
􀂃 NGOs should be financially supported.
􀂃 Trade Unions should be involved.
􀂃 Major general initiatives (e.g., for vulnerable populations) should include the mentally-ill (mental ill health).
􀂃 The critical role of schools, workplaces the community should be stressed.
􀂃 Need for re-labelling of mental ill health.
􀂃 Rehabilitation vs. cure orientation of care.
􀂃 Approaches should be intersectoral.
3. How can the EU undertake or give support to these actions?
The EU needs to monitor the transcription of principles to policies in the MS. A specific need is to monitor that the mentally ill to not be left out. Structural funds should be used to non-discrimination such as, making the life of institutions better. Given the important variations across countries in relevant issues related to institutionalisation. There is need to have more information about these differences. Needs may be different by country, due to different stages in the economic/social development level. Differences in legal systems may imply differential barriers to social inclusion. There is need to share information among all the countries about all these issues.
Major EU contributions identified include:
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􀂃 Devoting structural funds to adequate development of community-oriented problems in certain countries.
􀂃 Facilitating interchange of experiences, best practices.
􀂃 Promoting legal harmonisation.
􀂃 Harmonising concepts: definition of all types of concepts (from discrimination to services).
􀂃 Providing a vision (e.g., a better Green Paper).
􀂃 Coordinating the different initiatives (e.g., Council of Europe).
􀂃 Monitoring the transcription of EU directives into MS policies.
􀂃 Developing educational programs.
􀂃 Evaluating the impact of action against exclusion (as well as that of inaction).
4. Additional comments on existing gaps in the Green Paper:
Some additional comments to the current version of the Green Paper include limitations and suggestions for a revised version:
􀂃 It is weak on social exclusion. The GP should describe better its tangible and intangible costs.
􀂃 It should elaborate more in social inclusion.
􀂃 The role of NGOs is not sufficiently addressed, nor their participation in the consultation process.
􀂃 The Green Paper should highlight the move from long-term institutionalisation to community-based services, as part of a vision: inclusion of the mentally ill.
􀂃 It should stress the importance of: school, education at all levels, and evaluation of interventions.
Group session 2:
Human rights of people with disabilities at the EC and Member States levels
1. The situation of social exclusion in Europe
􀂃 Human rights cannot be separated from other issues.
􀂃 A balance is needed:
􀂃 Some rights conflict one each other
􀂃 Human right to health, to health services, and also to health determinants.
􀂃 Care should come with values: respect, professionalism, and responsibility.
􀂃 Special rights issues: children and mentally-ill parents.
2. Further actions to promote human rights Report Recommendations of
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􀂃 Green Paper, WHO declaration: even if imperfect, they represent a starting point.
􀂃 Open method coordination: know it and use it.
􀂃 Regions local authorities should promote human rights legislation and develop indicators to monitor adherence.
􀂃 Discussion at national level is very important, and NGOs should participate.
􀂃 Need to identify who should implement (beyond legislation).
􀂃 Need to identify the barriers to human rights.
3. How can the EU undertake or give support to these actions?
􀂃 Providing vision, leadership and political role, even if there is no mandate.
􀂃 Monitoring the treaties that all MS have signed and participating in all human rights initiatives.
􀂃 Producing specific, comparable information beyond the number of beds.
􀂃 Repository of existing legislation.
􀂃 Guiding on standards and basic rights.
􀂃 Monitoring reports of countries.
􀂃 The Agency for Fundamental Human Rights is crucial:
􀂃 Collect independent information about performance
􀂃 Liaise with policy makers.
􀂃 Emergence of the Platform on Mental Health.
􀂃 Intersectoral approaches, starting at the EU Commission level: different DGs.
􀂃 DG Enlargement, Employment. Role of Media in TV Directives, Structural funds.
4. Additional comments on human rights issues:
􀂃 Importance of the internal market forces framework.
􀂃 Issues to gather information about:
􀂃 School drop-outs
􀂃 Nurse schooling, kindergartens.
􀂃 Develop legislation at the Regional and Local levels and indicators of outcome should be monitored.
􀂃 Add an appendix to the Green Paper concerning definitions of community based services, suing an existing conceptual framework.
Rapporteur: Jordi Alonso
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Third Thematic Meeting
Luxembourg, 18-19 May 2006
Introduction:
This second session, the group addressed research and knowledge needs that could be taken forward at European level. As this was the final group session of the three consultation meetings, the EU Platform was then asked to reflect on all three meeting to identify key priorities and allow for any suggestions on issues that might not have been covered during the three meetings.
Research and knowledge needs
Mental well-being is of paramount importance to the Lisbon Agenda. Thus, research into mental health and well-being, mental health determinants, and mental health services is an investment in the realisation of Europe"™s economic and social ambitions.
The new 7th Community Framework for Research and Development is an obvious mechanism to support this research, but it should by no means be the only one. Other Community programmes, such as the one on Public Health, could also help to improve the knowledge base and stimulate research. Similarly, existing collaborative processes such as the open method of coordination on social inclusion, and on health care and long-term care, could support research efforts through as they involve work on indicators and the exchange of expertise.
An integrated EU mental health Strategy could co-ordinate research efforts across and within the Commission"™s services to ensure best use of resources, could foster links between research, policy and practice, and could support mechanisms to reinforce these links. It could also help to identify gaps is knowledge and target future research priorities accordingly. Such a strategy could support cross-national learning and knowledge transfer. For that to happen, mechanisms for the transfer of knowledge across countries and regions as such should become the object of more research, as should the organisation and structure of (sub)national mental health systems.
An integrated EU mental health Strategy could also stimulate research across EU policy areas. That way we can also learn more about the interrelationship between mental health and its determinants, about the mental health impact of broader policy interventions, and about the important contribution of mental health to the attainment of EU social and economic objectives.
It could also help to ensure the results of research into mental health and mental health services are fed into objectives of the wider EU agenda. For instance, evidence on mental health interventions and community-based services could help target EU structural funds in support of health infrastructure en social cohesion across Europe.
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While there are many gaps in our current knowledge, there is a pressing need for more research into determinants of positive mental health, and ways to develop and sustain mental health during the course of life. Also, the shift away from hospital-based services has not run parallel to an increased focus on the effectiveness of prevention and care at community level, or on factors that can positively influence these services. Consequently, there is a major knowledge gap here. In a more general sense, more research into the reach and (cost) effectiveness of -specific and mainstream- services for people with mental health needs is necessary. The same holds true for research into access and responsiveness of services.
The perspective of mental health service users is another pressing research issue. Client-centeredness, patient needs, voice, user focus, and feedback panels are familiar topics of research -and action- in the acute health care sector. We should learn more about the views and needs of people with mental health problems, and about opportunities to increase their influence and deliver services accordingly. We also need to explore possible differences in the needs of the various communities as to accommodate for the increasing diversity within our societies.
Whereas the importance of specific mental health research is clear, there was also very strong plea for mainstreaming mental health research into broader research agendas on health policy, promotion, services and systems.
Looking back at the three consultative meetings
The EU mental health agenda is huge. The group agreed that priority setting is an inevitable and daunting challenge. While there is much to be said to develop a structured format for priority setting, this could also lead to compartmentalisation of topics that need to be addressed, loosing sight of t