FFaced with the serious and lasting crisis in psychiatry, the reform of ambulatory care is a priority. They should, in fact, be much more developed than they are today. Care in the city only has advantages for people affected by psychological disorders, such as avoiding family and social disintegration as well as the use of coercion, limiting stigma and making care more acceptable and therefore more accepted.
This recommendation is that of all successive reports on mental health but, apart from some marginal progress here and there, the objective is far from being achieved. Many hospitalization beds have been eliminated, but ambulatory care has not been sufficiently developed to replace them, with the consequence of saturation of remaining services, unacceptable waiting times in emergency rooms and a distressing number of interruptions in care.
Cut-off funding
The main obstacle to the advent of a new model of care seems to be the hospital attachment of outpatient psychiatric teams. This connection contributes to the preeminence of a hospital culture in the design of care, distant from the lives of patients and that of other medical and social actors. In addition, funding still tends to value hospitalization activities significantly more than outpatient care.
This is evident when it comes to community interventions unknown to other specialties: home visits, social and professional rehabilitation, therapeutic outings, group therapies, interprofessional consultations, etc. Thus, the positions allocated and staff time are taken up by the care of hospitalized patients, to the detriment of psychiatry outside the walls.
Furthermore, no protection of psychiatric budgets is possible in the current system: in multi-purpose establishments, it is common to see this funding taken to support other needs of the hospital.
Another vision of mental health is necessary, we must take psychiatry out of the hospital. We therefore propose to radically change the organizational model. The heart of the psychiatric care system must be placed outside the hospital, as close as possible to patients.
This development could take place in two stages.
Ambulatory and inclusive care
The first would aim to bring together, within a coordination body, all the actors involved in the care pathway of a territory: psychiatric and child psychiatry services and establishments (sectorized and non-sectorized, public and private), city professionals, associations representing users and caregivers, medico-social institutions and organizations, municipal social action centers, etc.
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