From community mental health services to specialized psychiatry: the effects of a change in policy on patient accessibility and care utilization.

In 1975, a community mental health (CMH) centre with most of its resources channelled to outpatient services was set up in a defined catchment area of 75,000 inhabitants near Stockholm. In 1981, the CMH centre was allocated 3 inpatient wards of its own. An outpatient unit to treat long-term psychotic patients was also built up from existing resources. Emergency cases were directed to the primary health care services or to the emergency department of a hospital. During the same period, the number of doctors in the area's primary health care services increased fourfold. The social, demographic and diagnostic composition of the patient population and its utilization of in- and outpatient care in connection with these organizational changes are described. The population of the cathment area increased by 12.5% and the patient population decreased by 40%. The decrease was particularly great among first-time visitors (-54%), patients from lower social groups (-53%) and those with crisis diagnosis (-71%). The number of patients with psychoses increased (+26%). Outpatient visits and hospital utilization increased by one third. The number of compulsory admissions increased by 20% (still being far below the mean number in Stockholm). The decrease in the patient population is attributed to the reduction in accessibility to the CMH centre at a time when primary care services in the area were undergoing a sizeable expansion. The increased care utilization is the result of an internal redistribution of resources in favour of resource-demanding, long-term psychotic patients.