What can NHS Mental Health Trusts learn from Geel in Belgium?
Welcome to Geel. Buried in depths of the Belgian countryside, it is one of the oldest models of community based mental health care. In a resource scarce NHS– our consultant Mikoto asks what we can learn from Geel.
In our roundtable earlier this year: “What can Mental Health and Acute Trusts learn from each other?”, we started a discussion on whether our current design for mental health services were designed to truly meet every patient’s individual needs.
A key topic from the discussion was the inherent complexity of people’s needs. In our current medical model of care, best practice standards for treatments are often established by single diagnosis. However, more than half of those with a mental health disorder meet the criteria for one or more additional diagnoses. This leaves a difficult question for clinicians to determine what is truly best for the individual at hand.
At a system-level, there are challenges with a subset of patients who struggle to respond to treatments that specialist services offer. A common characteristic for this group is individuals who are diagnosed with a personality disorder or schizophrenia and struggle with co-occurring emotional challenges. Often these individuals with complex presentations are also more likely to return to the same pathways repeatedly. Although these users are often dispassionately categorised by a ‘treatment-resistant’ label, it may be reflecting an uncomfortable reality where their pathways are not set out to provide long-term care.
The conversation from the roundtable demonstrated an appetite for inspiration from innovative approaches to support people towards meaningful and sustainable recovery. This got us thinking: what are some alternative models of care we could draw from?
Geel - an alternative approach to Mental Health Care
Stepping outside of UK landscape, we find a small town called Geel in the Belgian countryside. At a glance, it's difficult not to notice its unique design that stretches 700 years back in its historical roots.
Geel started as a temporary or long-term sanctuary for those ill-fitted in society, with inhabitants in the town offering accommodation to anyone during their stays as standard practice. In the 21st century, the practice has developed into a progressive example of integrated community-based care for those with mental health conditions. The practice centres around a long-term fostering system where individuals with psychiatric problems are matched with a foster family with the help of clinicians. They proceed to live among a social network with delegated responsibilities for day-to-day life.
There are three key principles ingrained in Geel’s community-based care:
- Recovery at your own pace
Firstly, there are no set timeframes in which individuals are expected to improve their conditions up to a standard that is pre-determined by the system. In Geel, the patients define what recovery means to them; the focus is simply to ‘be’. As subjective as this may sound, this principle has manifested in an astonishing outcome where the average length of stay in one family is currently 30 years.
- A non-medicalised view of patient needs
The term ‘mentally-ill’, or language that reflects clinical diagnoses are rarely used in their society. The distinction between families and borders are made in social terms and not a medical one. This approach allows the whole community to acknowledge idiosyncratic needs for everyone without assumptions built from psychiatric labels.
- True integration into the community
A key part of this model is how meaningful work and social opportunities are integrated into their system. Local schools, arts centres, sports centres, and the central institution owning this programme provide a wide range of options for individuals to participate. Social scientists state that high levels of exposure to normal behaviour would have a strong impact on the individual’s expectations for themselves, as well as the wider society in building a shared belief in their ability to organise themselves into a productive community.
How could these principles apply to mental health care in the UK today?
The Geel model is radical, but the principles underpinning it are increasingly accepted across the mental health sector. Below, we start exploring what applying them to the UK system could look like in practice.
- Recovery at own pace: Measuring outcomes based on individual goals
In a nationally-run healthcare system where resources are naturally scarce, it feels unrealistic to strive towards a system where everyone gets to determine their own length of stay in a service. However, there are feasible ways to shift the ownership of recovery towards the patients themselves, e.g. through goal-based outcomes. With this approach, progress during the time spent in a service is evaluated based on the goal set at the beginning of an intervention. Such thresholds and trajectories would vary significantly across each individual, requiring a high degree of shared decision making with patients to understand what they could aim to gain at the minimum from each admission. By attuning to each individual’s priorities and objectives in life, there is more space created for culturally sensitive treatments to take place as well.
- A non-medicalized view of patient needs: Maximising multidisciplinary team efforts to make discharge-related decisions
Traditionally, decisions for when an individual is ready to leave a service have been made primarily from a clinical, psychiatric perspective. There are some efforts being made to shift away from a decision-making processes that are led by consultants. For example, the commonly used term “medically fit for discharge” has been converted to “fit for discharge” at one service in Camden and Islington. This subtle change in language calls for a more collaborative, multidisciplinary approach to the decision-making process. By mixing professional inputs from a wide variety of perspectives beyond a medical one, patients and their needs can be seen from a much more holistic angle.
- True integration into the community: Social prescribing models of care
This model of care is designed to connect individuals with a diverse range of services in the community addressing social, emotional or practical needs. Through a professional advocate, commonly known as link workers, individuals can be referred into these services from GPs, hospitals, pharmacies, social care services and much more. The aim is to match individuals with a personalised set of support structures beyond a clinical setting. It is a promising model which also embodies the principles of holistic needs and long-term, patient-led recovery discussed above.
What we can learn from Geel is an alternative model of community-based recovery, contrary to our medical model where drastic levels of individual change is expected from a linear journey through our healthcare system. In our systematic move towards preventative and personalised care, we are presented with an opportunity to shed light on these practices that are paving the way towards a more humanised perspective to mental health provision.
Author: Mikoto Nakajima
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