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2014年7月14日 (月)

精神医療改革 社会的入院の解消を図りたい

The Yomiuri Shimbun
Mental health care reform urgently needed for ‘deinstitutionalization’
精神医療改革 社会的入院の解消を図りたい

It is a matter of urgency to transform the nation’s mental health care system to shift away from the current hospital-centered treatment to making arrangements for encouraging care at the homes of the mentally ill.
 入院中心の治療から、在宅療養を支える体制へと、精神医療を転換させることが急務である。

A report recently produced by the Organization for Economic Cooperation and Development has pointed out that the number of psychiatric care beds in hospitals in Japan is four times the average of OECD member countries. While treatment of the mentally ill at their homes has been increasingly spreading in industrially advanced countries, Japan trails other nations in “deinstitutionalization,” the shifting of care away from hospitals and toward patients’ homes or in the community, the report noted.
 経済協力開発機構(OECD)が、日本の精神病床数は、人口当たりで加盟国平均の4倍に上っているとする報告書をまとめた。先進諸国で在宅療養が広まる中、「脱施設化」が遅れていると指摘している。

About 320,000 of the nation’s 340,000 psychiatric beds at hospitals are occupied by patients, 200,000 of whom are long-stay patients having been hospitalized for one year or longer, according to the report. Psychiatric patients in this country are hospitalized for about 300 days on average, far longer than the approximately two weeks in other developed countries, it said.
 国内では、34万の精神病床に32万人が入院し、このうち20万人が1年以上の長期入院だ。入院期間は平均約300日で、2週間前後の先進諸国との差が大きい。

Many patients stay for a long period at hospitals even though the need for their hospitalization is low, only because they have nowhere to go after being discharged. In many cases, people with mental illnesses suffer further declines in their living competence due to long-term hospitalization, finding it all the more difficult to get out of the hospital. It is imperative to resolve the problem of such patients in long-stay beds, a situation often referred to as “social hospitalization,” or socially unavoidable hospital admissions.
 入院の必要性が低いのに、退院後の行き場がないため、病院にとどまる患者が少なくない。長い入院で生活能力が低下し、退院が困難になる例も多い。こうした社会的入院を解消する必要がある。

In Japan after the end of World War II, the government adopted a psychiatric medical treatment policy of largely separating the mentally ill from society, encouraging establishment of private-sector psychiatric hospitals through the introduction of a subsidy system. Special steps have also been taken to relax staffing requirements to allow a relatively small number of medical doctors to take care of many psychiatric inpatients. The increases in the number of social hospitalizations were partly due to these steps.
 日本では戦後、隔離収容型の精神医療政策の下、補助金を出して民間の精神科病院の開設を促した。少ない医師数で多数の入院患者を受け持つ特例も設けた。社会的入院が増加した背景である。

‘Social hospitalization’

In 2004, the government hammered out a policy changeover in favor of “shifting from hospitalization to the community” in mental health care, setting a goal of reducing the number of psychiatric beds at hospitals by 70,000 during a period of 10 years. The actual number of reduced beds in the 10-year program, however, is considered to be no more than around 10,000, primarily because hospitals are not keen on the cuts in beds as they mean less revenue.
 政府は、2004年に「入院から地域へ」の転換を打ち出し、10年間で7万床の病床削減目標を掲げた。だが、この間の削減数は1万床程度にとどまる。収入減を嫌って病院側が消極的なためだ。

In April this year, the government announced a set of guidelines for psychiatric treatment aimed at having patients discharged from hospitals within a period of one year after their first-time hospitalization and improving support measures for treatment of patients at their homes.
 今年4月には、新規の入院患者を1年以内に退院させる体制や、在宅患者の支援体制の整備を掲げた精神医療の指針が示された。

The guidelines should be considered proper in seeking to limit hospitalization to those patients with serious disorders, while having those with mild and moderate problems taken care of in communities where they are accustomed to living.
 入院は重度患者に限り、他の患者は住み慣れた地域で暮らし続ける。その方向性は適切である。

A key task in this connection is how to expedite the discharges from hospitals of social hospitalization patients, the long-stay inpatients.
 課題は、長期の社会的入院患者の退院をいかに促進するかだ。

A study panel of the Health, Labor and Welfare Ministry has created a report in favor of the idea of converting part of the hospitals with such long-stay beds into residential facilities for the patients. The idea is designed to proceed with the reduction of hospital beds in consideration of the desires of inpatients reluctant to be discharged from hospitals, while also taking into account the need to prevent hospitals from suffering declines in revenue.
 厚生労働省の検討会は、病床の一部を居住施設に転換することを認める報告書をまとめた。退院の意欲が低い患者の受け皿にして、病院の経営にも配慮しながら病床削減を進めるのが狙いだ。

However, the proposed conversion into residential facilities has been strongly criticized for being only a change in name. In addition, anxieties on the part of patients and their families over the possibility of being enclosed in the compounds of hospitals are understandable.
 しかし、居住施設への転換には、「看板の掛け替えに過ぎない」といった批判が強い。病院の敷地内に囲い込まれるという患者や家族の懸念は、理解できる。

The ministry panel’s report said the planned conversion should be contingent on the choice of the patients themselves, while stipulating the length of the periods of accommodation at the envisioned facilities. It also came up with an idea of limiting the users of the facilities to currently long-staying patients.
 報告書では、患者本人の選択の自由を確保し、入居期間の規定を設けることなどを転換の条件とした。利用者を現在の長期入院患者に限定する案も示した。

The envisaged facilities should certainly be used as temporary measures, placing priority without fail on creating a system to enable patients to return to their communities.
 あくまでも例外的な施策と位置づけ、患者が確実に地域社会に戻れるよう制度設計すべきだ。

To ensure sufficient support for the patients’ life in their communities, it is indispensable to help them manage such pecuniary affairs as those relating to public assistance benefits, as well as improving counseling services for them.
 患者の地域生活を支えるには、生活保護費などの金銭管理の支援や相談体制の充実が欠かせない。

It is also important to ensure the provision of housing or group homes for them. To accomplish these objectives, coordination of efforts is essential between municipal governments and medical and welfare service organizations.
アパートやグループホームなどの確保も重要だ。自治体と医療・福祉機関の連携が求められる。

(From The Yomiuri Shimbun, July 13, 2014)

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