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Abstract Background Health systems increasingly try to make their services more responsive to users' expectations. In the context of the World Health Report 2000, WHO developed the concept of health system responsiveness as a performance parameter. Responsiveness relates to the system's ability to respond to service users' legitimate expectations of non-medical aspects. We used this concept in an effort to evaluate the performance of mental health care in a catchment area in Germany. Methods In accordance with the method WHO used for its responsiveness survey, responsiveness for inpatient and outpatient mental health care was evaluated by a standardised questionnaire. Responsiveness was assessed in the following domains: attention, dignity, clear communication, autonomy, confidentiality, basic amenities, choice of health care provider, continuity, and access to social support. Users with complex mental health care needs (i.e., requiring social and medical services or inpatient care) were recruited consecutively within the mental health services provided in the catchment area of the Hanover Medical School. Results 221 persons were recruited in outpatient care and 91 in inpatient care. Inpatient service users reported poor responsiveness (22%) more often than outpatients did (15%); however this was significant only for the domains dignity and communication. The best performing domains were confidentiality and dignity; the worst performing were choice, autonomy and basic amenities (only inpatient care). Autonomy was rated as the most important domain, followed by attention and communication. Responsiveness within outpatient care was rated worse by people who had less money and were less well educated. Inpatient responsiveness was rated better by those with a higher level of education and also by those who were not so well educated. 23% of participants reported having been discriminated against in mental health care during the past 6 months. The results are similar to prior responsiveness surveys with regard to the overall better performance of outpatient care. Where results differ, this can best be explained by certain characteristics that are applicable to mental health care and also by the users with complex needs. The expectations of attention and autonomy, including participation in the treatment process, are not met satisfactorily in inpatient and outpatient care. Conclusion Responsiveness as a health system performance parameter provides a refined picture of inpatient and outpatient mental health care. Reforms to the services provided should be orientated around domains that are high in importance, but low in performance. Measuring responsiveness could provide well-grounded guidance for further development of mental health care systems towards becoming better patient-orientated and providing patients with more respect.

While the German mental health system is extensive and well differentiated, at the same time it is fragmented and lacks coordination. Services do not necessarily follow regional demand. They are not sufficiently integrated into the local social infrastructure. Competition and market mechanisms obstruct cooperation in regional networks. Service management proposed by the 1975 German psychiatric reform ("enquete") has proven to be dysfunctional.This article explores the question of what is necessary to allocate available resources for treatment and care according to modern service concepts and both ethical and professional standards adequately.Based on several years of observation and of playing an active part on the national, federal, and local level, this paper presents concepts of coordination and planning of community mental health services over the last 40 years. As a result, four topics of mental health service planning are presented: individual need for support, institutional quality development, regional networking, and political frameworks.More than ever, psychiatric reform is in need of good planning. A suggested concept integrates the following: (1) good planning of individual assistance, (2) organizational development of mental health services, (3) cooperation in regional networks, and (4) a political framework. Thus, national, federal, and regional activities should be sustainably aligned. We recommend a working group integrating national, federal, and regional policy makers - backed by a trialogic expert advisory board.

Background: Long-stay hospitalization is often a consequence of insufficient care structures. This article examines the characteristics and care conditions of long-stay hospitalization (LSH) in an urban area in Germany., Methods: Extensive data of patients in the urban catchment area of the Medical School of Hannover, capital of Lower Saxony, were evaluated during a 10 years period., Results and Conclusion: Community psychiatric efforts certainly help to reduce long-stay hospitalization, but cannot fully prevent it. Reference figures are given for comparable urbanized areas: consequently 500 chronically mentally ill persons per 100.000 inhabitants must be expected, 20% of which must be considered as long stay hospitalized according to a given definition. We estimate 250 places per 100.000 inhabitants to be required for institutionalised outpatient care, further 30 places for day clinic and full-time in-patient treatment and 40 places for residential home treatment. We suggest these results as a guidance for psychiatric planning in comparable communities.

Background: Health systems increasingly try to make their services more responsive to users' expectations. In the context of the World Health Report 2000, WHO developed the concept of health system responsiveness as a performance parameter. Responsiveness relates to the system's ability to respond to service users' legitimate expectations of non-medical aspects. We used this concept in an effort to evaluate the performance of mental health care in a catchment area in Germany., Methods: In accordance with the method WHO used for its responsiveness survey, responsiveness for inpatient and outpatient mental health care was evaluated by a standardised questionnaire. Responsiveness was assessed in the following domains: attention, dignity, clear communication, autonomy, confidentiality, basic amenities, choice of health care provider, continuity, and access to social support. Users with complex mental health care needs (i.e., requiring social and medical services or inpatient care) were recruited consecutively within the mental health services provided in the catchment area of the Hanover Medical School., Results: 221 persons were recruited in outpatient care and 91 in inpatient care. Inpatient service users reported poor responsiveness (22%) more often than outpatients did (15%); however this was significant only for the domains dignity and communication. The best performing domains were confidentiality and dignity; the worst performing were choice, autonomy and basic amenities (only inpatient care). Autonomy was rated as the most important domain, followed by attention and communication. Responsiveness within outpatient care was rated worse by people who had less money and were less well educated. Inpatient responsiveness was rated better by those with a higher level of education and also by those who were not so well educated. 23% of participants reported having been discriminated against in mental health care during the past 6 months. The results are similar to prior responsiveness surveys with regard to the overall better performance of outpatient care. Where results differ, this can best be explained by certain characteristics that are applicable to mental health care and also by the users with complex needs. The expectations of attention and autonomy, including participation in the treatment process, are not met satisfactorily in inpatient and outpatient care., Conclusion: Responsiveness as a health system performance parameter provides a refined picture of inpatient and outpatient mental health care. Reforms to the services provided should be orientated around domains that are high in importance, but low in performance. Measuring responsiveness could provide well-grounded guidance for further development of mental health care systems towards becoming better patient-orientated and providing patients with more respect.

Background: The problem of long-stay hospitalization is still a pressing issue. In this study we examined the possibility of detecting and characterising the group at risk of long-stay hospitalization in advance., Methods: This study examines the data of patients in the urban catchment area of the Medical University of Hannover, capital of Lower Saxony, Germany, during a period of 10 years., Results and Conclusion: The introduced "psychosocial risk-score", calculated at the first institutional contact, was able to predict the risk of long-term hospitalization. Characteristics of social disintegration, especially with regard to employment status, are of particular importance.

Caring for psychiatric patients, Social Psychiatric Services (SpDi) carry out advising and therapeutic tasks and give medical opinions. They also participate in the management of the community psychiatric care system. The services differ widely in giving priorities to these tasks. In Germany there are no standards concerning quality and quantity of individual help being offered by SpDis. Evaluation of this individual client related help is essential for quality management. Besides rates, which partly describe the utilisation of the service, such parameters are of interest that hint at the psycho-social risk. Furthermore, figures indicating continuity or discontinuity of help are of importance. The statistics of the documentation in 1999 and 2000 of the SpDi Wolfsburg serve as an example for such an evaluation.

This paper describes the procedures in planning support programmes for persons with long term psychiatric disabilities in the Region of Hannover (1.15 mill. inhabitants) and presents some results of a research project concerning process quality of all 570 planning procedures, which took place in the year 2001. The study covers the evaluation of the type and extent of recommended support programmes in the different catchment areas of this region in relation to the psycho-social risk of the patients. Following the presentation of the results deductions for the implementation of a systematic quality development process in community psychiatry are discussed.

Against the background of the model pattern conceived in West Germany in 1975 on the basis of the so-called "Psychiatrie-Enquête" and in 1988 on recommendations made by a committee of experts, the article describes and discusses the history, composition, manner of working, thematic scope and the results of the coordination round table concerning psychiatric care under community council auspices. This model has been realised in Hanover since 1976 as part of the segmentation of psychiatric care according to community districts. The study aims at stimulating suggestions for a general solution regarding coordination- and planning of communal psychiatric care and how to translate these suggestions into reality, both on a scientific basis and with due reference to the realities of the prevailing circumstances. This can help to avoid developments in a wrong direction and also to avoid delays that may arise in solving this core problem of sociopsychiatric reform.

We have performed percutaneous transhepatic biliary drainage on 27 patients; of these, thirteen were examined by CT before and after the procedure. Our experience suggests that CT or sonography is indicated every case of obstruction due to tumour in order to: 1. Decide on treatment by a non-invasive method thereby saving the patient an unnecessary laparotomy and 2. Plan the biliary drainage accurately, leading to the lowest possible number of complications.

Results of percutaneous transluminal angioplasty (PTA) for peripheral arterial occlusion were compared between a group of 41 patients aged over 60 years and one of 39 patients under 60 years. In the older patients the proportion of those in a decompensated state was 61%, more than double that in the younger ones. 54% of the older patients were diabetics with a poor peripheral vascular outflow bed; conservative treatment failed in them and surgical intervention was not possible. A primary success rate of PTA was 87% in the older patients, no worse than in the younger ones. Long-term follow up of both groups indicated that PTA in the compensated stage achieved prolongation of pain-free walking distance or absence of symptoms in 74%. Threatened leg amputation could be avoided in 80% of the younger and 60% of the older patients. Limited amputation was performed in 20% of the older patients with decompensated vascular disorders. The most frequent complication of PTA was embolization into the small vessels of the lower leg, in nearly 30% of patients. But only once did this worsen the clinical state, and this was transitory.

Chest roentgenography of artificially ventilated persons not only reveals morphological changes in the lungs but may also provide information regarding their pathogenesis and prognosis. To safeguard against misinterpretation of the findings they should be supplemented by blood gas analyses and function tests (e.g. effective compliance of the respiratory system). The chest roentgenogram also apprises of the development, and consequently of the need for treatment, of such complications as interstital emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum and subcutaneous emphysema.

Evaluation of x-ray films of 44 early carcinomas of the stomach in a total of 163 patients from 1970--1978 confirms the high diagnostic value of x-ray examination with adequate technique. In 93% of the cases lesions caused by the carcinoma were seen. To assess the severity of the roentgenologically detected lesions it will be necessary to perform endoscopic-bioptical examination. Final diagnosis, however, must be left to histological examination of the resected stomach preparations.

To evaluate computer tomography (CT) for assessment of aorto-coronary bypass graft patency, 45 patients with 85 grafts were studied by non-dynamic CT before and after intravenous bolus injection of 50 ml contrast material. 28 patients had undergone postoperative coronary angiography (37 grafts patent, 11 occluded), while 17 (37 grafts) were studied in the early postoperative period without angiographic confirmation. 60 of 74 grafts (81.1%) which were angiographically patent or not checked by postoperative angiography could be visualized by CT. In patients in whom graft patency was documented by angiography, 32 of 37 grafts (86.5%) were identified correctly, including all 18 grafts (100%) to the left anterior descending branch (LAD). With the exception of one LAD graft which was judged differently by the two evaluators, none of the 11 definitely occluded grafts could be visualized by CT. The results suggest that non-dynamic CT allows correct identification of patent aorto-coronary bypass grafts in a high percentage of cases. So far, however, the method does not allow any deduction as to the functional status of the grafts.

The transpapillary passage of a catheter for internal biliary drainage may produce complications due to reflux or acute pancreatitis. A review of 573 biliary obstructions due to malignant tumours showed that in half the obstruction lay in the proximal two-thirds of the biliary passages. Fibrous strictures are nearly always in this region. In these patients, suprapapillary instead of transpapillary internal biliary drainage can be used, thereby maintaining the physiological relationship in the papilla. For this purpose we use a specially designed catheter which meets the requirements of suprapapillary internal drainage.

The postnatal growth of the dorsal part of the lateral geniculate nucleus (LGNd) is studied in paraffin sections through the brains of 32 cats of known age. The changes in shape and position of the LGNd are described and it is shown that its volume increases from about 3.4 mm3 at birth to about 26.4 mm3 in the adult cat. When this value is corrected for shrinkage, the volume of the LGNd in the adult cat turns out to be about 44 mm3. The detailed measurements reveal that during the second and third week of postnatal life there is a particularly steep increase in volume and that the final values are already reached at around the 40th day. Concomitant with the increase in volume there is a decrease of the number of cells per unit volume of grey matter. In the binocular segment of lamina A the number of cells decreases from about 470 per (0.1 mm)3 at birth to between 95 and 130 per (0.1 mm)3 in the adult cat. Separate measurements of nerve cells and neuroglial cells indicate that the absolute number of nerve cells remains fairly constant during postnatal life, whereas between the second and sixth week a great number of neuroglial cells are newly formed.

The antetorsional angle was determined in several patients as well as in an isolated femoral bone by means of computer tomography. A comparison with Rippsteins method shows good correlation, taking different definitions of the antetorsional angle into consideration. Due to a mathematical correction method, the CT determination method is independent of the positioning of the patient.