In interviews with health care, social care and mental health care professionals in 14 European countries, four components characterising good practice in mental health care across six different socially marginalised groups were identified: a) establishing outreach programmes to identify and engage with individuals with mental disorders; b) facilitating access to services that provide different aspects of health care, including mental health care, thus reducing the need for further referrals; c) strengthening the collaboration and co-ordination between different services; and d) disseminating information on services both to the marginalised groups themselves and to health care practitioners in the area.
These components were applicable in different countries and across different marginalised groups.
The study has a number of strengths. A substantial number of experts in 14 countries were interviewed. A consistent methodology for selecting areas and defining marginalised groups was used across all countries. All experts had actual experience providing care to the specific marginalised group they were being interviewed about. The findings reflect experiences gained in countries with very different social care and health care systems and with six groups that represent different types and histories of social marginalisation. The identified good practice components reflect commonalities across countries and groups despite national and group differences, and may therefore be seen as widely applicable.
The above-mentioned strength of the study to draw general conclusions based on material from so many countries and six very different social groups is also a limitation. Such analysis inevitably simplifies and does not reflect the richness of the material. Since the interview was semi-structured and did not explicitly investigate views on pre-defined components of good practice, negative findings (i.e. if experts did not raise a theme) are difficult, if not impossible, to interpret. Interviewees might have held strong views on certain issues but not expressed them in the interview. In fact, none of the 13 themes was raised in all countries and more often than not a theme was mentioned by only one of the two experts in one country. The analysis in this exploratory study reflects only what was put forward as explicit opinions concerning good practice, but did not, for example, go back and test the wider validity of the components with all interviewed experts.
There are further shortcomings of the study. Experts were selected based on local knowledge and experience or research teams, but the recruitment was still opportunistic and may have been inconsistent. The interviews were of different length and detail. Most importantly, the analysis used material that was translated into English, and relevant and specific factors may have been lost in translation. Also, the analysis was mainly conducted by a group based in the United Kingdom with inevitably limited understanding of specific contexts and whose perspective may have been influenced by their own national experience, despite regular cross-checking with all sites. All these aspects can be associated with a possible interpretation bias. Finally, the study having been conducted in highly deprived urban areas, findings cannot necessarily be generalisable to other types of settings.
The identified components are based on a common denominator across countries and groups. They are therefore rather general and reflect widely held views among experts. For some of the groups similar components have been suggested in the literature previously [26–33]. Outreach was described as an important component, which is in line with an increasing consensus in the literature that outreach activities are an essential element of community mental health care for difficult to engage groups [34, 35]. These activities are also increasingly recognised form of delivering other health care to individuals from marginalised groups whose needs are not effectively addressed by existing services [36–38]. However, outreach may be particularly significant in mental health care. Experts pointed towards a requirement for close contacts and proactive support whilst at the same time avoiding any form of intrusiveness. Services have to take responsibility for providing health care to vulnerable groups and at the same time respect their autonomy. This ongoing tension between paternalism and respect for autonomy applies to relationships between clinicians and individual patients, and between services and specific communities . Lack of trust in services was a frequent theme. Health care may be resisted in socially marginalised communities if it is perceived as a threat to a group’s autonomy . Respect for the autonomy of marginalised groups may require increasing professionals’ awareness of the particular social issues of those groups among professionals  and subsequently adapting service provision to the different lifestyles .
Facilitating access may require overcoming institutional inertia and is linked to initiatives of having person centred care instead of institution centred care [43, 44]. The requirements may vary by groups and by size of institution. For example, a very small service may be able to establish personal links and trust, but struggle to ensure opening times beyond office hours. Yet, the findings of this study suggest that the major challenge to mental health services is not only ease of access, but to be closely linked to general health care and help patients access all health care and treatments as and when required. A split between mental health and other health care might sometimes simplify the organisation of services, but it is not in the interest of marginalised groups who have difficulties navigating complicated health care systems and whose main and initial focus is often obtaining care for general health problems rather than mental health care.
The coordination of services becomes more difficult the more services there are and can potentially be involved in providing care for marginalised groups. Other European reports on health needs of marginalised groups have described problems in working across traditional areas of responsibility [45, 46]. Well resourced health and social care systems tend to have more services , and although this may widen the range of available care options for patients, it will also make coordination more complicated. Of all the identified components of good practice, coordination of services appeared to many interviewees the easiest to achieve with limited additional activities and input. At the same time, the isolation of services and their fragmentation have been identified as a problem previously without being overcome. An increasingly diverse landscape of provider organisations might make this even more difficult.
It may seem surprising that simple information on care options and existing services is often not available, yet this finding was frequently reported by the experts from different care domains. Similar to problems with coordination, this issue is linked to working across usual boundaries which is often a necessity in case of marginalised groups. The authorities overseeing and coordinating health and social care services may be seen as the most obvious candidate for providing such information, and new technologies should facilitate the compilation of the required data. More challenging than compiling the data is getting the information to marginalised groups and providing it in a form that is suited to their needs, a finding supported by other European studies . Marginalised groups often do not actively search the internet or other sources for information. Helping them to do so may be one important task for services which provide the first point of contact to these groups.
Implementing the good practice components can be achieved through sufficient funding, appropriate service organisation and training of staff. Establishing outreach programmes and providing and disseminating information require resources. Organisational development may help to reduce administrative barriers and complex referral procedures focusing on outreach and establish good collaboration and co-ordination between services. Training and supervision programmes in both specialised and generic services may enable staff to develop a better understanding of the specific needs of marginalised groups; improve their awareness of the existence of other relevant services in the area and how these other services function; facilitate collaboration, and help develop a respectful, non-intrusive approach.