1993
2013
France. Mission nationale d'appui en santé mentale
La Mission nationale d’appui en santé mentale (MNASM) a été mise en place en 1993, à la suite de la parution du rapport du docteur Gérard Massé intitulé La psychiatrie ouverte, une dynamique nouvelle en santé mentale. L’objectif de la mission était d’accompagner les établissements et les administrations dans l’évolution de la psychiatrie vers l’hôpital général, mais aussi vers les structures médico-sociales et sociales, alternatives à l’hospitalisation. Jusqu’en 2013, elle a été renouvelée à plusieurs reprises par lettre de mission adressée à un coordinateur (d’abord pour cinq ans, puis pour seulement trois ans). Trois coordinateurs se sont ainsi succédés : le docteur Gérard Massé (de la fondation en 1993 au mois de mai 2007), le docteur Serge Kannas (d'abord coordinateur par intérim puis nommé par la lettre de mission du 4 février 2008, parti en retraite le 1er mars 2011) et enfin le docteur Catherine Isserlis.
La nécessité de donner à la MNASM des bases de fonctionnement juridiques et financières conformes à la réglementation a été soulignée dans le rapport de l’Inspection générale des affaires sociales (IGAS) de 1999 ainsi que dans celui de la Cour des Comptes de 2000. Le rapport de la Cour des Comptes de décembre 2011 (L’organisation des soins psychiatriques : les effets du plan « psychiatrie et santé mentale » 2005-2010) a prescrit la consolidation du financement et de la gestion de la MNASM dans des conditions conformes à la réglementation en vigueur. Dans cette perspective, un rapprochement de la mission avec l’Agence nationale d’appui à la performance des établissements de santé et médico-sociaux (ANAP) a été envisagé : en février 2012, la Direction générale de l'Offre de soins (DGOS) a demandé à l’ANAP de travailler sur un rapprochement entre les deux organismes. A la suite de cela, la MNASM a cessé ses activités le 31 mars 2013. C'est depuis lors l'ANAP qui assure la continuité de ses missions essentielles.
La MNASM était composée d’une équipe pluri-professionnelle de membres permanents et de correspondants travaillant dans le champ de la psychiatrie dans les établissements de l’ensemble du pays. Les correspondants étaient choisis par cooptation ; ils intervenaient bénévolement en mission sur délégation de leur chef d’établissement, à la demande du coordinateur de la MNASM.
Les missions de la MNASM étaient fixées et évaluées par un comité de pilotage qui se réunissait annuellement. Celui-ci était composé des directeurs de la Direction générale de l’Offre de soins (DGOS), de la Direction générale de la Cohésion sociale (DGCS, ancienne Direction générale de l’Action sociale), de la Direction générale de la Santé (DGS), de la Caisse nationale de solidarité pour l’autonomie (CNSA) ainsi que des représentants des agences régionales d’hospitalisation (ARH), DRASS et DDASS (puis agences régionales de santé - ARS) et des permanents de la MNASM. Les comités de suivi, qui regroupaient les mêmes acteurs, avaient pour rôle la préparation et le suivi des interventions sur site et l’échange sur les dossiers en cours.
La MNASM ne disposait ni d’une personnalité juridique ni d’un budget propre. C’est l’Association de santé mentale du 13e arrondissement de Paris (ASM 13), qui assurait le financement de ses dépenses de fonctionnement. Depuis la création de la mission, l’ASM 13 mettait également à sa disposition des locaux ainsi qu’une secrétaire. Elle prenait en charge la plus grande partie de l’exécution de la logistique, liquidait les dépenses et recouvrait les recettes. Un état prévisionnel des dépenses était préparé conjointement avant d’être inclus dans le projet de budget de l’ASM 13 et soumis au directeur de l’ARH (devenue ARS) d’Île-de-France. L'État et l’ARH pouvaient avoir communication de l’ensemble des comptes sur simple demande.
Le cœur de l’activité de la MNASM consistait en des interventions sur site à la demande des ARH (puis des ARS), sur la saisine de la DGOS. Elle devait alors analyser la situation existante à l’échelle d’un département, d’une région, d’un pays ou d’un établissement, et appuyer le changement. Elle pouvait aussi intervenir en amont d’opérations spécifiques, comme la conception de projets de territoire, le transfert de structures ou encore la construction de nouveaux bâtiments. Toutes ces interventions étaient gratuites, les structures visitées ne payant que les frais de déplacement. Il ne s’agissait pas d’une action d’inspection ou d’audit, mais bien d’une action de médiation et d’assistance à l’évolution des dispositifs de santé mentale. Les visites sur site faisaient l’objet d’un rapport au commanditaire qui rassemblait la problématique locale, les solutions préconisées et leur délai prévisionnel de mise en œuvre.
La MNASM contribuait également par son expertise à l’élaboration des politiques nationales : elle pouvait en effet être sollicitée par l’administration centrale pour faire remonter les résultats des expériences menées sur le territoire, participer à des groupes de travail ou construire des outils à partir de problématiques observées sur le terrain.
Elle jouait enfin un rôle de conseil et d’aide pour la diffusion de bonnes pratiques, notamment par l’intermédiaire de la revue Pluriels, de séminaires (deux séminaires annuels permettent de former les correspondants) et de formations organisées en partenariat avec l'École des hautes études en santé publique et l’Association nationale de la formation du personnel hospitalier.
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