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Up for the challenge

In an exclusive article for the Medical Independent, Minister for Health Simon Harris discusses his vision for achieving a world-class health service, while continuing to deliver improvements for patients along the way

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The future of mental healthcare in Ireland

Ireland’s mental health system has never lacked for reports, reviews and reassessments. From the early 1800s onwards there have been committees, commissions and enquiries every few years, all producing reports of varying lengths and usefulness. The most recent addition to the library was published in October 2018 by the Oireachtas Joint Committee on the Future of Mental Health Care. The Committee was a cross-party body established in July 2017 and it published two interim reports during the course of its deliberations.

The Committee’s third and final report, in the words of its chair, Senator Joan Freeman “sets out to present a clear and compelling vision for mental healthcare and the direction of mental health policy in Ireland and the associated actions and targets that it considers necessary and capable of implementation”.

So, what does this latest report actually say? The Committee makes 22 key recommendations under 11 headings. Under “stigma and mental health promotion”, for example, the Committee’s recommendations include greater study of the “causative factors” implicated in mental illness and more targeting of resources to “areas of highest need”, with a priority focus on the Traveller community.

Looking at the “current state of services”, the Committee suggests that “the Department of Health should conduct a comparative study as to which countries ‘do mental health well’ and how Ireland compares”. Looking abroad is certainly a good idea, but it is far from clear which countries “do mental health well” in the sense meant by the Committee. To take one example, Ireland’s rate of involuntary admission is now less than half of that in the UK and Ireland’s suicide rate has fallen significantly over recent years. Surely, this counts as Ireland “doing mental health well”, at least in these respects?

“As an interim measure,” the Committee continues, “the number of acute beds should be increased to 50 per 100,000 over the next three years, with a commitment to reach the EU average [approximately 70] within the subsequent two years.” This is a welcome recommendation and clear recognition of this need is long overdue in Ireland.

Moving on to “physical infrastructure”, the Committee “recommends that the Mental Health Act be amended to provide for the regulation of all premises where mental health services are provided” and that the role of the Mental Health Commission be strengthened. Although these aims are laudable, it is far from clear that regulation through legislation is always the best way to achieve better services. The Committee underpins their recommendation by calling for “major additional capital investment to ensure compliance with the regulations, which should also have the knock-on effect of attracting clinicians and creating environments conducive to the recovery of people experiencing mental ill-health”.

The Committee recommends improved “signposting, referral pathways and communication”, and suggests that “consideration be given to reviewing the role of psychiatrists and streamlining their workloads by distributing some or all of [a number of specific] functions to other team members”. Interestingly, some of the tasks mentioned are already undertaken by team members other than psychiatrists in many mental health services, but presumably the Committee means that such task-sharing should become more widespread. They also recommend that there should be “access to a wide variety of treatment options” so as to increase “the likelihood that individuals will recover”.

The Committee says it may be necessary to appoint a senior manager with responsibility for mental health in the HSE on a statutory basis. In the meantime, the Committee recommends that a National Director for Mental Health be reinstated who will be solely accountable for decision-making in mental health. For funding, the Committee suggests “as Sláintecare is implemented that the recommended increase to 10 per cent for mental health services be ring-fenced and prioritised” and to enhance accountability, “A permanent Oireachtas Committee on Mental Health must be established.”

Recruitment is a real issue and in this context the Committee recommends improved remuneration for clinicians, various other incentives, and consideration of “the possibility of special allowances for psychiatric nurses and psychiatrists”. For “staff development”, it suggests that “a mental health centre of excellence be established and resourced in an academic hospital”.

As these reports go, the Joint Committee report is a perfectly reasonable addition to the now enormous library of such reports produced over the years. While it could have done with another read-through before publication (to remove the more obvious glitches in continuity), the document undeniably makes many important and useful points. Its recommendations are mostly sensible and logical, albeit that it should not really have required an Oireachtas Committee to make them. And much of what they say is consistent with A Vision for Change, the 2006 mental health policy that is currently being refreshed – a process that will, presumably lead to another report.

It is probably useful that such reports keep on appearing, if only to draw attention to the very real challenges in mental healthcare today. It is especially encouraging that the Joint Committee recommends increasing the number of acute beds. Ireland’s shift to community mental healthcare has been positive and decisive, but it has resulted in a lack of inpatient beds. Hopefully, this report will help address that deficit.

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Irish health system is not a ‘basket case’

reland’s health system contains a complex mixture of public and private funding and provision of services and the overlaps between these have sometimes led to criticism of the system as being inequitable. However, similar overlaps are evident in other systems, albeit not to the same extent in many cases and similar concerns have been expressed in other countries about the interactions between the public and private elements of the system.

Comparing health systems internationally is fraught with difficulty, as systems have developed over long periods of time with distinct features becoming embedded. However, the UK and Australia have systems with broadly similar funding mechanisms to Ireland, in that they are all primarily tax funded, with contributions from private health insurance and out-of-pocket payments. (In each case, contributions from charitable donations provide a relatively small proportion of funding.)

By contrast, the German and Belgian health systems are predominantly funded through social health insurance, whereby employers and employees contribute a proportion of the employee’s earnings into sickness funds, with the State subsidising contributions in some cases. Again, private health insurance and out-of-pocket payments also form part of the health funding landscape.

Entitlements to health services are more clearly defined in these other four countries (albeit with varying degrees of cost-sharing) than they are in Ireland, with possession of a medical card here determining the degree of entitlements and/or charges to a large extent. In particular, Ireland is unusual in having a large proportion of the population subject to significant out-of-pocket payments for GP services, albeit this proportion has been reduced in recent years with the expansion of eligibility for GP visit cards.

In terms of health spending per capita, Ireland currently spends a similar amount to Germany and more than the other three countries.  However, Ireland only caught up with Australia, Belgium and Germany in the mid-2000s, having consistently under-spent relative to those countries in the 1970s, 1980s and 1990s. Compared with the UK, we spent broadly similar amounts until the mid-1990s; since then we have consistently spent more.

One issue that should be taken into account in this regard is that Ireland has a relatively younger population compared with the other four countries. In 2016, 13.2 per cent of Ireland’s population was aged over-65, compared with 14.3 per cent in Australia, 17.9 per cent in the UK, 18.2 per cent in Belgium and 21.1 per cent in Germany. Research has shown that average medical expenses rise with age, so we have an advantage in this regard, although demographic projections suggest that this will be eroded in the coming years.

In all five countries, private health insurance operates alongside the statutory healthcare system. However, the nature of this insurance varies between supplementary (providing benefits over and above those provided by the statutory system, such as faster access, greater choice of provider and/or superior accommodation), complementary (providing coverage for services not available under the statutory system and/or for co-payments payable for services that are provided by the statutory system) and substitutive (substituting for the statutory system). In Ireland, the UK, Australia and Belgium, private health insurance is primarily supplementary, with elements of complementary in the first two countries, while in Germany it is primarily substitutive.

In Ireland and Australia, private patients may be treated in private or public hospitals and many public hospital consultants have private practice rights (although, interestingly, many of these do not avail of those rights in Australia).

In the UK, there is less treatment of private patients in public hospitals, although recent legislative developments have encouraged this to a greater extent (the opposite of the proposed removal of private practice from public hospitals in Ireland envisaged under the Sláintecare proposals).

In Belgium and Germany, there is more of a contractual relationship, whereby public and private purchasers contract with the same providers.

In each of the countries, concerns have been raised over the equity of having a mixed public/private system, where take-up of private health insurance is higher among those with higher incomes and where such insurance confers faster access to treatment in some cases. There are also concerns about Government subsidisation of private health insurance in both Ireland and Australia. Furthermore, in a number of these countries, significant premium increases have led to concerns about the sustainability of private health insurance. Interestingly in this regard, having risen rapidly during the recession, premiums in Ireland have actually begun to fall back slightly in the last year or so.

Despite a perception that Ireland’s health system is something of a basket case, it appears that our system shares a number of characteristics with other health systems, although it does also have some unusual features. However, it is somewhat consoling that other countries are also grappling with some similar issues.  Perhaps we could learn from their experiences and vice versa.

This article is based on a report, entitled The Irish Healthcare System: An Historic and Comparative Review, published by The Health Insurance Authority, to which the author contributed the comparative review.

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