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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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A new fragmented era for primary care

It’s the morning of Budget Day 2019 as I sit down to write this column. Well trailed in advance, the overall health budget is set to be €17.2 billion, an increase of 6.6 per cent, to include measures previously listed under the Sláintecare heading.

With health breasting the €17 billion tape for the first time, surely the draconian FEMPI measures will be reversed. And imagine the difference if the primary care budget became a steady 6.6 per cent of the annual health budget, rather than the measly 3.5 per cent it gets at present?

But you’re right, I need to snap out of my Walter Mitty-like reverie. General practice will be in as much trouble, faced with managing an additional 100,000 medical card patients on top of its existing stresses.

Those of us who were brought up on, and helped shape what was a reasonably successful general practice model in Ireland, have been hopeful of a return to stability and even growth in the sector. Sadly, and I take no joy in saying this, general practice as we have known it will never return to these shores.

This won’t come about for purely financial reasons: There are seismic societal changes already in train, which will be major drivers of this transformation.

Walk-in clinics, as already established in Canada and elsewhere, will be the choice of millennials and future generations. For the peripatetic young person, whose job location changes several times a year because of the contractual nature of work, having a relationship with a primary care physician is an anachronism. Not for them the hassle of making an appointment and driving to another city or county to the family doctor. Far easier to drop in to the nearest urgent care centre, be seen reasonably promptly, pay a fee and be on their way. Convenience, fast service, and price transparency matter much more than cradle-to-grave avuncular medical care.

In Ireland, we are clinging by our fingertips to the same-day medical appointment system. But it is crumbling, with practices here opening up a week’s appointments on a Monday morning when they are all snapped up within hours. For a younger generation used to convenience from most service industries, this is crazy. Waiting up to a week to have an acute problem dealt with makes no sense.

The trusted medical advisor (based on a long relationship), who coordinates their care, guides them to specialist services and helps them navigate complex treatment options, is not a priority in their world view.

What do this group value? Same-day appointments, hassle-free repeat prescriptions ordered via a dedicated app and sent straight to the pharmacy and a messaging system for the transmission of test results are minimal requirements.

They would like to be the true ‘owner’ of their medical record. Electronically portable, they would bring the record with them to urgent care clinics and specialist appointments.

I’m no fan of video consultations, but I can see the attraction for patients. Typically, eligible patients can register online in a few minutes and have a video consultation on their smartphone with a GP within two hours.

In Britain, GP at Hand is a free app that claims to offer most of the services of a traditional practice. Run under an NHS contract, GP at Hand is essentially a large practice of 20,000 patients that does most of its consulting online. Currently, to be eligible to register for the service, patients must live within 30 minutes of the physical location of the practice building in London. And while most consultations are carried out online, in some circumstances the patient will be required to be seen face-to-face.

The GP at Hand model answers one of my main concerns of video consultation and that is the complete lack of ‘hands-on’ involvement by the doctor. By restricting patient registration to those living or working within a half-hour of the practice centre, it is easier to turn an online consult into a person-to-person one when necessary.

But we don’t know how safe or effective such a model-of-practice will be. Indeed recent research shows that maintaining a relationship with the same doctor is associated with lower death rates in patients. Seeing the same GP has also been shown to decrease the number of specialist referrals made and make it more likely that the patient will follow medical advice.

It’s hard to see how any of the new models of primary care will not result in more fragmented care. It’s a recipe for over-treatment and also poses a significant risk to antimicrobial stewardship.

But at the end of the day consumer demand will win out. It doesn’t matter what we want or what best practice research recommends. General practice as practiced by many of us will fade away as society places a lower value on continuing care.

General practice in Ireland is dead. Long live general practice.

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Fighting for fairness and equality

Dr Lucia Gannon wrote insightfully in the 12 October issue of this publication about her experiences at the Women in Medicine in Ireland Network (WIMIN) conference in September, so I almost feel apologetic for bringing it up again.

Then I remember that it is a particularly feminine trait, to start a conversation by saying “sorry, I just thought… I hope you don’t mind… I was wondering if possibly, maybe I could bring this to your attention…but only if it’s no trouble… ”

So.

I’ll start again.

There are nearly nine-thousand female doctors in Ireland, 41 per cent of the total number of registered medical practitioners. Currently, female medical students outnumber male students — 58 per cent of all new-entrant medical students in 2015/16 were female (the percentage is even higher for graduate-entry students, at 62 per cent). The women are taking over! We’ll be overrun with oestrogen in our hospitals! (Remember that 79 per cent of all HSE employees are female.) Well, if you would like to work in a less oestrogen-rich environment, I can recommend academia, where you will find that just 17.5 per cent of professors in Ireland are female. If you can get yourself a surgical professorship, then 93 per cent of your peers will be men. And if you would like an almost exclusively male environment, you could become a maxillofacial surgeon, where only a tiny number of women will be around to disturb the peace.

Girls are good at school and get the points to do medicine. Female medical students are hard-working and get themselves out of med school and onto training schemes. But then something funny happens to them and their ability to excel just, sort of, evaporates. That old oestrogen is bad for the brain, it seems. And if you go adding HCG and prolactin and oxytocin, well you can just wave goodbye to those pretty little brain cells.

Because it must be biological, right? Why else would 16 per cent of recent male medical graduates earn more than €45,000 within nine months of qualification, but only 5 per cent of female ones do? And 8 per cent of the same female cohort earn less than €25,000, versus 2 per cent of their male counterparts?

The women don’t work as hard. They suit themselves with their hours. Part-time, less-than-full-time, lengthy baby holidays. That explains the gender pay gap, doesn’t it? If they worked hard, they would get paid just as much.

This is where the real puzzlement begins. Gender pay gaps are not a result of unequal pay for equal work because that, as we know, is illegal. It is much more insidious than that. It is about the types of jobs that women tend to get. It is about their tendency to not ask for more money when sitting at an interview (Ladies — men do this. All the time). So women are more likely to find themselves in poorly-paid jobs and are less likely to climb the ranks.

Any profession that has a high proportion of female employees tends to be lagging behind in terms of both decent pay and decent working conditions — think nurses, care assistants, teachers, childcare workers, social workers. Within medicine, it is very interesting to see that the specialities with the highest proportion of women tend not to be the highest-earning. It is of particular note that specialists in public health medicine, which is a speciality in which women have been predominant for decades, are consistently paid less than their consultant colleagues in other specialities. Mental health is often described as the ‘Cinderella of the health services’ and the ongoing battle for funding and appropriate resources is well known. It should be no surprise, therefore, to find that there are more female than male consultant psychiatrists.

The other areas with a female preponderance include palliative and rehabilitation medicine, and paediatrics is rapidly joining them. These are what could be seen as more ‘caring’ roles (though I am not suggesting that orthopaedic and maxillofacial surgeons care any less, just because they are mostly men).

Microbiology, histopathology and haematology are also attracting higher numbers of women. This is where the gender pay gap develops; none of these specialities are likely to earn you the big bucks. These are areas which might be considered ‘low-yield’ in terms of pay-per-procedure, or massive private practice.

Of course, it goes without saying that this Government continues to show a complete lack of respect for general practice. And guess what — it is filling up with women (75 per cent of GPs aged under 35 are female). This is not a good omen for general practice. Unless we address the underlying issues of gender inequality in society (unconscious bias, gender schemas, inequity of childcare responsibilities), then the contagion will spread, and men in female-dominated areas of medicine could get dragged down with us.

WIMIN hopes to shine a light on these disparities and to bring about change. WIMIN intends to do this through supporting female doctors with formal mentoring, advocating on their behalf and developing practical solutions to address structural inequities that can ultimately impact health service morale and patient experience.

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A duty of care

f all the forms of inequality, injustice in healthcare is the most shocking and inhuman.”

Dr Martin Luther King Jr

October 10 marked the third anniversary of the tragic fire at Carrickmines, which claimed the lives of 10 members of the Travelling community. This appalling tragedy shocked the nation and was extensively covered in the media in the following days and weeks, as the various funerals took place and were reported on.

Subsequently, the issue of housing of Travellers was kept alive for a time by the need to accommodate those who survived the fire, and by President Michael D Higgins, who spoke about the plight of Travellers and then welcomed the survivors of the Carrickmines fire to a reception at Áras an Uachtaráin.

In the wake of the Carrickmines disaster, it was reported that funding for Traveller accommodation was cut from €40 million to €4 million between 2008 and 2013. This has resulted in overcrowding in many halting sites, which are often also poorly maintained and unsafe. That said, most, if not all, halting sites have been the subject of safety inspections by local authorities since this fire occurred for the purposes of preventing further tragedies.

Subsequently, an audit by the National Directorate for Fire and Emergency Management (Department of Housing, Planning and Local Government) revealed that 81 per cent of dwellings surveyed had no working smoke alarm, 57 per cent of households were less than the safe six metres apart from each other, and there was a lot of unsafe use of multiple plug adaptors.

In the area of education, Archbishop Diarmuid Martin has called on all Catholic schools to address the educational needs of Travellers more effectively. This is in the context of a Traveller child initially being denied a secondary school placement — a situation later reversed. During the austerity cuts, there were substantial cuts to resource teaching for Traveller children.

Let us now turn to the issue of Traveller health. I am a GP in Waterford City. My practice is mainly GMS and about 10 per cent of my patients are members of the Traveller community. Many of these patients are settled Travellers and some would live on two halting sites, being settled in the winter but travelling in the summer. Many other patients come from deprived areas or backgrounds but are not of Traveller ethnicity.

The last study on Traveller health was conducted by researchers from University College Dublin (UCD) and published in 2010 as The All Ireland Traveller Health Study. This research covered the island of Ireland and a population of 40,129 people of various age cohorts, 90 per cent of them resident in the Republic of Ireland. The study took place between 2007 and 2010. It is a lengthy publication, stretching to 236 pages (including references) and its foreword is by the then Minister for Health Mary Harney. This passage made reference to previous studies of Traveller health and noted that a health strategy report published in 2001, Quality and Fairness: A Health System for You, identified Travellers “as a group at significant disadvantage in health status and remarked on the findings of the Travellers Health Status Study” (1986), which had shown that life expectancy at birth in 1987 for Traveller men was 9.9 years less than for settled men and 11.9 years less for Traveller women than for settled women.

It is not possible in a short article to cover The All Ireland Traveller Health Study in depth. The study covers a range of the complex issues affecting health, which include education and literacy, income adequacy, and enablers to training and employment. The key findings concerning the state of health of Irish Travellers were that Traveller infants were 3.6 times more likely to die before the age of one year than infants in the general population, which was worse than in 1987.

Traveller male life expectancy at 61.7 years was similar to what it was in 1987 and was at a similar level to that of males in the general population in 1947, when it was 60.5 years. A male Traveller can expect to die 15.1 years before his general population counterpart, which is significantly worse than in 1987. Traveller females now have a level of life expectancy experienced by the general population in 1960-1962, when it was 71.9 years, or put another way, they can expect to die 11.5 years earlier than their counterpart in the general population. Suicide rates in Traveller men are seven times that of the general population.

The cuts to Traveller health in Waterford included the withdrawal of a dedicated public health nurse for Travellers. This was a significant loss, as her presence aided such aspects as women registering for BreastCheck and CervicalCheck, identified health issues in children, and promoted attendance with GPs and hospital outpatient departments, etc. The Waterford Traveller Community Development Project and Traveller Health Projects have supplemented this deficit to some extent and I am thankful to Emma Maguire and Niall Devereux in this regard.

One of the principles of the Constitution of the World Health Organisation is that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being, without distinction of race, religion, political belief, economic or social condition”.

In deploying resources to meet the health, accommodation and educational needs of Travellers, this Government would demonstrate a readiness to mourn the death of five adults and five children in Carrickmines.

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Memoirs of madness and recovery

Mental illness is common, complex and costly, but it is personal suffering that lies at its very heart.

Mind on Fire: A Memoir of Madness and Recovery is a new book about one person’s experience of depression, mania and various other forms of psychological suffering. Written by Arnold Thomas Fanning and published by Penguin Ireland, Mind on Fire belongs firmly to a small but highly distinguished canon of work about personal experiences of mental illness and treatment in Ireland.

There are few, if any, surviving personal accounts of mental illness in Ireland from the 1700s or 1800s. This is very regrettable. In the UK in 1838, John Thomas Perceval (1803-76), son of Spencer Pervecal (1762-1812; UK Prime Minister, 1809-12), published an exceptionally valuable account of his 17-month stay at Dr Edward Fox’s Lunatic Asylum in Brislington, near Bristol.

In the US in 1908, Clifford Whittingham Beers (1876-1943) published his account of psychiatric hospitalisation, titled A Mind that Found Itself: An Autobiography (Longmans, Green and Co). Beers went on, in 1909, to co-found the National Committee for Mental Hygiene. Ireland, however, had to wait until the mid-1900s for similarly personalised accounts of psychiatric institutionalisation, with the appearances of It Happened in Ireland by the Reverend Clarence Duffy in 1944 (Christian Press) and Hanna Greally’s memoir Bird’s Nest Soup in 1971 (Allen Figgis and Co).

It Happened in Ireland presented an account of the Reverend Duffy’s six-month admission to Monaghan Mental Hospital in the mid-1930s. Duffy wrote that, prior to admission, he had developed the belief that a Communist cell had been established near his parents’ home.

Duffy wrote that the treatment of patients in the mental hospital was brutal and rough. Some of the attendants were more compassionate than others; however, while kind in manner and seemingly aware of the injustices endured by patients, even these attendants seemed powerless to remedy matters in the overall scheme of the asylum. Duffy provided an especially interesting account of his fellow patients, stating that most were there owing to diseases of the brain or mind, poor diet, lack of self-restraint or in order to avoid prison.

Similar issues came to the fore again almost three decades later in 1971, in another valuable, thinly veiled account of the Irish psychiatric inpatient experience, this time written by Hanna Greally. In 1943 Greally was admitted to St Loman’s Hospital, Mullingar, ostensibly for a rest, based on a civil committal signed by her mother, who died six months later. Greally was to remain in St Loman’s until 1962 when a newly-appointed doctor approved her discharge.

In her book, Greally described her tearful parting from her mother following her arrival at St Loman’s and painted a picture of grey walls, bad food and a profound lack of privacy. She wrote about treatments including sedatives, liquid paraffin, ECT (which Greally received) and insulin therapy. Following her period of six months in the admission ward, Greally spent six years moving between other wards, apparently based on efforts at behavioural modification (reward, punishment, etc.); seven years working in the hospital laundry; and a final six years in Prospect House, where there was less supervision and a certain amount of autonomy.

Ultimately, a change in medical staffing was accompanied by the establishment of a new rehabilitation centre to which Greally was discharged in 1962. She went on to work in Ireland and later travelled to England. Greally also wrote poetry, short stories and three full-length manuscripts, and made a memorable appearance on The Late, Late Show on RTÉ. Greally died in Roscommon in 1987, but Bird’s Nest Soup remains a valuable, if harrowing, account of her experience of an Irish mental hospital in the mid-1900s.

 Mind on Fire is a very welcome addition to this collection of memoirs. Fanning had his first experience of depression during adolescence, following the death of his mother. Several years later, as an up-and-coming playwright, he was overcome by mania and delusions. This was followed by a period during which Fanning was often suicidal, increasingly disconnected from friends and family, sometimes in trouble with the law and even homeless in London.

Fanning’s account of these experiences is unsparingly direct, searing and honest. An early passage provides a startling vision of an elated mind rushing along at high speed, tripping over itself as it leaps from topic to topic, generating unsustainable momentum that is somehow sustained for a seemingly impossible period of time. It is gripping to read and must have been exhausting to live.

Of course, many health professionals reading the book will hear much that is familiar: The symptoms of mania, the torment of depression and the devastation that episodes of mental illness wreak in the lives of sufferers and their families. But there is also much that is new. Fanning provides very affecting personal accounts of symptoms, explores the impact of illness and treatment on relationships (especially between episodes of care) and demonstrates the extraordinary ability of people to somehow live through deeply challenging mental states and to recover.

Mind on Fire is well worth a read and richly merits a place alongside the testimonies of the Reverend Clarence Duffy and Hanna Greally in the history of psychiatry in Ireland.

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The burning issue in healthcare

I know what you’re thinking. I cannot read another article on burnout.

But, before you move on, let me highlight some key lessons I have learned discussing the issue of physician burnout with the world’s leading experts.

Let me start by emphasising what this article is not about.

1. Physician suicides – As tragic as this growing problem is, it is unlikely to be the lever that is required to effect the changes we wish to see in healthcare.

2. Mindfulness as a treatment of burnout – As much as I am a proponent of contemplative practices, we need to understand that offering mindfulness classes is likely to make the issue of physician burnout worse rather than better.

Physician burnout is a quality and safety issue

Yes, the welfare of those working in healthcare is of paramount concern and a figure of more than 400 physician suicides a year in the USA alone is unacceptable. But largely this only ever results in a round of concerned statements from governing groups and organisational leaders. These announcements then fade into the background until the next tragedy strikes. Cue another series of concerned statements.

For organisational leaders to sit up and listen, the language must be of the key performance indicators of quality and safety. Physician burnout is tightly linked to several key measures of quality and safety in healthcare. To not address physician burnout is to not address fundamental quality and safety issues in healthcare.

Patients who are managed by burned out physicians are significantly more likely to suffer adverse events; to be less compliant with prescribed therapies; to be less satisfied with their care and even run a higher risk of dying during an inpatient admission. The literature is quite clear here; for every increase in a physician’s rating of burnout, medical errors increase proportionately with it.

Addressing physician burnout is not about having physicians like what they do; it is about delivering safe and effective healthcare. To not address physician burnout is to make healthcare progressively more unsafe and of lesser quality. Unfortunately, to achieve the desired effect of fewer physician suicides we will need to highlight its impact on patients; perverse logic I know, but ironically what is required.

Stop with the mindfulness classes

Acquiring a personal meditation practice is one of the most important skills I have ever developed and, in general, I am a major proponent of contemplative practices. However, to offer this as a solution to those who are burning out in healthcare, routinely enrages rather than enriches physicians.

The reason for this is that doing so shifts the onus of responsibility of tackling burnout, from the organisation to the individual.

The evidence is very clear here. Burnout is primarily caused by the environment in which people work, rather than the personality characteristics of the individual within it.

To address burnout, organisational leadership groups need to change the ecosystem, not the people. To think that a mindfulness class will make a difference is akin to arming someone with a better fire extinguisher as they run into a burning building. What we need is fewer burning buildings, not better fire extinguishers.

Change your mind or your environment

When it comes to changing your environment it may mean leaving a post or even the country, as evidenced by the number of unfilled GP and consultancy posts. Though that may seem drastic, if the ecosystem in which you foresee yourself in is unlikely to change in the near future then try not to be surprised when the inevitable occurs.

Choosing to stay means that one needs to develop a progressive attitude towards the immense task of changing the environment of healthcare; no doubt daunting, but possible in small stepwise increments.

The key to addressing physician burnout is in recognising it as a quality and safety issue, focusing less on the mindfulness classes and more on the ecosystem factors that drive the issue.

Burnout is a quality and safety issue. The question is: Are healthcare systems interested in quality and safety?

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Should patients with anorexia ever be force-fed?

Irish newspapers regularly feature reports of High Court rulings on anorexic patients. The story in nearly all cases goes like this: The patient’s doctors (psychiatrists and physicians) inform the Court that she is in imminent danger of dying and lacks capacity to make decisions about treatment. Invariably, the Court grants permission to proceed with involuntary treatment, including force-feeding. I have been involved in the care of several anorexic patients over the years, but thankfully I have never been asked to force-feed a patient. I have often thought about how I would respond to such a request.

Patients with severe anorexia are assumed to lack capacity, on the grounds that malnutrition impairs cognitive function, including the ability to make rational decisions about treatment. The sparse literature on the subject doesn’t really support this view. Dr Jacinta Tan, a psychiatrist and ethicist, has written several papers on capacity in anorexia. In a 2006 study based on interviews with 10 adolescent anorexic girls, she found that they performed well on standard tests of competence. A more recent 2016 study from the Netherlands investigated capacity in 70 adult women with “severe” anorexia, and found that mental capacity was “diminished” in a third, but was preserved in two-thirds. Many legal academics, such as Ms Beverley Clough of the University of Leeds, argue that the current binary approach to capacity in anorexia is crude and simplistic and may lead to violations of human rights.

I could find no data in the medical literature on outcome in anorexic patients who have been force-fed. There are occasional newspaper reports of cases returning to the High Court where doctors outline progress since the initial court order. I suspect — although I have no evidence — that some patients may indeed gain weight after force-feeding, but after discharge, revert to previous eating patterns and lose the weight briefly gained by force. Force-feeding doesn’t exactly foster a trusting relationship between patient and doctor either. Prof Penney Lewis, Professor of Law at King’s College London, wrote: “As her trust has been violated, she may be less likely to seek help for her anorexia or for any other medical problem. The gain has been short-term, rather than long-term. The immediate crisis has been averted, but long-term damage has been done.”

As a gastroenterologist, I have concerns about the insertion and maintenance of a nasogastric tube in a patient who doesn’t want to have it. Again, the literature has remarkably little to say on the subject. The only — very brief — discussion of the matter I could find was in the Royal College of Psychiatrists 2014 MARSIPAN Report: “Insertion of a nasogastric tube against the patient’s will usually require the presence of mental health nurses trained in safe control and restraint techniques, and psychiatric advice should be sought before embarking on this procedure.” Presumably, these tubes are kept in place with a nasal bridle, but a determined patient can dislodge both bridle and tube. I have often wondered who actually carries out the nasogastric tube insertion in these unwilling, and (presumably) sometimes actively-resisting, patients: The physician involved in the High Court application, or a junior member of the medical team? If the latter, do they have the right to refuse? Are the patients sedated? How exactly are they restrained? How is the patient then prevented from sabotaging the tube and the bridle?

Although the medical literature is conspicuously quiet on the subject, details on the mechanics of force-feeding can be gleaned from press reports on the US detention centre in Guantánamo Bay, where hunger-striking prisoners have been regularly force-fed. The procedure is complicated and much can go wrong. Navy doctors insert nasogastric tubes while the prisoners are immobilised in a specially-designed ‘restraint chair’. Although the head is immobilised with padding and a strap, even slight movements can cause pain, damage to the nose (bleeding and occasionally fracture), and it carries the risk of tube misplacement into the lungs. The prisoners are often held in these chairs for several hours while feeding is administered and then moved to a ‘dry room’, where they are given antiemetics and monitored to ensure they do not induce vomiting.

The physician or gastroenterologist generally becomes involved in the care of an anorexic patient at a moment of crisis. In an ideal world, the physician would be part of a multidisciplinary specialist eating disorders unit, but this is seldom the case in Ireland. Patients are often transferred as an emergency from a psychiatric facility to an acute general hospital when the BMI drops below 13.5, or there is metabolic or haemodynamic instability; the physician takes on the patient for the simple reason that they happen to be on-call. Earlier this year, the HSE launched the long-overdue National Clinical Programme for Eating Disorders. Hopefully, this will lead to the establishment of specialist units where physicians with training in nutrition can develop an expertise in eating disorders.

I have sympathy for psychiatrists treating gravely-ill anorexic patients. The mortality in this young population is significant and families commonly exert extreme pressure on doctors to ‘do something’. I’m just not convinced that force-feeding is the answer.

Prof Seamus O’Mahony is the author ofThe Way We Die Now’.

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We’re all going on a summer holiday…

There is an obligation to have your plans made, ideally months in advance, so that you can answer the hairdresser confidently when she asks, ‘have ya any holidays booked?’ To not have something up your vacationing sleeve is a societal faux-pas of the highest order. Of course, we medics are also obliged to suck our teeth in the manner of the builder faced with dodgy electrics, and say “if only I could get away, sure, there isn’t a locum to be had from here to the Arctic Circle… ”

Then you have the ‘resilience fighters’ whispering ‘burnout’ and ‘recharging’ and ‘early grave’.

So you MUST go on holidays, and it MUST be good, and you certainly MUST enjoy every minute, because it’s all been so expensive and complicated and aren’t you so lucky to be so happy and soooo relaxed (drinking your badly-ordered cocktail through gritted teeth).

If we are honest, there are probably only about 15 minutes in an average holiday day where we feel truly at peace, and that’s the moment when you open your eyes, the sun is shining outside, and you remember you don’t have to get up for work. You do have to get up though, because the children can’t reach the cereal in the holiday home cupboard or (worse) you have to get dressed to bring them to the hotel breakfast buffet (cold scrambled eggs, anyone?).

Over the years, my husband and I have made some fairly dodgy holiday decisions. We hired a convertible to drive on Highway 66 for our honeymoon, only for it to snow for the first time in 40 years and the soft-top roof of the car froze shut. We took a wrong turn in a camper van on the Alaska Highway, and ended up having to reverse down a glacier. We stayed in a B&B in Blackpool (England, not Cork), where a stag party dressed as magic mushrooms tried to break into our bedroom while we cowered under our 100 per cent nylon sheets.

This year, we opted for the self-catering-on-our-own-wheels theme, and rented a camper van in Madrid. We drove north, stopping at the small village of Riaza, which was about to host a huge American music festival, but we got out just in time. We made our way up to the coast west of Bilbao and screeched our way down a hairpin hill to a tiny beach with a cosy campsite, Playa de Arenillas. That was when the rain started. They don’t call it the Costa Verde for nothing. Lush green vegetation should have been a very strong hint to us that it is regularly irrigated by the cumulonimbus in the sky. But we didn’t mind. We had some very helpful advice from Maurice in the camper van directly in front of ours. Maurice was from Dublin, though his accent betrayed that he was from somewhere else originally but the kind of place a person denies any knowledge of once they move to Dublin (doesn’t happen to Cork people, I tell ya). Maurice had bikes and a wife and an adult daughter and was very obviously a professional at all things camper van-related. Thankfully, Maurice was not selfish with his vast wealth of wisdom and was kind enough to give us any advice we required. Any time at all. He was right there whenever we needed any little tips.

We drove away from Maurice.

But not from the rain. Our next stop was a fancy bells-and-whistles campsite, Playa Joyel. This was what the kids had been waiting for: Multiple swimming pools, loud music, oodles of potential friends that they would skirt around for days before finally summoning the courage to say ‘hello’, just as we were packing to leave. The beach was next to the campsite and on our first day, it was gloriously empty. Because it was soaking wet. Our great plan to avoid the heat was beginning to look a bit like the frozen cabriolet debacle all over again. But the sun came out again and we got out the sand-encrusted suncream and had ice cream for breakfast. Happy daze.

We moved on to Playa de Franca, with a stunning backdrop of the Picos de Europa mountains. There were huge, dark, drippy caves to explore and massive rolling waves to bodysurf, and football matches to watch with dozens of foreigners (and not a single nationality supported the poor English). Having failed to listen to Maurice’s sound advice, we nearly lost our canopy when more rain came and it filled and filled to buckling point. Thankfully, someone came running into the bar to tell us about the imminent disaster and I abandoned the penalty shoot-out to save our rental excess.

Two nights spent in a parched and landlocked campsite in La Cabrera outside Madrid reminded us why soaking beats heatstroke any time, but with two massive swimming pools and a playground next to the bar, realistically all our needs were met.

We held our breath as the rental man poked and prodded and inspected the van. I looked away as he passed his finger over the ground-in bits of tree embedded in the roof. He didn’t open the canopy. Phew! Deposit returned.

A successful holiday all round. And a few good stories for the hairdresser.

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Analysing Ireland’s health spending

The Central Statistics Office (CSO) released the 2016 figures for the System of Health Accounts in Ireland in June, which show not only how much we spent as a nation on health, but also by whom and on what. Although the headline figures tend to garner attention, digging a little bit deeper also uncovers some interesting patterns.

Let us briefly remind ourselves of the high-level figures. In 2016, we spent €20.3 billion on health, representing 7.4 per cent of GDP or 10.7 per cent of the new measure of GNI (drawn up by the CSO after GDP rose by a quarter in 2015 —the so-called ‘leprechaun economics’ phenomenon).  Of this spending, 72 per cent came from Government funding, with 13 per cent coming from out-of-pocket payments and 12 per cent from voluntary health insurance schemes (the remaining 3 per cent was accounted for by other funding sources, including charitable donations).

The main providers on which this money was spent were: Hospitals (36 per cent); ambulatory healthcare providers (20 per cent); long-term residential facilities (18 per cent); and retailers of medical goods (14 per cent).  The corresponding figures for 2015 (the last year for which international comparison figures are available on the Eurostat website) were 35 per cent, 20 per cent, 19 per cent and 13 per cent, respectively.

Despite some suggestions that Ireland is overly-reliant on hospital care, the expenditure figures actually rank us 23rd of 31 European countries in 2015 in terms of the proportion of health expenditure going on hospitals, with 13 countries spending over 40 per cent of their health budgets on hospitals.

The proportion of our spending going on long-term residential facilities in 2015 was second only to the Netherlands among 31 European countries, with 21 of those countries spending less than 10 per cent of their health budgets on this provider category.

In 2015, we were ranked 27th out of 31 countries in terms of the proportion of health expenditure going towards ambulatory healthcare providers (a category that includes much of what we would consider primary care).

However, what is perhaps more interesting in terms of this category — particularly given criticism of the relatively low expenditure on general practice — is the spending on the sub-category of medical practices, which includes GPs as well as consultants, some HSE mental health, primary care and Primary Care Reimbursement Service-funded services, and other public-funded expenditure in relation to the armed forces and prisons.

In 2015, we were ranked 26th out of 29 European countries in terms of the proportion of health expenditure going towards medical practices, with 4.55 per cent of the health budget being spent in this area. Interestingly, only seven countries spent 10 per cent or more of their budgets on this sub-category, while eight (including Ireland) spent less than 5 per cent.

When it comes to spending on retailers of medical goods, Ireland ranked 23rd of the 31 countries for the proportion being spent on this category, although there is quite a wide range on this measure, from less than 4 per cent in Liechtenstein to over 43 per cent in Bulgaria.

It is also interesting to examine the 2016 figures further in terms of where the money comes from for various providers. In this context, significant variations are evident.  Not surprisingly perhaps, given its heavy weighting in the overall figures, Government spending follows broadly similar patterns to the overall spending highlighted above.

However, out-of-pocket payments display a very different pattern, with less than 5 per cent of these being spent on hospitals, 25 per cent on long-term residential facilities, 41 per cent on ambulatory healthcare providers (including 13 per cent on medical practices) and almost 30 per cent on retailers of medical goods.

These figures reflect entitlements to services, whereby those who do not hold medical cards (or GP-visit cards) pay only statutory bed charges in public hospitals (while very few would self-pay in private hospitals), but must pay full charges for visiting primary care providers and a significant excess before the Drugs Payment Scheme threshold is reached.

Voluntary health insurance scheme spending displays a very different pattern again, with 78 per cent of spending going on hospitals, reflecting the fact that private health insurance benefits are largely focused on covering hospital treatment. Although many plans in recent years provide more generous cover for day-to-day benefits, less than 5 per cent of the spending goes towards ambulatory healthcare providers.

When looking at the figures broken down by healthcare function, the patterns already identified by provider are, to an extent, evident again.  In 2016, nearly 55 per cent of health expenditure went on curative and rehabilitative care, 22 per cent on long-term care (health) and 14 per cent on medical goods. Interestingly, just over 3 per cent was spent on preventive care, although in 2015 we were ranked 10th out of 31 European countries for this measure, which tends to account for a low proportion of spending internationally.

The above figures show that, while the headlines might be grabbed by a small group of findings, there is much of interest in the CSO’s System of Health Accounts figures and the European comparisons available from Eurostat.

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The ‘sanctuary’ of choice and liberty

Sanctuary is a 2016 feature film set in the world of people with intellectual disabilities. Just released on DVD, the movie tells a touching and funny love story about Larry and Sophie, two people who long to be together in a world that does everything to keep them apart. The film is set in Galway, directed by Len Collin, and released by Zanzibar Films in association with the Blue Teapot Theatre Company.

Sanctuary is both hugely enjoyable and ferociously relevant. In 2011, the census found that approximately 600,000 people in Ireland reported having a disability. That is around 13 per cent of the population, according to the National Disability Authority.

As a result, the issues raised in Sanctuary are relevant to virtually every family in Ireland. One of the film’s key themes relates to liberty and having the freedom to make your own choices when you have a disability. This is an issue of great relevance in contemporary Ireland for many reasons, not least of which is the Assisted Decision-Making (Capacity) Act 2015.

The 2015 Act was passed by the Oireachtas and signed by President Michael D Higgins on 30 December 2015. Preparations for implementation are underway. The new legislation will place the “will and preferences” of persons with impaired mental capacity at the heart of decision-making in relation to “personal welfare” (including healthcare) and “property and affairs”. 

This will include some, but by no means all, persons with intellectual disabilities because mental capacity is now to be “construed functionally”. This means that while a person might lack mental capacity in relation to one specific area (eg, finance), he or she might have mental capacity in relation to another (eg, healthcare). And while a person might lack mental capacity at one time, he or she might have mental capacity at another.

All interventions under the new Act must be made “in good faith and for the benefit of the relevant person”. The 2015 Act also presents a set of principles, including a presumption of mental capacity, provision of information and assistance, identifying clearly the necessity for any intervention, minimisation of restriction, dignity, bodily integrity, privacy and autonomy. Critically, making “an unwise decision” will not indicate lack of capacity. And for those with impaired mental capacity, the Act will introduce three levels of supported decision-making, along with new and revised procedures for “advance healthcare directives” and “enduring powers of attorney”.

The provisions of the legislation are complex and challenging but they are also hugely important, especially for people with intellectual disabilities. In 2004, the Government launched the National Disability Strategy in order to underpin the participation of people with disabilities in Irish society. The strategy built on existing policy and legislation, including the policy of mainstreaming public services for people with disabilities.

In 2013, a new National Disability Strategy Implementation Plan was prepared and agreed by the National Disability Strategy Implementation Group. The Plan emphasised the need for “a whole-of-Government approach to advancing the social inclusion of people with disabilities”. The 2015 legislation is another important advance in this area and will hopefully progress briskly from this point onwards. The appointment of a Director of the Decision Support Service in October 2017 was a step forward.

The Dáil’s decision to ratify the United Nations Convention on the Rights of Persons with Disabilities (CRPD) in March 2018 was also significant. The purpose of the CRPD (2006) “is to promote, protect and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities, and to promote respect for their inherent dignity”. The Convention specifies that “persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others”.

Dismantling these barriers is vital. It requires not just specific policy measures, but also a broad cultural shift in how disabilities are viewed. To this end, the CRPD emphasises a range of principles, including respect for inherent dignity, individual autonomy, independence of persons, non-discrimination, full and effective participation and inclusion in society, respect for difference, and acceptance of persons with disabilities as part of human diversity and humanity. The Convention also emphasises equality of opportunity, accessibility, equality between men and women, respect for the evolving capacities of children with disabilities, and respect for the right of children with disabilities to preserve their identities.

While Ireland signed the CRPD in March 2007, we only started formal ratification in 2018. And while the Convention undoubtedly presents challenges in a number of areas, it is a uniquely important articulation of the rights of persons with disabilities.

This issue is not new. In 1907, Dr Conolly Norman, a progressive medical superintendent at the Richmond District Asylum (later St Brendan’s Hospital, Dublin), lamented the absence of services for people with an intellectual disability. Using the language of the times, he said that “it is neither wise nor humane to neglect this class as they are neglected in this country”. Clearly there was — and still is — much to be done.

And that, essentially, is why Sanctuary is so important. The film explores key issues relating to disability in Ireland today, celebrates ability in people with disability, and is also hugely enjoyable to watch. I warmly recommend the DVD.

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