As the Mental Health Commission launches its strategic plan and rolls out the decision-making support service, Niamh Cahill examines the challenges facing mental health services
The Mental Health Commission (MHC) was established just over 20 years ago under the Mental Health Act 2001.
While improvements in mental health services have been made since that time, MHC Chief Executive Mr John Farrelly told the Medical Independent (MI) further developments are essential.
“Compliance in mental health services is on an upward trend. Over the last number of years the inpatient services we regulate have improved significantly,” according to Mr Farrelly. However, he also warned of the need for greater funding to improve a number of inpatient facilities.
“The quality of a number of HSE premises remains a concern, especially in Cork, and capital investment is required.
“There is more room for improvement in key areas, most notably premises, risk management, and care planning. There is a lot more to achieve in relation to community services which remain unregulated.”
The MHC recently launched its Supporting Change: Strategic Plan 2023-2027. The document is the Commission’s seventh strategic plan.
It highlights areas where improvements are needed, including the need to support the human rights of people who use mental health services.
The plan was published as the Decision Support Service (DSS), which commenced in April, launched nationally, and coincided with the introduction of a new national quality framework by the Commission.
These developments come as the Commission’s regulatory remit is expected to extend to community mental health settings in about a year’s time through the new Mental Health Act.
The strategic plan and framework are aligned to and support the roll-out of the Government’s mental health strategy Sharing the Vision.
In its role, the MHC regulates and inspects approved inpatient mental health services in Ireland, as well as ensuring the development of service standards.
Staff numbers have increased from 50 in 2018 to 132 currently, which reflects the growing remit of the Commission, which must inspect all inpatient residences at least once a year.
Decision Support Service
The DSS is provided by the MHC for adults who have difficulties with decision-making capacity.
As reported previously in MI, the establishment of the service has faced numerous delays. The DSS was expected to be established in 2018, but this deadline was not achieved. The MHC then aimed to establish the service in 2020. However, this was also not possible due to a range of factors. The MHC board heard in January 2020 that key issues relating to funding, the ICT project and governance had “not yet been fully addressed” and would delay the roll-out of the initiative. The Covid-19 pandemic then caused further challenges in its establishment.
In September 2020, the Director of the DSS Ms Áine Flynn warned its launch may be delayed beyond 2022 if it did not receive its requested budget allocation in Budget 2021.
In June 2022, the Department of Children, Equality, Disability, Integration and Youth formally notified the DSS that amending legislation necessary for the full commencement of the Assisted Decision-Making (Capacity) Act 2015 would not be passed before the summer recess.
The DSS had been working to a time-bound and costed plan to have the service fully established by mid-2022.
However, now the DSS is established, and MHC Chairperson Dr John Hillery said it is a revolutionary service, which marks a huge change for clinicians and those who need support making decisions.
Dr Hillery, a Consultant Psychiatrist, has spent the past 25 years performing ward of court assessments and is extremely pleased a more equitable system will now be offered to those who need support making decisions.
The new system abolishes the outdated ward of court option under use in Ireland since the Lunacy Regulation (Ireland) Act of 1871.
All current wards of court are undergoing review and will be discharged from wardship within three years.
“The sadness of sitting down with someone who knows they need help with decisions and you’re explaining to them the only option is the ward of court where they lose all control of their life,” Dr Hillery said.
“We’re now moving from that Victorian legislation to a very person-centred approach where support will be available for decisions at a level that’s needed. It’s revolutionary, it’s resource intensive, but it’s very human and allows everyone to be more equal citizens of the State.”
The service will assist people with an intellectual disability, mental illness or acquired brain injury, as well as people with age-related conditions. It can also assist people who wish to plan ahead for a time when they might have diminished decision-making capacity.
Mr Farrelly described the DSS as a “critical new State service, which puts individual will and preference at the centre of all decisions”.
He added: “It provides new tools for any adult who wishes to plan ahead by way of an advance healthcare directive, or a revised form of an enduring power of attorney. The DSS can also support people to plan for the future by utilising these tools. It is a service that can be used by anyone and I would encourage all adults out there to plan ahead.”
Mr Farrelly told MI the national quality framework sets out the themes, standards, and associated criteria from which providers of services can benchmark and deliver quality and recovery-oriented mental health services across the State.
It is a revision of the original quality framework published in 2007.
“This new and revised evidenced-based framework is applicable to all mental health services including inpatient services, community residences, and community mental health services,” he said.
“The framework encourages quality and continuous improvement. However, until the new Mental Health Act commences, these community services will remain unregulated and the MHC cannot provide any assurance on the quality of these services.”
At the launch of the framework, MHC Director of Regulation at the Mental Health Commission, Mr Gary Kiernan, said that it includes a new digitised self-appraisal toolkit to help mental health services perform online self-assessments. The toolkit allows oversight of quality criteria across multiple sites at service, regional, and national levels, he added.
According to Dr Hillery, the framework provides a roadmap or guidance for people using mental health services and their families, so that they are fully informed about the levels of care and standards that should be provided.
He stressed that the Commission wishes to work with and not against staff, who sometimes operate in difficult environments with limited resources.
“The quality framework, a lot of the ideas it contains are pointed at delivery of resources for frontline staff to do their work….
“Mental health services need to be considered and robust, and to be a place of safety for people feeling vulnerable and ill and for the people who work with them so that they can support them. That is all about structure and resources before you then start talking about staff, because there are issues getting staff. In ways it’s a circular problem, because if you don’t have proper places for people to do their work and you don’t have proper teams, then you won’t attract people into those places of work.
“There are a lot of monies being put in and things are happening, but the Commission has still had to point out issues in the last year or so about certain places. While we’re just dealing with inpatient services now, the new [Mental Health] Act will likely extend the mandate of the Commission to community services. The Minister has told us it’s now a priority for the next Dáil term so that’s good news and we wait to see how that develops. It is really important we realise that psychiatry is a community-delivered health service, but you need proper places in the community to do that. That’s why they should be regulated. Since the introduction of regulation in inpatient services a lot of improvements have come from that, but that’s the minority of where treatment occurs, so the other extension has to happen.”
The targets outlined in the plan are “ambitious”, according to Dr Hillery. However, he argued that the aims are achievable.
“We describe it as ambitious, but it’s also necessary. Sometimes when the word ambitious is used I think people say ‘ah well that’s a get out clause’ and will be hard to do. But I look at ambitious as being a positive thing,” he explained.
The strategy contains five priorities it aims to achieve by 2027. They include promoting and supporting assisted decision-making in society; driving standards and improving quality in approved centres; acting in the public interest; communicating and engaging to promote the voice of mental health service users; and being a leading voice in mental health and assisted decision-making.
However, Dr Hillery pointed out there is only so much the Commission can do without greater State investment in mental health services.
“The Commission inspects services and determines whether or not they are fit-for-purpose and what changes may need to occur for that to happen, but we cannot finance services, build buildings, and employ staff,” he stressed.
“That’s why in our new strategy we’ve [highlighted] the fact that we want to work with people to make improvements, but without the main service providers responding this is challenging.”
Almost €73 million for mental health services was announced in Budget 2023, representing the largest ever single year commitment to funding in mental health services in Ireland.
Around €44 million is to maintain existing service levels, €14 million is for measures contained in Sharing the Vision and €15 million is once-off funding.
But more funding is required to boost service levels and to ensure greater equality and uniformity of service levels nationally.
Child and adolescent mental health service
Dr Susan Finnerty, Inspector of Mental Health Services, will retire later this year and a replacement for the role will be announced shortly.
Her interim report into operations at the child and adolescent mental health service (CAMHS) highlighted severe gaps in care for children and the difficult working environments for staff where important team members are lacking.
“In Dr Finnerty’s interim CAMHS report, she stated how staff are working in difficult environments without the supports needed to do their work,” Dr Hillery said.
“What often gets said about the HSE is that there are too many administrators. But a lot of the problems we’ve come across is that there are not enough frontline administrators for simple, but important work, like the receptionists in clinics, people to answer phones, triage patients and ensure people are followed up, that’s not uniformly available across the country.
“There’s a lot of things needed to support clinicians to do their work. The CAMHS report found that clinicians are doing this administrative work, but it should be done by others who are equally important members of the team. But that can get lost in the discussion of, ‘oh well we’ve too many administrators in the HSE’.”
The report found that children were being “lost” in the system, meaning they were not given an appointment in some cases for up to two years.
Inappropriate monitoring of children prescribed antipsychotic medication was also described, as well as staff deficits.
The second, final report on CAMHS is due to be published imminently. According to Dr Hillery, the first report was issued due to the concern “things weren’t moving on”.
“But we’ve got a lot of reassurance [from the HSE] since then.” Dr Hillery said there will be more discussion when the final report is published.
Mr Farrelly said Dr Finnerty is currently working to complete the final report and it will be launched in the coming months. “It is not possible to say at this early stage whether lessons have been learned,” he said.
Recruitment and retention
While a shortage of mental healthcare professionals is a global problem, greater efforts could be made to boost staff numbers in Ireland, according to Dr Hillery. This includes increasing the number of training places provided to students.
“We need to train more people across the disciplines,” he said.
“There is a problem in certain disciplines about the number of training places that are available; clinical psychology would suffer a bit from that. That’s about financing training and making it more attractive. I think it is attractive, but there are issues how people training in various disciplines are encouraged to go forward. So in medicine, for instance, we know historically, not just in Ireland, there is an inherent bias against psychiatry and general practice that’s known as the ‘hidden curriculum’ where people are told ‘why would you want to be doing psychiatry or general practice’ when you could be doing something like medicine or surgery.
“That’s something both the College of Psychiatrists and the ICGP have been fighting against and are looking for resources to employ more trainees and ensure the training is robust. That’s a constant battle because one has to prove this is necessary and one has to fight the claims of limited budgets from others.”
The Commission released eight inspection reports in May this year. All of the reports highlighted “risks associated with an inability to recruit and retain staff, which results in an inappropriate skill mix to meet the needs of residents”, Dr Finnerty said at the time.
Poor practices included insufficient numbers of registered psychiatric nurses, among other vacant posts, insufficient staff training, and fire safety risks.
Despite challenging work environments, however, Dr Hillery argued that psychiatry is a very interesting and diverse profession.
“It’s a very varied career with lots of different options,” he said.
“We have to ensure people work in places that allow them to do their work and support them in doing their work and taking time to do their work.
“The trouble is there is a lot of firefighting that puts people off staying in the area and as people leave there is more firefighting as there are less people to deal with emergencies and less time. If you have 50 people to be seen in a morning, it’s at odds about our thoughts of psychiatry when we’re junior doctors or students where we’re taught it’s a place where you have time to give people and listen to their stories and formulate a plan with them.”
Dr Hillery also pointed out positive outcomes in psychiatry are not always tangible in terms of figures.
“Psychiatry is about soft outcomes. Did you get people back to work? Did you get people back into the community with their family? Those outcomes are hard to capture.”
The Mental Health Commission published its Annual Report 2022 on Friday 9 June.
The report, which includes the Annual Report of the Inspector of Mental Health Services, highlights that there has been an overall and continued improvement in compliance across all services when comparing pre- and post-pandemic figures.
However, it shows that just 27 per cent of centres were compliant with the regulation on premises, a drop from 2021 when 33 per cent of centres were compliant with the same regulation.
“Compliance with the regulation on premises has been low over the past five years, most particularly in a number of HSE premises,” according to Chief Executive of the MHC Mr John Farrelly. “Many of our premises are simply not fit-for-purpose for a modern mental health service and this is something that we have been saying for many years and will continue to do so until things change. To be clear, a targeted, funded strategic capital investment programme is urgently required now in our public system.”
Individual care planning
Just over 30 per cent of centres were not compliant with the regulation for individual care planning. “While there is clear clinical leadership evident in some centres – and the individual care plan is the blueprint for the resident’s care, treatment, and eventual recovery – in others, the basic concept of care planning does not seem to have been understood or appreciated. Goals are vague and meaningless and obviously not developed with residents,” said Mr Farrelly.
The MHC has written to the HSE seeking an updated action plan to address the significant issues raised in its annual report, particularly around premises, individual care plans, staffing, and risk management practices.