Concerns growing among psychiatrists about incoming legislation

Consultant psychiatrists have raised issues about the Mental Health Bill at recent meetings held by the IMO and the IHCA. David Lynch reports

In mid-April, the Irish Hospital Consultants Association (IHCA) held a psychiatry symposium in Dublin on the Mental Health Bill 2024 and wider resource challenges. Later in the month, the Irish Medical Organisation (IMO) focused on similar issues during a session at its AGM in Killarney, Co Kerry.

Different locations and different organisations, but both events were united by a single theme – psychiatrists are worried.

There are numerous reservations about the new bill, but they principally focus on the issue of consent to treatment and involuntarily admitted patients.

At the IHCA’s symposium, Dr Donal O’Hanlon, Consultant Psychiatrist and former IHCA President, told the Medical Independent (MI) there was “significant concern” within the community of consultant psychiatrists regarding the bill.

“Because we really want to be in a position… [to help] those people who lack capacity and where the State has to intervene in order to help restore them to health,” he said.

“We want an efficient and stress-free journey for those patients to improve their chances of recovery… we are quite concerned that this bill doesn’t provide that.”

In response to the Mental Health Bill, the IHCA has produced a new position paper. Dr O’Hanlon said the Department of Health had previously taken on board some of the Association’s representations “which I think is good”.

“It helped the draft bill to be a better piece of legislation,” he added.

“But the biggest area of concern we have at the moment is really to do with consent to treatment” for the minority of patients who lack such capacity.

Complexity

Under the current system, there is a single level of oversight through a tribunal for these cases. The draft bill proposes more stages, he said. This includes retaining the tribunal or a review board, but it also requires a Circuit Court order for treatment decisions where a patient lacks capacity – and, in certain instances, even a High Court order.

Dr O’Hanlon said this new scenario would prove “very difficult” for patients.

“It will create an awful lot of stress – instead of one hearing we will have three.

“It’s not clear how all those stages will operate. I would hate to have to see patients having to go publicly to the local Circuit Court, for example. We do our best to try and reduce stigma, to reduce the stress of being an involuntary patient in hospital.”

He explained that such a structure could also lead to delays in treatment, negatively altering the long-term prognosis for patients.

Dr O’Hanlon said this was an important moment in terms of the future trajectory of the bill and he encouraged doctors to raise their concerns with public representatives and others.

“I think [there should be] more engagement with all the people who will be involved in this process, including service user groups, patient groups, the IMO, the IHCA, College of Psychiatrists… that would be really valuable. I think that would lead to it being a better, more informed, and more modern bill.”

Launching the Association’s position paper at the symposium, IHCA Vice-President and Consultant Psychiatrist Prof Anne Doherty said: “While we welcome the broad principles of the Mental Health Bill, we, as an Association, have some concerns in relation to ensuring that legislation is workable in practice so that patients can access services in a timely and care-focused manner.”

The IHCA said it remained committed to constructive engagement with the Department and Minister for Mental Health Mary Butler on legislation that “can transform psychiatric care in Ireland, bringing it in line with international best practice”.

‘Unworkable’

Speaking to MI at the IMO AGM, the Organisation’s consultant committee Chair Prof Matthew Sadlier said the current bill was “not workable”. The AGM had a session titled ‘Confronting the care deficit for patients with severe and enduring mental illness’. In addition, Organisation members passed a motion put forward by Prof Sadlier calling on the Government to ensure recommendations of the previous Oireachtas committee on mental health were not adopted into the Mental Health Act as they posed “significant risks to future patients and will have an overall negative effect on the most vulnerable in our society”.

Prof Sadlier, a Consultant in Old Age Psychiatry, told MI that “unfortunately, there are lots of things that need to be changed” in the draft legislation.

“There needs to be a connection between services, logistics, and law – but the problem here is that there is none in this [bill].”

He said there were not enough “authorised officers” in the country to deal with the reforms envisaged in the bill.

“You won’t ever get enough authorised officers appointed on a 24/7 roster in order to have them available to start a detention under the [bill].”

Prof Sadlier feared that, as a result, people might be held illegally in emergency departments, garda stations, or otherwise outside of mental health facilities because the legalities of getting them into a mental health facility “will be impossible”.

He also said the proposed bill raised diagnostic concerns.

“It’s another sign that the Mental Health Commission, and the Oireachtas sub-committee on mental health, do not understand mental illness,” said Prof Sadlier.

“They have such a superficial opinion of what a mental illness is, of what neuroscience is, of the complicated neurobiology behind psychiatry, and it is just a slap in the face for everybody.”

He said that there was widespread concern among those working in the specialty.

“I do not know one consultant psychiatrist who does not feel that this is going to lead to a significant deterioration of their ability to care for their patients.”

Prof Sadlier said involuntary admissions occurred infrequently and he was unsure why the proposed changes in legislation were necessary.

“Our detention rate is half of what it is in the UK… under the Mental Health Act 2001 there is a system of checks and balances for people who are admitted under the Mental Health Act. There is a tribunal; there is an external review of the admission.”

Prof Sadlier said that the bill would have to change. But if the bill is introduced as currently drafted, the change would occur only after a period of “absolute chaos” in the system. 

In November, President of the College of Psychiatrists, Dr Lorcan Martin, told MI certain provisions in the Mental Health Bill 2024 represented “the greatest threat to our patients’ wellbeing for some considerable time”. Dr Martin, a Consultant in General Adult Psychiatry, said the legislation was a “major challenge facing the specialty”.

Dr Martin also addressed last month’s IHCA symposium and IMO AGM, where he reiterated his serious concerns about the draft legislation. At the Association’s symposium, he emphasised this was an important moment in the development of the bill, and that members of the specialty and others must raise their concerns.

The Mental Health Bill passed second stage in the Dáil last September. At the start of the current Dáil term, Minister Butler restored the bill to the order paper at committee stage.

According to a Department spokesperson, committee stage is expected to commence “in the coming weeks”. Asked whether the Minister was still open to feedback on the draft bill from medical bodies, the spokesperson said Minister Butler and Department officials “have engaged extensively with stakeholders” throughout the drafting of the bill.

“The Minister and officials have continued to meet with stakeholders following publication of the bill last year. Amendments to the bill have been prepared in light of consultation with stakeholders and will be presented at committee stage in the coming weeks.”

The IHCA position paper on the Mental Health Bill 2024 is available at: www.ihca.ie/_fileupload/ihca-positionpaper-final.pdf

Seeking resolution – success and challenges of a crisis service

A mental health crisis resolution team in the HSE Sligo-Leitrim area has made a positive difference to patient care, but is experiencing staffing deficits, according to Dr Elizabeth Gethins, Consultant Psychiatrist, who is a member of the team.

The multi-disciplinary service treats patients at home and out-of-hours. It was formed following a significant increase in patients with mental health conditions presenting to Sligo University Hospital’s emergency department (ED) during the Covid-19 pandemic, Dr Gethins told the Irish Hospital Consultants Association (IHCA) psychiatry symposium last month.

The service has helped to reduce the number of people admitted from the ED to the adult mental health unit in Sligo. It has also received positive feedback from patients. The HSE created a national model of care in 2023 based on the experience of the Sligo team.

However, staffing and recruitment difficulties have hampered the service.

“It’s a systems issue,” Dr Gethins told the Medical Independent. “For example, we have a senior occupational therapist who is on maternity leave and there is no provision in finding a replacement for her. So there is no occupational therapist [now] on the team. We flagged up the fact that one of our CNSs [clinical nurse specialists] was retiring at the beginning of April last year; we had flagged that for months. A year later and we still have not had her replaced.

“At one point we did get permission to replace her, but the very same day we were informed that the CNS panel had been dissolved.”

Dr Gethins said there has been a series of “deep issues” within the HSE regarding recruitment.

“We’ve gone from the moratorium on staffing and recruitment to a Pay and Numbers Strategy, but nobody knows what the pay and numbers are.”

She said there seemed to be an attitude of “kicking the can down the road in regards recruitment” within the health service.

Such challenges are having a direct impact on staff in the Sligo crisis resolution services and other areas of the health service.

“The goodwill of the staff, who are invested in this service, is being abused.”

Dr Gethins said staff “are carrying leave over… so we’ve not been able to take the leave we are entitled to”.

She raised concerns in relation to staff burnout and the possible impact on the quality of service provided.

“We’re invested in this service, we want it to work, we want it to be safe, and we want to protect our colleagues as well as the people we work with.

“I know this [recruitment and retention] is not just an issue with our crisis resolution service, it’s an issue across the board.”

The feedback from patients in the Sligo crisis resolution service has been positive. The model of care it provides “absolutely could be rolled out in every part of the country”, she added.

Dr Gethins noted there are currently five similar pilot projects where the model of care is being introduced “to try and see how it works [and] learn from that before finalising it”. It is enshrined within the Sláintecare strategy that the health service should have the capacity to manage mental health crises. “So that is something we should be all working towards.”

“The difficulty, of course, is that the pilot project has been delayed in terms of rolling out because of the recruitment restrictions,” she said.

Dr Gethins added that a research and evaluation study has been commissioned on the pilot projects, with results expected shortly.

“But the meaningfulness of that exercise will have been impacted because a lot of teams aren’t up and running fully; they aren’t fully functional. A lot of teams are just nine-to-five, Monday to Friday, for example. So they have not been able to run with the full flow of what the model of care is.”

She added that these issues are “delaying” the introduction of the services.

During her address at the IHCA symposium, Dr Gethins also noted “housing insecurity” as a challenge faced by a number of patients who engage with the service.

“And… when we are looking at ‘bed blocking’ within hospitals – getting accommodation for people to move on to has been increasingly difficult.”

MHC report

Last month, the Mental Health Commission (MHC) published a new report demonstrating substantial variations in the level of mental health services provided in hospital EDs across all health regions in Ireland.

According to the report, Acute Mental Healthcare in Hospital Emergency Departments in Ireland, there is a need to increase the range of acute mental health services to improve urgent access and quality of unscheduled mental healthcare.

Mental health assessment in EDs was associated with substantial delays, especially for out-of-hours assessment, and there was a “poverty of appropriate space” across most departments. The report also included references to prolonged and inappropriate placement in EDs of children seeking acute support.

“Every year, an estimated 51,000 people access mental health services for the first time through a hospital emergency department,” according to MHC Chief Executive John Farrelly.

“It is clear from the Inspector’s report that model 4 hospital emergency departments are overburdened and need to be supplemented with services in lower-level hospitals, or in the community where people need them most.”

In response to the report, Minister of State for Mental Health Mary Butler said it was the Government’s ambition to develop “alternative care pathways and therapeutic environments” to reduce the number of people who have to attend emergency departments for acute care.

This work included the development of crisis resolution teams and the “establishment of crisis cafes working out-of-hours and in the community to enable recovery”.