Paul Mulholland examines the latest updates on implementation of the national mental health strategy and uncovers continuing difficulties with meeting timelines
The national implementation and monitoring committee (NIMC) steering committee for the mental health strategy recently published two of its quarterly update reports on the implementation of Sharing the Vision.
The first report concerns the implementation status of the recommendations contained in the strategy for the second quarter of 2023. The second report provides an analysis of the implementation process over the same period.
Sharing the Vision is organised around four core domains: Promotion, prevention, and early intervention (12 recommendations); service access, coordination, and continuity of care (53 recommendations); social inclusion (nine recommendations); and accountability and continuous improvement (26 recommendations).
In response to feedback and the need for a more focused, qualitative approach to reporting, the NIMC steering committee is trialling, for the fourth time, domain-themed reports. While an update on all recommendations in the mental health strategy is provided, the two latest reports focus on ‘accountability and continuous improvement’ (domain 4).
Of the 100 Sharing the Vision recommendations, 55 are “on-track”; 26 have a “minor delay issue”; eight are “paused”; five have “not started”; and six have a “major delay issue”.
The NIMC stated the majority of recommendations in domain 4 (70 per cent) are “on-track”. However, it also noted two medium-term recommendations have yet to commence as they are dependent on the implementation of the new health region structure. The first of these, recommendation 75, states the organisation of mental health services should be aligned with emerging integrated care structures under Sláintecare such as the health regions. The second, recommendation 76, states implementation of the mental health policy over the first 10-year period should “achieve a re-balancing of resources and take account of population deprivation patterns in planning, resourcing, and delivering mental health services”. Implementation of the health regions is due to begin in February 2024.
Two recommendations under domain 4 have “major delivery issues”. They are recommendation 89, which concerns safeguarding and recommendation 100, which concerns specialist mental health training programmes. Recommendation 89 in Sharing the Vision states access to safeguarding teams and training should be provided for staff working in statutory and non-statutory mental health services in order to apply the national safeguarding policy. However, according to the latest implementation report, there is a need to update the existing safeguarding policy for this recommendation to be implemented. This is because the policy currently does not directly reference mental health services.
“The timeline for publication of a revised safeguarding policy that will incorporate mental health is yet to be confirmed…,” according to the report. The recommendation was one of 42 “short-term” recommendations, which were originally meant to be implemented by September of this year.
The report noted the mental health section in the HSE is exploring alternative methods to progress safeguarding across mental health services.
Recommendation 100 calls for a joint review of the two specialist training programmes by the College of Psychiatrists of Ireland and the ICGP to be undertaken to develop “an exemplar model of mental health medical training and integrated care”.
According to the implementation report, the HSE’s National Clinical and Group Lead for Mental Health was continuing to engage with both colleges to advance this recommendation, with the support of the National Office for Suicide Prevention (NOSP) and the ICGP National Clinical Lead for Mental Health.
The College of Psychiatrists of Ireland told the Medical Independent the review of training was “ongoing, not delayed”. In a separate statement, Dr Martin Rouse, the National Director of GP Training, ICGP, said progress in implementing the recommendation is being made through meetings with stakeholders. A pilot teaching model, resourced by the NOSP, is being delivered through the Sligo GP training scheme this month.
“This pilot model will be reviewed, with a view to rolling this model throughout GP training nationally,” Dr Rouse said.
Budget and funding
In the quarter two analysis report, the NIMC noted “with concern that for the first time… the problem category of cost and budget outweighs recruitment”.
The report stated that funding provided by successive Budgets has contributed to commencing implementation of many Sharing the Vision recommendations, including: Enhanced resources for community mental health teams; community adolescent and mental health service hubs and teams; adult crisis resolution services; increased supports in employment; peer support workers; bereavement co-ordination; and dialectical behaviour therapy, among others.
“While significant progress has been made, continued resourcing… is essential to ensure momentum,” according to the report.
“There needs to be evidence of more critical use of budget and financial resources in implementing [Sharing the Vision].”
Like the previous report analyses, the NIMC emphasised implementation of the strategy is “heavily dependent” on adequate recruitment.
The committee noted that the HSE approved the release of 303.7 previously designated Programme for Government posts for recruitment in 2021. Alongside this, Budget 2021 allocated new development funding for an additional 155.4 posts and Budget 2022 allocated new development funding for 325 posts. This provided an additional 784.1 posts across services.
“Significant progress was made in recruitment in 2022, and this continued in Q1 2023 with 36 new posts recruited in this quarter. There are 459.5 new posts in place, and the remaining 324.7 posts at various stages in the recruitment process.”
However, despite this progress, there remained a “significant recruitment challenge, resulting in underachievement in key aspects of [Sharing the Vision] implementation”.
The NIMC stated there were concerns about adhering to current timelines for implementation. The committee acknowledges factors that have impacted on delivery. These have included: Covid-19; the cyberattack on the HSE; the HSE restructuring process with the development of health regions; and “the complexity” of implementing recommendations across multiple departments and HSE structures.
“The Chair also acknowledged that planning and processes within large, complex organisations can be burdensome and having the structures in place to make policy work in action is challenging, but not insurmountable,” according to the report.
“Noting the robust policy implementation structures which are in place, the strong monitoring processes established an ongoing commitment to tracking delivery issues, an alternative timeline for implementation has been agreed in principle by NIMC.”
At the time the report was written, the NIMC was awaiting the outcome of the Department of Health’s consideration of the revised timeline proposal.
“The NIMC will continue to track and advocate strongly for recommendations to be completed on time,” according to the report.
Reference group concern
The analysis report also included a section on feedback from the NIMC reference group (RG). The reference group was established in May 2022 to provide the perspective of service users and family members. The RG wished to express serious concerns regarding the impact of timeline extensions.
“Life expectancy for a person with significant mental illness is 10-to-15 years less than the average population,” according to the RG section of the report.
“People experiencing mental illness do not have the luxury of time to wait for services. The RG is frustrated that workstreams have not engaged with external stakeholders who could have supported and expediated the implementation of a number of the short-term recommendations in Sharing the Vision. Some working groups have wasted valuable time replicating existing reports and services that are already available in the community. There appears to be still an unfortunate cultural mentality within the HSE that believes that everything needs to be created ‘in-house’. It has been a concern of the RG from the beginning of our work in reviewing reports in how many recommendations were delayed because of ‘explorations’, ‘reviews’, ‘framework developments’, and many of the other ‘buzz words’ that have been prevalent across all reports over the past 18 months.”
A spokesperson for the Department of Health confirmed the timeline for the implementation of the short-term recommendations has been extended.
“The initial timeline for delivery of the 42 short-term recommendations was by September 2023; for a variety of reasons including the impact of the pandemic and time needed to undertake and pilot complex initiatives, this timeline has now been revised to December 2024,” according to the spokesperson.
“The timeline for delivery of medium- and long-term recommendations will be given ongoing consideration by the Department of Health, with the Sharing the Vision policy due to conclude by the end of 2030.”