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Putting a price on mental health

To put it mildly, the past decade has not been the best time for the Irish property market. From the crash in house prices following the recession to the current housing shortage and rising rents, the market continues to lurch from one crisis to another. In healthcare, the failure to invest adequately in new infrastructure has been cited as one principle reason behind the perennial problem of emergency department overcrowding and long waiting lists. The prolonged delay in building the proposed National Children’s Hospital is symptomatic of the recent difficulty in delivering large scale capital projects in this country.

One area that has been particularly hampered by a lack of infrastructural investment is mental health. Even before the recession, capital investment in mental health was low. The proportion of the total health capital spend devoted to mental health services in Ireland has fluctuated between 2 per cent in 1997 to 5.7 per cent in 2000 before reverting to lower percentages in later years. In England and Wales capital spending in this area was much higher in these years – in the years 2000, 2001 and 2002, the percentage of total health capital expenditure allocated to mental health was 23 per cent, 24 per cent and 15 per cent, respectively, with most of the money being spent on buildings.

The Office of the Inspector of Mental Health Services has issued numerous critical reports on the reliance of HSE psychiatric services on outdated 19th century institutional buildings. The Office and other advocates have argued repeatedly that such structures, most of which have fallen into disrepair and neglect, are wholly inappropriate for the delivery of a modern health service.

The national mental health strategy, A Vision for Change, published in 2006, stated that a plan to bring about the closure of all old mental hospitals should be drawn up and implemented. The resources released by these closures should be protected for reinvestment in the mental health service, according to the strategy.

This proved easier said than done. No progress regarding the plan was made two years later when the College of Psychiatrists of Ireland published a document entitled The Lie of the Land. The document chronicled the failures and delays in providing capital development for community-based mental health services. It outlined “the widespread asset striping” of the old Victorian asylums and how the proceeds were not reinvested into mental health. The document said a more equitable, transparent approach to funding services could be developed to support the strategy’s goals.

Sales plan



Politicians and health officials were listening. Funds were needed to implement A Vision for Change and selling psychiatric buildings and land was recognised as a way to generate the necessary resources. In 2010, a plan was developed between the then Fianna Fáil Mental Health Minister John Moloney and HSE Estates for a large-scale programme of building sales and capital investment. In March of that year it was announced the HSE would dispose of surplus assets and reinvest an initial sum of €50 million in the development of  new mental health infrastructure. A similar amount was planned to be raised each year through the sale of psychiatric assets.

The Minister’s priorities included: Transferring acute admissions from St Brendan’s Hospital to Connolly Hospital, Blanchardstown; a new acute unit at Beaumont Hospital, Dublin, to remove all acute admissions from St Ita’s Hospital, Portrane; constructing a new acute unit in Letterkenny; a new community nursing unit in Clonmel and the closure of St Luke’s Hospital, Clonmel, in 2010; a new community nursing unit in Mullingar and the closure of St Loman’s Hospital, Mullingar, to mental health patients.

The plan, however, could not have come at a worse time. As a result of the recession, the property market crashed. Many planned sales were indefinitely delayed as the buildings would have gone for a fraction of their previous value. It soon became clear the aim of raising €50 million annually for mental health capital construction was unachievable. 

Money raised

However, while the plan failed to be fully realised, sales did not stop completely.

New figures provided to the Medical Independent (MI) by the HSE show how much money was raised through the sales of psychiatric buildings and land since 2010. According to the Executive, proceeds of all sales of property/lands by the HSE between January 2010 and January 2017 was €28.5 million. Of these sales, two involved the sale of lands associated with large psychiatric hospitals. These were the sale of 100 acres at St Loman’s in Mullingar for €3.5 million in 2010 and 57 acres in Letterkenny for €2.3 million in 2011. The rest of the proceeds were from the sale of smaller properties. St Senan’s Hospital in Enniscorthy, was also put on the market earlier this year. A spokesperson for Purcell Properties, who are handling the sale, told MI that terms with the proposed purchaser have been agreed and the process is currently going through the legal process, with a view to having the contract signed imminently.

“We believe the sale will go through and for all practical purposes, the building is sold,” they stated.

The spokesperson also explained the challenges of selling a property such as St Senan’s.

“This was a building of some 130,000 square foot and had never been for sale since constructed in 1860,” they said.

“Institutional buildings of that nature in provincial locations are very challenging to sell because of the limitations of end use. There isn’t a market in a town like Enniscorthy for offices, apartments don’t work provincially and there is a very substantial ‘what the hell do you do with it’ element. We have not had a building of this nature for sale for a number of years and we are not aware of similar [buildings] for sale anywhere in the south-east in recent times.”

Awaiting a new Central Mental Hospital

A major outdated mental health institution that remains to be disposed of is the Central Mental Hospital in Dundrum, which first opened in 1850.

This is despite the fact that approval has been received for the development of the new National Forensic Mental Health Services in Portrane and building works are scheduled with a completion date in 2020.

The Dundrum facility has been repeatedly criticised by the Office of the Inspector of Mental Health Services, which has stated the original Victorian hospital building is no longer suitable for the care and treatment of patients experiencing mental illness.

“Due to the age of the building it was not possible to minimise hazards, including ligature points, within the centre. While the approved centre had a schedule of maintenance work it was not possible to keep it in a good state of repair,” according to the 2016 report from the Office.

Like previous reports, the hospital was found to be non-compliant with regulations in relation to physical infrastructure.

The future of the hospital was raised in the Seanad last month by Fine Gael Senator Neale Richmond. He queried if the lucrative site was to be used for social housing, and said that local residents were concerned about what was to be done with the site when the hospital’s patients move to Portrane.

Replying to his queries, Fine Gael Deputy Damien English said the disposal or otherwise of the site of the Central Mental Hospital “cannot proceed until such time as the hospital is vacated following the completion of the new national forensic mental health service facilities at Portrane.

“However, I think it makes total sense, as Senator Richmond noted, for us to have this discussion and make plans for the future because 2020 is not that far away.”

Continuing, he added that: “It would make total sense to look at this site and, as the Senator rightly notes, involve the community in that conversation, including the needs of the Dundrum area and how they can be serviced.”

A spokesperson for the Department of Health told MI the Government’s commitment to delivering a new Central Mental Hospital is set out in the Programme for Government and funding has been earmarked for this purpose in the Capital Plan.

“Therefore, the construction of the National Forensic Mental Health Services Hospital in Portrane is not dependant on the sale of the Dundrum site.

“That said, there is a Government decision and policy as set out in A Vision for Change that proceeds from the sale of older mental health assets, such as the Dundrum site, will be reinvested in new developments within mental health.”

Following the signing of a contract in June, construction of the new 170-bed national forensic mental health complex started at Portrane. The new national centre will provide psychiatric care in a modern and high-quality facility that rivals the best abroad, according to the Government.

The new 120-bed national forensic mental health hospital at Portrane will replace the existing 93 beds at the Central Mental Hospital and will also provide a new 10-bed CAMHS forensic unit and a new 10-bed unit for mental health intellectual disability. In addition, the complex will include a 30-bed intensive care rehabilitation unit, the first of its kind in the country.

The projected cost is in excess of €160 million. The project will also involve a second phase at a later stage, during which new regional Intensive Care Rehabilitation Units (ICRUs) will be built in the HSE West and HSE South areas.

New developments

Although the recession hampered infrastructural investment, new facilities continued to be constructed, albeit at a slower rate than planned. The total capital investment in mental health infrastructure from 2010 to 2017 was approximately €226 million, according to the HSE, with the €28.5 million raised from property sales reinvested into mental health developments.

Mental Health Ireland CEO Mr Martin Rogan was HSE Assistant National Director for Mental Health for a number of years during this period. Mr Rogan acknowledged to MI that the property market crash delayed the sale of assets, but said there were some advantages in terms of construction.

“One of the few upsides of the recession, if you can find one, is that we have got really good value,” according to Mr Rogan.

“So we were able to build some excellent new facilities in mental health when builders were very happy to have something to do. And it became very attractive from a Government point of view.”

Examples of new developments include acute mental health units in Cork (€16 million); Beaumont (€13.5 million); Drogheda (€13.5 million); Limerick (€10 million); and Letterkenny (€5.5 million).

Mental health residential units were also opened in Clonmel (€7.5 million); Mullingar (€7.5 million); Ballinasloe (€4 million); Killarney (€12 million); and Wexford (€8.5 million); while child and adolescent residential units opened in Cherry Orchard in Dublin and Cork.

In spite of these developments, mental health advocates argue that there have not been enough new buildings.

A study commissioned by the Psychiatric Nurses Association (PNA) last year into the implementation of A Vision for Change found that while the strategy recommended the closure of traditional mental health institutions be accompanied by the provision of services in the community to which patients may be transferred, the failure to adequately resource community-based infrastructure has led to significant access problems. According to the study, this failure has resulted in a blockage of beds in acute units and hostels and the placing of patients almost to wherever there is a bed rather than to a unit that best serves their particular needs, as well as inequalities in service provision within and between regions.

Young people

Access problems are particularly serious for children and adolescents. Earlier this year the Mental Health Commission (MHC) stated that the continued admission of children and adolescents to adult mental health units remains a totally unacceptable but common feature of mental healthcare practice in Ireland.

The Commission’s 2016 annual report showed a downward trend in such admissions in that year compared to 2015 (a 29.2 per cent decrease), but figures for 2017 showed a continuing increase at the time of publication. The fact that the MHC was notified of 68 admissions of children and adolescents to adult mental health units in 2016 shows a stark failure to abide by established policy, according to the chairman of MHC Mr John Saunders.

One reason for this trend is a fall in the number of beds for child and adolescent mental health services (CAMHS).

The decline is due to a shortage of personnel to staff them, geography, clinical decisions and family preference. At the end of May 2017, there were 77 operational beds for the CAMHS service, a decline of 16 on the same time last year.

Insufficient replacement

The argument made by the PNA is that while many of the old institutional buildings have been shut down in line with the mental health strategy, there have not been a sufficient number of new community units constructed to replace them.

In 2006, 17 approved centres were operating in inappropriate institutional settings. By 2016, only three remained, according to the MHC’s annual report 2016: The Central Mental Hospital, Dundrum; Maryborough Centre, St Fintan’s Hospital, Portlaoise; and St Davnet’s Hospital, Blackwater House, Monaghan.

In a previous interview with MI, PNA General Secretary Mr Peter Hughes said that, ultimately, A Vision for Change was used as a cost-saving measure by the HSE in closing the old hospitals, but not opening enough new units. Continuing staffing shortages also mean the units that have been built face significant operational difficulties.

President of the College of Psychiatrists of Ireland Dr John Hillery told MI that there are continuing problems with finding out whether public money earmarked for mental health services and infrastructure in Ireland, is actually put back into the service.

“We were promised the majority of the money would go back into the mental health budget,” according to Dr Hillery.

“I am not sure if it is possible to trace that. There are two negatives regarding the sales. The first was totally outside the control of the people planning this, which was the recession. But I do think there was a slowness about doing it, but there were a lot of reasons for that. The second one then is where the money goes. Does it go into the general pool, does it go into the general health services pool or does it actually target what it was meant to do at a local level. I was involved in a few areas of the country and it was meant to go back into the local services to ensure there were structures – both concrete structures and personnel structures – for community services, which we all wanted to have. I am not sure if that is possible to trace. We hear amounts of money bandied around … the Department of Health will announce a certain number of millions for mental health services, then the mental health section of the HSE will say ‘We haven’t received that money yet’. So it is very difficult for people like myself, either as a practising psychiatrist or as someone involved in the advocacy and training area in the College to actually know what is really happening. That is not good. We have as a College looked for clarity about what is actually going on.”

Given the term of A Vision for Change came to an end last year, a national review of mental health policy is currently being undertaken by the Department of Health. Ensuring there is sufficient capacity within the psychiatric system will be a central part of this. As ever, the willingness of the Government and the HSE to fund the construction and staffing of new units will be key to the success of any future strategy.

Sample list of mental health property disposals since 2010

2010

Land at St Claire’s, Glasnevin  &nbs €1.36m

Land at St Loman’s, Mullingar  &nbs €3.5m

Site at Trim Civic Offices    €0.81m

2011

2 x House, Tuam Rd, Galway   & €0.5m

Lands in Letterkenny  &n €2.3m

75 Eglington Rd, Donnybrook  &nb €1.35m

CPO of lands at Ballyboden  &nb €0.55m

Borris HC     €0.11m

2012

Houses in Midlands    €1.83m

Maysal Lodge, The Ward   &nb €0.29m

Lands at Clonbrusk, Athlone    €0.5m

Dundrum HC     €0.37m

County Infirmary, Navan   &n €0.26m

2013

Carbury HC        €0.49m

GU Building, Meath Hosp Campus   & €0.65m

The Vinyard, Rathdrum    €0.13m

Lands at Clara Rd, Tullamore     & €0.15m

69 Beneiven Rd, Dublin    &          €0.18m

2014

Ballyfermot HC      €1.06m

Lands in Ballybofey    &             €0.51m

75 Terenure Rd, Dublin    &        €0.35m

Clonard HC     &    &   €0.16m

Kill HC     &    &          €0.42m

2015

157 Rathgar Rd    &                   €1.51m

House, Weafer St, Enniscorthy  &n €0.22m

House, Crossabeg, Wexford    &   €0.15m

2016

Borrisoleigh former convent    &   €0.26m

Deilginis HC     &    &   €0.19m

House, Ashe Rd, Nenagh    &       €0.15m

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