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The future looked bright for mental health services just over a decade ago. A new comprehensive strategy, A Vision For Change, was launched in 2006. It promised a radical overhaul of services, transforming the model of care previously centred in psychiatric hospitals to one that would be community-based. Significant investment was promised for new facilities and teams.
And then the recession happened. Promised investment never occurred. The sale of psychiatric assets, which was needed to fund new facilities, did not proceed to the scale envisaged. The moratorium on recruitment meant most mental health teams, both in adult and child psychiatry, had significant personnel gaps.
Last year, a joint report by the Psychiatric Nurses Association (PNA) and the RCSI examining the implementation of A Vision For Change was published. It found that the failure of the national mental health system to translate the principles of recovery into meaningful practice stemmed from not providing key resources vital to the full implementation of the strategy. Severe staff shortages emerged as the most striking deficiency in the functioning of the mental health services, impacting on all levels of service provision.
The document confirmed that services have been reduced without the proper replacements being put in place and numbers of staff have been reduced, despite a growing care demand.
The study found that while A Vision For Change recommended that the closure of traditional mental health institutions be accompanied by provision of services in the community, the failure to adequately resource the community-based infrastructure has led to a deficit in patient-appropriate options. While there were 4,173 mental health service inpatient beds in 2004, there were only 1,656 beds in 2015, which represents a 60 per cent drop in bed numbers. Between this period, the number of community residential beds also fell from 942 in 2004 to 285 in 2015.
The failure to provide sufficient community services has led to 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.
PNA General Secretary Mr Peter Hughes told the Medical Independent (MI) that the lack of implementation of Vision mirrors what happened with the previous mental health strategy, Planning for the Future, which was launched in 1984. Mr Hughes said that Vision, like the previous strategy, was used as a “cost-saving measure”.
“To date, we have seen two mental health strategies over the last number of years,” Mr Hughes said. “I have to say, both of them were used to decimate mental health services. They were used to close beds, but not put the alternative in place. At the time, we would have welcomed A Vision For Change. In the end, we saw plenty of vision, but no change.”
CEO of Mental Health Ireland Mr Martin Rogan sees things differently. For Mr Rogan, who was HSE Assistant National Director for Mental Health during the time Vision was being implemented, both mental health strategies were launched at unfortunate times in terms of the economic climate.
Mental health funding has grown in recent years, with the national gross non-capital budget rising from €711 million in 2012 to €853.1 million last year. However, in 2016, Ireland spent 6.4 per cent of the overall health budget on mental health, even though Vision recommended this should be over 8 per cent. In the UK and Canada, 13 per cent of the health budget is allocated to mental health, while in New Zealand, it is 11 per cent. In 1984, in Ireland, mental health spending as a percentage of the health budget was 13 per cent. Although during 2016, funding of €35 million was received by the HSE for the continued development of new and existing mental health services, in other years such funding was unavailable, despite promises by policy-makers.
“If you look at Vision, and read Planning for the Future, which was November 1984, and you read the Commission of Inquiry into the Mental Health Services from 1966, there are certain themes that are constant: That there should be better community-based services; better integration of mental health services; [and] inpatient services should be in acute hospitals,” according to Mr Rogan.
“Many of the themes are recurring. Some people have described that as ‘implementation deficit disorder’, so we write lovely policy, but don’t necessarily implement it. The big challenge with Vision is that it coincided with the worst and most prolonged recession and that meant that a lot of the commitments about creating mental health teams and staffing them up were not implemented.”
Vision proposed that, in terms of staffing, the composition of these adult community mental health teams should include the following: One consultant psychiatrist; 10-to-15 psychiatric nurses for an Assertive Outreach Nursing Team; mental health support workers; two occupational therapists; two social workers; two clinical psychologists; and cognitive behaviour therapist/psychotherapist and an addiction counsellor. It is widely acknowledged that few teams have the full complement of staff.
For instance, MI recently reported that there were almost 30 vacancies for consultant psychiatrist posts within the HSE, with some posts vacant for more than a year. According to the HSE careers website, 28 posts, including some locum consultant posts, were vacant and include positions within general adult psychiatry and child and adolescent psychiatry.
Also, research conducted by the PNA indicated that there are approximately 600 nursing vacancies within the psychiatric service.
Only 67 child and adolescent mental health teams are in existence out of the 95 recommended in Vision based on the current population.
Linn Dara in Dublin, a new purpose-built, 22-bed unit that opened 18 months ago, recently closed 11 beds due to nursing shortages. The unit has only 50 per cent of the nursing resources required. These 11 beds have been closed, despite a list of 20 children awaiting admission.
In spite of the problems filling posts, Mr Rogan insisted some gains have been made over the past decade in terms of staffing.
“In fairness, over the time frame of Vision, there was a huge increase in the number of allied health professionals,” he said.
“In terms of a much broader mix of staff, prior to that, the mental health service was largely populated by doctors and nurses, whereas now you find a much better mix, which means that service users get more options. So it is not so heavily dependent on the medical models or medications. There are better options now in relation to access to social therapies and psychotherapies and creative therapies.”
Consultant Psychiatrist at Connolly Hospital, Blanchardstown, Dublin, Dr Matthew Sadlier, also wanted to highlight the positive aspects of mental health services in Ireland. Dr Sadlier said that in some ways, the mental health service has historically pioneered policies that have only recently been followed by other parts of the health service, a fact that is seldom acknowledged.
“In some ways we are the vanguard, what all the rest of the health service has been trying to catch up to,” Dr Sadlier told MI.
Dr Matthew Sadlier
“We had the inspectorate of mental hospitals since the late 19th Century, while the concept of inspecting and accrediting a physical health hospital has only really come about in the last 15 years… we’ve had national strategies and the Mental Health Commission, which I think does a very good job. From that perspective, sometimes you can get lost in the individual problems without taking an overall view.”
In saying this, Dr Sadlier admitted that a lack of funding has prevented full implementation of the strategy. He also pointed to elements of Vision that hindered its own implementation.
“It didn’t have a prioritisation implementation plan, which is what I think any future mental health strategy needs to have. It gives a picture of the ideal service. But what are the priorities through which we are hoping to deliver this? What is the first thing we are looking to introduce? What is the first change?”
Another flaw of the document, according to Dr Sadlier, is the lack of any consideration given to social and regional distinctions.
“There is a lack of the cultural appreciation of what the general Irish member of the public expects from the health service. Now, to be honest, as a working general adult psychiatrist, one of the big criteria as to whether somebody is admitted or not to hospital is social reasons. What is their family support? Who is at home? Who is there? I would have thought with Vision For Change, it needs to take into consideration different demographics of the country, in general.
“So, if you are in a very rural sector and your admission unit might actually be 100 miles away, that is not the fault of anybody and I am not saying you need to have an admission unit every 20 miles … but that needs to be taken into consideration as to what are your bed numbers, because you are more likely to admit people in those sorts of circumstances than you are to admit somebody if your unit is just down the road.”
A new mental health strategy?
Now that the time frame for A Vision For Change has lapsed, there is a need to provide a new direction for mental health services in the country.
In September 2016, an external evidence and expert review was commissioned from WRC Consultants as the first step in determining the parameters of a revision of A Vision For Change. This review was published this month and will provide evidence to determine the policy direction for “a revision” of Vision, both in terms of international best practice and the experience of implementing the strategy.
Consultant Psychiatrist in Tallaght Hospital, Dublin, Prof Brendan Kelly, does not believe there is a particular need for a new mental health strategy.
“A Vision For Change is still a generally good strategy,” Prof Kelly told MI. “Implementing it in full would be the best strategy of all.”
However, he said there needs to be greater focus on youth mental health, with a seamless service that continues past the ages of 16-to-18 years.
“While Ireland’s overall suicide rate is falling, rates are increasing in young men,” he said. “Young people deserve a seamless service from childhood into adulthood. This should be prioritised. There also needs to be greater involvement of families in services.”
Prof Kelly also argued that funding should only be taken into consideration at implementation — not policy — level.
“The policy should be developed without any regard for funding issues,” he stated. “Then, the policy should be presented along with an implementation plan that takes funding issues into account, so that we can see clearly and explicitly the extent to which budgetary considerations are limiting the development of ideal services.
“There are two separate tasks: Outlining the ideal service in the policy, and then outlining how much is achievable within budgetary parameters in an implementation plan. The first task should involve service users, families, clinicians and others.
“The second task should also include politicians who make decisions about allocation of scarce resources. The two tasks should not be conflated.”
Meanwhile, Mr Rogan said while most aspects of Vision are still entirely valid, a new strategy would place a greater emphasis on recovery, self-direction and peer-led services, mental health promotion, protection and fostering resilience.
He also said the role of primary care in assessing and treating the frequently-seen mental health issues needs to be addressed and properly resourced.
“Any new mental health strategy in Ireland will need to make a more honest appraisal and recognise the negative impact of alcohol, drug use and the all-too-common reality of dual diagnosis,” added Mr Rogan.
“This was a missed opportunity and has failed many people with complex needs. Finally, a robust multi-annual workforce planning model to ensure the availability of suitably-skilled, capable and well-structured multidisciplinary teams [is needed]. The equitable distribution of mental health funding, resources and infrastructure needs to reflect the population, demographic needs and deprivation index.”
Dr Sadlier said that future mental health policy needs to remember that, while better community services are essential, it is important that resources and supports are put in place for residential care.
“There will always be a need for long-term residential care for people with mental health needs,” according to Dr Sadlier.
“This is the most important point: Previously with mental health services in Ireland, this was the only model of care delivery and that was wrong. Currently, however, I think we have gone too far the other way.
“Our biggest need, where I work, is to address the lack of long-term hospital beds. And we have people who are unsuitably living in unsupervised community dwellings. With mental health, unfortunately, there is always going to be the need for long-term residential placement. I think that the number of long-term residential care placements needs to be evaluated and that is an urgent need.
“I would certainly say from my service that is an urgent need and I am sure that is reflected throughout the country.”
Dr Sadlier believes any new strategy needs to be “aspirational” in nature.
“Because nothing will ever get achieved if you don’t set yourself a goal, even if it is a goal you know in your heart of hearts you won’t ever achieve.”
Consultant Psychiatrist in the HSE Wicklow Mental Health Services Dr Justin Brophy also said that a new strategy needs to prioritise core mental health services.
“I think the danger with a new strategy would be that there would be a softening of focus from core severe and enduring mental health services into high public-demand services for counselling and for other valuable [services], but not at the expense of clinical mental health services,” Dr Brophy told MI.
“I think the danger would be that the public appetite is for community spend, whereas there is still a very significant need for core mental health services.”
Dr Brophy said he has been disappointed with the level of political commitment to mental health services over the last decade.
“I have to say, I am very disappointed with the follow-through in political interest in mental health,” he said.
“What it largely translates into are initiatives that aren’t carried through and blame or criticism of existing services. I have seen that, regardless of political party. Perhaps I would single-out [the former Minister of State for Mental Health] Kathleen Lynch as somebody whose commitment was impressive, but other than that, I have not seen anything from the other political parties. I think there is a lot of political opportunism with regard to suicide figures or adolescent crises, and there is absolutely no follow-up on the solution to those problems. I have been very unimpressed in the past and I am not optimistic of the future.
Former Minister Kathleen Lynch
“I think what people still don’t get is the extraordinarily pervasive nature of mental health difficulties. Everywhere I look I see people, very ordinary people, friends, family, acquaintances in the community, with mental health difficulties that are completely unaddressed.
“We really need a major change in recognition of the prevalence and seriousness of mental health problems, but more importantly, to realise that most of these are readily accessible, entirely solvable, while the consequences of not addressing them are catastrophic.”
A spokesperson for the HSE told MI that A Vision For Change definitely needs to be updated to reflect current priorities.
“Given that it is 10 years old, there is a need to ensure that it enables mental health services to be delivered in an integrated way, eg, within primary care settings where appropriate and also that the needs of those with severe and enduring mental health problems are met in appropriate and safe environments,” according to the spokesperson.
Oireachtas Committee on Mental Health
The new Minister of State for Mental Health, Jim Daly (Fine Gael), does not believe that a new mental health strategy may be necessary, stating that many of the recommendations of Vision are still relevant.
The future direction of mental health services and the slow implementation of A Vision For Change are issues that will be examined by the all-party Oireachtas Committee on Mental Health, which is due to begin its work in September.
“I think an awful lot of A Vision For Change is still relevant to the challenges we face. I am not sure an entire new strategy is where we need to be going,” Minister Daly, who took up post in June, told MI.
“I think there is an argument that A Vision For Change can be continued. It is only a 10-year -old strategy; it is not that old. And I don’t think the problems have evolved massively in the meantime, or have significantly changed in focus, so I think it is about looking at how we do what we do, as opposed to devising a new strategy.”
However, the Minister said that the work of the Committee, the terms of reference of which were only completed at the time of going to press, would ultimately inform the future direction of mental health policy.
Minister Daly said the Committee would operate in a similar manner to the recent Future of Healthcare Committee and would also work closely with the Department of Health.
Although the lack of funding for mental health services has frequently been criticised and provided as a reason for the slow implementation of the strategy, Minister Daly said that more money will not necessarily be a solution to all the issues facing the service.
“I don’t think resources are the number-one issue,” according to the Minister. “I think it is how we do what we do that is actually more important and what we are doing with the resources that we have. I would love if it was that simple, if the solution was just to throw more money at the problem. If that was the solution, it would make my life really, really easy.”
Minister Daly has already requested that the HSE examine the possibility of instigating a regional approach to recruitment to address the numerous vacancies across the mental health service.
“I have asked my Department to examine this with the HSE as a beginning and to look at a more regional recruitment process as opposed to national recruitment,” he added.
“In other words, currently, the HSE does all its recruitment nationally. And I think it is too long, it is too slow, it is too cumbersome, it is too difficult… I understand that Tusla does more regional recruitment and it works better. You can do recruitment in a shorter time frame.
“I have asked my Department to start liaising with the HSE immediately to see can we look at a more productive way [of recruitment]… I think there is an appetite to resource mental health adequately… but I think there are many more challenges in terms of getting the services to people than just resources.”