The doctor's diagnosis

Dr John Owens is charged with overhauling Ireland's outdated mental-health system. However, he must first tackle the prejudices of his colleagues and the state. He talks to Justine McCarthy

When he agreed to take on the task of reforming the Cinderella of the chaotic health service, Dr John Owens must have anticipated it would win him more enemies than friends. It has taken the state five long, tediously pedantic years to implement the provisions of the 2001 Mental Health Act, which kicked in on 1 November – but that has been the easy part. Despite his evident compassion and commitment, the chairman of the Mental Health Commission cannot hide his weary frustration with the powerful selfish interests that continue to prop up Ireland's inflexible and antiquated mental-health service.

Not a pugnacious man by nature, his credo that people with mental illness need strong advocates makes him steely determined to overhaul the system once and for all. If Ireland is ever to overcome its rigidly institutionalised and deleterious approach to mental health, Owens has to face down the collective resistance of his own medical colleagues as well as the Health Service Executive itself. First, however, he has to tackle the state's prejudices.

By planning to relocate the Central Mental Hospital from Dundrum to the new prison complex at Thornton Hall in north Dublin, the Department of Justice is, he argues, perpetuating the fallacy that mental ill-health is inherently threatening. He and his commission have pleaded with the minister, Michael McDowell, to abandon his plan to embed the facility in the penal system and, instead, to decentralise it to secure hospital units in the regions. Their petitions have met a brick wall.

"We're not happy with that at all," he confirms. "It's very difficult to get rid of the perception that mental ill-health is somehow dangerous when they're in the same grounds as a prison. When you are mentally ill, you have the right to be treated but special hospital rooms with a lot of security can be used. You don't stick them in the middle of a prison. They [the Department of Justice] say that it will be separate from the prison and they'll be in separate buildings and that might be so but, in the public's mind, it's not separate. It adds to the confusion in people's understanding of mental health. I don't really understand why they're doing this.

"We have made extensive submissions to both departments [justice and health] and they have decided in their wisdom to go on with what they're doing. Selling Dundrum is worth a lot of money and we could use that, of course, but there are other sites available that could have been used, like St Loman's or St Brendan's. We prepared very intensive papers on this which we sent to the Department of Justice.

"In terms of forensic services in general," he adds, "we need something other than a central unit run on a high-security basis, particularly in urban areas. I'm thinking of recidivist and relatively petty crimes and people who are down and out, for instance. These people should not be held in a high-security unit."

With state policy hot-housing the bias against people with mental ill-health, the media is more likely to compound it, as if by subliminal license. Owens, who retired on compulsory age grounds from public practice but continues to see patients privately in Monaghan, is scathing in his criticism of the media. "The media are very badly behaved, running scare headlines saying 'Nutter Does This' and 'Nutter Does That'. They are totally insensitive but they sell newspapers. The attitude is 'lock them all up'. There's nothing like having your prejudices reinforced to give you satisfaction."

Contrary to the cartoon stereotype, Irish people are not disproportionately prone to mental ill health, he says (except that the suicide rate among young males is the second-highest in Europe). It is our over-eagerness to hospitalise people with mental illness that gives the false impression. Ireland currently has 3,475 in-patient beds: roughly 100 beds for every 100,000 people. Italy, as an example, has a quarter of that, at about 25 beds for 100,000 of the population

"A lot of people who are admitted to acute beds do not need to be admitted," Owens believes. "They could be treated, not just as well but better, on a community basis. Of the total admissions in the country, between 65 per cent and 90 per cent are re-admissions. Clearly, if you need 80 per cent readmissions, your first admission wasn't of any value. About five per cent of patients make up about 25 per cent of admissions. Our services are demand-led. They keep coming in and out, in and out.

"What you need is focused, individual care. We need home-based teams of advanced nurse practitioners who are highly skilled, even for quite acute illness, so that families can be skilled-up as well.

"We also need assertive outreach teams for people who do not easily get well – people with chronic schizophrenia or frequently relapsing depressives. Those people who were thought in the past to be incurable can cope very well outside. Sometimes, it's easier to have somebody else make decisions for you, but people can be taught social skills to get rid of their passive dependency."

Last January, a policy document entitled 'A Vision for Change', proposing this multi-disciplinary community-based model, was published by an expert group including John Owens. It envisaged a National Mental Health Service Directorate, operating within the HSE, which would incorporate local teams dedicated to catchment areas of 250,000 to 400,000 people. The document has been left lying on some shelf to gather dust ever since.

"I would have concern that it's going to be long-fingered," Owens admits. "I've raised it with the minister and the HSE. The department is very keen on it. The HSE should be acting more quickly. They have set up specialist advisory groups and implementation committees but, to my mind, that's missing the point. It's now almost a year since the policy document was published and very little has been done. The document's priority was to establish a new system of management to help in the radical reform of the mental-health system but very little has happened to put that system in place."

If John Owens is going to overthrow the old system, he will have to confront many of his doctor colleagues in the opposing frontline of the establishment. Already, the College of Psychiatrists, the Irish Medical Organisation and the Irish Hospital Consultants' Association have been vocally critical of new measures contained in the 2001 act that replaced the 60-year-old law. Many of his fellow psychiatrists were alarmed at the prospect of Big Brother intruding on their prescribing practices, especially in the realm of electroconvulsive therapy (ECT), where patients are given a modicum of control over their own treatment. Doctors have also protested that personnel and resources are insufficient to comply with the requirements of the new tribunals, which will deliberate on applications for release from compulsorily admitted in-patients. Owens, who accepts that mental-health funding "has been progressively declining" as a proportion of total health expenditure, dismisses the claim that money is the core of the problem.

"Doctors can get satisfaction from saying, 'If I had money, I could do this.' Nobody blames them when things go wrong. Doctors are privileged in that everyone sees them as advocates. Everybody blames the managers," he says in a soft voice that belies the harshness of his criticism. "That sort of accountability should be required of people who have professional jobs and are on large salaries. If there is a lack of resources, it's not so much a need for more psychiatrists as for specialist therapists

"There were 2,300 compulsory admissions last year. At any one time, about 500 people were being certified under the old act. That's 50 people every week. The new law puts restraints on who can be compulsorily admitted. You cannot be admitted, for instance, for addiction on its own, or for a personality disorder. I don't think there'll be a major problem with the tribunals. Whenever things change, everybody gets uptight which, to be honest, I don't understand."

Responding to claims that the accommodation in hospitals is inadequate for the tribunals, he says the commission has toured the country approving them and that people who will work at these tribunals have undergone special training.

"Funding for mental health was 20 per cent of total health spending 30 years ago. It's seven or eight percent now. But, 30 years ago, all treatments were on an in-patient basis with large institutional staff. Even now, most of the money is spent on beds. There's never enough money, but funding isn't the issue. Resources are not being properly used. There's a lack of management competence. It's beginning to improve but it's very, very slow."

Issues of citizenship, liberty and personal integrity take precedence over resources, he insists. He points out that, in the past, Ireland's system of mental-health care was deemed repugnant to the UN Convention on Human Rights.

"Management of mental health is dysfunctional," Owens maintains. "It always has been. We have huge amounts of money being spent and making no difference. What everybody has an obligation to do is to modernise it. We've been operating under the 1945 act up to last week. I doubt there is any jurisdiction in Europe operating under a 60-year-old law. The priority given to mental health has always been very low. A lot of it is stigma. I have never liked mental hospitals. The old mental hospitals were set up in the 19th Century. We have a situation where funding is still going where the British said it would go in the 1840s."

Mental-health act is 'crisis management'

The Irish Medical Organisation (IMO), the Irish College of Psychiatrists (ICP) and the Irish Hospital Consultants' Association (IHCA) have criticised the Mental Health Commission (MHC) and the HSE for not having adequate resources and information in place by 1 November to cope with the demands of part two of the Mental Health Act 2001.

On 1 November, part two of the act established that all people who are involuntarily detained must have their case reviewed by a tribunal after 21 days; psychiatrists must seek a second opinion in relation to some mental-health patients; and children and adolescents must be accommodated in designated centres.

Under the act, psychiatrists must seek a second opinion on mental-health patients who change from being voluntarily to involuntarily detained, on patients who are being treated with electroconvulsive therapy and on patients who have been on medication for three months. They must seek this second opinion, fill out documentation and fax it to the MHC within 24 hours.

Finbarr Fitzpatrick, secretary general of the IHCA, says he knows of consultants who were only receiving the documentation from the MHC – about 30 pages in total – days before 1 November. They therefore had little time to familiarise themselves with it. Kate Ganter, chairperson of ICP, says some people have been given the wrong forms.

The IMO and the IHCA had also requested that the HSE set up a panel of available physiatrists for second opinions. This had not happened as of the 1 November deadline, but the HSE hopes it will be in place by mid-November.

Siobhan Barry of the IMO said a guide for patients had been published by the commission, but its metal spiral-bound spine had been deemed unsafe for the St John of God's acute-admission ward. They now have to photocopy all 82 pages of it for patients.

As well as these last-minute teething problems, the IMO, IHCA and the ICP say additional resources promised by the HSE were not in place by the 1 November deadline. The HSE had promised 21 additional psychiatric-consultant posts; this had not happened by the 1 November. The HSE has filled 11 locum positions and hope to fill another 18 by the end of the year. Eight child psychiatrists that were promised are not in place either.

Finbarr Fitzpatrick says: "It is crisis management. A lot of simple organisational matters have not been completed. It was signed in 2001 and here we are five years later and it's a scramble and a shamble and it's an essential piece of legislation for patients' rights."