More promises on mental health

A new national mental health policy document, 'A Vision for Change', has just been released by the Department of Health and Children. But is this just another agenda of commitments again to be broken? By Siobhan Barry

In the last four decades, two national mental health policy documents have been adopted – the 'Report of The Commission of Inquiry on Mental Illness' in 1966, and 'Planning for the Future' in 1984. Both of these national policies were focused especially on the need to reduce the use of in-patient care. However, the introduction to Chapter 6 of 'A Vision for Change' refers to the current state of the Irish mental health services and acknowledges that the "recommendations of the 'Commission of Inquiry' were only partly implemented and while the recommendations of 'Planning for the Future' were more widely implemented, there is still considerable room for improvement".

Once again, in 2006, a reduction in the number of acute admission beds for adults in mental health services from approximately 3,500 nationally at present to approximately 700 ie 50 beds per 300,000 population, and the ongoing development of psychiatric services in the community, as well as specialist services for those with particular mental health needs is advocated.

It is essential that the community developments outlined precedes the reduction in beds. In the past two decades the numbers of people in Irish mental hospital care has dropped from 11,100 in 1987 to approximately 3,500 in 2004. Currently more than half of those occupying beds in mental hospitals/units have been in hospital for more than a year and are aged over 65 years. In scaling down or shutting large institutions, existing patients have been moved in many instances "into the community" via nursing homes. For example, in 2005, 23 long stay patients were reported to have been moved from St Ita's Hospital to the now infamous Leas Cross Nursing Home in the months before its Primetime exposure.

A further consideration in relation to community developments needs to be the extent to which "the community" will welcome these developments. Will the situation that arose in Charleville, North Cork, in mid 2005 whereby local residents picketed a house set up for mental health service users by the organisation, Slí Eile, abetted by the reported obstructive behaviour by a local TD happen again? A similar situation arose in Lispopple in Swords in 2003. The topic of stigma and discrimination is raised in Chapter 4 of 'A Vision for Change' dealing with Social Inclusion.

'A Vision for Change' recommends the development of 100 dedicated inpatient beds for children and adolescents with mental health difficulties. This is a very long-awaited development and was also strongly recommended as part of the previous national mental health policy, 'Planning for the Future' in 1984 but such services have contracted rather than expanded over the past 22 years.

'Planning for the Future'advised that children and adolescents needed dedicated inpatient facilities and it aspired to extend existing facilities beyond those then available in Dublin, Cork and Galway to include units in Sligo, Limerick and Waterford. Since 1984, the unit in Cork is no more and the units in Sligo, Limerick and Waterford were never progressed. As a consequence, in those cities, not alone are older adolescents admitted to adult mental health units, but also 24 children under the age of 16 years, including a child as young as 11, were admitted in 2003, in the absence of dedicated child and adolescent facilities.

At present, there are a total of 20 dedicated inpatient beds for children and adolescents with mental health issues organised between Dublin and Galway and many of the more disturbed children are, of necessity, sent abroad for inpatient treatment.

Two reports that were very critical of the Irish mental health services were published by the Irish Psychiatric Association within the past two years. 'The Stark Facts' in 2003 looked at the availability of clinical resources, specialist services and clinical leadership in services and found that there was a huge variation in access to services; many services lacked key clinical personnel, eg 23 per cent of services had no psychologist and more than half the senior clinical posts had temporary or acting post holders whose ability to advocate for service development was likely to have been diminished by their temporary status. 'The Black Hole' in 2005 examined the variations in the funding of mental health services throughout the country – the haphazard distribution of staffing; the lack of logic and transparency in terms of where the attributed funding went – and found that there was a 13-fold variation in funding, a 10-fold variation in the number of acute beds, a 9-fold variation in the number of administrative staff, a 7-fold variation in the number of nursing staff and a 5-fold variation in the number of doctors across the country. Funding allocated to improve mental health services was not felt to have been allocated as described, and may have been diverted from adult mental health to other service areas.

To make 'A Vision for Change' happen will require both a re-deployment of existing resources and a substantial investment. The proportion of Irish mental health spend has fallen in the past 15 years from 13 per cent of the total health spend to 6.7 per cent. This is happening against a background of increased prosperity, with a trebling of the GDP in the past decade. Our current investment in mental health services compares poorly with the percentages of the overall health spend that is spent on mental health in the UK, currently running at 13 per cent.

An Implementation Group will need to be set up to detail and oversee the sequence of changes that 'A Vision for Change' proposes and the timeframe within which these need to happen. Funding will need to be set aside for the new service developments but the 'National Health Strategy' and the 'Primary Care Strategy' – both launched with enormous fanfare in 2001 – are stuttering and limping along five years after commencement, due to the failure to fund as planned and the public service staff embargo. Developing appropriate community services will not be a cheaper option than the still largely bed-reliant service we have at present.

'A Vision for Change' was launched on 24 January 2006. The Irish Psychiatric Association plans to launch a report entitled 'A Vision in Hindsight' on the 24 January 2007 that will independently monitor the first year of implementation of 'A Vision for Change'. Annually thereafter we will continue this exercise up to the seven year implementation deadline set in January 2006. Thus we plan to inform the public on the progress made in meeting the targets the new mental health policy document has set.

Siobhán Barry is PRO of the Irish Psychiatric Association and Clinical Director of Cluain Mhuire Service, Blackrock, Co Dublin