Political ambivalence to mental health costs up to €3bn annually
Mental health issues are on the increase in Ireland, debilitating more and more people, placing greater strain on health services and costing the country up to €3bn annually. However, neither funding nor political commitment are being given to adequately address mental health issues. By Justin Frewen and Anna Frewen.
Mental health is a significant medical issue in Ireland. Studies have shown that a quarter of the population will experience a mental health problem at some point in their lives. And between 20-25% of health-related disabilities come under the category of mental ill health.
Mental health issues also account for a significant total of patient visits. The Irish Health Research Board (HRB) found 9% of their sample had visited their GP about mental health problems at an average of approximately 4.4 visits per person. Similarly, a 2003 South Western Area Health Board report found 25% of primary care consultations consisted of patients with mental health problems.
Dealing with mental health problems in Ireland requires an effective mental health policy, a strategic service implementation plan and the allocation of sufficient resources to minimise the socio-economic consequences of mental health problems.
In early 2006, A Vision for Change was established as the Irish national mental health policy. From its conception, A Vision for Change was widely recognised as a relatively enlightened approach to mental health issues and was one of the first to actively include services users and carers in its formulation.
However, since its introduction, the implementation of A Vision for Change has been at best disappointing.
Firstly, A Vision for Change still lacks a specific and effective implementation plan. Although mental health is covered in the overall HSE implementation plan, there should be a specific mental health implantation plan outlining how the policy recommendations in A Vision for Change will be realised as well as the resources required to do so.
As noted in the World Health Organisation (WHO) publication Mental Health Issues and Actions Plans, the articulation of such an implementation plan is crucial to the realisation of any vision. Indeed, the WHO goes as far as describing the absence of a strategic implementation plan to realise policy objectives as nothing more than idle dreaming.
As it stands, the HSE vision for mental health remains unclear. Although certain elements of A Vision for Change have been introduced, the implementation process has displayed a lack of overall coherence, as the HSE has generally failed treat the policy’s recommendations as an integrated whole.
One example of where the lack of such an implementation plan has proved detrimental has been the tendency to base funding of the different mental health services on historical trends rather than allocating funding according to evolving needs. The development of a specific and detailed mental health implementation plan, equipped with an effective monitoring and evaluation mechanism, could help eliminate this problem as future planning would be based on the results of previous mental health investments.
A further concern lies in the refusal by the HSE to appoint a national directorate for mental health, supported through a person-centred approach, which, in addition to reflecting best practice, would be devised and agreed upon with service users and their carers.
As pointed out by the Inspector of Mental Health Services, the appointment of such a directorate, supported by a team with the necessary skills and service-user involvement would “be budget-beneficial and improve outcomes”. The unwillingness to set up such a National Directorate can only heighten public concerns as to the level of genuine political commitment to the realisation of A Vision for Change.
A second crucial issue has been the consistent under-funding of the mental health services. Although, funding has increased in the area of mental health, its proportion of the overall health budget has experienced a general decline over the years. Whereas in 1984, expenditure on mental health accounted for 14% of the overall health budget, it had declined to just 6.6% in 2009.
In this respect, the announcement in the 2010 Budget that funding would be provided for capital investment by the disposal of current assets is crucial. It was initially envisaged that the selling of surplus assets, such as former institutions, would free up €43m for reinvestment in the mental health capital programme.
However, in mid-February this year, the government announced that this funding would be increased to €50m. It should be noted, however, that if this €50m is not raised through the sale of existing psychiatric hospital lands this year, health authorities might be obliged to repay the shortfall to the Exchequer.
The €50m allocated is intended to support the development of a patient-centred, flexible and community based mental health service with a corresponding reduction in hospital admissions. Future provision from 2011 on will apparently continue to depend on the sale of psychiatric facilities and assets.
However, several concerns remain. Firstly, there is the worry that, as has happened in the past, some of these monies might be diverted to other areas of the health system or to shore up budgetary constraints. Furthermore, the indeterminacy with respect to funding, reliant as it is on the outcome of asset sales that will not be determined in advance, renders future capital planning tentative at best.
At the same time, investment in improving community-based care is essential if the objective of A Vision for Change to reduce the comparatively large number of residential beds in the Irish mental health system is to be realised. Ireland currently has an unsustainable situation whereby community care tends to be organised around institutions in the community with a relatively minimal use of outreach and home care facilities.
The undertaking of such a radical transformation in the mental health system will evidently incur short to medium term transitional costs. These will be required both to establish the required new facilities as well as providing personnel with the necessary training to adapt and perform effectively in their new work environment.
Transitional costs are a significant issue given Ireland’s current economic woes, but the cost of mental health problems to the Exchequer exceeded €3bn in 2006 alone, according to O’Shea and Kennelly of the Irish Centre for Social Gerontology, Department of Economics, NUI Galway. Two billion of this alone stemmed from lost economic output. Therefore, failure to firmly grasp this budgetary nettle will only result in greater economic and social costs further down the road.
Given the significant economic consequences of mental health issues as well as the personal suffering they entail, it is essential that adequate resources are made available. Moreover, expenditure on mental health service policy, implementation planning, outputs and activities should, in addition to other appraisal criteria, be transparently costed and their relative effectiveness evaluated on economic terms.
The introduction of such an economic evaluation modality is even more urgent given the current straitened financial circumstances of the Irish public services and the need to justify all expenditures including those of mental health.