Mental Health in Ireland
Mental Health Reform’s analysis of the mental health system in Ireland supports the need for major transformation.
Mental health services have not been prioritised by Government and the quality of services lag behind international best practice and developments in other areas of healthcare. There is over-reliance on the medical model and in-patient treatment.
A Vision For Change (AVFC), a modern national policy framework was adopted by Government in 2006 and has been slow to implement. The recovery model that is central to AVFC will challenge the traditional psychiatry power base. Successful implementation will require a paradigm change in how mental health is understood and how services are provided.
The HSE has primary responsibility for the delivery of AVFC. However, the action needed to make this important paradigm shift / cultural change, to bridge the gap between AVFC policy and practice, is challenging. Furthermore, within the HSE full, single-point executive accountability for execution and budgetary control is lacking.
Mental health service users tend to have low visibility due to the nature of mental health difficulties and the stigma of mental illness. However the service user movement is growing as a radical challenge to the status quo.
The need for advocacy and campaigning and the development of a strong NGO and service user stake-holding is evident.
Mental health as a pervasive feature of society
The universality of mental health difficulty is recognised by the World Health Organization:
Mental and behavioural disorders are found in people of all regions, all countries and all societies. They are present in men and woman at all stages of the life course. They are present among the rich and the poor, and among people living in urban and rural areas.
National and international studies suggest that 25% of the population will experience a mental health difficulty at some point in their lives and that 44% of people in Ireland have had a direct experience of mental health problems (either their own, or within family/friends).
It is estimated that the direct annual costs of poor mental health in Ireland was €3Bn in 2006, or 2% of GNP.
The approach to mental health support in Ireland
The mental health system in Ireland is at an early stage of transition to the modern mental health service envisaged in Government policy, A Vision for Change (AVFC), 2006.
There are some general features of the current mental health system in Ireland that are likely to affect a significant number of those with mental health difficulty:
- An approach to mental health support that, in practice, focuses almost exclusively on a medical services model and fails adequately to recognise the role of social and economic supports for individuals (housing, employment, etc.) in supporting and maintaining recovery.
- Limited access to anything other than medication-based treatment for those whose mental health (e.g. clinical psychology / talking therapy services).
- Over-reliance on in-patient rather than community-based care, with a high level of readmission, indicating lack of treatment efficacy.
- An inconsistent level of mental health support coverage across Ireland.
- A lack of specialist mental health services (e.g. for children and adolescents, older people or people with intellectual disability).
- Few resources directed towards mental health promotion / wellbeing and early intervention programmes that can reduce incidence of mental health difficulties.
- A general population whose attitudes and misconceptions mean that many people with mental health difficulties experience stigma isolation and discrimination.
- A growing service user movement, beginning to challenge the dominant paradigm of psychiatric care.
Five key aspects of the mental health system in Ireland are discussed further below:
a) Dominance of the medical model of care
Traditionally, Ireland’s response to mental health needs has been almost exclusively medical, with decision making power focused in the hands of the clinician (psychiatrist) and with medication as the dominant form of treatment.
The recovery ethos, central to AVFC, represents the rebalancing of decision making power that is required to move to a modern mental health service.
The transition to a modern community based model, informed by the recovery ethos, requires new knowledge, skills and approach, a challenge to professionals working within traditional services. The increase in multidisciplinary staffing (psychologists, social workers, occupational therapists) envisaged in AVFC supports this transition.
Mental health and wellbeing is highly correlated to other aspects of an individual’s life; personal, social and economic status and experience impact upon and are impacted by a person’s mental health.
For many people, the experience of mental health difficulties and the challenges faced in recovery are compounded by the absence of social and economic supports such as access to housing, adequate income and social inclusion (education, employment and civic participation).
b) Recovery Model
The Mental Health Commission has developed the concept of a recovery service model, as part of the implementation of AVFC. The recovery concept is a process of personal growth, the individual developing the resources and hope to live a fulfilling life beyond the limits of mental illness. As a result, the mental health care system needs to be configured such that it puts service users at the heart of service delivery. That means the service delivery model will have the following key features:
- Services are person-focused – the individual is respected as their own expert and a partner in the treatment process.
- Peer support –partnerships between service user-led services and traditional mental health services.
- The involvement of ‘experts by experience’ in the service planning, development and evaluation – the authority of personal experience of service users, families and carers is valued and respected.
- Social integration and ease of access to services and community resources such as housing, education, employment.
c) Development of the service user movement
Internationally, service user movements have emerged as a force for mental health reform and the recovery movement is part of this change. The concept of recovery, emerging in mental health in the 1980s, grew from the publication of personal stories and research studies that showed that people diagnosed with severe mental illness could recover and lead meaningful lives.
In Ireland service user advocacy is developing both within the mental health system and as public advocacy.
The Irish Advocacy Network (IAN) was established in 1999 through Mind Yourself, a peer-led and run advocacy organisation in Derry, is now a formal organisation providing peer advocacy in most HSE regions and aims to facilitate user empowerment by supporting people to speak up and speak out and take back control of their own lives.
The National Service Users Executive (NSUE), representing service users, family and carers, was created under AVFC policy. The organisation is now established as the official body to inform the HSE and the Mental Health Commission on issues relating to user involvement and participation in service planning, delivery, evaluation and monitoring.
Other service user movements hold more public advocacy positions.
d) Over-reliance on in-patient provision
The move from a hospital, in-patient focus to a community based model symbolises the transition required to implement AVFC. Irish mental health services have traditionally been ‘hospital prone,’ reflected by the fact that the rate of institutionalisation in Ireland was at one point the highest in the Western World. The large Victorian mental hospital was, and in some cases remains, a dominant presence in many Irish towns.
Victorian and older asylums still comprise 15 of the 63 approved centres inspected by the Inspector of Mental Health Services in 2008. The conditions of these institutions are not up to acceptable standards, as evidenced by a report of the Mental Health Commission published in April 2009.
e) Inadequacy of funding for mental health services
Non-capital expenditure on mental health services was €770M in 2009, in comparison to 1.1billion in 2008. Spending on mental health has dropped from 13% of the overall health budget in 1986 to 6.4% in 2009 and 5.3% in 2010. AVFC recommends that the rate reach 8.4%. This is still a low level compared to international standards: the equivalent rate is 12% in England and 18% in Scotland; other European countries allocate over 20% of their total health spend on mental health service and support.
The 2010 staff moratorium has disproportionately impacted on the mental health services: mental health represents just 9% of the healthcare work force but accounted for 20% of the 1,500 posts lost through the moratorium.
Mental health legislation and policy in Ireland
a) Key legislative frameworks
Domestically, the principal legislation governing mental health in Ireland is the Mental Health Act 2001. Its primary purpose is to provide protections for patients who are involuntarily admitted to treatment. It also establishes two key bodies, the Mental Health Commission and the Inspector of Mental Health Services. The Mental Health Act is limited in terms of providing a broader set of rights around access to services and supports. It also does not afford rights to those who are voluntarily admitted but who may require some form of advocacy on their behalf.
Another piece of legislation of particular relevance to mental health is the Disability Act which provides a basis for (i) independent assessment of individual needs and (ii) a multi-sectoral approach to supporting disabled people. Mental health falls within the definition of disability; in theory this provides an important potential lever for advancing mental health reform through the National Disability Strategy.
MHR identifies two other priority areas of need in terms of legal reform in mental health: the introduction of capacity legislation (promoting supported decision making and protection for individuals who do not have the capacity to make decisions in any part of their lives as a result of disability) and a legislative framework underpinning mental health policy currently being progressed by Amnesty.
b) Government policy
The Department of Health and Children (DOHC) has primary responsibility for the development of health policy including policy in respect of mental health. An important development has been the establishment of the Office for Disability and Mental Health, in 2008, to support cross department policy development and implementation in relation to mental health.
In 2006, the DOHC published A Vision for Change – the government’s key policy framework for mental health in Ireland.
A Vision for Change – key principles
- AVFC details a comprehensive model of mental health service provision for Ireland. It describes a framework for building and fostering positive mental health across the entire community and for providing accessible, community-based, specialist services for people with mental health problems.
- An expert group, which combined the expertise of different professional disciplines, health service managers, researchers, representatives of voluntary organisations, and service user groups developed this policy. A broad consultation process was undertaken between the expert group and service users and providers, through invited formal submissions and through public meetings. The results of this consultation informed the policy described in this document.
- AVFC proposes a holistic view of mental health and recommends an integrated, multi-disciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems. It proposes a person-centred treatment approach which addresses each of these elements through an integrated care plan, reflecting best practice.
- Special emphasis is given to the need to involve service users and their families and carers at every level of service provision. Interventions should be aimed at maximising recovery, and building on the resources within service users and within their immediate social networks to allow them to achieve meaningful integration and participation in community life.
- AVFC also proposes a transfer of resources from hospital and institutional services to community services and recommends that 8.4% of the overall health budget is dedicated to mental health services to achieve full implementation. The funding commitments by government and the HSE, to incrementally implement AVFC, have not been honoured and given the crisis in public service funding, defending the mental health budget is a priority.
A review of AVFC shows that the Health Services Executive (HSE) is the lead agency for implementing 80% of its recommendations.
The Mental Health Commission report, From Vision to Action identifies the following key barriers to implementing AVFC:
MHR believes that these various barriers can be distilled into two critical issues :
- A lack of understanding of the paradigm shift promoted by AVFC, with important cultural and systems change implications.
- The absence of political and institutional will to drive change in line with the mandate set out in AVFC.
Clearly, the HSE is the pivotal organisation in addressing both these issues and, ultimately, to bridge policy and practice.
c) The National Disability Strategy
In addition to direct decision making by the HSE and others, the National Disability Strategy in theory provides a framework for progressing the ‘whole of Government’ approach required to provide social and economic supports for those with mental health difficulties.
While implementation of the National Disability strategy is complex and slow, six Departments are required under the Disability Act 2005 to produce Sectoral Plans every three years. A 2010 report by AI drew on service user experience to illustrate many areas and focused on matters such as housing, employment and social welfare (rather than mental health services per se). The MHR represents the needs of people with mental health difficulties on the Disability Stakeholders Group (DSG). The DSG comprises six NGO umbrella groups appointed by the Minister for Equality, Justice and Law Reform to monitor the delivery of commitments under the National Disability Strategy.
Restructuring within the HSE
The HSE was set up under the 2004 Health Act 2004 and is responsible for providing health and personal social services in Ireland. Under the Act the HSE is required to submit an annual service plan for the Minister for Health and Children for approval. The overarching objective of the HSE is to provide services that will improve, promote and protect the health and welfare of the public, and under this remit it has the power to determine exactly how the total health budget is spent, depending on relative priorities and needs across a range of services. To date, MHR’s view is that the HSE has failed to deliver on this objective in relation to the systems, governance and service reforms necessary for mental health services.
The lack of any momentum to put in place a robust implementation of AVFC within the HSE at the national level is exacerbated by ongoing structural reorganisation and change. The latest view of the emerging HSE structure as it relates to mental health is captured in the box below:
|Emerging HSE Structure
AVFC was adopted as policy 4 years ago now, and given the slow pace of reform there is a risk that as a detailed policy document any additional significant delays will render it out-dated and / or un-implementable. As the original end date of 2012 for implementation of AVFC draws closer, there is real risk that a narrative will emerge that abandons AVFC in favour of pragmatic, reactionary developments without a coherent connection to the policy framework. This puts at risk the fundamental ethos of AVFC, namely the adoption of the recovery model at the heart of the delivery of mental health services in Ireland.
It should be noted that the lack of progress to date does not necessarily reflect the commitment and expectations of stakeholder groups such as clinical staff and health service management to achieve a full implementation of AVFC. The slow pace of reform is also at odds with the stated commitment to implementation by Government and the Minister of State with responsibility for mental health.
The appointment in late 2009 of an Assistant National Director for Mental Health, was heralded as an important step in ensuring national level leadership for implementation of AVFC. The reality is that the effectiveness of this post is significantly undermined by the lack of executive responsibility with appropriate authority and resources for making decisions.
Societal attitudes and behaviour towards the issue of mental health has a direct impact on the experiences of those with mental health difficulties; they impact lives at home, at work and potentially in many social contexts. The evidence suggests that social attitudes around mental in Ireland can lead to stigmatisation, discrimination and social exclusion for those with mental health issues. These attitudes are influenced by messages and opinions coming from politicians, public commentators and the media.
See Change is Ireland’s new national partnership to reduce stigma and challenge discrimination associated with mental health problems, led by Shine. It is an alliance of over 30 organisations working together through the National Stigma Reduction Partnership to bring about positive change in public attitudes and behaviour towards people with mental health problems. Although the partnership has yet to make a significant national press or political impact it does need to be considered as a new key initiative and the Department of Health officials see this as fulfilling part of their AVFC implementation obligations.
The need for advocacy and a credible voice on mental health
The emergence of the IMHC and Amnesty Ireland, campaigning for mental health reform has significantly changed what is historically a low profile campaigning sector.
The absence of a credible campaigning and advocacy voice in mental health cannot be understated. The very existence of the Disability Act and the Disability Strategy are testament to the strength of the disability sector advocacy and point to the need for such a strong public lobby in mental health. The recent protest against cuts to disability service providers is something that has been unimaginable to date in mental health.
The mental health debate to date has been typified by the lack of voices of those directly affected. AVFC notes “there is no equivalent advocacy for improving mental health services as exists for various other health services.
The need to develop a strong mental health advocacy voice is evident.