THE
LACK OF IMPLEMENTATION OF THE HEALTH STRATEGY
ON MENTAL HEALTH
Guiding
Principles: Equity, People-Centred, Quality, and Accountability.
Structural Developments
Mental Health Legislation and Suicide Prevention
Issues in Mental Health
- Policy
- Structures
- Service Levels
- Advocacy and Responsiveness
It is over one year since the publication of the Health Strategy.
Under Mental Health, the Strategy outlined a number of issues
that required development and set out specific action points for
mental health. Little of this has been delivered. In fact, few
of the actions points were specific to the Strategy, and many
of them had already been in progress prior to the Strategy’s
publication and were independent of the development of the Strategy.
Guiding
Principles: Equity, People-Centred, Quality, and Accountability.
These are
the principles underlying the new Strategy. Equity, quality, and
accountability were set out in the previous strategy and a people-centred
service has been added for this strategy. Prior to looking specific
action points for mental health, the core principles of the Strategy
in relation to mental health are examined. The first of these
and the most fundamental is equity and fairness. This does not
seem to apply to Psychiatry.
Funding for
mental health as part of the overall non-capital health budget
has continued to fall in the last ten years. In the late 1980’s,
mental health attracted approximately 12% of the annual non-capital
budget for health. This dropped to 9.4% in 1994, and in 2001 again
dropped to 7.2%. This is a clear indication of the lack of equity
and fairness being applied to sufferers of mental illness. This
drop in funding is not due to psychiatric units moving to general
hospitals, as a considerable number of these continue to pay their
staff and receive budgets from the local mental health budget.
Nor is it attributable to budgets being moved to community services;
as day hospitals, day centres and community nurses again are all
paid through the local mental health budget. Mental health services
have been treated inequitably compared to other health programs
in recent years. This is even more apparent when the percentage
of the health budget provided for mental health is compared to
the percentage of the population with mental health difficulties.
In addition,
there is inequity between local mental health services. Because
mental health services work on a catchment area basis, individuals
within the public health service have no choice regarding the
mental health service they may attend, and each service delivers
mental health services to a specific population. For this reason,
it is easy to compare resources per head of population between
mental health services in different areas. The figures available
from the Inspector of Mental Hospitals’ report point to
an alarming lack of equity between mental health services throughout
the country. This split is particularly obvious between urban
and rural services. This is obviously because as urban areas have
developed and the population has grown, yet there has been little
corresponding increase in funding of their services. It is also
because many rural services tended to be based around older, large
psychiatric hospitals, and those services retained a large budget
from the old hospital, which could then be used to develop community
services as the hospitals’ inpatient base reduced.
However, in
urban areas, brand new services were set up without such a base
or budget attached. These services have had to fight for every
service development. Presently, compared to rural areas, urban
areas receive approximately half the funding per head of population
for mental health services. This is not to say that rural areas
are awash with money – they certainly are not, and the Inspectors’
report confirms this. What it means is that urban areas are starved
of cash for the development of mental health services. Those services
with the least funding per head of population are the Kildare
Mental Health Services; Mental Health Services based in James
Connolly Memorial Hospital; the Cluain Mhuire Mental Health Services
in South-East Dublin; the South Lee Mental Health Services in
Cork; and the West Galway Mental Health Services based in Galway
City. All these services are new mental health services established
separately from large independent psychiatric hospitals. In fact,
a recent SWAHB report stated because of lack of resources, the
unit in Naas had become “anti-therapeutic” and incredibly,
had an occupancy rate of 106%! Again, it is no shock to learn
that the services with largest funding per head of population
are those attached to large old psychiatric hospitals. Clearly,
equity of funding does not exist within psychiatric services.
And as individuals cannot choose their psychiatric service, a
large number of individuals, especially in urban areas, are being
discriminated against.
Incredibly,
the situation is in fact worse than that outlined above. Research
recently conducted in the Cavan/Monaghan mental health services,
and in the Cluain Mhuire mental health service in South Dublin,
has confirmed what previous international research has already
found. This is that the incidence of serious mental illness in
urban areas is twice that of rural areas. Therefore, mental health
services in urban areas suffer from having half the funding of
services in rural areas, yet they have to deal with twice the
incidence of mental illnesses. This does not take into account
the higher rates of substance and drug abuse that occurs in urban
areas. Also, the recent high rate of immigration into this country
has been centred on urban areas, and it is a fact that immigrants
have a higher rate of mental illness than the local population.
All of this contributes to a gross inequity in resourcing of mental
health services.
Unfortunately,
there is another clear example of discrimination against mental
health sufferers in relation to such acute bed shortages. The
government set up a review of acute bed capacity in the health
services to report on the number of new acute bed required in
the health services. This report specifically excluded acute psychiatric
services. This was drawn to the attention of the Department of
Health and Children and it was confirmed that this was the case.
No reasoning was given for this.
Yet an other
place where this is evident is in the area of waiting lists, waiting
list initiatives and the new treatment purchase fund. Because
the published waiting list figures only relate to waiting lists
for procedures they specifically exclude psychiatry. To be placed
on such a waiting list a patient must first be seen by a consultant
in outpatients. No waiting list figures are published to cover
the period a patient has to wait from the time of the GP referral
to the outpatient clinic appointment. Therefore, in psychiatry,
no figures are published for outpatient waiting lists, admission
to acute beds, for elective admissions, for day hospital places,
for referral for psychological assessment and treatment, for social
work interventions or for hostel placement. Because of the nature
of psychiatry there are no “procedures” and psychiatry
and those who attend its services do not benefit from any waiting
list initiatives or the new treatment purchase fund. Why shouldn’t
those with mental health needs be offered the opportunity to avail
of psychological services in the private sector or in the North
of Ireland, as those with physical illness are? No extra psychiatrists,
psychologists, or social workers are temporarily employed to treat
such patients in areas that need them. This compares to the appointment
of temporary surgeons and anaesthetists to clear waiting lists
for varicose veins or cataracts. Who has decided that these illnesses
are more worthwhile prioritising ahead of mental illness?
Similarly,
those with mental illness are again discriminated against compared
to those with physical illness when services are not available
in their local service. If the problem is physical, the patient
is referred to a regional hospital or an other local hospital
that has the service. There may be a period of waiting but at
least the service is available. In psychiatry, because of catchment
areas and sectorised services, if the need cannot be met locally
the patient cannot avail of the service even if it is available
in the neighbouring service or regional centre.
The area of
psychiatry for those with learning disability
is ignored in both the mental health and disability sections of
the Strategy. The only mention is to confirm the policy of providing
appropriate accommodation for those individuals with severe learning
disabilities currently placed in general psychiatric hospitals.
Such omission is clearly evident in current provision of mental
health services for those with learning disabilities.
It
is very clear that the principles of equity and people-centeredness
are not applied to sufferers of mental illness. Accountability
for this rests with the fund holders and planners of the services;
the Health Boards and the Dept. of Health and Children.
Structural
Developments
Under this
section, the Strategy specifically recognises the pressure on
acute psychiatric units, particularly in the Eastern Region, and
states that these pressures will be significantly eased by the
provision of additional community residences. In fact, acute psychiatric
units in the Eastern Region have 50% less beds per capita than
the remainder of the country. There are 2.4 times as many community
residences in non-ERHA areas as there are in the ERHA. Again,
this inequity is unsustainable. There have been further community
residences developed in the Eastern Region, but the majority of
these have been for long-term inpatients in psychiatric hospitals,
and their development does little to relieve pressure on acute
psychiatric units, which require community residences for new,
chronically unwell patients.
The ERHA region
is fortunate to have had its own bed capacity study undertaken
in recent years; “We Have No Beds”. This clearly stated
that 45% of acute psychiatric inpatient beds were inappropriately
occupied and that there was a significant shortfall in day hospitals,
community residences and rehabilitation beds. The report outlined
a number of very clear recommendations to address this situation
but very little, if anything has been implemented in the 4 years
since its publication.
Furthermore,
Planning for the Future gave clear recommendations on the number
of acute, medium, long stay, rehabilitation and day hospital places
per head of population needed for mental health services. After
19 years these objectives still remain a distant aspiration for
most services.
The decision
to move acute psychiatric units was made in Planning for Future
in 1984. How the Strategy can now boldly state, 19 years later,
that this policy will be “accelerated” so that there
will no acute admissions to older psychiatric hospitals by 2008
beggars belief. The evidence since the publication of the Strategy
is that this target will not be met.
The last item
in this section states that health boards will be developing psychiatric
intensive care units following on from a department paper in 1999.
This issue is even more urgent given the recent publication of
the Criminal Law (Insanity) Bill, which allows for diversion of
offenders with mental illness to local psychiatric units. Few
health boards have made progress on providing such intensive care
units that will fill a vital gap between local low secure units
and the high security Central Mental Hospital. The Strategy makes
no mention of the need to provide an enhanced Forensic psychiatric
service in the country to accompany the development of these regional
medium secure units and in light of the impending new Criminal
Law (Insanity) Bill. Attempting to implement the new Criminal
Law (Insanity) Bill without such facilities, and without an enhanced
Forensic psychiatric service, would be foolhardy.
Mental
Health Legislation and Suicide Prevention
Two main items
of the Strategy are suicide prevention programmes and mental health
legislation. Both of these were already well in train prior to
the development of the Strategy, and the Strategy has added little
to their further implementation. One of the action points for
mental health was the establishment of the Mental Health Commission.
The funding and legislation for this had already been passed prior
to the publication of the Strategy document.
The Report
of the National Taskforce on Suicide in 1998 was already being
implemented before the publication of the Strategy. Both these
initiatives are to be welcomed, but it is not correct to attribute
their development and implementation to the Health Strategy.
Issues
in Mental Health:
Policy
The Strategy
talks about certain issues in mental health. One of these is the
need to update policy as the main document in this area, “Planning
for the Future”, is more than eighteen years old. Again,
no action has been taken on this point to date. It has been promised
that there will be a new National Policy Framework for the mental
health services, yet there is no evidence of any action to drive
this commitment. The Irish College of Psychiatrists is
extremely keen to be involved in such policy development, and
awaits the Department of Health & Children’s moves
in this area. At this stage, it will be almost
two years after the publication of the Strategy before the group
that develops such policy will even be established. Therefore
it will be at least three to four years after the publication
of the Strategy, before such policy will be published. It is impossible
to determine how long it will be before that policy will be implemented.
This is in light of the recommendations of “Planning for
the Future” still not being fully implemented in many services
throughout the country, nineteen years after its publication.
Structures
Advocacy
and Responsiveness
The Strategy
also mentions the need to develop advocacy networks for users
of mental health services. It discusses programmes to promote
positive attitudes to mental health, and regional advisory panels
including service providers, consumers and carers to be developed
in each health board area. All of these items are to be welcomed
for the reduction of stigma associated with mental health, and
the involvement of users and carers can only benefit the system.
However, the
College has grave concerns that such programmes and the enhancement
of suicide prevention programmes will lead to a heightened awareness
among general practitioners, hospital doctors and individuals
of mental health problems, leading to increased referrals to the
appropriate services. Unless the appropriate services have the
required funding and services in place, such extra referrals could
only bring about longer waiting lists and increased frustration
for those people suffering from mental illness. Any such programmes
may result in more negative attitudes towards mental health services,
as peoples’ experiences may be those of frustration and
desperation because of the lack of resources they find in the
services they are referred to.
One of the
planks of the Strategy document is the need to develop an advocacy
service. It is important that any individuals involved in an advocacy
service require appropriate clearance and receive appropriate
training. It must be noted that, at present, psychiatrists are
available to the patient, the patient’s family and their
general practitioner for advice and discussion. Under the new
Mental Health Act, in the case of involuntary patients, psychiatrists
must also be available to the independent second reviewing psychiatrist,
and to the patient’s appointed independent legal advisor.
If an advocate is to also be appointed, it will mean a considerable
amount of clinical time being diverted into meeting up to five
different individuals wishing to receive information about the
patient’s condition and care. This is to be welcomed, as
mental health legislation provides for the power of detention
to be available to psychiatrists, and naturally this should be
open to scrutiny. However, it is of concern to the College that
these structures will place such demands on psychiatrists that
they can only be accommodated by a reduction in levels of care
to other patients within the service.
Despite the
mention within the Strategy of all these positive programmes for
advocacy, regional advisory panels and programmes to promote positive
attitudes to mental health, little if any action has been seen
to date on these issues.
It is
clear that none of the actions listed in the Health Strategy for
Mental Health have been implemented to date. Progress has only
been made on those items that were independent of the Strategy
and that were well under way prior to its publication. Also, it
is clear that psychiatry does not appear to fall under the remit
of fairness or equity as espoused by the Strategy, and is continually
experiencing gradual erosion of its funding with the subsequent
impact on those suffering from mental illness, their families
and carers.
Dr
B Cassidy, Hon. Secretary
Irish College of Psychiatrists
February 2003
