Health and care services

Reviewing the mental health strategy

Mental Health Reform, a coalition of mental health organisations has published a report assessing the achievements of Ireland’s mental health strategy ‘A Vision for Change.’

A decade after the publication of the mental health strategy ‘A Vision For Change,’ the coalition of 51 mental health organisations, Mental Health Reform (MHR) has published a report assessing how much of the strategy’s vision has been achieved.

In the report MHR seek to provide a wide-ranging review of the strategy’s implementation and as such has provided an overview of all the main elements of the policy, these are:

•   service user and family supporter involvement;

•   mental health promotion;

•   mental health in primary care;

•   social inclusion;

•   mental health services for children, adults and older people;

•   special categories of service provision;

•   accountability and governance issues.

The report documents a lot of activity related to recommendations in the strategy but notes that there is no doubt that the mental health system set out by the expert group has yet to be realised across the country. The report makes clear that in each chapter, partial realisation of the policy to a greater, or lesser extent, has been achieved. It does however make clear that with a variation in service models, choice of treatments and resources, inequality remains.

The report also finds that primary care mental health services remain under-resourced and uncoordinated with mental health services and that people with mental health difficulties continue to face significant social exclusion. The implementation of the strategy continues to be hindered by shortfalls in staffing and the lack of a clear implementation plan providing a framework for implementation. MHR also uses the report to express its ‘serious concern’ that throughout the last nine years, there has been no information system that can report on inputs, outputs and outcomes of mental health service delivery.

Implementation

Looking at the factors that have impeded the strategy’s delivery, the report states that in the early years of the policy, its implementation was slowed by the wider re-structuring that took place within the new Health Service Executive and was further hampered by the task of reconfiguring area management and delivery structures. It also notes that there was a problem with finance in the early years of the policy as designated investment funds were lost to other parts of the health service and were eventually stopped. A lack of a mental health directorate with the skills and authority to manage and drive implementation and the absence of a mental health plan also impacted upon the early implementation of the policy.

The report also credits the economic crisis with a significant role in restricting the full implementation of the policy. With 1,000 nurses lost in the first few years of the recession, the wider Government agenda to reduce the size of the public sector hit mental health services disproportionately and these losses have yet to be made up. Despite a funding increase in 2015, staffing levels are still 11 per cent below those recorded in 2008, rather than the increase envisaged by the expert group in 2006.

“the mental health system set out by the expert group has yet to be realised across the country”

Increasing demand

At the same time as staff numbers were being cut, demand for mental health supports was increasing. The report notes that the consequence of this increased demand and reduced supply were highlighted in the rising child and adolescent waiting lists and the difficulties for adults seeking emergency treatments. It also states that at this time, the remaining staff were focused on crisis management rather than fulfilling a new vision for mental health service delivery.

However, the report suggests that many of the changes demanded by people who use mental health services and their family supporters do not cost money and that to ensure patients are listened to, treated with respect and can have a say in their own treatments is not impossible, even in an under-resourced service. MHR acknowledges that some professionals attempted to drive this innovation at local level by involving people with self-experience and family supporters in their work. The report highlights the commendable work done by the Advancing Recovery in Ireland project, Headstrong and other initiatives as some of the successes in this area but warns that project-orientated mental innovation is not enough to develop a new mental health system.

The expert group that devised the policy said that it needed to be implemented as a complete plan and stressed that for its effective implementation, key recommendations must be regarded as inter-related and interdependent. The group warned that a piecemeal approach to implementation would undermine the potential for real and complete change in mental health services and stated that a failure to implement all the recommendations in appropriate sequence would result in a less than effective mental health system.

Despite this warning MHR finds that finds that a piecemeal approach to this policy is exactly what has happened, noting that the implementation of the policy has been incomplete and uneven. It claims the uneven nature of this report is unsurprising given the lack of a detailed implementation plan. The report is also critical of the fact that despite the Mental Health Commission’s call for such a plan in 2009, no such plan has been forthcoming.

 Conclusion

A Vision for Change was intended as a whole-of-government policy and in an era where most people with mental health difficulties live in the community, the expert group stated that social inclusion services would be vital in an effective mental health system. However, the report is critical of the current socio-economic position of some people with mental health difficulties and reinforces the widely held belief that the grinding realities of poverty, insecure housing and lack of employment are not good for anybody’s mental health, much less those struggling to recover from mental or emotional distress.

Looking ahead, MHR suggests that the key to the future recovery of people experiencing such distress rests with the Government departments responsible for housing, education, employment and social welfare. It is their desire to become fully engaged in promoting the recovery and social inclusion of those with mental health difficulties that will be the key driver in improving mental health services in the future.

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