Orla Barry, Director of Mental Health Reform, outlines how community-based services, an ethos of supporting recovery across the public sector, and greater accountability can change Ireland’s mental health for the better.
In considering what is needed to deliver improved mental health services, the quick answer is the full implementation of ‘A Vision for Change’, Ireland’s mental health policy published in 2006. This policy framework marks the transition from the institutional care model of the old psychiatric hospitals to a modern, person-focused, community-based mental health service, integrated with primary care.
There is an emphasis on the involvement of service users and family members, respect for human rights and values of equity and inclusiveness. The concept of Recovery may be viewed as a metaphor for the positive cultural change required.
When we speak of mental health we are referring to a wide spectrum of experience, reflecting mental health promotion for all, responses in primary care for people with common mental health difficulties and specialist services for people with severe mental health conditions. The term ‘mental health services’ refers to the specialist services, which offer treatment to the 10 per cent of adults (and 2 per cent of children and adolescents) who experience a mental health difficulty.
The vast majority of people (90 per cent) are treated by a GP or avail of psychological supports. The delivery of improved mental health services must consider all of these needs in the context of a local community.
Mental Health Reform’s ‘Agenda for Action’ identifies the following three priorities.
Modernising the mental health services
Community mental health services are not a new concept and many areas have had services in place since the 1970s. Indeed, home-based treatment (the gold standard in community treatment) was established in Monaghan and Clondalkin at that time. However, implementation of ‘A Vision for Change’ has been slow and inconsistent around the country, and there are still significant differences in resources and quality of services.
The 2011-2012 Children and Adolescent Mental Health Service (CAMHS) report stated that only 63 of 107 teams, and
38 per cent of multi-disciplinary staffing, are in place. In adult mental health services, staffing from disciplines other than medical and nursing continued to be under-represented on community mental health teams at the end of 2012 and overall staffing levels were 23 per cent below recommended.
There are exemplary services leading the way and the National Service Users Executive annual awards this year honoured two HSE mental health services: Ballincollig, County Cork, and Dunshaughlin, County Meath. The planned development of the National Counselling Service is very positive, offering access to counselling and psychotherapy for people with medical cards on GP referral.
In calling for the modernisation of the mental health service, we look for:
• supports to be put in place for the establishment of comprehensive community services;
• the overhaul of legislation affecting mental health services, including new capacity legislation, which protects the human rights of all people who lack capacity to make decisions;
• ratification and implementation of the Convention on the Rights of Persons with Disabilities and its operational protocol;
• increased mental health promotion; and
• the needs of marginalised groups to be met, including the Traveller community, asylum seekers and other immigrants, people who are homeless, people with a dual diagnosis and the deaf community.
Promoting the recovery ethos
The organisational change required is significant, yet surely the most important consideration is to truly achieve a person-focused and two-way model of service. There is a clear message coming through Mental Health Reform’s consultations with service users and family members: people want to be listened to, to have a consistent supportive relationship with a professional and an offer of treatment that is not exclusively focused on medication: a seemingly simple request.
However, the reliance on rotating junior doctors, difficulty in accessing psychological therapies and an approach that focuses on the professional as expert, works against the experience of a person-focused service.
An important shift in thinking is the recovery approach focused on supporting the person to play an active role in their own recovery. For Mental Health Reform, this model conveys hope that people can recover and lead full lives, often with the support of peers who have their own experience of recovery. Mental health services can facilitate this by promoting the values of partnership, listening, hope, choice and social inclusion.
Front-line staff in agencies handling housing, social welfare, education, employment and other public services all have a role to play in the new model of mental health in Ireland, ensuring their services support the recovery of their customers with a mental health condition.
Increasing accountability, transparency and governance
This call for accountability relates to the need for national leadership for mental health services in Ireland. The Director of Mental Health announced by Minister James Reilly as part of the re-organisation of the health service is an important achievement. The need for a national budget and implementation plan is a priority. An information system for mental health services is also a priority.
The Programme for Government 2011 committed the coalition partners to incorporating the recommendations of ‘A Vision for Change’ into their policies, including:
• the reduction of stigma related to mental health;
• the ring-fencing of €35 million annually over three years to develop community mental health teams;
• the transfer of residents from psychiatric facilities to more appropriate community residences; and
• the establishment of a cross-departmental group on mental health.
However, the economic crisis has impacted seriously on progress towards these and other goals. Once again, money allocated for mental health services was siphoned off to support cost overruns elsewhere in the health service in 2012 and the promised staff were not appointed.
Given the delays experienced last year, Mental Health Reform is wary of further delays and time-related savings in the recruitment of this year’s staff. To deliver improved mental health services that ensure equity and quality, national leadership with control of the national mental health budget is a priority.
In this the seventh year of the ten-year time frame of ‘A Vision for Change’, a review of the policy is due. The Government and the HSE must now ensure the consolidation of the development of community mental health services, the review of the Mental Health Act and enactment of capacity legislation.
It is time to take a fresh look at what is beyond ‘A Vision for Change’ and to consider the integration of primary care and specialist mental health services to allow seamless access and egress, improved advocacy and communication mechanisms that support listening to people who are using services, and a greater emphasis on peer support and the role of the voluntary sector in providing accessible local services.
‘A Vision for Change’s end date of 2016 is a marker for Ireland in demonstrating commitment to modernising our mental health services.
Mental Health Reform
Mental Health Reform is the national coalition of organisations working to promote improved mental health services and implementation of ‘A Vision for Change’. It works with its members through education, campaigning and support to achieve good mental health services that are available to everyone.