August 13, 2009

OPINION: It is time to put our mental health services into the hands of a team committed to change, writes PATRICK DEVITT 

FOR YEARS now, health policymakers, service users, practitioners and society as a whole have been in favour of moving away from the practice of locking up people with mental illness in Victorian institutions, and developing better community-based services instead.

Yet we continue to accommodate many people with mental illnesses in those Victorian institutions we all want to see closed down. Why? Because wanting something to happen is not enough. We need to make it happen. We can have more reports calling for change, or we can have a dedicated team that delivers change.

Mental health services are important, different and badly-neglected. They need to be based in the community. Having them run from within the broad health services administrative structures means they do not get the focused attention needed for radical change to take place. Only a focused mental health service directorate can bring about the modernisation around which there is overwhelming consensus.

What form should such a directorate take?

It should be headed by a director with proven mental health leadership ability.

It should have a cabinet consisting of human resources, finance, operations, clinical and quality experts.

It should have an executive role with control of its own budget as opposed to the advisory role as proposed in the Government’s policy, A Vision for Change .

It should articulate a clear vision and mission, establish governance best-practice and champion the cultural changes that are needed.

Well-trained staff should be deployed to local catchment areas supporting and provoking clinical innovation and monitoring quality.

The Mental Health Act 2001 considers a mental health service as one that is provided by a specialist mental health team. The implication, here, is that such services cater for those individuals with serious mental illnesses, for example, those with serious psychotic, mood, anxiety and personality disorders.

This is very specialised and important business. The care, treatment, rehabilitation and recovery of such individuals are important to the State in human, economic, social and community terms. Failure to provide adequate services can have serious repercussions on the smooth functioning of society.

In addition, the reputation of the State as an upholder of human rights may be damaged. Matters of such importance require specific, focused attention. Mental health services are different to other health services. This was well recognised in the former health boards where a programme and a programme manager for special hospitals existed. Despite wide variations throughout the State, some good examples of high-quality, innovative care exist as a result.

Mental health care is wider in scope and more complicated than any other healthcare area and involves important legal, social, psychological, medical, political and economic aspects.

Successful service delivery is more dependent upon good systems, the quality of individual staff and their ability to relate to those with mental illness. High-tech equipment is unimportant. With a proper system of community service, regarded internationally as the “gold standard”, a far lower percentage of individuals with mental illness would need to be accommodated in hospitals.

Systems of delivery would be based around a population sector and could be embedded in the community more so than any other health speciality. Administering such a different system requires a different focused set of skills, knowledge and experience.

When account is taken also of the decades of neglect of the mental health services, the establishment of a mental health service directorate becomes even more urgent. Even to continue with the current model of care (mainly custodial) and provide modern and humane buildings respectful of the human rights of residents, requires a project-team approach. Compounding further the urgency of a directorate is the vital need to adopt new approaches towards the communitisation of services as in other developed countries.

The major cultural change needed here can only be accomplished by passionate committed leadership. This is frequently stressed in all literature on change-theory.

In our current system where the mental health services are part of the Primary Continuing & Community Care Directorate and soon to be more amorphously absorbed into the general HSE, it has become increasingly difficult to recognise those accountable and those who can make decisions with respect to everyday services, never mind innovation.

Furthermore, frontline mental health clinical staff are increasingly reporting “a raiding of the monasteries” with respect to transfer of resources from mental health to primary care. Why has the HSE to date turned its face against such a directorate?

No reasons have been articulated, but it appears that fears may exist of a loss of central control, that a separate directorate would become a runaway train with respect to budget or that there may be duplication of resources.

A well-administered progressive HSE should be well able to accommodate a degree of necessary autonomy in one or more of its divisions.

Indeed a well-run, accountable and partly-autonomous division would be budget-beneficial and improve outcomes.

A separate mental health service directorate is not a radical idea which would be unique to the Irish system. It is well established in other jurisdictions and, indeed, many states in the US have their own government department of mental health.

The mental health of our community is too important to subsume its administration into the general body of the health services. We need clarity, focus and commitment to change and we need it now.


Dr Patrick Devitt is the Inspector of Mental Health Services

This article appears in the print edition of the Irish Times

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