June 11, 2010

Still waiting for changes in mental health services
06 June 2010 By Susan Mitchell

The report A Vision for Change, which was published in January 2006, was widely lauded as providing a radical approach to a newly-prioritised mental health system.

More than four years later, another report on accountability for delivering on A Vision for Change has been published by Amnesty International.

The disappointing findings of the report, carried out by Indecon consultants, will not have surprised close observers of the sector.

In the Indecon report, Amnesty’s executive director, Colm O’Gorman, said there had been ‘‘some progress’’ on capital development, but that Ireland continued to have an ‘‘over-reliance on acute inpatient care’’ and there was a lack of transparency about where and how money was being spent.

O’Gorman said community mental health teams remained ‘‘critically under-staffed’’, and that the implementation of A Vision for Change remained severely behind schedule.

Martin Rogan, the man charged with running the mental health service, said implementing A Vision for Change was a ‘‘huge challenge’’.

‘‘Vision was crafted at the top of the boom. It was predicated on the assumption that the economy would continue to do well, even if it wasn’t doing as spectacularly well as it had been," Rogan told The Sunday Business Post.

‘‘It is not that all bets are off, as Vision describes a good quality system, but it set a target of seven to ten years.

We are now at the four-year mark so we still have the bulk of our time ahead of us.

‘‘You have to do the enabling work first before getting to the more productive phase," said Rogan.

Last week, junior minister John Maloney turned the sod on a 100-bed unit in Mullingar, Co Westmeath. It is one of 12 new capital projects coming on stream.

Work on a new 66-bed unit to replace all accommodation in Grangegorman, Co Dublin, is due to start by the end of this year. The new 34-bed acute unit at Letterkenny General Hospital, Co Donegal, is another sizeable project.

Rogan, who was appointed assistant national director for mental health of the Health Service Executive last November, said most of the 12 projects were due to open next year, while the rest would open in 2012.

Ireland’s mental health institutions have come in for severe criticism, with recent reports from the Inspector of Mental Health Services describing ‘‘forgotten and neglected’’ residents living in places that were ‘‘unfit for purpose’’.


A Vision for Change advocated the closure of the state’s 15 ageing psychiatric hospitals in favour of more community based care.

The development of multidisciplinary teams was another key objective.

‘‘The old buildings, unfortunately, are very graphic reminders of the past. Vision for Change recommends the selling of these old buildings and their lands.

‘‘It is a great idea, even though property values are significantly lower than they were some years ago," Rogan said.

‘‘We are trying to rebuild the service, as opposed to refreshing it.

You could probably do it quicker with a large bucket of magnolia paint, but that is not what we are about.

‘‘We are trying to modernise the service and improve it for people who have continual care needs."

Rogan said two institutions, St Brendan’s in Dublin and St Connell’s in Letterkenny, would cease admissions at the end of this month as they were being wound down.

Maloney recently announced plans to rehouse mental health patients in unused social and affordable housing.

‘‘Within three years, most of those hospitals will be decommissioned, but it is not as simple as just closing their doors.

You need to put in a credible alternative.

They have been living in a very cocooned environment and you can’t simply put them into an anonymous housing estate," said Rogan.

‘‘Some people in psychiatric hospitals will have very complex needs and they will move into adapted community nursing units, as they will need full-time care.

They will have much better quality accommodation – such as single en suite rooms in a modern setting."

Rogan spoke of a ‘‘cascading model’’ that would see some people move from psychiatric institutions into high support settings, where there is 24-hour care, while others will shift to medium-support settings where there is daytime care.

The last stage is low support, which will see the last grouping provided with housing and given some support by HSE staff or voluntary organisations.

‘‘We have worked with the Department of the Environment on this. It will provide the housing and we will provide the care element.

‘‘That piece of work is being prepared for government, and the strategy is due to go to government in a few weeks," he said.

Rogan said two new 20-bed youth and adolescent units – one in Cork and another in Galway -would open this year.

‘‘In 2006,we had 13 beds for children and adolescents.

We will have 52 by the end of this year.

Vision for Change recommended 80 beds by the end of the ten years so we are actually ahead on that front," he said.

Amnesty pointed out that 247 children were admitted to adult mental health wards in 2008, although it acknowledged there had been a reduction in this figure in 2009 (155).

The Inspector for Mental Health Services has described the practice as counterproductive and almost purely custodial.

Rogan said it was hard to disagree with those conclusions.

‘‘It is actually counter therapeutic. What we have done is worked with the youngest kids to make sure they are not admitted to adult units. Since last July, under-16s have not been admitted to adult units. By the end of this year, no under-17s will be admitted and, by the end of next year, we will have no under-18s in adult units," he said.

Slow progress

Critics of the status quo have argued that delays in closing outdated psychiatric institutions have been exacerbated by shortages in community mental health teams, as it has encouraged an excessive rate of hospitalisation.

The HSE claims 124 community mental health teams, but Rogan said few were fully developed, although community care has been government policy since 1984.

Vision for Change recommended that an additional 1,800 staff be appointed in mental health.

At that time – January 2006 – about 10,300 people worked in the sector. Today, about 9,500 are employed, leaving mental health some 2,600 off the target.

Rogan said there was no escaping the manpower shortage, but said Ireland generally offered good access to adult psychiatrists.

We have the recommended number of adult psychiatrists, but 30 fewer child psychiatrists than we should.

We have a dearth of other mental health specialists, and access to different therapies is patchy at best, however.

Someone with anxiety might get cognitive behavioural therapy in Cork, but that treatment might not be available in Donegal, for example.

Increase in demand

The problem is being exacerbated by an increase in deman
d for mental health services, said Rogan, who qualified as a psychiatric nurse.

‘‘People are beginning to feel more comfortable talking about their mental health needs.

The stigma is beginning to abate.

‘‘In the past, people were willing to tolerate more. Now they will do something about their problems, which is a much more constructive and positive place to be."

Rogan said the HSE had carried out a national audit to determine where shortages were most pronounced.

However, beefing up community teams in the current environment – where funding for mental health has fallen – was no mean feat.

While mental health is exempt from the moratorium on recruitment, it still has to be done within budget.

A key recommendation of Vision for Change was that the assistant national director for mental health should have overall responsibility for the HSE’s mental health budget.

There has been criticism of the fact that the HSE only provides top line figures in relation to expenditure on mental health services.

Rogan said controlling the budget would simply distract him from strategic thinking – something he said was greatly enhanced by a mental health conference which took place in Ireland last month.

‘‘International leaders in mental health came to Ireland to share their knowledge and experiences. It provided a great platform to gain an insight into emerging trends and promising practices from other member countries," he said.

Rogan was philosophical about the criticism levelled at the services to date.

‘‘I take the Oscar Wilde approach to this: I would rather be talked about than not. It keeps us on our toes and it means people genuinely are concerned about mental health.

‘‘It is a constructive interest. Radio silence would not be a good thing."