There was great optimism over plans to modernise our mental health service. So what happened and why did it all go so spectacularly wrong?
THE SENSE of optimism was palpable. It was January 2006 and the Government had just adopted a new blueprint to modernise our antiquated mental health service. Ministers solemnly pledged it would be implemented in full over the next seven to 10 years. Campaigners dared to believe we had reached a turning point.
Finally, after decades of neglect, here was a plan to transform the sector backed by unprecedented resources and, most importantly, political will to implement the changes.
Almost five years on and halfway through the plan, most of that optimism has vanished. Mental health professionals and patient groups say little has changed except that promises over funding have been broken, timescales for developments pushed back, with no meaningful improvements for many individuals and families who access the mental health services.
About 1,000 people continue to reside in outdated and often inhumane mental hospitals. Hundreds of children continue to be admitted into inappropriate adult units. Community mental teams are under-resourced and woefully incomplete.
At a time when mental services are at the coalface of the personal trauma associated with the economic downturn, most of those involved in the sector believe we are reaching a critical crossroad: either what remains of the plan is salvaged, or hopes of modernising our mental health service will stagnate for another generation.
So, where did it all begin to go so spectacularly wrong? And are things really as bad as campaigners, patients and psychiatrists make it out to be?
No one is in dispute over the merits of the plan. Over the course of its 200 recommendations, the report proposes to establish fully-staffed community-based multidisciplinary mental health teams to offer local services to people with mental health problems; closing down the 15 remaining psychiatric hospitals and using their funding to build new community mental health centres and residential units; establish a mental health directorate in the HSE to ensure there is leadership and accountability; involve service users in their day-to-day care.
But from the outset, it has been starved of funding and a lack of leadership. The strategy, for example, involved investing an extra €150 million in the sector over a period of seven years. Some of the promised extra funding arrived, but nowhere near enough.
Much of the money was diverted into other parts of the health sector in the early years. More recently, no extra money was found to develop additional services in either 2008 or 2010. Instead of increasing funding, the proportion of the health budget being spent on mental health has been falling steadily, from 23 per cent in 1966 to 6.7 per cent in 2009 and 5.3 per cent this year.
Despite these problems, there has been some progress over recent years. The College of Pyschiatry of Ireland, for example, acknowledges that child and adolescent mental health services are finally improving, with more beds coming on stream to reduce the numbers inappropriately place in adult psychiatric hospitals. Many of the most inhumane wards in outdated mental hospitals have been closed and admissions have been stopped to a number of Victorian-era institutions. Early intervention programmes are beginning to work well in some areas to provide support to those with mental health problems before they escalate into crises.
But virtually everyone agrees that progress has been too patchy and too slow. The independent monitoring group established to oversee the implementation of the plan said earlier this year there was “little substantial progress” made and pointed to the absence of “determination, leadership and understanding” to ensure that a recovery ethos underpins all aspects of mental healthcare services.
To add to the challenges already facing the mental health services, health spending cuts are taking their toll. A ban on recruitment is having serious implications for the staffing of multi-disciplinary teams. In addition, the number of people retiring and not being replaced is leading to major gaps across existing services.
As the Mental Health Commission has noted, it is unfortunate and ironic that when cuts are made, it is the progressive community services that are culled which, in turn, leads to a more custodial form of mental health service.
With public funding under pressure as never before, it would be easy to hold our collective hands up and simply despair. Yet, many agree that progress can still be made by using existing resources more effectively and protecting against further cuts to the mental health budget.
Martin Rogan, the most senior official in the HSE responsible for mental health, says the executive is committed to making the best possible use of existing resources.
It is increasingly obvious that we need to reassess how we fund services and drive change within our mental health services. This does not necessarily require extra money. Take the need to improve accountability and leadership over the delivery of the plan. The HSE last year appointed a national assistant director with responsibility for mental health area last year – but this falls well short of what is needed.
Campaigners such as the Irish Mental Health Coalition say we urgently need a standalone national directorate with a strong executive and budgetary powers, as was provided for in A Vision for Change. This, they say, needs to be accompanied by real targets, time-lines, guaranteed resources and assigned responsibility. Urgent issues will also need to be resolved such as spreading resources more equally across regions; placing more emphasis on community-based services; better ways to measure outcomes for patients; fulfilling the aim of building a recovery-oriented mental system.
Simply monitoring the implementation of the plan or decrying the lack of progress haven’t achieve much so far. Groups such as Amnesty International Ireland have suggested introducing a statutory obligation to ensure accountability and the progressive implementation of existing policy.
There are few certainties over what resources will be available in the coming years, but there is at least one: at times of economic instability, the pressure on our mental health service will only increase. Policymakers, ministers and patient groups will need to do every- thing in their power to ensure a recovery-based mental health service becomes a reality. The only alternative is long-term and possibly irreparable damage to a sector where patients have been neglected by Government and society in general for far too long.
