Without proper funding or political will, the Government's mental health plans will be just good intentions, writes Carl O'Brien, Social Affairs Correspondent.
Most mornings, in the brightly painted basement where she runs a homeless support service, Alice Leahy sees the casualties of the State's chaotic mental health service.
Dozens file into the Trust centre where they can get breakfast, a shower, a change of clothes and help with practical issues, such as welfare, medication or job applications. For many, however, it is just a case of day-to-day survival.
"These are people clearly in need of some support, and who could be helped, but they're not getting it," says Leahy, who co-founded the service in the 1970s. "There's no acknowledgement that this is happening. And there's only so much we can do. We're seeing these people going slowly downhill, becoming more neglected."
As many as one-third of all homeless people have a mental illness. Most have ricocheted through a rough-and-tumble health system which more often than not hasn't been able to offer any meaningful support or rehabilitation.
The closure of beds in old psychiatric hospitals and the limited number of secure beds mean many are discharged into the community with little or no support services. Like a giant pin-ball machine, they have bounced from service to service, but never long enough to get to grips with their illness.
And when things get really bad, they hit rock bottom, in services that were never designed to cope for them: remand prisons, overnight Garda cells, and homeless support services.
It's the latest chapter in a long saga of neglect of our mental health services. For decades it has been one of the most neglected arms of the health services, with expenditure on the sector falling from 13 per cent of the health budget in the early 1980s to around 7 per cent today.
But, just two years ago, many campaigners for a better mental health service believed they had reached a turning point. For the first time there was a new blueprint for transforming mental health services, unprecedented resources at the disposal of the Government and, most importantly, apparent political will to implement the changes.
Today, though, most of the optimism has vanished. Campaigners say little has changed except that promises over funding have been broken, time-scales for developments pushed back, with no real improvements for those individuals and families who access the mental health services.
The Health Service Executive has also taken a pounding from psychiatrists who have accused them of asset-stripping the sector by selling land and buildings and not re-investing the money into mental health services.
So, where did it all begin to go so spectacularly wrong? And are things really as bad as campaigners and psychiatrists make it out to be? Is the Vision for Change plan already dead in the water?
No one is in dispute over the merits of the plan. Over the course of its 200 recommendations, the report proposes: establishing fully staffed community-based multi-disciplinary mental health teams to offer home-based services to people with mental health problems; closing down the 15 remaining psychiatric hospitals and using their funds to build new community mental health centres and residential units for those with chronic mental illness; that service-users and their carers would be involved in their day-to-day care.
The Government adopted the blueprint as official policy early in January 2006 and pledged it would be implemented in full over the next seven to 10 years.
The plan makes clear that institutional changes in the management of mental health are needed to drive the transformation of the service. Most of this essential framework is not in place, however.
The National Mental Health Service Directorate was seen as a foundation stone in the plans. Instead, the HSE has set up a less ambitious structure in which - as the independent monitoring group commented - the role and authority of staff are not clear in relation to the implementation of Vision for Change.
The formation of new mental health catchment areas with smaller populations and new management teams would help drive change at a local level. This has not happened. Indeed, as the Inspector for Mental Health Services noted in her most recent report, the "ad-hoc nature of mental health provision has been noted in the past and there is no sign currently that this will change".
At a more local level, there are no figures available for the number of community-based mental health teams that have been established. Anecdotally, the recruitment embargo is hindering this process, although the HSE says it has appointed 200 "primary care" teams which can offer mental health support.
Perhaps most serious of all is the funding issue. Vision for Change states that an additional €25 million is required annually over the next six years to expand and improve mental health services.
While such money was provided in 2006 and 2007, no such funding has been allocated for this year. Furthermore, the Irish Mental Health Coalition has uncovered, under the Freedom of Information Act, that almost half of the money allocated for the plan in 2006 and 2007 has been spent in other areas.
The Minister of State with responsibility for mental health, Dr Jimmy Devins, has defended the withholding of funds this year on the basis that "it is appropriate to pause and review the situation to ensure consolidation of the investment to date".
This seems to be code for the fact that there are alarm bells ringing in the Department of Health over money not being used for what it was intended for.
Just why it has taken more than two years for these concerns to be raised, or why services should suffer this year as a result, is worthy of an inquiry in itself.
For example, the national office responsible for tackling suicide will receive just half the funding it needs this year to implement a suicide prevention strategy which the Government has described as an "urgent priority".
More than 400 people die by suicide each year, more than the number who die on the roads. Yet, the effect of the limited funding is likely to be a scaled-down national advertising campaign on positive mental health and less funds for developing prevention services around the country.
The HSE says it is inevitable that such fundamental changes will take time to implement, but insists there has been "steady progress" towards achieving the aims of the plan.
It points to the appointment of 23 consultant psychiatrists last year as a sign of its commitment. Additional funding has been provided to increase training places for psychologists and post-graduate training for psychiatric nurses in 2008.
It says a comprehensive programme for the valuation and sale of facilities previously used for mental health care is currently in progress, with a view to selling properties in the next two years. All revenue raised from these sales will be directed towards improving modern mental health services. The changes, however, can't come quickly enough for those in need of mental health support.
Children are continuing to wait months, if not years, for psychiatric assessments. Young people are still being detained in adult psychiatric hospitals. Adults with chronic mental illness are being readmitted to psychiatric hospitals where there are no meaningful community-based services.
People such as Dr Serena Condon, clinical director of St Brendan's Hospital in Dublin, see the effects of a neglected service up close. Some of the most vulnerable patients, however, are those who end up passing through Alice Leahy's homeless service because there is nowhere else to go.
"There is a huge problem with the underfunding of community-based services that could help many patients," Condon says. "We don't have the old asylum any more - not that they were necessarily a good place - and we don't have the range of services, so inevitably people end up on the streets or in prison.
"You try to patch people up, but it's heart-breaking to discharge people back into the community when you know the services aren't there."
