Analysis: The ad hoc development of public psychiatric services in Ireland means the affluent get the best deal, writes Dr Muiris Houston
The Irish Psychiatric Society's survey finding that clinical resources - including the availability of multi-disciplinary staff, a range of treatment options and access to a variety of specialist expertise - are overstretched will not come as a huge surprise. However. its other findings are damning.
Although it is a survey of our public psychiatric health service, it has found that the best-developed clinical services are in areas of greatest affluence. In other words, an already overstretched and under-funded service has been developed in a way that favours the better-off . This does not appear to be the result of systematic planning, but rather because of the ad hoc and locally-driven nature of psychiatric services.
Nevertheless, the outcome is disturbing. How could local planners - almost without exception - favour the well-off when psychiatric illness is clearly associated with deprivation and poverty? Is it the product of health board policy, traditionally driven by local political interests, or does this reality reflect the power of lobbying by the better-off?
The authors of the survey hint at this possibility when they consider the distribution of psychologists, social workers and occupational therapy services. "The trends [for these services\] to be better-resourced . . . was possibly because service users in such areas (of relative affluence) would not tolerate such inadequacies," they note.
This finding is especially important in the light of Amnesty International's recent report on mental health services in the Republic. It was especially scathing about the lack of access to "non-drug" therapy for patients with psychological illnesses. It rightly pointed out the risk of over-dependence on a purely medical model of treatment in the absence of adequate therapists.
The Stark Facts report brings this concern to an even greater level and confirms Amnesty's conclusion that people's right to adequate psychiatric care is completely ignored by our health system.
The small area health research unit in the Department of Community Health and General Practice in Trinity College Dublin has developed an innovative five-point scale to measure deprivation. When coupled with an analysis of medical card coverage on an area-by-area basis, the researchers have been able to measure service need and inequality of access accurately.
In Dublin, for example, the level of deprivation in the South-Western Area Health Board is 42 per cent, compared to a level of 4 per cent in the affluent coastal strip that makes up the East Coast Board.
At a regional level, medical card distribution varies from 51 per cent in Donegal to less than 17 per cent in areas of south Dublin. Therefore, psychiatric services should be primarily concentrated in regions that are socially deprived and that have high levels of medical card-holders.
This report clearly shows that the reverse is the case.
Of all medical specialities, psychiatry has historically suffered from a high level of temporary consultant appointments. Many of these are allowed to drag on for years with the result that post-holders have no sense of tenure.
It is understandably difficult for these doctors, both from a motivational and a management perspective, to engage in forward planning.
Service funding for the sector has now dropped to 7 per cent of the overall health budget. Such under-funding is clearly unacceptable. However, in the unlikely event of the Government committing additional resources to mental health in the short term, it must first create a system where resources follow need.