Twenty five years ago I was on some of the first teams that began closing down large asylums and setting up mental health community and day services. Attitudes and policy towards mental health were changing. It was an exciting time; it felt like we were at the start of a new age of enlightenment in terms of our attitude to mental health services.
Less than two months ago, I commenced in the role of chief executive of the Mental Health Commission, the government body which has oversight of mental health services. Thinking back to the high hopes of progress 25 years ago, the picture today is very disappointing.
While some areas have moved on, others have not. There are conditions in some mental health services that simply should not be tolerated in a modern Ireland.
In 2018, the inspector of mental health services is still finding smelly, dirty wards and rooms, medication being given incorrectly and services that still cannot show that care is planned and delivered on an individual person-centred basis by a multidisciplinary care team.
When discussing the slow pace of change in mental health services, people often allude to big systemic or policy issues which are hard to solve, and yes there are some. However, dirt, below-par conditions and lack of integrated care planned around the person are not big systemic issues.
They are a symptom of a lack of governance and a lack of respect for the dignity of patients and service users.
Human rights
When a regulator sees this, our job under law is to end it. The Mental Health Commission has and will promote high standards and quality. We will work with and support all stakeholders who wish to create improvement.
However, where standards are not acceptable and human rights are not upheld, we will intervene, using all powers necessary, without fear or favour.
The people of Ireland have shown that we are becoming a more enlightened society than in the past. In family life, gender equality and women’s health, we have shown a determination to move forward, to change our attitudes and to show great compassion and respect.
However, the evidence is that in many of our mental health services there remains a legacy of disrespect for people with mental illness. It comes from an era we should have left behind, when people whose behaviour was sometimes unusual and which made us sometimes feel uncomfortable were institutionalised, stigmatised and forgotten about.
Many good dedicated people have in recent decades put in Trojan work to advance the human rights, care and treatment of people with mental illness. However, the facts show significant deficits in a large number of services, many of which are provided by State bodies. If the public could see some of the worst examples, they would be shocked and immediately request it to be stopped. The law provides us with the ability to bring these poor practices to an end and the Mental Health Commission will take every measure available to it.
Many good dedicated people have in recent decades put in Trojan work to advance the human rights, care and treatment of people with mental illness
When one peels back the detailed legal framework, the central role of the Mental Health Commission is the promotion of high standards and the protection of the human rights of vulnerable people. We vindicate and protect the rights of thousands of people every year. Mental Health Tribunals ensure all involuntary detentions of patients are absolutely required. Our regulations, rules and codes require practice of the highest level and our inspections monitor service compliance.
But in Ireland in 2018, there are still many users of mental health services whose human rights are not adequately protected.
Vulnerable people
There are very vulnerable people living in unregulated “community residences”. While regulation now protects older persons and people with disabilities living in residential settings, it does not protect more than 1,200 people who live in State-provided mental health community residences.
This must change. The recent past has shown that without oversight and scrutiny, vulnerable people can be forgotten and forced to live in substandard conditions.
Seclusion and restraint remain part of mental health services in many centres. In 2018, these practices should very rarely be used. Yet, the incidences of these restrictive practices reported to us indicate that 79 per cent of approved centres use physical restraint and 68 per cent of acute inpatient services still use seclusion. There were 325 episodes of restraint in 2016; 1,475 of seclusion with 213 seclusion episodes for over 24 hours and 42 for over 72 hours.
As regulator, we will be asking why these practices are so relatively frequently used in some areas and yet other centres can treat and care without using them at all. People who use mental health services should enter a place of hope and healing, not a place of fear and restraint.
People who use mental health services should enter a place of hope and healing, not a place of fear and restraint
In promoting high standards, the commission will ensure that care and treatment is about recovery, not containment and management. Many professionals, services, civil society groups, patients and their families now “get” this. However, some service providers, many of which are run by the State, do not.
The law requires individual care plans, geared towards patient recovery as a basic standard. Yet, in many services the individual care plans are found again and again to be inadequate, and in some they do not exist at all. One has to question the governance of any service that cannot provide the basics. Good governance that integrates corporate and clinical management is a given in high-performing Mental Health Services. In weaker, unacceptable services, this integration is absent.
Intervention and treatment
Services for children and adolescents require improvement in many areas. Waiting lists for children deemed “non-urgent” can be up to 15 months; there are too few specialist services to assist our most vulnerable children. There is no emergency service for children or adolescents after 5pm or at weekends except an inappropriate adult emergency department unit. And for parents and children in some rural areas, accessing inpatient services may involve a round trip of 500km.
Yet all the evidence shows we need to help and treat our children as early as possible. Research indicates that if mental ill-health takes hold and becomes enduring, it can reduce life expectancy by 20 years. Some 75 per cent of adult mental health problems are present before the age of 25.
Early identification, intervention and treatment changes these young people’s future lives. The commission will publish a new strategy in early 2019. We are determined to work with policymakers, service providers, professionals, civil society groups, patients and their families. Our preference is a shared approach which delivers in the present and creates a future of hope. We must have the courage to learn from the past, scrutinise the present and act to create a better future. The commission will play its part.
However, notwithstanding the need to work together, where human rights are not vindicated and where services do not improve, we shall intervene robustly.
John Farrelly is the chief executive of the Mental Health Commission