More than 14 years on from ‘A Vision for Change’, Ireland finds itself in the middle of a public health emergency that is expected to place additional demands on already stretched mental health services.
So where do services go from here? And will a ‘refresh’ of the 2006 policy bridge critical service gaps? Maresa Fagan speaks to those involved in mental health services to see where the challenges lie and what the next government must prioritise to deliver for those most in need.
Waiting lists to access care. Children admitted to adult units. An overreliance on acute care for adults. A lack of community and home-based services. No crisis intervention and limited out of hours supports. Increasing use of restrictive practices. A lack of specialist services. Unregulated mental health facilities. Staffing gaps on the frontline.
These are just some of the more critical and pressing challenges facing mental health services across the country.
These challenges come 14 years after successive governments adopted ‘A Vision for Change’, a blueprint that promised to radically overhaul mental health services and deliver care in the community.
While the landmark report was not lacking in ambition it was hindered by the economic collapse of 2008 and failed to get the necessary political and financial backing to deliver the scale of change promised.
The policy succeeded in ending the detention of thousands of people in outdated psychiatric hospitals and units. The closure of these institutional facilities saw the number of acute in-patient beds fall from more than 12,000 in the mid-1980’s to around 4,000 by 2004 and to just over 1,000 today.
The strategy failed, however, to reinvest funding to develop a range of supports and services in the community, tailored to meet the varying needs of individuals in emotional or psychological distress.
The range of challenges across the service come as the next government will consider a ‘refreshed’ mental health policy that was approved in December before the arrival of Covid-19 this year.
In the 14 years since ‘A Vision for Change’ was published, funding for mental health is only now returning to levels last seen before the Celtic Tiger collapse.
Around €1 billion was invested in mental health services every year between 2006 and 2010 when the economy came crashing down.
In 2011 and 2012, the mental health budget fell to just over €700 million and it has taken several years of economic recovery to see funding levels restored to €1 billion this year.
The Psychiatric Nurses Association (PNA), which represents 6,000 psychiatric nurses and students across the country, said the service can no longer be neglected.
PNA General Secretary Peter Hughes said the sector requires “serious investment” and that the incoming government must reverse decades of underinvestment.
“The mental health sector has and continues to be neglected. Coming up to every election we hear promises about mental health and how it is every high up on the agenda. But as soon as a government is formed it seems to drop down the pecking order very quickly,” Mr Hughes said.
The nursing union, Mr Hughes said, was disappointed with the lack of engagement on the ‘refreshed’ strategy for mental health and leaks suggesting that technology could become a key feature of future services.
“There has been no consultation or dialogue with us. We haven’t had sight of the strategy and only learned what might be in it through the media and that’s totally unacceptable,” he said.
He dismissed the possibility that “digital psychiatry” could meet the needs of people or bridge existing gaps in services.“I am concerned, dealing with someone with mental health issues is based on a therapeutic relationship and I’m not convinced that you can build up a therapeutic relationship as effectively through video or zoom calls; being face to face is key.”
Among Mr Hughes’ top priorities is the need to develop 24/7 crisis intervention services and rehabilitation and recovery teams in the community.
“Mental health doesn’t finish at 5pm on any evening,” he said, adding that these services were needed to support people to live independently and avoid hospitalisation.
Those involved in adult mental health services say institutionalisation is still happening because of an overreliance on acute beds and limited alternatives in the community.
This runs contrary to the objectives of ‘A Vision for Change’ and also means that many individuals are not receiving care appropriate to their needs or rights.
While a small number of regions, such as Cavan/Monaghan and South Tipperary, boast a modern and diverse range of services, there is a post-code lottery for community mental health supports elsewhere in the country.
Earlier this year the Mental Health Commission, the independent regulator of services, found an “almost total absence” of community services and supports, which it said led to prolonged stays in acute units.
That experience is echoed by peer-led advocates, who offer support to individuals in acute mental health units.
A census carried out by the Mental Health Commission in 2018 found that one in eight adults admitted to acute units had stays of more than six months. There is also anecdotal evidence that some people may remain in acute care for two years and more.
Chief Executive of the Mental Health Commission John Farrelly said investment and governance are critical to addressing existing challenges but that he also wants to see “mental health at the cabinet table”.
“The number one priority is the governance, management, and prioritisation of mental health within the HSE. The reinstatement of the National Director for Mental Health as proposed under ‘A Vision for Change’ and ownership of mental health at board level are also key.
“We can have laws, regulations, and policies but unless we have a strategy that’s actually implemented and driven by those leading our services we will stay in the past,” he said.
The risks associated with not delivering the required change are “significant”, he said, pointing to waiting lists, service gaps, and acute care units that are not fit for purpose, which the regulator had already identified.
A mental health strategy for young people, Mr Farrelly said, could provide earlier intervention and support and reduce the number of adults presenting with mental health challenges later in life.
“If you can get in there early, you can help people to solve a lot of problems and also eliminate a lot of pain,” he said.
Rehabilitation and recovery services are also needed for people with enduring mental illnesses, he added.
“There is very little investment in that and some people are left struggling in chronic illness”.
The Covid-19 pandemic has and will present challenges for mental health services and the ‘refreshed’ strategy that was drafted before the public health crisis unfolded earlier this year.
The Department of Health hopes to publish the ‘refreshed’ policy this year and confirmed that, once approved, a committee will be set up to oversee its implementation over the next ten years.
While the new roadmap has yet to be published, it is expected to include provisions for greater use of technology and telehealth initiatives across mental health services, some of which have recently been rolled out.
The HSE said mental health services were “disrupted” by Covid-19 but remained operational and accessible.
A HSE spokesperson said new telehealth options, including “innovative online, text and phone therapeutic supports”, had been “fast-tracked” to improve access to services during the public health crisis.
“Many of these have been in development for some time, as part of a range of digital mental health initiatives underway in the HSE, and others have been developed specifically in response to Covid-19,” they said.
While the PNA is not convinced by the use of technology, Mr Hughes said the pandemic has added to the sense of urgency to deliver on mental health commitments.
“Take the waiting list for child and adolescent services, which is at around 2,000; that doesn’t give you a lot of confidence about how we’re going to deal with any increase post-pandemic,” he added.
Dr Jim Lucey, a consultant psychiatrist at St Patrick’s Mental Health Services and Professor of Psychiatry at Trinity College, said any renewed focus must reimagine services for a post-Covid Ireland.
He takes a more radical approach to simply refreshing ‘A Vision for Change’ and proposes merging public and mental health services and trebling the level of investment.
Mental health spend is “way too low”, he said, and funding will be critical to the success or failure of the next strategy.
“Now we have to make a decision. Are we going to spend money that delivers healthcare? And if we’re going to do that we need to spend money on mental health and public health because they are the things that make people better,” he said.
By the age of 16, Tammy Donaghy was taking antidepressants and struggling with depression and self-harm.
Her home life in Finglas had presented significant personal challenges from an early age. Both of her parents had addiction issues and her father took his own life when she was in sixth class. Tammy was reared by her grandparents.
By the time the Dublin teenager reached secondary school she was in distress.
“I began realising things about my life and I felt I wasn’t like other girls in my year. I got really depressed and started to self-harm.
"Everyone in my eyes had a stable home life and had these goals that I didn’t have when I was in school. I didn’t really care about school and wanted to get out of it."
While she accessed a range of therapies during her childhood the support was not there when she needed it most in her teen years.
Five years ago, at the age of 16, Tammy no longer had access to child and adolescent mental health services and faced a two year wait to access adult services – an anomaly that has since been addressed.
“I was two years waiting on the list before I got an appointment to see a psychologist in adult services.
Looking back, the now 21-year-old counts herself as one of the lucky ones, as she was able to access psychotherapy counselling through her school that marked the beginning of a slow, hard road to recovery.
“I was lucky enough during those two years that the school offered further counselling and I just connected with that therapist, who I have been seeing since.
“It’s not easy and you have to do a lot of work on yourself. You still have those days or those thoughts but you will have better coping mechanisms,” she said.
Now studying youth and community studies at Maynooth University, and working with youth organisation, Spun Out, Tammy said gaps remain in services.
While youth projects and centres are useful, she said, they not designed to provide counselling to young people in distress.
"I haven’t been able to direct them to services or supports. What do you tell a young person who is feeling down but not suicidal?.
“People from socio-economically disadvantaged areas may not have the money for counselling; they may be using any money they have to self-medicate or trying to find other ways to make themselves feel better,” she added.
Greater investment in services is needed, she said, to provide earlier intervention and prevent people from becoming ill.
“People are suffering at the moment. It’s so important to have mental health services available because people are dying; that’s the reality of it. People are dying, people are hurting themselves, people have addiction issues,” Tammy said.
“It’s an awful thing to see but it is preventable. If people had the necessary coping mechanisms so they could deal with challenges in their lives they wouldn’t be where they are."
SpunOut.ie was created by young people for young people and offers a range of information on education, employment, health, life and opinion.
A lack of community mental health services has led to the continued institutionalisation of individuals, some of whom can spend up to two years in an acute unit.
The Irish Advocacy Network (IAN), which offers peer-led support to individuals north and south of the border, said prolonged placements in acute units were not appropriate to the care needs of individuals and were contrary to the ambitions of ‘A Vision for Change’.
The network and its team of 20 staff advocate for individuals in acute mental health units and can help to secure legal advice around detention and provide support at mental health tribunals.
IAN chief executive Colette Nolan, said ‘A Vision for Change’ did end institutionalisation “up to a point” but that the network continues to deal with people staying in acute units for long periods.
“The idea was that people would come through an acute unit and then move on to a step-down facility in the community and onto other supports from there. But that hasn’t really happened and the focus remains on acute units,” Colette said.
The 2006 strategy, she said, was “very aspirational” and, while bringing many positive developments, it did not have the government backing and funding to deliver the scale of change required.
“The biggest aspiration was that people thought they would have a greater say in their care and that alternative care or treatment options might be available. ‘A Vision for Change’ did have that aspiration but I think for most people it never got to that point; those options were never realised,” she added.
IAN training and development officer Jim Walsh said prolonged stays in acute units amounted to institutionalisation and that alternative care and support options are long overdue.
“There is a significant number of people staying in acute care units for six months to a year, sometimes even longer,” Jim said.
“The effects on the individual is institutionalisation over the long term, regardless of what you call it or the reason for the prolonged stay. That’s one thing I would like to see happen from ‘A Vision for Change’; to say that’s no longer acceptable and to have alternatives to hospitals for people."
The network believes there is a need for a broader conversation around mental health and a “whole of community” approach to take account of an individual’s environment as well as how people are supported through health, housing, education and social services.
Plans to publish a refreshed and updated mental health strategy this week should focus on delivering more community and home-based care and treatment options to suit the wide range of needs arising.
“Staying in an acute unit is great if you need it but we also need alternatives to acute units,” Colette said.
More interventions and supports, such as stepdown facilities and crisis houses, could provide more appropriate support.
“If you have to go to an acute unit it should be short and sharp; some people can come out within six weeks but most people can’t. If we could keep stays in acute units to a strict timeframe and then at that point look at providing other services to assist recovery,” Colette explained, adding that extra acute beds were not the answer.
By way of example, she cites a 24/7 home treatment programme offered by the health service in Belfast, where members of the mental health team can pay a home visit and provide care and treatment as needed.
They argue that Open Dialogue models of care and intervention and Soteira crisis houses should also be given serious consideration as effective alternatives to institutional care.
Mental health services need to be rights-led to give people more say in their care.
“The rights issue needs to be addressed at the service level and at societal level. We need to be consistently reminded of people’s rights as citizens and as individuals with their own sense of self," Jim said.
The views of service users and carers, Colette added, also need to be heard when developing or changing how services are provided into the future.
“We need change and we need to bring more views into the conversation. We need to listen to what people want and need and also to listen to carers who often feel left out in the cold,” she said.
The Irish Advocacy Network offers peer support to individuals experiencing mental health challenges. Further information can be found at http://irishadvocacynetwork.com/wp/
Mental health and public health services should be merged and funding should be trebled if Ireland wants to deliver modern, responsive, supports and services for those in need.
That’s according to Clinical Professor of Psychiatry at Trinity College Dublin, Jim Lucey, who said it’s time to move on from the 14-year-old ‘A Vision for Change’ strategy to reimagine how services can be delivered.
Professor Lucey, who retired as the Medical Director of St Patrick’s Mental Health Services last year, said unforeseen social and economic changes and a lack of funding hindered the “wonderful ambitions” of the 2006 strategy.
The economic collapse of 2008 and an explosion of common mental health disorders could not have been predicted when the strategy was first adopted as government policy, he said, adding that the Covid-19 pandemic is likely to present unforeseen challenges into the future.
The consultant psychiatrist at St Patrick’s University Hospital said common mental health disorders, such as anxiety and depression, “boomed” in the last decade, rising by 25% in ten years to 2019.
“They didn’t predict the huge rise in common mental health disorders from stress and distress that can manifest as anxiety or depressive disorders, self-harm, addiction, and suicidal behaviours,” he said.
The 2006 blueprint, Professor Lucey said, was unconsciously institutional and too focused on structures and geography but also lacked government investment.
“They needed to start in a different place. It was full of wonderful ambition and a sincere desire to deliver high quality mental health care right across the country,” he said.
Any new plan, he said, must come with signifant investment as historically mental health funding was too low.
Professor Lucey said 40% of healthcare need is in mental health services but that this was not matched by funding. Exchequer earnings, he added, were €50 billion in 2019 yet less than one billion euros was spent on mental health services.
“The two most pressing needs of our society are mental health and public health and we spent less than two billion out of a €17 billion health spend on them,” Professor Lucey said.
Society has moved on in many ways and the next strategy, he said, needs to sync with the societal changes that have already happened while also preparing for the impacts of the Covid-19 pandemic.
Greater investment in preventative mental healthcare, such as early intervention and awareness in schools, is key and technology and telehealth will also have a role to play in future services.
“We now have a new Ireland that is much more open and with lots of young people.
“The data tells us that 75% of adults with mental health difficulties had that difficulty before they were aged 25,” he said, adding that investment in core services for common disorders and severe and enduring disorders must come before investment in technology and other therapies.
The Covid-19 pandemic is already impacting on mental health services and any new strategy will have to meet the needs of a post-Covid Ireland, he said.
“We’re discovering the enormous distress among people working in the healthcare sector, nurses, doctors, and therapists, working on the frontline. 50% are experiencing some degree of substantial distress.
“That’s just in those working on the frontline of our health services; we don’t know yet the emergence of Covid-19 stress disorders in the rest of society,”
Professor Lucey said, adding that we are still in the acute phase of the pandemic.
Immediate strategic priorities for Professor Lucey include mental health services for young people, integrating addiction and mental health services to provide for people presenting with a dual diagnosis, and merging mental and public health services.
The Trinity professor said funding should be trebled for mental health and public health as both were critical to the health and wellbeing of society.
“I would stop talking about mental disease and illness and start talking about building services that are about public health and public mental health. I would roll them together and fund them substantially; they need at least a trebling of their investment,” he explained.
Coherent planning, funding, and political will, Professor Lucey added, are needed to deliver modern mental health services.
“Post-Covid everything is different so let’s reimagine things. A reimagined service would be one that is responsive to people in the community and meets their needs in the community.
“We’ve had visions and dreams but what we need now is new imagination and total commitment backed up by real spending,” he added.
It will be apparent to most people in this country that there are significant and ongoing challenges within the mental health system.
Over the last 12 months, the Mental Health Commission – the independent regulator of mental health services in Ireland - has published a series of reports and papers that have set out in stark terms the reality of our current services.
Since the start of June last year, the commission has published over 50 inspection and overview reports, the findings of which have unapologetically exposed a weak and ineffectual system.
We have revealed that people with severe mental illness are being denied access to essential physical healthcare services. We have exposed serious and ongoing concerns with hygiene and maintenance of some centres. We have evidenced that the provision of inadequate rehabilitation services has led to long-term neglect of people with serious and enduring mental illness.
Within other reports, we have revealed a 57% increase in episodes of restrictive practices on patients over the past 10 years; we have shown that care planning is still commonly regarded by some service providers as a tick-box exercise; and we have presented evidence that modern community mental health supports across the State are almost totally absent.
In addition to all this, we have reported on the continuing human rights breaches of approximately 1,200 residents of unregulated 24-hour supervised residences for people with mental illness.
While these failures are clear and obvious, the Covid-19 pandemic has exposed further failings. While recent studies have correctly shown that frontline medical staff and vulnerable groups must be a priority for mental health support at this time, we also need to think of what is referred to as ‘the missing middle’.
Our mental health system, primarily because it has an institutional mind-set to respond to people with a diagnosed mental illness, does not respond well to people who are seriously distressed to prevent them from ‘tipping over’ into crisis situations.
Many people with common, disabling problems such as stress, depression, anxiety, trauma and substance abuse have few options available through the public system.
Of course, what is deeply frustrating about all this is that we introduced a policy in 2006 called ‘A Vision for Change’ that, if it had been fully implemented, would have solved many of the failures that we see in our system today. Unfortunately, to date this policy has only been partially executed.
Ireland has come a long way in the last 60 years and has largely moved away from the old institutional type model. In 1967, a commission of enquiry recommended ‘radical and widespread changes’ that involved community services, while ‘Planning for the Future’ in 1984 stated that ‘services should be located in the community’.
The 2006 policy moved things on again and described a framework for building and fostering positive mental health across the entire community.
Yet, we are still waiting for this community model to come to pass.
From whichever angle you look at mental health care in this country, it’s clear that it has never received the priority it deserves. If we are to finally remedy that, some key measures must be taken.
First, the incoming government must commit to implementing ‘A Vision for Change’ within the lifetime of the government. Second, and to ensure there is the best possible oversight and accountability, we must ensure robust governance and leadership to deliver within the HSE.
Second, we must press ahead with the repeal and replacement of the current Mental Health Act to reflect a human rights approach and to expand the remit of the Commission to regulate the 24-hour community residences. Work to update the Act is underway and the Commission has already fed into this process.
Third, funding for mental health must be ring-fenced and all the money allocated should be used to implement our new policy. There is no question that there continues to be significant resourcing challenges, not least in the area of staffing. During this pandemic, our outstanding frontline staff have quite literally put their lives on the line to save the most vulnerable. We need more of them – and we need them now.
Finally, we must improve services for children and adolescents. The placing of children in adult units remains a totally unacceptable but common feature of mental health care practice in Ireland that should only happen in exceptional circumstances.
There are only child and adolescent units in three counties nationally, and they generally do not take out-of-hours admissions. The lack of services for children continues to have a detrimental effect on the mental health and wellbeing of young people in Ireland.
If all this happens, we can finally look forward to a system of care in this country that will provide care in the community for all. This will include the aforementioned ‘missing middle’, but will also cater appropriately for other groups including children, adolescents, the elderly and minorities.
This is not a new concept. This notion has not come from a new policy. This is something that has been recognised, accepted and requested time and time again by patients, residents, families, carers and mental health staff for more than half a century.
They have waited long enough. It’s time.
John Farrelly is the Chief Executive of the Mental Health Commission
• 25% - the rise in common mental health illnesses, such as depression, since 2009
• 6% - the percentage of the total health budget allocated to mental health - international best practice recommends 16%
• 2,470 – the number of children waiting to be seen by child and adolescent services in April 2020 – 10% are waiting more than 12 months
• 37 – the number of children admitted to adult mental health facilities between January and September 2019
• 57% - the percentage increase in the use of restrictive practices in mental health facilities between 2008 and 2018
• 40 – the number of enforcement actions taken by the Mental Health Commission for regulatory breaches in 2019
• 1,200 – the number of people living in unregulated 24-hour mental health facilities
• 700 – the number of psychiatric nursing vacancies across services
• 2,422 – the number of new whole time positions across mental health services since 2012
• 10,000 – the number of staff employed across mental health services