Mental health: a forgotten scandal

IF YOU want an emotive image to portray the Irish health service, the chances are that you are going to wheel a trolley into your argument.

Nothing raises the ire of people more than hearing of patients spending days in hospital A&E units on chairs or trolleys.

Nobody’s every going to deny that that type of situation is unacceptable. But this one component of the health service seems to dominate debate. Without diminishing the problem, it’s like giving out that the spare tyre is flat while ignoring the fact that somebody has nicked the four wheels.

Take mental health. In terms of impact on the national consciousness, it ranks up there with philately. Ah, but aren’t you forgetting the Special Olympics in June 2003? Well I am, like everybody else. It’s in danger of becoming like Live Aid, a salving of conscience that quickly faded when the next worthy cause rolled up.

This week, the Mental Health Commission published the first annual report of Teresa Carey, the new Inspector of Mental Health Services. Dr Carey’s tightly-argued, 25-page overview of the state of the services in Ireland makes for gripping, compelling and sober reading.

She points out that the public and media perception of the mental health services is unduly critical and negative and tends not to highlight “areas of high quality provision”.

But Dr Carey then gives a searing critique of the major gaps and deficiencies in services before describing the community-based model on which the service should be based.

It is scandalous that funding for mental health services has dwindled over the past two decades in proportion to the rest of the health services. In 1985, it amounted to 12% of the overall health budget. The current funding is €680 million, or 6.8%.

It’s 20 years since Planning for the Future was published. This strategy document was bold and visionary for its time and set out a plan to transfer long-stay patients in psychiatric hospitals out to the community.

On a cursory glance, the figures are relatively impressive. In 1984, there were 12,900 “clients” in hospitals. By 2002, that figure had fallen to 3,860. But in those 18 years, only 3,200 places were created in alternative communities, an average of just 177 per year. Other factors were that death of long-stay patients, a reduction in admissions to long-term care and dedesignation. In the latter instances, some wards and units - usually for patients with intellectual disabilities (ID) - were removed from the remit of the mental health services at the stroke of a pen.

SO HOW momentous has the shift been? “The use of beds and community structures still dominate service provision and the move to alternative community models of care has been slow and piecemeal,” Dr Carey states.

That’s borne home by a salient statistic she quotes, that 70% of admissions are re-admissions.

Funding is not the only problem to transforming the service. Resources haven’t been utilised adequately. The move to community-based models has been disjointed.

There has been reluctance among some personnel to embrace community care over institutional. Nor has there been a proper joined-up approach to providing a modern service to children, adolescents, to those with ID or for forensic psychiatry.

In particular, long-stay wards in mental hospitals and St Ita’s Hospital in Portrane still house significant numbers of ID patients “who would be more appropriately be cared for in community-based residences”. The Central Mental Hospital provides accommodation that is “of a totally unacceptable standard”.

Ministers like Michael McDowell and Tim O’Malley have been great on aspiration but not too hot when it comes to the urgency of delivery.

In another section, Dr Carey writes: “The challenge will have to be faced, with recognition that large institutions have no future role in the delivery of mental health care.”

That is being written in 2004 but the very same sentiment is also to be found in Planning for the Future. That was 20 years ago.

So how does mental health score on the Government’s priority list?

Will it take it another 20 year before people with mental illness and ID have their human rights recognised?