How many more years must we wait for meaningful reform of mental health services

More than a thousand vulnerable adults and children will continue to languish in deeply unsuitable institutional care year after year unless there is a transformation in the provision of mental services, writes John Saunders.

Each year since 2012, the Mental Health Commission has dutifully highlighted the same inadequacies in our mental health services.

Each year we point to the same drearily familiar failings. They are evidently very easy for those who make and implement policy to ignore.

These are not victimless failings. Dozens of traumatised children are admitted annually to adult psychiatric units, often compounding their trauma. More than a thousand people with enduring mental illness or intellectual disability languish in unsuitable and unregulated community residences, prevented from taking the next step towards independent living.

For six years now, we have been saying that some of our mental health services are unsafe, substandard, and breach patients’ rights.

The truth is that this will continue, year in, year out, unless there is major transformational change in the provision of mental health care services.

Without a change in priority and in attitude to some of our most vulnerable citizens, Ireland will continue to provide a level of unsafe and substandard services, which are not aligned to best practice and breach the fundamental rights of those who need such services.

More than a decade ago, under the Government policy of A Vision for Change, we began the process of moving large numbers of users of mental health services from dilapidated, old institutions into community care. This was the right policy and one which the Mental Health Commission continues to support enthusiastically.

But there have been major failings in the implementation of this policy.

Many of those who moved from the old institutions did not end up living in the community in the way intended by the policy.

Instead, more than 1,300 of them have ended up in what are known as “community residences”. Having spent decades in psychiatric hospitals, they are now accommodated in 118 of these unregulated, often poorly maintained residences that are restrictive, too big, and not respectful of patients’ privacy, dignity and autonomy.

These are people with enduring mental illness or disability and they have simply moved from one institution to another.

According to A Vision for Change, these residences should not have more than 10 beds. However, the commission’s report has found that 58% of the 118 community residences have more than this, with some having up to 30. This is not community living.

Anyone who has been an inpatient on a psychiatric ward will not be surprised by the mental health commission's report. We need investment but also we need to change the way we treat people experiencing mental health difficulties. Also too much emphasis on meds. Change needed.

— Marie Duffy (@Donegalabu) July 26, 2018

These community residences should be a staging post, a step on a journey from institutionalised care to more

independent living. However, for many, that next step is not happening and they are remaining in highly-supported and unsuitable accommodation.

This is not to say that that all of this accommodation is inadequate. However, it is not regulated. In short, we don’t nactually know what it is like, but many of these facilities are institutionalised settings with little or no rehabilitation or prospect of moving to more independent living.

These people appear to have been simply forgotten by both the nmental health services and by society. We have highlighted their position for several years. Nothing has been done.

A change in the law is needed to let the Mental commission regulate these institutions. We don’t want to suggest that that many of these institutions are not doing their best, in difficult circumstances, to give good services to vulnerable people.

Very well-intentioned and diligent staff and managers are trying hard to provide respectful and dignified care to these service users. However, this is not true in all cases. The lack of regulation dramatically increases the risk of neglectful incidents occurring, and also creates an atmosphere in which it is possible for deliberate abuse to take place and to remain undetected.

For years, we have been asking for the law to be changed to enable the commission to regulate and inspect these residences. This hasn’t happened. It is deeply frustrating to feel that, next year, the commission will be making the same call for the same, relatively simple, legal change.

We are equally frustrated by the lack of progress in dealing with the long-term and totally unacceptable practice of

admitting children into adult units. This happens because of a lack of dedicated places for children and adolescents.

The inability of Child and Adolescent Mental Health Services to admit children after hours also often forces their admission to adult care services.

This is not only an unsatisfactory situation for the child and his or her family but is also a clear breach of the human rights and dignity of the child.

We have been highlighting this for many years. The response? The number of children admitted to adult mental health services actually increased from 68 in 2016 to 82 last year.

The waiting time for a child and adolescent mental health appointment is up to 15 months.

Recent years have seen huge progress in reducing the stigma attached to mental illness, and in raising awareness of the concept of recovery.

In other words, mental health services are no longer to be seen only as a means of managing people with mental illness. Rather, they have the same aim as all health services, which is to help each patient to recover and to have as full a life as possible.

However, we continue to see some services failing to put in place individualised care plans and therapeutic programmes designed to bring about recovery. Restrictive practices such as seclusion and physical restraint are still seen as ‘normal’ in some places.

"The lack of any real progress and commitment on these matters undermines the fundamental human rights of people using mental health care services”, Mental Health Commission speaking on the patterns of non-compliance by #MentalHealth services in Ireland in Annual Report 2017 pic.twitter.com/EirMjstVeD

— Mental Health Reform (@MHReform) July 25, 2018

Some premises simply remain dilapidated and dirty. In some areas of mental health service provision, the modern view that the central aim is patient recovery has really taken hold. In others, the ambition seems to be more limited to that of management and containment.

Yes, there has been some change. In 2017, there was an improvement in services’ compliance with regulatory requirements. In many cases, local services with the support of the commission have striven to bring about improvements and have succeeded.

The big picture shows, however, a difficulty in sustaining these positive changes.

The regulations with the lowest levels of compliance were related to staffing, premises, maintenance of records and medication practices. Last year, less than half approved centres were found to be compliant in these areas. In areas such as staff training, there has still been little change.

The commission is now calling on the Government with the Health Service Executive as the statutory provider of services, to initiate a major transformation programme to deal with the service issues we are highlighting this year, and have highlighted repeatedly, year after year, to little effect.

John Saunders is chairman of the Mental Health Commission.