We need to improve our sub-standard mental health
services, but without adequate funding that won’t happen, writes Susan Finnerty.
The Mental Health Commission was established in April 2001 under the Mental Health Act and is the regulator for mental health services in Ireland. Each year, my team and I determine compliance with legal requirements, assess the quality of a service, identify good practice and areas for improvement, and highlight any concerns in relation to the safety, wellbeing or human rights of service users.
Apart from my annual review, I also regularly publish reports about various aspects of our mental health services, such as 24-hour supervised community residences, physical health in people with severe mental illness, mental health rehabilitation services, and child and adolescent mental health services (CAMHS).
We have seen improvement in many aspects of care provision, such as medication management, information provision, training of staff, and the range of therapies provided to patients.
These are positive developments, but are not consistent across the country. There is work yet to be done to ensure people receive the same high quality care and treatment, no matter where they are located.
In 2006, there were 17 Victorian mental institutions still in operation. By 2020, only two remain, one of which will move to new premises this year. Some new, state of the art buildings have been provided, which are spacious, have single en-suite rooms and respect people’s privacy and dignity.
However, I continue to highlight concerns in relation to the physical infrastructure of some mental health facilities, the overall suitability of premises to meet patient needs and the maintenance of the premises, including basic repair works and cleanliness.
There are ongoing difficulties in providing a comprehensive care plan for residents in mental health units. Reasons for this include lack of leadership, lack of cultural change, insufficient staffing resources and lack of adequate training. There has been no improvement in providing adequate care planning over the past three years.
It is the position of the Mental Health Commission that there is no therapeutic benefit to the use of restrictive practices such as seclusion or physical restraint.
Seclusion is where a person is involuntarily confined in a room or area.
Physical restraint is the use of force to prevent the free movement of a person’s body. These practices should only be used as a last resort, where there is a serious and urgent safety concern.
I am concerned that there is a lingering complacency in the use of these practices. In many services, these practices are accepted and commonplace. Such practices directly affect a person’s human rights to liberty, autonomy and bodily integrity.
We have seen little real engagement in the proper scrutiny and reduction of these practices by the mental health services.
Last year, I published a report that highlighted serious concerns in relation to the provision of general health services to persons with severe mental illness in continuing care in-patient units, with inadequate and inconsistent monitoring of patients’ physical health needs.
There was also insufficient and inequitable access to essential healthcare services such as dietetics, speech and language therapy and physiotherapy. While there is now more awareness of physical ill-health in people with mental illness, compliance in this area did not improve in 2019.
Over the past three years, I have undertaken a systematic review of all 24-hour staffed community residences in the State. There are 122 such community residences nationally, accommodating over 1,200 service users.
The residents of these services represent a large number of potentially vulnerable adults with enduring mental illness whose voice is rarely heard. The community residences are often poorly maintained, too big, institutionalised, restrictive and at times not respectful of service users’ privacy, dignity and autonomy.
Many residences were in substandard physical condition. Twenty percent of bedrooms were shared and of those 43% had no privacy in the bedrooms. A significant number of people living in these residences should, with appropriate support and rehabilitation, move to smaller, less institutionalised accommodation.
The Mental Health Commission has repeatedly called for these residences to be regulated. Regulation would allow the Commission to enforce changes where deficits and risks are found, protect the human rights of people living in these residences and help mental health services provide care and treatment in accordance with best practice standards.
Progress in the provision of mental health care, especially for people with severe mental illness, should result in better quality of service and better outcomes.
We cannot allow stagnation, where there is little improvement in compliance with standards; we cannot allow people to continue to reside in institutionalised care that does not provide privacy and dignity; we must not permit facilities to remain dirty or badly maintained; we cannot accept that people who use our mental health services are being denied a comprehensive care plan; and we must address the lack of health professionals across our services.
We have an under-resourced but dedicated and committed staff, as well as a “refreshed” mental health policy, National Clinical Programmes and Models of Care that show the way to comprehensive and evidence-based mental health services.
But without adequate funding in mental health services we are unlikely to see any significant improvement in the way mentally ill people are treated in the immediate future.
Dr Susan Finnerty is the Inspector of Mental Health Services