New era of care fails to bloom


Instead of building a new mental health service to meet patients' needs, we are repeating many of the mistakes of the past, writes Carl OBrien,Social Affairs Correspondent

FROM THE outside, at least, it looks like progress. The numbers in our outdated, high-walled psychiatric institutions are falling steadily, with many being transferred to community-based centres. Legislation designed to protect the rights of patients detained against their will is in place. A long-term blueprint to develop our outdated mental health services, A Vision for Change, sets out ambitious reforms and investment priorities.

And we have a Government which has promised to invest unprecedented resources into this most neglected arm of the health service.

And yet, for all that, the crushing reality on the ground is that we are continuing to struggle with an outdated, fragmented, and massively under-resourced system, with no end in sight to decades of institutional neglect.

Take one apparently encouraging indicator: the fall in numbers of patients residing in antiquated institutions. The good news is that many are being transferred to community-based services which are aimed at providing a break with the old hospitals of the past by providing multidisciplinary services, alternatives to medication and opportunities for patients to participate in their own care and treatment.

Yet, as the Inspector for Mental Health Services notes in her most recent report, it's abundantly clear this is not happening. Most community services are hampered by a lack of staff, poor management and shortage of resources. Instead of a new era of care in the community, we are creating a new generation of mini-institutions in the community.

When the dust settles, and the old institutions are closed down, it is highly questionable whether patients will be served much better in the new system.

And what of the oft-quoted Vision for Change, adopted by the Government as official policy early in January 2006 and due to be implemented in full over a seven- to 10-year timeframe?

Its 200 targets include establishing fully staffed community-based multidisciplinary mental health teams to offer home-based services to people with mental health problems; closing down the 15 remaining psychiatric hospitals and using their funds to build new community and residential units for those with chronic mental illness; involving service-users and their carers in day-to-day care; making institutional changes in the management of mental health which are needed to drive the transformation of the service.

The truth is that the plan is being starved of funds. Over 2006 and 2007, a total of €50 million was allocated to develop services. At least €20 million of that was diverted into other parts of the health sector.

This year, in theory, another €25 million was due to be allocated in development money. Just €3 million has materialised.

The Health Service Executive will argue that the dramatic downturn in the economy is affecting all areas of the health sector; and it's right. Yet, there was no recession in 2006 or 2007, and still the mental health budget was slashed.

If we are to have hope for the development of mental health services, it would be encouraging to see it in the development of child and adolescent services.

Sadly, some of the most unacceptable of practices continue apace. Latest figures show that well over 3,000 children are waiting long periods to get a psychiatric assessment following concerns by health professionals; more than 1,000 of this number have been waiting for more than a year.

This is despite overwhelming evidence that delays in assessment can lead to many children's conditions worsening over time.

Another 200 children with severe mental health problems were admitted to adult psychiatric hospitals last year because there was nowhere else for them to go. The trend has continued this year; between January and June 2008, a further 113 children were placed in adult psychiatric facilities.

The Mental Health Commission (MHC) says the practice can have an adverse effect on children and should take place only where there is no alternative. Some of the children admitted to adult institutions were as young as 14.

For its part, the HSE says there is progress on the ground: a total of 18 interim beds are coming on stream, while construction of a new 20-bedded unit for Cork has commenced and is due to be completed in the last quarter of 2009.

What is most dispiriting about the neglect of the service is the fact that many campaigners for a better mental health service dared to believe they had reached a turning point a few years ago. For the first time there was a new blueprint for transforming mental health services, unprecedented resources at the disposal of the Government and, most importantly, apparent political will to implement the changes.

Today, though, much of that optimism has vanished. Campaigners say little has changed except promises over funding have been broken, time-scales for developments pushed back, with no real improvements for those individuals and families who access the mental health services.

All is not lost yet, though. The HSE says it is inevitable that fundamental changes will take time to implement, but insists there has been "steady progress" towards achieving the aims of the plan.

It says the selection process of 26 new consultants is taking place, while six additional community mental health teams will be in place at the end of this year. A major programme for the valuation and sale of facilities previously used for mental healthcare is currently in progress with a view to selling properties over the coming years. All revenue raised from these sales will be directed towards improving modern mental health services.

There are signs that this is more than just rhetoric. For example, the sale of land at St Loman's psychiatric hospital in Mullingar has yielded €36 million which the Minister for Health has confirmed will be spent on priority mental health infrastructure.

The changes, however, can't come quickly enough for those in need of mental health support.

It is estimated that one in four people in Ireland will experience a mental health problem at some point in their lives. Many will never need to seek services and supports. But for those who will, their future will depend on the right help being available when they need it.

At the moment, this isn't happening for too many vulnerable people when they reach out for support.