FOURTH SUBMISSION TO
THE INDEPENDENT MONITORING GROUP ON
A VISION FOR CHANGE
November 2010
Please direct any queries to Orla Barry, Director, Irish Mental Health Coalition,
c/o 38 Blessington St, Dublin 7; obarry@imhc.ie 01 882 7752 / 086 8146865
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1. INTRODUCTION
The Irish Mental Health Coalition welcomes this opportunity to make a submission to
the Independent Monitoring Group (IMG) for A Vision For Change (AVFC). The
Irish Mental Health Coalition (IMHC) is a coalition of non-governmental
organisations who campaign for an Ireland where people experiencing mental health
difficulties achieve and enjoy their right to the highest attainable standard of mental
(and physical) health.
In this fourth year of review of AVFC, the implementation of this radical policy is
under threat as the economic crisis impacts across public services. The IMHC
considers that in this context it is important to capture the impact of AVFC to date
rather than focusing on the past year only. In this we will identify the gains and
challenges to implementing this important policy for mental health reform.
2. IMPLEMENTATION OF A VISION FOR CHANGE
2.1. The HSE Implementation Plan
The Mental Health Commission (MHC) has identified a failure within the HSE to
grasp the complexity of the implementation process, as a factor in why the
implementation of AVFC has not progressed and identifies the need for specific skills
and competencies in implementation.1
The IMHC acknowledges the commitment of HSE management to make
improvements within mental health services including the innovative projects
supported through Genio. The IMHC considers that the efforts to drive improvements
are compromised by the lack of a clear plan and the dedication of leadership with the
authority and resources to implement AVFC.
Mental Health Commission, “From Vision to Action? An Analysis of the Implementation of A Vision
for Change” 2009, pg. 32
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The present HSE implementation plan does not provide a costed and time-lined plan
in order to achieve progress towards AVFC. The IMHC is also concerned that the
omission of key performance indicators will mean the inability to track progress.
Overall, the lack of specifics in the HSE implementation plan diminishes
accountability and hampers delivery of AVFC.
The IMHC is concerned that HSE’s failure to grasp the radical nature of AVFC
presents a serious challenge to the implementation of that policy. The MHC reflects
that implementing AVFC demands a new paradigm in mental health in embracing the
recovery ethos and that the current style of implementation planning within the HSE
is supporting more of the same rather than embracing the radical change in culture
and behaviour that is required to reform Ireland’s mental health services.2
The IMHC recommends that a detailed plan and a dedicated implementation
team lead by a National Director for Mental Health with executive authority and
accountability is required to manage the effective implementation of AVFC.
2.2. National Mental Health Services Directorate
The IMHC welcomes the appointment of an Assistant National Director for Mental
Health Services and Regional Directors of Operations. However we are concerned
that the position of Assistant National Director for Mental Health Services is an
advisory role, rather than a role with real authority and accountability. We support the
work of the Assistant National Director in influencing the development of services,
however the IMHC considers that the paradigm shift that is needed to reform mental
health services requires a single pointed executive accountability for implementing
AVFC.
AVFC called for the establishment of a National Mental Health Services Directorate.
The National Mental Health Services Directorate was to be one of the main drivers in
the implementation of AVFC. There remains a need to establish an office with single
2
ibid
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pointed executive authority, responsibility and accountability for implementation of
AVFC.
It is clear that the establishment of an office overseeing the HSE’s responsibility for
implementation of AVFC must:

Lead the reform of mental health services creating a whole-system vision and
mission

Have budget holding responsibility for mental health services across the HSE

Have responsibility for developing and monitoring key performance indicators

Develop and implement the national multi-profession manpower plan as
recommended by AVFC.
2.3. Managing Implementation of A Vision for Change – Local and National
Perspectives
The IMHC welcomes the appointment of the fourteen Executive Clinical Directors.
These appointments provide clearer local accountability for the implementation of
AVFC. The IMHC also welcomes the establishment of the thirteen mental health
super-catchment areas under the authority of the Executive Clinical Directors.
While the IMHC welcomes these developments, we are concerned that the absence of
an executive national office risks inconsistent implementation of AVFC. We are
concerned that the lack of central accountability may mean that local management
may focus on pragmatic, cost-cutting service delivery rather than the quality service
envisaged in AVFC.
2.4. Investing in Community-Based Mental Health Services
Overall investment in mental health services has dropped dramatically. Non-capital
expenditure on mental health services was €770M in 20093, in comparison to
1.1billion in 2008. Spending on mental health has dropped from 13% of the overall
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Estimate based on HSE’s December 2009 Performance Report
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health budget in 1986 to 6.4% in 2009 and 5.3% (estimated) in 2010. AVFC
recommends that the rate reach 8.4%. This is still a low level compared to
international standards.
The IMHC is gravely concerned that the dramatic reduction of funding is causing a
regression in our national mental health services that is not only putting the
implementation of AVFC at serious risk but also the quality and sustainability of
services. We are concerned that as reported by the Inspector of Mental Health
Services it is the community services that are most at risk.
“when cuts are made, it is the progressive community services which are culled, thus
causing reversion to a more custodial form of mental health service.”4
Cuts in recovery-centred, community-based services are being made despite evidence
indicating these services are more cost-effective5, have lower remission rates and
fewer relapses6.
In particular the HSE’s staff moratorium is having a devastating impact upon
community-based mental health services. Out of a total of 1500 staff cuts in the HSE,
700 came from mental health services in 2010. The priority to maintain in-patient
facilities has resulted in these cuts impacting primarily on community-based mental
health services.
Due to the lack of both legislation requiring care group accountability and a national
accounting system within the HSE, at present there is no way of guaranteeing that the
appropriation for mental health services set out in the Revised Estimates will be spent
on mental health services; and the HSE still does not account for its expenditure on a
care group basis. There is no published information on the breakdown of recurrent
mental health expenditure by catchment areas or specialist services. There is,
therefore an urgent need to strengthen the accountability framework for the HSE in
order to ensure that designated mental health funding is spent as intended and that
4
Mental Health Commission, Annual Report, 2009, pg.82
Mental Health Commission, “From Vision to Action? An Analysis of the Implementation of A Vision
for Change” 2009, pg. 25
6
Mental Health Commission, Annual Report, 2009, pg. 85
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mental health services do not continue to suffer disproportionately in the current
economic crisis.
The IMHC is concerned that the cuts in mental health services are resulting in a
reduction in specialist services such as rehabilitation services.
The IMHC request that the HSE Service Plan improves transparency in relation
to the level of detail provided on actual and planned mental health service
expenditures. This should include a breakdown of annual mental health funding
allocations by service area and mental health catchment area.
The IMHC requests that the Government commits to adequately funding mental
health reform.
Government should consider introducing a legal framework to underpin the
provision of comprehensive and community based services, and to ensure
transparent planning and reporting on funding and delivery of mental health
services by the HSE.
The IMHC request that the IMG clarify the HSE’s intentions with regard to
rehabilitation services and other specialisms such as eating disorders in the
context of reduced funding.
2.5. Closure of Hospitals
The IMHC welcomes the closure of the St. Conal's Hospital in Letterkenny and the
construction of a modern acute mental health unit. The IMHC also welcomes the
closure of wards at St. Brendan’s Hospital in North Dublin, the transfer of services to
James Connolly Memorial Hospital and the construction of a new psychiatric unit in
Mullingar. However the move away from outdated acute care institutions towards
community-based services has been worryingly slow. In order to free up resources
away from inappropriate acute in-patient care there must first be investment in
community-based services. Unfortunately the development of community services is
dependent on the closure of acute beds and this is now under threat.
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The IMHC requests the IMG to clarify if inpatient beds have been closed
without the agreed transfer of staff resources to community services.
The IMHC is concerned that the slow pace of hospital closure is also impacting upon
investment in other areas. Last year, the Minister of State for Disability and Mental
Health, John Maloney stated that €50 million from the sale of lands housing old
mental health institutions would be reinvested in mental health services. The sale of
lands has not been realised and the IMHC is concerned that this redeployment of
resources may be under threat.
2.6. Forensic Mental Health Services
The IMHC welcomes the commencement of forensic in-reach services; however we
are concerned that among the prison population there is a very marginalised group
with complex issues such as homelessness; dual diagnosis; substance abuse and
intellectual disability. This population is further marginalised within mental health
services and is at serious risk.
2.7. Child and Adolescent Services
The IMHC welcomes amendments to the Mental Health Commission’s Code of
Practice on the Admission of Children, which will prohibit the admission of children
under 17 to adults units from the 1st December 2010 and children under 18 to adults
units from the 1st December 2011. The IMHC also welcomes the establishment of
Children and Adolescent Mental Health teams (CAMHs) in Cork and Galway.
The IMHC welcomes the quality of reporting on children’s mental services based on
HealthStat and the service planning that is evident based on quality information.
IMHC is concerned that only 55 of the 99 CAMH’s teams are in place and that the
established teams are suffering from low staffing levels and this has had an impact on
service provision and waiting lists.
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The IMHC is also concerned at the lack of availability of mental health services to
young people in the youth justice system and detention schools. The most recent
Health Information and Quality Authority (HIQA) inspection of Oberstown Boys’
Detention School found that the school still has no access to child and adolescent
mental health services7. Similarly, HIQA’s inspection in April and May of 2010 found
that staff were not accessing child and adolescent psychiatric services for children at
Trinity House Detention School8.
2.8. Eating Disorder Services
No progress was made in enhancing services for people with eating disorders as
outlined in the service plan for 2010. Further the Service Plan 2010 contains no
commitment in respect of the development of eating disorder services.
2.9. Housing and Employment
While 80% of recommendations in AVFC relate to the Department of Health and
Children, there still remains an onus on other Government Departments to implement
policies as outlined in AVFC. IMHC welcomes the establishment of the Social
Housing Advisory Group by the HSE, to advise on housing options for moving
people from HSE long-stay accommodation towards more appropriate housing and
support services.
There has been no progress in the provision of longer-term employment support for
people with mental health problems and no arrangements between the HSE and FÁS
on how to move this issue forward.
3. CONCLUSION
The IMHC welcomes new developments such as the appointment of an Assistant
National Director for Mental Health Services; the establishment of new Children and
Health Information and Quality Authority ‘Oberstown Boys’ Detention School Inspection Report ID
Number: 396, published 22 October 2010
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Health Information and Quality Authority ‘Trinity House Children Detention School Inspection
Report ID 393, published 4 November 2010
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Adult Mental Health Teams; the establishment of mental health catchment areas; and
the closure of antiquated hospitals such as St Conal’s in Donegal. However, overall
progress in the implementation of AVFC is in danger of stalling.
The HSE staff moratorium has severely impacted upon community-based mental
health services; community-based services are under resourced and hospital closures
are behind schedule. Poor planning and lack of accountability threaten the
implementation of AVFC. The long-term vision of AVFC is in danger of being
sacrificed for ad-hoc decisions driven by short-term cost-cutting and inertia.
The implementation of AVFC was intended to bring about a profound change in how
mental health services are delivered within a recovery ethos 9. Despite continued
funding constraints, progress can still be achieved. It is time or the HSE and
Department of Health and Children to show commitment to the recovery model of
service delivery and show leadership in the implementation of AVFC.
Mental Health Commission, “From Vision to Action? An Analysis of the Implementation of A Vision
for Change” 2009, pg. 32
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