PRE-BUDGET SUBMISSION 2010

REFORMED MENTAL HEALTH SERVICES VITAL TO

RECOVERY
The Irish Mental Health Coalition (IMHC) calls on the Government to sustain
mental health reform as a vital part of its response to the economic and social
difficulties facing the country.

The Government mental health policy A Vision for Change provides a blue
print for reform of mental health services. While the Government has
consistently stated its commitment to implementing mental health reforms,
progress to date has been painfully slow. Implementation must be
accelerated and underpinned by clear measures to protect mental health
investment and accountability for how funding is used.

Failure to maintain reform and investment in mental health services risks

undermining progress, ineffective use of resources, heightened non-health
costs and will put health and lives at risk.

URGENT NEED FOR REFORM

Irish Mental Health Services are in urgent need of reform. Development of

mental health infrastructure and community mental health teams, along with
enhanced accountability for funding must be delivered in Budget 2010. The
urgent need for reform is heightened by increasing mental health needs in
times of economic difficulty.

The need for fundamental reform of mental health services to a community

based, user centered, recovery orientated approach, is acknowledged in the
Government’s mental health policy A Vision for Change.

At the centre of mental health reform is the need to develop community based
mental health services, the provision of which is dependant on skilled and
multi-disciplinary staffing and an adequate infrastructure to support service
delivery.

Despite pockets of progress, many people have difficulty in accessing the

most basic services. Waiting lists of up to a year for referral to psychological
services, the absence of any specialist service for specialist needs such as
eating disorders, the admission of children to adult wards or young adults to

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nursing homes in the absence of appropriate services remain the daily lived
experience of people struggling to cope.

EXPERT OPINION SUPPORTS THE CASE FOR MENTAL HEALTH INVESTMENT

“It is essential… to learn from past mistakes and counter this period of economic downturn
by increasing investment in health and the social sector.” (Secretary General of the World
Health Organisation)

‘For the first time, we have an estimate of the overall cost of mental health problems for the
Irish economy, which at 2 per cent of GNP should leave no one in any doubt about the
national significance of the overall economic burden.… All of the economic evidence
suggests that the individual and social returns from judicious investment in mental health in
Ireland are likely to be high and sustained’. (Eamon O’Shea and Brendan Kennelly in ‘The
Economics of Mental Health Care in Ireland’ 2008)

What we have seen recently with respect to financial cutbacks is the tendency to reduce
staffing in community programmes to maintain acute in-patient programmes. This short-term
type of solution will cause further problems in the future. The effects of cutting resources to
mental health services are often only apparent on a gradual basis after a number of years.
This factor may make mental health cutbacks a soft target for administrators, but the
detrimental effect on vulnerable people is no less devastating in the longer run. (Dr Patrick
Devitt, Inspector of Mental Health Services in 2008 Report of the Inspector of Mental
Health Services)

The review highlighted the fact that there remains an over-reliance on traditional acute and
long-stay inpatient beds within the Mental Health Services compared with the
recommendations of A Vision for Change and this is unlikely to be consistent with achieving
the best value for money;.. In order to ensure the most effective use of scarce public
expenditure and to improve value for money, an increased focus is required on reducing the
overall dependency in Mental Health Services on acute and long-stay inpatient beds, and
community residences, and to continue to increase the provision and usage of community-
based services and teams. (2009, Indecon International Consultants in ‘Review of
Government Spending on Mental Health and Assessment of Progress on Implementation of A
Vision for Change’ submitted to Amnesty International Ireland)

ABSENCE OF BASIC INFRASTRUCTURE

Many people with mental health problems continue to receive treatment in

buildings which are simply unfit for purpose. Not only do the conditions
breach the most basic and fundamental rights, with patients devoid of
minimum levels of privacy, adequate facilities and risk of injury, the facilities
themselves remain a drain on public resources.

While many community facilities simply do not exist or are not subject to
Inspection, the following extracts from the Report of the Inspector of Mental
Health Services regarding in-patient facilities are illustrative:

The unacceptable conditions within the hospital have been highlighted by the
Inspectorate each year for a number of years… There were insufficient
bathing facilities in the acute admissions wards and the furniture in
Willowbrook was unacceptable. (St Ita’s Portrane)

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This was an old institution unsuited to the needs of a modern therapeutic
mental health service. The layout was unsuitable for the needs of the
residents and restrictions on funding and planning permission do not allow for
the facilities to be adapted to any significant degree to allow for privacy or
modernisation. (St Brendan’s, Grangegorman)

St. Joseph’s Hospital was an old psychiatric hospital built in the nineteenth
century. The Inspectorate had repeatedly stated that the hospital was
unsuitable and that there was a need to transfer residents to more suitable
accommodation based on needs. (St Joseph’s, Limerick)

The sale of the lands at these sites and others will provide a significant
contribution towards the costs of providing the infrastructure needed to
support the reform of mental health services.

A Vision for Change recognised that significant capital investment (€786.5m

at 2005 prices) is needed to provide the infrastructure required to support
mental health service provision. Capital expenditure on mental health in 2008
was €42m. Budgeted capital spending declined to €12 million in budget 2009
– a decrease of over 71% compared to the level of investment undertaken in
2008.

ACTION BUDGET 2010

1. Funding must be provided to implement capital programmes outlined in
HSE Implementation Plan for 2010;
2. Government commitment to using funding from the sale of mental health
lands for the improvement of mental health services;
3. The €42 million already raised from the sale of mental health lands must
be released to fund planned mental health services infrastructure.

ABSENCE OF COMMUNITY MENTAL HEALTH TEAMS (CMHTS)

Community Mental Health Teams are at the backbone of mental health
service provision and the reforms proposed in A Vision for Change. Based on
December 2008 figures, there remains a substantial deficit in overall staffing
across mental health services and in particular in community mental health
teams. Already under-resourced services have been further impacted by
recruitment restrictions imposed by the HSE.

The following is illustrative of the extent of the deficit:

 The number of staff in place in CMHTs nationally is less than half the
overall required minimum recommended1.
 The overall number of CMHTs initiated for Mental Health Services for
Adults with Intellectual Disability currently stands at 13. This

1
2009, Indecon International Consultants in ‘Review of Government Spending on Mental Health and
Assessment of Progress on Implementation of A Vision for Change’ submitted to Amnesty
International Ireland

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 equates to half of the number required to meet the recommended ratio
of 2 teams per 300,000 persons in the population, i.e. 26 teams. 2
 There are currently only three dedicated but partially complete Child &
Adolescent liaison teams nationally with these teams based in each of
the Dublin Pediatric Hospitals. These teams are currently operating at
around 36% of their recommended staffing levels set out in A Vision for
Change.3 Meanwhile children continue to be admitted to adult wards in
the absence of adequate specialist services. The situation is
intolerable, with staff in adult wards unable to offer adequate treatment,
leading the Inspector of Mental Health Services to note that such
admissions as ‘almost purely custodial in nature’. The situation for
young people with eating disorders is illustrative of the absence of
specialist services. There were 406 admissions for children and
adolescents under 18 years to psychiatric in-patient services in 2008.
18% of these admissions (73) had a diagnosis of eating disorders. Yet
there is no public specialist child and adolescent services to treat
children or adolescents with eating disorders.
 Rehabilitation teams provide support to individuals with serious
mental health problems, many of whom may have been in institutions
for many years. There are currently 20 Mental Health Rehabilitation &
Recovery teams nationally employing a total of 156 whole time
equivalent staff (WTEs) – this represents a shortfall of almost 750
WTEs on the staffing levels set out in A Vision for Change4. Speaking
of the absence of adequate rehabilitation services in his 2008 Report,
the Inspector of Mental Health Services notes ‘As the most seriously ill
group, these individuals should have the most intensive treatment but
instead many are left to live out cold, empty, colourless lives in old
institutions, forgotten and neglected’.5

ACTION BUDGET 2010

4. Make progress towards addressing the gaps in the multidisciplinary teams

in the Health & Social Care6 and Other Patient & Client Care personnel 7
5. Line items for specialist mental health services must be established in
Budget 2010, and those budget levels protected.

INCREASING MENTAL HEALTH NEEDS

The challenges facing mental health services are immense. Traditionally
under resourced the services face immense challenges in reforming services
to a user led, community based mental health service. Those challenges are
intensified in times of economic difficulty placing increasing demands on
already overstretched services.

2
ibid
3
ibid
4
ibid
5
Inspector Report, p.64, 2008
6
This includes Occupational Psychology, Clinical Psychology, Social Work, Cognitive Behavioural
Therapists, Family Therapists, Addiction Counsellor and other therapist posts
7
Includes Care Assistant and Attendant Posts

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A report of the Health Research Board published in 2008 identified
employment status as the most important predicator of psychological distress,
with 30.4% of those unemployed reporting mental health problems, with the
unemployed more than four times more likely to exhibit psychological distress
than those employed.8 It is to be expected that the recent rise in
unemployment as well as associated difficulties of debt are placing increased
demands on already overstretched services.

Emerging information is worrying and there is a real risk that progress made
in recent years will be undermined in the absence of enhanced prevention
and support services to individuals experiencing personal crisis. Official
figures from the National Suicide Research Foundation show there were a
total of 11,700 cases of deliberate self harm at hospital emergency
departments in 2008. Overall the national reports of self harm increased by 6
%, with an 11% increase in the level of reported self harm amongst men – the
highest rate since records began six years ago.

In addition to new mental health needs, there are increasing demands on

public mental health services from persons, who might previously have
accessed private provision, placing increasing demands on an already
stretched service.

ACTION BUDGET 2010

6. Particular attention should be paid to maintaining access to cost effective

and openly accessible community based supports to address
psychological distress.
7. Sustain existing investment in suicide prevention initiatives and provide
additional funding for services that can respond to increasing need.

FUNDING MUST BE LINKED WITH SERVICE REFORM

Restricting spending on mental health services does not necessarily lead to
cost savings. Evidence shows that the costs of mental health are largely
borne outside the mental health service reflecting prolonged dependence on
social welfare, lost productivity, higher levels of physical illness 9. Moreover a
failure to sustain reform will mean people will continue to be admitted to
services which simply cannot meet their needs, fail to support recovery
consequently leading to prolonged and incalculable distress, as well as a
drain on public resources.

While cuts in mental health budgets does not necessarily led to cost savings,
conversely increasing spending does not necessarily lead to better services or
better outcomes. Investment in mental health services must be linked to clear
accountability, and improved outcomes for mental health services.
8
Health Research Board (2008) Psychological distress, mental health problems and use of health
services in Ireland.
9
The Mental Health Commission Report Economic of Mental Health Care in Ireland (2008) notes that
the health care system accounts for less than one quarter of overall costs.

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The vulnerability of mental health funding must be addressed by clear
accountability as to how funding is allocated and used by health services.
The absence of adequate accountability for mental health funding is
highlighted by Indecon Consultants in a report prepared for Amnesty
International Ireland. The authors note ‘gaps in the availability of detailed
data/information required to facilitate the ongoing monitoring of funding and
expenditures, and human resource allocation, across the mental health
services and the assessment of progress on the implementation of A Vision
for Change’.

Even in times of economic prosperity funding intended for the development of

mental health services was diverted to meet needs in other parts of the health
service. In 2006 and 2007 €51.2m was allocated by Government to the HSE
to develop mental health services in line with A Vision for Change. In January
2008, the HSE admitted that just “57% of the developments funded in 2006
have been put in place … and 40% or €10m of the funding provided in 2007
has also been put in place”. It conceded: “The balance of the funding from
2006 and 2007 was time delayed to address core deficits in existing Mental
Health services thus ensuring that the HSE met its obligations to deliver
services within the vote.” In other words not only was almost half the money
for extra services from 2006 and 2007 not spent by January 2008, but was
diverted to address existing deficits in mental health services. While the
HSE has indicated that 90% of this funding will be in place in mental health
by the end of 2009, the vulnerability remains. The Report of the Inspector of
Mental Health Services 2008 notes, ‘In an era of financial cutbacks, we had
concerns that overall community budgets would be balanced by
disproportionate cutbacks in specialist mental health services. We discovered
examples of “donations” to the primary care services of staff resources that
had been properly assigned to the specialist services. This was over and
above what might be considered reasonable and effective liaison
involvement10.’

ACTION BUDGET 2010

8. Investment in mental health services must be informed by a value for

money analysis which takes account of the direct and indirect, economic
and social costs of mental ill-health as well as the benefits of investment in
mental health;
9. Budget 2010 must be accompanied by robust measures to ensure that
oversight is exercised in how allocated budgets are expended, linked with
the requirements of effectiveness, transparency, and accountability.
10. Funds expended on mental health services must be tracked and reported
by the HSE and the Department of Health and Children, and this
information published.

10
Report of the Inspector of Mental Health Services 2008 at p. 60

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 IRISH MENTAL HEALTH COALITION

The Irish Mental Health Coalition campaigns for improved and prioritised
mental health services in Ireland.
The organisers of the campaign are Amnesty International, Bodywhys – The
Eating Disorders Association of Ireland, GROW in Ireland, the Irish
Advocacy Network and Shine (formally Schizophrenia Ireland).
The Coalition seeks to improve the lives of people with mental health
difficulties by advocating for people’s rights to the highest attainable
standard of mental health and mental healthcare. The campaign aims to
increase the pressure on those with the power to improve mental health
services.
The Irish Mental Health Coalition campaign was launched in June 2006. The
campaign will put mental health on the political and public agendas,
including in the run up to the next General Election.
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 of us who will, our future, and that of our children and
families, will depend on the right help being available when we need it. At
the moment, this is not what many people around the country are
encountering when they reach out for support. The Irish Mental Health
Coalition campaign believes that we can and must confront the issues and
take practical steps to improve mental healthcare in Ireland.