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REACHING RECOVERYAGREED AGENDA ONMENTAL HEALTH

REACHING RECOVERY AGREED AGENDA ON MENTAL HEALTH | 1

REACHING RECOVERY

AGREED AGENDA ON MENTAL HEALTH

FINE GAEL AND THE LABOUR PARTY

SEPTEMBER 2006


REACHING RECOVERY Agreed Agenda on Mental Health

Introduction One in four Irish people will suffer from some form of mental illness during their lifetime. Mental illness can be as debilitating, and occasionally as life-threatening, as physical illness. The impact of conditions such as depression, anorexia or schizophrenia extends beyond the individual to families and communities, and can be the cause of great unhappiness. Although mental health is central to our well being, the treatment of mental illness and the promotion of good mental health do not receive the same attention, investment and resources as physical illness. Most of us will know at least one person who has suffered from mental illness, yet it is frequently misunderstood. The resulting stigma often prevents people seeking out the help they need. People suffering from mental illness often speak of the isolation they feel, describing their condition as a prison that cuts them off from friends, families and society. In a new Government Fine Gael and Labour will deliver an effective and well-resourced mental health programme that will be directed, as far as possible, towards recovery. Recovery involves a way of living a satisfying, hopeful and productive life even within the limitations caused by illness. In recent times Ireland has undergone rapid change. Economic growth and greater mobility have benefited many of us but there is a downside to this transformation. We in Fine Gael and Labour recognise that such dramatic societal change can bring increased pressures on those who often feel left behind and marginalised. We also recognise that good governance matched with economic success can provide the means to tackle mental illness effectively. It is now over 20 years since the report on the Mental Health Services ‘Planning for the Future’ was adopted as government policy. The cornerstone of the recommendations in this report was the establishment of multi-professional teams of service delivery in the psychiatric services. Yet today, nowhere in this country have fully-staffed teams been delivered. Community-based care was another central tenet of ‘Planning for the Future’, yet admission rates do not reflect any substantial shift in focus from beds to a community approach and readmission rates, in particular, are persistently high. The Mental Health Commission has stated that ‘the lack of governance in both management systems and clinical systems within the mental health service is both evident and disturbing’. We still do not have enough psychiatrists, psychologists, social workers, therapists, nurses and back-up staff. We do not intervene early enough to make a real difference for those who develop serious mental illness. There are large tranches of the 20 year old report still not implemented. The Government must be held accountable by the public for its failure to fully implement this national policy and the reduction in the proportion of the health budget allocated to mental health from 11% in 1997 to 7% in 2006.


We still do not have enough beds for those that need them, resulting in young teenagers being treated in adult psychiatric wards. Many sufferers from mental illness experience great difficulty in obtaining and keeping paid employment. At the same time, access to employment and a reasonable income, is a cornerstone in the recovery process for many people with mental health problems. We need to put in place flexible work arrangements such as job share, flexi-time and part-time work to allow people to attend medical and other support appointments. Wise investment in mental health services and in community supports will deliver significant improvement in the dignity and health of the mentally ill who are among the most vulnerable and neglected members of our community. It is a challenge that we in Labour and Fine Gael are ready to accept. This paper is the first of a series of health policy papers which we, as the alternative Government, will be publishing in the coming months. To underline the seriousness of our intention on health reform we agreed to publish our joint strategy on mental health first. In drawing up these proposals we have taken account of the many excellent reports produced in recent years, including ‘A Better Future Now’ (Faculty of Child and Adolescent Psychiatry, Irish College of Psychiatrists: August 2005), ‘Reach Out – A National Strategy for Action on Suicide’ (September 2005) and ‘A Vision for Change’ (Expert Group on Mental Health Policy, January 2006). It is now time to act. Our policy proposals reflect our commitment to setting targets, delivering within deadlines, and providing sufficient resources as detailed in these expert recommendations. If evidence were needed to support our decision we would refer to just one aspect of mental health. An average of 450 people die each year from suicide. Most of those who die are young people who could have enjoyed full and fulfilling lives. Their loss underlines just how important is the task we have set out in this paper.


SUMMARY Fine Gael and Labour recognise that the mental health services have been neglected and under-funded and are resolved to change this. These are the Key Components of Our Plan Adult Mental Health Services We will build and foster positive mental health across the community and provide accessible, community based, fully staffed, multi-disciplined services for people with mental illness. The provision of these services will be brought at least on par with the general health services both in hospital and community services. Specific commitments include: • Put in place multidisciplinary community mental health teams, thus reducing the need for

in-patient care. Early and consistent intervention is the most effective way of helping those experiencing mental illness to recover or to manage their personal situation.

• Close those psychiatric institutions which are inappropriate for their purpose and which undermine the dignity of their patients. However, this will only happen when we have put in place adequate out-patient services. Funds from the sale of these institutions will be ring-fenced for mental health services.

• Long term manpower strategy to address staff shortages. • Appoint adequate number of psychologists to all prisons. Suicide Suicide rates are rising exponentially. Labour and Fine Gael will introduce a suicide prevention strategy, the fundamental aim of which is to prevent suicide and deliberate self-harm and to reduce level of suicide ideation in the general population. Continuous quality control and ongoing modification and improvement of the strategy will be central to its implementation. Specific commitments include: • Increase the budget of the National Suicide Prevention Office to €10 million initially and

to €20 million over 5 years. • Provide a comprehensive package for all primary and secondary schools, including mental

health programmes and comprehensive counselling services. • Formal structured partnerships between the voluntary and community sector and the

statutory sector to strengthen community-based suicide prevention strategies and bereavement support.

Child and Adolescent Services We know that the lack of attention given to the mental health of children and adolescents can lead to mental disorders with lifelong consequences, undermine compliances with mental health regimens and reduce the capacity of society to be safe and productive. The mental health service alone cannot respond to the mental health needs of children and adolescents in isolation. They are the concern of a wide range of services and agencies such as education, community care and paediatric medicine. Fine Gael and Labour will increase the number of multi-disciplinary community based child and adolescent psychiatric services and provide the required in-patient facilities.


Specific commitments include: • Act to solve the crisis in child and adolescent psychiatric services by increasing specialist

out-patient teams by 50 per cent and bring the established team up to the recommended staffing complement.

• Ensure early intervention. To cover the crucial period during adolescence and early adulthood adequately, we propose a Youth Mental Health initiative which is aimed at teachers and other adults who have frequent contact with young people.

• Develop specialist child and adolescent intellectual disability services, establish specialist eating disorder services, develop multidisciplinary teams nationally to deal with addiction and increase the in-patient facilities to meet the needs of the 0–15-year age group and the in-patient needs of the 16 to 17-year old age group.


Adult Mental Health Services “…under funding is reflective of the prevalence of mental disorder and generally negative and stigmatized attitudes toward mental illness generally”. The Mental Health Commission (2004) The provision of and quality of mental health services have received a low priority over decades. Despite report after report on the need to properly resource, refocus and reorganise the mental health services to make them patient-centred, community based and comprehensively available, the services remain below par for many of those who need them. Many of the problems associated with mental illness arise from the stigma that is also associated with it. Measures must be introduced to combat stigma and discrimination. We plan on leading by example through our commitment to end the isolation of the mentally ill through the comprehensive provision of community-based care. From Institutions to Community The standard of care for patients in large psychiatric institutions has been severely criticised by the Inspector of Mental Health Services in his 2005 report. Despite repeated Government pledges to close these institutions, just four have closed over the past 20 years and patients continue to be admitted to long-stay wards. Many of these wards have little or no therapeutic activity, multidisciplinary input, regular physical or psychiatric assessments or care plans for patients. Community residences for former long-stay patients were found by the Inspector to be “an exercise in relocation rather than part of a rehabilitation programme.” In order to make the change from hospital to community we must first set up adequate services. There is little point in replacing one inadequate service with another. There will need to be a transition period so that community services are up and running before any other services are removed. Mental health needs of : The Elderly Roughly 5% of people over 65 years suffer from some form of dementia and a further 15–20% suffers from other mental problems such as depression and anxiety. These problems are normally of a mild severity but a significant proportion require specialist intervention. This needs to be addressed. People with intellectual disabilities While people with intellectual disabilities have a higher than average risk of developing a mental illness, there are just two units approved for in-patient care and the other units in which people receive their care are not inspected and are outside the legal framework that protects their rights. The Homeless Homeless people are far more likely than the general population to be mentally ill. Mentally ill people are far more likely than the general population to be homeless. We need to provide for the particular needs of this doubly vulnerable group.


Prisoners There is a high incidence of psychiatric symptoms among prisoners. The Inspector of Prisons has consistently expressed his concern regarding the treatment of mentally ill or insane people and also people with personality disorders. A 2002 international study found that prisoners “were several times more likely to have psychosis and major depression” and that one in seven inmates suffers from a mental illness that could be a risk factor for suicide. The recently published report by the Inspector of Prisons is damning in its criticism of our prison system. We must help those in our prisons who are mentally ill. As far as is possible, those suffering from mental illness should be removed from the justice system and brought into the health system. Formal partnerships between the Prison Service and the HSE should be established. We must establish a legal right to advocacy. Our proposals on Adult Mental Health services Fine Gael and Labour commit to: • Ensure that service users and their carers will be involved in every aspect of service

development and delivery. We support the concept of “recovery orientated mental health services”.

• Introduce programmes to promote mental health for all age groups, to enhance protective factors and decrease risk factors for developing mental health problems.

• Put in place well trained, fully staffed, community-based multidisciplinary Community Mental Health Teams for all mental health services across all generations. The service will see patients in their homes and other appropriate settings, including General Practice, the community based day centres and, relatively rarely, hospitals. This will be styled on the Hospice Home Service.

• Care plans will be put in place reflecting the service user’s particular needs, goals and potential and addressing community factors that may impede or support recovery.

• Service provision will be prioritised where there is greatest need. This will be done equitably and across all service user groups. The provision of mental health services must be consistent and uniform throughout the country and provided by locally led multidisciplinary teams. People must not be disadvantaged because of where they live.

• A plan to close all mental hospitals will be drawn up and implemented. These will be replaced by modern purpose-built hostels for long stay patients. Acute psychiatric units will be provided in general hospitals for patients in need of acute, short-stay treatment. Modern special secure facilities will be made available for the relatively small number of long term severely disturbed patients. Any resources released by the hospital closures will be protected for reinvestment in the mental health services.

• Each HSE area will develop further specialised hostel accommodation for homeless patients discharged from mental institutions.

• There is currently no dedicated service for those with personality disorder or with anti social disorder. It is not appropriate that they are referred to psychiatrists, as they are not mentally ill. Under our plan each HSE area will provide a dedicated facility for inpatient and outpatient care staffed with expertise in cognitive psychology and forensic psychiatry/psychology.

• There are no facilities for brain-damaged persons under 65 years of age. Each HSE region will introduce a dedicated facility for these patients to cater for rehabilitation and long-term care where needed and home support where preferred.

• We will engage in a long-term manpower strategy to address the ongoing and growing problem of staff shortages.

• Transfer responsibility for prisoners with psychiatric illnesses to the Department of Health and Children and immediately appoint an adequate number of psychologists to all prisons.


Suicide Prevention “Those with mental illness are known to be at higher risk of death by suicide but the type of mental health service one can access is a matter of luck. Funding for mental health services is allocated in a random manner with scant regard for need. The provision of mental health services for adolescents is high on aspiration but low on action”. (Joint Committee on Health and Children’s report on the high level of suicide in Irish society, 5th July 2006) These are the stark facts: In the first half of the 1960s an average of 64 people a year died by suicide in Ireland. By 2004 there had been a seven-fold increase in this shocking statistic with an average of 455 dying by suicide each year. Suicide accounts for 3 out of every 10 deaths in the 15-24 age group and is the most common cause of death in young males. The published scientific research and the invaluable experience of those working in the area of suicide prevention provide us with clear paths and programmes to help to reduce this death toll. The loss of so many young lives and the devastation of families bereaved by suicide demand a decisive and immediate response. Fine Gael and Labour will introduce clear, systematic programmes aimed at the prevention of suicide and suicidal behaviour. We will improve support for all families in Irish society, especially those socially excluded and those in crisis. We will help to combat the stigma associated with mental illness. Our Proposals on Suicide Prevention Labour and Fine Gael commit to: • A comprehensive package for all primary and secondary schools including positive mental

health programmes, developing counselling services.

• The introduction of a Community Early Intervention service with particular emphasis on manpower planning.

• Develop, pilot and introduce effective staff guidelines for responding to people presenting in hospitals following deliberate self-harm and resource services for dealing with this situation in primary or secondary care settings.

• Support development of mental health care within primary care and develop suicide prevention awareness and skills training for primary health care workers.

• Develop services and initiatives that will help young men to cope with changing roles in society.


• Establish effective and integrated national information systems relating to suicidal behaviour to inform service development and to improve the availability and accessibility of information on where and how to get help.

• Challenge the permissive, harmful attitudes to alcohol abuse and base this action on the recommendations of the Second Report of the Strategic Task Force on Alcohol Abuse.

• Determine the risk of suicidal behaviour associated with prescription and over-the-counter medication, with a view to developing, implementing and evaluating recommendations on the availability and marketing and prescribing of these medications.

• Develop awareness of the increased risk of suicidal behaviour among victims of abuse and develop support services building on the services provided currently by the National Counselling Service.

• Ensure that an effective and standardised service and supportive response is provided by relevant professionals and voluntary agencies across a range of settings for the bereaved when death by suicide occurs.

• Labour and Fine Gael recognise that the voluntary sector and community groups have an important role to play across all aspects of suicide prevention. We will develop formal and structured partnerships between voluntary and community organisations and the statutory sector in order to support and strengthen community based suicide prevention, mental health promotion and bereavement support initiatives.

• Develop the potential of sports clubs as settings for positive mental health promotions.

• Over 5 years increase the budget of a revamped National Suicide Prevention Office to €20m per annum.

• Systematically plan research into suicidal behaviour to address deficits in our knowledge, ensure that the development of services is evidence-based and bridge the gap between research and practice.

• We will investigate the provision of public information and other suicide prevention campaigns being run on an all-Ireland basis as has been done on road safety campaigns.


Child and Adolescent Service in Crisis Child and adolescent psychiatric services account for only 5-10% of spending on mental health services, while serving 22.68% of the population. This under-investment has resulted in a child and adolescent service which is at best sporadic and at worst non-existent. The needs are clear: • In excess of 200,000 children have a mental or behavioural problem at any one time –

with one in ten of them having a disabling disorder. • Over 1,900 children under the age of 18 years sought addiction treatment in Dublin

during 1990s, representing 20% of all new attendances. • Suicide accounts for 30% of all deaths for 15-24 age group. In 2004 11,200 presented at

A&E having deliberately self-harmed. • Approximately 5,330 children and adolescents (under age 16) nationally have autism

spectrum disorder. • The numbers of people suffering from eating disorders is rising every year. Up to 7,000

Irish adolescents are currently living with bulimia or anorexia. 500 of those with anorexia will die of medical complications or suicide. Suicide risk among girls with anorexia is 200 times higher than in the general population. Binge Eating Disorder (BED) is a condition which has increased in incidences in recent years.

• Between 1% and 5% of school age children suffer from Attention-deficit hyperactivity disorder.

The infrastructure provision to meet these pressing needs is sadly lacking. There are currently 55 whole-time equivalent (WTE) consultant child and adolescent psychiatry posts, a ratio of 1:16,150 of the population under 16 years of age. In Finland this ratio is 1:6,000 (of population aged 0-19 years). The lack of specialised services for children and adolescents has resulted in waiting lists of up to two years, while many are being admitted into adult services. Of the 236 in-patient child and adolescent psychiatric beds required, only 20 are currently available. There are shortages of psychotherapists, family therapists, clinical psychologists, occupational therapists and other suitably qualified personnel to work in multi-disciplinary teams which are acknowledged as international best practice. For children who come before the courts there is no forensic psychiatric service available, nor is there any national secure psychiatric unit. There is no national availability of teams to provide addiction treatment for children and no specialist outpatient teams to deal with suicide and deliberate self harm. Specialist multi-disciplinary teams to provide for the mental health needs of young people with intellectual disability are very poorly developed.


Our Proposals on Child and Adolescent Services Fine Gael and Labour will: • Ensure early intervention. The most critical time for early intervention is when people are

first developing a mental disorder. Three quarters of lifetime cases of mental illnesses emerge by the age of 24. To cover this crucial period during adolescence and early adulthood adequately, we propose a Youth Mental Health initiative which is aimed at teachers and other adults who have frequent contact with young people.

• Increase the number of specialist out-patient sector teams 50% and bring the established teams up to the recommended staffing complement.

• Establish sufficient specialist adolescent out-patient psychiatry teams.

• Increase the in-patient facilities to meet the needs of the 0–15-year age group and the in-patient needs of the 16 to 17-year old age group.

• Develop specialist hospital liaison teams.

• Develop specialist child and adolescent intellectual disability services.

• Establish specialist forensic teams.

• Develop multidisciplinary teams nationally to deal with addiction.

• Develop autism spectrum disorder services.

• Expand specialist eating disorder services in hospitals and within out-patient teams. At present there are only 3 beds in specialist eating disorder services. We will increase this to the recommended 24.

• Establish specialist outpatient teams to deal with suicide and deliberate self-harming.

• Achieve the target of comprehensive, fully staffed, child and adolescent services for the specific needs of ADHD/hyperkinetic disorder and conduct disorder.

• Establish an infant psychiatric service and increase the number of places on the higher Specialist Training Scheme in child and adolescent psychiatry.


The cost of our proposals: The three major components of our policies are suicide prevention, improving general adult mental health services and developing a comprehensive service for young people. Based on costings contained in the reports “Vision for Change” and “A Better Future Now”, the additional current costs will rise incrementally over the next five years as follows: Year 1 €30m for Mental Health Services €16m for Child and Adolescent Services and €10m for Suicide prevention To Year 5 €151m for Mental Health Services €80m for Child and Adolescent Services and €20m for Suicide prevention Estimates for the capital expenditure required contained in the same reports over the next 5 - 10 years amount to approximately €100m per annum. While these costs are substantial, so also are the capital assets comprising existing psychiatric hospital buildings and lands. The existing public psychiatric hospitals have substantial areas of land located within urban settings. The full economic value of these will be professionally assessed towards identifying appropriate future use. The value of these assets will significantly counterbalance the capital cost of the new mental health service infrastructure. The percentage of total health spending devoted to mental health has declined from 11% in 1997 to 7.3%. This policy makes a firm commitment to implementing plans which will incrementally increase the spending on mental health from this internationally low base. In time we envisage a minimum funding baseline for mental health services of 10% of current health spending. The World Health Organization suggests that the cost of mental health problems accounts for between 3% and 4% of GNP in the EU. Based on the figures of Sainsbury Centre for Mental Health in Northern Ireland, the annual cost of mental illness in the Republic of Ireland is estimated at €11 billion. Quite apart from vindicating the human rights of people with mental health difficulties and the incalculable social gain of a comprehensive and responsive mental health service, there are potentially enormous economic benefits to be gained from investing in mental health.

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