^{Dr Shari McDaid was appointed Director of Mental Health Reform as of October 1, 2013, having previously been Policy Officer since August 2011. Prior to that, Shari worked with Amnesty International Ireland, the National Disability Authority, and Schizophrenia Ireland. Shari received her doctorate in 2008 from the Equality Studies Centre at UCD, with a thesis entitled “Power, Empowerment and User Involvement in the Public Mental Health Services in Ireland”.}

A Vision for Change, nine years on

Nine years on from the publication of our national mental health policy A Vision for Change is a good time to take stock of how far our mental health system has journeyed down the road to the vision set out in 2006.

A Vision for Change was ambitious in scope, reflecting the full continuum of supports from mental health promotion and early intervention, through primary care, to specialist mental health services and social inclusion supports for people with long-term mental health difficulties.

Importantly, the policy identified a core set of principles to underpin all delivery, including citizenship and human rights, effectiveness, partnership, quality, equity, respect, non-discrimination and recovery, among other principles.

Mental Health Reform recently launched our report A Vision for Change nine years on: A coalition analysis of progress. The intention behind the report was to show how close Ireland’s mental health system is to the vision set out in 2006.

The report draws on evidence gathered from the Department of Health and other Government Departments, the HSE and other public agencies, our member organisations’ and advisory groups’ feedback and the views gathered at our public meetings of people who use mental health services and their family supporters.

We acknowledge in the report the progress that has been made and the staff whose commitment has helped to bring about change so far. From listening to people using mental health services, we know things are changing. As one person told us: “the passion and pride of individual nurses shines through the bad infrastructure and the lack of resources”. In one case study in the report, an individual describes the hugely positive impact on her life of receiving a good quality, multidisciplinary community-based mental health service. Her life has been transformed by this service.

However, it is clear that the mental health system set out in A Vision for Change has yet to be realised across the country. Nine years on, despite pockets of innovation, implementation of A Vision for Change is incomplete and uneven. Inequity remains throughout the system, with variation in service models, choice of treatments and resources. Primary care mental health services remain under-resourced and uncoordinated with specialist mental health services.

The report highlights concerns that the involvement of service users in decisions about their own treatment and in planning mental health services is sometimes tokenistic.

Mental Health Reform is particularly concerned about the lack of attention given to some of the most vulnerable groups at high risk of developing mental health difficulties. Under the human right to the highest attainable standard of mental health, the Irish Government has a particular responsibility to provide services to marginalised groups. It is unacceptable that long-neglected services such as mental health care for people with an intellectual disability, for people with co-occurring substance misuse difficulties, or for those who are deaf or homeless have seen so little development. For example, according to the mental health policy, the HSE should have 300 posts for mental health services for adults with an intellectual disability, with another 150 posts for children. In reality, within the HSE there are just thirteen posts to serve the needs of adults and five posts to serve the needs of children with an intellectual disability.

The report also draws attention to the need for a whole-of-government approach to tackling mental health difficulties and promoting positive mental health. In an era where most people with mental health difficulties live in the community, Departments with responsibility for social welfare, housing, education and employment need to play a role in an effective mental health system.

People with a mental health disability continue to experience social exclusion in Ireland, and are nine times more likely to be outside the labour force than those of working age without a disability. Access to housing can be a problem, and information from the Housing Agency indicates that there were 1,034 households in Ireland needing housing in 2013, where the main need for social housing support is as a result of a mental health disability. This figure is likely to be a gross under-estimate of the need. The prevalence of mental health difficulties among the homeless population also shows the need for joined-up supports.

We hope that A Vison for Change nine years on: A coalition analysis of progress will contribute to the discussion as the Government begins the process of renewing Ireland’s mental health policy for the next ten years. We can learn lessons from experience to date. There is a need for greater accountability for delivery. The Independent Monitoring Group’s tenure ended in 2012 and no new independent monitoring mechanism has been put in place. An information system that would enable proper planning is yet to be put in place and the type of performance management system that can demonstrate outcomes is urgently needed. We now have a National Director for Mental Health in the HSE – leadership is required at all levels of the service to drive reform. So too, leaders need the resources to deliver on the reform programme: at the end of 2014 mental health staffing was still 11% below the level in 2008 and almost 25% below the level set out in the policy.

We encourage the Government to continue to show commitment to reform of the mental health system. In the next ten years, proper priority must be given to services for marginalised and disadvantaged groups, building up specialist mental health supports and ensuring cultural competency of all mental health staff. And the HSE must ensure that people who use mental health services and family supporters have opportunities to be genuinely engaged as equal partners in their own treatment and in planning the support system.

Importantly, all of us concerned about mental health in Ireland must encourage staff involved in delivering mental health supports to continue their journey with us towards a new type of service that is imbued with respect, compassion and responsiveness to everyone involved.