On the Programme for Government’s Commitment to “A Vision for Change”

Opinion piece by Dr Shari McDaid,
Director of Mental Health Reform

Shari previously wrote an article for PAI, regarding the progress made on
A Vision for Change, nine years after its publication.
You can read “A Vision for Change”: Nine Years On 
(June 2015) here.

In 2006, A Vision for Change was adopted as Ireland’s National Mental Health Policy. The strategy, which received widespread support, envisaged an Ireland where “positive mental health” would be fostered “across the entire community” and “accessible, community-based, specialist services for people with mental illness” would be provided.

A Vision for Change set out a comprehensive policy for the future direction of Ireland’s mental health services, central to which was the closure of the older Victorian mental health institutions and a shift from in-patient to community-based care.

A decade on, while much work has been done on closing the older mental health institutions and  developing a community-based service, unfortunately, for a large proportion of those affected by mental health difficulties —  particularly those whose mental health is most at risk – A Vision for Change remains just that: a vision.

In our report, A Vision for Change: Nine Years On, a coalition analysis of progress (published in 2015), we described the implementation of the national mental health policy as “incomplete and uneven”, despite pockets of innovation.

One area in which it is clear that implementation had been almost non-existent is in the provision of mental health services to specialist or high-risk groups. These include groups such as homeless people, those with a eating disorders, people with intellectual disabilities and those with co-morbid severe mental health difficulties and substance abuse problems.

Our report found that

“the evidence on the provision of special categories of mental health service provision shows that these services have received the least development since 2006 compared to other areas of the mental health service”.

The lack of any real progress in the development of mental health services for these marginalised groups is not news. The issue has been consistently raised by successive monitoring groups established to oversee the implementation of A Vision for Change since 2006.

In its sixth and final report published in July 2012, the Independent Monitoring Group (IMG) called for specialist mental health services for older people, rehabilitation and recovery, eating disorders, intellectual disability, co-morbid severe mental illness and substance abuse problems, and others described in A Vision for Change, to be fully-developed and delivered “as a matter of urgency”.

The IMG’s tenure lapsed in 2012 and a replacement group has not been appointed since.

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.

The recently published Programme for Government makes a broad commitment to fully implement A Vision for Change. According to the document “the new Government is committed to meeting the recommendations of A Vision for Change.”

In our pre-election manifesto Mental Health Reform (MHR) asked the Government to produce a detailed, time-lined, whole-of-Government action plan to continue the reform of mental health supports and improve the mental health of the whole population, in line with A Vision for Change and the Healthy Ireland Framework, ensuring that adequate funding and the structures for good governance and oversight of the plan are in place.

In order to meet this objective the Government must commit to ensuring that mental health funding reaches €973m in real terms within the five-year term of the Government, which would bring staffing levels in the mental health services up to the A Vision for Change recommended level of 12,000.

While the Programme for Government does not set out a budgeted, time-lined whole-of-Government Action Plan for the implementation of A Vision for Change, it does commit to

“conducting an evidence-based expert review of the current status of implementation

[of A Vision for Change] in Ireland and of international best practice in the area of mental health.”

It also states that the review will

“inform the next steps in the development of our mental health policy within the frame of human rights generally, feeding into the annual budgetary process and building upon the additional investment and progress of recent years.”

In addition, the Programme for Government states that “proceeds from the sale of older assets used for mental health services will be retained for new developments in mental health.”

In the past, funds raised from sale of lands were used solely to fund capital developments in mental health; however, the Programme for Government suggests these funds may also be used for new developments/new services in mental health. The sale of the Central Mental Hospital in Dundrum, Co Dublin on  prime residential area/land could potentially raise a substantial amount of money for investment in mental health services.

MHR also believes that in order to continue the reform of mental health supports and improve the mental health of the whole population, in line with A Vision for Change and the Healthy Ireland Framework, the Government must ensure access to 24/7 crisis supports.

Apart from the lack of specialist mental health service, 24/7 crisis intervention services are also seriously lacking. People in a mental health crisis are still sitting through lengthy waits in busy Emergency Departments (ED), sometimes for eight hours or more, before getting support.

The Programme for Government further commits to “ensuring support in crisis.” It states that

“since early 2015, Clinical Nurse Specialists (CNS) in psychiatry have started to work in Emergency Departments (EDs) to provide a more rapid response to those who present with episodes of self-harm. We will work to ensure that every Emergency Department has such a team, and that greater linkages to aftercare and primary care are provided for”.

The provision of CNS, while welcome, is, we believe, not good enough. A busy ED is not an appropriate place for a person in severe mental health distress.

There are no specific details in the Programme for Government in relation to the mental health funding, however, it does note “the mental health budget will be increased annually during the lifetime of this new Government”.

This lack of detail on a budget is severely disappointing particularly given recent reports that €12m was diverted from the mental health budget to other areas in the health service.

This €12m has been described as a “time-related saving” to the health service that has been accrued due to delays in recruiting staff. While we acknowledge and understand that it takes time to employ new staff, we also believe that these funds could have been spent in other areas of mental health rather than being used to prop up other sectors of the health service.

This is the second time this year that mental health funding has been unfairly targeted. While other areas of the health service received additional funds to deal with pressures, mental health did not. Yet now we learn that the funds that were to be ring-fenced for new developments in mental health are to be diverted to other areas.

The 2016 HSE Service Plan provides additional funding for a number of areas, such as acute hospitals, disability and primary care, to deal with unfunded costs brought forward from 2015, but there is no such additional funding for mental health.While other so-called “politically sensitive” areas of the health service will receive additional funds this year to deal with service pressures, mental health is expected to deal with these pressures from within existing funds.

Therefore the diversion of funds does not recognise the huge ground that still needs to be made up in the mental health services in terms of staffing; e.g. we are still at only 75% of required staffing recommended in A Vision for Change; and as mentioned there are some areas of the mental health service which have been largely ignored, such as the mental health of homeless people, of people with intellectual disabilities, and maternal mental health. There is no spare capacity within mental health services to take care of over-runs in other parts of the health service.

While assurances have been given that the €12m will be returned to mental health in 2017, we believe that this is simply not good enough. People in severe mental distress cannot, nor should they be expected to, wait another 12 months for accessible, community-based, specialist services that were first promised a decade ago.