Concern grows as strains on mental health policy intensify

There is an alarm bell ringing across the mental health service. It’s the sound of anxiety that as demand rises and concern grows over suicide, cutbacks to crucial supports are placing badly needed services under real strain.

Latest figures show the number of suicides and people self-harming is up, while mental health groups such as Pieta House and others say they are struggling to meet demand for assistance.

There are some encouraging projects on the ground and new governance arrangements aimed at ensuring mental health has a greater level of priority. We are also making good progress in closing down out-dated institutions. But just when mental health services are needed most, say many campaigners and professionals, they are in danger of fraying at the seams.

You can't fault the policy. A Vision for Change, published in 2006, set out a world-class blueprint on how to modernise mental health services within a decade, moving from old-style institutional care to a community-based model. It also promotes a recovery-based model where patients have a say in their care and where there is access to a wide variety of supports.

Implementation
The problem is the implementation. Ongoing cutbacks to the public sector, a recruitment moratorium, delays over spending "ringfenced" money for community mental health teams all mean that progress in turning rhetoric into reality has been – in the words of the Mental Health Commission earlier this year – "slow and inconsistent".

The Government and the Health Service Executive have difficult choices to make trying to spread scarce resources across a sector where everything seems to be a priority. But, in the case of mental health services, cutting back will simply store up problems for the future. As the Mental Health Reform lobby group argues, implementing a Vision for Change involves cost-effective solutions that, ultimately, would lead to more efficient and effective services.

The Government often points to its pledge to ringfence €35 million annually for the recruitment of hundreds of specialist staff as a sign of how committed it is to modernising the sector and fulfilling its policies.

It was a bold and ambitious pledge. But there is more than a hint of smoke and mirrors around it.

For one, a pattern has emerged over recent years where this ringfenced money ends up being diverted into containing cost-overruns in other parts of the health sector. Then, in order to keep up the pretence, some posts are taken up at the tail-end of the year, so authorities claim they have met their spending pledges.

Major gaps
These time-related savings aren't fooling anyone. Last year, for example, the HSE announced a total of 414 posts would boost community mental health teams, suicide prevention and other crucial services.

By the end of the year, the vast majority of the posts weren’t in place. In fact, just 62 staff had taken up their positions in December. Mid-way through this year a majority of these 2012 posts were finally in place, but there were still major gaps.

Some 80 or more had yet to be appointed. The same pattern has emerged this year.

Why does this matter? Nurses and nurse managers say unfilled posts are resulting in professionals being pulled out of community services to plug gaps in inpatient care, a move that flies in the face of Government policy.

“With the huge exodus of nurses who are retiring, coupled with the recruitment embargo, the community services of which we are so proud are being decimated,” commented one clinical manager.

Dr Patrick Devitt, the inspector for Mental Health Services, said this year that he found the system of support for patients was "stagnant and perhaps slipped backwards" during the previous 12 months as a result of dwindling staff numbers and poor governance.

These promised posts are crucial for developing specialist services for the elderly, those with intellectual disabilities, rehabilitation and moving away from a largely medicalised response to people’s needs to a service that includes psychology, social work and occupational therapy.

Even if these staff were being appointed in time, the staffing floor for the wider mental health services has been lowering.

As of April this year, there were more than 1,000 fewer staff in the mental health services than there were four years ago, as retirements and the recruitment embargo take their toll. So hiring new staff is akin to pouring water into a leaking bucket.

A Vision for Change in 2006 said more than 1,000 additional staff would be needed to fully implement the policy. By any measure, then, we are lagging way behind the numbers required to run an effective service.

So far, so gloomy. But there have been some encouraging signs of progress in parts of the mental health service.

For hundreds of years, people with psychiatric health problems were locked away in asylums, behind high walls. We led the world in locking people up in institutions, with inpatient admission rates that were multiples of other countries.

Real progress
In recent decades, we have made real progress in either closing down institutions or ceasing admissions to them. That work has continued, even during the downturn. Latest figures show just over 300 patients remain in these settings, down from some 25,000 about 20 years ago.

Several projects around the country are also ensuring that residents are being “deinstitutionalised” and are provided with necessary supports to ensure they are able to transition to new lives in the community. In addition, some regions are making real strides in implementing a recovery ethos and involving service users and their families in their care, thanks to local leadership.

Another key gripe over the years has been the fact that mental health has been a “Cinderella” of the health services.

This year, the HSE has appointed a new national director, Stephen Mulvaney, who will be directly accountable for the funding, planning and delivery of mental health services. If he is given the resources and control to get reform of these services back on track, there are real reasons to be hopeful.

But there is no getting away from the alarm bell still ringing in the background. Concerns are growing that patients in the community may fall through the cracks of an underfunded and understaffed service into homelessness, prison or back in acute inpatient units, unless we breathe new life into our national mental health policy. It’s an alarm which has been growing louder in recent years – the only question is, can the Government hear the message?