Selling hospital land could provide long-awaited services, writes Carl O'Brien.
The pages of the blueprint for the development of mental health services have yellowed and faded, yet many of its recommendations are still waiting to be implemented.
Planning for the Future, published in 1984, recommended the development of community residences for long-term patients and the closure of old institutions.
Two decades ago it was seen as a common-sense solution to replacing the institutional approach to the delivery of services, but only now is there hope that these aims are coming close to being fully realised.
Government plans to sell off hundreds of acres of land from some of the State's biggest psychiatric hospitals would provide a much-needed funding boost for a sector long regarded as the Cinderella of the health services.
Officials say the money will be ringfenced to ensure that long-awaited community-based care facilities are developed and a multi-disciplinary approach to care is introduced to the service.
It is still too early to estimate how much money would be raised by the sale of the land. However, given that the 34-acre Central Mental Hospital in Dundrum is worth around €70 million, it likely that hundreds of millions of euro could be raised.
The future of individual psychiatric hospitals will be decided on a case-by-case basis. However, it is clear that institutions that have been repeatedly criticised by campaigners and the Inspector of Mental Hospitals will have to be closed or redeveloped.
In his latest report for 2002, the Inspector of Mental Hospitals, Dr Dermot Walsh, repeated a long-running mantra of criticism directed at a number of Victorian institutions.
One ward at St Brigid's Hospital in Ballinasloe was described as "a museum piece from another, unenlightened age". Facilities at the Central Mental Hospital, he said, were archaic and patients in the older building still had to "slop out" in the mornings. He also said seclusion accommodation at the hospital was "unfit for a mental health institution of the 21st century".
"These archaic conditions still prevailed at the time of this inspection and no attempts had been made to redecorate these areas in order to bring some little acceptability to them," he wrote.
While the number of beds in mental hospitals has fallen from 12,900 in 1984 to 3,860 in 2002, the drop has been achieved mainly through deaths of patients, re-classification of units, along with the development of some community-based care.
Despite the decline in numbers, however, mental health services still remain influenced by an institutional approach to care.
The dangers of this approach were flagged as recently as last week by two State bodies, the Mental Health Commission and the Inspectorate of Mental Health Services, both charged with upholding standards in the mental health sector.
The inspectorate warned that patients in institutional care were at a higher risk of being detained against their will as community-based services help defuse crisis situations which often result in patients being detained. It also cited figures which suggested that admissions to hospital brought little if any lasting benefit, given that some 70 per cent of admissions were re-admissions.
The bed-based approach to mental health services also swallows up resources. Around 2 per cent of people with mental health problems are treated as in-patients at any one time. Yet hospital beds consume more than 50 per cent of the total budget.
Few treatments in psychiatry require an in-patient setting and mental health campaigners have been calling for the development of community-based, multidisciplinary mental health teams.
There is evidence that community-based services are superior to acute bed-based models by providing more appropriate care, reducing the risk of involuntary detention and allowing patients to keep engaged with society.
The development of such facilities, however, has been "slow and piecemeal", according to the Inspector of Mental Health Services, Dr Teresa Carey.
But experts say curing the ills of the mental health service is not as simple as merely moving facilities into the community. There is also a need for specialist facilities for patient groups such as children, adolescents and people with intellectual disabilities.
All these specialist services are "severely underdeveloped", according to Dr Carey.
Discussions on a new strategy, to take over from Planning for the Future, are still at a relatively early stage. However, it is expected to recommend that many of these services be developed.
Given the stigma attached to mental illness and the lack of political priority attached to the area, change has traditionally come dropping slow to the sector. However, unlike the yellowing pages of the 1984 document, there is growing hope that with ringfenced funds, updated legislation and a growing advocacy network for patients, the new strategy will not be allowed to simply gather dust.