Ireland a good policy implemented very slowly

Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries Ireland Country Report Ireland: A good policy implemented very slowly Mental Health Integration Index Results Mental Health Integration Index: Results for Ireland Ireland Best Average Worst Environment Governance 100 80 60 40 20 Overall: Environment: Opportunities: Access: Governance: 68.0/100 (14th out of 30 countries) 83.3/100 (9th) 55.6/100 (17th) 66.2/100 (16th) 62.0/100 (11th) Other Key Data 20 40 60 80 100 Access Opportunities l Expenditure: Mental health budget as a proportion of government health budget (2012): 5.3%1 l Burden: Disability Adjusted Life Years (DALYs) resulting from mental and behavioural disorders as a proportion of all DALYs (World Health Organisation(WHO) estimate for 2012): 14.4%2 l Stigma: Proportion of people who would find it difficult to talk to somebody with a serious mental health condition (Eurobarometer 2010): 20%3 Highlights Ireland has an above-average ranking in the Economist Intelligence Unit’s Mental Health Integration Index result of the government’s austerity programme have slowed implementation of the most recent policy Its biggest strength in this area is its very advanced policy, but it has a record of poor implementation However, recent developments, such as the appointment of a national director of mental health, indicate that progress will at least continue or perhaps accelerate Wider health service upheaval and funding cutbacks as a SPONSORED BY Data from the EIU Mental Health Integration index, which ranks 30 European countries based on their commitment to integrating people with mental illness into society and employment (http://www mentalhealthintegration.com ) available at http://www.who.int/entity/healthinfo/ global_burden_disease/GHE_DALY_2012_country xls?ua=1 The WHO estimates not include dementia as a mental illness, although it is listed as one under the WHO’s International Classification of Diseases (ICD-10) Figures derived from World Health Organisation (WHO) national figures for individual index countries for 2012, Eurobarometer, Mental Health, Special Eurobarometer 345, 2010 © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries The journey to an advanced policy Ireland ranks slightly above average in the Mental Health Integration Index, placing 14th overall, and in joint ninth position in the “Environment” category with a score of 83.3 out of 100 The country benefits from the emphasis that the index places on policy John Saunders, chief executive for Shine, a mental health non-governmental organisation (NGO), and chair of Ireland’s Mental Health Commission, believes that “in policy terms [Ireland] would score highly It promotes and has a vision of community mental healthcare services where people should receive a range of interventions from the biopsychosocial model of mental health, provided by professional, multi-disciplinary teams.” If Ireland’s strength is its roadmap to the kind of service provision that it wants, its weakness is the pace at which that plan is being executed Mr Saunders adds, “if you look at implementation of [the government’s] model, you will find the situation very much mixed We are in transition from an asylum-based, pre-Victorian model to a new one.” One of many demonstrations of this dichotomy became apparent during The Economist Intelligence Unit’s experience of building the Mental Health Integration Index Three indicators that focused on actual service provision within the community rather than on underlying policy had to be dropped late in the process because of a lack of data from other countries This shifted the emphasis of the index in favour of policy, and led to Ireland’s overall score rising by nearly 10% The need to change how the country deals with mental illness has long been recognised in Ireland In 1958 Ireland had the highest number of people in psychiatric institutions in the world, and in 1961 the government established a Commission of Enquiry on Mental Illness Its 1966 report recommended more community-based facilities, the use of multidisciplinary teams to provide a range of medical care, and the establishment of small, acute psychiatric wards in general hospitals rather than the continued use of physically isolated, large asylums Little systemic change occurred, however, although the country’s institutionalised population began to fall steadily, mostly through the number of new patients admitted being lower than the number of older, long-stay patients who died while still in asylums A further report, Planning for the Future, published in 1984 by Ireland’s Department of Health, again complained of a highly hospital-centred system and called once more for a community-based one The outcomes were also disappointing The number of long-stay patients in psychiatric hospitals continued to decline, but these facilities still housed over 4,000 people by the year 2000 Moreover, notes Shari McDaid, director of the NGO, Mental Health Reform, care “continued to have a medical orientation”, with very few patients seeing even psychologists Any community facilities that did exist tended to segregate the mentally ill in parallel services, rather than helping to integrate them into the broader community Despite earlier disappointments, the release in 2006 of the current blueprint for a new service, A Vision for Change (AVFC), brought hope for substantial improvement Written by an expert group appointed by the Ministry of Health, it drew on consultations with a wide range of relevant stakeholders Like earlier policies, AVFC called for community-based care, but it went much further It explicitly advocated: the recovery model for care; on an individual level, personal, © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries integrated care plans that address the biological, social, and psychological needs of those with mental illness; at policy level, a whole-of-government approach to mental health where the specific needs of those with mental illness are recognised in all relevant policies; and the active participation of service users and their families at every level of service provision, from planning through peer-to-peer counselling national HSE assumed responsibility for healthcare provision from 11 regional health authorities and a variety of other organisations, becoming the country’s largest employer and holder of the largest single public-sector budget Such change inevitably takes years of effort: the information technology consolidation is still incomplete “Mental health,” says Ms McDaid, “got lost in wider issues of reconfiguration.” Unfortunate timing impedes implementation Getting attention for mental health issues has been all the more difficult because the appointment of a national director for mental health, as proposed in AVFC, and the creation of a Mental Health Division within the HSE did not take place until 2013 Before that, the office of assistant-director for mental health had merely had an advisory role within the HSE, while other parts of the organisation controlled budgets and exercised operational responsibility Overall, says Mr Saunders, “there wasn’t any energy or leadership that led out Vision for Change The changes that did occur often did so only because of local or regional clinical management making a decision.” AVFC remains the core of Ireland’s mental health strategy and, as Mr Saunders puts it, “is a modern policy that is fit for purpose.” Its roll out, however, has been highly problematic In a 2012 report, the Independent Monitoring Group (IMG) established to evaluate the implementation of the programme found that progress had been “slow and inconsistent.” Similarly, in its latest report the government’s Mental Health Commission found, to cite a few examples, that in 2013 only 44% of approved mental health centres met regulations for sufficient staffing (including breadth of expertise) and only 60% fulfilled the requirements relating to patients’ individual care plans Worse still, efforts to close down major psychiatric hospitals has led Ireland’s Health Service Executive (HSE) to establish a number of large, supervised hostels that have several of the negative attributes of the institutions that were being closed, such as a lack of patient access to psychologists So what went wrong? Two major factors, both in different ways the result of unfortunate timing, have impeded the implementation of AVFC The first is institutional In 2004 the Irish government launched a major overhaul of healthcare management A new, The second major problem with implementation has been that AVFC, like the HSE reform, was drafted during Ireland’s heady economic boom period in the early part of the last decade Expanding budgets were an underlying assumption As implementation of the new mental health policy was set to begin, however, recession and then the financial crisis in the Euro zone turned the Celtic Tiger into one of Europe’s PIIGS (Portugal, Italy, Ireland, Greece and Spain) The ensuing government budget austerity measures cut total funding of mental health services from €937m in 2006 to €733m in 2013 (although after the budget was adopted an additional investment in personnel added €25m to the latter figure) © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries Worse still, mental health suffered more than other healthcare sectors In the early years of the downturn, money previously earmarked for AVFC implementation was seized to cover costs elsewhere in the health service More generally, mental health spending as a percentage of the total health budget dropped from 7.2% to 5.3% in the same period, even though AVFC was predicated on an increase to over 8% An important practical implication of cost reduction, notes Mr Saunders, was that an austerity-driven hiring moratorium introduced by the government had an exaggerated effect in this area because mental health services are highly labour dependent Although the government has earmarked funds for hiring in the field of mental health over the last few years, the Health Service Executive estimates that still about one-quarter of the 12,000 posts envisioned under AVFC remain unfilled4 Improvements to the present situation are still needed These barriers much to explain the current state of mental health provision and the integration of those with mental illness into Irish society Looking at the present, says Ms McDaid, “Ireland is behind in terms of moving to day services that support integration and of thinking how people with mental health services can be full citizens.” Our Index data reflects this in several ways Ireland’s lowest score (55.6 out of 100) is in the “Opportunities” category, which focuses on the workplace Only 18% of those with a mental illness are in employment, although a further 51% had been employed in the past (and most of those had left their job because of their medical conditions) A small majority those with a mental illness who were unemployed would like to return to work under the right circumstances5, but these circumstances not arise frequently Our data show that, although Ireland does reasonably well in terms of policies to support those with mental illness in finding employment, it has no regulations on workplace stress, which would almost inevitably make it harder to maintain a job A truly whole-ofgovernment approach would include such rules, and would benefit all employees, not just those with a mental illness This situation illustrates a problem that goes beyond employment Ms McDaid notes that AVFC’s chapter on social inclusion as a whole “is one of the least implemented,” with government departments (other than the Department of Health) having done little so far One notable recent exception has been the National Housing Strategy for People with a Disability, written as part of the National Disability Strategy, which includes a chapter dealing with the specific needs of those with a mental health disability Another area of weakness for Ireland in the Index is the “Access” category, where it places 16th out of 30 The problem is not so much that individuals cannot get care, but rather that the care provided is based on an outdated approach The IMG, for example, complained in 2012 of “an absence of the ethos of recovery, and poor development of recovery competencies in service delivery, resulting in a reactive rather than proactive approach to the needs of individuals and their families.” According to Mr Saunders, the system remains “primarily focused on the medicalised model of mental illness and the use of medical psychiatry and mental health nursing.” This is reflected in the personnel available Ireland has the second-highest number of psychiatric nurses per head in the Index (113 per 100,000 population) and is in joint fourth place for the number of psychiatrists (21 per 100,000) On Health Service Executive, Mental Health Division Plan 2014, page 17, http:// www.hse.ie/eng/services/Publications/corporate/mentalhealthplan.pdf Dorothy Watson and Bertrand Maître, Understanding Emotional, Psychological and Mental Health (EPMH) Disability in Ireland: Factors Facilitating Social Inclusion, 2014 © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries the other hand, it ranks 13th for the number of specialised social workers (4 per 100,000) and 17th for psychologists (6 per 100,000) In both of the latter two categories, Ireland has under half the overall average per head for countries listed in the index Part of the problem is an ongoing cultural one Ms McDaid believes that “we have a way to go in making it the norm that, for instance, mental health professionals expect to work in partnership with their service users rather than having a directive-based approach.” The College of Psychiatry, however, is positive about the thinking behind the AVFC, and cultural change is taking place The more immediate issue, explains Mr Saunders, is that the moratorium on new hiring has slowed the acquisition of the wider range of expertise needed to move beyond a purely medical model “Very few of the new community mental health teams are fully staffed,” he says, “with significant vacancies in psychology, social work and occupational therapy, and among other support staff It is like having football teams where one or two people are missing on the field.” .but there are hopeful omens for the future taking place, such as the recent appointment of a national director of mental health and the National Housing Strategy Looking ahead, Ms McDaid sees other good signs: a new employment strategy under the National Disabilities Strategy is expected to address the needs of those with mental illness and the Advancing Recovery in Ireland project, set up this year, has “increased the critical mass of services making organisational change.” The country is also witnessing extensive civil society discussion as the government wrestles with a new law to modernise the legislation on assisted decision making, especially for those who have a mental illness, to meet its goal of bringing the law into line with the UN Convention on the Rights of Persons with Disabilities More important than any specific development, though, has been a shift in the belief that change will happen Mr Saunders says that “most people agree that we have now reached a tipping point We have closed all the significant psychiatric institutions and most are being served outside of residential options.” It may take several years, he believes, but eventually significant investment in public services will occur and the new system will take proper shape because, he concludes, “We can’t go back.” Despite this very slow progress, both Ms McDaid and Mr Saunders are cautiously optimistic Positive changes are © The Economist Intelligence Unit Limited 2014 Mental health and integration Provision for supporting people with mental illness: A comparison of 30 European countries About the research This study, one of a dozen country-specific articles on the degree of integration of those with mental illness into society and mainstream medical care, draws on The Economist Intelligence Unit’s Mental Health Integration Index, which compares policies and conditions in 30 European states for integrating people with mental illness into society and employment Further insights are provided by two interviews— with John Saunders, chairman of Ireland’s Mental Health Commission and chief executive of Shine, and Shari McDaid, director of the NGO Mental Health Reform—as well as extensive desk research The work was sponsored by Janssen The research and conclusions are entirely the responsibility of The Economist Intelligence Unit © The Economist Intelligence Unit Limited 2014 ... only because of local or regional clinical management making a decision.” AVFC remains the core of Ireland s mental health strategy and, as Mr Saunders puts it, “is a modern policy that is fit... multidisciplinary teams to provide a range of medical care, and the establishment of small, acute psychiatric wards in general hospitals rather than the continued use of physically isolated, large asylums... implementation Getting attention for mental health issues has been all the more difficult because the appointment of a national director for mental health, as proposed in AVFC, and the creation of a