Ireland a good policy implemented very slowly

Ireland has an above-average ranking in the Economist Intelligence Unit’s Mental Health Integration Index.. SPONSORED BY Ireland Country Report Ireland: A good policy implemented very sl

Ireland has an above-average ranking in the Economist

Intelligence Unit’s Mental Health Integration Index

Its biggest strength in this area is its very advanced policy, but

it has a record of poor implementation

Wider health service upheaval and funding cutbacks as a

result of the government’s austerity programme have slowed implementation of the most recent policy

However, recent developments, such as the appointment of a national director of mental health, indicate that progress will at least continue or perhaps accelerate

Mental Health Integration Index Results

Overall: 68.0/100 (14th out of 30 countries) Environment: 83.3/100 (9th)

Opportunities: 55.6/100 (17th) Access: 66.2/100 (16th) Governance: 62.0/100 (11th)

Other Key Data

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

SPONSORED BY

Ireland Country Report

Ireland: A good policy implemented very slowly

Highlights

Environment

Opportunities

Access Governance

Mental Health Integration Index:

Results for Ireland

100

100

80

80

60

60

40 40

20 20 0

1 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 )

2 Figures derived from World Health Organisation (WHO) national figures for individual index countries for 2012,

available at http://www.who.int/entity/healthinfo/ global_burden_disease/GHE_DALY_2012_country xls?ua=1 The WHO estimates do not include dementia

as a mental illness, although it is listed as one under the WHO’s International Classification of Diseases (ICD-10).

3 Eurobarometer, Mental Health, Special Eurobarometer

345, 2010.

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

multi-disciplinary 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,

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

Unfortunate timing impedes implementation

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,

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.”

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.”

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)

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 do 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 do 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-of-government 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

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

Despite this very slow progress, both Ms McDaid and Mr

Saunders are cautiously optimistic Positive changes are

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.”

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

About the research