THIRD ANNIVERSARY OF A VISION FOR

CHANGE

“Late for a Very Important Date”

 Irish Mental Health Coalition, 38 Blessington Street, Dublin 7
Tel: 01 860 1620, Email: info@imhc.ie, Web: www.imhc.ie

A VISION FOR CHANGE

A Vision for Change, launched in January 2006 is Ireland’s national mental health
policy. It is a policy which sets the basis for reforming the Irish mental health service
into one which promotes and protects human rights, places people using services at
the centre of service design and delivery is community based and recovery
orientated.

The urgent need to reform mental health services is heightened given increased
demands on services. There were 20,769 admissions to inpatient mental heath units
and hospitals in 2007 compared to 20,388 in 2006 – the first time there has been a
year on year increase since 19861. Figures from the Mental Health Commission also
reveal more admissions of children to adult psychiatric facilities in 2008 than in 2007.
A total of 196 children (under 18) were admitted to approved adult centres from
January to October ‘08. This is three more admissions than the total figure of 193
recorded from January to December ’07.

Demands on services are likely to increase further in the year ahead. The
established link between economic recession, financial pressures and mental health
needs, make the case for reform and investment in mental health services more
urgent. The Secretary General of the WHO has stated that “it is essential .. to learn
from past mistakes and counter this period of economic downturn by increasing
investment in health and the social sector2” In Europe, the WHO Regional Director
for Europe has stated “The governments are already facing severe financial and
economic problems; if they don’t protect the health sector then there may be a social
crisis as well.3”

The reform process has been painfully slow, as evidenced in the report which
follows. Despite statements of support for mental health reform from Government
and the HSE, basic systems to promote reform are not in place, targets for service
delivery have not been met and development funding has all but ceased. On the
third anniversary of the publication of A Vision for Change, the Irish Mental Health
Coalition calls on the Government to answer the following questions:
1
HRB (2008)
2
http://www.wpro.who.int/media_centre/pressreleases/pr20081311.htm
3
http://www.euro.who.int/mediacentre/200811213

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1. Why has no Directorate of Mental Health been appointed despite
recommendations of A Vision for Change, the Minister and the Independent
Monitoring Group?
2. When will the practice of admitting children to adult wards end?
3. When will the HSE publish an implementation plan with detailed year-on-year
targets, timeframes and human and financial resource commitments that has
been approved by the Minister?
4. How many fully staffed Community Mental Health Teams are presently in
place around the country?
5. Will the Government commit to revising and ring-fencing existing mental
health funding in light of increasing demands on the services?

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 HSE PRIORITIES FOR 2008

The HSE Service Plan for 2008 set out modest targets for implementing A Vision for
Change, focusing on systems development, child and adolescent services, forensic
mental health services and information systems. A review of the HSE targets is
outlined below.

SUMMARY POSITION HSE COMMITMENTS FOR 2008

HSE PRIORITES 2008 POSITION COMMENT

SERVICE PLANNING AND
DESIGN
Publish Implementation Plan
for A Vision for Change
National Service Users
Executive (NSUE) established
and elections to the board
supported
Reconfiguration of mental
health services to community
based settings in line with
PCCC Transformation
Reconfiguration Programme
(Primary Care Teams and
Health and Social Care
Networks) supported
ADULT MENTAL HEALTH
SERVICES
Filling of the Consultant
Psychiatric Posts progressed
subject to agreement on
consultant contract talks
JANUARY 2009
Late An implementation plan
published by the HSE in January
2008 was rejected by the
Minister as inadequate. A
revised plan has been submitted
to the Minister but has not been
published.
Behind Schedule An NSUE has been established,
service users are not
represented at National Steering
Group for A Vision for Change.
Late Catchment areas for mental
health have not been
announced. While work has
progressed behind the scenes
the process has been delayed
by restructuring with the HSE.
Late Twenty six consultant
psychiatric posts were
advertised in 2006. Following
agreement on the consultant

4

Eating Disorder services will
be progressed as part of
development of Child and
Adolescent Psychiatric Teams
in Dublin mid-Leinster and the
South
Planning and design for
relocation to Thornton Hall
progressed
CHILD AND ADOLESCENT
SERVICES
Complete 8 X 7 person child
and adolescent mental health
teams
4 additional beds at St Annes,
Galway commissioned
Construction of the new 20
bedded unit in Galway
commenced
Construction of the new unit
in Cork Commenced
8 beds St Stephens Glanmire
contract in July, recruitment now
progressing.
Late No progress has been made on
development of eating disorder
services.
Late The HSE indicated to Dáil sub-
committee in July 2008 that
work is in progress despite
opposition to the move. While
the HSE has publicly stated that
it is complete, the cost benefit
analysis for the report has not
been published.
Late The planned addition of the
eight teams in 2008 should have
increased provision to 55 teams
– at present 49 teams are in
place. The provision of 7
person teams falls short of the
13 person teams recommended
by A Vision for Change.
Delivered Achieved - 4 additional beds
have been commissioned.
Behind Schedule Tenders have been invited for
the construction of the 20 bed
unit in Galway.
Behind Schedule A contractor was appointed in
November 2008. The HSE have
reported the timeline for
completion as the last quarter of
2009.
Late Due fourth quarter 2008. HSE
has indicated that the beds are
due to be commissioned by end
January 2009
5
A 6 bedded adolescent in-
patient unit commissioned at
St Vincent’s Hospital,
Fairview
Development of an additional
six beds at St Vincent’s
Hospital Fairview progressed
Service provision at
Warrenstown House
increased from 5 to 7 days
per week in Quarter 1
MANAGEMENT
INFORMATION
Interim data set (derived from
the suite identified in 2007) to
meet the accountability
requirements of the main
stakeholders developed and
implemented
Development of a
comprehensive information
system for mental health
commenced
Late Due fourth quarter 2008. HSE
has indicated that the unit will be
commissioned by end of
January 2009
No Progress No reported progress.
Achieved In June 08 the HSE reported this
as a 7 day service though later
report indicates staffing
difficulties.
In progress. The HSE reported in June 2008
that a series of metrics were
agreed which will extend routine
data capture to areas such as
referrals, assessments and
waiting times.
In progress. WISDOM project underway in
partnership with the Health
Research Board – project being
piloted in Donegal.

SERVICE PLANNING AND DESIGN

Implementation Plan
A Vision for Change is a policy document outlining the shape of mental health
services into the future. It requires a full and detailed implementation plan to ensure
its objectives are achieved and ensure accountability for the public funding allocated
to support its implementation. Three years on, an implementation plan has yet to be

6
published. In 2008 a plan was published but was inadequate and the HSE
committed to providing a new Implementation Plan by the end of 2009. The IMHC
understands that a new implementation plan has been submitted by the HSE to the
Minister. While the plan has yet to be published the IMHC is concerned that it will fail
to establish a clear time-lined and costed plan with targets and lines of accountability
for the implementation of A Vision for Change.

Publishing a detailed and adequate plan is only one part of the practical measures
necessary to implement a Vision for Change. A Vision for Change recommends the
establishment of a Directorate for Mental Health to lead the reform of mental health
services. Both Minister John Maloney and the Independent Monitoring Group4 have
indicated the need to put in place a Director for Mental Health. Despite this, in
response to a parliamentary question on the issue, the HSE stated in November ‘It is
not envisaged that the HSE will appoint a directorate of mental health, as
recommended by the Independent Monitoring Group’. The IMHC believes that
implementation has been hampered to date by the lack of a clear authority within the
HSE with overall policy and budget-holding responsibility.

National Service Users Executive

A Vision for Change recognises that service users should be involved in planning and
implementing mental health services at all levels, recognising that service user
involvement is fundamental to quality service provision. While the IMHC has
previously welcomed the establishment of the interim National Service Users
Executive (NSUE), the IMHC calls on the HSE to include service user representation
on the National Steering Group for the implementation of A Vision for Change.

Reconfiguration of Mental Health Services to Community Based Settings

Mental Health Services are organised on a population basis across catchment areas.
A Vision for Change recommends that traditional catchment areas for mental health
services change with the establishment of 12 or 13 Mental Health Catchment Areas
in the country.

In its first report to the Independent Monitoring Group for A Vision for Change
submitted in early 2007 the HSE reported “The HSE has finalised their proposals for
4
The Independent Monitoring Group was established by the Minister for Health to monitor the
implementation of A Vision for Change. The Group reports annually to the Minister.

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the realignment of the catchment area boundaries to take account of current social
and demographic realities and are awaiting sign off in the HSE”. One year later the
situation appeared stalled. In its second report to the Independent Monitoring Group,
the HSE reported “The realignment of the catchment area boundaries is being
progressed as part of the Transformation process”.

The reality is that three years after the publication of A Vision for Change, despite
significant early work towards reform, the catchment areas and teams in which
services are to be organised are still not in place. The IMHC is particularly
concerned that the urgent need for reform in mental health services is being delayed
by HSE concerns to coordinate implementation with impending changes to
institutional structures in the wider HSE. Much of the implementation of new services
under A Vision for Change depends on reorganising the catchment areas. Delay in
their implementation is impeding delivery of Government policy.

Closure of Mental Hospitals

At the very heart of A Vision for Change is a plan to close old mental hospitals.
Doing so means developing appropriate community based services and freeing up
resources (both finance and staffing) for reinvestment and deployment in community
based services.

The IMHC recognises that closing hospitals is not a straight forward task. In many
instances residents have been in the old institutions for long periods of time and
know no other home. Staff too must be supported in the process of moving to
community based services. The complexity of the task does not distract from its
urgency. The continued use of old hospitals represents a fundamental breach of
international human rights obligations5.

Closing old institutions means not only moving to community based services, but
reforming the allocation of mental health funding and staffing. Traditionally mental
health service funding in Ireland has been allocated on a local area basis with
funding reflecting old institutional settings. Per capita funding is dramatically different
depending upon where a service is based or if an old mental health institution
previously existed or still exists in that area.

5
Principle 9 of the UN Principles on the Protection of Persons with Mental Illness and the
Improvement of Mental Health Care provides that “Every patient shall have the right to be treated in
the least restrictive environment and with the least restrictive or intrusive treatment appropriate to the
patient's health needs and the need to protect the physical safety of others”.

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The IMHC welcomes recent assurances from the Minister John Maloney that funds
from sale of lands will be ring-fenced for mental health use and will be allocated
where necessary outside of the area in which it is presently based. The IMHC
knows that freeing up of resources is not straight forward and implementing an
appropriate resource release process is fraught with difficulty. There are likely to be
transition costs – a need for additional investment in the short to medium term to get
new facilities underway, to train staff moving into new work settings and double
running costs for an initial period. This will inevitably mean that the resources freed
up in an area may very well be needed in that area to implement appropriate
community services. However the principal must be that financial and human
resources released from the sale of lands must be ring fenced for use in the mental
health service wherever priority need exists.

ACTION NEEDED
Publication of a detailed HSE implementation plan approved by the Minister for
Health that contains specific year-on-year targets, timeframes and human and
financial resource commitments.

Establish service user representation at National Steering Group of A Vision for

Change and complete the NSUE elections.

Minister to direct the HSE that community mental health services should not be
diminished in any efforts to reduce HSE costs.

Include provision to meet costing in place to address the early “transition costs” in
proposals to close institutions.

ADULT MENTAL HEALTH SERVICES

At the heart of the community based mental health services outlined in A Vision for
Change is the provision of services through community based mental health teams.
(CMHTs). The report recommends that general adult mental health services be
coordinated through community-based mental health teams (CMHTs). These
CMHTs should comprise the following populations:
• Two consultant psychiatrists

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 • Two doctors in training
• Two psychologists
• Two psychiatric social workers
• Six to eight psychiatric nurses
• Two or three occupational therapists
• One or two addiction counsellors/psychotherapists
• Two or three mental health support workers
• Administrative support staff.

The IMHC understands that of the Community Mental Health Teams already in place,
but very few are functioning with a full team of staff. Mental Health development
funding in 2006 and 2007 including funding for 213 additional posts in mental health
services. By end of November 2008, 136 of these posts had been filled. The HSE
Service Plan for 2008 indicated a commitment to appoint 26 new consultants subject
to agreement on the consultants’ contract. No development funding was provided in
2009 for the development of adult community mental health teams.

The failure to develop general and specialist community based mental health
services means that people are denied access to appropriate services and the right
to be treated in the least restrictive environment. Community based services reduce
the need for hospital admissions and the lack of provision of Community Mental
Health Teams (CMHTs) is a factor in acerbating the number of admissions to
inpatient mental health units. The IMHC is particularly concerned by the figures
reported by the Health Research Board, indicating that almost one third (30.3%) of
residents in psychiatric care in 2007, have been in hospital for more than five years
and (17.7%) in hospital between one and five years. This issue was highlighted by
the recent High Court case of SM v The Mental Health Commissioner and Others. In
the course of this case, the treating psychiatrist noted that the most suitable regime
for the applicant's care [was] by way of supported accommodation rather than
involuntary admission, but that such provision was not in place.

ACTION NEEDED
HSE to report on how many fully staffed CMHT’s are currently in place and the
professional profile of CMHT teams.

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The Implementation Plan should include a time lined and costed programme for
development of Community Mental Health Teams in line with A Vision for Change
detailing how prioritisation will be made in light of the existing deficits and level of
need emerging nationally.

Employment floors should be set in respect of disciplines currently inadequately

represented in CMHTs

CHILD AND ADOLESCENT SERVICES

The HSE identified the development of child and adolescent services as a priority for
2008. Developments proposed related to increasing in-patient facilities, community
services and eating disorder services.

In-patient Facilities
In its 2008 Service Plan the HSE committed to provision of 18 additional child and
adolescent beds by the fourth quarter. In correspondence to the IMHC, dated the 5th
September 2008, the HSE stated: “The Executive will .. be providing 18 additional
acute children’s beds at St. Anne’s in Galway, St. Vincent’s in Fairview and St.
Stephen’s Hospital, Cork. The provision of these beds will increase the acute bed
compliment from a current provision of 12 to 30 by the fourth quarter of 2008. Four
of these beds have already been commissioned in Galway with a balance of 14 to be
provided in the last quarter of the year.”

None of the balance of 14 beds were provided by the end of year. The HSE in a
report to the Joint Oireachtas Committee on Health and Children on 27th November
2008 stated “On the child and adolescent psychiatry beds, the four are already open
in Galway. There are eight in St. Vincent’s Hospital in Fairview. They are currently
recruiting the staff for those. Hopefully they will be open by the end of the year or
certainly in the first month of next year. The same is true of the additional six beds in
Cork. The new units in Cork and Galway will be under construction next year, but the
teams are being recruited to put the facilities in place.”

The HSE Service Plan for 2009 includes a commitment to providing an additional 14
child and adolescent in-patient beds in the first quarter of 2009. The Service Plan
fails to mention that these are the same beds promised in 2008 but not delivered.

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The urgency of moving to complete the in-patient facilities at Cork, Galway and
Dublin is highlighted by figures released by the Mental Health Commission indicating
that figures for 2008 indicate a higher number of admissions of children to adult
wards in 2008 than in 2007.

Child and Adolescent Community Mental Health Teams

Most young people experiencing mental health difficulties do not require in-patient
services but should be able to access the services they need through primary care
and child and adolescent community mental health teams.

A Vision for Change recommends the provision of two child and adolescent CMHTs
for a population of 100,000 i.e. 78 teams nationally. Each Child and Adolescent
Community Mental Health Team should comprise 13 team members as follows:
• One consultant psychiatrist
• One doctor in training
• Two psychiatric nurses
• Two clinical psychologists
• Two social workers
• One occupational therapist
• One speech and language therapist
• One child care worker
• Two administrative staff

The HSE Service Plan for 2008 committed to the provision of eight new child and
adolescent teams with seven members per team. While such teams fall short of the
team composition outlined in A Vision for Change it nonetheless would represent an
increase to 55 child and adolescent teams nationally. As at November 2008 the
HSE reported 49 child and adolescent teams in place, representing a significant short
fall in committed provision for 2008.

The Minister for Health indicated in November 2008 that funding would be provided
in 2009 for 35 additional therapy posts for child and adolescent mental health
services. It is unclear whether such posts will relate to education based or mental
health service based reports.

ACTION NEEDED

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HSE to clarify when the eight additional child and adolescent community mental
health teams promised in 2008 will be in place, where the teams are in place and the
professional profile of those teams.

Dept to clarify where the 35 additional posts outlined in Budget 2009 will be provided.

Minister for Children to directly intervene with the HSE and the Mental Health
Commission in order to establish an action plan to end admission of children to adult
mental health wards

HSE Implementation Plan must include detailed time line and a costed programme
for the development of Adolescent Community Mental Health Teams in line with A
Vision for Change. The Plan must include proposals for how resource allocation will
be prioritised in light of the existing deficits and level of need emerging nationally.

WHERE DO WE GO FROM HERE?

There is a risk in times of economic difficulty that mental health services will fall
victim to cutbacks. Indeed the diversion of development funding allocated for mental
health services in 2006 and 2007 away from its intended purpose to meet budget
deficits elsewhere indicates the vulnerability of mental health services in good times
as much as bad. The IMHC urges Government to recognise the particular need for
improved mental health services at this time and to protect and drive the momentum
for reform of mental health services.

In times of recession, certain public services inevitably have increasing demands –

unemployment assistance, debt management, and mental health services. The
Samaritans and Aware have both recorded increases in calls to their helpline
services in the latter part of 2008. The Health Research Board reported increased
admissions to in-patient units and hospital in 2007 – the first year on year increase in
over two decades. In times of social change and economic difficulty, mental health
services are not a discretionary public service but a vital and sometimes emergency
public service.

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Investment in mental health services is money well spent - the Mental Health
Commission study, The Economics of Mental Health Care in Ireland, 6 estimates that
the overall cost of poor mental health in Ireland was just over €3 billion in 2006, or 2
per cent of GNP. It sets out the compelling economic case for increased investment
in mental health services, concluding that “policy makers cannot afford not to invest
in mental health”. International research initiatives in mental health economics also
support the case for greater investment in mental health7.

The IMHC is not just concerned with levels of funding, but how funding is allocated
and expended. The enormous variations in funding between different mental health
services, with some of the most socio-economically deprived urban areas among the
least well resourced, have still not been resolved. Specialist services continue to be
most under resourced.8

The IMHC has previously highlighted diversion of development funding allocated to

mental health services in 2006 and 2007 to other purposes. In September 2008, the
HSE in correspondence to the IMHC stated that €19m of the €26.2m allocated in
2006 is now in place, and “by the end of 2008, 74% of the resources provided in
2007 for mental health services will be committed and in place” and that the “balance
of developments will be advanced in 2009”. This position is welcome.

The failure to adequately account for funding spent to date has provided a basis for
the Government to resist the further allocation of funding to mental health services. In
January 2008 the Minister for Health stated “Before any additional funding is
provided it is essential that the HSE are in a position to demonstrate that money
allocated for mental health services is efficiently used and that the substantial
changes in the organisation and delivery of mental health services envisaged in A
Vision for Change are progressed.” While clear accountability is required, the reform
of mental health services cannot be achieved in the absence of sustained investment
in that process.

6
By Eamon O’Shea and Brendan Kenneally, National University Ireland, Galway.
7
E.g. work by the Mental Health Economics European Network (MHEEN) and the WHO CHOICE
(Choosing Interventions that are Cost–Effective) programme. Estimates prepared by the WHO for
Western European countries show that mental health problems now account for more DALYs lost per
year than any other health condition. By 2020, depression is expected to be the highest-ranking cause
of disease in the developed world (WHO, World Health Report 2001, p. 11.
http://www.who.int/whr/2001).
8
For instance, the Irish College of Psychiatrists has concluded that child and adolescent psychiatric
services account for only 5-10% of spending on mental health services, while serving 22.68% of the
population.

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ACTION NEEDED
Government to revise and ring-fence existing mental health funding in light of
increasing demands on services.

Publish quarterly reports of the HSE to the Independent Monitoring Group which
must include detailed information on progress to meeting commitment and how
funding is spent

The Department of Health and Children and the HSE should publish an annual
breakdown of capital and revenue spend (rather than allocation) of mental health
funding. The report in respect of 2008 should be published without delay.

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