Joint Oireachtas Committee on Health and Children

National Priority Issues for the Quarterly Meeting with the Minister for Health and the CEO of the Health Services Executive.

Q1: An update on Mental Health Services with particular reference to suicide prevention and resources allocation – Senator John Gilroy.

Suicide numbers in Ireland fell by 12% between 2003 and 2007 but rose by 10.5% in 2008 and then by a further 4% in 2009 to a provisional number of 527, the highest ever recorded in Ireland. Within the EU, Ireland’s suicide rate for the whole population is considered low at 9.2 per 100,000, however for young people,Ireland has the fourth highest rate at 14.4% per 100,000 population. In Ireland 4 young men end their lives through suicide for every young woman dying by suicide.

International research correlates an economic downturn with a rise in suicides and it is likely that these high numbers could continue in the short to medium term. Research shows a correlation between rising unemployment and completed suicide, with a 0.79% increase in completed suicide for every 1.0% increase in unemployment. Initial CSO data from 2010 shows an 8% reduction in completed suicide.

Similarly, self harm presentations to our hospital emergency departments have increased by 12% between 2007 and 2009. National Suicide Research Foundation research shows 12,000 attendances at Emergency Departments following an incident of self harm. Further research suggests that another 60,000 individuals self harm annually in Ireland without seeking medical attention.

The National Office for Suicide Prevention

The HSE's National Office for Suicide Prevention (NOSP) is responsible for overseeing the implementation of ‘Reach Out’ the National Strategy for Action on Suicide Prevention 2005 – 2011 which calls for a multi-sectoral approach to the prevention of suicidal behaviour in order to foster cooperation between health, education, community, voluntary and private sector agencies.

The Strategy contains 96 recommendations and progress has been made in the following areas:

  • Training - since 2004 approximately 22,500 people have been trained in the 2 day ASIST (Applied Suicide Intervention Skills Training) internationally recognised programme (training is provided to health workers, Gardai, Defence forces, veterinary organisations, teachers, community and youth workers). 3,000 people have also been trained in SafeTalk, a half day training programme that prepares anyone over the age of 15 to identify persons with thoughts of suicide and connect to suicide first aid resources;
  • Mental health awareness - campaigns have been developed and will be run again this year – ‘Your Mental Health’ awareness campaign and the ‘Let Someone Know’ campaign aimed at young people.
  • Response to current economic situation - launch of a ‘Tough Economic Times’ programme following requests from organisations such as Citizens Information and the Money Advice and Budgeting Service for information and training because of the increasing number of people presenting in distress. 150,000 information leaflets highlighting the practical things we can do to protect our mental health were produced for the public, as well as a guidance book for organisations which advises how to prepare staff to recognise and respond to suicidal behaviours.

Funding

The total funding available in 2011 to support suicide prevention initiatives is in the region of €8.7m. This includes the annual budget of €4.2m for the National Office for Suicide Prevention and €4.5m which is used to fund Resource Officers for Suicide Prevention, self harm nurses in Emergency Departments and the development of local suicide prevention initiatives.

An additional €1 million was provided to the NOSP in 2011 to enable the Office to build on initiatives to date and bring added momentum and new impetus to their activities to address the increasing incidence of suicide. The NOSP plan for 2011 sets out 10 action areas;

  • Progress all Reach Out action areas
  • Work with Clinical Care directorate to implement more uniform process in Emergency Departments
  • Maintain the existing ASIST and Safetalk suicide prevention training programmes
  • Support pilot primary care projects in suicide prevention
  • Coordinate the services provided by phone/fax/text to those in emotional distress
  • Continue both the general population and young people’s mental health awareness campaigns
  • Implement through the inter departmental group (Education, Health, HSE) the results of the evaluation of school’s mental health promotion programmes
  • Continue to fund the suicide prevention work of 15 national organisations
  • Maintain and extend the ‘Tough Economic Times’ programme
  • Continue cross border work and initiatives

Mental Health Resource Allocation

Budget 2011 provided special consideration for the mental health and disability sectors, which ensures a maximum reduction of 1.8% in the 2011 allocation for those sectors. The relatively lower reduction, compared to other sectors of health, recognises that these services are provided to vulnerable groups. It is anticipated that the savings necessary will be achieved through efficiencies, economies, innovation and flexibility.

The HSE’s National Service Plan for 2011 commits €708m to mental health care. However some 90% of mental health problems are dealt with in Primary Care and expenditure on such services is not captured in mental health spend.

Over 80% of mental health spending relates to staff salaries; the reduction in pay costs and staff numbers have had the effect of reducing the total spend on mental health. The WHO recommends that 12% of health spending be allocated to mental health. A Vision for Change proposed that 8.4% of the Health budget be allocated to mental health care. In 2011, 5.3% of the HSE budget is allocated to secondary care mental health services. However it should be noted that 35% of attendances at Primary Care relate to a mental health need (approx 5.6m visits annually) and drugs for psychiatric and neurological treatmentswas funded by the Primary Care Reimbursement Service (over €360m in 2009).

Staffing

The particular staff profile and demographic in mental health creates a special exposure to staff losses through retirement and significant numbers of nurses retired during 2009 & 2010;this trend is expected to continue through 2011. (In October 2010 the HSE had 9,525 staff deployed in mental health but by the end of April 2011 this number had reduced to 9,091. This represents a 4.5% reduction in the workforce in a six month period).

In light of the significant loss, the 2010 Employment Control Framework for the health service provided an exemption from the moratorium and allowed the filling of 100 psychiatric nursing posts. Of the 100 posts exempted from the moratorium on recruitment in 2010, approx. 57 (WTEs) psychiatric nurses have been recruited and 47 (WTEs) are currently in the recruitment process. The 2011 Employment Control Framework again provides an exemption from the moratorium in respect of 100 posts where they are required to support the implementation of A Vision for Change.

In order to preserve service access and safety, the equitable distribution and allocation of the available resource is a key priority. The targeted replacement of retirees can provide an opportunity to rebalance resource availability across the country.

2. Mental Health Services/Vision for Change – Mr Seamus Healy TD.

A Vision for Change is a progressive, evidence based and pragmatic policy document, which describes an entirely new service model which is designed around the service user, is recovery orientated and community-based. A Vision for Change is strong on values and requires a comprehensive change programme from our mental health services. The document also included a number of very significant commitments; new funding (€150m revenue), new multidisciplinary staff (+1,800) and completely new infrastructure (+€796m Capital).

Vision was built on the assumption that additional resources would assist in the reconfiguration of the existing resource base. In the economic downturn, this additional resource has not been available in full (development funding to date is €54m). In addition, there has been an accelerated loss of staff from mental health services through retirements which, have not been replaced due to the moratorium on recruitment. This loss of skilled staff is compounded by the associated loss of financial resource from mental health services. In light of the significant staff losses from the Mental Health Service,an exemption from the moratorium in respect of 100 posts was provided in both the 2010 and the 2011 Employment Control Framework.

A Vision for Change remains the strategic direction for the future delivery of mental health services in Ireland. However, in the light of current economic realities, it will not be possible to fulfil all aspects of Visionwithin the agreed 7 - 10 year timeframe. Mental Health services must refocus their efforts to making the best use of the available resource.

Progress

Despite the financial constraints much progress has been made in the implementation of AVision for Change in the first 5 years;

Community Mental Health Teams: 124 CMHTs are working throughout the country. It is hoped to complete the professional membership of these teams with new ringfenced €35m funding committed in the Programme for Government.

Bed Numbers: As inpatient bed numbers are rationalised, additional staff will become available to expand the community based teams. In the past 18 months the number of beds in the old psychiatric hospitals has reduced from 1,342 to 925, a reduction of 427 beds.

Child & Adolescent Mental Health Services:61 CAMHS Teams are now in place. The number of CAMHS beds has increased from 12 beds in 2007, to 52 at present. Additional funding and posts have been secured to extend this further to 66 beds by 2012. Two bespoke 20 bed units have been opened in Cork and Galway in the first quarter of 2011 and additional capacity will be commissioned at St Vincent’s Hospital in Fairview and a new interim unit at St Loman’s in West Dublin will be in place by the end of 2011.

Hospital Closures: The closure of the old psychiatric hospitals and replacement with more appropriate acute units and community services continues. Since Vision was published, the following hospitals have either closed completely, or closed to acute admissions;

St Brendan’s Hospital,Dublin,

St Conal’s Hospital, Donegal

St Brigid’s Hospital, Ballinasloe

St Mary’s Hospital, Castlebar

St Loman’s Hospital, Dublin

St Senan’s Hospital Enniscorthy

The last of the remaining old hospitals have active closure programmes in train.

Capital Development in Mental Health: AVision for Change recommended the investment of €796m to create a new environment for mental health care in Ireland. While the sale and reinvestment programme is not now likely to generate funds of that magnitude, a number of major capital projects are currently underway including 5 new Acute Units at Letterkenny, Galway, Cork, Beaumont and Co Louth, high quality continuing care accommodation at Mullingar, Ballinasloe, Clonmel, Wexford and West Dublin and the redevelopment of the Central Mental Health Hospital is at an advanced stage of planning. Additional Community Mental Health Centresare being developed with Primary Care Centres.

Housing: The HSE currently provide supported housing (at high, medium and low support levels) for 2,789 persons. Vision recommends that the health service should step back from the provision of medium and low support housing. SeniorHSE mental health service personnel have been actively involved in the preparation of the Housing Strategy for People with a Disability which has been led by the Department of the Environment, Heritage and Local Government. The Strategy, which makes special provision for the housing needs of individuals with significant mental health needs, has been submitted to Government.

Forensic Mental Health Services:

  • The Forensic Psychiatry Barricade Incident Support protocol and agreement went live on Jan 1st 2011. This provides for on call forensic consultant psychiatric support to An Garda Siochana in critical emergency incidents in line with the recommendations of the Barr Tribunal.
  • The Criminal Law (Insanity) Act 2010 commenced on Feb 8th 2011; additional facilities are being developed in association with Dublin City Council and a partner agency to provide accommodation for patients conditionally discharged from the CentralMental Hospital.
  • An effective prison in-reach and court liaison service is now in operation at Cloverhill Prison - 13 persons were diverted to local mental health services in 2010

Mental Health & Primary Care: A number of initiatives are underway in partnership with colleagues in Primary Care;

  • Community Mental Health Centres are being included in the newly developed Primary Care Centres.
  • Over 70 Primary Care staff have participated in the specially commissioned Team Based Approaches to Mental Health in Primary Care course at DCU.
  • A HSE funded Mental Health Project Officer promotes mental health issues within the IrishCollege of General Practitioners.

Service User engagement: Vision places the Service User at the heart of modern mental health care.

  • The National Service User Executive (NSUE) was established in 2007 as the elected representative body for mental health service users and carers and is active in all national mental health programmes.
  • All acute inpatient settings now have a trained peer advocate available on-site.
  • An academic Expert by Experience post has been funded at DublinCityUniversity. Collaborative Leadership course has been developed for Service Users, Carers and Professionals, to integrate all three perspectives into change management initiatives in mental health.

Recovery: Recovery is a central theme in Vision for Change and many initiatives promote the Recovery model. A national working group is devising detailed guidance for services. In a 2010 ‘Second Opinions’ NSUE survey, 67% of Service Users felt that their mental health service was promoting a recovery based model of care. The recovery approach encourages the Service User to achieve the greatest level of independence to return to education, work or training and to live in their own accommodation supported by the community based mental health services.

Leadership and Management: In June 2009, 13 Extended Catchments Areaswere introduced with an Executive Clinical Director appointed to each (+1 for the National Forensic Mental Health service). This provides a more efficient model to provide specialist services across a larger population base.

Mental Health and Intellectual Disability: Without additional resources it has not been possible to introduce additional services for individuals with a learning disability; however many individuals are being offered alternative services away from institutional mental health settings. In the past year Service Users with an Intellectual Disability have moved to greatly improved accommodation at Knockamann (Portrane), Clonmel and Wexford.

Old Persons: A number of additional Mental Health Services for Older Persons Teams were introduced in 2006. The HSE aim to introduce specialist Mental Health Services for Older Persons in Kildare, Wicklow, Kerry and Roscommon.

Fostering Innovation: The HSE has established a working partnership with philanthropic partners to create the GENIO project to fund innovation in mental health and disability. An additional €2m was invested in GENIO in 2011 and will be targeted towards working with named individuals and promoting greater independence away from institutional and congregated care settings. A further €1m will be provided to fund the expansion of Jigsaw, (currently in 5 counties) to other counties. Jigsaw is an innovative community based support service for young people which has been developed by Headstrong and is designed to promote systems of care that are accessible, youth-friendly, integrated, and engaging for young people.

3. To ask the HSE what action is being taken to address the unacceptable conditions in residential care for many persons with intellectual disabilities. (Caoimhghín Ó Caoláin TD)

Response 3:

The HSE published a report ‘Time to Move on from Congregated Settings- A Strategy for Community Inclusion’ on the 28th June 2011. The Report was initiated by the Primary Community and Continuing Care Directorate in 2007 to develop a national plan and associated change programme for moving people from congregated settings to the community in line with Government policy and identifies that around 4,000 (based on 2008 census) people with disabilities in Ireland live in congregated settings, defined as a residential setting where they live with ten or more people. The membership of the Working Group was made up of representatives of key stakeholders including voluntary and statutory service providers, representatives and advocates for people with disabilities, the National Disability Authority and the Department of Health. Notwithstanding the commitment and initiative of dedicated staff and management, the picture that emerged in the course of preparing this Report is one of a group of people who live isolated lives apart from any community and from families; many experience institutional living conditions where they lack basic privacy and dignity. Most have multiple disabilities and complex needs. The model of service is highly medical – almost 40 per cent of staff are nurses – while many do not have access to basic therapies or activities. Just over a quarter of residents had no day programme or a very limited day programme in their wards.

In response to public policy and investment, the numbers in congregated settings have been declining, and most centres have made arrangements to enable a number of residents to move to the community, the Report identifies 619 people moved from a congregated setting during the period 1999 to 2008; however admissions have continued. Furthermore, during the lifetime of preparing the Report approximately 500 people have moved on from Congregated Settings into smaller homes and community services. There are active plans in place for a further 50 people to move to more appropriate settings during the course of 2011.

The Report proposes a new model of support in the community for those in congregated settings. The model envisages that people living in congregated settings will move to dispersed forms of housing in ordinary communities, provided mainly by housing authorities. They will have the same entitlement to mainstream community health and social services as any other citizen, such as GP services, home help and public health nursing services, and access to primary care teams. They will also have access to specialised services and hospital services based on an individual assessment. People will get the supports they need to help them to live independently and to be part of their local community. The Report proposes a 7 year phased closure of congregated settings with individuals actively supported to live full, inclusive lives at the heart of the family, community and society.