The world is suffering from an increasing burden of mental disorders, which has been further aggravated by a widening “treatment gap”. The World Health Organization (WHO) estimates that mental health ranks second amongst global illnesses. Furthermore, recent WHO analyses calculate that neuropsychiatric conditions impacted upon some 10% for adults or approximately 450 million people.
Irish-based studies reveal that around 25% of the population will experience a mental health problem at some point in their lives. Mental health concerns are responsible for almost 10% of patient visits to G.P.s. A 2003 South Western Area Health Board report revealed that about a quarter of primary care consultations were made up of patients with mental health issues.
Mental health is clearly a significant social and economic as well as medical issue for Ireland. The demands these mental health concerns place on the Irish economy are likely to escalate even further given the ongoing economic recession and public sector cutbacks. In response, it is imperative that there is an effective mental health policy, and strategic service implementation plan together with the allocation of sufficient resources to minimise the socio-economic consequences of mental health problems.
Early 2006 saw the release of the Irish mental health policy document A Vision for Change. A Vision for Change replaced the 1984 Irish mental health policy document Planning for the Future and was supposed to have a lifespan of some 7 to 10 years.
A Vision for Change was broadly recognised as an enlightened approach to mental health issues and was one of the first to actively include services users and carers in its formulation. This new policy drew up a blueprint for a new approach to mental health, which would move the Irish mental health service away from providing “inequitable services and institutional care to community based holistic services” while emphasising principles such as “social inclusion, choice, participation and equity.”[i] A Vision for Change also emphasised that it was critical that the social determinants of mental health problems were addressed in addition to the more traditional medical approach.
However, to date, the implementation of A Vision for Change´s recommendations has been extremely disappointing.
A Vision for Change still lacks a specific and effective implementation plan. Although mental health is covered in the overall HSE implementation plan, there should be a specific mental health implantation plan outlining how the policy recommendations in A Vision for Change will be realised as well as the resources required to do so. Failure to provide such a plan renders the aspirations and recommendations of A Vision for Change as little more than idle dreaming.
In effect, the HSE vision for mental health remains unclear. Although certain elements of A Vision for Change have been introduced, the implementation process has displayed a lack of overall coherence, as the HSE has generally failed to treat the policy’s recommendations as an integrated whole.
One example of where the lack of such an implementation plan has proved detrimental has been the tendency to base funding of the different mental health services on historical trends rather than allocating funding according to evolving needs. The development of a specific and detailed mental health implementation plan, equipped with an effective monitoring and evaluation mechanism, would help eliminate this problem as future planning would be based on the results of previous mental health investments.
A further concern lies in the refusal to appoint a National Directorate for mental health, supported through a person-centred approach which, in addition to reflecting best practice, would be devised and agreed upon with service users and their carers’. As pointed out by The Inspector of Mental Health Services the appointment of such a Directorate, supported by a team with the necessary skills and service-user involvement is essential to ensure the modernisation of the present system as well as being “budget beneficial” and improving outcomes. The unwillingness to set up such a National Directorate can only heighten public concerns as to the level of genuine political commitment to A Vision for Change.
A second crucial issue has been the consistent underfunding of the mental health services. Although, funding has increased in the area of mental health, its proportion of the overall health budget has experienced a general decline over the years. In 1984, expenditure on mental health accounted for 13% of the overall health budget. This percentage had declined to just 5.4% in 2010.
The announcement in the 2010 Budget of the funding to be provided for capital investment by the disposal of current assets is of critical importance. It is envisaged that the selling of surplus assets, such as former institutions, will free up €43m for reinvestment in the mental health capital programme. This funding will be allocated to support the development of a patient-centred, flexible and community based mental health service with a corresponding reduction in hospital admissions. Future provision from 2011 on will depend on sales of assets in the previous year.
However, several concerns remain. Firstly, there is the worry that, as has happened in the past, some of these monies might be diverted from the development of an improved mental health system to other projects or to shore up budgetary constraints. Furthermore, the indeterminacy with respect to funding, reliant as it is on the outcome of asset sales that will not be determined in advance, renders future capital planning tentative at best. A National Mental Health Directorate, were it to be established, would play an important role in ensuring that any funding allocated is used for mental health purposes only.
At the same time, investment in improving community-based care is essential if the objective of A Vision for Change to reduce the comparatively large number of residential beds in the Irish mental health system is to be realised. The present situation whereby community care tends to be organised around institutions in the community with a relatively minimal use of outreach and home care facilities is unsustainable.
Creating the necessary personnel capacity is also well behind schedule. In the first three years after the publication of A Vision for Change, only 136 new positions were established, over 60% less that had been recommended in the policy document. The embargo on recruitment in the public sector has also added to the human resource shortages, thus further hindering the implementation of A Vision for Change´s recommendations.
It is clear that the radical transformation of the mental health system outlined in A Vision for Change will incur relatively substantial short to medium term transitional costs. These will be required both to establish the required new facilities as well as providing personnel with the necessary training to adapt and perform effectively in their new work environment.
While transitional costs are evidently a significant issue given Ireland’s current economic woes, it should be borne in mind that according to O’Shea and Kennelly the cost of mental health problems exceeded €3 billion in 2006 alone, with over €2 billion stemming from lost economic output. Therefore, failure to firmly grasp this budgetary nettle will only result in greater economic and social costs further down the road.
In effect the process of underfunding the mental health services during the Celtic Tiger has to be reversed. As Geraldine Clare, the CEO of mental health charity, Aware cogently warns us:
“It’s unacceptable from Aware’s point of view that this was the case through good economic times. We’re now in recession and when we didn’t do it in good times, I’d have little confidence that the Government will implement A Vision for Change in the climate of cutbacks.”
Given the significant economic consequences of mental health issues as well as the personal suffering they entail, it is essential that adequate resources are made available. Moreover, expenditure on mental health service policy, implementation planning, outputs and activities should, in addition to other appraisal criteria, be transparently costed and their relative effectiveness evaluated on economic terms. The introduction of such an economic evaluation modality is even more urgent given the current straitened financial circumstances of the Irish public services and the need to justify all expenditures including those of mental health.
[i] Moore J. Mental Health and Routes to Inclusion. National Economic and Social Fund Scoping Document, 2006. Available from http://www.nesf.ie/dynamic/pdfs/b.%20Scoping%20Document%20-%20Mental%20Health.pdf. [Accessed 2 June 2010]
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