The future of mental healthcare in Ireland

Ireland’s mental health system has never lacked for reports, reviews and reassessments. From the early 1800s onwards there have been committees, commissions and enquiries every few years, all producing reports of varying lengths and usefulness. The most recent addition to the library was published in October 2018 by the Oireachtas Joint Committee on the Future of Mental Health Care. The Committee was a cross-party body established in July 2017 and it published two interim reports during the course of its deliberations.

The Committee’s third and final report, in the words of its chair, Senator Joan Freeman “sets out to present a clear and compelling vision for mental healthcare and the direction of mental health policy in Ireland and the associated actions and targets that it considers necessary and capable of implementation”.

So, what does this latest report actually say? The Committee makes 22 key recommendations under 11 headings. Under “stigma and mental health promotion”, for example, the Committee’s recommendations include greater study of the “causative factors” implicated in mental illness and more targeting of resources to “areas of highest need”, with a priority focus on the Traveller community.

Looking at the “current state of services”, the Committee suggests that “the Department of Health should conduct a comparative study as to which countries ‘do mental health well’ and how Ireland compares”. Looking abroad is certainly a good idea, but it is far from clear which countries “do mental health well” in the sense meant by the Committee. To take one example, Ireland’s rate of involuntary admission is now less than half of that in the UK and Ireland’s suicide rate has fallen significantly over recent years. Surely, this counts as Ireland “doing mental health well”, at least in these respects?

“As an interim measure,” the Committee continues, “the number of acute beds should be increased to 50 per 100,000 over the next three years, with a commitment to reach the EU average [approximately 70] within the subsequent two years.” This is a welcome recommendation and clear recognition of this need is long overdue in Ireland.

Moving on to “physical infrastructure”, the Committee “recommends that the Mental Health Act be amended to provide for the regulation of all premises where mental health services are provided” and that the role of the Mental Health Commission be strengthened. Although these aims are laudable, it is far from clear that regulation through legislation is always the best way to achieve better services. The Committee underpins their recommendation by calling for “major additional capital investment to ensure compliance with the regulations, which should also have the knock-on effect of attracting clinicians and creating environments conducive to the recovery of people experiencing mental ill-health”.

The Committee recommends improved “signposting, referral pathways and communication”, and suggests that “consideration be given to reviewing the role of psychiatrists and streamlining their workloads by distributing some or all of [a number of specific] functions to other team members”. Interestingly, some of the tasks mentioned are already undertaken by team members other than psychiatrists in many mental health services, but presumably the Committee means that such task-sharing should become more widespread. They also recommend that there should be “access to a wide variety of treatment options” so as to increase “the likelihood that individuals will recover”.

The Committee says it may be necessary to appoint a senior manager with responsibility for mental health in the HSE on a statutory basis. In the meantime, the Committee recommends that a National Director for Mental Health be reinstated who will be solely accountable for decision-making in mental health. For funding, the Committee suggests “as Sláintecare is implemented that the recommended increase to 10 per cent for mental health services be ring-fenced and prioritised” and to enhance accountability, “A permanent Oireachtas Committee on Mental Health must be established.”

Recruitment is a real issue and in this context the Committee recommends improved remuneration for clinicians, various other incentives, and consideration of “the possibility of special allowances for psychiatric nurses and psychiatrists”. For “staff development”, it suggests that “a mental health centre of excellence be established and resourced in an academic hospital”.

As these reports go, the Joint Committee report is a perfectly reasonable addition to the now enormous library of such reports produced over the years. While it could have done with another read-through before publication (to remove the more obvious glitches in continuity), the document undeniably makes many important and useful points. Its recommendations are mostly sensible and logical, albeit that it should not really have required an Oireachtas Committee to make them. And much of what they say is consistent with <em>A Vision for Change</em>, the 2006 mental health policy that is currently being refreshed – a process that will, presumably lead to another report.

It is probably useful that such reports keep on appearing, if only to draw attention to the very real challenges in mental healthcare today. It is especially encouraging that the Joint Committee recommends increasing the number of acute beds. Ireland’s shift to community mental healthcare has been positive and decisive, but it has resulted in a lack of inpatient beds. Hopefully, this report will help address that deficit.