Ireland needs a new mental health act. has passed through the houses of Oireachtas and now awaits implementation in the Department of Health¹. The 2001 Act is not perfect, but it is an improvement on the existing legislation. There is an urgent need to provide the resources and structures needed to implement the new Act.

addresses two key aspects of mental health care: involuntary detention of persons in approved psychiatric centres, and mechanisms for assuring standards of mental health care. It is notable the Act does not address in detail the process of voluntary admission to hospital, nor does it clearly establish a minimum standard of care to which patients are entitled.

The 2001 Act divides mental disorder into three components: mental illness, severe dementia and significant intellectual disability (section 3). Persons admitted to an approved centre on an involuntary basis will have their detention reviewed by a mental health tribunal within 21 days of admission (section 18). Each mental health tribunal will comprise a consultant psychiatrist, a practising barrister or solicitor, and one other person (section 48).

The Tribunals will be appointed by a new body called the Mental Health Commission (section 32). The Mental Health Commission will promote the maintenance of high standards and good practice in the delivery of mental health services. The Commission will take all reasonable steps to protect the interests of detained patients. It will consist of thirteen representatives: one barrister or solicitor, three doctors (including two psychiatrists), two nurses, one social worker, one psychologist, one member of the general public, three representatives of voluntary bodies and one representative of the chief executives of the health boards.

The Mental Health Commission will have a Chief Executive, appointed by the Commission, and a chairperson, appointed by the Minister for Health and Children. The Commission will have a number of functions, including the appointment of Mental Health Tribunals, administration of the requisite legal aid scheme, registration of approved centres and the appointment of an Inspector of Mental Health Services.

provides patients with explicit rights to information pertaining to their detention and review (section 18), and provides automatic legal representation for patients at Tribunals (section 17). The Act also addresses the issue of consent in a number of ways, requiring, for example, that involuntary psychiatric inpatients sign a consent form for psychiatric medication continued for longer than three months without interruption (section 60).

Many aspects of the Act are welcome: automatic review of involuntary status, explicit guarantees of patients rights to information, and the establishment of the Mental Health Commission with the purpose of promoting high standards of mental health care. It is hoped that these provisions will form the basis for the ongoing development of a mental health service that is effective, accessible and appropriate to Irelands mental health needs.

Certain aspects of the Act, however, give cause for concern. Mental Health Tribunals will present an enormous logistic challenge to the psychiatric service. In 1999 there were 2,729 involuntary admissions to Irish psychiatric hospitals or inpatient units². If 60% of these are still inpatients after 21-days, there will be 1,637 Mental Health Tribunal hearings for these patients in any one year. If involuntary status is maintained for 3-months, further hearings will be necessary. This would probably lead to over 2,000 Tribunal hearings per year.

Mental Health Tribunals have the potential to serve as powerful forums which protect the rights of the patient and provide a guaranteed opportunity for the patient to express their views however unwell or psychotic they may be. Similar systems work quite well in other countries. New Zealand, for example, has a system of mental health tribunals not unlike the incoming system here. In New Zealand, however, a judge is present to make final decisions, based on the contributions of patient, family, psychiatrist, nurses, social workers and other stake-holders³.

In Ireland, substantial additional resources are needed to implement the system of Mental Health Tribunals proposed in the 2001 Act. Admittedly, the Act indicates that psychiatrists who are less than 7 years retired from an approved centre may participate in Tribunals, but there will still be a need for practicing psychiatrists to participate and their regular clinical duties will need to be covered in their absence. Appropriate arrangements will need to be put into place if the quality of patient care is to be maintained.

There are various other aspects of the Act which require clarification prior to implementation. The text refers to several new forms which will be used throughout the process of involuntary admission and review: these forms have not yet been seen. There is also a need for clear guidelines about confidentiality. Furthermore, it is not yet clear how persons will be recruited to serve on Tribunals, nor what criteria, if any, will apply in selecting the third member of each Tribunal.

The Irish Division of the Royal College of Psychiatrists has welcomed the new Act. The Division has constructively highlighted some of the particular challenges the Act presents to the psychiatric service, particularly with regard to independent reviews of detained patients, the provision of second opinions and the involuntary admission of children⁴.

is not perfect, but it represents a substantial improvement on the present situation. In any case, it has already been passed by the Oireachtas. Appropriate resources should be put in place and the Act should be implemented as soon as may be. Legislative work, however, should continue after this Act is implemented. Mental health is a dynamic field, requiring dynamic legislation that reflects advances in the science and practice of psychiatry.

Legislation alone is not enough. There is a strong need for enhanced funding of psychiatric services across the board. In this regard, it is encouraging to note that the recent Health Strategy published by the Department of Health and Children renewed the Departments commitment not only to the implementation of the Mental Health Act 2001, but also to the development of a comprehensive community-oriented mental health service in Ireland⁵. Certainly, there is little point in having an elegant legislative framework if the resources are not in place to provide high quality mental health care to all. There is also a strong need to continue the development of advocacy structures, address issues related to stigma, and promote ongoing meaningful public debate on mental health issues.

Brendan D Kelly,
Stanley Research Foundation (Ireland),
Cluain Mhuire Family Centre,
Newtownpark Avenue,
Blackrock,
Co Dublin,
Ireland.
Telephone: + 353 1 2833766.
Fax: + 353 1 2833886.
Email: [email protected]

References

1. Department of Health and Children. Mental Health Act, 2001. Dublin: The Stationery Office, 2001a
2. Daly A, Walsh D. Irish Psychiatric Services: Activities 1999. Dublin: The Health Research Board, 2000
3. Turner TH. Why do so few patients appeal against detention under section 2 of the Mental Health Act? New Zealands system ha