Ir Med J. 2006 Jun;99(6):164-6





In August 2003 the Minister of State at the Department of Health and Children with special responsibility for mental health established an Expert Group on Mental Health Policy to develop a blueprint for comprehensive, modern, high quality mental health services in Ireland. In January 2006 this group published its report, entitled A Vision for Change, outlining theirrecommendations for future developments in mental health services.¹ A Vision for Change can be downloaded free-of-charge from the website of the Department of Health and Children (www.dohc.ie/publications/vision_for_change).

Background to the new mental health policy
A Vision for Change is a tremendously important document, if only because it represents the first major revision of mental health policy in Ireland since 1984, when the Department of Health published The Psychiatric Services - Planning for the Future.² A progressive policy for its time, Planning for the Future indicated that mental health services should be comprehensive and community-oriented, and should be clearly aimed at delivering continuous, coordinated, multi-disciplinary mental health care. The policy recommended that the population be divided into sectors, each comprising 25,000 to 30,000 individuals; that psychiatric care be delivered by consultant-led multi-disciplinary teams in each sector; that a dedicated crisis team be developed in each sector; and that additional specialized
services be developed to cover more than one sector. Day hospitals were to provide intensive treatment equivalent to that available in an inpatient setting and there were specific recommendations for the numbers of day places and hostel places to be provided.

While the two decades following the publication of Planning for the Future saw considerable changes in the delivery of mental health care in Ireland, not all of the report’s recommendations were implemented;^3,4 in particular, there was evidence of notable variations in the levels of service provision across different geographical areas.^5-7 Nonetheless, as the Mental Health Commission pointed out in its inaugural Annual Report,³ the principles outlined in Planning For The Future remained highly relevant to psychiatric care throughout this time, and while all its recommendations had not yet been implemented, Planning for the Future had brought significant improvements to Irish psychiatric services, particularly in relation to de-institutionalisation.

Between 1984 and 2006, however, much has changed in Irish society: unemployment has fallen from 16.9% in 1987 to 6% in 1999;⁸ net outward migration of 2% of the population in 1988/1989 has reversed, with the number of immigrants into Ireland between 1995 and 2000 amounting to some 7% of the entire population;⁹ the proportion of elderly people in the population has increased to 11.4% (in 1996) and this is projected to increase to 18% by 2031.¹⁰ There have also been significant developments in general health policy in Ireland over this time, especially following the publications of Shaping A Healthier Future: A Strategy For Effective Healthcare In The 1990s ¹¹ and Quality and Fairness: A Health System For You ¹² both of which placed increased emphasis on the
principles of equity, quality, accountability and people-centredness in the planning and delivery of health care.

The period since 1984 has also seen considerable changes specifically in relation to psychiatry and mental health care. At an international level, the World Health Organisation devoted its 2001 annual report to the topic of Mental Health: New Understanding, New Hope.¹³ This renewed emphasis on mental health policy was supported by a similar renewal of interest in the principles of evidence-based medicine^14,15 with organizations such as the Cochrane collaboration (www.cochrane.org/) providing systematic reviews of scientific and clinical evidence to support interventions in all areas of health care, including mental health care. At a national level, a new Mental Health Act was passed in Ireland in 2001 and, although this act has yet to be implemented in full, the new Mental Health Commission was established in April 2002 with the aim of advancing high standards and good practice in mental health services throughout Ireland.³ These developments, combined with increased public interest in psychological wellbeing and mental health care, created the context in which Ireland’s new mental health policy was developed.

Ireland’s new mental health policy
A Vision for Change 1 aims to outline a framework for promoting positive mental health in all sectors of the community and for providing accessible
specialist mental health services for individuals with mental illness. The policy is divided into three main sections outlining

1. the vision underlying the policy;
2. the plan for service developments; and
3. the process of implementing policy measures.

The vision outlined in section 1 describes the process of consultation that informed the development of the policy; discusses relevant definitions (e.g. mental health); and underlines the need for a population-based approach to mental health, involving not only mental health services but also primary care and community supports (e.g. informal sources of support). This section also emphasizes the importance of partnership with serviceusers, carers and the broader group of stakeholders in modern mental health services. The links between mental health and education, poverty, unemployment, housing and social exclusion are explored; mental health promotion is discussed; and various protective factors and risk factors for mental illness are listed.

Section 2 of the policy deals in more specific detail with the plan for service developments based on this vision. After a brief summary of current mental health service provision, the policy explores the role of primary care in the provision of mental health care and recommends that a comprehensive range of services be available at primary care level for individuals who do not require specialist services; a consultation/liaison model should ensure formal links between specialist services and primary care, especially in relation to discharge planning; suitably trained staff should be available in primary care settings to meet mental health needs;
and relevant education, training and research should be developed.

In terms of adult mental health services, the report recommends that one multidisciplinary community mental health team (CMHT) be provided per 50,000 population, with two consultant psychiatrists per team. The report recommends the provision of 50 beds per 300,000-person catchment area, comprising 35 beds for general adult mental health services (including 6 close observation beds), 8 beds for mental health services for older people, 5 beds for individuals with intellectual disability and 2 beds for individuals with eating disorders. In addition, the report makes many other recommendations, including the provision of:

• One crisis house per 300,000 population (10 places)
• Four intensive care rehabilitation units (30 beds each)
• Eight high support intensive care residences (10 places each)
• Two early intervention services
• Various other facilities as detailed in the report itself.

In terms of child and adolescent psychiatry, the report recommends the provision of two multidisciplinary teams per 100,000 population to provide assessment and care to children and adolescents aged 0-18 years, and five inpatient units (20 beds each), as well as one paediatric liaison team and one day hospital per 300,000 catchment area. In terms of rehabilitation psychiatry, the report recommends one multidisciplinary team, three community residential units (10 places each) and one serviceuser provided support centre per 100,000 population; and one to two day centres (with a total of 30 places) per 300,000 population.

The report also addresses services for other specific service-user groups, including older people, individuals with intellectual disability, the homeless, individuals with substance misuse disorders and individuals with eating disorders, as well as forensic mental health services and liaison mental health services. Attention is paid to special categories of service provision including individuals with co-morbid severe mental illness and substance abuse problems, individuals with neuropsychiatric disorders requiring specialist services, and individuals with borderline personality disorder. In terms of suicide prevention, the report supports implementation of the recommendations of National Strategy for Action on Suicide Prevention.¹⁶ In addition to making specific recommendations about levels of service provision in these and other areas, the report also explores more general principles that should inform mental health care and particular attention is paid to multidisciplinary team-work, care-planning, the process of recovery and the development of needs-based models of service delivery.

The third section of A Vision for Change ¹ is devoted to implementation, and the report recommends that:

• Mental health catchment areas should be established with populations of 250,000-400,000) and these should be managed by multidisciplinary Mental Health Catchment Area Management Teams
  
• A National Mental Health Services Directorate should be established
  
• Other recommendations are also made in relation to many other areas including clinical governance, service-user involvement, and integration with other community care area programmes and the work of voluntary groups.

Implementation of the measures outlined in A Vision for Change will require substantial extra funding and the report recommends that resources are remodelled so as to increase equity, with special attention paid to areas of socio-economic disadvantage that have a high prevalence of mental illness. Implementation of these recommendations will also have implications for manpower, education and training and these areas are also explored in the report; in particular, it is suggested that amulti-profession manpower plan be put in place. A Vision for Change also emphasizes the importance of mental health information systems and research, and recommends that a national mental health minimum data set be prepared, in consultation with stakeholders.

A change of vision?
The preparation and publication of A Vision for Change ¹ reflects a welcome renewal of emphasis on mental health policy in Ireland. Overall, A Vision for Change advances many of the recommendations outlined by the World Health Organisation in Mental Health: New Understanding, New Hope, especially in relation to the provision of treatment in primary care settings, increased community involvement in mental health structures, improved educational initiatives, the development of national mental health policies and increased research into mental health.¹³

A Vision for Change re-affirms many of the principles outlined in The Psychiatric Services - Planning for the Future.² For example, both documents place considerable emphasis on the community basis for mental health care, with A Vision for Change recommending very clearly that a plan should be developed to close down all psychiatric hospitals and invest the resultant resources back into mental health services. The key to the success of this and all other measures in A Vision for Change will lie in the process of implementation: many of the recommendation of Planning for the Future remain un-implemented some twenty-two years after its publication;^3,4 it is to be hoped that the positive service developments outlined in A Vision for Change are progressed more effectively.

Specific areas raise specific issues. For example, A Vision for Change recommends that four community-based forensic mental health teams be provided, one in each of the Health Service Executive (HSE) regions.¹ This recommendation, while apparently consistent with the principle of ‘equity’ ^11,12 does not appear to take adequate account of need, and appears to presume that there is equal need for forensic mental health services in all geographical areas. In fact, while all areas certainly need some level of forensic mental health service, there is strong evidence that forensic mental health need is inequitably distributed throughout Ireland; O’Neill et al,⁵ for example, studied all admissions to the national forensic psychiatry service from courts and prisons between 1997-1999 and found that 63% of admission were from the area of the former Eastern Regional Health Authority (ERHA). While service use does not necessarily reflect service need, these findings nonetheless strongly suggest that the presumption of equal need in all geographical areas (‘horizontal equity’) may not be consistent with the efficient distribution of services on the basis of need (‘vertical equity’). Based on the evidence of O’Neill et al,⁵ the development of a community forensic mental health team to cover Dublin’s inner city is a clear priority.

The re-definition of catchment areas outlined in A Vision for Change ¹ also raises important operational issues, especially in relation to the re-distribution of current patient populations and the development of arrangements for transfers of care. Implementing this element of policy will require a phased approach that takes careful account of existing arrangements while also advancing the process of change. This process of implementation will also require the development of specific proposals for specific patient groups, including the homeless, up to one-third of whom have mental health problems, ^17,18 and migrants, who also tend to have increased need in terms of both physical and mental health.¹⁹ In addition, the policy’s endorsement of early intervention programmes for psychosis is a welcome recognition of the specific needs of this patient group; the expansion of such services is wholly consistent with international developments in this field.²⁰

The sequencing of implementation is likely to be critical. It is imperative, for example, that community mental health services are substantially strengthened prior to any changes in levels of inpatient care; at present, levels of service provision vary considerably in different geographical areas throughout Ireland;^5-7 these disparities need to be better characterised and resolved as a matter of priority. Linked to this, A Vision for Change ¹ places a welcome emphasis on the need for effective health information systems in mental health services throughout Ireland; this is a need that is also emphasised by the Inspector of Mental Health Services.⁷ The absence of such information systems severely impedes the performance of clinical audit in day-to-day clinical practice. Moreover, strengthening mental health information systems would not only help develop models of good clinical governance at both local and national levels, but would also help advance and monitor the implementation of many other policy measures outlined in A Vision for Change.¹

Overall, A Vision for Change ¹ represents a welcome renewal of emphasis on the importance of establishing a clear strategic direction for mental health services. In terms of implementation, it is critical that the demonstrated needs of populations inform the determination of models and levels of service provision. This requires careful epidemiological consideration of the socio-demographic composition and mental health needs of specific populations and sub-populations, and the development of evidence-based models of care that will ensure the effective and equitable distribution of limited resources throughout mental health services.

Correspondence:
Brendan D. Kelly
Department of Adult Psychiatry,
University College Dublin,
Mater Misericordiae University Hospital,
62/63 Eccles Street, Dublin 7
E-mail: [email protected]

References

1. Expert Group on Mental Health Policy. A Vision for Change. Dublin The Stationery Office, 2006
2. Department of Health. The Psychiatric Services - Planning for the Future. Dublin: The Stationery Office, 1984
3. Mental Health Commission. Annual Report 2002. Dublin: The Mental Health Commission, 2003
4. Kelly BD. Mental health policy in Ireland, 1984-2004: theory, overview and future directions. Irish Journal of Psychological Medicine 2004; 21: 61-8
5. O’Neill C, Sinclair H, Kelly A, Kennedy H. Interaction of forensic and general psychiatric services in Ireland: learning the lessons or repeating the mistakes? Irish Journal of Psychological Medicine 2001; 19: 48-54
6. O’Keane V, Jeffers A, Moloney E, Barry S. Irish Psychiatric Association survey of psychiatric services in Ireland. Psychiatric Bulletin 2004; 28: 364-7
7. Inspector of Mental Health Services. Report of the Inspector of Mental Health Services 2005. Dublin: The Stationery Office, 2005
8. Department of Finance. National Development Plan. Dublin: The Stationery Office, 1999
9. MacÉinrí P. Immigration into Ireland: Trends, Policy, Responses, Outlook. Cork: Irish Centre For Migration Studies, 2001
10. Department of Health and Children. Long-stay Activity Statistics. Dublin: The Stationery Office, 2001
11. Department of Health. Shaping A Healthier Future: A Strategy For Effective Healthcare In The 1990s. Dublin: The Stationery Office, 1987
12. Department of Health and Children. Quality and Fairness: A Health System For You. Dublin: The Stationery Office, 2001
13. World Health Organisation. The World Health Report 2001. Mental Health: New Understanding, New Hope. Geneva: World Health Organisation, 2001
14. Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. British Medical Journal 1996; 312: 71-2
15. Kelly BD. Evidence based medicine: what it is and why it matters. Irish Psychiatrist 2002; 3: 133-8
16. Health Services Executive. Reach Out, National Strategy for Action on Suicide Prevention 2005-2014. Dublin: Health Services Executive, 2005
17. George SL, Shanks NJ, Westlake L. Census of Single Homeless People in Sheffield. British Medical Journal 1991; 302: 1387-9
18. Holohan TW, Holohan W. Health and Homelessness in Dublin. Irish Medical Journal 2000; 93: 41-3
19. Gavin B, Kelly BD, Lane A, O’Callaghan E. The Mental Health of Migrants. Irish Medical Journal 2001; 94: 229-30
20. Yung A, Phillips L, McGorry PD. Treating Schizophrenia in the Prodromal Phase. London: Taylor & Francis, 2004