I thank the committee for the invitation to address the committee on the future of mental health care. As general secretary of the Psychiatric Nurses Association, I would like to highlight my concerns in relation to the future of mental health care in Ireland. The inadequacies and underinvestment in the current provision of mental health services is something the PNA has consistently drawn attention to and I would hope that the interest of the committee in this area will help to address the many gaps in the mental health services that exist throughout the country.
In 1984, the first major mental health policy, Planning for the Future, was published, recommending the development of community services to coincide with the closure of hospital beds. The closure of a large number of beds occurred but very limited community services were provided, as outlined in the table in my submission.
In 2006 A Vision for Change was published with recommendations to close more beds and develop comprehensive community services. The policy envisioned an active, flexible and community-based mental health service where the need for hospital admission would be greatly reduced. It would require substantial funding but there was considerable equity in building and lands within the mental health system, which could be realised to fund the plan. The report recommended that steps be taken to bring about the closure of all mental hospitals and to reinvest the resources released by these closures in the mental health service.
The report, An Impact Evaluation of "Vision for Change" (Mental Health Policy) on Mental Health Service Provision, phase 1, 2016, which was commissioned by the PNA and completed by the faculty of nursing and midwifery of the Royal College of Surgeons in Ireland, RCSI, aimed to explore the extent to which the principles and practices enshrined in A Vision for Change have been realised and implemented over the past decade. While the study participants identified a multiplicity of prerequisites for the full implementation of A Vision for Change, their top priorities were identified as: comprehensive staffing and resourcing of community-based services; the provision of 24/7 crisis home care teams; the development of crisis houses; developing alternatives to hospital admission; the establishment of rehabilitation assertive outreach teams in all mental health services; and regional intensive care units to be established as per A Vision for Change.
The PNA-RCSI study 2016 clearly shows that 76% of beds were closed but only 30% of the community services were provided. The table in my submission outlines the reduction in beds since Planning for the Future. In 1984, there were 12,484 beds; in 2004, just two years prior to A Vision for Change, there were 4,173 beds; and in 2016, there were 1,002 beds. In percentage terms, between 1984 and 2016, there was a drop of 92% and between 2004 and 2016, there was a drop of 76%.
It is very evident that the necessary agreed closure of inpatient beds has not coincided with a well-developed and resourced comprehensive community-based alternative in line with the national policy. As outlined in the table in my submission the stark reduction in funding coincides with the timeline of both policies, clearly indicating that both policies have been used as cost-cutting measures. The findings indicate that there has been a significant failure to implement national policy and clearly indicate that this failure has a very significant impact on the quality of mental health services and care available to the public. The report concludes that unless the community-based mental health service is fully staffed and resourced the system will continue to malfunction and fail to meet the needs of its users, people with mental health needs and mental illness, an already vulnerable cohort in society.
The table in my submission indicates the mental health budget as a percentage of the health budget. In 1984, coinciding with the table in my submission, this was 14%; in 2004, it was 7.34%; and in 2015, it was 6%. A Vision for Change estimated it would require a budget share of 8.4%, at a minimum.
In the UK and Australia, the mental health services percentage of the health budget is between 12% and 14%. It is imperative that the mental health budget as a percentage of the health budget is significantly increased. Research would show that one in four people develop a mental health problem in their lifetime equating to 25% of the population, yet only 6% of the health budget is allocated to mental health.
Another key factor in the lack of service development is the crisis in recruitment and retention of psychiatric nurses. In December 2016, HSE figures showed that there were 885 psychiatric nurses over the age of 55 and 867 nurses between the ages of 50 and 54. Under fast accrual potentially 885 psychiatric nurses may retire immediately, while a further 867 may retire within the next five years, a total of 1,752, which equates to 34.2% of the mental health nursing workforce. The headcount as of September 2017 was 4,746. These figures would suggest that there are 374 vacancies but a recent survey of PNA branches suggests vacancies are closer to 500. Services with high levels of vacancies are: the Tallaght-St. Loman’s service, Dublin, with 43 vacancies which equates to over 20% of the whole-time equivalents, WTEs; St. Joseph’s, Portrane, with 58 vacancies, which is over 20%; Waterford with 26 vacancies, which is over 19%; and Louth-Meath with 34 vacancies, which is over 16%.
When the service developments outlined in A Vision for Change and not yet implemented are factored in, the requirement for additional nurses reaches more than 700. A Vision for Change recommended between ten and 15 nurses per assertive outreach team. Calculated on the basis of one team per 100,000 population, this requirement alone would equate to 675 nurses where there are 45 teams with 15 nurses per team. Figures from the Health Service Executive revealed that by August 2017, only 93 new staff had been recruited in that year to date, despite soaring demand in all areas of the mental health services and the HSE's admission that 1,963-new posts had to be filled if the level of staffing required in A Vision for Change was to be achieved.
I will provide some examples of the impact of nursing shortages on service provision. In May 2017, 50% of the admission beds in Linn Dara child and adolescent mental health services, CAMHS, in Dublin were closed until the end of October. This meant 11 of the 22 beds at the facility were closed as a direct result of nursing shortages as the service was short 50% of its nursing complement. A Vision for Change recommended 100 CAMHS beds nationally. Following the closure of beds in Linn Dara, bed numbers nationally declined to 52 and currently stand at 63.
The construction of the new national children's hospital is a welcome development. The new hospital will have 20 beds for child and adolescent mental health, eight of which will be dedicated to a service for eating disorders. However, considering the difficulties in recruiting and retaining nursing staff in the child and adolescent mental health services, this development will also create some challenges.
As a result of the failure to provide assertive outreach teams and intensive care rehabilitation units, ICRUs, more than 16% of beds are occupied by patients who were admitted more than six months previously. As a consequence of the 76% reduction in beds and the lack of community services, significant demand on beds has resulted in bed usage reaching 120% in many areas. To give an example of this excessive demand, service users in Waterford and Kilkenny regularly resort to sleeping on chairs because beds are not available. This means a person admitted during the day may be informed that he or she will have to spend the night on two chairs in a corner. Also in Waterford, service managers proposed to suspend parental leave and cancel annual leave for four weeks over the Christmas period owing to nursing shortages.
The Tallaght-St. Loman's mental health services have 43 nursing vacancies. As a consequence, the assertive outreach team, which should have 45 nurses as per A Vision for Change, had 13 nurses last year. This figure has since declined to eight. This is a vital service for those with an enduring mental illness if we are to ensure that service users can live as independently as possible in the community. The diminution of this service will ultimately result in an increase in the number of admissions among this client group. As a result of staffing shortages, the same service proposed to close its six-bed high observation unit at the end of December 2017. This is a unit for those with an acute mental illness who require a higher level of observation.
In County Kerry, the home based team recommended in A Vision for Change has been disbanded. St. Joseph's intellectual disability and mental health services has 58 nursing vacancies and relies heavily on overtime and agency work. This has a significant impact on the continuity of care for clients.
I will refer to some examples of challenges in recruitment. The figures presented in the submission show the purchasing power parity ratio, PPPR, in main destination countries for Irish nurses. Based on the staff nurse salary minimum point of the scale, the hourly rates using the PPPR are 27.13 in Canada, 21.10 in Australia, 16.66 in Ireland and 19.87 in the United Kingdom once the high cost area supplement available in Britain is factored in. Moreover, all nurses in the UK commence employment on the second point of the salary scale in recognition of the nursing degree qualification and are recruited to areas where the high cost area supplement automatically applies.
According to the Department of Health, the top five destinations for Irish nurses emigrating are Australia, the United Kingdom, the United States, Canada and New Zealand. The Nursing and Midwifery Board of Ireland found that a total of 1,343 nurses and midwives sought certificates of current professional status in 2017. These documents verify qualifications and are sought by nurses when they intend to work overseas. They provide a strong indication of a nurse's intention to work abroad.
The UK has 24,000 nursing vacancies and the figure is expected to increase after Brexit. Mr. Jim Campbell, director of the World Health Organization's workforce department, speaking at the global forum on human resources for health in Dublin in November 2017, raised concerns that, post-Brexit, the UK may try to fill gaps left by migrant health workers from the European Union by attracting nurses from Ireland under the traditional UK-Ireland bilateral agreement. The UK is offering packages such as €8,000 relocation costs, which is more than five times higher than the figure offered in the HSE's Bring them Home campaign. They also offer educational opportunities, low cost accommodation and a 37.5 hour week. Mental health nurses are in significant demand in the UK and other countries and services in these locations are offering relocation and incentive packages to attract Irish nurses. The HSE Bring them Home campaign in 2015, which offered a relocation package of €1,500, attracted only six psychiatric nurses to return to Ireland.
Domestically, St. Patrick’s Hospital, Dublin, starts all graduates on the second point of the scale. A welcome package of €3,000 is also on offer, with €1,500 paid after six months and a further €1,500 paid after 12 months. Nurses in St. Patrick's Hospital work a 37.5 hour week and are not subject to the pension levy.
The work environment for psychiatric nurses is characterised by overcrowding, staff shortages, the failure to implement service developments as per A Vision for Change, poor job satisfaction, workplace stress, a lack of cohesion and continuity of care, an unsustainable workload, an acuity of symptoms among service users due in part to a lack of community development, a lack of career opportunities and incidences of violence and aggression. These factors help explain poor nurse retention rates.
There are also significant delays in the HSE recruitment process, which can take between four and six months to complete.
At a time of recruitment crisis, these delays are inefficient and unacceptable. Authority needs to be delegated to the community health care organisation, CHO, areas to speed up this process. In the UK, the professional qualifications of the nurse are recognised, with the first point of the nurse’s scale higher than the maximum of the HSE scale. In the UK, the nurse is recruited at the same level as the therapy grades - physiotherapists, occupational therapists, podiatrists etc. In Ireland, the nurse is treated as a lesser professional than the therapy grades.
Please note the comparative salaries. A staff nurse on the first point of the scale earns €29,122 whereas someone on the first point of the therapy grade scale earns €34,969. There is almost €6,000 in the difference. The midpoint for a staff nurse is €37,129 whereas it is €43,191 for someone in a therapy grade. The 12th point of the scale for a staff nurse is €43,754 while it is €48,851 for someone in a therapy grade. The long-service increment for a staff nurse is €45,086 compared with €51,033 for someone in a therapy grade. When one factors in that those in therapy grades work a 37 hour week while staff nurses work a 39 hour week, there is a difference of 20% in their hourly rates. It is the view of the PNA that the staff nurse scale must commence at a point equivalent to that of therapy grades. Having regard to the comparable minimum qualifications, that is, an honours degree, and the role and responsibilities of the posts, the salary scale for therapy grades should be applied in its entirety to nurses. The development of the staff nurse scale in this way would enhance recruitment and retention.
The mental health service is in dire need of psychiatric nurses and other professionals who will join and stay in the public system after qualifying. One of the most significant consequences of the recession and of the decisions of Government in cutting public service pay, introducing the graduate scheme and enforcing a recruitment embargo was the creation of a culture of graduate emigration. For those who were unable to emigrate or who chose to remain at home, the private sector continues to offer exciting and financially rewarding opportunities.
The current crisis in nursing is forecast to get significantly worse over the next few years. Should the Public Service Pay Commission fail to recommend remedial pay measures, then the chance for this country to resolve this crisis will be lost for a generation, with horrendous implications for the delivery and development of mental health services and patient care.