I welcome the opportunity to make this submission. The Mental Health Commission is the regulator for mental health services in Ireland. We are an independent statutory body that was established in April 2001 under the Mental Health Act 2001, under which the role of the inspector is set out.
Some 90% of mental health services are delivered in primary care settings. A further 10% are delivered within specialist mental health services, including community residences. Under the 2001 Act, the statutory scope of mental health regulation is limited to inpatient services only, which are estimated to make up less than 1% of mental health services in Ireland.
The joint committee has sought information on developments in mental health services in the State. The basis of this report is taken from recent inspection findings as well as information compiled by the commission as part of our ongoing monitoring of compliance and receipt of quality and safety notifications from services. While the scope of the commission’s regulation is limited, we nevertheless closely monitor developments across the broad range of mental health services in Ireland, including acute adult mental health services, rehabilitation, continuing care, child and adolescent mental health services, forensic mental health services, and community mental health services. As a general comment, it is evident that the provision of mental health services is inconsistent across the country and lacks proper integration. For example, a young person in need of mental health services in Galway will be able to access a vastly different range and level of services than a young person in Waterford. Similarly, a person in Cavan-Monaghan or Sligo-Leitrim will have access to mental health rehabilitation services, while a person in Donegal will not, even though they are in the same community healthcare organisation, CHO, area.
The commission therefore welcomes the implementation of Sláintecare, which envisages a system of integrated care provision based on need rather than on location, age, or diagnosis. We hope that this will finally realise the goals included in A Vision for Change, which set out Government policy 13 years ago in 2006. We understand A Vision for Change is undergoing a review and refresh, and we look forward to seeing the revised policy.
In regulated services, we have seen a number of positive developments. We have seen an overall increase in the national average compliance with regulatory requirements, from 74% in 2016, to 76% in 2017, to 79% in 2018. Progress is slow but is consistently trending in the right direction. For the most part we have seen good engagement from services in working towards compliance and implementing the judgment support framework, the Mental Health Commission’s quality framework. There have been some notable improvements. For example, the department of psychiatry in Roscommon University Hospital has gone from being 52% compliant with regulatory requirements in 2017 to being 83% compliant in 2018. Another marked improvement was seen in St. Brigid’s Hospital, Ardee, which went from 64% in 2017 to 93% in 2018.
We have also seen some improvement in fundamental aspects of care provision such as medication management, individual care planning, and consent procedures for involuntary patients. These are positive developments but are not consistent throughout the country. There is work yet to be done to ensure people receive the same consistent high-quality care and treatment no matter where they are located. There has been ongoing progress towards decommissioning outdated and unsuitable buildings for the provision of inpatient services. In 2006, 17 approved centres were operating in inappropriate institutional settings. By 2019, only three remained, with two due to close by 2020.
We do, however, have ongoing concerns. The commission continues to highlight concerns relating to the physical infrastructure of mental health facilities and premises. Inspection reports have consistently identified concerns relating to the overall suitability of premises to meet patient needs, concerns relating to the physical safety of premises, and concerns relating to the maintenance of the premises, including basic repair works and cleanliness. In 2018, 70% of regulated services were found to be non-compliant with the regulatory requirements relating to their premises. It is unacceptable that in 2019 we still find service users in long-stay units living in dormitory-style accommodation and in units where one shower is shared between 20 people, and to find units which are dirty and in disrepair. This does not respect the basic privacy and dignity of service users.
It is the position of the commission that there is no therapeutic benefit to the use of restrictive practices such as seclusion or physical restraint. These practices should only ever be used as a last resort where there is a serious and urgent safety concern. Despite this, physical restraint was used in 81% of all approved centres in 2018 and 97% of acute adult services. Seclusion was used in 42% of all approved centres in 2018 and 65% of acute adult services. We are concerned that there is a lingering complacency in the use of these practices. In many services, these practices are accepted and commonplace. Such practices directly affect a person’s human rights to liberty, autonomy and bodily integrity. We have seen little real engagement in the proper scrutiny and reduction of these practices by the mental health services
In a recent report, I highlighted serious concerns regarding the provision of general health services to persons with severe mental illness in continuing care approved centres. People with a severe mental illness will die, on average, 20 years earlier than the general population for largely preventable reasons unrelated to their mental illness. Following a review of ten services across the country, I highlighted inadequate and inconsistent monitoring of patients’ physical health needs and inadequate and inequitable access to essential healthcare services. The commission has sought a national response from the HSE to address these serious concerns.
I also have concerns about the provision of specialist rehabilitation and recovery services for people with enduring mental illness. This can be summarised as a lack of appropriate housing for people to move to more independent living; too few rehabilitation teams - we only have 48% of the number recommended by A Vision for Change; existing teams which are poorly staffed; and a lack of localised community and inpatient specialist rehabilitation units. We have a large number of people who are still residing in institutional care who, with rehabilitation and recovery services, could live more autonomous, satisfying lives as part of their own communities.
While the statutory scope of mental health regulation is limited to inpatient services, as inspector I have the statutory power to visit and inspect any premises where a mental health service may be provided. Over the past three years I have been undertaking a systematic review of all 24-hour nurse-staffed community residences in the State. There are 118 such community residences across the nine HSE community healthcare organisation areas, accommodating more than 1,200 service users. The residents of these services are often in long-term accommodation and the community residence is their only home. They represent a large number of potentially vulnerable adults with enduring mental illness whose voice is rarely heard.
The community residences are often poorly maintained, too big, institutionalised, restrictive and at times not respectful of service users’ privacy, dignity and autonomy. Many residences were in poor physical condition, with 19% of those inspected in 2018 requiring urgent maintenance and refurbishment. A significant number of people living in these residences should, with appropriate support, move to smaller, less institutionalised accommodation. These units remain without regulatory oversight or safeguards, despite the number of units and vulnerability of service-users accommodated in such units. Over a number of years, the Mental Health Commission has called for these residences to be regulated. Regulation would allow the commission to enforce changes where deficits and risks are found, protect the human rights of people living in these residences and help mental health services to provide care and treatment in accordance with best practice standards.
At the end of 2017, I reviewed the provision of child and adolescent mental health services, CAMHS. This review highlighted a number of concerns about the provision of the services nationally. These include: poorly staffed community teams - overall the staffing in 2017 was 60% of that recommended in A Vision for Change; the number of young people admitted to adult units, which the commission had continued to raise as a concern across a number of years; the variation in funding for CAMHS across the CHOs, which varies from €40 per capita in CHO 5 to €92 per capita in CHO 2; the lack of out of hours emergency CAMHS both for assessment and for inpatient beds; and waiting times of up to 15 months for non-urgent outpatient appointments with CAMHS teams.
The commission recommends national oversight and governance to address the ongoing concerns within regulated mental health services, noting that the ongoing and widespread nature of the concerns points to systemic issues that will not be addressed with a solely local or regional focus. The commission recommends that the revised national mental health policy, A Vision for Change, should reflect the aims set out in Sláintecare, in particular a focus on the provision of integrated care based on need, not on location, age or diagnosis. The commission recommends putting proper regulatory safeguards in place to uphold the human rights and ensure the safety and well-being of persons in specialist community-based residential mental health services, that is, 24-hour nurse supervised community residences. The commission recommends the establishment of an out-of-hours mental health service for young people in crisis, including a clear pathway for their families and loved ones. The commission recommends the proper provision of funding ensure there are adequate services for persons with severe and enduring mental illness, including appropriate accommodation, general health and rehabilitation services. The commission recommendations the prioritisation of funding to ensure all accommodation in residential mental health services - approved centres and community residences - are safe and fit for purpose.