I am general secretary of the Psychiatric Nurses Association, PNA, and I am joined by my colleague Ms Aisling Culhane, who is the research and development officer with the association. We represent the vast majority of psychiatric nurses in the country. I thank members for the invitation to address the committee this morning.
I want to raise our concern about the mental health budget. Despite all the concerns expressed regarding the impact of Covid-19 on the mental health of the community, no extra funding was allocated for mental health in the HSE’s winter plan. Several weeks later an extra €4 billion in spending was allocated to the health budget for 2021, with just €50 million allocated to mental health. Of this €50 million it emerged that €12 million was to support existing levels of services. This equates to mental health receiving less than 1% of the overall €4 billion budget increase.
The health budget is now €20 billion, including the additional €4 billion, and of this, mental health has a budget allocation of €1 billion. This means the mental health budget has been reduced from just over 6% to 5% of the overall health budget. Reducing the budget by 1% is incomprehensible and a retrograde step, especially when it comes just four months after the launch of the latest ten year Government strategy entitled Sharing the Vision. The PNA has always been a strong advocate for the implementation of Government policy on mental health, and has endorsed and supported the move from residential services to comprehensive patient centred community based services.
It is important to address the matter of policy from a sequential perspective, noting that Sharing the Vision builds on its predecessor, A Vision for Change. In this regard the committee may note that the recommendations of A Vision for Change have never been achieved in relation to the development of services. The definitive PNA and RCSI 2016 review of A Vision for Change concluded that only 30% of the promised community developments were delivered, yet 76% of the beds were removed from the services. We continue to have the third lowest number of psychiatric beds per 100,000 population in the EU, with only Cyprus and Italy having fewer. Some of the knock-on effects of this include: 120% bed capacity in some acute admission units; 12.3% of acute beds being occupied by patients who are resident for six months or longer; and a high proportion of people with mental illness in prison, of which the recent report by the European Committee for the Prevention of Torture was highly critical.
It is 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 national policy. Indeed, in its February report, Access to Acute Mental Health Beds in Ireland, the Mental Health Commission cites "an almost total absence of crisis houses, intensive care high support hostels, rehabilitation high support hostels and specialist rehabilitation units in each mental health area". At our conference last month Mr. John Farrelly, CEO of the Mental Health Commission, noted that "creating a proper evidence based integrated community health care system must be the primary goal of our generation".
We also have a responsibility for future generations, which leads me to highlight the deficits and under-investment in the child and adolescent mental health services, CAMHS. These inadequacies have severe consequences for service users, families and staff throughout the country. Once again, A Vision for Change recommended one day hospital per 300,000 population, which currently leaves a shortfall of 12 day hospitals nationally. It also recommended 100 beds nationally, of which only 74 are operational. The multidisciplinary teams remain inadequately resourced and the present waiting list for CAMHS is 2,200. To address the inadequacies regarding the delivery of CAMHS, the following are required: full provision of CAMHS day hospitals; full provision of the 100 recommended beds; and the provision of small regional, units. Fully resourced multidisciplinary teams and pathways of support need to be examined, such as 24-7 crisis support and the provision of a network mental health nurse at primary care level. We also endorse the proposal of the Youth Mental Health Task Force report cited in Sharing the Vision, which recommends the age range for eligibility for CAMHS be increased to 25 years of age in order to improve continuity of care and ease the transition.
Having regard to specialist training, some members may be aware that the 1998 Commission on Nursing expressed the view that we should have a distinct pre-registration education programme for psychiatric nursing. Today, psychiatric nursing in Ireland is an internationally regarded module-based degree programme. Psychiatric nursing is continuously adapting to policy and service user needs, which are underpinned in mental health legislation. This programme provides an excellent foundation for the complexities in the nursing role.
In the present climate, fresh ideas are emerging that provide a vocabulary for the need to recognise the community dimension to mental health, and the mental health dimension to public health. Nurses encounter persons with mental health problems and mental illnesses in all areas of healthcare, such as people with depression after surgery, drug induced psychosis, or a person suffering from a crisis with post-traumatic stress symptoms. Covid-19 presents additional challenges, including fear of the virus itself, collective grief, prolonged physical distancing and associated isolation, which compound the impact on our psyches. A critical part of the psychiatric or mental health nurse’s role is helping people recognise mental disorders, seeking assistance with the same urgency as any other health condition and making recovery the expectation. While there will always be a requirement to provide acute inpatient facilities, the future of psychiatric or mental health nursing has to concern itself with leading the development and integration of mental health in primary care.
The primary focus for mental health, both within Sláintecare and Sharing the Vision, is the need to integrate services in a dynamic and robust fashion. This integration is at present missing between mental health services and primary care. To bridge the gaps between these services we assert the need for a mental health care network nurse, which would facilitate the integration of care in the community while working within the primary care team. This will allow for a more seamless delivery of designated care across each multidisciplinary team and contribute to the facilitation of a lifespan or chronological approach across all locations of care.
In the context of reframing mental health with the associated priorities of our national health policies, A Vision for Change 2006, Sharing the Vision 2020 and Sláintecare, we need to emphasise the care gap for people affected by mental disorders, the quality gap, which is the quality of care received by people with mental disorders, and the prevention gap, that is, the coverage of interventions that target the risk factors for mental disorders. Having regard to the that, I will leave the committee with these key messages. Current research suggests that by the age of 13, one in three young children in Ireland is likely to have experienced some type of mental disorder. By the age of 24 that rate will have increased to over one in two. Clearly, time is not on our side to address this crisis. The mental health share of the budget has to be at a minimum the percentage recommended in Sláintecare, which is 10%. Notwithstanding that, all evidence shows that mental health must have parity of esteem with physical healthcare. Psychiatric or mental health nursing is intrinsic to an enhanced, comprehensive and community-based mental health service. Collaboration, human interaction and the working alliance between nurse and service user are integral to a service that offers respect, compassion, equity and hope.