The Mental Health Commission welcomes the invitation to discuss deficiencies in mental health services. However, as the organisation with statutory responsibility to regulate, promote, encourage and foster the maintenance of high standards and good practice in the delivery of mental health services, we are disappointed that it has taken so long for this opportunity to meet with the committee.
The principal function of the commission is to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centres under the Act.
Recently, the Assisted Decision-Making (Capacity) Act 2015 provided for the establishment of the decision support service, DSS, within the commission as part of a new legal framework that reforms the law relating to the treatment of people who require or who may shortly require assistance in exercising their decision- making capacity, therefore, it expands the functions of the commission beyond mental health. The DSS forms a key part of the new legal framework for both the provision of information and the regulation of the diverse forms of assisted decision making arrangements.
In the past couple of years, the commission has continued to emphasise the human rights of mental health service users across all of its core functions. All service users should be involved in decisions about their care and be supported to exercise their legal capacity. Mental health service users should not be subjected to undue restrictions and should have access to basic general health services. Residents should have access to adequate living standards in inpatient settings where their privacy and dignity is respected at all times. These basic rights should be assumed in any modern mental health service and is a minimum we would expect for ourselves, our family and our loved ones. Furthermore, people who use mental health services need to be afforded the same rights as those who use general health services.
The commission registers, inspects and regulates mental health services delivered through approved centres. Over many years of activity, a number of core issues have emerged. These include the inappropriate admission of children into adult mental health inpatient services; inadequate staffing and variable funding in community child and adolescent mental health services, leading to unacceptable waiting times and forcing young people into emergency services; the continuing inability of some services to put in place an individualised care plan and therapeutic programme, which are the corner stones of a recovery focused, person centred service as per our national policy; the widespread use of restrictive practices such as seclusion and physical restraint as a normalised behaviour in services, which lack sufficient numbers of staff and-or appropriately trained staff; the fundamental and careless lack of attention to basic issues such as dirty and dilapidated premises, which do not ensure adequate privacy and where there has been a disappointing drop in compliance from already low levels; and the provision of services to vulnerable people with long-term mental illness who are accommodated in 24-hour community residences that are not subject to regulatory oversight.
In the view of the commission there is a glaring and inconsistent pattern of standards in service provision. The lack of any real progress and commitment on these matters undermines the fundamental human rights of those people who use mental healthcare services.
Due to a failure of Government to update the statutory powers of the commission, more people are now using unregulated mental healthcare services, that is, services outside the approved centres, which leads to a significant risk of neglect and abusive incidents occurring.
The commission is calling on the Government, with the Health Service Executive as the statutory provider of services, to initiate a major transformation programme to deal with the service issues highlighted by the commission.
Reform of the 2001 Mental Health Act is urgently needed and the commission urges the Department of Health to take heed of our commentary in this area to ensure that the provision and regulation of a modern mental health service in Ireland is the norm. If that does not happen, Ireland will continue to provide a level of unsafe and substandard services which are not aligned to best practice and, as stated, breach the fundamental rights of vulnerable people who require such services.
The commission notes the continued endeavours of the Government, the statutory and independent service providers and the voluntary sector in the implementation of A Vision for Change. The commission has repeatedly indicated that much needs to be done to ensure the delivery of consistent, timely and high-quality services in all geographic regions and across the full range of clinical programmes and age groups.
The commission is aware of a review group established to consider progress in the implementation of A Vision for Change. However, the Mental Health Commission has not received any formal communication from the Department of Health in this matter. This is a grave cause of concern, given the statutory role of the Mental Health Commission in overseeing quality in mental health care services.
The commission welcomes the almost annual €35 million budget allocation for spending on additional mental health care services. The commission is cognisant that the current level of expenditure on mental health as a proportion of overall health expenditure is still less than the 8.24% target envisaged in A Vision for Change.
The commission is also conscious of the continued difficulties in maintaining and increasing staffing levels in mental health care services. From its inspections, it is aware that this has a significant effect on the quality and quantity of services that can be provided. Given the labour-intensive nature of mental health care, it is imperative that this matter is addressed urgently to achieve full staffing across the mental health care services.
Since its establishment, the commission has seen significant changes in the provision of services, but challenges remain in the delivery of high quality recovery-oriented services. Although the commission believes that staff understand the concept of recovery, it is not evident that this translates into recovery-focused care, particularly in the development of individual care plans. It is concerning that while compliance has increased, just a small minority of approved centres had individual care plans that were recovery-oriented, with strong service user involvement and multi-disciplinary inputs.
The commission is of the view that there needs to be an emphasis on changing the corporate culture in the mental health services to bring about the required systematic shift towards recovery in service provision. In this regard, it will continue to focus on the need for individualised, recovery-oriented services that place service users and families at the centre of activity.
In respect of involuntary admissions, there were 2,337 involuntary admissions in 2017 compared to 2,414 in 2016, representing a slight decrease. We are pleased to note that over many years there has been a decline in the number of families involved in referring people to involuntary detention, and this is welcome. Their involvement still stands at 44% and we hope that in the future this figure will be driven down further.
In respect of community residences, the commission continues to have concerns about 24-hour staffed community residences, which are providing care to a large cohort of vulnerable people with long-term mental illness. The residences have been found to be accommodating too many people, to have poor physical infrastructure, to be institutional in nature and to lack individual care plans. A major issue is that the residences are not regulated. Although the Mental Health Act permits the inspector to visit and inspect "any other premises where mental health services are being provided", community residences are not subject to regulation by the commission.
We are currently undertaking a three-year programme and the inspection of 43 residences in 2017 has already been published. Once again, this report highlighted glaring issues around the size of the residences, the limitation of staffing, the absence of privacy and space, the poor repair of buildings and the degree of institutional care provided in these homes.
Many of those living in 24-hour residences are ex-patients of the large institutions closed over the past 20 years. This is a vulnerable population, and the emerging patterns from the inspections is that they are a forgotten group of people who are living their lives in unsatisfactory conditions.
It is recommended in the Report of the Expert Group on the Review of the Mental Health Act 2001 that community services should be registered and inspected. The commission is of the view that the regulation of 24-hour staffed community residences must be prioritised as a matter of urgency.
A most unsatisfactory situation still prevails, whereby children are being admitted to adult inpatient units. There were 82 such admissions to 19 units in 2017 compared to 68 in 2016. The admission of any child to an adult service is unsatisfactory. A contributory factor to the continued admission of children to adult units is a shortage of operational beds in dedicated child units. A significant influence is the inability of child and adolescent mental health service, CAMHS, units to admit children after hours thereby forcing admissions to adult care services. This trend has been prevalent for many years and is not only an unsatisfactory situation for the child and his or her family but a clear breach of the human rights and dignity of the child. This matter has been a concern to the commission for many years. It needs to be urgently addressed by the Government, the Department of Health and the Health Service Executive, as the main provider.
In 2017, the commission has also highlighted serious concerns in community child and adolescent mental health teams. The inspector found these teams to be inadequately staffed and to have considerable variation in funding depending on their geographic region. There was also a notable variation in waiting lists for CAMHS referrals and in the provision of emergency cover. While CAMHS should be focused on children and young adults with severe mental illness, the staffing deficits in primary care have meant that children and young adults with mild and moderate mental illness are also reliant on CAMHS services.
In conclusion, the commission is concerned that there are serious human rights issues to be addressed in relation to the admission of children to adult services and the shortage of operational beds for young service users. Additionally, the commission is concerned about the long waiting times for those children referred to child and adolescent mental health services. It is particularly concerned about the 1,300 vulnerable people with long-term mental illness who are accommodated in 24-hour community residences that are not subject to regulatory oversight.
Fundamentals in in-patient settings, such as individual care plans, privacy, the provision of therapeutic activities and staff training are also areas that require urgent attention. There continues to be fundamental shortfalls in compliance with basic hygiene, physical repair and space restrictions within many services.
The 2017 inspections have once again highlighted the inappropriate use of seclusion and physical restraint in services which have become in many instances the normalised environment.
As the committee will be aware, there continues to be a chronic shortage of staff and appropriately trained staff. Notwithstanding this, the commission is acutely aware that the front-line staff presently operating services are highly motivated and working under extreme pressure to meet the demands made on the service.
The commission is aware of other issues of access to approved centres which warrant attention. These include, for example, policies of having to access mental health care services via accident and emergency units, which do not always have appropriately trained mental health staff, and difficulties in gaining admission to approved centres, as well as perceived early discharges.
Much work remains to be done to change service culture and to refocus on the full delivery of A Vision for Change. Services must be accessible, comprehensive, responsive and timely. Now more than ever, it is necessary to address systemic issues that hamper the delivery of services and the development of new, more appropriate, services.
Reform of the Mental Health Act 2001 is now a matter of urgency as a significant number of people are now using unregulated mental health care services, both day and residential. This situation dramatically increases the risk of abusive or neglectful incidents occurring.
The commission is concerned that over the past five years there has been a consistent pattern in the operation of mental health services. Year-on-year similar issues such as individual care plans, the admission of children into adult units as well as issues of compliance with regulations, and privacy and medication issues, continue to be highlighted in inspection reports. This continuing trend is worrying and indicates for the commission a lack of interest and motivation by both Government and services providers to make meaningful change. The commission is strongly of the view that there is apparently little heed given to the commentary of the commission by the Department of Health or Health Service Executive.
Nonetheless, the commission will continue to work in supporting the rights of individuals and families who use mental health services and to seek to ensure that the service providers provide the highest quality of service provision in line with best practice, and to which they are entitled as a basic human right.