Behind the walls of medication
Despite some progress on closing our outdated mental health facilities, a lack of resources means medication rather than community care is replacing the institutional wall.Mary Raftery’s Behind the Walls series exposed Ireland’s unique and excessive rates of institutionalisation in asylums in the 1950s and 1960s. Aired in 2011, months before she died, it also highlighted that hundreds of adults were still in these institutions, often in crowded wards, with no privacy and insufficient care to assist recovery or any chance of independent living.
Government policy for decades, reinforced in the 2006 national mental health policy A Vision for Change, is for people with acute and or enduring mental illness to be cared for in the community. Instead of “warehousing” them in institutions, the policy is to prevent people going into psychiatric hospital, to minimise lengths of stay there and for most people to live and receive care in the community.
There has been progress in achieving this; a lot fewer people now live long term in psychiatric hospitals. Most are living in supported community houses. Even since 2011, some of the oldest asylums have been closed. In May of this year, the last 33 residents in St Brendan’s Hospital moved to the new Phoenix Care Centre on the same grounds in Grangegorman.
Figures from the Health Research Board show that, in 2011, the most recent year currently available, there were just over 200 people in in-patient psychiatric care for more than one year and 86 people remaining as in-patients for five years or more. These figures reflect the policy of increasingly caring for people in the community.
Other research by Trinity College Dublin reveals a failure on behalf of the State to transfer either money or staff from hospitals to the community. Analysis of the HSE mental health budget and staff show not one percentage point change in either between 2008 and 2012. So while patients are being cared for in the community, the resources needed to care for them has not followed.
Analysis of the overall health budget shows a disproportionate cut to mental health services during the economic crisis. In 2008, more than €1 billion was allocated to mental health. For 2013, it is €733 million, representing just 5 per cent of total health spend, well below the 8.2 per cent recommended in A Vision for Change.
The budget cut is reflected in staffing levels. In March 2009, there were 9,997 HSE mental health staff. By June of this year, the figure was 8 per cent less at 9,138, despite an 8 per cent population growth since the publication of A Vision for Change and persistent announcements of “new” mental health staff by Minister of State for Mental Health, Ms Kathleen Lynch, during the last two years.
Staffing is crucial to mental healthcare. A lot of promoting good mental health and enabling recovery is about support, counselling and talk therapies. These are labour intensive. Community mental health teams are meant to be made up of a wide range of professionals including occupational therapy, social workers and counsellors, as well as more traditional medical professions of doctors and nurses.
The 900 new posts that were announced in 2011 and 2012 are meant to fill these much needed allied health professional posts. However, none were put in place until December 2012. At present, less than half of these posts are filled and many are being filled as temporary positions.
Continuity of care is also essential in mental health and this is made very difficult by temporary posts and the non-replacement of existing posts.
But ultimately it all comes down to numbers. Despite the new posts, there are more people leaving mental health services than coming in and as a result the teams are staffed at less than half the level recommended in A Vision for Change.
There is a huge geographical disparity when it comes to adult community mental health services. A patient living in Cavan or Monaghan should be very well provided for, whereas down the road in Meath there is a skeletal community mental health team.
The impact of this postcode lottery is hard to quantify as there is little useful data on referrals, not to mind outcomes. The Inspector of Mental Health Services has said it results in over medicalisation of mental healthcare and reduces the chance of recovery. People who run the services say it means people are more likely to end up in hospital and remain there for too long. People who use the services talk about being left on medication with no review of drugs and no, or insufficient, support to recover or live independently. Prof Ivor Browne talks about medication being the new institutions, where people are locked up on drugs instead of behind walls in the absence of comprehensive, holistic mental healthcare.
This column draws on work done by Sara Burke with the support of the Mary Raftery Journalism Fund. Podcasts are available at http://maryrafteryfund.ie/sara-burke/and http://www.rte.ie/radio1/drivetime/podcasts/.