Report of the expert group on mental health policy A Vision for Change details a comprehensive model of mental health service provision for Ireland. It

Report of the expert group on mental health policy

A Vision for Change details a comprehensive model of

mental health service provision for Ireland. It

describes a framework for building and fostering

positive mental health across the entire community

and for providing accessible, community-based,

specialist services for people with mental illness.

Report Presents

• Vision for Mental Health Services

• Plan of Action: Framework for delivery of Mental Health

Services

• Implementation of the Plan

The Vision

• Person-centred

• Multidisciplinary Community-based Teams

• Comprehensive best-practice interventions

• A recovery orientation

• Meaningful integration in community life

• Effective partnership

• Staff training and support

Values and Principles

• Values are at the heart of this policy, they

inform and underpin the service philosophy

that it proposes

Consultation process

- Foundation on which a vision for change is built

• Written submissions - 154

• Service Users Survey throughout the Mental Health Services -

369

• Two consultation seminars in Dublin and Limerick – 200

stakeholders attended

• Irish Advocacy Network in-depth survey of 100 service users

• 19 Advisory sub groups - +100

Expert Group

• was established in August 2003;

• consisted of 18 widely experienced people;

• a wide range of knowledge and a balance of views on many issues;

• drawn from the medical, nursing and paramedical professions;

• health service managers, voluntary bodies and mental health service users.

The Expert Group

• Professor Joyce O’Connor, President, National College of Ireland (Chair)

• Dr. Tony Bates, Principal Psychologist, St. James’s Hospital, Dublin• Mr. Edward Boyne, Psychotherapist, Dublin & Galway• Mr. Noel Brett, Former Programme Manager for Mental Health and

Older People, Western Health Board• Dr. Justin Brophy, Consultant Psychiatrist, Wicklow Mental Health

Service• Mr. Brendan Byrne, Director of Nursing, Carlow Mental Health Service• Ms. Kathy Eastwood, Senior Social Worker, West Galway Mental

Health Services• Ms. Mary Groeger, Occupational Therapy Manager, North Cork,

Mental Health Services, Southern Health Board• Dr. Colette Halpin, Consultant Child and Adolescent Psychiatrist,

Midland Health Board

The Expert Group

• Mr. Michael Hughes, Director of Nursing, Wicklow Mental Health Service and former Assistant to the Inspector of Mental Hospitals

• Dr. Mary Kelly, Consultant Psychiatrist Intellectual Disability, Daughters of Charity/Brothers of Charity, Limerick

• Dr. Terry Lynch, GP and Psychotherapist, Limerick• Mr. Paddy McGowan, Former Director, Irish Advocacy Network• Ms. Bairbre nic Aongusa, Principal, Mental Health Division,

Department of Health and Children• Dr. John Owens, Chairman, Mental Health Commission• Mr. John Saunders, Director, Schizophrenia Ireland• Dr. Dermot Walsh, Former Inspector of Mental Hospitals and

Mental Health Research Division, Health Research Board• Mr. Cormac Walsh, Former Mental Health Nursing Advisor,

Department of Health and Children

The Expert Group

The expert group was supported in its work by:

• Dr. Fiona Keogh, Research Consultant

• Marie Cuddy – Secretary to the Group

• Ailish Corr - Mental Health Division, Dept. of Health and

Children

• Joan Byrne – Mental Health Division, Dept. of Health and

Children

Terms of Reference

• To prepare a comprehensive mental health policy framework for the next ten years;

• To recommend how the services might best be organised and delivered; and

• To indicate the potential cost of the recommendations.

A framework for mental health service provision

The Community Mental Health Team (CMHT)

• The cornerstone of mental health service delivery should be an enhanced multidisciplinary Community Mental Health Team (CMHT), which incorporates a shared governance model, and delivers best-practice community-based care to serve the needs of children, adults and older people.

Characteristics of the Community Mental Health Team :• Multidisciplinary

• Composition appropriate to needs/social

circumstances of sector population

• Home-based care

• Assertive outreach

• Comprehensive range of interventions

• Needs-based care plans

• Shared governance

• Involvement of users, families and

community resources

Framework for MHS delivery

• First proposal is to increase the size of catchment areas from the current ~100,000 population size to 200,000 to 400,000.

• This is to ensure the full range of MH services can be provided to a defined population, wide range of MH specialities available, more choice for service users.

• Total 12 or 13 MH catchment areas in the country

Framework for MHS deliveryOne catchment area: Proposed structure

• 6 Adult mental health teams -1 per 50,000• 3 Rehab and recovery teams -1 per 100,000• 6 Child & adolescent teams -2 per 100,000• 3 MHS for older people -1 per 100,000• 2 Adult mental health for ID -1 per 150,000• 1 Child & adolescent MH for ID- 1 per 300,000• 1 Substance misuse MHS per 300,000• 1 Adult liaison MHS per 300,000• 1 Child and adolescent liaison MHS per

300,000

Specialties

• Child and adolescent mental health services

• General adult mental health services

• Rehabilitation and recovery mental health services for

people with severe and enduring mental illness

• Mental health services for older people

• Mental health services for people with intellectual disability

• Forensic Mental Health Services

• Mental Health Services for Homeless People

• Mental Health Services for people with co-morbid severe

mental illness and substance abuse problems

• Mental Health Services for people with eating disorders

• Liaison Mental Health Services

• Neuropsychiatry Services

• Suicide Prevention

• People with borderline personality disorder

Child and adolescent mental health services

• 2 multidisciplinary CMHT per 100,000 population

• Based in community MH centres

• Providing MDT to ages 0-18 years and covering the day hospital in each catchment area

• 1 additional MDT in each 300,000 catchment area to provide paediatric liaison MHS

• 1 day hospital per 300,000

• 100 in patient beds nationally for 0-18 years, in five units of 20 beds each.

General adult mental health services• 1 multidisciplinary CMHT per 50,000 population• 2 Consultant psychiatrists per team• Based in community MH centres• 1 acute in patient unit per 300,000 with 35

beds• 1 crisis house per 300,000 with 10 places• 4 Intensive care rehabilitation units (ICRU); one

in each of 4 HSE regions, with 30 beds• 2 high support intensive care residences of 10

places to each HSE region (80 places nationally)

• 2 early intervention services to be provided on pilot basis.

Recovery and rehabilitation mental health services


• Based in community Mental Health centres

• 3 community residential units per 300,000 with 10 places

• 1-2 day centres per 300,000 with total of 30 places

• 1 service user-provided support centre/ social club per 100,000.

Mental health services for older people



• Providing MDT assessment and treatment with emphasis on home and community treatment.

• 8 in patient beds in the general acute in patient unit

• 1 unit per 300,000 with 30 places for continuing care/ CB

• 1 day hospital per 300,000 with 25 places specifically for MHS for older people +/- sessional / mobile day hospitals

Mental health services for people with intellectual disability

• 2 multidisciplinary CMHT for adults with ID per 300,000 population

• 1 multidisciplinary CMHT for children & adolescents with ID per 300,000 population


• Providing MDT assessment and treatment with emphasis on home assessment and treatment if possible in the family home or at a residence provided by an ID service.


• 5 acute beds in the general acute inpatient unit

• 1 day hospital per 300,000 with 10 places

• 10 rehabilitation beds in intellectual disability residential centres which have approved centre status.

Forensic mental health services

• 1 multidisciplinary CMHT per HSE region• Based in community MH centres• Providing court diversion and liaison and

support for local Gardai and other MHS in the region.

• 2 multidisciplinary CMHT for children & adolescents nationally- one to be based in a ten bed secure unit for children& adolescents and one to be a community based resource

• One national ID Forensic MH team and national secure unit to provide secure care for those with ID.

• The CMH should be replaced or remodelled to allow it to provide care and treatment in a modern, up to date humane setting, and the capacity of the CMH should be maximised. (current number=74)

Mental health services for the homeless

• 2 multidisciplinary CMHTs for Dublin


• Providing assessment and treatment on an outreach basis

• 1 crisis house of 10 beds for those not requiring admission to acute psychiatric beds

• Use of psychiatric beds from overall Dublin complement.

• 1 day hospital and 2 day centres

Mental health services for people with co-morbid severe mental illness and substance abuse problems

• 1 multidisciplinary CMHT per 300,000 catchment area

• 2 existing consultants who work with adolescents with substance misuse and mental illness should have full MDTS, 2 additional teams should be set up giving 1 team per 1 million

Mental health services for people with eating disorders

• 1 multidisciplinary CMHT per HSE region (4 in total nationally)

• To work closely with adult MHS and primary care

• 6 beds in regional in patient units to be available to teams

• A national tertiary referral centre for Children and adolescents with a full MDT should be developed.

Liaison mental health services

• 1 multidisciplinary liaison team per regional hospital (roughly one per 300,000-13 in total nationally)

• 2 multidisciplinary teams providing a national neuropsychiatry service.

• 1 national neuropsychiatry unit with 6-10 beds

• 1 perinatal mental health resource to be

provided in a national maternity hospital

Inpatient care

• 1 acute in-patient unit per catchment area with 50 beds to be used as follows:

• (Should be located in major/ regional hospital, while taking into account existing units, can be 2 x 25 beds)

• 35 beds for general adult MHS including 6 close observation beds

• 8 beds for MHS for older people• 5 beds for MHS for people with ID

(subunit)

• 2 beds for eating disorders

Inpatient care

• 1 crisis house per 300,000 with 10 places

• 4 Intensive care rehabilitation units (ICRU); one in each of 4 HSE regions, with 30 beds

• 2 High support intensive care residences of 10 places to each HSE region (80 places nationally)

• 1 unit per 300,000 with 30 places for continuing care/ CB for mental health services for older people

Inpatient care

• 10 rehabilitation beds in intellectual disability residential centres which have approved centre status.

• 10-bed national secure unit for those with intellectual disability

• 100 in-patient beds nationally for 0-18 year olds in 5 units of 20 beds each.

• 10-bed national secure unit for children and adolescents


Mental health services for people with intellectual disability- recommendations:

1. The process of service delivery of mental health services to people with intellectual disability should be similar to that for every other citizen

2. Detailed information on the mental health of people with intellectual disability should be collected by the NIDD. This should be based on a standardised measure. Data should also be gathered by mental health services for those with intellectual disability as part of national mental health information gathering.


3. A national prevalence study of mental health problems including challenging behaviour in the Irish population with intellectual disability should be carried out to assist in service planning.

4. The promotion and maintenance of mental well-being should be an integral part of service provision within intellectual disability.


5. Mental health services for people with intellectual disability should be provided by a specialist mental health of intellectual disability (MHID) team that is catchment area-based. These services should be distinct and separate from, but closely linked to, the multidisciplinary teams in intellectual disability services who provide a health and social care service for people with intellectual disability.


6. The multidisciplinary MHID teams should be provided on the basis of two per 300,000 population for adults with intellectual disability.

7. One MHID team per 300,000 population should be provided for children and adolescents with intellectual disability.

8. All people with an intellectual disability should be registered with a GP and both intellectual disability services and MHId teams should liaise with GPs regarding mental health care.


9. A spectrum of facilities should be in place to provide a flexible continuum of care based on need. This should include day hospital places, respite places, and acute, assessment and rehabilitation beds/places. A range of interventions and therapies should be available within these settings.


10. In order to ensure close integration, referral policies should reflect the needs of individuals with intellectual disability living at home with their family, GPs, the generic intellectual disability service providers, the MHId team and other mental health teams such as adult and child and adolescent mental health teams.


11. A national forensic unit should be provided for specialist residential care for low mild, and moderate range of intellectual disability. This unit should have ten beds and be staffed by a multidisciplinary MHID team.

Core MDT to deliver mental health services to people with intellectual disability

• one consultant psychiatrist• one doctor in training• 2 psychologists• 2 clinical nurse specialists (CNS) and

registered nurses with specialist training

• 2 social workers• 1 occupational therapist• administrative support staff• each team should have a clearly

identified clinical leader, • team coordinator and practice

manager.

Needs of Specific Groups

• Mild ID- one third will need specialist service for MH needs and two thirds will avail of generic MHS

• Autism- dependent on need where service provided.

• Older people/ dementia- either MHId in liaison with older persons or mental health team for older persons in liaison with MHId.

Needs of Specific Groups

• Forensic MHID- None presently.• Proposal that national forensic unit be

provided for specialist residential care for low mild and moderate range of intellectual disability.

• Should have ten beds• Be staffed by a multidisciplinary MHId team

• Needs assessment recommended for those who are in ‘out of state placements’ to see if they can be accommodated in Ireland.

Other issues highlighted

• Capacity and Consent• Seclusion and restraint• Mental Health Act 2001and the need for

approved centres which are inspected regularly

• Need for enactment of capacity legislation.

Implementation:

Implementation

Mental Health Catchment Areas should be established with populations of between 250,000 and 400,000 with realigned catchment boundaries to take into account current social and demographic realities. These catchment areas should be coterminous with local health office areas and the new regional health areas. They should take into account the location of acute psychiatric in-patient units in general hospitals.

Implementation

Substantial upgrading of information technology systems should occur to enable the planning, implementation and evaluation of service activity.

National Mental Health Service Directorate should be established, which includes senior professional managers, senior clinicians and a service user. The new National Mental Health Service Directorate should act as an advisory group and be closely linked with the management of the Primary and Continuing Community Care Division of the Health Service Executive.

Implementation

Multidisciplinary Mental Health Catchment Area Management Teams should be established. These teams should include both professional managers and clinical professionals along with a trained service user and should be accountable to the National Care Group Manager and the National Mental Health Service Executive.

Community Mental Health Teams should self-manage through the provision of a team coordinator, team leader and team practice manager.

Implementation

Community Mental Health Teams should be responsible or developing costed service plans and should be accountable for their implementation.

A management and organisation structure of National Mental Health Service Directorate, multidisciplinary Mental Health Catchment Area Management Team and local, self-managing CMHTs should be put in place.

Implementation

Mental Health Catchment Area Management Teams should facilitate the full integration of mental health services with other community care area programmes. This should include the maximum involvement with self-help and voluntary groups together with relevant local authority services.

Community Mental Health Teams and Primary Care Teams should put in place standing committees to facilitate better integration of the services and guide models of shared care.

Investment in the Future: Financing the Mental Health Services

• Substantial Extra Funding is Required to finance

this new Mental Health Policy.

• A programme of capital and non-capital investment in mental health services as recommended in this policy and adjusted in line with inflation should be implemented in a phased way over the next seven to ten years, in parallel with the reorganisation of mental health services.

Investment in the Future: Financing the Mental Health Services• 1,803 new posts to manage proposed CMH

teams will require non-capital investment of € 151 million per annum in addition to existing funding.

• Need for capital funding for Modular Community Mental Health Centres with one unit of accommodation per community mental health team- 311 units required - 497.6 million.

• Mental Health Crisis houses- 13 units required- 20.8 million

Investment in the Future: Financing the Mental Health Services

• Later Life Challenging Behaviour continuing care beds- 360 beds required- 64.8 million

• Day hospitals- 27 required at 48.6 million• User-run Day Support Centres or equivalent-

39 required at 46.8 million• Staffed hostel places- 650 places- 91 million• Intensive Care Rehabilitation unit places- 120

places-24 million

• No new funding for acute beds is requested as there are sufficient in the system.

• TOTAL 796.5 million

Transition and Transformation: Making it Happen- Managing Change

• The National Mental Health Service

Directorate, in conjunction with the Health

Service Executive, should put in place

advisory, facilitatory and support capacity to

assist the change process.

• The first step that should be taken is the re-organisation and restructuring of mental health services. This should involve:– The appointment of the National Mental

Health Service Directorate

– The reorganisation of Mental Health Catchment Areas in to the larger catchments proposed in this policy

– The appointment of Local Catchment Area Management Teams in these catchment areas.

First Steps

First Steps

• A plan to bring about the closure of all

psychiatric hospitals should be drawn up and

implemented. The resources released by

these closures should be protected for re-

investment in the mental health service.

First Steps

• Allocation of beds for every catchment area for

people needing admission.

• Implementation of a crisis intervention plan

that will reduce the need for early admission to

psychiatric hospitals.

Making it Happen

• An implementation review committee should

be established to oversee the implementation

of this policy and publish a status report twice

a year.

Documents

Report of the expert group on mental health policy A Vision for Change details a comprehensive model of mental health service provision for Ireland. It