Report of the expert group on mental health policy

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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.

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Report Presents

• Vision for Mental Health Services
• Plan of Action Framework for delivery of Mental
  Health Services
• Implementation of the Plan

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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

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Values and Principles

• Values are at the heart of this policy, they
  inform and underpin the service philosophy that
  it proposes

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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

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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.

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The Expert Group

• Professor Joyce OConnor, President, National
  College of Ireland (Chair)
• Dr. Tony Bates, Principal Psychologist, St.
  Jamess 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

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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

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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

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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.

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A framework for mental health service provision
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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.

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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

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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

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Framework for MHS delivery

• One 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

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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

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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.

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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.

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Recovery and rehabilitation mental health services

• 1 multidisciplinary CMHT per 100,000 population
• 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.

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Mental health services for older people

• 1 multidisciplinary CMHT per 100,000 population
• Based in community MH centres
• 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

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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
• Based in community MH centres
• 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.

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Mental health services for people with
intellectual disability

• 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.

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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 number74)

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Mental health services for the homeless

• 2 multidisciplinary CMHTs for Dublin
• Based in community MH centres
• 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

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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

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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.

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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

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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

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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

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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

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Mental health services for people with
intellectual disability

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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.

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Mental health services for people with
intellectual disability- recommendations

• 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.

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Mental health services for people with
intellectual disability- recommendations

• 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.

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Mental health services for people with
intellectual disability- recommendations

• 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.

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Mental health services for people with
intellectual disability- recommendations

• 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.

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Mental health services for people with
intellectual disability- recommendations

• 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.

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Mental health services for people with
intellectual disability- recommendations

• 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.

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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.

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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.

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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.

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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.

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Implementation
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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.

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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.

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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.

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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.

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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.

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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.

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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

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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

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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.

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First Steps

• 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.

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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.

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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.

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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.

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