Transcript Document

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
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Vision for Mental Health Services
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Plan of Action: Framework for delivery of Mental Health
Services
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Implementation of the Plan
The Vision
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Person-centred
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Multidisciplinary Community-based Teams
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Comprehensive best-practice interventions
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A recovery orientation
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Meaningful integration in community life
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Effective partnership
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Staff training and support
Values and Principles
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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
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Written submissions - 154
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Service Users Survey throughout the Mental Health Services 369
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Two consultation seminars in Dublin and Limerick – 200
stakeholders attended
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Irish Advocacy Network in-depth survey of 100 service users
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19 Advisory sub groups - +100
Expert Group
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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
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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
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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:
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Dr. Fiona Keogh, Research Consultant
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Marie Cuddy – Secretary to the Group
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Ailish Corr - Mental Health Division, Dept. of Health and
Children
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Joan Byrne – Mental Health Division, Dept. of Health and
Children
Terms of Reference
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To prepare a comprehensive mental health
policy framework for the next ten years;
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To recommend how the services might best be
organised and delivered; and
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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
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First proposal is to increase the size of
catchment areas from the current ~100,000
population size to 200,000 to 400,000.
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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.
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Total 12 or 13 MH catchment areas in the
country
Framework for MHS
delivery
One catchment area: Proposed structure
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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
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Child and adolescent mental health services
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General adult mental health services
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Rehabilitation and recovery mental health services for
people with severe and enduring mental illness
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Mental health services for older people
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Mental health services for people with intellectual
disability
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Forensic Mental Health Services
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Mental Health Services for Homeless People
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Mental Health Services for people with co-morbid severe
mental illness and substance abuse problems
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Mental Health Services for people with eating disorders
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Liaison Mental Health Services
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Neuropsychiatry Services
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Suicide Prevention
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People with borderline personality disorder
Child and adolescent
mental health services
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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
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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
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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.
Mental health services for
older people
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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
Mental health services for
people with intellectual
disability
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2 multidisciplinary CMHT for adults with ID per
300,000 population
1 multidisciplinary CMHT for children &
adolescents with ID per 300,000 population
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Based in community MH centres
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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.
Mental health services for
people with intellectual
disability
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5 acute beds in the general acute inpatient unit
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1 day hospital per 300,000 with 10 places
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10 rehabilitation beds in intellectual disability
residential centres which have approved centre
status.
Forensic mental health
services
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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
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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
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
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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
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1 perinatal mental health resource to be
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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)
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2 beds for eating disorders
Inpatient care
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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
Mental health services for
people with intellectual
disabilityrecommendations:
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.
Mental health services for
people with intellectual
disabilityrecommendations:
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 wellbeing should be an integral part of service
provision within intellectual disability.
Mental health services for
people with intellectual
disabilityrecommendations:
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.
Mental health services for
people with intellectual
disabilityrecommendations:
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.
Mental health services for
people with intellectual
disabilityrecommendations:
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.
Mental health services for
people with intellectual
disabilityrecommendations:
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.
Mental health services for
people with intellectual
disabilityrecommendations:
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
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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
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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
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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
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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 selfmanage 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, selfmanaging 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
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Substantial Extra Funding is Required to finance
this new Mental Health Policy.
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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
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1,803 new posts to manage proposed CMH
teams will require non-capital investment of € 151
million per annum in addition to existing
funding.
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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.
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Mental Health Crisis houses- 13 units required20.8 million
Investment in the Future:
Financing the Mental
Health Services
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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 equivalent39 required at 46.8 million
Staffed hostel places- 650 places- 91 million
Intensive Care Rehabilitation unit places- 120
places-24 million
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No new funding for acute beds is requested as
there are sufficient in the system.
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TOTAL 796.5 million
Transition and Transformation:
Making it Happen
- Managing Change
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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.
First Steps
• The first step that should be taken is the reorganisation 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
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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
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Allocation of beds for every catchment area for
people needing admission.
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Implementation of a crisis intervention plan that
will reduce the need for early admission to
psychiatric hospitals.
Making it Happen
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An implementation review committee should
be established to oversee the implementation
of this policy and publish a status report twice
a year.