Senator Mullen Calls for the Government to Implement Vision for Change by 2016

Statements on Medical Health Vision for Change

When A Vision for Change was published in January 2006 it was greeted by near universal approval. No one doubted that mental health services in Ireland badly needed a substantial overhaul and the Vision for Change document was seen as containing a credible blueprint for that do happen by 2016. Since publication the credibility of the proposed mental health services blueprint has remained a constant. What has changed, unfortunately, is the optimism which first greeted its publication. Scepticism as to the implementation of A Vision for Change is largely down to the lack of political will and failure to commit government finances to the project, meaning that many of its proposals and recommendations remain in limbo. The Government should publicly and unequivocally commit to fully implementing A Vision for Change no later than 2016 – the original due date.

A Vision for Change proposed a new model of mental health service provision centred on a community-based, specialist service for people with mental illness. Ease of access was to be a hallmark of a system where the involvement of service users, their families and their carers would be encouraged and facilitated, in both development of services and their delivery. The establishment of highly professional Community Mental Health Teams (CMHT’s) to offer multi-disciplinary home-based and outreach care would signal a much needed shift away from the old “battery hen” paradigm of mental health services. The new model would free formal links between mental health services, primary care services and voluntary groups. It would operate along updated geo-demographic trends and within catchment areas of between 250,000 and 400,000. To make room for these changes Vision for Change recommended the closure of the existing mental hospitals with a view to selling off these capital assets to fund the implementation of the recommendations.

It sounded fantastic. But bureaucracy and lethargy stymied momentum. Three successive reports in 2007, 2008 and 2009 by the Independent Monitoring Group, established to monitor progress in implementing A Vision for Change, criticised the HSE for its delay in implementing key recommendations of the document. The first report took issue with “the lack of a systematic approach to implementation and the lack of clarity in responsibility for implementation in the HSE.” The lack of real leadership and of comprehensive implementation plan was noted in all three reports. Though the 2009 report recognised that progress was being made with regard to the provision of child and adolescent services, and also engagement with service users and mental health information systems, it did warn “that the recommendations of A Vision for Change cannot be implemented effectively without a National Mental Health Service Directorate.

The absence of a dedicated leader at senior, national level has impeded progress in the implementation of A Vision for Change and may be contributing to continuing poor facilities and standards of care in some areas and an inconsistent approach to embedding the recovery ethos in services.” Two of the key tenets of A Vision for Change have not yet been properly addressed: catchment areas have not yet been put in place, while the resourcing of Community Mental Health Teams (CMHTs) has not been sufficiently prioritised. What adds to the disappointment is the insistence on behalf of the HSE that they have in fact released a comprehensive implementation plan. This document is however aspirational in tone and largely uncosted, ambiguous and lacking in a rigorously defined timescale.

Indeed, Siobhan Barry, co-author of a 2009 report by the College of Psychiatry  of Ireland which encompassed issues relevant to mental health services, has claimed that “[a]t the current rate of staff recruitment it will take 40 years to implement (A Vision for Change).” The report, entitled A Gloomy View, found that 53% of the services surveyed across the HSE had consistently low levels of recruitment of the promised multi-disciplinary team members, with only 16% of services receiving the resources which they had been promised. It is not as if this shortfall in resources and commitment was unforeseen. In welcoming A Vision for Change upon its publication the Irish College of Psychiatrists added the caveat, “we would be concerned that the necessary funding to drive the recommendations will not be made available over the seven years.” They pointed out that mental health services in this country have historically suffered from “an acute lack of funding.” The College further highlighted that even if all went according to plan the percentage of health monies allocated to mental health would rise from 6.8% to 8.24% - still a considerable distance off the 12-14% it recommends. The Department of Health has admitted that while from 2006-2009 the HSE was provided with €51.2m to implement A Vision for Change, €24m of this money was used to meet “overriding obligations of the HSE to live within its approved allocation.”

In 2009 the Centre for Ageing Research and Development in Ireland produced a report on the progress of A Vision for Change. While acknowledging Minister Moloney’s total commitment to the project they highlighted several areas where implementation was severely behind schedule: the selling off of old psychiatric hospitals to raise the €796m needed for the new project; the appointment of a Director for Mental Health Services in the HSE; and the establishment of CMHTs to specialise in different areas such as adult mental health, child and adolescent services, psychiatry of old age and intellectual disability.

I am not suggesting that absolutely nothing has been done to implement A Vision for Change. In 2006 there were 47 Community Child and Adolescent Mental Health Teams (CAMHS). By January 2009 this had increased to 50 teams while now there are roughly 60 teams: all told a 30% increase since 2006. Furthermore, since 2006 at least 18 Adult Community Mental Health Teams have been created. Earlier this month Minister Moloney announced that a total of 14 Victorian-era psychiatric hospitals were to be closed with a total of 1,200 patients to be transferred to the more modern community based facilities within three years. Some of these antiquated facilities were at various stages described as “inhuman” and “deplorable”. At the announcement the Minister pointed out that there had been a doubling in the number of child and adolescent beds to 30, and shorter episodes of in-patient care.

Yet it would be delusional to think that the response by the HSE to A Vision for Change this far has been anything other than piecemeal. The reality is that implementation is behind schedule, still lacking a truly comprehensive plan and relying on the sale of property to avoid the worst of the property collapse so to be an adequate source of funding. The final key recommendation of A Vision for Change was that it “should be accepted and implemented as a complete plan.” To date that has not happened. What is required is a renewed resolve on the part of the Government and the HSE in particular to honour this document. This resolve must be public and must be framed by a genuine commitment – I repeat my call on the Government to publicly commit to fully implementing A Vision for Change by its original due date of 2016.