A long journey with many roads

Progress to date has been painfully slow on the implementation of A Vision for Change, which has at its heart, the objective of achieving a truly modern mental health care service, one which is based in the community, involves the service user and is based on recovery, writes John Saunders, Chairman Mental Health Commission.

John Saunders
John Saunders

In 2006 the Minister of State at the Department of Health and Children, Mr. Tim O’Malley launched a new policy called A Vision for Change which set out a ten year plan to shift the delivery of mental health services from old style institutional care to a more modern community based service.

Among its enlightened recommendations were the needs to position service users as partners in their own care, to involve them in every aspect of service development and delivery, and that the service, and indeed the service user, should have a focus on recovery.

On staffing, the policy outlined the need for fully staffed community based multidisciplinary CMHTs (Community Mental Health Teams) that would offer home based and assertive outreach care. To that end a multi-professional manpower plan needed to be put in place, linked to projected service plans.

There was also considerable focus on moving to a truly modern mental health care service, a shift away from the old institutionalised type of care, with a plan to bring about the closure of all mental hospitals. To achieve that a programme of capital and non-capital investment in mental health services was recommended for the duration of the policy, in parallel with the reorganisation of mental health services.

There has been, in some parts of the country, passionate protest against the closure of old hospitals and units, objections to the lack of significant investment in community mental health services.

The policy document, which was welcomed by all stakeholders as an innovative and proactive policy for the 21st century, set out that A Vision for Change should be accepted and implemented as a complete plan.

A Slow Start

The reality is that progress on the implementation of A Vision for Change to date has been painfully slow. The Independent Monitoring Group (IMG), charged with reporting on implementation of A Vision for Change, has year on year highlighted its concerns saying progress was slow, inconsistent and showed wide regional variation.

In its 4thannual report for 2009, the IMG noted that there had been little substantial progress in the implementation of A Vision for Change, citing an absence of corporate leadership, a reduction in revenue allocation and little or no attention given to service user involvement or the fundamental recovery ethos of A Vision for Change.

There were a number of other factors too leading to significant delays including: the inability to free up existing resources trapped in old fashioned mental health care services; the reduction in the expected allocation of new resources from Government; the effects of the HSE embargoes 2007-2009 and the public service moratorium from 2009; and organisational cultural factors such as work flexibility, allegiance to established care models, a reliance on bed numbers and lack of understanding of concepts such as recovery and person centeredness.

Progress in recent years

It is only in recent years that we have seen significant improvements in implementation. The creation of a centralised mental health services management team has helped to prioritise change. In addition, the increase in the number of posts in Community Mental Health Teams being filled and the closure of unfit for purpose large psychiatric hospitals, coupled with a significant reduction in the number of acute hospital beds, have had a very positive impact.

Formal processes such as residential admission (voluntary and involuntary) must be seen as last resort options.

Furthermore, in many areas locally led reorganisation and development of services are in line with A Vision for Change and actions to change organisational culture are being adopted.

However, the operational changes demanded by A Vision for Change have been painful. There has been, in some parts of the country, passionate protest against the closure of old hospitals and units, objections to the lack of significant investment in community mental health services. Concerns have also been raised about admission and discharge protocols and how services appear to be constantly responding only to crises.

In terms of the quality of service provision there are concerns mainly relating to the inconsistency of comprehensive care planning, the involvement of families and communication between primary and secondary services and little has been done since 2006 to improve mental health services for the elderly, those with intellectual disability and forensic mental health services (although plans are well advanced for the development of a new National and Regional Forensic Service). There also needs to be greater development of housing, training and employment supports for people with long term mental health needs.

The HSE’s estimate is that in 2014 it is still operating with a shortfall of approximately 25% in Vision for Change staffing requirements.

Looking to the future

While change has been slow and painful at times, there is no doubt that progress has been made most particularly in relation to the reduction in bed numbers and the closing of institutional doors.

However, A Vision for Change has at its heart, the objective of achieving a truly modern mental health care service, one which is based in the community, involves the service user and is based on recovery.

In order to achieve this, the focus now needs to be put on providing localised, appropriate and readily accessible multidisciplinary interventions. It means having fully staffed teams that can respond in a timely manner to new or known needs. It also means attitudinal change in terms of how professionals work with clients and their families.

Modern mental health care demands person centeredness, partnership approaches, sharing of information and agreed consensus on interventions. Formal processes such as residential admission (voluntary and involuntary) must be seen as last resort options.

Unfortunately, eight years on since the publication of the policy, we have still some way to go to see full implementation of A Vision for Change. A Vision for Change was devised following a review of best practice. It addresses both the physical infrastructure and care standards and if fully implemented we would truly have a world-class mental health care service.