We are very pleased to welcome this guest post from Dr. Claire Murray, Lecturer in Law at University College Cork.
Under section 51 of the Mental Health Act 2001 (MHA 2001) the Inspector of Mental Health Services is required to visit every approved centre in the country at least once during the year and to report to the Mental Health Commission. The Commission has a statutory responsibility to promote high standards and good practices in the delivery of mental health services. The 2010 Annual Report of the Commission was published on the 2nd June 2011. As with previous annual reports the slow rate of change in mental health service provision is emphasised. This delay in moving to a modern rights-based mental health framework is particularly frustrating when, as stated by the Inspector, “mental health services have been traditionally neglected, need radical reform/modernisation, are chronically under-resourced and deal with individuals with severe conditions which adversely affect themselves, their families and society.”
To begin briefly with some of the positive comments in the report, the Inspector notes an improvement in the facilities available for child and adolescent service users. The Inspector also welcomes the winding down of acute admissions to a number of wards, including St. Ita’s in Portrane, which have been deemed unsuitable for many years. The closing down of old wards has been accompanied by a building programme which will deliver modern and appropriate facilities. There are an increasing number of approved centres achieving full compliance with rules, regulations and codes of practice. This is encouraging and hopefully will allow the Inspector to begin to focus on improving the quality of care provided. However, there are a significant number of issues which continue to give rise to concern.
The Commission expresses disappointment with the lack of progress in achieving some of the key recommendations of the report of the expert group on mental health policy. A Vision for Change was published in 2006 and set out a framework for developing accessible, community-based, specialist services for people with mental disorders. In general these objectives have not been met and the current shortage of resources will ensure that many of these objectives will not be met within the agreed ten year timeframe. In particular, the continued absence within the HSE of a Mental Health Services Directorate that would have full executive and budgetary powers was noted as an impediment to proper governance of the services. Launching the annual report Patricia Gilheaney, CEO of the Commission stated “[j]ust as the establishment of a Cancer Services directorate helped the drive to transform the State’s cancer services, a Mental Health Directorate would provide the momentum to transform our mental health services.” The urgent need for a Directorate with budgetary control is compounded following the commitment in the Programme for Government to ring-fence €35 million annually from within the health budget for community mental health services.
From a rights perspective the comments of the Inspector highlighting carelessness in completion of seclusion forms are very worrying. Section 4(3) of the MHA 2001 states that in making a decision concerning the care or treatment of a person “due regard shall be given to the need to respect the right of the person to dignity, bodily integrity, privacy and autonomy.” The rules and guidelines on seclusion were developed in accordance with the principles set out in section 4 in order to protect the rights of people subject to this practice and failure to comply with them indicates at best a lack of understanding of the significance of patient rights. The Inspector refers to “examples of glaring ignorance of aspects of the Mental Health Act” and states that “lack of respect for the Act can only be interpreted as lack of respect for service users/patients.” The Inspector’s recognition of the link between rights and respect is to be welcomed but the concerns raised in relation to seclusion are only one of the most recent examples in the annual reports of a lack of fit between the provisions of the legislation and the operation of the mental services in practice.
The Inspector also observes that the existence and quality of individual care plans remains disappointing, with some service providers viewing this as a “paper only” exercise and deliberately deciding not to implement the plans. There is a failure on the part of many service providers to buy into the concepts of patient-centeredness and a recovery approach to mental disorder. The Inspector states very strongly that “the absence of proper care planning is emblematic of the failure by a number of teams … to embrace the philosophical underpinnings of a modern mental health service.” This emphasises the importance of providing ongoing training and information to service providers on the significance of the rights-based model of mental health law contained in the MHA 2001 and the key concepts at the core of a modern mental health framework.
The report also draws attention to ongoing concerns of the Inspector relating to admission of adolescents into adult units, inadequate community mental health multi-disciplinary teams, high rates of prescribing sedative medications, and the absence of inpatient therapeutic activities. It is outside the scope of this post to examine all of these issues in detail. The overall picture which emerges from this report is of a mental health service which has been starved of funding, where a portion of the service providers have failed to grasp the significant shift in approach required under the new framework and where staffing shortages are having a very direct and damaging impact on service users. The comments of the Commission on the moratorium on public sector recruitment are discussed here. If, as a society, we are to be measured by the way we treat some of the most vulnerable members of that society then this report reflects very badly on us all.