Whatever happened to the Government's ambitious policy for reforming mental healthcare? asks Carl O'Brien
It was a plan that promised much. Over the course of 200 pages, it unfurled an exciting vision of how mental healthcare would be transformed over the next decade: the high walls of old institutions would come crumbling down to be replaced by well-staffed community-based residences with 24-hour care over the next decade; rehabilitation and training programmes for patients; readmissions to hospitals would fall; families would take a key role in the care of patients.
The Minister for Health and the Government nodded approvingly, pledging to end the Victorian approach to mental healthcare in Ireland. A short consultation period with relevant professionals would be held first. But after that, the report's recommendations would be implemented within months. It was a priority issue.
The report was never implemented. Planning For The Future, published in 1984, suffered from a death of a thousand cuts. Lacking the political clout of other sectors of the health service, it suffered as budgets were trimmed and cutbacks were inflicted on the health service.
Despite its progressive goals and clear-sighted solutions, it was marked by a lack of political will to implement it.
Today, more than 20 years later, many are grumbling that the Government's latest blueprint on psychiatric care, A Vision for Change, has already met the same fate of its predecessor.
It, too, is progressive and ambitious. Over the course of its 200 recommendations, the report suggests putting in place fully staffed community-based multidisciplinary mental health teams to offer home-based services to people with mental health problems; the 15 remaining psychiatric hospitals would be closed down and their funds used to build new community mental health centres and residential units for those with chronic mental illness; service-users and their carers would be involved in their day-to-day care.
The Government adopted the blueprint as official policy early in January 2006 and solemnly pledged it would be implemented in full over the next seven to 10 years.
But many patient groups, doctors, psychiatrists and health professionals are already losing faith. The evidence of progress so far isn't exactly inspiring.
The promised National Mental Health Directorate that would drive organisational changes in the Health Service Executive (HSE) has not materialised. No capital programme has been put in place to replace the crumbling and shoddy parts of the service. A ban on recruitment introduced by the HSE is having serious implications for the staffing of multi-disciplinary teams.
No one ever expected mental health services would be transformed over night - but they at least expected that the plan for developing the services would at least be gathering pace.
"Given that a seven-year timetable has been agreed for the delivery of the strategy's targets, it is now a matter of concern that so little has been achieved to date," says John Saunders of the Mental Health Coalition, an alliance of non-governmental organisations.
"Unless progress is accelerated, the seven-year timetable will become irrelevant very soon. This would seriously undermine our already under-resourced mental health services."
Dr Siobhán Barry of the the Irish Psychiatric Association (IPA) says its members are "dismayed" that almost no progress has been made yet in delivering key recommendations.
It points out that almost one-third of community mental health teams have less than half the staff they need. At the current rate at which they are being filled, it estimates it will take 25 years before A Vision for Change is implemented.
Of even greater concern are the consequences of starting a process of change and not completing it. For example, the Government has committed itself to the revenue-generating step of closing down old mental hospitals. But if community services are not in place, the numbers of people with mental illness falling through society's cracks and ending up homeless or in prison will increase.
"You can't close down one section of the service and automatically start another," says Dr Edmund O'Dea, chairman of the Mental Health Commission, the State's watchdog on mental health services.
"There is a need for parallel funding on both sides until the newer model is ready. At the moment, that's not identified in the HSE's implementation plans."
On a deeper level, campaigners such as John McCarthy, who ran on a mental health reform platform in the general election, says the promise of improving services for patients rings hollow.
He says legislation such as the Mental Health Act still endorses too much control of patients themselves. "It's illogical to expect that to change with A Vision for Change. That is ultimately an aspirational document. The Act has the force of law and control behind it."
So far, so gloomy. But is it really as bad as people are making out? Does change inevitably come slowly in the bureaucratic world of the health service? Are signs of progress just around the corner?
The HSE sounds decidedly more upbeat about the plan's prospects.
Its national director for mental health, Martin Rogan, says it is investing an additional €25 million in services and will employ an additional 250 staff in 2007, as well as investing €796 million in capital infrastructure over the coming years.
Some of the 200-plus recommendations have been ticked off. A service users' executive has been established to provide a patient's voice in the mental health service. It has begun forming multidisciplinary community mental health teams and "is currently working towards filling remaining positions" on these teams as soon as possible.
The HSE has also begun overseeing the closure of long-stay psychiatric units and reinvesting the proceeds into the mental health services.
Whatever about the positive sounds coming from the the HSE, it is clear the plan is entering a critical phase over the next few months.
If it cannot produce a concrete implementation plan, or a credible structure responsible for driving the changes, the critics and sceptics will be fully justified.
"Appointing a National Mental Health Directorate which would manage the change process is vital," says Dr Edmund O'Dea. "If that's not implemented, there will be serious and significant consequences for the rest of the plan," he says.
It is understood that the HSE has appointed a project manager who will oversee an implementation programme to be unveiled shortly. Many groups will see this as a key litmus test as to whether the plan will meet the same fate as its predecessor.
There are, however, a number of important differences in the mood music that accompanied Planning for the Futurecompared with A Vision for Change.
The State is not facing savage cutbacks on a scale witnessed in the 1980s. There is also a more organised non-governmental campaign to promote the rights of the mentally ill, with human rights organisations such as Amnesty now part of a stronger mental health lobby.
And there is also the economic argument for investing in mental health, with dramatic savings to be gained in sick days and lack of productivity.
"Every family in the country is affected by mental health problems, directly or indirectly," says John Saunders of the Mental Health Coalition. "Where people with mental health problems do not receive timely and appropriate services, the costs of dealing with the fallout are borne by other systems, and by taxpayers.
"Political leadership from the highest level is now required to ensure the delivery of all of the targets set out in the mental health strategy."
In the meantime, the lack of progress will affect the lives of thousands of people with mental illness.
Children will continue to wait months, if not years, for psychiatric assessments. Young people will continue to be detained in adult psychiatric hospitals.
Adults with chronic mental illness will go on being readmitted to psychiatric hospitals without any real rehabilitation.
The most vulnerable of all will keep ending up in the prisons and homeless shelters because there is nowhere else for them to go.