The fundamental rights of the mentally-ill should not be used as a bargaining chip in a drive for more resources, writes Dr John Owens
In all the controversy about the quality of the Irish health service, mental health services are rarely mentioned. People feel personally threatened by obvious inadequacies in the delivery of general health care. Yet somehow these same people feel less vulnerable to mental health problems and are a good deal less exercised by deficiencies in mental health care.
This is very much a false sense of security. Prevalence studies suggest that, at any one time, 16 per cent of adults of working age have a mental illness, and up to half of these people are seriously ill. Other studies suggest that 25 per cent of people will develop a mental illness at some time in their life.
Stigma is the major factor in preventing the open acknowledgement of mental illness. In many ways it is the illness that "dares not speak its name".
Those suffering from mental illness, together with their families, tend to be silent, which results in a lessening of the normal advocacy for service improvement. To some extent this role has been taken up by voluntary bodies and providers of services. Advocacy by professional bodies, perhaps understandably, can to some degree be self-serving, with emphasis being placed on the needs of the different clinical professions.
At a national level, the mental health services which have existed over the years can best be described as exhibiting a phenomenon of punctuated equilibrium in which long periods of relative inactivity are interspersed with attempts at major reform.
Currently, another attempt is being made to reform these services. However, the reform on this occasion has real potential to be both radical and sustained.
Sections of the Mental Health Act 2001 brought about the establishment in 2002 of the Mental Health Commission. On the one hand, this commission has responsibility to foster and promote high quality in the delivery of mental health services, while on the other hand it is responsible for safeguarding the rights of those who need to be detained.
In 2003 the Government set up an expert group to prepare a new national mental health policy to inform the modernisation of the mental health service. The Mental Health Commission, in its recent annual report, has also outlined the nature of the fundamental reforms required to modernise mental health services. It is likely that mental health services in the future will be delivered by well-resourced specialised multi-disciplinary community mental health teams operating in an "advanced community care model" of service delivery.
There should be much greater focus on users of the service, with more user involvement in treatment decisions and in the planning and management of services. The commission, informed by the recommendations of the expert group's policy report, and supported by its inspectorate, will be in an ideal position to monitor the rolling out of these new services in the years ahead.
Of more immediate concern is the delay in implementing sections of the Mental Health Act 2001 which are designed to protect the rights of individuals who still need to be involuntarily admitted and treated in in-patient units. Ireland has been very slow to modernise its mental health law. Despite attempts to introduce new legislative provisions in 1981 - by way of the Health (Mental Services) Act 1981 - the procedures for compulsory admission to in-patient units are still governed by the 1945 Mental Treatment Act. This Act belongs to a different era and does not reflect modern attitudes towards human rights.
Ireland has been found to be in breach of its responsibilities under the European Convention on Human Rights for the management of those with mental health problems. Similarly, Ireland does not conform to the United Nations' "principles for the protection of persons with mental illness and the improvement of mental health care".
Every year, about 3,000 people are compulsorily admitted to in-patient units. At any one time between 500 and 600 people are detained without an automatic independent review of the decision to detain. It is possible for an individual to be detained indefinitely. Psychiatrists and other clinical professionals recognise the need for, and have long advocated, reform of mental health law. These professionals recognise the need for vigilance in ensuring respect for human rights. However, there is still the potential for fundamental human rights not to be given the absolute priority they should have.
The Mental Health Commission is concerned that Ireland is among those countries which have the highest levels of certification in Europe. It is also concerned that marked variations in compulsory admission rates show up across the country, with certification rates in mental health catchments varying substantially in the absence of a similar variance in mental health morbidity. In short, models of service provision and clinical practice seem to be the major factors responsible for this variance.
Full implementation of the Mental Health Act 2001, allowing for an automatic independent review of decisions to detain people and regulating the use of certain treatment procedures, is necessary to ensure protection of patient rights. The Act requires all patients who are compulsorily admitted to have an independent clinical assessment by a second examining consultant psychiatrist, to have a legal representative and to be referred to a mental health tribunal comprising a legal professional, a consultant psychiatrist and a lay person.
The Mental Health Commission has advanced the preparatory work to enable implementation of this Act, apart from the involvement of consultant psychiatrists. Unfortunately, for the last year, consultant psychiatrists have declined to participate in mental health tribunal panels and in second examining consultant panels as a result of an ongoing dispute over resource issues relating to the availability of consultant psychiatrists to provide services.
This is a matter of concern to the Mental Health Commission. In an issue of this sort, relating as it does to the protection of the fundamental rights, freedoms and dignity of some of the most vulnerable individuals in society, issues of resource should not be the determining factor.
While resource issues will have to be addressed in the much-needed modernisation of mental health services, within any existing resource priority must always be given to the protection of fundamental rights. Representative bodies of mental health professionals should not use the protection of these fundamental rights as a bargaining tool in the drive for additional resources.
The Mental Health Commission will continue to do everything it can to fulfil its mandate. In this regard it is looking at other ways of involving consultant psychiatrists in the independent review mechanisms. The commission would prefer to do this in co-operation with all mental health professionals. However, as the protector of the rights of those with a mental illness, it is determined to ensure that the fundamental rights and freedoms of service-users are upheld.
Dr John Owens is chairman of the Mental Health Commission.