Mr. Martin Rogan:

I thank the Chair and the members of the committee for the invitation to address them today. As members know, Mental Health Ireland, MHI, has already made a previous written submission on a number themes such as mental health primary care, staff recruitment and funding. I understand today's session is to look at the area of health promotion and early intervention.

Mental Health Ireland is a national voluntary body and our mission is to promote positive mental health for individuals and communities through our network of 82 local mental health associations operated by volunteers. We support people who experience mental health difficulties on their journey to recovery. Our vision is of an Ireland where mental health is valued as an essential part of personal well-being and the health of the nation. MHI leads the way in terms of society’s understanding of mental health and fostering a culture where people with mental health difficulties are respected and supported. Our work at a national level is supported by the Health Service Executive under a number of formal service level arrangements and these specify common objectives and quantums of service. Mental Health Ireland was founded following a commission of inquiry in 1966. The report recognised that people were recovering and moving from mental hospitals. At that time there was a need to promote positive mental health and community understanding of mental health issues and also to provide practical support for service users.

In Mental Health Ireland, we envisage an Ireland where all of our people have a better understanding of their own mental health and its needs, the factors that improve and the factors that can compromise their quality of life and mental health. We recognise that mental health needs to be reviewed and understood as a resource for life, where people have access to programmes that can help develop their skills and strategies for dealing with family life and daily life. These should be readily available throughout the community. We support a model where there should be an openness to discuss mental health issues among family, friends, and peers and where there is a sense of connectedness. This is vital to a sense of belonging and is protective of our mental health. As Irish citizens, we need to have confidence in health services, to feel they are available to us, that they are appealing and accessible and ultimately treatment will be successful. It is important that as people use services or following their use of services, they do not have a sense of alienation or being removed from their community in any way. It is important that positive mental health and well-being enjoys the same profile and parity as physical health.

Over the past 50 years mental health association volunteers and our affiliated partners have engaged actively in mental health promotion right across the country. This is closely aligned to a vision of a more positive Ireland where personal well-being, health and economic success are all recognised as of equal value. We see the importance of promoting positive mental health in an evidence based way. We want to strengthen our efforts to promote the protective factors and reduce the risk factors and prevent mental illness to move towards a more flourishing and inclusive society. We understand that we have certain strengths in this field in terms of our long commitment and our relationship with communities right across the country. We have our own dedicated mental health department, we are building upon that and Ms Aisling Doherty has joined us here today. The model is that we would be in a position to adopt best practice in Ireland, learn from international colleagues and academic research and make this available to communities right throughout the country.

Over the years of our organisation the question has changed somewhat from "what is mental health?" to "how do I care for my own mental health?". Having begun this conversation over 50 years ago we feel a responsibility to advance that dialogue further and to deepen it. We work with many NGOs right across the sector to do so.

We see promoting positive mental health and well-being on three different levels. It is about building on strengthening the individual to improve emotional resilience through various interventions designed to promote self esteem and self efficacy, strengthening communities in terms of having an inclusive and participative community where neighbourhoods and environments are designed to be conducive to mental health and also reducing any structural barriers that still remain and we will talk about these in today's session. It is about reducing elements like discrimination and stigma and making sure people have access to meaningful education, employment opportunities and housing. We support people at a vulnerable time in their lives and that has been a continuing role. We are aware that there can be a lot of well intentioned activity in this space. While that can demonstrate a collective concern or a societal solidarity, we need to move beyond simple awareness. This is why mental health promotion needs to have the same robust evidence base and have a credibility, as with any other form of health promotion.

At Mental Health Ireland we have been delivering evidence-based services. This is why we are working further in this field and commissioning further research so that we have a much better understanding of what are successful interventions and why they are successful.

International research suggests that there are about seven principles we really need to be active on in order to succeed in mental health promotion. One is around empowerment. This facilitates individuals and communities to take greater control of their own decisions, health behaviours and life choices. This must be well-informed for it to show understanding and for us to have confidence in it.

Another important value is participation, meaning that all stakeholders play a much more active role in decision-making. This has been an issue in the past for many mental health service users. We are very heavily involved in working in the recovery space, especially in the area of co-production, where service users, family members and professionals collaborate in a more positive way.

We need to have equitable access. This is discussion that will come up later. There are quite limited resources in the mental health space, but are they evenly distributed? Equitable access means that there is equal access for all our citizens throughout the country to the resources that are available.

MHI supports an inter-sectoral approach. There is a recognition that mental health is not the sole preserve of any one component or agency, and we are very well positioned to work across different disciplines. We are working across a spectrum, with housing agencies, local sports, arts and cultural communities so that we can touch people's lives in a positive way. Working in health promotion, particularly mental health promotion, it is very important to carry out sustainable interventions and not just once-off actions. These need to have follow-through if the benefits are to be realised and sustained.

Another important principle is that the approach needs to be holistic, and not just working with the individual in one domain. Embracing people's physical health, mental health, social health and indeed spiritual health are really important if they are to enjoy full, happy and healthy lives in conducive communities. Finally, it is really important that we have a multi-strategy stance, so that there is no single approach that will be effective. Each of these enhances the other when they work in combination.

In Mental Health Ireland, our work is guided by the Healthy Ireland strategy, and by chapter 5 of A Vision for Change. Unfortunately, this is perhaps the shortest chapter in A Vision for Change, but it has very important points to make. It is a little overlooked that in Ireland we are at a key point in our history regarding the demographic shape and profile of our population. Some 23% of our population are children, so there is a real opportunity here and a closing window that we need to grasp in laying down positive life events and life approaches to build resilience. It is something that we really need to tend to very quickly.

In A Vision for Change the authors identify four different areas of priority including promoting positive mental health and well-being; raising awareness of the importance of mental health; enhancing capacity of mental health service providers and the general community to promote positive mental health, an area in which Mental Health Ireland has been actively involved; and suicide prevention, which is also an area of activity for our organisation. It also points to the need to build capacity to promote mental health in an effective manner that is robust and is evidence-based. That is certainly an area of focus for our organisation.

In regard to early intervention, which the committee is keen to explore today, the role of primary care is really important in mental health. Our written submission reflects this aspect. There are about 5.6 million occasions of care in Ireland in a year. Some 35% of all GP interventions relate to mental health issues. Not everyone recognises their GP or their family practice as a place where they can receive help. However, 90% of mental health issues can be effectively recognised and resolved successfully in primary care, with 10% of service users being referred forward to specialist community-based mental health services. There is a network of day hospitals and community mental health centres throughout Ireland, and this really should be the first point of referral for GPs. It is important that it should happen that way.

There are a number of factors that can delay referral and the acceptance of support in the mental health space. These can include the costs of service; its availability; geographic isolation; historical stigma and prejudice; negative perception of service; and perhaps the most limiting factor of all, hopelessness, where the individual does not believe that a successful intervention is possible. This belief limits a person's ability to step forward in a timely and effective way. It is important that we address these barriers, some of which are more pronounced for certain cohorts of the population. For young people the foremost difficulty may be cost. Men are sometimes reluctant to accept that they need help, and perhaps feel vulnerable at a certain time of their lives. There is also a tendency for people to minimise their difficulties, or indeed to self-medicate with drugs or alcohol. If we are to be successful in early intervention in Ireland, we need to have a much better understanding of help-seeking, help-finding and help-accepting behaviours. I note that the last of these is critical to successful mental health care.

We know that people with quite significant mental health needs can be reluctant to engage with services. Sometimes they fear a loss of independence or control of decision-making. They may feel that the relationship has something of a power imbalance. That needs to be revisited. This is why Mental Health Ireland has been working very closely with people with self-experience throughout the country to create roles for peer educators and peer workers. We have also been active in a collaboration with the HSE entitled advancing recovery in Ireland. These actions are intended to ensure that people who use services are very active not just in their own care and treatment, but also in designing models for others. Certainly the whole area of co-production is one about which we need to hear a lot more.

In discussing the importance of recovery, we need to understand that in the past, gaining access to mental health services was not always the issue. Gaining egress and leaving the service was a much greater challenge. In 1960 in Ireland, 23% of the entire health budget was dedicated to mental health spending. I began my career in 1983; in 1984, this percentage of health spending had dropped to 12%. The World Health Organization, WHO, recommends that 12% is the minimal threshold. If a mental health service is to be provided, 12% is the minimal standard. When A Vision for Change was published in 2006, a target for this figure was set at 8.4%, significantly below the WHO recommendation. Sláintecare, an excellent report published last year, recommends 10%, still below the WHO's recommended norm. We know that the last ten years have been a really difficult decade for the Irish public. There has been unprecedented growth in the demand for mental health services. Mental health spending is currently 6.4% of health spending. If it is going to be so low, it is really important that resources are evenly distributed right throughout country and available to all of our citizens equally. This is why recovery is such an important topic, certainly when we are talking about prevention and early intervention. If people are to avail of the mental health services, it is also important that they successfully leave the mental health services. They must be able to reposition themselves into community living and get back into their whole lives, be that in education, family, community or employment, and live full lives again.

Mental Health Ireland's mission involves working with people to ensure that they successfully make their way back into their communities and fully reintegrate by not living in a psychiatric model within the community setting, but fully availing of community life. In 1950, around the time our organisation was established, Ireland had the highest rate of hospitalisation in the world. There were 22,000 of our citizens living in psychiatric hospitals, with little prospect of return. Our volunteers throughout the country have been very active in ensuring that people have a way back to their communities, and that they can succeed in that pathway.

We also know that a huge level of hospitalisation created a very graphic image in the public mind. This is often quite a hopeless message regarding people's ability to recover and their likelihood of doing so. As a national organisation and through our volunteers and mental health associations throughout the country, Mental Health Ireland has been working to ensure that people succeed in returning to their community, are celebrated and feel absolutely accepted in that space. This is a really vital role and it absolutely wraps around our need to promote positive mental health in a much more effective manner, and to intervene early so that lifelong disability, distress, and unnecessary risk is not realised.