Dr. Shari McDaid:

I thank the Chair and members of the committee for inviting Mental Health Reform to appear to discuss the important topics of funding and performance indicators for the public mental health system. We very much appreciate the opportunity to inform the thinking of the committee in preparing its upcoming report. We strongly welcomed the establishment of the Oireachtas Joint Committee on the Future of Mental Health Care, which signalled the priority of mental health as an issue across all political parties and provided an opportunity for Ireland’s mental health system to be scrutinised at parliamentary level in a new way. We also support many of the recommendations of the committee’s interim reports, in particular those on increasing the proportion of the health budget allocated to mental health, including development funding, the prioritisation of the development of a mental health information technology, IT, system and the expansion of the existing suite of key performance indicators in the mental health services, all of which are relevant to today's discussion.

Mental Health Reform is Ireland’s leading national coalition on mental health, with more than 60 member organisations which campaign together to drive progressive reform of mental health services and supports in Ireland. Since 2012, it has actively campaigned for increased funding for mental health services and supports for specialist mental health services and the mental health system as a whole. In addition, in pre-budget submissions for the past six years it has called on the Government to invest in and ensure the implementation of a national mental health information system.

Investment in mental health services must be understood as a question of resources for staffing because it accounts for 80% of expenditure on mental healthcare. Investment in public mental health services is about ensuring that the right people are in place and available to provide support to people in mental and emotional distress across the country. Between 2012 and 2018, €210 million in development funding was allocated to the development of new mental health services. However, it must be acknowledged that the investment occurred in the context of increasing demand for mental health supports and much of it was spent on areas of service delivery not specified in A Vision for Change. That does not mean that those are not very important and worthy areas. The amount invested in our mental health services is calculated based on the cost of implementing A Vision for Change but much of the development funding has gone to supports not specified in that framework, such as the National Office for Suicide Prevention and counselling in primary care. The funding has also been used to maintain existing levels of service in the face of increased demand, to obtain out-of-area placements for services for which we do not have the appropriate facilities in Ireland and to cover the cost of agency staff who cover unfilled posts. While the investment is welcome, it has been vastly outstripped by the challenges in the operation of the mental health services. The ongoing shortfall of investment in mental healthcare in the context of significant increased demand since A Vision for Change was published in 2006 has led to a system that is at breaking point and in dire need of financial attention.

In 2017, the HSE reported it required an additional €98 million to achieve the staffing for mental health services set out in A Vision for Change. This figure did not include investment in primary care and the voluntary sector for providing complementary supports. Accordingly, notwithstanding investment by successive Governments since publication of A Vision for Change, the reality is that upwards of 10% more funding is needed in today's terms and in light of today's demographics simply to fulfil the mental health services programme published in 2006. Millions of more euro is also needed to develop adequate capacity in primary care.

These figures reveal that a step change in investment in mental healthcare is needed. We must be much more ambitious than heretofore. We must think in terms of ensuring that everyone has speedy access to the mental health support they need. If not, the costs will be felt everywhere else in our health and social system, from higher costs for physical healthcare to higher disability and illness benefit payments to higher supported housing costs and lost productivity for employers.

A report published by the London School of Economics, LSE, identified total expenditure on healthcare for mental illness - the term used in the UK - amounts to some £14 billion a year. In addition, untreated mental illness amounts to more than £10 billion in physical healthcare costs each year. If the same model were used for Ireland, which has higher cases of untreated mental illness, that cost would be in order of €700 million.

The Healthy Ireland framework reports the economic cost of mental health problems in Ireland is €11 billion per year, much of which is related to loss of productivity. Similarly, a recent report published by the Work Research Centre, WRC, identified:

The economic costs of mental health disorders are enormous, with figures suggesting this may amount to as much as 4% or more of GDP in some countries. Although substantial costs accrue to mental healthcare systems, the main economic costs are located in the labour market and social protection systems, not just for those experiencing poor mental health but also for other family members.

The high burden of disease attributed to mental health difficulties highlights the need for adequate investment in mental health. The evidence based review on the refresh of A Vision for Change clearly identified:

Studies have shown the substantial returns on investment that a broad range of prevention and treatment mental healthcare interventions can yield. This may include better outcomes for the mental healthcare sector and for the physical healthcare sector, cost-savings arising from prevention, and substantial cost-savings and other contributions across other areas of the public sector, economy and society.

In addition, the World Health Organization, WHO, recently reported that every $1 invested in scaling up treatment for depression and anxiety leads to a return of $4 in better health and ability to work. That is a 4:1 return on investment.

In 2018, the total budget for mental health in Ireland is just €912 million. If fully realised, this level of expenditure will equate to just 6% of the overall health budget. This proportion represents a decrease on previous years and is severely lagging behind both national and international standards. Notwithstanding difficulties in comparing expenditure between countries, the WRC evidence review acknowledged that Irish expenditure was lower than better performing mental health systems. An increase in mental health expenditure is required not only for new developments but to maintain existing level of service costs. These costs increase each year due to demographic changes and other related factors.

Even though it is proving difficult to recruit and retain various specialist mental health staff, we believe it is possible to increase investment by broadening the scope of roles within mental health services and reserving scarce clinicians for roles they can uniquely perform. Mental Health Reform has consistently recommended a shift of focus in recruitment of staff from primarily medical professionals to health and social care professionals, including psychologists, occupational therapists and social workers. Currently in child and adolescent mental health services, CAMHS, there are fewer than 40% of the required number of clinical psychologists in post, fewer than 50% of social workers and fewer than 60% of occupational therapists. How can a holistic service be provided in that context?

While there is a fundamental requirement to invest in specialist mental health services, there is also substantial scope to develop mental health services elsewhere in the system, including in primary care and across the community and voluntary sectors. It is imperative that mental health is afforded financial parity of esteem in the wider health budget to reflect its significance in contributing to the burden of disease.

Mental Health Reform recommends increasing public expenditure on mental health services to 10% of the health budget within ten years and mental health staffing to ensure timely access to all relevant supports for anyone in mental health need, as well as population-wide prevention programmes. This investment must include resourcing services at all levels of the system, from prevention to community supports to primary care and through to specialist mental health services.

There is no national mental health information system to report on the full extent of service resources, provision, quality and outcomes for community-based mental health service delivery. Mental Health Reform has been calling for such a system in budget submissions since 2013. It is not acceptable that more than 12 years after publication of A Vision for Change, there is no information system to account for the performance of more than €800 million in public expenditure on mental health care each year. There is widespread acknowledgment of the importance of such a system from national and international experts, the Mental Health Commission and from the HSE. The development of an appropriate, electronic mental health information system based on key performance indicators, will assist in the full transparency and accountability for the evaluation, planning, funding and effective and efficient delivery of mental health services. The WHO's guidance and the UN's human rights framework can inform the creation of an appropriate framework for performance indicators. Such indicators are in use in England, Scotland, Canada, New Zealand and Australia. Mental Health Reform recommends introducing a national, electronic mental health information system within three years of completion of the review of A Vision for Change to enable the planning, implementation and evaluation of service activity. It also recommends developing up-to-date key performance indicators that show delivery of human rights standards and national mental health policy within one year of the review.

We are concerned that the restructuring of governance and accountability mechanisms within the HSE this year has led to the dissolution of the HSE's mental health division and national director of mental health position. It is vital that coherent leadership in mental health at the national level is not lost in the new HSE structure and that there is clear authority and accountability for a distinct, national mental health budget each year and driving reform of the mental health services.

Committee members may want to consider making proposals in this regard in the context of legislation which we understand is due before the Oireachtas to increase the HSE’s accountability more widely.

We welcome the wide range of recommendations made by the committee thus far in its interim reports. We ask members when issuing their final report to consider the following issues which we believe are in line with the committee’s terms of reference. We need to develop mental health services for particular groups that might not get adequate access, including older people, children and young people in the care system, people experiencing homelessness, people from the deaf community, people with intellectual disability, those with autism and people from minority ethnic communities.

We believe in establishing a national independent advocacy service for adults and children engaged in mental health services. We have heard so many stories of individuals frustrated at not being able to get the support they need and yet it is remarkable that there is no national independent advocacy service to support individuals to seek redress, to seek the services they need and to ensure their voices are heard by the services.

We need to ensure that the needs of carers and supporters of individuals with a mental health difficulty are attended to. We need to ensure the development of adequate services for people engaged in the criminal justice system. We must acknowledge that the criminal justice system is now sadly an ongoing part of the delivery system for our mental health services and that we must address the mental health need arising in the criminal justice system. We need to invest in infant and early years mental health services. We need to recognise and support the valuable, essential and complementary role of the community and voluntary sector in supporting people's mental health needs, including the development of peer-led services

The committee previously received our full submission containing a review of A Vision for Change. Further details of all those areas of concern are contained in that submission.

Given the scale of money involved in mental health and considering the lack of systems in place to track and support performance against such spending at care group level, our specific appeal to the committee today is that accountability in mental health funding and expenditure is prioritised in its final report.