Mr. John Farrelly:

On behalf of the Mental Health Commission, I thank the Chairman and members for the opportunity to address the Joint Committee on Health. I am joined today by my colleagues, Dr. Susan Finnerty, Inspector of Mental Health Services, and Ms Rosemary Smyth, director of standards and quality assurance. We are pleased to be here today to discuss workforce planning.

The commission is the regulator for mental health services in Ireland. We are an independent statutory body established in April 2001 under the Mental Health Act. The commission’s mandate is to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to protect the interests of persons admitted and detained under the 2001 Act. In addition, under the provisions of the Assisted Decision-Making (Capacity) Act, the commission is responsible for establishing the new decision support service to support decisionmaking by and for adults with capacity difficulties.

At this juncture, it is important to point out that 90% of mental health services are delivered in primary care settings. A further 10% are delivered within specialist mental health services, including community residences. Under the 2001 Act, the statutory scope of mental health regulation is limited to inpatient services only, which are estimated to make up less than 1% of mental health services in Ireland.

Although the Inspector of Mental Health Services can inspect all mental health services, there is effectively no regulatory oversight of the majority of services that are delivered outside of inpatient facilities. We welcome the work of the Minister of State with responsibility for mental health and older persons, Deputy Jim Daly, to facilitate change in this area by commencing a process to amend the current Mental Health Act.

The principal functions of the Inspector of Mental Health Services are to visit and inspect regulated services, that is, approved centres or acute units, annually to assess compliance with the regulations, rules and codes set out by the commission; to visit and inspect any premises where mental health services are provided; and to review the quality and safety of mental health services in the State. Following every inspection, a detailed report is produced and published by the commission. The inspector also reports annually on themed inspections carried out each year. For example, in the past two years, the inspector has reported on child and adolescent mental health services, CAMHS, 24hour supervised community residences, the physical health of people with severe mental illness, and mental health rehabilitation services. While we do not have regulatory oversight of these areas, the fact that the inspector visits and we publish the report creates a transparency about the reality of life for people who are receiving our services.

As a general comment, it is evident that the provision of mental health services is inconsistent across the country. The services lack proper planning, resourcing and integration to ensure each geographical area receives the same level of quality and care.

Regarding mental health policy, in a wellorganised health system, policy is set by the Government on foot of a political mandate. It is then implemented by the relevant stakeholders or service providers. Implementation is monitored against agreed metrics using a data evidence based approach and reviewed and evaluated on a regular basis. The Irish national mental health policy, A Vision for Change, has been in place since 2006. Its core concepts, which are admirable, are recovery, person centred services, partnership, user and family involvement and the delivery of multidisciplinary, communitybased services. However, the commission has referred on numerous occasions to the absence of any independent monitoring of A Vision for Change, a situation that has remained unchanged since 2013. The commission strongly advocates that any reviewed or refreshed document should include and consider modern evidenced based approaches to service transformation, leadership, workforce planning and development. It should learn the lessons of the years since 2006 in terms of the application of policy.

At the highest level of our mental health services workforce, it is both noteworthy and disappointing that the Health Service Executive removed the post of national director for mental health. The removal of this core leadership position sent out a clear and unambiguous, although perhaps unintended, message that mental health is not a priority. It is also evident to the commission that this has negatively impacted on the delivery of services nationally. That it was permitted to occur, in addition to the slow, ad hocand unmonitored implementation of A Vision for Change, is disappointing.

In terms of resources, Irish mental health services have significant resourcing challenges, not least in staffing. To make progress in these areas, adequate funding is required. The commission welcomed the additional funding allocated by the Government to mental health services in 2019. However, we are conscious that the current level of expenditure on mental health is still less than the target set out in A Vision for Change, which was a document from 2005.

As will be discussed in more detail, the commission is cognisant of the continued difficulties in maintaining and increasing levels of adequately trained staff. The HSE’s workforce planning document, published in October 2018, outlined that the mental health workforce is at 76% of the levels recommended in A Vision for Change. Interestingly, the main data findings indicate that community staff, which is where our vision was to be, account for only 27% of the overall workforce in mental health. Based on our inspections, we are aware of the serious effect that a lack of adequately trained staff has on the quality and quantity of services. Given the labour intensive, human oriented nature of mental health care services, it is imperative that the mental health service budget be increased to at least the level outlined in A Vision for Change if full and effective staffing is to be provided in mental health care teams across the country.

Research clearly indicates the economic returns and benefits of investing in mental health supports and the effective training of staff, as well as the enormous cost of limiting investment, both on the health and the economy of our country. If we are to put in place modern community services and move out of the shadow of institutional care, workforce planning and change management are key.

Additional funding is fundamental to changing workforce practices and development. However, there is also a need to change how the State uses existing funding to redevelop services. Creative and innovative approaches, improved team working, building up community services and changing work practices are having an impact in certain CHO areas, while others appear to be stagnant and trapped in a closed loop of unhealthy logistical and clinical practices from the traditional institutional system. The mental health services in the country that are of the highest quality have adapted by changing their approaches and practices. Some services have recruited and trained mental health support workers to undertake nonnursing duties, which has allowed for the further development of specialist nursing roles. Nursing staff in some services facilitate additional specialist outpatient services, for example in early intervention and homeless services. These services contribute to reduced admissions to inpatient facilities, shorter stays and early discharges. As a result, the pressure on the staff in approved centres is also reduced. Lack of these community services has the knockon effect of longer lengths of stay for people in inpatient services, which has resulted in overcrowding in some facilities. Another key development is the use of the voluntary sector in providing services to people with psychiatric illnesses in nonresidential community care. That is often forgotten. If we are to move into communities in the future, it will not be with just the HSE. It must also be with the voluntary sector and the people who are at the coalface.

In countries with highly developed mental health services, clinical workforce planning is rooted in and supported by prudent and decisive strategies and programmes. While these may exist in Ireland, it is not evident to the commission that governance, leadership development and transformation strategies link to or drive workforce development our mental health services. It is disappointing to observe the continued lack of development of rehabilitation services in Ireland.

I want to talk briefly about performance management, development and support, PMDS. This is often forgotten about but it is critical to enable a service to develop and function. Following on from public service agreements, PMDS is now common practice across the civil and public services. It is a process for establishing a shared understanding about what is to be achieved and how it is to be achieved, and an approach towards managing people that increases the probability of success. If we are to transform our health services, it is an essential aspect of governance and management to facilitate individuals and teams to link performance to policy and operational plans. The commission is aware that in 2012, the HSE introduced a formal performance management system to fulfil the terms of the public service agreements. However, the commission has found very little evidence of this approach in practice. The commission has reservations about the success of any national policy, workforce initiatives or plans that are not underpinned by an appropriate performance management framework.

We inspect approved centres in the context of regulation 26, which relates to staffing. The most common reason for noncompliance within regulation 26 over the three year period was subsection 4, which relates to training. We also look at skill mix and the number of staff. That does not raise its head as much as staff training. The regulation states: "The registered proprietor shall ensure that staff have access to education and training to enable them to provide care and treatment in accordance with best contemporary practice." Essentially, many approved centres were noncompliant with this because not all health care professionals were up to date with mandatory training in, for example, basic life support, professional management of aggression and violence, fire safety and the Mental Health Act 2001.

The past number of years have been difficult in the context of providing and maintaining a high-quality and safe mental health service for our people. However, we have ample opportunity for the future lives of those people suffering with mental ill health to transform our mental health service, if we put in place, fund and implement the right policy. The end goal for each and every one of us must be to move out of the shadow of institutional care by creating modern, wellstaffed community services in the areas where people live and can be close to their families and homes. The commission recommends that any workforce planning should be aligned with national policy to ensure that the system as a whole develops, innovates, and transforms. The Department of Health and the HSE should reinstate the national director role for mental health to ensure dedicated, senior level executive oversight and accountability. The transformation of our mental health service must be evidencedbased, connected to and underpinned by a performance development and support system. I thank the committee for listening. We will be happy to take any questions.