Tim O'Malley (Limerick East, Progressive Democrats)

I am delighted to be able to speak to Senators on the Government's policy document A Vision for Change, the report of the expert group on mental health policy. The report outlines an exciting vision of the future for mental health services in Ireland and sets out a framework for action to achieve that over the next seven to ten years. It is the first comprehensive review of mental health policy since Planning for the Future was published in 1984 and has been accepted by the Government as the basis for the future development of mental health policy.

I established the expert group on mental health policy in August 2003 in recognition of the need to review long-standing policy in this area and to formulate a blueprint for a modern, comprehensive, world-class service that can meet the mental health challenges that now face our society. Not least of those is our significant suicide rate, particularly among young people.

From the outset I was convinced that a collaborative approach between service users, professionals and health service providers represented the best way forward. Accordingly, I appointed an expert group chaired by the president of the National College of Ireland, Professor Joyce O'Connor, and which consisted of 18 widely-experienced people drawn from a range of backgrounds within the mental health services.

A Vision for Change builds on the approaches to mental health service provision proposed in previous policy documents and outlines a set of values and principles that will guide both the Government and service providers as we proceed to develop and put in place a modern, high-quality mental health service for our citizens.

The group undertook a wide-ranging and comprehensive public consultation process whose findings, which were published in two reports in December 2004, are central to the framework outlined in A Vision for Change. The consultation not only showed the wide-ranging knowledge and expertise of mental health issues that professionals and service providers possess but allowed service users to make clear their views on the present state of mental health services and on how such services should be developed in the future. The expert group felt it important to ensure that service providers articulated their priorities concerning the need for adequate resources to enable them to respond to the full medical, psychological and social needs of service users and their families.

Throughout the consultation process calls were made for significant change at all levels of service provision and in particular for the delivery of community-based interventions that are accessible, user-friendly and effective in promoting recovery and reintegration into society. The necessity of involving service users and their carers in all aspects of service delivery was a key message. This is the foundation on which A Vision for Change was built.

Another theme that permeated the consultation process and informed the development of every part of the policy was the need for greater access to psychological therapies, which are commonly known as "talk therapies". The demand for psychological and social therapies and the evidence for their effectiveness has been growing steadily in recent years. The clear consensus among users and service providers was that such therapies should be regarded as a fundamental component of basic mental health services rather than additional options that are not consistently available.

Although alternatives to medication is consistently a topic in any consideration of the future direction of mental health services, the expert group places strong emphasis on the need for much greater availability of mental health professionals within the community, especially mental health nurses, psychologists, counsellors, occupational therapists and social workers. It is vital that future service provision is person-centred and takes account of the resources and wisdom that already exist within the community. In recognition of this, the expert group proposes a holistic view of mental illness and recommends an integrated multidisciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems. The group recommends a person-centred treatment approach that addresses each of these elements through an integrated care plan which, reflecting best practice, is evolved with and agreed by service users and their carers.

As we are all aware, primary care provides most people's first point of contact with the health and personal social services. Primary care is the appropriate setting for meeting 90% to 95% of all health and personal social services needs, including mental health needs. All but the most complex and acute health care needs of individuals, families and groups can be effectively met in the local primary care setting. The provision of a wide range of care close to service users represents the most appropriate, effective and user-friendly approach to health care delivery. The development of primary care services as recommended in the report will contribute significantly to enhanced levels of care and treatment for those who suffer from mental difficulties.

One of the fundamental principles of this report is what is termed "recovery", in the sense that people with mental illness can and should be facilitated in reclaiming their lives and becoming involved in society, that is, to be what is termed "socially included". To achieve this people need supportive mental health services but they also need supportive communities where actions are taken to address basic needs such as housing, employment and education. All of these elements are included in the vision for the future outlined in this report.

A modern health care system accepts that each person must play a central role in their own treatment and recovery. It recognises that each individual plays a critical and essential role in the assessment of their own needs and that quality of care is inextricably linked to the involvement of the user in determining their health care. The goal of mental health promotion must always be the enhancement of potential, that is, building psychological strengths and resilience rather than focusing on reducing disorders. I believe it is a key task of the health services not just to treat mental illness but, more importantly, using the principles of health promotion, to improve the mental health and well being of all our people, both as individuals and members of communities within the population. I am pleased to note this report reiterates that ideal.

Thankfully, there is a growing awareness among service providers that establishing a good quality of life for service users requires their involvement in the planning of the services that are important to them and which support their choices. The perspective of the service user and their family or carers needs to be understood and appreciated. The vision that guides this policy requires that mental health services be characterised and led by a partnership between all stakeholders. A comprehensive mental health care system requires that services at all levels — from community support groups, to voluntary groups, to primary care, to specialist mental health services — work in an integrated, co-ordinated fashion for the benefit of all people with mental health difficulties.

This policy envisions an active, flexible and community based mental health service where the need for hospital admission will be greatly reduced. In this report, the expert group has stated:

Mental hospitals have been the mainstay of mental health services in Ireland for many years. However, the type of person-centred, recovery-oriented care recommended ... cannot be provided in institutions of this size or environment.

On that basis, it is recommended that steps be taken to bring about the closure of all remaining psychiatric hospitals which are a legacy of a bygone age and to re-invest the resources released by these closures in the mental health services.

Since coming to office, I have taken the opportunity of visiting a number of mental health facilities and have seen at first hand the commitment of staff to the provision of a high-quality service. From the outset, I accepted that further investment was required to upgrade or replace some of the physical facilities and that greater capital investment was required to provide a modern comprehensive community-based infrastructure.

The closure of large mental hospitals and the move to modern units attached to general hospitals, together with the expansion of community services, has been Government policy since the publication of Planning for the Future in 1984. A great deal of progress has been achieved since then, with the number of acute psychiatric units in general hospitals increasing from eight in 1984 to 24 at present. As a result of these developments, more than 50% of all admissions to the mental health services are now made to general hospital psychiatric units. Supported residential places in the community have also expanded, rising from 1,180 in 1984 to 3,508 in 2004.

A number of the large mental hospitals around the country have already closed completely — Our Lady's in Cork, St. Patrick's in Castlerea, St. Columba's in Sligo, St. Mary's in Castlebar and Our Lady's in Ennis. The reorganisation of services which these closures entailed resulted in the expansion of community facilities, new acute psychiatric units in some cases and an overall improvement for service users, their families and carers. The remaining hospitals cater in the main for long-stay patients, many of whom are over 65 years of age. This report recommends that a plan be drawn up for the phased closure of each of these hospitals.

It is recommended that this plan consist of a four stage process, as follows: stage 1 — identify measures required to enable admissions to cease and put these measures in place; stage 2 — cease admissions to the hospital and draw up plans for relocation of existing patients; stage 3 — implement plans for the relocation of existing patients; and stage 4 — final closure of hospital. It is emphasised that this process should take place on a phased basis with wards closing sequentially. It also makes clear that the process will require funding for training and upskilling of staff who will subsequently be redeployed to work within the mental health services provided in the community. This major change process will be undertaken and completed in full consultation with patients, their families and carers and, of course, the staff involved.

The expert group has indicated in this report that community mental health teams should be the cornerstone of mental health service delivery. It has recommended that well trained, fully staffed, community based, multidisciplinary teams be put in place in all services, providing mental health care across the individual's lifespan, from childhood to old age. To provide an effective community based mental health service, these teams should provide multidisciplinary home-based and assertive outreach care. A comprehensive range of medical, psychological and social therapies relevant to the needs of the individual service user and their families and carers should also be available.

The new national policy framework, A Vision for Change, makes clear recommendations on how the mental health services should be managed and organised in the future. These recommendations include the establishment of a national mental health service directorate within the HSE. It is envisaged that this directorate will play a key role in facilitating the implementation of this policy and thereby developing a modern mental health service that will benefit the entire population.

Another important recommendation in this area relates to the reorganisation of the current mental health catchment areas. It is proposed that each catchment area will serve approximately 300,000 people and the community mental health teams will be developed on that basis. Each catchment will be managed by a mental health catchment management team which would include key professionals, a service user and the managers of the relevant local health offices.

The report recommends that a programme of capital and non-capital investment in mental health services adjusted in line with inflation should be implemented in a phased way over the next seven to ten years, in parallel with the proposed reorganisation of mental health services. The proposed new workforce will comprise more than 11,000 staff throughout the service. Allowing for the assimilation of all existing posts, the expert group has estimated that a total of 1,803 new posts across the services, together with a total non-capital investment of €151 million per annum in addition to existing funding, are required.

Due to the current non-availability of certain health professionals, this investment will be required on an incremental basis, resulting in a proposed non-capital investment of an additional €21.6 million each year for the next seven years. Substantial additional funding will be required to finance the implementation of the recommendations outlined in this report. In this regard, I am pleased to confirm that in the Estimates for 2006, an additional €25 million has been allocated to the HSE for mental health services and it is hoped to continue this level of investment in the coming years.

It is important to point out that the expert group has recommended that this policy be implemented on a phased basis over the next seven to ten years. The proposed changes, therefore, will be incremental. In my opinion this is vital, not least due to the level of additional resources required but also the need for the changes to take place in a planned and co-ordinated manner in consultation with all those involved.

To date, mental health services, both statutory and voluntary, have met the challenges of change in recent years with enthusiasm and vigour and I am confident that the further development of our services, in a spirit of partnership between statutory and voluntary bodies, will be approached in the same positive manner. The Government is fully committed to the implementation of this report, which, as I said at the outset, has been accepted as the basis for the future development of mental health services. I will shortly appoint a group, as recommended in the report, to monitor the implementation of its recommendations.

I am confident the implementation of the recommendations contained in this report, in conjunction with the ongoing implementation of the national strategy for action on suicide prevention, Reach Out, will result in far greater provision of accessible, sensitive, appropriate and, where required, intensive support for all who need it. It will also ensure that mental health services will have the necessary resources to enable them to do that in a more comprehensive, co-ordinated and cohesive manner.

I again acknowledge the work of the expert group chairperson, Professor Joyce O'Connor, and of all the members of the group over the past two years. I look forward to working with those who will be involved in the implementation of this important report and the work therein.