New mental health policy fails to address critical staffing deficits, says IHCA

• Policy is aspirational and does not address real pressures on the system;
• ‘Sharing the Vision’ fails to address shortfall in number of Consultant Psychiatrists which are half the EU average; 
• Previous 2006 ‘Vision for Change’ was never fully implemented, and new policy likely to have same fate;
• Deficits in staffing and bed capacity will continue to result in significant access problems in the acute psychiatric services.

Commenting on the publication today (17 June 2020) of the new national mental health policy, ‘Sharing the Vision – a Mental Health Policy for Everyone’, IHCA President Dr Donal O’Hanlon said: “The new mental health policy has failed to set out the urgent workforce requirements needed to staff a modern psychiatric service. The Mental Health Services must recruit the required number of Consultant Psychiatrists, a near doubling in the current number, and other staff prescribed by the previous policy ‘A Vision for Change’ and a plethora of other expert reports. This requires the filling of all Consultant Psychiatrist posts on a permanent basis. We simply do not have the resources and the number of Consultant Psychiatrists required to provide high quality, timely care and treatment to patients who need it.”

The IHCA has warned that the new national mental health policy ‘Sharing the Vision – a Mental Health Policy for Everyone’ has failed to address the critical staffing deficits in the mental health services that continue to result in significant access problems in the acute psychiatric services.

The Association said the new mental health policy is aspirational, short on concrete priorities for implementation and says little about the real pressures on the system that have been only heightened by the COVID-19 pandemic.

Commenting on the new policy, IHCA President Dr Donal O’Hanlon said: “The new mental health policy has failed to set out the urgent workforce requirements needed to staff a modern psychiatric service. The Mental Health Services must recruit the required number of Consultant Psychiatrists, a near doubling in the current number, and other staff prescribed by the previous policy ‘A Vision for Change’ and a plethora of other expert reports. This requires the filling of all Consultant Psychiatrist posts on a permanent basis. We simply do not have the resources and the number of Consultant Psychiatrists required to provide high quality, timely care and treatment to patients who need it. 

“There is no plan to address the significant deficits in our mental health services - the majority of the 99 recommendations do not address the current gaping deficits in manpower or frontline resources. Even on the issue of bed capacity, the new policy kicks the problem down the road with a suggestion of a further review of acute inpatient capacity. This is simply not good enough. 

“Our experience with the previous national mental health policy ‘A Vision for Change’ is that the recommendations made in 2006 were never implemented. We are concerned that this new strategy will suffer a similar fate and the limited vision will never become a reality.” 

These deficits include:

• Number of Consultant Psychiatrists: Ireland has just 6.1 Consultant Psychiatrists per 100,000 population, just half the EU average number of specialists and one-third to a quarter the number in many EU countries. Ireland is ranked below such countries as Romania, Slovakia and Greece, and has four-and-a-half times fewer Consultant Psychiatrists than Finland.
• Recommended number of Consultant Psychiatrists: The Hanly Report in 2003 and the HSE National Doctors Training and Planning Unit in 2014 recommended that the number of approved Consultant Psychiatrist posts be significantly increased to 712 by 2016 and 755 by 2024 respectively to ensure that safe and effective mental health services can be provided on a timely basis. Additional increases have been recommended, up to as many as 858 Consultant Psychiatrists by this year (2020), by the College of Psychiatrists of Ireland – or almost a doubling in current numbers. Yet as at 31 March 2020, there were 492 approved Consultant Psychiatry posts and 440 Consultant Psychiatrists employed.
• Recruitment and retention: The prolonged and deepening Consultant recruitment and retention crisis is due to the imposition of discriminatory terms and conditions on New Entrant Consultants appointed since October 2012. This 30% cut imposed on new entrants must be reversed immediately in order to fill all Consultant Psychiatrist posts on a permanent basis including those that are currently vacant or filled on a temporary or agency basis.
• Overall staffing levels: Compared with 2008, overall staffing levels in the mental health services have been cut by 522 (5%) to 9,954 WTEs in December 2019. The previous policy ‘A Vision for Change’, based on a 2002 population of 3.9m, recommended mental health staffing of 10,647, equivalent to 13,436 in today’s population terms. The new mental health policy completely fails to address these workforce deficits.
• Inpatient psychiatric beds: Ireland also has the third lowest number of inpatient psychiatric care beds in the EU (34.83 beds per 100,000 population), at half the European average, with bed capacity declining sharply from 101 beds per 100,000 population in 2004. This has occurred at a time when Ireland’s population increased by more than 500,000 during the past 12 years, and while those aged 65 years and over increased by 35%. While ‘A Vision for Change’ had planned for a marked reduction in acute psychiatric hospital beds, the promised alternative services have not been provided in the community. The new policy ‘Sharing a Vision’ does not even attempt to quantify current bed capacity needs. 
• Child and Adolescent Mental Health Services: Capacity deficits can also be seen in the Child and Adolescent Mental Health Services (CAMHS), where only three quarters of the 74 available CAMHS beds are open at any one time. This falls far short of the 108 CAMHS beds recommended in the previous mental health strategy and has resulted in the inappropriate admission of children and adolescents to adult mental health units, which increased by 24% over three years to 84 children in 2018. This constitutes a breach of Ireland’s obligations under the UN Convention on the Rights of the Child. Instead of having a zero tolerance on this practice, ‘Sharing the Vision’ seems to accept it, indicating that adult inpatient units are “generally speaking” not appropriate environments for children and adolescents.
• Proposal to increase eligibility for CAMHS to 25 years: The proposal under today’s policy to increase the age range for eligibility for CAMHS to 25 years is unrealistic without addressing the current significant deficits in the service.
• Waiting lists: These deficits are contributing to persistent and damaging long waiting lists for treatment and the unavailability of specialist services. HSE data confirms that the number of patients waiting to be seen by a Consultant Child & Adolescent Psychiatrist nationally was 1,876 in September 2019, with 36% (668) waiting longer than 6 months and 11% (204) waiting longer than 1 year. 
• Children’s waiting times: The percentage of children or adolescents offered an appointment and seen by the CAMHS Team within 12 weeks was 3.6% below target nationally in September 2019, but even worse in some regions. Only 51.6% of children and adolescents in CHO4 (Cork and Kerry) were offered an appointment and seen by the CAMHS Team within 12 weeks in September 2019, compared to the national target of 72%.
• Adult waiting times: The HSE does not collect waiting list figures for Adult Mental Health Services. However, nationally the HSE was 7.7% off its target for the number of new Adult cases seen in September 2019 and 3% below its target to see 75% of accepted referrals/re-referrals within 3 months. The worst performing areas on this last metric in September 2019 were: CHO9 – Dublin North City & County (57.4%); CHO7 – Kildare/West Wicklow, Dublin West/South City/ South West (58.2%); and CHO4 – Cork and Kerry (59.8%). 
• Older adults: The percentage of older patients offered an appointment and seen within 12 weeks by the Psychiatry of Later Life Team was 2.3% below target nationally (95% target) in September 2019, but significantly worse in CHO9 where just 59.5% of older patients were seen within 12 weeks.
• All of these waiting times are likely to have significantly increased over the past number of months due to the COVID-19 pandemic. 
• Budget: These waiting times are not surprising given that the 2020 Mental Health Budget of €1,031.3m is just €9.3m (0.9%) above the equivalent 2009 expenditure level. At 6% of the total health budget (€17,056m), it is low by international standards and approximately half that of most Northern European Countries.  

IHCA President Dr Donal O’Hanlon said: “The funding for mental health services needs to be increased to deliver timely, high quality care to patients and to ensure that children and adolescents are admitted to age appropriate units. Mental Health Services must recruit the required number of Consultants and other staff.  Addressing the lack of Consultant Psychiatrists, inpatient beds and frontline resources would resolve most of the problems facing the mental health service”.

ENDS

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