What would Jonathan Swift make of it?

Denis Doherty
Denis Doherty

Prompted by the focus there is on the way Covid-19 and the restrictions imposed in managing the pandemic are impacting on our mental health services, I wondered if our mental health services infrastructure is equipped to deal with the extra demands it is likely to experience, writes Denis Doherty.

The fact that 11% of approved centres were found to be non-compliant on a pre announced visit is surely noteworthy.

My curiosity coincided with the publication of the 2020 Annual Report of the Mental Health Commission, which incorporates the Annual Report of the Inspector of Mental Health.

The reports of the Commission and the Inspector are couched in measured and temperatelanguage but revealgapsbetween requirements, entitlements and realities experienced by service users in many instances. I soon formed the view that the role of the Commission needs to be expanded andgiven the powers necessary to enforce the mental health legal and regulatory entitlements of mentally ill people.

The stated Mission of the Commission is –“To regulate and engage to promote, support and uphold the rights and well being of all people who access mental health and decision support services.” The Inspector of Mental Health Services has a statutory role under the Mental Health Act 2001 and is appointed by the Mental Health Commission to carry out inspections of mental health services nationally.

The majority of inspections in 2020 were announced in advance due to restrictions related to the COVID pandemic.

Not unreasonably, clinical practice matters do not come within the remit of the Commission or the Inspector; the regulators of the healthcare professions perform that role.

It seems to me that aregulator needs to be in a position to formally accept and deal with complaints that come within its area of responsibility. The Mental Health Commission does not have the legal power to investigate complaints but if an issue of concern is received it is referred to an‘Issues of Concern Committee”for consideration and action. It seems extraordinary that a statutory regulator should still, in 2021, have to resort to employing an Irish solution to a very Irish problem on matters as important as the experience of users of the services it regulates.A total of 321 issues of concern, relating to 143 individuals, were review edin 2020; the figure is divided into categories but no further information is provided.

Everyone using mental health services has a legal right to a care plan that is personal to them. In her report, the Inspector notes that although care plans are provided for almost all inpatients, the quality is poor in most approved care centres.I take that to mean that the letter of the law was complied with, but that compliance fell short of the spirit of the law.

Back in 2015,an Expert Group recommended that legislation be introduced to provide that all applications for involuntary detention should be made by authorisedofficers.I assume the reason was that a decision to detain a person involuntarily on mental health grounds ought to be initiated bysomeone professionally qualified and authorised to do so.It appears that nothing has changed in the meantime. In 2020, authorised officers were attributed with initiating only 13% of involuntary admissions from the community.

During 2020, large amountsof public money werespent on measures aimed at enabling service providers to comply with public health advice. Some approved acute mental health care facilities were judged to be not suitable to provide a mental health service; the number of such unsuitable facilities is no stated.

Average overall compliance with regulations improved from 78% in 2019 to 89% in 2020. Nevertheless, the fact that 11%of approved centres were found to be non-compliant on a pre announced visit is surely noteworthy.

One in six of the approved centres, where services are provided, were judged on pre announced inspection visits to be unclean, 58% lacked maintenance and decoration and 11% had no programme of maintenance. Lack of space for residents was an issue in a third of the centres visited. The importance of good ventilation of buildings is being stressed during the COVID pandemic, but one in five mental health buildings were judged to be poorly ventilated.

The Inspector can inspect any mental health facilitythat is underthe direction of a consultant psychiatrist but is not an approved centre,but the Mental Health Commission has no enforcement powers in relation to these facilities because they are not regulated under the Act. It is an indictment of the slowness of legislative change in relation to mental health services that a large number of service users reside in accommodation that is unregulated.

The Annual Report of the Inspector states in relation tothe increasing elderly population –“we are currently not providing a nationwide, comprehensive mental health service for elderly people. Wehave highly trained and committed specialist clinicians, yet we have only 66% of the recommended specialist teams which themselves are staffed at an overall level of only 54%of the level recommended”. One of the nine HSE CHO areas has 75% of the staffing level recommended whileanother has only 31%. Acute beds provision for olderpeople here is poor relativeto neighbouring health care systems. For example, we have only 1.2 beds per 100,000 of population.compared to 9.7 in Northern Ireland and 15 in Scotland.

The ordinary meaning of the word regulation denotes obligation rather than guidance; in the case of our mental health services it appears that the latter interpretation is the preferred approach of many approved providers even where statutory entitlements are concerned.

That outlook may be a consequence of funding levels not matching service needs, of serious disparities between service regions,resulting in serious staffing shortages, inadequate staff trainingin some, poor working conditions, it would appear, in premises that are unfit for purpose and poorly maintained. The powers of the regulator are, it seems, noton a parwith those of the regulators of other health services in Ireland. Most mental health services delivered in residential care settings here are provided directly by the HSE, acting as commissioner and service provider. Thatis a very good reason why theauthority of the Regulatorand the Inspector ought to enable them to act in the best interest of the users of mental health services irrespective of the status of the provider.

The experience of the Regulator, Inspector and providers of services during COVID-19 ought to be invaluable in informing the reforms that shouldbe introduced as a matter of urgency.

“There is nothing consistent in this world but inconsistency” JonathanSwift.