Mental Health Nurse Managers Ireland

Mental Health NurseManagers, Ireland.

Position paper re:

Health Service Executive

National Guidelines on Long Stay Charges.

Mental Health Nurse Managers Ireland, representing the majority of senior mental health nurse managers, has constantly engagedwith relevant agencies (including the Mental Health Commission) in a positive pro-active way in the development of the mental health services in this country. We would support the view that the Mental Health Commission is a key body in the protection and promotion of the rights of people who use mental health services.

As you know, we have submitted our views on numerous issues which have likely impact on how best mental health services might be organised and delivered in Ireland e.g. submissions to The Expert Group on Mental Health Policy, Criminal Law (Insanity) Bill 2002, Suicide Prevention group, Primary Health Care Strategy, etc.

We believe we must offer our views at every opportunity to contribute to the sensibledevelopment of mental health services, ensuring that services remain on the right track with the overall reform of health services nationally, guidance from the Mental Health Commission and the interests of clients foremost in mind.

Whilst we are cognisant of the realities of funding for health care we are concerned at the recently published HSE National Guidelines on Long Stay Charges available on the HSE website ( ).See Appendix 1.

It appears from the guidance document that in addition to clients residing in a long stay institution, charges will be applied to “those persons with an intellectual, physical or mental disability that are residing in community type residences” (p1). There is an exemption from charges when a person is “detained involuntarily under the Mental Health Act 1945 to 2001” (p2).

On the one hand, Ireland has been successful in recent years in achieving economic progress and improving the overall standard of living and quality of life of citizens. On the other hand, spending in mental health care has decreased from 10.6%of the total health budget in 1990 to 6.8% in 2003 (MHC, 2003). We strongly contendthatthe challenge of funding mental health services should be addressed through central funding and adequate resourcing of services without adversely affecting the user of the service.

We are mindful that mental health services have changed dramatically over the past 20 years. We also believe that services have quite a way to go before they represent a truly person-centred service with the clients interests centre stage. The recent guidance document regarding long stay charges, if implemented, does not protect the client’s interests, may well be to the detriment of developments in community mental health care by hampering attempts to engage the client in rehabilitation activities and does not appear to consider the restrictions it will impose on the clients ability to participate as an equal member of society.

We have set out below a number of points for consideration prior to the guidance document being operationalised and we would hope that these would be considered carefully by policy makers.

In 1996, the governments National Anti-Poverty Strategy’s (NAPS) health targets were to reduce health inequalities and associated poverty. The NAPS identified the social determinants of health, poverty and social exclusion, as critical factors influencing physical and mental health.The definition of poverty underpinning the National Action Plan against Poverty and Social Exclusion 2003-2005 is as follows:

“People are living in poverty if their income and resources (material, cultural and social) are so inadequate as to preclude them from having a standard of living which is regarded as acceptable by Irish society generally. As a result of inadequate income and other resources people may be excluded and marginalised from participating in activities, which are considered the norm for other people in society”.

It is widely acknowledged that people experiencing poverty report higherlevels of mental illness and stress. There is astrong relationship between the experienceof basic deprivation and psychologicalwell-being. To subject vulnerable clients who are in need of continuous care, support and supervision to these increased charges is likely to reduce the opportunity for staff whose efforts are focused on empowering residents and equipping them with the necessary skills to participate fully in society.
The term 'institutionalism', in the context of residential care, was originally used to describe a process whereby long-stay patients in psychiatric hospitals could gradually adopt, over a period of years, an attitude of indifference about leaving or of positively wishing to stay. Mental health workers in community services are involved in helping clients build supportive community connections outside the mental health system, with a view to rehabilitation towards a greater level of independence. Overcoming the effects of institutionalisation, established in mental hospitals when there was no alternative service provided, is an important aspect of residential services in the community. It could be argued that the long-term nature of their need for continued support and rehabilitation would not be so if mental health services had adequately provided alternatives to the institutional based model of care.

Rehabilitation, defined as the process of enabling the person to make the best use of their residual abilities in order to function at an optimum level in as normal a social context as possible will not be a realistic option, if the proposed charges are introduced.The efforts of health care professionals in equipping clients with the necessary skills (e.g. money management, budgeting, shopping, etc) to reintegrate into society are significant. This process of enabling the client with enduring mental disorder to engage in all aspects of community living, to sustain and develop social relationships and to make enjoyable and creative use of their leisure time is to a large degree dependent on teaching the client to manage finances constructively.

Residents in supported community accommodation are some of the more economically disadvantaged members of society. Most will have suffered mental disorders from very early adulthood, and for many, by virtue of their illness and prolonged periods of hospitalisation, have been denied the opportunity to accumulate wealth. We believe that to introduce such sizeable charges to residents is counter-productive to our clients well being and we would suggest that it is important that the Department of Health & Children ensure that this policy proposal is reviewed in the context of being ‘poverty proofed’, as recommended by the National Anti-Poverty Strategy.

As outlined in “Quality and Fairness”, Goal 1, Objective 1, Action 1of the Health Strategy (2001), a Health Impact Assessment (HIA) should be carried out on all new government policies. If not already done, westrongly suggest that a HIA be carried out on the likely outcome for clients in mental health services if this guidance document is implemented.

There is significant anecdotal evidence of similar charges in community mental health facilities in the United Kingdom having a detrimental effect on the clients’ health & well-being. Clients whose weekly income is in the region of €30 to €40 and who smoke cigarettes often resort to begging for loose change, engage in petty shoplifting and other minor anti-social behaviours. The public perception of the mentally ill person as a nuisance may well be reinforced and thus eradicate the gains made in demystifying and reducing the stigma of mental illness.

Some clients may refuse to pay these charges and prefer to have their social welfare benefits to themselves while living on the streets. This is obviously a very dangerous situation as the obvious vulnerabilities of clients make them an easy target for those who look for easy victims. The risk of disengaging from mental health services and subsequent relapse and the increased risk of engaging in harmful behaviours which threaten their lives and the lives of others is very real. A frequent finding by inquiries into failures in mental health community care in the UK was disengagement and / or loss of contact with services (Reed 1997, Ritchie et al 1994).

For the client to engage in community resources, finances are vital. If the client is to be charged the rates suggested in the guidance document, it is presumed that their needs in terms of clothing, footwear, personal care such as hairdressing, social activities etc will be provided by the health service provider. If this is indeed the case, in effect this will destroy the slow but steady progress in mental health care of the past 50 years, moving from a client-focused service where independence is promoted back to a replication of the total institution as described by Goffman (1961).

We call for the exemption criteria to be expanded to include mental health clients in supported accommodations where there is an emphasis on rehabilitation and normalisation. We assert that the cost of maintaining the status quo in terms of charges for supported accommodations in mental health services will be exceeded by the benefits to the client.

References:

Goffman E / 1961 / Asylums: Essays on the Social Situation of Mental Patients and Other Inmates. New York: Doubleday.
Mental Health Commission / 2003 / Annual Report 2002. Mental Health Commission: Dublin.
Reed J / 1997 / Risk assessment and clinical risk management: the lessons from recent inquiries. British Journal of Psychiatry. 170 (suppl.32), 4-7.
Ritchie J, Dick D, Lingham R. / 1994 / Report of the Inquiry into the Care and Treatment of Christopher Clunis. London, HMSO.

Bibliography:

Department of Health & Children. / 2001 / Quality and Fairness: A Health System for You. Dublin: Stationery Office.
Department of Social and Family Affairs. / 2004 / National Action Plan against Poverty and Social Exclusion. Office for Social Inclusion.Dublin: Stationary Office.
Department of Social and Family Affairs. / 2005 / What is being done about poverty and social exclusion? Office for Social Inclusion.Dublin: Stationery Office.
Department of Social, Community and Family Affairs. / 1996 / National Anti-poverty Strategy – Sharing in progress. Dublin: Stationery Office.