The deinstitutionalisation of mental health services has advanced significantly in recent decades. The move to community based residences was developed in line with the mental health policy, Planning for the Future (1984). In the past decade, a programme transferring older residents to more appropriate facilities with mental health support was developed and implemented.
12.2.1 Rationale, Objective and Continuing Relevance
A key policy aim in A Vision for Change is the closure of old psychiatric hospitals and the transfer of patients to more appropriate community based settings. A Vision for Change estimates that mental health services should provide in the order of 2,800 beds/places in total between acute and continuing care beds and high support community residential places. Excluding the independent (private) sector there are approximately 1,200 acute mental health beds, and a similar number of continuing care beds catering for a variety of needs on mental health campuses. In addition there are 2,790 places in 363 community residences.
The primary objectives of the Long Stay Residential Care programme are the closure and reconfiguration of Long Stay Mental Health facilities and the transfer of responsibility for low and medium support accommodation to non HSE agencies.
Generally, the following categories of people could, with appropriate peer advocacy support structures, live independently;
• the current and upcoming generation of new long stay service users (1 - < 5 years in psychiatric institution) who have little experience of inpatient care and who have not developed a dependency on institutionalised care;
• the majority of service users currently residing in low and medium support HSE accommodation would be capable of making the transition to independent living with the support of the community mental health team and other community and social supports that may be required from time to time.
This transition would need to be implemented on a phased basis and would be subject to a number of variable factors.
Money obtained by the sale of mental health assets will be redirected into the development of new mental health infrastructure. It was proposed that in 2010 the HSE would proceed to dispose of assets and reinvest an initial sum of €50m in the mental health capital programme.
The programme for Government commits to the closure of institutions:
• Will close unsuitable psychiatric institutions moving patients to more appropriate community-based facilities and will develop specific strategies for elderly patients and those with intellectual disabilities who will remain under the care of mental health services.
12.2.2 Programme Effectiveness
Significant progress has been made in reducing the number of patients resident in Irish psychiatric units and hospitals over the last 40 years – a decline from 19,801 in 1963 to 2,812 in 2010. Recent progress has been made in relation to the closure of old psychiatric hospitals, for example, ceasing admissions to St Brendan’s Grangegorman and developing a 54 bedded replacement long stay facility. The Acute Unit of St Ita’s Portrane is to be replaced and admissions have ceased in St Senan’s Hospital Enniscorthy. It is anticipated that in 2011, the closure of one institution/hospital and the provision of cost effective
community based respite care would be achieved as a result of Innovation funding that was provided to the Genio Trust.
12.2.3 Programme Efficiency
Expenditure on this sub-programme is outlined in Table 12.1 below. As the HSE is unable to provide a breakdown at this level, the figures are taken from the Revised Estimates. Table 12.1: Trend in Expenditure - Long Stay Residential Services Mental Health 2008-2011 Provisional Outturn 2008(€) Provisional Outturn 2009(€) Provisional Outturn 2010(€) Estimated Expenditure 2011(€) Total Expenditure 607,000,000 585,000,000 560,000,000 534,000,000 The latest breakdown (provided by the HRB) of patient/clients in psychiatric hospitals and HSE community residences is as follows:
Table 12.2: Breakdown in number of Mental Health patients/clients length of stay and level of support
A Value for Money and Policy Review of the efficiency and effectiveness of long-stay residential care for adults within the Mental Health Services was undertaken and the report published in 2009. The review examined the services provided to long-stay adult mental health residents. It did not include patients who were receiving acute psychiatric hospital care.
Examples of the key findings of the review include:
• About one-quarter of clients reviewed were inappropriately placed, most could have had their needs met in lower supported accommodation and at a lower cost.
• Inappropriately placed long-stay service users should be prioritised for placement in community-based services. The provision by the HSE of low and medium care support accommodation should be discontinued. Instead, housing needs should be met by non- HSE agencies.
• There is scope for significantly increasing the proportion of service costs that are recovered in community residence charges. The existing system of charges to people living in community residences should be reviewed.
• There are too many beds in the system at present, relative to that recommended in A Vision for Change and the quality of the infrastructure is poor; only 335 of the 2,790 community beds are in units which are disability accessible and fit for purpose.
Savings can be generated by the full implementation of ‘A Vision for Change’ by reducing the number of in-patient beds including long-stay beds. The capital and human resources
Long Stay
1 - <5 years 494 (new long stay) 5 - < 10 years 260
10 < 25 years 238 25 years and over 194
Community Residences
High Support 1,613
Medium Support 547
freed up will be reconfigured to address current imbalances, develop assertive outreach, rehabilitation and home-based treatment teams as well as generic mental health teams etc. These teams will maintain service users in their homes/community, reduce hospital admissions and prevent inappropriate long-stay.
Collaborative work is ongoing between the Departments of Health, Environment, Community and Local Government and the HSE to develop a housing strategy for people with a disability (including mental health) to progress the recommendation that housing needs should be met by non HSE agencies.
12.2.4 Conclusions
There may be scope for raising revenue if the recommendation of the VFM group on charges is examined. It is expected that the money generated from the disposal of land and assets in the mental health sector would continue to be reinvested in the provision of community based services.