A Policy Approach to embedding rights in Mental Health Services: A Vision for Change and the experience in Ireland Irish Mental Health Coalition Conference, Dublin May 18 th 2009 Mary Keys, School of Law, NUI Galway

Introduction Brief on Vision for Change Implementing Vision for Change The impact of current practices Is legal action realistic? Some possible explanations The future Conclusions

Brief on Vision for Change

Implementing Vision for Change

The impact of current practices

Is legal action realistic?

Some possible explanations

The future

Conclusions

Real Life Dave, aged 64 years, spent a number of years in a psychiatric hospital. Discharged to a medium support hostel, his home for a number of years Attended a day centre each day, paid rent from his DA Difficulty with using the stairs -nursing home was proposed Now lives in a nursing home and complains that he has no-one to talk to as many of the residents have communication difficulties

Dave, aged 64 years, spent a number of years in a psychiatric hospital.

Discharged to a medium support hostel, his home for a number of years

Attended a day centre each day, paid rent from his DA

Difficulty with using the stairs -nursing home was proposed

Now lives in a nursing home and complains that he has no-one to talk to as many of the residents have communication difficulties

Vision for Change 2006 1 Framework for complete model of mental health service provision Principle based and respect human rights Holistic approach to mental health problems Person centred approach based on Recovery ethos to inform every aspect of delivery Service user as partner in own care plan- to reflect needs, goals and potential

Framework for complete model of mental health service provision

Principle based and respect human rights

Holistic approach to mental health problems

Person centred approach based on Recovery ethos to inform every aspect of delivery

Service user as partner in own care plan- to reflect needs, goals and potential

Vision for Change 2 Service user involvement the norm in every aspect of service development and delivery- similarly with carers Integrated multi-disciplinary approach to factors that contribute to mental health problems Specialist community mental health teams to address needs across life span Effective community service

Service user involvement the norm in every aspect of service development and delivery- similarly with carers

Integrated multi-disciplinary approach to factors that contribute to mental health problems

Specialist community mental health teams to address needs across life span

Effective community service

Vision for Change 3 Managed by a National Directorate-working directly within the HSE Locally by Mental Health Catchment Area Management Teams Service provision to be prioritised on needs basis Services should be meaningfully evaluated Closure of all psychiatric hospitals

Managed by a National Directorate-working directly within the HSE

Locally by Mental Health Catchment Area Management Teams

Service provision to be prioritised on needs basis

Services should be meaningfully evaluated

Closure of all psychiatric hospitals

Implementation-who’s watching? Independent Monitoring Group 1 Vision cannot be implemented effectively without a National Mental Health Services Directorate Has impeded progress on poor facilities Inconsistent approach to embedding Recovery ethos in services Absence of comprehensive implementation plan Progress made on some priorities, child and adolescents, engagement with service users, 2009 Report- www.doh&c.ie

Vision cannot be implemented effectively without a National Mental Health Services Directorate

Has impeded progress on poor facilities

Inconsistent approach to embedding Recovery ethos in services

Absence of comprehensive implementation plan

Progress made on some priorities, child and adolescents, engagement with service users,

2009 Report- www.doh&c.ie

Implementation-Who’s watching ? 2 Inspector of Mental Health Services Lumping all mhs tog. in PCCC + no Mental Health Directorate “caused confusion, misunderstanding, muddied mission, poor decisional capacity ” Broad Impact –people admitted to institutions No progress in resource equalisation Lacking comprehensive community services Impact of restrictive work practices

Lumping all mhs tog. in PCCC + no Mental Health Directorate “caused confusion, misunderstanding, muddied mission, poor decisional capacity ”

Broad Impact –people admitted to institutions

No progress in resource equalisation

Lacking comprehensive community services

Impact of restrictive work practices

Implementation-Who’s watching? 3 Irish Mental Health Coalition “ Late for a Very Important Date” progress painfully slow No Mental Health Directorate Children in Adult wards HSE Implementation plan with lack of detailed commitments-finance, resources HSE should publish quarterly reports of progress for the Implementation Group The number of fully staffed Community Mental Health Teams are limited and not clear Government commitment to ring fencing existing mental health funding

“ Late for a Very Important Date” progress painfully slow

No Mental Health Directorate

Children in Adult wards

HSE Implementation plan with lack of detailed commitments-finance, resources

HSE should publish quarterly reports of progress for the Implementation Group

The number of fully staffed Community Mental Health Teams are limited and not clear

Government commitment to ring fencing existing mental health funding

Real Life Community in the Gaeltacht presented a purpose built house to the HSE for sole use of the mental health service (proposed in 2001) Five service users, local Irish speakers selected-no comprehensive rehabilitation process House furnished by HSE and ready for occupation in 2005 One person lives in a high support hostel, the other people remain in institutional care where between them they have spent many years of their lives The house remains unused… How is policy assisting their recovery and life potential?

Community in the Gaeltacht presented a purpose built house to the HSE for sole use of the mental health service (proposed in 2001)

Five service users, local Irish speakers selected-no comprehensive rehabilitation process

House furnished by HSE and ready for occupation in 2005

One person lives in a high support hostel, the other people remain in institutional care where between them they have spent many years of their lives

The house remains unused…

How is policy assisting their recovery and life potential?

Issues arising Offer by an Independent sector to manage the service What are the expectations? Greater cost than the HSE original cost? At least a good solid knowledge of current mental health policy? At least a good solid knowledge of what the Recovery Ethos means?

Offer by an Independent sector to manage the service

What are the expectations?

Greater cost than the HSE original cost?

At least a good solid knowledge of current mental health policy?

At least a good solid knowledge of what the Recovery Ethos means?

Impact Mental Health Act 2008-Dail Debate-Minister Harney “unthinkable” that anyone would lose his/her liberty because of a lack of supported accommodation Has Dave lost his liberty, other five people? Informed consent-is it a robust approach? Does it include information on choices and possible disempowerment? That his place in the supported accommodation will be gone?

Mental Health Act 2008-Dail Debate-Minister Harney “unthinkable” that anyone would lose his/her liberty because of a lack of supported accommodation

Has Dave lost his liberty, other five people?

Informed consent-is it a robust approach?

Does it include information on choices and possible disempowerment?

That his place in the supported accommodation will be gone?

Re-institutionalisation? What are Dave’s options? He is re-institutionalised in a generic service designed for some older people Principles and values applying in mental health policy are lost to him He is in a service that is not focused on his needs What about his human rights, his everyday life activities, his Recovery?

What are Dave’s options?

He is re-institutionalised in a generic service designed for some older people

Principles and values applying in mental health policy are lost to him

He is in a service that is not focused on his needs

What about his human rights, his everyday life activities, his Recovery?

Principles and Capacity Least restrictive alternative Dignity and respect Capacity means: ( Proposed Scheme of Mental Capacity Bill) the ability to understand the nature and consequences of a decision in the context of available choices at the time the decision is to be made Best interests- ( Proposed Scheme of Mental Capacity Bill) Applies when person is unable to decide Person focused

Least restrictive alternative

Dignity and respect

Capacity means: ( Proposed Scheme of Mental Capacity Bill)

the ability to understand the nature and consequences of a decision in the context of available choices at the time the decision is to be made

Best interests- ( Proposed Scheme of Mental Capacity Bill)

Applies when person is unable to decide

Person focused

Is legal action an option? Olmstead v. Zimring 527 US (1999) Costs of segregated institutional environment vs appropriate community-based care R v. Nth & East Devon HA ex p Coughlan (2000) 3 AER 850 Person had a been assured of a home for life-she had a legitimate expectation- the decision to close her community residence for financial reasons was unlawful

Olmstead v. Zimring 527 US (1999)

Costs of segregated institutional environment vs appropriate community-based care

R v. Nth & East Devon HA ex p Coughlan (2000) 3 AER 850

Person had a been assured of a home for life-she had a legitimate expectation- the decision to close her community residence for financial reasons was unlawful

Is legal action an option? Courts are reluctant to get involved in directing how the public purse is spent Rarely make mandatory orders-directing the government (HSE) to do something If there are enforceable rights or specific agreements have been made and reneged on may make order then

Courts are reluctant to get involved in directing how the public purse is spent

Rarely make mandatory orders-directing the government (HSE) to do something

If there are enforceable rights or specific agreements have been made and reneged on may make order then

Why is this happening? Key issue- Political Motivation No director for mental health at top level of HSE where key decisions are made Unstable, fragmented and inappropriate structures in HSE Local level very important but unless principles and values are recognised…

Key issue- Political Motivation

No director for mental health at top level of HSE where key decisions are made

Unstable, fragmented and inappropriate structures in HSE

Local level very important but unless principles and values are recognised…

Bird’s Eye View Are we witnessing the new generation of human rights abuses? Moving people with mental health problems to nursing homes, or Keeping them in institutions while the community service is available The context is different from the 1800s and the institutions are smaller now…

Are we witnessing the new generation of human rights abuses?

Moving people with mental health problems to nursing homes, or

Keeping them in institutions while the community service is available

The context is different from the 1800s and the institutions are smaller now…

Optimism Office for Disability and Mental Health Mental Health Inspector’s Report 2009 “ Sense of beginnings of a cultural shift in term of increased professionalism, accountability and awareness of importance of good governance The central importance of service users/patients is increasingly recognised by clinicians Human rights obligations increasingly understood” www.mhcirl.ie

Office for Disability and Mental Health

Mental Health Inspector’s Report 2009

“ Sense of beginnings of a cultural shift in term of increased professionalism, accountability and awareness of importance of good governance

The central importance of service users/patients is increasingly recognised by clinicians

Human rights obligations increasingly understood” www.mhcirl.ie

Conclusion Policy approach is not enough Extreme caution and careful monitoring of local activities Temptation to use established systems as finance in place –it must stop State supported nursing home system-extraordinarily costly approach to “community care”

Policy approach is not enough

Extreme caution and careful monitoring of local activities

Temptation to use established systems as finance in place –it must stop

State supported nursing home system-extraordinarily costly approach to “community care”

Recommendations Immediate need for administrative/ management protocol Advocacy/representation must be made available where any major changes like accommodation are proposed Such decisions must be carefully addressed with the person Staff managing and working in mental health services must become more aware of impact

Immediate need for administrative/ management protocol

Advocacy/representation must be made available where any major changes like accommodation are proposed

Such decisions must be carefully addressed with the person

Staff managing and working in mental health services must become more aware of impact