2021 Annual Report: gaps in care between private and publicly funded mental health services
Thursday, June 30th, 2022
Independent privately-run inpatient mental health centres typically offer a better level of care than HSE-run facilities, according to the Mental Health Commission’s (MHC) 2021 Annual Report.
The report shows that significant investment is required into HSE-run inpatient services to ensure all people, regardless of their financial means, have access to a similar standard of inpatient care throughout Ireland.
“Unfortunately, this means that only a select number of people - who either possess private health insurance, or the financial means to pay out of pocket - can access many of Ireland’s high-performing independent centres,” said the Chief Executive of the Mental Health Commission, John Farrelly. “Costs should not prevent people from receiving adequate mental healthcare,” Mr Farrelly added.
The report - which has been published this morning and includes the annual report of the Inspector of Mental Health Services - shows that, apart from one HSE Community Healthcare Organisation (CHO), the 10 independent and privately-run inpatient centres scored a higher average overall compliance rate. The one HSE area that scored higher than the privately operated facilities was CHO 5, which covers south Tipperary, Carlow/Kilkenny, Waterford and Wexford.
The 2021 compliance and monitoring data highlights concerns in four key areas: premises, individual care planning, risk management procedures, and staffing. The report also shows that the independent centres are also scoring better in these areas than HSE-run services, with the notable exception once again of CHO 5.
“Our 2021 Annual Report shows clear evidence that the independent, private mental health service providers are generally providing care in superior standard premises than those within the public system,” Mr Farrelly said. “The independent and private services are also more compliant with the requirement to ensure that each resident has an individualised plan of care.
“Publicly-funded mental health services require significant improvement in terms of compliance and funding if we are to create a more equitable health care system for people who need to access inpatient mental health services.
“In recent years, Sláintecare set out a high-level policy roadmap to deliver whole-system reform and universal healthcare through a single-tier health service providing treatment solely on the basis of health need,” said Mr Farrelly. “In addition, a key purpose of our current mental health policy, ‘Sharing the Vision’, is to introduce a more comprehensive, accessible, community-based, specialist mental health service based on need, rather than ability to pay.
“Although it is clearly evident that access to acute adult inpatient mental health care is not currently equitable in Ireland, the policy and vision to bring the public system in line with the private system is in place. It is time for the health service to now deliver on this vision and implement the policy to ensure that all of our citizens have access to the best care and treatment, as soon as they need it and irrespective of their financial means.”
The MHC has written to the HSE seeking an updated action plan to address the significant issues raised in its Annual Report, particularly around premises, individual care plans, and risk management practices.
Premises
The report highlights that the premises-related concerns in HSE approved centres is related to both inadequate resourcing and to poor governance arrangements.
Of the 19 instances of non-compliance that received a critical risk rating during 2021 – meaning that there was a high likelihood of continued non-compliance and a high impact on the safety, rights, health, or wellbeing of residents – seven of these related to premises.
“The quality of premises remains the primary cause of concern, as it has done for many years,” said Mr Farrelly. “For example, over the past five years, compliance with regulations on premises has been very low, with an average compliance rate of just 35%.”
In 2021, the compliance rating for the regulation on premises for each CHO was: 25% for CHO 1 (comprising four centres); 33% for CHO 2 (nine centres); 25% for CHO 3 (four centres); 20% for CHO 4 (10 centres); 57% for CHO 5 (seven centres); 0% for CHO 6 (four centres); 25% for CHO 7 (four centres); 33% for CHO 8 (six centres); and 25% for CHO 9 (eight centres). This compares with a 70% compliance rating for the same regulation across the 10 independent providers.
The Inspector of Mental Health Services, Dr Susan Finnerty, acknowledged that although several new centres have been built in recent years which provide a modern environment - including communal and private spaces with rooms for leisure and therapeutic activities - there remains a significant number of outdated, unsuitable buildings within the HSE stock, which have suffered years of environmental neglect.
“Progress is slow on replacement of buildings or on renovations to bring them up to a modern standard. Of particular concern are risks in relation to fire safety and ligature anchor points. Inspectors’ findings in relation to these risks should be recognised and remedied by the service to make an approved centre safe. It should not be the case that service providers wait until the annual inspection identifies them and enforcement action takes place. Such knee-jerk response to adverse findings of an inspection does not indicate good governance. The comparatively better compliance rates in CHO 5 shows that the capacity is in the HSE to adequately address the premises challenges.”
The Inspector highlighted the identification of multiple serious risks and poor environments across five HSE approved centres in Co Cork, which has required repeated focused inspections and escalating enforcement actions to compel the HSE to begin to remedy the non-compliances. These enforcement actions have had to continue into 2022.
“While we recognise the investment in premises to date, the current approach to structural improvements is inadequate,” said Mr Farrelly. “To ensure every person in Ireland can access a place of hope and healing we require a new targeted, funded strategic capital investment programme.
“More generally, if we are to address the findings set out in this report, the need for enhanced leadership and governance across the health service is essential. This is imperative if we are to achieve the delivery of the wide-ranging and innovative actions set out in ‘Sharing the Vision’ over the next 10 years.”
Individual Care Plans
Dr Finnerty was particularly critical of the persistent low compliance with the regulation on individual care plans, with negligible change in 2021, where 36% of approved centres were non-compliant with this regulation.
“The HSE states that care planning and the individual care plan document are essential to person-centred recovery-based care within inpatient and community residential settings and has provided a step-by step guidance in how to develop and review an individual care plan,” she said. “Despite this, the HSE has failed to significantly improve care planning for service users over the past five years. This shows poor leadership and accountability.”
Applications for involuntary detention
In relation to people who were detained against their will at inpatient centres, the data from 2021 showed that applications to involuntarily detain people by An Garda Síochána continued to increase. In all, there were 1,971 admission orders for involuntary detention from the community in 2021 (compared to 1,919 in 2020), with 35% of these initiated by An Garda Síochána (compared to 32% in 2020)
“As we pointed out in last year’s annual report, the only person to sign applications for involuntary admission to an inpatient centre should be an authorised officer of the health service,” said Mr Farrelly. “The thought process behind this is that it will have the effect of lessening the burden on families and carers, while it will also reduce the involvement of Gardaí in the admission process.
“We expect that this area will receive particular scrutiny ahead of the publication of the amended 2001 Act. We acknowledge that funding and resources will be required, but this investment is imperative as we cannot allow applications by the Gardaí to continue.”
Positives
The report paid tribute to all professionals and centre staff who worked hard to ensure each person who was involuntarily detained in 2021 received a tribunal, despite the restrictions placed on them as a result of COVID-19.
This report also shows that there has been a continued upward trend in compliance with regulations. Approximately 89% of approved centres achieved an 80% rate of compliance or higher, compared to 82% of services in 2020. Only seven services had a compliance rating lower than 80% in 2021, and no individual service had a regulation compliance rate lower than 68%.
“These improvements around compliance are very welcome, and we commend all clinical staff and management who delivered these improvements,” said Mr Farrelly.
In relation to restrictive practices, there was a welcome reduction in episodes of both physical and mechanical restraint, while episodes of seclusion were similar to the level reported in 2020. In order to increase the protections provided to people who experience restrictive practices, the MHC intends to publish updated rules and codes of practice governing these practices in 2022.
The report showed that there also continues to be a very high compliance with the rules on electro-convulsive therapy (ECT), reflecting the move to centres of excellence over a number of years, while since the MHC issued guidance on general health monitoring in 2019, the report demonstrated that there has been a steady improvement in monitoring patients’ physical health.
