Dr Mary Keys A Policy Approach to Embedding Rights in Mental Health Services

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 18th 2009Mary 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

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

Vision for Change 20061

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 Change2

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 Change3

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

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

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

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?

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?

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?

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?

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

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

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

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…

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…

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

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”

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