The recent St Patrick’s Hospital Founder’s Day Forum saw what was described as ‘a real beginning’ on the issue of whether universal health insurance will result in improved mental health services. Pat Kelly reports.
Held on October 9, The St Patrick’s University Hospital Founder’s Day Programme culminated in the Founder’s Day Forum, which debated the subject: ‘Will Universal Healthcare Deliver Better Mental Healthcare?’ and provided a much-needed platform for interested parties to explore the proposed introduction of universal health insurance (UHI) and its relevance to mental health services.
The Founder’s Day is one of the only mental health events in Ireland to include all stakeholders in mental healthcare nationally, including clinicians, researchers, advocates and service users themselves.
The need to maintain and enhance the focus on mental health services with the introduction of UHI was highlighted by recent research released by the Oireachtas Cross-Party Group on Mental Health. The nationally-representative survey of almost 1,000 adults revealed that more than two-thirds (68 per cent) were of the opinion that the importance of mental health provision has increased in recent years, and 66 per cent felt that such services had suffered disproportionately from budget cuts.
Chaired by broadcaster Pat Kenny and with introductory comments from Minister for Mental Health Kathleen Lynch TD, the Forum heard the thoughts and proposals of some individuals with a special interest in how UHI will be implemented and its effect on mental health services. Among these were Dr John Hillery, Consultant Psychiatrist and former President of the Medical Council, and Maurice O’Connell, CEO of the Alzheimer Society of Ireland. The Forum heard the aspirations and trepidations of the panel and opened up what was described as the first meaningful attempt to address UHI and mental healthcare in a structured environment.
Speaking to Irish Medical Times after the event, Dr Hillery explained: “It seemed that everyone was supportive of a certain type of universal healthcare; by ‘certain type’, we mean that it would be of a high quality and with equal access to all. It emerged from some discussions I had that people weren’t going to want something that just meant that everyone was going to be in a position where they couldn’t access services.”
Dr Hillery lamented the lack of access to associated services, such as counselling, for psychiatrists and GPs alike and commented that Ireland was “stuck in a uni-model” where the psychiatrist was often the first port of call for someone with a mental health problem. “The issue is access,” said Dr Hillery, “and UHI can go some way towards addressing that if it gives more control to the patient and if we put more resources into educating patients. There are pilot schemes in the UK and the Netherlands where patients get more control over their own budgets and this would help, along with the availability of a wider variety of interventions.”
He emphasised that the implementation of UHI should be crafted in such a way that the quality of services would be improved in this fashion. “It shouldn’t bring about a position where everyone is equal, but things stay exactly the same as they seem to be at the moment,” said Dr Hillery. “What it should do is produce a system whereby people have quick access to services when they need them. If that’s what it turns out to be, then people would welcome it and it will definitely improve mental healthcare.”
This need for improvement was emphasised by the results of the nationwide IMT GP survey, reported on in this issue, which showed that 96 out of 102 GPs reported a marked increase in patients presenting with symptoms of stress or depression associated with the economic downturn. Assuming that the economy does not make a dramatic recovery in the very short term, the importance of protecting and enhancing mental health services in the coming years assumes even greater import.
In regard to this, Dr Hillery commented that along with UHI implementation, there should be a drive to use the resources at the disposal of mental health professionals more efficiently: “We should be looking at where we can achieve the best value — and by ‘value’, I mean what will result in the best outcomes for patients. We don’t seem to quantify that in the health services at the moment in Ireland. We talk about value for money all the time but we don’t talk about how this relates to good outcomes for patients. Good value should mean good results for patients.”
Dr Hillery told IMT that while there was a real need for more resources in mental health, the implementation of UHI should include more efficient use of the ones that already exist.
“How are we all judged as a health service?” he asked. “Are we judged on the number of patients we see, or on the outcomes? Of course, it should be on outcomes.”
One of the points Dr Hillery raised in the Forum was that UHI should ensure fast, equal access to quality care on the basis of needs. Others stressed the need for good governance within the system to make sure the resources are used efficiently. “We should build on what we have at the moment, not start a whole new system, ensuring that we fully utilise what we have available to us right now,” he said. “We should build on that and it’s hugely important that what is best for patients should be at the heart of every decision.”
However, rather than simply calling for greater resource efficiency, Dr Hillery offered a practical, tangible service improvement suggestion. He raised at the Forum a concept that exists in certain parts of the US, whereby patients could have ‘advisors’ or ‘mentors’. “These are people who have been service users and who are available to people to help them make their way through the system. This is possibly a wider subject for a later debate, but it wouldn’t be particularly expensive to implement and we could actually save a lot of money by ensuring that people receive the appropriate treatment when they need it.”
The panel also included Consultant Psychiatrist Dr Justin Brophy and Irish Times journalist Carl O’Brien. O’Connell emphasised the usefulness of the event in establishing how much common ground existed between representatives from different areas as to what is expected from UHI in terms of mental healthcare.
The panel and delegates alike were united in their appreciation of the need for effective, efficient mental healthcare under crippling budget constraints: the Oireachtas Cross-Party Group survey also showed that 85 per cent of respondents agreed that the State needs to prioritise mental health by increasing its budget over the next three years, while an overwhelming 92 per cent believe awareness and understanding of mental health issues should be part of the curriculum in Irish secondary schools.
Long way to go
“There is a great willingness to engage,” O’Connell told IMT. “Everybody recognises that there is a long way to go to get mental health and community care services up to a level that serves the people well. The kind of debate that we had [here] is the beginning of a real, genuine ask for something more.”
Describing the Founder’s Day overall as a “well-organised vehicle for communication”, O’Connell commented: “There has been very little space for debate as to what universal healthcare is really all about. The challenge — certainly for people with dementia — is for a UHI programme to have a couple of certain things. One is that clear, integrated clinical pathways will be needed because what was evidenced was clearly that what happens in the hospital today, will happen in the community tomorrow. In other words, the person who is hospitalised needs to go home at some point and if we don’t have the kind of structures that are consistent with the patients’ needs, they are going to end up back in hospital again very quickly.”
O’Connell called for any implementation of UHI to include a holistic approach to the patient journey through the healthcare system. “Any UHI programme needs to make sure that it fundamentally invests in the whole journey of the person with dementia, not just at the medical end of services, but from the community services point of view,” he told IMT.
There were also calls for details and guidance — or at a minimum, a loosely-structured framework — on how UHI will be implemented so that there may be meaningful buy-in from healthcare professionals and patient representatives. “Dr Reilly said initially, way back when this was first mooted, that it might not happen in the lifetime of this Government but in fact, one needs some kind of framework to make sense of it. I would be calling on the Government, wherever there is a strategy, we should be asking them to put some kind of direction on it,” commented O’Connell.
“We have to have some semblance of a framework and there is a big fear out there that the new system might not actually be any better than the one we have and we need to influence it so that it becomes the best that we can afford.”
Regarding the role of the Alzheimer Society in helping to shape policy, O’Connell revealed to IMT: “There has actually been a consultation by the Department of Health regarding a dementia strategy, which was promised in the programme for government by 2013, and submissions have gone in. We are very clear about what we feel would make up an effective dementia strategy and some of the challenges that will face the Government too. Dementia planning is going to be key to the future planning of services. That commitment from the Government is not too far away, so we need to get our finger out.”
He indicated that the Society will be asking the Government for a clinical lead on dementia care. “That’s not going to cost a lot of money but would begin to join some of the disjointed approaches to dementia care in the community and in hospitals.
“So what we have with UHI is an opportunity to reconfigure and that’s one of our big asks. Another is integrated care pathways, and another is to raise awareness to help people with dementia to be diagnosed earlier. This could help people to be cared for longer in the community, without rushing them into long-term care.”