Terence Cosgrave speaks to Dr Justin Brophy about the recent establishment of the Irish College of Psychiatry and his hopes for better mental health care in Ireland
The attitude to mental health and services for the mentally ill in Ireland has been ‘get on with it, put up with it or get over it’ for years, but with the creation of an Irish College of Psychiatry, it is hoped that a boost will be provided to both the profession of psychiatry and Irish mental health itself.
According to the new President of the College, Dr Justin Brophy, there was a need for an indigenous Irish body to react and relate to the reality on the ground in Irish mental healthcare, because that reality was increasingly diverging from the UK in legal and other practical ways.
In this newspaper in the last few months, Dr Dermot Walsh has written about the history of Irish psychiatry and its relationship with UK-based institutions that oversaw the profession of psychiatry and its practice in the UK and here.
While that system had a potted history, it was perhaps surprising that after independence it took so long for an Irish College to be established. But as time went by, and with the introduction of more and more complex legislation, it was obvious that it would be a case of when, rather than if, a separate Irish College would be established.
h4. Spring conference
That finally came to head recently — particularly in the wake of the Medical Practitioners Act 2007 – and the Irish College of Psychiatry will be launched next week at its first spring conference.
“The UK College was going down a different road in certain circumstances – in relation to training, in relation to its relationship with government and in its relationship with the profession,” Dr Brophy said.
“Accreditation of Irish schemes, which had always been done on a reciprocal basis with the UK, was no longer possible — which meant that Irish schemes had to be accredited by a body with Irish statutory recognition. But that wasn’t the primary driver. The primary driver was that the timing was right. It had been coming for a long time and it was on the back of that buoyancy and optimism – a feeling that ‘we can do it’. That was as important as anything else.”
Discussions began between the three different bodies – the Irish Psychiatric Association (IPA), the Irish division of the Royal College and the Irish Psychiatric Training Committee (IPTC) and they came together – ‘very quickly, actually’ – to make it happen.
“It took about a year to put all the pieces together because there was quite a choreography in terms of the Medical Council, the disentangling from the UK, establishing a body here and transferring over responsibilities and functions. So that all took time.
h4. Fraternal links
“We’ve severed formal links with the UK, though fraternal links remain, and we’ve recruited 450-plus members. We’ve employed six people and found an office, so we’re well up and running within eight weeks of kick-off. We’re in full production.”
Dr Brophy says that it is a very exciting time in Irish psychiatry and that there is ‘a sense of goodwill, a sense of excitement, a sense of optimism that it has been achieved and a sense of promise of what it might achieve’.
He says that a lot of psychiatrists who were not particularly active in College affairs have come on board and are prepared to give a lot of time and energy to it, which he believes is ‘greatly encouraging’.
The Medical Practitioners Act was a large driver in creating the College. When the 2007 Act came into law, it bore no resemblance to the UK legal arrangements, and training in Irish law – which was evolving at a very rapid pace – needed to be done here. There was also difficulties in terms of the NICE guidelines, which are common in the UK but have no currency here, and other issues like how the health service is structured. HSE reform meant that the health systems here increasingly bore no resemblance to the NHS in the UK. So Irish psychiatry could not relate to initiatives occurring in the UK as being relevant here and vice versa.
“The problem,” said Dr Brophy, “was that many of the UK College’s initiatives – while worthy in themselves — couldn’t really be adapted to an Irish context.”
The Irish College of Psychiatrists was the name of the Irish division of the Royal College, but it was not recognised by the Medical Council because it was a subsidiary of a UK body. The Medical Council can only deal with something that exists under Irish statute. That is why the IPTC needed to exist because the Irish division could never fulfil that function, by definition, because of its constitutional embarrassment before Irish law.
The College has now set itself up in its offices in Corrigan House on Fenian Street, which used to house the Postgraduate Medical and Dental Board. The organisation will have four main areas of activity: Training, Continuing Professional Development, Public Relations/Public Affairs and Members Affairs.
There has been a ‘massive recruitment drive’, according to Dr Brophy who says that the College is supporting members and developing a database of trainees while accreditation schemes have already begun.
“We hit the ground running in terms of showing that there’s a serious commitment to training. Until now, Irish schemes were accredited by UK teams and they lacked the rigour in implementation that needs to be applied. They were a little hesitant about applying the full effect of their recommendations. They just didn’t feel it was appropriate,” he said.In terms of members, there are about 700 potential members, so there are still quite a few who have not joined yet.
“Not all will join,” says Dr Brophy. “Not all are current members at any particular time. But the 450 that we have already signed up is better than what we projected and we expect by the end of the spring conference, it will be even higher.
“When the Medical Practitioners Act is enacted, all doctors who wish to remain on the specialist register will have to belong to their College group. When that comes into law, we expect membership to be completed at that time.”
The next big event for the College is the spring conference — which is due to take place next week on March 26/27 at Carton House in Maynooth, Co. Kildare. It is expected to be a ‘very special event’ given that it is the first conference of the College — and something that many feel should have happened years, if not decades ago.
But will the College have an effect outside the world of psychiatrists and will it have any benefit to patients?
h4. Public relations
Dr Brophy believes so and says this is one of the reason the College is the Irish College of Psychiatry, rather than the Irish College of Psychiatrists.
But the public relations and public affairs aspect of the College will be key, he says, to improving mental health treatment in Ireland.
“Before this, public relations was never seen as a priority of any of the professional bodies. The obligation was around training. It’s becoming increasingly clear – not just to psychiatrists, but to all the professional training bodies — that they need to influence and shape the external environment in which they operate and react to it. So we see it as a key priority for us in terms of representing the College to its public, but also trying to influence and engage with other stakeholders like the HSE, the Commission for Mental Health, the general public and the NGO sectors such as Amnesty, Schizophrenia Ireland and AWARE. We’re in the same scrum as everybody else – listening to what they have to say and accommodating their legitimate concerns about our activities, but also trying to communicate our activities to them in a way that perhaps is sometimes misrepresented and misunderstood.”
What then is the current state of mental health services? Is there a lack of implementation of mental health policy?
“There’s a sense of great concern that the political and administrative urgency, which is reflected in A Vision for Change, is not having its full effect. I think A Vision for Change reflected not just a general policy review, but a real public concern that we need to modernise and change mental health services. I think we’ve fallen victim to political inertia and HSE re-organisation.
h4. Priority list
“Mental health has gotten bumped down the priority list. And we’re now in danger of facing a third hurdle – a resource famine, a retrenchment and the cutting of services. Since A Vision for Change came out, we’ve had an ill wind, but we haven’t abandoned hope. We have deepened our resolve to try to make it clear that we are ready to lead the reforms as much as possible.
“A Vision for Change has also been delayed by the finalisation of the consultant contract and the clinical director bit of that, which has stymied it as well. In addition, the introduction of the Medical Practitioners Act muddied the waters in terms of where the priorities were because the legal priority seems to divert and take impetus from the reform agenda – even though they’re one and the same.
“While the Commission will ultimately lead to reform in quality, it can’t be at the expense of resources and energy and actual reform on the ground as well.”
What is the state of mental health services in Ireland at the moment? “Like the curate’s egg, it’s good in spots — but only in spots. There’s a serious lack of sophistication and diversity in the modality and philosophies of treatments within our services. We offer very little other than medical and nursing care. We offer very little in terms of other therapies – the result is that we are blamed for what we do offer.
h4. Greatest difficulty
“What we offer in of itself is not bad; it’s just not balanced with the other things that should be there. That’s the greatest difficulty. Let’s say a young person develops a depressive illness. Maybe he has dabbled in drug abuse, maybe has unresolved issues in terms of career choice. He will go to his GP but the GP will have very little on offer apart from a brief intervention, an option of medication or referral to a psychiatrist. “The psychiatrist will say ‘yes, you’re depressed; you need to deal with your substance abuse but I have no counsellor available to whom I can send you. The substance abuse counsellor you need is very difficult to access and the service is very slow to make that person available to you’.
“We can’t give any other support. We can’t offer visits at home, we can’t offer a peer support group, we can’t offer a psycho-education programme in terms of improving general well-being and mental health and we can’t offer exercise or a physical well-being programme. We can’t offer anything we should be offering. Basically, what we offer is a chat, to keep the patient alive with tablets and let the rest take care of itself.
“It’s not what we want to do and it’s not what the patient needs. So we’re very hampered and we’re frustrated.
“On the in-patient side, because of the lack of community services, there’s an over-reliance on beds. There’s occasionally an appalling and shocking lack of decent adequate accommodation and standard of care for the long-term ill. That’s well-documented. There’s a deeply shameful part of that which never receives the attention and the direction that it needs.
“It’s a big ask for the College to address these issues because Ireland has little regard for its mental health. It has little priority for mental health – at least up to now. There was an explosion in Europe regarding the relevance of and need for psychological health and psychological services after the Second World War, with so many people traumatised in its aftermath.
“We never saw that and never accepted the need to take care of psychological health – we simply looked after the most severe cases in institutions and culturally we have missed out. That’s a big cultural shift.”
But Dr Brophy is hopeful that the new College will keep the focus of all stakeholders on the issue of mental health and improvements will come in time.
The input of the College into decision-making should ensure that mental health services of the future in Ireland are based more on what the modern patient needs, rather than some of the antiquated models of the past. And with the College being launched officially next week, it surely is a new spring and start for the College of Irish Psychiatry and mental health in this country in general.