Irish Mental Health Policy: Lessons from the UK?

Transcription

1 Irish Mental Health Policy: Lessons from the UK? JAMES RAFTERY James Raftery is a lecturer in health economics at St George's Hospital Medical School, London. He worked in the jvesc Secretariat on social policy between 1981 and This paper outlines the similarity between the 1984 Irish official report, The Psychiatric Services Planning for the Future, 1 and its earlier (1975) UK counterpart, Better Services for the Mentally III, 2 and, noting the problems of implementation in the UK, suggests that Ireland might learn from the UK experience. Both countries have adopted policies which aim to radically shift psychiatric care from lunatic asylums to the community. Attempts to resolve the twin difficulties of funding the transfer of patients to the community, and of double funding new and old institutions over a transition period, have led to interesting UK policy initiatives. The similarity of the UK and Irish reports These two reports, which have been accepted as official policy, are almost identical in their aims, their proposed levels of service and the costs thereof. Both propose a shift to a community-based service. Each envisages acute general hospitals filling short- and medium-term psychiatric requirements. They accept a need for some long-stay accommodation, to be provided outside the lunatic asylums which are to be closed. A local or 'sectorised' approach is favoured, with a comprehensive array of services to be provided, mainly in the community. Hospital admission would be only as a last resort. Improved primary care plays a key role in both reports, including closer coordination between general practitioners and local psychiatric teams. In addition, the special needs of the elderly, drug-abusers, children and adolescents are to be provided for. The emphasis on non-institutional care prompts concern in both reports over housing and employment requirements. The levels of service proposed for Ireland and the UK are 39

2 40 Administration Vol. 35, No. 1 identical as measured by bed population ratios: 0.5 short- and medium-term beds per 1,000 persons, to be provided in general hospitals, and a further 0.5 beds per 1,000 for new long-stay patients in both purpose-built and adapted accommodation. Because of the projected demise of the psychiatric hospitals, some new long-stay accommodation would be needed elsewhere. Thus the overall target for new service provision is a total of around one bed per 1,000 persons with an additional but declining number based on the closure rate of the existing psychiatric hospitals. Current long-stay patients would, according to each report, be rehabilitated as far as possible, leading to discharge to community accommodation. The two reports take what can only be termed a casual approach to costing these ambitious objectives. Cost issues receive only half a page in the UK report and four pages in its Irish equivalent. Both agree that no additional running costs should be required. The necessary capital costs are considered to be well below those of renovating the existing hospitals. Indeed the underlying economic rational of the shift to the new community-oriented approach seems to relate mainly to the high cost of replacing the lunatic asylums in each country. Progress in the UK Despite the similarity of the two reports and the nine-year time lag in publication, the Irish report lacks any assessment of progress in the UK. Further, the different starting points in the two countries receive no attention, particularly the much higher level of psychiatric hospital bed provision in Ireland. For example, Ireland's ratio of psychiatric beds over 1,000 population is currently at the English level of 1960, the date when the run-down of the psychiatric hospitals first became official policy there. Since it has taken England 25 years to reduce its bed population ratios from 3.5 to the current levels of around 1.5, Ireland may take at least as long unless some lessons can be learnt. At an aggregate level, the indicators of progress in the UK are hardly reassuring. Only one mental illness hospital has been closed; Banstead Hospital in south London which closed in late 1986, with its patients 'decanted' into a nearby asylum. 4 The overwhelming majority of psychiatric beds remain in the old

3 Psychiatric Services 41 mental hospitals. Although the number of beds fell 16 per cent in the period 1976 to 1983, the real cost per inpatient has risen by one third' as more money was spent on fewer patients. The lack of progress can be gauged by the following: only around 10 per cent of total psychiatric beds are in units attached to general hospitals, 6 day care facilities remain well below the 1975 guidelines, with the number currently provided only one third of the hospital beds lost, some 50 per cent of local authorities lack hostels for the mentally ill, no routine monitoring exists of patients who have been discharged. Funding problems Slow progress has been due to difficulties of planning and implementing the major policy shifts, particularly where the constraint of fixed current expenditure apply. Two of the central problems seem to be: 1. how to transfer funds from the hospital to whatever new agency in the community receives patients, and 2. the difficulties of double funding old hospitals and new community services, side by side. The problem of transferring funds may be more difficult where different agencies are involved, as in England where local authorities provide personal social services. Where social services are combined with health services, as in Wales, Northern Ireland and, of course, the Republic of Ireland, this problem will apply mainly when the transfer of services is to voluntary bodies and the like. However, the second problem of double funding applies to all these countries, but to a lesser degree when extra funds are available, as in Wales 7 and to some extent Northern Ireland. The Republic of Ireland shares with England the zero-cost constraint thus worsening the double funding problem. Following concern over lack of progress, the UK government published in 1981 a consultative document 8 on ways that resources might be moved towards community care. In 1983 the

4 42 Administration Vol. 35, No. 1 DHSS announced support 9 for two of the more modest options, namely relaxing the joint finance arrangements which had existed since 1976, and allowing health authorities to make payments ('dowries') for patients discharged to other agencies. The more radical options, such as allocating administrative responsibility for the client group to a single authority, or of central transfer of funds to local government, were rejected only to surface again in later reviews. While the changed joint finance arrangements have not been particularly successful, the dowry system has made possible the closure of a number of mental handicap hospitals. The dowry system The dowry scheme results in patients who are discharged bringing with them an annual sum related to the average cost of keeping that patient in hospital. Each resident discharged receives a standard dowry, to be given to the receiving agency to help pay for an alternative service. In addition, discharged patients often become eligible for normal social security benefits. Receiving agencies thus can have an incentive to take patients who are being discharged, subject of course to the proviso that the alternative service meets certain standards. The theoretical basis of this approach is outlined in a pamphlet by economist Nick Bosanquet for the pressure group MIND 10 and a detailed account has been provided of the use of such a scheme in the rundown of the Darenth Park mental handicap hospital in Kent. 11 Double funding A number of initiatives have also been developed to deal with the problem of temporarily funding both the hospital and the new community service. Bridging finance, required to meet the transition costs, can be reduced in a number of ways for example: closing the hospital in stages so as to cut overheads; reducing the transition period; and adjusting discharge policies so that the less dependent and hence least costly are discharged first. Health authorities have financed their transition costs in a variety of ways which include: reallocating funds from other services, using special regional transition funds, selling and leasing back hospital sites to realise the site values in advance of

5 Psychiatric Services 43 closure, and tapping social security benefits by ensuring discharged patients claim fully any entitlements. At present, the South East Thames Regional Health Authority 12 is considering mortgaging four hospitals which are due for closure. The Short Committee Report Recent progress has been comprehensively reviewed in two recent official reports, one from a House of Commons Select Committee, the other from the Audit Commission. The Select Committee Report 13 (or Short Report, after the name of its Chair, Mrs Short) noted that theirs was the first inquiry of similar scope hitherto carried out by elected representatives. Despite misgivings, the Committee decided to continue to use the term 'community care', whose underlying principle they defined as: Appropriate care should be provided for individuals in such a way as to enable them to lead as normal an existence as possible given their particular disabilities and to minimise disruption of life within the community. After reviewing a wide range of submissions, the Committee considered that 'the cart had been before the horse', in that the removal of hospital facilities had far outrun the provision of services in the community to replace them. 'Any fool can close a long-term hospital: it takes time and trouble to do it properly and compassionately.' More positively, the Short Report recommended improved planning, increased involvement of patients and their families, and higher take-up by patients of social security. Most importantly, the Select Committee advocated increased funding. 'The proposition that community care could be cost neutral is untenable.' Real increases in expenditure on services for mentally ill and mentally handicapped people were seen as essential if community care policies were to be achieved. The committee, however, did not attempt to quantify the extra finances needed. The Audit Commission Report The necessity for extra finance has been challenged in a more recent report from the Audit Commission 14 which argues

6 44 Administration Vol. 35, No. 1 strongly that much more could be achieved within the existing budgets. Community care has been successfully implemented in some areas. Overall, however, policies are in disarray, it suggests, due to agencies pulling in different directions. Health and social services, in particular, are poorly coordinated. The methods for transferring funds have been inadequate in a number of ways. Dowry payments which take no account of the degree of disability have led to some agencies accepting and making a profit on the most fit. The inability to transfer all longstay patients has meant that some hospitals have to remain open, thus preventing the full transfer of resources. Dowries have been confined to patients discharged, thus ignoring those in need of care who have not managed to be admitted. This report also details problems of bridging finance, suggesting that strategies have been developed in ad hoc ways, leading to perverse incentives and cost shifting from one public authority to another. 15 However, the Commission argues strongly that the success of some authorities indicates that much can be achieved with committed local leadership and a preparedness to ignore the rules where necessary. Other identified ingredients for success include: delegated budgets to provide services at small localities, multi-disciplinary care teams, and partnership between statutory and voluntary organisations. The Audit Commission, concluding that radical change is necessary, suggests seriously considering making a single authority responsible for community care for the mentally ill. 16 Such an authority would have a single budget, to be used to purchase services from other agencies if, and as, appropriate. As was noted above, this proposal was raised but rejected by UK policymakers in the early 1980s. New government review Finally, at the end of 1986, the UK government announced 17 a twelve-month review of the arrangements for community care under the chair of Sir Roy Griffiths, whose earlier report has led to fundamental restructuring of NHS financial practices. In the light of the policy developments and shortcomings discussed above, Griffith's report seems likely to reopen the debate over whether more centralised authority and funding is required.

7 Psychiatric Services 45 Lessons for Ireland? If the UK has experienced such problems in achieving the same policy objectives from a much more advantageous starting point, as measured by having relatively fewer beds, what are the chances for such a policy in Ireland? And, taking advantage of Ireland's late commitment to these policy goals, what can it learn from the mistakes of its neighbour? Although the above gloomy account of progress in the UK should warn policymakers in Ireland against any rosy expectations that the policies adopted will be easy to implement, a number of the UK developments discussed above could facilitate the changes proposed. Firstly, a number of disincentives and impediments have been identified, particularly to do with a planning funding and organisational change. Secondly, a number of initiatives have been developed, including dowry payments and bridging finance schemes, both of which have many variants and which will undoubtedly continue to develop. Thirdly, community care has been successfully implemented in a number of places, due to factors like local commitment and a preparedness to break rules. Ireland's policymakers may be able to learn from these initiatives and the mistakes of others; which may be essential if they are to successfully implement the strategy that has been adopted. Ignorance is no excuse! Notes to article 1 The Psychiatric Services Planning for the Future. Report of a Study Group on the Development of the Psychiatric Services. Published by the Stationery Office, Dublin, December PI Better Services for the Mentally III. Presented to Parliament by the Secretary of State for the Social Services by Command of Her Majesty, October HMSO Gmnd Statistical Bulletin 1/85, 'Mental illness hospitals and units in England, results from the Mental Health Inquiry 1983.' Department of Health and Social Security, London, H. Reid and A. Wiseman, When the talking had to stop, community care in crisis: The case of Banstead Hospital, Mind Publications, London, Making a Reality of Community Care, A Report by the Audit Commission, London, HMSO, 1986, p S. Mangen and B. Rau, 'United Kingdom: socialised system better services?' in S. Mangen (ed) Mental health care in the European Community, Croom Helm, London, ' C. Wistow and B. Hardy, 'Transferring care: can financial incentives work?' Health Care 1986, pp.

8 46 Administration Vol. 35,.Vo CIPFA, London, Care in the Community: A Consultative Document on Moving Resources for Care in England, DHSS, London, Department Circular HC(83)6, DHSS, London, Nick Bosanquet, Extending choice for mentally handicapped people: The case for service credits, MIND Discussion Paper Xo. 1. MIND, London, Nancy Korman and Howard Glennester, (-losing a hospital: The Darenth Park project, Occasional Papers in Social Administration 78, Bedford Square Press, London, "Authority seeks to mortgage four hospitals," Guardian, 25 April Community care,.with Special Reference to Adult Mentally and Mentally Handicapped People, House of Commons Social Services Committee Session HMSO Making a Reality of Community Care, A Report by the Audit Commission, London, HMSO, Audit Commission, op. cit.' pp Audit Commission, op. cit. p. 75. Guardian, 17 December IRISH PUBLIC BODIES MUTUAL INSURANCES LTD. Irish Public Bodies Mutual Insurances Limited' is the leading Irish Insurance Company for Municipal and other Local Authorities. Experienced Advisors on Fire Prevention. Head Office: 1, 2 and 3 WESTMORELAND STREET DUBLIN 2 Telephone: (01) Telex: Telegrams: Associated Dublin