Inspection of Mental Health Division 4 November 2013 Introduction: The Inspectorate of Mental Health Services had long advocated for the introduction of a HSE Mental Health Directorate with Executive and Budgetary responsibilities as recommended in A Vision for Change (2006). The appointment of a new Director in July 2013 was therefore most welcome. As part of the inspection process of Mental Health Services, the National Director was asked to attend the Mental Health Commission Offices for inspection on the 4 th November 2013. By letter dated the 15 th July 2013, the National Director was asked to make a presentation covering the following areas:- 1. Your overall assessment of the current state of the national mental health services. 2. Particular areas of concern requiring urgent attention. 3. How you intend addressing these areas of concern. 4. Your vision for the future of Ireland s mental health services. 5. Practical steps to implement that vision. 6. Individual care planning. 7. Management structure of the Mental Health Directorate. 8. How you will measure the quality of the mental health services. 9. Funding. The following information was obtained: 1. Overall assessment of the current state of the national mental health services. The National Director had spent the first hundred days in office (started on the 25 th July 2013) canvassing the views and opinions of local Mental Health Management Teams including Executive Clinical Directors. This internal engagement process comprised a combination of one to one and group meetings. At the one to one meetings, a series of standard questions were used to prompt discussion. Issues raised with the National Director included staffing (both approvals and recruitment process), governance, ICT deficits, risks and serious incidents (including suicides and other deaths), reconfiguration plans, service variation, recovery focus, service user involvement and others. Page 1 of 9
2. Particular areas of concern requiring urgent attention. The National Director was made aware through these consultations of dissatisfaction at local level with the current arrangements with respect to staffing approval and recruitment. Work was underway to identify those posts, the replacement of which was essential, and, on the other hand, posts the replacement of which was not essential. In addition, a middle group of posts would require further analysis and specific approval at the time, should they become vacant. It was also hoped to provide greater control at a local level in relation to the recruitment process with greater local input to the interview and selection process. A need was identified to devise a mental health training and development strategy. In addition, necessary improvements in ICT were flagged in respect of patient records and rostering. 3. Addressing these areas of concern. Areas of concern to be addressed: New staffing arrangements ICT interim programme Long term ICT programme 4. National Director s Vision for the future of Ireland s mental health service. The establishment of the Mental Health Division is in keeping with the recommendations of the Report of the Expert Group on Mental Health Policy A Vision for Change (2006) and represented an important step beyond that which the report had assumed was achievable. The Mental Health Division carried operational and financial accountability for all mental health services with the core objectives of: Providing high quality services by implementing A Vision for Change to deliver a modern, recovery focused, clinically excellent service built around the needs and wishes of service users, carers and family members. Supporting an improvement in the mental health of the population and in our approach to suicide prevention. Page 2 of 9
Implementing the health reform programme fully within mental health services in a way which ensures they are properly integrated with other health and social services. The Mental Health Division provides a specialised secondary care service for children and adolescents, adults, older persons, those with an intellectual disability and mental illness as well as a range of suicide prevention initiatives. Services were provided by the HSE and voluntary sector partners in a number of different settings including the service user s own home. The modern mental health service would be integrated with primary care, acute hospitals, services for older people, services for people with disabilities, and with a wide range of non health sector partners. The provision of a ring-fenced investment of 20 million for mental health services in Budget 2014 will allow for the continued strengthening of community teams, increased suicide prevention resources and clinical programme development and implementation. 5. Practical steps to implement that vision. Following on from the National Director s consultations with services, the following were expected to be key elements of the mental health work plan for 2014. 5.1 BEGIN TO ADDRESS FOUNDATIONAL ISSUES/OPERATIONAL BARRIERS WITHIN MENTAL HEALTH SERVICES: - Develop an initial workforce plan for 2014 to bring greater certainty around essential replacements. - Streamline recruitment to allow for more local control and specialisation, where appropriate. - Develop an initial training and development strategy for mental health. - Build national capacity to respond in a standardised way to serious adverse incidents. - Commence key projects to address ICT gaps including: o National Mental Health Information System (MHIS) (4 to 5 year project) o E- Rostering solution for mental health (2 year project) o ICT fundamentals in mental health (current baseline and improvement plan 1 year) o Interim data gathering solution (6-9 months project) This was intended to free up senior clinical and management time and energy to focus on developing and implementing a standard model of care. Page 3 of 9
5.2 DEVELOP AN IMPLEMENTATION PLAN FOR LAST 3 YEARS OF A VISION FOR CHANGE A STANDARD MODEL OF CARE. During 2014, focus will be on developing a major work stream within the mental health clinical programme which will seek to address a variety of issues which have existed for some time and have been raised during the initial engagement process with internal and external stakeholders. These include (indicative but not exhaustive list): - Reduce variation over time provide a relatively standard level of basic service regardless of location. - Access to, egress from and flow through the service general care pathways - out of hours access. - How mental health can best support and integrate with primary care, acute hospitals and other services. - Local Team Standard Operating Procedures Team co-coordinators, central referrals, core basic assessment by team members, case load management, authorised officers, assisted admissions etc. - Involving service users, cares and family members moving from consultation to co-production. - Over arching model of care - making step change in recovery focus and enhancing clinical excellence. - Change management plan - get to desired level of acute and non-acute beds, day hospital versus day centre, etc. - Mental health quality metrics move to an outcome focus. 5.3 PROMOTING POSITIVE MENTAL HEALTH AND IMPROVING SUICIDE PREVENTION. - Develop a new strategic framework to build on and enhance the implementation and governance approach associated with suicide prevention based on the learning from Reach Out Irish National Strategy for Action on Suicide Prevention 2005-2014. - Continue to implement the outstanding actions in Reach Out. - Invest in additional suicide prevention resources. Page 4 of 9
5.4 A VISION FOR CHANGE IN-PATIENT RESOURCES - A Vision for Change recommended a rate of 17 acute beds per 100,000 population (50 per 300,000). The National Director advised that the HSE in recent years had operated an intermediate target rate of 20 beds per 100,000 and that this required review as additional community team resources come on stream. - A Vision for Change recommended a rate of 30 beds per 300,000 for continuing care challenging behaviour and older people. The National Director intended to reduce the number of continuing care beds as outlined in A Vision for Change on a phased basis supported by the continued investment in community teams. 6. Individual Care Plans (ICPs) The National Director outlined that he questioned services as to why ICPs were not being fully implemented in some approved centre settings. Responses varied but it appeared to be a management/leadership focus issue. There were also examples of where there might have been some valid reasons for a lack of full compliance. The National Director was clear, based on inspection reports, that further work was necessary by the mental health services. Pending completion of this work, the National Director could not be assured or provide assurance of full compliance with this statutory provision. Page 5 of 9
7. Management structure of the Mental Health Division The structure of the Mental Health Division will be similar to the structure of the other new National Directorates. The Division will consist of 5 key roles along with the National Director. 1. Head of Quality, Patient Safety, Standards and Compliance * (appointed). 2. Head of Operations and Service Improvement * (commencing 9/12/2013). 3. Head of Performance, Planning and Programme Management * (appointed). 4. National Clinical Advisor, Mental Health Division (to be appointed). 5. National Service User Advisor (to be appointed). * Note their roles are at Assistant National Director level. Other Management Positions: Regional Directors of Operations (RDOs) The Regional Directors of Operation had been replaced by Regional Directors of Performance and Integration (RDPI) and they were accountable to the five National Directors for their respective care groups. Regional Directors of Performance and Integration report to the National Director for Mental Health on matters relating to mental health. It was envisaged that in the future RDPIs will not hold responsibility for budgets. They will instead hold the responsibility for performance and integration and will report in that context to the Chief Operating Officer who had overall responsibility for assuring the HSE Director General around performance matters. Integrated Service Area Managers (ISA Managers) ISA Managers will be responsible for social care, mental health, primary care and elements of health and wellbeing. The National Director Social Care was currently chairing a review of the current ISA structures and functioning and was due to report back on this area before year end. When any revisions to the current ISA structures are known, it was anticipated Page 6 of 9
that the mental health super catchment areas will be realigned to match the revised ISAs. 8. Quality of the Mental Health Services The National Director has appointed a Head of Quality, Patient Safety, Standards and Compliance who will take the lead on quality and regulation within the Mental Health National Management Team. The National Director had identified that a key step in providing a quality service was to provide the appropriate infrastructure in terms of governance arrangements and staff within the available budget. The National Director wished to see established a standard model of care, focused on the operation of Community Mental Health teams and how they interface with primary care including GPs, Emergency Departments, Children & Family services and the general population. This was seen as the key to beginning to tackle variation in services across the country and make it clear to the general public and services users what they can expect from the Mental Health Service. It was anticipated that relevant Key Performance Indicators (KPIs) will emerge on completion of consultations. 9. Funding Funding in the current climate presented a number of challenges. Page 7 of 9
10. Other issues Non Consultant Hospital Doctors (NCHDs) The National Director outlined that the issues around recruitment of NCHD s and Consultant Psychiatrists was more about the market (i.e. availability, retention etc) than the recruitment process per se. 24 Hour Nurse Staffed Community Residences The Assistant National Director Mental Health outlined that a review was currently taking place in relation to community residences in conjunction with the HSE Estates Office. Children s Advocacy Suitable agencies and models for children s advocacy were being explored at present. Page 8 of 9
Inspectorate Conclusions: 1. The Inspectorate welcomed the appointment of a National Mental Health Director. 2. Also welcomed is the appointment of a broadly based Directorate which will include a service user representative. 3. The breadth of consultation in the initial 100 days of the National Director is impressive and has identified a number of key areas for immediate attention, particularly staffing and risk. 4. Clarifying the management structure as well as providing a sound infrastructure of staffing and ICT are welcomed as a first step to ensuring a high quality service. 5. The Inspectorate recommend that local clinical management areas be soon identified and clearly mapped. 6. The National Director is committed to the implementation of A Vision for Change within the established time frame (within the next three years) in as much as is possible given the financial circumstances. 7. The National Director is aware of the importance of individual care planning as the foundation of all therapeutic activity. 8. The National Director also regards as vitally important the implementation of quality measures and clinical accountability. Page 9 of 9