Ireland a good policy implemented very slowly

Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries

Ireland Country Report
Ireland: A good policy implemented very slowly
Mental Health Integration Index Results

Mental Health Integration Index:
Results for Ireland
Ireland

Best

Average

Worst

Environment

Governance

100
80
60
40
20

Overall:
Environment:
Opportunities:
Access:

Governance:

68.0/100 (14th out of 30 countries)
83.3/100 (9th)
55.6/100 (17th)
66.2/100 (16th)
62.0/100 (11th)

Other Key Data
0

20
40
60
80
100

Access

Opportunities

l Expenditure: Mental health budget as a proportion of
government health budget (2012): 5.3%1.
l Burden: Disability Adjusted Life Years (DALYs) resulting
from mental and behavioural disorders as a proportion of all
DALYs (World Health Organisation(WHO) estimate for 2012):
14.4%2.
l Stigma: Proportion of people who would find it difficult
to talk to somebody with a serious mental health condition
(Eurobarometer 2010): 20%3.

Highlights
Ireland has an above-average ranking in the Economist
Intelligence Unit’s Mental Health Integration Index.

result of the government’s austerity programme have slowed
implementation of the most recent policy.

Its biggest strength in this area is its very advanced policy, but
it has a record of poor implementation.

However, recent developments, such as the appointment of a
national director of mental health, indicate that progress will at
least continue or perhaps accelerate.

Wider health service upheaval and funding cutbacks as a

SPONSORED BY

1

Data from the EIU Mental Health Integration index,
which ranks 30 European countries based on their
commitment to integrating people with mental
illness into society and employment (http://www.
mentalhealthintegration.com )

available at />global_burden_disease/GHE_DALY_2012_country.
xls?ua=1. The WHO estimates do not include dementia
as a mental illness, although it is listed as one under the

WHO’s International Classification of Diseases (ICD-10).

Figures derived from World Health Organisation (WHO)
national figures for individual index countries for 2012,

3

2

1

Eurobarometer, Mental Health, Special Eurobarometer
345, 2010.
© The Economist Intelligence Unit Limited 2014


Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries

The journey to an advanced policy
Ireland ranks slightly above average in the Mental Health
Integration Index, placing 14th overall, and in joint ninth
position in the “Environment” category with a score of 83.3
out of 100. The country benefits from the emphasis that
the index places on policy. John Saunders, chief executive
for Shine, a mental health non-governmental organisation
(NGO), and chair of Ireland’s Mental Health Commission,
believes that “in policy terms [Ireland] would score highly. It
promotes and has a vision of community mental healthcare
services where people should receive a range of interventions

from the biopsychosocial model of mental health, provided by
professional, multi-disciplinary teams.”
If Ireland’s strength is its roadmap to the kind of service
provision that it wants, its weakness is the pace at which
that plan is being executed. Mr Saunders adds, “if you look
at implementation of [the government’s] model, you will
find the situation very much mixed. We are in transition
from an asylum-based, pre-Victorian model to a new one.”
One of many demonstrations of this dichotomy became
apparent during The Economist Intelligence Unit’s experience
of building the Mental Health Integration Index. Three
indicators that focused on actual service provision within
the community rather than on underlying policy had to be
dropped late in the process because of a lack of data from
other countries. This shifted the emphasis of the index in
favour of policy, and led to Ireland’s overall score rising by
nearly 10%.
The need to change how the country deals with mental illness
has long been recognised in Ireland. In 1958 Ireland had the

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highest number of people in psychiatric institutions in the
world, and in 1961 the government established a Commission
of Enquiry on Mental Illness. Its 1966 report recommended
more community-based facilities, the use of multidisciplinary teams to provide a range of medical care, and the
establishment of small, acute psychiatric wards in general
hospitals rather than the continued use of physically isolated,
large asylums. Little systemic change occurred, however,
although the country’s institutionalised population began

to fall steadily, mostly through the number of new patients
admitted being lower than the number of older, long-stay
patients who died while still in asylums.
A further report, Planning for the Future, published in 1984
by Ireland’s Department of Health, again complained of a
highly hospital-centred system and called once more for a
community-based one. The outcomes were also disappointing.
The number of long-stay patients in psychiatric hospitals
continued to decline, but these facilities still housed over
4,000 people by the year 2000. Moreover, notes Shari McDaid,
director of the NGO, Mental Health Reform, care “continued
to have a medical orientation”, with very few patients seeing
even psychologists. Any community facilities that did exist
tended to segregate the mentally ill in parallel services, rather
than helping to integrate them into the broader community.
Despite earlier disappointments, the release in 2006 of the
current blueprint for a new service, A Vision for Change
(AVFC), brought hope for substantial improvement. Written by
an expert group appointed by the Ministry of Health, it drew
on consultations with a wide range of relevant stakeholders.
Like earlier policies, AVFC called for community-based
care, but it went much further. It explicitly advocated: the
recovery model for care; on an individual level, personal,

© The Economist Intelligence Unit Limited 2014


Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries

integrated care plans that address the biological, social, and
psychological needs of those with mental illness; at policy
level, a whole-of-government approach to mental health
where the specific needs of those with mental illness are
recognised in all relevant policies; and the active participation
of service users and their families at every level of service
provision, from planning through peer-to-peer counselling.

national HSE assumed responsibility for healthcare provision
from 11 regional health authorities and a variety of other
organisations, becoming the country’s largest employer and
holder of the largest single public-sector budget. Such change
inevitably takes years of effort: the information technology
consolidation is still incomplete. “Mental health,” says Ms
McDaid, “got lost in wider issues of reconfiguration.”

Unfortunate timing impedes implementation

Getting attention for mental health issues has been all the
more difficult because the appointment of a national director
for mental health, as proposed in AVFC, and the creation of
a Mental Health Division within the HSE did not take place
until 2013. Before that, the office of assistant-director for
mental health had merely had an advisory role within the
HSE, while other parts of the organisation controlled budgets
and exercised operational responsibility. Overall, says Mr
Saunders, “there wasn’t any energy or leadership that led out
Vision for Change. The changes that did occur often did so
only because of local or regional clinical management making
a decision.”

AVFC remains the core of Ireland’s mental health strategy
and, as Mr Saunders puts it, “is a modern policy that is fit for
purpose.” Its roll out, however, has been highly problematic.
In a 2012 report, the Independent Monitoring Group (IMG)
established to evaluate the implementation of the programme
found that progress had been “slow and inconsistent.”
Similarly, in its latest report the government’s Mental Health
Commission found, to cite a few examples, that in 2013 only
44% of approved mental health centres met regulations for
sufficient staffing (including breadth of expertise) and only
60% fulfilled the requirements relating to patients’ individual
care plans. Worse still, efforts to close down major psychiatric
hospitals has led Ireland’s Health Service Executive (HSE)
to establish a number of large, supervised hostels that have
several of the negative attributes of the institutions that were
being closed, such as a lack of patient access to psychologists.
So what went wrong?
Two major factors, both in different ways the result of
unfortunate timing, have impeded the implementation of
AVFC. The first is institutional. In 2004 the Irish government
launched a major overhaul of healthcare management. A new,

3

The second major problem with implementation has been
that AVFC, like the HSE reform, was drafted during Ireland’s
heady economic boom period in the early part of the last
decade. Expanding budgets were an underlying assumption.
As implementation of the new mental health policy was set to

begin, however, recession and then the financial crisis in the
Euro zone turned the Celtic Tiger into one of Europe’s PIIGS
(Portugal, Italy, Ireland, Greece and Spain). The ensuing
government budget austerity measures cut total funding
of mental health services from €937m in 2006 to €733m in
2013 (although after the budget was adopted an additional
investment in personnel added €25m to the latter figure).

© The Economist Intelligence Unit Limited 2014


Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries

Worse still, mental health suffered more than other healthcare
sectors. In the early years of the downturn, money previously
earmarked for AVFC implementation was seized to cover costs
elsewhere in the health service. More generally, mental health
spending as a percentage of the total health budget dropped
from 7.2% to 5.3% in the same period, even though AVFC was
predicated on an increase to over 8%. An important practical
implication of cost reduction, notes Mr Saunders, was that
an austerity-driven hiring moratorium introduced by the
government had an exaggerated effect in this area because
mental health services are highly labour dependent. Although
the government has earmarked funds for hiring in the field
of mental health over the last few years, the Health Service
Executive estimates that still about one-quarter of the 12,000
posts envisioned under AVFC remain unfilled4.

Improvements to the present situation are still
needed...
These barriers do much to explain the current state of mental
health provision and the integration of those with mental
illness into Irish society. Looking at the present, says Ms
McDaid, “Ireland is behind in terms of moving to day services
that support integration and of thinking how people with
mental health services can be full citizens.”
Our Index data reflects this in several ways. Ireland’s lowest
score (55.6 out of 100) is in the “Opportunities” category,
which focuses on the workplace. Only 18% of those with a
mental illness are in employment, although a further 51% had
been employed in the past (and most of those had left their
job because of their medical conditions). A small majority
those with a mental illness who were unemployed would like

to return to work under the right circumstances5, but these
circumstances do not arise frequently. Our data show that,
although Ireland does reasonably well in terms of policies to
support those with mental illness in finding employment, it
has no regulations on workplace stress, which would almost
inevitably make it harder to maintain a job. A truly whole-ofgovernment approach would include such rules, and would
benefit all employees, not just those with a mental illness.
This situation illustrates a problem that goes beyond
employment. Ms McDaid notes that AVFC’s chapter on social
inclusion as a whole “is one of the least implemented,” with
government departments (other than the Department of
Health) having done little so far. One notable recent exception
has been the National Housing Strategy for People with a
Disability, written as part of the National Disability Strategy,

which includes a chapter dealing with the specific needs of
those with a mental health disability.
Another area of weakness for Ireland in the Index is the
“Access” category, where it places 16th out of 30. The problem
is not so much that individuals cannot get care, but rather
that the care provided is based on an outdated approach.
The IMG, for example, complained in 2012 of “an absence
of the ethos of recovery, and poor development of recovery
competencies in service delivery, resulting in a reactive rather
than proactive approach to the needs of individuals and their
families.” According to Mr Saunders, the system remains
“primarily focused on the medicalised model of mental illness
and the use of medical psychiatry and mental health nursing.”
This is reflected in the personnel available. Ireland has the
second-highest number of psychiatric nurses per head in the
Index (113 per 100,000 population) and is in joint fourth
place for the number of psychiatrists (21 per 100,000). On

Health Service Executive, Mental Health Division Plan 2014, page 17, http://
www.hse.ie/eng/services/Publications/corporate/mentalhealthplan.pdf

4

Dorothy Watson and Bertrand Maître, Understanding Emotional,
Psychological and Mental Health (EPMH) Disability in Ireland: Factors
Facilitating Social Inclusion, 2014.

5

4

© The Economist Intelligence Unit Limited 2014


Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries

the other hand, it ranks 13th for the number of specialised
social workers (4 per 100,000) and 17th for psychologists (6
per 100,000). In both of the latter two categories, Ireland has
under half the overall average per head for countries listed in
the index.
Part of the problem is an ongoing cultural one. Ms McDaid
believes that “we have a way to go in making it the norm that,
for instance, mental health professionals expect to work
in partnership with their service users rather than having
a directive-based approach.” The College of Psychiatry,
however, is positive about the thinking behind the AVFC, and
cultural change is taking place. The more immediate issue,
explains Mr Saunders, is that the moratorium on new hiring
has slowed the acquisition of the wider range of expertise
needed to move beyond a purely medical model. “Very few of
the new community mental health teams are fully staffed,”
he says, “with significant vacancies in psychology, social work
and occupational therapy, and among other support staff.
It is like having football teams where one or two people are
missing on the field.”

...but there are hopeful omens for the future

taking place, such as the recent appointment of a national
director of mental health and the National Housing Strategy.
Looking ahead, Ms McDaid sees other good signs: a new
employment strategy under the National Disabilities Strategy
is expected to address the needs of those with mental illness
and the Advancing Recovery in Ireland project, set up this
year, has “increased the critical mass of services making
organisational change.” The country is also witnessing
extensive civil society discussion as the government wrestles
with a new law to modernise the legislation on assisted
decision making, especially for those who have a mental
illness, to meet its goal of bringing the law into line with the
UN Convention on the Rights of Persons with Disabilities.
More important than any specific development, though, has
been a shift in the belief that change will happen. Mr Saunders
says that “most people agree that we have now reached a
tipping point. We have closed all the significant psychiatric
institutions and most are being served outside of residential
options.” It may take several years, he believes, but eventually
significant investment in public services will occur and the
new system will take proper shape because, he concludes, “We
can’t go back.”

Despite this very slow progress, both Ms McDaid and Mr
Saunders are cautiously optimistic. Positive changes are

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© The Economist Intelligence Unit Limited 2014

Mental health and integration
Provision for supporting people with mental illness: A comparison of 30 European countries

About the research
This study, one of a dozen country-specific articles on the
degree of integration of those with mental illness into society
and mainstream medical care, draws on The Economist
Intelligence Unit’s Mental Health Integration Index, which
compares policies and conditions in 30 European states
for integrating people with mental illness into society and
employment. Further insights are provided by two interviews—

6

with John Saunders, chairman of Ireland’s Mental Health
Commission and chief executive of Shine, and Shari McDaid,
director of the NGO Mental Health Reform—as well as extensive
desk research. The work was sponsored by Janssen. The
research and conclusions are entirely the responsibility of The
Economist Intelligence Unit.

© The Economist Intelligence Unit Limited 2014