This article is the first in a series looking at mental health and illness in Northern Ireland, covering relevant reviews, policies, reports, services, treatments and access to these services. This blog post sets the scene and highlights key policies, strategies and action plans to date. A more detailed RaISe briefing on many of the issues is available.
Introduction – defining mental health and illness
The World Health Organisation defines good ‘mental health’ as:
A state of wellbeing in which the individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.
Good ‘mental health’ is regarded as being as essential as good physical health. Children and young people who develop good mental health are better equipped for dealing with emotional challenges they face later in life.
A combination of factors, including genetics, family history, psychological, social, environmental influences and traumatic life events (for example, experience of the ‘Troubles’, in Northern Ireland (NI)), may all play a part in the development of mental health problems.
A mental illness concerns a diagnosed clinical condition. The diagnosis of mental illness is usually made by a psychiatrist, working with other health professionals. Dual Diagnosis describes mental illness co-existing with drug or alcohol problems. Mental illness in those with learning disabilities may be misdiagnosed or overlooked as symptoms are often attributed to the learning disability.
In children and young people symptoms of mental illness may manifest in different ways to adults, for example, mood change, self-harming, being fearful or anxious, becoming withdrawn, poor school performance, or use of drugs or alcohol.
Mental illness in Northern Ireland – overview
Mental illness is the largest cause of ill health and disability in NI and there are higher levels of mental ill health than any other region in the UK. In the 2015-16 NI Health Survey, 21% of women, 16% of men scored highly on the GHQ12 (General Health Questionnaire), suggestive of a mental health problem. Respondents in the most deprived areas were twice as likely to record a high score (27%), as those in the least deprived areas (13%).
It is estimated that around 45,000 children and young people in NI have a mental health problem at any one time and that more than 20% of young people are suffering ‘significant mental health problems’ by the time they reach 18.
With regard to suicide, 318 suicides were registered in NI during 2015 – the highest since records began in 1970. Of these, 245 (77%) were male and 132 were aged between 15 and 34-years-old. Suicide rates in the most deprived areas are three times higher than in the least deprived.
The 2006-2011 suicide prevention strategy ‘Protect Life – A Shared Vision’ listed risk factors as depression, alcohol/drug misuse, personality disorder, hopelessness, low self-esteem, bereavement, break-up of a relationship and social isolation. In NI, inequality is a strong factor, with the suicide rate in the 20% most deprived areas three times higher than in the least deprived.
A recent National Confidential Inquiry found that risk factors also include economic adversity and recent self-harm. The Inquiry also identified that patients in NI missing their final appointment with mental health services proved to be an antecedent to suicide. This did not appear to be the case in Scotland or England where more assertive outreach services have been introduced.
Statistics from the NI Self-Harm Registry show that between April 2014 and March 2015 there were 8,888 self-harm presentations to emergency departments, involving 6,633 people. Young people aged 15-29 accounted for 46% of all of these cases.
History of relevant policies, strategies and action plans in Northern Ireland
Mental health and learning disability
In 2002, the then Department of Health, Social Services and Public Safety initiated the Bamford Review of the law, policy and services affecting people with mental illness or a learning disability, which concluded with the publication of eleven reports by 2007.
The Review’s key messages included – the promotion of positive mental health; a need for reform of mental health legislation (Mental Capacity Act (NI) 2016); a shift from hospital to community-based services; and the need to develop specialist services, including for children and young people.
There have been two Bamford Action Plans, 2009-11 and 2012-15. An evaluation of the Action Plan 2009-11 listed the challenges identified in 2009, including:
- Streamlining access and establishing a stepped care approach;
- Enhancing the range of options available to primary care professionals;
- Improving access to psychological therapies;
- Home-based care and support to be the norm;
- A systematic approach to focus on ‘recovery’ from long term conditions; and
- Increasing the range of specialist mental health services.
The 2012-2015 Action Plan contained 76 actions. The interim monitoring report noted that good progress had been made with 63 actions on target. In 2016, the Department of Health (NI) initiated a full evaluation of the 2012-2015 Action Plan – publication is expected by the summer of 2017. It will assess how Departments have performed, include the views of service users and carers, and identify needs and service gaps.
Initial findings include a continuing need to – promote psychological therapies and the ‘recovery’ concept; provide more practical support to carers; improve access to mental health crisis services; improve patient experience in acute facilities; increase involvement of the voluntary/community sector; and increase (supported) employment opportunities/social enterprises.
Suicide and self harm strategies
The NI Suicide Prevention Strategy and Action Plan (2006-2011) ‘Protect Life – A Shared Vision’, was first published in 2006, followed by an updated version (2011-2013). The 2006 Strategy was successful in a number of areas, including:
- Raising awareness of mental health issues through public information campaigns and ensuring the media report suicide sensitively; and
- Enhancing the support role of the voluntary and community sectors.
An eight week consultation on the new ‘Protect Life 2’ draft strategy ended in November 2016 and a summary of the consultation responses was published on 1st March 2017. Objectives in the draft strategy include:
- Improving both the understanding/identification of suicidal and self-harming behaviour and the care and support response in the voluntary, community, and statutory sectors;
- Restricting access to the means of suicide;
- Continuing to enhance responsible media reporting; and
- Risk reduction by identifying emerging suicide clusters.
Overarching strategy and policy
The present direction of healthcare service reform stems from at least 2011 with the review ‘Transforming Your Care’ (TYC), which acknowledged that the Bamford Review set the agenda for transforming mental health services. TYC highlighted the need to focus on promoting mental health and reducing the suicide rate; the need for a consistent pathway through the regional care model and for urgent mental health care; the provision of clearer information to clients/families; the promotion of personalised care; and the closure of long stay institutions and complete resettlement by 2015.
In early 2016, the then Health Minister, Simon Hamilton MLA, appointed an expert panel to lead debate on the configuration of health care services. His successor, Michelle O’Neill, published the Panel’s report in October 2016, alongside the Department’s report Health and Wellbeing 2026, Delivering Together. She highlighted a commitment to achieving a parity of esteem between mental and physical health, including better specialist services (such as perinatal mental health), expansion of community services and those to deal with trauma of the past.
The Minister is keen to move to a model of ‘co-production’ (patients, service users and staff are empowered to design the system). She highlighted Mental health Recovery Colleges in each HSC Trust as a good example of co-production. The ‘Recovery’ focus is about building a meaningful and satisfying life, whether or not there are recurring/ ongoing mental health problems.
‘Improving Mental Health’ was ‘indicator 6’ in the Draft Programme for Government 2016-2021. The lead measure proposed is “% of population with GHQ12 scores ≥4 (signifying a possible mental health problem). It is acknowledged that the score only gives an indication and a range of more specific performance measures is envisaged.
Making Life Better 2012–2023 is the public health strategic framework. ‘Improved Mental Health and Wellbeing, Reduction in Self Harm and Suicide’ is a key objective and actions have included:
- Development of policy to promote positive mental health, reduce self-harm and suicide (‘Protect Life 2’ draft strategy); and
- Improving mental wellbeing in children and young people through initiatives such as ‘Roots of Empathy’.
Discussion
An NI Assembly debate in June 2016 highlighted significant reform and modernisation of services through the ‘Bamford’ process and beyond, including the mental health framework and the regional mental health care pathway – a stepped care model for adults and one for children and adolescents and the move to a recovery focus; improved working with primary care and development of psychological therapies.
However, gaps remain and there are challenges remaining that were first identified back in 2009, for example, improving access further to psychological therapies. Current challenges also include financial constraints; implementation of the Mental Capacity Act 2016; and improved services for early intervention, dual diagnosis and suicide prevention. The Department is considering service needs in relation to perinatal mental health, psychological therapies, mental trauma and eating disorders.
The Assembly debate also highlighted cross-party support for the:
Minister of Health to explore the role and remit of a mental health champion to protect and promote the interests of those suffering poor mental health and well-being.
This has also been supported by a number of key organisations, including AMH, the Royal College of Psychiatrists, the MHF and Mindwise. At a recent Policy Forum for NI seminar, the MHF also called for a new ten-year mental health strategy for NI building on the legacy of the Bamford Review.
Today, a Knowledge Exchange Seminar Series event on Mental Health: Treatment and Interventions will take place at the Northern Ireland Assembly.