€900M – that’s what we currently spend on dedicated, public mental health services in Ireland. It sounds like a big number and a lot of money, but is it too much, or not nearly enough to provide adequate mental health care for everyone in Ireland?
It’s an important question as we head into the budget announcement for 2019. Now is the time to ask whether or not our Government should give the HSE more funding for mental health, and how much.
The first question we might ask is whether or not that €900M is enough to meet current demand. Unfortunately we don’t have a good measure of the total amount of mental healthcare needed in Ireland. We don’t actually know how many people here have mild, moderate and severe mental health difficulties each year, and of those, how many might need treatment.
We do know that there are a lot of gaps in the availability of services at the moment.
For instance, we still have fewer staff in HSE mental health services than there were in 2008, and this despite the €210M of additional funding that has gone into the HSE’s mental health services since 2012. Why? Because the HSE lost 1,000 staff from the mental health services between 2008-2011 (almost 10% of the workforce) before that additional funding came on stream.
Importantly, demand went up during the same time period that this additional funding was given:
- The percentage of people with a disabling psychological or emotional condition increased by 28.7%, between 2011 and 2016, according to the Census
- Between 2012 and 2016 there was a 26% increase in the number of referrals to child and adolescent mental health services
- the number of referrals to the national Counselling in Primary Care service increased by almost 5% between 2016 and 2017, and still only supports a tiny fraction of those who experience mild to moderate mental health difficulties each year
Wrong place, wrong time
Disturbingly, people in severe distress may not even be ending up in our mental health services. According to the Irish Penal Reform Trust, the proportion of people with a severe and enduring mental health difficulty in Ireland’s prisons has doubled since 2005. So some of those in need of for mental health services have ended up diverted into other parts of our social services, and people who are at a very vulnerable point in their lives are ending up, entirely inappropriately, in the prison system.
Similarly, research on Ireland’s homeless population has found high rates of mental health difficulties, including severe mental health difficulties. Dublin Simon’s Health Snapshot for 2013 showed that 71% of its clients had a diagnosed mental health difficulty, of whom 22% had a diagnosis of psychosis or schizophrenia. So some people with mental health difficulties are ending up in the homeless population, with little access to specialist community mental health services.
All of this evidence points to unmet need for mental healthcare in Ireland, suggesting that more investment and more staff to provide more services is required.
Another way of assessing how much more we need to spend on mental health care is to compare ourselves to other developed countries.
One informal bench marking exercise undertaken recently has found that, at an estimated $200 (US) per person, Ireland spends lower per capita on mental health care than the Netherlands, Sweden, Wales, Scotland, Australia, England, Switzerland and New Zealand (information from the International Initiative for Mental Health Leaders).
And yet, investing in ensuring more people have access to good quality mental healthcare represents good value for money. Investing in mental healthcare reaps rewards to the wider health system in reduced costs for physical healthcare, and beyond the health system in lower social welfare costs, housing supports, subsidised transport, imprisonment and other costs. It also benefits employers who gain higher productivity, lower absenteeism and lower presenteeism from their employees.
Good mental health enables those of us of working age to show up at work and do our job effectively. Upwards of half of the State’s costs for disability benefits can be attributed to mental health difficulties,.
Good mental health also helps us to be well physically, while poor mental health increases the costs of common chronic conditions like diabetes, cardiovascular disease and chronic obstructive pulmonary disorder by 45% (according to the London School of Economics).
So, it’s obvious that increasing access to mental healthcare will reduce costs for our health and social services overall. In fact, for every €1 that we would spend on mental healthcare, we could save €4 in these other costs. That means that the Department of Employment & Social Affairs should be very interested in supporting investment in early intervention for mental health difficulties, because they could save significantly on social welfare payments. And the Department of Housing should be keen to see investment in mental healthcare that will reduce the numbers of people with mental health difficulties ending up homeless. So too, the Department of Justice should want greater investment in support for people with severe mental health difficulties in the community that will result in fewer people ending up inappropriately in prison.
How much should we spend?
For 2019, Mental Health Reform proposes that the Government invest €105M extra in our public mental health services, with €50M of this going to plug gaps in funding for current services and €55M to invest in new developments that would expand the services available.
The reality is that in recent years, delays in spending development funding have been used to cover an underlying deficit in core mental health services, being spent on:
- maintaining existing levels of service in the face of increased demand
- private placements for people whose needs can’t be met in the public mental health services, and
- agency staff cover for unfilled posts
In 2017 the HSE estimated that approx. €62M would be required to maintain existing levels of service in 2018. Mental Health Reform is asking that the Government set aside €50M to address this gap in 2019.
But, as we’ve shown, there is a need also to develop our mental health services so that they can better respond to people experiencing a mental health difficulty. That’s why the Government needs to keep its commitment to invest €55M in new developments in mental health in Budget 2019.
Why not do it?
So why not do it? Why not take a punt, Ministers Donohoe, Harris and Daly, and invest in Ireland’s mental health this year with an ambitious programme to reduce the proportion of people with mental health difficulties who will not get treatment. Then everyone in Ireland could look forward to seeing the benefits next year as more and more people can get back to work and be more productive, while fewer people end up in front of their GP, in homeless services, in prison, or in an Emergency Department. Wouldn’t that be worth it?