Rights in Action:Changing Mental Health Services28th November 2007

Rights in Action:Changing Mental Health Services28th November 2007

Participation and the Practice of Rights Project

Findings of the International Panel

North BelfastParticipation and Practice of Rights Project54 York StreetBelfastBT15 1ASTel: +44 (0)28 9032 6980Fax: +44 (0)28 9032 8102Email: [email protected]

North Inner City DublinParticipation and Practice of Rights ProjectC/o ICRG57 Amiens StreetDublin 1Tel: +353 (0)1 855 7207Fax: +353 (0)1 855 4705Email: [email protected]

www.pprproject.org

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On 28th November 2007, an international panelwas convened to hear evidence presented bymembers of the Public Initiative on the Prevention ofSuicide (PIPS) and Reaching Across to Reduce YourRisk of Suicide (RAYS) on a set of prioritized issuesthey and other mental health service users face inaccessing mental health care in North Belfast, aneconomically-deprived area that, according tonational statistics, suffers one of the highest rate ofsuicide and self-harm in Northern Ireland. Theevidence was gathered, organized, and presentedusing a participatory human rights-based approachto health. This means that those individuals whoare most affected by health service delivery failuresare directly involved in the identification, monitoring,and implementation of effective solutions to suchfailures. Such a participatory approach is crucial toensuring the full realization of the right to thehighest attainable standard of physical and mental

health (‘the right to health’) for all persons within aState’s jurisdiction.1

The international panel heard clear and convincingevidence on the failings of health authorities to fulfilthe right to health, and specifically the right tomental health, in Northern Ireland. The mostpowerful evidence came from the personaltestimonies of mental health service users and theirfamilies. These testimonies were presented to thepanel either directly by forum participants, via shortDVD films, or in the results of a baseline survey ofusers, entitled ‘Experiences of Mental HealthServices Users in Belfast: A Baseline Survey.’ Theywere accompanied by detailed descriptions ofcurrent legislative and policy efforts to address thedelivery of mental health services in NorthernIreland. Such evidence painted a powerful picture:Of a government that recognizes the crisis of mental

Introduction

1 International Covenant on Economic, Social and Cultural Rights, Article 12 (1) “The States Parties to the present Covenant recognisethe right to everyone to the enjoyment of the highest attainable standard of physical and mental health.”

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health service delivery within its jurisdiction, andthat has formally committed to addressing it throughlegislative undertakings, but that has yet to take thespecific, concrete, targeted measures necessary toensure that the right to health is meaningful inpractice for users of mental health services in NorthBelfast.

The panel’s findings from the evidence hearing,together with its specific recommendations are setout below. The panel’s comments andrecommendations seek to encourage a process ofmental health decision-making that is both fullyparticipatory and genuinely responsive to locally-identified needs. They are therefore intended to beof use to those working in the health care system inNorthern Ireland as well as to mental health serviceusers and their families. We conclude that aprocess of sustained and active engagementbetween health authorities and mental healthservice users, such as the PIPS/RAYS group, isnecessary for effectively ensuring the right to health

for all service users. Such engagement must accordwith the core principles, values, and precepts ofinternational human rights law, in particular non-discrimination, equality, full civil societyparticipation, and the real availability of publicaccountability mechanisms.

Rights in Action: Changing Mental Health ServicesFindings of the International Panel

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The government of Northern Ireland has undertakento ensure the right to health for all persons withinits jurisdiction. This obligation has been undertakenpursuant to a variety of human rights treaties, mostimmediately the International Covenant onEconomic, Social and Cultural Rights (ICESCR). Thattreaty, ratified by the United Kingdom in 1976,enshrines in Article 12 “the right of everyone to theenjoyment of the highest attainable standard ofphysical and mental health.”2 To ensure the fullrealization of that right, Article 2 of the Covenantcommits all governments of ratifying states to “takesteps” through “all appropriate means” to achievethe right. As the UN Committee on Economic, Socialand Cultural Rights has affirmed:

The Covenant clearly imposes a duty on eachState to take whatever steps are necessary toensure that everyone has access to healthfacilities, goods, and services so that they can

enjoy, as soon as possible, the highest attainablestandard of physical and mental health.

This means that all national ministries, departmentsand agencies, and all of their local counterparts,bear a legal duty to take concrete, decisive, andappropriate measures to ensure the full realizationof the right to health for all persons within theirrespective jurisdictions. In the health context ofNorthern Ireland, this includes most immediately theDepartment of Health, Social Services and PublicSafety (DHSSPS), the four Health and SocialServices Boards, and the more locally-directedHealth and Social Care Trusts, which provide directcare through their hospitals, community care, andsocial services.

At the evidence hearing, the PIPS/RAYS rights groupcorrectly identified the government, and morespecifically the Department of Health and itsagencies, as the primary duty-bearers responsible

1. Human Rights Obligations ofGovernments and Public Officials

2 Ibid.

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for ensuring the right to the highest attainablestandard of physical and mental health. Indischarging this obligation, the panel wishes toemphasize that it is the Minister for Health, as headof the executive department in charge of health,who may be held directly to account for ensuringthat appropriate steps are taken within the HealthMinistry and throughout the health system to securethis right on behalf of all health service users.

The duty to take appropriate steps to achieve thefull realization of the right to health is multi-facetedand multi-dimensional. It includes not only the dutyto refrain from taking measures that directly injureor restrict the right to health of particular individualsor groups, but also the affirmative duty to takepositive, concrete measures to ensure constantimprovements in the availability of health services,facilities, and goods; their accessibility to all

individuals and groups (physically, economically,legally, and informationally); their cultural andethical acceptability to all groups; and their scientificand medical quality.3

The panel underscores that the government is duty-bound under international human rights law toengage in constant performance-monitoring, gaugingand assessing its progress (or lack of progress) withrespect to each of the above four “essentialelements” of the right to health. As the UNCommittee on Economic, Social and Cultural Rightshas affirmed, governments and their agencies areunder a human rights obligation to:

“monitor the actual situation with respect to eachof the rights on a regular basis and [thus be]aware of the extent to which the various rights


3 General Observation No. 14, para. 12 (“The right to health in all its forms and at all levels contains the following interrelated andessential elements, the precise application of which will depend on the conditions prevailing in a particular State party:(a) Availability….(b) Accessibility….(c) Acceptability….(d) Quality.”)

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are, or are not, being enjoyed by allindividuals…under its jurisdiction.”4

Such knowledge and diagnosis of the existingsituation is the first essential step towardspromoting the right to health, as it provides thebasis for the elaboration of clearly stated andcarefully targeted policies designed to remedyidentified health care deficiencies and to ensurethat constant improvements are in fact beingmade.5 Indeed, as the UN Rapporteur on the Rightto Health states:

“One of the most urgent steps which many Statesneed to take to facilitate the realisation of theright to health of persons with mentaldisabilities…is to enhance monitoring andaccountability at the national and internationallevels.”6

4 CESCR General Comment No. 1. para. 3.5 Ibid. para. 4.6 E/C.4/2005/51, para. 68.

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The duty of “progressive realization” is often held

up as a limit on the duties of government to achieve

the right to health, used to justify official failures to

take action in the field of economic, social and

cultural rights. It is critical to underscore, however,

that this duty—which applies as fully to civil and

political rights, as social rights—refers principally to

outcomes or results in the enjoyment of rights. That

is, it represents a clear-sighted recognition that,

given resource constraints and competing duties in

a democratic society, the full realization by all

individuals of any given right can rarely be achieved

immediately, but rather will take time, effort, and

coordination on many different levels and fronts. It

is for that reason that measurement of the duty of

progressive realization of any given right generally

focuses on outcome indicators that can track

results in the enjoyment of a right over time.

All rights, however, also include correspondingobligations of conduct, which are of immediateeffect. The Committee on Economic, Social andCultural Rights explains:

“While the Covenant provides for progressiverealisation and acknowledges the constraints dueto the limits of available resources, it alsoimposes various obligations which are ofimmediate effect.”7

Among these obligations of immediate effect is theundertaking in article 2.1 of the ICESCR to ‘takesteps’ towards the full realization of protectedrights, which “in itself, is not qualified or limited byother considerations.”8 As applied to the right tohealth, the Committee has underscored that “[s]uchsteps must be deliberate, concrete and targetedtowards the full realization of the right to health.”9

2. “Progressive Realization” andObligations of Immediate Conduct


7 CESCR General Comment No. 3, para. 1; CESCR General Comment No. 14, para. 30.8 CESCR General Comment No. 14, para. 30; see also CESCR General Comment No. 3, para. 2.9 CESCR General Comment No. 14, para. 30.

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States therefore cannot invoke the duty of“progressive realization” in an effort to avoid takingspecific, concrete actions with respect to improvinghealth services. Rather, the key question becomeswhat steps are in fact “appropriate” to the localcircumstances. As the Committee recognizes:

The most appropriate feasible measures toimplement the right to health will vary significantlyfrom one State to another. Every State has amargin of discretion in assessing which measuresare most suitable to meet its specificcircumstances. The Covenant, however, clearlyimposes a duty on each State to take whateversteps are necessary to ensure that everyone hasaccess to health facilities, goods and services sothat they can enjoy, as soon as possible, thehighest attainable standard of physical andmental health.10

It is precisely because each measure a State musttake to achieve the right to health cannot bedefined a priori that international human rights lawimposes process requirements on States forpurposes of accurately identifying necessary stepsin collaboration with civil society. These include,most notably, (1) performance monitoring, (2)outcome-indicator disaggregation, and (3) effectivecommunity participation in setting priorities,identifying appropriate indicators, making decisions,and planning, implementing, monitoring, andevaluating health-related policies and strategies.

The panel commends the PIPS/RAYS group fortaking the initiative to insist on its proper role inhelping to define the indicators and benchmarksthat define the “appropriate” policies theDepartment of Health is required to takeimmediately in North Belfast. It also commends thePIPS/RAYS group for identifying benchmarks that

10 Ibid. para. 53.

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are eminently reasonable in scope and attentive tothe fact that full achievement of the healthimprovements they seek can not ordinarily beachieved immediately, even if concrete, deliberateand targeted “steps” toward that end areimmediately required.

The panel recommends that the Ministry of Healthand other relevant health authorities work closelywith the PIPS/RAYS group and other mentalhealth service users to identify, implement,monitor and review the most appropriate targetedpolicies for remedying the service deliveryproblems the group has identified. Services userswill be able to provide valuable first-hand insightsinto the policies that rob them and their families ofdignity and impede their enjoyment of the highestattainable standard of physical and mental health.They are thus uniquely situated to workcollaboratively with health authorities to rectifyproblem areas by identifying effective steps and

measures the government can and shouldundertake.


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In facilitating the process of performance monitoringwith respect to the right to health, the UN SpecialRapporteur on the Right to Health has identifiedthree sets of indicators that governments shouldestablish and monitor: process indicators, outcomeindicators, and structural indicators.11 The panelnotes that these indicators are increasingly beingadopted by monitoring bodies and tribunals aroundthe world with respect to their own periodicreporting requirements.12

It also notes, however, that the trend has been toassume that governments will identify their ownperformance indicators, drawing in particular on theindicator-identification work of international bodiessuch as the UN specialised agencies and regionalbodies. Governments are then expected to monitorthemselves with respect to the chosen indicators,

reporting periodically to international bodies on theirprogress in achieving corresponding improvements.

The panel notes that this process, while importantin key respects, is not fully consistent with thehuman rights-based approach to health, whichrequires the active and informed participation ofindividuals and communities in policy decisions thataffect them. Experience shows that whengovernments are left to measure progress againsttheir own choice of indicators, those measurementsoften do not coincide with the real concerns andpriorities of local populations. That is, the processruns the risk of measuring the wrong things. Forthis reason, the panel underscores the vitalimportance of ensuring that local communitiesparticipate actively in the process of defininghuman rights performance indicators and in

3. Importance of Service Users IdentifyingPerformance Indicators and Benchmarks

11 See, e.g., Report of the Special Rapporteur on the Right to Health, Paul Hunt, on health systems and human rights-based approachto health indicators, UN Doc. E/CN.4/2006/48, submitted to the Commission on Human Rights on 3 March 2006.12 Most recently by the Inter-American Commission on Human Rights with respect to monitoring fulfilment of the rights guaranteed inthe Additional Protocol to the American Convention on Human Rights in the Area of Economic, Social and Cultural Rights.

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monitoring and revising them over time. Only inthis way will indicators genuinely correspond to localpopulations’ experiences with rights deprivations,and hence truly serve as a metric for human well-being in our diverse communities.

The panel commends the work of the PIPS/RAYSrights group in identifying a set of indicators thatcorrespond directly and immediately to the rightsdeprivations recurrently experienced by mentalhealth service users in North Belfast. The work ofthe PIPS/RAYS rights group directly evidences thebenefit that can be derived by having health serviceusers identify the components of the right to healthas it relates to them and setting in place a systemto monitor the progress of its realisation.

It recommends that the health authorities, startingwith the Minister for Health, work closely with thegroup to ensure that real improvements to theright to health are experienced by mental healthservice users throughout Northern Ireland. To thisend, the panel believes the example provided by the

PIPS/RAYS rights group is capable of broadreplication elsewhere and recommends that itshould be actively embraced by national healthauthorities.


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The PIPS/RAYS rights group presented a number ofhuman rights indicators to the panel by which theyproposed to measure whether the right to thehighest attainable standard of health is being madea reality in North Belfast. These indicators weredeveloped through the use of a baseline survey onthe experiences of mental health service users inBelfast.

Through the use of that survey and other fact-gathering methods, the PIPS/RAYS group identifieda long list of deficiencies and failings in mentalhealth services in Belfast. Using a human rights-based analysis, they then narrowed these down tofour priority areas, each of which met two significantand strategic guidelines:

• The deficiency inhibited or impeded theeffective realization of the right to health fora large number of mental health serviceusers.

• Core improvements could be realisticallyand easily achieved with small but critical

changes in the way the mental healthsystem operated.

The resulting indicators of the right to mental healthidentified by the PIPS/RAYS group as priorities foraction included the following:

(1) lack of follow-up appointments on dischargefrom hospital for persons with severe mental healthissues,

(2) inadequate provision of medical information bygeneral practitioners,

(3) lack of information on and access to complaintsmechanisms; and

(4) lack of opportunities for participation in mentalhealth decision-making.

With the assistance of the Participation and Practiceof Rights Project, the group then identified a set ofbenchmarks, representing the level of improvementthat could reasonably be expected to be achieved insix months and one year, respectively, if the

4. PIPS/RAYS Rights Group Human RightsIndicators

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indicators were in fact taken seriously by publichealth authorities. Each of the chosen indicators,together with their corresponding benchmarks, isconsidered below.

a) Availability of Essential Mental Health Services:Follow-Up Appointments

A core element of the right to health is theavailability of public health and health-careservices.13 Correspondingly, the first indicatoridentified by the PIPS/RAYS group measures thenumber of follow-up appointments received bymental health service users following dischargefrom a hospital for severe mental illness or recenthistory of self-harm. These follow-up appointmentsare of crucial importance given that statisticallysuch individuals are at high risk of suicide or self-harm. Forum participants stressed that such follow-

up appointments often serve as a “life-line” for suchpersons at this most vulnerable time. Inaccordance, National NHS Guidance on the issuestates that patients at risk of harming themselvesor others, or who are suffering a serious mentalillness should receive follow-up within one week.14

Notwithstanding, the baseline research of thePIPS/RAYS rights group found that 87% of themental health service users they surveyed had noteven received a follow up appointment followingdischarge from hospital within one week.

The panel finds that remedying this unnecessarydeficiency would not take significant resources, andyet would have a tremendous impact on protectingthe right to life and health of many people at risk ofself-harm and/or suicide in North Belfast, ademographic that experiences the highest levels of


13 General Comment No. 14, 12 (a)14 Recommendation from Safety First: Five Year report of the National Confidential Inquiry into Suicide and Homicide by People withMental Illness, Dept of Health, United Kingdom, 2001 (“All discharged patients who have severe mental illness or a recent (less thanthree months) history of deliberate self-harm should be followed up within one week.”).

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suicide in Northern Ireland. The panel also findsthat the benchmarks set by the PIPS/RAYS groupare eminently reasonable. The group proposes in ayear the number of people receiving follow upappointments within one week of discharge shouldbe increased to 87% within one year. The panelrecommends that the PIPS/RAYS benchmarksshould be embraced by the Minister for Health asan urgent priority.

The panel recognises the National Guidance thatthose with severe mental illness or recent history ofself-harm should receive a follow-up appointmentwithin a week. The Mater’s guidance states thatcare plans should contain follow up arrangements.The panel strongly urges the Minister to work withthe group to ensure that mental health patientsdischarged from hospital receive an appointmentbefore they leave in order to fulfil their right toaccess health care. This is a low-cost and simplerequirement but one which would be ofconsiderable benefit to vulnerable individuals.

As a further action, the panel recommends that theMinister of Health, as the primary duty-bearer,issues a directive to regional hospitals, includingthe Mater Hospital in Belfast, to change theirhospital guidelines so that they provide not that“All discharged patients who have severe mentalillness or a recent history of deliberate self harmshould be followed up within a week,” but ratherthat they “must” be followed up within a week.The Hospital administration should then be urged ordirected to take targeted training action to ensurethat all practitioners are aware of this Hospitalrequirement, that they know that administrativesanctions will follow if they do not adhere to it, andthat administrative sanctions are in fact imposed onany practitioner who unjustifiably fails to fulfil theHospital mandate.

b) Access to Adequate Information: InformedMedical Decision-making

The panel recalls that the right to information, as acore predicate to the right to free and informed

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consent to health care interventions, is an integralpart of the right to health. International standardsaffirm that receipt of information is inextricablylinked to accessing healthcare and that“accessibility includes the right to seek, receive, andimpart information and ideas concerning healthissues.”15

At the same time, health care interventions can notbe deemed acceptable where appropriateinformation is not provided to the patient. Receipt ofsuch information protects against unwarrantedinfringements of a patient’s autonomy and integrityinterests, ensuring that he or she can make freeand informed decisions about all health careinterventions that impact her physical and mentalwellbeing. In this respect, the panel reaffirms thatthe right to receipt of appropriate medicalinformation by health care practitioners is necessaryto protect not only an individual’s autonomy

interests, but also those to physical and mentalintegrity.

Given the importance of ensuring that generalpractitioners are sufficiently trained in mental healthissues to provide appropriate information to mentalhealth service users on their conditions andtreatment options, the panel was alarmed at thePIPS/RAYS group’s findings that found only 36% ofmental health users surveyed reported that theywere satisfied with the information they receivedfrom general practitioners on mental health issuesand only 38% were satisfied with the informationreceived on medications prescribed to them. Thepanel recommends that the Health Ministry andDepartment take up the group’s benchmarks as amatter of priority, working to increase the numberof satisfied mental health service users to 45%(information on mental health issues) and 50%(information on prescribed medication) within six


15 General Comment, No. 14, paragraph 12 (b).

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months, and to 60% and 70%, respectively, withinone year.

The panel recognizes that the government ofNorthern Ireland appreciates the need for expandedtraining of general practitioners in depressionawareness and in suicide prevention. As such, ithas developed a Depression Awareness TrainingProgramme for general practitioners, and hasrecognized “appropriate suicideawareness/prevention training [as] a priority for allfront line health service staff, in particular primarycare staff.”16

Nevertheless, the action research of the PIPS/RAYSrights group has identified a key reason why thattraining has not translated into better outcomes in

clinical contexts: It has experienced a very lowuptake, with only 13.9% of GPs in the Health Boardarea covering North Belfast having undertaken thetraining by October 2007,17 despite the existence oflocum cover. In his report of 11 February 2005 tothe United Nations Commission on Human Rights(now Human Rights Council), the UN SpecialRapporteur on the Right to Health stated:

“General practitioners, and other primary careproviders, should be provided with essentialmental health care and disability sensitizationtraining to enable them to provide front-linemental and physical health care to persons withmental disabilities.”18

16 Protect Life: A Shared Vision, The Northern Ireland Suicide Prevention Strategy and Action Plan, 2006-2011. The DepressionAwareness Training Programme was initiated in 2004, as part of the 2003-2008 five year action plan for the Promoting Mental Healthstrategy.17 According to figures received from the Department of Health in October 2007 in response to a request under the Freedom ofInformation Act.18 Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mentalhealth, Commission on Human Rights, 61st Session, E/CN.4/2005/51

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The low uptake of GP training is clearly indicativethat something in this process is going wrong. Thepanel recommends that the Minister of Healthtake decisive action to ensure that all generalpractitioners do in fact take the required trainingcourse. A wide variety of positive and negativeincentives could be implemented, all of which wouldconstitute an “appropriate step” in fulfilling the rightto health of mental health users in Belfast and inachieving the identified benchmarks as quickly aspossible.

The panel also recommends that mental healthservice users be involved in assessing the contentof the training program, in contributing to itsexpansion if necessary, and in monitoringcontinued uptake and satisfaction with its results.Such involvement will ensure that the key pieces ofinformation deemed necessary by users of themental health system with respect to treatment

options are taken into account, while allowing usefultracking of both the measures adopted by healthauthorities to achieve the right to health and theoutcomes of those measures as evaluated bymental health service users.

c) Accountability: An Effective Complaints System

The panel wishes to underscore that, as affirmed bythe UN Committee, “Any person or group victim of aviolation of the right to health should have accessto effective judicial or other appropriate remedies”19

The Committee has also stated that administrativeremedies, such as the Health Service complaintssystem should take into account human rightsstandards on the right to health in their decision-making. In addition, the Committee identifies theessential characteristic of administrative remediesas “accessible, affordable, timely and effective”.


19 General Comment No. 14, para. 59

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During ‘Rights in Action: Changing Mental HealthServices’ the panel heard testimony from membersof the group with experience in using the healthservices complaints system. Evidence waspresented relating to the inaccessibility of thecurrent complaints procedure, and concerns over itsinability to make changes as a result of lessonslearned. The key role an effective complaintsprocess can play in highlighting and addressingmental health service shortcomings cannot beover-emphasised.

The panel notes that the PIPS/RAYS rights groupcontributed to the public consultation in 2006 onreforms to the current complaints system, and thatnew proposals are forthcoming. The panelrecommends that both the indicators selected inrelation to the complaints process and thecorresponding human rights standards must betaken into account in any endeavours to improvethis service.

d) Participation: An Informed Voice in Health CareDecision-making

The panel was encouraged to hear the PIPS/RAYSrights group identify the right to participate as themost important indicator they had identified formeasuring the effective achievement of the right tohealth. The Committee on Economic, Social andCultural Rights has underscored the absoluteimportance of people’s participation in securing theright to health, concluding that:

“the right of individuals and groups to participatein decision-making processes, which may affecttheir development, must be an integralcomponent of any policy, programme or strategydeveloped to discharge governmental obligationsunder article 12. Promoting health must involveeffective community action in setting priorities,making decisions, planning, implementing andevaluating strategies to achieve better health.Effective provision of health services can only be

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assured if people’s participation is secured byStates.”20

Notwithstanding, the PIPS/RAYS group has foundthat almost 80% of mental health service users ratetheir participation in mental health service decision-making as “not involved.” The panel recommendsthat the Minister of Health prioritize actions aimedat increasing the opportunities for participation inmental health service decision-making by mentalhealth service users.

In this respect, the PIPS/RAYS group hashighlighted the difference between the human rightsrequirement of participation and the diluted versionof consultation often experienced by groups such astheirs. Consultation processes which do not allowaffected groups to impact and shape decisions thatare made fall far short of participation. According tothe UN Rapporteur on the Right to Health,

participation must enable groups to affectprocesses:

“…at all stages of the development,implementation and monitoring of legislation,policies, programmes and services relating tomental health and social support, as well asbroader policies and programmes, includingpoverty reduction strategies, that affect them.”21

The UN Rapporteur goes on to state thatgovernment should affirmatively solicit the input ofpersons with mental health problems, their familiesand representative organisations. It is necessary toassess whether the current arrangements put inplace by government are adequate to secureparticipation of affected groups in policy making,above and beyond consultative structures that donot allow groups to be actively involved in coredecisions. The panel recommends a review of the


20 CESCR General Comment No. 14, para. 5421 E/CN.4/2005/51

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current formal mechanisms for “participation” inorder to ascertain whether the internationalobligations and the Minister’s own commitmentsto put service users at the heart of the healthservice can be met through them. If they cannot,new mechanisms must be envisioned and put intooperation to ensure that mental health serviceusers can effectively participate in the decision-and policy-making processes that affect them.

The panel emphasises that such participation iscrucial if States are to meet their obligations underthe right to health. In order to determine whatmeasures they must take to implement the right tohealth, States must establish a constant dialoguewith health care users who can help them identifyand address the most pressing issues relating totheir right to health.

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The panel wishes to underline the importance of,and commend the work undertaken by, thePIPS/RAYS rights group to identify those mentalhealth service users who are facing particulardisadvantage and are in need of particular attention.Evidence was provided during ‘Rights in Action:Changing Mental Health Services’ on the highincidence of suicide in areas characterised byincome deprivation, including North Belfast, in whichthe suicide rate is almost twice that of NorthernIreland as a whole. Indeed, evidence indicates thatin Northern Ireland suicide rates in economicallydeprived areas are twice that in non-economicallydeprived areas, and that three of the mosteconomically deprived wards in Northern Ireland arelocated in North Belfast.

Throughout their monitoring the PIPS/RAYS rightsgroup plan to collect information by age and genderto reflect the realities behind the particularly high

suicide rate among youth and, particularly, youngmales.

The UN Special Rapporteur stated in his report onMental Disability:

“Under international human rights law, States notonly have an obligation to prohibit discrimination,they also have a positive obligation to ensureequality of opportunity for the enjoyment of theright to health by persons with mentaldisabilities.”22

This obligation encompasses special measures forparticular groups when required. However, the panelis concerned that the work of the PIPS/RAYSrights group to address the situation of the mostdisadvantaged does not appear to be mirrored bypolicy makers. The panel was concerned to hearevidence at the Mental Health Forum concerning thedecision by the Department of Health not to subject

5. Identifying and addressing the needs ofvulnerable or marginalised groups


22 E/CN.4/2005/51

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the Protect Life Suicide Strategy to an equalityimpact assessment. Under s75 of the NorthernIreland Act, public authorities including theDepartment of Health are under an obligation to paydue regard to promoting equality of opportunity in alltheir functions among those of different age,religious belief, political opinion, racial group,marital status or sexual orientation, and alsobetween men and women, persons with a disabilityand persons without, and persons with dependentsand persons without.

Among the requirements under s75 is the obligationfor public authorities to carry out equality impactassessments to gauge the effect of their policies onthe affected groups. Notwithstanding, the ProtectLife Suicide Strategy did not undergo an equalityimpact assessment. According to evidencepresented at the Mental Health Forum, the Equality

Impact Assessment is a tool which can be used totarget and positively address the inequalitiesbetween groups, and so this omission isdisappointing. The panel hopes that this can bepartially addressed by thorough monitoring of theimpact of the Protect Life Suicide Strategy on eachof the named group, in order to evaluate itssuccess and to discharge government obligationsunder s75 of the Northern Ireland Act 1998 andinternational human rights law. As the UNRapporteur on the right to health states:

“One of the most urgent steps which many Statesneed to take to facilitate the realisation of theright to health of persons with mentaldisabilities…is to enhance monitoring andaccountability at the national and internationallevels”23

23 E/C.4/2005/51, para. 68

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The panel likewise notes that monitoring anddisaggregation is critical for engaging in targetedand appropriate health care budgeting. It wasconcerned to learn in the evidence hearing of thesignificant gaps in mental health service provision inNorth and West Belfast. In particular, it wasreported that, despite the increased needs, thereare fewer mental health practitioners in the Northand West Belfast area than elsewhere in NorthernIreland. At the same time, North and West Belfastmental health services experienced an equity deficitof 2.5 million compared to the average level ofinvestment across the Health Board’s area in 2005.

The panel was also concerned to learn of the lowbudgetary amounts allocated to mental healthservices throughout Northern Ireland.

It recommends that the Minister of Health take aclose and systematic look at differential spendinglevels and differential needs across the region,taking civil society inputs directly into account. Italso recommends that mental health service users

be actively involved in decision-making affectingbudgetary allocations in the health sector.

6. Appropriate Health Care Budgeting


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As stated at the outset, the panel has been struck

by the innovative and determined work carried out

by the PIPS/RAYS rights group in their efforts to

improve mental health services for all. The panel

heard evidence of forthcoming legislation which will

enshrine into law the obligation to seek out the

views of mental health service users and to show

how these views were used in policy-making. In

addition the panel has been made aware of the

commitment given by the Minister for Health on

many occasions to ensure that the views and

experiences of service users are sought and heard

when decisions are made. As a result of the

sustained effort made by the PIPS/RAYS rights

group, tangible and achievable changes have been

identified which could have real impact on improving

the experiences of mental health service users and

progressively realising the right to health. Ultimately

the changes identified could save lives.

As the group moves forward with its work, thepanel recommends the creation of a formalinstitutional mechanism connecting thiscommunity level work with government health-caredecision making processes. Such a mechanismwould reinforce the human rights obligation ofgovernment and its agencies to be accountable, andto ensure that the right of health service users toparticipate in making decisions, and planning andimplementing strategies to achieve better health isintegrated into day to day practice.

Governments and its agencies are under a humanrights obligation to:

“monitor the actual situation with respect to eachof the rights on a regular basis and is thus awareof the extent to which the various rights are, orare not, being enjoyed by all individuals…underits jurisdiction”24

7. Institutional Mechanisms for Service-User Participation

24 CESCR General Comment No. 1. para. 3

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The creation of a mechanism which will enable theexperience and expertise of the PIPS/RAYS rightsgroup to truly inform and shape decision makingprocesses, beyond current consultative processes isessential to move the process forward andpotentially provide a best practice example that canbe emulated around the world.


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Christian Courtis, International Commission ofJurists, Geneva

Christian Courtis is the Legal Officer for Economic,Social and Cultural Right for the InternationalCommission of Jurists, Geneva. He holds aBachelor in Law and a Law degree from theUniversity of Buenos Aires, Argentina, and a LL.M.degree from the University of Virginia, U.S.A.

He is a law professor at the University of BuenosAires Law School, and invited professor at ITAM LawSchool, Mexico City. He has acted as consultant forthe World/Pan-American Health Organisation,UNESCO and the UN Division for SocialDevelopment. He was a lawyer for a human rightsNGO in Argentina, Centro de Estudios Legales ySociales (CELS), legal counsel for the ArgentineSenate, and legal clerk for the Buenos AiresSuprema Court. He has worked in legal reformissues in Latin American, Caribbean and Africancountries. He was a legal adviser at the Argentinesenate and a law clerk for the Buenos Aires

Supreme Court. He has published books andarticles on human rights, constitutional law, legaltheory and sociology of law.

Camilla Parker, Mental Health and Human RightsSpecialist, UK

Camilla Parker is a legal and policy specialist inmental health, disability and human rights. She is aconsultant to the Open Society Mental HealthInitiative (MHI). MHI seeks to promote the humanrights and social inclusion of people with mentalhealth problems and/or learning disabilities inCentral and Eastern Europe and the former SovietUnion. Her publications include: Developing mentalhealth policy: a human rights perspective in MentalHealth Policy and Practice across Europe, editorsMartin Knapp et al, McGraw Hill, Open UniversityPress (2007) and Independent Living and theCommission for Equality and Human Rights,Disability Rights Commission January 2007.

Biographies of International PanelMembers

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Tara J. Melish, Visiting Professor, University ofGeorgia School of Law, 2008; Legal Advisor,Mental Disability Rights International, USA

Professor Melish specializes in the legal protectionof economic, social and cultural rights in a variety ofinstitutional settings. She has served as StaffAttorney and Legal Advisor to the Center for Justiceand International Law, a law firm specializing inlitigation before the inter-American human rightssystem; as Associate Social Affairs Officer in theDisability Unit of the United Nations Department ofEconomic and Social Affairs; and as MentalDisability Rights International’s United Nationsrepresentative in the drafting negotiations of the UNConvention on the Rights of Persons withDisabilities and its Optional Protocol. Active inreporting procedures and litigation initiatives beforeUN and OAS bodies, Professor Melish serves asconsultant or adviser to a range of domestic andinternational organizations, publishes and lectureswidely on human rights issues, and has taught onhuman rights law, international litigation,

constitutional law, criminal law, and torts at avariety of law schools, most recently at theUniversity of Georgia and University of VirginiaSchools of Law and Oxford. She has clerked on theU.S. Court of Appeals for the Ninth Circuit and theSouth African Land Claims Court, receivedprofessional fellowships from the MacArthurFoundation, Fulbright Foundation, and Yale LawSchool, and has degrees from Brown University andthe Yale Law School.


Rights in Action:Changing Mental Health Services28th November 2007

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Transcript of Rights in Action:Changing Mental Health Services28th November 2007