Sharing the Vision€¦ · a person to deal with negative thoughts and feelings. They help a person...

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Prepared by the Department of Health health.gov.ie Sharing the Vision A Mental Health Policy for Everyone Prepared by the Department of Health health.gov.ie

Transcript of Sharing the Vision€¦ · a person to deal with negative thoughts and feelings. They help a person...

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Prepared by the Department of Healthhealth.gov.ie

Sharing the VisionA Mental Health Policy for Everyone

Prepared by the Department of Healthhealth.gov.ie

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Sharing the VisionA Mental Health Policy for Everyone

Prepared by the Department of Healthhealth.gov.ie

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Sharing the Vision | A Mental Health Policy for Everyone

List of Abbreviations 6

Chapter 1 | Background and Context 11 Introduction 13Therefreshprocess 13OversightGroup 13Methodology 14Framework 15CoreValues 16Thevision 16Principles 17Implementation 19

Chapter 2 | Promotion, Prevention and Early Intervention Domain 23 Introduction 24Positivementalhealthandwellbeing 25Mentalhealthlifecycle 26TheLifecycleApproach 26MentalHealthacrosstheLifecycle 27Mentalhealth,prioritygroupsandstigma 29Additionalhealthpromotionsupports 30HealthPromotionProgrammes 30VoluntaryandCommunitySector 30DigitalMentalHealth 30

Chapter 3 | Service Access, Coordination and Continuity of Care Domain 33 Introduction 34Pathwaystosupport 36PrimaryCare 40Integratedservices 41CommunityMentalHealthTeams 44Clinicalleadership 45AlternativeAccessRoutestoEmergencyCare 45Specialistmentalhealthservicesacrossthelifecycle 47Childandadolescentmentalhealthservices 47The0–25cohort 47Generaladultmentalhealthservices(GAMHS) 48Adultinpatientcapacityandalternativestoinpatientadmission 48Mentalhealthservicesforolderpeople 50

Table of Contents

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Tailoredinterventions 50Forensicmentalhealthservices 50Dualdiagnosis 53Mentalhealthservicesforhomelesspeople 54Liaisonmentalhealthservices 54

Specialistneeds-basedservices 54Intensiverecoverysupportservices(forindividualswithcomplexmentalhealthdifficulties) 54Mentalhealthservicesforearlyinterventioninpsychosis 55Peoplewithanintellectualdisability 56ADHD 56Suicideprevention 56Eatingdisorders 57Specialistperinatalsupports 57Neuro-rehabilitation(includingacquiredbraininjury) 57

Providingmentalhealthservicesthatrecogniseandrespondtodiversity 57Accesstoadvocacy 58

Chapter 4 | Social Inclusion Domain 65 Introduction 66Equalityofaccess 67Housingsupports 67Employmentsupports 68Trainingandvocationaleducationsupports 68Incomeprotectionandsocialwelfare 68Peer-led,peer-runandcommunitydevelopmentprojects 68

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Sharing the Vision | A Mental Health Policy for Everyone

Chapter 5 | Accountability and Continuous Improvement Domain 71 Introduction 72Accountabilityandcontinuousimprovement 73Governanceleadershipandorganisation 73PatientSafety 74Disadvantageandserviceplanning 74Physicalinfrastructureformentalhealthservices 75Measuringperformance 75Capturingandembeddinginnovation 75Meetingstandardsinqualityframeworksandbestpracticeguidelines 76Enablers 76Safeguardingvulnerablepeople 78Serviceusers,self-harmandsuicide 78Involuntarydetention 78

Chapter 6 | Implementation 83 Introduction 84NationalImplementationandMonitoringCommittee 85HSE Sharing the Visionstructure 85Implementationroadmap 85

List of Appendices 89 AppendixI: TermsofReferencefortheOversightGroup 90AppendixII: MembershipoftheOversightGroup 91AppendixIII: ImplementationRoadmap 94References 111Bibliography 113

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Glossary of Abbreviations

ACEs Adverse Childhood Experiences

AHPs Allied Health professionals

AVFC A Vision for Change

CAMHS Child and Adolescent Mental Health Services

CFL Connecting for Life

CHN Community Health Network

CHO CommunityHealthcareOrganisation

CIPC Counselling in Primary Care

CMH Central Mental Hospital

CMHTs Community Mental Health Teams

CNS Clinical Nurse Specialist

COG CAMHSOperationalGuidance

CPD ContinuingProfessionalDevelopment

CRRs CommunityRehabilitationResidences

CRTs CrisisResolutionTeams

DA DisabilityAllowance

DEASP Department of Employment and Social Protection

DES DepartmentofEducationandSkills

DHPLG Department of Housing, Planning and Local Government

DoH Department of Health

ED Emergency Department

EMAP EuropeanMentalHealthActionPlan

FCAMHS Forensic Child and Adult Mental Health Service

FCS Family, Carers and Supporters

FMHS Forensic Mental Health Service

GAMHS General Adult Mental Health Service

IAN Irish Advocacy Network

ICRU IntensiveCareRehabilitationUnit

IPS Individual Placement and Support

IRSS IntensiveRecoverySupportServices

IRST IntensiveRecoverySupportTeams

LMHS Liaison Mental Health Service

MHC Mental Health Commission

MHIAP Mental Health in all Policies

MHIDT MentalHealthIntellectualDisabilityTeams

MHR MentalHealthReform

MHSOP Mental Health Services for Older People

MOC Models of Care

MOCEIP EarlyInterventionPsychosisModelofCare

NCHD Non-Consultant Hospital Doctors

NEPS NationalEducationalPsychologicalService

NGBRI NotGuiltyByReasonOfInsanity

NOSP NationalOfficeforSuicidePrevention

OTs OccupationalTherapists

PBP Population-BasedPlanning

PH&HS PopulationHealth&HealthServicesResearch Research

PICU PsychiatricIntensiveCareUnit

POLL Psychiatry of Later Life

RICO RegionalIntegratedCareOrganisations

SLTs Speech and Language Therapists

SOG StandardOperatingGuideline

SOP StandardOperatingProcedure/Scope ofPractice

SPPMO StrategicPortfolioandProgrammeManagementOffice

SRF SocialReformFund

SRUs SpecialisedRehabilitationUnits

TILDA The Irish Longitudinal Study on Ageing

UNCRPD UNConventionontheRightsofPersonswithDisabilities

VCS Voluntary Community Sector

WHO WorldHealthOrganization

WRC WorkResearchCentre

YMHTF Youth Mental Health Task Force

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Sharing the Vision | A Mental Health Policy for Everyone

A Note on Terminology

Assertive outreach Theassertiveoutreachteamsprovideintensive support for a person with complex needs. The teams aim to support the person to get help from other services. This support can help thepersontomanagetheirconditionbetterandreducetheperson’schancesofgoingbacktohospital.

Crisis resolution CrisisResolution(CR)offersafter-hoursand urgent mental health assistance. CrisisResolutionisanintegralpartof each community mental health team,providing24-houradviceandassessmentforpeoplepresentingin crisis associated with a known or suspectedmentalhealthproblem.

Digital health Digital health refers to using online or other digital technology to provide preventionandcare.Somedigitalhealthprogrammesfocusonpromotinghealthandwellbeingandpreventingill health, while others may deliver earlyinterventionandmentalhealthtreatment. There are numerous digital healthprogrammesavailable,coveringa range of mental and physical health concerns, and thus increasing individual healthcare management choices and improving access to support.

Dual diagnosis ‘Dualdiagnosis’isthetermusedwhenapersonexperiencesbothasubstanceabuseproblemandamentalhealthissue such as depression or an anxiety disorder.Treatmentoptionsmustaddressboth.Dual diagnosis may also refer to someone who has a mental health difficultyalongsideanintellectualdisability,autismorboth.

Mental health difficulty Theterm‘mentalhealthdifficulty’hasbeenusedthroughouttodescribethefullrangeofmentalhealthdifficulties

thatmightbeencountered,fromthepsychologicaldistressexperiencedbymany people, to severe mental disorders thataffectasmallerpopulation.

Peer support Peer support is a system of giving and receiving help founded on key principles ofrespect,sharedresponsibilityandmutual agreement as to what is helpful. Peersupportisnotbasedonpsychiatricmodelsanddiagnosticcriteria.Itisaboutunderstandinganother’ssituationempathicallythroughthesharedexperienceofemotionalandpsychological pain.

Recovery colleges Recognisingthatpeoplecananddorecover from mental health distress, recovery colleges work to create an empowering and inclusive culture of recovery and acceptance in the community through the provision of person-centred,strengths-basedholisticlearning,underpinnedbyvaluesofself-determination,choiceandhumanrights.Recoverycollegecoursesaredesignedanddeliveredbypeoplewithexperienceof overcoming mental health distress in partnership with other key stakeholders including supporters such as family membersandfriends,andprofessionals,usingaprocessofco-production.Recoverycollegespromoteacultureofrecovery in Irish society and throughout mental health services, to empower individualsandcommunitiestoembraceand overcome mental health challenges collectively;toimprovequalityoflife;and to promote acceptance, community involvement and opportunity for advancement.

Referral pathway Apatientreferralpathwayistheprocessbywhichapatientisreferredfromonedoctor to another. Normally you do not see specialists without a referral from a generalist (i.e. family doctor).

Scope of practice Thescopeofpracticesetsouttheprocedures,actionsandprocessesthatthe registered or licensed professional is allowed to perform. The individual practitioner’sscopeofpracticeisdeterminedbyarangeoffactorsthatgives them the authority to perform a particularroleortask.

Social prescribing SocialprescribingenablesGPs,nursesand other primary care professionals to refer people to a range of local, non-clinical services.

Talking therapies Talking therapy is a general term to describeanypsychologicaltherapythatinvolves talking such as counselling or psychotherapy. Talking therapies are psychological treatments. They involve talking to a trained therapist to support apersontodealwithnegativethoughtsand feelings. They help a person to makepositivechangesandtheytakeplace in groups, one-to-one, over a computer or over the phone.

Trauma-informed care Trauma-informed care is an approach which acknowledges that many people who experience mental health difficultieshaveexperiencedsomeformof trauma in their life, although this is not the case for everyone. A trauma-informed approach seeks to resist traumatisingorre-traumatisingserviceusersandstaff.Trauma-informedservice delivery means that everyone at all levels of the mental health services and wider mental health provision hasabasicunderstandingoftraumaandhowitcanaffectfamilies,groups,organisationsandcommunitiesaswellas individuals.

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Sharing the Vision | A Mental Health Policy for Everyone

Message from Minister

ThepublicationoftheVision for Changementalhealthpolicyin2006setahighstandardforthedevelopmentofmentalhealthpolicyinIreland.Asaresult,therehavebeenmanyimportantchangesinthepastdecadeaimedatimprovingpeople’shealthandwellbeing.Inrecenttimes,mentalhealthhasreceivedmuchattention.TheoutbreakofCOVID19throughouttheworldcreatedsignificantstress,anxiety,worryandfearformanypeople.Thediseaseitselfwasfurthercompoundedbyotherimpactssuchassocialisolation,disruptiontodailylife,uncertaintyaboutemploymentandfinancialsecurity.TheGovernmentresponsewasrapidandawhole-of-populationplanwasputinplacetosupporthealthcarestaffandthegeneralpopulationbyprovidinghealthandwellbeingadvice,resiliencebasedtrainingandprovidingfreeonlineinterventionssuchascounsellingandcrisistextingforallinneed.Indeed,theabilitytocreateadditionalonlineinterventionstoaugmentexistingserviceswithsuchawidereach,hasinmanywayschangedhowwetreatthemildtomoderatementalhealthneedsofthepopulation. InmanywaysthepandemicassistedIrelandtoimprovepublicattitudestomentalhealth becauseofthestatutory,voluntaryandcommunitycommitmenttoraisingawarenessand creatingpositivechangesinhowIrelandthinksaboutanddeliversmentalhealthservices.

ThispolicyhasbeendevelopedfollowingaprocessofresearchandconsultationwhereinternationalevidencewasexaminedandwherethoseconsultedprovidedtheOversightGroupwithinformationaboutwhattheywouldliketoseeprioritisedintherefreshedpolicy.Basedonthisapproach,theareasthatpeoplefeltwereimportanttothemwereidentified.Thispromptedthedevelopmentofthisaction-oriented,outcome-focusedpolicy,whichadoptsalifecycleapproach that places the individual at the centre of service delivery.

Ourgoodhealthisveryprecioustousall.Mentalhealthparticularlyrequiresarangeofcommitmentsandresponsestoensuregoodoutcomes.Withinthisoutcome-basedframework,high-leveloutcomeshavebeensetthatwilldeliverimprovedbenefitsforeveryone.

Iwouldliketothankallofthosewhogenerouslygavetheirtimeandknowledgetoengageinthisveryvaluableprocess.AspecialthankyoutotheOversightGroupmembers,ablychairedbyHughKane,andtoallthosewhocametotheconsultationstoprovideessentialinputthathelpedshapethis service user-centred policy.

AsMinisterwithresponsibilityformentalhealth,Iamencouragedthatthispolicyiswide-rangingandinnovative.Itpromotesearlyaccesstosupportinvariouslocationsandseekstoprovideindividualisedcaretothosewhoneedhelpassoonaspossible.Thispolicybuildsonexistingservicesandprovidesaframeworkthatwillseektomeasureimplementation.Therearemanychallengesahead,butIamveryconfidentthatSharing the Vision will improve the mental health ofthenationsignificantlyoverthenexttenyearsandbeyondaslongasweallremaindedicatedto working together.

Jim DalyMinister for Mental Health and Older People

Jim Daly

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Chapter 1

Background and Context

Sharing the Vision | A Mental Health Policy for Everyone

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1 KevinCullenandDavidMcDaid.EvidenceReviewtoInformtheParametersforaRefresh of A Vision for Change (AVFC)–Awide-angleinternationalreviewofevidenceanddevelopmentsinmentalhealthpolicyandpractice(Dublin:WRCandLSE,2017).

Chapter 1 | Background and Context

Introduction

ThepublicationofA Vision for Change (2006)represented an important milestone in the development of mental health policy in Ireland. Many significantchangesandimprovementshavetakenplaceoverthelifetimeofthepolicysince2006.Although A Vision for Change (AVFC) has supported significantdevelopmentoverthepast13years,wehave much more to do in developing stronger, more appropriate mental health supports at community andprimarycarelevelsandindevelopingrobustandreliableservicesandensuringeffectiveuseofappropriateinpatientcare.

TheeconomicdeclineexperiencedinIrelandin2008influencedtheabilityoftheStatetofundtheoriginalAVFCpolicytoanticipatedlevels;however,between2012and2020,theHSEMentalHealthServicesbaseincreasedby€315m,oraround44%,with€233.6mofthis funding new developments. AVFC did not include aframeworkbywhichtomeasureoutcomesorassesstheimpactoftherecommendationsoverthelifetimeofthepolicy;thereforethesignificantgrowthwithinmentalhealthservicesisdemonstratedbyincreasedactivity,improvedaccessandotheroutputs,someofwhicharehighlightedbelow:

• Between2012and2018,therewasanincreaseof24%inthenumberofreferralsacceptedbyChild and Adolescent Mental Health Services (CAMHS).Whilewaitinglistsincreasedbyjust4%over the same period, it is noted that the CAMHS waitinglistreducedbyabout20%betweenDecember2018andAugust2019.IncreasedaccesstoCAMHSissupportedbytheadditionalstaffingofCAMHSteamsbetween2008and2017.

• InlinewithnationalpolicytoenhancecommunityservicestherehasbeenadecreaseinadmissionstoadultacuteinpatientunitsoverthelifetimeofAVFC. Acute hospital admissions were reduced by4,138between2008and2017andthe

re-admissionratewasreducedby8%.Thisindicatesthattheshiftfrominstitutionalcaretocommunity care has progressed.

• Overall,mentalhealthstaffinghasincreasedwithanadditional1,700new-developmentpostssince2012,andincreasedmentalhealthcapacityhasbeenbuiltintoprimarycaretohelprelievepressures on CAMHS services.

• FourNationalClinicalProgrammes(NCPs)formental health are in various stages of design and implementation:(i) Assessment and management of service

userspresentingtoemergencydepartmentsfollowingself-harm;

(ii) Thenationalclinicalprogrammeforeatingdisorders;

(iii) Anearlyinterventioninpsychosismodelofcare;and

(iv) Theestablishmentofamulti-disciplinarynationalworkinggrouptoprogressanNCPfor ADHD in adults.

• Voluntary and community services have also seenimprovedaccessandincreasedactivity.Non-governmentalorganisations(NGOs)havesupportedindividualsbyprovidingworkshopsand training on healthy living, mental health awareness,resilienceandmentalhealthfirstaid,andbybuildinginclusivityandcohesion.Importantly the development of peer support andserviceuserinvolvementatnationallevelhasensured that the voice of those using services is heard and incorporated into service provision.

IrelandhaschangedsignificantlysinceAVFC wasfirstpublishedin2006andourunderstandingofmentalhealthhasimprovedgreatlyinthattime.Sharing the Visionisapolicythatbuildsuponthegoodworkachieved over the past decade and it will provide aframeworkforinvestinginamodern,responsivementalhealthservicefitforthenexttenyears. Workbeganin2016onthisprocess

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2 Kevin Cullen. Stock-take of progress on A Vision for Change (AVFC)(Dublin:WRC,2018).3 A Vision for Change Oversight Group. Change for the Future – A Vision for Change ‘refresh’(Dublin:2019).

The refresh process AVFCcametotheendofitsten-yeartermin2016andpreparationsforareviewandupdateofthepolicycommencedwiththecommissioninginFebruary2017ofanExpertEvidenceReviewbytheWorkResearchCentre(WRC)toinformtheparametersofthe planned refresh of mental health policy in Ireland.1 The approach encompassed a stock-take of recent successinmentalhealthandareviewofinternationaldevelopments,innovation,evidenceandgoodpractice.Thereviewhadabroadbriefcoveringthevariousdimensions of the mental health terrain that might have relevance for informing the refresh of mental health policy in Ireland.

Thekeyprioritiesthatemergedoutofthereviewwere: • TheprioritisationofmentalhealthinIrelandasa

majorsocietalissue• Theimportanceofprimarypreventionand

positivementalhealth• Arequirementtofocusonsocialinclusionand

recovery • Expansion of mental health services to address

thespectrumofconditionsandneeds• Developmentofgovernanceandfinancingto

includeresearch,evaluationandqualityassurance

TheWRCcompletedasupplementarypapertobuildontheworkintheExternalEvidenceReview,whichidentifiedspecificpolicychangesforwhicharequirementmayhavearisensince AVFCwasdrafted.2 Thereviewidentifiedpolicythemesthatmayrequireattentionintherefreshsuchastheidentificationofvulnerablegroupsandassociatedactionsnotmentionedinthepreviouspolicy.Thereportalsosought to consider new policy areas including a wider focusoneducationandprevention,andthewideruseofaccrediteddigitalhealthinterventions.Inaddition,thereportsoughttoevaluateeachrecommendationfrom the previous policy and to rate progress to date onwhatactionswereimplemented,whatrelevantactionsremainedandwhatactionswerenolongerneeded.BothWRCreportsassistedinidentifyingpriority areas for the newly formed Oversight Group toconsiderastheydraftedtheirreportfortheDepartment of Health.

Oversight Group AspartoftheRefreshprocess,andinlinewithacommitment given in Dáil Éireann, an Oversight Group (OG)wasestablishedinOctober2017toprovideareporttotheDepartmentofHealthsettingoutcurrentandfutureserviceprioritiesforconsiderationbygovernment in the development of a successor policy to AVFC.ThisreportwasrequiredtotakeaccountofexistingmentalhealthpolicyandtohaveregardtotheExpertEvidenceReviewofinternationalbestpracticeandprogressoncurrentservicedevelopmentsinIreland.TheOversightGroupwaschairedbyMrHughKane,withamembershipreflectingservice users, advocacy groups, service providers, operationalmanagers,andprimarycareandmentalhealthclinicians.TheGroup’stermsofreferenceandmembershipcanbefoundatAppendicesIandII.

In accordance with the terms of reference, the OversightGroupsubmitteditsreporttotheDepartmentofHealthforconsideration.3 The OversightGroupreportwasreviewedbytheDepartment and a successor policy document to AVFC was produced that carries forward those elements oftheoriginalpolicywhichstillhaverelevance,whileintroducingnewrecommendationstocreateamodernmentalhealthgovernmentpolicysuitableforthenextten years.

Sharing the Vision, the successor policy to AVFC, considersthemanyvarieddeterminantsthataffectgood mental health and seeks to incorporate inter-departmentalrecommendationsintothepolicy.Theambition,intendedoutcomesandrecommendationsset out in Sharing the Vision are the product of intensive work coordinated through the Department ofHealthandtheOversightGroup.Theyarebackedbyextensiveresearch,benchmarkingactivityandevidence-basedreviews,togetherwithawide-rangingconsultationprocess.Asaresult,thispolicyfocusesverystronglyondevelopingabroad-based,whole-systemmentalhealthpolicyforallofthepopulationthat aligns closely with the main provisions of Sláintecare.

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4 DepartmentofHealth.Women’sTaskforcementalhealthreport(Dublin:2020).5 England,Scotland,Canada,AustraliaandNewZealand.TakenfromCullenandMcDaid,EvidenceReview.

Chapter 1 | Background and Context

Methodology Sharing the Vision wasinformedbyamajorstakeholderconsultationprocessundertakenbytheOversightGroupandsupportedbytheDepartmentofHealth.Over1,200individualsrepresentingserviceusers,peerworkers, carers, health workers, managers and others attendedfivestakeholdersessionsatvariouslocationsthroughoutIreland.Participantswereprovidedwithan overview of the proposed organising framework (Figure1.1)andwereaskedtoconsiderpriorityareasfor each domain within that framework.

The work of the Oversight Group was further guided byaReferenceGroupestablishedtoconnectwithawider group of experts as the policy proposals were evolving.Thisincludedrepresentativesofclinicalbodies,NGOsandserviceuserorganisations,whomettodiscusstheframeworkandfeedbackfromthestakeholder process.

TheconsultationprocesswasalsoinformedbyareviewbytheOversightGroupofexistingpoliciesandreportswithmentalhealth-specificrecommendations.Toavoidduplicationandmaintainconsistency,theGroup made reference to and supported relevant recommendationsfromthefollowingkeydocuments:• LGBTQ Strategy (DCYA)• Children First (DCYA) • Connecting for Lifesuicidestrategy(DoH/HSE)• HSE Service Plan • Peer Advocacy Services report (Irish Advocacy

Network) • AllsubmissionstoJointOireachtasCommitteeon

the Future of Mental Healthcare in Ireland • RecommendationsarisingouttheNational Youth

Mental Health Task Force Report 2017 • HSE service user Engagement Document • ReportoftheReviewoftheIrishHealthServices

forIndividualswithAutismSpectrumDisorders(HSE)

• JointWorkingProtocolswithChildandAdolescent Mental Health Services (CAMHS) and Primary Care

• NationalMHIDServiceDevelopmentProgramme• ‘MyVoiceMatters’serviceusersurvey(Mental

HealthReform)• MentalHealthReformreportonprogressof

A Vision for Change.

TheworkoftheOversightGroup,supportedbythecommissionedresearchbyWRCandtheinputoftheJointOireachtasCommitteeontheFutureofMentalHealth,informsthispolicy.ItisnotablethatthereisasynergybetweentherecommendationsoftheOversightGroupandtheworkoftheJointCommitteeon the Future of Mental Health. Many of the issues andactionsemergingfromtheworkoftheJointCommitteeresonateandalignwiththoseencounteredduring the countrywide stakeholder engagement bytheOversightGroup.Thecross-partySláintecare report,withitscoreemphasisonintegrationanddelivery of services at community level, represents a new development in whole-system leadership in Irish healthcare and a real opportunity to deliver our specificvisionformentalhealth.

Inadditiontotheseinputs,theconsultationprocesshasbeeninformedbyrecentworkundertakenbytheDepartmentofHealth’sWomen’sHealthTaskforce,2019.Earlyresearchbythisgrouphasidentifiedarangeofgenderdifferencesinmentalhealthwhichhaveasignificantimpactontheneedsandservicerequirementsofwomen,andgirlsinparticular.TheWomen’sHealthTaskforce,workingwiththeNationalWomen’sCouncilofIreland,haspreparedasummarydocumentofthisresearch,whichispublishedalongside this report on the Department of Health website.4

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Framework The Oversight Group decided to focus on outcomes in order to emphasise the importance of policy supportingtangiblechangesinthelivesofpeopleusing mental health services. The Oversight Group engaged in a literature review of mental health outcomesfromotherjurisdictionstogainasenseofthevariousinterventionsanddescriptionsofoutcomesandoutcomemeasuresbeingdeliveredinternationally.Fivecountrieswereidentifiedashavingwell-developed and well-resourced mental health outcome infrastructures that moved from a focus on the volume of services delivered to the value created for service users.5

The Oversight Group proposed developing an overarching framework containing domains, and organised outcomes into groups focused on ‘what

matters’.Thisisanimportantfirststepandisseparateto choosing outcome measures or indicators. Central tothedeliveryofavalue-basedhealthcareserviceisthecustomerandwhattheydefineasvalue,andwhatoutcomestheyexpectfromtheirinteractionwiththeservice. To achieve this streamlining, the Oversight Groupcombinedrelatedpolicy/servicedeliveryareasintofour‘domains’requiringactionandoversightintherefreshedpolicy.ThesearereflectedintheorganisingframeworkdetailedinFigure1.1,whichfollows through to the report structure. The Oversight Groupalsoidentifiedanumberofspecifichigh-leveloutcomes within each of the four domains and thesearedescribedatthebeginningofeachof the domain chapters.

To test the logic of the organising framework, additionalinter-departmentalmeetingswere

Figure 1.1: The Organising Framework

Outcome Enablerse.g. Mental Health Information Systems, Legislative enablers/reform, Investing in the Workforce and Commissioning Models/Framework

Actionsi.e. services/supports/interventions

that should be in place to meet prevailing needs

Processesi.e. the working practices needed to implement and

track delivery

Domain 1Promotion,

Prevention and Early Intervention

Domain 3Social

Inclusion

Domain 2Service Access,

Co-ordination and Continuity of Care

Domain 4Accountability

and Continuous Improvement

Outcomes Domain 3

Outcomes Domain 2

Outcomes Domain 4

Outcomes Domain 1

Core Values and Service Delivery Principles

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Chapter 1 | Background and Context

conducted across government and with wider publicservices/agenciestoconnectrelatedpoliciesandinitiativestotheworkoftheOversightGroup.TheconsultationprocessandtheassociatedworkcompletedbytheOversightGroupandvariouscommitteestoincorporatethosefindingsintothispolicyhasresultedinrecommendationsthattrulyrepresentthemanyvoicesofthosewhoparticipated.Consequently, Sharing the Vision is a powerful representationoftheviewsofmany,whoemphasisedthattherevisedpolicybeunderpinnedbythecorevaluesofrespect,compassion,equityandhope.

Core Values Consistent with the original policy, core values are central to Sharing the Vision and underpin its service philosophy.Becausehumaninteractionisattheheartof the delivery of mental health supports and care, and isanexpressionofindividualandorganisationalvalues,thispolicyisunderpinnedbythefollowingcorevalues.

CORE VALUES

Respect

Respecting each person as an individual and treating everybody with dignity at every level of service provision

Compassion

Treating everybody in a friendly, generous and considerate manner and developing a rapport with each person – demonstrating understanding and sensitivity

Equity Access to services characterised by inclusiveness, fairness and non-discrimination

Hope

Interactions during the course of service delivery full of positivity, and empowerment, with a strengths-based focus

AVFC contained mixed principles underpinning servicedelivery,characteristicsof‘good’servicesandapproachestoservicedelivery–allofwhichhavebeenreviewedbasedontheconsultationtodevelopthese core values as well as the service delivery principles outlined in Appendix III.

The vision Several aspects of the original policy remain core to theeffectivedeliveryofmentalhealthservicesandsupportinIreland.Theholisticviewofmentalhealthis maintained in this policy while also recognising the complexinterplayofotherfactorsthatcontributetomentalhealthdifficulties.Theperson-centredapproachthatfocusesonenablingrecoverythroughan emphasis on personal decision-making supported byclinicalbestpracticeandthelivedmentalhealthexperiencewasamajorrecurringthemeinthestakeholderconsultationprocess.

The policy that follows has captured all of the feedbackreceivedtoshapetherevisedvisionformental health in Ireland:

The vision embodied in this policy is to create a mental health system that addresses the needs of the population through a focus on the requirements of the individual. This mental health system should deliver a range of integrated activities to promote positive mental health in the community; it should intervene early when problems develop; and it should enhance the inclusion and recovery of people who have complex mental health difficulties. Service providers should work in partnership with service users and their families to facilitate recovery and reintegration through the provision of accessible, comprehensive and community-based mental health services.

AVFCenvisagedthatasignificantproportionofmental health services and supports could and should beprovidedaspartofprimarycare,anapproachreiterated/supportedintheSláintecare report. Over thedecadeofthepolicy(2006–16),thisincreasedroleforprimarycarehasnotbeensufficientlyresourced,resultinginshortfallsincreatingthenecessaryintegrationbetweenprimarycareandspecialistmental health services. Sharing the Vision is therefore groundedintherealitiesofthechallengesandissuesthat presently exist. The revised policy acknowledges thatwhileconsiderablechange,ongoingreformandre-investment are needed, much of the AVFC policy remainsrelevanttoday.Somerecommendationsremainvalid(withminorrefinements);othershaveledtoadvanceswhichrequireupdates;andothersarenolongervalidor,havingbeendelivered,arenolongerneeded.Finally,therearemanyrecommendationsinthispolicythatareentirelynew,reflectingissuesthathave arisen during the course of the refresh work.

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Principles Mental health for individuals is neither separate nor isolated from the other dimensions of their overall personalwellbeing.Peoplewithmentalhealthneedsarenotinsulatedorshieldedfromvariouspolitical,

economic,materialandsocialconditionsaroundthem.Multiplefactorsacrossthesedimensions,aswellasanindividual’smorepersonalbiologicalandpsychologicalwellbeing,haveaninfluenceonmentalhealthasshowninFigure1.2(overleaf),the‘determinantsofhealth’.

* HSE.ANationalFrameworkforRecoveryinMentalHealth2018–2020(2017).Availableat:https://www.hse.ie/eng/services/list/4/mental-health-services/advancingrecoveryireland/national-framework-for-recovery-in-mental-health/recovery-framework.pdf

Recovery

Recoverymeanspeopleexperiencingandlivingwithmentalhealthissueswhilepursuingthepersonal goals they want to achieve in life, regardless of the presence or severity of those mental healthdifficulties.Thisunderstandingofrecoveryisbestachievedthroughtheprimacyofpersonaldecision-making,supportedbyinformedclinicalbestpracticeandlivedmentalhealthexperience.

InlinewiththeNationalRecoveryFramework*,recovery-orientedservicesempowerandfacilitatetheprocessofaperson’sself-determinedrecovery.Suchservicesofferhopeandchoice,workinpartnership with service users and FCS and are outward-looking. They engage with all the aspects andsupportsthatwillconstituteandsustainrecoveryinaperson’slife.

Trauma-informed

Trauma-informed service delivery means that everyone at all levels of the mental health services andwidermentalhealthprovisionhasabasicunderstandingoftraumaandhowitcanaffectfamilies,groups,organisations,communitiesandindividuals.Peopledeliveringservicesrecognisethesignsoftrauma,whichmaybegender-,age-,orsetting-specific.Servicesrespondbyapplyingtheprinciplesofatrauma-informedcare.Staffineverypartoftheorganisationchangetheirlanguage,behaviourandpoliciestotakeintoconsiderationtheexperiencesofthosewhohavetraumahistories,includingstaffmembersthemselves.

Atrauma-informedapproachresiststraumatisingorre-traumatisingserviceusersandstaff.Staffaretaughttorecognisehoworganisationalpracticesmaytriggerpainfulmemoriesforserviceuserswith trauma histories. Applying a trauma-informed approach does not mean that everyone with a mentalhealthdifficultyoreveryoneusingmentalhealthserviceshasexperiencedtrauma.Itsimplymeansthattheservicesystemneedstobeawareofandrespondtothepresenceoftraumainpeoplewhomaybeusingawidevarietyofsupports.

Human rights

Humanrightstreatiesrecognisetherightofeveryonetothehighestattainablestandardof physicalandmentalhealth.AtthecoreofIreland’shumanrightstreatycommitmentsisarange ofprinciplesthatunderpinthefulfilmentofallcivilandpolitical,socialandeconomicrightsfor all people.

Service users and their FCS as appropriate should lead in the planning and delivery of their care. Partnershipshouldexistintheplanning,development,delivery,evaluationandmonitoringofmentalhealthservicesandsupports,andincludeallstakeholders.Partnershipwillbuildtrust for all involved.

Valuing and learning

Everyoneaccessinganddeliveringmentalhealthservicesshouldbevaluedandrespectedashumanbeingsintheirownright,andfortheexperience,expertiseandskillstheybring.Staffandallthoseinvolvedalsoneedtobevaluedandrespected.Reflectivepracticeandopennesstolearningareessentialqualitiesforstaff,peopleusingmentalhealthservicesandfortheservicesystemitself.Allneedtobeopentocontinuouslearninganddevelopment.

Service Delivery Principles

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Chapter 1 | Background and Context

Understandingthevariouscomponents,personalandsocietalthatinfluencementalhealthisimportantin order to deliver a comprehensive mental health policythatprovidesinterventionsandsupportsthataddressthewellbeingofthewholepopulation,preventingmentalhealthdifficultiesandenhancingthepossibilitiesfortherecoveryandinclusionofpeopleexperiencingmentalhealthdifficulties.Sharing the Visionisunderpinnedbyapopulation-basedplanningapproachwhichhelpstoguidethedistributionanddevelopment of mental health services and supports inIrelandinresponsetoneed(Figure1.3).Individualsmovethroughdifferentlevelsofsupportandservices, from informal care and support in their own community to primary care, to specialist mental health services,allbasedontheirmentalhealthneeds.

This policy recognises the need for a whole-of-population,whole-of-governmentapproachtothe

delivery of mental health services.6Inadoptingthisapproach,thepolicyisunderpinnedbyanecologicalmodel which uses a stepped care approach that ensures that the values from Sharing the Vision are preservedthroughout.A‘steppedcare’approachseeks to ensure that each person can access a rangeofoptionsofvaryingintensitytomatchtheirneeds.Inotherwords,therecanbea‘steppingup’ora‘steppingdown’inaccordancewiththestageofrecovery. A stepped approach to care should also help toincreaseefficiencyby‘shifting’constituenciesofneedtowardsmoreofthe‘upstream’services,thatis,promotion,prevention,earlyintervention,recoveryandparticipation.Overtime,thisshouldreducetheneedformoreexpensive‘downstream’acuteandcrisisresponse services. In this context, strategic investment in‘upstream’servicesshouldbeviewed as an investment rather than a cost.

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Figure 1.2: Determinants of health

Age, sex and

hereditaryfactors

Individual Lifestyle factors

Social and community networks

General socioeconomic, cultural and environmental conditions

Living andworking conditions

UnemploymentWorkenvironment

Water andsanitation

Education

Agricultureand foodproduction

Healthcareservices

Housing

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It is understood that throughout life individuals mayexperienceharmfulphysical,emotionalor life-threatening life events that could undermine their mental health. The emerging evidence that trauma-informedsystemscanresultinbetteroutcomesforpeopleaffectedbytraumaisacknowledged. A‘trauma-informedapproach’highlightshoweveryonecanhaveapositiveroleinpreventingmentalhealthdifficultiesfromarisingbyinterveningearlytolimitfurtherescalationofdistress.

Inaddition,acommunity-basedapproachtocareis central. It is wider than providing mental health services and includes a core role for the Voluntary andCommunitySector(VCS)andforotherpublicagenciesandorganisationsnotspecificallyengagedin mental health. Integrated and coordinated care accordingtoaserviceuser’stotalindividualneedsshould include these wider community supports. Mentalhealthservicesshouldbeaccessibleforall, notjustgeographicallyaccessiblebutprovidedat atime,inasetting,inaculturallycompetentmanner,thatmakesaccessaseasyandstraightforward aspossible.

Implementation Theimplementationofgovernmentpolicyisachallenging process. The literature on what determines asuccessfultransitionfrompolicythinkingintorealityemphasisesthatimplementationiscomplex,contextualandasmuchabottom-upasatop-downimperative.ThisisparticularlythecasesincethestrategicambitionofSharing the Vision is characterised byitsbeing: • Long-term–aten-yearframeworkwithsome

returnsmeasurableonlyoverseveralyears• Whole-system –coversallaspectsofthemental

healthdomainandbeyond• Dispersed governance–multipleactorswith

distinctmandatesandaccountability• High requirement for collaboration –working

through partnership is a core value. A repeated theme in the extensive process of consultation,reviewandvalidationwhichunderpinnedthe review process was the need to do everything possibletoensureeffectiveimplementationofthenextphaseofthenationalplan.Inconsideringthe

6 Mentalhealthisnotamatterforthehealthsectoralone.Itsitsinamuchbroadercontextofhowsocietyviewsmentalhealthandhowdecisionscanbemaderightacrossthespectrumofrelevantpublicservicestoinvestinthewellbeingofthepopulationandsupport individualslivingwithamentalhealthdifficultyontheirrecoverypath.GoodmentalhealthforthepopulationofIrelandcannotbe achievedwithoutmeasuresbeingtakenbyothergovernmentdepartmentsaswellbyastheDepartmentofHealth.

Figure 1.3: Population-Based Planning

Population-based planning approach – For effective and efficient person-centered system

People-to-People Support

Through actions to foster positive mental health and resilience; actions that invest in prevention and early intervention;

and anti-stigma initiatives to build community support and empathy for people living with a mental health difficulty.

Including CMHTs as the first line of care, supporting recovery of individuals in their own community. Also a range of crisis response and more acute

services including where appropriate access to residential in-patient supports.

Including informal one-to-one support from family, carers and supporters (FCS) as well as access to

structural peer support groups.

Local, accessible, personalised supports – with clear referral pathways (from primary care) for those who need further support.

Through resources available to the entirepopulation including e-mental health tools.

Complex and enduring needs.

Mental Health, Wellbeing and Resilience

Self-Agency

Primary Care and VCS

Specialist MentalHealth Services

Increased frequency of need for the

services andsupports

Increasing cost of the

services andsupports

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Chapter 1 | Background and Context

implementationapproachagainstthisbackdropwehaveborneinmindanumberofcriticalsuccessfactorswhichexperiencehasshowntobedecisive.Thesekeyfactors include:

Leadership

Implementation structures

Planning

Resourcing

Communication

Data and research evaluation

In order to ensure delivery on the commitments made inthispolicy,anoverarchingNationalImplementationandMonitoringCommittee(NIMC)willdrivereconfiguration,monitorprogressoverallandensuredelivery.TheNIMCwillhaveparticularregardtotangibleoutcomesandtheirmeasurementsothatrealimpactforserviceusersandtheirfamiliescanbeassessed.Thisstructurewilltakeaccountofactionsandoutcomesrelatingto‘all-of-government’–notjustthosewithintheremitofthehealthservice.TheNIMCwillbeestablishedwithserviceuserandpeerrepresentationtorollouttherecommendationswithinthissuccessorpolicy.Itwillhaverepresentationfromthe statutory, voluntary and community sectors.

The NIMC will work together with the key stakeholders involved in delivering this policy and strategyactions–identifiedinFigure1.4/identifiedbythePolicyRoadmap-todeliversharedgoalsandcommonactions.Together,theywillalsoensure momentum is maintained in delivering the recommendationscontainedinthispolicy.WehavesetouttheproposedimplementationstructureinFigure1.4opposite. Theoutcomes-basedapproachthatunderpinsthispolicywillrequireafundamentalshiftinhowmentalhealth services are delivered. If a person-centred, whole-of-governmentapproachistobeachievedinpractice,therewillneedtobearealfocusonhowmental health services are planned and delivered. Sharing the Vision promotes outcomes that are dependentonpartnershipsbetweengovernmentdepartments, service providers, voluntary and communityorganisations,andserviceusers.Thesegroupswillworktogethertopromotebettermentalhealth,buildmentalresilienceandofferservicesspecifictotheirresourcesandcapabilitiestothosewithmentalhealthrequirements.

Furtherdetailsinregardtotheimplementation,planningandevaluationofSharing the Vision are set outinChapter6.

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Figure 1.4: Implementation committee structure

National Implementation Monitoring committee

National Implementation

Team

Healthy Ireland SláinteCare

HSE and Lead Agencies

National Steering and Implementation

GroupsStakeholder Groups

Government Departments

Voluntary Community Sector

Service Users

Cabinet Committee of Social Policy and Public Services

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Chapter 2

Promotion, Prevention and Early Intervention Domain

Sharing the Vision | A Mental Health Policy for Everyone

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Chapter 2 | Promotion, Prevention and Early Intervention Domain

Introduction

Mentalhealthdescribeshowwethinkandfeelaboutourselvesandourrelationshiptoothers,andhowweinterpreteventsineverydaylife.Italsorelatestoourabilitytocopewithchange,transitionandsignificantlifeevents,andtounderstandhowtodealwiththestressesthatoftencomeourway.

Everyonehasmentalhealthneeds,whetherornottheyhaveadiagnosisofmentalillhealth.Thepopulation-basedactionsoutlinedinAVFCfocusontheprotectivefactorsforenhancingwellbeingandqualityoflife,togetherwithpreventionandearlyintervention.Mentalhealthpromotionworksonthreelevels:tostrengthenindividualsandimprovetheiremotionalresilience;tostrengthencommunitiesandimprovesocialcapitalthroughincreasedparticipation;andtoreducestructuralbarrierstogoodmentalhealththroughinitiativesthatreducediscriminationandinequalities.Theimportanceofsupportingpositivementalhealthaspartofaspectrumofpopulation-basedresponsesrecognisesarangeofpolicydevelopmentssincethepublicationofAVFC.Figure2.1showstheoutcomesforthedomainpromotion,preventionandearlyintervention.

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Figure 2.1: Outcomes: Promotion, prevention, early intervention

Positivementalhealth,resilience andpsychologicalwellbeing amongstthepopulation

as a whole

Reducedprevalenceofmental healthdifficultiesand/orreducedseverity of impact(s) through early interventionandpreventionwork

Positivementalhealth,resilience andpsychologicalwellbeing amongst priority groups... throughtargetedpromotion andpreventivemechanisms

Reducedstigmaanddiscriminationarising through improved

community wide understanding ofmentalhealthdifficulties

Outcome 1(a) Outcome 1(b)

Outcome 1(d) Outcome 1(c)

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Sharing the Vision | A Mental Health Policy for Everyone

Positive mental health and wellbeing Positivementalhealthbuildsresiliencesothatpeoplecan adapt to challenges and adversity, get the most outoflifeandmaintainapositivesenseofwellbeingandself-worth,combinedwithasenseofcontrolandself-efficacy.Theconceptalsomeansthat‘mentalhealth’isnotjustanabsenceof‘mentalillness’butisaseparablecharacteristicfocusedonpositivewellbeingandhavinggoodmentalwellbeingwhilelivingwithamentalhealthdifficulty.Itinvolvesmovingcontroltowardsthecommunitythrougheducatingthewiderpublicaboutmentalhealthandwellbeingandmentalhealthdifficulties,andprovidingstructuralsupportsthatencourageresilience.Promotingwellbeingforeveryoneinthecommunityalsoinvolvestargetingboththesocialfactorsoutsidethedirectcontrolofthehealthservicesthatfosterpositivementalhealth,andthe development of resilience.

Theneedfora‘wholeperson’approachtoachievingthehighestpossiblestandardsofphysicalandmentalhealthandwellbeingisacknowledged,andtheinterdependenciesbetweenphysicalandmentalhealtharerecognisedbytheWorldHealthOrganization(WHO).WHOresearchsuggeststhatkeyrisk factors for poor physical health and reduced life expectancy are more prevalent among people living withamentalhealthdifficultythanamongthegeneralpopulation.7Equally,therecanbehigherratesofmentalhealthdifficultiesamongpeoplewithlong-termphysicalhealthproblemsandaneedtosupportthewider psychological aspects of such physical health challenges.

This domain is consistent with the overarching nationalframeworkforhealthandwellbeing,Healthy Ireland, and recognises the need to explore improved integrationbetweenphysicalandmentalhealthasprioritisedintheSláintecare report.

7 WorldHealthOrganization.TheWorldHealthReport2001–MentalHealth:NewUnderstanding,NewHope(Geneva:WHO,2001). Availableat:https://www.who.int/whr/2001/en/whr01_en.pdf?ua=1

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Chapter 2 | Promotion, Prevention and Early Intervention Domain

Mental health lifecycle

You said...

Mentalhealthaffectseveryone in some way. The refreshed policy should seek to provide mental healtheducation,supports and services to all people when and where they need it.

We listened.

The Lifecycle Approach Mentalhealthdifficultiescanbeginearlyinlife,buttheseverityofimpactcanbereducedthroughactionsacrossarangeofsectorsthatpromotehealthyenvironmentsandfostermentalwellbeinginschools,communitiesandworkplaces.Positivementalhealthisnotamatterforthehealthsectoralone,andthereforethisdomainproposesthatrelevantpublicservicesinvestinthewellbeingofthepopulationtosupportindividualslivingwithamentalhealthdifficultyintheirrecovery. The lifecycle approach acknowledges that thefoundationsformentalwellbeingareestablishedbeforebirthandthatmuchcanbeachievedthroughinterventionsandsupportstobuildresilienceandimprovewellbeingthroughoutchildhood,theteenageyears and on into adulthood and later life. As a result, greateremphasisonpromotingmentalhealthandbuildingresilienceatallstagesinthelifecycleisrequiredandshouldincludetailoredapproachesforprioritygroupsdeemedtobeatrisk.

Centraltoallofthisisempowerment,atbothpersonaland community levels. At a personal level, individuals are empowered to take charge of their health andwellbeingandtoaccessinformationtomakeinformeddecisionswhenpossible.Atacommunitylevel,empowermentisabouthavingopportunitiestoparticipateinandinfluencedecisionsaboutaccesstolocal services and supports.

Thereisgeneralagreement–atbothnationalandinternationallevel–thatmentalhealthpromotioncanbeimprovedbybuildingoncurrentinfrastructureandembeddingprinciplesofmentalhealthpromotionintotheexistingfabricofcommunities.The Healthy IrelandFrameworkseekstostrengthencommunities’capacitytofostermentalhealthbyaddressingtheenvironmentalfactorsthatcontributetomentalhealthandwellbeingandthebuildingofresilienceinindividuals.TheFrameworkaimstobuildsustainable,nurturingcommunitiesbydrawingonresourcesfromallsectorsofsociety,includinghealth,education,employment and transport, to promote mental health. Healthy Ireland recognisesthatpositivelifestylechanges can prevent mental health issues arising andseekstobuildawarenessaboutthebenefitsofgoodnutritionanddietonbothmentalandphysicalhealthandwellbeing,forexample.Toenhancethiswork,aNationalMentalHealthPromotionPlanwillbeproducedbyHealthy Irelandthatwillbetheframeworkof reference and the overarching context for all mental healthpromotionandcampaignactivityinIreland.

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Sharing the Vision | A Mental Health Policy for Everyone

Mental Health across the Lifecycle

You said...

Mental health issues canbeginfrombirth.Awareness,educationand supports are essentialcomponentstobuildresilienceandcreate understanding.

We listened.

‘First 5’, A Whole-of-Government Strategy for Babies, Young Children and their Families 2019–2028 was launchedinNovember2018bytheDepartmentofChildrenandYouthAffairs(DCYA).8Objective6ofthestrategyisthat‘babies,youngchildrenandtheirparentsenjoypositivementalhealth’.Theaimofthisobjectiveistoimprovetheearlyidentificationofmentalhealthdifficultiesamongbabies,youngchildren and families, and to provide access to mental health supports and services that integrate into child-servingsettingsandthewidercommunity.TheDepartmentofHealthwillcontinuetoworkwiththeDCYAtoimplementtheactionsoutlinedintheFirst 5 policy.Inadditiontothiswork,specialconsiderationwillbegiventotheprovisionofadditionalsupportsforchildrenwhohavebeenexposedtoAdverseChildhoodExperiences(ACEs)suchasdomesticviolence,alcoholordrugabuse,mentalhealthdifficultiesandbereavement.Preventionandearlyinterventionarecriticaltothereductionoftrauma

associated with these early events, which can lead todifficultieslaterinadultlifeifnotaddressedatanearlyage.TherelevantrecommendationsoftheFirst 5strategyunderObjective6relatingtoprimaryprevention,earlyinterventionandpositivementalhealthshouldbeimplemented.

Schoolsandeducationalsettingsprovideapowerfulcontextforthepromotionofwellbeing.In2018,theDepartmentforEducationandSkills(DES)launcheditsWellbeing Policy Statement and Framework for Practice (2018–2023) which recognised that the mental health andwellbeingofyoungpeopleiscriticaltosuccessin school and life. Within its policy statement and framework,theDESproposesawhole-school,multi-component,preventiveapproachtowellbeingandmentalhealthpromotionineducationthatincludesinterventionsatbothuniversalandtargetedlevels.Itprovides an overarching structure that encompasses existinganddevelopingworkintheareaofwellbeingandmentalhealthpromotionineducation,includingtheJuniorCyclewellbeingprogramme.TheroleofNEPSpsychologistsintheareaofwellbeingpromotionandearlyinterventionwillalsobedeveloped.Assuch,itwillcontributestronglytothetargetedoutcomesin,andambitionof,thisDomainoftherefreshedAVFCpolicy.ToreinforcetheeffectivenessoftheDESframework,aneffectivestructureforcross-sectoralcollaborationintheareaofwellbeingandmentalhealthpromotionwillbeincorporatedintotheNationalMentalHealthPromotionPlan.

TheNationalYouthMentalHealthTaskForce(YMHTF)wasestablishedinresponsetoanundertakinginthe Programme for Partnership Government to provide nationalleadershipinthefieldofyouthmentalhealthandtoensurethatthepublic,private,andvoluntaryand community sectors work together to improve thementalhealthandwellbeingofyoungpeople.InDecember2017theTaskForceproducedasetoftenrecommendationareasthatweredistilledfrom12monthsofdiscussionandconsultation.Initsdomainofeducationandprevention,theYMHTFreportcontainsseveralkeyrecommendationsthatareconsistentwiththemes raised during the engagements and work done during the refresh process. While it is acknowledged

8 GovernmentofIreland.First5,AWhole-of-GovernmentStrategyforBabies,YoungChildrenandtheirFamilies2019–2028 (Dublin:GovernmentPublications,2018)Availableat:https://assets.gov.ie/31184/62acc54f4bdf4405b74e53a4afb8e71b.pdf

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Chapter 2 | Promotion, Prevention and Early Intervention Domain

thattherehasbeenprogressonmanyoftheactionsoutlined in the report, it is important to maintain momentumandimplementthereport’sremainingrecommendationswithinthethree-yeartimeframeidentified.

AdultsinIrelandtakeonvariousnewresponsibilitiessuchasraisingfamilies,settingupahome,caringforill parents, and maintaining employment. While many oftheselifetransitionsarepositivelifeexperiences,sometimesnegotiatingthemanydifferentrolesandresponsibilitiescanbechallengingandstressfulandacttothedetrimentofanindividual’spositivementalhealth.Manyadditionalchallengescanariseinthelifeofanadult.Unpredictableadditionalstressorssuchasunemploymentorfinancialinsecuritycancauseanxietyandnegativelyimpactonmentalhealth.Inaddition,theHealthy IrelandFrameworkestimatesthatmentalhealthdifficultiescosttheIrisheconomy€11billioneachyear,muchofitrelatedtolostproductivityinthelabourmarketfrombothabsenteeismandpresenteeism,thatis,functioningatlessthanoptimumcapacitywhileatwork.Improvedwellbeingreducesabsenteeismandincreasesperformanceandproductivity.Workplaceswhichallowforopendiscussionaboutmentalhealth,includingpeople’sown personal experiences, can promote overall organisationalandindividualwellbeing.Sharing the Visionsupportsindividualsbyraisingawarenessoflifeinfluencesthatcanleadtothedevelopmentofmentalhealthproblems,butthepolicyalsoseekstoimprove access to mental health supports in a variety ofsettings.

An important element of healthy ageing is the promotionofgoodmentalhealthandwellbeing.As

Ireland’spopulationover60issettodoublebefore2050itisimportanttopromotepositivementalhealthamongthispopulation,manyofwhomareatrisk of developing poor mental health. Older people areexposedtomultipleriskfactorsthatcontributetopoormentalhealthsuchasreducedmobility,chronicpain,frequentillness,loneliness,lossandbereavement.TheHealthy Ireland Framework makes a clear commitment to improving ‘partnerships, strategiesandinitiativesthataimtosupportolderpeople to maintain, improve or manage their physical andmentalwellbeingbyaddressingriskfactorsandpromotingprotectivefactorstosupportlifelonghealthandwellbeing’.Thiscommitmentwillsupportthegoalsof the National Positive Ageing Strategy byprovidingadditionalmentalhealthtrainingandsupportsforhealth professionals, home help teams and carers who provide services for older people. The Framework will also lead to increased mental health supports for those inlong-termpalliativecareandthedevelopmentofage-friendlyservicesandsettingsincommunityandprimarycaresettings.

It is important to acknowledge that throughout the lifecycle,anindividual’smentalhealthcanalsobeinfluencedbyotherstressors,suchasdisability.Peoplewithdisabilities,likeeveryoneelse,canexperiencementalhealthdifficulties,andtherecanbean increased prevalence among people with certain conditions.Itisimportanttoincludepeoplewithdisabilitiesinmainstreampublicservicesandprovidesupportstomaintainpositivementalhealththataredisability-competentandaccessible.

Intermsofhealthcarethatshouldbeavailableforthewholepopulation,Sláintecare is the ten-year programme that seeks to transform our health and socialcareservices.Itistheroadmapforbuildinga world-class health and social care service for the Irish people. The Sláintecare vision is to achieve a universalsingle-tierhealthandsocialcaresystemwhereeveryonehasequalaccesstoservicesbasedonneed,andnotabilitytopay.Itishopedthatovertime,everyonewillbeentitledtoacomprehensiverangeof primary, acute and social care services. This policy supportsthemaingoalsandobjectivesofSláintecare andseekstocreateeasieraccesstomulti-disciplinary,service user-centred supports at primary care level thatwillresultinbetteroutcomes.TheSláintecare ImplementationStrategywaspublishedinJuly2018andimplementationwillactasanenablertosupportactionscontainedinthispolicy.

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Sharing the Vision | A Mental Health Policy for Everyone

Mental health, priority groups and stigma Thepopulationhealthapproachthatthispolicyadvocatescontainsuniversalrecommendationsthatbenefiteveryoneinsociety,butalsoacknowledgesthatadditionalworkisrequiredtopromotepositivementalhealthandbuildresilienceamongspecificprioritygroupsdeemedtobe‘atrisk’.Theidentificationofprioritygroupsdisplayingevidenceofvulnerabilitytoandincreasedriskofsuicidalbehaviourin Connecting for Life (2015–2020) is a useful reference point.PrioritygroupsincludemembersoftheLGBTQ+community;membersoftheTravellercommunity;peoplewhoarehomeless;drugusers;peoplewhocomeincontactwiththecriminaljusticesystem;peoplewhohaveexperienceddomestic,clerical,institutional,sexualorphysicalabuse;asylumseekers;refugees;migrantsandsexworkers.Thisisnotanexhaustivelistandadditionalgroupssuchaschildrenincare,careleavers,peoplewithdisabilities,peoplewho have severe-to-profound deafness and people withsubstance(drugandalcohol)misuseproblemsshouldalsobereviewed.Tailoredinterventionstofulfilunmetneedsandtobuildstrengthsamongthesegroups,includingtargetedcampaignsandpreventiveoutreachwork,shouldbedoneinpartnershipwithorganisationsworkingwiththeprioritygroupstoachieveincreasedeffectivenessandimpact.

Arecurringthemearisingoutoftheconsultationprocesswasthatmentalhealthstigma,self-stigmatisation,prejudiceanddiscriminationaresome of the main reasons why people experiencing mentalhealthdifficultiesdonotseekhelp.Reducingthestigmaanddiscriminationassociatedwithmentalhealthdifficultiesiscentraltoimprovedwellbeingatasocietallevel.TheNationalStigma-ReductionProgramme(NSRP)willexpandtopromoteawarenessofthenatureandextentofprejudiceanddiscriminationinrespectofallmentalhealthconditionsandfocusonstigma-reductioninitiativesforthegeneralpopulation,workplaces,healthandsocialcaresettings,andothergroups.TheNSRProgrammeisthereforenotasingleintervention,butaportfolioofcoherentandparallelstigma-reductioninitiativesdevelopedcollaborativelyandwithsharedresponsibilityacrossgovernmentandhealthservices.

Inaddition,theConnecting for Life strategy (2015–2020),whichaimstoreducethelossoflifebysuicide and limit cases of self-harm, also maintains a healthpromotionagenda.Thisinvolvespreventiveandawareness-raisingworkthroughouttheentirepopulation,supportiveworkwithlocalcommunitiesand targeted approaches to priority groups. Local actionplansplayanimportantroleinenhancingcommunity capacity to reduce suicide and more widelyinbuildingthecapacityofcommunitiestosupportwellbeingandmentalhealth.Aninterimreview of Connecting for LifeconductedinFebruary2019requestedthatthelifetimeofthestrategybeextendedto2024.Thisongoingfocuswillaugmenttheprominenceofnationalmentalhealthpromotionmessagesaboutstigmaandsuicideprevention.

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Chapter 2 | Promotion, Prevention and Early Intervention Domain

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Additional health promotion supports Health Promotion Programmes Historically,theparticipationofpeoplewithmentalhealthdifficultiesinhealthpromotionprogrammeshasbeenlowerthanthatofthegeneralpopulation.Allhealthpromotionprogrammesmustbeexpandedtotargetpeoplewithexistingmentalhealthdifficultiesandpromotetheirwellbeingandrecovery.Staffinmentalhealthandotherserviceshaveacriticalroletoplayinmentalhealthpromotion.TherearenowanumberofnationalhealthpromotionandimprovementofficersoperatingacrossHSEareasandtheHSEmustensureaconsistentfocusonmentalhealthpromotionaswellasphysicalhealthpromotionbytheseofficerstoachieveparityofeffortinthepromotionofmentaland physical health.

Voluntary and Community Sector The Voluntary and Community Sector (VCS) engages inmentalhealthpromotionworkandcanplayanimportant role in providing mental health support servicesforthecommunitieswithwhichitworksby

tailoringnationalmentalhealthpromotionprogrammesto the needs, preferences and circumstances of those communities.Itisthereforeimportantthatlocalcommunityprojectsconnectwithanationalmentalhealthpromotionagendatoensurethattheirjointeffortsareeffectiveandappropriatelyresourced.

Digital Mental Health Engagement with digital mental health technology is increasing in popularity and although it is acknowledgedthatthisisalargelyunregulatedfield,well-designedproductscanhavebeneficialimpacts.Thegrowthine-healthinitiativessuggeststhatopportunitiesformentalhealthpromotion,preventionandearlyinterventionusingdigitalchannelsandsocialmedianeedtobeconsideredandresearched.It is proposed that digital developments will form partoftheNationalMentalHealthPromotionPlanunderpinnedbyevaluationandqualityassuranceinrelationtocontentanddesign.

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Domain: Education, prevention, early intervention recommendations

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1

Healthy Irelandalreadyhasaremitforimprovedmentalhealthandwellbeing.Tofurtherstrengthenthis,adedicatedNationalMentalHealthPromotionPlanshouldbedevelopedandoverseenwithinHealthy Irelandimplementationframeworks,withappropriateresourcing.TheplanshouldbebasedontheprinciplesandscopedescribedinChapter2ofSharing the Vision.

2 Evidence-baseddigitalandsocialmediachannelsshouldbeusedtothemaximumtopromotementalhealthandtoprovideappropriatesignpostingtoservicesandsupports.

3

TheDepartmentofHealthWomen’sHealthTaskforceandtheNationalImplementationMonitoringCommitteewillundertakeajointprojectwithin12monthstooutlineaneffectiveapproachtothementalhealthofwomenandgirls.Theprojectshouldensurethatmentalhealthprioritiesandservicesaregender-sensitiveandthatwomen’smentalhealthisspecificallyandsufficientlyaddressedintheimplementationofpolicy.

4 Theworkprogrammeforhealthpromotionandimprovementofficersshouldbereviewedtoensureparityofeffortandemphasisonmentalhealthpromotionandphysicalhealthpromotion.

5Newandexistingcommunitydevelopmentprogrammeswhichpromotesocialinclusion,engagementandcommunityconnectednessshouldbeappropriatelyresourcedanddevelopedinlinewiththeproposedNationalMentalHealthPromotionPlan.

6TheproposedNationalMentalHealthPromotionPlanandtheexistingworkofConnecting for Life shouldincorporatetargetedmentalhealthpromotionandpreventionactionsthatrecognisethe distinctneedsofprioritygroups.

7

ANationalStigma-ReductionProgrammeshouldbeimplementedtobuilda‘wholecommunity’approachtoreducingstigmaanddiscriminationforthosewithmentalhealthdifficulties.Thisshouldbuildonworktodateanddetermineaclearstrategicplan,withassociatedoutcomesandtargetsacrossrelated strands of work.

8

Learningfrominnovationsinimprovingoutcomesforchildrenandyoungpeopleshouldbeidentifiedandshouldinformrelevantmainstreamserviceprovision.ThisincludeslearningfrompreventionandearlyinterventionprogrammessuchasTusla’sAreaBasedChildhood(ABC)andPrevention,PartnershipandFamilySupport(PPFS)Programmesaswellascross-borderprogrammesaddressingtheimpactofAdverse Childhood Experiences (ACEs).

9

AllschoolsandcentresforeducationwillhaveinitiatedadynamicWellbeingPromotionProcessby2023,encompassingawhole-school/centreapproach.SchoolsandcentresforeducationwillbesupportedinthisprocessthroughtheuseoftheWellbeingFrameworkforpracticeandWellbeingResourceswhichhavebeendevelopedbytheDepartmentofEducationandSkills.

10

AprotocolshouldbedevelopedbetweentheDepartmentofEducationandSkillsandtheHSEontheliaisonprocessthatshouldbeinplacebetweenprimary/post-primaryschools,mentalhealthservicesand supports such as NEPS, GPs, primary care services and specialist mental health services. This is neededtofacilitatereferralpathwaystolocalservicesandsignpostingtosuchservices,asnecessary.

11

TheNationalMentalHealthPromotionPlanintegratedwiththeHealthyWorkplaceFrameworkshouldincorporateactionstoenhancethementalhealthoutcomesoftheworking-agepopulationthroughinterventionsaimedatmentalhealthpromotionintheworkplace.Thisshouldconsiderenvironmentalaspectsoftheworkingenvironmentconducivetosupportingpositivementalhealthandwellbeing.

12ArangeofactionsdesignedtoachievethegoalsoftheNationalPositiveAgeingStrategyforthementalhealthofolderpeopleshouldbedevelopedandimplemented,supportedbytheinclusionofmentalhealthindicatorsintheHealthyandPositiveAgeingInitiative’sresearchprogramme.

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Chapter 3

Service Access, Coordination and Continuity of

Care Domain

Sharing the Vision | A Mental Health Policy for Everyone

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Chapter 3 | Service Access, Coordination and Continuity of Care Domain

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Figure 3.1: Outcomes: service access, coordination and continuity of care

All service users haveaccesstotimely,

evidence informedinterventions

Health outcomes for people with dualdiagnosisareimprovedby ensuringgreatercollaboration betweenmentalhealthand

other relevant services

Service delivery is organised toenableincreasednumbers

of people to achieve personal recovery

Services are coordinated through a’steppedcare’approachto

providecontinuityofcarethatwilldeliverthebestpossibleoutcomes

for each service user

Outcome 2(a) Outcome 2(b)

Outcome 2(d) Outcome 2(c)

Introduction

Theoverridingintentioninthisdomainistoensurethatserviceusersandtheirfamilies,carersandsupporters(FCS)havetimelyaccesstoevidence-informedsupports,asaresultofanoutcomes-basedfocusthatputspeoplebeforeprocesses.Inlinewiththecorevaluesandprinciplesofthispolicy,mentalhealthserviceswillbeevidence-informedandrecovery-oriented and will adopt trauma-informed approaches to care, basedonlivedexperienceandindividualneed.Mentalhealthserviceswillbeclinicallyeffective,deliveredinadherencetostatutoryrequirementsandbasedonanintegratedmulti-disciplinaryapproach.ThiseffectivepartnershipandinterworkingbetweendifferentservicesandprofessionalsalongthecarepathwaywillequipserviceusersandtheirFCStobebetterinformedabouttherangeofresourcesavailable,andremovebarriers,inorder to assist people to achieve personal recovery. The renewed focus on partnership in care will strive to ensure service users and FCS are central in the design, development and delivery of services and take a lead role in recoveryplanning.Figure3.1summarisesthefourhigh-leveloutcomesforDomain2.TheoutcomessuggestwhataserviceuserorFCSmightexpectfromthementalhealthservicesinthefuture.Therecommendationssetoutforthisdomainaredesignedtocontributetotheachievementofoneor more of these outcomes.

You said...

Servicesneedtobeservice user oriented and recovery plans must include service users,familymembers,carersandsignificantothers.

We listened.

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Figure 3.2: Stepped care approach

Thisdomainsetsoutproposalsforthecontinuousrange of integrated service elements needed in a modern recovery-oriented mental health system. All serviceswillbecoordinatedthrougha‘steppedcare’

approachtoprovidecontinuityofcare(seeFigure3.2)inordertodeliverthebestpossibleoutcomesforeachservice user.

Tier 2

GP, Primary care team, community pharmacies, CIPC, social prescribing, etc.

Primary Care

Tier 1

Social support, peer support, support from families, friends and carer (FCSs), support for FCSs, support from Community and

Voluntary groups, housing support, employment.

Interventions where focus is not specialist mental health care

Tier 3

Full range of Community Mental Health Teams

Specialist Mental Health Services

Tier 4

Specialist Inpatient or Residential Unit

Specialist inpatient or Residential services

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Chapter 3 | Service Access, Coordination and Continuity of Care Domain

Pathways to support This policy recognises that no single service can cater for the diverse needs of a person with mentalhealthdifficulties.Toimproveapopulation’shealthand social care outcomes, a multi-sectoral,multi-stakeholderapproachisrequired.The‘steppedcareapproach’enablesan individual to avail of a range of supports and services as closetohomeaspossibleatthe level of complexity that correspondsbesttotheirneeds and circumstances. This approach focuses on working toshapeacontinuumofmentalhealth services in which local VCS groups have a recognised role, where primary care supports are closely linked to specialist mental health services and where mental health services across the lifespan are integrated and coordinated. Figure3.3setsoutthisenvisagedcontinuumofmentalhealth services and pathways.

36

Figure 3.3: Envisaged continuum of mental health services and pathways

Access to a range of Talking Therapies in

Primary Care Settings

Social Prescribing

Digital-HealthInterventions

Community-basedSupports provided

by CMHT

Access to Talking Therapies and related

supports in the Voluntary or Community Sector

Peer Networks and

Recovery Education

One-to-One Sessional

Other state agencies

as required

One-to-One Sessional

Community-basedSupports providedby CMHT

Digital-HealthInterventions

Access to Talking Therapies andrelated supports in the Voluntary or Community Sector

Access to a range of Talking Therapies in Primary Care Settings

Peer Networks andRecovery Education

In-patient supports

Day Hospitals

Home-Based Supports

Specialised Rehabilitation

Units

GP PrimaryCare Team

Community Rehabilitation

Units

Acute Units

Planned Short-BreakCare Facility

Crisis House

Crisis Resolution

Assertive OutreachTeams

High IntensityMedium IntensityLow Intensity

ACCESS ACCESS

Self-referral Community MentalHealth Teams

Out-of-hours crisis cafes

Emergency department

GPs / Primary Care Centres

Combined VCS, Primary Care and Specialist Mental Health Services

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Access to a range of Talking Therapies in

Primary Care Settings

Social Prescribing

Digital-HealthInterventions

Community-basedSupports provided

by CMHT

Access to Talking Therapies and related

supports in the Voluntary or Community Sector

Peer Networks and

Recovery Education

One-to-One Sessional

Other state agencies

as required

One-to-One Sessional

Community-basedSupports providedby CMHT

Digital-HealthInterventions

Access to Talking Therapies andrelated supports in the Voluntary or Community Sector

Access to a range of Talking Therapies in Primary Care Settings

Peer Networks andRecovery Education

In-patient supports

Day Hospitals

Home-Based Supports

Specialised Rehabilitation

Units

GP PrimaryCare Team

Community Rehabilitation

Units

Acute Units

Planned Short-BreakCare Facility

Crisis House

Crisis Resolution

Assertive OutreachTeams

High IntensityMedium IntensityLow Intensity

ACCESS ACCESS

Self-referral Community MentalHealth Teams

Out-of-hours crisis cafes

Emergency department

GPs / Primary Care Centres

Combined VCS, Primary Care and Specialist Mental Health Services

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Thecontinuumbuildsontheprogress with service reform in recent years. The service elements will integrate with one anotherandwiththedifferentcontexts in which a service user may live to ensure that needs are met in keeping with their stage of recovery and individual wishes and preferences. In interpretingthecontinuumofcare, it is important to recognise that an individual may need services and supports from one or more of the service elementsatthesametime,depending on their prevailing needs and preferences. The continuumaimstoreducetheconfusionbetweenprimarycareandcommunity-basedcarebyprovidingclarityintermsoflocation,settingsandlevelsofspecialism.

Inordertodescribethedifferentserviceelementsinsome detail and to propose recommendations,thecontinuumwillbeseparatedinto supports accessed through primary care, VCS and self-referral, as shown in Figure 3.4,andreferralpathwaysandspecialist mental health services, asshowninFigure3.5.

Talking therapies are psychological treatments. They involve talking to a trained therapist to support peopletodealwithnegativethoughts and feelings. They helptomakepositivechangesinanindividual’slife.Talkingtherapies can take place in: groups, one-to-one, using a computer or over the phone.

Peer-support A system of giving and receiving help founded on key principles of respect, sharedresponsibilityandmutualagreement of what is helpful. Peer-supportisnotbasedonpsychiatricmodelsanddiagnosticcriteria.Itisaboutunderstandinganother’ssituationempathicallythrough the shared experience of emotionalandpsychologicalpain.

Other state agencies as required

Social-prescribing

One-to-One Sessional

Community-basedsupports providedby CMHT

Digital-HealthInterventions

Access to Talking Therapies andrelated supports in the Voluntary or Community Sector

Access to a range of Talking Therapies in Primary Care Settings

Peer Networks andRecovery Education

One-to-One Sessional

Community-basedSupports providedby CMHT

Digital-HealthInterventions

Access to Talking Therapies andrelated supports in the Voluntary or Community Sector

Access to a range of Talking Therapies in Primary Care Settings

Peer Networks andRecovery Education

Medium IntensityLow Intensity

ACCESS ACCESSGPs Primary Care Teams

Self-Referral

Figure 3.4: Supports accessed through primary care, the voluntary and community sector or self-referral

Supports accessed through Primary Care, Voluntary & Community Sector or Self-Referral

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Some digital health programmes focus onpromotinghealthandwellbeingandpreventingillhealth,whileothersmaydeliverearlyinterventionandmentalhealth treatment. There are numerous digitalhealthprogramsavailable,coveringa range of mental and physical health concerns, and thus increasing individual healthcare management choices.

Social-prescribing,orcommunityreferral,enablesGPs,nurses and other primary care professionals to refer people toarangeoflocal,non-clinicalservices.Anindividual’shealthisdeterminedprimarilybyarangeofsocial,economicandenvironmentalfactors,andsocial-prescribingaimstosupportpeopletotakegreatercontroloftheirownhealth.Referralscanbemadetoavarietyofactivitieswhicharetypicallyprovidedbyvoluntaryandcommunitysectororganisationssuchasartsactivities,grouplearning,gardening,befriending,cookery,healthyeatingadviceandarangeofsports.

Other state agencies as required

Social-prescribing

One-to-One Sessional

Community-basedsupports providedby CMHT

Digital-HealthInterventions

Access to Talking Therapies andrelated supports in the Voluntary or Community Sector

Access to a range of Talking Therapies in Primary Care Settings

Peer Networks andRecovery Education

One-to-One Sessional

Community-basedSupports providedby CMHT

Digital-HealthInterventions

Access to Talking Therapies andrelated supports in the Voluntary or Community Sector

Access to a range of Talking Therapies in Primary Care Settings

Peer Networks andRecovery Education

Medium IntensityLow Intensity

ACCESS ACCESSGPs Primary Care Teams

Self-Referral

Supports accessed through Primary Care, Voluntary & Community Sector or Self-Referral

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Chapter 3 | Service Access, Coordination and Continuity of Care Domain

9 HSEMentalHealthDivision.DeliveringSpecialistMentalHealthServices2017(2018).Availableat:https://www.lenus.ie/bitstream/handle/10147/626957/2017%20Delivering%20Specialist%20Mental%20Health%20Report.pdf?sequence=1&isAllowed=y

40

Primary Care

You said...

There is a real need for additionalsupportsinprimary care that are accessibletopeoplewhen and where they need help.

We listened.

Generalpractitionersplayapivotalroleasthefirstandcontinuingpointofcontacttopatientsbutitisacknowledgedthatthereisarequirementtoscaleup access to supports for common mental health difficultiesinprimarycaresettings.Over90%ofmentalhealthneedscanbesuccessfullytreatedinaprimarycaresetting,whiletheremaining10%referredto secondary care services are greater and more clinically complex.9 In line with Sláintecare, this policy envisages an increasing role for the primary care sector which, if appropriately resourced and with appropriate governance, can provide a comprehensive range of interventions.

AVFC recommended increased access to primary care supports for people with mental health needs who do notrequirespecialistmentalhealthservices.WhileinitiativessuchasCounsellinginPrimaryCare(CIPC)havebeenintroduced,thereisstillinsufficientaccessto these types of supports in primary care. This, in turn,hascontributedtoanover-relianceonspecialistsecondarycaresystems,resultinginwaitinglistsforsuch care in various mental health services.

Consequently,thispolicycontainsseveralrecommendationsadvocatingadditionaluniversalsupportsdeliveredbyappropriatelyqualifiedtherapiststo provide care to individuals with mental health needs,includingthosepresentingwithco-existinghealthrequirementssuchasaddiction.Thescalingup of access to supports in primary care should help to reduce the over-reliance on specialist mental healthcare. For example, developing further capacity forAttentionDeficitHyperactivityDisorder(ADHD)andautism-specificserviceswillplayaroleinreducingthenumberofreferralsintoChildandAdolescentMental Health Services (CAMHS). Furthermore, the recommendationsalsoconsiderhowbesttoutilisedigitalhealthinterventionstofacilitateincreasedavailabilityandspreadofsupports.

Morebroadly,therevisedpolicyseekstoimprovecollaborationbetweenprimarycare,secondarymentalhealth services and specialised services to facilitate integrationofcareforserviceusers–akeythemein the original AVFC.Theco-locationofCMHTsandprimarycareteamsinsomeareas,withthecreationof a Team Coordinator role in some CMHTs, has contributedtoreducingreferralsofmildermentalhealthdifficultiestosecondaryservices.Thisliaisonmodelremainsrelevantandwillbesupportedbyadditionalrecommendationsrelatingtoa‘sharedcare’approach to mental health in primary care.

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Integrated services

You said...

People using specialist mental health services should have access to all primary care services.

We listened.

As set out in AVFC, it should remain the case that all users of specialist mental health services, including thoseinlong-stayfacilities,mustberegisteredwiththeirGP.However,registrationinitselfisinsufficientand the physical healthcare of people with a mental healthdifficultyshouldbeledbytheirGP.Thisisconsistent with the priority in the Sláintecare report attributedto‘creatinganintegratedsystemofcare,withhealthcareprofessionalsworkingcloselytogether’,bringingtogetherphysicalandmentalhealthservicesto improve the physical health of people with mental healthdifficultiesandviceversasimultaneously.

VCSorganisationsshouldbekeypartnersinthedesignanddevelopmentoftheHSE’smentalhealthservicesatnationalandlocallevel,aswellasreferralpartnersfor primary mental healthcare. Their services extend to therapeuticandotherrecoverysupportsforindividualsand FCS and can, therefore, help to reduce the use of inappropriate referrals to specialist mental health services.Inaddition,recognisingthatpeople’shealthisdeterminedprimarilybyarangeofsocial,economicandenvironmentalfactors,theVCScanbeanactivepartnerinthedevelopmentofsocialprescribing–

sometimescalledcommunityreferral–whichisawayfor GPs, nurses and other primary care professionals to refer people to a range of local, non-clinical services. Sociallyprescribedactivitiescanincludevolunteering,engaging in the arts, group learning, gardening, befriending,cookery,healthyeatingadviceandarangeof sports.

ManyofthesupportsprovidedbytheVCSsectorarefundedand/orprovidedthroughaserviceagreementwiththepublicmentalhealthsystem.Togetthebestvalue from the VCS sector and to draw upon the sector’sstrongpositionwithincommunities,itisvitalthatpublicprimarycareandmentalhealthserviceswork in partnership with VCS groups, involving them in the design and delivery of integrated area support services. This partnership approach will allow those working in primary care and CMHTs to connect serviceuserswithVCSorganisationsandfacilitate theintegrationofpatientsintotheirlocalcommunity.

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ACCESS ACCESSOut-of-hours crisis cafes

Emergency department

GPs / Primary Care Centres

High IntensityMedium IntensityLow Intensity

Peer Networks and

Recovery Colleges

Home-Based Supports

Access to a range of Talking Therapies in

Community/Voluntary Sectors

Inpatient Supports

Community-basedsupports provided

by CMHTDay Hospitals

Community Mental Health

Teams

Specialised Rehabilitation

Units

Community Rehabilitation

Units

Acute Units

Planned Short-BreakCare Facility

Crisis House

Crisis Resolution

Assertive OutreachTeams

Digital-HealthInterventions

One-to-One Sessional

Figure 3.5: Secondary care and specialist mental health services

Recovery Collegesoftenfocusonequippingstudentswithnew skills that can foster their recovery, as well as enhancing theiroverallcapacitiesandcapabilities.Commonofferingsinclude classes focused on self-care, life-skills, physical health, employmentandinformationtechnology.

Crisis Resolution (CR)offersafterhoursandurgentpsychiatricassistance.CRis an integral part of each Community Mental Health Teamproviding24houradviceand assessment for people presentingincrisiswhichis associated with a known or suspected mental health problem.

Assertive outreach teams provide intensive support for people with complex needs. The team aim to support individuals to get help from other services. This support can help people manage their conditionbetterandreduce thechancesofgoingback to hospital.

Talking therapy is a general termtodescribeanypsychological therapy that involves talking. You may also hear the terms counselling or psychotherapy.

Referral Pathways and Specialist Mental Health Services

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ACCESS ACCESSOut-of-hours crisis cafes

Emergency department

GPs / Primary Care Centres

High IntensityMedium IntensityLow Intensity

Peer Networks and

Recovery Colleges

Home-Based Supports

Access to a range of Talking Therapies in

Community/Voluntary Sectors

Inpatient Supports

Community-basedsupports provided

by CMHTDay Hospitals

Community Mental Health

Teams

Specialised Rehabilitation

Units

Community Rehabilitation

Units

Acute Units

Planned Short-BreakCare Facility

Crisis House

Crisis Resolution

Assertive OutreachTeams

Digital-HealthInterventions

One-to-One Sessional

Referral Pathways and Specialist Mental Health Services

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Community Mental Health Teams

You said...

Service users need to access coordinated care, maintain a person-centred care plan and have access to a keyworker who understands the system and assists individuals, family and carers to avail of all supportsoffered.

We listened.

The cornerstone of service delivery in secondary care willcontinuetobethemulti-disciplinaryCommunityMentalHealthTeams(CMHTs).Themulti-disciplinarynatureoftheCMHTsenablesavarietyofprofessionalperspectivestobecombinedincaseformulation,careplanningandservicedelivery.Multi-disciplinaryteamwork provides integrated care to service users, withtheemphasisonsupportingindividualstorecoverin their own community.

TheprescribedcompositionofCMHTsintheoriginalAVFC may have restricted the development of appropriate responses in some teams and for some patientgroups.TheCMHTshouldcontinuetoinclude,butnotnecessarilybelimitedto,thecoreskillsofpsychiatry, nursing, social work, clinical psychology andoccupationaltherapy.Givendevelopmentsover the last decade and the emphasis on achieving recovery-orientedoutcomes,thereshouldbe

additionalcompetenciesinteamssuchasdieticians,peersupportworkers,outreachworkers,jobcoachesandothers.Ratherthanspecifyabsolutenumbersofspecificprofessionalsthatshouldbeonthedifferentteams, the approach in this policy is to emphasise the importanceofdeterminingthespecificskillsthatarerequiredbyateam.Thus,thecompositionandskillmixofeachCMHTshouldtakeintoconsiderationthe needs and social circumstances of its sector population,withflexibilityastohowtheseneedsaretobemet.Aswellasthecoreskillsthiscouldinclude,forexample,bringinginsessionalworkerswithspecifictherapeuticskillsandotherprofessionalsasrequired.The proposed model of mental health supports re-conceptualisestheroleoftheoutpatientclinictoabroaderconceptofcommunity-basedsessionalsupportprovidedbymentalhealthprofessionalsand peer workers. The physical environment where theseservicesaredeliveredandthelocationsoftheCMHTsshouldbeaccessible,modern,fitforpurposeand conducive to recovery. Such centres should also facilitate VCS provision to integrate CMHT and VCS supports,whereappropriate.ThelocationofCMHTsin physical environments of this kind will reinforce the access that individuals have to short-term assistance in their own community, drawing on a wide range of therapies and supports in the wider mental health systemincludingaccesstoe-healthalternatives.Allfuturenewprimarycarebuildingplanningdevelopments should therefore include appropriate settingsfordeliveryofamentalhealthservice.

CMHTswilllinkinwithlocalVCSsupportstobuildasustaining network around the service user and their FCS. Together, CMHTs and the VCS should work toprioritisecareplanningwithserviceusersaskeydecision-makers in their own care or recovery plan. Suchplansareimportantbecausetheyreflecttheserviceuser’sparticularneeds,preferences,goalsandpotential,includingcommunityfactorsthatmayimpede or support recovery. In many cases there may bemorethanoneteammemberinvolvedinthecareofanindividual;therefore,thispolicyre-emphasisestheneedforakeyworker,thatis,amemberoftheexistingteamthroughwhomservicescouldbepersonalisedandcoordinated.Teammembersmustbetrainedadequatelyinactivelisteningandbesupportedbytheirmanagerstotalktopatientsabouttheirrecovery.

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Clinical leadership The engagement for this policy indicates that models ofleadershipfortheCMHTsshouldbereviewedinlinewithinternationalpractice.Clinicalleadership,asdescribedinAVFC2006–16,wasvestedintheconsultant psychiatrist role, in keeping with the requirementsoflegislation.Considerationshouldbegiventoamendinglegislationtofacilitatethedeliveryof a shared governance model.

Inthemeantime,asdescribedinAVFC, Team CoordinatorsshouldbeinplaceinallCMHTstofacilitate enhanced intra-team management of referrals and clinical inputs as well as to create appropriate coordinated linkages into the community. Such a shared governance model necessitates a focus on teameffectiveness,requiringeachteammembertoworktothemaximumoftheirscopeofpractice,aswell as to develop shared team competencies. In this way,eachmemberoftheteamtakesresponsibilityfortheeffectivenessoftheteamsothatthereisappropriate service delivery and the outcomes set out in this policy are achieved.

TherangeofsupportsavailablethroughCommunityMentalHealthTeamsaresetoutinFigure3.4.Access to CMHTs is generally through GP referral or itcanoccurfollowingattendanceatanemergencydepartment (ED). Investment in acute medical emergencyservicesundertheHSE’sAcuteMedicineClinicalProgrammeneedstobeprioritisedtoincludethe streamlining of the triage process so that access to thecorrectmentalhealthassessmentcanbeprovidedasearlyaspossible.

Alternative Access Routes to Emergency Care

You said...

EDsarenotsuitableenvironments for children to wait for assessment and alternativesshouldbeexplored.

We listened.

Quiteoften,peopleinneedofsupportorurgentcareattendemergencydepartments(EDs)toaccessmentalhealth treatment. While individuals are in many cases appropriatelyseeninanED,itcanbeachallengingenvironment for some people with mental health difficulties.Specifically,thestakeholderconsultationsforthisreportprioritisedtheavailabilityofnon-ED-basedout-of-hoursalternativesofferingreferraltomental health services.

Out-of-hours crisis cafés are proposed as a new referraloption,tosupportindividualstodealwithan immediate crisis and to plan safely, drawing on their strengths, resilience and coping mechanisms to managetheirmentalhealthandwellbeing.Attendeeswouldbeabletoaccesstalktherapies,copingstrategiesandone-to-onepeersupport,providedbypaidcorestaffassistedbyateamofappropriatelytrainedvolunteers,workingonarotabasis.ThecafésmayreducedemandsonEDsbyprovidingan environment more suited to the needs of some individuals who present. Moreover, appropriately and safelystaffedcrisiscaféscanalsobeanalternativeaccesspointforchildrenandadolescents.Inaddition,

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tele-psychiatrymodelscouldbeawaytoprovide24-hourpsychiatryconsultationstoserviceusersofall ages, who can access supports from a variety of locationssuchasprimarycarecentres,GPpracticesand VCS services.

InproposingthecontinuumofservicessetoutatFigure3.3asthevisionforamodernrecovery-oriented mental health system, it is recognised that thebalanceofemphasisacrosseachserviceelementmay vary in HSE areas across the country, in line with prevailing needs and geographies. Every service elementmustbepresentineachRegionalIntegratedCareOrganisation(RICO)areabuteachareawouldneedtoconsiderthebestbalanceandmodelsofdelivery and service elements to meet their area needs,takingintoaccounttheirstaffinglevels.Theseproposals include the proviso that all service elements inFigure3.3shouldincludeaccesstotalktherapiesasafirst-linetreatmentoptionformostpeoplewhoexperiencementalhealthdifficulties.

Specialist mental health services across the lifecycle Thissectiondetailsthementalhealthservicesthatshouldbeavailableforindividualsaccessingspecialistservicesatdifferentstagesofthelifecycle.

Child and adolescent mental health services Child and adolescent mental health services CMHTs arethefirstlineofspecialistmentalhealthservicesforchildren and young people who are directly referred totheCAMHSteamfromanumberofsources.The CAMHS teams accept referrals for moderate-to-severementalhealthdifficultiesofchildrenandadolescentswhichcannotbemanagedwithinprimarycare.ReferralstoCAMHSalsosupportchildrenandadolescents with a mental illness and intellectual disabilities.Wherethechildoradolescentpresentswithamoderate-to-severementaldisorderandautism,CAMHSteamsprovideappropriatemulti-disciplinarymental health assessment and treatment for the mental disorder in partnership with other agencies includingHSEPrimaryCare,Children’sDisabilityNetworkTeams,andotheragenciessupportingchildren and adolescents.

The 0–25 cohort The Youth Mental Health Task Force Report recommends thattheagerangeforeligibilityforCAMHSbeincreasedto25inordertoimprovecontinuityofcareandleadtobetteroutcomesforserviceusers,asthetransitionfromCAMHStoadultservicesiscomplex.Atpresent,youngpeoplemakethetransitiontoadultservicesattheageof18.Thiscanbeanageinlifewhenchange,uncertaintyandvulnerabilitiesprevail.Failuretosecureasafetransitioncanleadtodisengagementandultimatelytopoorerhealthoutcomes.Thereareconsiderableimplicationsinthisreconfigurationofservices.Apilotreconfigurationofservicesthatcouldascertainthespecificmentalhealthneedsofthe0–25cohortshouldbeestablishedtoinformthestaffingrequirementsofCAMHSandGeneral Adult Mental Health Service (GAMHS) teams.

Itisrecognisedthatitwilltakeanumberofyearstoprovide the necessary training for a new cohort of mentalhealthprofessionalstofacilitatesuchashiftand therefore the current relevant professionals are requiredtobeflexibleandopentonewapproaches.Inthemediumterm,itshouldbepossibletoprovidea seamless, age-appropriate specialist mental health serviceforthoseagedupto25years.Intheinterim,an immediate priority is to ensure that short-term additionalsupportsareavailableforindividualswhoaremakingthetransitionfromCAMHStoGAMHSatage18,giventheissuesandvulnerabilitiesthatcanprevail.

AlthoughtherehasbeenanincreaseinthenumberofCAMHSinpatientbedssincetheoriginalAVFC policywaspublished,itisacknowledgedthattherehavebeensomechallengesinaccessingsufficientage-appropriateinpatientbeds,exacerbatedbystaffavailabilityissuesandcomplexityofcases.Adultinpatientunitsare,generallyspeaking,notappropriateenvironments for children and adolescents. However, intheeventthatthereisnoCAMHSinpatientbedavailableandshort-termadmissiontoanadultunitistheonlyoption,thenarangeofactionsarenecessary.TheseactionsneedtobeconsistentwiththeCAMHSinpatientstandardoperatingguidelinestoprovideappropriate,effectiveandsafecare.

One of the main challenges regarding access to inpatientorresidentialcareconcernsthesmallnumberofchildrenandadolescentswhohavemultipleneeds,

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includingintellectualdisability,autismorboth,andwhorequirehigh-intensitysupport.Aspecialistunitforsuch children and adolescents would not necessarily addresstheuniqueneedsofeachandwouldbegeographicallyinaccessibleformany.Apreferredapproachistodevelopabespokesetofsupportsthataddress the needs of each individual case in the most appropriatesetting.

General adult mental health services (GAMHS) Majorlifeeventsoccurmoreoftenduringadulthood.Significantadditionalpressuressuchasunemployment,bereavementorlackofaccommodationcancontributetopoormentalhealth.Asaresult,themajorityofservices provided are designed to support the general adultpopulation.

Thereare114GeneralAdultCMHTsoperatingacrossthecountrywithastaffin2017of1,522clinicalwhole-time-equivalents(WTEs)–about76%ofthatenvisaged in AVFC2006–2016.Itisworthnotingthattheadultpopulationaged18to65yearshasbeengrowingonlymodestlyinrecenttimes,averaging0.8%eachyearbetweenthe2011andthe2016censuses.AserviceimprovementprojectintheHSEhasbeenexaminingtheserviceuser’sjourneythroughGeneral Adult CMHTs to ensure consistency in user experiencesandserviceofferingsacrossthecountry.KeythemesandpriorityareashavebeenidentifiedwhichagreewithmanyoftherecommendationsalreadymadeinDomain2andapplytoandbeyondGeneral Adult CMHTs. These themes include information,educationandsignpostingforpatients;realmulti-disciplinaryworking;greaterlinkswithexternalcommunityservices;FCSinvolvementandsupport;amongmanyothers.Animplementationplanwillbedevelopedtothisend.

InlinewiththelegalobligationsundertheDisabilityAct2005,generaladultmentalhealthserviceswillbeaccessibletopeoplewithdisabilitieswhodonotrequireamorespecialistservice.

You said...

Thereshouldbesupported respite facilitiesasanalternativetoinpatientacute care to meet the needs of the service user. The provision of day services or home outreachshouldbeconsidered.

We listened.

Adult inpatient capacity and alternatives to inpatient admissionFollowingstakeholderengagementandnotingtherecommendationscontainedwithintheJointOireachtasCommitteeontheFutureofMentalHealthcare report, the Oversight Group report highlightedtheneedtoconsidertheadequacyofacuteinpatientbedsprovidedforthegeneraladultandolderadultpopulation.Whiletherearecurrentlymoreacuteadultinpatientbedsper100,000thantherecommendednumbersuggestedintheoriginalAVFC,occupancylevelsinacutebedsindicatethattheacuteinpatientsystemisunderconsiderablestress.Considerationofcapacityneedstotakeintoaccounttheavailabilityorlackofotherbeds,suchasthoseinforensic,mentalhealthandintellectualdisability,child and mental health services and other specialist provisionwhereadditionalcapacityisplanned.Capacitymustalsolookatthealternativestoacuteinpatientcare,suchashomecareteams,assertiveoutreachteamsanddayhospitals,asdescribedbelow.Theambitiousfocusofthispolicyistoprioritiseand

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develop a full suite of services to operate alongside appropriateandeffectiveacuteinpatientcareandthentoconsidertheneedforfurtheracuteinpatientbeds.Inthisway,anyneedforadditionalinpatientbedswillbeconsideredagainstavailablelocalservices.Addedtothisthereisaresponsibilityforproviderstoexaminetheuseofbedsandensurethatacutebedsare used as intended and that delayed discharges are reviewed.Systematicanalysisofcapacityrequirementsshouldbeanormalcomponentofourmentalhealthcaresystem’splanningcycleandtakeintoaccountinternationalevidencetoassistplanningandprovision.Itisproposedinthispolicythatacommitteebeestablishedintheshorttermtoreviewacuteinpatientcapacityandpatientflow.Recommendationsfromthisgroupwillfeedintotheimplementationmonitoringcommitteeforconsideration.

Inaddition,thecontinuumprovidesforadditionalday hospitals and home-based care teams to provide continuousintegratedcareinpartnershipwithassertiveoutreachteamsandcrisis resolution teams. These services will operate according to agreed standardoperatingproceduresthatprovideforarangeofalternativestoinpatientcare.Theseserviceswillofferadditionaloptionstoacuteinpatientcareandassistwithpatientflowfromhospitalwardstoalternativesuitablesettings.Recoverycollegeswillaugmentbothservicesbyofferingserviceusersanopportunitytocreateeducationcoursesinpartnershipwith mental health professionals with a focus on equippingserviceusersandtheirfamilies,carersand supporters with new skills that foster recovery, promote self-care and enhance resilience. Together, theseserviceswillprovidevaluableappropriatealternativestotheacutehospitalsetting.

AVFC recognised the role of day hospitals as an alternativetoinpatientadmissionforsomeserviceusers,therebydivertingadmissionstoacuteunits.Thefunctionofadayhospitalistoprovideintensivetreatmentequivalenttothatavailableinahospitalinpatientsettingforacutelyillindividuals,wheretheytypicallyattendfromtheirhomeorcaresettingfor assessment, care and support. In day hospitals, multi-disciplinaryteamsprovidearangeoftherapeuticservicesincludingoccupational,psychologicalandsocial therapy programmes. Service users have integrated recovery care plans and can access

individual or group support programmes. Day hospitals willrequirecorestaffinadditiontoCMHTs,andinordertomeetvariedgeographicneeds,flexibilityofinfrastructureshouldbeconsidered,withdayhospitalsoperatingasafixedfacilitywithmobilestaff,ormobilestaffprovidingdayhospitalcareinanumberoffacilities.

Inadditiontodayhospitals,home-based crisis resolution teams provide intensive support to individualswithseverementalhealthdifficultiesorthosewithfirstincidencepresentationwhoareincrisis.Crisisresolutionteamsalsoprovideanalternativetoinpatienttreatment.Supportfromtheseteamsistime-limited,providingintensiveinterventionandsupportwithsufficientflexibilitytorespondtodifferentserviceuserorcarerneeds.Typically,thisentailsarangeoftherapeuticapproaches,includingmedicationmanagement,cognitiveandbehaviouralinterventionsandevidence-informedfamilyinterventions.Theteamsprovidearapidresponseand24-hourservice,withsupportprovidedintheserviceuser’sownenvironmentandwiththeactiveinvolvement of service users and their family, carers andsupporters,andliaisonwithlocalpartners– GPandVCSservices.Home-basedcrisisresolutionteamscouldalsoplayaroleinsupportingout-of-hourscrisis cafés. The Recovery College is another service element whichhasbeendevelopedmorerecently.ThegoalofaRecoveryCollegeistocreateacultureofrecovery,andtoempowerpeoplewithmentalhealthproblems,theirfamiliesandfriendsandthebroadercommunitytoimprovequalityoflifeandtopromotecommunityinvolvement through the provision of co-produced and co-facilitatedlearningandconversation.

Individualswhohavemultifacetedneedsrequirehigh-intensitysupport–beyondthosediscussedinthissection–andspecialistunitswillnotnecessarilyaddresstheiruniqueneeds.Inaddition,someunitsaregeographicallyinaccessibleformany.Theperson-centred approach of this policy suggests that it might bemoreappropriatetodesignaspecialsetofsupportsthataddresstheneedsoftheindividualinasuitablesetting.Tothisend,AVFCsoughttheestablishmentofanumberof intensive care rehabilitation units (ICRUs) forasmallnumberofpeoplewithdifficult-to-manage

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behaviour.ICRUsareunitswhichprovidesecurecareforasmallnumberofpeopleonalonger-termbasis.

Inaddition,thereisalsoacontinuedneedforshort-term psychiatric intensive care units (PICUs) for a smallnumberofpeoplewhocannotbeaccommodatedinacuteunitsduetothenatureoftheirbehaviour.Two psychiatric intensive care units to meet this need havealreadybeendevelopedinresponsetoAVFC anditisproposedthattwomoreunitsbedevelopedand future capacity considered as part of the acute inpatientgroup.Thesewillbediscussedinfurtherdetailintheforensicmentalhealthservicessectionlater in this chapter.

AnalternativeformofcaretoICRUsandPICUsisthe development of individualised packages of care forpeoplewhosebehaviourandcomplexityofneedrequiresahighlevelofcare.Individualsmayhaveotherdiagnosesaswellasmentalhealthdifficulties.Apreferred approach is to have a special set of supports thataddresstheneedsofeachcaseinthebestsetting.Thisshouldalsofacilitatecareformanywhoare currently on placements outside their area.

Mental health services for older people AsinotherEuropeancountries,thepopulationover65yearsisrisinginIreland.Mentalhealthdifficultiesinlaterlifearebothcommonandtreatablebutwhenunrecognisedand/oruntreatedareassociatedwithincreasedmorbidityandmortality.Dementiaforexample,affects5%ofpeopleover65increasingto20%ofthoseover80years.Peoplewithdementiaare typically referred to mental health services for older people teams when their diagnosis is associated withsignificantbehaviouraland/orpsychologicalsymptoms. Access to services for people with early onsetdementiaisinconsistentacrossthecountry.Inaddition,commonandpredictablelifeeventssuchasbereavementshouldbeprovidedforthroughidentificationofneedandserviceaccessbutalsothroughstrengthened,enhancedcommunities.

Theexpertisefortheassessmentandtreatmentofmentalhealthdifficultiesinolderpeopleisfoundinmental health services for older people (MHSOP) teams.Accesstotheseteamscanbedifficult.Olderpeoplewhohavementalhealthdifficultiesshouldhaveaccesstospecialistexpertiseandjointcare

arrangementsshouldbeputinplacewhereexpertisetomeetthe‘whole’needsofanindividualislocatedinboththegeneraladultteamsandthementalservicesfor older people teams. The age range for mental health services and general adult health teams needs tobereviewedtoreflectthehigherlifeexpectancyandchangingexpectationsofageinginIreland.

Home-basedassessmentandsupportsareparticularlyimportant for older people. Voluntary community sector(VCS)organisationscanworkwithMHSOPteamsandplayanimportantroleinconnectingolderpeopletoactivitiesintheirlocalcommunity.Giventhatoneinthreepeopleover65regularlytakesfiveormoremedications,acombinedfocusonimprovingaccess to talk therapies for older people and on more effectivemedicationmanagementisapriority.

Tailored interventions Forensic mental health services The forensic mental health services (FMHS) are concerned with the treatment of people with mental healthdifficultieswhohavecomeincontactwithlawenforcement agencies, that is, An Garda Síochána, the courts and the Prison Service. The FMHS also provideexpertisetootherspecialistmentalhealthservices on the assessment and management of peoplewithmentalhealthdifficultieswhohaveapropensityforviolenceandchallengingbehaviour.Inthis refresh it is important to repeat the commitment made in AVFCthatservicestothisgroupshouldbebasedonthesamevaluesandprinciplesappliedthroughout the policy. Thus this policy reinforces the needforeverypersonwithmentalhealthdifficultiescoming into contact with the forensic system to have accesstoacomprehensivestepped(ortiered)mentalhealthservicethatisrecovery-orientedandbasedonintegrated co-produced recovery care plans supported byadvocacyservicesasrequired.

Aswithallothermentalhealthservicesdescribedinthis domain, the stepped care approach applies to those in need of forensic mental health support and services.Accesstopreventionservices,primarycarementalhealthservices,earlyinterventionandspecialistmentalhealthservicesasdescribedinearliersectionsshouldbeopentothisgroupastoanyother.

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Thereareanumberofforensicmentalhealthinitiativesthatwillworktogethertoenhancementalhealthservicesoverthelifetimeofthisrevisedpolicy:

• The development of a new state-of-the-art facilityinPortrane,NorthCountyDublinin2020willprovidecareforupto170individualsandwillcontinuetoprovideservicesbothinthecommunity and in prisons. The facility will also have a forensic child and adolescent mental health service (FCAMHS) unit and an intensive carerehabilitationunit(ICRU).

• The2015New Connections report set out a series ofrecommendationsforadequatelymeetingthepsychologicalneedsoftheprisonerpopulation.These include access to a range of talking therapies and the development of mental health peersupportsinprisons.Therecommendationsof the New Connections report are promoted and endorsed in this policy.

• Court diversion schemes seek to ensure that offenderswithamentalhealthdifficultydonotgetinvolvedneedlesslyinthecriminaljusticesystem.Whenoffendingbehaviourisclearlyrelatedtoamentalhealthdifficulty,adiversionschemecanallowoffenderstobedivertedtothe care of the mental health services. In those circumstances,offendersdonotgointothePrisonService,wheretheremaybeadelayinidentifyingand responding to their mental health needs.

• Thenationalforensicmentalhealthservice(NFMHS)beganitsprisonin-reachandcourtliaisonservice(PICLS)in2007.Theserviceaimstoidentifyprisonerswithamentalhealthdifficultyasrapidlyaspossibleandputinplacepracticalsolutionsforappropriatementalhealthcare.

Whilemanycountrieshaveintroducedspecificand comprehensive mental health policy changes to provide for court diversion, Ireland does not yet haveaspecificpolicytoprovideforcourtdiversiontocommunitysettingsorcommunitytreatment.Theeffectivenessoftheservicedependsonongoingresourcingandaccesstofacilitiesandservicesinthecommunitytowhichindividualscanbediverted.

A small group of individuals each year who are found notguiltybyreasonofinsanity(NGBRI)mustbedetained under the Criminal Law Insanity Act in a designated centre under the Act. An intensive care

rehabilitationunit(ICRU)willbebuiltasanadjuncttothe new forensic facility on the Portrane campus. This unitwillhavedualregistrationasanapprovedcentreunder the Mental Health Act and a designated centre under the Criminal Law Insanity Act. It will therefore beavailabletoacceptthosewhohaveNGBRIstatusbutwhodonotrequirethelevelofcareprovidedintheCentralMentalHospital(CMH).TheoperationofthenewICRUcentrewillbereviewedtodeterminetheneedforandeffectivenessofthismodelofcareandthepossiblelocationoffurtherICRUs.

Furthermore,theprofileofthementalhealthneedsoftheprisonpopulationneedstobeexploredtogatherdataontheprevalenceofautism,intellectualdisabilityandneedsrelatingtoaddictionanddualdiagnosis,oftennotspecificallycateredforbyanassociatedmodel of care (MOC) in prisons. Such data will allow foramorejoined-upapproachbyallprofessionalsdeliveringcareinaprisonsetting.Inanefforttosupportthisjointapproach,mentalhealthadvocacygroupscouldbeencouragedandsupportedtoconnectintoprisonsettingstoensurethatindividualsare aware of and can access the services they need to support them in their recovery.

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Dual diagnosis

You said...

Peoplewithaddictionsshouldnotbeexcludedfrom accessing mental health services. People with a dual diagnosis needtobeabletogetthebestcareavailableto assist their recovery.

We listened.

(a)Oneformofdualdiagnosisisdefinedastheco-existenceofmentalhealthproblemsandsignificantsubstance–drugandalcohol–misuseproblemsinanindividual.Drugandalcoholmisusefrequentlyco-existwithmentalhealthdifficulties.Oncementalhealthanddrugandalcoholproblemsbecomeestablished,theycannegativelyimpacteachother.

Accesstoprimarycareaddictionservicesandexistingmentalhealthsupportswhenthereisaco-existingmentalhealth/addictionproblemremainscomplicated.Itisrecognisedthatthereissignificantoverlapbetweentheseconditionsandthatanindividualwithanaddictionhasarighttoaccessrelevantmentalhealthsupportswithinprimarycare.Thenationalpolicyonsubstancemisuse,Reducing Harm/Supporting Recovery,describeshowtieredlevelsofalcoholaddictionsupportsareneededinordertodevelopeffectivementalhealthservicesforpeoplewithco-existingmentalhealthdifficultiesandaddictionordualdiagnosis.Thistieredapproachshouldextendto mental health supports within primary care. The HSE Dual Diagnosis Improvement Programme also emphasises the need for integrated services across

primary care and specialist mental health services. There is a need to further develop universal access to primarycareaddictionservicesthatincludeassociatedmodels of leadership and governance.

AVFC recommended that general CMHTs include counsellorsskilledinworkingwithaddictionissues,and further develop specialist adult and adolescent dual diagnosis mental health teams to manage complex,severesubstanceabuseandmentalhealthdifficulties.Thesespecialistteamswouldoperatethrough clear linkages to CMHTs and would clarify pathways in and out of their service. AVFC further recommended that the dual diagnosis mental health teamsbemulti-disciplinary,similartoothermentalhealth services, and that those working with such teamsshouldhaveaspecialinterestandexpertiseinsupportingpeoplewithadualdiagnosisinvolvingmoderate-to-severementalhealthdifficulties.Theserecommendationsremaininplace.

AVFC recommended that specialist mental health services should support only individuals ‘whoseprimarydifficultyismentalhealth’.Thisrecommendationisnowreversed.Individualswithco-existingmentalhealthdifficultiesandaddictiontoeitheralcoholordrugsshouldnotbepreventedfromaccessingmentalhealthservices.Consequently,itwillnotbenecessarytoestablishwhetheramentalhealthdifficultyis‘primary’foranindividualtoaccessthe support of a mental health team. A shared case managementapproachmayberequiredforparticularlycomplexpatients.

Collaborativeworkingbetweenmentalhealthservicesandsocialinclusionaddictionserviceshascommencedwith the development of shared areas such as alcohol liaison posts with acute hospitals and an emerging model of tele-psychiatry support for adolescents with bothmorbidmentalhealthandaddictionproblems.Thisapproachagreeswiththerecommendationsofthenationalpolicyonsubstancemisuse,Reducing Harm/Supporting Recovery, which are consistent with theaspirationsofthismentalhealthpolicy.Inorderto provide care with clear pathways, a model of care describingthetieredlevelsofsupportneedstobedevelopedand,infact,workiscontinuingintheHSEto prepare such a model. The model should provide forpsychiatrysupportatprimarycarelevel,ifrequired,

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butdevelopedasan‘outreach’serviceprovidedbydual diagnosis specialist mental health teams.

(b) Another form of dual diagnosis is where someone hasanintellectualdisabilityorautismandaconcurrentmentalhealthcondition.Itisacceptedthatmentalhealthproblemscanbemorecommonforpeoplewithautismspectrumdisorder(ASD)thaninthegeneralpopulation.Inlinewiththesteppedcareapproachandthecontinuumofcare,primarycareandCommunityMental Health Teams need to have the training and skillsrequiredtosupportpeoplewithsuchdualdiagnoseswherethatistheappropriatetierofcare.

Mental health services for homeless people Regardingotherpeoplewhoneedmentalhealthsupport, a stepped approach to providing mental healthcare and access to specialist mental health servicesforpeoplewhoarehomelessshouldbeconsidered.Wherepossible,individualsshould receive support at the primary care level through aGPandifnecessarybereferredtotherelevantCMHT in their area.

When those living in long-term emergency accommodationcannotgainaccesstothementalhealthservicestheyrequire,homelessservicesshouldprovide for their mental health needs. This would includelow-levelinterventionsandappropriatereferralstospecialistservices.Duplicationofservicesshouldbeavoidedand,wherepossible,homelesspeople should access their local community mental healthteam.Homelessnessshouldnotcreateabarrierto accessing mental health services. For the rough-sleepingpopulation,adedicatedmentalhealthserviceoperatingonanoutreachmodelisrequiredinlargeurbanareas.

Liaison mental health services Liaison mental health services (LMHS) provide a criticalspecialistmentalhealthserviceforeverybody,youngandold,attendingemergencydepartments,aswellaspatientswithbothphysicalandmentalhealthsupportneedswhoareinpatientsinacutehospitals. Liaison mental health deals with the area

where physical and mental health meet and ensures that individuals in acute hospitals can access mental health services. AVFC recommended an increase from 9LMHSteamsto13;however,servicepressuresin acute hospitals regarding the provision of liaison mentalhealthservicesareemerging,specificallyinthe areas of psycho-oncology, perinatal mental health andthementalhealthofolderpeople–notleastinthecontextoftheageingpopulation.Investmentinthe expansion of LMHS services is needed to address emerging liaison demands while responding to newer LMHS service developments.

Specialist needs-based services Intensive recovery support services (for individuals with complex mental health difficulties) Toreflecttherecoveryethosandthenatureoftheworkinrehabilitationteams,itisproposedthatrehabilitationandrecoveryservicesforpeoplewithcomplexmentalhealthdifficultiesbere-named‘intensiverecoverysupportservices’(IRSS).Theseteamscanbeaccessedbypeoplewhohavecomplexandmultipleneedsandwhorequireintensivesupport,often,butnotalways,onalong-termbasis.

Emerging models of care recommend a range of alternativecarestructuresandassociatedintensiverecovery support services for service users across all Community Health Networks.10 These include specialisedrehabilitationunits(SRUs)providinganintensiveinpatientrehabilitationprogrammeforserviceuserswiththegreatestneed,andactivemedium-termrecoverysupportsbasedonanintegratedrecoverycareplan.Specialisedrehabilitationunitsareincludedintheproposed‘continuumofcare’,togetherwithcommunityrehabilitationresidences(CRRs).Unitsdependonamulti-disciplinaryteamtosupportandenablethepersonconcernedtomove towards independent community living accommodation.ThefullrangeofsupportsandservicesdescribedinFigure3.4shouldbeavailabletothisgroupandincludeadditionalsupportfromassertiveoutreachteams.

10HSE.ModelofCareforPeoplewithSevereandEnduringMentalIllnessandComplexNeeds(2019).Availableat:https://www.hse.ie/eng/services/list/4/mental-health-services/rehabilitation-recovery-mental-health-services/model-of-care-for-people-with-severe-and-enduring-mental-illness-and-complex-needs.pdf

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Assertive Outreach Teams

You said...

We need more outreach teams to meet people where theyare;meetingpeople in their homes, nursing homes, asylum centres or homeless services shouldbeavailableand should provide earlyintervention/preventionandsupport.

We listened.

Assertiveoutreachteamshaveaspecificfocusonrehabilitationandrecoveryandoperatespecialisedmobiletreatment.Theyworktoreducehospitaladmissions and readmissions, prevent relapse, andimproveaperson’schancesofreturningtoemployment,educationortraining,and,moregenerally,toenhancetheirqualityoflife.Suchinterventioninvolvesamulti-disciplinaryteamthatcould include a range of professionals including clinical psychologists,nurses,occupationaltherapists,peerand mental health or social care support workers, psychiatrists and social workers. The emphasis must beonanassertiveapproachtomaintainingcontactwith service users and on encouraging them to return tonormalvocationalandotherlifepursuits.Theworkoftheassertiveoutreachteamsandtheintensiverecovery support services will provide linkages

betweenpatientsandappropriatesupportssuchashousing,employmentandeducation.Thispolicyadvocatesthatassertiveoutreachteamsbeexpandedsothatspecialistmentalhealthcareisaccessible tothosewhomightotherwisefacedifficultiesaccessing it.

Mental health services for early intervention in psychosis The HSE National Clinical Programme for Early Intervention in Psychosishasthepotentialtotransformthelivesofpeoplewithemergingorfirst-episodepsychosis. Where access to a specialist integrated serviceisnotavailable,theriskandexperienceoflong-termdisabilityinthispopulationiswellknown.Theclinicalprogrammepublishedamodelofcareforearlyinterventioninpsychosis(MOCEIP)inJune2019.Followingthismodeltherehasbeenextensivetrainingofcliniciansinbehaviouralfamilytherapy(BFT) as well as ongoing work to provide specialist cognitivebehaviouraltherapy(CBT)forpatientswithpsychosis.Thisisenhancedbythedevelopmentofan individual placement and support (IPS) service tofacilitateprogressionorreturntocompetitiveemployment.Threedemonstrationpilotsiteshavebeenactivatedandifpositivelyevaluated,additionalsiteswillbenefitserviceusersinotherregions.TheSocialReformFundcoordinatesasimilarIPSprogramme that works with Community Mental HealthTeams;thisisdescribedingreaterdetailinChapter4,SocialInclusion,undertheheading‘Employmentsupports’.

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People with an intellectual disability

You said...

There are many groups in Ireland who have specificneeds.Mentalhealth services should beequippedandtrained to deal with themultifacetedneedsof these individuals.

We listened.

AsdescribedinAVFC, mental health and intellectual disability(MHID)teamsshouldbedevelopedtoprovidepopulation-widecoverageandensurefairandequalaccesstomentalhealthcareforpeopleofallageswithanintellectualdisability(ID).Thetieredapproachtopatientcareadvocatedinthispolicywillsupportpeoplewithintellectualdisabilityinaccessingmainstream services especially where the MHID model of care is not yet in place.

Significantmentalhealthandintellectualdisabilityservice gaps remain across the country and a key objectiveoughttofocusonfurtherdeliveryofanationalnetworkofMHIDteams–foradultsandchildren–withclearcatchmentareasdefined.Aperson-centredMHIDteammodelofcareisbeingformalised to ensure consistent service delivery. This modelshouldbeadoptedandreplicatednationally.Aphasedresourceplanisinplacetodevelop‘baselineteams’involvingaconsultantpsychiatrist,aclinicalnursespecialist,apsychologistandadministrativesupportinareaswherethereisnoexistingteamandtoaugmenttheexistingteamsasneeded.Giventhecommunicationchallengesthatcanexistforthesepatients,itisalsoimportanttoincludespeechand

languagetherapists(SLT)ascoremembersoftheAdult-ID and CAMHS-ID teams.

AVFCrecommendedthedevelopmentofacutebedsand day hospital services for mental health and intellectualdisabilitytreatment.InvestmentinacuteMHIDservicesneedstobeprioritised,asenvisagedinAVFC, and developed as part of the HSE MHID service improvementprogrammeandinconjunctionwithHSEsocialcareandSection38/39socialcarevoluntaryagencies.Innovativeacutetreatmentservicesneedtobeexplored,whichmightincludetherapeuticrespiteforchildrenwithintellectualdisabilitiesandsignificantmentalhealthandbehaviouralsupportneeds.

ADHDWhileattentiondeficithyperactivitydisorder(ADHD)inchildrenisaclearlyrecognisedconditionrequiringa stepped care approach, as is evident in a growing bodyofclinicalresearch,ADHDinadultsisanimpairinglifelongcondition.Itisaconditionwhichisunder-recognised and under-diagnosed, and one that leadstoimpairedqualityoflife,resultsinongoingdistress,andisoftenassociatedwithinappropriatetreatmentinterventions.Oncediagnosed,adultswithADHDcanbenefitfrommentalhealthtreatment,includingpsychosocialinterventions.Sharing the Vision supportsimplementationoftheHSEnationalclinicalprogramme for adults with ADHD. This programme emphasises the need for appropriate specialist assessmentandpsychosocialinterventionstosupportaffectedpeopleastheymovefromchildren’sintoadultmental health services.

Suicide preventionConnecting for Life(CFL)(2015–2020)isawhole-of-societystrategytocoordinateandfocusnationaleffortsinIrelandtoreducethelossoflifebysuicideand to reduce cases of self-harm. The strategy applies tothewholepopulationandtospecifiedprioritygroups.Itinvolvespreventiveandawareness-raisingworkwiththepopulationasawhole,supportworkwithlocalcommunitiesandtargetedapproachestopriority groups. The strategy notes that in high-income countries,mentalhealthdifficultiesarepresentforupto90%ofpeoplewhodiebysuicide.Itrecognisesthatlinking with AVFC is central to the success of the work outlined in Connecting for Life. This policy supports continuedimplementationoftheConnecting for Life recommendations.

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Eating disordersEatingdisordersareassociatedwithhighmortalityandmorbidity.TheHSENational Clinical Programme for Eating Disorders(NCP-ED)isacollaborativeinitiativebetweentheHSE,theCollegeofPsychiatristsofIrelandandBodywhys–thenationalsupportgroupforpeoplewitheatingdisorders.Thisprogrammeappliesacross the age range, that is, child and adult, and has developed a model of care to introduce new services andtoimproveexistingservicesforpeoplewitheatingdisorders.Theeightrecommendationsoneatingdisorders made in AVFCarecoveredintheactionsinthe model and are endorsed in this policy.

Specialist perinatal supportsTheperinatalperiodbringsrisksofmentalhealthdifficultiesforsomewomen.Perinatalmentalhealthdisordersincludebothnewonsetandarelapseorrecurrenceofpre-existingdisorders.11 Mental healthdifficultiesatthissensitivetimemayaffecttherelationshipbetweenmother,childandfamilyunit. This carries the risk of the later development of significantemotionalandbehaviouraldifficultiesinthechild.Inits2016ServicePlan,theHSEMentalHealthDivision,inrecognitionoftheimportanceofperinatal mental health, included the development of a Model of Care for Specialist Perinatal Mental Health servicesthatfocusonthemother,thebabyandtheirrelationshipinthecontextofthefamily.TheModelof Care for Specialist Perinatal Mental Health should continuetoberesourcedandrolledoutnationally.

Neuro-rehabilitation (including acquired brain injury)Neuro-rehabilitationistheprocessofsupportingindividualswithbrainorspinalinjuries,whooftenexperiencesignificantmentalhealthdifficultiesrequiringspecialistcare.Peoplewiththesetypesofinjuriesoftenexperiencesignificantdifficultiesinaccessingappropriateservicesthatrequireanintegrated response from the health service. In 2019theHSEpublishedtheNational Strategy and Policy for the Provision of Neuro-rehabilitation Service in Ireland – Implementation Framework (2019–2021), whichprovidesforspecificspecialistmentalhealth

servicesincludingneuro-psychiatry,anessentialpartofaneffectiveneuro-rehabilitationservice.12 These mentalhealthsupportscouldbeprovidedaspartofthe development of liaison mental health services and in the context of the proposed integrated Liaison MentalHealthModelofCare.Implementationofthe National Strategy and Policy for the Provision of Neuro-rehabilitation Service in Ireland –ImplementationFramework should remain a priority and should include theessentialmentalhealthsupportcomponentsof this service development, in the context of the proposed Liaison Mental Health Model of Care.

Providing mental health services that recognise and respond to diversityThe AVFC policy recognised that there are groups ofpeopleinthepopulationwhohaveadditionalneedswhentheydevelopamentalhealthdifficulty.Specifically,itrecognisedthatserviceusersfromother countries and cultures, Travellers and the LGBTQ+communitymayhavespecificvulnerabilitiesordifficultiesthatshouldbeconsideredinthewaymental health services are delivered. Sharing the Vision proposes that a more developed framework for theimplementationofcultural,diversityandgendercompetencyisrequiredtorespondtotheneedsofthesegroupsaspertheDCYALGBT+ National Youth Strategy,2018–2020.

Aroundsevenper10,000peopleinthegeneralpopulationhavesevere-to-profounddeafnessatanyonetimeandtheprevalenceofmentalhealthdifficultiesamongthisgroupismuchhigherthaninthegeneralpopulation.Mentalhealthservicesmustbeculturallyappropriateandaccessibletomembersofthe deaf community through the provision of training, supervisionandsupportforstaff.Alliedtothisthereis a need to ensure that interpreters are appropriately qualifiedtoworkinamentalhealthservicecontext.Outreachinitiativesfrommentalhealthservicestopeople who are deaf, live in the community and are at risk, or who are already living with a mental health difficulty,shouldalsobeavailable.

11Theperinatalperiodcommencesat22completedweeks(154days)ofgestationandendssevencompleteddaysafterbirth:WorldHealthOrganization.‘Maternal,new-born,childandadolescenthealth:Maternalandperinatalhealth’.Accessed17February2020.Availableat:https://www.who.int/maternal_child_adolescent/topics/maternal/maternal_perinatal/en/

12HSE.NationalStrategy&PolicyfortheProvisionofNeuro-RehabilitationServicesinIreland:ImplementationFramework2019–2020(2019).Availableat:https://www.hse.ie/eng/services/list/4/disability/neurorehabilitation/national-strategy-policy-for-the-provision-of-neuro-rehabilitation-services-in-ireland.pdf

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Chapter 3 | Service Access, Coordination and Continuity of Care Domain

People living in Direct Provision can have a higher prevalenceofmentalhealthdifficultiesthanthegeneralpopulation.Thisgroupshouldhaveaccesstomentalhealthservicesandsupports,asdescribedinthesteppedcareapproach,onthesamebasisastherestofthepopulation.Provisionofspecialist,in-reachmentalhealthservicesshouldbeconsidered,whenappropriate. The mental health needs of this group shouldbetakenintoaccountwhenDirectProvisionservicesarebeingplanned.

Access to advocacyAdvocacyisabouthavingsomeoneavailabletohelpapersonmakedecisionsabouthealthcareorotherservices such as access to social welfare, housing or othersocialentitlementsorservices.Advocatescanalso help an individual to make a complaint or seek redress,therebyholdingpublicservicestoaccount.Advocates are people whose primary role is to support an individual around decision-making or having their voice heard. For a variety of reasons, people may notbeabletoadvocateforthemselves.Peoplemayneedtoadvocateforthemselves(‘self-advocacy’),needsupportfromapeer(‘peeradvocacy’)orneedsomeonetospeakontheirbehalf(‘representativeadvocacy’).

AVFC,inRecommendation3.2,recommendedthat‘advocacyshouldbeavailableasarighttoallpatientsinallmentalhealthservicesinallpartsofthecountry’.However, the research and engagement for Sharing the Vision showed that there are gaps in access to advocacy supports and that some needs are unmet. Challengesincludealackofawarenessofexistingadvocacysupports.Thisisparticularlyrelevantforpeoplewithmentalhealthdifficultieslivinginthecommunity,relativetothosebeingsupportedinacuteunitsandlonger-stayfacilities.

Therighttoadvocacyneedstobere-emphasisedandthedevelopmentofadditionaladvocacyservicespursued. There is also a need for research to determine the advocacy needs of people with a mental healthdifficultylivinginthecommunity,asknowledgeof the scale and nature of need in this area is limited.When the Assisted Decision-Making (Capacity) Act is commenced,adultswithamentalhealthconditionwillhavetheoptiontoappointanassistanttohelptheminmakingdecisionsinrelationtotheirmentalhealthtreatmentandinmakingAdvanceCareDirectivesinrelationtoanticipatedfuturetreatment.

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13 DirectoriesofinformationonVCSsupportsshouldbeprovidedtostaffworkinginprimarycareandCMHTstoensuretheyareawareofandinformserviceusersandFCSaboutallsupportsavailableincludingthosefromVoluntaryandCommunitySectororganisationsinthelocalarea.

14 WhereVoluntaryandCommunitySectororganisationsareprovidingservicesalignedtotheoutcomesinthispolicy,operationalgovernanceandfundingmodelsshouldbesecureandsustainable.

15Socialprescribingshouldbepromotednationallyasaneffectivemeansoflinkingthosewithmentalhealthdifficultiestocommunity-basedsupportsandinterventions,includingthoseavailablethroughlocal Voluntary and Community Sector supports and services.

16

Accesstoarangeofcounsellingsupportsandtalktherapiesinthecommunity/primarycareshouldbeavailableonthebasisofidentifiedneedsothatallindividuals,acrossthelifespan,withamild-to-moderatementalhealthdifficultycanreceivepromptaccesstoaccessiblecarethroughtheirGP/PrimaryCareCentre.Counsellingsupportsandtalktherapiesmustbedeliveredbyappropriatelyqualifiedandaccreditedprofessionals.

17 Thementalhealthconsultation/liaisonmodelshouldcontinuetobeadoptedtoensureformallinksbetweenCMHTsandprimarycarewiththepresenceof,orin-reachby,amentalhealthprofessionalaspart of the primary care team or network.

18

AnimplementationplanshouldbedevelopedfortheremainingrelevantrecommendationsinAdvancing the Shared Care Approach between Primary Care & Specialist Mental Health Services(2012)inordertoimproveintegrationofcareforindividualsbetweenprimarycareandmentalhealthservicesinlinewithemerging models and plans for Community Health Networks and Teams.

19 ThephysicalhealthneedsofallusersofspecialistmentalhealthservicesshouldbegivenparticularattentionbytheirGP.Asharedcareapproachisessentialtoachievethebestoutcomes.

20ThereshouldbefurtherdevelopmentofearlyinterventionandassessmentservicesintheprimarycaresectorforchildrenwithADHDand/orautismtoincludecomprehensivemulti-disciplinaryandpaediatricassessmentandmentalhealthconsultationwiththerelevantCMHT,wherenecessary.

21Dedicatedcommunity-basedAddictionServiceTeamsshouldbedeveloped/enhancedwithpsychiatryinput,asrequired,andimprovedaccesstomentalhealthsupportsinthecommunityshouldbeprovidedtoindividualswithco-existinglow-levelmentalhealthandaddictionproblems.

22 Theprovisionofappropriateenvironmentsforthosepresentingatemergencydepartmentswhoadditionallyrequireanemergencymentalhealthassessmentshouldbeprioritised.

23Thereshouldbecontinuedinvestmentin,andimplementationof,theNationalClinicalCareProgrammefortheAssessmentandManagementofPatientsPresentingtoemergencydepartmentsfollowingself-harm.

24 Out-of-hourscrisiscafésshouldbepilotedandoperatedbasedonidentifiedgoodpractice.SuchcafésshouldfunctionasapartnershipbetweentheHSEandotherproviders/organisations.

25 Themulti-disciplinaryCMHTasthecornerstoneofservicedeliveryinsecondarycareshouldbestrengthenedthroughthedevelopmentandagreedimplementationofasharedgovernancemodel.

26CMHTs’outreachandliaisonactivitieswithVoluntaryandCommunitySectorpartnersinthelocalcommunityshouldbeenhancedtohelpcreateaconnectednetworkofappropriatesupportsforeachservice user and their FCS.

Domain: Service access, coordination and continuity of care recommendations

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27 Anindividualisedrecoverycareplan,co-producedwithserviceusersand/orFCS,whereappropriate,shouldbeinplacefor,andaccessibleto,allusersofspecialistmentalhealthservices.

28 AllserviceusersshouldhaveamutuallyagreedkeyworkerfromtheCMHTtofacilitatecoordinationandpersonalisationofservicesinlinewiththeirco-producedrecoverycareplan.

29 FurthertrainingandsupportshouldbeputinplacetoembedarecoveryethosamongmentalhealthprofessionalsworkingintheCMHTaswellasthosedeliveringserviceselsewhereinthecontinuumofservices.

30 CMHTsandsessionalcontactsshouldbelocated,wherepossibleandappropriate,inavarietyofsuitablesettingsinthecommunity,includingnon-healthsettings.

31 Thepotentialfordigitalhealthsolutionstoenhanceservicedeliveryandempowerserviceusersshouldbedeveloped.

32

ThecompositionandskillmixofeachCMHT,alongwithclinicalandoperationalprotocols,shouldtakeintoconsiderationtheneedsandsocialcircumstancesofitssectorpopulationandtheavailabilityofstaffwithrelevantskills.AslongasthecoreskillsofCMHTsaremet,thereshouldbeflexibilityinhowtheteamsareresourcedtomeetthefullrangeofneedswherethereisstrongpopulation-basedneedsassessment data.

33 The shared governance arrangements for CMHTs as outlined in AVFC2006–16shouldbeprogressed,including further rollout of Team Coordinators.

34 ReferralpathwaystoallCMHTsshouldbereviewedandextendedbyenablingreferralsfromarangeofotherservices,(asappropriate)includingSeniorPrimaryCareProfessionalsincollaborationwithGPs.

35 Acomprehensivespecialistmentalhealthout-of-hoursresponseshouldbeprovidedforchildrenandadolescentsinallgeographicalareas.ThisshouldbedevelopedinadditiontocurrentEDservices.

36AppropriatesupportsshouldbeprovidedforonaninterimbasistoserviceuserstransitioningfromCAMHStoGAMHS.Theageoftransitionshouldbemovedfrom18to25,andfuturesupportsshouldreflectthis.

37 Nationallyagreedcriteriashouldbedevelopedtogovernandresourceindividualisedsupportpackagesforthespecificneedsofasmallcohortofchildrenandyoungpeoplewhohavecomplexneeds.

38 Inexceptionalcaseswherechildandadolescentinpatientbedsarenotavailable,adultunitsprovidingcaretochildrenandadolescentsshouldadheretotheCAMHSinpatientCodeofGovernance.

39TheHSEshouldconsultwithserviceusers,FCS,staff,andthosesupportingprioritygroupstodevelopastandardisedaccesspathwaytotimelymentalhealthandrelatedcareinlinewiththeindividual’sneeds and preferences.

40 Sufficientresourcingofhome-basedcrisisresolutionteamsshouldbeprovidedtoofferanalternativeresponsetoinpatientadmission,whenappropriate.

41AStandardOperatingGuidelineshouldbedevelopedtoensurethatsufficientlystaffeddayhospitalsoperateaseffectivelyaspossibleasanelementofthecontinuumofcareandanalternativetoinpatientadmission.

42IndividualswhorequirespecialistMentalHealthServicesforOlderPeople(MHSOP)shouldreceivethatserviceregardlessoftheirpastorcurrentmentalhealthhistory.Peoplewithearlyonsetdementiashould also have access to MHSOP.

43 TheagelimitforMHSOPshouldbeincreasedfrom65yearsto70yearssupportedbyjointcarearrangementsbetweenGAMHSandMHSOPteamsforindividualswhorequiretheexpertiseofboth.

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44 GPs,mentalhealthserviceprescribersandrelevantstakeholdersshouldcollaboratetoactivelymanagepolypharmacy.

45 TheHSEshouldcollatedataonthenumberandprofileofdelayeddischargesinacutementalhealthinpatientunitsanddevelopappropriatelyfundedresponses.

46

AnExpertGroupshouldbesetuptoexamineAcuteInpatient(ApprovedCentre)bedprovision(includingPICUs)andtomakerecommendationsoncapacityreflectiveofemergingmodelsofcare,existingbedresources,andfuturedemographicchanges,withsuchrecommendationsbeingalignedwith Sláintecare.

47 SufficientPsychiatricIntensiveCareUnits(PICUs)shouldbedevelopedwithappropriatereferralanddischarge protocols to serve the regions of the country with limited access to this type of service.

48

Across-disabilityandmentalhealthgroupshouldbeconvenedtodevelopnationalcompetenceinthe commissioning, design and provision of intensive supports for people with complex mental health difficultiesandintellectualdisabilitiesandtodevelopasetofcriteriatogoverntheprovisionofthisservice.

49IntensiveRecoverySupport(IRS)teamsshouldbeprovidedonanationalbasistosupportpeople withcomplexmentalhealthneedsinordertoavoidinappropriate,restrictiveandnon-recovery-orientedsettings.

50 ThedevelopmentofanationalnetworkofMHIDteamsandacutetreatmentbedsforpeopleofallageswithanintellectualdisabilityshouldbeprioritised.

51 SpeechandLanguageTherapists(SLT)shouldbecoremembersoftheAdult-IDandCAMHS-IDteams.

52 InvestmentintheimplementationoftheModelofCareforEarlyInterventionPsychosis(EIP),informedbyanevaluationoftheEIPdemonstrationsites,shouldbecontinued.

53ThephasedimplementationandevaluationofappropriateserviceresponsestosupportadultswithADHDshouldbedevelopedandresourcedinlinewiththeNationalClinicalProgrammeforAdults with ADHD.

54Everypersonwithmentalhealthdifficultiescomingintocontactwiththeforensicsystemshouldhaveaccesstocomprehensivestepped(ortiered)mentalhealthsupportthatisrecovery-orientedandbasedonintegratedco-producedrecoverycareplanssupportedbyadvocacyservicesasrequired.

55Thereshouldbeongoingresourcingofandsupportfordiversionschemeswhereindividualswithmentalhealthdifficultiesaredivertedfromthecriminaljusticesystemattheearliestpossiblestageandhavetheirneedsmetwithincommunityand/ornon-forensicmentalhealthsettings.

56 ThedevelopmentoffurtherIntensiveCareRehabilitationUnits(ICRUs)shouldbeprioritisedfollowingsuccessfulevaluationofoperationofthenewICRUonthePortraneCampus.

57

Atieredmodelofintegratedserviceprovisionforindividualswithadualdiagnosis(e.g.substancemisusewithmentalillness)shouldbedevelopedtoensurethatpathwaystocareareclear.Similarly,tieredmodelsofsupportshouldbeavailabletopeoplewithadualdiagnosisofintellectualdisabilityand/orautismandamentalhealthdifficulty.

58In order to address service gaps and access issues, a stepped model of integrated support that provides mentalhealthpromotion,preventionandprimaryinterventionsupportsshouldbeavailableforpeopleexperiencing homelessness.

59 Assertiveoutreachteamsshouldbeexpandedsothatspecialistmentalhealthcareisaccessibletopeople experiencing homelessness.

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60 ContinuedexpansionofLiaisonMentalHealthServicesforallagegroupsshouldtakeplaceinthecontext of an integrated Liaison Mental Health Model of Care.

61 The HSE should maximise the delivery of diverse and culturally competent mental health supports throughout all services.

62 Building on service improvements already in place, individuals who are deaf should have access to the fullsuiteofmentalhealthservicesavailabletothewiderpopulation.

63PersonsinDirectProvisionservicesandrefugeesarrivingundertheIrishrefugeeprotectionprogrammeshouldhaveaccesstoappropriatetieredmentalhealthservicesthroughprimarycareandspecialistmental health services.

64 Appropriatelyqualifiedinterpretersshouldbemadeavailablewithinthementalhealthserviceandoperate at no cost to the service user.

65 The HSE should ensure access to appropriate advocacy supports in all mental health services.

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Chapter 4

Social Inclusion Domain

Sharing the Vision | A Mental Health Policy for Everyone

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Chapter 4 | Social Inclusion Domain

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Figure 4.1: Outcomes: social inclusion

Service users are respected, connected and valued in

their community

Improvedoutcomesinrelationtoeducation,housing,employment

and income for service users relativetothepopulationasawhole (i.e. reduced disparity).

Increasedabilityofservice users to manage their own lives [self-determination]viastronger

socialrelationshipsand sense of purpose

Outcome 3(a)

Outcome 3(c) Outcome 3(b)

Introduction

This domain focuses mainly on people living with complexmentalhealthdifficultieswhoaremostvulnerabletosocialexclusionarisingfromstigmaanddiscrimination,inadequateaccommodationoftheirneedsinworkplaces,andinsufficientaccesstoincome,housing,employmentandtrainingoreducation.Theepisodicnatureofthesementalhealthproblemscanleadtoemploymentdifficultiesandchallengesavailingof social support systems.

Peoplewithdisabilities,includingmentalhealthdifficulties,oftenexperiencenumerousbarrierstoemploymentandhousing.Theremayalsobebarrierstomoregeneralsocialinclusionofpeoplewithmentalhealthdifficulties.Tacklingstigmaanddiscrimination,asoutlinedinDomain1(promotion,preventionandearlyintervention),canhelptobuildsocialinclusion.Beingempoweredtoliveinone’sownhomeandcommunity,withadditionalsupportswhere

appropriate,isakeyfactorinfacilitatingandsustaining recovery.

Thevariousrecommendationsandinterventionsproposedinthisdomainareallaimedatenablingservice users living with complex mental health difficultiesandtheirfamily,carersandsupporterstofeel connected and valued in their community. This domain will facilitate improved outcomes for people withmentalhealthdifficultiesinhousing,employment,incomeandtrainingoreducation.Betteroutcomes,broughtaboutbybuildingstrongersocialrelationshipsand through developing and enhancing access to housing,employment,incomeandeducationortraining, will nurture social inclusion and respect for diversity.Theserecommendationsaimtoempowerserviceusersbysupportingthemtoachievefullandeffectiveparticipationinsociety.Figure4.1showstheoutcomes for the domain social inclusion.

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Sharing the Vision | A Mental Health Policy for Everyone

Equality of accessAVFC recognised that individuals with mental health difficultiesshouldhaveaccesstohousing,employmentandeducationortrainingonthesamebasisaseveryothercitizen.TheUnitedNationsUniversalDeclarationofHumanRightsrecognisesthatpeoplewithdisabilitiesshouldhaveequalrightstoliveina community and that measures to facilitate their fullinclusionandparticipationshouldbeprioritisedincludingaccesstoeducation,health,employmentandsocialprotection.Thispolicyincorporatesthesamefundamentalprincipleofequalityofaccesstohousing,employmentandtrainingoreducationforpeoplelivingwithamentalhealthdifficulty.

Housing supports Peoplewithpoormentalhealthrequireaccesstogood-quality,secureandappropriatehousingtofacilitateandsustaintheirrecovery.Alackofsuitablehousingasanalternativetoinstitutionalcarecanleadtoaninefficientandexpensivementalhealthsystem,withserviceusersreceivingunsuitablecare.Housingsupportsforthesepeoplerequireeffectivecollaborationbetweengovernmentdepartments,localauthoritiesandsocialhousingorganisations.Apartfrom housing, there is also a need to ensure that thosewithcomplexmentalhealthdifficultiesreceivemulti-disciplinarysupportsfromhealthprofessionalsandVCSorganisationstoimprovetheirqualityoflife.Serviceusersalsorequireassistancetosustaintenancies and live independently. As a result, there mustbeeffectiveliaisonbetweenmentalhealthservicesandlocalauthoritiesintheprovisionofsocialhousingforpatientswhorequireit.Centraltothisis ensuring that people with complex mental health difficultieshaveequalaccesstohousingallocationsandthatparticularneedsconcerningtheirlivingenvironment are properly addressed.

AVFC highlighted that many people in HSE hostel accommodationwouldbebetterofflivingmoreindependently in the community. It recommended that the housing and mental health sectors work togethertoachievethisandclarifiedtherolesofthe

twosectors.Importantprogresshasbeenmadeandgoodpracticedevelopedthroughrecentpilotprojectsthat provide access to appropriate housing, as well as practicalsupportstosustainindependentliving,alongwithmentalhealthrehabilitationsupports.13AjointprotocolagreedbytheDoHandtheDepartmentofHousing, Planning and Local Government (DHPLG) in consultationwithkeystakeholdersisrequiredtoassistpeople living in HSE mental health service congregated settingstomovetomainstreamcommunity-basedliving.14

Sustainableresourcingbasedonidentifiedneedfortenancy-related/independentlivingsupportsforpatientswithcomplexmentalhealthdifficultiesmustbeconsideredforserviceusersmovingfromHSE-supportedaccommodationtoindependentlivingand for individuals in hospital or homeless services identifiedashavingahousingneed.

Rebuilding Ireland – the Action Plan for Housing and Homelessness commits to delivering supports to homelesspeoplewithmentalhealthandaddictionissues. The plan recognises that homelessness is a complex phenomenon. It is usually the result of anumberofinterrelatedissues,whichcanincludementalhealthissues,addictions,relationshipbreakdown,familyissues,domesticviolence,financialloss, economic insecurity, rent arrears, tenancy issues, anti-socialbehaviour,crime,prisonerreleaseandthevulnerabilityofmigrants,amongotherfactors.Theplan therefore recognises that a successful ‘whole-of-government’responseisneededtosuchissuesifthecurrenthomelessnesscrisisistobetackledeffectively.Assuch,recommendationsinthispolicyneedtobeimplementedtogetherwithvariousrecommendationscoveredinchapter3,includingaccesstoprimarycareservices;supportsforindividualswithadualdiagnosis;and access to outreach mental health services for homelesspeopleinemergencyaccommodation.

In2016newhousingdesignguidelineswerelaunchedbytheHSEandtheHousingAgencytopromoteindependent living and recovery for people living withmentalhealthdifficulties.15Theguidelinesoffer

13ExamplesofcollaborativepilotprojectsaretheDorasandSlánAbhaileprojectsinNorthDublinfundedbytheGenioProgrammebetween2012and2016.

14Acongregatedsettingisaplacewheretenormorepeoplewithadisabilitylivetogetherinasinglelivingunit.15ÁineO’Reilly,EmerWhelan,andIsoildeDillon.DesignforMentalHealth–HousingDesignGuidelines(Dublin:HousingAgencyandHSE,2016).Availableat:http://www.housingagency.ie/sites/default/files/publications/36.%20Design%20for%20Mental%20Health%20Housing-Design-Guidance-MAY-2017.pdf

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Chapter 4 | Social Inclusion Domain

aperspectiveonhousingtypeanddesignforpeopleconsideringalternativestocongregatedsettingsandshouldbeafactorforallofthehousing-relatedrecommendationsinthispolicy.

Employment supports Forindividualswithenduringmentalhealthdifficulties,orthoserecoveringfromaonce-offbutsignificantmentalhealthdifficulty,thepossibilityofsecuringemploymentorreturningtoworkcanbeakeyfactor in recovery. Employment is important to social statusandidentityasitprovidessocialconnectionand promotes self-esteem, self-worth, increased confidence,responsibilityandindependence.Meaningfulemploymentfostershope,participationandasenseofabetterandbrighterfuture.Inaddition,employmentcanreduceand/orstabilisesymptoms,increaseself-worthandprovidegreaterdisposableincome.

Thereareanumberofemploymentandtraininginitiativesthatareimportantintermsofkeepingpeopleconnectedwithotherindividualsandofferingpracticalsupportsforgainingfutureemployment.Theindividual placement and support (IPS) employment model helps people with a complex mental health conditiontoremaininorhaveaccesstoworkinmainstreamsettingswhilealsosupportingemployerstoaddressrelatedrecruitmentandretentionissues.Assuch,itdiffersfromothervocationalrehabilitationapproaches that employ people in sheltered workshopsandothernon-mainstreamjobs.TheIPSmodelisinternationallyrecognisedasacost-effectivemethodofsupportingpeoplewithseverementalhealthdifficultiestoachievesustainable,competitiveemployment.TheoperationoftheSocialReformFundhas provided an opportunity to roll out and implement the IPS model in all nine Community Healthcare Organisations(CHOs)andinthenationalforensicmentalhealthservice.IPScouldbescaledupifthatprovesappropriateafterafullpositiveevaluationhasbeencompleted.

Training and vocational education supports TheHSE’sNew Directions – Personal Support Services for Adults with Disabilities Report(2012)included

peoplewithmentalhealthdifficulties,andtheprinciplesandmodelsdescribedinitarehighlyrelevantforpeoplewiththesedifficulties.16 It commits to developing services that are person-centred andsupportingthesocialinclusionofindividualsintheircommunitybybuildingpersonalcapacityandcompetencies. Where desired, services can provide bridgingprogrammestovocationaltrainingandotherformaleducationandlearningopportunities.ExistingresourcesshouldbeusedbytheHSEtoreconfigureexistingadultdaysupportsforpeoplewithcomplexmentalhealthdifficulties,inlinewiththeNew Directions policy. Peer-provided and peer-led supports could have an important role to play in the range of servicesoffered.

Income protection and social welfare In AVFC, measures were put forward to protect the incomeofindividualswithmentalhealthdifficultiesthatcentredoninformingthemaboutthebenefitstowhichtheyareentitled.AVFC also recognised that help and advice are needed to ensure such individuals aresupportedbythesocialwelfaresystem,includingtheflexibleprovisionofsocialwelfarepayments.Theseissuesarestillprevalent,andacrucialrequirementisthatincomesupportsbeflexibletoallowpeopleenterorleavetheworkforceintimesofillnesswithconfidenceandsecurity.

Peer-led, peer-run and community development projects Peer-ledandpeer-runprojectsinthecommunityareimportant ways to promote the social inclusion of peoplewithamentalhealthdifficulty.Specifically,therearekeysocialandcommunityactivitiesthatcanenhancepositivementalhealthbygeneratingsocialcapitalandpromotinganindividual’ssocialinclusionand mental health recovery. Such networks are a bufferagainststress,whilecreatingopportunitiesfor meaningful social engagement and personal development.Severalpeer-ledprojectsexistbutaremainlyvolunteer-ledinitiativesthatdonothaveaccesstoreliablefundingstreams.Itisimportanttofundpeer-ledprojects,butfundingmustbeinformedbyprojectevaluationandhavestandardoperatingguidance (SOG) in place.

16NationalWorkingGroupNewDirections.New Directions–ReviewofHSEDayServicesandImplementationPlan2012–2016–WorkingGroupReportFebruary2012(2012).Availableat:http://www.inclusionireland.ie/sites/default/files/documents/Reports/new_directions.pdf

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66Tailoredmeasuresshouldbeinplaceinrelevantgovernmentdepartmentstoensurethatindividualswithmentalhealthdifficultiescanavail,withoutdiscrimination,ofemployment,housingandeducationopportunitiesandhaveanadequateincome.

67 Localauthoritiesshouldliaisewithstatutorymentalhealthservicestoincludethehousingneedsofpeoplewithcomplexmentalhealthdifficultiesaspartoftheirlocalhousingplans.

68The Department of Health and the Department of Housing, Planning and Local Government, in consultationwithrelevantstakeholders,shoulddevelopajointprotocoltoguidetheeffectivetransitionofindividualsfromHSE-supportedaccommodationtocommunityliving.

69InconjunctionwithsupportsprovidedbytheHSEincludingIntensiveRecoverySupportteams,sustainableresourcingshouldbeinplacefortenancy-related/independentlivingsupportsforserviceuserswithcomplexmentalhealthdifficulties.

70ThehousingdesignguidelinespublishedbytheHSEandtheHousingAgencyin2016topromoteindependentlivingandmentalhealthrecoveryshouldbeareferencepointforallhousing-relatedactionsinSharing the Vision.

71

AsustainablefundingstreamshouldbedevelopedtoensureagenciescanworkeffectivelytogethertogetthebestoutcomesfortheindividualusingtheIndividualisedPlacementSupportmodel,whichisanevidence-based,effectivemethodofsupportingpeoplewithcomplexmentalhealthdifficultiestoachievesustainable,competitiveemploymentwheretheychoosetodoso.

72 ThecurrentHSEfundingprovidedfordaycentresshouldbereconfiguredtoprovideindividualisedsupportsforpeoplewithmentalhealthdifficultiesandbeconsistentwiththeNew Directions policy.

73

InlinewiththestrategicprioritiesoftheComprehensiveEmploymentStrategyforPeoplewithDisabilities,thewaypeoplecomeon/offincomesupportsshouldbestreamlinedtomaximiseentryorre-entrytotheworkforcewithconfidenceandsecurity.Thisshouldhappenwithoutthreatoflossofbenefitandwithimmediaterestorationofbenefitswheretheyhaveanepisodicconditionormustleaveajobbecauseoftheirmentalhealthdifficulty.

74 TheHSEshouldcontinuetodevelop,fundandperiodicallyevaluateexistingandnewpeer-led/peer-runservicesprovidedtopeoplewithmentalhealthdifficultiesacrossthecountry.

Domain: Social inclusion recommendations

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Chapter 5

Accountability and Continuous Improvement Domain

Sharing the Vision | A Mental Health Policy for Everyone

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Chapter 5 | Accountability and Continuous Improvement Domain

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Figure 5.1: Outcomes accountability and continuous improvements

Continuousimprovementis futurefocussedanddrivenbyadequatelyresourcedinnovationacross the mental health system

and related sectors

Services that deliver consistently highqualitypersoncentred

supports that meet the needs and havetheconfidenceofservice

users and FCSs

Mentalhealthisembedded asanationalcrosscuttingprioritythatiseffectivelyintegrated

into the key policies and settingsinsociety

Outcome 4(a)

Dynamic performance reportingprovidesvisibility

of the performance and impact of Sharing the Vision

Outcome 4(b)

Outcome 4(d) Outcome 4(c)

Introduction

Positivementalhealthisnotamatterforthehealthsectoralonebutsitsinamuchbroadercontextofdecisionsmadeacrosstherelevantpublicservices.Thesecanimpactpositivelyornegativelyonthewellbeingofthepopulationgenerally,aswellasonthe mental health of individuals living with a mental healthdifficulty.Mentalhealthpolicymustthereforebeanintegralnationalcross-cuttingpriority.Assuchitneedstobeintegratedintoallkeyandrelevantpoliciesandsettingsinsociety.Thisdomainfocusesontheorganisationalprocessesneededtoimplementand track delivery of the reforms proposed with an emphasisoninnovationandcontinuousimprovement.

Aspartoftheimplementationplanning,allrecommendationsandassociatedactionshaveassignedleadresponsibilitiesacrossrelevantgovernment departments and agencies, as set out intheImplementationRoadmap(AppendixIII).SuchgovernancewillbereinforcedbythesettingupoftheNationalImplementationManagementCommittee,representativeofcross-sectoralinterestsaswellaspatients,FCSandpeerorganisations.Figure5.1showstheoutcomesforthedomainaccountabilityandcontinuousimprovements.

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Sharing the Vision | A Mental Health Policy for Everyone

Accountability and continuous improvement Theneedtobuildamoreaccountableandtransparenthealth service is a focus of Sláintecare and is also a keyobjectiveforSharing the Vision.Patients,FCSandthewiderpublicneedtohaveconfidenceintheinformationavailablesothattheycanjudgethepaceandimpactofthisrefreshedpolicyandthedifferenceitmakestothehealthandwellbeingofpatients.Policyimplementationandreforminthefuturemustmaintaintheeffortandbuildontheevidenceof‘whatworks’inthepresent.Continuousimprovementandthe capacity to address new challenges depend on innovationandnewwaysofworkingacrosssystemsand sectors.

Thereareanumberofestablishednationalinitiativestosupportinnovationinreplicating‘whatworks’.Theemphasisnowmustbeonfuture-focused,continuousimprovementdrivenbyadequatelyresourcedinnovationwhileactivatingtheprocessesandskillstosupportchange.Thefocusoncontinuousimprovement must extend to other sectors contributingtothewellbeingofthepopulation,supportingpeoplelivingwithamentalhealthdifficultywhile they recover.

Governance leadership and organisation AVFCrecommendedthataNationalMentalHealthDirectoratebeestablishedundertheleadershipofanationaldirectortoprioritisethementalhealthagenda and to drive it centrally within the HSE. ThiswasachievedwiththeappointmentofthefirstHSEnationaldirectorin2013.Aspartofstructuralchangesannouncedin2016,anewnationaldirectorofcommunityhealthserviceoperationssubsumedtheoperationalrolesoftheexistingnationaldirectorsforprimarycare,socialcare,healthandwellbeing,andmentalhealth.Thesechangesenabledtheexistingnationaldirectorstoworkcloselywiththechiefstrategyandplanningofficertoplantheintegrationof acute care, primary care, social care, mental health andhealthandwellbeing.Thechangesintroducedbythe HSE were designed to enhance performance and management across the health service and to integrate HSEservicestodeliverthehealthprioritiesoutlinedinthe Programme for Government.

There is an ongoing need for a dedicated focus on

mentalhealthstrategy,withnational-levelleadership,togivetherequiredattentiontooperationalissuesandtomaximiseintegrationacrosscaregroups.HealthAreaswilloperateonanintegratedbasisdeliveringservicesbaseduponpopulationneeds.Mentalhealthserviceswillnolongerbeseenasaseparateservicewithinalargerstructurewhereintegrationandcohesionareaspiredtobutnotalwaysdelivered. The model for delivery of care proposed suggests that mentalhealthservicesshouldaligntoexistingandemerginghealthstructurestoenabletheprovisionof community health and social care services across primary care, social care, mental health, and health andwellbeinginamorecoordinatedandintegratedway.Consequently,MentalHealthServiceswillfullyparticipateintheSláintecare programme reforms and beatthecentreofthenewstructuresofhealthcaredelivery.Themovetocollaborativeandcross-boundaryworkinginCommunityHealthNetworks(CHN),operatingatlowerpopulationlevelswithinRegionalHealthAreas,willencourageprimaryandsecondarycaretobealignedanddeliveredclosertothe community.

AVFCstipulatedthatforgeneraladultmentalhealthservicesthereshouldbeonecommunitymentalhealthteam(CMHT)forsectorpopulationsofapproximately50,000.ThisremainsvalidandprovidesagoodbasisforsynergywiththeCHNmodel,whichalsooperatestoacatchmentpopulationof50,000,therebyprovidingscopefor‘co-terminosity’ofservicedelivery.Effectiveorganisationalstructuresareessentialtodeliverintegratedmentalhealthservicesandtobringaboutthereformandimplementationoftheassociatedrecommendationsproposedinthisrevisedpolicy.Butthereisaneedtoprioritisetheimplementationofrecommendationsandactionsthatwill directly impact on the lives of people with mental healthdifficultiesassoonaspossibleandnottowaituntilallstructuralchangesarefinalised.

Inordertoreconcilefullintegrationofmentalhealthservices within the Sláintecare reforms with the need forgovernanceandanevidence-basedapproach,theimplementationofSharing the VisionwillbeoverseenbytheNationalImplementationandMonitoringcommittee.AstheSláintecare programme evolves, it willbetheworkoftheNationalImplementationandMonitoringCommitteetoreconsiderandre-evaluatehow to ensure governance for mental health services within the programme.

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Chapter 5 | Accountability and Continuous Improvement Domain

Patient Safety InNovember2015,theGovernmentapprovedamajorprogrammeofpatientsafetyreformswhichincludedtheestablishmentofaNationalPatientSafetyOffice(NPSO) in the Department of Health. The NPSO wasestablishedinDecember2016tooverseeaprogrammeofpatientsafetymeasures. Ensuringthedeliveryofhighqualityandsafehealthand social care is a top priority of the Department andtheNPSO.ThepatientisatthecoreofpolicydecisionsandtheDepartmentiscommittedtoworking with the HSE and other key stakeholders in drivingthedeliveryofamajorprogrammeofpatientsafetyreforms.Theseareenabledbydevelopingandintroducingeffectivepatientsafetypoliciesandlegislationthat–

• are founded upon improving understanding of safetybydrawingintelligencefrommultiplesourcesofpatientsafetyinformation,

• promote engagement and involvement of service usersandproviderstoimprovepatientsafetythroughout the whole system,

• ensuresprovidersdelivereffectiveandsustainablechange in the most important areas,

• promotescollaborationtoachievehealthprioritiesandcontributetowidersocialandeconomicgoals,sothatpolicyalignswithnationalinitiativessuch as Sláintecare

• promotesapositivecultureofpatientsafetywherethereisgoodteamwork,openness,patient-centred approaches and support for learning.

The work of the NPSO includes progressing aprogrammeofpatientsafetylegislation,theestablishmentofanationalPatientSafetyAdvocacyService,settingupanIndependentPatientSafetyCouncil,extendingtheclinicaleffectivenessagenda,themeasurementofpatientexperience,andtheintroductionofpatientsafetysurveillance. HSE’s Patient Safety Strategy The HSE Patient Safety Strategy 2019-2024, launched bytheHSEBoardinDecember2019,setsoutstrategycommitmentsandactionstoimprovethesafetyofallpatientsbyidentifyingandreducingpreventableharmwithinthehealthandsocialcaresysteminIreland.Itrecognisesthatkeytopatientsafety and person-centred care is a culture where patients,carers,families,advocatesandhealthcare

professionals work together in partnership to ensure positivepatientexperiences,maximisepositivehealthoutcomes and minimise the risk of error and harm. The goalistoachieveaculturethatwelcomesauthenticpatient-partnershipintheircareandintheprocessofco-producing, delivering and improving care. Leadership in Safe, High Quality Mental Health Care Leadership, governance, clinical commitment and clinicaleffectivenessapproachesarerequiredtodeliversafe,highqualitymentalhealthcareatnational,regional and local level. There is a need for investment incapacitydevelopmentforqualityandpatientsafetyin our mental health services. Thisrequiresthateachservicehasadedicatedpatientsafetyandqualityleadershipandoversightfunction,whichencompassesbothpatientsafetyelements(e.g.complaints procedures, advocacy, and management of riskandadverseevents)andqualityelementssuchasstandards,clinicaleffectivenessguidelines,auditandkey performance indicators.

Disadvantage and service planning AVFC highlighted the need to take account of local deprivationpatternsinplanninganddeliveringmentalhealthservices.Thereisaneedforacontinuedemphasisonthisnotjusttopromotegreateraccountabilityandtransparencyinresourceallocation,butalsotosupporttheachievementofsomeoftheoutcomes regarding access to services and social

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inclusion.Takingdeprivationfiguresintoaccount,areasthathavepoorlevelsofprovisionforspecificservicesrelativetootherareaswillbeprioritised.Thismeansthatwhennewresourcesbecomeavailable,theywillbeallocatedbasedonneed.Thisallocationmodelshouldinclude the skill mix in mental health human resources. Skillmixanalysisshouldbecarriedouttodeterminetheoptimumnumberandtypeofhealthandsocialcareprofessionals in any given service. The emphasis will beonmeetingtheneedsofpatientsratherthanfillingquotasforanysingleprofessionalgroup.

Physical infrastructure for mental health services AsnotedinDomain2,Sharing the Vision envisages greater use of appropriate mainstream premises, such as family resource centres, schools and community centres in the delivery of a more individualised and recovery-oriented mental health service. Modern primarycarecentresandothernew-buildfacilitiesshouldbeusedwherepossibletoprovideagood-qualitybuiltenvironmentforpeopleaccessingandstaffworkinginmentalhealthservices.Approvedcentresoracuteunitsareaparticularpartofthementalhealthinfrastructureneedingspecialattention.Many psychiatric units in acute hospitals were not purpose-builtandweredesignedasstandardhospitalwards and simply designated as psychiatric units. This environment did not take into account the needs of peoplewithmentalhealthdifficulties,particularlyfor access to outside space, and, indeed, more space generally.

Akeyelementofcontinuousimprovementisthereforethe provision of physical environments which are conducive to recovery and which create a good working environment for professionals delivering services.Asageneralprinciple,multi-stakeholderservicedesignmethodologiesshouldbeemployedwhenmentalhealthpremisesandinpatientunitsarebeingdesignedorrefurbished.17

Measuring performance Toestablishtargets,allocateresourcesandsetmentalhealthpriorities,standardisedperformanceindicators (PIs) and targeted service outcome data arerequired.Thesemustbesetatnationallevel,led

andcoordinatedbytheDepartmentofHealth.TheformatofprogressreportingshouldalsofacilitatethecaptureofuniqueissuesinRICOareas.Animportantcomponent of measuring and monitoring performance isregulartrackingoftheviewsofserviceusersabouttheir experiences with the mental health system and the impact of these experiences on their health and wellbeingoutcomes.Itisalsoimportanttocapturetheexperiences of FCS to ensure that they understand the supportbeingaccessedbytheirrelativeorfriendandthe expected outcomes.

Complaintsrepresentavaluablesourceofinformationontheperformanceofasystemandcanofferuseful guidance for service improvement. Dealing effectivelywithcomplaintscanbeapowerfulwaytoprovideavisibleresponseinrelationtocontinuousimprovement.Duringtheconsultationprocess,acommonthemethatemergedsuggestedthatattimespeoplewithmentalhealthdifficultiesmayfinditdifficulttomakeacomplaint.Modelsforcomplaintshandlingthatincludebetterqualityinformationandtraining in making complaints do exist. Each HSE regionhasanindependentcomplaintssystembutthereneedstobeawarenessofthe‘yourserviceyoursay’complaintsprocess,andthisprocessmustbeclearabouthowtomakeacomplaintandmustsupportindividuals who do not know how to make a complaint.

Capturing and embedding innovation ThementalhealthdivisionoftheHSEhasbeenworkinginpartnershipwiththeCentreforEffectiveServices(CES)since2015toimplementchangeandwider reform in line with AVFC. This partnership has resultedintheco-establishmentofaStrategicPortfolioandProgrammeManagementOffice(SPPMO).18 A core functionofthispartnershipisfosteringinnovationandtheapplicationandadaptationofevidence-informedmethodstosecuresustainableimplementationandimprovement in delivering mental health services. PatientandFCSengagementisintegraltoallserviceimprovementprojects,withaconsistentfocusonthedevelopment of recovery-focused services through co-production.

Afurtherinitiativetofosterinnovationandcontinuousimprovementisthesocialreformfund(SRF).Thiswas

75

17PublicServiceDesign.Availableat:https://www.socent.ie/wp-content/uploads/2015/10/PSD_manual_UK_LR.pdf.(Accessed14February2020).18MHDSPPMOBackground:MentalHealthDivisionStrategicPortfolioandProgrammeManagementOffice”.HSE.Accessed14February2020.Availableat:https://www.hse.ie/eng/staff/resources/mentalhealthdivisionsppmo/

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intendedtosupportthereconfigurationofservicestowards more person-centred supports which are alsotransparent,accountableandcost-effective.ThementalhealthcomponentoftheSRFhasfocusedonthreeareas:advancingandembeddingrecoverypractices,implementingemploymentsupportsforpeoplelivingwithamentalhealthdifficultythroughdeliveryoftheIPSmodeloutlinedinDomain3(socialinclusion),andcommunity-basedliving,whichsupportspeoplewithmentalhealthdifficultiestoidentifyandaddresstheirhousingneedsandtomakethebestoftheiropportunitiestoliveindependentlyinthecommunity.

Thereareotherareasofinnovationinthementalhealth services and the wider mental health system. Itisimportantthatinformationisgatheredonallinnovationssothatlearningcanbesharedandreplicated,andduplicationavoided.AllinnovationinmentalhealthservicesshouldbedrivenbytheStrategicPortfolioandProgrammeManagementOffice,sothatproveninnovationscanbeintroducedmorewidelyandthepracticesorserviceswhichtheysupersedecanbeceasedormodifiedappropriately.

Meeting standards in quality frameworks and best practice guidelines In2008theDepartmentofHealthandtheHSEcommittedtothedevelopmentofahealthservicecharter.TheNationalHealthcareCharter,You and Your Health Service,wasdevelopedbypatientadvocacygroupsandotherinterestgroupstodescribewhatpatientscanexpectwhenusinghealthservicesinIreland. The charter focuses on eight principles that underpinhigh-quality,people-centredcaretoinformandempowerindividuals,familiesandcommunitiestolookaftertheirownhealthandinfluencequalityhealthcareinIreland.Mentalhealthprinciplesmustbepart of the charter so that people using mental health services know what to expect from those services. Theseprinciplescanbeincludedinstaffcontractsandininductiontoencouragequalityinmentalhealthservice delivery.

The Quality Framework for Mental Health Services in Ireland(MentalHealthCommission,2007),theJudgement Support Framework (Mental Health Commission,2015),andtheBest Practice Guidance

for Mental Health Services(HSE,2017)allplayanimportantroleincontinuousimprovementandmeasurement/monitoringofdesiredstandardsandpracticesinmentalhealthcareinIreland.ThesereportswillaugmenttheworkoftheNationalImplementationandMonitoringCommitteeandconsiderationoftheirrecommendationswillaidthedevelopmentofstandardised improvement systems that are aligned to the outcomes focus in this policy.

Enablers Newpolicyrecommendationsareimplementableandachievablewhenthereareoverarching‘enablers’tosupportandencouragechange.Thefollowingenablerswillbeimportantleversforimplementation:

(1) Resource allocation Recenthealthsystemthinkinghasemphasisedtheneedtomoveawayfromtraditionalincrementalbudgetingarrangements,ofteninblocksums,andtowardsamorestrategicapproachtoinvestinginhealthpromotion,earlypreventionandcareservices. Sláintecare sets out a very extensive agenda of strategic planning and commissioning reform to supportthegoalofasingle-tierintegrateduniversalhealthcare system. Sláintecare seeks to: • develop a way to determine resources and

integratedservicesonaregionalbasis• developanintegratedregionalresourceallocation

formula • designproposalsformulti-annualbudgeting• designasystemofpopulation-basedfunding• benchmarkquantumofhealthandsocialcare

budgetinacomparativeinternationalcontext• advancecommunity-basedcostingandworkwith

key health stakeholders and academic researchers todevelopanactivityandcostdatabaseforhealth and social care in Ireland

For many sectors of the health and social care system theseapproacheswillmarkasignificantdeparturefromthetraditionalresourceallocationmethodologiesatnational,regionalandservice-providerlevel.Building on the original AVFCrecommendations,anationalmentalhealthresourceallocationsystemisnowinplacewhichinformsdecisionsontheprioritisedallocationofavailableresources.Itrepresentsavaluableplatformonwhichtobuildthecomparativecasesfortheinvestmentrequiredintheserviceand,ultimately,todemonstratetheoutcomesachieved.

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Sharing the Vision | A Mental Health Policy for Everyone

(2) Mental health information systems Domain2emphasisestheimportanceofinformation-sharing,fromtheinitialpointofaccessrightthroughtoaftercarearrangementsandtheprocessofdischarge(asappropriate).Effectiveinformation-sharingwillavoidthefrustrationofpatientsoftenhavingtorepeatthedetailsoftheircircumstances‘fromscratch’witheach professional encountered. It will also facilitate partnershipandinterworkingbetweendifferentservicesandprofessionals–contributingtobetterorganisationofthementalhealth‘system’thatmayhelpincreasednumbersofpeopletoachieverecovery.

NationalmentalhealthserviceswithintheHSEhavelongrecognisedtheneedforasinglenationalinformationsystemforalloftheabove.Considerableworkhasbeenundertakenwithinmentalhealthservices to develop and deliver on the vision for a mentalhealthelectronichealthrecord(MHEHR).InseekingtodeveloptheMHEHR,HSEnationalmentalhealthserviceseffortswereandcontinuetobeinformedbyboththeeHealth Strategy for Ireland (2013)andtheHSE’sKnowledge and Information Strategy(2015). (3) ICT enabled health systems TheestablishmentoftheMentalHealthDivisionin2013ledtotheinclusioninthe2014ServicePlanofaninterimData-GatheringSolutionProjectwiththeaimofsupportingtheCMHTstomanagetheperformanceinformationrequiredofthemforreportingontheServicePlan.AspartoftheInterimData-GatheringSolutionProject,aproofofconceptinitiativewasconductedwiththreeCommunityMentalHealth Teams across CAMHS, General Adult, and PsychiatryofLaterLife(PoLL)services.ThisinitiativeledtoanagreementwiththeOfficeoftheChiefInformationOfficerforaframeworkforICT-enabledsupports for the mental health services which included threeprojects:• NationalMentalHealthICTInfrastructure

ImprovementProject• NationalMentalHealthe-RosteringProject• NationalElectronicMentalHealthRecordProject.Progressinalloftheseareasmustbeprioritisedtocontributestronglytotheambitionoutlinedwithinthispolicyforongoingreformandcontinuousimprovement.

(4) Digital technologies Throughout Sharing the Vision, thepotentialforapplicationofdigitaltechnologieshasbeenrecognised as an aid to core service delivery. The use of digital technologies can support individualised care, provide online professional development and enhanceonlinetherapeuticsupportinterventions.Digitalinteractionscaninvolvedirectinteractionbetweenahealthprofessionalandthepatient.It also encompasses mental health professionals supportingprimarycareproviderswithexpertisewithvariousconsultations.Mentalhealthcarecanbedeliveredinalive,interactivecommunication.Itcanalsoinvolverecordingmedicalinformation(images,videos, etc.) and sending this to a distant site for later review.Digitalhealthhelpsmeetpatients’needsforconvenient,affordableandreadily-accessiblementalhealthservices.Itcanbenefitpatientsinanumberofways, such as: • Improve access to mental health specialty care • Helpintegratebehaviouralhealthcareand

primarycare,leadingtobetteroutcomes• Reducetheneedfortripstohospitals• Reducedelaysinaccessingcare• Improvecontinuityofcareandfollow-upHowever,whenpromotingthepotentialofutilisingdigitalhealthinterventions,itisacknowledgedthatsafetyandriskissuesneedtobeconsidered.

(5) Mental health research Mentalhealthresearchispotentiallyaverybigfield,rangingfromresearchongeneticsandpharmacological treatments to the outcomes produced bymentalhealthservices.AVFCprioritisedtwoareasof mental health research in Ireland that needed furtherinvestment.Thesearepopulationhealth(PH)researchandhealthservices(HS)research.Thefirstisafieldwhichanalyseshealthoutcomesandpatternsofhealthdeterminantsaswellasthepolicyinterventionslinking them. The second examines how people get access to healthcare, how much that care costs and what happens as a result of the care. These two areasofresearcharereferredtocollectivelyas PH&HSresearch.

As part of the process of developing a strategy, researchprioritiesformentalhealthPH&HSresearchshouldbeidentified.AllthoseworkinginthementalhealthservicesshouldbeencouragedtogetinvolvedinmentalhealthPH&HSresearchandthereshouldbe

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Chapter 5 | Accountability and Continuous Improvement Domain

acontinuingfocusonensuringthatpeoplewithlivedexperienceofmentalhealthdifficultiesareinvolvedateverystageoftheresearchprocess.Theallocationofresearchfundinginthisareashouldreflectparityof esteem for mental health compared to other health conditions.

(6) Legislative reform The fundamental aim of mental health services is to protect, promote and improve the lives and mental wellbeingofallpatients.Peoplewithcomplexmentalhealthneedsare,orcanbe,particularlyvulnerabletoabuseandviolationoftheirrights.Whilelegislationiscreatedtoprotectthemostvulnerableinsociety,itisacknowledgedthatfurtherworkisrequiredtoensurethat all individuals accessing services, voluntarily or involuntarily,areguaranteedrespectandprotectionoftheir human rights.

Aprogrammeofcontinuouslegislativereformunderpins the modern mental health system articulatedwithinthispolicy.Legislationinvariousareasisbeingupdatedatpresent.TheMentalHealthAct2001iscurrentlysubjecttoreview;theAssistedDecision-Making(Capacity)Act2015isbeingupdated;andanewdecisionsupportserviceisbeingestablished.

Self-determinationisavitalpartofsuccessfultreatment and recovery. The Assisted Decision-Making (ADM) Capacity Act creates the right for a person whosecapacitymaybeinquestiontobesupportedtomaketheirowndecisions,andthereisanobligationonservicestofulfilthisright.TheguidingprinciplesoftheADMCapacityActincludethepresumptionofcapacityandtherequirementthatapersonshouldbegivenallpossiblesupporttomaketheirown decision. The Act provides for two categories of assistance to people with capacity issues to make theirowndecisions–adecision-makingassistant,andaco-decision-maker,whowouldbeasubstitutedecision-maker.Forchildren,managingpositiverisk-takingrequiresacollaborativeapproachwherethefamily, the child and mental health professionals work outapositiverisk-takingstrategyaspartofthecareplanning process.

Safeguarding vulnerable people Thenationalsafeguardingpolicy,Safeguarding Vulnerable Persons at Risk of Abuse – National Policy and Procedures(2014),appliestoallHSEandHSE-fundedservices.19Itrecognisesthatallvulnerablepeoplehavearighttobeprotectedagainstabuseandtohaveconcernsaboutabusiveexperiencesaddressed.Ithighlightsthatitistheresponsibilityofallserviceproviders, statutory and non-statutory, to ensure thatpatientsaretreatedwithrespectanddignity,and that they receive support in an environment in whicheveryeffortismadetopromotetheirwelfareandtopreventabuse.TheimplementationofthepolicyisunderpinnedbytheworkoftheHSENationalSafeguardingOffice.AnadultsafeguardinghealthsectorpolicyisbeingdevelopedbytheDepartmentof Health. This policy will cover all health services and it should inform the delivery of care in mental health services when it is complete.

Service users, self-harm and suicide Forhealthandsupportservicestoeffectivelyrespondto suicide and self-harm in the community, there mustbeaccesstotimelyandhigh-qualitydataonsuicideandself-harm.Thecollectionandreportingofincidentsofsuicideshouldbereviewedandrevised,toprovidetimelydataforenhancedandfocusedsuicidepreventionactionsinthecommunity.Thisisconsistentwith the Connecting for Life strategy.

Othercountrieshaverecognisedthepotentialofstrategicallyfocusingonlevelsandpatternsofself-harmandsuicidalityamongpeopleattendingmentalhealthservicesasaneffectivemeansofpotentiallyreducinglevelsofmorbidityandmortalitythroughstrategicserviceenhancementsandresponsesbasedontheavailabilityofgooddata.

Involuntary detention Most admissions to approved centres occur on a voluntarybasis,butsituationsstillarisewhereapersoncanbeadmittedtoanapprovedcentreinvoluntarily.

People with a diagnosis of mental illness have the same human rights as everyone else, including a civilrighttolibertyandautonomy.AccordingtotheNationalDisabilityAuthority,thepurposeofthe

19SafeguardingVulnerablePersonsatRiskofAbuse–NationalPolicyandProcedures:incorporatingservicesforelderabuseforpersonswithadisability.SocialCareDivision,HSE.(2014)

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ConventionontheRightsofPersonswithDisabilitiesistopromote,protectandensurethefullandequalenjoymentofallhumanrightsandfundamentalfreedomsbyallpersonswithdisabilities,andtopromote respect for their inherent dignity. It applies establishedhumanrightsprinciplesfromtheUNDeclarationofHumanRightstothesituationofpeoplewithdisabilities.Itcoverscivilandpoliticalrightstoequaltreatmentandfreedomfromdiscrimination,andsocialandeconomicrightsinareaslikeeducation,healthcare, employment and transport. These rights continuetoapplyforpeoplewhoaredetainedonaninvoluntarybasis.

RestrictiveinterventionsarestillinuseinIrelandinvariousapprovedcentresregulatedbytheMentalHealth Commission (MHC). The MHC recognises that anyinterventionemployedthatmaycompromiseaperson’slibertyshouldinallinstancesbethesafestandleastrestrictiveoptionoflastresortnecessarytomanagetheimmediatesituation.20Suchinterventionoughttobeproportionatetotheassessedriskandemployedfortheshortestpossibleduration.Fourmainareas of seclusion and restraint are currently in use in approved centres:

Seclusion

When a person is left alone in a room at any time where the exit door is locked, preventing person from leaving.

Physical restraint

When a person is prevented from free movement due to physical force applied by one or more persons.

Involuntary medication

When a person receives intramuscular or intravenous medication against their will.

Mechanical restraint 21

When a bodily restraint involving a device or special clothing is used to limit an individual’s free movement.*

While a zero restraint and seclusion service may not alwaysbeachievableduetosafetyrequirementsofserviceusersandstaff,thereareexampleswheremajorreductionsintheuseofrestraintareworkingeffectively.Therefore,ahigh-levelaimofthispolicy is to reduce the use of restraint and seclusion.

20CodeofPracticeontheUseofPhysicalRestraintinApprovedCentresIssuedPursuanttoSection33(3)(e)oftheMentalHealthAct2001.CodeofPracticeMentalHealthCommission(2009).

21MentalHealthCommission.SeclusionandRestraintReductionStrategy.Dublin,2014.Availableat:https://www.mhcirl.ie/File/Seclusion-and-Restraint-Reduction-Strategy.pdf

* MechanicalRestraintuseIrelandisactivelybeingphasedoutandisusedonlyinveryrarecircumstances.

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Chapter 5 | Accountability and Continuous Improvement Domain

80

Domain: Accountability and continuous improvement recommendations

75Theorganisationofmentalhealthservicesshouldbealignedwithemergingintegratedcarestructuresunder SláintecarereformsincludingtheproposedsixRegionalHealthAreasandwithinthesetheCommunityHealthNetworkscorrespondingtopopulationsofabout50,000.

76Implementationofthispolicyoverthenexttenyearsshouldachieveare-balancingofresourcesandtakeaccountofpopulationdeprivationpatternsinplanning,resourcinganddeliveringmentalhealthservices.

77

A standardised set of performance indicators (PIs) directly aligned with the desired outcomes in Sharing the VisionandagreedstandardsofcareandqualityframeworksshouldbedevelopedbytheDepartmentofHealthandtheNationalImplementationMonitoringCommitteeaccountingforquantitativeandqualitativedeliveryofintendedoutcomes.

78 RegularsurveysofserviceusersandFCSshouldbeindependentlyconductedtoinformassessments of performance against PIs and target outcomes in this Sharing the Vision.

79Informationontheprocessofmakingacomplaint,includingnecessarycontactdetails,shouldbevisible,accessibleandwidelyavailableinavarietyofmedia,languagesandformatsformaximumaccessibilityinallmentalhealthservicesettingsandinotherfora.

80 Acultureofopendisclosuretosupportpatientsafetyisembeddedinmentalhealthservices.

81 Trainingshouldbeprovidedforservicesusersandstaffonmakinganddealingwithcomplaints.

82 MentalhealthservicesshouldensurethattheprinciplessetoutintheNationalHealthcareCharter, You and Your Health Service,areembeddedinallservicedelivery.

83FutureupdatesoftheQualityFramework,theJudgementSupportFrameworkandtheBestPracticeGuidanceshouldbeconsistentwiththeambitionandthespecificoutcomesforthementalhealthsystem set out in this policy.

84

TherelevantbodiesshouldcometogethertoensurethatthemeasuresfortheQualityFramework,theJudgementSupportFramework,theBestPracticeGuidance,Sharing the Vision PIs and performance system,andanyfuturemeasurementsystemsarealignedandthattherequireddataisderived,wherepossible,fromasinglecommondataset.

85TheworkunderwayatnationalleveltodevelopacostandactivitydatabaseforhealthandsocialcareinIrelandshouldprioritisementalhealthservicestoleveragedevelopmentalworkalreadyunderwayandsupporttheevolutionofoutcome-basedresourceallocation.

86 ANationalMentalHealthInformationSystemshouldbeimplementedwithinthreeyearstoreportonthe performance of health and social care services in line with this policy.

87TheDepartmentofJusticeandtheImplementationandMonitoringCommittee,inconsultationwithstakeholders,shoulddeterminewhetherlegislationneedstobeamendedtoallowforgreaterdiversionofpeoplewithmentalhealthdifficultiesfromthecriminaljusticesystem.

88Trainingandguidanceshouldbeprovidedtostaffonthepracticeofpositiverisk-taking,basedontheprinciplesoftheAssistedDecision-Making(Capacity)Act2015,wherethevalueofpromotingpositiverisk-takingisrecognisedbytheMentalHealthCommissionregulator.

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81

89 Accesstosafeguardingteamsandtrainingshouldbeprovidedforstaffworkinginstatutoryandnon-statutorymentalhealthservicesinordertoapplythenationalsafeguardingpolicy.

90TheJusticeandHealthsectorsshouldengagewiththecoroners,theGardaSíochána,theNationalOfficeforSuicidePrevention,theCSOandresearchbodiesinrelationtodeathsincustody,recordingdeathsbysuicideandopenverdicts,tofurtherrefinethebasisofsuicidestatistics.

91Significantimprovementsshouldbemadeinthemonitoringandreportingoflevelsandpatternsofself-harmandsuicidalityamongpeopleattendingmentalhealthservices,toinformacomprehensiveandtimelyserviceresponsetoeffectivelyreducelevelsofharmanddeath.

92 Inkeepingwiththeevolvingunderstandingofhumanrightstoempowerpeopleandimprovequalityofcareinmentalhealthcarefacilities,legislationmustbeupdatedandadditionalsupportsputinplace.

93ANationalPopulationMentalHealthServicesResearchandEvaluationStrategyshouldbedevelopedandresourcedtosupportaportfolioofresearchandevaluationactivityinaccordancewithprioritiesidentifiedintheresearchstrategy.

94

Inordertobringaboutchange,astrategicapproachisrequiredinvolvingthenecessaryskillsinchangemanagement.ThisapproachhasbeendevelopedintheformerHSEMentalHealthDivisionStrategicPortfolioandProgrammeManagementOfficeandshouldbemainstreamedandembeddedinthewiderHSE.

95

TheinitiativesundertheformerMentalHealthDivisionStrategicPortfolioandProgrammeManagementOffice(SPPMO)andtheongoingSocialReformFund(SRF)shouldbegatheredtogetherandmadeavailablebothtoencouragefurtherinnovationandtoavoidduplicationinthepublicserviceand NGO sectors.

96Innovationswhichhavegoodevidenceforclinicaland/orsocialandcosteffectivenessshouldberolledoutnationally.Thiswillrequirethechangingofpracticesandmodificationorcessationofserviceswhicharesupersededbythenewformofdelivery.

97Mentalhealthservicesshouldmakeuseofothernon-mentalhealthcommunity-basedphysicalfacilities,whicharefitforpurpose,tofacilitatecommunityinvolvementandsupporttheimplementationoftheoutcomes in this policy.

98Capitalinvestmentshouldbemadeavailabletoredesignorbuildpsychiatricunitsinacutehospitalswhichcreateatherapeuticandrecoverysupportiveenvironment.Itisessentialthatallstakeholdersareinvolvedinastructuredservicedesignprocessforallredesignsornewbuilds.

99Anational‘whole-of-government’ImplementationCommitteeshouldbeestablishedwithstrongserviceuserandVCSrepresentationtooverseetheimplementationoftherecommendationsinthispolicyandto monitor progress.

100AjointreviewofthetwospecialisttrainingprogrammesbytheIrishCollegeofPsychiatristsofIrelandandtheIrishCollegeofGeneralPractitionersshouldbeundertakentodevelopanexemplarmodelofmental health medical training and integrated care.

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83

Chapter 6

Implementation

Sharing the Vision | A Mental Health Policy for Everyone

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Chapter 6 | Accountability and Continuous Improvement Domain

22NorthernIrelandAuditOffice.PerformanceManagementforOutcomes:AGoodPracticeGuideforPublicBodies(2018).Availableat: https://www.niauditoffice.gov.uk/sites/niao/files/media-files/NIAO_performance%20management%20for%20outcomes.pdf

84

Figure 6.1: Good practice guide – key areas for performance management

Introduction

AVisionforChange(2006)containednoimplementationplanandthisresultedinpoormeasurementofoutcomes.Theextensiveprocessofconsultation,reviewandvalidationundertakenbytheOversightGroupunderlinedtheneedtoensureeffectiveimplementationoftherevisedpolicy.Therefore,underpinningthedeliveryofthekeyoutcomesenvisagedbySharing the Vision is performance management. The NorthernIrelandAuditOfficepublishedagoodpracticeguideandstatesthatperformancemanagementoccurswithinsixkeyareas(Figure6.1).22Thispolicyrecognisestheneedforcontinuingmonitoringandperformance management.

Understanding the environment

Establishpriorities,withserviceuserinput,thatarerelevanttotheoutcome-focusedrecommendationscontainedinthispolicy.

Setting priorities Implementrecommendationsthatmattertotheserviceusernottheorganisation(outcomesasopposedtooutputs).

Allocating resources and understanding

levers for action

Moveawayfromhigh-leveldecisionsaboutfundingandtowardsafocusontheoutcomesbeingachieved.Alignspendingwithdeliveryplansbuiltuponinter-agencyconsultation.

Performance managing projects

Work with key partners to share the vision with all service providers, encouragingacultureofreportingbothpositiveperformanceandpoorperformance.

Monitoring of progress

Effectiveperformancethatismonitoredregularlyandreviewedagainstcriteriathatmeasuresimplementation.

Making improvements

Put mechanisms to evaluate good performance or under-performance in place.Implementfluidresourceallocationandmovetosupportservicesthatperformwell.Capturepoorperformancetrendstodeterminerequiredcorrectiveactions.

Making improvements

Put mechanisms to evaluate good performance or under-performance in place.Implementfluidresourceallocationandmovetosupportservicesthatperformwell.Capturepoorperformancetrendstodeterminerequiredcorrectiveactions.

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Sharing the Vision | A Mental Health Policy for Everyone

National Implementation and Monitoring Committee AssetoutintheIntroductiontothisdocument,aNationalImplementationandMonitoringCommittee(NIMC)istobeestablishedtooverseeimplementationofthepolicyandmonitorprogressatnationallevelandstrategicallyacrosstheHSE.TheCommitteewillbemandatedtodrivereconfiguration,monitorprogressagainst outcomes and deliver on the commitments madeinthispolicy.ItisexpectedthattheCommitteewill work with partners to evaluate performance against the key performance indicators, check overall progressguidedbyresearchandlearningfrombestpractice,andgatherinformationonexamplesofbothgoodandbadpractice.Itisonlywhenthesemechanismsareinplacethatthesystemwillbeinapositiontorespondeffectivelytosupportthementalhealthneedsofthewholepopulation.

ItisenvisagedthattheNIMCwillbefullyrepresentativeofthosestakeholdersprincipallyinvolvedinensuringeffectivedeliveryofthepolicyrecommendations,includingstrongserviceuserandVCSrepresentation.WeoutlinebelowtheindicativecompositionoftheNIMCmembership:

• Serviceusers/advocacyorganisations• HSE • DepartmentofHealth/Sláintecare • DepartmentofJusticeandEquality• DepartmentofEducationandScience• Department of Housing, Planning and Local

Government • DepartmentofEmploymentandSocialProtection• Housing Agency • ReceptionandIntegrationAgency• HealthResearchBoard• College of Psychiatrists of Ireland • IrishCollegeofGeneralPractitioners• NationalOfficeofSuicidePrevention. TheNIMCwillmeetregularlyandpublishaprogressreportontheimplementationstatusofSharing the Vision.

HSE Sharing the Vision structure ToensureongoingoperationalimplementationofrecommendationscontainedinSharing the Vision onaday-to-daybasis,itisproposedthattheHSEestablishastructuretoassisttheNIMCindrivingimplementationoverthetermofthepolicy.TheHSEstructurewillreportto,andparticipatein,theNIMC and will ensure that the policy programmes are deliveredinlinewiththeimplementationplanagreedwith the NIMC to include key performance indicators andregularprogressreportsasrequired.

Implementation roadmap Sharing the VisionincludesanImplementationRoadmapwith outcome indicators that will encourage alignment betweendifferentservices.Theroadmapallocatesownershipofrecommendationstoleadagenciesandsetstime-boundimplementationtargetsagainsteachrecommendation.

Focusingonearlyinitiationandcompletiontargets, theroadmapisbasedonananalysisofeachofthe100recommendationsinthepolicy.It:• indicateswhererecommendationsarealready

complete • assignsaproposedcompletiontimeframeto

everyrecommendation/associatedactionthat is either •short(18months)•medium(36months)or•long(36months–10years).

Someofthe99recommendationsarefarreachingandsosmalleractionsareassignedtoenableimplementation.Thisworkhasalsoprovidedthebasisforacostanalysisandbudgetingexercise,focusingontherecommendationstargetedforcompletionoverthenext18months.ThefulllistofrecommendationsandtheirassociatedimplementationandcompletiontimeframesisincludedatAppendixIIIofthisdocument.

The HSE Sharing the VisionstructureandtheNationalImplementationandMonitoringCommitteewill:

• Developadetailedimplementationplantoensurethatthedeliveryofallrecommendationsisplannedandmanagedeffectivelywithappropriate•leadresponsibilityallocation

85

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Chapter 6 | Accountability and Continuous Improvement Domain

•actions• outputs • outcomes •prioritisation•timelines• key performance indicators.

• Ensurethatimplementationactionsarekeptunder review for ongoing appropriateness.

• Develop an Outcomes Framework to allow for ongoingevaluationoftheimpactof Sharing the Vision.

• AssessonacontinualbasistheexistingcapacityandrangeofservicesavailabletodeliverontheobjectivesofSharing the Vision.

• Developariskregisterandmitigationplan.• Identifyandfosterthedisseminationofinnovative

high-qualitymentalhealthpracticeinIreland.• Researchinternationalbestpracticemodelsto

serveasbenchmarksofmentalhealthservicesinIreland.

• BeaccountabletogovernmentforoveralldeliveryoftherecommendationsofSharing the Vision.

The HSE Sharing the Vision Structure will providecostingsforallmedium-andlong-term

recommendations;thesewillbeincorporatedintotheImplementationPlanatanearlystagetoensurethatthedeliveryofthepolicyisfullycosted.Additionally,itshouldbenotedthattheimplementationofthepolicyoverthemedium-andlong-termwillbesubjecttosecuringresourcesintheannualestimates.

Recognisingtheoutcomesfocuswhichwasattheheart of Sharing the Vision, it is considered that the development of the Outcomes Framework is an essentialcomponentintheimplementationandevaluationoftherevisedpolicy.Thefourdomainschosenandthe15domain-basedhigh-leveloutcomesidentifiedinearliersectionsofthispolicyformaveryusefulbasisforthedevelopmentofafully-fledgedOutcomes Framework. Work on this framework, whichwillbeapriorityfortheSharing the Vision implementationstructure,willlooktoidentifyinparticularsetsoftangibleindicatorswhichcanbeusednotjustbymanagersandpolicymakersbutalsobythewiderpublictoassesstheongoingimpactofSharing the Vision.Figure6.2isaschematicversionofhowtheOutcomes Framework aligns with the overall policy.

86

Figure 6.2: Sharing the Vision Outcomes Framework

Promotion, prevention and early intervention domain

SocialInclusion

Service access, co-ordination and continuity of care

Accountability and continuous improvement

IndicatorSet

IndicatorSet

IndicatorSet

IndicatorSet

Sharing the Vision Outcomes

Outcomes

1a

1c

1b

1d

Outcomes

2a

2c

2b

2d

Outcomes

3a

3c

3b

Outcomes

4a

4c

4b

4d

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Sharing the Vision | A Mental Health Policy for Everyone

WhileitwillbetheresponsibilityoftheNIMCtobringstrategicinsight,externalrigourandamultilateralperspectivetooversightofthedeliveryoftheactionsarisingoutoftherecommendations,thehealthsystem itself will need to recognise the importance of collaborativeworkingtomeettheneedsofitsspecificdefinedpopulation.Understandingthementalhealthneedsofthepopulationbeingserved,defininglocal

andregionalprioritiesandmakingdecisionsaboutresourceallocationwillbeacatalystfortargetedmental health service delivery.

87

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89

AppendicesAppendix I: TermsofReferencefortheOversightGroup90

Appendix II: MembershipoftheOversightGroup91

Appendix III: ImplementationRoadmap94

References112

Bibliography114

Sharing the Vision | A Mental Health Policy for Everyone

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Appendix

Appendix I:Terms of Reference for the Oversight Group

A Vision for Change – Part II 1. Reviewandupdatetheexistingmentalhealth

policy A Vision for Change(2006)havingregardtotheExpertEvidenceReviewofinternationalbestpractice,progressoncurrentservicedevelopmentsinIrelandandtherequirementofthePublicSpending Code23,withaparticularfocuson:(a) primaryprevention,earlyinterventionandpositivementalhealth,includinghavingregardtotheworkunderwaywiththePathfinderProjectandtheYouthMentalHealthTaskforce;

(b) integrationofcareanddeliverysystemsbetweenprimaryandsecondaryservicestakingaccountofthemovetoappropriate24/7servicesupports;

(c) developmentofe-mentalhealthresponses;(d) workforceplanning,forecastingandskillmixincludingmechanismstoattractandretainstaffwithinexistingnationalHRpolicy;

(e) emergingneedsofvulnerablegroups,peoplewithco-morbiditiesandspecialistneedsinformedbytherelevantclinicalprogrammes;and

(f) developmentofresearch,dataandevaluationcapabilitytoensureachievementofbestmentalhealthoutcomescanbedemonstratedwiththeresourcesavailable.

(g) proposingpolicychangesthatwillbenefitallthose engaging with mental health services. Aparticularemphasisonsocialinclusionandtheneedsofvulnerablegroupsshouldbeincorporatedwithafocusonreducingstigmaanddiscrimination.

2. Identifyandconsultoncross-sectoralandcross-societalresponsibilitiesinthecontextof(1)above.

3. AlignasfaraspossibletherefreshedpolicywithexistingnationalpoliciesandimplementationarrangementsthathavebeendevelopedsincethepublicationofA Vision for Change(2006).

4. Conductaconsultativeprocesswithkeystakeholders to inform proposals.

5. Produce,forsubmissiontotheDepartmentofHealth,anupdateddraftpolicyframeworkwhichsetsoutcurrentandfutureserviceprioritieswithinatime-boundimplementationplan,forconsiderationbygovernmentasasuccessorpolicyto A Vision for Change(2006).

23InaccordancewiththePublicSpendingCode,allIrishpublicbodiesareobligedtotreatpublicfundswithcare,andtoensurethatthebestpossiblevalueformoneyisobtainedwheneverpublicmoneyisbeingspentorinvested.ThePublicSpendingCodeimposesobligationsat allstagesoftheproject/programmelifecycle,withthestagesoftheprojectdefinedasfollows:•Appraisal:assessingthecaseforapolicyintervention•Planning/Design:apositiveappraisalshouldleadontoaconsideredapproachtodesigninghowtheproject/programmewillbeimplemented•Implementation:carefulmanagementandoversightisrequiredforbothcapitalandcurrentexpenditure.Ongoingevaluationshouldalsobe

a feature of current programmes•Post-ProjectorPost-ImplementationReview:checkingfordeliveryofprojectobjectives,andgainingexperienceforfutureprojects.

90

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Sharing the Vision | A Mental Health Policy for Everyone

Appendix II:Membership of the Oversight Group

91

Mr Stephen Brophy DoH(November2018–March2019)

Dr Amanda Burke Consultant Psychiatrist

Mr Greg Canning DoH(January2018–October2018)

Mr Colm Desmond DoH(October2017–December2017)

Dr Philip Dodd NationalClinicalLead

Ms Martha Griffin ExpertbyExperienceLecturerDCU

Mr Liam Hennessy Head of Mental Health Engagement

Mr Hugh Kane Chairperson

Dr Fiona Keogh NUIGalway

Mr Leo Kinsella HSE Mental Health Lead

Mr Dave Maguire DoH(March2019–June2019)

Dr Shari McDaid MentalHealthReform

Mr John Meehan HSEMentalHealth/NOSP

Ms Stephanie Morrow Research

Mr Tom O’Brien DoH

Ms Yvonne O’Neill HSE Mental Health Division

Dr Brian Osborne GeneralPractitioner

Secretariat

Mr Martin O’Dwyer DoH

Ms Emily Flaherty DoH

Ms Anna Wallace DoH

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Appendix

92

The Department of Health acknowledges the additionalsupportprovidedbytheWorkResearchCentre, MorrowGilchrist and Prospectus, who assisted the Department to gather research, interpret data andsupportthedraftingoftheImplementationRoadmap.TheDepartmentalsoacknowledgesthemanystakeholderswhocontributedtotheprocessandthoseindividualswhomadetimetoattendadvisory

groupsessions.Thoseinvitedtoattendtheadvisorysessionsaredetailedbelow.Itisveryimportantthatthe Department thank the many service users and family carers who engaged with us and shared their experiencessohonestlytoensurethispolicybeginspositivechangeforhowmentalhealthservicesaredelivered in Ireland.

Alzheimer Society of Ireland

Association of Occupational Therapists

Association of Professional Counsellors & Psychotherapists (APCP)

Association for Psychoanalysis and Psychotherapy (APPI)

Barnardo’s

BeLonG To

Bodywhys – the Eating Disorders Association of Ireland

CAIRDE

DCYA

DEASP

DES

DHPLG

DoH units (Healthy Ireland/Primary care, etc.)

DoJE

Family Carers

Gateway

Housing Association for Integrated Living

HSE

HSE Mental Health Heads of Service

Institute of Guidance Counsellors

Irish Advocacy Network

Irish Association for Counselling and Psychotherapy

Irish Association of Speech and Language Therapists

Irish Council for Psychotherapy

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Sharing the Vision | A Mental Health Policy for Everyone

93

Irish Forum of Psychoanalytic Psychotherapy (IFPP)

Irish Institute of Mental Health Nursing

Irish Nutrition and Dietetics Institute

Irish Society of Chartered Physiotherapists

Jigsaw

Mental Health Engagement Leads

Mental Health Nurse Managers Ireland

National Advocacy Service for People with Disabilities

National Association for Pastoral Counselling and Psychotherapy

National Family Support Network

National Social Work Organisation of Ireland

NEPS

PCHEI

Peer Support Workers

Psychological Counsellors in Higher Education Institutes

Recovery College Coordinators

Rehab

Samaritans

Simon Communities of Ireland

Soar Foundation

Social Care Ireland

SpunOut.ie

Threshold Training Network

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Appendix

94

Appendix III:Implementation Roadmap

TheImplementationRoadmapbelowprovidesadditionalactionsandoutcomeindicatorsforeachrecommendationtosupporttheNationalImplementationandMonitoringCommitteewithitswork.Notallpartnersaredefinedandonly‘leadagencies’arelisted.However,acohesivepartnershipapproachisessentialandwillbethefocusofthe

NIMCduringtheimplementationphase.Inaddition,thetimeframesbelowpertaintoactions–notrecommendations.

• Short = 0–18 months • Medium = 18–36 months • Long = 36 months–10 years

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Sharing the Vision | A Mental Health Policy for Everyone

95

Dom

ain

1 |

Pro

moti

on, P

reve

ntion

and

Ear

ly In

terv

entio

n

Out

com

e 1aPositivementalhealth,resilienceandpsychologicalwellbeingamongthepopulationasawhole

Out

com

e 1bPositivementalhealth,resilienceandpsychologicalwellbeingamongprioritygroups…throughtargetedpromotionandpreventivemechanisms

Out

com

e 1cReducedstigmaanddiscriminationarisingthroughimprovedcommunity-wideunderstandingofmentalhealthdifficulties

Out

com

e 1dReducedprevalenceofmentalhealthdifficultiesand/orreducedseverityofimpact(s)throughearlyinterventionandpreventionwork

Reco

mm

enda

tion

Actio

ns/T

asks

Lead

Out

com

e In

dica

tors

Targ

et

Tim

efra

me

Out

com

e

1H

ealth

y Ire

land

alre

ady

has

a re

mit

for i

mpr

oved

mentalhealthandwellbeing.Tofurtherstrengthen

this,adedicatedNationalMentalHealthPromotion

Planshouldbedevelopedandoverseenwithin

Hea

lthy

Irela

ndimplementationframeworks,with

appropriateresourcing.Theplanshouldbebasedon

theprinciplesandscopedescribedinChapter2of

Shar

ing

the

Visio

n.

DevelopaNationalMentalHealthPromotionPlan.

Establishamentalhealthpromotionpolicypriority

prog

ram

me

in H

SE in

line

with

Hea

lthy

Irela

nd

implementation.

DoH/H

ealth

y Ire

land

Fully

com

plet

ed p

lan

in p

lace

with

ap

prop

riate

reso

urce

s.Sh

ort

Med

ium

1a

2Evidence-baseddigitalandsocialmediachannels

shouldbeusedtothemaximumtopromotemental

healthandtoprovideappropriatesignpostingto

serv

ices

and

sup

port

s.

Utilisedigitalandsocialmediatopromotemental

heal

th a

war

enes

s

Appl

y re

sour

ces

to fu

rthe

r dev

elop

evi

denc

e on

the

extentofthepositivementalhealth,resilienceand

psychologicalwellbeingofthepopulationincluding

the

rele

vant

impa

ct o

f soc

ial m

edia

. C

o-pr

oduc

e ev

iden

ce o

n im

prov

emen

ts in

the

mentalhealthofthepopulationincludingthose

accr

uing

thro

ugh

the

use

of s

ocia

l med

ia.

Build

on

evid

ence

em

ergi

ng fr

om T

he Ir

ish

Long

itudi

nal S

tudy

on

Agei

ng (T

ILD

A) a

nd th

e H

ealth

y Ire

land

Sur

vey.

HSE

Dig

ital a

nd s

ocia

l med

ia u

sed

topositivelyinfluenceMH

promotion.

Increasedpublicengagementin

onlinementalhealthinitiatives.

Reportableevidenceofthe

positivementalhealthofthe

population.

Evid

ence

on

impa

ct o

f soc

ial m

edia

on

men

tal h

ealth

. TI

LDA

indi

cato

rs fo

r Old

er P

erso

ns

andtheirMHwellbeingembedded

in c

ross

gov

t fra

mew

orks

and

st

rate

gies

, HI–OutcomesFramework,

DC

YA O

utco

mes

Fra

mew

ork.

Med

ium

1a

3TheDepartmentofHealthWomen’sHealth

TaskforceandtheNationalImplementation

MonitoringCommitteewillundertakeajoint

projectwithin12monthstooutlineaneffective

appr

oach

to th

e m

enta

l hea

lth o

f wom

en a

nd

girls.Theprojectshouldensurethatmentalhealth

prioritiesandservicesaregender-sensitiveandthat

women’smentalhealthisspecificallyandsufficiently

addressedintheimplementationofpolicy.

EnsurethatWomen’sHealthTaskForceand

NationalImplementationMonitoringCommittee

developaprojecttofocuson:

mentalhealthprioritiesandservicesthatare

gender-sensitive;

worktoensurewomen’smentalhealthis

specificallyandsufficientlyaddressedinthe

implementationofpolicy;and

wor

k to

em

pow

er a

ll m

enta

l hea

lth s

ervi

ce u

sers

andtheirfamiliesequitably.

Women’sHealthTask

Forc

eFu

lly c

ompl

eted

pla

n in

pla

ce w

ith

appr

opria

te re

sour

ces.

Shor

t1b

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Appendix

96

4Theworkprogrammeforhealthpromotionand

improvementofficersshouldbereviewedtoensure

parityofeffortandemphasisonmentalhealth

promotionandphysicalhealthpromotion.

Reviewandamendexistingjobspecification.

HSE/H

ealth

y Ire

land

MentalHealthPromotionPlans

incorporatethedistinctneedsof

prio

rity

grou

ps.

Shor

t1a,1b

5Newandexistingcommunitydevelopment

prog

ram

mes

whi

ch p

rom

ote

soci

al in

clus

ion,

en

gage

men

t and

com

mun

ity c

onne

cted

ness

shouldbeappropriatelyresourcedanddeveloped

inlinewiththeproposedNationalMentalHealth

PromotionPlan.

Ensurethefundingfornewandexistingcommunity

deve

lopm

ent p

rogr

amm

es e

nhan

ces

com

mun

ity

connectednessandmentalhealthpromotion.

Designanddeliverhealthpromotioninitiatives

sotheyincludeandareaccessibletopeoplewith

disabilities

HSE/H

ealth

y Ire

land

Appr

opria

tely

fund

ed c

omm

unity

de

velo

pmen

t pro

gram

mes

demonstratingenhanced

com

mun

ity c

onne

cted

ness

and

mentalhealthpromotion.

Med

ium

1a

6TheproposedNationalMentalHealthPromotion

PlanandtheexistingworkofC

onne

cting

for

Life

sho

uld

inco

rpor

ate

targ

eted

men

tal h

ealth

promotionandpreventionactionsthatrecognise

thedistinctneedsofprioritygroups.

EnsuretheNationalMentalHealthPromotionPlan

incorporatesthedistinctneedsofprioritygroups.

Supp

ort C

onne

cting

for L

ife to

del

iver

targ

eted

mentalhealthpromotionandpreventionactions

thatrecognisethedistinctneedsofprioritygroups.

Hea

lthy

Irela

nd/DoH/NOSP

MentalHealthPromotionPlansincorporatethe

distinctneedsofprioritygroups.

Hea

lthy

Irela

nd/DoH/

NO

SPMentalHealthPromotionPlans

incorporatethedistinctneedsof

prio

rity

grou

ps.

Conn

ectin

g fo

r Life

del

iver

s m

enta

l healthpromotionactionsthat

incorporatethedistinctneedsof

prio

rity

grou

ps.

Shor

t

Shor

t

Shor

t

1b,1d

7ANationalStigma-ReductionProgramme

(NSRP)shouldbeimplementedtobuilda‘whole

community’approachtoreducingstigmaand

discriminationforthosewithmentalhealth

difficulties.Thisshouldbuildonworktodateand

dete

rmin

e a

clea

r str

ateg

ic p

lan,

with

ass

ocia

ted

outc

omes

and

targ

ets

acro

ss re

late

d st

rand

s of

w

ork.

DevelopastrategicwholecommunityNSRPplan

forpublicationandannualreviewwithspecific

outc

omes

and

targ

ets.

Dep

artm

ent o

f Hea

lth s

houl

d ex

tend

the

timeframeandfundingforthestrategyfor

Conn

ectin

g fo

r Life(CFL)to2024.

HSE/DoH

NSRPplanevaluatedtomeasure

itsbeneficialimpactacrossthe

population.

Extendedtimeframeand

asso

ciat

ed fu

ndin

g fo

r Con

necti

ng

for L

ifeuntil2024.

Med

ium

1a,1b,1c,

1d

8Learningfrominnovationsinimprovingoutcomes

forchildrenandyoungpeopleshouldbeidentified

and

shou

ld in

form

rele

vant

mai

nstr

eam

ser

vice

provision.Thisincludeslearningfromprevention

andearlyinterventionprogrammessuchasTusla’s

AreaBasedChildhood(ABC)andPrevention,

Part

ners

hip

and

Fam

ily S

uppo

rt (P

PFS)

Pro

gram

me

aswellascross-borderprogrammesaddressingthe

impa

ct o

f Adv

erse

Chi

ldho

od E

xper

ienc

es (A

CEs

).

EnsuretheWhatWorksinitiativedeliveredby

DC

YA s

eeks

to c

aptu

re a

nd d

issem

inat

e th

is learningtoinformeffectivepolicy,provisionand

practitionerresponsestotheneedsofchildrenand

youn

g pe

ople

.

HSE

Evid

ence

of i

nteg

rate

d re

spon

ses

tovulnerablefamiliesinformed

byACEandlearningfrompilot

prog

ram

mes

.

Med

ium

1d

9Allschoolsandcentresforeducationwillhave

initiatedadynamicWellbeingPromotionProcess

by2023,encompassingawhole-school/centre

approach.Schoolsandcentresforeducationwill

besupportedinthisprocessthroughtheuseofthe

WellbeingFrameworkforpracticeandWellbeing

Resourceswhichhavebeendevelopedbythe

DepartmentofEducationandSkills.

ImplementWellbeingPolicyStatementand

FrameworkforPracticeinallschoolsandcentres

foreducation,aswellasNEPS,withappropriate

reso

urci

ng.

DES

WellbeingPolicyStatement

andFrameworkforPractice

impl

emen

ted

in a

ll sc

hool

s an

d centresforeducationsupportedby

adequateresources.

Med

ium

1a,1d

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Sharing the Vision | A Mental Health Policy for Everyone

97

10Aprotocolshouldbedevelopedbetweenthe

DepartmentofEducationandSkillsandtheHSEon

theliaisonprocessthatshouldbeinplacebetween

primary/post-primaryschools,mentalhealth

serv

ices

and

sup

port

s su

ch a

s N

EPS,

GPs

, prim

ary

care

ser

vice

s an

d sp

ecia

list m

enta

l hea

lth s

ervi

ces.

This

is ne

eded

to fa

cilit

ate

refe

rral

pat

hway

s to

loca

l servicesandsignpostingtosuchservices,

as n

eces

sary

.

Establishworkinggroupwithappropriate

representationtodevelopliaisonprotocolbetween

scho

ols

and

men

tal h

ealth

ser

vice

s an

d su

ppor

ts.

DoH

Prot

ocol

in p

lace

whi

ch fa

cilit

ates

re

ferr

al p

athw

ays

to lo

cal s

ervi

ces

andsignpostingtoNEPS,GPs,

prim

ary

care

ser

vice

s an

d sp

ecia

list

men

tal h

ealth

ser

vice

s.

Med

ium

1d

11TheNationalMentalHealthPromotionPlan

inte

grat

ed w

ith th

e H

ealth

y W

orkp

lace

Fra

mew

ork

shouldincorporateactionstoenhancethemental

healthoutcomesoftheworking-agepopulation

throughinterventionsaimedatmentalhealth

promotionintheworkplace.Thisshouldconsider

envi

ronm

enta

l asp

ects

of t

he w

orki

ng e

nviro

nmen

t conducivetosupportingpositivementalhealth

andwellbeing.

Developactionplantoenhancethementalhealth

outcomesoftheworking-agepopulation,with

prioritisationofthoseworkinginmentalhealth

servicesthroughcollaborationwithDoHH

ealth

y Ire

land

and

rele

vant

par

tner

s.

ToreinforcetheeffectivenessoftheDES

framework,aneffectivestructureforcross-sectoral

collaborationintheareaofwellbeingandmental

healthpromotionwillbeincorporatedintothe

NationalMentalHealthPromotionPlan.

HSE

Actionplaninplacesupporting

thepositivementalhealthand

wellbeingoftheworkforce.

Startingwiththementalhealth

wor

kfor

ce.

Developwellbeingandpromotion

withcrosssectoralcollaboration

andincorporateintonational

mentalHealthPromotionPlan.

Med

ium

1a,1d

12Arangeofactionsdesignedtoachievethegoalsof

theNationalPositiveAgeingStrategyforthemental

healthofolderpeopleshouldbedevelopedand

implemented,supportedbytheinclusionofmental

healthindicatorsintheHealthyandPositiveAgeing

Initiative’sresearchprogramme.

Developspecificmentalhealthactionstoachieve

thegoalsoftheNationalPositiveAgeingStrategy.

Identifymentalhealthindicatorstobeincludedin

theHealthyandPositiveAgeingInitiative’sresearch

prog

ram

me.

DoH

Actionsinplacetoachievethe

goalsoftheNationalPositive

Agei

ng S

trat

egy.

Mentalhealthidentifiersinplace

intheHealthyandPositiveAgeing

Initiative’sresearchprogramme.

Shor

t1d

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Appendix

98

Dom

ain

2 |

Ser

vice

Acc

ess,

Coor

dina

tion

and

Conti

nuity

of C

are

Out

com

e 2aAllserviceusershaveaccesstotimely,evidence-informedinterventions

Out

com

e 2bServicedeliveryisorganisedtoenableincreasednumbersofpeopletoachievepersonalrecovery

Out

com

e 2cServicesarecoordinatedthrougha‘steppedcare’approachtoprovidecontinuityofcarethatwilldeliverthebestpossibleoutcomesforeachserviceuser

Out

com

e 2dHealthoutcomesforpeoplewithdualdiagnosisareimprovedbyensuringgreatercollaborationbetweenmentalhealthandotherrelevantservices

Reco

mm

enda

tion

Actio

ns/T

asks

Lead

Out

com

e In

dica

tors

Targ

et

Tim

efra

me

Out

com

e

13DirectoriesofinformationonVCSsupportsshould

beprovidedtostaffworkinginprimarycareand

CM

HTs

to e

nsur

e th

ey a

re a

war

e of

and

info

rm

serviceusersandFCSaboutallsupportsavailable

incl

udin

g th

ose

from

Vol

unta

ry a

nd C

omm

unity

Sectororganisationsinthelocalarea.

Mapavailablesupports.

ProvidestaffworkinginprimarycareandCMHTs

withinformationaboutavailablesupportssuchas

‘yourmentalhealth.ie’.

HSE

Com

mun

ity a

sset

map

in p

lace

. Al

l ser

vice

use

rs a

nd F

CS

are

mad

e aw

are

of s

uppo

rts

incl

udin

g th

ose

in th

e Vo

lunt

ary

and

Com

mun

ity

Sect

or.

Shor

t2a

14W

here

Vol

unta

ry a

nd C

omm

unity

Sec

tor

organisationsareprovidingservicesalignedtothe

outcomesinthispolicy,operationalgovernanceand

fundingmodelsshouldbesecureandsustainable.

Maximisetheuseofexistingandemerging

operationalgovernanceandfundingmodelsto

supportcollaborativealignmentwithrequired

outc

omes

.

HSE

Collaborativelyagreedoperational

gove

rnan

ce a

nd fu

ndin

g m

odel

s inplacewhichmaximisereliable,

secureandsustainablefunding

linke

d to

out

com

es.

Med

ium

2a,2b

15Socialprescribingshouldbepromotednationally

asaneffectivemeansoflinkingthosewithmental

healthdifficultiestocommunity-basedsupports

andinterventions,includingthoseavailablethrough

loca

l Vol

unta

ry a

nd C

omm

unity

Sec

tor s

uppo

rts

and

serv

ices

.

Enablethedevelopmentofserviceuser-ledand

responsivesocialprescribingthroughidentified

com

mun

ity li

nks

and

supp

orts

.

HSE

The

expa

nded

use

of s

ervi

ce

user

-led

and

resp

onsiv

e so

cial

prescribing.

Shor

t2a,2c

16Ac

cess

to a

rang

e of

cou

nsel

ling

supp

orts

and

talk

therapiesincommunity/primarycareshouldbe

availableonthebasisofidentifiedneedsothat

all i

ndiv

idua

ls, a

cros

s th

e lif

espa

n, w

ith a

mild

-to-moderatementalhealthdifficultycanreceive

promptaccesstoaccessiblecarethroughtheirGP/

Prim

ary

Car

e C

entr

e. C

ouns

ellin

g su

ppor

ts a

nd

talktherapiesmustbedeliveredbyappropriately

qualifiedandaccreditedprofessionals.

Incr

ease

rang

e an

d ea

se o

f acc

ess

to c

ouns

ellin

g su

ppor

ts a

nd ta

lk th

erap

ies

in th

e co

mm

unity

. As

sess

cur

rent

ser

vice

s an

d en

sure

futu

re

coun

selli

ng a

nd ta

lk th

erap

y se

rvic

es a

re p

rovi

ded

byappropriatelyqualifiedandaccredited

prof

essio

nals.

HSE

Acce

ss to

cou

nsel

ling

supp

orts

and

talktherapiesavailablebasedon

identifiedneed.

Com

plet

ed a

sses

smen

t of t

he le

vel

ofqualificationandaccreditation

of c

urre

nt p

rovi

ders

. C

ouns

ellin

g an

d ta

lk th

erap

ies

are

deliveredbyappropriatelyqualified

and

accr

edite

d pr

ofes

siona

ls.

Med

ium

2a,2c

17Thementalhealthconsultation/liaisonmodel

shouldcontinuetobeadoptedtoensureformal

linksbetweenCMHTsandprimarycarewith

thepresenceof,orin-reachby,amentalhealth

prof

essio

nal a

s pa

rt o

f the

prim

ary

care

team

or

netw

ork.

Ensu

re th

at th

e de

velo

pmen

t of t

he C

HN

and

PC

T operatingmodels

adoptthementalhealthconsultation/liaisonmodel.

HSE

CHNandPCTsutilisingmental

healthconsultation/liaisonmodel

with

CM

HTs

.

Shor

t2b,2c

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Sharing the Vision | A Mental Health Policy for Everyone

99

18Animplementationplanshouldbedeveloped

fortheremainingrelevantrecommendationsin

Adva

ncin

g th

e Sh

ared

Car

e Ap

proa

ch b

etw

een

Prim

ary

Care

& S

peci

alist

Men

tal H

ealth

Ser

vice

s(2012)in

ordertoimproveintegrationofcareforindividuals

betweenprimarycareandmentalhealthservicesin

line

with

em

ergi

ng m

odel

s an

d pl

ans

for C

omm

unity

H

ealth

Net

wor

ks a

nd T

eam

s.

Developanimplementationplanwithupdated

recommendationsfromA

dvan

cing

the

Shar

ed C

are

Appr

oach

bet

wee

n Pr

imar

y Ca

re &

Spe

cial

ist M

enta

l H

ealth

Ser

vice

s(2012).

HSE

Appropriaterecommendations

from

Adv

anci

ng th

e Sh

ared

Car

e Ap

proa

ch b

etw

een

Prim

ary

Care

&

Spec

ialis

t Men

tal H

ealth

Ser

vice

s (2012)areimplemented.

Shor

t2b,2c

19Th

e ph

ysic

al h

ealth

nee

ds o

f all

user

s of

spe

cial

ist

mentalhealthservicesshouldbegivenparticular

attentionbytheirGP.Asharedcareapproachis

essentialtoachievethebestoutcomes.

Ensu

re a

ny p

erso

n us

ing

a sp

ecia

list m

enta

l hea

lth

serv

ice

has

acce

ss to

GP

and

prim

ary

care

ser

vice

s onthesamebasisasothercitizens.

Dev

elop

a s

hare

d ph

ysic

al h

ealth

pro

toco

l for

mentalhealthserviceuserspresentingtoGPs.

HSE

A sh

ared

phy

sical

hea

lthca

re

prot

ocol

for m

enta

l hea

lth s

ervi

ce

user

s in

pla

ce w

ith G

Ps.

Mentalhealthpatientsaccess

prim

ary

care

ser

vice

s w

ith s

uppo

rt

asrequired.

Shor

t2c

20Thereshouldbefurtherdevelopmentofearly

interventionandassessmentservicesinthe

prim

ary

care

sec

tor f

or c

hild

ren

with

AD

HD

and

autismtoincludecomprehensivemulti-disciplinary

and

paed

iatr

ic a

sses

smen

t and

men

tal h

ealth

consultationwiththerelevantCMHTwhere

nece

ssar

y.

Developagreedearlyinterventionandassessment

serv

ices

in p

rimar

y ca

re fo

r chi

ldre

n w

ith A

DH

D

andautismthroughcollaborationofPCandMH

serv

ices

.

HSE

ChildrenwithADHDandautism

rece

ivin

g ag

reed

mod

el o

f ear

ly

intervention/assessmentinprimary

care

.

Med

ium

2a

21Dedicatedcommunity-basedAddictionService

Teamsshouldbedeveloped/enhancedwith

psychiatryinput,asrequired,andimprovedaccess

to m

enta

l hea

lth s

uppo

rts

in th

e co

mm

unity

sho

uld

beprovidedtoindividualswithco-existinglow-level

mentalhealthandaddictionproblems.

Assesscurrentavailableresponsetowards

development/enhancementofintegrated

community-basedaddictionteamswithrequired

leve

l of m

enta

l hea

lth s

ervi

ce in

put.

Primarycare/HSE/

DoH

(loc

al d

rug

task

forc

es)

Integratedcommunity-based

addictionteamswithappropriate

men

tal h

ealth

ser

vice

inpu

t in

plac

e.

Med

ium

2a,2b

22Th

e pr

ovisi

on o

f app

ropr

iate

env

ironm

ents

for

thosepresentingatemergencydepartmentswho

additionallyrequireanemergencymentalhealth

assessmentshouldbeprioritised.

Assesscurrentavailableenvironmentanddevelop

improvementplansforprovisionofsuitable

emergencymentalhealthassessmentfacilities.

HSE

Appr

opria

te m

enta

l hea

lth

assessmentfacilitiesinemergency

depa

rtm

ents

are

pro

vide

d.

Shor

t2a,2b

23Thereshouldbecontinuedinvestmentin,and

implementationof,theNationalClinicalCare

Prog

ram

me

for t

he A

sses

smen

t and

Man

agem

ent

ofPatientsPresentingtoEmergencyDepartments

Follo

win

g Se

lf-H

arm

.

ImplementtheNationalClinicalCareProgramme

fortheAssessmentandManagementofPatients

PresentingtoEDsFollowingSelf-Harm.

HSE

Impl

emen

ted

fund

ed c

are

prog

ram

mes

. D

emon

stra

ted

impr

oved

out

com

es

forpatientsattendingEDs

follo

win

g se

lf-ha

rm.

Med

ium

24Out-of-hourscrisiscafésshouldbepilotedand

operatedbasedonidentifiedgoodpractice.Such

cafésshouldfunctionasapartnershipbetweenthe

HSEandotherproviders/organisations.

Developandpilotmodelinlinewithgoodpractice

for o

ut-o

f-ho

urs

crisi

s ca

fé.

HSE

Out

-of-

hour

s cr

isis

café

s pi

lote

d an

d ev

alua

ted.

Shor

t2a

25Themulti-disciplinaryCMHTasthecornerstone

ofservicedeliveryinsecondarycareshouldbe

stre

ngth

ened

thro

ugh

the

deve

lopm

ent a

nd a

gree

d implementationofasharedgovernancemodel.

Dev

elop

and

agr

ee a

sha

red

gove

rnan

ce m

odel

for

implementationbyallCMHTs.

HSE

OperationofCMHTsis

strengthenedbyuseofashared

gove

rnan

ce m

odel

.

Med

ium

2a,2b

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Appendix

100

26CMHTs’outreachandliaisonactivitieswithVCS

partnersinthelocalcommunityshouldbeenhanced

to h

elp

crea

te a

con

nect

ed n

etw

ork

of a

ppro

pria

te

supp

orts

for e

ach

serv

ice

user

and

thei

r FC

S.

Co-designenhancedoutreachandliaisonactivities

to h

elp

crea

te a

con

nect

ed n

etw

ork

of a

ppro

pria

te

supp

orts

for e

ach

serv

ice

user

and

thei

r FC

S.

HSE

A co

-des

igne

d co

nnec

ted

netw

ork

of a

ppro

pria

te s

uppo

rts

for e

ach

serv

ice

user

and

thei

r FC

S is

in

plac

e th

roug

h C

MH

Ts.

Med

ium

2b

27An

indi

vidu

alise

d re

cove

ry c

are

plan

, co-

prod

uced

withserviceusersand/orFamilies,Carersand

Supporters,whereappropriate,shouldbeinplace

for,andaccessibleto,allusersofspecialistmental

heal

th s

ervi

ces.

Ensu

re c

onsis

tent

use

of c

o-pr

oduc

ed

indi

vidu

alise

d re

cove

ry c

are

plan

s fo

r all

user

s of

sp

ecia

list m

enta

l hea

lth s

ervi

ces.

HSE

Men

tal H

ealth

Con

siste

nt u

se o

f co-

prod

uced

in

divi

dual

ised

reco

very

car

e pl

ans

for a

ll us

ers

of s

peci

alist

men

tal

heal

th s

ervi

ces.

Med

ium

2b

28Al

l ser

vice

use

rs s

houl

d ha

ve a

mut

ually

agr

eed

key

workerfromtheCMHTtofacilitatecoordination

andpersonalisationofservicesinlinewiththeirco-

prod

uced

reco

very

car

e pl

an.

Ensu

re s

ervi

ce u

sers

are

sup

port

ed th

roug

h th

e pr

ovisi

on o

f a m

utua

lly a

gree

d ke

y w

orke

r.H

SE M

enta

l Hea

lthAl

l ser

vice

use

rs h

ave

a m

utua

lly

agre

ed k

ey w

orke

r.Sh

ort

2b

29Furthertrainingandsupportshouldbeputinplace

toembedarecoveryethosamongmentalhealth

prof

essio

nals

wor

king

in th

e C

MH

Ts a

s w

ell a

s th

ose

deliveringserviceselsewhereinthecontinuumof

serv

ices

.

Designtrainingandsupportprogrammetoembed

a re

cove

ry e

thos

in m

enta

l hea

lth p

rofe

ssio

nals.

Toensuredisabilitycompetence,ensurethat

appropriatetraininginaccommodatingand

supportingpeoplewithautismandwithother

formsofdisabilityisundertakenbyteammembers.

Strategy&Planning

HSE/S

láin

teca

re

part

ners

Trainingwillbedeliverednationally

and

incl

ude

reco

very

as

an in

tegr

al

com

pone

nt.

Trainingwillalsobedeliveredto

supportpeoplewithdisabilities.

Shor

t2b

30CMHTsandsessionalcontactsshouldbelocated,

wherepossibleandappropriate,inavarietyof

suitablesettingsinthecommunity,includingnon-

healthsettings.

ReviewlocationsofCMHTsandsessionalcontacts.

Strategy&Planning

HSE/S

láin

teca

re

part

ners

Completedreviewandoptimised

locations.

Med

ium

2a,2b

31Thepotentialfordigitalhealthsolutionstoenhance

serv

ice

deliv

ery

and

empo

wer

ser

vice

use

rs s

houl

d bedeveloped.

Identifyanddeveloppotentialdigitalsolutions.

Strategy&Planning

HSE/S

láin

teca

re

part

ners

Del

iver

and

dev

elop

dig

ital

interventionsnationallyand

evaluateefficacytomeasure

impa

ct.

Med

ium

2a

32ThecompositionandskillmixofeachCMHT,

alongwithclinicalandoperationalprotocols,

shouldtakeintoconsiderationtheneedsand

socialcircumstancesofitssectorpopulationand

theavailabilityofstaffwithrelevantskills.Aslong

as th

e co

re s

kills

of C

MH

Ts a

re m

et, t

here

sho

uld

beflexibilityinhowtheteamsareresourcedto

mee

t the

full

rang

e of

nee

ds, w

here

ther

e is

stro

ng

population-basedneedsassessmentdata.

Empowerlocalmanagerstoreviewcomposition

and

skill

mix

of C

MH

Ts a

ppro

pria

te to

the

loca

l needsofthepopulation.

Incl

ude

non-

men

tal h

ealth

pro

fess

iona

ls in

C

MH

Ts (e

.g. e

mpl

oym

ent s

peci

alist

s ca

n pr

omot

e em

ploy

men

t as

an a

spec

t of r

ecov

ery)

. Developflexibleclinicalandoperationalprotocols.

Strategy&Planning

HSE/S

láin

teca

re

part

ners

CMHTsaredeliveringtimely

interventionsdefinedbythe

specificneedsoftheirpopulation.

Med

ium

2a

33Th

e sh

ared

gov

erna

nce

arra

ngem

ents

for C

MH

Ts a

s ou

tline

d in

AVF

C2006–16shouldbeprogressed,

incl

udin

g fu

rthe

r rol

lout

of T

eam

Coo

rdin

ator

s.

Prog

ress

sha

red

gove

rnan

ce a

rran

gem

ents

.Strategy&Planning

HSE/S

láin

teca

re

part

ners

Shar

ed g

over

nanc

e ar

rang

emen

ts

implementednationally.

Team

Coo

rdin

ator

s in

pla

ce.

Med

ium

2a,2b

34ReferralpathwaystoallCMHTsshouldbereviewed

andextendedbyenablingreferralsfromarange

of o

ther

ser

vice

s (a

s ap

prop

riate

) inc

ludi

ng s

enio

r primarycareprofessionalsincollaborationwithGPs.

Reviewandextendreferralpathwaysto

inco

rpor

ate

a ra

nge

of o

ther

ser

vice

s.H

SE M

enta

l Hea

lth

Serv

ices

Evid

ence

of e

nhan

ced

refe

rral

pa

thw

ays.

Med

ium

2a

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Sharing the Vision | A Mental Health Policy for Everyone

101

35A

com

preh

ensiv

e sp

ecia

list m

enta

l hea

lth o

ut-o

f-hoursresponseshouldbeprovidedforchildrenand

adolescentsinallgeographicalareas.Thisshouldbe

developedinadditiontocurrentEDservices.

Dev

elop

a c

ompr

ehen

sive

spec

ialis

t men

tal h

ealth

out-of-hoursmodelusingatieredapproach.

HSE

Men

tal H

ealth

Se

rvic

esIm

plem

ente

d co

mpr

ehen

sive

spec

ialis

t men

tal h

ealth

out

-of-

hour

s m

odel

with

evi

denc

e of

tieredapproachinallareas.

Shor

t2a

36Appropriatesupportsshouldbeprovidedforon

aninterimbasistoserviceuserstransitioningfrom

CAMHStoGAMHS.Theageoftransitionshouldbe

movedfrom18to25,andfuturesupportsshould

reflectthis.

Con

vene

an

Expe

rt G

roup

to:

Developareconfigurationplanwhichwillfacilitate

the

prov

ision

of a

ge-a

ppro

pria

te s

peci

alist

men

tal

healthservicesuptoage25.

Prov

ide

appr

opria

te s

uppo

rts

for i

ndiv

idua

ls transitioningfromCAMHStoGAMHSat18years.

Identifyrequiredadditionalsupportsforindividuals

transitioningfromCAMHStoGAMHSat18years.

ProducetransitionplaninlinewithCAMHSCOG.

Put i

n pl

ace

a no

min

ated

key

wor

ker t

o su

ppor

t the

transitionplan.

Additionaltrainingprovidedtoup-skillnominated

keyw

orke

rs.

DoH

Plan

in p

lace

whi

ch fa

cilit

ates

th

e pr

ovisi

on o

f age

-app

ropr

iate

sp

ecia

list m

enta

l hea

lth s

ervi

ces

up

toage25.

Supportsidentifiedandinplacefor

allindividualstransitioningfrom

CAM

HS

to G

AMH

S.

Shor

t2b

37Nationallyagreedcriteriashouldbedeveloped

to g

over

n an

d re

sour

ce in

divi

dual

ised

supp

ort

packagesforthespecificneedsofasmallcohort

of c

hild

ren

and

youn

g pe

ople

who

hav

e co

mpl

ex

need

s.

Developnationalcriteriaforindividualisedsupport

packagesforthespecificneedsofasmallcohort

of c

hild

ren

and

youn

g pe

ople

who

hav

e co

mpl

ex

need

s. Secureresourcingfortherequiredsupport

pack

ages

.

HSE

Chi

ldre

n an

d yo

ung

peop

le w

ho

have

com

plex

nee

ds in

rece

ipt o

f fu

lly re

sour

ced

supp

ort p

acka

ges

inlinewithnationalcriteria.

Shor

t2a

38Intheexceptionalcaseswherechildand

adolescentinpatientbedsarenotavailable,adult

units

pro

vidi

ng c

are

to c

hild

ren

and

adol

esce

nts

shouldadheretotheCAMHSinpatientCodeof

Gov

erna

nce.

EnsureadherencetotheCAMHSinpatientCodeof

Governancenationally.

HSE

Men

tal H

ealth

EvaluationtoensureCAMHS

inpatientcodeofGovernanceis

appliednationally.

Shor

t2a,2b

39Th

e H

SE s

houl

d co

nsul

t with

ser

vice

use

rs, F

CS,

staff,andthosesupportingprioritygroupsto

developastandardisedaccesspathwaytotimely

men

tal h

ealth

and

rela

ted

care

in li

ne w

ith th

e individuals’needsandpreferences.

Dev

elop

sta

ndar

dise

d ac

cess

pat

hway

to

timelymentalhealthandrelatedcarethrougha

comprehensiveconsultationprocess.

HSE

Stan

dard

ised

acce

ss p

athw

ay in

pl

ace.

Shor

t2a,2b

40Sufficientresourcingofhome-basedcrisisresolution

teamsshouldbeprovidedtoofferanalternative

responsetoinpatientadmission,whenappropriate.

Developandresourcehome-basedcrisisresolution

team

s.H

SE M

enta

l Hea

lth

Reducedlevelsofinpatient

admissionsduetoalternativecrisis

intervention.

Med

ium

2a,2b

41AStandardOperatingGuidelineshouldbe

developedtoensurethatsufficientlystaffedday

hospitalsoperateaseffectivelyaspossibleas

anelementofthecontinuumofcareandasan

alternativetoinpatientadmission.

DevelopandpublishStandardOperatingGuideline.

Provideadditionalstaffingindayhospitals.

HSE

Men

tal H

ealth

CirculatedStandardOperating

Gui

delin

e.

Adequatelystaffeddayhospitals.

Med

ium

2a,2b

42IndividualswhorequirespecialistMentalHealth

Serv

ices

for O

lder

Peo

ple

(MH

SOP)

sho

uld

rece

ive

that

ser

vice

rega

rdle

ss o

f the

ir pa

st o

r cur

rent

m

enta

l hea

lth h

istor

y. P

eopl

e w

ith e

arly

ons

et

dementiashouldalsohaveaccesstoMHSOP.

DevelopandpublishStandardOperatingGuideline

ensuringequalaccessforrelevantindividualsto

spec

ialis

t Men

tal H

ealth

Ser

vice

for O

lder

Peo

ple.

HSE

Men

tal H

ealth

Acce

ss to

spe

cial

ist M

enta

l H

ealth

Ser

vice

for O

lder

Peo

ple

is pr

ovid

ed re

gard

less

of m

enta

l he

alth

hist

ory.

Shor

t2a,2b

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Appendix

102

43TheagelimitforMHSOPshouldbeincreased

from65yearsto70yearssupportedbyjointcare

arrangementsbetweenGAMHSandMHSOPteams

forindividualswhorequiretheexpertiseofboth.

Incl

ude

the

revi

sed

age

limit

in th

e ne

w S

tand

ard

OperatingGuidelineforMHSOP.

HSE

Agelimitincreasedto70years.

Shor

t2a,2b

44GPs,mentalhealthserviceprescribersandrelevant

stakeholdersshouldcollaboratetoactivelymanage

poly

phar

mac

y.

SupportcollaborationbetweenGPs,mentalhealth

serviceprescribersandrelevantstakeholdersbased

oninformedactionplanandtrainingprogramme.

HSE

Polypharmacyisactivelymanaged.

Shor

t2b

45HSEshouldcollatedataonthenumberandprofile

of d

elay

ed d

ischa

rges

in a

cute

men

tal h

ealth

inpatientunitsanddevelopappropriatelyfunded

resp

onse

s.

Collatedataonthenumberandprofileofdelayed

dischargesinacutementalhealthinpatientunits.

Dev

elop

app

ropr

iate

fund

ing

and

serv

ice

resp

onse

s to

min

imise

del

ayed

disc

harg

es.

HSE

Dataisavailableanddelayed

disc

harg

es a

re a

ppro

pria

tely

m

anag

ed.

Med

ium

2c

46AnExpertGroupshouldbesetuptoexamineAcute

Inpatient(ApprovedCentre)bedprovision(including

PICUs)andtomakerecommendationsoncapacity

reflectiveofemergingmodelsofcare,existing

bedresourcesandfuturedemographicchanges,

withsuchrecommendationsbeingalignedwith

Slái

ntec

are.

SetupanExpertGrouptoexamineAcuteInpatient

(ApprovedCentre)bedusageanddevelop

recommendations.

HSE

Men

tal H

ealth

Appr

opria

te le

vel a

nd u

sage

of

AcuteInpatient(ApprovedCentre)

beds.

Shor

t2c

47SufficientPsychiatricIntensiveCareUnits(PICUs)

shouldbedevelopedwithappropriatereferraland

disc

harg

e pr

otoc

ols

to s

erve

the

regi

ons

of th

e co

untr

y w

ith li

mite

d ac

cess

to th

is ty

pe o

f ser

vice

.

DevelopPsychiatricIntensiveCareUnits(PICUs)to

meetidentifiedneed.

Agre

e up

date

d re

ferr

al a

nd d

ischa

rge

prot

ocol

s.

HSE

SufficientPsychiatricIntensive

CareUnits(PICUs)inoperation.

Long

2a

48Across-disabilityandmentalhealthgroupshould

beconvenedtodevelopnationalcompetence

in th

e co

mm

issio

ning

, des

ign

and

prov

ision

of

inte

nsiv

e su

ppor

ts fo

r peo

ple

with

com

plex

men

tal

healthdifficultiesandintellectualdisabilitiesandto

deve

lop

a se

t of c

riter

ia to

gov

ern

the

prov

ision

of

this

serv

ice.

Convenecross-disabilityandmentalhealthgroup

todevelopnationalcompetenceandcriteriaforthe

prov

ision

of t

his

serv

ice.

HSE

Appr

opria

te s

ervi

ces

are

in p

lace

fo

r peo

ple

with

com

plex

men

tal

healthdifficultiesandintellectual

disabilities.

Shor

t2a,2b,2c,

2d

49IntensiveRecoverySupport(IRS)teamsshould

beprovidedonanationalbasistosupportpeople

with

com

plex

men

tal h

ealth

nee

ds in

ord

er to

avo

id

inappropriate,restrictiveandnon-recovery-oriented

settings.

DevelopIRSteamstoprovidetargetedsupportsto

indi

vidu

als

with

com

plex

men

tal h

ealth

nee

ds o

n a

nationalbasis.

HSE

Recovery-orientedcommunity-

basedsupportsinplacefor

indi

vidu

als

with

com

plex

men

tal

heal

th n

eeds

.

Long

2a,2b,2c

50ThedevelopmentofanationalnetworkofMHID

teamsandacutetreatmentbedsforpeopleof

allageswithanintellectualdisabilityshouldbe

prioritised.

DevelopnationalnetworkofMHIDteamsand

acutetreatmentbeds.

HSE

Equitableaccesstomentalhealth

serv

ices

for p

eopl

e of

all

ages

with

anintellectualdisability.

Med

ium

2a,2b

51SpeechandLanguageTherapists(SLT)shouldbe

coremembersoftheAdult-IDandCAMHS-ID

team

s.

Put i

n pl

ace

Spee

ch a

nd L

angu

age

Ther

apy

as a

co

re p

art o

f the

Adu

lt-ID

and

CAM

HS-

ID te

ams.

HSE

Spee

ch a

nd L

angu

age

Ther

apy

availabletoserviceuserswith

MH

ID s

uppo

rt n

eeds

.

Med

ium

2a,2b

52InvestmentintheimplementationoftheModelof

CareforEarlyInterventionPsychosis(EIP),informed

byanevaluationoftheEIPdemonstrationsites,

shouldbecontinued.

InvestintheimplementationofEIPservice

deliv

ery.

EvaluateEIPdemonstrationsites.

HSE

Men

tal H

ealth

EIPservicesavailableinlinewith

EIP

Mod

el o

f Car

e.Lo

ng2a,2b

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103

53Thephasedimplementationandevaluationof

appr

opria

te s

ervi

ce re

spon

ses

to s

uppo

rt a

dults

with

ADHDshouldbedevelopedandresourcedinline

withtheNationalClinicalProgrammeforAdultswith

ADH

D.

DevelopanimplementationplanfortheNational

Clin

ical

Pro

gram

me

for A

dults

with

AD

HD

. Undertakephasedimplementationandresourcing

of p

lan.

Undertakeevaluationofdemonstrationsites.

HSE

Prov

ision

of a

ppro

pria

te s

ervi

ces

for a

dults

with

AD

HD

.M

ediu

m2a,2b

54Everypersonwithmentalhealthdifficultiescoming

into

con

tact

with

the

fore

nsic

sys

tem

sho

uld

have

accesstocomprehensivestepped(ortiered)mental

healthsupportthatisrecovery-orientedandbased

on in

tegr

ated

co-

prod

uced

reco

very

car

e pl

ans

supportedbyadvocacyservicesasrequired.

Com

plet

e m

enta

l hea

lth n

eeds

ana

lysis

of t

he

prisonpopulation.

Developacomprehensivetieredforensicmental

heal

th m

odel

of c

are.

Deliverphasedimplementationofthetiered

men

tal h

ealth

ser

vice

.

HSE/PrisonService

Acce

ss to

app

ropr

iate

men

tal

heal

thca

re fo

r ser

vice

use

rs w

ithin

theforensicservicenationally.

Med

ium

2a,2b

55Thereshouldbeongoingresourcingofandsupport

for d

iver

sion

sche

mes

whe

re in

divi

dual

s w

ith m

enta

l healthdifficultiesaredivertedfromthecriminal

justicesystemattheearliestpossiblestageand

havetheirneedsmetwithincommunityand/ornon-

forensicmentalhealthsettings.

Prov

ide

ongo

ing

reso

urci

ng a

nd s

uppo

rt fo

r di

vers

ion

sche

mes

.DoJE/HSE

Div

ersio

n sc

hem

es in

pla

ce a

nd

in u

se.

Med

ium

2b

56Th

e de

velo

pmen

t of f

urth

er In

tens

ive

Car

e RehabilitationUnits(ICRUs)shouldbeprioritised

followingsuccessfulevaluationofoperationofthe

newICRUonthePortraneCampus.

Carryoutacomprehensiveevaluationandreview

oftheICRUonthePortraneCampus.

Developanationalplanforthedevelopmentof

ICRUs.

Undertakephasedimplementationofthenational

ICRUdevelopmentplan.

HSE/PrisonService

AppropriateICRUprovisionforthe

relevantpopulation.

Med

ium

2b

57Atieredmodelofintegratedserviceprovisionfor

individualswithadualdiagnosis(e.g.substance

misusewithmentalillness)shouldbedevelopedto

ensu

re th

at p

athw

ays

to c

are

are

clea

r.

Similarly,tieredmodelsofsupportshouldbe

availabletopeoplewithadualdiagnosisof

intellectualdisabilityand/orautismandamental

healthdifficult.

Developaspecificserviceimprovementframework

acrossHSEPrimaryCare/MentalHealth/Acute

Hospitalstoadvancethisrecommendation.

Developatieredmodelofcare.

Developdemonstrationsitesofthetieredmodelof

care,withevaluation.

Developphasedimplementationofcomprehensive

serv

ice.

HSE

Tier

ed m

odel

of s

ervi

ce p

rovi

sion

developedandavailable.

Med

ium

2a,2d

58In

ord

er to

add

ress

ser

vice

gap

s an

d ac

cess

issu

es, a

st

eppe

d m

odel

of i

nteg

rate

d su

ppor

t tha

t pro

vide

s mentalhealthpromotion,preventionandprimary

interventionsupportsshouldbeavailableforpeople

expe

rienc

ing

hom

eles

snes

s.

Dev

elop

a s

tepp

ed a

nd in

tegr

ated

mod

el o

f su

ppor

t for

peo

ple

expe

rienc

ing

hom

eles

snes

s. Developanimplementationplanwhichincludes

evaluationofnewservicedevelopments.

HSE/HousingAgency

Step

ped

mod

el o

f sup

port

is

availablenationally.

Med

ium

2a

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Appendix

104

59Assertiveoutreachteamsshouldbeexpandedso

thatspecialistmentalhealthcareisaccessibleto

peop

le e

xper

ienc

ing

hom

eles

snes

s.

Carryoutneedsanalysistodefineservicedeficit.

Developanimplementationplaninlinewiththe

step

ped

mod

el o

f men

tal h

ealth

sup

port

for t

he

homelesspopulation.

Advancethephasedexpansionoftheexisting

serv

ice.

HSE/HousingAgency

Out

reac

h te

ams

expa

nded

and

in

plac

e.M

ediu

m2a

60ContinuedexpansionofLiaisonMentalHealth

Serv

ices

for a

ll ag

e gr

oups

sho

uld

take

pla

ce in

the

cont

ext o

f an

inte

grat

ed L

iaiso

n M

enta

l Hea

lth

Mod

el o

f Car

e.

Dev

elop

an

inte

grat

ed L

iaiso

n M

enta

l Hea

lth

Mod

el o

f Car

e.

Developanimplementationplanwhichincludes

evaluationofservicedevelopments.

Supp

ort p

hase

d ex

pans

ion

of s

ervi

ces.

HSE

Com

preh

ensiv

e an

d in

tegr

ated

Li

aiso

n M

enta

l Hea

lth S

ervi

ces

areavailableinallrelevantacute

hosp

itals

Med

ium

2a,2b

61Th

e H

SE s

houl

d m

axim

ise th

e de

liver

y of

div

erse

an

d cu

ltura

lly c

ompe

tent

men

tal h

ealth

sup

port

s th

roug

hout

all

serv

ices

.

Gatherserviceuserandservicedeliveryfeedback

rega

rdin

g cu

ltura

lly a

ppro

pria

te s

ervi

ce p

rovi

sion.

Pr

ovid

e di

vers

e an

d cu

ltura

lly c

ompe

tent

sup

port

s ac

ross

all

serv

ices

.

HSE

Userfeedbackindicatesthat

serv

ices

are

del

iver

ed in

a d

iver

se

and

cultu

rally

com

pete

nt m

anne

r.

Med

ium

2a

62Bu

ildin

g on

ser

vice

impr

ovem

ents

alre

ady

in p

lace

, in

divi

dual

s w

ho a

re d

eaf s

houl

d ha

ve a

cces

s to

the

fullsuiteofmentalhealthservicesavailabletothe

widerpopulation.

ConductanevaluationoftheNationalSpecialist

Serv

ice

and

Mod

el o

f Car

e fo

r men

tal h

ealth

se

rvic

es fo

r the

dea

f com

mun

ity.

Basedonevaluationfindings,developagap

anal

ysis

and

serv

ice

impr

ovem

ent p

lan.

Su

ppor

t pha

sed

serv

ice

deve

lopm

ent a

nd

impr

ovem

ent.

Ensurethatstaffworkinginmentalhealthservices

have

the

appr

opria

te s

kills

and

kno

wle

dge

to w

ork

with

the

deaf

com

mun

ity.

Car

ry o

ut a

trai

ning

nee

ds a

naly

sis to

info

rm

thetrainingrequirementsofmentalhealthstaff

wor

king

with

the

deaf

com

mun

ity.

Dev

elop

and

impl

emen

t a tr

aini

ng, s

uppo

rt a

nd

supervisionplanformentalhealthstaffworking

with

the

deaf

com

mun

ity.

HSE

Dea

f com

mun

ity w

ith m

enta

l he

alth

sup

port

nee

ds c

an a

cces

s comprehensivetieredmental

heal

th s

ervi

ces.

Basedontargetedfeedbackfrom

deaf

men

tal h

ealth

ser

vice

use

rs,

mentalhealthstaffarecompetent

to s

uppo

rt th

e de

af c

omm

unity

attendingmentalhealthservices.

Shor

t2a,2b

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Sharing the Vision | A Mental Health Policy for Everyone

105

63Pe

rson

s in

Dire

ct P

rovi

sion

and

refu

gees

arr

ivin

g undertheIrishrefugeeprotectionprogramme

shouldhaveaccesstoappropriatetieredmental

heal

th s

ervi

ces

thro

ugh

prim

ary

care

and

spe

cial

ist

men

tal h

ealth

ser

vice

s.

Con

vene

an

Expe

rt G

roup

(with

ser

vice

use

r co-production)toadviseonbestpracticefor

theadequateprovisionoftieredmentalhealth

supp

orts

to th

ose

in D

irect

Pro

visio

n an

d re

fuge

es

whohavesignificantissuesrelatingtotrauma.

DevelopanimplementationplanofDirect

Prov

ision

men

tal h

ealth

sup

port

acr

oss

HSE

Pr

imar

y C

are

and

Men

tal H

ealth

with

cle

ar

evaluationtargets.

Resourcephasedimplementation.

HSE/Reception&

IntegrationAgency

Pers

ons

in D

irect

Pro

visio

n ca

n ac

cess

the

sam

e su

ppor

ts a

s th

e widerpopulation.

Med

ium

2a

64Appropriatelyqualifiedinterpretersshouldbemade

availablewithinthementalhealthserviceand

oper

ate

at n

o co

st to

the

serv

ice

user

.

Dev

elop

gui

danc

e on

the

appr

opria

te te

nder

ing

andcommissioningofinterpretationservicesand

eval

uate

the

proc

ess

once

it is

in p

lace

. Resourcehigh-qualityinterpreterservicesfor

men

tal h

ealth

ser

vice

use

rs.

HSE

High-qualityinterpreterservices

areavailableatnocosttoservice

user

s.

Med

ium

2a

65Th

e H

SE s

houl

d en

sure

that

acc

ess

to a

ppro

pria

te

advocacysupportscanbeprovidedinallmental

heal

th s

ervi

ces.

Con

duct

a g

ap a

naly

sis o

f adv

ocac

y su

ppor

ts

need

s.

Developanimplementationplanforadvocacy

serv

ices

. Resourcephasedimplementationwithappropriate

evaluation.

HSE

Accessibleadvocacysupportsin

plac

e.M

ediu

m2a

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Appendix

106

Dom

ain

3 |

Soc

ial I

nclu

sion

Out

com

e 3a

Ser

vice

use

rs a

re re

spec

ted,

con

nect

ed a

nd v

alue

d in

thei

r com

mun

ity

Out

com

e 3bIncreasedabilityofserviceuserstomanagetheirownlives[self-determination]viastrongersocialrelationshipsandsenseofpurpose

Out

com

e 3cImprovedoutcomesinrelationtoeducation,housing,employmentandincomeforserviceusersrelativetothepopulationasawhole(i.e.reduceddisparity)

Reco

mm

enda

tion

Actio

ns/T

asks

Lead

Out

com

e In

dica

tors

Targ

et

Tim

efra

me

Out

com

e

66Tailoredmeasuresshouldbeinplaceinrelevant

gove

rnm

ent d

epar

tmen

ts to

ens

ure

that

indi

vidu

als

withmentalhealthdifficultiescanavail,without

discrimination,ofemployment,housingand

educationopportunitiesandhaveanadequate

inco

me.

Developmulti-departmentalinitiativetoensure

mea

sure

s ar

e in

pla

ce fo

r ind

ivid

uals

with

men

tal

healthdifficultiestoavail,withoutdiscrimination,of

employment,housingandeducationopportunities

andhaveadequateincome.

DoH

Equalopportunitiesforindividuals

withmentalhealthdifficultiesto

avai

l of e

mpl

oym

ent,

hous

ing

and

educationopportunitiesandto

haveadequateincome.

Med

ium

3b,3c

67Localauthoritiesshouldliaisewithstatutorymental

heal

th s

ervi

ces

in o

rder

to in

clud

e th

e ho

usin

g ne

eds

of p

eopl

e w

ith c

ompl

ex m

enta

l hea

lth

difficultiesaspartoftheirlocalhousingplans.

Incl

ude

the

hous

ing

need

s of

peo

ple

with

com

plex

mentalhealthdifficultiesaspartoflocalhousing

plan

s, w

ith a

ssoc

iate

d re

sour

ces.

HousingAgency/local

authorities

Hou

sing

need

s of

peo

ple

with

complexmentalhealthdifficulties

are

met

.

Long

3c

68D

epar

tmen

t of H

ealth

and

Dep

artm

ent o

f Hou

sing,

PlanningandLocalGovernment,inconsultation

with

rele

vant

sta

keho

lder

s, sh

ould

dev

elop

a

jointprotocoltoguidetheeffectivetransitionof

individualsfromHSE-supportedaccommodationto

com

mun

ity li

ving

.

Developajointprotocoltoguidetheeffective

transitionofindividualsfromHSE-supported

accommodationtocommunityliving.

DoH/DHPLG

Implementationofagreedjoint

prot

ocol

. Sh

ort

3a,3b,3c

69InconjunctionwithsupportsprovidedbyHSE

includingIntensiveRecoverySupportteams,

sustainableresourcingshouldbeinplacefor

tenancy-related/independentlivingsupportsfor

serviceuserswithcomplexmentalhealthdifficulties.

Developsustainableresourcingsupportsfor

individualswithcomplexmentalhealthdifficulties.

HSE/HousingAgency/

localauthorities

Serv

ice

user

s w

ith c

ompl

ex

need

s pr

ovid

ed w

ith a

ppro

pria

te

tenancy/independentliving

supp

orts

.

Med

ium

3a,3b,3c

70Thehousingdesignguidelinespublishedbythe

HSEandtheHousingAgencyin2016topromote

inde

pend

ent l

ivin

g an

d m

enta

l hea

lth re

cove

ry

shouldbeareferencepointforallhousing-related

actionsinthispolicy.

Usehousingdesignguidelinesasbasisforall

housing-relatedactions.

HSE/HousingAgency/

localauthorities

Hou

sing

desig

n gu

idel

ines

are

incorporated,wherepossible,inall

housing-relatedrecommendations

cont

aine

d in

STV

.

Shor

t3a,3b,3c

71Asustainablefundingstreamshouldbedeveloped

toensureagenciescanworkeffectivelytogetherto

getthebestoutcomesfortheindividualusingthe

Indi

vidu

alise

d Pl

acem

ent S

uppo

rt m

odel

, whi

ch is

anevidence-based,effectivemethodofsupporting

peoplewithcomplexmentalhealthdifficultiesto

achievesustainable,competitiveemploymentwhere

they

cho

ose

to d

o so

.

Developasustainablefundingstreamtosupport

the

IPS

mod

el.

DoH/HSE

IPS

mod

el e

valu

ated

and

exp

ande

d supportedbyasustainablefunding

mod

el.

Med

ium

3a,3b,3c

72Th

e cu

rren

t HSE

fund

ing

prov

ided

for d

ay c

entr

es

shouldbereconfiguredtoprovideindividualised

supportsforpeoplewithmentalhealthdifficulties

andbeconsistentwiththe

New

Dire

ction

s po

licy.

HSEtoengageinevaluationofcurrentfunding

providedandreconfigureserviceswherenecessary.

HSE

Fundingreconfiguredtoeffectively

supp

ort i

ndiv

idua

lised

sup

port

in

line

with

New

Dire

ction

s po

licy.

Med

ium

3a,3b,3c

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107

73Inlinewiththestrategicprioritiesofthe

Com

preh

ensiv

e Em

ploy

men

t Str

ateg

y fo

r Peo

ple

withDisabilitiesthewaypeoplecomeon/off

incomesupportsshouldbestreamlinedtomaximise

entryorre-entrytotheworkforcewithconfidence

and

secu

rity.

Thi

s sh

ould

hap

pen

with

out t

hrea

t oflossofbenefitandwithimmediaterestoration

ofbenefitswheretheyhaveanepisodiccondition

ormustleaveajobbecauseoftheirmentalhealth

difficulty.

Streamlinethewayindividualscomeon/offincome

supp

orts

to m

axim

ise e

ntry

or r

e-en

try

to th

e workforcewithconfidenceandsecurity.

DEA

SP

Proc

esse

s fo

r ind

ivid

uals

com

ing

on/offincomesupportsmaximise

the

entr

y or

re-e

ntry

to w

orkf

orce

.

Med

ium

3c

74TheHSEshouldcontinuetodevelop,fundand

periodicallyevaluateexistingandnewpeer-led/

peer

-run

ser

vice

s pr

ovid

ed to

peo

ple

with

men

tal

healthdifficultiesacrossthecountry.

Evaluatepeer-led/peer-runservicesforpeople

withmentalhealthdifficulties.

Developnewandsupportexistingevaluated

peer-led/runservicesforpeoplewithmentalhealth

difficulties.

HSE

Evaluatedpeer-led/peer-run

serv

ices

sup

port

ed a

nd e

xpan

ded.

Shor

t

Med

ium

3a,3b

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Appendix

108

Dom

ain

4 |

Acc

ount

abili

ty a

nd C

ontin

uous

Impr

ovem

ent

Out

com

e 4aMentalhealthisembeddedasanationalcross-cuttingprioritythatiseffectivelyintegratedintothekeypoliciesandsettingsinsociety

Out

com

e 4b

DynamicperformancereportingprovidesvisibilityoftheperformanceandimpactofS

harin

g th

e Vi

sion

Out

com

e 4c

Servicesthatdeliverconsistentlyhigh-qualityperson-centredsupportsthatmeettheneedsandhavetheconfidenceofserviceusersandFCS

Out

com

e 4dContinuousimprovementisfuture-focusedanddrivenbyadequatelyresourcedinnovationacrossthementalhealthsystemandrelatedsectors

Reco

mm

enda

tion

Actio

ns/T

asks

Lead

Out

com

e In

dica

tors

Targ

et

Tim

efra

me

Out

com

e

75Theorganisationofmentalhealthservicesshould

bealignedwithemergingintegratedcarestructures

unde

r Slá

inte

care

refo

rms

incl

udin

g th

e pr

opos

ed

sixRegionalHealthAreasandwithinthesethe

Com

mun

ity H

ealth

Net

wor

ks c

orre

spon

ding

to

populationsofabout50,000.

Ensurethededicatedlineofauthorityisvisiblein

the

stru

ctur

es a

t reg

iona

l lev

el.

HSE

Visiblelineofauthorityfor

inte

grat

ed m

enta

l hea

lth s

ervi

ces.

Med

ium

4a,4c

76Implementationofthispolicyoverthenextten

yearsshouldachieveare-balancingofresources

andtakeaccountofpopulationdeprivationpatterns

in p

lann

ing,

reso

urci

ng a

nd d

eliv

erin

g m

enta

l hea

lth

serv

ices

.

Usepopulationdeprivationpatternsinplanning,

reso

urci

ng a

nd d

eliv

erin

g m

enta

l hea

lth s

ervi

ces.

Rebalanceresourcingofmentalhealthserviceson

thisbasis.

HSE

Men

tal h

ealth

ser

vice

reso

urci

ng

targetedtosupportthespecific

needsofthepopulation.

Med

ium

4a,4b,4c

77A

stan

dard

ised

set o

f per

form

ance

indi

cato

rs

(PIs)

dire

ctly

alig

ned

with

the

desir

ed o

utco

mes

in

STV

and

agr

eed

stan

dard

s of

car

e an

d qualityframeworksshouldbedevelopedby

theDepartmentofHealthandtheNational

ImplementationMonitoringCommitteeaccounting

forquantitativeandqualitativedeliveryofintended

outc

omes

.

Dev

elop

app

ropr

iate

per

form

ance

indi

cato

rs

alig

ned

to S

TV o

utco

mes

.D

oHPe

rfor

man

ce in

dica

tors

in p

lace

as

sess

ing

stan

dard

s of

car

e an

d qualityperagreedframeworks.

Med

ium

4b

78RegularsurveysofserviceusersandFCSshouldbe

inde

pend

ently

con

duct

ed to

info

rm a

sses

smen

ts

of p

erfo

rman

ce a

gain

st P

Is a

nd ta

rget

out

com

es in

ST

V.

Con

duct

and

repo

rt o

n re

gula

r sur

veys

with

ser

vice

us

ers

and

FCS.

Anationalmentalhealthserviceexperiencesurvey

proposalshouldbedevelopedtobeconsidered

forinclusionundertheNationalCareExperience

Prog

ram

me.

HSE

Serv

ices

pla

nned

and

dev

elop

ed in

linewithfindingofsurveys.

Med

ium

4b

79Informationontheprocessofmakingacomplaint,

includingnecessarycontactdetails,shouldbe

visible,accessibleandwidelyavailableinavariety

of m

edia

, lan

guag

es a

nd fo

rmat

s fo

r max

imum

accessibilityinallmentalhealthservicesettingsand

in o

ther

fora

.

Publishclearandaccessiblecomplaintsprocedure.

HSE

Clearandvisiblecomplaints

proc

edur

e.Sh

ort

4b

80Acultureofopendisclosuretosupportpatient

safetyisembeddedinmentalhealthservices.

Men

tal h

ealth

ser

vice

s al

ign

open

disc

losu

re to

serviceusersandFCSwithnationalpolicyand

legislation.

HSE

Ope

n di

sclo

sure

to s

ervi

ce u

sers

andFCSisalignedtonational

policyandlegislation.

Ong

oing

4c

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109

81Trainingshouldbeprovidedforservicesusersand

staffonmakinganddealingwithcomplaints.

Prov

ide

com

plai

nts

trai

ning

for s

ervi

ce u

sers

and

staff.

HSE

Trai

ning

pro

vide

d on

impr

oved

use

an

d m

anag

emen

t of t

he c

ompl

aint

s pr

oces

s.

Shor

t4b

82M

enta

l hea

lth s

ervi

ces

shou

ld e

nsur

e th

at th

e principlessetoutintheNationalHealthcare

Cha

rter

, You

and

You

r Hea

lth S

ervi

ce,areembedded

in a

ll se

rvic

e de

liver

y.

EmbedtheprinciplessetoutintheNational

Hea

lthca

re C

hart

er.

HSE

Principlesembedded.

Shor

t4c

83Fu

ture

upd

ates

of t

he Q

ualit

y Fr

amew

ork,

the

JudgementSupportFrameworkandtheBest

PracticeGuidanceshouldbeconsistentwiththe

ambitionandthespecificoutcomesforthemental

heal

th s

yste

m s

et o

ut in

Sha

ring

the

Visio

n.

Ensu

re fu

ture

upd

ates

of t

he Q

ualit

y Fr

amew

ork,

theJudgementSupportFrameworkandtheBest

PracticeGuidanceareconsistentwithS

harin

g th

e Vi

sion.

DoH/HSE

Futu

re u

pdat

es o

f the

Qua

lity

Framework,theJudgement

Supp

ort F

ram

ewor

k an

d th

e Be

st

PracticeGuidancecompletedin

a m

anne

r con

siste

nt w

ith S

harin

g th

e Vi

sion.

Al

l fun

ded

cont

ract

s fo

r ser

vice

de

liver

y in

men

tal h

ealth

in

futureshouldembedthecore

prin

cipl

es a

nd g

uida

nce

from

thes

e fr

amew

orks

, as

stre

amlin

ed a

nd

rele

vant

.

Med

ium

4c

84Therelevantbodiesshouldcometogethertoensure

that

the

mea

sure

s fo

r the

Qua

lity

Fram

ewor

k, th

e JudgementSupportFramework,theBestPractice

Gui

danc

e, S

harin

g th

e Vi

sion

PIs

and

perf

orm

ance

sy

stem

and

any

futu

re m

easu

rem

ent s

yste

ms

are

alignedandthattherequireddataisderived,where

possible,fromasinglecommondataset.

Agre

e an

d al

ign

the

mea

sure

s an

d pe

rfor

man

ce

mea

sure

men

t inc

ludi

ng th

at o

f the

Qua

lity

Framework,theJudgementSupportFramework,

theBestPracticeGuidance.

DoH/HSE

Sing

le c

omm

on d

ata

set a

nd

mea

sure

men

t sys

tem

is in

pla

ce.

Med

ium

4c

85Theworkunderwayatnationalleveltodevelopa

costandactivitydatabaseforhealthandsocialcare

inIrelandshouldprioritisementalhealthservicesto

leve

rage

dev

elop

men

tal w

ork

alre

ady

unde

rway

and

supporttheevolutionofoutcome-basedresource

allocation.

Prioritisementalhealthservicesinthework

underwayatnationalleveltodevelopacostand

activitydatabaseforhealthandsocialcarein

Irela

nd.

HSE

Dev

elop

men

t of t

he m

enta

l hea

lth

servicecostandactivitydatabase

unde

rway

.

Shor

t4d

86Anationalmentalhealthinformationsystemshould

beimplementedwithinthreeyearstoreportonthe

perf

orm

ance

of h

ealth

and

soc

ial c

are

serv

ices

in

line

with

this

polic

y.

ImplementaNationalMentalHealthInformation

Syst

em.

HSE

NationalMentalHealth

InformationSystem

implementationinprogress.

Med

ium

4a,4d

87TheDepartmentofJusticeandtheImplementation

MonitoringCommittee,inconsultationwith

stakeholders,willdeterminewhetherlegislation

needstobeamendedtoallowforgreaterdiversion

ofpeoplewithmentalhealthdifficultiesfromthe

criminaljusticesystem.

Assesstheneedforamendedlegislationfor

diversionofpeoplewithmentalhealthdifficulties

fromthecriminaljusticesystemandamendif

nece

ssar

y.

DoJE

Appropriatelegislationisinplace

for d

iver

sion

of p

eopl

e w

ith m

enta

l healthdifficultiesfromthecriminal

justicesystem.

Med

ium

4a,4d

88Trainingandguidanceshouldbeprovidedtostaff

onthepracticeofpositiverisk-taking,basedon

the

prin

cipl

es o

f the

Ass

isted

Dec

ision

-Mak

ing

(Capacity)Act2015,wherethevalueofpromoting

positiverisk-takingisrecognisedbytheregulator.

Providetrainingandguidancetostaffonthe

practiceofpositiverisk-taking,basedonthe

prin

cipl

es o

f the

Ass

isted

Dec

ision

-Mak

ing

(Capacity)Act2015.

HSE

Trai

ning

and

gui

danc

e is

prov

ided

onthepracticeofpositiverisk-

taking,basedontheprinciples

of th

e As

siste

d D

ecisi

on-M

akin

g (Capacity)Actandapprovedbythe

regu

lato

r.

Shor

t4c

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Appendix

110

89Ac

cess

to s

afeg

uard

ing

team

s an

d tr

aini

ng s

houl

d beprovidedforstaffworkinginstatutoryandnon-

stat

utor

y m

enta

l hea

lth s

ervi

ces

in o

rder

to a

pply

thenationalsafeguardingpolicy.

Prov

ide

acce

ss to

saf

egua

rdin

g te

ams

and

trai

ning

fo

r men

tal h

ealth

ser

vice

s.H

SEMentalhealthstaffarefullytrained

andsupportedinimplementingthe

nationalsafeguardingpolicy.

Shor

t4c

90TheJusticeandHealthsectorsshouldengagewith

the

Cor

oner

s, th

e G

arda

Sío

chán

a, N

OSP

, CSO

and

researchbodiesinrelationtodeathsincustody,

recordingofdeathsbysuicideandopenverdicts,to

furtherrefinethebasisofsuicidestatistics.

Refinesuicidestatisticsthroughengagementwith

coro

ners

, the

Gar

da S

íoch

ána,

NO

SP, C

SO a

nd

otherresearchbodies.

DoJE/DoH

Refinedsuicidestatisticsfordeaths

incustody,recordingofdeathsby

suic

ide

and

open

ver

dict

s.

Shor

t4c

91Significantimprovementsarerequiredinthe

monitoringandreportingoflevelsandpatternsof

self-harmandsuicidalityamongpeopleattending

men

tal h

ealth

ser

vice

s to

info

rm a

com

preh

ensiv

e andtimelyserviceresponsetoeffectivelyreduce

leve

ls of

har

m a

nd d

eath

.

Reviewcurrentreportingandmonitoringoflevels

andpatternsofself-harmandsuicidalityamong

peopleattendingmentalhealthservices.

HSE

Appr

opria

te m

onito

ring

and

reportingprocessesoflevels

andpatternsofself-harmand

suicidalityamongpeopleattending

men

tal h

ealth

ser

vice

s ar

e in

pla

ce.

Shor

t4c

92In

kee

ping

with

the

evol

ving

und

erst

andi

ng o

f hu

man

righ

ts to

em

pow

er p

eopl

e an

d im

prov

e qualityofcareinmentalhealthcarefacilities,

legislationmustbeupdatedandadditionalsupports

put i

n pl

ace.

Progressa‘zerorestraint,zeroseclusion’action

plan,whichshouldbedevelopedinpartnership

with

men

tal h

ealth

ser

vice

s.

Prioritisecomprehensivelegislationtoreformthe

Men

tal H

ealth

Act

in li

ne w

ith th

is po

licy

and

in li

ne

withinternationalhumanrightslaw.

In k

eepi

ng w

ith th

e ev

olvi

ng u

nder

stan

ding

of

humanrights,particularlytheUNConventionon

theRightsofPersonswithDisabilities,ensurethat

involuntarydetentionisnotusedexceptinalife-

savi

ng e

mer

genc

y.

Makeavailablearangeofadvocacysupports

includingbothpeerandrepresentativeadvocacyas

a rig

ht fo

r all

indi

vidu

als

invo

lved

with

the

men

tal

heal

th s

ervi

ces.

Arangeofadvocacysupportsincludingbothpeer

andrepresentativeadvocacyshouldbeavailableas

a rig

ht fo

r all

indi

vidu

als

invo

lved

with

the

men

tal

heal

th s

ervi

ces.

DoH/DoJE

Com

plet

ed re

view

of M

enta

l H

ealth

Act

. Representativeadvocacyavailable

to a

ll in

divi

dual

s. Developanactionplanfor‘zero

restraint,zeroseclusion’inmental

heal

th s

ervi

ces.

Shor

t4b,4c

93ANationalPopulationMentalHealthandMental

HealthServicesResearchandEvaluationStrategy

shouldbedevelopedandresourcedtosupport

aportfolioofresearchandevaluationactivityin

accordancewithprioritiesidentifiedintheresearch

stra

tegy

.

DevelopaNationalPopulationMentalHealthand

MentalHealthServicesResearchandEvaluation

Stra

tegy

.

HealthResearchBoard

PublishedandresourcedNational

PopulationMentalHealthand

MentalHealthServicesResearch

andEvaluationstrategy.

Shor

t4d

94Inordertobringaboutchange,astrategicapproach

isrequiredinvolvingthenecessaryskillsinchange

management.Thisapproachhasbeendeveloped

in th

e fo

rmer

HSE

Men

tal H

ealth

Div

ision

(MH

D)

StrategicPortfolioandProgrammeManagement

Officeandshouldbemainstreamedandembedded

in th

e w

ider

HSE

.

Embedthestrategicapproachtochange

managementutilisedintheformerMHDStrategic

PortfolioandProgrammeManagementOfficein

the

HSE

.

HSE

Visible,quantifiablechange

managementprojectsdeliveredin

men

tal h

ealth

ser

vice

s.

4d

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111

95TheinitiativesundertheformerMentalHealth

DivisionStrategicPortfolioandProgramme

ManagementOffice(SPPMO)andtheongoing

SocialReformFund(SRF)shouldbegathered

togetherandmadeavailablebothtoencourage

furtherinnovationandtoavoidduplicationinthe

publicserviceandNGOsectors.

CollateandalignallinitiativesfromSPPMOand

SRFtosupportfurtherinnovation.

HSE

Innovationsupportedinmental

heal

th s

ervi

ces

acro

ss a

ll pr

ovid

ers.

Shor

t4d

96Innovationswhichhavegoodevidenceforclinical

and/orsocialandcosteffectivenessshouldberolled

outnationally.Thiswillrequirethechangingof

practicesandmodificationorcessationofservices

whicharesupersededbythenewformofdelivery.

Rolloutinnovationsthatdemonstrateclinicaland/

orsocialandcosteffectivenessincludingde-

commissioningofservicesnolongerfitforpurpose.

HSE

Neweffectiveinnovativeservices

arepromotedandexistingservices

withlimitedefficacyreplaced.

Med

ium

4d

97M

enta

l hea

lth s

ervi

ces

shou

ld m

ake

use

of o

ther

non-mentalhealthcommunity-basedphysical

facilities,whicharefitforpurpose,tofacilitate

com

mun

ity in

volv

emen

t and

sup

port

the

implementationoftheoutcomesinthispolicy.

Eval

uate

cur

rent

and

futu

re u

se o

f non

-men

tal

healthcommunity-basedfacilitiesandmake

recommendationsonhowtheycouldbebetter

used

to d

eliv

er m

enta

l hea

lth s

ervi

ces.

HSE

Widerangeoffacilitiesused

as a

ppro

pria

te to

sup

port

the

effectivedeliveryofmentalhealth

serv

ices

.

Med

ium

4c

98Capitalinvestmentshouldbemadeavailableto

redesignorbuildpsychiatricunitsinacutehospitals

whichcreateatherapeuticandrecoverysupportive

environment.Itisessentialthatallstakeholdersare

invo

lved

in a

str

uctu

red

serv

ice

desig

n pr

oces

s fo

r allredesignsornewbuilds.

Investinco-producedredesignand/orbuildingof

psyc

hiat

ric u

nits

in a

cute

hos

pita

ls.

Includeinallfutureprimarycarenewbuilding

developmentsappropriatesettingsfordeliveryofa

men

tal h

ealth

ser

vice

.

DoH/HSE

Refurbished/newco-designed

psyc

hiat

ric u

nits

in p

lace

for

patients.

Long

4c

99Anational‘whole-of-government’Implementation

Committeeshouldbeestablishedwithstrong

serviceuserandVCSrepresentationtooversee

theimplementationoftherecommendationsinthis

polic

y an

d to

mon

itor p

rogr

ess.

Establish‘whole-of-government’Implementation

CommitteewithserviceuserandVCS

representationtooverseetheimplementationof

therecommendationsinS

harin

g th

e Vi

sion.

Prioritisesustainable,continuousinvestmentand

financialresourcingoverthe10-yearlifeofthis

polic

y to

ens

ure

that

the

wid

er m

enta

l hea

lth

systemcandeliveroptimumoutcomesforpeople

withmentalhealthdifficulties.

Ensurethat,throughoutthelifetimeofthispolicy,

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