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Health funding in Northern Ireland Contents

4Mental health

Defining mental health

106.The World Health Organisation defines mental health as:231

A state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.

This follows from the World Health Organisation’s definition of health more broadly as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”232 It is possible to be in a state of poor mental health with no diagnosed mental disorder and conversely to cope well with life, be productive and enjoy a high level of mental well-being while living with a diagnosis of mental disorder.

107.A mental disorder is a diagnosed clinical condition. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, which serves as the principal authority on the diagnosis of mental disorders, defines a mental disorder as:233

A syndrome characterised by clinically significant disturbance in an individual’s cognition, emotion regulation, or behaviour that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress in social, occupational, or other important activities. An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder. Socially deviant behaviour (e.g. political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.

Mental health in Northern Ireland

108.Mental health is difficult to measure as it relies either on self-reporting, which may under-report certain conditions, or indicators such as hospitalisation rates, which only capture the more severe end of the spectrum. However, Northern Ireland appears to have a relatively high prevalence of mental health problems in the general population. It has been reported to have a 25 per cent higher rate of mental health problems than England234 and significantly higher rates of depression than the rest of the United Kingdom according to prescribing trends.235 Indicator 6 in the Draft Programme for Government Framework 2016–2021, which aims at improving mental health, uses as its lead measure the percentage of the population with General Health Questionnaire scores of ≥4.236 The General Health Questionnaire (GHQ) is a screening tool designed to measure mental well-being in the general population, with a score of four or more indicating possible mental disorder. The most recent health survey of Northern Ireland found that around a fifth (18 per cent) of the population reported a score of four or more.237 This number has remained fairly constant over the last decade.238 Furthermore, it found that one in four (26 per cent) had concerns about their own mental health239 of which three-fifths (58 per cent) sought help, with 82 per cent seeking help from their GP and 44 per cent from a family member.240 Respondents in the most deprived quintile were more likely (22 per cent) to report a score of four or more than those in the least deprived quintile (15 per cent).241 The age groups most likely to report a score of four or more were women aged 55–64 followed by men aged 16–24 and women aged 45–54.242

109.Northern Ireland has significantly higher rates of trauma-related disorders than other countries. A recent study by Ulster University found that Northern Ireland had the highest rate of post-traumatic stress disorder in the world—ahead of war-hit regions in the Middle East, with violence as a distinctive cause in one in four cases.243 Northern Ireland also has the highest suicide rate in the United Kingdom with rates steadily rising since records began in 1970. While suicides in 1970 totalled 73 this had grown to over 100 by 1978; over 200 by 2005; and rates have remained around 250–300 per year since 2008. 2015 saw the most suicides recorded (318) since records began. This number has not fallen significantly since, with 305 suicides recorded last year.244

The Bamford Review

110.In 2002, the Department of Health, Social Services and Public Safety initiated a review, overseen by a Steering Committee chaired by Professor David Bamford of Ulster University and comprised of representatives in the mental health and learning disability fields, into the law, policies and provisions affecting people with mental health needs or a learning disability. The review envisaged a 10–15-year timescale for full implementation of its recommendations. These included:245

The Executive’s response to the findings of the Bamford Review led to the publication in October 2009 of the 2009–2011 Action Plan. This set out a number of key actions to be completed within associated timeframes for improving the mental health and wellbeing of the population and delivering service improvements for those with mental health needs or a learning disability through:246

An evaluation of the Action Plan in 2012 identified a number of key challenges in achieving delivery. These included:247

Uncompleted actions were carried through to the 2012–2015 Action Plan, which contained 76 actions.248 The most recent review of the 2012–2015 Action Plan was published in November 2014. It concluded that 63 actions were on target and 13 were at risk or delayed.249 Some of those judged to be at risk or delayed have stalled since the collapse of the Executive including implementing a revised cross-sectoral mental health strategy and progressing the next phase of the suicide prevention strategy, both of which require ministerial sign-off. A further evaluation, which would have assessed how Departments were performing against the Action Plan, was due in the spring of 2017 but not published due to the collapse of the Executive.250 Its preliminary findings included the need to:251

You in Mind pathway

111.In October 2014 the Health and Social Care Board in conjunction with the Public Health Agency published the regional care delivery pathway You in Mind (2014). It advocated a stepped care model which would “enhance the quality of service experience and promote consistency of service delivery across Northern Ireland.”252 The foreword acknowledged that while “aspects of this Care Pathway are challenging to implement immediately, due to the constraints on resources, it does commit health and social care services to make better use of existing resources and to secure additional resources to address gaps in service provision.”253

Figure 6: The stepped care model

Source: Health and Social Care, You in Mind, October 2014, page 16

The stepped model of care aims to match the level of need with the level of support—the aim being to ensure that patients are referred to appropriate services and professionals with the right skills to meet their needs. Patients can be ‘stepped up’ or ‘stepped down’ depending on the need for more or less intensive specialist support and treatment with any changes arranged by the patient’s existing care team.

112.The care pathway set out in You in Mind is built on the principle of ‘recovery.’ Recovery as a concept in mental health refers to an holistic model of care that aims to facilitate recovery from mental ill health by building the individual’s resilience and providing support so that they may regain control over their own lives. This is envisaged as a process rather than an outcome and requires a partnership between the patient and those caring for them, with an emphasis on finding ways for the individual to live a meaningful life with or without their symptoms. The approach is consistent with the overarching strategy in healthcare of a shift towards community-based services and away from reactive models of acute care. Recovery colleges, which offer educational courses and workshops co-designed by service users, carers, and mental health professionals to assist those living with a mental health condition in their recovery are now established in all five HSC Trusts.254

113.In March 2018 the Department published the Service Framework for Mental Health and Wellbeing 2018–2021. The Framework sets out the standards and outcomes measures against which the standards and services in You in Mind will be audited.255 The Framework states that:256

Many of the standards contained in the Framework do not require additional resources as they are focussed on quality improvement and should be capable of delivery by optimising the use of existing resources and funding. Where there are additional costs associated with specific standards (including non-recurrent costs associated with such areas as informatics and data collection), these will be dependent upon, and sought through existing financial planning, service development and commissioning processes.

The Framework includes five standards, each with a number of service indicators, experience indicators and data sources against which to measure outcomes. These are:

114.The framework will be completed in two phases. Phase 1 will use existing sources of performance and experience data to report on progress against each standard, while Phase 2 will commence in 2019–20 and utilise newly developed methods of data collection that it is hoped will provide more standardised, practice-based evidence for monitoring performance.257

Funding for mental health

115.Mental health is sometimes referred to as a ‘Cinderella service’ that has been historically undervalued and underfunded. However, there is now a broad consensus around the value of effective mental healthcare and the principle of ‘parity of esteem’ between mental and physical health. Parity of esteem has been defined as “equal access to effective care and treatment; equal efforts to improve the quality of care; equal status within health care education and practice; equally high aspirations for service users; and equal status in the measurement of health outcomes.”258 A commitment was made by the last Health Minister to achieving parity of esteem between mental and physical health, meaning that “mental health would, in time, receive the allocation of attention, effort and resources on a basis which fully meets local needs.”259

116.Despite many of the positive changes made in the wake of the Bamford Review funding for mental health as a proportion of the health budget in Northern Ireland has remained comparatively low, despite the higher prevalence of need. In 2015–16, spending on mental health totalled £255 million, which represents 5.5 per cent of the overall health budget.260 In 2016–17, 5.2 per cent of the health budget was spent on the Mental Health Programme of Care by HSC Trusts (not including spend on mental health services delivered by GPs or the Public Health Agency, which the Department does not collect data on).261 By comparison, 13 per cent of total expenditure by clinical commissioning groups and specialised commissioning services (not including direct commissioning such as that by general practitioners) was spent on mental health by NHS England in 2015–16, with 13.3 per cent spent in 2016–17 and 2017–18.262 NHS Wales allocated 11.4 per cent of expenditure to mental health in 2017–18263 and NHS Scotland allocated 7.6 per cent in 2019–20.264

117.Start360, a charity based in Northern Ireland working with marginalised young people and vulnerable adults, told us that funding allocated to mental health is “nowhere close to the amount needed to provide adequate support for all those who need it”265 while the Royal College of Psychiatrists told us that mental health funding should be closer to 13 per cent of the overall health budget.266 Many contributors emphasised the contrast between Northern Ireland’s lower proportional spend on mental health when set against its higher need.267

118.We heard of a number of impacts that underfunding is having on mental healthcare in Northern Ireland. Action Mental Health told us that its New Life Counselling service, which provided 2,000 free counselling sessions last year, was not sustainable due to a lack of funding.268 The British Psychological Society Northern Ireland highlighted the underfunding of clinical psychology training numbers and posts,269 claiming that out of over 250 applications only 11 training places could be allocated and that this had recently been scaled down to seven.270 The British Association for Counselling and Psychotherapy pointed to PPR’s findings that, following cuts to expenditure for counselling provision to GPs, “less than two thirds of all GP practices in Northern Ireland are currently able to offer access to in-house counselling.”271 Inspire emphasised the impact that budget cuts had had on the community and voluntary sectors, telling us that “if there is a cut to funding or a challenge on funding, one of the easy hits is to reduce funding to our sector.”272 The Royal College of Psychiatrists brought attention to the fact that increases in expenditure for mental health initiatives and services announced by the Secretary of State for Health and Social Care do not necessarily translate across to Northern Ireland in Barnett consequentials as “while the money may come to Northern Ireland, it does not mean that expenditure will be on the same services.”273 The College identified the “lack of parity of esteem for mental health services” and “a relative underfunding of mental health services compared to acute services” as among the main issues facing mental healthcare in Northern Ireland.

119.Despite a higher prevalence of need, the Department of Health spends a comparatively low percentage of its overall budget on mental health. Years of underfunding have meant that those in need of mental health services have struggled to access the same quality of care as those with physical health needs. The Department should increase its level of investment in mental health as a share of the overall health budget in line with recent increases in other UK jurisdictions, with the aim of reaching 13 per cent in the long-term.

120.The Confidence and Supply Agreement pledged a total of £50 million specifically for mental health, at £10 million per annum for five years. For 2018–19, Parliament approved a further £410 million to be added to the grant to the Northern Ireland Executive, with £30 million allocated specifically to address mental health and severe deprivation.274

121.The Royal College of Psychiatrists stated in correspondence with the Committee that “there has been a long-standing underfunding of mental health services in Northern Ireland and [ … ] this shortfall will not be addressed by the additional [Confidence and Supply] funding.”275 Furthermore, the College told us that “short-term and time-limited projects will not, in our opinion, be of benefit for mental health services.”276 They provided a list of potential projects with estimated costings that the College believed would deliver long-term savings to the Department, including:277

122.However, in a response to a Freedom of Information request issued on 29 June 2018, the Department stated that the £10 million of Confidence and Supply funding allocated to mental health that year would be spent on addressing increasing pressures on services, including increases in costs due to inflation and “addressing funding gaps to ensure that current services are not stopped.”278

123.The Committee heard concern that Confidence and Supply funding was being used to relieve existing pressures rather than on developing new care pathways or other much needed transformation projects. Professor Nichola Rooney, Chair of the British Psychological Society Northern Ireland commented:279

The non-recurrent nature makes it very difficult to use this money in a way that is transformative. Even in terms of training, there are very few programmes that train people in less than a year that would make substantial changes. A lot of money has gone towards cost pressures for previous ministerial agreements, but there is very little opportunity for innovation and change.

124.We heard that consultation between the Department and the wider sector on where to allocate funding appears to have been lacking. David Babington, Chief Executive of Action Mental Health told us that the first he had heard of the funding was “in the public domain, on BBC News.”280 When asked whether there was a particularly close working relationship between the community and voluntary sectors and the Department of Health, Professor Peter McBride, Chief Executive of Inspire told us that “it is fair to say there is not a joined-up approach.” Action Mental Health further commented:281

Exactly where this funding has gone is unclear, it appears it has gone to relieve increasing pressures, with £6 million going to [ … ] projects including Talking Therapy hubs, drug and alcohol abuse and forensic mental health. Effectively the new money is not having any new impact.

125.In the absence of a mental health strategy measures should be taken to ensure that Confidence and Supply funding ring-fenced for mental health is being used as effectively as possible. The Committee recommends that the Department consult widely with professionals, service users, staff, and the community and voluntary sectors on where funds would be most effectively deployed and to make this information clearly available to the public so that decisions can be properly scrutinised. Furthermore, the Department’s decision to use funding to maintain existing services raises the prospect of what will happen once the deal expires. The Department should set out how it will respond to the exhaustion of additional funds for those programmes supported by the Agreement in 2018–19 and 2019–20.

Mental health strategy

126.The Committee heard that mental health in Northern Ireland was operating within a policy vacuum and this was preventing long-term, strategic investment in service improvements. The Committee heard that this was needed in a number of areas and that much of the ambition of Bamford had yet to be realised. In particular, we heard concerns raised over:

127.This was made most clear to us in our session with service users. Rev. Dr. Scott Peddie, who has lived with a diagnosis of bipolar affective disorder for 10 years and a diagnosis of major depressive disorder before that, has experience of accessing services in both Scotland and Northern Ireland and compared his experiences in Northern Ireland unfavourably:282

I was a service user in Scotland about 16 years ago and I remember there, when I went along for my appointments, we would go into a shiny new hospital where you would see the psychiatrist very quickly, you would be referred to other psychological therapists. That worked really well, in hindsight. Here it is very different. You will go along to a dilapidated building, primarily with paint falling off the walls sometimes, and it promotes this stigma almost of mental health being different to physical health.

Rev. Dr Scott Peddie further commented that the “parity of esteem issue is very closely felt in mental health because you do feel as if you are right at the bottom of the pile in terms of health provision.”283

128.Inspire told us that “effective recovery may involve a combination of medical, psychological and community-based services” and that “for some people a range of these services is needed all the time, while others may best be served by one service or by progressing from one to the other.” However, the service users we heard from had experienced difficulties in accessing and transitioning through a full range of therapies, particularly psychological therapies. Rev. Dr Scott Peddie told us:284

Here in Northern Ireland [ … ] it is very much focused on medication, which in my case with bipolar disorder, medication is really important that you get that right. But in order to help people to live a meaningful and productive life, you need to have psychological therapy as well, or certainly I did, and it just was not there.

Rev. Dr Scott Peddie told us that HSC staff were working “with their hands tied behind their back, in that they cannot offer you the services that would be best for your condition”285 and that he had to go private to get the treatment he required.286 Catherine O’Reilly told us that “the first thing you get offered is medication, when really the most beneficial things I found were learning coping skills.”287 She contrasted a recovery-based programme provided by the voluntary sector through which she was engaged in meaningful work with the support of an understanding community with the services provided by the HSC which “don’t leave you with a lot of hope.”288

129.Particular concern was also raised over a lack of continuity in care. Catherine O’Reilly said that “with some of the initiatives, you are given a course and it lasts maybe six weeks, and then after that there is nothing. It does not go anywhere.”289 Speaking of his experience as an inpatient, Rev. Dr Scott Peddie told us:290

I felt very much as if it was a warehousing exercise, if you like. You go into the ward and you are given your drug treatment. You may, if you are lucky, get some input from a psychologist but that is quite difficult to get. Then you find when you are discharged you have to go on a waiting list to see another psychologist, so there is not that continuity of care there, which is detrimental, at least from my perspective. That is how I experienced it.

This was more common in certain Trust areas than in others, with service levels being described as “very patchy” across locations.291

130.Inspire told us that “a suite of appropriate stepped services that are available when people require them” is necessary for the treatment of a wide variety of experiences but that “current systems are not joined up and suffer from limited or no cross sectoral care-plan management and frequently, have no information sharing protocols.”292 They went on to say:293

Although significant pieces of work have been undertaken to develop effective care planning, to date none of the suggestions put forward have been implemented and remain ‘on the shelf.’ Clear direction and leadership is required to ensure the solutions identified are introduced as a matter of urgency.

This point was also made to us by the Compass Advocacy Network, who told us that “the evidence of Joint-Up working by departments (which is critical to the implementation of Bamford) is scant—there continues to be a lot of ‘lip service’ and a lack of follow through” and that “we see this situation becoming heightened whilst we continue to exist in a political vacuum.”294

131.The experiences we heard with respect to the availability of care in times of mental health crisis were particularly negative. Catherine O’Reilly told us “if you are in a situation where you do not feel safe, you are told that you can avail of ringing up the out-of-hours doctor, but [ … ] it takes six hours for an out-of-hours doctor to contact you” going on to say “if I had to say something to somebody who is in that situation, I would tell them to ring the Samaritans or Lifeline. That is the best thing to do.”295 Rev. Dr Scott Peddie told us:296

You may present as being suicidal and you will go perhaps to a crisis response team, and they will make a decision as to whether you are admitted to hospital, which these days is increasingly unlikely. If you are admitted to hospital it is really a lottery. You could be sent anywhere in Northern Ireland. A lot of the time you are sitting waiting for a bed to come up, so that is a big issue and that impacts on people in terms of the trauma that they suffer as well. The resources are not there when people go forward. [ … ] When you go through a crisis it is incredibly tough and you really need to have the resources there in order to help you through that. Those resources, as far as I can see and as far as I have experienced, are not there to make that impact. I have no doubt that that impacts on suicide figures.

132.Inspire told us that presenting at Accident and Emergency was often the only route available to access assistance in times of crisis and that alternative models of emergency mental healthcare were required, claiming that “rather than the current piecemeal approach to mental healthcare provision, the implementation of an effective, wrap-around mental health services strategy is urgently required.”297

133.The general consensus was that the ambition of Bamford had yet to be realised and a refreshed strategy was needed urgently to direct investment into service transformation. In our session with mental health organisations, when asked what the priority of the next Health Minister should be, every one of our witnesses said that their number one priority would be a fully resourced mental health strategy.298 Dr Gerry Lynch, Chair of the Royal College of Psychiatrists in Northern Ireland told us:299

The time has come to build on Bamford and its many achievements. There are some things that Bamford has not achieved [ … ]. We would like to see the publication of the evaluation report and develop [ … ] a strategy similar to the one they have in Scotland or, in England, the five-year forward view, which builds on Bamford but refreshes it and looks forward, because [ … ] the strategy for Bamford began as far back as 2002.

Dr Lynch went on to say that in the absence of a strategy there was a lack of clear leadership and meetings with the Department to decide on priorities had been taken “on an ad hoc basis.”300 This had been brought to the fore with the announcement of extra funding for mental health through the Confidence and Supply Agreement. Professor Peter McBride told us that “in the absence of a mental health strategy, it is very hard to create a narrative around why that money should not be spent on what is easily presented as a critical situation in the acute sector” and that “very little came into prevention, mental health promotion or community-based support.”301

134.In the absence of a strategy, a number of community and voluntary organisations described being treated as “low-hanging fruit” in budget decisions, with core services protected at their expense.302 Professor McBride commented:

I cannot stress this enough. There is a huge need for us to create a strategy, on which we all agree, that we can work towards. That would allow each of us to fulfil our responsibilities, recognising that we will all have to make concessions, perhaps start collaborating, and work genuinely in partnership together to achieve the vision of that strategy. In the absence of that, we all end up fighting for our own corner and sometimes fighting with each other.

135.Mental health services in Northern Ireland are not delivering the model of care that Bamford envisaged. In the absence of clear lines of decision-making in mental health, Northern Ireland is in need of a comprehensive, up-to-date mental health strategy that will provide the direction necessary for developing collaborative partnerships and services that are capable of meeting the dynamic needs of service users. The Committee recommends that the Department publish the latest Bamford evaluation and use this as a first step to begin work on the mental health strategy for Northern Ireland in collaboration with the HSC Trusts, professionals, service users, staff, and the community and voluntary sectors.

Child and Adolescent Mental Health Services

136.The regionally agreed service model for the organisation and delivery of Child and Adolescent Mental Health Services (CAMHS) was published in 2012 and aimed to provide “a framework against which to remodel CAMH service provision, thus promoting an improved and more consistent approach across all Trust areas.”303 It agreed a needs-based care pathway based on the stepped care model, whereby interventions are ‘stepped up’ or ‘stepped down’ as clinically required.304 The service model was developed in response to the Bamford report A Vision of a Comprehensive Child and Adolescent Mental Health Service (2006).305

137.While figures were not provided on the level of funding required to implement fully the model across the region it was acknowledged that aspects of the model would require additional funding.306 However, the Committee heard that CAMHS had in fact been subject to chronic underfunding. In 2017 only 7.8 per cent of Northern Ireland’s mental health budget was allocated to CAMHS.307 The Health and Social Care Board have calculated that investment in CAMHS should be around 10 per cent of the mental health budget, an acknowledged funding gap of £4.8 million.308 According to the most recent full year budgeting information reviewed by the Northern Ireland Commissioner for Children and Young People, approximately £30 million was spent on CAMHS in 2015–16, which equates to 0.8 per cent of the health budget and less than 1p in every pound invested.309 Of this funding, the majority was invested in steps 3–5, which are statutory services310 and less than 8 per cent of spend on statutory services went to under-18s.311 This is despite research showing that half of all mental disorders begin by the age of 14.312

138.Hearing evidence from service users, when asked about her experience of mental health services as a young person, Catherine O’Reilly described a “sticking plaster” approach which was “okay enough to keep me alive and functioning”313 but that the tools she needed were ultimately provided by the voluntary sector—whereas in the statutory sector she had been diagnosed and prescribed antidepressants by a psychiatrist. In her case, this had not helped.314 This reflected a widely held concern that mental health services in Northern Ireland, both child and adult, were still overly reliant on medication.315 Lynda Wilson, Director of Barnardo’s Northern Ireland told us:316

We need to look at the total system and have a system that allows young people to step up and step down, to get intensive interventions when they need them quickly and to be seen quickly, so we know what pathway they need to be directed to, so they have somebody who is there with them early on.

139.The Committee heard that implementation of the service model had not been carried out in a unified or consistent manner and that, in common with adult mental health services, provisions were more developed in some HSC Trust areas than in others.317 We also heard that services were fragmented, with a lack of parity of esteem between prevention and early intervention services (steps 1–2) and more specialist mental health services (steps 3–5).318 We were told that early intervention could help prevent mental health conditions from progressing into adult life and that this would reduce the need for more costly acute services.319 Yet the majority of services in steps 1 and 2 are provided by the community and voluntary sectors, which have reported reductions in funding and a lack of formal support from Government.320 We were told that “service commissioners need to more routinely consider the wider opportunities that can come from distributing this funding to the [community and voluntary sectors].”321

140.This reflected a fragmentation of commissioning more broadly. The Northern Ireland Commissioner for Children and Young People told us that it was difficult to identify appropriate funding sources for innovations or changes to services and that “in some cases staff must approach a number of commissioners across different Directorates to fund important work.”322 The Commissioner argued that serious consideration should be given to a reconfiguration of the Health Programmes of Care rather than “continuing with structures and processes that are aligned to outdated historical legacies.”323

141.The Committee heard that the Education Authority was not aligning itself with the stepped care model, perceiving it to be relevant only to statutory mental health services and not the education system.324 This was also apparent in other parts of the system, such as Accident and Emergency, suggesting a lack of collaborative working and understanding of professionals’ roles in supporting children and young people’s mental health and wellbeing.325 Lynda Wilson called for earlier intervention in primary schools as “we cannot afford the intensive interventions that are required when young people get to the other end of the line.”326 Professor Nichola Rooney, Chair of the British Psychological Society Northern Ireland, told us that there needed to be “better joined-up working between health and education, and CAMHS services and education services.”327 She described a system characterised by a lack of understanding, collaboration and access:328

There are some projects going ahead, and pockets of very good practice, but there are wide areas within schools where the teachers are not trained to deal with the presentations. They feel that the children fall between stools. If they take them to A&E or CAMHS, they are told they are not severe enough and they do not have a mental illness. If they go to primary healthcare hubs, they are told they are too risky because they are self-harming. They have limited access to educational psychology, because there are, in one school, 1,600 people, five hours of educational psychology and only 15 children allowed to be statemented. They are choosing, in very difficult circumstances, who should have access to these services.

142.The dominant themes of the evidence we heard on Children and Adolescent Mental Health Services were of underfunding and fragmentation. The acknowledged funding gap must be closed by the Health and Social Care Board. We recommend that spending on CAMHS is brought into line with the HSCB’s own recommendation of 10 per cent of the mental health budget. To ensure that funding is deployed strategically measures should be taken to better integrate the commissioning of services and develop a culture of multi-disciplinary and multi-sectoral team working. The recent review into CAMHS conducted by the Northern Ireland Commissioner for Children and Young People contained a number of recommendations based on wide-ranging consultations with key stakeholders. We agree with the Commissioner’s recommendation that a long term and sustainable ‘funding and practice partnership’ model be established for driving change which takes account of the investment required across all key services and sectors included in the stepped care model.

Suicide

143.Northern Ireland has been described as facing a “suicide epidemic.”329 Incidences of suicide have been steadily rising since records began in 1970 along with a widening of the gap in rates between men and women.330 More people have died from suicide since the signing of the Belfast Agreement than died in over thirty years of the Troubles.331

Figure 5: Suicide deaths in Northern Ireland, 1970–present

Source: Northern Ireland Statistics and Research Agency, Suicide deaths 2017, 7 November 2018

144.The reasons behind these trends are not well understood. The Committee was told that suicide is “a very complex phenomenon”332 and that more research was needed before attributing causality.333 However, recent research has pointed to the legacy of the Troubles as likely playing a key role in these trends.334

145.Uniquely in the United Kingdom however, and despite its higher need, Northern Ireland does not have an up-to-date suicide prevention strategy in place. Its most recently implemented strategy, Protect Life, covered from 2006 until March 2011 with an updated version covering until March 2014.335 A consultation on a new suicide prevention strategy for Northern Ireland, Protect Life 2, was launched by the Department of Health in September 2016. The draft strategy set out a number of wide-ranging objectives including: reducing incidences of repeat self-harm; restricting access to the means of suicide; strengthening the evidence base on suicide patterns; identifying and responding to emerging suicide ‘clusters;’ the provision of information and support for those affected by suicide; and enhancing responsible media reporting.336 However, it has remained in draft since the collapse of the Executive.

146.While there was some scepticism over the efficacy of prevention strategies, given that suicide rates continued to rise under the original Protect Life, there was broad agreement that effective suicide prevention required the cross-departmental, coordinated and evidence-based approach contained in Protect Life 2.337 Speaking to the Committee, the Permanent Secretary at the Department of Health told us that under the Northern Ireland (Executive Formation and Exercise of Functions) Act 2018 the Department would now be able to bring forward the strategy. However, the Permanent Secretary remarked that it has “potentially significant resource implications” and the decision would be deferred “until we see the 2019–20 financial settlement.”338

147.Urgent action must be taken to bring down suicide rates in Northern Ireland. The comprehensive measures set out in Protect Life 2 are evidence-based and would provide clear direction and focus for tackling Northern Ireland’s suicide epidemic. The Committee recommends that the Department implement the Protect Life 2 strategy as soon as the next budget is agreed.

231 World Health Organisation, Mental health: a state of well-being, accessed 28 November 2018

232 World Health Organisation, Constitution of WHO: principles, accessed 28 November 2018

233 Diagnostic and Statistical Manual of Mental Disorders Fifth Edition DSM-5, 2013, page 20

234 Making Life Better, A whole system strategic framework for public health 2013–2023, June 2014, page 18

235 Northern Ireland Audit Office, Primary Care Prescribing, 27 November 2014, page 36

236 Draft Programme for Government Framework 2016–2021, 26 May 2016, pp. 55–56

237 Department of Health, Health Survey (NI) First Results 2017/18, 20 November 2018, page 3

238 Department of Health, Health Survey NI Trend Tables, 20 November 2018

239 Department of Health, Health Survey (NI) First Results 2017/18, 20 November 2018, page 3

240 Ibid.

241 Department of Health, Health Survey NI Trend Tables, 20 November 2018

242 Ibid.

243 Ulster University, NI Has World’s Highest Rate of Post Traumatic Stress Disorder, accessed 3 December 2018

244 Northern Ireland Statistics and Research Agency, Suicide statistics 2017

245 Department of Health, Evaluation of the 2009–2011 Bamford Action Plan, page 4

246 Department of Health, Bamford Review Action Plan (2009–2011), October 2009, pp. 6–7

247 Department of Health, Bamford Review Action Plan (2012–2015), November 2012, page 7

248 Department of Health, Bamford Review Action Plan (2012–2015), November 2012, pp. 31–62

249 Department of Health, Bamford Review Action Plan (2012–2015), Monitoring Report, November 2014, page 3

250 Department of Health, Freedom of Information DOH/ 2018–0140, 22 October 2018

251 Northern Ireland Assembly Research and Information Service Research Paper, Mental Health in Northern Ireland: Overview, Strategies, Policies, Care Pathways, CAMHS and Barriers to Accessing Services, Briefing Paper No. 08/17, 24 January 2017, page 16

252 Health and Social Care, You in Mind, October 2014, page 4

253 Ibid., page 4

254 NI Direct, Health and Social Care Trusts—Mental health, accessed 17 August 2019

255 Department of Health, Service Framework for Mental Health and Wellbeing 2018–2021, March 2018, page 5

256 Ibid., page 9

257 Department of Health, Service Framework for Mental Health and Wellbeing 2018–2021, March 2018, pp. 24–25

258 Royal College of Psychiatrists, Whole-person Care: from rhetoric to reality, 2013

259 Department of Health, O’Neill launches new mental health recovery services, 13 October 2016

260 Minister of Health, Answer to written question AQW 3186/16–21, 4 November 2016

261 Department of Health, Freedom of Information DOH/2018–0010, 9 February 2018

262 Secretary of State for Health and Social Care, Answer to written question 195072, 3 December 2018

263 Welsh Government, NHS Expenditure Programme Budgets, 2017–18, 10 April 2019, page 1

264 Based on figures from the Scottish Budget 2019–2020, accessed 19 August 2019

265 Start360 (HTH0019)

266 Q267

267 Action Mental Health (HTH0013); British Association for Counselling and Psychotherapy (HTH0006); British Association of Social Workers Northern Ireland (HTH0022); Q267

268 Q275

269 Q265

270 Q280

271 British Association for Counselling and Psychotherapy (HTH0006)

272 Q275

273 Q267

274 Northern Ireland Office, Supplementary Estimates Memorandum 2018–19, 1 May 2018, page 15

275 Correspondence from the Royal College of Psychiatrists relating to underfunding of mental health services in Northern Ireland, 29 November 2018

276 Ibid.

277 Ibid.

278 Department of Health, Freedom of Information, DOH/2018–0070, 29 June 2018

279 Q272

280 Q272

281 Action Mental Health (HTH0013)

282 Q133

283 Q147

284 Ibid.

285 Q133

286 Q135

287 Q129

288 Q130

289 Q128

290 Q136

291 Q137

292 Inspire (HTH0045)

293 Ibid.

294 Compass Advocacy Network (HTH0003)

295 Q128

296 Q144

297 Inspire (HTH0045)

298 Q310

299 Q269

300 Q284

301 Q272

302 Association for Real Change Northern Ireland (HTH0002); Compass Advocacy Network (HTH0003); Start360 (HTH0019); Q275

303 Department of Health, Child and Adolescent Mental Health Services: a Service Model, 31 July 2012, page 3

304 Ibid., page 6

305 Department of Health, A Vision of a Comprehensive Child and Adolescent Mental Health Service, July 2006

306 Department of Health, Child and Adolescent Mental Health Services: a Service Model, 31 July 2012, page 5

307 Northern Ireland Commissioner for Children and Young People, ‘Still Waiting’, September 2018, page 3

308 Northern Ireland Commissioner for Children and Young People (HTH0049)

309 Ibid.

310 Northern Ireland Commissioner for Children and Young People, ‘Still Waiting’, September 2018, page 227

311 Northern Ireland Commissioner for Children and Young People (HTH0049)

312 Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE, Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication, July 2005

313 Q126

314 Q128

315 British Association for Counselling and Psychotherapy (HTH0006)

316 Q99

317 Northern Ireland Commissioner for Children and Young People (HTH0049)

318 Ibid.

319 Q270

320 Inspire (HTH0045); Northern Ireland Commissioner for Children and Young People (HTH0049); Start360 (HTH0019); Q295

321 Northern Ireland Commissioner for Children and Young People (HTH0049)

322 Ibid.

323 Ibid.

324 Ibid.

325 Ibid.

326 Q99

327 Q295

328 Q294

329 The Independent, Northern Ireland is facing a suicide epidemic—but continues to be ignored in UK mental health funding, 4 June 2018

330 Office for National Statistics, Suicides in the UK: 2017 registrations, 4 September 2018

331 Based on 4,630 suicides registered between 1999–2017 and 3,532 deaths attributed to the Troubles between 1969–2001.

332 Q273

333 Q302

334 Commission for Victims and Survivors, Towards A Better Future: The Trans-generational Impact of the Troubles on Mental Health, March 2015

335 Department of Health, The Northern Ireland Suicide Prevention Strategy 2012–March 2014

336 Department of Health, Protect Life 2: a draft strategy for suicide prevention in the north of Ireland, pp. 8–11

337 Q273

338 Q332



Published: 2 November 2019