Memorandum by The Northern Ireland Association
of Mental Health
The Bamford Review of Mental Health and Learning
Disability (Northern Ireland) See footnote
MENTAL HEALTH PROMOTION
THE NEED
FOR A
CROSS-SECTORAL
APPROACH
The Report of the Expert Working Committee of
The Bamford Review of Mental Health and Learning Disability (Northern
Ireland) "Mental Health Improvement and well-being—a
personal, public and political issue" (Full Report attached)
recommends the implementation of a cross sectoral approach and
partnership working rather than the siloing of mental health promotion
into the health portfolio as has been the case in the past.
To Realise the Vision for Mental Health Promotion
there is the need for a focused, resourced, centrally driven,
cross-sectoral, cross-departmental and prioritised approach. Collaborative
work among key agencies and central government departments—partnerships
between health and social services and education agencies hold
particular potential. Mental health should be promoted in the
context of social justice, equality and citizenship.
The coordination between member states to promote
the integration of mental health into the health and non-health
policies and stakeholder action is essential to the well-being
and prosperity of the European Community.
The questions set out in the Green Paper have
been addressed as follows:
(1) How relevant is the mental health
of the population for the EU's strategic policy objectives, as
detailed in section 1?
MENTAL HEALTH
IS A
RESOURCE
The Green paper referres to The Mental Health
of the population of Europe as a Resource.
This view is endorsed by the Expert working
Committee on Mental Health Promotion of the Bamford Review of
Mental Health and Learning Disability under the chairmanship of
Prof Alan Ferguson, Chief Executive of the Northern Ireland Association
for Mental Health.
"Mental Health Improvement and well Being—A
personal, public and political issue"
The foreword to the report states:
"Mental Health is as important as physical
health. Mental health promotion is not just for those with mental
health problems. Mental well-being underpins all health and well-being:
it is a resource which must be protected and promoted" .
Under the heading Vision and Principles the
Expert Working Committee express the view that the following vision
is central to the success of a mental health improvement strategy
for Northern Ireland.
There must be a recognition at all levels in
Northern Ireland that:
— everyone has mental health needs;
— mental well-being underpins all aspects
of health and well-being; and
— mental health, like physical health,
is a resource to be promoted and protected.
THE COSTS
OF MENTAL
ILL-HEALTH
AND THE
NEED FOR
INVESTMENT IN
MENTAL HEALTH
PROMOTION
The Green paper referres to the fact that Mental
ill health causes significant losses and burdens to the economic,
social, educational as well as criminal and justice systems.
The Northern Ireland Association in Collaboration
with the Sainsbury Centre for Mental Health produced a policy
document on Counting the Cost, the economic and social costs of
mental illness in Northern Ireland (Document enclosed). The economic
and social costs of mental illness in Northern Ireland amounted
to nearly £3 billion in 2002-03—more than the total
spend on all health and social care for all health conditions.
The Mental Health Promotion report refers to
the burden of disease as follows and makes reference to the figures
pertaining to Northern Ireland.
Over 19 per cent of the total burden
of disease in Western European countries was attributable to mental
illness compared with 17 per cent for cardiovascular disease and
16 per cent for cancer. In 2002 no other condition exceeded 8
per cent (World Health Organisation, WHO 2004).
Of the total disease burden in Western
Europe, just over half is attributable to non-fatal outcomes of
morbidity and disability, of which mental ill health accounts
for over 30 per cent. No other health condition accounts for more
than 10 per cent. In Northern Ireland we are only spending approximately
9.3 per cent of our Health AND Social Services Budget on mental
health.
The 2001 Northern Ireland Health and
Well-Being Survey found that 21 per cent of our population aged
over 16 considers themselves to be depressed and a similar percentage
had a potential psychiatric disorder. The Department of Health,
Social Services and Public Safety (DHSSPS) estimate that in terms
of the scale of the problem, prevalence figures for mental health
problems in Northern Ireland are 25 per cent higher than in England.
Addressing these challenges for the
whole community in Northern Ireland, as exemplified by the WHO
Action Plan for Europe (WHO 2005), as a long-term investment.
That investment must reflect the growing body of evidence that
positive mental health cannot be gained by treating mental disorders
alone (Cp Green Paper Section 4 ).
Suicide rates for Northern Ireland
Suicides in Northern Ireland soared by almost 50 per cent last
year. 213 people there took their lives in 2005.
THE ECONOMIC
CASE FOR
MENTAL HEALTH
PROMOTION
The Northern Ireland Association for Mental
Health is in the process of commissioning a study on the economic
case for mental health promotion with the help of an expert on
mental health promotion and an expert in health economics. The
feasibility study will apply economic analysis to mental health
promotion The study will complement the earlier publication.
The promotion of Mental Health and well-being
for all is seen by the Review Committee as a long term investment,
an investment which must be predictable and sustainable.
In addressing the challenge mention is made
of the WHO action plan (2005) which cites certain actions as beneficial,
such as the adoption of mental health as a long term investment,
with education and information programmes having a long time frame.
(2) Would the development of a comprehensive
EU-strategy on mental health add value to the existing and envisaged
actions and does section 5 propose adequate priorities?
EU MENTAL HEALTH
STRATEGY FOR
EUROPE
The Green Paper in Section 5 refers to the need
for an EU mental health strategy and the establishment of a strategy
on mental health at EU-level would add value by:
(1) Creating a framework for exchange and
cooperation between Member States.
(2) Helping to increase the coherence of
actions in different policy sectors.
(3) To open up a platform for involving
stakeholders including patient and civil society organisations
into building solutions.
INVESTMENT IN
MENTAL HEALTH
PROMOTION THROUGHOUT
EUROPE
The Green Paper refers to structural funds and
how these can be better used to improve long term care facilities
and health infrastructure in the field of mental health/
Whilst there is the need to provide effective
and high quality mental health care and treatment services, accessible
to those with mental ill health, tackling mental ill-health on
its own cannot address and change social determinants.
The Bamford Report on Mental Health Promotion
fully endorses this approach—"Investment must reflect
the growing body of evidence that positive mental health cannot
be gained by treating mental disorders alone".
The Mental health Promotion Report of the Bamford
review emphasises the need to invest in mental health promotion
for the whole of society to prevent the occurrence of mental ill-health
and to tackle the issues of stigma and social exclusion.
The Bamford Report referres to the growing body
of evidence that positive mental health cannot be gained by treating
mental disorders alone (WHO2004). For example, providing the most
effective evidence based treatment for one half of all people
with depression would only reduce the current burden of depression
by less than one quarter. On the other hand, evidence demonstrates
that mental health promotion and prevention can lead to health,
social and economic gain, increases in social inclusion and economic
productivity, reductions in the risks for mental and behavioral
disorders and decreased social welfare and help costs (Jane Llopis
& Anderson 2005, WHO 2005).
THE NEED
FOR CROSS-SECTORAL
WORKING
The main thrust of the report is similar to
the emphasis in the Green Paper that there is a need for a cross
sectoral approach and partnership working rather than the siloing
of mental health promotion into the health portfolio as has been
the case in the past.
To Realise the Vision for Mental Health Promotion
there is the need for a focused, resourced, centrally driven,
cross-sectoral, cross-departmental and prioritised approach.
The experience in Northern Ireland has been
that whilst there have been many initiatives on mental health
promotion and these are happening at a local level. Indeed the
hard work and commitment of individuals and groups must be commended.
However a single Department approach has not delivered on a focused
outcome. There is the lack of an effective, focused regional structure,
properly resourced, sustainable and able to drive forward and
build on existing policy such as the current strategy and action
plan 03/08.
VISION—UNDERPINNING
PRINCIPLES
The Bamford Mental Health Promotion Report notes
that such a Vision must be underpinned by the following principles.
To achieve a society where everyone plays a
role in and takes action to create an environment that promotes
the mental well-being and improvement of individuals, families,
organizations and communities, there is a need for:
— increased cross-sectoral, collaborative
work among key agencies and central government departments—partnerships
between health and social services and education agencies hold
particular potential.
THE PRIMARY
RECOMMENDATION OF
THE BAMFORD
REVIEW REPORT
ON MENTAL
HEALTH PROMOTION
IS THE
CREATION OF
A REGIONAL
MENTAL HEALTH
PROMOTION DIRECTORATE
AT THE
HEART OF
GOVERNMENT
The Review, having agreed and recommended a
Directorate as necessary for providing strategic, coordinated,
cross-sectoral and multi-agency action on mental health promotion,
then considered the appropriate structures and siting to achieve
this function.
The Review considered where the centre of gravity
should be for this recommendation. Should it be focused within
the health sphere or if we are looking to wider contributions,
including those of education, culture and employment to produce
the change we want, what mechanism and approach is most effective
in making those linkages.
The Review considers that it is necessary, in
order to achieve this strategic vision, to place the Mental Health
Promotion Directorate at the heart of Government. The Review's
recommendation is that to ensure mental health promotion is a
policy priority across the whole of the public sector the Directorate
would best be placed within the Office of the First Minister and
Deputy First Minister (OFMDFM).
The assigning of the Directorates to a single
department or Quango should be avoided to ensure that ownership
of mental health promotion is not perceived as being the sole
responsibility of a single department, such as health and personal
social services. The assigning of a Directorate for Mental Health
Promotion to OFMDFM fits in well with the portfolio of responsibilities
already assumed by this Department. These include such issues
as equality, children and young people, disability, human rights,
as well as the Department's responsibility for promoting co-operation
between Government Departments in Northern Ireland.
The Creation of a Framework for exchange and
cooperation between Member States would be welcomed by the Steering
Committee of the Bamford Review and also by the Northern Ireland
Association for Mental Health.
(3) Are the initiatives proposed in
sections 6 and 7 appropriate to support the coordination between
Member States, to promote the integration of mental health into
the health and non-health policies and stakeholder action, and
to better liaise research and policy on mental health aspects?
SUPPORT AND
CO -ORDINATION
BETWEEN MEMBER
STATES
The Bamford Report on Mental Health Promotion
fully is in full agreement with the development of the initiatives
as set out in the Green Paper with regard to the need for coordination
between member states. The report notes the need for a regional,
national and international approach to mental health promotion
and quotes from the resolution passed by the council of the European
Union in November 1999 calling on the European Commission to recognise
the importance of promoting mental health and to access the mental
impact of policy.
The coordination between member states to promote
the integration of mental health into the health and non-health
policies and stakeholder action is essential to the well-being
and prosperity of the European Community.
The development of a EU policy on mental health
needs to take into account the matter of social capital which
refers to such features as social organisation to include networks,
norms, and social trust that facilitate coordination and cooperation
for mutual benefit.
PRIMARY RECOMMENDATION:
THE CREATION
OF A
REGIONAL MENTAL
HEALTH PROMOTION
DIRECTORATE AT
THE HEART
OF GOVERNMENT
Recommendation 1 of the Report considers settings,
stages and levels for actions
— Settings for Action: Schools, Primary
Care, Workplace, further and higher education, communities, including
marginalized groups and faith communities.
— Stages of Life: Children and Adolescents,
older people, people in receipt of statutory mental health services.
— Levels of Action: Regional level/capacity
building.
Recommendation 2 Deals with the identification
of resources and recommends a resource allocation (Northern Ireland)
in the region of £5-6 million over the initial three year
period.
Recommendation 3 Suicide prevention is an integral
part of mental health promotion and the recommendation is that
suicide prevention needs to be placed as a public health priority
and a Regional Mental Health Promotion Directorate needs to ensure
that a separate suicide prevention strategy is implemented as
part of its overall responsibility
The initiatives proposed in the Green Paper
on seeking solutions—options for action which includes:
— Promoting mental health and addressing
mental ill health through preventive action.
— Promoting the mental health of the
population.
— Addressing mental ill health through
preventive action.
— Promoting the social inclusion of
mentally ill or disabled people and protecting their fundamental
rights and dignity.
— Improving information and knowledge
on mental health in the EU.
The Bamford Report on Mental Health Promotion
has addressed the above issues and has identified three key domains
for action (See chapter 3 "The Action").
KEY DOMAINS
FOR ACTION
— The promotion of mental health and
well-being for all the population at large.
— The prevention of mental health problems
in key risk groups:
— children and adolescents;
— people who are deaf or hard of
hearing;
— people with a learning disability;
— people affected by unemployment;
— people with physical illness;
— people with gender and sexuality
issues;
— people traumatized by sexual
abuse; and
— people within the criminal justice
system.
— Improving the quality of life for
people who have experienced mental health problems:
— people with enduring mental illness;
— people with eating disorders;
— people at risk of suicide;
— people emotionally and physically
traumatized due to the NI "Troubles"; and
— people involved in substance
abuse/dual diagnosis.
THE GREEN
PAPER
A Consultation Process for the Development of
an EU-strategy on Mental Health
The crosscutting relevance of mental health
makes it appropriate to develop an EU-strategy on mental health
based on a broad and inclusive consultation process.
The following activities are envisaged:
7.1 Creating a Dialogue with Member States
on Mental Health.
7.2 Launching an EU-Platform on Mental Health.
7.3 Developing an interface between policy
and research on mental health.
Given the extensive work on mental health and
learning disability which has been undertaken in Northern Ireland
by the Bamford Review which includes nine detailed reports—A
review which will shape the nature of services in Northern Ireland
for the next 20-30 years—The Expert working Committee on
Mental Health improvement and well-being invite the Commission
to consider a Belfast Conference on Mental Health Promotion in
Europe to take place in to include :
— Papers on mental health promotion
initiatives.
— Examples of good practice.
— Development a mental health strategy
for Europe and the necessary structures to achieve this.
— Consolidation and the future.
The Bamford Review of Mental Health and Learning
Disability (Northern Ireland)
See Strategic framework, Terms of Reference
and list of the expert working Committees below.
Four reports have been concluded (Mental Health
Promotion Report is the fourth to be published) with the others
coming to fruition later this year.
A STRATEGIC FRAMEWORK
FOR MENTAL
HEALTH AND
LEARNING DISABILITY
A NEW VISION
FOR MENTAL
HEALTH AND
LEARNING DISABILITY
SERVICES
The vision behind this strategic framework is
to give a real and meaningful priority to the challenges of mental
health and learning disability, embracing a reduction in the incidence
and prevalence, a reduction in mortality and in the extent and
severity of problems associated with mental ill-health and learning
disability. Central to the vision is a valuing of people with
mental health needs or a learning disability, their rights to
full citizenship, equality of opportunity and self-determination.
It anticipates a process of reform, renewal and modernisation
of services.
The strategic framework embraces the complementary
challenges of mental health and learning disability. It also recognises
the requirement for:
— a balanced response to the need for
better services for people with mental health and learning disability;
and
— a clear framework to promote positive
mental health and reduce stigma.
VALUES AND
PRINCIPLES
The framework is based on a set of fundamental
values and guiding principles. People with mental health needs,
learning disability and their carers should look forward to a
response from services which:
— respects their individual autonomy—through
openness and honesty in the providing of information, respect
and courtesy in individual interactions with service users, partnership
and empowerment in service planning and delivery—with Government,
providers and wider society each accepting their respective responsibilities;
and
— demonstrates justice and fairness—resources
for services should be allocated and managed according to criteria
which are transparent, and which demonstrate equity.
The framework for service development and service
provision is based on the following principles:
— partnership with users and carers
in the development, evaluation and monitoring of services;
— partnership with users in the individual
assessment process, and in the development of their programme
of treatment and care and support;
— delivery of high quality, effective
treatment, care and support;
— provision of services which are readily
accessible;
— delivery of continuity of care and
support for as long as is needed;
— provision of a comprehensive and
co-ordinated range of services and accommodation based on individual
needs;
— take account of the needs and views
of carers, where appropriate, in relation to assessment, treatment,
care and support;
— provision of comprehensive and equitable
advocacy support, where required or requested;
— promotion of independence, self-esteem
and social interaction through choice of services and opportunities
for meaningful employment;
— promotion of safety of service users,
carers, providers and members of the public;
— staff are provided with the necessary
education, training and support; and
— services are subject to quality control,
informed by the evidence.
FRAMEWORK GOALS
AND HIGH
LEVEL OBJECTIVES
Informed by these values and principles, the
service review provides a unique opportunity to address the full
spectrum of issues relating to mental ill-health and learning
disability. The Review goes beyond specific mental health problems
or individual groupings, to include, for example, mental health
promotion, public health measures to reduce mental ill-health
and suicide, and the challenges of stigma. In responding to the
needs of individual service users and their carers, there is a
need for clear specification of models and standards.
To ensure a balanced and inclusive framework,
the following high level objectives have been set:
1. recommend specific reforms of service
for each of the following user groups—children, young people,
men and women with mental health needs or a learning disability;
[Service reforms will specify models of care and standards of
provision in relation to the quality, comprehensiveness, effectiveness,
accessibility and acceptability of provision. They will include
detailed consideration of primary and secondary care services,
the interface between these services, the linkages and interfaces
between health and social care, education, culture arts and leisure,
employment and housing, the complementary roles of statutory and
non-statutory services, and the issues surrounding multi-disciplinary
and multi-agency working.]
2. review the strategy for mental health
promotion, embracing public health measures to reduce mental ill
health and suicide;
3. review of the law:
1. review of relevant legislation and
other requirements relating to human rights, equality of opportunity
and social inclusion of people with mental health needs or learning
disability and their carers;
2. review of the Mental Health Order
(NI) 1986; and
3. make recommendations regarding future
legislation to reflect the needs of users and carers in the context
of the framework values and principles.
All proposals will be evidence-based, noting
the quality of evidence presently available.
TERMS OF
REFERENCE
1. To carry out an independent review of
the effectiveness of current policy and service provision relating
to mental health and learning disability, and of the Mental Health
(Northern Ireland) Order 1986.
2. To take into account:
— the need to recognise, preserve,
promote and enhance the personal dignity of people with mental
health needs or a learning disability and their carers;
— the need to promote positive mental
health in society;
— relevant legislative and other requirements,
particularly relating to human rights, discrimination and equality
of opportunity;
— evidence—based best practice
developments in assessment, treatment and care regionally, nationally
and internationally;
— the need for collaborative working
among all relevant stakeholders both within and outside the health
and personal social services sector;
— the need for comprehensive assessment,
treatment and care for people with a mental health need or a learning
disability who have offended or are at risk of offending; and
— issues relating to incapacity.
3. To make recommendations regarding future
policy, strategy, service priorities and legislation, to reflect
the needs of users and carers.
SOCIAL JUSTICE
AND CITIZENSHIP:Convenor:
Bill Halliday, Praxis
To consider relevant legislative and other requirements,
particularly relating to human rights, discrimination and equality
of opportunity; and how best to promote the social inclusion of
people with a mental health problem or learning disability and
their carers, taking account of employment, housing, education,
social security, personal finance and other social issues.
LEGAL ISSUES:Convenor:
Master Brian Hall, Master of Care and Protection
To include a review of the Mental Health (N
Ireland) Order 1986; the Mental Health Commission; the Mental
Health Review Tribunal; the procedures for the transfer of patients
to and from N Ireland; issues relating to people who are not able
to look after their own property and affairs as a result of a
mental health problem or learning disability; and issues relating
to people with a mental health problem or a learning disability
who are in contact with the criminal justice system.
LEARNING DISABILITY:Convenor:
Siobhan Bogues, Manager, ARC (NI)
To review policy and services for children and
adults with learning disabilities.
ADULT MENTAL
HEALTH:Convenor: Professor
Roy McClelland, Deputy Chair of the Review
To include consideration of primary care provision,
acute services, rehabilitation and community care for adults with
a mental health problem.
MENTAL HEALTH
PROMOTION:Convenor: Professor
Alan Ferguson, Chief Executive, N Ireland Association for Mental
Health
To include consideration of how best to promote
positive mental health in society, with particular reference to
the impact of the recently-published Mental Health Promotion Strategy,
and how best to meet the needs of people at risk of suicide.
CHILD AND
ADOLESCENT MENTAL
HEALTH:Convenor: Moira Davren,
Royal College of Nursing
To include consideration of primary care provision,
acute services, rehabilitation and community care for children
and adolescents.
DEMENTIA AND
MENTAL HEALTH
ISSUES OF
OLDER PEOPLE:Convenor:
Nevin Ringland, Praxis
To include consideration of primary care provision,
acute services, rehabilitation and community care for older people
with a mental health problem or dementia.
ALCOHOL AND
SUBSTANCE MISUSE:Convenor:
Dr Diana Patterson, Shaftesbury Square Hospital
To include consideration of the links between
mental health and alcohol and substance misuse, and the provision
of the most appropriate assessment, treatment and care for those
involved.
FORENSIC SERVICES:Convenor:
Dr Fred Browne, Chief Clinician, Shannon Clinic.
To consider the assessment, care and treatment
of people with a categorical mental illness, severe personality
disorder or who engage in dangerous or persistently challenging,
aggressive behaviour, and who may be in contact with the criminal
justice system.
NEEDS AND
RESOURCES:Convenor: Glenn Houston,
Chief Executive of Craigavon and Banbridge HSS Trust.
To support other working committees in assessing
the financial implications of their recommendations.
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