Mental health: Making parity a reality
Despite having the highest mental illness levels in the UK, a male suicide rate double that of England and the Republic of Ireland and a critically underfunded health service, Northern Ireland remains the only region of the UK without a mental health strategy. Ulster University’s Professor of Social Policy, Deirdre Heenan, outlines the imminent need for a 10-year mental health strategy in Northern Ireland.
Northern Ireland has the highest levels of mental illness in the UK, with rates of mental health at least 25 per cent higher than in England. In Northern Ireland the legacy of the conflict and socio-economic factors have been identified as major contributors to the high levels of mental illness, with deprivation being a major predictor of area level mental wellbeing.
The legacy of the Troubles has cast a long shadow. Suicide rates are the highest in the UK and Ireland and are showing no signs of declining. More people in Northern Ireland have taken their own lives since the signing of the Good Friday Agreement in 1999 than were killed as a result of the Troubles between 1969 and 1997. The male rate of suicide in Northern Ireland is currently twice that of England and the Republic of Ireland.
Despite relatively high levels of mental illness Northern Ireland is the only region of the UK that does not have a mental health strategy and services are fragmented and poorly funded.
In the last decade the health service in Northern Ireland has been subject to seven major reviews culminating in the Bengoa Report, ‘Systems Not Structures’. This wide-ranging review formed the basis of a 2016 ministerial statement, ‘Delivering for Change’ described as an ambitious 10-year plan for change. These reviews said relatively little about mental health, focusing instead on the reconfiguration of existing systems for delivery.
The Bamford Review continues to inform policy on mental health in Northern Ireland, despite having begun in 2002 and completed in 2008. The proportion of the health budget in Northern Ireland devoted to mental health is around 6 per cent, which is half that of England. This relatively low level of investment has led to underfunded psychological and mental health services and increasing waiting times. This legacy of increased psychopathology and under-resourced services is reflected in general practitioner prescribing rates for antidepressant medication, which are the highest in the UK.
Alongside this are disturbing trends of increased prescribing to children and young people. Perinatal mental health problems are a major public health concern as, where these concerns are not addressed, they can have long lasting effects on family relationships and the mental health and social adjustment of children. Yet 80 per cent of Northern Ireland does not have access to the specialist perinatal it needs.
Figures released by the Department of Health in March 2019 highlighted once again that hospital waiting times are continuing to spiral out of control. In some cases, waits of up to four years for a first outpatient appointment are not uncommon. Patients are expected to endure waits of more than two years after being referred as an urgent case. The figures also highlighted a “postcode lottery” for patients, with the wait time for a first outpatient appointment in the same specialty varying by more than three years.
The equivalent of one person in five is on a waiting list with over 120,000 people waiting over a year for treatment. In March, there were 120,000 people waiting more than a year in Northern Ireland, compared to 5,000 across England and Wales combined. This means that a citizen of Northern Ireland is more than 3,000 times as likely as a citizen of England to have been waiting more than one year for healthcare. An examination of other regions across the UK illustrates how anomalous these waits are. For example, in the Merseyside and Cheshire region, which has a population of around two million, similar to Northern Ireland, 10 people were waiting more than a year.
A study by the Patient and Client Council in Northern Ireland in 2018 reported that long waits for any treatment can lead to poorer mental health, with increased levels of anxiety and stress. Waiting for excessive periods of time for investigation and treatment were shown to have a devastating impact on patients, their families and communities.
The Permanent Secretary at the Department of Health advised in May 2019 that the public should not expect change to waiting times soon. Richard Pengelly noted that the transformation agenda could not tackle waiting lists and estimated a cash injection of around £1 billion was required to clear the backlog. Whilst policy on waiting lists is a priority in other regions of the UK, with specific initiatives to address them, this is not the case in Northern Ireland.
Pockets of money have been released to ease pressures, but as expected, have had very limited impact. It is difficult to gain the trust of the public for a transformation agenda when the situation regarding waiting lists is so poor. Tinkering at the margins, and short-term sticking plasters will not address fundamental underlying issues. Lack of scrutiny and accountability around performance is compounding an already challenging situation.
The devolved Executive and Assembly collapsed in January 2017 and Northern Ireland has now been without a functioning government for over 30 months. The political impasse and the absence of Direct Rule effectively means the region being run by civil servants in an unprecedented system of disjointed incrementalism.
Unsurprisingly this prolonged period without a government has had a particularly negative impact on health and social care. Key strategic developments have stalled. Most notably, Protect Life 2, Northern Ireland’s suicide prevention strategy, completed in 2016, remains unimplemented as it requires ministerial sign off.
Similarly, the Children and Young People’s Strategy 2017–27 has been put on hold. The Psychological Therapies Strategy is not fully implemented, and the psychology workforce continues to be under-resourced, leading to restricted access to specialist psychological services and concerns over training and governance of psychological interventions. Northern Ireland is still waiting for a regional trauma centre and the final evaluation of the Bamford Review which was due to have been published in 2017.
The failure to provide appropriate and timely health care to people who have mental illnesses and to provide early intervention will extract a high cost on this post-conflict society. Advances in medical treatments and knowledge mean that many mental illnesses are treatable and early intervention underpins recovery.
The challenges around mental health require radical action where stakeholders including politicians, healthcare leaders, clinicians, academics, the voluntary sector and service users work together to develop and deliver an agreed vision for the future. Providing efficient and effective healthcare is complex and challenging. However not addressing these issues is a false economy and comes at a significant human and economic cost.
Making parity a reality, a review of mental health policies in Northern Ireland was written by the Ulster University’s Professor Siobhan O’ Neill, Professor Deirdre Heenan and Dr Jennifer Betts.
