review of mental health policies in northern ireland: making … · 2019-08-21 · 1june 2109re...

1Ulster University

June 2019Professor Siobhan O’NeillProfessor Deirdre HeenanDr Jennifer Betts

Review of Mental Health Policies in Northern Ireland: Making Parity a Reality

ulster.ac.uk

This review was supported by funding from the Public Health Agency, Northern Ireland’s Research and Development Division

2 Review of Mental Health Policies in Northern Ireland: Making Parity a Reality

3Ulster University

Table of Contents

Introduction 4HealthcareReforminNI:KeyPoliciesandStrategies 6BamfordReviewImplementation 8MentalHealthCapacityLaw 11TransformingYourCare:AReviewofHealthandSocialServicesinNI 12MakingLifeBetter–FrameworkforPublicHealth 14HealthandWellbeing2026:DeliveringTogether 15HealthandSocialCareWorkforceStrategy2026:DeliveringforOurPeople 16DraftProgrammeforGovernmentFramework2016–21 17ChildandAdolescentMentalHealthServices(CAMHS) 19ProtectLife–ASharedVision(2006–2011) 22ImROC(ImplementingRecoverythroughOrganisationalChange) 25PerinatalMentalHealth 27Conclusion 28References 30


Introduction ThereisstrongevidencethatNorthernIreland(NI)hasveryhighlevelsofmentalillnessandthesuicideratesarethehighestintheUKandIrelandandareshowingnosignsofdeclining.The2008worldmentalhealthsurveyinNIshowedthat23%metthecriteriaforamentalillnessinthepastyear[1]and39%ofthepopulationhadamentalillnessintheirlifetime[2].TheNIHealthStudyfoundthat19%ofthepopulationarelikelytohavehadamentalillnessinthepreviousyear[3].TheratesofmentalillnessinNIarehigherthananyotherregionintheUK;andatleast25%higherthaninEngland[4].InNIthelegacyofviolenceandsocio-economicfactorsarecitedasmajorcontributorstothehighlevelsofmentalillness,withdeprivationbeingamajorpredictorofarealevelmentalwellbeing.InNIdeprivation,andhighratesofmentalandphysicalillnessco-occurintheareasmostimpactedbytheviolence:

“…Multi-morbidities increase with age but are also evident in younger people in areas of high deprivation. Mental health illness is associated with physical health conditions and again these are prevalent in areas of high deprivation which are also areas where the Troubles have had the most impact and the legacy of the Troubles has caused trauma and poor mental health.” [5].

TheworldmentalhealthsurveyalsoshowedthatNIhashighratesofpost-traumaticstressdisorder(PTSD)andagain,thattraumaexposureresultingfromtheconflictaccountsforthisexcess[6].Mentalhealthissuesarethelargestcauseofillhealthanddisabilityinthepopulation[7][8].NI’ssuicideratesarealsohigh.2015sawthehighestnumberofsuicides(318)sincerecordsbeganin1970andofthese,77%weremale[9].

MorepeopleinNIhavetakentheirownlivessincethesigningofthepeaceagreementin1999thanwerekilledasaresultoftheTroublesbetween1969and1997[10].Despiteover£7millionhavingbeenspentannuallyontheservicesdeliveredaspartoftheProtectLifesuicidepreventionstrategy,themalerateofsuicideinNIiscurrentlytwicethatofEnglandandtheRepublicofIreland,andNIhasnotseenthereductioninsuicideratesexperiencedinIrelandandtheotherUKregions[11].Thelegacyoftheconflict,andthehighlevelsofdeprivationhaveonceagainbeenacknowledgedasmajorcontributoryfactors[12][13].

Health,andtheprovisionofmentalhealthservices,isadevolvedmatter.Despitethesestatistics,NIistheonlyregionintheUKthatdoesnothaveanoverarchingmentalhealthstrategyandthedeliveryofmentalhealthtreatmentsandcareisfragmentedandnotproperlyresourced.Nonetheless,

stepshavebeentakentoaddresstheuniquementalhealthneedsofthepopulation.TheVictims’Servicewasestablishedin2013andprovidessupporttothosewhohavebeenaffectedbytheTroublesincludingthosewhohavementalillnesses.ThedevelopmentofanewservicetoprovidetreatmentsforpeoplewithtraumarelatedmentalillnesswasincludedintheStormontHouseAgreement.In2016£175,000fundingfortheservicefortheregionaltraumanetworkwasannouncedand,threeyearslater,plansareunderwayforthecommencementoftheservice.

Theneedtoreformhowhealthcareservicesaredeliveredisaglobalissue.Changingdemographicsandmedicaladvancementsmeanthatageingpopulationsarelivingwithmulti-morbiditiesandlong-termillnesses.NIemergesastheworstregionintheUKintermsofwaitinglistsforhealthcare,withtherelationshipbetweenlengthywaitingtimesandtheresultingimpactonmentalhealthoftenbeingoverlooked.AstudybythePatientandClientCouncilinNIin2018[14]supportedkeyfindingsfrompreviousresearch,thatlongwaitsfortreatmentleadtopoorerhealth,increasedlevelsofanxietyandcanimpactuponsociallifeandemployment.Waitingforexcessiveperiodsoftimeforinvestigationandtreatmentwasshowntohaveadevastatingimpactonpatientsandtheirfamilies.

FiguresreleasedbytheDepartmentofHealthhighlightedonceagainthathospitalwaitingtimesarecontinuingtospiraloutofcontrol.Insomecases,waitsofuptofouryearsforafirstoutpatientappointmentarenotuncommon.Patientsareexpectedtoendurewaitsofmorethantwoyearsafterbeingreferredasanurgentcase.Thefiguresalsohighlighteda“postcodelottery”forpatients,withthewaittimeforafirstoutpatientappointmentinthesamespecialtyvaryingbymorethanthreeyears.

InMarch2019therewere120,000peoplewaitingmorethanayearinNI,comparedto5000acrossEnglandandWalescombined.Theequivalentofonein16peopleinNIhasbeenwaitingmorethanayear,comparedtoatmostonein750inWales,andonein48,000inEngland.ThismeansthatacitizenofNIismorethanthreethousandtimesaslikelyasacitizenofEnglandtohavebeenwaitingmorethanoneyearforhealthcareyear[15].ThePermanentSecretaryoftheDepartmentofHealth,RichardPengelly,advisedinMay2019thatthepublicshouldnotexpectchangetowaitingtimessoon.Henotedthatthetransformationagendacouldnottacklewaitinglistsasacashinjectionofaround£1billionwasrequired[16].Clearlylongwaitsforanytypeofdiagnosis,treatmentandsupportcanhavedevastatingknockonmentalhealtheffectsandbedistressingforpeople.Thelongerpeoplewait,themoreproblemsarelikelytoescalatetocrisispointandthegreatertheenduringnegativeimpactfortheirphysicalandmentalhealth.

5Ulster University

WhilstpolicyonwaitinglistsisapriorityinotherregionsoftheUK,withspecificinitiativestoaddressthem,thisisnotthecaseinNI.Pocketsofmoneyhavebeenreleasedtoeasepressures,butasexpected,havehadverylimitedimpact.Itisdifficulttogainthetrustofthepublicforatransformationagendawhenthesituationregardingwaitinglistsissopoor.Tinkeringatthemargins,andshort-termstickingplasterswillnotaddressfundamentalunderlyingissues.Lackofscrutinyandaccountabilityaroundperformanceiscompoundingachallengingsituation.

Whilstadvancesintalkingtherapiesandmedicaltreatmentsmeanthatmanymentalillnessesarenowwidelyregardedastreatable,butaccesstoevidence-basedserviceshasbeenidentifiedasakeyprobleminNI,withmentalhealthservicesinNIhavingbeenviewedasthe‘Cinderellaservice’ofthehealthsector.InFebruary2018agroupofcampaignersandexpertsinmentalhealthservicespresentedstatisticsforsuicide,self-harmandmentalillnesstoMPsatWestminster,expressingconcernforwhattheydescribedasNI’s“worseningmentalhealthcrisis”.Inabriefingpaperfromvoluntaryorganisationsdeliveringcommunitymentalhealthservices[17],itwasstatedthatsuiciderateswerehighestinthemostdeprivedareaswheresomeofthepoorestwardsintheUKhadexperiencedthehighestlevelsofviolence.Inpresenting

theirfindingstheycalledfor:1. TheappointmentofaMentalHealthChampion.2.Investmentinmentalhealthsupportforpeopleofall

ages,withacommitmentthatpublicspendingwilldeliveradividendformentalhealth,particularlyintheareasofhealth(includingpublichealth),socialcare,education,employment,housingandcriminaljustice.

3.Thedeliveryofa10-yearMentalHealthStrategy.4.Fundingforaprevalencestudyonchildrenandyoung

people’smentalhealth.

InDecembercliniciansfromNIwereinvitedtopresentoralevidencetotheNIAffairsCommitteeonfundingprioritiesfortheNI2018-19healthbudget[18].Theexpertwitnessesincludedmentalhealthpractitionersfromthestatutoryandvoluntaryandcommunitysectors,andtogethertheycalledforadditionalresourcesforastrugglingmentalhealthserviceandanewregionaltraumacentretodealwiththementalhealthlegacyoftheTroubles.Whilstthelackofamentalhealthstrategyremainsasignificantissue,strategieshaveincludedinitiativeswhichaddressareasrelatingtomentalhealth.Thispaperreviewsthosethathavebeenpublishedintheprevious10years,summarisestheirmainpointsandassessestheextenttowhichtheyhavebeenimplemented.

Healthcare Reform in NI: Key Policies and Strategies TheWorldHealthOrganisation(WHO)definesgoodmentalhealthas:

A state of wellbeing in which the 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 his or her community. [19]

TheWorldHealthOrganisationprovidesthreemaingoalsfortheorganisationofmentalhealthservices:todeinstitutionalisementalhealthcare;tointegratementalhealthintogeneralhealthcare;andtodevelopcommunitymentalhealthservices[20].ThesegoalswereintegraltotherecommendationsresultingfromtheBamfordReviewofmentalhealthandlearningdisability.TheissueforNImentalhealthcareisnotalackofknowledgeorawarenessofwhatisrequired.Rather,itisalackofcommitmenttoprioritise,adequatelyresourceandimplementrecommendationsthathavealreadybeenmade.Themostrecent10-yearplanforthedeliveryofhealthcareservicesinNIwaslaunchedbythe(then)HealthMinister,MichelleO’NeillinOctober2016,priortothecollapseoftheNIAssembly.‘HealthandWellbeing2026:DeliveringTogether’[21](‘DeliveringTogether’)wastheresponsetorecommendationscontainedinareportfromanexpert

internationalpanelappointedtoreviewhowhealthandsocialcarewasbeingdelivered.‘Systems,NotStructures:ChangingHealthandSocialCare’’[22]becameknownastheBengoaReport,namedafteritsChairProfessorRafaelBengoa.ItwaspublishedinOctober2016andemphasisedtheneedtomoveservicesintothecommunitytorelievethepressuresonacuteservices.TheDepartmentofHealth’sresponsetotheBengoaReportrecognisesthehighratesofmentalillnessinNI,listingmentalillness(andtrauma)asareasofpriorityinvestmentstating:“We will expand services in the community and services to deal with the trauma of the past.”[21].However,thewaysinwhichmentalhealthcareshouldbedeliveredarenotdiscussed.IntheHealthMinister’sstatementsatthelaunchofDeliveringTogether,sheemphasisedherawarenessofthecurrentcrisisinmentalhealthinNIandvowedtobeachampionformentalhealthintakingtheplanforward.However,withthecollapseoftheNIAssemblyandthebroadpoliticalagreementforthedemandsoflobbyistsonbehalfofmentalhealthservices,itisfearedthemomentumhasbeenlost.

ThehealthreformagendainNIprecedestheDepartment’sproposedDeliveringTogether10-yearplan.TheBamfordReviewofMentalHealthandLearningDisability[23]continuestoformthefoundationforthedeliveryofmentalhealthservicesinhealthcarepolicyandstrategyinNI,althoughthedirectionoftravelinrecentpoliciesandstrategiesdemonstrateanevolutiontowardsthe‘healthandwellbeing’ofthegeneralpopulation.

Review of Mental Health Policies in Northern Ireland: Making Parity a Reality6

7Ulster University

Bamford Review of Mental Health and Learning Disability MentalhealthservicereformcontinuestobeguidedbytheBamfordReviewthatwascompletedin2008.TheBamfordReviewofMentalHealthandLearningDisability(‘theBamfordReview’),namedafterProfessorBamford,Chairofthereview’ssteeringcommittee,wasanindependentreviewinitiatedbytheDHSSPSin2002witharemittoreviewthelaw,policyandserviceprovisionforthoseaffectedbymentalillhealthoralearningdisabilityinNI.ThescopeoftheReviewtookintoaccountrecentpolicyanddevelopmentsintheEuropeanUnionandwouldaddresstheneedsofthosewithspecificmentalhealthneedsoralearningdisabilityinaccordancewiththestatutoryequalityobligationsoftheNIAct1988andtheHumanRightsAct1998[23].TheBamfordReview’ssteeringcommitteepresidedover10expertworkinggroupsandpublished11phasedevidence-basedreportsbetween2005and2007.Theseoutlinedareasthatneededaddressingincludinglegalissues,olderpeople,CAMHS,adultmentalhealthservicesandlearningdisabilityservices.Thepublicationsdrewonexistinginformationandcommissionednewresearchwherenecessary[24].Thefirstpublication,“ReviewofMentalHealthandLearningDisability(NI):AStrategicFrameworkforAdultMentalHealthServices”(June2005)[24],setoutavisionforadultmentalhealthservicesforthenext15-20yearswhenitwasenvisagedthattheBamfordReviewrecommendationswouldbeimplementedovera10to15yearperiod.Keyrecommendationscalledfor:

• Acontinuedemphasisonpromotingpositivementalhealth;

• Areformofmentalhealthlegislation(theMentalCapacityAct2016forNIhasnotbeenimplementedatthetimeofwriting);

• Acontinuedshiftfromhospitaltocommunity-basedservices;

• Developmentofspecialistservicesforchildrenandyoungpeople,olderpeople,thosewithaddictionproblems,andthoseinthecriminaljusticesystem;and

• Afullytrainedworkforcetodelivermentalhealthservices.

AspartoftheDepartment’scommitmenttothe2009-2011ActionPlanthethenMinisterofHealth,MichaelMcGimpsey,launched‘AStrategyfortheDevelopmentofPsychologicalTherapyServices(June2010)[25].

Itsoverarchingaimwastoimprovethehealthandwellbeingofthepopulation,providingearlyinterventionandimprovedaccesstopsychologicaltherapies.Italsohighlightedtheneedtoprovideinformationtothepubliconwhatserviceswereavailableandacknowledgedthat“…Almost 40 years of civil unrest during the Troubles continues to impact on society, with services becoming more aware of the impact of trans-generational trauma on children and families. …”.

DespiterecognisingtheimpactoftheTroublesandtheircontinuinginter-generationalaffect,thedevelopmentofpsychologicaltherapieshasnotbeenrealised[18].However,preliminaryresearchshowsthatlowlevelCognitiveBehaviouralTherapyhasprovenusefulinimprovingmentalhealthinanNIpopulation,withapilotstudytoevaluatetheeffectivenessoflow-intensitycognitivebehaviouraltherapy(CBT)inprimaryandcommunitysettingsshowingarecoveryrateof47.9%,improvementrateof76.7%anddeteriorationrateof6%[26].

TheBamfordReviewwasnotableforemphasisingpartnershipwithserviceusersintheplanning,developmentandevaluationofservicesandalsointhevariousaspectsofassessmentandtherapy.Interestingly,duringthecourseofthereview,serviceusersobjectedtobeinginvitedtobeinvolvedonlyatalatestageoftheproceedings,andcommentatorshavenotednegligiblechangestotheextentofinvolvementinareassuchasservicelevelplanning[27].Todate,thoughtherehasbeenrelativelylittleresearchonthenatureandextentofserviceuserinvolvementinNI.IntheirassessmentofthefutureoftheNHSinNItheRoyalCollegeofSurgeons[28]emphasisedtheneedforauthenticengagementtoempowerpeopletoengageinthedesignoftheirowncare.Turningawayfromahospital-baseddeliverysystemrequiresco-productionbasedaroundcommunitycontributiontoasustainablesystemofhealthandsocialcare.

Bamford Review Implementation RecommendationsfromtheBamfordReviewweretobeimplementedin‘DeliveringtheBamfordVision–ActionPlan(2009-2011)’bytheHealthandSocialCare(HSC)BamfordTaskForce.ThiswasjointlyledbytheHealthandSocialCareBoardandthePublicHealthAgency.In2009thePatientandClientCouncilalsosetuptheBamfordMonitoringGrouptogatherviewsandexperiencesofserviceusers,theirfamiliesandcarersacrossNIontheeffectofchangestoservices.

Anevaluationofthe2009-2011ActionPlan[29]identifiedthekeychallengesin2009forthedeliveryofmentalhealthservices.Theseidentifiedtheneedforthefollowing:

• Establishmentofasteppedcareapproachtoserviceprovision;

• Theenhancementoftherangeofoptionsavailabletohealthcareprofessionalsfortherangeofmentalhealthneedspresented;

• Improvedaccesstopsychologicaltherapies;

• Streamliningofaccesstomentalhealthservicesgenerally;

• Provisionofhome-basedcareandsupportasthenormformentalhealthservices;

• Asystematicapproachfortherecoveryofpeoplewithlongtermconditions;

• Buildinguptherangeofspecialistmentalhealthservicestomeetneed;and

• Theredesign,extensionandretentionofaneffectiveworkforce.

ArevisedActionPlan(2012-2015)[30]tocontinueactionsnotcompletedintheprevious2009-2011ActionPlanwaspublishedinMarch2013.Itwastorepresent“…the Northern Ireland Executive’s continued commitment to the development of mental health and learning disability services in Northern Ireland, and to the promotion of independence and social inclusion for those people within our community”anddescribedasa“…truly cross-cutting agenda” requiring a “…commitment across all parts of Government …”.[30]

Thenewrevisedactionplancontained76actionsundertheBamfordReview’sdeliverythemesof:

1. Promotingpositivehealth,wellbeingandearlyintervention.

2.Supportingpeopletoleadindependentlives.3.Supportingcarersandfamilies.4.Providingservicestomeetindividualneeds.5.Developingstructuresandalegislativeframework.

AMonitoringReportofthe2012-2015ActionPlanwaspublishedinNovember2013[31]whenprogressatOctober2013showedthatofthe76actions,63wereontarget,and13wereatriskordelayed.AfurtherMonitoringReportwaspublishedinNovember2014andstatedthatingeneraltermstherehadbeengoodprogressmadeontheBamfordActionPlan2012-2015[32].Thetableoppositecomparesprogressonkeyactionpointsthatwereatrisk/delayedinOctober2013,October2014,orboth.


Action No.

Key action Progress October 2013 Progress October 2014

1 Publish and implement a revised cross-sectoral promoting Mental Health Strategy (DHSSPS)

A suicide prevention and positive mental health promotion strategy is expected to be published for consultation May 2014. Final strategy expected September 2014.

A suicide prevention and positive mental health promotion strategy is substantially drafted. The aim is to issue for consultation in March 2015.

6 Progress the next phase of the suicide prevention strategy

A suicide prevention and positive mental health promotion strategy is expected to be published for consultation May 2014. Final strategy expected September 2014.

A suicide prevention and positive mental health promotion strategy is substantially drafted. The aim is to issue for consultation in March 2015.

13 Resettle long stay patients from learning disability and mental health hospitals (OFMDFM)

On target Oct. 2013. Resettlement ongoing. 2012/13, 28 patients resettled from mental health hospitals and 41 from learning disability hospitals. Target for 2013/14, 33 long stay patients from mental health hospitals and 75 from learning disability hospitals.

At risk/delayed Oct. 2014. The resettlement target is largely on track for completion by March 2015 and figures for 2014/15 are in line with the expected profile of plans for this year which expects the majority of placements to take place in the 4th quarter.

25 To support the uptake of self-directed support and individual budgets in line with Transforming Your Care (DHSSPS)

On Target Oct. 2014. “Who Cares” published September 2012. Review to be completed by 2015. HSCB committed to increasing uptake of direct payments and by March 2015 aims to provide a personal care budget to 100% of those eligible for social care services and that 20% of these people will access self-direct support.

At risk/delayed Oct. 2014. “Who Cares?” the first stage of the reform of adult care and support was published in September 2012. A Project Board has been established and work ongoing to carry out essential financial modelling of the cost reforms. Anticipated that consultation on stage 2 proposals will be launched in the Autumn 2016. HSCB has committed to increasing uptake of direct payments – mental health has seen an increase of 26% from 2012/13 to 2013/14.

27 Implementing “Developing Advocacy Services – A Policy Guide for Commissioners (DHSSPS)

Service user groups and implementation teams are in place. Key actions being taken forward include a scoping study of advocacy provision, development of commissioning guidance and training awareness raising for health and social care staff and practitioners.

An independent Advocacy Code of Practice and Standards Framework was launched in June 2014. Members of the Advocacy Network NI have committed to the code of practice and are using it as part of their induction and training programmes for new staff and volunteers.

35 Enhance and develop the services to assist clients who transfer from incapacity benefit to Job Seekers Allowance (JSA) (DEL)

The Condition Management Programme (CMP) is available to JSA clients who have come through the Incapacity Benefit Reassessment process. Around 40% of people referred to CMP have mental health and around 25% have a learning disability.

The CMP is available to all JSA clients throughout the Jobs and Benefits Offices/Job Centre Network. All front-line advisers have been provided with a desk-aid designed by Disability Sector consortium to help them recognise behaviours and traits of people who have a mental health condition or learning disability and advises them how to respond and appropriate referral, including to CMP.

38 To provide support to all carers in order that they may continue in their caring role (DHSSPS)

The HSCB is striving to ensure that all carers are offered a carers assessment. The number of carers assessments offered has increased by 35% from 2011 to 2013. The number of carers assessments completed has increased by 18% in the same period.

The HSCB is striving to ensure that all carers are offered a carers assessment. The number of carers assessments offered has increased by 27.5% from 2012/13 to 2013/14.

60 Implement the Mental Health Service Framework across HSC (DHSSPS)

On target Oct 2013. The HSCB and PHA are developing agreed care pathways as part of an ongoing incremental process to develop Integrated Care Pathways (ICPs) which reflect the Framework and NICE guidance. Pathways currently in preparation include those for General Adult Mental Health, Addiction Treatment and Eating Disorders – these are in addition to the existing regional Care Pathways for Perinatal Mental Health, Forensic Mental Health Care and Autism/ASD.

At risk/delayed Oct 2014. There has been some progress on some of the standards. A fundamental review of the Mental Health Framework is under way and a revised framework is expected by April 2016.

61 Provide information on children’s, adolescent and adult mental health services for use by the public, GPs and other clinicians (DHSSPS)

On target Oct 2013. A web-based map of all mental health services is due to go live by the end of 2013.

At risk/delayed Oct 2014. Data collection for the Mental Health Service Mapping was completed in 2013 and work is ongoing with NI Direct to resolve technical difficulties in relation to hosting the web page. It is anticipated these pages will be fully operational on or before April 2015.

64 Enhance availability of psychological therapies

Additional £1M has been invested in primary mental health will provide greater access to GPs to psychological therapies and clarity on referrals. Additional training is also being provided for existing staff.

Pilot Primary Care Talking Therapy Hubs have now been established in each Trust.

71 Ensure provision of appropriate low secure and community forensic services in line with 2011 Review (DHSSPS)

Community forensic teams are now in place and a centrally funded training programme continues. 3 newly refurbished low secure facilities are now in use.

Community mental health forensic teams are now in place and a centrally funded training programme continues. 3 newly refurbished low secure facilities are now in use. Work is ongoing to prepare a bid for the required resources to support these.

76 New mental capacity legislation DHSSPS)

The timescale for completion of this legislation has slipped to March 2016. Consultation on a full draft of the Bill is expected to take place in 2014 and the Bill is to be introduced to the Assembly by Spring 2015.

Consultation on the civil provisions for the draft Bill was completed on 2nd September 2014. The consultation included a policy statement on the criminal justice provisions (Department of Justice). It is intended to submit the Bill to the Executive in March 2015 for approval to introduce in the Assembly, with a view to attaining Royal Assent by March 2016.33

Bamford Monitoring Reports November 2013 and November 2014: Progress on key action points considered to be at risk/delayed

AfullevaluationoftheBamfordActionPlan2012-2015wasinitiatedbytheDepartmentofHealthin2016toassesstheperformanceofExecutiveDepartmentsagainstthetargetsforaction.Theevaluationwastoincludetheviewsofserviceusersandcarersinordertoidentifyneedsandgapsintheservice.TheevaluationwasexpectedtohavebeenpublishedinSpring2017.However,thelastavailableminutesofameetingoftheBamfordReviewMonitoringGroup[34]heldon2ndFebruary2018notesthatthepreviousmeetinghadagreedthatinthecontinuedabsenceoftheBamfordEvaluationReportitwassuggestedandapprovedthatnonewmembersoftheMonitoringGroupshouldberecruitedatpresent[35].Todate(June2019)thefinalevaluationoftheBamfordReviewhasstillnotbeenpublishedbytheDepartmentofHealth.

TheRoyalCollegeofPsychiatristshadhighlightedtheimportanceoftheexpectedevaluationduetothesignificanceoftheActionPlaninmappingthefutureofmentalhealthservicesforthenextnumberofyearsandtheneedforittoalignwiththeoutcomesfromtheBengoaReport.

Althoughthefinalevaluationhasnotbeenpublished,initialfindingsincludetheneedto[7]:

• Furtherembedandpromotepsychologicaltherapiesandtheconceptofrecovery;

• Providemorepracticalsupporttocarers;

• Improveaccesstoservicesintimesofmentalhealthcrisis;

• Improvetheexperienceofpatientsadmittedtoacutementalhealthfacilities;and

• Increasetheinvolvementofthevoluntaryandcommunitysector.

RecentoralevidencetotheNIAffairsCommittee[18]fromexpertsinthefieldofmentalhealthinNIreportedthatpsychologicaltherapiesarestillpoorlydevelopeddespitehavingapsychologicaltherapiesstrategythatwaspublishedin2010[25].


11Ulster University

Mental Health Capacity Law Medicineingeneralhasshiftedawayfrompaternalismandplacesincreasingemphasisonpatientchoiceandautonomy.AreviewofmentalhealthlegislationwasincludedwithintheremitoftheBamfordReview.Itconcludedthatexistinglegislationwasnolongerfitforpurposeasitwasnotcompliantwithprinciplesofautonomy,justiceandhumanrights.Asinglecomprehensiveframeworkforthereformofmentallegislationwasrecommended.Followingextensiveconsultationitwasagreedthat,uniquelyintheUK,thementalhealthlawandmentalhealthcapacitywouldbefusedintoasinglebill[36].TheMentalHealthOrderwhichhadbeeninplacesince1986wasreplacedbytheMentalCapacityAct(NI)2016.Thislegislationmarkedadramaticmoveawayfrominvoluntarypsychiatrictreatmentandwasmorecompatiblewitharight-basedframework.However,asSzmuklerandKelly[37]havenotedthecollectionandevaluationofrobustevidenceonitseffect

andimplementationareessentialifthisground-breakingBillistomeetitspotential.

InDecember2016theDepartmentadvised[38]thatnocommencementdateshadbeenagreedfortheMentalCapacityAct(NI)2016,butthatplanswereunderwayanddecisionsoncommencementweresubjecttothenecessaryresourcesbeingmadeavailable.However,therewerenoplanstodraftorlayanycommencementordersbefore2019attheearliest.

Transforming Your Care: A Review of Health and Social Services in NI InJune2011,EdwinPootsthethenMinisterforHealth,SocialServicesandPublicSafety(DHSSPS)announcedamajorreviewofhealthandsocialcareinNItomakerecommendationsforthefutureofservicesandprovideanimplementationplan.Itsfocuswasonhowserviceswerestructuredanddeliveredinordertomakethebestuseofresourcesandexaminetheextenttowhichtheneedsofpatients,serviceusersandcarerswerebeingmet[39].Theindependentreviewpanelengagedwiththepublic,clinicalandprofessionalhealthcareleaders,healthandsocialcareorganisationsandstakeholdersinthevoluntaryandcommunitysector.

WhenTransformingYourCare(TYC)waspublishedthenumberofregisteredsuicidesinNIhadrisenfrom146in2005to313in2010.OneofthemaindriversforreviewinghealthandsocialcareservicesinNIhadbeen

“…the shadow of our recent history in NI, particularly in the mental wellbeing of the citizenry…”(DHSSPS,2011).

ThefocusforTransformingYourCarewas:

• ImprovingcareprovidedforindividualsandfamiliesinNI;

• Morecaretobedeliveredathomeratherthaninhospitals;

• Peoplesupportedtoliveasindependentlyandhealthilyaspossibleforaslongaspossible;

• Betterpreventionofillhealth;and

• Easieraccesstohealthandsocialcare.

Thegoalofdeliveringservicesasclosetoapatient’shomeaspossiblewasnotanewone.In2005DHSSPShadpublished‘CaringforPeopleBeyondTomorrow-a20-yearstrategicframeworkforprimarycare’[40],thatrecognisedtheneedtofurtherdevelopcommunity-basedalternativestohospitaladmission.Keytothishadbeentheintroduction


13Ulster University

ofPrimaryCarePartnerships(PCPs),withGPsdevelopingvoluntaryalliancesofhealthcareprofessionalsworkingtogetherwiththevoluntaryandcommunitysectorforcloserintegrationofprimaryandcommunitycare,hospitalspecialistsandthesocialservices.

FollowingpublicationoftheReviewPanel’sreportapublicconsultation‘TransformingYourCare:VisiontoActionConsultation’[41]waslaunchedinOctober2012outlininghowanewmodelofcarewastobeorganisedwithfourkeythemes:

• Keepingindividualshealthybyhelpingthemtoimprovetheirownhealthandwellbeing;

• Deliveringservicesaslocallyaspossible;

• Ensuringemergencyandspecialistcarewassafeandsustainable;and

• Collaborationwithneighbouringjurisdictions.

TheTYCConsultationstatesthatNIhasgreatermentalhealthneedsthanotherpartsoftheUnitedKingdomandthereasonsforthisinclude“…persistent levels of deprivation in some communities in Northern Ireland and the legacy of Northern Ireland’s troubled history.”Despiteitsrelativelylonghistoryofanintegratedhealthandsocialcaresystemenablingdifferentpartsofthesystemtoworktogether,serviceswereoftenfragmentedandpoorlyco-ordinated[42].

Keyproposalsformentalhealthserviceswere:

1. BetterearlierinterventionbyjoininguphowmentalhealthservicesworkwithGPsandotherprimarycareproviders.

2.Areductioninthenumberofpeopleininstitutionalcareandinpatientbeds.

3.Thedevelopmentof6in-patientmentalhealthunitsforthoseaged18+-onesiteinNorthern,Southern,SouthEasternandBelfastareas,withtwointheWesternarea.

4.Enhancedsupportforcarers.5.Promotionofuptakeofself-directedsupportandother

programmesinorderthatpeoplewouldhavechoiceandcontroloverthecaretheyreceive.

TheConsultationresponsesshowedbroadsupportfortheproposalsrelatingtomentalhealthservices,particularlyfortheneedtoprogresstheBamfordrecommendations.CommentingonthehealthandsocialcareinNIthePublicAccountsCommittee(PAC)said“TransformingYourCareisheraldedasthegreattransformationsaviourforhealthandsocialcare,butthepaceofchangehasbeen,atbest,mediocre.”[43]

ThePsychologicalTherapiesStrategy[25]recommendedthatthosewithmildtomoderatementalhealthproblemsshouldbeabletoaccesspsychologicaltherapiesandinitssubmissiontotheTYCReview,theRoyalCollegeofPsychiatristsemphasisedtheneedforasystemcapableofearlyintervention.TYCintroducedtheSteppedCaremodeladoptingagraduatedapproachtomeettheserviceuser’sindividualneeds.

OperationalplanninganddeliveryforTYCwasundertakenbytheHealthandSocialCareBoardandthePublicHealthAgency.However,by2014thefocusforhealthcarereformwason‘governance’.‘TheDonaldsonReview:Therighttime–therightplace’[44]wasestablishedtoreviewhowhealthandsocialcareinNIwasgoverned.DuringthereviewprocesstheReviewTeamheardcriticismthatTYCwasnotbeingimplementedduetoalackofplanningandresources.ThisledtoProfessorLiamDonaldson[45]includingasoneofhis10recommendationsacallfor‘actionnotwords’inrelationtoTYC.Herecommended“…that a new costed, timetabled implementation plan for Transforming Your Care should be produced quickly.”(P.44)[44]

TheprogressofhealthandsocialcarereformwasalsobeingmonitoredbytheNIAssemblyCommitteeforHSSPSduringthe2011-2016mandate.TheCommitteewasconcernedthattheDepartmentwasnotworkingtoameasurable,costedplanandraisedquestionsregardingthemonitoring,governanceandfundingofTYC.AkeycomponentforthedeliveryofTYCwasashiftof£83millionfromhospitalservicestocommunityservices.ThiswasnotbeingachievedduetotheDepartment’sfinances,andalthoughtheDepartmentweremakingbidsduringMonitoringRoundstoachievethe£83million,thesewerenotalwayssuccessful[5].

ProvidinganupdateonTYCtotheAssemblyin2014,thethenHealthMinister,EdwinPoots,describeditasa3-5year-journeytodeliver‘theRightCare,attheRightTime,intheRightPlace’[46].InFebruary2015,hissuccessorJimWellsstatedthatthethreetofive-yearimplementationplanforTYCwasdependentonfinancialconsiderations.HealsoacknowledgedthatJohnCompton,theauthorofTYC“…could not have envisaged the current financial backdrop”[47].By2015TYCwasvirtuallyabandonedwhenitbecameclearthattheresourceswerenotavailabletosustainitsimplementation[5].

Step 1 Recognition,AssessmentandSupport

Step 2 TreatmentforMildDisorders

Step 3 TreatmentforModerateDisorders

Step 4 TreatmentforSevere/ComplexDisordersSource:TYC(2011)

Stepped Care Model

Making Life Better – Framework For Public Health TheExecutive’sframeworkforpublichealth‘MakingLifeBetter–awholesystemframeworkforpublichealth2013-23’[4](‘MakingLifeBetter’)waspublishedin2014andbuildsonthepreviouspublichealthstrategy‘InvestingforHealth’.Ittakesaccountofconsultationresponsesonthedraftframework‘FitandWell–ChangingLives’[48].Thisplanproposedadoptinga‘lifecourseapproach’,focusingonhowthesocialdeterminantsofhealthoperateatmanylevelstoinfluencehealthinlaterlife.Foreachlifestagetheframeworkproposedapolicyaim,longtermaspirationaloutcomesandshorteroutcomestobeachievedby2015.

Outcomeswerebasedonencouragingactionaround:

• Securingsafeandsupportiveenvironments.

• Seekingtomaximisepotential.

• Promotinggoodphysicalandmentalhealthandwellbeing.

AprogressreportforMakingLifeBetter2014/15[49]reflectedtheExecutive’scommitmenttoimprovehealthandwellbeingandreducehealthinequalitiesbyfocusingonactiononthewidersocial,economicandenvironmentaldeterminantsofhealthworkingacrossdepartments.Onthethemeofgivingeverychildthebeststart,projectsincludedincreasingFamilySupportHubsthroughcoalitionsofagencies;EarlyInterventionTransformationtodeliversocialchangebyequippingparentstogivetheirchildrenthebeststart;aswellascreatingandsustainingchild-careplaces.

In2015-16theDepartmentidentifiedanumberofkeyoverarchingissuesthatwouldbelikelytoimpactontheMakingLifeBetterframeworkincluding:“… At a policy level the need to consider population health and wellbeing as integral to the development of the next Programme for Government and underpinning strategies both economic and social”.[49]


15Ulster University

Health and Wellbeing 2026: Delivering Together HealthandWellbeing2026:DeliveringTogether’[21](‘DeliveringTogether’)isaten-yearstrategyandactionplanforthetransformationofNIhealthandsocialcarepublishedinresponsetotheexpertpanelreport‘SystemsNotStructures:ChangingHealthandSocialCare’’[22],knownasthe‘BengoaReport’.

ThethenMinisterofHealth,MichelleO’Neill,saidmentalhealthwasoneofherpriorities.Shewantedtoprovidebetterspecialistmentalhealthservicesaspartofacommitmenttoachievingparityofesteembetweenphysicalandmentalhealth.Theimpactofhealthinequalitiesoncommunitiesmeans30%ofthoseinthemostdeprivedareasreportamentalhealthproblem;thisisdoubletherateintheleastdeprivedareas.

DeliveringTogetherwastobedeliveredinlinewithPfG2016-21andtheExecutive’spopulationhealthframework“MakingLifeBetter”.Itsaimistobuildcommunitycapacityandsupportthevulnerableinsociety;thoselivingindeprivation,theelderlyandthosewithlearningdisabilitiesandmentalhealthissues.Itmovesthefocustopeopleratherthanbuildings,providingcareandsupport,wherepossible,incommunitysettings.ThisisinlinewiththedirectionoftravelinhealthcarereformfromtheBamfordReviewtoBengoa.DeliveringTogetherpromisesmoresupportinprimarycareforpreventiveandproactivecarefortreatmentofbothphysicalandmentalhealthproblems.AddressingtheNIAssemblyon25October2016tolaunchDeliveringTogether,thethenMinistersaidsheintendedtobea‘MentalHealthChampion’andstressedtheneedforcontinuedco-productioninserviceplanning.TheBengoaReport(2016),DonaldsonReport(2014)andTransformingYourCare(2011)wereallinstrumentalinthedevelopmentofDeliveringTogether.However,DeliveringTogetherwasnowdescribedas“the only roadmap for reform”andisintendedtoaddressissueswheresocio-economicfactorsinfluenceaperson’squalityoflife,healthoutcomesandultimatelytheirlifeexpectancy.DeliveringTogetheristoprovidetheroadmapforaradicaltransformationinthewayhealthandsocialcareservicesaredelivered.TheMinistersaidtherewouldbeno‘quickfix’giventhesizeandscaleofthechallenge,andsheexpectedthetransformationprocesstotaketwomandatestoplan,implementandembed.

DeliveringTogetherwastoprovidemorefundingforearlysupportservices,particularlymentalhealthinterventionsandMentalHealthHubsinprimarycare.Mentalhealthissuesaremainlyreferredtoinrelationto‘servicesforphysicalandmentalhealth’.However,asectionconsisting

oftwoparagraphsisspecificallydevotedtomentalhealthandacknowledgestheparticularchallengesinrelationtomentalhealthinNI.Professionalsinthestatutoryandcommunitysectorarecommendedfortheservicestheyprovide,acknowledgingthatthementalhealthservicestheyprovideneedtoevolve,improveandbuildontheBamfordreformsfromthelastdecade.

AProgressReportforDeliveringTogetherinOctober2017[50]refersdirectlytomentalhealthonfouroccasions,ratherthanreferringto‘physicalandmentalhealth’generally.Mentalhealthisspecificallymentionedinrelationtoreforminghospitalandcommunityservicesandachievingparityofesteem,whichcontinuestobeapriority.Itstatesthatinvestmentisdependentonfunding,althoughatthetimeofpublicationworkhadprogressedonestablishingaRegionalMentalTraumaServicetoaddressconflictlegacyissues.AyearonfromthelaunchofDeliveringTogether“…a Partnership Board and Implementation Group have been put in place to take forward this service, and recruitment of staff to manage trauma caseload across the Trusts is underway.”Apapersettingouttheoptionsforthefuturedevelopmentofperinatalservices,includingproposalsforaspecialisedMotherandBabyUnit,wasalso“…ready for consideration by an incoming Minister.”(para.44).However,sincetherehasbeennoMinisterforover30months,to-datetheseplanshavenotbeenprogressed.Paragraph63refersto£200mundertheconfidenceandsupplyagreementtobemadeavailablefortransformationofHSC,withafurther£50mistobeinvestedinmentalhealthservicesover5years.Theprogressreportstatesitisimportantthatthefundingisinvestedininitiativesforthefuture,ratherthanaddressingcurrentpressures.AlinktothelatestpositioninJanuary2018lists18keydeliverablesandtheircurrentposition.ThesedonotmentiontheproposedRegionalMentalTraumaServiceorthespecialisedMotherandBabyUnit[51].

TheimportanceofworkforceplanninghasbeenhighlightedinpoliciesandstrategiessincetheBamfordReviewrecommendations.AnactionofDeliveringTogetherhasfinallyseenthepublicationofaworkforcestrategyforthenext10years.Itoutlinesthecurrentproblemsandchallengesgoingforward.

Health and Social Care Workforce Strategy 2026: Delivering for Our People TheHealthandSocialCareWorkforceStrategy2026:DeliveringforOurPeople[52](‘theworkforcestrategy)isalong-termstrategytomatchtherequirementsofhealthcaretransformationinNI.Aninitialallocationof£15millionwastobespentworkforcedevelopment,fromthe£100milliontransformationfundfor2018-19.Athirdofthe£15millionwastobespentonnursing,midwiferyandAlliedHealthProfessionalworkforcewith74additionalpre-nursingplaces,andanadditional25midwiferyplaces,meaningtherewillbeatotalof1,000nursingandmidwiferyplacescommissionedfromuniversitiesinNI.Transformationfundingwasalsoallocatedtosupporttraininginvestmentinnursingassistants,physiotherapy,radiography,paramedicsandmedicalspecialities[53].Thereisnospecificmentionofmentalhealthservicestaffrecruitmentortraining,despitetheWorkforceStrategyoutliningurgentareasneedingaddressedinrelationtomentalhealthservicestaff.

Therearesignificantpressuresonsocialworkersincludingthosewhoworkinadultmentalhealth,childprotectionandservicesforlooked-afterchildren.TherewillalsobeincreaseddemandonsocialworkservicesfromtheExecutive’stargettoimprovesocialwellbeingthroughperson-centredcare,communitydevelopment,self-directedsupportandco-production.NewlegislationincludingtheMentalCapacityAct(NI)2016[54]andtheDraftAdoptionandChildren’sBill[55]willalsomeanadditionalstatutoryrolesandresponsibilities.Inthenextfiveto10years,socialworkerswillbeexpectedtohavemorespecialistknowledgeandskills.

TheunprecedentedincreaseinrecognitionoftherelevanceandneedforpsychologicalinterventionsinhealthandsocialcareisreflectedinNICEguidanceforphysicalaswellasmentalhealthpresentations.Psychologicalinterventionsarerelevanttoimprovedhealthandwell-being,alsoreducingcostsassociatedwithdisability,healthcaredependenceandsocialexclusion.TheimplementationoftheMentalCapacity(NI)Act2016willimpactondemandforclinicalpsychologists.InlinewithNICEguidelines,inrecentyearstherehasbeenincreaseddiversificationoftheareasofemploymentincludingstaffwellbeing,AutisticSpectrumDisorderservices,andearlyinterventionservices.However,NIhasthelowestrateofclinicalpsychologistsperheadofpopulationacrosstheUKandtheRepublicofIreland.Italsohasthelowestnumberoftrainingplacesperheadofthepopulation.Approximately19%oftheworkforcearerecruitedfrom

outsideNIwitha19%vacancyrateacrossTrustswhoreportbeingunabletokeepupwithincreaseddemand[56].

SincetheStrategyfortheDevelopmentofPsychologicalTherapyService(June2010)developmentsinrecruitmenthaveseenotherprofessionsrecruitedintopsychologicalservices.Theseincludepsychologicaltherapists,behavioursupportworkers,autismworkersandrehabilitationassistantsandeffectivegovernancearrangementsarerequiredforprofessionalsdeliveringpsychologicalinterventions.

Mentalhealthnursesarethelargestmentalhealthworkforceandamentalhealthnursingreviewisunderwaytoexamineandstrengthentheirrole.Thereisalsoaneedtorevisetheundergraduatecurriculumtosupporttheprovisionofpsychologicaltherapiesandpromotethedevelopmentofadvancedpracticeroles.Recruitmentandretentionremainachallengeandanewcareerframeworkisbeingdevelopedtoenhancetheroleoflearningdisabilitynursing.Theaimistoenablethemtocontributemoresignificantlyin“… improving physical, psychological, behavioural and social outcomes across primary care, community care, and acute and specialist learning disability services.”TheMentalCapacity(NI)Act2016willalsoimpactontheworkofnurses,nursingassistantsandmidwives[57].


17Ulster University

Draft Programme for Government Framework 2016 – 21 TheDraftProgrammeforGovernmentFramework[58]waspublishedinMay2016.Thefocuswasonmeasuredoutcomesbasedonresultsratherthanintentionsandwould“require significant change to approach and behaviour to deliver the outcomes.”(p.7).Itreiteratesthatmentalwellbeingisaconsiderationofarangeofgovernmentobjectivesasitinfluencessocialcircumstancesthatcanincludeemployment,familyrelationshipsandparticipationinthelocalcommunity.

FollowingExecutiveagreementontheframeworktherewasaperiodofconsultationduringtheSummerof2016.Basedonthis,theExecutivepublisheditsProgrammeforGovernmentConsultationDocument[59],withaforewordthatstated:“Government first and foremost must be about making people’s lives better”.Theintroductionalsobeginswith“…This Programme for Government is designed to help deliver improved wellbeing for all our citizens.”

GHQ12isusedasanindicatorofmentalwellbeing.Thisisatooldesignedtodetect“…the possibility of

psychiatric morbidity in the general population”andisaquestionnairecontaining12questionsrelatingtorecentgenerallevelsofhappiness,depression,anxietyandsleepdisturbance.However,‘wellbeing’isaconceptmeaningdifferentthingstodifferentpeopleatdifferenttimesandiscircumstantial.Theuseofthetermrunstheriskthateffortswillfocusoninitiativesthatgenerateimprovementsinindicatorsofwell-beingforthemajoritywhoenjoygoodmentalhealth,ratherthantacklingthefactorsthatcontributetocreatingmeaningfulchangeforthosewithmentalillnessandsuicidalbehaviour.Withoutmeasurableoutcomesthataremeaningfulforthosewhoarethemostvulnerabletoillnesstherewillbealackofaccountability.

Intheoutcomes-basedmodelthatwillinformtheapproach,eachoutcomewillbesupportedbyseveralindicatorssothatwecanmeasuretheextenttowhichtheoutcomeisbeingachieved,“…the important principle being that indicators are attached to outcomes rather than strategies.”[59]

GrayandBirrellhaveoutlinedanumberofconceptualconcernsaroundtheuseofOutcomeBasedAccountability.TheysuggestthatinthisiterationofOutcomeBasedAccountabilitythetermoutcomeisconflatedwitharangeofperformancemanagementmetricsincludingobjectives,goals,targets,benchmarksandoutputs.Generally,inpublicadministrationoutcomesrelatetowhathasbeenachievedandaretangible.Here,outcomesrefertodesiredoutcomes,ratherthanactualoutcomeswhichcanbesomewhatmisleading.Additionally,asignificantnumberoftheseoutcomesareextremelyvague,suchaswe‘enjoylonghealthy,activelives’.Theyfurthercautionagainstfocusingonproxymeasuresandmakingassumptionsaboutcauseandeffect[60].IntheirresponsetotheconsultationontheProgrammeforGovernment,theBMAexpressedconcernthattheframeworkwasbasedsolelyonOutcomeBasedAccountabilityandquestionedifthiswasanappropriate,reliableevidencebase.

TheNIBudget2018-19[61]wasannouncedinMarch2018toprovideclaritytoDepartmentsplanningforthefinancialyearahead.Anextra£25millionwasgeneratedbyincreasingtheregionalrateandadecisionwastakentoallow£100millionofcapitalfundingtobeusedforongoingpublicserviceprovision.TherewasanincreasefortheDoH,althoughwiththepressuresonexistingservicesandincreasesindemand,itislikelythattheincreasewillpreserveratherthanenhanceservices.However,£4millionwassetasidetoenableDepartmentstotransformthedeliveryofservices.Inaddition,throughtheConfidenceandSupplyAgreement,£100millionwastobeinvestedtoprogresshealthtransformation;£20millioninseveredeprivationprogrammes,£10millioninmentalhealthservicesand£80millioninhealthandeducationprogrammes.

The‘OutcomesDeliveryPlan2018-19:Improvingwellbeingforall–bytacklingdisadvantageanddrivingeconomicgrowth’[62]isbeingtakenforwardbycivilservantsduring2018-19“… to give effect to the previous Executive’s stated objective of improving wellbeing for all – by tackling disadvantage and driving economic growth.”(p.3).

TheDeliveryPlanwillguideDepartmentsbasedontheframeworkagreedbythepreviousExecutiveandAssemblyfollowingpublicconsultationin2016.“That framework reflects population conditions in 12 key areas of economic and societal wellbeing that people said mattered most to them.”(p.3).ItwillrequireDepartmentstoworktogethertodeliver‘wellbeing’tothepopulationofNI,presumablyreflectingthe‘joined-upgovernment’thathasbeencalledforbylobbyistsforanumberofyears.

Outcome4thatweenjoylong,healthy,activeliveswillbebasedonthecross-cuttingstrategicframeworkforpublichealth.Theplannedactionsareintendedtocapturetheethosof‘MakingLifeBetter’4publishedinJune2014andaddressingwidersocialdeterminantsofhealth.Delivering

Togetherpublishedin2016alsoprovidesa“… clear vision for the transformation of Health and Social Care by putting citizens at the centre both in terms of access to care and the quality of the care they receive.”[21]

ThepriorityIssuestobeaddressedinrelationtoachievinglong,healthy,activelivesandpreventabledeathsareprioritisedaspoverty,unemployment,andhealthbehaviourssuchassmoking,alcohol/drugmisuse,poordiet,lackofphysicalactivityandbeingoverweightorobese.Otherkeyfactorsincluderoadsafety,accidentsinthehomeandwork,andsuicide.However,itisacknowledgedthatthesefactorsandbehavioursarenotsimplyamatterofpersonalresponsibilitybutareinfluencedbysocio-economiccircumstances.Inresponsetotheissuesidentified,andincollaborationbetweenGovernmentDepartments,LocalGovernment,otheragencies,theprivatesectorandthepublicitisintendedtoundertakea‘HealthierLives’programme.Onefocusoftheprogrammewillbeonhealthierpregnancywithothersonhealthierplaces,careandworkplaces,supportingpeopletotakemorecontroloftheirlives.Importantly,inrecognitionoftheimpactofsocialcircumstancesonmentalhealth,theprogrammeproposesactiontoreducehealthinequalitiesimplementedonanintensityandscalethatreflectsthelevelsofdisadvantage(‘proportionateuniversalism’).Keyareastobetargetedalsoincludealcoholanddrugmisuseandsuicide.Undertheheading‘ImproveMentalHealth’(outcome4:p.30andoutcome8:p.60),researchtheNIstudyofHealthandStress[63]iscitedestimatingthatapproximately213,000peopleinNIaresufferingfrommentalhealthissuesdirectlyrelatedtotheTroubles.Duetobudgetrestraintsanyactionsneedtohavemaximumimpact,andthereforeitisintendedtofocusresourcesonaRegionalMentalTraumaNetworkforNI.ThiswillbebasedonthePsychologicalTherapiesSteppedCareModeltoprovidearangeofservicesinclinicalsettingsandinthecommunitytodealwiththespectrumofseverityofneed.Specifically,actionstobetakenin2018-19tocreatetheRegionalMentalTraumaNetwork(‘theNetwork’)include:

• TherecruitmentofaNetworkManagertodrivethedevelopmentofandco-ordinatetheNetwork;

• Therecruitmentof10additionaltherapiststobegintobuildthecapacityoftheHSCelementoftheNetwork;

• Training10therapiststoMasterslevelinCognitiveBehaviouralTherapy(CBT);


Outcomes Indicators

Outcome 4: We enjoy long, healthy, active lives

• Healthy life expectancy at birth• Preventable mortality• % population with GHQ12 scores ≥ 4

(signifying possible mental health problem)• Satisfaction with health and social care• Gap between highest and lowest deprivation

quintile in healthy life expectancy at birth• Confidence of the population aged 60 years or

older (as measured by self-efficacy)

Outcome 8:We care for others and help those in need

• % of population with GHQ12 scores ≥ 4 (signifying possible mental health problem)

• Number of adults receiving social care services at home or self-directed support for social care and a % of the total number of adults needing care

• % of population living in absolute and relative poverty

• Average life satisfaction score of people with disabilities

• Number of households in housing stress• Confidence of the population aged 60 years or

older (as measured by self-efficacy)

Outcome 12:We give our children and young people the best start in life

• % babies born at low birth weight• % children at appropriate stage of development

in their immediate pre-school year• % schools found to be good or better• Gap between % non-FSME school leavers and

% FSME school leavers achieving at Level 2 or above including English and Maths

• % care leavers who, aged 19, were in education, training or employment

Outcomes delivered through collaborative working across Departments and beyond government and through the provision of high quality public services

Source:OutcomesDeliveryPlan2018-19[62]

• Developingandimplementingaregionalreferralpathwaywhichspansacrossstatutoryandnon-statutorydomainsforallfiveHealth&SocialCareTrusts.

Therationaleforthisistobenefitfrombetterco-ordinationacrossthefiveHSCTrustsandvoluntaryandcommunityorganisationstoensurethereistimelyaccesstohighqualitysupportandtherapy.

ThescaleoftheSelf-HarmInterventionProgrammeistobeincreasedwithanimprovedpathwaytosupportandcounsellingforthosewhopresenttoEmergencyDepartments(EDs)asaresultofself-harm.Thisisintendedtoreducetheoccurrenceofself-harmandreducesuicides.Researchhasshownthatalthoughself-harmisaknownprecursortosuicide,thosewhopresentedatemergencydepartmentsinNIwithself-cuttingalonewerethemostlikelytobedischargedwithouttreatment,ortoleavewithoutbeingseen.ResearchhasshownthatalthoughpresentationtoanEDisaknownprecursortosuicideinNI[64],thosewhopresentedatEDsinNIwithself-cuttingalonewerethemostlikelytobedischargedwithouttreatment,ortoleavewithoutbeingseen.MissingafinalappointmentwithmentalhealthservicesinNIcanalsobeanantecedenttosuicide,whereasthisisnotthecaseinEnglandorScotlandwhereoutreachservicesfocusonkeepingcontactwithpatients[7].

Child and Adolescent Mental Health Services (CAMHS) ChildandAdolescentMentalHealthServices(CAMHS)continuetobeshapedbytheBamfordReview[65].In2006theBamfordReviewidentifiedthatCAMHSwasunder-resourced,fragmented,andlackedstrategicdirection.RecentresearchfromtheChildren’sCommissioner,theNSPCC,PrincesTrustandtheEducationandTrainingInspectorateshowthatthesecontinuetobeissuesintheprovisionofmentalhealthservicesexperiencedbychildrenandyoungpeopleinNI.

Itisestimatedthataround45,000childrenandyoungpeopleinNIhaveamentalhealthproblematanyonetimeandthatmorethan20%ofyoungpeoplehavesufferedfrom‘significantmentalhealthproblems’bythetimetheyreachtheageofeighteen[7].Ina2018surveyofover2,00016–25-yearoldsinNI[66],44%ofyoungpeoplehadexperiencedamentalhealthproblemand;

• 68%alwaysoroftenfeelstressed.

• 60%alwaysoroftenfeelanxious.

• 33%alwaysoroftenfeelhopeless.

InJuly2012a‘preferred’modelfortheorganisationanddeliveryof(CAMHS)waspublished.Ratherthan

19Ulster University

beingastrategyforCAHMS,itprovidedaframeworkforservicecommissionersandpractitionerstouseinordertoremodelCAHMS[68].ThedevelopmentoftheservicemodelintroducingasteppedcareapproachwasadirectresponsetoarecommendationoftheRQIAreviewofCAMHS68andalignedwiththeoverallstrategicdirectionsetoutintheBamfordReview.Fivelevelsofsupportwereintroducedinthesteppedcareapproach;prevention,earlyintervention,specialistinterventionservices,crisisinterventionandinpatientandregionalspecialistservices.However,thesteppedcaremodelhasbeencriticisedbypractitionersandserviceusersforalackofresources,withchildrenbeingpassedfromservicetoservicewithinthemodelduetotheindividualservicesstrugglingtocopewiththedemand[69].

AnEducationandTrainingInspectorate(ETI)evaluationofemotionalandwellbeingsupportinschools[70]pointsoutthattheChildren’sServicesCo-operationAct(2015)[71]“placesanumberofdutiesonallchildren’sauthoritiestoworktogetherinthebestinterestsofchildrenandyoungpeople”.Inresponseadraftstrategy‘NewChildrenandYoungPeople’sStrategy2018–2028’[72]aims“Toworktogethertoimprovethewell-beingofallchildrenandyoungpeopleinNorthernIreland-deliveringpositivelong-lastingoutcomes”(DE,2018).ETIalsowelcomedanintegratedapproachtosupportyoungpeople[73]andthepublicationoftheChildrenandYoungPeople’sStrategyconsultationresponsereport[74].However,ETI’sevaluation

foundthatschoolswerestrugglingwithdiminishingresources,tocopewiththedemandonavailableservices.AlthoughschoolsandEOTAScentrescanaccesssupportservicesthroughtheEducationAuthorityandhealthcareservices,someschoolshavehadtousetheirownresourcestoaccesssupportinurgentcasesduetothelongreferralprocess.Itwasalsoreportedthatcounsellingservicesandotherinterventionsweretooshorttobeeffective.IntheETIreportthefivemostcommonreportedareasthatimpactedonpupils’emotionalhealthandwellbeingwereanxiety,stress,anger,relationshipsandhomelife.Bereavement,suicidalideation,identifyingastransgender,negativebodyimage,self-harmandpovertyorhighsocialdeprivationwerealsoidentifiedasbeingimportant.Anxietywasthemostcommonissuethroughoutallages,generallyrelatingtoschoolwork,friendshipsandfamilyissues.Themisuseofsocialmediawashighlightedashavinganegativeimpact,withtheinappropriatesharingofinformationonlineleadingtobullyingandsocialisolation.Selfesteemappearedtobetiedtopeersocialmediaendorsement,andparentslackedknowledgeofonlineservices,theageappropriatenessofonlinegames,andofhowtouse‘parentalcontrols’ondevices.

AnevaluationofNurturegroups[75]reportedthattheyledtoaconsistentandsignificantimprovementinsocial,emotionalandbehaviouraloutcomesamongchildrenwhohadbeenhavingdifficultyinmainstreamclasses.TheDepartmentofEducationprovidesfundingfor32Nurture


21Ulster University

GroupsinprimaryschoolsinNI.ETI’sreportfoundthatjustunderathirdofprimaryschoolshaddevelopedNurtureprovision.TheNICCYReviewalsofoundthatthementalhealthcareservicesforchildrenandyoungpeoplewereunabletocopewiththedemandsandcomplexityofissuesbeingpresented.Itwasclearthatthecorebudgetforservicesforchildrenandyoungpeoplehasnotkeptpacewiththerecommendationsforservicereform.Therewaschronicunder-investmentwithfundingallocatedtoservicesthatwerenotbasedonknownmentalhealthneeds.Thiswasresultinginamixedexperienceforyoungpeopleintheavailability,accessibilityandqualityofservices.

Reviewsofservicesforchildrenandyoungpeoplealsoidentifiedproblemswithmissedappointmentsformentalhealthservices.TheRQIAreviewofCAMHS68recommendedthatTrustsfindawaytomorecarefullymonitor‘DidNotAttend’(DNA)and‘CouldNotAttend’(CNA)asthesewereadrainonresources.Theissuewasraisedagainin2018[69]whenGPsreportedincidenceswhereserviceusersweredischargedfromcareinthecaseofCNAorDNA.Thiswashappeningatstep3(treatmentformoderatedisorders)withouttheserviceuser’sknowledgeandGPsviewedthisaspotentiallysignificantsinceitdidnotcomplywiththeregionalIEAPguidelines[76].Theserequirethat“… if a patient/client DNA/CNA their appointment, a review of the risk factors should be undertaken in partnership with the patient/client’s General

Practitioner (GP) and a second appointment offered if required. Any decision to discharge should be fully documented and the patient/client informed in writing.”[76]

SchoolsalsoreportedfrustrationaroundDNAsandCNAs,explainingthatsomeparentsdidnotattendnecessaryreviewappointments.Thiscouldbeduetoperceivedstigmaorasaresultoftheirownemotionalormentalhealthissues.Thepupilwasthenderegisteredfromtheserviceandhadtobereferredagainbytheschoolandgobackonawaitinglist[70].

RespondingtoNICCY’s‘StillWaiting’review,aspokespersonfortheRoyalCollegeofPaediatricsandChildHealth(RCPCH)[77]saidthatduetothestigmaaroundmentalhealthhavingshifted,serviceshavefailedtokeepupwithandincreaseddemand.Theresultinglackofsupportcouldhavealastinginfluenceonchildren’slivesleadingtopooremploymentprospectsandanincreasedriskofalcoholanddrugabuse.Shecalledforpolicymakerstoensurethatthoseworkingwithchildrenhadmentalhealthtrainingtoallowthemtoidentifysignsofmentalhealthissuesforearlyinterventiontotakeplace.Secondlychildrenneedtobeabletoaccessmentalhealthservicesatanytimeandanyplace,whetherthisisthroughtheeducationsystem,primarycare,orchildhealthservices.However,inorderforthistohappeneffectivelyservicesneedtobeintegratedandproperlyfunded[77].


Protect Life – A Shared Vision (2006 – 2011) SuicideratesinNIcontinuetobehigherthanotherregionsintheUKorRepublicofIreland.

Inthetableabove,suicideratesforEngland,Scotland,WalesandRoIrelateto2017.However,theNIratesarefor2016asthe2017suicidedatawasnotavailableatthetimeofpublicationinSeptember2018.Althoughtheratesarenotdirectlycomparable,“…Rates in NI have increased dramatically over the last 30 years, particularly in men.”[11].TheSamaritan’sreportcallsforimprovementsintheavailabilityofstatisticsfromtheNIStatisticsandResearchAgency(NISRA),toalignwithotheragenciesandquotesaWorldHealthOrganisationreportonsuicide:“…Measuring the success, or lack thereof, of efforts to reduce suicides, suicide attempts or the impact of suicide on society at large requires access to reliable and valid data.”[78].ThereisalsoacallforareviewoftheregistrationprocessinNI,England,WalesandtheRepublicofIreland,wheresuicidesareregisteredfollowinganinquestwhichcancauseadelayofuptoayearormore.ThisisunlikeScotlandwherethemaximumtimebetweenadeathanditsregistrationis8days[11].“Suicide rates in the general population in UK countries have shown a recent downward trend, although this is less clear in Northern Ireland which continues to have the highest rate.”[79]In2009/10itwasestimatedthatthetotalcostofsuicideinNIwasintheregionof£436million[80].AseriesofrecentstudiesintosuicideinNIdemonstratedtheassociationsbetweensuicideandadverselifeevents,mentalillnessandshowedthatsuicidedeathswereassociatedwithdeprivationandconflict-relatedtrauma.TheresearchalsoshowedthathighproportionsofthosewhodiedhadattendedtheirGPintheperiodpriortodeath,andattendanceattheEDwasalsoapredictorofdeathbysuicide.Nonetheless,only29%ofthosewhodiedbysuicideinNIbetween2000and2008hadbeenincontactwiththesecondarymentalhealthservicesinthe12-monthperiodpriortotheirdeath[81].

InOctober2006theNISuicidePreventionStrategyandActionPlan(2006–2011)forthefirstsuicidepreventionstrategy“ProtectLife–ASharedVision”waspublished,

witharefreshedversionpublishedinJune2012tocovertheperiod2011-2013[80].

The2006Strategysetoutanactionplantoincludethefollowingareas:

• Community-ledsuicidepreventionandbereavementsupportservices;

• Localresearchintosuicide;

• GPdepressionawarenesstraining;

• Enhancedcrisisinformationservices;

• All-islandpublicinformationcampaigns;

• Lifelinecrisisreferraltelephonehelpline;

• Self-harmregistry;

• Developmentoflocalsuicideclusterresponseplans;and

• Supportforrecoveryfromsuicidalbehaviourandself-harming.

Themainfindingsfromanevaluationoftheimplementationofthe2006Strategy[82]foundithadbeensuccessfulinareasincluding:

• Raisingawarenessofmentalhealthissueswithpublicinformationmediacampaignsandmediaguidelinestoensuresuicideisreportedsensitively;and

• Enhancingthesupportroleofthevoluntaryandcommunitysectorforbereavedfamiliesandthosewhohadmadeprevioussuicideattempts.

Ensuringearlyrecognitionandinterventionwithappropriatefollowupsupportserviceswasnotwhollyachievedduetoavariableawarenessofsupportservicesamongprimarycareproviders.

ThefirstProtectLife2006Strategyidentifieddepression,alcoholanddrugmisuse,personalitydisorder,hopelessness,lowself-esteem,bereavement,relationshipbreakdownandsocialisolationasriskfactorsforsuicide.However,itwasfoundin2016thatthemostcommonriskfactorsincludedeconomicadversityandrecentself-harm[83].InNIinequalityisseenasastrongcontributingfactorintheincidenceofsuicide.

Followinganeight-weekconsultationtheProtectLife2DraftStrategy[84]waslaunchedinSeptember2016withthepurposeofreducingthesuiciderateandthedifferentialintheratebetweenthemostandleastdeprivedareasinNI.Objectivesincluded:

Table: Suicide rates per 100,000 of population by gender

NI England Scotland Wales RoI

Male Female Male Female Male Female Male Female Male Female

27.3 9.2 14.0 4.6 19.9 5.7 20.9 5.8 13.2 3.3

Source:Samaritanssuicidestatisticsreport,September2018

23Ulster University

• Improvementintheunderstandingandidentificationofsuicideandself-harmingbehaviour;

• Awarenessofpreventionservicesanduptakebythosewhoneedthem;

• Enhancementoftheinitialresponseto,andcareandrecoveryofpeopleexperiencingsuicidalbehaviourorself-harming;

• Restrictionofaccesstothemeansofsuicide;

• Provisionofeffectiveandtimelyinformationandsupportforindividualsandfamiliesbereavedbysuicide;

• Provisionofeffectivesupportinthecommunitythroughvoluntary,community,andstatutorysectorsprovidingsuicidepreventionservices;

• Responsiblemediareportingofsuicide;and

• Identificationofemergingsuicideclustersandpromptactiontoreducetheriskoffurtherassociatedsuicides.

TheProtectLife2objectivesareheavilydependentonotherExecutiveDepartmentsassuicideisimpactedbyarangeoffactorsincludingunemployment,thelegacyoftheTroubles,loweducationalachievement,anddrugandalcoholmisuse.AtconsultationstageitwastobeconsideredbytheDepartmentofHealthwhetherthe‘purpose’ofthestrategyshouldincludeself-harm.Self-harmhasnotbeenincludedinthepurposestatementto“Reduce the suicide rate in the north of Ireland”and“Reduce the differential in the suicide rate between the most deprived areas and the least deprived areas”.Giventhatself-harmandEDattendanceareprecursorstosuicide[7]thiswouldappeartobequestionable.

TheProtectLife2StrategyhasbeenfinalisedbutcannotbepublishedwithoutaHealthMinisterinplace.However,theChiefMedicalOfficerDrMichaelMcBride,hasstatedthatsuicidepreventionremainsapriorityfortheDepartmentandnewinitiativesarebeingimplemented[85].HestatesthatasProtectLife2isan“enhancementanddevelopment”oftheexistingProtectLifestrategy,the“Public Health Agency continues to invest over £8m a year to deliver suicide prevention, and emotional health and wellbeing services.”Inaddition,newinitiativesthatareapartofProtectLife2arebeingfundedseparatelyaspartofwidertransformationproposals.Theseare:

1. TheLifeline24/7crisisresponsehelplinewastransferredtoBelfastHSCTruston1April2018andisavailableforanyoneindistressordespair.

2.ABelfastcrisisde-escalationpilotservicewillcommenceinearly2019.Thiswillbeanout-of-hoursfacilityprovidinga‘safeplace’forindividualsincrisis.Itwillprovidede-escalationsupportoveraperiodofhoursfollowingpresentationtoEDorcommunityandvoluntarysectorproviders.AsimilarpilotledbyDerryandStrabaneCouncilisalsoexpectedtostartshortly.

3.AstreettriagepilotcommencedinJuly2018intheSouthEasternArea.Thisinvolvesamulti-agencytriageteamwhoareavailabletorespondtopeopleinemotionalcriseswhohaveaccessedthe999system.

4.Anewprogrammetoenhancepostprimarypupilresilienceisplannedtocommencein2019/20.Aprogrammetoembedmentalwellbeinginfurtherandhighereducationisalsoplannedtocommencein2019/20.

5.Intotalfor2017/18therewere14,932participantswhoattendedandcompletedtraininginachosenmentalhealthand/orsuicidepreventionarea.

Itisclearthatsuicidepreventionisacross-departmentalresponsibility.AnanalysisofconsultationresponsesforProtectLife2identifiedfactorstobeaddressedinrelationtosuicidepreventionthatincluded:equality;debt;homelessness;domesticandsexualviolence;victimsandsurvivorsofconflict;impactofcrime;drugsandalcoholabuse;prisonreform;rehabilitationfollowingpsychiatricandprisonrelease;employability;educationandtraining.ProtectLife2identifiedprioritygroupsforsuicideprevention:LGBTpeople;migrantpopulationsandethnicminorities;homelesspeople;thosewhohaveexperiencedabuse/conflict,includingsexualanddomestic;Lookedafterchildren;thosewithPTSDasaresultoftheconflict;long-termunemployed;certainoccupationsincludingfarmers,themilitary,dentistryandlowstatusoccupations;malesaged19-55,especiallylivinginhighdeprivationareas;thoseincontactwiththejudicialsystem;peoplewithmentalillnessincludingaddictiondisorder;andthetravellingcommunity.

TheinvestmentbytheDepartmentofHealthwhentheDraftProtectLife2Strategywaspublishedwas£7millionannually.Therewasanadditionalsignificantcontributiontosuicidepreventionfromcharitiesandthevoluntarysector,mentalhealthservices,andfromotherDepartments.ThefundingcoveredarangeofservicesincludingLifeline;training;counselling;Self-harmRegistry;Self-harmInterventionService;publicinformationcampaigns;andcommunityresponseplans.

Astudyofyoungmenaged16-34inNI[86]identifiedmajorchallengestoaccessingmentalhealthservices;stigmaandfearofdiscrimination.Thetype,natureandgeographicallocationofformalmentalhealthservicesofferedlimitedhelpforyoungmencontemplatingsuicide.Astudyrecommendationwasforpro-activeservicestobecommunitybasedwithopenaccess.Theseshouldbein

non-mentalhealthserviceenvironmentssuchassportsclubs,schools,workplaces,andcommunityinterestandself-helpgroups.

Thefindingsconfirmedthevalueofcommunity-basedinformal‘drop-in’suicidecentreswhereyoungmencouldsociallyinteract.Beingpartofapeergroupwasimportant,providinganopportunitytodiscusstheirconcernswithothers.Theywerealsoabletointeractwiththosewhowerenolongersuicidalandexposedtoaninsightintothepainsuicidewouldinflict,aviewofsuicideasunacceptable,andallowingthemtoseethatrecoverywaspossible.Recoverywasseenasalong-termprocessthatwouldbeimpactedbytheirrelationshipwithmentalhealthprofessionals.Whenfirmrelationshipswereestablishedearly,theseformedthebasisforfutureinterventions.

Continuedsupportandinvolvementfrommentalhealthprofessionalsandtheirpeerswhoweremakingthejourneywiththemwasimportantforthepathtorecoveryandcounsellingwasalsofoundtobeuseful.However,avarietyofformsofcounsellingwererequiredtoaddressissuessuchaschildabuse,relationshipproblems,addictions,lossandbereavementandfamilydysfunctionality.Psychologicaltherapiesneedtobemadeavailableinroutinecaretoequipyoungmenwithcopingstrategiesthatcandealwithstress,anxietyanddisappointment,andhelptobuildself-esteem.Learninglifeskills,socialskillsandtakingpartineducationalprogrammesprovidesarangeofskillstoequipthemforfacingdaytodaylifechallenges.

Recoveryhasprovenimportant,particularlyforyoungmen.ThenextsectionlooksatrecoveryandRecoveryCollegesestablishedineachofthefiveHealthandSocialCareTrustsinNI.


25Ulster University

ImROC (Implementing Recovery through Organisational Change) Thenotionofrecoveryfrommentalillnessdatesbacktothe1980swhenamajorstudyshowedthatthecourseofmentalillnessdidnotinevitablyleadtodeterioration[87].AconceptualmodelofrecoverywasdevelopedinWisconsininAmericaalmosttwodecadesago[88]withtheaimofdevelopinga‘recovery-oriented’mentalhealthcaresystem.Recoveryreferredtobothinternalandexternalconditionsexperiencedbypeoplewhodescribedthemselvesasbeinginrecovery.Internalconditionsdescribedinlayingtheconditionsforrecoverywerehope,healing,empowerment,andconnection.Theexternalconditionsfacilitatingrecoverywere“the implementation of the principle of human rights, a positive culture of healing, and recovery-oriented services”.Theaimoftherecoveryhealthcaremodelwastolinkabstractconceptsdefiningrecoverywithpracticalactionsandstrategiesthatcouldbeusedtofacilitaterecoveryfrommentalillness[88].

TheconceptofrecoveryfrommentalillnessbecameaUKgovernmentkeyobjective.AstrategyforEnglandin2011[89]providedsharedobjectivesforhealthandwellbeing,supportingtheaimofachievingparityofesteemforphysicalandmentalhealth.Thestrategystressedconnectionsbetweenmentalhealth,housing,employment,andthecriminaljusticesystem.In2008tenkeychallengestoimplementingrecoverywereidentified[90].Theseincluded:

• Changingthenatureofday-to-dayinteractionsandqualityofexperience;

• Deliveringcomprehensive,serviceuser-lededucationandtrainingprogrammes(co-production);

• Ensuringorganisationalcommitmenttocreatethe‘culture’;

• Increasingpersonalisationandchoice;

• Redefininguserinvolvement;

• Transformingtheworkforceandsupportingstaffontheirrecoveryjourney;and

• Increasingopportunitiesforbuildingalife‘beyondillness’.

Tenyearsafterthekeychallengestoimplementingrecoverywereidentified,anImROCbriefingpaperhighlightsthe

successofrecoverycolleges[91].Sincetheideaofa‘RecoveryCollege’wassuggestedin2007-08andpilotedinLondonin2009,theirnumberhasgrowntoover75intheUKwithothersestablishedglobally.

An international Community of Practice has been established and in 2017, the European Union Development Fund invested 7.6 million Euros to build on existing initiatives and create a ‘Cross-Border Recovery College Network’ serving 8000 people facing mental health challenges in Northern Ireland and the border counties of the Republic of Ireland.[91]

RecoveryCollegesarebasedonco-production.Thisdiffersfrompreviousinitiativessuchasthe‘ExpertPatientProgramme’intheUKin1999.Whilepeerswithlivedexperienceofmentalhealthissuesco-facilitatedthecourses,thecontentwaslargelyprescribedbyprofessionals.RecoveryCollegesrepresentadeparturefromthisintermsofthemodelandapproach.EightprinciplesofaRecoveryCollegeare:

1. Theyarefoundedonco-productionbringingtogethertheexpertiseoflivedexperienceandprofessionalexpertise.

2.Theyreflectrecoveryprinciplesinallaspectsoftheircultureandaspiration.

3.TheyoperateonCollegeprincipleswithstudentschoosingtheircoursesfromaprospectus.

4.Theyareforeveryoneincludingserviceusersandthoseclosetothem,stafffrommentalhealthandrelatedagencies,andpeoplefromthelocalcommunitywhoareoutsideofthementalhealthcaresystem.

5. Thereisapersonaltutor(orequivalent)whocanofferinformation.

6.Thereisaphysicalbasewithclassroomsandalibrary.MostRecoveryCollegesadopta‘hubandspoke’approachwithabaseandsatellitecoursesindifferentlocations.

7.Theyarenotasubstituteforthespecialistassessment,treatmentandtherapyofferedbyclinicalteams.

8.Theyarenotasubstituteformainstreamcolleges.

InNI,RecoveryCollegesareestablishedineachHealthandSocialCareTrust.Theyofferarangeofclassesandcoursesonaspectsofmentalhealthtoserviceusers,theircarersandfamiliesandmentalhealthprofessionals.Basedonco-production,thosewithlivedexperienceofmentalhealthissues(serviceusers),theircarersandfamiliesworktogetherwithprofessionalstodevelopservices.Thisenabledthedevelopmentoftheregionalmentalhealthcarepathway‘YouinMindMentalHealthcarePathway’[92](‘theCarePathway)in2014thatchangedhowservicesaredeliveredinordertocreateanenvironmentandcultureofrecoveryandsupport.

Theworkbeingtakenforwardatoperationalleveldependsoncolleaguesacrosshealthandsocialcareandbeyondbringingskillsfromawiderangeofbackgrounds.Partnershipworkingandco-production“…remain key tenets of the way change is developed and implemented moving forward”.Co-productioniskeyinmentalhealthservices,withDeliveringTogethercitingtheexampleofRecoveryCollegesoperatingineachofthefiveHealthCareTrustsasgoodpracticetobebuilton.

TheCarePathway:

• Explainshowtoaccessmentalhealthcareservicesfromreferraltorecovery;

• Describesthestandardsofcareserviceusers

shouldexpectfromhealthcareprofessionalswhowillbetheirpartnersintheirrecovery;

• Outlineshowdecisionsabouttheircarewillbemadebothforthemandwiththem;and

• Putsthepersonand/ortheirfamilyornominatedfriendatthecentreofalldecisionmaking.

TheCarePathwayemphasisedtheneedforaccesstotreatmenttobespecifictotheindividualneedsofserviceusersandbasedonasteppedcareapproachdependentonthelevelofneedatthetime.Inlinewiththefocusonrecovery,thelevelofcarecanbesteppedupordownbasedondecisionstakenbythehealthcareteam.

Step 1:Self-directed help and health and wellbeing services

Step 2:Primary CareTalking Therapies

Step 3:Specialist Community Mental Health Services

Step 4:Highly Specialist Condition Specific Mental Health Services

Step 5:High intensity Mental Health Services

Responding to stress and mild emotional difficulties which can be resolved through making recovery focused lifestyle adjustments and adopting new problem solving and coping strategies.

Responding to mental health and emotional difficulties such as anxiety and depression. Recovery focused support involves a combination of talking therapies and lifestyle advice.

Responding to mental health problems which are adversely affecting the quality of personal / daily and/or family / occupational life. Recovery focused support and treatment will involve a combination of psychological therapies and/or drug therapies.

Involves providing care in response to complex/specific mental health needs. Care at this step involves the delivery of specialist programmes of recovery focused support and treatment delivered by a range of mental health specialists.

Responding to mental health problems which are adversely affecting the quality of personal / daily and/or family / occupational life. Recovery focused support and treatment will involve a combination of psychological therapies and/or drug therapies.

Source:RegionalMentalHealthcarePathway

Stepped Care Mental Healthcare model


27Ulster University

Perinatal Mental Health NIhashada‘RegionalPerinatalMentalHealthCarePathway(PNMHP)since2012,(revisedin2017)[93].ThePNMHPguidancestatesthatthisisamajorpublicissueduetotheimpactitcanhaveonthefamilyunit,yet80%ofNIdoesnothaveaccesstothespecialistperinatalmentalhealthservicesitneeds[94].However,PNMHPguidanceforhealthcareprofessionalsinNIsays“…Perinatal mental health issues which may complicate pregnancy and the postpartum year are common with 10-20% of women developing mental ill health during this time.”[95]

Perinatalmentalhealthillnessescanincludeanxietyanddepression,obsessivecompulsivedisorder,post-traumaticstressdisorder(PTSD)andpostpartumpsychosis.Theseconditionscanrangefrommildandmoderatetosevere,requiringdifferentkindsofcareandtreatment[94].KeyrecommendationsforperinatalmentalhealthcarefromtheRoyalCollegeofPsychiatristsin2015[96]includedtheprovisionofspecialisedunitswithatleast6motherandbabybedstoservetheneedsoflargepopulationswith15,000–20,000deliveries.InNIin2017therewereover23,000births[97],yetthereisnospecialistin-patientbabyunitinNI.

ANIstudyin2013hadconfirmedthatamentalhealthmotherandbabyunitwasrequired[98].ThestudywascarriedouttotesttheassumptionofserviceprovidersinNIthatnumbersofwomenrequiringmentalhealthcaredidnotjustifyamotherandbabyunit.Atthetimeofthestudytherewereestimatedtobearound860womenperyearwithaseriousmentalhealthdisorder,eitherassociatedwithchildbirthorapre-existingconditionthatdeteriorated.Datacollectiontookplaceduringa32-weekperiod.Itincludedwomenadmittedtoacutepsychiatricunitswhowereover32weekspregnantorhadachildunderoneyear.Duringthisperiodtherewere87admissionsofwomeninNIwhofittedthecriteriatorequireacutepsychiatriccare.

Perinatalmentalhealthproblemsareamajorpublichealthconcern.Childbirthisknowntoincreasetheriskofmentalillhealthforamother,andalsotheriskofarecurrenceofanexistingmentalillness.Conditionssuchasdepressionandanxietyarecommonduringandfollowingpregnancy.Whereperinatalmentalhealthissuesarenotmanged,theycanhavelonglastingeffectsonfamilyrelationshipsandthementalhealthandsocialadjustmentofchildren.Ifaconditionisacuteitcanleadtoin-patientcareandseparationofmotherandinfantduringearlydevelopmentoftheinfant.Thiscancausedistressforthemotheralsoandpreventbreastfeeding.Depressionandanxietywhenitischronicorleftuntreated,canalsoaffectaninfant’smentalhealthandhavelong-standingeffectsonachild’semotional,socialandcognitivedevelopment.Perinatal

psychoticdisorderisalsoassociatedwithanincreasedriskofsuicide[96].

Arecentreport[99]estimatedthetotalnumberofwomenaffectedbyperinatalpsychiatricdisordersin2016tobe:

ThereportfoundthatNIremainedtheonlypartoftheUKthathadnotcommittedtoinvestmentoffundsforperinatalmentalhealth.ThiswasdespitemajorfundinghavingbeenpledgedviatheBarnettformulaforthepurpose.InconsistencieswerealsofoundbetweenpolicyandpracticeintheuseofscreeningtoolsacrossHSCTrusts.Therewereconcernsamongprofessionalsregardingtheresponsewhenperinatalmentalhealthissueswereidentified,andaneedforcloseralignmentbetweeninfantmentalhealthandperinatalmentalhealthpractice[99].

AreviewofperinatalhealthservicescarriedoutbyRQIA[100]foundthatallHSCTrustshadadaptedthePNMHPandwomenwouldgenerallybeseenandmanagedusingasteppedcaremodelasrecommendedbytheNationalInstituteforHealthandCareExcellence(NICE).However,theBelfastTrustprovidessmallscalespecialistperinatalmentalhealthservicescomprisingparttimepsychiatry,socialworkandacommunitypsychiatricnurse.ThereisalsoaPerinatalMoodDisorderServicetoidentifywomenatriskandprovidetreatmentduringtheante-natalperiod.Therewasnospecificfundingfortheseservices.However,havingidentifiedaneed,theBelfastTrusttooktheriskofrespondingwithoutadditionalfunding.ArecommendationofthereviewwasthatasinglemotherandbabyunitshouldbeestablishedinNI.

Number Condition

48 Postpartum psychosis – severe mental illness with symptoms such as confusion, delusions, paranoia and hallucinations. Rate: 2/1000

48 Chronic serious longstanding mental illnesses such as schizophrenia or bipolar disorder. Rate: 2/1000

722 Post-traumatic stress disorder. Rate 30/1000

2,408 - 3,611

Mild to moderate depressive illness and anxiety states. Rate: 100-150/1000

3,611 – 7,223

Adjustment disorders and distress exhibiting distress reaction that lasts longer or is more excessive than would normally be expected. Rate: 150-300/1000

Note: Some women may experience more than one of these conditions

Source:NSPCCReport,November2018


Conclusion Thechallengesassociatedwithdesigninganddeliveringefficient,effectivehealthandsocialservicesarewell-documented.InNIhealthandsocialcareareintegrated[42]thereforeintheorythedeliveryofchangeshouldbeeasier.Thefindingsandrecommendationsofnumerousexpertreportsonhealthcarehavenotbeprogressedorimplemented.Departmentssuchashealthandeducationoperateinsiloswhichworksagainststrongeffectiveintegratedgovernance.

InthelastdecadethehealthservicehasbeensubjecttosevenmajorreviewsculminatingintheBengoaReport,“systemsnotstructures”.ThiswiderangingreviewformedthebasisofDeliveringforChangein2016describedas

anambitioustenyearplanforchange.InBengoaReportuserparticipationisstronglyadvocatedbutasalreadystated,NIisstartingfromalowbase.Thesereportssaidrelativelylittleaboutmentalhealthfocusinginsteadonthereconfigurationofexistingsystemsfordelivery.TheBamfordreviewcontinuestoinformpolicyonmentalhealthinNI,despitehavingbegunin2002andbeencompletedin2008.

Despiteaplethoraofevidence-basedresearchbeingcitedinstrategiesforhealthcareinNI,thereisstillnooverarchingmentalhealthstrategyhere.Thechallengesaroundmentalhealthrequireradicalactionwherestakeholdersincludingpoliticians,healthcareleaders,clinicians,academics,thevoluntarysectorandserviceusersworktogethertodevelopanddeliveranagreedvisionforthefuture.

29Ulster University

Itwouldbenaivetopretendthatresourcingthehealthcaresectoriseasy.However,evidenceshowsthatnotdoingso,ornotdoingsoadequatelyisafalseeconomy.Suicideisonemanifestationoffailingtoadequatelyfundanddeveloppsychologicaltherapiesandthevoluntaryandcommunitysector.Strategiescitetheimportanceofearlyintervention.Thisneedstostartinschools,evenatprimarylevelwherenurturegroupshavebeenfoundtobeeffective.

MentalhealthprofessionalsfromNIprovidedexpertwitnessoralevidencetotheHouseofCommonsNIAffairsCommitteeinDecember2018[18].TheCommitteewereinformedthat“... Bamford had its time. It raised the issue of psychological therapies, implementing the NICE guidelines and the shift to the community…”.However,theCommitteeheardthatalthoughapsychologicaltherapiesstrategywaslaunchedin2010,psychologicaltherapiesinNIare

poorlydevelopedandhavenotbeenfullyimplemented.Thevoluntaryandcommunitysectorisunder-resourced,particularlygiventhereliancethatisplaceduponthemtosupportthementalhealthcaresystem.

Researchhasshownthementalhealthimpactsandinter-generationaleffectsofover30yearsofviolence[101].Inaddition,statisticsshowthatNIhasthehighestratesofsuicideintheUK.Inwhathasbeendescribedasa“mentalhealthcrisis”NIisstillwaitingforaregionaltraumacentre,theimplementationofthemostuptodatesucidepreventionstrategy,thedevelopmentofpsychologicaltherapies,andlast,butnotleastthepublicationofthefinalevaluationoftheBamfordReviewwhichwastohavebeenpublishedin2017.


1. Bunting, B., Murphy, S., O’Neill, S. Ferry, F. (2013a).Prevalenceandtreatmentof12-monthDSM-IVdisordersintheNorthernIrelandstudyofhealthandstress,SocialPsychiatryandPsychiatricEpidemiology,48,1,81–93.

2. Bunting, B.P., Murphy, S.D., O’Neill, S.M., Ferry, F.R. (2011).Lifetimeprevalenceofmentaldisordersanddelayintreatmentfollowinginitialonset:EvidencefromtheNorthernIrelandStudyofHealthandStress.PsychMed,42,1727-1739.

3. Bell, C., Scarlett, M. (2015). Health Survey Northern Ireland: First Results 2014/15.https://www.health-ni.gov.uk/publications/health-survey-northern-ireland-first-results-201718.

4. Department of Health, Social Services and Public Safety (DHSSPS)’ Making Life Better: A Whole System Strategic Framework for Public Health 2013 - 2023 (June 2014).Available:https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/making-life-better-strategic-framework-2013-2023_0.pdf

5. Thompson, J. (2016) TransformingHealthandSocialCareinNorthernIreland–ServicesandGovernanceNorthernIrelandAssemblyResearchandInformationServicePaper40/16.http://www.niassembly.gov.uk/globalassets/documents/raise/publications/2016-2021/2016/health/4016.pdf

6. Ferry, F., Bunting, B., Murphy, S., O'Neill, S., Stein, D., Koenen,K. (2013).TraumaticeventsandtheirrelativePTSDburdeninNorthernIreland:aconsiderationoftheimpactofthe“Troubles”.Soc.PsychiatryPsychiatr.Epidemiol,43,435–446.

7. Betts, J., Thompson, J. (2017).MentalHealthinNorthernIreland:Overview,Strategies,Policies,CarePathways,CAMHSandBarrierstoAccessingServices.NorthernIrelandAssemblyResearchJanuary2017.http://www.niassembly.gov.uk/globalassets/documents/raise/publications/2016-2021/2017/health/0817.pdf

8. O’Neill, S., Ferry, F. Heenan, D (2016) MentalhealthdisordersinNorthernIreland:theeconomicimperative.LancetPsychiatry,3(5)398-400.

9. The Detail, 29 July 2016, K. Torney“SuicidedeathsinNorthernIrelandhighestonrecord”;TheDetail.Available:http://www.thedetail.tv/articles/suicide-deaths-in-northern-ireland-highest-on-record

10. McKee, L. (2016).SuicideoftheCeasefireBabies.Available:https://mosaicscience.com/story/conflict-suicide-northern-ireland/[accessed29.11.2018].

11. Simms, C., Scowcroft, E. (December 2018) SuicideStatisticsReport.https://www.samaritans.org/sites/default/files/suicide_statistics_report_final_dec_0.pdf

12. O'Neill, S., Ferry, F., Murphy, S.D., et al. (2014a).PatternsofsuicidalideationandbehaviourinNorthernIrelandandassociationswithconflictrelatedtrauma.PLoSOne,https://doi.org/10.1371/journal.pone.0091532

13. O’Neill, S., Corry, C., Murphy, S., Brady, S., Bunting, B. (2014b).CharacteristicsofdeathsbysuicideinNorthernIrelandfrom2005to2011anduseofhealthservicespriortodeath.JAffectDisord,168,466-471.

14. Patient and Client Council (2018).Ourlivedexperienceofwaitingtimesforhealthcare–PeopleinNIsharetheirstory.PatientandClientCouncil;Belfast

15. Source: The Nuffield Trust for Research and Policy Studies in Health Services.

16. “£1bn ‘needed to eradicate Northern Ireland waiting lists’” 15 May 2019;BBCNewsHealthCorrespondentMarie-LouiseConnolly.https://www.bbc.co.uk/news/uk-northern-ireland-48281652

References

31Ulster University

17. Mental Health in Northern Ireland, 20 February 2018;TogetherforYou,MentalHealthFoundation,ActionMentalHealth,Nexus,Cause.https://www.amh.org.uk/wp-content/uploads/2018/02/Briefing-Mental-Health-Crisis-in-Northern-Ireland.pdf

18. Northern Ireland Affairs Committee, Oral evidence: Funding Priorities for 2018-19 Budget: Health,HC1447;HouseofCommons,12December2018.Available:http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/northern-ireland-affairs-committee/funding-priorities-for-the-201819-budget-health/oral/94124.pdf

19. World Health Organisation (2014).MentalHealth:astateofwellbeing,http://www.who.int/features/factfiles/mental_health/en/

20. World Health Organisation (2019).Mentalhealthpolicy,planning&servicedevelopment,(WHO)https://www.who.int/mental_health/policy/services/en/

21. Dept of Health (2016).HealthandWellbeing2026:DeliveringTogether.https://www.health-ni.gov.uk/sites/default/files/publications/health/health-and-wellbeing-2026-delivering-together.pdf

22. Dept of Health (2016).Systems,NotStructures:ChangingHealthandSocialCare.https://www.health-ni.gov.uk/publications/systems-not-structures-changing-health-and-social-care-full-report

23. Dept of Health (2009).BamfordReviewofMentalHealthandLearningDisabilityhttps://www.health-ni.gov.uk/articles/bamford-review-mental-health-and-learning-disability#toc-0

24. Dept of Health.ReportsoftheBamfordReviewTeamshttps://www.health-ni.gov.uk/articles/bamford-review-mental-health-and-learning-disability

25. Dept of Health (2010).AStrategyfortheDevelopmentofPsychologicalTherapyService(June2010).https://www.health-ni.gov.uk/publications/strategy-development-psychological-therapy-service-june-2010

26. Orla McDevitt-Petrovic, Karen Kirby, Orla McBride, Mark Shevlin;‘preliminaryFindingsofaNewPrimaryandCommunityCarePsychologicalServiceinNorthernIreland:Low-IntensityCognitiveBehaviouralTherapyforCommonMentalHealthDifficulties.BehaviouralandCognitivePsychotherapyVol.46,Issue6,pp.761-767

27. Heenan, D (2009)MentalHealthPolicyinNorthernIreland:TheNatureandExtentofUserInvolvement.SocialPolicyandSociety,vol8,no4,pp.451-462.

28. Royal College of Physicians (2018).TheFutureoftheHealthServiceinNorthernIreland,RCSGGi,Edinburgh.

29. Evaluation of the 2009-2011 Bamford Action Plan as at December 2011 (January 2012);DHSSPSavailable:https://www.health-ni.gov.uk/publications/evaluation-2009-2011-bamford-action-plan

30. Delivering The Bamford Vision: The Response of the Northern Ireland Executive to the Bamford Review of Mental Health and Learning Disability Action Plan 2012-2015available:https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/bamford-action-plan-2012-15.pdf

31. Bamford Monitoring Report 2013;DHSSPS

32. Bamford Monitoring Report 2014;DHSSPS

33. The Mental Health Capacity Act (2016)receivedRoyalAssentbuthasnottodatebeenimplemented.

34. The Bamford Review Monitoring Group wasestablishedbythePatientClientCounciltorepresentserviceusersandcarersandwastomeetonamonthlybasis.

35. Minutes of meeting of 2 February 2018


33Ulster University

36. Lynch, G., Taggart, C., Campbell, P. (2017).MentalCapacityAct(NorthernIreland)2016.BritishJournalPsychologyBulletin,41(6)353-357.

37. Szmukler G., Kelly, B.D. (2016).Weshouldreplaceconventionalmentalhealthlawwithcapacity-basedlaw.BritishJournalPsychiatry,209(6),449-53.

38. Email response to Assembly Research and Information Service (RaISe) from the Department of Health Mental Capacity Implementation,MentalHealthandCapacityUnit,received14thDecember2016inBetts,J.,andThompson,J.(2017).

39. DHSSPS (2011).TransformingYourCare:AReviewofHealthandSocialServicesinNorthernIreland.https://www.health-ni.gov.uk/topics/health-policy/transforming-your-care

40. DHSSPS (2005).CaringforPeopleBeyondTomorrow–a20-yearStrategicFrameworkforPrimaryCare.https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/caring-for-people-beyond-tomorrow.pdf

41. DHSSPS (2013).TransformingYourCare:VisiontoActionConsultationAconsultationdocument9October2012-15http://www.transformingyourcare.hscni.net/wp-content/uploads/2012/10/TYC-Vision-to-Action-Consultation-Document.pdf

42. Heenan, D., Birrell, D. (2018).TheIntegrationofHealthandSocialCareintheUK:PolicyandPractice:PalgraveMacmillan,London.

43. Northern Ireland Audit Office (2017).ManagementoftheTransformingYourCareProgramme,NIO,Belfast.

44. The Donaldson Review: The right time – the right place (2014);DHSSPS.Available:https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/donaldsonreport270115_0.pdfaccessed17.1.2019

45. Professor Liam Donaldson was the former Chief Medical Officer for England.

46. Oral Statement to the Assembly by Health Minister Edwin Poots, 11 March 2014;ProgressUpdateonTransformingYourCare[Available]https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/tyc-statement110314_0.pdfaccessed27.11.2018

47. Transforming Your Care: Costs,OralAnswerstoQuestions,HSSPS,intheNIAssembly,17.2.2015available:http://www.theyworkforyou.com/ni/?id=2015-02-17.4.2

48. Dept of Health (2013).FitandWell–ChangingLives2012–2022:A10-YearPublicHealthStrategicFrameworkforNorthernIreland,Reportofresponsetopublicconsultation.https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/making-life-better-fit-well-consultation-report.pdf

49. Dept of Health (2015).MakingLifeBetter1stProgressReport2014/15https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/making-life-better-1st-progress-report-2014-15.pdf

50. Dept of Health (2017).HealthandWellbeing2026:DeliveringTogether:12MonthProgressReport.https://www.health-ni.gov.uk/sites/default/files/publications/health/hwb-2026-progress-report-october%202017.pdf

51. Dept of Health (2018).HealthandWellbeing2026:DeliveringTogether:LatestPositionfor18ActionsasatJanuary2018.https://www.health-ni.gov.uk/sites/default/files/publications/health/dlt-latest-action-point-jan-18.pdf

52. Dept of Health (2018).HealthandSocialCareWorkforceStrategy2026:Deliveringforourpeople.https://www.health-ni.gov.uk/sites/default/files/publications/health/hsc-workforce-strategy-2016.pdf

53. Dept of Health (2019).https://www.health-ni.gov.uk/news/department-health-launches-health-and-social-care-workforce-strategy

54. Mental Capacity Act (Northern Ireland) 2016http://www.legislation.gov.uk/nia/2016/18/contents/enacted


55. Dept of Health (2016).DraftAdoptionandChildrenBill.https://www.health-ni.gov.uk/sites/default/files/consultations/health/Draft%20Adoption%20and%20Children%20Bill.PDF

56. The British Psychological Society (2016).AreviewoftheClinicalPsychologyworkforceinNorthernIreland2015.https://www1.bps.org.uk/system/files/user-files/Division%20of%20Clinical%20Psychology/public/new_rep109_cp_workforce_in_northern_ireland.pdf

57. Health and Social Care Workforce Strategy 2026: Delivering for our people (May 2018);HSC,DoH.

58. Draft Programme for Government Framework;NorthernIrelandExecutive.Available:https://www.northernireland.gov.uk/sites/default/files/consultations/newnigov/draft-pfg-framework-2016-21.pdfaccessed12.11.2018

59. Northern Ireland Executive (2016).ProgrammeforGovernmentConsultationDocument2016-21.https://www.northernireland.gov.uk/sites/default/files/consultations/newnigov/pfg-consulation-document.PDF

60. Gray, A.M., Birrell, D. (2018).OutcomesBasedAccountability:ACriticalPerspective,NIA,KESS.

61. Department of Finance (2018).Latestnews,8March2018.https://www.finance-ni.gov.uk/news/ni-budget-2018-19-announced

62. The Executive Office (2018).OutcomesDeliveryPlan2018-19.https://www.executiveoffice-ni.gov.uk/sites/default/files/publications/execoffice/outcomes-delivery-plan-2018-19.pdf

63. Ulster University (2011).TroubledConsequences.https://www.cvsni.org/media/1435/troubled-consequences-october-2011.pdf

35Ulster University

64. O’Neill, S., Graham, B., Ennis, E. (2018).HealthServiceUsePriortoSuicide:APopulationBasedCaseControlStudy.JAffectDisord,246:195-200.

65. The Bamford Review of Mental Health and Learning Disability (Northern Ireland):AVisionofaComprehensiveChildandAdolescentMentalHealthService;DoHavailable:https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/Camh%20Vision%20Comprehensive%20Service%20Report.pdf

66. Prince’s Trust (2018).MacquarieYouthIndex.https://www.princes-trust.org.uk/about-the-trust/research-policies-reports

67. DHSSPS (2012).ChildrenandAdolescentMentalHealthServices:AServiceModel(July2012).https.://www.health-ni.gov.uk/publications/child-and-adolescent-mental-health-services-service-model-july-2012

68. RQIA Independent Review of Child and Adolescent Mental Health Services (CAMHS) in Northern Ireland Summary (February 2011).Available:https://rqia.org.uk/RQIA/files/05/05c7dd97-93c1-45d2-a48d-15cc85f48cfb.pdf

69. NICCY (2018).StillWaiting:ARightsBasedReviewofMentalHealthServicesandSupportforChildrenandYoungPeopleinNorthernIreland,Belfast:NICCY.https://www.niccy.org/StillWaiting

70. ETI (2018).AnevaluationoftheeffectivenessofEmotionalHealthandWellbeingsupportforpupilsinschoolsandEOTAScentres.https://www.etini.gov.uk/publications/evaluation-effectiveness-emotional-health-and-well-being-support-pupils-schools-and71. Children’s Services Co-operation Act (Northern Ireland) 2015 Chapter 10.http://www.legislation.gov.uk/nia/2015/10/pdfs/nia_20150010_en.pdf

72. Dept of Education (2017).NewChildrenandYoungPeople’sStrategy2018–2018;DE.Available:https://www.education-ni.gov.uk/articles/children-and-young-people#toc-1

73. ‘NI Health and Social Care Board (2018).WorkingTogether:APathwayforChildrenandYoungPeoplethroughCAMHS.http://www.hscboard.hscni.net/download/PUBLICATIONS/MENTAL%20HEALTH%20AND%20LEARNING%20DISABILITY/you_in_mind/21122018-HSCB-CAMHS-Pathway-Document.pdf

74. Children and Young People’s Strategy: Consultation Response Report (2018);DepartmentofEducation.Available:https://www.education-ni.gov.uk/publications/children-and-young-people

75. Sloan, S., Winter, K., Lynn, F., Gildea, A. & Connolly, P. (2016)TheimpactandcosteffectivenessofNurtureGroupsinPrimarySchoolsinNorthernIreland.Belfast:CentreforEvidenceandSocialInnovation,Queen’sUniversityBelfast.Available:https://www.education-ni.gov.uk/sites/default/files/publications/education/162037_QUB%20Nurture%20Evaluation%20Exec%20Summary%20-%20new.pdf

76. Integrated Elective Access Protocol: Guidance for Staff;BelfastHSCTrustavailable:http://www.belfasttrust.hscni.net/pdf/Integrated_Elective_Access_Protcol__Screening_template_Jan_15_2.pdf

77. RCPCH Ireland responds to NICCY’s ‘Still Waiting’ review,27September2018available:https://www.rcpch.ac.uk/news-events/news/rcpch-ireland-responds-niccys-still-waiting-review

78. World Health Organisation (2014).Preventingsuicide:Aglobalimperative.https://apps.who.int/iris/bitstream/handle/10665/131056/97892?sequence=1

79. The National Confidential Inquiry into Suicide and Safety in Mental Health.AnnualReport:England,NorthernIreland,Scotland,Wales.October2018.UniversityofManchester.https://www.hqip.org.uk/wp-content/uploads/2018/10/Ref-69-Mental-Health-CORP-annual-report-v0.4.pdf

80. DHSSPS (2012).ProtectLife–ASharedVision:TheNorthernIrelandSuicidePreventionStrategyandActionPlan2006–2013(refreshedDecember2011).

81. O’Neill, S. (2018).PolicyandPracticeBriefing:SuicidepreventioninNorthernIreland:resultsfromstudiesofsuicideandsuicidalbehaviour.UlsterUniversity.https://docs.wixstatic.com/ugd/198ed6_e939d3bfce0346029d3fa6f43f957e1f.pdf

82. DHSSPS (2012).EvaluationoftheImplementationoftheNIProtectLifeSuicidePreventionStrategyandActionPlan.https://www.health-ni.gov.uk/publications/suicide-prevention-strategy-and-reports

83. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness: Annual report and 20-year Review,October2016;UniversityofManchester.http://research.bmh.manchester.ac.uk/cmhs/research/centreforsuicideprevention/nci/

84. Dept of Health (2016).ProtectLife2:adraftstrategyforsuicidepreventioninthenorthofIreland.https://www.health-ni.gov.uk/sites/default/files/consultations/health/protect-life-2-consultation.pdf

85. Department of Health Press Release, 24 September 2018‘Newinitiativescontinuingonsuicideprevention’https://www.health-ni.gov.uk/news/new-initiatives-continuing-suicide-prevention

86. Jordan, J. et al (2011)Providingmeaningfulcare:usingtheexperiencesofyoungsuicidalmentoinformmentalhealthcareservices,ShortReport’;Queen’sUniversityBelfast,UniversityofUlsterandPublicHealthAgency.www.publichealth.hscni.net/sites

87. Harding C M., Brooks GW., Ashikaga T. (1987).TheVermontlongitudinalstudyofpersonswithseverementalillness:II.long-termoutcomeofsubjectswhoretrospectivelymetDSM-IIIcriteriaforschizophrenia.AmericanJournalofPsychiatry144:727-735.

88. Jacobson, N., Greenley, D. (2001).Whatisrecovery?Aconceptualmodelandexplication.PsychiatricServices52:482-485.

89. HM Government (2011).Nohealthwithoutmentalhealth:across-governmentmentalhealthoutcomesstrategyforpeopleofallages.https://www.gov.uk/government/publications/no-health-without-mental-health-a-cross-government-outcomes-strategy.

90. Sainsbury Centre for Mental Health (2008).ImplementingRecovery:Anewframeworkfororganisationalchange.

91. Perkins R., Meddings S., Williams, S and Repper, J.,ImRocBriefingPaper‘RecoveryColleges10YearsOn’;Nottingham:ImROCavailable:http://imroc.org/wp-content/uploads/2018/03/ImROC-Recovery-Colleges-10-Years-On.pdfaccessed29.1.2019

92. Health and Social Care Board (2014).RegionalMentalHealthcarePathway.


37Ulster University

93. Public Health Agency (2017).RegionalPerinatalMentalHealthCarePathway.http://www.publichealth.hscni.net/sites/default/files/July%202017%20PNMHP_1.pdf

94. NI Maternal Mental Health Alliance (2017).PerinatalMentalHealthisEveryone’sBusiness.https://maternalmentalhealthalliance.org/wp-content/uploads/NI-Briefing-Paper-Jan-2018.pdf

95. Public Health Agency (2017).RegionalPerinatalMentalHealthCarePathway,Revised.

96. Royal College of Psychiatrists (2015).CollegeReportCR197(revisionofCR88)PerinatalMentalHealthServices:Recommendationsfortheprovisionofservicesforwomenhttps://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/college-report-cr197.pdf?sfvrsn=57766e79_2

97. Register General (2017).AnnualReport2017https://www.nisra.gov.uk/statistics/births-deaths-and-marriages/registrar-general-annual-report.

98. RQIA (2013).Isaperinatalin-patientunitneededinNorthernIreland?GAINGuidelinesandAuditImplementationNetwork.https://www.rqia.org.uk/RQIA/files/94/94e6b89b-3846-43bb-b6f3-ddffefd654e0.pdf

99. Time for action on perinatal mental health care in Northern Ireland:Areportontheperspectivesofhealthvisitorsandmidwives,November2018;NSPCCavailable:https://learning.nspcc.org.uk/media/1585/time-for-action-perinatal-mental-health-care-northern-ireland-summary.pdf

100. RQIA (2017).ReviewofPerinatalHealthServicesinNorthernIreland.https://www.rqia.org.uk/RQIA/files/28/28f4ee85-a5e9-4004-b922-525bc41ae56d.pdf

101. O’Neill, S. et al. (2015) TowardsaBetterFuture:TheTrans-GenerationalImpactoftheTroublesonMentalHealth.CVSNI:Belfast.https://docs.wixstatic.com/ugd/198ed6_87e9d0a63623423497f4d0693ac7314d.pdf

39Ulster University


@ulsteruni

/ulsteruni

@ulsteruni

ulster.ac.uk

review of mental health policies in northern ireland: making … · 2019-08-21 · 1june 2109re...

Documents