Investment into HSE-run inpatient mental health services is required to ensure that people, regardless of their financial means, have access to a similar standard of mental health care, according to a report.

The latest annual report by the Mental Health Commission (MHC) has found that independent privately-run mental health centres typically offer a better level of care than Health Service Executive-run facilities allowing a "select number of people" with health insurance or financial means, being able to access the country's high-performing centres.

Only two thirds of individual care plans for in-patients at HSE mental health centres are of an acceptable standard, according to Dr Susan Finnerty, Inspector of Mental Health Services for the Mental Health Commission.

She told RTÉ's Drivetime: "Every person has a right, under the Mental Health Act, to their own care plan. This maps out their needs, recovery goals and the therapies needed to achieve those.

"There is poor compliance in this area, and it has been slow to improve over the past five years.

"We continue to see a lack of appropriate goals and a lack of resources."

The Mental Health Commission's 2021 Annual Report found that over a third (36%) of approved centres were non-compliant with individual care plan regulation.

Looking to the future, Dr Finnerty said there is no quick fix but that 10% of the total health budget should be allocated to mental health - at present, Ireland is only allocating 6% of resources to mental health.

Mental Health Commission Chief Executive John Farrelly said the report showed "clear evidence that the independent, private mental health service providers are generally providing care in superior standard premises than those within the public system".

The one HSE area that scored higher than the privately operated facilities last year in commission inspections was CHO 5, which covers south Tipperary, Carlow/Kilkenny, Waterford and Wexford.

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The MHC has sought an updated action plan from the HSE addressing issues relating to premises, individual care plans, and risk management practices in its mental health services.

Over the past five years the quality of premises remained the primary cause of concern for the commission, according to the report.

The 2021 annual report highlighted that premises-related concerns in HSE approved centres centred around inadequate resourcing and poor governance arrangements.

Speaking on RTÉ's Morning Ireland, Mr Farrelly said that MHC deems five HSE premises in Cork to be "unsuitable".

"People who don't have private health insurance will be going into those premises in Cork, which are also low in terms of individualised patient care," Mr Farrelly said.

"Meanwhile someone who lives in the Dublin area - where the majority of private and independent centres are - who has private health insurance, has much better choice and access.

He said that is "not equitable and not fair."

Mr Farrelly added that the HSE has invested in new buildings with special teams to "make it work" in counties Tipperary, Wexford, Carlow and Kilkenny.

"You would have to beg the question then, if it can happen in one area why can't it happen in the other?" he said.

Inspector of Mental Health Services Dr Susan Finnerty acknowledged that several new centres had been built in recent years. However, she said there remained a significant number of outdated, unsuitable buildings within the HSE stock that had suffered years of environmental neglect.

Dr Finnerty said service providers needed to act before the annual inspection identified them and enforcement action took place.

The one HSE area that scored higher than the privately operated facilities last year in commission inspections was CHO 5.

"Such knee-jerk response to adverse findings of an inspection does not indicate good governance. The comparatively better compliance rates in CHO 5 shows that the capacity is in the HSE to adequately address the premises challenges," she said.

Dr Finnerty called for "enhanced leadership and governance across the health service" if the wide ranging and innovative actions set out in the mental health policy 'Sharing the Vision' are to be achieved.

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Care plans

Dr Finnerty criticised the "persistent low compliance" with the regulation that related to individual care plans.

36% of approved centres were non-compliant with this regulation, despite the HSE stating that care planning and the individual care plan document were essential to person-centred recovery care within in-patient and community residential settings.

"Despite this, the HSE has failed to significantly improve care planning for service users over the past five years. This shows poor leadership and accountability," she said.

Mental health programme in development

The HSE has said its Mental Health Services continue to invest in premises, with €14.2 million allocated for capital development in 2022.

Responding to the MHC report, it said that in the last three years, a recurring fund of €6m has also been available to invest in the safety and compliance of mental health service infrastructure.

In a statement, it said a Mental Health Capital Programme is now in development, with the focus on upgrading existing facilities, replacing inappropriate community residential and non-residential facilities and the continued expansion of services.

It says its policy is that every patient has an Individual Care Plan and improvements in individual services have been made locally and that a national service improvement initiative has been implemented.

The HSE has said that Mental Health Services have invested additional funding in last number of years to increase the numbers of consultant psychiatrists in training, assistant psychologists leading to more clinical psychologists, and psychiatric nurses in training both at under and postgraduate levels.

It added that it would continue to invest in Mental Health Services, enhancing existing services and developing new services to cater for the population's increasing and emerging needs.

Child and Adolescent Mental Health Service

In 2021, there were 32 admissions involving children to 11 adult units compared with 27 admissions to nine adult units in 2020 and 54 admissions to 15 adult units in 2019.

In percentage terms, 6.3% of child admissions were to adult units.

This figure is slightly higher than in 2020, when admissions to adult units accounted for 5.6% of all child admissions, the lowest number since records began.

The report said the decline in child admissions to adult units in 2021 and 2020 may relate to changed admission and isolation practices in response to the Covid-19 pandemic.

However, it added that based on the data available, "it is not possible to determine a direct causal relationship".

Last year, 78% of children admitted to an adult unit were an immediate risk to themselves, while 16% were admitted due to an immediate risk to themselves and others.

31% of child admissions to adult approved centres in 2021 also occurred when there was no bed available in a CAMHS unit.

The report said this was "part of a trend" over the last number of years where the number of admissions of children to adult units "has fallen dramatically".

It pointed out that in 2009 there were more children admitted to adult units than CAMHS units.

Involuntary detention

The report shows applications to involuntarily detain people by gardaí continued to increase last year.

There were 1,971 admission orders for involuntary detention from the community in 2021 (compared to 1,919 in 2020). 35% of these initiated by An Garda Síochána (compared to 32% in 2020).

In its report last year, the commission was particularly critical of this approach to detention - pointing out that the only person to sign applications for involuntary admission to an inpatient centre should be an authorised officer of the health service.

The commission says applications by gardaí cannot be allowed to continue.

While there was a reduction in restrictive practices of both physical and mechanical restraint, episodes of seclusion were similar to the level reported in 2020.

In order to increase the protections provided to people who experience restrictive practices, the Mental Health Commission says it intends to publish updated rules and codes of practice governing these practices in this year.

The report showed that there also continued to be a very high compliance with the rules on electro-convulsive therapy, reflecting the move to centres of excellence over a number of years.

Two-tier system 'endemic' across health services

Roisin Clarke, Interim Chief Executive of Mental Health Reform, said today's report highlights a two-tier system which is endemic across health services.

Speaking on RTÉ's News at One, Ms Clarke said it is causing "serious inequities" among people suffering with mental health issues, and that while funding is an integral part of the issue, it is not the only problem.

"In addition to investment we also need stronger leadership and governance across the health service," she said.

"Mental Health Reform has been calling for the re-instatement of a national lead for Mental Health in the HSE. That role ceased in 2016 but it must now be re-instated."

Ms Clarke also raised concern over an increase in the admission of children to adult in-patient units, describing it as "unacceptable".

"In 2021, 32 children were admitted to adult in-patient units."

She said this stems in part from the closure of a CAMS unit in Dublin.

"The admission of a child to an adult in-patient unit is a contravention of their human rights and contradicts the Government's commitments under the UN Conventions on the rights of a child," she said.