Transparency & Accountability in Budget 2009: A Call to Government on World Mental Health Day
Transparency & Accountability in Budget 2009:
A Call to Government on World Mental Health Day
10 October, 2008
Summary
Today is World Mental Health Day, the theme for which is “Making Mental Health a Global Priority: Scaling Up Services through Citizen Advocacy and Action”.
The recent Mental Health Commission report, The Economics of Mental Health Care in Ireland, estimates that the annual overall cost of poor mental health in Ireland is €3 billion, or 2 per cent of GNP. It sets out the compelling economic case for increased investment in mental health services – it says, “policy makers cannot afford not to invest in mental health”. It also points out that “advocacy groups … need to increase their efforts to persuade the public that increased investment in mental health services represents a wise and just use of resources”.
Therefore, as a civil society grouping set up to promote Government’s fulfillment of the right of everyone to the highest attainable standard of mental health and mental health care, the Irish Mental Health Coalition takes the opportunity of World Mental Health Day to highlight the urgency of the Irish Government’s providing adequate, transparent and accountable financial investment in mental health services in Budget 2009.
Not alone are mental health services under-funded, but the alarming lack of transparency and accountability continues in how funding is allocated and expended. For example, since the IMHC discovered in January 2008 that almost half of the €51.2mdevelopment funding provided to the HSE in 2006 and 2007 for A Vision for Change had been diverted to meeting deficits in other areas, we found in out from the HSE in September 2008 that the lack of transparency has not ended:
· Only ¾ of the 2006 and 2007 development money will be committed/spent by the HSE by end-2008;
· Despite the Minister for Health and Children’s intervention, some of the remaining development money may well be used again by the HSE to meet deficits;
· It is still not clear what outputs have been, or will actually be delivered and when, on these 2006 and 2007 allocations; and
· No further development money was provided in 2008, and we do not yet know if any will be allocated for 2009.
The funding issue is not a pedantic matter of numbers. In announcing these additional funding allocations, the Department of Health stated that they would be used to improve and expand services, including specialist services for our most vulnerable - children and adolescents,older people, homeless people, and people with an intellectual disability. If this was what was proposed, why did it not happen? Was the money not spent on these expansions by the HSE because there were obstacles to their delivery or because of the overriding demands of existing services? Almost three years into this seven-to ten-year policy, we simply do not know why we are no closer today to the vision set out in 2006.
This lack of transparency and accountability must finally be resolved in implementing Budget 2009. The following are our eight recommendations to the Department of Finance and the Office of the Minister for Disability and Mental Health.
Making Mental Health a Priority – An eight point Agenda for Budget 2009
1. The cost of mental ill health, and the potential financial saving from investing in prevention and more effective intervention in mental health, must inform decision-making about resourcing priorities in Budget 2009
2. The amount of funding allocated to mental health is inequitable compared with other areas of health. Budget 2009 must mark a step towards achieving equity for mental health services.
3. Government must respond to the Mental Health Commission’s recommendation that investment in mental health services should reach 10% of health spend. If Government agrees, it should begin setting a time-lined target of apportioning a floor budget of 10% of total health spend to mental health. If Government does not agree, it should state so, and why.
4. Budget 2009 must be accompanied by robust measures to ensure that oversight is exercised in how allocated budgets are expended, linked with the requirements of effectiveness, transparency, and accountability. Funds expended on mental health services must be tracked and reported by the HSE and the Department of Health and Children, and this information made available to civil society.
5. Line items for specialized mental health services, including children’s services, must be established in Budget 2009, and those budget levels protected.Safeguards must be put in place to ensure that funds allocated cannot be diverted to other to mental health service areas, at central and regional levels.
6. A capital programme must be published as soon as possible setting out the steps towards the modernisation/construction of community-based facilities, together with a plan and timeline for closure of mental hospitals and release of funds.
7. The revised HSE implementation plan for A Vision for Change for 2008-2014 due by end-2008 must include estimates for the funding required over that period.
8. In parallel to the revised HSE implementation plan for A Vision for Change, a cross-departmental implementation plan must be produced for A Vision for Change across responsible Government Departments for the period up to 2014, to include funding projections.
“Everyone has the right to the enjoyment of the highest attainable standard of … mental health.”
Article 12, International Covenant on Economic, Social and Cultural Rights
“Without adequate financing, mental health policies and plans remain in the realm of rhetoric and good intentions.”
World Health Organisation
“All of the economic evidence suggests that the individual and social returns from judicious investment in mental health in Ireland are likely to be high and sustained.”
Mental Health Commission
“The balance of the funding provided in 2006 and 2007 was time delayed to meet core expenditure pressures within existing mental health services, thus ensuring that the HSE met its obligations to deliver services within the vote, however, the balance of developments is being advanced in 2008 and 2009. […] The above, however, will be progressed in the overall context of ensuring that the HSE meets its obligations to deliver all services within the vote.”
Health Service Executive, September 2008
“It is not apparent to the Monitoring Group who in the HSE has budgetary responsibility for mental health services or how budgetary decisions affecting mental health services are met”.
Independent Monitoring Group for A Vision for Change, June 2008
Introduction
The Irish Mental Health Coalition (IMHC) brings together a wide variety of voices including voluntary mental health organisations, medical professionals, trade unions, human rights organisations and disability groups to campaign for the right to the highest attainable standard of mental health for everyone. A Core Group of five organisations is responsible for the operation of the IMHC:
Schizophrenia Ireland
Amnesty International (Irish Section)
Bodywhys – The Eating Disorders Association of Ireland
GROW in Ireland
Irish Advocacy Network
A Vision for Change
The national mental health policy framework, A Vision for Change, published by the Department of Health and Children in January 2006, and adopted as Government policy in the new Programme for Government 2007 – 2012, provides a blueprint for a radical new approach to a newly prioritised mental health system. It contains important recommendations for empowerment, advocacy, peer support, offering a range of therapies, supporting carers, and, perhaps most importantly, recovery. It recognises the crucial importance of having service users centrally involved in all planning and decision-making, from official processes to their individual cases.
The human rights of people with mental health problems were to be put at the heart of government policy. It set out comprehensive proposals for improvements and reforms in services, and the additional funding required for this neglected area of the health service. A Vision for Change notes that the “provision of adequate resources for mental health is a prerequisite for the implementation of this policy”.
Regrettably - and bearing out our concerns and those of many others – as we approach the third anniversary of A Vision for Change, mental health service users and providers are still struggling with an outdated, fragmented, and severely under-resourced system, with no end in sight to the decades of neglect.
Adequate funding is of central importance if A Vision for Change is not to follow the path of the 1984 policy, Planning for the Future, and become yet another unimplemented policy, gathering dust in Government offices. While the IMHC welcomed the addition allocation of €51.2m in 2006 and 2007 development funding to the HSE to implement this policy, these allocations were substantially used instead to shore up existing deficits. In addition, these funding injections were superimposed on an already under-resourced system. Further and more transparent investment is required if the proposed reform and expansion of mental health services outlined in A Vision for Change is to happen. The theme for World Mental Health Day, “Making Mental Health a Global Priority”, is therefore timely in Ireland’s domestic context.
Cost of mental ill health
The Mental Health Commission study, The Economics of Mental Health Care in Ireland, [1] published on 18 September 2008 estimates that the overall cost of poor mental health in Ireland was just over €3 billion in 2006, or 2 per cent of GNP. While noting the “social and individual gains to be had from increasing expenditure on mental health care services”, it sets out the compelling economic case for increased investment in mental health services. It advises: “The reasons that policy makers should invest more in mental health are: (1) the economic cost of poor mental health in Ireland is very significant; (2) the Irish public has expressed a willingness to pay extra taxation for a mental health programme that would enable more people to live in the community; (3) there is a burgeoning economic base of evidence about particular interventions which have a positive effect on the quality of life of people with mental health problems.” It concludes that “policy makers cannot afford not to invest in mental health”. International research initiatives in mental health economics also support the case for greater investment in mental health[2].
Therefore, in the current economic climate, a factor in Government deliberations towards Budget 2009 must be the billions of euro potentially lost through mental ill health and economic inactivity compared with the cost of providing a comprehensive mental health service and related supports - i.e. that, from not just a social but also a financial point of view, mental health is a good investment.
Recommendation 1 - The cost of mental ill health, and the potential financial saving from investing in prevention and more effective intervention in mental health, must inform decision-making about resourcing priorities in Budget 2009
Mental health as a proportion of total health spend
Ireland’s non-capital mental health expenditure has dropped from 13% of the national health non-capital budget in 1984 to just 6% today. A Vision for Change states: “In the context of the proportion of overall ill health caused by mental ill health (estimated at 20–25%) it is evident that the progressively declining percentage of total health funding devoted to mental health is inequitable.” A Vision for Change recommends that this percentage reach 8.24%.
Other countries such as the UK spend significantly higher proportions of their health budgets on mental health – the relative percentage is 12% in England and 18% in Scotland. The Mental Health Commission economics report calls for mental health care funding to be set at 10% of overall health spending. In adopting the WHO Mental Health Action Plan for Europe in 2005, the Irish Government undertook to provide “sufficient resources for mental health, considering the burden of disease, and make investment in mental health an identifiable part of overall health expenditure, in order to achieve parity with investments in other areas of health”.
Recommendation 2 - The amount of funding allocated to mental health is inequitable compared with other areas of health. Budget 2009 must mark a step towards achieving equity for mental health services.
Recommendation 3 – Government must respond to the Mental Health Commission’s recommendation that investment in mental health services should reach 10% of health spend. If Government agrees, it should begin setting a time-lined target of apportioning a floor budget of 10% of total health spend to mental health. If Government does not agree, it should state so, and why.
Transparency & Accountability
The IMHC is not just concerned about the levels of funding, but also the lack of transparency and accountability in how funding is allocated and expended. The enormous variations in funding between different mental health services, with some of the most socio-economically deprived urban areas among the least well resourced, have still not been resolved. Specialist services continue to be most underresourced.[3]
The ongoing lack of accountability is illustrated by the HSE’s delay in spending the €51.2mdevelopment funding provided to the HSE in 2006 and 2007 for A Vision for Change. No development funding was provided in 2008. The Department declared that, instead, 2008 should be a time to “pause and review the situation to ensure consolidation of the investment to date”. Why?
In January 2008, the HSE responded to Freedom of Information requests lodged by the IMHC finally admitting that just “57% of the developments funded in 2006 have been put in place … and 40% or €10m of the funding provided in 2007 has also been put in place”. It conceded: “The balance of the funding from 2006 and 2007 was time delayed to address core deficits in existing Mental Health services thus ensuring that the HSE met its obligations to deliver services within the vote.” In other words not only was almost half the money for extra services from 2006 and 2007 not spent by January 2008, but was diverted to address existing deficits in mental health services.
Regarding the Department’s decision not to allocate additional development funding in 2008, the then Minister for Mental Health, in his response to the IMHC in January 2008, stated: “Before any additional funding is provided it is essential that the HSE are in a position to demonstrate that money allocated for mental health services is efficiently used and that the substantial changes in the organisation and delivery of mental health services envisaged in A Vision for Change are progressed.” He also stated that the Minister for Health and Children had pointed out to the HSE that there can be no question of diverting service development funds to meet expenditure pressures arising in relation to core services.
In September 2008, the HSE responded to a further information request submitted by the IMHC stating that €19m of the €26.2m allocated in 2006 is now in place, and “by the end of 2008, 74% of the resources provided in 2007 for mental health services will be committed and in place”. The HSE letter stated that the “balance of developments will be advanced in 2009”. Services for children – amongst the most neglected – were to be prioritised at last, it promised. Worryingly, however, it added: “The above, however, will be progressed in the overall context of ensuring that the HSE meets its obligations to deliver all services within the vote.” In other words, the lack of transparency has not ended:
· Only ¾ of the 2006 and 2007 development money will be committed/spent by the HSE by end-2008;
· Despite the Minister for Health and Children’s intervention, some of the remaining development money may well be used again by the HSE to meet deficits;
· It is still not clear what outputs have been, or will actually be delivered and when, on these 2006 and 2007 allocations; and
· No further development money was provided in 2008, and we do not yet know if any will be allocated for 2009.
This lack of transparency and accountability must finally be resolved in implementing Budget 2009.
While money must be invested wisely, in that services and interventions must demonstrate efficiency and effectiveness, the pace of change cannot be dictated by accountability deficits, but by A Vision for Change itself. According to WHO, a mental health budget serves four functions: policy, planning, control and accountability. If A Vision for Change were being implemented on schedule, the 2006 and 2007 allocations would have been spent in full on service expansion, and the 2008 allocation made. That sorely needed service expansion and improvement funding can be “time delayed” and used to shore up core services, is itself a matter of serious concern, but also illustrates the wider issue of the lack of predictability, transparency and accountability in how mental services are planned and funded more generally.
Recommendation 4 – Budget 2009 must be accompanied by robust measures to ensure that oversight is exercised in how allocated budgets are expended, linked with the requirements of effectiveness, transparency, and accountability. Funds expended on mental health services must be tracked and reported by the HSE and the Department of Health and Children, and this information made available to civil society.
Recommendation 5 – Line items for specialized mental health services, including children’s services, must be established in Budget 2009, and those budget levels protected.Safeguards must be put in place to ensure that funds allocated cannot be diverted to other to mental health service areas, at central and regional levels.
Recommendation 6 – A capital programme must be published as soon as possible setting out the steps towards the modernisation/construction of community-based facilities, together with a plan and timeline for closure of mental hospitals and release of funds.
Planning for the Vision
Of critical importance in ensuring that A Vision for Change will actually be implemented is an Implementation Plan. Since A Vision for Change was published, we have constantly lobbied for the production and publication by Government of a comprehensive implementation plan, setting out obstacles and challenges and how they will be overcome.
The implementation plan finally published by the HSE in January 2008 for its areas of responsibility - i.e. mental health services - was wholly inadequate. It did not cover the full spectrum of A Vision for Change recommendations regarding mental health services, and lacked detail in most areas it actually addressed. WHO advises: “Planning should drive the budgetary process. Too often, however, plans and budgets are developed independently, with the result that objectives are not explicitly reflected in the budgets.” However, nowhere in the HSE plan was it indicated where additional funding would be required.
The HSE has been requested by the Department of Health to produce a new plan by end-2008. It is critical that the revised HSE implementation plan for A Vision for Change for the period 2008 – 2014 which will set out the HSE’s approach to implementing A Vision for Changerecommendations for that period contains estimated costs and funding projections for what it plans to deliver if this plan stands any chance at all of being delivered.
A Vision for Change is not just a mental health services policy, and addresses a range of Government Departments and agencies - interdepartmental responsibility for mental health should also be reflected in their budgets. The World Health Organisation (WHO) Mental Health Policy and Service Guidance Package advises: “it is necessary for (the) ministry of health to convince other policy-makers and planners, e.g. the executive branch of government, the ministry of finance and other ministries, the judiciary, the legislature and political parties, to focus on and invest in mental health”.
While we welcome the establishment of the Office for Disability and Mental Health in January 2008 on an interdepartmental basis, the performance of Government Departments outside Health was criticised in the two annual progress reports published by the Independent Monitoring Group for A Vision for Change, as was the lack of formal coordination arrangements across those Departments. If A Vision for Change is not to remain an aspirational document, a detailed implementation plan must be produced at the earliest opportunity across all responsible Government Departments, setting out their major activities to implement A Vision for Change, with explicit annualized performance targets and indicators, and timelines. Equally, budgets cannot be set separately from this plan on an ad hoc basis – this cross-departmental implementation plan should outline specific funding projections.
Recommendation 7 – The revised HSE implementation plan for A Vision for Change for 2008-2014 due by end-2008 must include estimates for the funding required over that period.
Recommendation 8 – In parallel to the revised HSE implementation plan for A Vision for Change, a cross-departmental implementation plan must be produced for A Vision for Change across responsible Government Departments for the period up to 2014, to include funding projections.
Conclusion - Budget 2009 is a human rights issue
Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR), to which Ireland is a party, provides: “Everyone has the right to the enjoyment of the highest attainable standard of … mental health.”This places a legal obligation on the Irish Government to provide mental health services that are available,
accessible (including economically accessible), acceptable
, and of appropriate quality.
Article 2(1)ICESCR requires the Irish Government
“to take steps, … especially economic and technical, to the maximum of its available resources, with a view to achieving progressively the full realisation of the rights recognised in the … Covenant”.
The under-availability of adequate, appropriate and comprehensive mental health services in Ireland is a significant human rights issue. At present, children and adolescents continue to wait years for assessment, and, because children’s in-patient facilities are unavailable, are placed in adult facilities in breach of the UN Convention on the Rights of the Child. There is widespread unavailability of psychological and social interventions as alternatives to medication, in breach of the right to the most appropriate and the least restrictive or intrusive treatment. While there has been a dramatic decline in the number of beds in mental hospitals, the development of community services has been painfully slow. We still have a high rate of hospitalisation for mental health problems, conflicting with the right to treatment in the least restrictive environment, and the annual reports of the Inspector of Mental Health Services finds some mental health facilities unacceptable for care and treatment of patients.
If A Vision for Change were implemented in full, it could reverse many of these pressing human rights concerns. The WHO Mental Health Policy and Service Guidance Package advises that funding allocation should form part of mental health policy: “Mental health financing is a powerful tool with which policy-makers can develop and shape quality mental health systems. Without adequate financing, mental health policies and plans remain in the realm of rhetoric and good intentions.” While A Vision for Changehas been committed to at a political level, it is essential that its roll-out be adequately resourced. The issue is not just insufficiency of funds, of course, and other challenges unrelated to funding face the mental health system. We are also conscious that resourcing is not simply a matter of figures, and that money must be invested wisely in that services and interventions must demonstrate efficiency and effectiveness. However, adequate, transparent and accountable funding is a critical factor. Civil society needs to see that A Vision for Changehas been and will be funded, and that funding can be accounted for. Budget 2009, in its content and implementation, is a critical time for Government to provide evidence that it is truly committed to making mental health a priority.
[1] By Eamon O’Shea and Brendan Kenneally, National University Ireland, Galway.
[2] E.g. work by the Mental Health Economics European Network (MHEEN) and the WHO CHOICE (CHOosing Interventions that are Cost–Effective) programme. Estimates prepared by the WHO for Western European countries show that mental health problems now account for more DALYs lost per year than any other health condition. By 2020, depression is expected to be the highest-ranking cause of disease in the developed world (WHO, World Health Report 2001, p. 11. http://www.who.int/whr/2001).
[3]For instance, the Irish College of Psychiatrists has concluded that child and adolescent psychiatric services account for only 5-10% of spending on mental health services, while serving 22.68% of the population.