Report of the Working Group Service Planning Forum Report of the Working Group Mental Health Service Delivery Models and Inpatient Capacity for Persons with Significant Intellectual Disability and Mental Health Problems

Report of the Working Group Working Group Representation Health Service Executive Representation Irish Medical Organisation Representation Irish College of Psychiatrists Representation Irish Hospital Consultants Association Representation National Federation of Voluntary Bodies Representation Heads of Psychology Services Ireland Chairman: Mr Hugh Kane

Report of the Working Group Terms of Reference of the Working Group To explore options capable of creating immediate additional capacity for the provision on a regional basis of inpatient facilities for persons with a significant intellectual disability who require involuntarily admission under Part 2, Section 8 of the Mental Health Act, (2001). To identify the most appropriate, integrated and cost efficient models which can provide HSE with readily accessible quality service settings for the client group and make proposals to the Mental Health Directorate of the HSE on options to be pursued to ensure interim arrangements at commencement of the remaining sections of the Mental Health Act, (2001).

Report of the Working Group Definition of the Target Populations Population 2 (individuals with specific mental health problems requiring involuntary admission) adults with significant intellectual disability and mental health problems who require involuntarily admission under Part 2 of the Mental Health Act, (2001). Population 1 (individuals with general mental health problems) Individuals with intellectual disability with significant mental health problems

Report of the Working Group Main Guiding Principles of the Working Group Mental health services for people with intellectual disability must be reconcilable with the Mental Health Act, 2001 and the current framework for mental health policy (Vision for Change, 2006). Mental health services for those with mild ID and less severe mental health problems will be provided by generic services in accordance with the principle of mainstreaming Mental health services for people with intellectual disability (as defined in the target populations) should be provided by a specialist mental health of intellectual disability team. Mental health services for individuals with intellectual disability must be coordinated and draw on existing mental health and intellectual disability expertise. Maintaining continuity of care and building on existing networks of support and expertise should be a priority concern of the service-delivery system. Mental health services for individuals with intellectual disability must be underpinned by a recovery orientation.

Report of the Working Group The Working Group Recommends………. that the framework for specialist service provision be underpinned by the Report of the Expert Group on Mental Health Policy “A Vision for Change, (2006)” that existing clinical resources in ID services be reconfigured to form Community Intellectual Disability Teams on a catchment area basis that a catchment area based specialist Mental Health Intellectual Disability Team (MHID team) will be a core resource. (provided on the basis of two teams per 300,000 population). that the initial roll-out of the proposed model builds on the capacities and resources currently deployed within statutory and non statutory sectors. that in areas of the country where there is a recognized lack of existing service an opportunity should be provided to the voluntary and private sector to tender for the provision of services in those areas. Proposed Model of Service Delivery

Report of the Working Group The Referral Pathway Intellectual Disability Services-Multidisciplinary Team, providing comprehensive Health & Social Care Individual at home- no Intellectual Disability Service Individual at home- day Intellectual Disability Service Individual residing in Intellectual Disability Service GP & PHCT Acute, Assessment and Rehabilitation beds and Day Hospital places as appropriate Mental Health Intellectual Disability Team (MHIDT) Multidisciplinary Team, providing Assessment, Treatment and Care GP & PHCT Referral point to Team

Report of the Working Group Clinical and Service Governance The Working Group Recommends………. the implementation of a integrated framework of service delivery (part of the mental health services for a defined catchment area) with measures put in place to ensure that the same service and clinical governance principles as outlined in Report of the Expert Group on Mental Health policy apply to the MHID team. (Vision for Change, 2006, p 172).

Report of the Working Group Model of Service Governance National Mental Health Service Directorate National Care Group Manager Mental Health Senior Management Staff National Medical Director National Director of Nursing Representatives of other professions in Mental Health Service User Mental Health Catchment Area Management Team (for population over 300,000) Managers of 2-3 local health offices Medical Director Nursing Director Heads of Discipline for Psychology, Social Work & Occupational Therapy Service User Mental Health Intellectual Disability Teams (MHIDT) Team Leaders Team Co-ordinators Practice Managers

Report of the Working Group Inpatient capacity and beds numbers The Working Group Recommends………. that a national review of mental health of intellectual disability acute in- patient bed capacity be undertaken prior to the 1st of November that initially 5 acute in-patient mental health intellectual disability beds, 10-day hospital places and 10 rehabilitation beds per 300,000- population catchment be made available. (Vision for Change, 2006, p 130). that a spectrum of regionally based facilities be put in place to provide a flexible and effective continuum of care based on need. the National Intellectual Disability Database Committee incorporate national statistics for individuals with intellectual disability & mental health problems in its annual report..

Report of the Working Group LHO Area Population Per Area**Acute Bed Requirement Current Capacity Additional Capacity Acute Beds Dublin Mid Lenister20.51 Area 1 East Coast Dublin181, Area 2 S.E. Dublin107, Area 3 S.W. Inner City 142, Area 4 & 5 S.W, Dublin258, Area 9 W Wicklow/ Kildare190, Area 10 Wicklow106, Longford / Westmeath 112, Laois / Offaly Dublin Nth East15.34 Area 6 N.W. Dublin159, Area 7 Nth Inner City 148, Area 8 Nth County Dublin234, Louth / Meath260, Cavan / Monaghan120, HSE West16.88 Clare110, Donegal138, East Galway106, Limerick188, Tipperary (North)65, Roscommon58, Sligo / Leitrim100, West Galway118, Mayo126, HSE South17.75 North Cork 79, North Lee 168, South Lee180, Kerry 142, Carlow / Kilkenny 119, Tipperary (South)85, Waterford109, West Cork54, Wexford125, Acute Beds

Report of the Working Group Rehab Beds LHO Area Population Per Area**Rehab Bed Requirement Current Capacity Additional Capacity Rehab Beds Dublin Mid Lenister41.11 Area 1 East Coast Dublin181, Area 2 S.E. Dublin107, Area 3 S.W. Inner City 142, Area 4 & 5 S.W, Dublin258, Area 9 W Wicklow/ Kildare190, Area 10 Wicklow106, Longford / Westmeath 112, Laois / Offaly Dublin Nth East30.68 Area 6 N.W. Dublin159, Area 7 Nth Inner City 148, Area 8 Nth County Dublin234, Louth / Meath260, Cavan / Monaghan120, HSE West33.73 Clare110, Donegal138, East Galway106, Limerick188, Tipperary (North)65, Roscommon58, Sligo / Leitrim100, West Galway118, Mayo126, HSE South35.5 North Cork 79, North Lee 168, South Lee180, Kerry 142, Carlow / Kilkenny 119, Tipperary (South)85, Waterford109, West Cork54, Wexford125,

Report of the Working Group Education The Working Group Recommends………. that staff educators examine educational and training opportunities and develop innovative strategies that address shared multi disciplinary learning and professional development. the strengthening of linkages between service and the tertiary academic and research communities not alone for the pursuit of scholarship but more importantly to ensure that practice development is continually shaped by the growing evidence base about the mental health needs of adults with intellectual disability

Report of the Working Group New Partnerships The Working Group Recommends………. that access to specialist service would be through one point-of-entry, the MHID team. the continued development of the national infrastructure of primary multidisciplinary supports i.e. Community Intellectual Disability Team (as there are many areas that lack such teams), which is a crucial element, to the success of the proposed model and must be in place. that all individuals with intellectual disability be registered with their General Practitioners. that a national mapping process be undertaken to align mental health intellectual disability services with Local Health Office catchment area designation.

Report of the Working Group The Working Group Recommends………. the need for specific interface and management contracts, protocols & service-level agreements between all agencies involved with the provision of specialist mental health service to individuals with intellectual disability. the development of fora and processes to facilitate integrated service planning and coordination in order to assure quality and to ensure that services and supports are coherent, linked and comprehensive. New Partnerships cont’d

Report of the Working Group Critical Factors Identification of current acute in-patient bed capacity Audit of the national acute in-patient bed requirements Identification of current resources Statutory & non Statutory Establishment of the MHID teams Continued development of the Community Intellectual Disability Teams that will work in parallel with the primary care teams Mapping process be undertaken to align mental health intellectual disability services with Local Health Office catchment area designation. Inclusion of all stakeholders, resolution of service & clinical governance issues Development of explicit joint-care protocols and service level agreements Utilisation of the Report of the Working Group to informs the “Vision for Change” implementation team

Report of the Working Group Organisation/funding is based on population service needs –Agency needs to be associated with a geographic catchment area. –Consultant Psychiatrists need to be associated with a geographic catchment area (as per Vision for Change). Recognise higher vulnerability and specialist nature of access –Same workload for consultant, same access for client (1 consultant team per 150,000 population). –Engage with psychiatrists to work through what service they currently provide and distinguish mental health needs. ID Clients access to same level of service as rest of population –Agencies to enhance existing services, supported by MHID team. –Legislative impact on practice – currently detain/seclude without legal framework in an intellectual disability setting. Not addressed under disability act. Options, choices and equivalence

Report of the Working Group Options, choices and equivalents The acute beds provided by HSE or designated provider. The rehab beds, in a step-up and step-down capacity, remain within the agencies. Day hospital provided by HSE or by designated provider, in actual or virtual capacity. Who is best placed to do this? The current providers, however MHID team is missing. Options for inpatient capacity

Report of the Working Group For the immediate future presentations will be addressed on a case by case basis. Children with an intellectual disability and mental health problem are a small cohort – a group within a group. In crafting a solution on an individual basis we can draw on multiple services, that is child and adolescent, id, childcare, etc. What about children?

Report of the Working Group Retain current status quo including provision within the existing adult mental health services Number of designated units, e.g. Stewarts Hospital & St. Josephs Look at developing and/or enhancing current services Address MHID team deficit Option to buy capacity in private sector Overseas treatment – preference to provide treatment here. Inpatient capacity on

Report of the Working Group We have overarching plan Local plan between HSE & agencies; need to enter into discussion and agree arrangements now Ongoing development funding through mental health and disability services. Sub-group of Implementation Team for Vision for Change to implement the recommendations made by the MHID Service Planning Forum. Reconfigure current resources - staff and infrastructure Option exists to become an approved centre operating under a consultant psychiatrist. The whole unit must be approved. HSE through its Local Health Managers obliged to provide service to all people in catchment area. What do we need to do now?