Annex A

17. You mentioned bed occupancy rates in February 1999 of up to 118%: where did the overflow go? What happens when there are no admission beds available anywhere? Is there a legal problem if patients are released prematurely? [Rev R Coulter]

1. It is custom and practice that as a patient gets better, he or she goes out on pass one or two days at a time, when the bed then goes to another. But since average occupancy rates have risen from 85% to 95% there is little or no leeway for peaks in demand. The patient often comes back to find that the bed is taken.

When no bed is available a patient will stay at home with a GP on stand-by, or go to Accident & Emergency. Depending on priorities, it may be a case of a consultant deciding that another patient should go home to free up a bed. There can often be waiting lists of 18 people for up to four weeks. The situation is most acute in the Eastern HSS Board area, where a policy of escalating need is being developed. The Board will meet the running costs of one or two extra beds.

The premature discharge of patients is a risk and certainly not good practice. It would be a decision not taken lightly. There ideally should be a planned procedure for discharge involving the family GP with the Trust. We are not aware of any legal cases pending. It is difficult to know where the legal liability would lie in such circumstances given the protracted lines of accountability from the Department to the Boards and then the Trusts.

17. You mentioned the problem with the lack of research on mental health: how could this matter best be taken forward? Why has the number of referrals doubled since 1995? Does the panel take the view that at least some of the in-patients in Muckamore Abbey Hospital do not need to be there? [Mr Berry]

1. We meet annually with the Department's Specialist Advisory Committee but the agenda does not seem to change much from year to year. We would like to see some epidemiological research. Northern Ireland would be an excellent location to adopt a regional approach to examining, for example, schizophrenia.

Primarily demands have increased because people increasingly suffer from anxiety and depression. Society is generally more aware of mental disorders and of the need to seek help. But as demands on the service have increased, resources have not kept pace. We thus need a full range of services so that the most seriously ill receive preferential treatment.

There is an acute need for a regional plan for in-patient psychiatric hospital care, particularly for children and adolescents, with minimum standards for each area. There is definite scope for cross-border liaison in this context. I do not believe that all the in-patients in Muckamore need to be there. Such developments will, of course, require additional resources, including trained staff.

17. We have been advised previously that as many as one in three children in Northern Ireland suffer from some sort of mental disorder, which seems very high. Can you confirm if this is correct? Also, could the massive increase in the number of psychiatric hospitals admissions from some 7000 in 1992 to over 11000 in 1999 be as a result of post traumatic stress disorder that may have been brought on by the end of the Troubles? Is this trend likely to get worse, and what steps are being taken to deal with it? Who measures it?[Mr McFarland]

1. The overall prevalence of mental health disorders among children in Northern Ireland is about 20%. The Eastern HSS Board has been meeting needs through a tiered approach. Some 69,000 are at tier one, the lowest level, with some 350 at tier 4, who receive in-patient psychiatric care. But there is a worrying upward trend in the figures. While a child or young person may appear to be coping well with trauma, they can become sensitive to other losses in the future.

Post traumatic stress disorder is a huge problem that went largely unnoticed during the Troubles. But there are multiple reasons for the big increase in admissions. For example, an increase in people with psychotic disorders, and patients who were released back into the community too early from hospital with insufficient support. Also people are making more demands on the system. Numbers requiring acute crisis intervention have gone up. Length of patients' stay in hospitals has reduced, which in turn results in more re-admissions. Better support structures in the community could save on some admissions.

Figures are collected but data is of a poor quality. We would like the Department to take this forward in a more structured fashion. Research on this area would be helpful.

17. Given the lack of facilities, beds and services in the community that you have highlighted, there is a clear need for more direction and workforce planning. We need to have a clear picture of the problems so that they can be addressed. How can psychotherapy services be developed? How do we begin to tackle stigma? I am concerned at suicide rates in the young male population. [Ms Hanna]

1. Although each HSS Board area makes its own plans, these do not deal with the totality of the problems. There is an urgent need for a co-ordination of policies on a regional basis, which should not be difficult to do as Northern Ireland has integrated health and social services. There ought to be overall uniformity of standards and timescales with the necessary resources. The establishment of the HSS Trusts system actually developed a lot of competition, whereas we need cross-Trust working and collaboration.

The development of psychotherapy services - indeed, all specialist services - are crying out for proper workforce planning. These could be properly planned if Trusts were to work together under a regional co-ordination unit.

In terms of dealing with stigma, there is no easy answer, but it is recognized as a major theme. We need to look towards developing partnerships between voluntary and statutory agencies in health promotion. However, this will be a long, slow process to get over.

Suicide is a great concern. The aim of child and adolescent health services would be to help prevent suicides with improved services created on a multi-agency basis, recognizing signs earlier and providing better support. Manpower is a problem for child and adolescent services, although funding is being made available for more beds. It seems there are broader social trends that contribute to higher suicide rates: sense of alienation without a role, drug and alcohol abuse, and peer pressures. It is not just a psychiatric issue. A suicide worker in the Greater Shankill area is currently doing research work but more extensive work needs to be done.

17. I should like to have the panel's views on the whether it believes the Department will meet its three stated objectives on mental health in the 'Priorities for Action' document for 2001/02. These were as follows:

• Boards and Trusts should increase the number of child and adolescent psychiatric beds from 6 as at 1 April 2000 to 16 by 16 December 2001.

• Boards and Trusts should secure an additional 35,000 consultations for the mentally ill in the community.

• Boards and Trusts should finalize plans for the provision of a Medium Secure Unit by December 2001.

Does the panel know anything about the implementation of the agreed programme flowing from the 'Minding Our Health' document? [Ms McWilliams]

1. There is a concern about the lack of trained staff. Multi-disciplinary courses are about to be run shortly. But without the extra staff, clearly the extra beds cannot be activated. As a child psychiatrist I would want to see a project group established to work on the implementation of the first target, which is a positive step towards to longer-term objective of 25 extra child and adolescent psychiatric beds. As an interim step I would envisage an increase from 6 to10 beds in the east and 10 in the west of the province.

The Department is targeting more resources for community and mental health teams aimed at getting more consultations, which is welcomed. But we are not sure of what exactly is meant by "consultations", how the figure of 35, 000 was reached, and by when the target figure is to be achieved? In terms of domicillary services, people do have greater access to psychiatric services in their own home, but the service can vary from Trust to Trust, and can also depend on other workloads.

There is a plan for a 34-bed Medium Secure Unit in Northern Ireland but this would not be able to meet all security needs; some would require a higher level of security. For example, at present we have 17 patients in Carstairs in Scotland and 5 need to be in maximum security. There is a secure unit in Dublin, and as we move to greater co-operation between North and South, there should be good opportunities for training harmonization possibilities. Some people will want to be in Dublin rather than Scotland.

We were not happy with the original draft of 'Minding Our Health' but have not seen anything else since.

17. In terms of people suffering from dementia, are there medical specialists who make assessments at the different levels and decide on the most appropriate levels of care needed? For example, patients in the same residential care home can require quite different levels of care, and this can make it difficult for the families to know what is the best for their relative who is ill. [Ms Armitage]

1. Dementia is a highly organized sub-speciality but needs more resources. We have step-down levels of care and multi-disciplinary specialists to make old age psychiatric assessments. A patient would start off in a home for people with dementia and then move eventually to a nursing home. The patient's family has, of course, the right of appeal against the assessment option. A range of support packages should be available in every locality to facilitate a person remaining in their own home as far as possible. A number of drugs for dementia have been introduced in recent years but we need to fully assess their suitability.

17. Does the panel have figures for people with dementia in younger years? Is there a segregation of data into age groups? With such an increase in the rates of teenage pregnancies, are there more problems after birth, for example, with depression? [Mrs Robinson]

1. We will take away the question on figures for dementia in younger people but we suspect that there is not much on segregation. In terms of teenage pregnancies, research shows that the rates of mental health problems are much greater when the parent lacks close support. There is not normally a problem where there is a tight-knit family circle. This group does, though, give birth to a higher rate of children with disabilities.




Health and Social Services Minutes 28 March 2001