• Mental Health Bill as proposed is ‘legally, clinically and logistically impractical’
   
• IMO will address Oireachtas Joint Committee on Health today (Wednesday) on priorities and concerns relating to the Mental Health Bill (2024)

 The Irish Medical Organisation (IMO) will today warn that the proposed Mental Health Bill (2024) could deny patients with serious mental illness the right to timely and often life-saving medical treatment, adding that the proposed Bill is “legally, clinically and logistically impractical”.
 
Consultant psychiatrist Professor Matthew Sadlier, who is also Chair of the Consultants’ Committee of the IMO, and consultant psychiatrist Professor Brendan Kelly will today (Wednesday) address the Oireachtas Joint Committee on Health on behalf of the IMO on priorities and concerns (including those related to involuntary admission) in the context of the Mental Health Bill (2024).
 
They will outline several concerns regarding the Bill, including those relating to the criteria for involuntary admission, the timing of patients’ psychosocial assessment and care plan regulations (see editors’ notes below for full list of IMO concerns relating to the proposed Mental Health Bill).
 
Professor Sadlier will also explain the concerns of the IMO relating to the creation of a dual process relating to patient detainment and treatment. “Patients who require voluntary or involuntary admission to a psychiatric unit are among the most ill and vulnerable in our society and require timely and accountable care. Effectively, where a patient is found to lack capacity to consent to treatment, the Bill would lead to a situation where rather than treating patients, Consultants will be required to make an application to the High Court to get permission to do so.

“While the intention of the Bill is to ensure the protection of patients’ rights in relation to autonomy, this would create a dual process for involuntary admission and consent to care which is legally, clinically and logistically impractical and could deny patients with serious mental illness the right to timely and often life-saving medical treatment.

“This will result in further decline in the patient’s condition, prolong distress and lead to potential long-term adverse outcomes. The suggested method of accessing treatment through court orders will result in a waste of precious medical time as well as court resources.”

Furthermore, Professor Sadlier will explain that the Bill will add a significant workload to a system that is already overburdened and staffed by too few doctors. “With approximately 2,000 involuntary admissions a year where many patients will lack capacity, the proposed system will put an inordinate strain on our courts and mental health services leading to increases in waiting lists and delays for treatment for many other patients.

"There are already significant workforce deficits: based on our current population we need approximately 760 consultant psychiatrists (WTEs). But of 570 approved posts, almost 30% are unfilled or filled on a temporary basis."
 
Editors’ notes
 
The IMO’s main concerns regarding the proposed Mental Health Bill are as follows:

1. The criteria for involuntary admission states that admission is “immediately necessary for the protection of life of the person or that of another person or necessary for protection from an immediate and serious threat to the health of the person or that of other persons”. The use of risk as an admission criterium asks mental health care professionals to do something that lacks a firm evidence base. Thus, the risk criteria should be removed. 

2. The provisions under Section 3 - Consent to Treatment (Involuntary Admissions) creates a dual process – one for detainment and a second for treatment. This has the potential to significantly delay the treatment of involuntary patients with severe psychiatric illness. Allowing patients to be detained without treatment will result in further decline in the patient’s condition, prolong distress and lead to potential long term adverse outcomes. The suggested method of accessing treatment through Courts orders will result in a waste of precious medical time as well as court resources.

Effectively, where a patient is found to lack capacity to consent to treatment, the Bill would lead to a situation where rather than treating patients, Consultants will be required to make an application to the High Court in order to provide necessary and often life-saving treatment to patients. With approximately 2,000 involuntary admissions a year where many patients will lack capacity, the proposed system will put an inordinate strain on our courts and mental health services leading to increases in waiting lists and delays for treatment for many other patients.
 
Patient’s decision-making capacity should be assessed at the time of admission, with due consideration to supports available under the 2015 Act, with the same criteria for admission and treatment. This would make the admission order an admission and treatment order, which would be better for the patient and the service. 
 
For additional oversight a second opinion on capacity could be provided by an independent consultant psychiatrist appointed by the Mental Health Commission and subject to ongoing review by the Mental Health Review Board.

3. The requirement for a Psychosocial Assessment (Section 22 and Section 37) at time of admission or change of admission status is not necessary for the urgent treatment of severe mental illness. Psychosocial assessments are a critical and important part of every patient’s care plan and recovery journey. However, making them part of the involuntary admission procedure could potentially lead to a situation where patients are more likely to be admitted involuntarily based on their social circumstances rather than on the basis of their mental state creating a two-tier detention process.

4. Regulations in relation to Care Plans (Section 179 and Section 181) where the Minister can determine the contents of care plans represents significant and unprecedented regulatory and political interference into clinical care and the doctor-patient relationship. Patients are entitled to a collaborative individualised care plan based on the best available options not based on political edicts.

5. In a number of areas, the Bill proposes to place statutory responsibility on clinicians (consultant and clinical directors) for administrative tasks that they have no ability to control. Such as the responsibility for obtaining staff to conduct second opinions; Psychosocial assessments; as well as the responsibility for transporting patients to the approved centre Clinical staff members do not have the authority to compel staff or approve budgets to complete these tasks. Thus, the Act should mandate a 24-hour Administration office under the HSE that is responsible for these functions, as well as bed management.

6. Under Section 28 (3) a person may be directed to give evidence to a Review Boards at a specified date and time.  This will have a significant impact on service delivery with cancellations of outpatient clinics to attend Review Boards. There should be some attempt to accommodate staff and schedules.

7. Finally, Part 6 expands the remit of the Mental Health Commission to include inspection of Community Mental Health Services. When inspecting Mental Health Services, the Mental Health Commission should assess the budget allocation received by that service to ensure that services are adequately funded. Inspections should also include an assessment of:

• Appropriate staffing levels within services and HSE recruitment services
• effects of national policy on individual approved centres, including external factors that affect a centres ability to comply with regulations