Why social care in Northern Ireland needs modernising: special report

Northern Ireland’s health minister announced a major overhaul of the province’s mental health and learning difficulties services this week.

Paul Goggins’ announcement comes on the back of four years of work by a government-commissioned review, which will continue into next year.

The Bamford review – named after original chair David Bamford, who was professor of social work at Ulster University until his death in January – has covered a huge range of subjects.

It has studied adults’ and children’s mental health services, the care of people with learning difficulties, autistic spectrum disorders, substance misuse, mental health promotion and criminal justice services for vulnerable people.

Each of these subjects has been addressed in a massive report and the review still has reports to come on the care of older people with mental health problems, promoting social inclusion and reforming the 1986 Mental Health Order, Northern Ireland’s main piece of mental health law.

The review embodied a belief these services had been historically neglected, that need, particularly in mental health, was significant in relation to the rest of the UK, and the Mental Health Order needed reform to better safeguard the rights of those detained.

Adult mental health
The review published its key report on adult mental health in June 2005.

It found Northern Ireland had significant levels of need compared to the rest of the UK. For instance, need was estimated to be 25 per cent higher than in England, for a number of reasons including higher levels of deprivation and unemployment and the impact of the Troubles.

However, a one-year study of the district of Derry found care needs were met in just 30 per cent of care episodes.

Part of the disparity was financial. The 1999 national service framework for mental health drove up spending in England and Wales to 11.8 per cent of public expenditure on health and social services in 2002-3, compared to 8.4 per cent in Northern Ireland.

But the nature of services was also an issue. Health minister Goggins said 54 per cent of the mental health budget was spent on hospital services, compared to 40 per cent in England. It also found that, despite progress in this regard, users and carers were insufficiently involved in the design and delivery of services.

Review chair Roy McClelland, professor of mental health at Queen’s University, says the over-prevalence of hospital care is down to “a legacy of a lack of strategy and vision over the years”.

The report made 136 recommendations to ensure services are based on need, sufficiently resourced, focused on mental health promotion and provided in primary and community settings unless secondary care is genuinely necessary.

McClelland says resources must double over the next 20 years, though he says that it will take at least 10 years to bring resources up to the England average.

He believes the biggest challenge will be with the workforce requirements. The report sets minimum workforce levels, for instance saying there should be 50 care staff per 100,000 population in community mental health teams.

One problem is that the number of student nurses who start training in mental health and switch to other specialisms is “unacceptably high”, he adds.

Learning difficulties
The review published its main learning difficulties report, Equal Lives in September 2005.

The report won significant praise from the province’s learning difficulties sector. Maureen Piggot, director of Mencap Northern Ireland, says: “I suppose it’s our equivalent of Valuing People. We are wholeheartedly behind the direction of travel.”

The report found that the previous decade had seen significant improvements in the lives of people with learning difficulties. Spending had risen by 53 per cent from 1997 to 2003, the numbers in long-stay hospitals had dropped by 300 since 1994, more people had supported tenancies and more children were attending mainstream schools.

However, it found levels of institutionalisation that were far higher than the rest of the UK. While 15 people per one million were in long-stay hospitals in England and Wales, and 163 in Scotland, the figure for Northern Ireland was 222. A quarter of people with learning difficulties in Northern Ireland were in nursing homes, compared to a 1997 figure for England and Wales of 7 per cent.

The report also found Northern Ireland had twice the rate of people with learning difficulties attending day centres as England, and a much lower rate of people enrolled full-time in further education.

And, it added, Northern Ireland, like the rest of the UK, faced increasing levels of need as a result of the increased life expectancy of people with learning difficulties.

The report also found that the number of organisations supporting the involvement of people with learning difficulties in services was low and limited public money was spent on advocacy and supporting participation.

It made 74 recommendations, which it said would cost £175m to implement. In 2003, spending on learning difficulties in Northern Ireland totalled £136m.

Recommendations included moving all people in long-stay hospitals into the community by 2011, with funding to ensure 80 people are settled per year between 2006 and 2011.

It also called for an extra 100 supported living places to be provided each year for the following 15 years so that people could move out of family homes into independence.

The report also demanded an independent advocacy service be set up in each area serving a population of 100-120,000, and money set aside to promote the increased take-up of direct payments which, in 2004, were used by just 12 people with a learning difficulty.

Piggot says some action has taken place to implement some of the report’s recommendations by the province’s four health and social services boards, but “much more concerted action is necessary”.

As with the mental health report, and the review’s other work, this will depend on next year’s UK comprehensive spending review and the Northern Ireland health department’s implementation plans, which are now being discussed by an inter-departmental task force.