Co-production and collaborative working has become part of the national agenda in mental health in Ireland. The origins of collaboration and co-production in mental health stem from legislative changes introduced under the Mental Health Act in 2001 (MHA 2001), which for the first time saw the establishment of a Mental Health Commission with service user representation and the formation of independent mental health appeals tribunals for those involuntarily detained.
In Ireland collaboration has become synonymous with coproduction and has become linked into the recovery movement. In 2005, the Mental Health Commission produced a Vision for Recovery (MHC, 2005:9) which considered that “… normal levels of psychosocial functioning and sustained periods of symptom remission cannot be reached through shortcuts. Rather clients, family members and practitioners will have to form partnerships to travel the long and hard road to organise and deliver services that are sustained, comprehensive, coordinated, collaborative and consumer-oriented”. It subscribed to two principles:
- Health professionals would work to reduce clinical distance:
Mental health professionals would be able to establish professional relationships with service users based on a respectful collaboration which acknowledges the expertise which the professional may be able to offer, the unique knowledge the individual has about his or her own experience and their common experience as human beings. Professionals would be highly qualified and skilled but would also be able to see themselves as human beings who will experience trauma at different points in their own lives and who can imagine what it is like to be ill.
- Service developments would incorporate the expert knowledge of service users:
Mental health service users, as important stakeholders, would be involved at all levels in the planning of all service developments. Management structures would be widened to incorporate the involvement of service users. At present our mental health system tends to disregard the valuable knowledge of those who have found a pathway to recovery as somewhat insignificant.
The concept of valuing people’s perspectives on mental health was brought to the fore in the Irish strategy for mental health development “A Vision for Change” (Government of Ireland, 2006:38-39) which sought to encompass the service user perspective in the future development of mental health services. In Chapter 3, “Partnership in care: Service users and carers” to increase engagement,it recommended that:
- Service users and carers should participate at all levels of the mental health system.
- Advocacy should be available as a right to all service users in all mental health services in all parts of the country.
- Innovative methods of involving service users and carers should be developed by local services, including the mainstream funding and integration of services organised and run by service users and carers of service users.
- The adult education system should offer appropriate and supported access to information, courses, and qualifications to service users, carers and their representatives that would help to enhance and empower people to represent themselves and others.
- A National Service User Executive should be established to inform the National Mental Health Directorate and the Mental Health Commission on issues relating to user involvement and participation in planning, delivering, evaluating and monitoring services including models of best practice; and to develop and implement best practice guidelines between the user and provider interface including capacity development issues.
- Carers should be provided with practical support/ measures such as; inclusion in the care planning process with the agreement of the service user, inclusion in the discharge planning process, timely and appropriate information and education, planned respite care and should have a member of the multidisciplinary team to act as a keyworker/designated point of contact with the team and to ensure these services are provided.
- The experiences and needs of children of service users should be addressed through integrated action at national, regional and local levels in order that such children can benefit from the same life chances as other children.
- Mental health services should provide ongoing, timely and appropriate information to service users and carers as an integral part of the overall service they provide.
- Information on the processes involved in making complaints or comments on mental health services should be widely available.
- Service user involvement should be characterised by a partnership approach which engages with a wide variety of individuals and organisations in the local community.
It could be considered that Ireland is in the early stages of moving to integration of service users into mental health services and there are acknowledged areas of good practice throughout Ireland examples of this include the DCU cooperative learning programme now in its 8th year, service user-led Recovery Colleges, which there are now five, and the EOLAS family and service user education programme. Other examples of peer-led community development projects are The Gateway Project, in Rathmines, Suicide or Survive, Áras Folláin, Open Dialogue, Trialogue, Hearing Voices Network Ireland.
There has also been mental health service user involvement in the Dublin North City management team for a number of years. Other areas of collaborative practice include the Clubhouse model, WRAP, IMHREC, Irish Advocacy Network, and the COMMUNE Project. A significant factor in growing collaborative practice has been the movement of Irish universities in developing more service user involvement in the curriculum and having peer support learning inputs into teaching and research.
In 2010 the Mental Health Commission produced a National overview of service user, family/carer and advocacy involvement in mental health services and this recommended:
- At a minimum, every service user should be involved in developing their individual care plan and be offered a written copy of it.
- Each service should introduce one new initiative to enhance service user, family/carer and advocacy involvement in 2011.
A significant presence in progressing collaborative working and coproduction is the Advancing Recovery in Ireland (ARI) initiative, created to drive recovery in Ireland. ARI operates as a HSE National Health Service improvement initiative, to integrate Recovery through Partnership, by bringing about organisational and cultural change in mental health services in becoming more “Recovery-oriented”.
ARI defines co-production as a “… means delivering public services in an equal and reciprocal relationship between professionals, people using the services, their families and their neighbours with equality of esteem and regard for the unique and essential expertise of all stakeholders.” (2017)
For ARI it is not “”about one person conceding to another’s position but both parties reaching consensus to go to a new place together, a place where recovery happens”.
The formation of Mental Health Consumer Panels by the HSE is seen as a potential way of strengthening collaborative working. MH Consumer panels are a collaborative approach to the development of mental health services seen as a key principle emerging from “A Vision for Change” (2006) the panels were designed to be a bridge between the HSE and members of the public who use or have experience of using mental health services, as well as people who have an interest in developing and improving the service. The Consumer Panels “… allow service users and their carers to share their direct experiences of dealing with the service and highlight areas for improvement”.
Challenges have been identified in Ireland’s approach to recovery and collaborative working. Mental Health Reform (2017) evaluated the progress of the implementation of “A Vision for Change” (2006). It identifies that although “some plans have been made on the development of a ‘shared care’ collaborative approach to mental health delivery in Ireland, national systems for shared care are not yet in place”. For example, in their survey of consumer panels inconsistency across the county with regard to service user involvement in local area management. It also raised concerns as to whether panels received adequate funding.
It is considered that there have been varied levels of service user engagement and involvement and that establishing consumer panels has proved challenging in some regions. On a positive side members of consumer panels agreed that service users were seen as as equal partners in the creation and development of care/recovery plans.
An acknowledged challenge is that whilst pockets of good practice exist, only a handful of peer-led projects are in place. There are wide variations in levels of support for service user engagement in mental health services across the country, and many initiatives to involve service users rely on keen individuals at local level.
Funding is also a key barrier to more widespread adoption of collaborative working, where peer-led and peer-run services have struggled to get sustainable funding. Many projects relied on philanthropy to drive initiatives and this resulted in projects receiving short term funding only. The Irish Advocacy Network and the GROW organisation are the only two national-level peer-run services with mainstream HSE funding.
A further limitation in collaborative working is that there no automatic right to advocacy under the Mental Health Act, 2001. For service users the only legal recourse is access to representation for a review tribunal. This often comprises a lengthy process sometimes fraught with delays. Existing peer advocacy services currently only provide support for adults in inpatient mental health services and there are currently no provisions for people availing of community mental health care. There is no national advocacy service for children and adolescents. The Citizens Information Act, 2007 envisaged the development a statutory advocacy service, but this has not been implemented yet.
Mental Health Reform (2017) also identifies inconsistency in approaches to working nationally, with variable levels of service user and family involvement in recovery planning. So, it appears that some professionals are adopting a partnership approach, but this is not a universal practice.
Ireland can possibly be considered as being in the early stages of moving to collaborative/co-produced mental health care and is probably no better or worse off that other countries. There is still a degree of uncertainty where the level of engagement will go next.
Opportunities exist to overcome organisational and individual challenges by the creation of a climate for organisations to seek opportunities for further development. This might be enabled by:
- Providing leadership for change
- Ireland needs to develop a critical body of ‘expert stakeholders’
- There needs to be greater opportunities for Service Users to be represented on HSE senior management teams
- Ensuring organisational commitment by creating a ‘culture’
- Ireland needs to join up the pockets of good practice
- There is the opportunity to focus on embedding change and ensuring the key principles become common place across all areas
- Train the trainer needs to extend into SU and family engagement to build the body of expert stakeholders
- The project of transformation of the workforce needs to be resourced adequately
- Changing the way risk assessment and management is approach
- The redefining service user/family member/carer involvement with services needs to continue and progress by:
- Changing the nature of day to day interactions and the quality of experience
- Developing collaborative plans for implementing change, guided by the ImROC challenges.
- Increasing opportunities within society for building a life ‘beyond illness’
Perhaps the biggest threat to collaboration is that “It’s complicated!”. It can mean different things to different people, for many the language is different in different places. Increased service user involvement is perceived by some as anti-psychiatry. There are also professional fears and anxieties about inviting service users on to teams, amid concerns for confidentiality, information sharing, and the security of health records.
As yet, the concept collaboration may be unproven and we do not know whether collaborative practice reduces admissions and reliance on mental health services, or whether collaboration and co-production is justified as being more ethical, moral and humane an approach to working in mental health.
The provision of funding for mental health is seen as the one of the greatest threats to progressing collaborative working in mental health. A question that may be asked is if recovery becomes too expensive is policy going to change? The College of Psychiatrists in Ireland state funding for mental health “…shows lack of commitment, vision and real concern for the mental health of the nation” and the budget total for mental health services “falls far short” of the international norms and standards at 6.3 per cent of the overall health budget in comparison to 13 per cent in the UK and 11 per cent in Canada and New Zealand.
A major threat to the future development of greater collaboration is the difficulty in involving service users and family members at higher levels of engagement. The reality is that many initiatives rely on a small number of dedicated individuals, service users and family members. With the nurturing of greater involvement there is a high risk of burnout for those involved as they try to sustain the increasing number of initiatives as collaborative working and co-production gathers momentum.