Specialist Rehabilitation Psychiatry services are intended to serve individuals with severe and enduring mental illness. Approximately 20% of individuals presenting to mental health services for the first time with a psychotic illness will require Rehabilitation Psychiatry services due to the severity of their functional impairment and symptoms. There is solid evidence that, with appropriate rehabilitation, significant functional recovery can be achieved, even amongst those with the most complex illnesses (Trieman & Leff, Reference Trieman and Leff2002; Nordentoft et al. Reference Nordentoft, Pedersen, Pedersen, Blinkenberg and Mortensen2012; Morgan et al. Reference Morgan, Lappin, Heslin, Donoghue, Lomas, Reininghaus, Onyejiaka, Croudace, Jones, Murray, Fearon, Doody and Dazzan2014; Killaspy et al. Reference Killaspy, Priebe, McPherson, Zenasni, Greenberg, McCrone, Dowling, Harrison, Krotofil, Dalton-Locke, McGranahan, Arbuthnott, Curtis, Leavey, Shepherd, Eldridge and King2019).
Multidisciplinary Specialist Rehabilitation teams work with individual service users to effectively manage psychiatric symptoms, develop occupational and social roles, build and restore function, encourage positive risk-taking and instil therapeutic optimism over the long term. See Fig. 1. People receiving support from these services are eight-times more likely to achieve and sustain community living, compared to those supported by generic Community Mental Health Teams (CMHTs) (Lavelle et al. Reference Lavelle, Ijaz, Killaspy, Holloway, King, Keogh, McDonagh, Spelman, Goggins, Daly, Murphy, McCrone and Drake2011).
Fig. 1. Some of the functions of rehabilitation and recovery psychiatry.
An effective rehabilitation service requires a managed functional network of services across a continuum of care, including inpatient and community based rehabilitation units, community rehabilitation teams, supported accommodation and supported independent living (Wolfson et al. Reference Wolfson, Holloway and Killaspy2009). See Fig. 2.
Fig. 2. Continuum of care in rehabilitation and recovery psychiatry.
A Vision for Change (2006) provided a comprehensive model of mental health service provision in Ireland and set out a framework for providing accessible, community based specialist services for people with mental illness. It made specific recommendations around caring for people with severe mental illness requiring Specialist Rehabilitation Services and discussed physical infrastructure, opportunities for independent housing, links with community groups, employment agencies, training support services, staff training and levels of staffing. Specifically recommendation 12.2 cited the need for 39 rehabilitation and recovery CMHTs, with assigned sector populations of 100 000 each. (Based on the current population, 48 teams would be required). AVFC recommended that these teams should include one consultant psychiatrist, 10–15 psychiatric nurses for assertive outreach work (maximum case load of 12 service users to one nurse), mental health support workers, two occupational therapists, two social workers, two clinical psychologists, one cognitive behaviour therapist/psychotherapist, one addiction counsellor as well as domestic skills trainers and creative/recreational therapists, administrative support plus staff associated with day centres and community residences.
Nationally today, rehabilitation teams are operating with just over one-third of that recommended in AVFC, ranging from 4% to 77% with a total of 23 Specialist Rehabilitation teams versus the 48 recommended in AVFC operating at a meagre 35% of recommended staffing levels.
The successor policy to A Vision For Change (AVFC), Sharing the Vision (2020), is billed as ‘a policy that builds on the good work achieved over the past decade and it will provide a framework for investing in a modern, responsive mental health service fit for the next 10 years‘. The policy suggested renaming Rehabilitation and Recovery Services to Intensive Recovery Support Services to reflect the recovery ethos. It cites emerging models of care structures and intensive recovery support services including Specialist Rehabilitation Units, Community Rehabilitation Residences and assertive outreach teams but does not make recommendations in terms of the number of facilities or staffing. While the document claims recovery to be at its core it does not place appropriate emphasis on services and pathways for people with Severe and Enduring Mental Illness with complex needs and is wholly lacking in detail. In response to the policy, The College of Psychiatrists of Ireland (2020) expressed concern over ‘serious gaps in [service] provision for people with serious mental illness’ and expressed concern that focusing investment in upstream mental wellbeing and mild mental illness further marginalised those with severe mental illness.
At a time when Mental Health occupies many column inches in every paper on a near-daily basis and dominates our radio, television and social media the mental illnesses of such severity and complexity that they render the sufferer utterly unable to function and indeed, often tortured with delusions and hallucinations go largely without comment.
The level of psychiatric services allocated to Rehabilitation Psychiatry to treat this group of patients is insufficient to even satisfy their basic needs. The overall mental health budget itself is wholly inadequate, and has remained at 6% of the overall health budget for many years. It is very concerning that, if such funding structures persist, in the face of ever-increasing demands for mental health services in general, that Rehabilitation Psychiatry funding will suffer further at the expense of the far more common, milder mental illnesses and the most marginalised, and largely silent service users, will not receive appropriate medical, psychological, occupational therapy or social work services; this may also contribute to this population being treated in overly restrictive surroundings and be denied access to social and occupational roles the majority of our citizens take for granted.
According to the Inspector of Mental Health Services report (2019) service users are often all-too-often trapped in the acute system due to lack of appropriate services. We know that long-term acute unit hospitalisation is counterproductive and contributes to disability in this population (Narayan & Kumar, Reference Narayan and Kumar2012). In her report, Finnerty (Reference Finnerty2019), concludes that ‘the short-sightedness of not providing adequate mental health rehabilitation services, from both a human rights and a financial viewpoint is quite astounding’. In a separate report on the Physical Health of People with Severe Mental Illness Finnerty (Reference Finnerty2019), Finnerty draws attention to the high mortality of people with severe mental illness, dying between 15 and 20 years earlier than their counterparts without severe mental illness and their physical illnesses are largely preventable.
Failing to invest in services for those suffering from Severe and Enduring Mental Illness and thus depriving them of their human rights is reminiscent of past Religious and Government scandals and surely, if it is not rectified immediately it will be major scandal of the future. If current policy and funding structures persist within the Health Service, Rehabilitation Psychiatry will suffer even further at the expense of the far more common, milder mental illnesses and the most marginalised will be failed, yet again.
Conflict of interest
None.
