in Malta":
"MentalHealthServices
A PositionPaper
A+MH
in Malta":a PositionPaper
"MentalHealthServices
5ummary
1, Executive
l.l lntroduction
1.2ldentified
Ne€ds
1.3Summary
of Eenefits
-Weaknesses
in CurrentSystem
Perspective
1.4Patients'
-Weakn€sses
Perspective
in Currentsystem
1.5Carers'
- weaknesses
in Curentsystem
1.6Professionah'
Perspe.tive
2.l Rationale
2.2MentalHealthServices
of MentalH€althseruices
2,3PossiblePrivatisation
2.4summaryofAnticipatedBenefits
Executive
Summary
rhe surdenotn€nta il healthin Maltais born€p.imarilybyihe ndvidualandthe
iamily,but additonallyby the workpace,the health5ervices
and societyat large,
however,the curent menial health care systemis archais poofy struciufedi
isolatedfrom the generalhealthcare seryices,largeLygnoresthe ieeds of the
indivldual
addconributesto nigmatisation
andsoclamarginalization.
RchmondFoundation,
the Menta t-tealthA$ociauon,the MalteseAssociauon
of
Psychiatryand the Malese Associationol PsychiatrlcNuBes, fespedivey
r€presentauves
orthe patienl the.ar€giver,andthe piote5slonal.
workingwithin
the nationaldenta healthsec(or,are in agr€€menr
that a rhoushtlul,holisticand
reformprocessGursenty requted,aid arealsoin aCreement
slakeholderdriven
on
theCoasofth€ requiredreformproces,asseloui nth sdocument.
Thisdocumentoudinesthe mi.imum stand:rdswhichare necessary
in ordef lo
achievethe lowest acceprabl€€ve of menlal heath care that is expeciedand
avaiablein other soclallymarufecountres.Th€ recommendatons
in this paper
wouldbrinAMa ta to a posltionwherethe needsof peope in needoI mentalheath
care and their caferscan f nd the profersonalhelp that th€y ne€d and deserye
Furthermo.e,impementationof these recommendatons
would alow Mahese
mentalheath prof€$ionas io sit at the tablewith European
and not
count€rparts
feelembaiiasedto dkcussthelocastuauon,
Fallngshorton €venone ofthe identinedneedswoud be iallng shorton our duty
1o the peoplewho encounlermenta il-healih everyday, as patenls, carersor
L
li.
iii.
iv.
v.
vi.
vii.
viil.
ix.
x.
xi,
tii.
xii
xiv.
A new Meital Healrh(MH) hospita is ursenty fequ red bur it3 opening
shoud bethe aiiivalpointofthe relormprocess,
not th€ fi6t 5rep,
A new MH hospttalmust b€.ontatned wtthin the Mater Dei Hospral
lootpfintandbe physicallyconnectedto
it.
AnVessential
chanB€s
in the provktonof Menta Heatthsedicesmuslrruty
safeguardlhe ieeds of the most chronic patienrs, who urils€ a
d sproponlonate
amountof resource5
and who are typicallyth€ oneswho
sufferwhena seruiceisprivatised,
Menlal Healthreform musr be coniideredas a whole prcces and not
Th€MentallleahhAdof2012 cannotbe implemented
meaninClutty
without
sufiicienthunad resources;
the sphit of the aw urgentlyneedsro be
addressed
astouchasrh€l€treroflhe aw.
Communitysefrlcesne€d to be intoduced and lncreased,and npatient
seruices
reducedconcomitandy.
Theaccess
to uGentcaren€€dstobe redeveloped
andconsderedwithinthe
requiredchanges.
5erviceusersmustbe an integrat€dpresenc€
at al decGion-nakiiglevesin
Supportsystemstor seryiceusereneedto be implemented
intolhe worktng
ol MH servic€s
PraCtices
The workinsenvironmentneedsro reflectthe m nima siandardsof salery
andcomfortthatshould
be expededaral workplaces,
Basicchanaesin line wlth patientand .arer needsand expectations
can be
i r f o d L ( e d T n e d i d r e l vr o L , . h l a r er l e u s e ' , e l p e . e a e .
The Menta HealthAct shoud be considered
asa work in progress,
whichi5
responsiveto th€ changingneeds of the community,and updated
The prof€ssiona
s worling within the Mental Heath s€crof will matntain
updal€dstandards
ofpracticeandcontinulng
education.
Th€continulngdevelopment
of the 5ervices
wil be guidedby inrernational
t e n d . d n dd r d i r 'o f p r e \ a 'n gp r a I c p .
1.3SumnarvofBeneits
A paradi8m
shift n menlalheslthredtceprovisionisrequtedto
i.
ii,
iii.
iv.
v.
vr.
vii.
viii.
ix.
r.
xi.
xii.
xiii.
xv.
xv.
Bringmentalhearh servicesin tine wilh acceptedinte.nauonat
standafds
andat parwitheenerathedcalsetoices;
Achieveimprovedpatientexpertencesandctinicalourcomesj
Inp.overelationships
betweenn€ntalheatrhprotessionah
andthe patienfs
suppol1network;
mprovesatGfactiononthepartof
thepauenrsupport
network,
Produceamoreefricientandefiectiveuseofresuurces;
Leadto a reducrionin time oif sjckat ihe workpacedue ro menlalheahh
lmproveproductivity
atth€ workplace,
Leadtoanifiprovedworkinsen!ionmentforprofessionak,
Reducemafginallzarion;
lmproveacce$tocare,
prodoteBreaterresponsvenesstochanCingsocieratand
parienr/user
needs;
AcheveparilyamonBnheathcareuser;
Developa more proacriveand fl€xibtementathesth systemrhar keepsup
wilh internauonal
standards;
Safesuard
the on€oin8care,saferyand Uvinsstandards
fofrhe mostchrcnic
patents,who urilhe a dkpfoportioialeamountof resoufcesby natureot
Ensure
the absoureadherence
to HumanRtghts.
-Weaknesses
1,4patients'Perepective
in the Curent Svstem:
i.
iii.
iv
v.
vi.
vli.
vii.
ix.
x.
xi,
xii.
xiii.
xiv.
rv.
xvl.
*1.
The primaryserulceusershave no involvementin deckion maklngthat
affedtsthem dnecty;
Inpatienrshave inadequale nformationabout the r righrs, ahe.native
treatmentopnons,ahdtheMentallealthacr;
Therei5 inadequate
repr€sentaton
of pauentand supportnetworkswthin
the psychistric
institution;
o d L i e r l..u * e . d u a l. r ' r \ B e r e ' a r e d ( a l < a ' e
Ihere is a markedlackof appropriate.are wlth n the ndivldual'snatural
envircnmentkonmun ty), and a lack of ahernativesbetweenoutpatient
clinicandinPatientcare;
Ihere s a acko{ professlona
specaktion;
The inpatientservicek utterV inadequate:the inpalientenvironmentis
antiquated,
uBy, dramaticandcounteefoductvelo recovery;
The npaUentenvnonmenthcompletelydetachedirom
gen€ralhealth
care;
There is inadequatecommun.ation between prmary health care and
specialsl services,
T h eN a t i o n a l H e aFt ho r m u l a rsyo u r d a t e d ;
Therek a ackof formalstructuresto addr€ssthe r€alityof phvsicalhealih
issuesforpeoplewlthchronicmentalheathp.oblems;
Therek a deadhofpatient advocacy
ln matteEthat affectpatienBdnectV,
suchasprofessiona
s, s€fvices
andpriorlties;
Therei5 a lackofsupporlsystems
for peoplestruggling
in the wofkpbcedue
to mentalill-h€alrhj
Thereisa lackof supportsystems
lor workplac€s
slrugglinC
with llmembers
oftheworkforce,
(e.s.child/adoh(em mental
Thereis a lackof lntersectorialcollaboration
healthsetulcetandeducauon)j
Therek no clearsyslem
lorlodglngol.omplaints;
The pathwaysto care, from a user peEpective,are both unclearand
prohibtiv€,especialyin t mesofcr sis.
1,5CareBP.isp.ctive Weaknelsesinth.CuiientSlrten
i.
Menta Neahh care is burd€nedwirh sicnificait nigma becausethe
providedwithln th€ Mat€r Dei Cofrplexas for orhef
ii.
Bea communty caredoei not exist;what we haveat pfesentk by-defauh
lamiy care,whch is a hugeburden n all aspectsand often leadslo poor
outcomeslormor€thanlustihepat ent;
P e 6 0 n s w l tm
h e n l ai l l i e s s a r e i n a d e q u a t e t y s u p p o r t e d t o i nbtaeceI G
i nlteo
iii.
i!.
v.
vi.
vii.
viii.
ix.
x.
ti.
xii.
xiii.
xiv.
xv.
Familesdo not knowwho to speaklowhentheyafe concerned
aboutan il
rerauvere.eivinccare,
lt k ojlen a matterof luckbetueenwh€theffelativ€snnd a supportiveand
understanding
profesionalor otherwiseat the 1ifre oi their€retesr dktre$,
to assistandgudelh€m whena reiauveis admittedto hospital;
Thereis nowhereto access
urgentmenta healthcare24/Tatrimesofcrkes,
andwhereproperlytranedprofe$lonalstaffcan
reliaby befoundj
Carelor pcoplewith meital lllnesss not providedw thin a dlgniliedand
humaneenvironmentj
Thefeis a lackof appropriate
privacywithininpatientrervicesforfanliesor
careGwho arevk tinCho5pitalised
persons;
Familesare not nvoved in care plan makingdEpite ca(VinCthe maii
burdenofcarej
Prolessonals
do iot recognk€familycar€tsas partnersin the care of ill
peope,anddo not involvethemin discharge
plannn8j
There are no infornation/counsel
lns offces, ln hospitaswh€r€ mental
heath care is Bven,wher€ r€lativescanbe adequateVadvisedand suided
whenfacinArucha dimcut andtraumatc situationi
Thepresence
ol mixed-gender
acutewardsk a sourceolsgnificantconcern
to tamiles and car€rs,also slnce severa jursdicuonsafe revertng io
separateAdmG5ion
unitsfo. maleandfemae patients;
Therek inadequat€
audilinEof the serucesprovidedin the MentalHealth
sectori and a ack oi an indep€ndentfe€uator thfi coud eisure that
nternaiional
slandards
arebeingmet;
Th€policefo.ceis insufficientytfa nedin the franaCement
ot mentatheahh
Th€reis lack oi party, thar ir, an indlvidlalwho is caringfor a pe6on
offclallyfe8ist€red
as sufferlngfroma chronicmentalh€althdirorderis not
conpensated
astheywouldbefor otherd sablnBcondlrions.
i.
negativ€porlravalofMenlalHeathand 'are provrdeon
ThereG a pervasively
iv
work are
protessionals
The physicalstru.turesaid environmentwithin which
oi several'vek
andcompetelvidappropflate
inadequaie
paiients
whefe patientcareh providedfor both in andout
Thevervstructures
care'
accepting
repellingpeoplefromseeklnSor
arethems€lv€s
work is often
lhe iocus on quantilv ol ihfoughput rath€r than qualiiv of
v
-Iheworkloaddoesnor alLowlor meanlisluLanrention
towardsthe peoprewho
ii.
iii.
vl
vil.
vili.
.
xl.
xil.
carewithin
focuson lnpatientcar€deniespatient3lromaccessinE
Th€prevallinc
thelr natural€nvironment
peopleSettingStucK in
The servicelocuson inpatientcare's gearedtowards
evenil"on leave.
hospitals,
proiesslonaband trarned
The stigmaof mentaLheahh extend3alsoro the
nu6es'
3sspecialGt
nu6insstaffareoftennot recosnised
t h e o ; e v a ' ha L e n o e r t lo f n o l i o P u a h n L ' ' 3 i d q l o
di radrt'!rid-\ 'e5 io:eer a res
,"
'*
",""i."- ".-i'.'
*aer.t* ""'--"te m motivatedstafi and deniesFtients sp€calised
"fi*t
based
Heaith ,eNices are not managedaccordlngto evidenc_"
doesnot mirrorlong a!aiable serunesIn
The s€tupof Mental Heahhserulces
otherEuroPeaicoun$ies
to iakedeckiveneps
are percevedasbeincunabL€
lhe MentalN€ahhs€ruices
lor the Soodoiihe patientandothersedi.€useE,€venwhen
to effectchanges
lh€seappeariobe self-evidenl
rher€i;;h.kof siructuredindlviduala^dpeersupetuklonforproressionak
pee6 lor helpor secondoplnions
rtk notcommonpractic€toapp.oach
chnca sov€tnan.es noi prioritired
r r , - " , - * r r . , r r . ' p ' a ( pr o e n . u t e( o n r n L " dp r o f " \ ' o n a d e ' " o p e n F n L
standafds
of proiessionaL
and maintenance
rtlenta Healthwasa posliivedevelopmentofthe
c"..],t.*.r"t
ir,"."L
hk/her
"t
blt sucha comm$oner cainot be efie'tlve as lons as
M;A of 2012,
tothe MlnistrythatprovidesMH seruices
olfce k answerable
PositionPaper
, 1&!9!!E
Health6r€ provisionin Maltarhows3 numberof stren8tns.
Thefamilyunitis $ilslron8er
providinC
for supportingpauentsand
than ii otherilarger,.ounlriesi
Sreateropportunitier
rah ng alerls.Both by vlrtu€ofou.5ize andaccess
bility, t s po$ibe b provde servces
aredelivered
that areclosertoa pat entt home.Thelimitednumberoislteswhereseruices
a owsfor rapidcomfrunication,
and reativelynralchtforwarda..essto clinicansln both
mentalhealthandorhe. areasra so, communty doctoGare nol solatedand are awar€ol
at timesoJneed.SimilarV,
rh€ vadltionalmodelof
howto contactpeoplewlthin5ervices
rapdly ntmesol
h€ath carein Maltaallowspeoplein authorityto be acc4sedreLativelV
n a l t as h s t o r i c a lsyt r o n g a n d w e l l e s t a b i s h e d , t h e v a s t
n e e d . 5 l n cper o f € s s i o nt raa i n i n s i M
providingcafeafe llkelyto be hlghlyskilledclniciant,albeitoft€n
majorltyolprofessionals
not exposedto other mod€lsof menta heath caredelvery.There s genuinecaretorlhe
w€lbeingotothe6, aid a lntedeitions afe.a(led out with fac€-tojacehumancontact,
haveexpresedsatkfaction
wth the sefr ce receivedby clidi.ians.
5uchthatpatientsurv€ys
ar€ often supportedextensivey
wthin seNice-delvery
sru.tures,lndividualprofessionals
withinprofesslonaLgroups
that
in timesofneed,andthereG oftena senseofcamaraderle
andfree
faciltatesflexib lty on an indivdualeve. Patenishavea.ce$1o tiee medicalion
heahh care wlthin the National Ueath servic€,wth st.ongy positve reviews in
iniernational reports, and when exleptiona cases require hi8hy-ndividuaked
mana8€ment,al efiorts are made to suppori their needs. i terms of educatona
developnent,
dev€lopment,
the departmentssuppon continuingindividuaprofessional
and educalonalefforts dnecteda1 palents and famiier are becomlngmore apparent.
ar€ helpng syslemsprovldea more cohefentand
Lo.a y-deLvered
lrain ng proBrammes
the governinC
addiishaton appeats
conrBtent,as wel as l€arnedservice.Fua(hermore,
k€enlyseisitive
to Esuesoinationalreevance,
evenifthesearem norityconcerns.
Nonetheess,the provisionof seryi.estargetingthe cate and lreatmenl for persons
sulteina from m€ntalhealth illnessesk a complexand .hallengingundertakiig.FnnV,
ther€ k rhe sheefsizeol the pfoblem,wth mentalheath issues^ow re.ognsedby the
Word HeahhorCanisatonas the argen-Crowiigheahhthrearln t€rmsol d sab ity, and
natisticsthat show that wond wde, abouta quader oi us wil be facedwith a menlal
healthchalenseat som€point in our lves.Thosenot directV sotrerns from them often
disrqard,mlnimkeor m sidentfy menra healthproblems,and a greatdealol ignorance
aboutneitalheath illnessaod Ltsfieatmentabounds,ocallyas it doesinternationallv.
serviceprovislonhasto take
Apartlrom the difficuties posedby th€ ilnessesth€mselves,
lnto accountthe fact thai tradtionallymental heath problemshave been olien an
orsenera
afterthoushtor.esardedasbeinsofsecondary
importance
in the largercontext
heallhplanninE.In
thissetungwhereavaiablefundinsis oftenwo€iu yinadequateforthe
heedsderlvingfrotothe burdenofmentalhearh isrueson ind viduah,familesandsoclety
al aGe,seruce provsionplannng alrohasto consderthe unpopul.rty oiaccessngmental
h e a h h r e a l f r e n t , o f t h e l m p a c t t h a t i l l h e a l t h h a s oi ensl a, amn dt r a d l t i o n a lol yn-t h el a . k
ofa strongoraconsisrenrvoice
on behalfofthepeoplewhoare frainlyaffed(ed
by hental
heakhprobems rhus, sucha complexchallengecannotbe expectedto iall on a single
entity Gochas a P5ychiatry
Depadmenlof a hospital)tosugg€st,
impement,provideand
m o n t o r a f r o d e l osf e r y i c e p f o v i s ifoant h; e r , l t i sn . ! m b e n t o n l h € w h o l € o
t hf e s t r u . t u r e s
availableto
a countrytota.k e ln a coherentand5ynchron
sedmanner.
WhilethesearendeedClobalissu€si
the .oncernin rhe loca conrer(isthatdtvid€between
servlcesiucture anddevelopmeninlernalionallV
andlhat availab€in Malta,continuerto
crow rapldly,and all stakeholde6in menta heahhcarein our counnvre.oeiisethat the
jn a developed
ocalstuations entir€lyuna.ceptable
andciv ked society.Inrecognltion
ol
this Culfbetweenwhere we shouldbe and where we are, RchmondFoundation,
the
MentalHeahhAssociation,
the MalteseAsociationol Psv.hiatrlc
Nurser,andthe Mahese
A$oclationof Psychlatry
haveacknowledged
that their role in MentalNealthcareseNic€
provisionsc€ntralandffti.al, andhavefu(hermorerecosnkedthattheysharea common
vkioi aboullhe standardsrequiredlor m€ntalheath careto be providedn a meaningfol,
humaneanddec€nt6ainer
The four Arsocations,who are principaistakeholders
in Mental Heath car€, and who
togetherrepresent
centra p la6ofMentalHeath careii Maha,Eenuiielyacknowledge
all
prof€ssionals,
the efiorts caried out by succersveCovernments,
orsansatons,
and
voluiteeGthrouchouttheyearsto improveMenta Healthcareandto combatsti8ma.
we
are ako fecqnisngthat at this time,there appeaEto b€ a wel.ome,genuineand publi.
acceptan.ethat inrerventions:reurgenllyr€qlhed n te.m5of lmprovementofservices
aimedat the care of peoplesuff€rng lrom mentalheaithdilfi.ulties.Th s environment
is
hugelyencouragin&
but at the sametime the iourAssoctarions
recognkethar wthout the
combinedlnputfrom the patieni,the careriandthe professionals
who wo* in the nenta
heath t€ams,there is a real risk that proposedchanseswill be well-intentionedbut
nisdt€cted,sinc€a majorr€thinkingol rhe cuftent MentalHealthSetuices
needsto be
undertaken,
it is cear that proposedchangeswill be mmenselV
onerousand ener8yandthatrhuswe needto ger t riBhtlhefrsttime round.
consuming,
It is with thh in hind rhar the Alliancefor M€nralHealth(A4MH)is makinsit very clear
lh3t we as a country cannot have a seriousor meaninEfuldis.u$ion abour how to
improveour c!tre.t MH services,
without nakine ev€ryefto.t to pla.e the patienr,the
careBandrheprofessionals
proc€ss.
atthe cenre ofthe de.ision,makinS
2,2 MemalHealthSeruices
t h s e l f e v i d e n t t h a i a n V f t r n h e r d e v e o p m e n t o f t h e NM
a tei on nt aaH e a l i h
S€rvice
o su g h l
to serooslyconsiderthe curientcha ensesand obstacles
beincfacedby the peope who
accessservices,
their caretsand lam ies,and by the prolessonals
who work wthin the
sameMF seruices,
asarelten sedln sed ons4, 5, and5 ofthk document.
Thebodyofthir
docufrentwjll lnsteadgivethe background
to part 2 of th s paper/i.e the summaryol
Needsidentiliedbythe 44MNlor meaninBful
reformofthe natonalMentalHeahh
5eryices.
The oblSalory{artinC polnl lo dscus menial health relorm is a concepruaone The
f€edbackand wshes of the very peopLewho the servicesare
oplnions,impresslons,
target€dtowards,ar€nowher€to befoundii th€ curent organsaton of MH care.Thusthe
sefli.e usermustbe put at the centreotthe proje.t.Whatthk meansis that at all evek,a
patientor patent representative
paiient body)mun be an
lnomlnatedby a r€cognised
g b € r o t e v e r y d e c s im
n l e g r a- a s o p p o s e d t o r u b b e F r t a m p
n ienm
on
a k i n g p r o c eT
s .h s i s
taken to indude (but not be iimiredto) decislonsresardlneempoymentor new staff
(nleryiews,boardt, hospital or servicemanasementme€tnss, proposedoperating
polices,Fo.mularydecsions,bud8etaryfreeunes,servkereviewmeetngs,and decsions
r e g a r d n g t h e r e c q n i t l o n o r o t h e t u i s e o i s t a f t m e m b e r e t o . t h e n p e r fIonram
da
dn
i i ci oen. ,
sensitviiyto the distre$inesituarionof peoplenewlVadmittedto hospitalmandatethat
identiliedstaff(or.epresenrariv€s
orpatieft orsankationtintroducethemsevesand help
peoplebe.omeaware ol rhen rights,optionsand the treatmentpro.esslo a evelthal
{ o d b e r o e _ d b l p o r G a ) o e r o r h e r n d ' . dd1t h
. atLm
Additioially,sensltiviiyro peopleapproa.hng MH servic€sior the n6t ume would also
s ! g g € sats i m i l a r b u t l e snst e n s e o r s t r u c t u . e d s e r v i c e e t t e n d € d t o p e 6 o n s b e i n g r e a r e d o n
an ambulatory
basis.Thereshoud be a systefrtn pla.eto receiveand acr uponfeedback
r€c€ivedfrom setuiceuse6 and ths ne€dsro be in.orporated nto reCularsetuice
franaCement
meetngs,togetherwith a Joha strategyto monitorMH caredelveryand
Ihe aniualfe€dbackreportlor the MH ieRces shoud a so includea patient report,a
reporlfrom an orcanisation
or a$ociauondelotedto suppotli^gthe careGor tahiles oi
peopler€quningpsychbtrictreatment,and annexeda.eport irom the Commksionels
ofiice.Strongconsderationshouldaho be givenfor an annexedreportto be providedby a
Hlman Rightsrepresentative
to encourage
oi goineartentionto rhe MH seruicetduues
lowardsthe peop€ it is assn ng.A systemfor dentl.ation andnominaUon
ofappropriate
patientrepresental
vesshouldbeforhalisedforthe MH syst€masa whoe.
Admksionto a psv.hiavichosptalor ward,andacc€ptance
ofrhe needlor MH treaiment,
powerful
caries
and disrupriveeffeds aho onto a parienfs next of kin, The potnt ot
adnissioni5 often a bewildering,leirfyinC
and5hatterinC
experience,
and there is urgent
needfora formalsedstru.torewherebypeopewhoselovedonesare illenouehto requne
formal help,are themselvessupporred,and helpedto understandp.ocesses,
outcomes,
structuresand paceswhere help.an be accessed.
Thiswould deaLybe set up with the
colabofaiionofassoclation5
that representcaretsfor individuaI with menta heahhitlnes5.
other arp€ctsthat are dktressng to tamiiesare the ou6 ng ofvery dkturbedpatenrs n
nlxed{ender warde, esp€cialyslnceother Europeancountriesa.e.eve.ting back to
separateAdmissionWards.wards shouldalsobe sensitiveto th€ needsof patents and
familesby€nslrin8^ot onlythat ad€quatear€asbe set up wherepaueitscahmeetthen
reatives n a pfvate nanher,but aGothatfamllymembershaved CniJied,
idenuiiedquier
areaswheretheycancomposethenselvesailer distre$ingv sits.
Th€ ntroduction
ofpatientaid carersupportwtth n th€ MN services
is a servicethat i5long
due to servic€usersand thal .an b€ implementedimmediatelvn the exktingsystem,
withouttherequtementfof the d scussion
and p annngthat woutdcharact€rrethe other
A reformpfocessshouldrestoredignllyto pe6onsrequiringMentalFealthServices
while
providing,orparityin Mentalll€althcare provkion;pereonsrequirinsmenta healthcare
shouldbe afiordedrervicesthat are at eastequa n standardto ac.essibiitvto that of
g e n e r am e d c a l h e a l t h c a r e i n M a r a a n d 6 0F2u0r t h e r f r o r e , l A
he
4 M Hd e m a n dt sh a t t h e
placesMentaltealth' backwhereit betongs,.€.within rhe
Menta HeahhRetormproc€ss
'H€:lth' .ommunity, thereby helpiig to counrerinstitulonalisarion,promoie hiSher
standardsof ca.e, and reducestisma whi.h is as prevalenlwithin the professona
communityasit is i^ the populationat largeaswellar ensurelhatmeitalheahhissuesas
beingaddressed
wth n a hoistn approa.hboth ln is own righr bur a so in view ol comofbidlty.Thus,a new hospitalJortheprovision
of npatientMentalHeath care,whichhas
be€npub cly m€nUoned,
nu5t be lo6t€d withinthesamehospltalCrounds
of MaterDei
'cose"
Hosptal(MDH),and not iinply be
ro the mainbu dinC,but b€ aciualVphvsica
ly
connectedtothemainhosplial.FalinEthis,Maltawi .ertainy mksthk uniqueopportunity
(presumably
the on y opporiuniryin the forese€abl€
luture) to avoida r€p€utionor the
sugmathat alwavsfollowsthe buildin8of a hosptradedkatedio treatmentof pereons
sufferinCfrom
MN condtionr. i olherwords,antthinsshortolab!ildlngatta.hedto MDH
wil nevtably€nd up dupicaringtheiMounr carmelN05pita'effectof5ri3ma,tgnoran.e,
unnecessary
fear,andlackofappropriateaccessiocare.
However,there k the danCerthat the proposedbuildlnCol a hospital,givenlts cakhy
.onceptand afiactivenesslo the media(bothtraditona and socia), willobscuregreater
needsthat cutrentlypague the naiionalMenraNeahhservicesIndeed,the face oilhe
s t i g m a a n d d r e a d o f m e n t a l i l i e $ a n d cnaM
r eat a i s e m b o d i ebdy M o u i t C a r m eH o s p i t a l
( I / C H ) .H o w e v eirt, i s n o t c h a n g i nM
g C Nt h a rw i u i i m a t e V h e p p e o p e i n n e e d o f c a r e
Rather,it h changingtheserviceprovsionmodel,su.hrhat ev€ntuallymuchiewer people
will needadmissionto hospital,and adnissionswill be far shorterthan thev are todav.
ThE meansthat th€ processof r€form must considerth€ lotalitv of the Menta Neath
sector as a svsted, rather lhan its lndividlal componeils separatelvThe pubicked
ol
ola new hospital,andthe effortsto en8agefamilvdoctots,are examples
consideratioi
process
lhat a lowstor
niuatvesihat needto be undertakeiwith n a larger5y5tem_wlde
seame5sransilionol careaoossrllleve s. a holstlcplanol reformmusttakelnto account
to addresscuneni lmitatonsincudlng
governmentaand non governmentalsrakeholdeu
( o n n u r r y 1 o u { n sa n d . o ' L l \ ' p p o ' 1 o o u - ao} n e T o o n ' r ' u p p o l e r r ' ie' 5 t e l r a r d
seNices,core.tionalservices,andexpertmentaLhealthservicestolhecourts
At presenl,a disproportionateperceniageof the Menlal Health budcet ls tpenl on
inpatient.ar€, refle.iingthe tradilionalbut out dated mode that focuseson chronic
delivery,
i n o a l e n r c a f e f o re o o e w l t hM Nl l l n e s sL.n t r i n i i c t o t hcios n c e p t o l M e n tNa€ a l t h
pau€ntsare 'let 3o' exceedincyBradually,with a surprisinEvlarE€pauenl population
activelyon the booksas McH inpatientsbut "on leav€",and re.eivingtheir outpatient
follow-upar that hospita, a prac(i.ethal runs counterto inler.ational practiceol
dBchaGin8 parients early to comnunity .arp wit n OF oreldrllg nodel
teams(MoT)arespreadthinly acro$ multipleand dlversesettnss,with
multidisciplinary
ln diveBesettingsn MDN
Thereareambuaioryservices
services.
verylloltedsub speciahv
and in communitvclinlcsitheseoften replcateseryicesand fai io providefor r€liable
with moreseverementalilness
outreachor morelntensecommunitytreaim€ntlo pereons
or for sub{oecialitvfollow up. €linicalserulcesacrossboth inpalient and oulpatient
d utins the intenstvand
settinssare usuallvstafiedby the samemedi@lprofessionals,
reguarilyolserviceprovisiona.rossa leve15otcareDocto6aretoo oftenthe bott eneck
s
in termsof what servicescanbe providcd,and not enoughnilative and independence
with dlii€r€nttieG
to provldea broaderrangeofseruices,
entrustedto other orofessionals
lhat insteadol the cuiienr va.uum betwee. lnpatie careand standard
A4MHadvis€s
needio be developedin a wavthat cansupponand
outpatietrtcareicommunityservlces
aretoo ilowa t ior anelectiveappointmedtatanoutpalientclinc, and
lollowD€oolewho
were th€v io be suflcientv
oi hospilalisation
vet couldavod the traumaricexperience
that unle$ lhe openineofwellresourceda
withinthe community.liis stressed
managed
communitye€ruiceis a.conpaniedbythe closureof an inpatientservrce(suchthal staft
modehorcare),
be relocated,
andthe svsiemforcedloabandonthelons_held
numberscan
anvoroce$G doom€dto repeattheetrorsolvariousinltiaiiv€soverthe pastvea6,wh ch
if
fail because
theyareinsuffcienty naffedof supportedor prioritsed.Now€ver,
ultimalelV
an lll pe6on.an be followedup within their home, or on a frequentba3isin a noi_
3ndsupport
their pr€ference,
andwith the inclusion
accordinBto
thr€ateninc
environmeni,
otthe lnd vidualt supponn€twork,the needfoi hotpiklkarion rs reduc€dThisnol onlv
butthar he/shecan eav€hospiialearlierto
meansthata peBoncanavoidhospltalsauon,
b€lollowedwithinthi5setul.e.
h must be poinied out lhat for an indivldualpatient,each of th€se and subsequent
wlthln€veryvaditionalFirmor MentalHeath team
s todaValreadypos5ible
sussestions
wirhlnthe Naiiona HeahhSerulce,but thal it s subje.tio the stvle ol €achteam,and
llmltedby the avaiabllitvof time and bv the umetableof that Flrm; it is not acl'vev
or drlvenfrom above.Forlh s to becom€the norm,an explicit5hlftin focusof
encouraged
MentalHealthServiceprovisionne€drto be made,wlth the statedand auditedBoalfor
carero becomeavaiableoutsidehospnakandclosetohome,andsel up n sucha manner
ieamsthat
mul 'disclplinarV
asto be avaiableatiimes orne€d andmannedbv speclalised
Modernpsychiatrccareis ako strudureda ongsefrlceprovisonthat isspeclfcallvgeared
tar8etingnew onsd psvchot'c
ro parucuLar
croupsithis is parlicuarly evidentln seryices
is aggincdramaucallvother arcaslhal
disord€B,wh ch is an areawherethe locaLsetup
substance
requir€seNicesto locus nore speciakedattentionare those of co_existing
and
m s.ant oenraLheaLthi
menralheahh,od ase psvchianv,
abuse,chid and adolescent
approachesto care, but ln truth
rehabllitauonpsychlatryio ioster recoverv_oriented
prof€ssiona
focus,andawavlrom
wouldbenett lrom a moreexclusive
multplespecialties
thal hasbeenlnheritedthrouChlhe veare
approach
the curentEeneralisl
On€ resull of thk prevaillnggeneralisrapproachto psvchiatri.setvicedelivervk that
patientshavea highdeCreeofcontinuitvoj car€,acrossinpali€ntand outpatientsettincs,
in mod€rnsocietv,
withinthe sameieam.Thecostofthis k howeverno longeracceptable
wouldonlvreviewa patent admitied
ng professionas
asthis meansthaithe decision-mak
to hospitaa&lnst their wi , onceor ai mosttwic€a week n addltion,it a so meanslhat
the outpatientr€vewscanonlybe providedon the davswhenthatream/firmis scheduled
for anoutpatent clinic.lt is our opinon that the lime hascom€whenthemedicalnruclur€
ol seruicep.ovisionmust change1o addressthe lnevitabl€and realistic m tationsoflhe
cenerali5tpsychatrist and to ensurethat admlttedpatientsare reviet€d fr€quentlvbv
to ensurethat
andconcomitantlv
p€oplewithdeckion-making
rol4, to taci ratedischarae,
peoplebeinslollowedup in the communitvhaveaccessto lheir treatmentteamswhen
teamrhat worksin tandemwith the outpalientteamln a
they needthem,or to a specifLc
inpalientwards
In Mata, AcutePsy.hiaryls vlnuallyabtent outsid€the m xed-diagnoses
at MCH.Thereis no 24-houracutepsychiakicseruiceat M0H, and inpatientsupportat
aid poorvstalfed TheA4MFbelievesihata crtlsl€am/s
MDHrenalnsundeFd€veloped
basedln the communitv,andthat woud be expectedio vet the vastmajortv or patienis
lo a lvlentaHealthh05pital,elther
admission
for a potentalcompul50ry
beinS.onsidered
with provisionoi:
aloneor in liaGonwith a seryicebasedin MDH,woud he p slSnificantlv
to patients
and acc€ssible
seruicethat would be far more acceptable
tlexlble,responsive
andtheir caretr,aswel asutimarelyimprovefolowup andreducerhenunbeEofpeople
whoarelostto care-with allthe attendantpfobl€mr afteranegativeinpatientexperience.
ln.tudhs rhe PoliceshaI be requnedto acheve
concomtandy,enersencr respondere
in managlngMentalHealth.ris€sas theseare,andwil
trainin8and rcheduledretralninC
continueto be, a oitical link in alowinglll personsto be reviewedwlihout the needtor
e hospitalkation.
The.oleofthe famllydodor in theseaswel asles5€mergent
unavoidab
settinssneedsto alsobe addres€dand revewed,asthe statilicaton ol ursentrevlews
y. Th!s,whi e the Menia Healthservicesneedto be accessiblefor
musiimprovesignliicant
for
resourceallocauon,
it is a wasleof fesources,
anda iailureof appropriate
uGentcases,
non'ureentcasesto be etron€ouslyor mheadinelyrefered ior urg€ntcare The huge
aho requirethat inieruenlions
not requiringa speclalisl
on MentalHeaLth
Setulces
demands
professioiah,and additonallythat non-hedlcalspeclalists
are deiv€r€dby non-specialisr
recognkedas havinga roLeas independentpractitioneEand clinician5
are increasingly
The managem€ntstructufesro moiitor the auality of Care,safety, and ContLnuing
Educationand on-golngAppraisalrenaln poory develop€dacrossmost professional
dkciplinesandal lelelsotcare.A4MHdemandsthatthequalityof M€ntalHeahhseruices,
inpatientandoulpatieil clinlcalenvtonments,
incudingtheorientationtowardsrecovery,
by lndependentbodle5or
as well as ttaffins evels,artirudesand skilLsbe assessed
by ihe united
regulator,serviceuse6,and representative
organsationsas recommended
(Anicle33).
ilationsconventlonof Risht'of P.Bomwith Disabilitles
The office of the cohfrissionerof Mental Healthwascreatedwllh the MHA 2012,and
represeitsa step in the rlSht diredon for the monitoringof the functioningof the
tnloluntarvand voluntarvproce$eswithin the Mental HealthAct and Mental Health
of the rishtsof persons
sep ces,in additionto a role in the promotionand safesuardlng
the effecriveness
oithe
sufferinsirom a menta disorderand their carec, Noneth€€ss,
is si8nif.anllylimit€dby hk beinganswerable
to the sameMlnistrythathis
CommGsioner
that iftbe
offi.e h monitoringand eventuallycalliigto order.Thu5,the 44MH advocates
intenuonh indeedto havean eftectivecommissonerfor MentalHealth,"to protectand
promore"as the office standardprocaims,the office should be independentol the
Parliailent,
Mtntsid resDonsible
tor MentalHealthandansw€rableio
a
once a8ain,there k nothin8in ih€ cu(ent setupthat pfeventsor blatantlydlscourages
professlonalfionmaintaining
the req!hedstandardoleducationor skils or i'roresslonal
TheA4MHbelievesthatlt i5to the
attitudes,butthk is leftro dkcreuonofthe indivldual,
of the professlonak
of patientcare,and additionaLV
lo the advantas€
defnite advantase
for a formalkedsystemfor maintenance
ofspe.lalkation,orother alternative
thedselves,
and
assoclations,
nandards,to be proposedand maintainedbV the relevantprofessionaL
yfo owedbythe MentalHealthSeRices
subsequent
The new Menta NealthA.1 (Ml'142012)was enactedwilh the coal ot enhancinsthe
8 e n t aF € a l t h S e d l . e s a s w e l l a s e n c o o r a S n g t h e
a u t o n o m y a nddc n i t y o f p e 6 o ^nse e d i nM
in
lnvolvement
of care6 in deckionmakincproce!es.Dueto the highiShtedLlmitanons
a4MH
5eruceorovkion,thespiritolthe MfiA k iotbelnSfollowedorevei acknowledged.
levelsolstaffing
theretoredemandsthaithe reforn pro.€rstakeaccountorthe n€cessary
andstructureofthe teamsand serucesprovidingMN care,andthe requrementsto fu fl
the true spiritofthe MHA2012,aswellas to tevie, and amendas necess.rvthe cuiient
MHAbasedonstakehoLderfeedback.tsnotnec€sarlvanGsueoflhrowingmorepeople
at the problem,allholgh the localnumbeBofprofe$ionalsper populationare afrongthe
veryowestlnEurope.lndeedillirmporiantrhatwhenstalfaivariousgrad.sar€assiEned
they are placedn a positioiwherethey cantruly achievewhatis expected
spe.ificduties,
of them. Thus,It a professionais put n a posltionof rcsponsiblily,5o.h as that ot
chairperon,or setuneLead,or coordnalorfor MHAmatlere,it is simplvnot sufticleitto
to
increasepavmentvet leavethe sameclinl.al oad. lt is very taxingand challenging
a d m i ns t e ra s e t u i caesl a r g e a ncdo m p e xa sM e n t a l N e a l tahn, dp r a c l i c a lal vc l n i c i a n 5 a r e
since
in pracucalterms,
at maxmumcapacty,Thisneedslobe recognGed
alreadvworklng
andresponsiveness
a systemwill othetuiseneverreachthe requredilexibiLltV
to the ofiiceof chiel txecutiveofiicer lor Mental Healthserui.es
Futu€ aooointments
catry with them the power to siSnlli.antlyaifect the whole nationalMenta Health
curicuLumand runninSof the iationa Mental Neath Services.t is thus the natural
would havea proventrack recordnoi onlv oi
exoectatonoi the A4MHthat appolnt€es
undestandin8ofthereailvot mentaL
butako a pre established
managemeitcompetence,
recordoiinterestin the ksuesrelevantio Menlal
lllne$,a5we las a clearanddocumented
Heahh,rincemenralheaih andilne$ is a subje.rthat canbe vagueandatt mescouiter
intultiveto thosenot wel'veEed in il, whichwooldrh€n undermineallthe effortsbeinC
andtargeledr€form.
madefo. approprlate
ThestiEmaattachedto menta healthextendslootherareasapartfrom lh€ moreobvious
on€sdocumentedherein.For erample,lhe sefrlcesprovded bV a relauveor scnifcant
other who is caringfor a pe6on officialyregGtefedas sullerlngirom a seriousmenta
in Llnewlh careEfor olh€r condtions A4MH
ilhess,shouldbe elslble for cofrpensation
treatment
strongVbeievesthat stigmaaboutnentalheahh,mentalilness,snd psV.hiatric
are pow€ ulnegativeinfuencesthat inpact stronSlyon the generaheath of socielydue
mentalill-heallh;
we al5obellevethatthis stigmacan
to ihe carryon eifectofunaddre5sed
only be reducedby oi soinE,tarcetededucationand the provisonof €ood and r€Lable
l nm
e sesn t a l
M e n r a H e d h h c a r e s e d i c e s T h e d l t v o f c a r e t o w a r d s p e o p l e s u f f e r i n g f r oi l m
thatlakeslnto ac.ounta hokticview of needs,
aho €xtendstowardadoptlnsan approach
liaitonto reviewand
andthisrhus ncludesboih inte.mlnHerlal and inter-dep3rrmental
that supportemploynentfor peBonswith seriousmentalillness,a
implementmeasures
and bulldingSreater
reviewol the socialbenefitstargetingthe specialcir.umslances,
svst€m
awarene$otMentaNealthinto d fferentlevelsofthe educauonal
olMentalHealthServl.es
2.3Theksoeof possibleP.ivatisatlon
througha changein the hierarchicaLapproach
Therek no doublthat muchcanbe achieved
ol manpower,through€reaternumbe6of
to Meiial Healthcare,throughrationaisation
staffto manaaethe mandatedMl_lArequtemenc,andthroughprloritkauonot outpauenl
care; in short,lhroush a dore .oord nated, efficlentand effecuve
aid sob{pecialised
and management
stvle Nonethele$,there is equaLyno doubl that th€ sickett
deLlvery
wlll renain si.k and w I coitiile to demanda lar greaterper capltasliceor the
DeoDle
availableserui.esthan peoplewhoar€nolso severelVllltkthe remitofth€ professional,
andofthe NationalN€althSeRlcein modernsocietv,to ensurelhat th€ sicke* peoplear€
tr€atedto the bestof our ablitv to minimkelhe severhvoftheir andtheir carets'dislress,
to sateguard
th€ r safetyand the safetyorothets,andto propa8atea cu tur€ ofcare and
Despil€lhe sup€rficalattractionollee forservicelprivate)
civlcdutynrhe grealersociety.
modek,ft appea6to us to be inevitableihal the most se.iouslvill palientswlll iot be
cateredforadeoualelvwiihin a svsremthat is basedon th€ starknumbereofeconomicsof
care.we canno morewkh awavthe re. hv olseverementalillne$than w€ canicnorethe
iact that without intenseaid onfoing lnput,loo maiy of these ill peoplewil end up
dead ot their own handsor due to
homeles, or ii the cotrectonal
h o m i c d eo, r v i d i m so l d r u Ea b u s ea n de x p l o t a t o n . l is t h e s e r i o u s b € l e l o f A 4 M H t h a t
privatemode15
of mentalhealthcaredellverycannottrulVcatef lor this se8menlof the
pareni populaton, andthat ih s k the sectorofpeoplerhat s uhimatelymostdesefrlngot
care,sincethev arerhe onesleastlikeLvJue to their ilness to copewth the d€man* of
of Re.ommendationr
Benefltsfrom lmplementation
2,4summar ol Anticipar€d
A p a f a d i g h s h li fntm e n t ah e a r h s e r v l c e p r o v i s l o n i s r e q u i r e d t o
i
ii.
lii.
iv.
v.
!i
vii.
viii.
ix,
x,
xi.
xl.
{ii.
xiv,
and atpar
internatonalstandards
BringmenialhealthseNicesin linewithaccepted
with generalmedlcals€Nicesj
Achiev€improvedpatientexperiencesandcLlnkaloutcomes;
lmprove relationshipsbetween mental health professonahand ihe pati€nt3
lmprov€satkfacuonon the part of the patientsupportn€tworkjProducea mofe
eficienrandefiecuveuseotresour.es;
Leadto a reductionin time offsickat theworkpac€dueto mentalheakhproblent;
lmprov€pfoducuvitvatthe workpace;
fof professionahi
Leadloanimprovedworkineenvironmenl
ma13ina
izauonj
Reduce
lmproveaccess
to care,
patient/usefneedsi
to changinE
socleraland
Promot€greaterre5ponsiveness
Achieveparityamon€slhea
th car€us€rs;
Developa more proadiveand nexiblem€ntalhealthsvstemth3t keepsup with
intemarional
standards;
Safeguardthe onSolngca.e, safety and living standardsfor lh€ most chronic
pali€nts,who uulisea dispropodonateamountof r€sourcesby natureof thek
HumanRights.
Ensure
the absoute adherenc€to
For$e Alll.ice tor MenlalHeahh:
MsStephanra
oimechsant,€Eo
Menu:lHerkhAssodation
Mr GodfreY
Bor&Periden
Today,rhe 9q O.rober,2016