Gerard Howlin: Mental health must be central to Stephen Donnelly's new system

Covid-19 has parted clouds that have hung over our health service since the HSE was formed in 2004, and before. That is not to say all is well, but for the first time, the atmosphere is a lot better. It is not all down to patriotism or self-sacrifice. Public money has cascaded down on parts of our health system because of Covid-19.

There will be a second wave of the pandemic, but there are signs we are geared up to cope. The real issue, the one Donnelly will be assessed on, is the depth of transformation of the health system afterwards, and the economic cost to us, in an ageing society supported by fewer active workers.

The timing of the arrival of the pandemic here was critical. When it came in March, we were past the peak winter flu season. The previous November it would have been a double whammy, with hospitals overwhelmed. It would have been in advance of an election, in which diminished coping capacity and bad weather favoured neither the incumbent minister nor the government.

Unseasonably good weather meant far fewer runny noses aerosol-spraying contaminating droplets of Covid-19. Sunshine in April and May meant the lockdown was more bearable. You could queue patiently outside your local shop because the sun was shining. Back gardens and public parks were a retreat. If you weren’t cocooned, you could walk in sunshine along the streets within the allowed radius.

In the second wave, it will be different. The minister will have to plan for it coinciding with the flu season and more typical Irish weather. The backlog of postponed procedures and appointments has to be addressed. Inconvenience and disappointment is tolerable only for so long.

And this is a Government that has foolishly promised no austerity. In that, it has made a fundamental misfit between its narrative and its capacity.

A second wave of Covid-19 will come not just in competing demands for physical health care but with a surging need for mental health care. Mental health, platitudes aside, is the Cinderella of the system. Stigma has faded significantly, but our healthcare system is not holistic. If there aren’t visible lumps or bumps, it’s simply not as serious in a system hardwired to funding medical hospitals. Everything else, including primary care, is an add-on and proportionately peripheral.

On Tuesday the CSO said that unemployment is over 22.5%. A study by the National Suicide Research Foundation found that by 2012, Ireland’s male suicide rate was 57% higher than it would have been if the pre-recession trend had continued. Referrals to child and adolescent mental health services rose by up to 25% following that recession. After it, the HSE said in 2018 that it needed €177m to provide the full staffing set out in the national mental health policy, A Vision for Change.

That was the national plan for mental health since 2006. It was good but never fully delivered. A new national mental health plan, Sharing the Vision, was published two weeks ago. It’s great. It has a posie of platitudes in the programme for government. It is also unfunded, and until money is provided on budget day, it is meaningless.

It is expected that a new minister of state for mental health will be appointed on Wednesday. Working as I do with Mental Health Reform — a coalition of organisations working in the sector — I can say that the new minister’s predecessors, Jim Daly, Helen McEntee, and Kathleen Lynch, were capable people. But there was a fundamental problem. Come the divvy-out, it was about making do with what was left. The last senior health minister who systematically prioritised mental health was Brian Cowen. A lot depends on the new minister of state, presuming there is one. But the fundamental call, on whether imperative priorities are realigned, will be with Donnelly.

On Wednesday, three universities — Maynooth, Trinity, and Ulster — along with Mental Health Reform published important research. More than half of people who use mental health services surveyed said the pandemic had a negative impact on their mental health. Many reported that they were no longer accessing treatment, and are less likely to seek help during the Covid-19 pandemic, even when needed. The suppressed care needs Donnelly must meet aren’t just for physical care, but include mental health too.

The lesson is that things can change, at a price. And the price is enormous. This year health spending is certainly going to be €3bn more than the €18.2bn budgeted. That was up €1,166m, or 6%, on 2019. This year €4bn more may be closer to the mark before it’s over. Nye Bevan corralled doctors into the NHS because in his boast, “I stuffed their mouths with gold.” Stuffing is now the gold standard in Irish health policy. But there are returns.

Telephone and video consultations are a new normal, here to stay. E-medicine that sends referrals and prescriptions by a HSE-encrypted email is suddenly a new normal too. Consulting remotely works well for most people, most of the time. It has some application in mental health too, but it absolutely can’t be the new normal there. And it won’t suit every elderly person. But, all in all, real change has happened quickly — which, because of professional and HSE inertia, had been achingly slow.

Come the second wave, there is more knowledge, and there is a plan. We are not starting from scratch. Donnelly as health minister has enviable leverage over his Public Expenditure and Finance colleagues in this ‘austerity-free’ Government. He also has the benefit of a markedly different atmosphere.

Professionals have started to seriously look out of their silos. The genuine commitment to patient care from most clinicians was evident over the past three months. It was also, we should remember, systematically undermined over the past 30 years by group behaviours that unashamedly used patients as bait to get public money into the net of their own pockets. Now, however, there is a moment.

Managers and the HSE, who are essential leaders and facilitators, are suddenly better regarded. Lots of things are being done differently and better. Community assessment hubs are up and running for people with suspected symptoms. Staff are trained, protocols are in place, and if most of us can refrain from foreign travel, we may be in a better place.

Don’t become doe-eyed. Medicine is about money, politics, and patients — in that order. It is a brutal game. But it is one in which the rules have changed. Maybe this is a moment of optimism.