The Gazette 1981

GAZETTE

SEPTEMBER 1981

service for one third of the national population is the financial equivalent of just one of these new general hospitals. There is international evidence available to show that countries that had a similar long-stay psychiatric problem in their mental hospitals and in which the alternative community-based psychiatric service was subsequently implemented, the long-stay population has been cut by over 80%, falling to a few hundred long-stay in-patients. Applying such knowledge to our national long-stay mental hospital population of some thirteen to fourteen thousand people, we can see just one measure of the unnecessary human and financial cost of an outmoded institutional approach to the care and treatment of the mentally disabled. In simple financial terms, at today's prices the cost of keeping one long-stay patient in a mental hospital throughout his life is approximately £j million. A community-based psychiatric service, underpinned by adequate facilities, will not only minimise the unproductive cost to the exchequer inherent in our existing institutional system, but is highly likely to reintegrate people into a community and working life with personally fulfiling and economically viable attributes, such as the grdwth of personal autonomy and responsibility. As well as the financial cost of perpetuating an out- dated institutional approach to psychiatric care, in human terms alone it has been internationally recognised for many years that prolonged and unnecessary confinement in a mental hospital actually destroys the benefits in treatment brought about by modern developments in psychiatric therapy. These can bring the treatment of patients to a certain level, but when it is necessary to progress the patient to a range of community-based rehabilitation facilities and when these are not available, resulting in the long-stay detention of a patient in hospital, then that patient's therapeutic progress is reversed. Such patients deteriorate into the pathological condition of being "institutionalised". This chronic state of demoralisation, apathy and total dependency on the institution and its staff destroys any sense of personal identity, self confidence or self-respect. It produces and continually reinforces a sense of failure in the patient, creating feelings of rejection and alienation from family and society. Paradoxically, this very condition, maintained and perpetuated by the current policies of the Department of Health, provides justification in the minds of the hidden decision makers that the right place for people with such a "hopeless" prognosis is, indeed, as an inmate of a 19th century mental hospital. Given the clear knowledge that 19th century institutions cannot provide for modern treatment, that prolonged stay in such institutions is damaging and that comparatively inexpensive modern community alternatives are available, one must ask why have repeated plans for the implementation of these modern facilities been ignored and delayed by the Department of Health? Why do successive Ministers for Health and the Secretaries of their Departments persist in a 19th century policy of containment of the mentally ill, even though such a policy clearly infringes on basic civil rights, offends human dignity and negates the very purposes of treatment for which the person has been admitted and detained?

Responsibility — Why and how has this happened? The genesis of the problem lies in the existence and perpetuation of a two-tiered health service in Ireland. Despite the common denominator that they are both run on tax payers' money, there is little co-ordination or integration between the services provided; these services cater for different sectors of the population and, up to now, have operated in very contrasting styles. The upper tier or "private sector" is largely comprised of those voluntary bodies and general hospitals which are under proprietary or private ownership. That they are the prestigious, fashionable and elitist section of the health services is not so much a criticism as a statement of fact which has to be recognised. This is a position which they have secured for themselves on the strength and efficiency of their organisation and the independence and autonomy with which they operate. These in turn are derived from the degree of local control and management over their own affairs which such voluntary bodies and institutions have acquired and jealously guard in their relations and negotiations with the Department of Health. The lower tier "public sector" of the health service, run by the various Health Boards, is the direct successor of the Poor Law system in its administration, image, funding and clientele. Seriously and chronically under-resourced, it has to cope with the lower socio-economic groups and the poor of Irish society, amongst whom the mentally ill and infirm figure prominently. It is a fact that 90% of the thirteen to fourteen thousand long-stay inmates of Irish mental hospitals are catered for in the public sector. The public sector health service is statutorily obligated to provide, from increasingly inadequate resources, what progressively becomes an inadequate service for patients relegated to second-class citizenship in second-class Poor

MEDICO-LEGAL SOCIETY

The October Meeting will be held at The United Services Club, St Stephen's Green, Dublin 2 on 29th October, 1981, at 8.15 p.m. Topic: "Irish Coroner System — has it outlived its use- fulness?" Speaker: Dr. Jack Harbison, State Pathologist. •

The November Meeting will be held at The U.S.C. on 26th November, 1981.

Topic: "Keening for Forensic Science". Speaker: Professor James E. Starrs, Professor of Law and Forensic Science, George Washington University, Washington D.C.

187