The Gazette 1981

GAZETTE

SEPTEMBER 1981

Law institutions. Despite that, it is important at this point to indicate that the answer to the problem is not to be found in reducing the role and operation of the private sector, for voluntary effort and local control over management of the service are essential ingredients of a good service. If anything, the answer lies in an upgrading of the public sector health service by the restoration to it of local control. The explanation for the origin of our two-tiered health service and the apparently high rate of mental illness in this country both lie in the period of our colonial history. Since the dark ages, the nature of mental illness has always evoked fear and mystery. The requirements of a colonial administration inspired the building of enormous mental hospital institutions throughout the country. It is an interesting fact that the social stigma of mental illness is particularly strong in Ireland, just as the number of people we have locked away in our mental hospitals since those times is particularly high. I suspect that the explanation of these facts lies as much in particular aspects of the Irish character and personality which have been moulded and fashioned by the later centuries of colonial domination as in any innate propensities of the Celtic gene. Oppression, poverty, dispossession and depopulation by death and emigration resulted in an increase in such reactions as escape through alcohol, melancholic depression and schizophrenia — the psychosis of isolation and withdrawal. These, and other coping styles, such as learned helplessness and dependency evolved in response to this period of domination, were understandable in their day but are maladaptive in present times in an independent nation with a growing economy. As a consequence, through the 19th century, a colonial administration responded to the social pathology and problems it had itself created by erecting the greatest per capita number of mental hospitals anywhere in the world to deal with an artificially produced "high" rate of mental illness. The Poor Law system which it had introduced to deal with widespread poverty eventually fused with the administration and image of the mental hospital system dealing, as they both did, with related aspects of the same colonially induced social pathology in Ireland. Because of the basic fear of mental illness and the Poor Law image, with its connotations of poverty and personal failure which have subsequently become attached to it, the sense of social stigma and self-protective withdrawal from contact with the mentally ill is particularly strong in this country. Thus there can be no doubt that society as a whole has acquiesced in the continuation of these Poor Law attitudes to the mentally ill. It is necessary to create and maintain an increased level of public awareness and an informed social conscience if we are ever to be successful in dismantling the barriers of ignorance, prejudice and fear which unnecessarily typify society's attitude to the mentally ill. It is a regrettable fact that because they, too, are members of society at large and share society's ignorance and fear of mental illness, our legislators and Health Department policy makers have likewise acquiesced in the perpetuation of Poor Law attitudes to the mentally ill. As such, they constitute a key group who have to be persuaded that their policy of institutional containment of the mentally disabled is an inefficient, costly and

damaging policy. Until the psychiatric profession and other concerned groups succeed in persuading central government that this is so, the lot of the mentally ill looks bleak. The cumulative effect of the lack of informed awareness of the lot of the mentally disabled at Department of Health level is clearly evident in the administrative structures which they have established and, in turn, in the distribution and utilisation of resources through these administrative structures. The Health Boards established 10 years ago were a noble concept and intended as a vehicle for local control over local health services. Unfortunately, they constitute a failed experiment, as the Department of Health has effectively centralised policy-making through total control of the allocation of resources in accordance with the Department's perception of policy and priorities. As a consequence, there has been an imbalanced distribution of resources, ' reflecting the selective developments of the health service according to Departmental policy, with little regard for the requirements indicated locally by the Health Boards. Regardless of White Papers or other expressions of intent, policy is where the money is spent. Analysis of 10-year trends of expenditure in the health service, both Revenue and Capital, demonstrates clearly that there is a policy to develop the general hospital sector, on which expenditure is growing exponentially. Certainly general hospitals are necessary and required. But one has to ask upon what moral, upon what social, and upon what professional values are they apparently being built, to the exclusion of any development in the care of the mentally disabled. Indeed, corrected for inflation, it is quite apparent that the lot of the mentally disabled is growing considerably worse, rather than better. The administrative structures within the Department of Health by which needs are identified and through which policy is formulated, are in urgent need of review. They do not reflect the needs of the weaker sectors of the community such as the mentally ill, the mentally handicapped and the elderly. Responsibility for this must ultimately rest with successive Ministers for health. It is a regrettable fact that there are few votes to be obtained behind the walls of mental institutions. The patients of the psychiatric and geriatric services, lacking a political voice or pressure group active on their behalf, constitute a disenfranchised and forgettable minority, who can be electorally ignored. Instead of using the available resources for the development of a balanced health service, based on an informed and equitable social policy, our politicians and successive governments have been content to lead safely from behind, by responding to the sources of pressure which, naturally, translate into votes. As a result and particularly for those sectors of the health service which are not politically rewarding to politicians, too much hidden policy-making power has fallen on the shoulders of a civil service which was never structured for it and which is not publically accountable for it. Turning to the role of professional staff in psychiatric service, it has become increasingly clear that the doctors and nurses who run the psychiatric service operate within a Civil Service structure. In this, by becoming officer- employees in a hierarchical administrative system, rather than by remaining separate contractors of their service,

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