A Vision for Change | Review

Healthcare Policy for Ireland – a Critical Review
1. Overview of the document

The document “A Vision for Change” reflects global concerns about mental health, mental illness and impacts on societies[1], and is a key policy document which outlines the projected mode of delivery for mental health services in Ireland. It provides an arguably innovative framework for developing and consolidating positive approaches to mental health and management of mental ill-health across the community context. It also outlines the plan to provide targeted, accessible services to those with mental illness across the whole country.

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2. Key points
Service users and their careers should be involved in every aspect of the service, at every stage, and should be treated as partners in their care.
There should be evidence-based mental health promotion programmes available for every sector of the population at whatever age, as a means of increasing wellbeing and preventing mental illness.
The service should be developed and implemented along a model that is focused on recovery, which meets the needs of the individual.
The document requires the development and implementation of Community Mental Health teams, fully staffed with appropriately trained staff, and based in the communities which they serve, who can meet any needs of an individual in relation to their mental health across their lifespan. This would involve outreach programmes and liaison and referral to a range of therapies, including pharmaco-medical therapies, and psychological therapies.
Services will be organised in designated catchment areas, monitored and managed by transparent processes.
Services will be prioritised for those areas which are deemed as of greatest need, with fully inclusive services that can be accessed and are relevant to all user groups.
A plan to close acute mental hospitals should be designed and put into place, and their resources re-invested in the new mental health services suggested.
Improvements in information systems, mulitprofessional working, training and education are intended.
Extra funding is required.
The whole plan needs to be accepted and implemented for its principles to work.
3. Provide a critique of the document with reference to its challenges, limitations and strengths

The document challenges the current provision of mental health services through particular means. To begin with, much like the NHS Plan[2], it requires the services to reorient themselves to a user-centred focus. To this end, the document itself was developed by a team which had service user input at all stages, which is laudable (Gagliardi et al, 2008). Service user input is a key element of good mental health service design, but also, this document is based on a range of evidence from clinical practice, including all levels of evidence[3]. This is a strength, that it contains the points of view of those who provide the service, those who use it, and some of the research evidence which supports the plan, including the inclusion of psychological therapies[4]. Improving access to such therapies can only benefit service users and providers in the long run[5].

4. Critically analyse the impact of the document on, and its relevance to, overall healthcare provision

The impact of this document on healthcare provision could be significant, particularly as it means closing acute inpatient hospitals and redirecting those resources to the new mental health services. This might affect a significant number of patients who are not prepared to return to the community, and would also affect staff. The drain on services initially might be significant, and only over time would this even out. The financial impact on other healthcare services would have to be evaluated.

However, this document clearly sets out to meet the unmet needs of all sectors of the community, and by taking a person centred, recovery oriented approach, seems to be trying to both manage mental illness and prevent deterioration or even development of such illness in the longer term. This is not news, and the urge to move psychiatric and mental health care fully to community contexts has long been argued for[6]. However, there is also the awareness of the impact community-based services would have on primary healthcare providers[7][8]. The document does attempt to address this, but it might not reassure those who will be most impacted by the changes[9].

5. Critically analyse the impact of the document on, and its relevance to, public health nursing practice

The role of the public health nurse is very much centred around improving public health for all, but the individual-needs focus here would allow public health nurses to identify ways in which to meet client needs in liaison with the new mental health services. Public health nurses would have to establish good working relationships with the staff of these services, and the parameters of practice would have to be transparent and be agreed upon by all parties. However, there may be implications for inter-professional working and challenges to professional hegemony[10], and the transition period could have some impact on service users. It might be important for public health nurses to be actively involved in the implementation of the plan from the beginning, as a means of ensuring its success (Carr, 2007).

6. Critically consider any recommendations, summaries or conclusions from the document

The document requires that the plan it outlines be implemented in full. This would have some significant impact on issues of resourcing and funding. While it would be possible to implement these changes, they are so radical and far reaching that it would be destabilisation of current service delivery over a marked period of time, and it would be financially very costly in the short term, despite the projected financial benefits in the longer term. Finding the resources to implement this could be the biggest challenge, as even single activities that form parts of the plan have significant cost implications[11].


Bower, P. and Gilbody, S. (2005) Managing common mental health disorders in primary care: conceptual models and evidence base BMJ. 330:839-842

Carr, S.M. (2007) eading change in public health – factors that inhibit and facilitate energizing the process. PrimaryHealth Care Research and Development. 8 207-215.

Currie, G. and Suhomlinova, O. (2006) The Impact of Institutional Forces Upon Knowledge Sharing in the UK NHS: The Triumph of Professional Power and the Inconsistency of Policy. Public Administration 84 (1) 1-30.

Gask L, Sibbald B, Creed F. (1997) Evaluating models of working at the interface between mental health services and primary care. Br J Psychiatry;170: 6-11

Goldberg D, Huxley P. (1980) Mental illness in the community: the pathway to psychiatric care. London: Tavistock.

Goldberg D, Gournay K. (1997) The general practitioner, the psychiatrist and the burden of mental health care. London: Maudsley Hospital, Institute of Psychiatry,

Gagliardi, A.R., Lemieux-Charles, L, Brown, A.D. et al (2008) Barriers to patient involvement in health service planning and evaluation: An exploratory study. Patient Education and Counseling 70 (2) 234-241.

Department of Health (2000) The NHS Plan London: Department of Health.

Department of Health. (2001) Treatment choice in psychological therapies and counselling: evidence based clinical practice guideline. London: Department of Health.

Lovell K, Richards D. (2000) Multiple access points and levels of entry (MAPLE): ensuring choice, accessibility and equity for CBT services. Behav Cognit Psychother ;28: 379-91

Shepherd M, Cooper B, Brown A, Kalton G. (1966)Psychiatric illness in general practice. London: Oxford University Press

Valenstein M, Vijan S, Zeber J, Boehm K, Buttar A. (2001) The cost-utility of screening for depression in primary care. Ann Intern Med;134: 345-60

World Health Organization. (2001) The world health report 2001mental health: new understanding, new hope. Geneva: WHO.

Woolf, N. (2000) Using Randomized Controlled Trials to Evaluate Socially Complex Services: Problems, Challenges, and Recommendations Journal of Mental Health Policy and Economics 3 (2) 97–109


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