Development of Mental Health & Disability Support in Ireland

1. Development of Mental Health & Disability Support in Ireland Dr Andrew Power Centre for Disability Law and Policy

2. Outline • Part 1 - Background to disability supports in Ireland • Part 2 – Formal (State) Evaluations in Ireland • Part 3 – Academic/Third Party Evaluations in Ireland & Elsewhere • Part 4 – Lessons to be learned in undertaking Evaluation of Public Policy

3. Part 1: Background to Disability Supports in Ireland • Historically, the disability sector in Ireland can be seen to be unique, given the: • role of the Catholic Church in shaping cultural expectations of voluntarism; • the Victorian institutional legacy; • the State’s reluctance to interfere with the family.

4. Development of Disability provision in Ireland • Roman Catholic Church has been hugely influential in Irish politics • Irish Beveridge? • Papal Encyclical ‘Quadragesimo Anno’ • espoused the principle of subsidiarity • The entire service for people with intellectual disabilities was ceded to a few religious orders in 1950s.

5. Mental Health Services • Institutional Bias • Ireland had highest rate of institutionalisation in the world (WHO, 1961) • Mental Health Support in Community – only began developing in the 1980s.

6. Disability Support in Ireland • 80% of community services provided by non-profit associations – Church & Lay groups (Inclusion Ireland, 2004). • In practice, statutory services complementary, with voluntary organisations providing, in many cases, essential services.

8. Start of De-institutionalisation • 1984 Planning for the Future • De-Designation: • Significant numbers of long-stay service users, particularly the elderly and people with intellectual disability, were ‘discharged’ through de-designation, a process which re-categorised the facility in which they were living as no longer being part of a mental hospital. • ‘A Vision for Change (2009)

9. Funding of Disability Sector • The Health Act (2004): • Section 38 grants: quasi-governmental • Section 39 grants: ‘similar or ancillary’ • Loosely defined service contracts • ‘Global’ or ‘Block’ grants based on Service Agreements • No evaluation mechanism • ‘Relaxed Control’ model • Decentralisation • Autonomous organisations • Accountability - Little or no national guidelines

10. Intellectual Disability Policy Needs and Abilities (DOH, 1990) “We have been fortunate in Ireland that our residential centres have generally been small by international standards and many have never had the institutional characteristics which have been a feature of such centres in a number of developed countries.”

11. 1997 ‘Realisation of Need’ • National Intellectual Disability Database • The Department of Health strategy, Services to Persons with a Mental Handicap/Intellectual Disability: An Assessment of Need 1997-2001. • The data showed that there was a requirement for 1036 extra places in day services and 1439 extra places in respite/residential care in Ireland.

12. Disability Strategy (2004) Disability Strategy (2004) included: • Multi-Annual Funding - €900 over 3 years 2005-2007. • No ‘right’ to a service – access to a service at the discretion of local service providers. • Block funding of agencies enables them to be autonomous

13. Disability Act 2005 • Sectoral Plans

14. Governance of Providers Relaxed Control Model for Provider Organisations: • Decentralisation • Autonomy • Accountability

15. HIQA National Standards • Currently Ireland has no mandatory standards or independent inspections for assessing care provided by residential services to disabled people. • 2010 budget announcement: HIQA standards were introduced on a ‘voluntary basis’ due to the pressure on public finances. • Irish Times article quotes that ‘officials privately say it would of cost between €5 million and €10 million’ (02 Feb. 2010). • Reflects the norms of practice in Ireland’s ‘evidence-based’ public policy

17. Comptroller & Auditor General Report (2005) • Widespread failure to provide audited financial statements or disclose levels of executive pay. • 12 groups did not file accounts for 2003. • One large organisation which received €288m during 2000-2004 had not provided financial statements for these four years. • Visits to three HSE regional offices found that the information captured from these processes were not used for monitoring service provision in nonprofit organisations. In 2004, the former health boards and the former Eastern Regional Health Authority (ERHA) collectively paid €877m to nonprofit organisations providing services to persons with disabilities. Findings:

18. Comptroller & Auditor General Report (2005) • Service agreements found to not relate the allocation to any measure of the service provided. • Service agreements differ substantially in format, content and detail of services to be provided from one nonprofit organisation to another. • There are often weak or no links between core activity and funding. • €75 of MAF used by HSE to cover their deficits • Demonstrates the pertinence of evidence-based evaluation

19. Value for Money Review

20. New Directions?

21. New Directions? Ireland is now at a juncture in disability support… • New appreciation from the Department of Health and Children, the HSE and voluntary service providers that the old way of doing things with its spiralling costs is no longer sustainable • Evidence that the old way of doings things is not safe • New appreciation of individualised support options