“Mental Health Services in Malta”: A Position Paper
9th October, 2016
Contents of Paper
The Burden of mental ill health in Malta is borne primarily by the individual and the family, but additionally by the workplace, the health services and society at large; however, the current mental health care system is archaic, poorly structured, isolated from the general health care services, largely ignores the needs of the individual and contributes to stigmatisation and social marginalization.
Richmond Foundation, the Mental Health Association, the Maltese Association of Psychiatry and the Maltese Association of Psychiatric Nurses, respectively representatives of the patient, the caregiver, and the professionals working within the national mental health sector, are in agreement that a thoughtful, holistic and stakeholder-driven reform process is urgently required, and are also in agreement on the goals of the required reform process, as set out in this document.
This document outlines the minimum standards which are necessary in order to achieve the lowest acceptable level of mental health care that is expected and available in other socially mature countries. The recommendations in this paper would bring Malta to a position where the needs of people in need of mental health care and their carers can find the professional help that they need and deserve. Furthermore, implementation of these recommendations would allow Maltese mental health professionals to sit at the table with European counterparts and not feel embarrassed to discuss the local situation.
Falling short on even one of the identified needs would be falling short on our duty to the people who encounter mental ill-health every day, as patients, carers or professionals.
A paradigm shift in mental health service provision is required to
Health care provision in Malta shows a number of strengths. The family unit is still stronger than in other, larger, countries, providing greater opportunities for supporting patients and raising alerts. Both by virtue of our size and accessibility, it is possible to provide services that are closer to a patient’s home. The limited number of sites where services are delivered allows for rapid communication, and relatively straightforward access to clinicians in both mental health and other areas; also, community doctors are not isolated and are aware of how to contact people within services at times of need. Similarly, the traditional model of health care in Malta allows people in authority to be accessed relatively rapidly in times of need. Since professional training in Malta is historically strong and well established, the vast majority of professionals providing care are likely to be highly skilled clinicians, albeit often not exposed to other models of mental health care delivery. There is genuine care for the wellbeing of others, and all interventions are carried out with face-to-face human contact, such that patient surveys have expressed satisfaction with the service received by clinicians. Within service-delivery structures, individual professionals are often supported extensively in times of need, and there is often a sense of camaraderie within professional groups that facilitates flexibility on an individual level. Patients have access to free medication and free health care within the National Health service, with strongly positive reviews in international reports, and when exceptional cases require highly-individualised management, all efforts are made to support their needs. In terms of educational development, the departments support continuing individual professional development, and educational efforts directed at patients and families are becoming more apparent. Locally-delivered training programmes are helping systems provide a more coherent and consistent, as well as learned service. Furthermore, the governing administration appears keenly sensitive to issues of national relevance, even if these are minority concerns.
Nonetheless, the provision of services targeting the care and treatment for persons suffering from mental health illnesses is a complex and challenging undertaking. Firstly, there is the sheer size of the problem, with mental health issues now recognised by the World Health Organisation as the largest-growing health threat in terms of disability, and statistics that show that world-wide, about a quarter of us will be faced with a mental health challenge at some point in our lives. Those not directly suffering from them often disregard, minimise or misidentify mental health problems, and a great deal of ignorance about mental health illness and its treatment abounds, locally as it does internationally. Apart from the difficulties posed by the illnesses themselves, service provision has to take into account the fact that traditionally mental health problems have been often an afterthought or regarded as being of secondary importance in the larger context of general health planning. In this setting, where available funding is often woefully inadequate for the needs deriving from the burden of mental health issues on individuals, families and society at large, service provision planning also has to consider the unpopularity of accessing mental health treatment, of the impact that ill health has on families, and –traditionally- on the lack of a strong or a consistent voice on behalf of the people who are mainly affected by mental health problems. Thus, such a complex challenge cannot be expected to fall on a single entity (such as a Psychiatry Department or a hospital) to suggest, implement, provide and monitor a model of service provision; rather, it is incumbent on the whole of the structures available to a country to tackle in a coherent and synchronised manner.
While these are indeed global issues, the concern in the local context is that divide between service structure and development internationally and that available in Malta, continues to grow rapidly, and all stakeholders in mental health care in our country recognise that the local situation is entirely unacceptable in a developed and civilised society. In recognition of this gulf between where we should be and where we are, Richmond Foundation, the Mental Health Association, the Maltese Association of Psychiatric Nurses, and the Maltese Association of Psychiatry have acknowledged that their role in Mental Health care service provision is central and critical, and have furthermore recognised that they share a common vision about the standards required for mental health care to be provided in a meaningful, humane and decent manner.
The four Associations, who are principal stakeholders in Mental Health care, and who together represent central pillars of Mental Health care in Malta, genuinely acknowledge all the efforts carried out by successive governments, organisations, professionals, and volunteers throughout the years to improve Mental Health care and to combat stigma. We are also recognising that at this time, there appears to be a welcome, genuine and public acceptance that interventions are urgently required in terms of improvement of services aimed at the care of people suffering from mental health difficulties. This environment is hugely encouraging, but at the same time the four Associations recognise that without the combined input from the patient, the carer, and the professionals who work in the mental health teams, there is a real risk that proposed changes will be well-intentioned but misdirected. Since a major rethinking of the current Mental Health Services needs to be undertaken, it is clear that proposed changes will be immensely onerous and energy- consuming, and that thus we need to get it right the first time round.
It is with this in mind that the Alliance for Mental Health (A4MH) is making it very clear that we as a country cannot have a serious or meaningful discussion about how to improve our current MH services, without making every effort to place the patient, the carers and the professionals at the centre of the decision-making process.
It is self-evident that any further development of the National Mental Health Services ought to seriously consider the current challenges and obstacles being faced by the people who access services, their carers and families, and by the professionals who work within the same MH services, as are itemised in sections 4, 5, and 6 of this document. The body of this document will instead give the background to part 2 of this paper, i.e. the Summary of Needs identified by the A4MH for meaningful reform of the national Mental Health Services.
The obligatory starting point to discuss mental health reform is a conceptual one. The opinions, impressions, feedback and wishes of the very people who the services are targeted towards, are nowhere to be found in the current organisation of MH care. Thus the service user must be put at the centre of the project. What this means is that at all levels, a patient or patient representative (nominated by a recognised patient body) must be an integral –as opposed to rubber-stamping- member of every decision-making process. This is taken to include (but not be limited to) decisions regarding employment of new staff (interviews, boards), hospital or service management meetings, proposed operating policies, Formulary decisions, budgetary meetings, service review meetings, and decisions regarding the recognition or otherwise of staff members for their performance. In addition, sensitivity to the distressing situation of people newly admitted to hospital mandate that identified staff (or representatives of patient organisations) introduce themselves and help people become aware of their rights, options and the treatment process to a level that would be tolerable or feasible to the individual at that time.
Additionally, sensitivity to people approaching MH services for the first time would also suggest a similar but less intense or structured service extended to persons being treated on an ambulatory basis. There should be a system in place to receive and act upon feedback received from service users and this needs to be incorporated into regular service management meetings, together with a formal strategy to monitor MH care delivery and results being produced.
The annual feedback report for the MH services should also include a patient report, a report from an organisation or association devoted to supporting the carers or families of people requiring psychiatric treatment, and annexed a report from the Commissioner’s office. Strong consideration should also be given for an annexed report to be provided by a Human Rights representative to encourage on-going attention to the MH service’s duties towards the people it is assisting. A system for identification and nomination of appropriate patient representatives should be formalised for the MH system as a whole.
Admission to a psychiatric hospital or ward, and acceptance of the need for MH treatment, carries powerful and disruptive effects also onto a patient’s next of kin. The point of admission is often a bewildering, terrifying and shattering experience, and there is urgent need for a formalised structure whereby people whose loved ones are ill enough to require formal help, are themselves supported, and helped to understand processes, outcomes, structures and places where help can be accessed. This would ideally be set up with the collaboration of associations that represent carers for individuals with mental health illness. Other aspects that are distressing to families are the nursing of very disturbed patients in mixed-gender wards, especially since other European countries are reverting back to separate Admission Wards. Wards should also be sensitive to the needs of patients and families by ensuring not only that adequate areas be set up where patients can meet their relatives in a private manner, but also that family members have dignified, identified quiet areas where they can compose themselves after distressing visits.
The introduction of patient and carer support within the MH services is a service that is long due to service users and that can be implemented immediately in the existing system, without the requirement for the discussion and planning that would characterise the other recommendations.
A reform process should restore dignity to persons requiring Mental Health Services while providing for parity in Mental Health Care provision; persons requiring mental health care should be afforded services that are at least equal in standard to accessibility to that of general medical health care in Malta and Gozo. Furthermore, the A4MH demands that the Mental Health Reform process places ‘Mental Health’ back where it belongs, i.e. within the ‘Health’ community, thereby helping to counter institutionalisation, promote higher standards of care, and reduce stigma which is as prevalent within the professional community as it is in the population at large as well as ensure that mental health issues as being addressed within a holistic approach both in its own right but also in view of co- morbidity. Thus, a new hospital for the provision of inpatient Mental Health care, which has been publicly mentioned, must be located within the same hospital grounds of Mater Dei Hospital (MDH), and not simply be “close” to the main building, but be actually physically connected to the main hospital. Failing this, Malta will certainly miss this unique opportunity (presumably the only opportunity in the foreseeable future) to avoid a repetition of the stigma that always follows the building of a hospital dedicated to treatment of persons suffering from MH conditions. In other words, anything short of a building attached to MDH will inevitably end up duplicating the ‘Mount Carmel Hospital’ effect of stigma, ignorance, unnecessary fear, and lack of appropriate access to care.
However, there is the danger that the proposed building of a hospital, given its catchy concept and attractiveness to the media (both traditional and social), will obscure greater needs that currently plague the national Mental Health Services. Indeed, the face of the stigma and dread of mental illness and care in Malta is embodied by Mount Carmel Hospital (MCH) . However, it is not changing MCH that will ultimately help people in need of care. Rather, it is changing the service provision model, such that eventually much fewer people will need admission to hospital, and admissions will be far shorter than they are today. This means that the process of reform must consider the totality of the Mental Health Sector as a System, rather than its individual components separately. The publicised consideration of a new hospital, and the efforts to engage family doctors, are examples of initiatives that need to be undertaken within a larger system-wide process that allows for seamless transition of care across all levels. A holistic plan of reform must take into account governmental and non-governmental stakeholders to address current limitations including community housing and social support, education, employment support services, welfare services, correctional services, and expert mental health services to the Courts.
At present, a disproportionate percentage of the Mental Health budget is spent on inpatient care, reflecting the traditional but out-dated model that focuses on chronic inpatient care for people with MH illness. Intrinsic to this concept of Mental Health delivery, patients are ‘let go’ exceedingly gradually, with a surprisingly large patient population actively on the books as MCH inpatients but “on leave”, and receiving their outpatient follow-up at that hospital, a practice that runs counter to international practice of discharging patients early to community care. Within the prevailing model, multidisciplinary teams (MDT) are spread thinly across multiple and diverse settings, with very limited Sub-Specialty services. There are ambulatory services in diverse settings in MDH and in Community Clinics; these often replicate services and fail to provide for reliable outreach or more intense community treatment to persons with more severe mental illness or for sub-speciality follow up. Clinical services across both inpatient and outpatient settings are usually staffed by the same medical professionals, diluting the intensity and regularity of service provision across all levels of care. Doctors are too often the bottleneck in terms of what services can be provided, and not enough initiative and independence is entrusted to other professionals to provide a broader range of services, with different tiers of acuity.
A4MH advises that instead of the current vacuum between inpatient care and standard outpatient care, community services need to be developed in a way that can support and follow people who are too ill to wait for an elective appointment at an outpatient clinic, and yet could avoid the traumatic experience of hospitalisation were they to be sufficiently managed within the community. It is stressed that unless the opening of well resourced a community service is accompanied by the closure of an inpatient service (such that staff numbers can be relocated, and the system forced to abandon the long-held models of care), any process is doomed to repeat the errors of various initiatives over the past years, which ultimately fail because they are insufficiently staffed or supported or prioritised. However, if an ill person can be followed up within their home, or on a frequent basis in a non- threatening environment, according to their preference, and with the inclusion and support of the individual’s support network, the need for hospitalisation is reduced. This not only means that a person can avoid hospitalisation, but that he/she can leave hospital earlier to be followed within this service.
It must be pointed out that for an individual patient, each of these and subsequent suggestions is today already possible within every traditional Firm or Mental Health team within the National Health Service, but that it is subject to the style of each team, and limited by the availability of time and by the timetable of that Firm; it is not actively encouraged or driven from above. For this to become the norm, an explicit shift in focus of Mental Health Service provision needs to be made, with the stated and audited goal for care to become available outside hospitals and close to home, and set up in such a manner as to be available at times of need and manned by specialised multi-disciplinary teams that are culturally sensitive.
Modern psychiatric care is also structured along service provision that is specifically geared to particular groups; this is particularly evident in services targeting new-onset psychotic disorders, which is an area where the local setup is lagging dramatically. Other areas that require services to focus more specialised attention are those of co-existing substance abuse, child and adolescent mental health, old-age psychiatry, migrant mental health, and rehabilitation psychiatry to foster recovery-oriented approaches to care, but in truth multiple specialties would benefit from a more exclusive professional focus, and away from the current generalist approach that has been inherited through the years.
One result of this prevailing generalist approach to psychiatric service delivery is that patients have a high degree of continuity of care, across inpatient and outpatient settings, within the same team. The cost of this is however no longer acceptable in modern society, as this means that the decision-making professionals would only review a patient admitted to hospital against their will, once or at most twice a week. In addition, it also means that the outpatient reviews can only be provided on the days when that team/firm is scheduled for an outpatient clinic. It is our opinion that the time has come when the medical structure of service provision must change to address the inevitable and realistic limitations of the generalist psychiatrist and to ensure that admitted patients are reviewed frequently by people with decision-making roles, to facilitate discharge, and concomitantly to ensure that people being followed up in the community have access to their treatment teams when they need them, or to a specific team that works in tandem with the outpatient team in a seamless manner.
In Malta, Acute Psychiatry is virtually absent outside the mixed-diagnoses inpatient wards at MCH. There is no 24-hour acute psychiatric service at MDH, and inpatient support at MDH remains under-developed and poorly staffed. The A4MH believes that a Crisis Team/s based in the community, and that would be expected to vet the vast majority of patients being considered for a potential compulsory admission to a Mental Health hospital, either alone or in liaison with a service based in MDH, would help significantly with provision of a flexible, responsive and accessible service that would be far more acceptable to patients and their carers, as well as ultimately improve follow up and reduce the numbers of people who are lost to care –with all the attendant problems- after a negative inpatient experience.
Concomitantly, emergency responders including the Police shall be required to achieve training and scheduled retraining in managing Mental Health crises as these are, and will continue to be, a critical link in allowing ill persons to be reviewed without the need for unavoidable hospitalisation. The role of the family doctor in these as well as less emergent settings needs to also be addressed and reviewed, as the stratification of urgent reviews must improve significantly. Thus, while the Mental Health Services need to be accessible for urgent cases, it is a waste of resources, and a failure of appropriate resource allocation, for non-urgent cases to be erroneously or misleadingly referred for urgent care. The huge demands on Mental Health Services also require that interventions not requiring a specialist are delivered by non-specialist professionals, and additionally that non-medical specialists are increasingly recognised as having a role as independent practitioners and clinicians within a team.
The management structures to monitor the Quality of Care, Safety, and Continuing Education and On-going Appraisal remain poorly developed across most professional disciplines and all levels of care. A4MH demands that the quality of Mental Health services, including the orientation towards recovery, inpatient and outpatient clinical environments, as well as staffing levels, attitudes and skills, be assessed by independent bodies or regulators, service users, and representative organisations as recommended by the United Nations Convention of Rights of Persons with Disabilities (Article 33).
The Office of the Commissioner of Mental Health was created with the MHA 2012, and represents a step in the right direction for the monitoring of the functioning of the involuntary and voluntary processes within the Mental Health Act and Mental Health Services, in addition to a role in the promotion and safeguarding of the rights of persons suffering from a mental disorder and their carers. Nonetheless, the effectiveness of the Commissioner is significantly limited by his being answerable to the same Ministry that his Office is monitoring and eventually calling to order. Thus, the A4MH advocates that if the intention is indeed to have an effective Commissioner for Mental Health, “to protect and promote” as the Office standard proclaims, the Office should be independent of the Ministry responsible for Mental Health and answerable to Parliament.
Once again, there is nothing in the current setup that prevents or blatantly discourages a professional from maintaining the required standard of education or skills or professional attitudes, but this is left to discretion of the individual. The A4MH believes that it is to the definite advantage of patient care, and additionally to the advantage of the professionals themselves, for a formalised system for maintenance of specialisation, or other alternative standards, to be proposed and maintained by the relevant professional associations, and subsequently followed by the Mental Health Services.
The new Mental Health Act (MHA 2012) was enacted with the goal of enhancing the autonomy and dignity of persons needing Mental Health Services as well as encouraging the involvement of carers in decision-making processes. Due to the highlighted limitations in service provision, the spirit of the MHA is not being followed or even acknowledged. A4MH therefore demands that the reform process take account of the necessary levels of staffing and structure of the teams and services providing MH care, and the requirements to fulfil the true spirit of the MHA 2012, as well as to review and amend as necessary the current MHA based on stakeholder feedback. It is not necessarily an issue of throwing more people at the problem, although the local numbers of professionals per population are among the very lowest in Europe. Indeed, it is important that when staff at various grades are assigned specific duties, they are placed in a position where they can truly achieve what is expected of them. Thus, if a professional is put in a position of responsibility, such as that of Chairperson, or Service Lead, or Coordinator for MHA matters, it is simply not sufficient to increase payment yet leave the same clinical load. It is very taxing and challenging to administer a service as large and complex as Mental Health, and practically all clinicians are already working at maximum capacity. This needs to be recognised in practical terms, since a system will otherwise never reach the required flexibility and responsiveness.
Future appointments to the office of Chief Executive Officer for Mental Health Services carry with them the power to significantly affect the whole national Mental Health curriculum and running of the national Mental Health Services. It is thus the natural expectation of the A4MH that appointees would have a proven track record not only of management competence, but also a pre-established understanding of the reality of mental illness, as well as a clear and documented record of interest in the issues relevant to Mental Health, since mental health and illness is a subject that can be vague and at times counter- intuitive to those not well-versed in it, which would then undermine all the efforts being made for appropriate and targeted reform.
The stigma attached to mental health extends to other areas apart from the more obvious ones documented herein. For example, the services provided by a relative or significant other who is caring for a person officially registered as suffering from a serious mental illness, should be eligible for compensation in line with carers for other conditions. A4MH strongly believes that stigma about mental health, mental illness, and psychiatric treatment are powerful negative influences that impact strongly on the general health of society due to the carry-on effect of unaddressed mental ill-health; we also believe that this stigma can only be reduced by on-going, targeted education and the provision of good and reliable Mental Health Care Services. The duty of care towards people suffering from mental illness also extends toward adopting an approach that takes into account a holistic view of needs, and this thus includes both inter-ministerial and inter-departmental liaison to review and implement measures that support employment for persons with serious mental illness, a review of the social benefits targeting the special circumstances, and building greater awareness of Mental Health into different levels of the educational system.
There is no doubt that much can be achieved through a change in the hierarchical approach to Mental Health care, through rationalisation of manpower, through greater numbers of staff to manage the mandated MHA requirements, and through prioritisation of outpatient and sub-specialised care; in short, through a more coordinated, efficient and effective delivery and management style. Nonetheless, there is equally no doubt that the sickest people will remain sick and will continue to demand a far greater per capita slice of the available services than people who are not so severely ill. It is the remit of the professional, and of the National Health Service in modern society, to ensure that the sickest people are treated to the best of our ability to minimise the severity of their and their carers’ distress, to safeguard their safety and the safety of others, and to propagate a culture of care and civic duty in the greater society. Despite the superficial attraction of fee-for-service (private) models, it appears to us to be inevitable that the most seriously ill patients will not be catered for adequately within a system that is based on the stark numbers of economics of care. We can no more wish away the reality of severe mental illness than we can ignore the fact that without intense and on-going input, too many of these ill people will end up homeless, or in the correctional system, or even dead of their own hands or due to homicide, or victims of drug abuse and exploitation. It is the serious belief of A4MH that private models of mental health care delivery cannot truly cater for this segment of the patient population, and that this is the sector of people that is ultimately most deserving of care, since they are the ones least likely –due to their illness- to cope with the demands of daily life.
A paradigm shift in mental health service provision is required to
For the Alliance for Mental Health:
Richmond Foundation – Ms Stephania Dimech Sant, CEO
Mental Health Association – Mr Godfrey Borg, President
Maltese Association of Psychiatric Nurses – Mr Pierre Galea, President
Maltese Association of Psychiatry – Dr Etienne Muscat, President
Dr Beppe Micallef-Trigona is a Maltese Psychiatrist and Visiting Lecturer in the Department of Psychiatry, Faculty of Medicine and Surgery at the University of Malta. He currently works as a consultant psychiatrist with the Ministry of Defence in the UK.