Dr Evan Yacoub Consultant Psychiatrist
Psychiatry provision is outlined in various counties and places in Ireland for people with intellectual disability.
Psychiatry input to people with intellectual disability in Ireland is provided mostly by the voluntary and non-statutory sector as described by the white paper A Vision for Change (Department of Health and Children 2006) alongside some statutory provision. This paper describes one such community voluntary sector service provision for County Galway. This service provides the psychiatry input to people with intellectual disability in County Galway (in addition to a fortnightly clinic to County Roscommon where there are 97 service users) in the west of Ireland. This service is responsible for the psychiatry provision to people with ID in the two counties with the exception of a small ‘closed’ statutory Health Service Executive-managed service no longer accepting new referrals in the east of County Galway which has 57 service users on its books. The psychiatry provision to this statutory service is 0-2 whole time equivalent Consultant Psychiatrist input with the remaining 0-8 WTE being provided to the voluntary sector.
The population of County Galway in 2011 was around 175000 (CSO 2011). It has a largely rural population with 77% of people living rurally. It is the second largest county in Ireland by area (over 6000 square kilometres).
This consists of a full time administrator who also provides input to the psychology service, 2 full time non-consultant hospital doctors, and 0-8 WTE Consultant Psychiatrist input. As 0-2 WTE is separately dedicated to the aforementioned statutory service, the additional pressure on this provision is through the fortnightly clinic to the neighbouring county and any clinical issues arising from this in between clinics. The Consultant and NCHDs are part of the local general psychiatry service on call rota.
‘Core business’ issues
The service sits within a voluntary organisation which like many others in Ireland has level service agreements with the Health Service Executive. However unlike many others it delivers services to people with mild ID. A significant numbers of voluntary sector services in Ireland work with people with moderate, severe and profound ID only. People with mild ID are often seen by psychiatric community mental health teams although some fall between the gaps in service provision. In County Galway however and for historical reasons, a significant number of people with mild ID receive service provision from voluntary services specialising in working with people with ID.
THe psychiatry service also provides input to children with ID which is also fairly unusual in voluntary sector bodies in Ireland where CAMHS or specialist child ID teams may be in place. This is through a clinic jointly provided with the local developmental paediatrics service.
A Vision for Change (Department of Health and Children 2006) has a number of recommendations in this area;
RECOMMENDATION 14.6: Mental health services for people with intellectual disability should be provided by a specialist mental health of intellectual disability (MHID) team that is catchment area-based. These services should be distinct and separate from, but closely linked to, the multidisciplinary teams in intellectual disability services who provide a health and social care service for people with intellectual disability.
RECOMMENDATION 14.7: The multidisciplinary MHID teams should be provided on the basis of two per 300,000 population for adults with intellectual disability.
RECOMMENDATION 14.8: One MHID team per 300,000 population should be provided for children and adolescents with intellectual disability.
Where do referrals come from?
The psychiatry team members are employed by the largest voluntary sector provider in the county and also provide input to smaller voluntary bodies. Essentially small multi-disciplinary teams (minus psychiatry) provide input to people with ID depending on age, geographical area and level of ability. If psychiatry input is required a referral is sent in via the GP.
Whilst the psychiatry team members are not part of an MDT as such service provision can be delivered through case conferences and team meetings. Much of the time however it is through psychiatry clinics which are attended by service users, families and/or key team members as appropriate.
The psychiatry service also receives referrals from CAMHS and community mental health teams. The referrals for children are for those attending special schools in the county and accessing multi-disciplinary services attached to those schools. The service is ‘cradle to grave’ and does not refer older service users to old age psychiatry services but can discharge service users to the care of their GP if they no longer require psychiatric input.
Number of service users
|Total||Mild ID||Moderate ID||Severe ID||Profound ID|
Table 1; service users by level of disability
As can be seen from table 1, there is a wide spread of ability levels amongst service users with a significant number of people with mild ID accessing specialist provision. There will be a needs assessment under way shortly to ascertain how many people with mild ID access community mental health teams in the county.
|Mixed anxiety and depression||10|
|Bipolar affective disorder||66|
|Autistic Spectrum Disorder||131|
|Obsessive Compulsive Disorder||17|
Table 2; Diagnostic category by number of service users
A number of service users will have co-morbid diagnoses, and in some cases service users will be referred with challenging behaviours in the absence of any diagnostic categories.
The service is well connected to local psychiatric services and arranging inpatient admissions when required is straightforward. The Consultant Psychiatrist is also employed by the HSE (due to the 0-2 WTE provision to a HSE-managed service) and this ensures that admitted inpatients are under the care of their community psychiatric service when in an inpatient HSE facility.
- The service covers a large geographical area.
- The service has children and people with mild ID on its caseload which is not always the case for voluntary sector psychiatry service provision. A Vision for Change (DOH 2006) makes a number of recommendations in this area.
- Ensuring that Consultant Psychiatrists providing input into the voluntary sector have HSE contracts can facilitate inpatient admissions when required.
Department of Health and Children (2006) A Vision for Change; Report of the expert group on mental health policy. The Stationery Office.
Central Statistics Office (2011) Census 2011 in Ireland and Northern Ireland.