The National Audit Office published their report on mental health services on Monday. Unlike the report published in 2016 – which was specific to health services for children and adolescents – this one addresses mental health services in general, policy, organisation, costs and results.
The report in 2016 marked the first time that a special policy was set on mental health in Iceland. The aim was to strengthen basic services in the local area, and also on prevention and early intervention.
In the opinion of the National Audit Office, the Ministry of Health has not made a formal assessment of the success of the previous action plan, and the follow-up of its progress was not systematic. As stated: “Overall, the results of the action plan were unsatisfactory and most of the problems that existed when the policy was set are still in place”.
The Ministry of Health is working on a new action plan in connection with the government’s vision for mental health, and the National Audit Office considers it important that goals are well defined, and realistic time criteria are set for the implementation of measures and a clear division of responsibilities.
The report states: “It is clear that there is a lot of work to be done to take good care of mental health issues, not only because of the impact of mental disorders on the quality of life of those who struggle with them and their relatives, but the cost to society of mental disorders is high. An inefficient mental health system results in a waste of time and money as well as having a negative impact on patients’ well-being and recovery.”
The Auditor General’s suggestions
Firstly, the Auditor’s belief is that the collection, management, and analysis of information needs to be strengthened, to support targeted policy making. This would ensure a solid overview of the issues, before making executive decisions on the allocation of funding and the amending of policies.
The disorganisation of the information systems is also highlighted in the report “there is a need to increase collaboration, interdisciplinary working methods and continuity in services”.
It adds: “The lack of this goes against the provisions of the Health Services Act, which stipulates that patients must be guaranteed continuity of treatment”. It would be beneficial to have the medical records systems of service providers harmonised.
Furthermore, the National Audit Office asks that the feasibility of people with serious problems having a case manager who follows matters across systems and service providers be earnestly considered.
“Within the mental health services, there are grey areas where individuals find themselves between measures and do not receive appropriate services”
It seems as though these grey areas aren’t actually unknown, on the contrary. Most of the problems have been identified, but it appears they are challenging to eradicate.
One example is the disagreements between the state and the municipalities over the divisions of responsibilities and costs, and the division of responsibilities between the service levels of the health care system. When the issue hangs unresolved for too long, these responsibilities eventually fall through the cracks, along with those most in need.
Often patients are not allocated to the correct resources, but rather to more expensive care that they do not need.
The report continues: “This problem is evident when there is a need for specific mental health services that no one thinks they should provide. There are examples of patients waiting for expensive remedies that are not suitable for them for years. Patients’ interests as well as efficiency considerations call for immediate solutions”. Some waiting lists are in fact measured in quarters or years.
This is notably the case in situations where patients have a chronic or recurring condition, or when they need the resources of both the health and the social services at the same time. This therefore especially affects those most vulnerable, such as people suffering from dementia, and children facing numerous challenges, such as learning disabilities, and/or troubled living circumstances, and especially those on the autism spectrum.
“The wait for mental health team services is too long and they can hardly handle the stress”
The long wait times are of course easily explained by the lack of staff and appropriate resources. However, there are also indications that the system has an incentive to dismiss difficult cases to avoid costs.
It is clear that more qualified professionals in mental health must be hired. The National Audit Office also mentions the need to consider wages, the working environment, and housing, as well as the need to provide enough learning opportunities and study programs to counteract the shortage of psychiatric nurses and psychiatrists.
The report states that “according to Landspítali’s informal assessment, the hospital’s psychiatric services need at least 50 full-time nurses, ten specially trained psychiatric nurses and ten psychiatrists, as well as other professionals.”
This fall, a new study program for psychiatric nursing will be offered by the University of Iceland. No psychiatrist has graduated in Iceland since 2018.
The Auditor General stresses the urgency to guarantee the future of mental health teams. Some have only been funded for a limited amount of time, their fate is uncertain. Only three of the capital area’s mental health teams have long-term financing.
Accessibility needs improvement- refugees, those who do not speak Icelandic, and socially disadvantaged individuals, have reduced accessibility to mental health services.
Work has been done, however agreements with self-employed psychiatrists and psychologists need to be concluded, and services which offer more languages other than Icelandic must also be confirmed.
Closing remarks from the abstract: “The National Audit Office believes that improved organisation, better dialogue between service providers, shorter waiting lists, increased accessibility and long-term thinking when it comes to mental health issues can increase efficiency, effectiveness and results in the area in the long term.”
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