CHARITIES PLAY A key role in Ireland’s mental health sector, but does the State rely too much on voluntary organisations to provide such essential services?
Non-profit and community groups have historically provided care to people with mental health difficulties – alongside decades where institutionalisation was the main method of treatment for mental illness.
This changed in the past 70 years or so as treatment moved towards medical care and the State got more involved. This has led to the current mental health system in Ireland which combines public, private and voluntary services.
As of now, the HSE provides mental health services across the country but many of its general mental health supports listed online link back to voluntary groups, many of which do receive State funding.
Martin Knapp, a professor of health and social care policy at the London School of Economics and Political Science, said it is relatively normal in Europe for governments to rely on charities to provide at least some mental health services.
“The first mental health services, if we can call them that, would have been within the charity sector linked to churches and other faith-based organisations,” he told The Journal.
“That’s where the roots lie. And then it was only in relatively recent history, maybe the last 200 years or 150 years, that government started to get involved in that.”
People experiencing mental illness in Ireland in parts of the 19th century and first half of the 20th century were often treated in institutions.
The first high-security psychiatric hospital was set up in Ireland in the 19th century in the form of a ‘criminal lunatic asylum’, according to a 2007 report on mental health policy in Europe.
Ireland and many other countries have largely moved away from this history of institutionalisation, but it remains in some parts of the world.
A study published in 2021 on mental healthcare in eastern Europe and central Asia said Ukraine continues to rely heavily on institutionalisation as a main form of mental health treatment.
Almost 90% of Ukraine’s mental health funding is used for inpatient psychiatric care, according to the study released before Russia’s invasion.
Knapp said the charitable sector has a mixed history, but an overall “good reputation for doing things in the mental health area” at this stage.
Given the sensitivities around mental illness, given the stigma, the shame that some people feel and discrimination they experience, I think many of those individuals do find the role of different charities and similar organisations to be really supportive.
He said there is a degree of “social responsibility” to ensure services like helplines are in place but that “the service itself doesn’t have to be delivered by public sector bodies”.
“I think maybe it’s something that we should be doing as citizens to say that we should be funding those services,” he said.
“But perhaps they would have better engagement with people who are going through a crisis, if they are not seen to be associated with the State.”
Ivan Cooper, director of advocacy with The Wheel – a national association for charities and voluntary organisations, said Ireland’s mental health sector is “very much a hybrid system” between State, voluntary and private services.
But he said there are questions to be raised about whether essential public services ought to be funded mainly by donations from the public.
“There’s a strong argument that they shouldn’t, and that the government should be moving to fund, or partly-fund, or at least sufficiently fund and enable those services to be sustainable in the long run,” Cooper said.
“Given the hybrid nature of public services in Ireland, and given that so many of our essential public services are in fact delivered by charitable organisation often funded or part-funded by the state, it is time that the funding of these services is put on a sustainable footing.
There is a general sense that what we now need is a more effective way of doing partnership working.
This was a key recommendation in an independent 2018 report on the role of voluntary organisations in publicly funded health and personal social services.
The group behind the report said it believed the voluntary sector should stay but with a need to recognise it as legally separate and enable it to work closer with the State.
This would require a “re-setting of the relationship between the State and the voluntary sector”, the report outlined.
Role of charities at the moment
Fiona Coyle, CEO of Mental Health Reform, said charities are “central to the fabric of the delivery of mental health supportive services across the country”.
“What has happened is that charities and the voluntary sector have stepped into the breach where public services were unavailable or inadequate,” she told The Journal.
“They very often get involved maybe in services or on a community level where the State is unlikely to ever get involved.”
But Coyle said people should not need to only depend on voluntary groups for mental health support.
We need State services, and the State services need to be there and what they’re there for is to support individuals who may be in crisis or who may need in-patient care.
She emphasised that there isn’t always an easy fix, one-stop solution, especially for people experiencing severe mental illness. A combination of low-level and more acute care is needed.
“There’s a lot of dialogue around mental health and wellness and eating your broccoli, going for your walk, listening to your podcasts, doing your self-care,” she said.
That’s just not enough [for some people]. There needs to be an acceptance as well that you can do everything in your power but you still need that extra support from primary healthcare or the acute services.
According to a 2018 OECD report, Ireland had among the highest prevalence of mental health disorders with around 18% of the population having at least one disorder such as anxiety or depression.
Benefits charities have
As expressed by multiple interviewees, charities believe they have certain advantages over State services in the mental health sector.
Martin Knapp said the voluntary sector can be an “important alternative” for people less trusting of State services.
“You need alternative services to protect people who feel vulnerable because of their mental illness,” he said.
I think many people who are going through a mental health crisis don’t want that additional anxiety of worrying about what will happen if they go to services and refer themselves for particular issues.
“It’s not like providing physical health services or something; mental health services raise different issues.”
CEO of Samaritans Ireland Niall Mulligan said: “Within the context of Ireland, I think the charity sector is a very important contributor to our health services.
“I think it’s necessary to have that range of services so it’s not just all run by the charity sector, nor should everything be run by the State.”
He said charities have more flexibility to respond quicker than State services, can be closer linked with local communities and can be generally easier to engage with.
“They provide a perspective and an experience that the State doesn’t have.”
But across the charity sector, there has been some criticism in the past over too many charities with the same goal.
For example a 2020 report commissioned by the Dublin Regional Homeless Executive found that additional on-street food services for homeless people “are not required” and recommended that these services be regulated.
Service providers interviewed for the report said there was an “excess provision” of food in Dublin as a result of an increase in soup runs and volunteers providing sandwiches.
Funding
Money is still at the crux of the issue for mental health voluntary groups relying on State funding alongside donations in a lot of cases.
The HSE said it provided more than €20 million to mental health NGO and community organisations in 2020.
A HSE spokesperson listed almost 30 voluntary organisations and NGOs that receive HSE funding on a national basis. Others outside of this also receive funding at a local level from Community Healthcare Organisations or from other government sources.
A HSE spokesperson said: “The range of mental health services delivered by, or on behalf of, the HSE is extensive and covers both specialist and non-specialist (lower level) mental health support.”
The health service said its “NGO partners” provide services like counselling, day programmes, peer support and advocacy services.
2021 research from the Charities Regulator said funding and income are a constant challenge for the sector, regardless of an organisation’s size or complexity.
When it comes to revenue, central government funding was mentioned by 40% of charity respondents when identifying their top five sources of funding.
Fiona Coyle from Mental Health Reform said the entire mental health sector still isn’t adequately funded.
“High quality services need high levels of investment, there’s no getting away from that,” she said.
5.1% of Ireland’s 2022 health budget was spent on mental health.
The World Health Organization does not have a set recommendation for mental health expenditure, but a WHO spokesperson said: “The Lancet Commission on Mental Health suggested years ago that countries spend between 5 and 10%.
“Other NGOs have also advocated for similar figures.”
Ivan Cooper from The Wheel said government funding is “usually done on the basis of annually renewable service level agreements which are periodically negotiated between the funded organisation and the HSE”.
“Around half of charity funding comes from the State, the other half from donations or fundraising.
I think there are questions then in relation to the future funding of services and how that’s going to be done.
What do charities think?
Niall Mulligan from Samaritans Ireland said the government relies “quite a lot” on charities to provide mental health services.
“If there was no Samaritans in the morning there would be a significant dent in service provision, or certainly in terms of the emotional wellbeing of people who use our services,” he told The Journal.
We work hand in hand with the government and the State in many ways so I think they’re definitely reliant on our existence and we bring something very positive to the table most of the time.
He said Samaritans has a “relatively small amount of money compared to what we actually deliver”.
“I think there needs to be more money pumped into the mental health services in Ireland.
“How that actually gets divided up and divvied out needs to be done based on need and who can be most effective,” he said.
Stephen McBride, director of services at Aware, said the depression support charity and other mental health voluntary organisations can “complement” State-run services.
“We provide something very much that goes alongside [State services] for people who maybe aren’t in a position to engage with the State or who have finished their work with a statutory organisation and want to continue their work with ourselves,” he told The Journal.
He said charities having freely available, easy-to-access services is crucial when it comes to mental health.
“Early intervention can prevent a mild situation becoming a moderate or severe problem.”
“I would always argue for as much funding as is possible in relation to mental health and that mental health is seen moreso as a societal issue and it’s not just the individual’s difficulty to overcome.”
Both Samaritans and Aware receive a portion of HSE mental health funding.
Fixing the system
The solution to improving Ireland’s mental health services and putting more focus on it may not be as simple as moving to a fully State-run mental health system.
Fiona Coyle said: “We need to look at the services that the State currently has full responsibility for, and how long the waiting lists are, and how challenging those are at the moment.
“At the moment, the community and voluntary sector organisations are doing a really good job at filling that gap.”
She said that “once we bring our State acute primary care services up to standard” with “no gaps” in place, the question of the role of charities may come to the fore.
“We need to be aware of the current context of how stretched our State services already are and that we have a model that is based on a partnership approach with the different array of actors,” Coyle said.
Ireland has always had that type of amalgamation between the community and voluntary sector and the State. It’s been a core piece of the development of social services in Ireland.
“If you’re looking at an ideal world, the services and support would be available at a State level. But even looking at countries which have hugely invested in State-led mental health services and support, you do find there is always a role for civil society.”
This work is also co-funded by Journal Media and a grant programme from the European Parliament. Any opinions or conclusions expressed in this work is the author’s own. The European Parliament has no involvement in nor responsibility for the editorial content published by the project. For more information, see here.
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