Emails Detail Gaps in Mental-Health Care for Homeless – and Stalled Plan to Address Them

This time last year, a key team that cares for those who are homeless with severe mental illnesses – those struggling with schizophrenia, bipolar disorder, or psychosis, for example – was having to turn away new patients.

Staff shortages were to blame.

The Assertive Community Care Evaluation Services (ACCES) team was “completely under resourced” for 12 months, said an email in January 2019, sent by Dr Joanne Fenton, a consultant psychiatrist with the ACCES team to members of the HSE’s Mental Health Division.

She raised concerns about patient care, staff shortages and staff safety, shows the email, released under the Freedom of Information (FOI) Act.

That team is now back working the way it was in 2018, said Dr Fenton, last week.

Unlike past periods, it has an occupational therapist, a senior social worker – they’re looking for another one – and psychologist on staff, she said. “Currently we are doing what we should be doing.”

Running services as in 2018 doesn’t mean, though, that all of the services required to meet the needs of Dublin’s homeless are in place.

Those who still need mental health care, but whose illnesses might not be as severe, are falling through the cracks, suggest other records also released under FOI – and a proposal for how to better serve them has stalled for lack of HSE funding.

The positions in the proposal “were not part of the developmental funding posts for 2020”, said a spokesperson for the HSE, by email on Tuesday.

More Money

In September 2018, staff at Dublin South City Mental Health Services – the HSE body that provides community mental health services in the south of the city – submitted a number of proposals to the HSEfor a new model of care for some of those who are homeless with mental health illnesses.

Homeless people have higher instances of severe mental illness, coupled with higher barriers to accessing the mental health care that they need, studies have shown.

While the ACCES team currently cares for those with severe mental health conditions, many with less severe conditions find their needs unmet, says Dr Fenton.

Two homeless mental health teams work with “the top 1 – 2 tier”, says Dr Fenton. “These are the most in need of mental health support.”

Then there are patients in the lower tiers who have mental health needs that can be addressed by a GP, but would need a little more support, she says.

These are the clients that the new community mental health teams were expected to reach.

Dublin South City Mental Health Services made an application to expand homeless mental health services in the area and the remit of the ACCES team in September 2018, due to an increased demand for their services.

In 2018 at St James’ Emergency Department, of 221 homeless people who were seen by primary mental health teams, 33 were admitted while 88 self-discharged or absconded, according to data quoted in their proposal.

Only 8 out of the 33 admitted were offered and attended follow-up appointments, show figures.

Accessing mental health services for those with a less serious mental health illness is hard, the proposal notes. Barely 10 percent of clients received the ongoing psychiatric care that they needed in 2018, it says.

“They’re not often getting the care that they need because you know, they don’t reach the top level. The stepped model of care was set up to try and reach those patients,” says Dr Fenton.

According to an internal email from Aiden Corvin, clinical director with Dublin South City Mental Health Services, to others in his team there, the department had positive feedback on their application for funding to increase the capacity of the team.

Extra funding would see an enhanced assertive outreach, employing two full-time nurses which would increase the team’s capacity by 30 percent, the proposal said .

It would also allow the team to provide hospital inreach to better support the 75 percent of clients who are currently lost to follow up or discharge.

“There was going to be a new stepped model of care but that funding didn’t come through,” said Dr Fenton, on Friday.

“Well, it had come through but then they said no, it wasn’t there, and this was before Covid or anything like that. So that’s kind of on hold,” she said.

The HSE press office didn’t directly respond to queries as to why the proposed funding for the stepped model was withdrawn.

Finding the Right Staff

“While the ACCES team is now taking referrals again, there are still challenges with how posts are filled and how staff are chosen, says Dr Fenton.”

The team is currently struggling to fill a role for a social worker on the team, she said.

It’s not the first time there have been staffing challenges. In 2018, the ACCES team had no occupational therapist from December 2017 until October 2019, according to an FOI seeking staffing levels at the team.

They had no psychologist from March 2018 to May 2019, while there was no occupational therapist on the team from November 2018 until October 2019.

Both the positions of occupational therapist and psychologist had been open because of a lack of cover for maternity leave. Dr Fenton says that the recruitment process makes it hard to find suitable replacements.

Candidates are chosen from panels of people who have already been interviewed, says the HSE website.

“But I would think for working within the homeless structures I think there should be bespoke panels for those jobs,” says Dr Fenton.

Not everybody who has trained as a mental-health occupational therapist would be interested because it would involve doing a different type of work, she says.

The social worker vacancy on the ACCES team went out to the HSE recruitment panel in January, says Dr Fenton. But there was little interest in the role.

“Again, that could be because they’re not bespoke interviews and they’re going out to national panel,” says Dr Fenton.

Staff at Dublin South City Mental Health Services have sought more control over recruitment, shows one of the emails released under FOI.

(The ACCES team operates under the Dublin South City Mental Health Services and the HSE.)

“We want people who have the correct experience and skills who are clinical practitioners not ‘managers’,” says an internal email between staff in the Dublin South City Mental Health Services.

A spokesperson for the HSE said that, “to ensure potential candidates would have the appropriate skills and experience to meet the needs of the homeless population, a local bespoke recruitment campaign ran last year”.

‘The team regrettably was unable to fill from that panel formed but there are plans to progress this again,” the spokesperson said.