Tipperary GP resigns from mental health committee over plans to close St Michael’s unit

Kylecourt Clinic,

Kylecourt Clinic,

Old Davitt Street,

Tipperary Town.

Dear Editor,

Since October of last year, I have sat as the General Practitioner representative on “The Acute Inpatient Subgroup Committee for Carlow Kilkenny / South Tipperary Integrated Mental Health Services”. This group consists of a large number of health professionals and also includes a Service User Representative, and Carer’s Representative. It convenes on a monthly basis, with an objective, as I understand it, is to oversee the reconfiguration of the Mental Health Services in the Carlow Kilkenny / South Tipperary area in line with the recommendations outlined in the “Vision for Change” document.

From the very first meeting I attended, I made my position clear, and that of my colleagues on the South Tipperary Irish College of General Practitioners faculty, whose views I represented, i.e. unanimous and vehement opposition to any proposed closure to the local psychiatric inpatient facility at St. Michael’s Unit in Clonmel. Following recent events, including Minister Kathleen Lynch’s comments regarding the imminent closure of St. Michael’s Unit, combined with the outcome of all the meetings of “The Acute Inpatient Subgroup Committee”, which I have attended to date, I recently tendered my resignation to the group. Unfortunately, and it is with great regret and frustration that I say this, I feel that the opinions, sentiments, and ideas which I brought to the committee meetings, on behalf of my fellow local General Practitioners, were ultimately not given any credence. However, I continued to attend the meetings, in the hope that any minimal influence which I had might help to prevent, or at the very least, bring about a rethink regarding the proposed closure of St. Michael’s Unit. Following Minister Lynch’s recent comments, it would seem that this has effectively been “rubber stamped”. Hence I felt that my ongoing attendance at the meetings would be hypocritical, as one of their mandates is to implement a course of action which my fellow local General Practitioners and I remain totally opposed to.

We are in agreement with the ideals outlined in the “Vision for Change” document, and particularly would advocate keeping the amount of admissions to any psychiatric inpatient facility, be it in Clonmel, Kilkenny, or wherever, to a minimum. However, in order for the “Vision for Change” model to be executed satisfactorily, this necessitates very substantial funding be put towards optimising the local Community based psychiatric services. We are fearful that this is not possible in the current economic climate. We fear that it will prove practically impossible, given these restraints, that the Community based services will be sufficiently developed in the weeks and months that follow, to adequately compensate for the imminent closure of St. Michael’s Unit.

Our main rationale for taking such a forceful stance in opposing the closure of St. Michael’s Unit comes down to the critical issue of service user care and safety. The vast majority of those with psychiatric illness can be managed more than adequately in the outpatient setting. It is the few service users who do meet the criteria for admission for inpatient care that form the basis of our concerns. The most at risk service users such as those that are severely depressed, actively suicidal, acutely psychotic, or manic, are very often sufficiently unwell that they simply cannot be managed safely with the current facilities available to us in the community. By definition, the service users who require inpatient care are usually those who are most at risk. We fear that relocating the inpatient psychiatric care facility a significant geographical distance away, will only serve to put these service users at further risk.

Following changes to the mental health legislation in recent years, there is now a new protocol in place for the involuntary admission of service users to a psychiatric inpatient facility. From a General Practitioner’s perspective, this creates significant difficulties. The service users in question are usually those which I have already referred to, suffering with very severe mental illness. They frequently have minimal insight into their condition, and actively resist admission, and refuse medication, or any form of help. Under the current legislation, we often have to wait for an assisted admissions team to help transfer these service users to the approved inpatient care facility.

The assisted admissions service for the sector where my centre of practice is in Tipperary Town, are despatched from Kildare. Often many hours can elapse before they arrive to help with the transfer of the service user. It is a not infrequent occurrence that service users attempt to abscond in the intervening period, when they realise the intention to hospitalise them against their wishes. Similarly, those service users at risk of self harm, or at risk of harming others, might be more likely to carry this out during this period. I have witnessed this happen even with the current admissions procedure whereby service users are transferred approximately twenty miles from my centre of practice in Tipperary Town to St. Michael’s Unit in Clonmel. I am very fearful that this will be potentiated significantly when the inpatient care facility is relocated a further fifty to sixty miles away to Kilkenny.

Even if a service user who meets the admission criteria is willing to be admitted voluntarily, the issue of transportation arises. If they do not have access to transport themselves, then the issue of ambulance transfer, or some other form of HSE funded transportation needs to be explored. We envisage very significant difficulties arising in this respect, regarding the transfer of service users from the South Tipperary area to Kilkenny, due to the distance factor involved. It is not practically possible that this could be undertaken by the already overburdened local ambulance service. Such a scenario would create a potentially unsafe situation whereby the transfer of local patients with severe life threatening physical illnesses to hospital, such as road traffic accidents, heart attacks etc, would be affected due to the lack of an available ambulance, if it was in the process of conducting a round trip to Kilkenny.

We feel that there are numerous other additional arguments against the proposed relocation of the inpatient psychiatric care facility from St. Michael’s Unit to Kilkenny. The issue of continuity of care needs to be addressed. If a service user from South Tipperary is to be admitted to Kilkenny, will they be under the care of another Consultant and team for the duration of their admission? Will their care be transferred back to another Consultant and team following discharge? It is commonplace during the course of a psychiatric inpatient admission that service users are primed for discharge by being allowed out home on temporary leave for a weekend, or for a few days during the week. The distance factor involved between South Tipperary and Kilkenny is again likely to be a significant limiting factor in such cases. The potential for service users from the South Tipperary area to be visited by friends and family during the course of an inpatient stay in Kilkenny is likely to be adversely affected due to the distance factor and transportation issues. Occasionally, service users are discharged from the inpatient care facility only to require urgent re-admission, on the grounds of crisis intervention, a short time later. If the new inpatient facility is some fifty odd miles from the service users home residence, this will obviously create difficulties.

The sentiments which I have outlined above are shared unequivocally by all of my General Practitioner colleagues on the South Tipperary Irish College of General Practitioner’s Faculty. We feel that it is very important that our opinions and reservations are put into the public domain. We are very fearful of the implications for the overall care and safety of service users from the South Tipperary area, should the complete closure of St. Michael’s Unit come to pass, and the inpatient care facility be transferred to Kilkenny. We appreciate that the current economic climate mandates cutbacks and reconfiguration, but we would suggest that a reduction of the number of inpatient beds in St. Michael’s Unit, as opposed to a complete closure, would be a consideration worth looking at.


Dr. Iver Hanrahan.

General Practitoner.