“Empowering Stakeholders: Building Bridges and Crossing them together” Annual Report 2018 18th September 2019 Table of Contents Page Empowering Stakeholders: Building Bridges and Crossing them together 5 Chapter 1: The Functions of the Office of the Commissioner 9 Vision, Mission, Commitment 10 Organisational set-up 10 Vacancies as on 31st January 2018 in order of priority 11 Management Committee Meetings 11 The CMH Agenda up to end 2019 11 Monitoring of Patient Rights 16 World Mental Health Day 2018 25 #StopStigma – A National Mental Health Awareness Campaign 27 Parliamentary Debate of Annual Report 2017 27 Customer Care 27 Curators 28 Public Relations and Media Presence 29 Mental Health Review Committee 31 Influencing Legislation and Policy 31 Working in Partnerships 38 Meetings 39 Participation in Conferences, Seminars, Workshops & other events 40 Continuous Professional Development of Staff 44 Involvement in Academic and Professional development of Others 45 Chapter 2: Analysis of MHA Applications processed in 2018 47 Introduction 48 Outcomes 49 Age and Gender 51 Geographical Characteristics and Relative Risk 54 2 Disease Burden 56 Re-Admissions 58 Substance Abuse and Addictive Disorder Analysis 59 Acute Mental Health in Youth Analysis 60 Suicide 61 Conclusion 63 Chapter 3: Report on Visits to Mental Health Licensed Facilities 65 Visitation Report 2018 – Main Findings and Recommendations 66 Section A: Findings from Patient Interviews 72 Section B: Findings from Staff Interviews 85 Section C: Findings from Responsible Carer Telephone Interviews 93 Section D: Findings from Environment Assessments 96 Chapter 4: Mental Health Staff Feedback 103 Chapter 5: Analysis of Incident Reports 137 ~~~ Appendix 1: Functions of the Commissioner 163 Appendix 2: Presentation to the Mental Health Strategy Team (Ministry for Health) 165 Appendix 3: Visitation 2018 – Questionnaires and Template 181 Appendix 4: EU Compass for Action on Mental Health and Well-being – Working Paper 209 Appendix 5: EU Compass Awareness-raising and training workshop – Malta Report 221 3 “Empowering Stakeholders: Building Bridges and Crossing them together” ...promoting and upholding the rights of people suffering from mental disorders ...li jinġiebu ‘l quddiem u jiġu rispettati d-drittijiet ta’ nies li jbatu minn diżordni mentali 4 Foreword – Empowering Stakeholders: Building Bridges and Crossing them together The Office of the Commissioner for Mental Health presents its Annual Report for the year 2018 which is its seventh full year of operation. As Commissioner, I am indebted to the hundreds of patients, responsible carers and professional staff and to several entities, NGOs and other stakeholder organisations whose input and trust in the ability of our Office to advocate for better mental health and well-being in our society have provided us with the energy and the facts which we present in this report. Through our advocacy and documentation throughout the past seven years and through updated information being published in this report, we have contributed heavily to the national evidence base that has been utilised by the Mental Health Strategy Team of the Ministry of Health in the draft Mental Health Strategy for Malta 2020-2030, launched for public consultation by the Ministry for Health on 5th December 2018. We are confident that empowered stakeholders will stimulate the ensuing discussions leading to the finalisation of the strategy in 2019 and will ensure that the voice of service users, families and providers are at the core of the strategy and policy making process. The findings from various initiatives taken by the Office during 2018 build upon, confirm and strengthen grassroot insights and provider perspectives on the state of mental health and well-being and the outcome is an incredible richness of observations and recommendations that can be meaningfully utilised as robust indicators of the way forward. The EU Compass Workshop in March 2018 provided a further baseline report on the state of mental health and well-being in Malta (Appendix 4) and a comprehensive description of ongoing local initiatives (Appendix 5) that were aligned to findings at European level. The gaps in the local scenario are evident and it is healthy to note that most have been duly considered in the draft strategy. Our recommended five pillars for effective mental health and well-being reform are confirmed: mainstreaming mental health and well-being in all policies and services; moving the focus of care from institutions to the community; moving acute psychiatric care to the acute general hospital setting; supporting rehabilitation through specialised units preferably in the community; and providing long- term care in dignified facilities. The challenge remains that of translating recommendations into coherent action plans that are appropriately funded and accompanied by sound human resource planning. Bold management decisions must be taken. Robust and resilient leadership is fundamental to bring about the desired changes. Through a multi-faceted approach, we strive to report factually and effectively on the state of the rights of persons suffering from mental disorders in Malta. We are not the National Preventive Mechanism for persons deprived of their liberty for reasons of mental disorder. However, the Office operates 5 within the guidelines established by the UN Subcommittee on Prevention of Torture and utilises the monitoring frameworks of the World Health Organisation. Through a constructive climate with all stakeholders, we seek to find solutions and provide the best protection possible for persons suffering from mental disorders whether in detention or living in our communities. The involuntary care process is being closely monitored. We confirm that patients deprived of their liberty are being followed up on a regular basis by their respective caring teams within the much shorter timeframes established by the new law. Although not strictly comparable, length of stay in involuntary care has diminished radically. Patients are being discharged from compulsory treatment orders or transferred to community treatment orders rather than being left on “leave of absence” for years on end. Community involuntary care is now by far the preferred option of following up difficult cases (86% of long-term compulsory treatment cases), also because it includes as a care option the possibility of short admissions for observation and stabilisation care if the need arises. This shift requires a renewed commitment to further strengthen community support services. The implications for service delivery challenges that emerge from the acute involuntary care admissions analysis include: a higher relative risk (20-30%) for Maltese citizens living in the South Harbour and the Northern regions; the impact of migratory flows from Africa and the Middle East with a 2.7 fold increase in relative risk; the mental health needs of foreign workers contributing to the Maltese economy; the challenge of addictive disorders with 30% of acute admissions linked to addictive behaviours mainly illicit synthetic drug abuse; the heavy presence of drug abuse (40% of all acute admissions) particularly among the younger males; and the epidemiology of suicidality and self- harm. 63% of acute involuntary admissions were persons aged less than 45 years, confirming the high burden of mental disorder in younger segments of society. Investing in the mental health and well- being of our younger generations is a policy priority which needs holistic action between health, education, employment, social welfare, workplaces and employers to address the core determinants of poor mental health and move to early intervention using available and targeted services in schools, in educational and training institutions, in all workplaces and in health and social care services. The richness of data available to the Office through the annual structured visitation process demonstrates our effort to faithfully capture and represent the thoughts, comments, opinion and recommendations of our stakeholders: patients, responsible carers, staff and care providers. The Office feels that standards of care have to be better aligned to the patients’ experience and expectations, in order to improve the quality of care being provided. Such standards should lead to less unwanted variations between services delivery settings and overall better care for patients. 6 Patients and responsible carers need to be better supported. Staff members need to be more looked after. The care environment should foster a continuous learning culture with services being effectively led, managed and resourced. Services delivery environments must be safe, clean and comfortable at all times for patients, responsible carers and staff. There are issues with the standard of the care environments in Mount Carmel Hospital, in the Child and Youth Psychiatric Service housed at St. Luke’s Hospital and in the mental health clinics housed in community centres. The huge disparity in the care environment among the wards at Mount Carmel Hospital is not acceptable. An 80% improvement in the current abysmal situation can be achieved by targeting the environment of practically all the male wards in Mount Carmel Hospital. In the latter months of 2018, MCH Management shifted a substantial number of elderly patients to alternative community residential care facilities. The Office was informed that in the early months of 2019, patients within Mount Carmel Hospital would be moved to wards with