This Bill is the first comprehensive piece of legislation concerned with the treatment of mental illness to come before the Oireachtas since the enactment of the Mental Treatment Act of 1945. Before 1945 the treatment of mental illness had not been the subject of legislation since the heyday of Victorian mental hospital building. From this chronology it might appear that legislation makes only sporadic and widely-separated forays into an area which raises many serious questions of importance to doctors and lawyers and which has effects on one of the most vulnerable sections of society. In a sense this is true and reflects a more widespread reluctance among the public to interest themselves in the whole area of mental illness and its treatment. On the other hand the years in this century in which legislation has been passed, 1945 and 1981, mark fairly obvious milestones in changes in attitudes to mental illness.
Nineteenth century legislation was enacted in an era which saw no hope or future for those diagnosed as suffering from mental disorders, and created large institutions, often in isolated parts of the country, to contain and separate those whose behaviour would not be tolerated or understood: little distinction was made between those who were considered lunatics and those who committed criminal offences. They were both dealt with by similar judicial procedures and consigned to almost identical institutions. The similarity in architecture between some of our older mental hospitals and prisons constructed at the same time is striking.
By 1945 attitudes to mental illness had changed considerably. The origins and causes of mental illness were better understood and consequently modes of treatment became available which, though they may not have effected cures in the strict medical sense, did at least help people to manage the symptoms of their conditions and so helped gain acceptance for the notion of mental "illness". These mental hospitals replaced lunatic asylums and, for the purpose of committals, judicial procedures were replaced by medical certification. This was the major advance made in the Mental Treatment Act of 1945.
During the entire span of human activity enormous changes have occurred since 1945 and so it is only proper that the legislation dealing with mental illness should be re-examined in the light of contemporary needs and attitudes. This is not to suggest, of course, that no legislative changes or changes in the organisation of services for the mentally ill have occurred in the past 36 years. The Mental Treatment Act of 1945 was amended in 1953 and again in 1961. The Report of the Commission on Mental Illness was published in 1966. Many of its recommendations which did not require legislation have since been implemented.
The Health Act of 1970 which radically altered the pattern of delivery of health services also affected the mental health services. That Act obliged health boards to provide in-patient and out-patient services for patients suffering from mental disability — a point missed by some critics of the Bill. Therefore, in the light of the number of amendments which had already been made to the 1945 Act, and the general re-organisation of the health services which had occurred in the early seventies, it was felt that the Bill which is now before you was necessary to reflect the changes which had already taken place as well as providing a legislative framework flexible enough to accommodate changes likely to occur in future years. The obvious question arises now of how to construct such a framework.
The first requirement is that the Bill should reflect contemporary and likely future attitudes to those suffering from mental illness. An obvious starting point is that mental illness is indeed an "illness" much like any physical ailment. Its causes may be more complex and difficult to find, but it most obviously must have a cause and much mental illness must have a cure. These characteristics are common to all branches of medicine. Therefore, a fundamental principle of this Bill and of the mental health services is that, where possible, mental illness is treated on a similar footing to physical illness.
There are obviously some areas where special facilities and procedures may be needed, and these must be the concern of mental health legislation. In my view there is no need for special legislation to deal with the patient who voluntarily presents for treatment for some acute disorder. The Health Acts are perfectly adequate to deal with such cases, which constitute the great majority of admissions to mental hospitals. Special provision needs to be made for those who, by reason of the severity of their illness, are no longer capable of making the rational decision to seek and accept appropriate treatment. I make no apology for the fact that the bulk of this Bill is concerned with the provisions which need to be made for this category of patient.
For the purpose of discussion the Bill can be readily divided into three areas: the registration and supervision of psychiatric institutions, admission and discharge procedures and safeguards for patients.
As I have just mentioned, these are areas which are not of general concern to voluntary patients except where indicated in the Bill, and this approach has led to some misunderstanding. Some critics have claimed that the Bill does nothing for the voluntary patient, and that it does not make provision for community care services or out-patient clinics. Anyone familiar with health legislation knows that there is provision for all of these categories of patient and service in existing health legislation.
In dealing with the three main areas of the Bill as I have outlined them I will indicate where major amendments were made to the Bill in its course through the Dáil. As I have said before, I welcome comments and suggestions as to how the Bill might be improved.
In dealing with the registration and supervision of psychiatric centres the Bill aims to simplify the existing categories of institutions. In future there will be only two basic types of psychiatric hospital, district psychiatric centres run by health boards and registered psychiatric centres run by private individuals or organisations. These centres will provide treatment and care for the overwhelming majority of psychiatric patients. A third minor category are registered psychiatric homes which would provide convalescent home care. There is only one such home at present.
In basing the services on psychiatric centres I do not mean to imply that hospital care is the only treatment for mental illness. I regard the modern psychiatric hospital or unit as a resource centre which provides in-patient care as only one element of a total service.
The hospital also services out-patient clinics, day hospitals and hostels. It is also the base for the community psychiatric nursing service. Of course hospitalisation will be needed for some patients, even if only for a short period. However the objective is to keep this period to a minimum and to return the patient to a full life in the community where treatment can be continued if necessary.
In dealing with admission and discharge procedures the Bill simplifies matters by proposing to have only one category of detained patient. In this context I should point out that the Bill abolishes the existing category of a person of unsound mind, who was subject to indefinite detention. However the major change is the requirement that two medical practitioners should sign a recommendation for reception before a person is detained in a psychiatric centre. This change has aroused some controversy, though I should point out that such a requirement already exists for private patients. It has been argued that there are areas of the country where it might be difficult to get two doctors in an emergency. To allay such fears I introduced an amendment in the Dáil which allows the Minister to designate geographical areas or circumstances in which the signature of one doctor will suffice. I hope that such areas do not exist and that such circumstances will not arise, as I believe that the two-doctor requirement is a reasonable one where nothing less than the deprivation of an individual's liberty is at stake. I could not consider the insertion of a more general emergency procedure as I believe that where such procedures are available they rapidly become the norm. Experience elsewhere provides ample evidence of this tendency.
As I mentioned earlier, these procedures apply only to those who need to be detained. They do not affect voluntary patients seeking treatment of their own accord.
Section 19, subsection (5) (vi) requires that the doctor who signs a recommendation for reception must each certify:
(i) that the person is suffering from mental disorder of such a degree that detention and treatment in a psychiatric centre are necessary in the interest of the person's health or safety of the protection of other persons or property, and
(ii) that the person is not prepared to accept or is not suitable for treatment otherwise than as a detained patient.
These criteria are as amended in the Dáil. In the course of the consultation process which I initiated on the Bill's circulation I was advised that this formulation of the criteria for detention is more in keeping with the contemporary terminology of psychiatry.
There is one point to which I must make special reference. I was, reluctantly I must say, persuaded to make one change in the area of the voluntary patient, and that was to agree under extreme pressure in the Dáil and by the medical profession to require that such a patient give 24 hours notice of his or her intention to leave hospital. I was persuaded primarily on the grounds that it was necessary in the interests of a small number of cases to do so. Deputy Browne took issue with me for doing so, and I found the amendment difficult to defend since it represented a marking out of a difference between the person undergoing treatment voluntarily for psychiatric illness and a person undergoing treatment for any other illness. This part of the Bill also makes considerable improvements to the whole area of patients' rights. New procedures are introduced to inform patients of what is happening at each step in the detention process and of their rights under the Bill.
The fear of indefinite detention in a mental hospital is almost certainly one of the main reasons for a certain reserve which attaches to the psychiatric service. To allay this fear and so, we hope, to remove any remaining concern on this point the Bill has a number of provisions establishing review procedures for all detained patients. The most significant change is the establishment of review boards to which a detained patient or other categories of persons designated by section 38 can apply for an independent review of the need for continued detention. These boards will consist of one consultant psychiatrist, one legal practitioner and a third person who is not a member of the medical or legal professions. Each health board area will be served by one or more review board or boards. This is a most significant development, which has been widely welcomed by those interested in the care of the mentally ill.
Some elements in the medical profession have been concerned that the consultant psychiatrist's advice might be ignored or over-ruled by the other two members of the review board. As I said during Second Stage debate in the Dáil, this seems to me to postulate a very abstract and unreal situation. I cannot seriously believe that highly qualified psychiatrists would not be able to articulate their opposition to the discharge of a patient in a manner which would convince their non-medical colleagues.
In practice, of course, the non-medical members of the board will have the fullest regard for the professional opinion of their medical colleague and also to the opinion of the medical consultant in the psychiatric centre where the patient is detained.
There has been, I might say, a criticism of the absence of definition of treatment. It is in my view impossible to provide a meaningful legislative definition of treatment. In any case such a provision would serve little purpose. Programmes of treatment now encompass not only the application of medical treatment and nursing care but increasingly demand the establishment and development of a very high degree of personal integration between staff and patients. Patient activation has become a major element in the treatment of mental illness—occupational and industrial therapies, workshop activity, social intergration and so on. Because treatment is not defined in this Bill does not mean treatment is not provided. Of the patients discharged from psychiatric hospitals 90 per cent have been there for less than three months and in 1978, total discharges came to 26,684 as opposed to a total admissions figure of 27,662. These figures reflect a high level of treatment activity. Further, despite a trebling of the number of annual admissions to psychiatric hospitals during the last 20 years, the public hospital in-patient population has fallen by about one-third over this period, that is from 19,400 patients in 1960 to 12,500 patients in public hospitals at present.
A feature of the hospital service provided for psychiatrically-ill persons is that provided by acute units associated with general hospitals. There are 400 such beds and a further 500 such beds are being built or are in planning. Even more significant are the developments which have taken place in the provision of informal treatment in the community setting. Day centres and the provision of treatment at home are both areas which can prevent unnecessary hospitalisation in the first place, while an increasing use of residential hostels to provide intermediate and after-care services for discharged patients can serve to provide rehabilitative care and thus minimise readmissions.
In 1977, there were 30 supervised hostels within a community setting, providing care for some 300 patients. There are now 600 patients cared for in more than 60 such hostels. Community psychiatric services are provided by 200 psychiatric out-patient clinics and by 150 community psychiatric nurses at which there are annually now more than 180,000 attendances by 36,000 patients.
It has been suggested by a number of critics that I should specify in the legislation minimum standards of care for mentally-ill patients. Such a proposition raises interesting questions. Can one, for example, set down minimum standards of professionalism and dedication on the part of medical nursing and other personnel caring for patients? Professionalism and dedication are, of course, essential not merely in ensuring the efficacy of treatment and in securing the necessary degree of individual attention for patients but also in developing a humane and caring environment within the hospital setting. However, it has never been made clear how professionalism and dedication could in practice be regulated and then "policed". Such a system would totally undermine the self-confidence of staff, assuming as it would a lack of basic competence on their part. Such a system would also necessitate a constant intrusion by central authority into the day-to-day operation of psychiatric hospitals, thus robbing staff of their basic authority and independence. This draconian situation would be a logical outcome of any attempt to define in law a concept as nebulous as that of "adequate treatment" for the mentally ill.
The question of minimum standards of mental health care would include matters such as accommodation, patient dignity and privacy and so on. The general question of the feasibility of providing for minimum standards in these tangible areas is at present under consideration in association with the Irish Medical Association. I am strongly of the opinion that any meaningful standards of mental health care would also have to encompass closely related questions such as activation programmes for patients, and the degree to which staff-patient integration contributes to simulating normal life settings. These are complex topics which cannot be provided for in legislation, but which might be catered for by general "guidelines".
In concluding may I ask Senators to approach the legislation in the spirit in which it has been introduced, namely, that of bringing the custodial element of the psychiatric service into line with the requirements of the late twentieth century to protect the best interests of those who need to be detained for treatment? The provision in section 13 of the Bill that nothing in the admission and discharge procedures should be seen as discouraging a person from being admitted voluntarily for care and treatment is intended to emphasise the fact that for more than 90 per cent of patients requiring to go to hospital for treatment for psychiatric illness there is essentially no difference between them and anybody entering hospital for treatment for a physical ailment.