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Dáil Éireann debate -
Wednesday, 19 Nov 1980

Vol. 324 No. 5

Health (Mental Services) Bill, 1980: Second Stage (Resumed).

Question again proposed: "That the Bill be now read a Second Time."

Deputy Boland was in possession but he is not here to resume. Is any Member offering from the Government side?

I will willingly give way if any Member from the Government side is anxious to contribute.

I am anxious to make a contribution to this debate mainly because there is a mental hospital in Waterford city, an institution that has done very good work in the field of mental health care down the years. I should like to deal with a number of provisions in the Bill. My first comment relates to the situation of voluntary patients, a very delicate area. On occasion when some citizens feel they are in a certain state of nerves, depression or alcoholism they have the facility to enter a mental hospital voluntarily. The removal of formalities in section 13 in relation to voluntary patients is very desirable. In relation to those voluntary patients who wish to discharge themselves from hospital, the present situation is that it is possible to insist on such a patient giving 72 hours' notice of his or her intention to discharge himself or herself. I understand that that condition is rarely demanded but the provision exists. I would not like to see it removed because the occasion may arise when a doctor or a consultant may be worried about the person anxious to discharge himself or herself. A doctor or a consultant may consider that person to be a danger to himself or herself, family, friends or society. The provision should be retained. The Minister should address himself to that matter when replying.

Many of us have been approached by patients anxious to discharge themselves and we all take great care when dealing with such people. I am aware of this problem because I live adjacent to the local mental hospital. For that reason I meet more such patients than most Members. Great care must be exercised when dealing with voluntary patients in relation to their admission, their personal problem and their discharge. They must be treated with the utmost delicacy. The provision in relation to the 72 hours' notice is desirable and important on health grounds and necessary for the protection of the patient. Doctors who are playing an important role in the effort to bring such people back to health must be given some control over them especially in relation to personal privacy and integrity. Great care must be taken to allow doctors, particularly the RMS, have some say in relation to voluntary patients so that they have time to consider the condition of such patients. They must be allowed time to make arrangements for the supervision of voluntary patients as soon as they leave hospital. I am sure the Minister is anxious to ensure that personal rights are given to a voluntary patient and that he is also anxious to ensure that there is no invasion of privacy or of the patient's person in so far as he could be forcibly detained. In relation to the voluntary patient, the doctors must have some facility to give them time to assess their own and the patient's position when he wishes to sign himself out of the hospital.

Section 15 deals with applications for recommendation for reception. This is an extremely delicate area for the family or the brothers or sisters making a recommendation for the detention of a person in a mental hospital. They envisage grave anguish to the people involved. I have come across a number of cases mostly, unfortunately, involving alcoholism, where it had become necessary for the reception and detention of a person in a mental hospital. They caused grave anguish to the people involved. I have come across four or five extremely delicate cases. This is a private area of legal medicine, I suppose. Subsection (2) sets out the procedure whereby an application can be made, and the people who are entitled to make such an application.

There is an anomaly in this section. It would appear that brothers or sisters cannot apply for a recommendation for reception unless they are actually residing with the patient. That comes under paragraph (d). This may cause difficulty where the person to be received is living alone. It might debar a brother or sister from taking action on a family basis. It is always desirable that the family should be involved in these circumstances. Admittedly, a member of the Garda Síochána may do that in certain cases, or an authorised officer. Where the family realises that there is a need for hospitalisation, and where it is desirable that a person should receive expert medical attention, irrespective of whether the brother or sister is living with the person involved, he or she should be able to make a recommendation for the reception of that person.

I am sure if he considers the matter further, the Minister will agree with me that we should have flexibility in this area. It is an extremely personal area and, to a very high extent, it involves the invasion of a person's privacy and, indeed, even the invasion of a person's home, in order to ensure that the person who may be at risk to himself can be taken into a mental hospital and receive expert attention. Irrespective of whether a brother or sister is living with the person concerned there should be an entitlement to make a recommendation for the reception of that person.

Section 19 (1), which is a major section, also deals with recommendations for reception and provides:

A recommendation for the reception of a person in a psychiatric centre shall require the written recommendation in the prescribed form of two registered medical practitioners in accordance with the following provisions of this section.

I agree it is extremely important to maintain a balance in respect of the right of a person to be free to go about his business and the need for protective devices being available to ensure that a person who is at risk to himself, or society, or his own family receives proper medical treatment. This is a very delicate area and it should be treated with great care. Heretofore, the recommendation for reception needed to be given in writing by one medical doctor only. It is now proposed to change that to two medical doctors.

Where there is a need to bring a person into a mental hospital on a non-voluntary basis there is always a degree of urgency about the admission. It may not be possible to get two doctors to sign the recommendation. For instance, if a person living in an isolated rural area is in need of immediate urgent and expert medical attention in a psychiatric hospital, two doctors may not be available to make the written recommendation for reception. This is a grave situation and there could be a time lapse during which the person could do damage to himself or others.

It is highly desirable in relation to non-voluntary patients that there should be a certain degree of flexibility available to the medical profession. One would like to assume that doctors will act with the highest motives in writing recommendations for reception. We must approach this problem on the assumption that doctors will adopt a very responsible and neutral attitude. Where we accept that a doctor will act for the benefit of a patient it is desirable that one doctor should suffice to write a recommendation for a reception especially in rural areas.

The introduction of the need for two written recommendations is unnecessary and may in certain circumstances be the cause of a person doing harm to himself or others in an emergency situation. A way around this would be to allow one doctor to write the recommendation for reception and to then have two doctors independent of the psychiatric hospital assess a patient to validate the original doctor's written recommendation for reception. I appreciate that what the Minister is trying to do is to protect the person concerned but in doing so the Minister may allow a situation to develop where because two doctors will not be available, in the time lag between getting them, the person, who we will accept needs immediate and urgent treatment, might damage himself or others. This provision if implemented will make certification almost impossible in many rural areas and will probably eliminate any kind of rapid action in an emergency. It is essential that provision should be made for the reception of a patient on the recommendation of one doctor only. That is very important in the interests of the patient.

Section 39 deals with the decision of a review board as to a person in detention. The review board can direct the discharge on a majority decision of two to one even if the dissenting member is the medical member. When making a decision to release an involuntary patient it is highly important that the view of the medical member of the board would have higher priority than that of a lay member. A situation is being created in which the opinion of the medical member can be neutralised because it will only need the decision of two members of the review board. That is undesirable. We are dealing with mental illness which is complicated and requires specialised medical attention. It is logical and rational that the medical member of the board would have an important part to play in making a decision to discharge a patient. The Minister should have another look at section 39 with a view to ensuring that if the medical member of the board disagrees with discharging a patient, then a second review board will be consulted. If a medical doctor gives his opinion that the patient should not be discharged greater notice should be taken of it than of the lay person's opinion. There must be a mechanism to allow the opinion of the medical doctor to have a delaying effect in relation to the discharge of the patient. Where a person should be released from a mental hospital I would not for one minute delay his release. I am merely taking the case where a medical doctor's opinion is allowed to be laid aside without further referral. In such a case there should be direct consultations between the medical officer of the Department of Health and the medical officer of the psychiatric centre. That would allow any doubts about the person's health or sanity to be cleared up.

It would be most unfortunate for such a person to be talked about in the community after his discharge if word got around that the doctor on the review board was not in favour of his discharge and it might possibly do him personal harm. I am sure the Minister will agree that that is the last thing he would like to happen. It is important from the point of view of the Minister, of the medical profession and of the personal integrity of the person to be discharged that his name upon discharge will be cleared on all medical grounds and he goes back into society with an absolutely clear medical certificate. Where a medical doctor raises doubts it is highly undesirable that a person should be discharged. Where a doctor states an opinion contrary to that of the two other members of the board and in favour of the retention of a patient in hospital, there must be some other referral means to ensure that there is no doubt about a person's right to be a private citizen free from a mental hospital.

For that reason some referral method must be established to remove any iota or strand of doubt about a person. I suggest that where the medical member of the review board states an opinion that the patient should be retained in hospital whereas the other two members of the board state that he or she should be released, there must be a referral procedure. Direct consultations between the review board and the Department of Health medical officer together with the medical officer of the psychiatric centre should first take place and an opinion be received from those two experts as to the right of a patient to be discharged with a clean bill of health, and that must be emphasised in this case; otherwise you are not really allowing the person to be freed from a mental hospital with a clean bill of health. I am sure that the Minister will give serious consideration to my suggestions.

Another section to which I would like to refer in general terms is section 44 which relates to consent for certain therapeutic procedures and states that the medical council may, with the consent of the Minister, make rules. This seems to be casting doubts on the medical profession and on the professional status of consultant psychiatrists. It is highly important that our consultant psychiatrists be trained to the highest possible standards, but, having been trained, it seems rather an unusual procedure to adopt not to allow them to make or carry out specific treatment. The Minister now is insisting that the medical council may make rules "in regard to the application to any person of any specified therapeutic procedure for the treatment of mental illness, and specifying the conditions to be complied with and the precautions to be taken to safeguard the rights and well-being of patients to whom the procedure is applied". I doubt very much if a consultant psychiatrist would act in any manner other than to the benefit of his or her patient. I do not think that this provision is desirable and I understand that it is the first instance of legal restraint on the medical profession regarding details of treatment and certainly in relation to the psychiatric profession I understand that grave doubts have been expressed about this section.

I would like to refer briefly to the admission of alcoholic patients involuntarily into a mental institution. There may be a very good case for provision to be made for the involuntary admission of alcholics in special circumstances. Again, this is an extremely difficult area which would require delicate consideration by the Minister. These are my direct comments in relation to the Bill.

I would like to make some general observations about the development of our mental hospitals. In my lifetime tremendous strides have been made in the provision of mental health services and I have seen a great change in attitude on the part of the medical profession towards the treatment of patients. I live in a city in which there is a mental institution and because I live in close proximity to it I come across the patients of that institution far more than many others do. Indeed I have the privilege of going to Mass in the mental hospital and from my observations, which can be only a layman's observations, I feel that a number, maybe as high as 10 per cent, of patients at present in mental hospitals should not be in mental hospitals at all. I would say with a certain amount of certainty as a layman—I am not a doctor—that the only reason they are in mental hospitals is that nobody, no member of the family, no friend is prepared to care for them. They may be suffering from old age, which in many cases is the only reason why people have to go into mental hospitals.

There is a lack of geriatric space for old people and the long waiting list of applicants for entry to our geriatric hospitals can only be described as unsatisfactory. We have an excellent geriatric hospital in Waterford. St. Patrick's Hospital, where there must be ten or more acres of waste ground upon which could be built a big extension to that geriatric hospital which would allow for the entry of a number of genuine geriatric cases. Sometimes geriatric patients are incarcerated in mental hospitals and that is an indictment of and a most unfortunate reflection on our present-day society. I have stated that 10 per cent, maybe more—I would bow to expert opinion in that—of people who are in mental hospitals are there only because no one will care for them. Whether they be geriatrics in the true sense of the word or whether there is perhaps a slight want, surely that alone is not reason for their incarceration in a mental hospital.

There is a need for some new approach by the Minister in relation to many people who at present are in mental hospitals. Some attractive financial incentive should be given to relatives or friends who are prepared to care for people. I do not know how much it costs per patient in mental hospitals but I am sure the sum is quite high and that the State would save money by giving a substantial, favourable allowance to relatives of people who otherwise would be patients in order to care for them. Part of that allowance should be in respect of the medical needs of the patient. By establishing this new type of allowance you could cut down substantially on the population in our mental hospitals. The way then would be open for more intensive care for patients in mental hospitals.

When I was a young man St. Otteran's Hospital had high walls and the attitude towards it was Victorian. That is only 20 years ago. The position now is that the walls are only six feet high and it has become an open hospital for many patients. I often see them going to the shop to buy cigarettes, sweets or whatever and it is great to see them walking on the streets. There was a farm attached to the hospital a little out of the city where some of the patients could go and do a day's work. We can be proud of the innovations that have been made in our mental hospitals and the professional staff in the hospitals should be praised.

The consultant psychiatrists, male and female nurses and so on who sometimes work in difficult circumstances have effected a profound change of attitude towards the treatment of mental illness and a more Christian way of looking at it. I have heard criticisms of our mental hospitals and I am sure they are valid. The attitude towards mental health and the treatment of patients has changed radically. I am sure the medical profession would like to see further changes and a different emphasis on treatment.

We have come a long way but I am satisfied that we could help further to reduce the numbers in our mental hospitals by ensuring that adequate finance is made available for those who could care for patients at home instead of putting them into mental hospitals which would mean a substantial saving to the State.

I want to get this ironed out. Deputy O'Connell missed his turn but as he is spokesman perhaps Deputy Brady would give way to him.

I bow to the spokesman on this matter.

Deputy Boland was in possession but as he was not here I offered to allow the Deputy opposite to speak.

Deputy Brady has agreed to give way.

On a point of order, this Deputy was not in the benches when you commenced speaking but I am bowing to Deputy O'Connell.

I offered—

There is no need to have any hassle about it but the Chair finds that it is calling three Opposition speakers one after the other.

I should like to express my gratitude to the Deputy for having facilitated me in this way. I welcome the Bill. It represents a step forward towards safeguarding the rights of patients. The purpose of the Bill should be to strike a balance between protecting the rights of the patients and the rights of the public. It is an honest attempt to protect the rights of the patients. Anything which helps the 14,000 mental patients in our hospitals must be welcome. These are the most vulnerable people in our community. They are not in a position to defend or protect themselves.

We have had a very bad attitude towards mental illness through the years. Patients' rights have been flouted. Patients have been committed to hospital by people, under the direction of doctors, and they have never got out again. People have ended their days in such hospitals simply because the person who originally signed them in was not available and but for that fact they would have been discharged. Anything to improve that situation would be an enlightened approach to the whole problem of mental illness. Mental hospitals have held people for years as we know from the lady in Roscommon who wrote a book about living a lifetime in one of them.

The Stigma attached to mental illness has persisted for too long. Our whole attitude to mental hospitals was such that we built high walls around them. Nobody wanted to know anything about these people and the attitude was that they must be alienated at all costs. It is because of this attitude that we have the appalling conditions that still exist in our mental hospitals. I do not blame the Government because the conditions have persisted despite the fact that we have had different Governments. The public have adopted an apathetic attitude towards these hospitals and the people who live in them. There was an expose on television some weeks ago and everyone was alarmed. These conditions were highlighted at different intervals by different people. I mentioned them on numerous occasions but I got no support because the public did not want to know. It was not something that concerned them.

If the public were serious about it they would not make the demands on the health service that they do make. This would mean there would be more money for our mental patients and hospitals. However, they are not concerned if they are not directly involved. An indication of their lack of concern is the fact that a high percentage of mental patients never receive even one visit a year. That is an indictment of the public. They are treated almost like social pariahs to be locked away and to have no one visit them or send them a card. Governments only react to public opinion and public opinion has not been on the side of mental patients.

There were appalling conditions in St. Brendan's. It was even falling down. They were the most inhuman conditions a patient could possibly live in. The same is true of parts of St. Ita's Hospital and I was constantly trying to highlight them. So much so, indeed, that people said I was on my hobby-horse again whenever I mentioned them. Doctors and officials who know of these conditions and condone them stand indicted in the public eye. They have no right to condone them. They should make a public protest against them and say that they will not work in such appalling conditions. They should say they will go on strike until the conditions improve. Those who are involved daily with the treatment of patients and see the deplorable conditions in which they live and under which the doctors work are the people who should have been out fighting against them, protesting and helping to mobilise public opinion against the appalling conditions. They did not do this and their silence indicts them. When people protested against the officials' defence of the status quo they felt they were being attacked personally. I am now asking doctors and officials concerned in the mental health services to make their voices heard so that improvements will be initiated.

The Bill should have set out minimum standards of care for these patients, uniformally throughout the country, because such patients are the least able to speak up for themselves. Therefore our obligation to them is strongest. I suggest that the Minister introduce immediately a five-year plan to improve the conditions in which mental patients live. He would earn the gratitude not only of the patients but of the entire nation. We know money is short, but when introducing ing a five-year plan to organise minimum standards of care for mental patients the Minister could say to the other health sectors: "Hold back, This is the top priority area and we must do something about it immediately". Let there be a curb on expenditure on other improvements until we first provide proper standards for mental patients.

On the question of keeping mental patients in hospitals, I ask the progressives please not to dump those people out in the streets. Unfortunately we have begun to display such a tendency under the mistaken idea that it is in the interests of the community at large. People who have been in hospitals for years have become sheltered, institutionalised, and when put out they tend to suffer from the revolving door syndrome — they return within a short time. Some of them go to hostels and some become involved in vandalism and may wind up in prison.

Those responsible for mental health care tell even schizophrenics that they can go home, and they are dumped in the streets. This must be stopped immediately. Those people have been protected and sheltered for years and it is criminally wrong to treat them in this way. When considering all those grandiose schemes to open up our mental hospitals we must be extremely careful.

Let us by all means open our mental hospitals, but to the public, to volunteer groups. Why not invite them in to help? There may be opposition from the trade unionists who might fear such people would be assuming some of their duties, but this could be sorted out. Above all, we should encourage young people to visit such institutions. I suggest it would be a good influence on young people to see at first hand how those patients live. It would give young people a sense of responsibility and we would have a lot less vandalism and juvenile irresponsibility. In America they brought high school children in to visit such institutions with excellent results. In consultation with the Minister for Education, the Minister for Health could do a lot of useful work in this respect, It would be of benefit to the young people concerned and would help to overcome the depression from which many mental patients suffer because of the conditions in which they live. It would eliminate the need for the anti-depressant drugs being used, which are a woeful waste of money.

I suggest the Minister should make provision for an ombudsman in each health board region. Patients with justifiable grounds for complaint could have their cases dealt with compassionately and quickly. I also urge on him the need to provide half-way houses for mental patients so that while being prepared to return home they will still live in sheltered communities after leaving hospitals. We have made progress in this respect, but there has been a £2 million cutback in psychiatric services and this is not doing anything to improve the lot of our mentally ill people.

All this Bill will do is to give certain rights to the mentally ill. Despite what has been said I do not think the provision requiring two doctors to certify a patient for admission will cause much inconvenience. Already this is a requirement for private patients and all we are doing is extending it to public patients. This will give more rights to patients. The number of patients admitted by one doctor only is an indictment not only of the State but the medical profession. The attendance of two doctors is a vital safeguard which must not be allowed to be sidetracked.

The provision of a review body is another safeguard for mental patients. However, it is to be limited to a membership of three — a lawyer, doctor and lay person. I hope the Minister will be persuaded to extend the membership to five, because it is possible that the two professionals could sway the lay person. The existence of such a body will ensure that people will not be detained for life in mental hospitals, and the composition of the review body should therefore be considered with great care.

The review body will review once a year but where there is a chronic patient they will not review for two years. This is wrong because enormous advances are taking place in the treatment of mental illness. What we may consider to be incurable today may be curable tomorrow. We are seeing great advances in the treatment of schizophrenia. At present they are at the experimental stages but even in one year there may be a cure for this illness. This Bill does not make provision for advances in therapy for mental illness. A patient may be detained for two years even though a new treatment may be discovered. All the evidence from research taking place at the moment suggests that there may be a complete cure for schizophrenia within the next few years.

I do not think it will create enormous problems if the review body have to review chronic cases once a year rather than once in two years. Because of the burgeoning interest in mental treatment research, to have the review body look at chronic cases every two years would be a retrograde step. As I said, we are seeing great advances in this area. It is not so long since we had these people in cages and could only shove their food through the bars. The earliest largactil tablets enabled those in charge to open those cages. Schizophrenics, with special phenothiazine treatment, can now take their place in their community.

I heard somebody criticise the medical council and the role they will play. We should not condemn anything that protects the rights of patients. The medical council are there to monitor the possibility that patients may be experimented on. They must ensure that ethical standards prevail. There is no harm in that. Any doctor who has the interest of his patients at heart must not be afraid of this council overseeing the treatment used. In my opinion that is not wrong. Doctors must welcome this council because it is an attempt to prevent unethical treatment, experimentation and so on.

We have seen evidence in Britain — we do not know about Ireland yet — where patients were experimented on, treated very badly and, without giving their consent, subjected to certain treatment. We badly need this legislation and I would oppose any attempts to dilute it.

I would like to consider injuries to patients. This happens but some of it is self inflicted. In such a situation I would like to see the patient's rights protected, but who will report the injuries to the medical officer? Section 45 does not answer that question. It merely says that the medical officer shall give a report to the Minister on the injury or the alleged assault. We must look more closely at this. I am opposed to allowing an appeal to the Minister, because that gives him too much power. We have seen in Russia that people were certified as psychiatric patients because they objected to the system. I very much oppose that. There should be an appeal to the courts against such decisions because this would be more attentive to the rights of the patient.

I fail to see why we should incorporate in this Bill immunity for the staff against civil proceedings. Why should we deprive a mental patient who may be assaulted from suing a member of the staff? To give the staff immunity is very dangerous. Again we are talking about the most vulnerable section of the community, those people who cannot defend themselves. To give immunity to the staff is negation of everything we are aiming for in this Bill and I oppose it.

There are a number of very good points in this Bill which makes an honest and determined attempt to protect the rights of patients, but there is still a lot to be done. This Bill gave me the opportunity to tell the House what I saw in a mental hospital. There are small points in different sections which need to be clarified and amended. In section 33 we talk about telling patients the reason for the refusal. Subsection (4) says

Where the application is refused the health board or medical officer shall so inform the applicant.

The applicant should be told the reason for the refusal, verbally and in writing. An independent inspectorate should examine our hospitals and the conditions which entitle a hospital to be given a licence. That would be more helpful for the patient. This is covered in section 36.

Section 24 (4) reads:

Where a reception order or extension order is made in respect of a person in any centre the medical officer in charge of the centre shall forthwith inform the person and the applicant...

That should be done verbally and in writing. That would clarify the point.

I am very worried about the Garda taking a person into custody. For how long will that person be detained? In my view the Gardaí have no part to play in this. There must be some alternative, but if the Minister insists on this provision, I would like to know for how long the person will be detained in the Garda station. Perhaps the Minister would elaborate on that point.

This Bill is long overdue. There was a great deal of necessary consultation with the profession, the authorities, the Garda and various interests throughout the country in the preparation of the Bill, which is an honest attempt to protect the rights of the patients. What is wrong is that there are not laid down any standards relating to quality of care or anything that would give the patient the right to proper detention. These are provisions that I should like to see being incorporated in the Bill. Consequently, I trust that the Minister will pay attention to this point and to the other points I have raised. I welcome the Bill wholeheartedly.

I have a special interest in the field of mental illness. This arises from my association with a psychiatric hospital in this city. At the outset I would refer to the words "mental hospitals" in the title of the Bill. Many years ago these hospitals were referred to as lunatic asylums but in more enlightened times they are referred to as mental hospitals. However, I suggest that we should refer to them as psychiatric hospitals.

I agree fully with the Minister that the Bill is a most important piece of legislation. It is the only new legislation in this area to come before the House since 1945 and the legislation that was enacted then superseded the Lunacy Acts of 1867 which gave power to justices of the peace to commit to any district asylum any person or persons considered to be of unsound mind or anybody apprehended in circumstances suggesting that there might be an indictable offence involved.

The 1945 Act was enlightened and progressive and was very well received by the medical profession at the time. The Act abolished judicial certification and transferred complete responsibility for the care and treatment of the mentally ill to the Minister and his officers. For the first time ever a person was entitled to enter a mental hospital as a voluntary patient. In 1947, the year in which the Act came into operation, more than 4,000 patients were admitted to public mental hospitals here. There were two types of committal procedure in respect of those who had to be certified. In one case there was the category of temporary patients while on the other hand there was the category of persons of unsound mind. Of those some 4,000 admissions, 900 were voluntary, 1,123 were temporary and more than 2,000 were classified as persons of unsound mind. Under the previous legislation, and also for the first time, out-patient clinic facilities were provided for the mentally ill. However, the development of these facilities was very slow and two years later only few such clinics were in operation. But since then and during a period of perhaps 25 years, admissions to mental hospitals continued to increase until in 1972 they reached a peak of 23,000 admissions while the out-patient clinics catered for 30,000 patients. Since then admissions have decreased considerably and the number of persons in public mental hospitals today represents a decrease of 30 per cent during a 15-year period. I consider this to be an advance in medical science and treatment.

Unfortunately, there was a stigma attaching to the mentally ill in the past. Those suffering from mental illness were put out of sight. Relatives were ashamed to acknowledge the existence of these people. That was a dreadful situation but attitudes have changed in many respects and there is now an acceptance of mental illness for what it is. This means that steps can be taken at an early stage in the treatment of patients.

Treatment facilities both in psychiatric hospitals and in clinics have improved greatly and the successful intervention of the GPs working in the general medical scheme has played a significant role in this area. Since the scheme was introduced increasing numbers of GPs have become involved, but despite these advances there are problems in relation to dealing with seriously disturbed patients in several of our hospitals. Most of our psychiatric hospitals do not have adequate facilities for dealing with such patients. In some instances there have been legal difficulties in transferring patients to the central hospital at Dundrum, the only psychiatric hospital where appropriate treatment facilities are available for these patients. The changes in section 207 of the Mental Treatment Act which provided for judicial transfer order are long overdue. The Minister should give very careful consideration to this section as it would not necessarily be good or in the interest of the patient that transfer to another hospital could be executed all too easily. Perhaps in those circumstances a declaration signed by two psychiatrists would be more suitable and more in the interest of all parties concerned, especially the patient who is the most important party in such cases.

The present legislation which requires judicial order can involve up to a two weeks delay in being put into effect. Such delays are far too long particularly in cases of patients reacting violently and perhaps endangering not only themselves but other people. The new Bill proposes the establishment of review boards which would take over completely in due course the responsibilities that now rest with the inspector of mental hospitals. As the Minister mentioned, it can be argued that a system based on one person is neither satisfactory nor acceptable in terms of contemporary opinion. However, I would suggest that many arguments could be made in favour of having only one person involved provided that that person is the right man or woman for the job. I agree that the title inspector of Mental Hospitals is totally outdated. If the position is to be retained the title should be changed so that there is less of the big stick about it. Perhaps the term, adviser to the Minister, could be used.

A more relaxed environment is absolutely necessary today to give to psychiatric hospitals the appearance of hospitals dealing generally in mental affairs. I am aware also that the medical profession are very anxious that there should be one person only who would be responsible to the Minister on behalf of mental hospitals in specific areas. This would be irrespective of the title used. This is a matter that should be considered fully. Such an appointment should be for a limited period of, for instance, not more than three years. This would ensure that the person appointed would have full experience of mental hospitals and mental health in general and would have to be a specialist in that sphere. I understand that such a system is now operating very successfully in the USA and Canada. It might be beneficial to the Bill if the Minister had another look at this particular aspect.

It is generally agreed that perfection and specialisation are absolutely necessary in any matters relating to health but that they are even more important when dealing with mental illness and psychiatric illness. Mental illness has far-reaching effects on the lives of the people concerned and on their families. It is vital that not only properly qualified people are appointed but also that the officers controlling psychiatric hospitals are completely up to date on the changes which take place daily in relation to the treatment of psychiatric illness. It is important for the Minister to give very careful consideration in regard to replacing the existing post of inspector of psychiatric hospitals.

The Bill has been criticised in some areas. Some speakers have said that it makes no reference to the day-to-day running or administration of mental hospitals. I agree with the Minister that if any standards of treatment to be provided in hospitals were incorporated this would be meaningless in practice. We all share the same views on the type of hospitals we would like to have and in relation to the care which we feel should be provided in those hospitals for patients. We share the same views in relation to the facilities which we feel should be provided which would benefit patients and staff. It does not mean, because this is not embodied in the Bill, that individual hospitals will not strive to attain the standards we would all like to see. I know, from my involvement with psychiatric hospitals, the care, attention and medical treatment given to patients by the staff in most mental hospitals.

Great progress has been made in recent years in relation to the care of patients in mental hospitals. I would like to put on record the gratitude felt by the general public to all the people involved in the care of mental patients. Anybody who has experienced the problems caused by mental illness understands what I say and knows the great work done by the people involved. This applies equally to the public sector and the private sector.

We have moved into a modern era of psychiatry. The focus for treatment will no longer be located on a full-time basis in mental hospitals. The general focus will be located in the community, which now understands and accepts mental illness for what it is. The emphasis should be on prevention at all levels and should be directed wherever the treatment is needed, whether it be the hospital, the home, or the day centre. This will also involve the family doctor and community nurses working alongside psychiatrists. I believe that then a very real effort will be made in providing the effective preventive services which are so badly needed.

It is an unfortunate fact of life that we will always have mental illness in our society. The pressures of modern day living are contributing in a major way to this. Mental stresses have never been greater than they are today. Unfortunately, a greater number of people are resorting to tranquilisers in an effort to alleviate their problems. Many medical people have expressed strong opposition to the increased prescribing of tranquilisers which very often create more serious disorders and illnesses which in quite a number of cases eventually necessitate psychiartic treatment. The medical profession have a great responsibility to do the right thing and not prolong the illness and even perhaps make the illness worse by continuing to prescribe tranquilisers and other drugs.

Deputy O'Connell made a number of excellent points. I agree with his reference to the attitude of the public towards mental illness. Attitudes have changed in comparison to many years ago. We can do a lot more by teaching our young people in the schools to understand mental illness and to have concern for those who are affected by this sickness. There is also a great responsibility on the relatives of such patients who can help in many ways.

I welcome the Bill. The proposals contained in it are an advance on previous legislation. The Minister indicated he will be putting down a number of amendments for Committee Stage. I am very pleased about his flexibility in that respect. The people involved in the psychiatric profession are very conscientious and dedicated people. I am sure the Minister will bear this in mind when he is considering the many suggestions which have been put forward by the people in the profession.

Deputy Browne rose.

Debate adjourned.
Business suspended at 1.30 p.m. and resumed at 2.30 p.m.