Amendment No. 1 is in the name of the Minister. Amendment No. 2 is cognate and the two may be discussed together.
Health (Mental Services) Bill, 1980: Committee Stage.
SECTION 1.
I move amendment No. 1:
In Page 3, subsection (2), line 16, to delete "1977" and substitute "1979".
These are technical amendments necessary to complete citation of legislation to be associated with this Bill. The Health (Family Planning) Act, 1979 is a Health Act for the purposes of the collective citation. It is purely a technical matter.
(Cavan-Monaghan): These appear to be technical amendments necessary to include an Act of 1979 which apparently is a Health Act within the meaning of the definition. I have no objection.
Amendment agreed to.
I move amendment No. 2:
In page 3, subsection (3), line 18, to delete "1977" and substitute "1979".
Amendment agreed to.
Section 1, as amended, agreed to.
SECTION 2.
Question proposed: "That section 2 stand part of the Bill."
(Cavan-Monaghan): This section provides that the Act shall come into operation on such day or days as may be fixed therefor by order or orders of the Minister either generally or with reference to any particular purpose or provision and different days may be so fixed for different purposes and different provisions of this Act. Further on in the Bill a number of important Acts are being repealed in toto: the Mental Treatment Act, 1945, the Mental Treatment Act, 1953, the Mental Treatment (Detention in Approved Institutions) Act, 1961, and the Mental Treatment Act, 1961. I assume that immediately those Acts are repealed it will be necessary to bring this Act into operation in its entirety. Could the Minister say when he proposes to bring in the Act?
The intention is to bring it in immediately, as soon as it is feasible to bring it in. Notwithstanding that, there are continuing provisions in the Bill until it is brought in so that the point is covered in that way. But it is our intention to bring it in immediately, as early as it is feasible.
(Cavan-Monaghan): Does the Minister mean immediately, because he said at first that he intended to bring it in “immediately, as soon as it is feasible to bring it in?”
As soon as it passes through all its Stages. There will be no delay on our part.
Question put and agreed to.
SECTION 3.
(Cavan-Monaghan): I move amendment No. 2 (a):
In page 3, line 28, after "psychiatrist" to insert "or as a psychiatrist".
Section 3 is an interpretation section and an authorised medical practitioner is defined as meaning a registered medical practitioner holding an appointment or providing services as a consultant psychiatrist in a psychiatric centre. As I understand it, a consultant psychiatrist is a psychiatrist who specialises. However, there is some difference between a psychiatrist and a consultant psychiatrist, just as there is a difference between a general practitioner and a consultant. The object of Deputy Boland's amendment which I am moving as spokesman on Health having exchanged spokesmanships with him, is to define an authorised medical practitioner as a consultant psychiatrist or psychiatrist. I am advised that definition is more appropriate and that it covers the position more adequately than the present definition. Before saying more on the amendment, I would like to hear the Minister's views on that.
I do not propose to accept this amendment, essentially because I do not wish to dilute the level of medical competence at which decisions in regard to the extension of detention and discharge of patients are taken under this Bill. These, in my view, are serious decisions affecting the freedom of the individual. The decision to have them made at consultant psychiatrist level was a calculated one.
(Cavan-Monaghan): Would the Minister spell out, for the House and myself, the difference between a psychiatrist and a consultant psychiatrist within the meaning of the Bill? Are there at the moment, in what I call mental hospitals, psychiatrists and consultant psychiatrists and would the Minister spell out the difference in status and explain the standing, qualifications and responsibilities?
In practice, a registered medical practitioner holding an appointment as a consultant psychiatrist would be a medical practitioner fully recognised in the Register of Medical Practitioners, possessing the MD degree in psychiatry or equivalent qualifications — for example, the MRCPI in Psychiatry and having at least seven years' experience in the practice of medicine, including five years' experience in psychiatry.
There are, in total, 184 consultant psychiatrists available which, if one were to compare that with the numbers of other consultants in any speciality is very——
(Cavan-Monaghan): One hundred and——?
184 consultant psychiatrist posts. In fact, the decision, as I said earlier, was to keep it to the level of consultant and not to dilute the standard in regard to the making of these decisions. They are very important decisions and this is the standard which applies generally at this time in psychiatry. I appreciate that people would have been practicising who would not have the qualifications to be consultant psychiatrists, but I believe there is a sufficient total number. That level is, of course, developing and growing at this stage. That is why we prefer to keep to the consultant level.
(Cavan-Monaghan): Will we see, as we proceed through the Bill, that the definition with which we are now dealing will entitle consultant psychiatrists to admit and discharge patients?
Yes.
(Cavan-Monaghan): Does it mean that only people holding the title of consultant psychiatrist will have that responsibility and that power? Will the Minister also tell me, please, whether there is a consultant psychiatrist in each of the health board mental hospitals at the moment and how many such consultants there would be in a normal hospital? Would the Minister also tell me whether the consultant psychiatrist is always the RMS — perhaps that is not the proper title for him now — the doctor in charge of the hospital, or whether one could have the situation where the doctor in charge would not have the necessary paper qualifications to entitle him to the title of consultant, although he still might be in charge of the hospital and whether there might be, under him, a person holding more advanced qualifications?
All the chief psychiatrists and directors are at the consultant psychiatrist level. The Deputy raised the question of the numbers. Let me take each health board, for instance.
(Cavan-Monaghan): Any one hospital. The Minister need not name the hospital.
In one hospital there are one chief and 11 consultant psychiatrists; in another, 2 consultant psychiatrists, depending on the size of the hospital. The next hospital has three consultant psychiatrists; the next six consultant psychiatrists; then four consultant psychiatrists; two consultant psychiatrists and three consultant psychiatrists. That gives the Deputy an idea of the spread.
(Cavan-Monaghan): May I take it that in none of the institutions about which we are speaking is there only one consultant psychiatrist?
Not in the list which I have here. There may, of course, be a psychiatric centre which is small enough to have only one, but in those about which we are speaking, the hospitals normally identified as psychiatric centres, I have given the numbers in the list.
(Cavan-Monaghan): This point might be more properly dealt with under a subsequent section. However, could the Minister tell me what would happen where two or three consultant psychiatrists were absent, either through illness, being on vacation, or some other reason? What would the position be then in regard to the duties which we are conferring on the consultant psychiatrist?
The arrangement is that there must be cover all the time so that, in the event of someone being absent or on leave and so on, if there was a situation where the cover is not provided internally in the centre, then the responsibility would be on the programme manager in the health board to provide the cover for that period, so it is provided, in any event.
(Cavan-Monaghan): The position, then, is that so much importance is attached to the presence of a consultant psychiatrist in the institution that all the psychiatrists could nor absent themselves from the institution without arrangements being made for cover during their absence?
That is correct.
(Cavan-Monaghan): The position would be just the same as with a consultant surgeon in a surgical hospital, that if he were not there, somebody else would have to take his place?
Someone would have to, yes. That cover would either be internally in the hospital or through the health board, if necessary.
Amendment, by leave, withdrawn.
I move amendment No. 3:
In page 4, to delete line 2 and substitute:
"of a class designated by the Minister for the purpose of this Act;".
The intention of the Bill is to have certain officers of the health boards, such as community psychiatric nurses, social workers, assistance officers, public health nurses and so forth, designated as authorised officers for the purposes of the Bill. Authorised officers will be empowered to make application for a recommendation for reception of a person under subsection (2) of section 15 of the Bill. As at present drafted, the Bill would require the Minister to designate each holder of certain health board offices as an authorised officer. As amended, the Minister is only required to designate certain health board offices, the holders of which will be authorised officers for the purposes of the Bill. Apart from being administratively simpler, this will avoid the possibility of errors of oversight or omission.
(Cavan-Monaghan): Section 15 is the section which deals with an application for a recommendation for reception. That application would be made to the consultant psychiatrist?
The application, in the first instance, would be made to the GP.
(Cavan-Monaghan): Subsection (2) sets out the list of people who may make an application for the recommendation. The Minister feels that, if he left that definition as it is, he would have to authorise every officer individually, by name——
Yes.
(Cavan-Monaghan):——and, instead of doing that, he is changing the definition from “‘authorised officer’ means an officer of a health board who is designated by the Minister to be an authorised officer;” to read “‘authorised officer’ means an officer of a health board who is of a class designated by the Minister for the purposes of this Act;”. The Minister is not confining this to a list of classes. If he likes he could designate ambulance drivers as authorised officers.
Theoretically that would be possible. The purpose here was to designate the office of, say, social worker, psychiatric nurse or public health nurse. I doubt if it would be used in a more extensive way so long as there would be in the community the kind of officers mentioned here and these officers exist in all communities. We want to ensure that someone is available, in the event of an emergency, to make such a request.
(Cavan-Monaghan): I am sure the Minister would behave in a reasonable manner in exercising his discretion under the definition. Does he not think that, for the guidance of future Ministers and the public in general, it would be better to spell these out. I picked on the ambulance drivers at random and I have no reason to think they would behave in an unreasonable manner. But does the Minister not think it would be better to write into the Bill a reasonable list of classes he could designate? At the moment he seems to be going from one extreme to another. In the Bill as drafted he was obliged to identify the authorised officers in each psychiatric institution. Now he is simply saying he can designate by class anybody who might come into his head. I am sure he would not——
I take that point.
(Cavan-Monaghan): Does the Minister not think that the list of classes he read out should be wide enough to cover any possible eventuality?
It could be. As the Bill stands, I have the power to designate classes. Nevertheless, I appreciate the point the Deputy is making. To allay fears in relation to the near and distant future, it might be possible to give an undertaking for an amendment of the list to come before the House as regulations. This would mean they would be considered at that time. I do not want to circumscribe the kind of people working within the health board areas unduly, and yet I appreciate the point the Deputy is making. If he leaves this matter with me, I will see if I can find a way to meet the question he raises — that at some future date an extension may be made without reference to the House.
(Cavan-Monaghan): The difficulty I see is that the Minister in his amendment is not specifying any number of classes which could be designated. I presume he will have to do that by regulation.
Yes.
(Cavan-Monaghan): Will the regulations in the first instance have to come before the House?
Yes. On Report Stage I could include an amendment which would make that point clear.
(Cavan-Monaghan): Am I right in thinking that the classes which the Minister is empowered to designate under the Bill, will be designated by regulation? Will the first regulations have to be laid before the House and ratified by the House, or do they become law by default if they are not annulled or amended?
They have to be laid before the House.
(Cavan-Monaghan): If they are not annulled, do they become law?
That is right.
(Cavan-Monaghan): I call that passive endorsement. I would like the Minister to think about spelling out on Report Stage those wide classes — community psychiatric nurse, social worker, assistance officer and public health nurses?
I will consider that.
Amendment agreed to.
I move amendment No. 4.
In page 4, to delete line 9 and substitute:
"officer of the centre, or
(c) the person for the time being acting on behalf of such chief psychiatrist or chief medical officer;".
As it stands this section does not permit the duties of a chief psychiatrist or chief medical officer to be performed by a deputy. Obviously, where the chief psychiatrist or chief medical officer is absent from the centre on annual leave or due to illness, very grave difficulties would ensue in relation to the operation of various provisions of the Bill and, consequently, provisions have been made for amendment of the definition accordingly.
(Cavan-Monaghan): Could the Minister spell out what some of those difficulties would be?
As it stands the power — such as the power of discharge, transfer or extension — is reserved entirely to the chief psychiatrist. In the event of the chief psychiatrist being absent the amendment would ensure that a deputy could be appointed and there would be no delay in relation to any of these acts.
(Cavan-Monaghan): This was the sort of thing I had in mind when discussing the amendment to the definition of “authorised medical practitioner”. I certainly agree that the definition of “medical officer in charge” should be wide enough to cover the person who might be acting in a temporary capacity during the absence of the medical officer in charge. Must the medical officer in charge always be a consultant psychiatrist?
Yes.
(Cavan-Monaghan): Must anyone acting on his behalf hold a similar qualification?
Yes, effectively that would be the case. As was explained earlier, cover would have to be provided in all psychiatric centres for the absence of the psychiatric consultant. This cover must be provided all the time and someone at that level must be there. The problem is that the chief medical officer would not necessarily be there all the time and this is why we want to make provision whereby a person acting on behalf of the chief psychiatrist or chief medical officer could discharge his duties.
(Cavan-Monaghan): Could the Minister tell me where in the Bill it is provided that the medical officer in charge must be a consultant psychiatrist?
The Bill states that "medical officer in charge" means in relation to a district psychiatric centre, the chief psychiatrist of the centre and, in relation to a registered psychiatric centre, the chief medical officer of the centre, or a person for the time being acting on behalf of such chief psychiatrist or chief medical officer. In effect it would always be a consultant and this is the current situation.
(Cavan-Monaghan): My difficulty is that there does not seem to be any stipulation in the Bill that the medical officer in charge shall be a consultant psychiatrist. The Minister has told us what is stated in the Bill, but I cannot see any stipulation that any of the gentlemen mentioned must be a consultant psychiatrist. The case could arise where a medical officer in charge could not either admit or discharge a patient but a person under him with more qualifications but less authority could do so.
The theoretical position is one thing but the Local Appointments Commission when making the appointment require that the person be a consultant psychiatrist. Theoretically what the Deputy says could be the case but it could not happen in practice.
(Cavan-Monaghan): The conditions of appointment laid down by the Local Appointments Commission change from time to time and are published frequently in Iris Oifigiúil. The qualifications required for each post are settled before it is advertised and there is no statutory provision regarding any particular qualifications. Perhaps the Minister should define “chief medical officer” more specifically so that the situation that I mention could not arise. The Minister admits that in theory it could happen and, if this is so, then this is a bad Bill. The definition section is loosely drafted and we would not be doing our duty if we did not seek to rectify this.
The Minister will agree that it would be an absurd situation if the chief medical officer in charge of a registered psychiatric centre or a district psychiatric centre could not admit or discharge a patient but someone under him could do so. It might well be that the man in charge would be very well qualified to hold the post but because he had not got these degrees he could not admit or discharge a patient while his junior could do so.
Furthermore, if the Local Appointments Commission in their wisdom decided to publish qualifications to meet a particular case, and this is not unheard of, then an amending Bill would have to be introduced.
In relation to the Local Appointments Commission it is the Minister who in effect defines the terms.
(Cavan-Monaghan): They are defined from time to time.
Unless a future Minister has an aberration it is most unlikely to occur. Since the 1945 Act such a problem has not arisen. The position has existed without causing any theoretical possibilities which the Deputy suggested could arise and there is no basis for them to arise because the definition is very clear. That is a most unlikely development in our existing situation and in the situation which will obtain in the foreseeable future. If this was changed in the future it would create a situation in which the anomaly referred to by the Deputy would arise. That would surely be taken into consideration if a future Minister or Government set about taking such a retrograde step in relation to the profession and the post of chief medical officer or medical officer in charge of a psychiatric centre. I do not see this having any practical application but I will have a look at it in relation to the theoretical possibilities.
(Cavan-Monaghan): I am glad that the Minister has agreed to give some consideration to it. The Minister leans heavily on the practical side as distinct from the theoretical aspect. The Minister holds very strongly that the person who is described as an authorised medical practitioner should be a consultant psychiatrist and stated that he was not prepared to yield on that because there was too much at stake, the liberty of the individual and the commitment or discharge of an individual. But when the Minister went on to define a medical officer in charge he talked about practicalities and the likelihood of this happening — of somebody getting a brainstorm — and he is prepared to leave the qualifications of the medical officer in charge to chance. The Minister admits that he is leaving it to chance, that he is leaving it to the wisdom of himself in the first instance and to the wisdom of future Ministers for Health. A medical Minister for Health might consider that he knew more about what is right and good for patients and about who was better qualified to perform this function and that function than anybody else and he might decide from his personal knowledge as a medical practitioner as to what was the right thing to do. Does the Minister think it right to leave this wide open so that a position would arise where the man in charge of the psychiatric hospital would have overall charge for the medical side of running the hospital but he would be forbidden to carry out some of the most important functions of a doctor within the institution? The Minister concedes that that can happen. If it happens does the Minister think that it will be calculated to promote harmony between the medical personnel in the hospital? Would the Minister not agree that it would create medical disorder in the hospital? The Minister admits that it is open to that interpretation and I feel that it should be put beyond doubt.
I would not like the Deputy to think that I thought it possible for this to happen.
(Cavan-Monaghan): The Minister only hopes that it would not happen.
It would be most impractical and it would be unlikely to happen because of the terms which apply to the post and because of the situation which applies. Even if it happened the Bill ensures that there will be a consultant psychiatrist to discharge duties. The question the Deputy is raising is that even in the event of such a theoretical possibility from some future change, it could result in this person being unable to perform some of the functions. The Bill still controls the discharge, the extension, the transfer and all those activities which would take place and there would have to be a psychiatric consultant to perform those functions. In such a theoretical situation we would be creating an office which would not have the power to do that. The Deputy has asked me to have a look at the situation and I will do so.
Amendment agreed to.
I move amendment No. 5:
In page 4, to delete lines 23 to 25 and substitute:
"‘special psychiatric centre' means a special psychiatric centre under section 30.".
The definition of "special psychiatric centre" as it stands has the effect of inadvertently excluding the Central Mental Hospital, Dundrum, from being a special psychiatric centre. This was not the intention since that hospital is the only such centre in the country.
Amendment agreed to.
Amendments Nos. 5(a) and 7(c) in the name of Deputy Boland are related so they can be taken together.
(Cavan-Monaghan): I move amendment No. 5a:
In page 4, between lines 25 and 26, to insert the following:
"‘voluntary patient' means a person who, acting by himself or, in the case of a person less than sixteen years of age, by his parent or guardian, submits himself voluntarily for treatment for illness of a mental or kindred nature."
Amendment No. 5a proposes to define "voluntary patient". It is important that the voluntary patient should be described fully and clearly and that is the object of this amendment. It really defines a voluntary patient for the purposes of this Bill. The term "voluntary patient" crops up here and there through the Bill.
I do not propose to accept this amendment or amendment No. 7(c). I have avoided to the greatest extent possible any attempt to define what is or is not a voluntary patient or to circumscribe a person who wishes to undergo treatment voluntarily by statutorily expressed admission procedure. If I were to do as Deputy Boland's amendment suggests I would be setting a real barrier between a patient in the general hospital situation and those who wish to undergo treatment voluntarily in a psychiatric hospital. So far as the attempt by Deputy Boland to define in his amendment the responsibility of parents and guardians for persons under the age of 16 is concerned, I do not see it as necessary to be done in this Bill. It would more appropriately fall to be dealt with, if it is necessary at all to do so, in a more comprehensive measure dealing with the problems of children. Such a measure is being considered in my Department at present following receipt of the report of the task force on child care services.
(Cavan-Monaghan): I am right in saying that the term “voluntary patient” is not defined in the Bill?
That is correct. It is purposely not defined.
(Cavan-Monaghan): I would argue that a lot depends on whether a patient is a voluntary patient or is committed against his will. Far-reaching consequences and decisions flow from whether a patient is voluntary or not. If a patient is admitted as a voluntary patient he can, as I understand it — I oppose this very strongly — discharge himself without any notice. He can virtually walk out the door and I am very concerned about that.
We define many things under the Bill including the term "doctor", "medical officer" and so on. The Bill encourages voluntary admissions into psychiatric hospitals and treats voluntary patients in a different way from other patients. Yet we do not have any definition of voluntary patient. That is a serious omission and it was in an effort to correct that defect that this definition was put in. It may be that the Minister does not agree entirely with Deputy Boland's definition of voluntary patient. It is one I adopt without qualification, but if the Minister does not accept that definition it is up to him to consult his advisers and the parliamentary draftsman and come up with a definition which will cover the point. To leave the Bill without such a definition is going too far.
As regards how a person under 16 years of age can be a voluntary patient without the consent of a parent or guardian is hard to follow. If the Minister is seriously rejecting this amendment he should spell out the pros and cons of defining voluntary patient and not defining it. In a system where we love definitions and where most of the Bills which go through the House work by reference to the definition section it is extraordinary to find no definition of "voluntary patient". We could have a situation where a doubt would arise as to whether a patient was admitted voluntarily or not. If that were so, the patient might be entitled to the benefit of the doubt and that could have far-reaching consequences which would not be in the interests of the patient or others. I would like the Minister to go into this in some depth and give us the benefit of his advice for and against.
I appreciate that the Deputy was not concerned with the Bill on Second Stage and consequently would not be readily aware of the very strong view we have in relation to the question of voluntary patient. The purpose of the Bill in general is to reduce to the smallest portion possible the number of patients who have to be catered for under the legislation — in other words, to treat psychiatric illness as normal illness in every way possible and to encourage people to go in for voluntary treatment without stipulation or undue regulation.
We had discussions with the profession in relation to the question of notice. Amendment No. 25, which I am proposing, will give 24 hours' notice in the case of voluntary patients and this would cover the point raised by the Deputy. This was designed to cover a situation where a patient was in a temporarily disturbed state and wanted to leave. The 24 hours' notice would give the opportunity to enable the patient to be reasonably composed in relation to that decision——
(Cavan-Monaghan): Or committed.
Or committed, as the case may be. Amendment No. 25 is intended for that reason.
(Cavan-Monaghan): Amendment No. 25 improves the position somewhat, but it might be in the patient's interest to be able to clearly define whether he was committed or voluntary. I know that it would be more appropriate to deal with this amendment and the section which it amends when we reach it, but, as the Minister mentioned it here, so did I.
The Bill, as drafted, without any notice, was the most outrageous proposition I heard for a long time. I am conscious of the words I have used — outrageous proposition. Many people may have experience of mental illness and what flows from it in their capacity as administrators or as medical people. Members of the legal profession have experience of it too. I had one of the most appalling experiences of my professional life in dealing with something which flowed from a person being treated casually, as I suppose a voluntary patient would be treated. I will not spell out the details because it is not long since it happened, and some of the people concerned are still alive.
When we come to deal with the Minister's amendment No. 25 I will say I do not think a period of 24 hours is sufficient. It is intended to encourage people to accept treatment for mental illness. That is good. It is good that the padded cells have been done away with, and it is good that the high walls have been taken down. It is also very good that the locks and keys are used to a much lesser extent than heretofore.
Some unfortunate people are still afflicted with mental illness to such an extent that they are completely irresponsible through no fault of their own. They are more to be pitied than anything else. They are entitled to protection for their own safety, and for the safety of others. In dealing with that sort of situation we should not have casual legislation without any proper definition of the different categories of patients who admit themselves voluntarily and those who are committed under compulsory procedures.
In his brief intervention the Minister did not satisfy me that a definition is not necessary. It could be useful to us as we go through the Bill and I should like the Minister to spell out at this stage the difference, as he sees it, between a voluntary patient and a patient who has been committed.
I should like to make it clear at the outset that the suggestion that the proposal is outrageous, even as it stands without the subsequent amendment, does not stand up. The reason for the introduction of the voluntary patient concept is to make their psychiatric treatment and care similar to that of people receiving other treatment and care in our health services. This is a vast progression in the services.
There was a 72 hour notice which was used very rarly in practice. It was seen to be so rarely used that it was doubted whether it was needed to have any cover of that sort. Some people in the profession were concerned that certain circumstances might arise where a person had entered voluntarily and, therefore, they felt they would like to have some provision included. It was on that basis that we introduced the 24 hour amendment. In effect, it is not as outrageous as it looks in black and white.
There is an amendment proposing some alteration to this definition, but the definition sets out only to define a detained person, a person for whom a reception order is made, or a reception order is sought. In that case one is talking about a person who is suffering from considerable mental disorder, or a mental disorder of a degree which requires detention. When we are talking about the voluntary patients we are talking about people who are not suffering from such a degree of mental disorder.
I appreciate that definitions are difficult in this area. They are also considered very difficult in the profession, and by those who have attempted to make definitions in various respects. It would be a very rare occurrence for a person who was detained voluntarily to become suddenly a person who should be detained permanently or involuntarily. Admittedly that can happen. To cover what would be a fairly rare situation, the 24 hour amendment is proposed to the Bill.
(Cavan-Monaghan): Could the Minister tell us who decides and at what stage whether a person is to be admitted as a voluntary patient or as a detained patient?
It occurs the other way around. Someone seeks a recommendation for the reception of a person to be detained. Everyone else would go to seek treatment. They would not have the history or the experience of mental disorder of such a degree that would require detention. That would arise within the community, or in the context of the family, or whatever.
In terms of detention we are talking about approximately 10 per cent of the total number of people who would be under psychiatric care or in a psychiatric institution of one kind or another. With the breaking down of the walls, the changes which have occurred, and with the new forms of treatment, the vast majority of people are in the voluntary area. We do not want to define them as anything other than people seeking care and assistance from the health services. As part of that movement the major hospitals which are being developed currently and the ordinary general hospitals will be associated with this. For instance, Beaumont Hospital will have an acute psychiatric centre attached to it to normalise and regularise psychiatric care, which is the vast majority of the care nowadays.
(Cavan-Monaghan): Am I right in thinking that anybody, no matter how ill, can become a voluntary patient in a psychiatric institution and discharge himself on 24-hours' notice, and that it is only in a case where the symptoms become so apparent and so drastic that it will be necessary for one of the authorised persons to seek a reception order? A person could be every bit as mentally ill, but he has not reached the stage where the symptoms have become apparent, but the symptoms could break out at any time when the patient was in residence in the institution. In my opinion this emphasises the necessity to spell out a definition of “voluntary patient”. Nobody likes to have a relative committed, or is that the proper term?
Detained, perhaps.
(Cavan-Monaghan): Let us say “detained against his will.” People do not like to have that and people would go to a lot of trouble to coax relatives to go in as voluntary patients rather than have the stigma with which mental illness is still regarded, though to a lesser degree. People would go to considerable lengths to coax relatives to go in as voluntary patients and such voluntary patients might be only a short time in residence when it might become apparent that it would be necessary to have them to stay in the institution for a considerable time for their own benefit and possibly for the benefit of society. That is why I suggest that more consideration should be given to this and that definitions of the various types of patients should be spelled out.
The point the Deputy has made is relevant but if the symptoms have not broken out the person will not become a detained person anyway, and if the symptoms have not become apparent it would be desirable to have such persons go along for treatment and care in a voluntary way, without designation. In a small proportion of cases it would be preferable that they would come in such a way. We want to think about people who have not exhibited such a degree of mental disorder that would require detention, and one would want such people to go for care and treatment without any tags or designations attached. They would come within the system and get care and treatment, and if their condition was to worsen I am sure the consultant psychiatrist would recognise that situation.
(Cavan-Monaghan): I am all in favour of treating mental illness as ordinary illness and all against padlocks where they are not necessary, but it is wrong to assume that all of us have reached the stage when we can regard mental illness in that way. The Minister said that if the symptoms have not broken out the person will not become a detained person. There is no use closing our eyes to the fact that we have not reached the stage when all of us are prepared to treat mental illness in the family as ordinary illness.
It could very well be that the symptoms could have broken out but that the outbreak would be suppressed — indeed it is more than likely it would be suppressed if the symptoms were of a violent nature: relatives would suppress it and hope to have the patient admitted quietly as a voluntary patient for a while and that, with the help of God, everything would be all right. We must consider such a situation. Not alone would the symptoms have broken out but they would have been known to have broken out.
I do not know if the Deputy is aware of the dramatic change in recent years. The Deputy appreciates there has been a change but I do not think he appreciates the size of the change. Currently, there are 183,000 attendances at out-patient clinics; there are 2,000 detained patients in present circumstances. Consequently, the whole movement of the development of the service is towards voluntary treatment in out-patient clinics. It is for that situation that the Bill is providing. We are anxious not to make definitions of what a voluntary patient is because of the way our psychiatric care is developing. There are about 12,600 long-staying patients.
(Cavan-Monaghan): I will have a chat with the Minister and tell him of an experience I know about.
Is Amendment No. 5a being withdrawn?
(Cavan-Monaghan): No, we will leave it there.
Progress reported; Committee to sit again.