The Mental Health Bill, 1999 is significant legislation. Its purpose is twofold. First, it will provide a modern framework within which people who are mentally disordered and who need treatment or protection, either in their own interest or in the interest of others, can be cared for and treated. The Bill will bring our legislation on the detention of mentally disordered patients into conformity with the European Convention on the Protection of Human Rights and Fundamental Freedoms.
The second purpose of the Bill is to put in place mechanisms by which the standards of care and treatment in our mental health services can be monitored, inspected and regulated. The vehicle for achieving this will be the Mental Health Commission to be established under the Bill. The commission's primary function will be to promote and foster high standards and good practice in the delivery of mental health services. The existing office of the Inspector of Mental Hospitals will be replaced with the office of the Inspector of Mental Health Services, who will be employed by the commission. Both the commission and the inspector will operate independently of the Minister for Health and Children and of the Department. This independent status will be crucial in driving the agenda for change and modernisation in the mental health services in the coming years.
The provision of new mental health legislation is an important milestone in how we care for people with a mental illness in a modern Ireland. Since the mid-1980s we have seen the development of an integrated and community-based approach to the care of the mentally ill. I have no doubt that the quality of care for persons with a mental illness has been enhanced by this development. These advances in management and treatment allow many people with mental illness to live normal lives and to continue to contribute to our society in a positive and fruitful way. Alongside the development of more effective treatment techniques, there is a need for change in the statutory safeguards for those considered to be in need of care in an in-patient setting. Since the 19th century, powers have existed in law to protect people with mental disorders from the consequences of their behaviour and, more particularly, from abuse and exploitation in society.
The current criteria under which mentally disordered people may be detained involuntarily are set out in the 1945 Mental Treatment Act, which was last amended in 1961. It provides the statutory framework for the detention of people with mental disorder and for the administration of the psychiatric services. The Act was innovative in the mid-1940s, and its principles have been described as enlightened for its time. However, successive Governments have acknowledged that this legislation is in need of substantial reform to bring it into line with current thinking and international norms on the detention and treatment of people with mental disorder.
The Bill before the House is a culmination of a long and detailed process of consultation and careful consideration. In 1992 the then Government published the Green Paper on Mental Health. Part one of the Green Paper set out the fundamental objectives of policy on the care of the mentally ill which have been adopted by successive Governments since the publication of Planning for the Future in 1984. Briefly, these objectives are: to provide a comprehensive and community oriented psychiatric service; to integrate psychiatric services with general hospital, general practitioner, community care and voluntary services; to improve the standard of care in psychiatric hospitals pending the transfer of services to alternative locations in general hospitals and in the community; and to improve services to meet the special needs of particular target groups, such as the elderly mentally ill, persons with an intellectual disability in psychiatric hospitals and children and adolescents with psychiatric problems. Part two of the Green Paper set out the reasons new mental health legislation was needed.
Comments were invited on the Green Paper, particularly in relation to the proposals for new legislation. The response was excellent with more than 100 submissions received from a wide range of professions, interested parties and individuals. There was unanimous endorsement of the principles of a modern psychiatric service as outlined in Planning for the Future. Nearly all the respondents also commented on the issues to be addressed in new mental health legislation.
Subsequently in 1993, following receipt of the majority of submissions, the Mental Health Association of Ireland held a public seminar on the theme, A Mental Treatment Act – Towards a Consensus. The seminar provided a further opportunity to discuss the main issues in new mental health legislation, to place proposed Irish developments in an international context and to exchange views. There was a broad representation of interested bodies in attendance: Departments, health boards, the voluntary mental health movement, the voluntary intellectual disability sector, professional associations and others. The submissions and the seminar showed that there was a large measure of agreement with the proposals for new mental health legislation outlined in the Green Paper.
This consultative process was followed by the publication in 1995 of a White Paper entitled A New Mental Health Act. Its purpose was to define more precisely the content of the new mental health legislation in the light of responses to the Green Paper, the best interests of the mentally disordered and our international commitments. It also provided a further opportunity for interested parties to examine proposed legislative provisions before the preparation of legislation.
The response and reaction to the Government's proposals was of enormous benefit in preparing this new Bill and I thank those who contributed to the process. There were differences of opinion on some issues at times, but overall there was a large measure of agreement on the proposals. It is heartening to realise that, despite some of the negative perceptions which are sometimes held about people with mental illness, it is evident that, ultimately, there is a deep concern about their welfare as they are among the most vulnerable in our society.
At the core of the Bill is the need to address the civil and human rights of persons receiving care and treatment in our psychiatric services. The Bill focuses on: improving and modernising the criteria and mechanisms for the involuntary detention of persons for psychiatric care and treatment; establishing a system of automatic and independent review of all detentions, including the provision of legal aid to all those who are detained; and putting in place a framework by which the standards of care and treatment provided in our in-patient mental health facilities can be supervised and regulated.
Central to meeting these objectives will be the establishment of the Mental Health Commission. The Mental Health Commission will have responsibility for promoting and fostering high standards and good practices in the delivery of mental health services and with ensuring that the interests of detained persons are protected. Its range of functions and responsibilities is far wider than that proposed in the White Paper for the Mental Health Review Board. Furthermore, it will be an independent body entirely separate from the Department of Health and Children and the health boards.
The commission's main functions will include promoting and encouraging the maintenance of high standards and good practice in the delivery of mental health services, arranging for an independent review by a mental health tribunal of all decisions to detain a patient on an involuntary basis and each decision to extend the duration of such detentions, the establishment and administration of a legal aid scheme for detained persons, the maintenance of a register of approved centres in which hospitals or residential facilities providing psychiatric care and treatment must be registered and the appointment of the Inspector of Mental Health Services.
The Bill provides that the commission will have ten members, including a practising barrister or solicitor, two registered medical practitioners of which one will be a consultant psychiatrist, two representatives of the nursing profession, a social worker, a psychologist, members of the general public and two representatives of voluntary bodies promoting the interests of people suffering from mental illness. The inclusion of these professions and groups will provide the commission with a range of knowledge and a balance of views on issues that affect our mental health service. The work of the commission will be greatly enhanced by this diversity of disciplines.
A key provision of the Bill is that each decision by a consultant psychiatrist to detain a person involuntarily for psychiatric care and treatment will be reviewed. The review will be independent, automatic and must be completed, except in certain circumstances, within 28 days of a person's detention. The process will be put in train immediately on a person's admission. All patients will have a right to review, even if they are discharged before 28 days, and section 27 of the Bill provides that they must be so informed when they are being discharged. Reviews will be carried out by one or more mental health tribunals, consisting of a consultant psychiatrist and a legal assessor and operating under the aegis of the Mental Health Commission. As part of the review process, the mental health tribunal will arrange, on behalf of the detained person, for an independent assessment by a consultant psychiatrist.
The review I am proposing in the Bill will be substantive and will focus on two issues, whether the person concerned is mentally disordered and whether the correct procedures were carried out in detaining him or her. A tribunal will be empowered to order the release of a patient if it considers that he or she does not require to be detained involuntarily.
I take this opportunity to clarify a number of points in relation to this review. Some commentators have referred to the fact that the White Paper proposed a review of detention after seven days and have suggested that what is contained in the Bill offers less protection to involuntary patients than was promised in the White Paper. This is incorrect.
The White Paper proposed that a procedural review of the legality of a person's detention would take place within seven days of involuntary detention. The type of review envisaged then would have been a paper exercise, simply checking that all the correct procedures had been carried out. It would not have touched on the crucial question which must arise in all cases of involuntary detention, that is whether the person is mentally disordered to the extent that it warrants a restriction on his or her liberty. The White Paper did not consider that the type of fundamental, clinical review which is proposed in the Bill was necessary until a person had been detained continuously for over a year. The proposal in the White Paper does not go far enough to ensure the rights and interests of the detained person are protected. My proposal for a substantive review within 28 days represents a major advance on that put forward in the 1995 White Paper.
This Bill also includes important provisions regarding the right of the patient to receive information concerning his or her detention. Section 15 requires that when a person is involuntarily admitted for psychiatric care and treatment, the consultant psychiatrist who makes the decision to admit is obliged to inform the person of his or her legal rights. This includes informing the patient of his or her right to be legally represented in any proceedings in relation to his or her review, or at appeals against a decision of the review tribunal. When people are being discharged, they are entitled, under the Bill, to be informed of their right to have their detention reviewed.
The Bill also obliges the Mental Health Commission to make arrangements for the granting of legal aid to patients. The precise details regarding the operation of this legal aid scheme must be agreed with the Minister and the Minister for Finance. It is my firm belief that the provisions of the Bill lay the foundations for achieving a sustained improvement in the quality of care provided in mental health services. In 1998, there were almost 26,000 admissions to psychiatric hospitals and acute psychiatric units. Approximately 6,000 of these were first time admissions. Approximately 23,500, or 90% of all admissions, were voluntary admissions. This leaves a balance of 2,500, or about 10% of admissions, which were involuntary. It is expected that with the introduction of new mental health legislation and more stringent procedures for involuntary detention, the number of involuntary admissions will decline.
The overall number of in-patients in psychiatric hospitals and in acute psychiatric units continues to decline and stood at 5,101 at the end of 1998. The proportion of patients being admitted to general hospital psychiatric units, as opposed to the old style psychiatric hospitals, is increasing and in 1998 accounted for approximately one third of all admissions.
It is of the utmost importance to help service providers to achieve high standards and good practice in the delivery of mental health services. The Mental Health Commission and the Inspector of Mental Health Services will play a pivotal role in this regard. The current Inspector of Men tal Hospitals has already begun this process. A document entitled Guidelines on Good Clinical Practice and Quality Assurance in Mental Health Services was prepared by the current inspector and published by my Department in 1998. The guidelines are an educational endeavour to increase awareness of the main quality issues in service delivery and their monitoring, refinement and improvement. They have been circulated to mental health professionals and service providers around the country. I anticipate that similar guidelines and other measures will be developed by the new commission to assist service providers in their pursuit of excellence in care delivery.
The new Mental Health Bill will also have major implications for the role of the Inspector of Mental Hospitals. The present inspector plays a crucial role in providing independent and detailed analysis of mental health services. The inspectorate has provided expertise and assistance in identifying problems and outlining the need for improvements in mental health services. Under the provisions of this Bill, the existing Office of the Inspector of Mental Hospitals will be replaced by the Office of the Inspector of Mental Health Services, thus giving the new inspector a much broader remit than that of the current incumbent. The inspector will be employed by the Mental Health Commission and will have complete independence from the Minister and the Department. This represents a major improvement on the proposal in the White Paper that the office of the inspector be associated with the Department of Health and Children.
In addition to the annual inspections of in-patient facilities which are carried out at present, the new Bill will require the inspector to carry out an annual review of all mental health services, including community residences and day centres as well as acute in-patient facilities. The inspector's review of the services, including reports of inspections carried out, will be published along with the Mental Health Commission's annual report and will be laid before the Oireachtas.
Another important responsibility of the inspector will be in relation to the regulation of standards in mental health services. A register of approved centres, in which each hospital or in-patient facility providing psychiatric care and treatment must be registered, will be maintained by the Mental Health Commission. Regulations will be made specifying the standards to be maintained in all approved centres, including requirements in relation to food and accommodation, care and welfare of patients, suitability of staff and the keeping of records. The execution and enforcement of these regulations will be the responsibility of the Inspector of Mental Health Services.
The Bill also addresses the need to provide safeguards for patients in relation to consent to treatment. The Mental Health Act, 1945, and subsequent amending legislation, does not cover the issue of informed consent to treatment given by a detained patient. However, as referred to in the Green Paper, it has been widely assumed that if a person was involuntarily detained in a psychiatric hospital his or her consent to treatment was not required. Concern about the rights of mentally disordered patients has led to a questioning of this assumption. In response to this concern, Part IV of the Bill clarifies, for the first time in Irish law, the obligations of mental health professionals regarding consent and brings our legislation in this area into conformity with the requirements of the European Convention on Human Rights.
The challenge facing mental health services is to provide all in-patients with a good quality alternative to care in large psychiatric institutions. Unfortunately, the rate of progress in providing this alternative service has fallen behind. It has to be acknowledged that mental health services have frequently lost out to other services which have been given priority in the allocation of development funding. If we are to sustain and develop the concept of a comprehensive psychiatric service located in the community close to where people live and work, it is important that adequate funding and support is provided to the service providers. I recognise that much needs to be done in this regard. It is my intention as Minister to facilitate health boards as far as possible in bringing about the necessary improvements and developments.
It is time to make a concerted effort to tackle in a determined and comprehensive manner the problems in our mental health services. To this end, an additional £12.2 million has been allocated to the mental health service this year. This represents an increase of more than 100% on the additional funding provided in 1999.
The provision of capital funding is also essential if mental health services are to be transformed in the way we would all wish to see. Substantial capital funding under the national development plan will go towards the development of mental health facilities. Approximately £150 million will be provided over the lifetime of the plan for mental health services. A significant part of this funding will go towards the development of acute psychiatric units linked to general hospitals. These units will replace services previously provided in psychiatric hospitals.
In addition to the 17 acute units already in place, a number of units are currently at various stages of development including the Mercy Hospital, Cork, Beaumont Hospital, Dublin, St. Vincent's Hospital, Elm Park, James Connolly Memorial Hospital, Ennis General Hospital, St. Luke's Hospital, Kilkenny, Portiuncula Hospital, Ballinasloe and at Nenagh, Portlaoise, Castlebar and Sligo General Hospitals. A further four acute psychiatric units are under consideration as part of the national development plan. These will be located at Dundalk, Wexford, Mallow and Mullingar.
At the end of the period of the national development plan in 2006, it is my intention to make substantial progress on completing the programme of acute psychiatric units. This will mean that acute admissions to the old psychiatric hospitals will become a thing of the past. I will also provide funding under the NDP for more community facilities such as mental health centres and community residences, thus further accelerating the phasing out of the old mental institutions.
As I have already said, this Bill improves on the proposals which were put forward in the 1995 White Paper in a number of significant respects. I acknowledge, however, that a number of other issues raised by the White Paper are absent from the Bill. The necessity to provide urgently for a reform of our legislation regarding involuntary detention, in order to bring this country into line with the European Convention on Human Rights, has resulted in my bringing forward a Bill which is shorter than originally envisaged. I am aware that this has caused some disappointment among those with an interest in the mental health services and I assure the House that these issues have not been overlooked or forgotten.
The issues discussed in the White Paper which have not been included in the Bill are ones which require further detailed consideration by my Department and discussions with other Departments and agencies. It is my intention, when this Bill has been enacted, to ensure that these outstanding issues are addressed by my Department as soon as possible.
Finally, I urge the House when examining this Bill to bear in mind that legislation is not the only means by which to effect change in the health service. The most acute problem for the mental health services for many years has been inadequate resources and, as I indicated earlier, I am taking steps to ensure that the position is improved on that front.
This Bill deals with the important issue of the civil and human rights of those who are involuntarily detained for psychiatric care and treatment. As a group, these people are among the most vulnerable in our society. They are often unable to speak for themselves. It is incumbent on us as a society to recognise our obligations in relation to these people and I am pleased to be able to introduce this Bill which will ensure that we will now adhere to the requirements of the European Convention on Human Rights in this regard.
In conclusion, I would take issue with those who assert that this Bill does no more than the minimum required to bring us into line with the European Convention on Human Rights. In many respects, it goes further that what was proposed in the White Paper. Crucially, it provides for the establishment of the mental health commission which will have the capacity, as an independent body, to drive the agenda in relation to modernising our mental health services. I am confident that the commission, as proposed in this Bill, in conjunction with the enhanced inspectorate, will enable us to develop in the years ahead a mental health service which is in keeping with the needs and requirements of a modern society.
I commend this Bill to the House.