Dáil Éireann debate -
Thursday, 6 Apr 2000

Vol. 517 No. 5

Mental Health Bill, 1999: Second Stage.

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

Minister for Health and Children (Mr. Martin)

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.

Mr. Shatter

I welcome this Bill. It is regrettable, however, that crucial issues which should have been addressed in it have been omitted. It is a long awaited Bill which has had an extraordinarily lengthy gestation period. The Minister referred to the deliberations which have taken place and the reports which have been published in the last ten years. The Green Paper was published in June 1992 and the White Paper in 1995. It should not have taken five years from the date of publication of the White Paper to develop legislation to reform an Act from 1945.

There are certain areas which the Bill addresses in principle and I welcome that, although I will comment on the manner in which they are addressed today and on Committee Stage. The new procedures for involuntary detention and the automatic, independent review of initial decisions for involuntary admissions which will be undertaken by the new mental health tribunal are welcome. The establishment of a mental health commission with a remit to supervise the delivery of all mental health services and ensure proper standards are attained and maintained is also welcome. The replacement of the Inspector of Mental Hospitals, who has done a good job, particularly in his most recent report, with an inspectorate of mental health services, which has a broader remit, is also a step in the right direction. The establishment of a register of approved centres and their regulation is a move forward in principle. There are aspects of the legislation, however, which need to be amended.

This Bill does not regulate mental health services in the comprehensive manner in which they should be regulated nor does it extend the provisions and protections for those who suffer mental illness. It is essentially a Bill about the involuntary care of those who require psychiatric treatment. In essence, this is an involuntary care Bill with some add on provisions. It addresses the position of the 10% who are admitted involuntarily every year but not the 90% who are voluntary psychiatric patients.

The Bill misses the opportunity to address the totality of the psychiatric service in the context of the obligations of the State and the prescription of patients' rights. A psychiatric patients' charter is required but the Bill does not provide for it. There is a need to prescribe statutory criteria to ensure consent to treatment is properly given by voluntary patients and that consent is fully informed and freely given. That is not addressed in the Bill. It simply assumes that a certain percentage will be admitted involuntarily and it prescribes the procedures which apply to them. There is a concern that, on occasion, people are admitted as voluntary patients without giving fully informed consent to the treatment they are about to undertake or to their stay in hospital. The Bill should address this issue.

The scandalous and appalling conditions tolerated for too long in our mental hospitals should be at the centre of this debate. The 1998 report of the Inspector of Mental Hospitals is an indictment of our mental health services. Hospital conditions and the standard of psychiatric treatment administered to patients are severely criticised. The report states that drug prescribing in some locations is often arbitrary and made without regard to appropriate clinical diagnosis and that the number of patients, particularly long stay patients, who are on numerous drugs simultaneously, often at high dosages, is striking. In some instances prescriptions had not been reviewed for some considerable time. The report goes on to say that the inspectorate feels that in some services, the practice of consultants in regard to medical note taking falls short of what might be considered good professional practice.

The facilities in which we treat those who require psychiatric care must be dragged out of the 19th century into the 21st century. That is happening in some places – the Minister referred to some of the development work under way – but it is not happening in other parts of the State. Progress in St. Ita's is far too slow and the conditions in the Central Mental Hospital, Dublin, bear relation to the structural conditions of institutions of that nature in the 19th century.

It is to be hoped that the Bill and the powers it confers on the mental health commission and the inspectorate of mental health services will prove to be a positive catalyst for changing this. The necessary investment required for this area of the health service must be provided to demonstrate for the first time that it is regarded as a priority.

It is disappointing, however, that those in prison who require psychiatric care are excluded from the Bill's concerns. That is yet another example of the piecemeal nature in which mental health services are addressed in the Bill. Some areas are picked out to be addressed through legislation while others are totally ignored, abandoned or postponed.

I do not buy the argument that the areas not covered in the Bill which are addressed in the White Paper will be addressed in the foreseeable future. We have waited 55 years for the reform of the 1945 Act. It has taken three years for this Government to produce this Bill, which was first promised over a year ago. I have no faith that issues omitted from the Bill will be returned to in the lifetime of this Government. The Minister must look at the areas addressed in the White Paper. In the interests of those who require psychiatric care or who are availing of mental health services, this Bill affords an opportunity to address issues which are currently being overlooked.

Regarding admitting prisoners who require psychiatric care, for years the Mountjoy visiting committee has complained about psychiatric conditions at the prison. In 1997, the visiting committee said the standard and quality of the psychi atric services continued to cause it grave concern. A psychiatrist did not visit the main prison during several weeks in 1997. The committee quoted Dr. Smith, Director of the Central Mental Hospital, as saying that at least 100 prisoners in Mountjoy should be in a psychiatric institution and not in prison. In 1996 the visiting committee reported that incarceration in padded cells for up to ten days was the only option available for the treatment of these prisoners. It again quoted Dr. Smith as saying the padded cell is a grotesque way of storing a human being. In 1998, the visiting committee said it was dissatisfied that people with obvious psychiatric problems are being committed to prison. The question must be asked why this area remains unaddressed. It is omitted from the Bill because of demarcation lines between the Departments of Health and Children and Justice, Equality and Law Reform and as a result we cannot comprehensively address the issues that have been ignored for too many years.

The failure of the Bill to address the needs of mentally disordered offenders appears to breach the United Nations resolution on standard minimum rules for the treatment of prisoners adopted on 30 August 1955 and the European prison rules contained in Recommendation No. R873 of the Committee of Ministers, Council of Europe 1987. Chapter 7 of the White Paper envisages that this legislation will address the needs of offenders. There is no valid reason for it not doing so. New legislation will not of itself result in a fundamental reform of our psychiatric services and tackle the fundamental discrimination suffered by psychiatric patients. We have grossly inadequate hospital and residential facilities and an absence of community supports. Emphasis has been placed on people who suffer psychiatric illness not being confined within institutions and hospitals but being treated within the communities in which they live and remaining part of those communities, yet we have failed abysmally to ensure essential community supports are available to make this a beneficial option for those who live in the community. We need significant additional funding, current and capital, and a change of attitude to prioritise the needs of the mentally ill.

The national task force on suicide emphasised the need for an extensive network of community based psychiatric services with specialist and multi-disciplinary teams being brought within reach and accessible to all who require such a service. There is an essential need for funding and manpower resources and I am not satisfied that to date the Government has remotely addressed this issue. It is only now starting to examine it. The gaps in services remain very wide. There is a need for vision and commitment as to the type of service that should be in place, which is sadly lacking, and for a dynamic to ensure it is put in place without undue delay in the context of the resources available to us as a community, which we heard the Minister for Finance celebrate in a champagne interview on RTE this morning.

The Bill does not deal with or prescribe the rules and obligations of health boards. There is a need to prescribe minimum standards for psychiatric treatment, including the provision to be made for those with learning difficulties, and there is a need to impose particular obligations on health boards to meet the needs of those who are psychiatrically unwell. The services in each health board area are different. They are diffuse, fragmented, unco-ordinated and the level of service one gets depends largely on one's location and the health board area within which one lives.

The central issue of inadequate funding for essential services is adequately illustrated by the position of young women who suffer from anorexia outside Dublin. Such young women may be kept alive in hospitals, but they will not get the comprehensive service required to overcome their illnesses. If a young Dublin woman who suffers from anorexia requires care, she may access and benefit from the required service. Six out of eight health boards have no facilities to deal with children with psychiatric illness. If a child requires care in those health board areas, there is nowhere for him or her to go except to an adult centre where adults with psychiatric problems are treated. This is inappropriate and damaging. In the context of a plethora of court cases involving young people who are disturbed or need psychiatric care, the courts have been forced to place them in inappropriate institutions. The Government has been consistently condemned in the courts for its failure to put in place coherent care policies and ensure that essential residential units are available so that such children receive the treatment to which they are entitled. Health boards should have a statutory obligation to promote good mental health and to provide a comprehensive after care service and community care programme for voluntary and involuntary patients after their hospitalisation.

The White Paper on Mental Health details the requirements of new legislation and, in doing so, deals with the areas the Minister omitted. I referred to the position of offenders. Chapter 8 of the White Paper proposes that provision be made for adult care orders to provide protection, where required, for mentally disordered adults living within the community. The emphasis in recent years on community care and the reduction in the use of institutional care has shone the spotlight on the need to ensure appropriate care and protection for those vulnerable to abuse, exploitation and neglect. There is also a need to make legislative provision for our community care services and to guarantee a right to psychiatric and other support services to those in the community reliant on care.

The Minister should explain why the proposal for adult care orders contained in the White Paper is not addressed in the Bill and why the recommendations are being completely ignored. Where a patient suffers from dementia, there is a need for an adult care order facility to be available to ensure that where that person lives within the community, there is an identified person with responsibility for his or her daily care. Addressing the issue of adult care orders is not complex legislatively. It would not be a difficult issue to address in the Bill. It does not require complex drafting by the parliamentary draftsman because, in the context of general family law legislation, there are adequate precedents that can be adapted to facilitate a comprehensive system of adult care orders to ensure the care of people within the community who require to be under the care of others but who do not require institutional care.

The rationale for not addressing this issue escapes me. There is only one reason this issue has not been addressed. After three years of prevarication the Government was finally forced to produce a Bill because it is being pursued by the European Court for a violation of an individual's rights in the context of the European Convention on Human Rights and Fundamental Freedoms as a result of its failure to put in place some of the protections for involuntary admissions provided for in the Bill. That is why the main focus of this Bill is unfortunately on involuntary admissions. It also deals with some other aspects that need to be addressed and omits important areas such as the care order area in the context of people living within the community, particularly the adult care order area. It omits those aspects for no reason other than the work and preparation had not been done properly over the period of the Government's term of office.

I wish to raise some issues with the Minister, which we will address in more detail on Committee Stage, in the hope that he will take on board some of these proposals and that they will not be issues of contention across party lines on Committee Stage. At the core of the Bill are the provisions which enable the involuntary admission of a patient suffering from what the Bill refers to as a mental disorder. Section 3 states that a mental disorder means mental illness, severe dementia or significant mental handicap. Mental handicap as a term is incorrect and not acceptable under the current international classification of diseases. The term "significant mental handicap" should be renamed as "significant mental impairment" or "significant intellectual disability".

The use of the phrase "mental handicap" is no longer correct.

Section 7 prescribes the criteria for involuntary admission to approved centres. Section 7(2) reads, "Nothing in subsection (1) shall be construed as authorising the involuntary admission of a person to an approved centre by reason only of the fact that the person (f2>a) is suffering from a personality disorder, (f2>b) is socially deviant, or (f2>c) is addicted to drugs or intoxicants.” The Bill does not define what is meant by “personality disorder” or “social deviance”. It should do so because there can be great dispute at the edges as to whether someone is suffering from a person ality disorder or a psychiatric illness. There is a need for the Bill to provide clarity in this area as to the distinction it is making.

In the context of mental health, it is right that the Bill excludes involuntary admissions on the sole ground of addiction to drugs or intoxicants. However, it must be asked whether the legislation should make provision for involuntary admissions where the sole problem is drugs or intoxicants and where, as a consequence of the use of such drugs or intoxicants, someone is clearly incapable of caring for himself or herself and is posing a serious risk to themselves and to others. There is a need to consider this issue either in the context of this Bill or other legislation.

Regarding those who can make application to have someone involuntarily admitted, section 3 provides for the exclusion of certain spouses from that category. The provisions do not deal adequately with this area. The White Paper states that in circumstances where spouses are in contention and there are marital differences between them, each spouse should be able to apply for an involuntary admission. The provision in the Bill which deals with spouses is extremely narrow. It excludes the spouse from making application for involuntary admission of the other spouse in circumstances where the couple are already separated or where a barring order has been sought or granted under domestic violence legislation. The White Paper states that "The Government propose in new legislation to disqualify a spouse from making application for the detention of his or her partner where the couple has separated or is in the process of separating or where an order has been sought." for what would be either a barring order or a protection order.

In the context of marriage breakdown, there are many other circumstances where it is appropriate that spouses be excluded. The Bill, as currently constituted, does not even meet the criteria of the White Paper. Clearly one spouse should not be able to apply for the involuntary admission of another where judicial separation proceedings or divorce proceedings are taking place or where proceedings have been issued over the custody of children pursuant to the Guardianship of Infants Act, 1964. As a lawyer who has practised in the area of family law for 25 years, I have had the experience in custody disputes between spouses over children where one or other spouse falsely alleged that the spouse with whom they are in dispute is suffering from a psychiatric illness and should be detained in a psychiatric hospital. I have had experience where husbands – it seems to be primarily something husbands do – have asked their GPs to have their wives committed under the Mental Treatment Acts. Some cases have gone to court where wives alleged they were wrongly admitted as involuntary patients at the behest of husbands approaching GPs who were unaware of the marital situation and who are led to believe they were acting properly in supporting such an application under the Mental Treatment Acts. This is not unusual because every year I would have two or three family law disputes going through my law firm where this type of difficulty arises and false allegations of psychiatric illness are made.

The Minister should treat with great caution the circumstance in which a spouse is excluded from making an application for involuntary admission. This is not adequately dealt with in the Bill. This does not mean there may never be circumstances where marriages have broken down and where one spouse has a psychiatric illness and requires an involuntary admission. However, others can make that application under the legislation and this is not properly addressed. This should also extend to circumstances where couples are in contention in nullity proceedings. Bearing in mind the large numbers of couples cohabiting outside marriage, the Minister should consider whether there are circumstances in which exclusions should apply to cohabitees.

The Bill refers to authorised officers and the role of the authorised officer in the context of the authorised officer making application for an involuntary admission. It defines an authorised officer as an officer of some particular grade within the health board. If authorised officers of a health board are to be able to apply for involuntary admissions, the Bill should specify the qualifications of authorised officers. It should not simply be a matter of their grading within a health board. Under section 11 a garda may apply to have someone involuntarily admitted. However, where it is clear an involuntary admission may be required a garda is only given a discretion to take action. Under the section, the garda should be obliged to take such action.

On the removal of persons to approved centres, there is the question of who should effect the removal. In this context, in circumstances where a removal is required and the family cannot do it, a fully qualified psychiatric social worker should be attached to multi-disciplinary units within approved centres who would have a particular role in the removal of patients.

On the duration of detention, the provision for initial admission of 28 days is too long. This period should be seven days, with a possible extension to 14 days and thereafter to 28 days. Where it appears the admissions must be for a particular period, for example, if the Minister adheres to 28 days or three months, whatever period is ultimately chosen, it should be for periods not exceeding those periods. If, for argument sake, the Minister decides to retain the 28 day admission, it should be possible for a psychiatrist making these decisions to determine that he could detain someone for a period not exceeding 28 days, that it would be an involuntary admission for just seven or 14 days and that at the end of each period there would be a review, not just in the context of the mental health tribunal but an internal hospital review.

On appeals to the courts, the Minister should look again at the Circuit Court procedure. If there is an appeal to the Circuit Court, the onus is on the patient to prove he or she is not suffering from a mental disorder. The onus is not on the hospital, health board or psychiatrist to establish the patient involuntarily admitted has a mental disorder. The concept of proving to the court that one does not have a mental disorder is very strange.

I do not know how one can do that. If there is an appeal to the Circuit Court, the onus should be on the psychiatrist to show that a patient suffers from a mental disorder if a detention is to continue. Schizophrenia Ireland is concerned about this area and that the review of a detention order will only take place after 28 days.

The issue of children is not adequately addressed. Court orders for detention of children should not be for definitive periods. For example where they can be detained for three or 12 months it should be for periods not exceeding three months or 12 months. In the context of the provisions relating to children, will the Minister clarify how this Bill will interact with section 16 of the Children Bill, 1999? Why does he envisage an initial court procedure, under the Mental Health Bill, and in the context of the Children Bill, 1999, which deals with children who suffer particular difficulties and require particular types of care, there is first a need for a family welfare conference? Why is there not a similar approach in the two Bills? Why is it that a family welfare conference is to be called for children who suffer such personal difficulties as to require detention in a secure unit, but if a child suffers from a mental disorder a family welfare conference is not first called but one goes to the courts? There is no clarity as to what type of psychiatric examination will take place prior to the court application being made. Under the Child Care Act, 1991, the child is entitled to independent representation and to the appointment also of a guardian ad litem. That should apply in the context of applications to have children admitted as involuntary patients under the Mental Health Bill.

A large number of other issues need to be addressed. I shall draw to the Minister's attention on Committee Stage other substantial amendments which I regard as necessary if the Bill is to work. For example, in the context of the mental health commission there is provision for only two medical practitioners on it, a GP and a psychiatrist. I would argue that there should be at least two psychiatrists and two GPs on the commission. The mental health tribunal should have a lay representative. Under the Bill it will have a psychiatrist, a legally qualified person and no lay adviser. I do not know how that tribunal will make decisions. That needs to be clarified. Is the legal adviser part of the decision making process or will that person advise the psychiatrist? Either way, the tribunal should reflect the structure proposed in the White Paper. It should be a three person tribunal with a lawyer, a psychiatrist and a lay person manning the tribunal.

Ms McManus

I wish to share time with Deputy O'Sullivan.

Acting Chairman (Mr. Briscoe)

Is that agreed? Agreed.

Ms McManus

The Labour Party welcomes the Bill. However, it is limited in its scope and does not address fully the complex issues surrounding mental health and the care of the psychiatrically ill. For that reason it is a disappointment. It is telling that the Bill is introduced at a time when industrial action is being taken by psychiatric nurses over matters outstanding from the nurses strike last year. The delay in producing the Bill and its narrow focus are indicative of the fact that the malaise that has gripped our psychiatric services for many years has not gone away completely. However, one must acknowledge progress that has been made, particularly improvements in therapeutic drugs and treatments and new approaches in care. These changes have not been reflected in legislative change. The present law dates back to 1945. At the time I have no doubt it was a progressive framework within which services could be delivered. Today we operate in a different context. The development of human rights legislation and developments in health care and best practice principles all require a new legislative framework. Sadly the Bill only provides for part of that.

The Bill, as the Minister said, does not deal with many of the issues relating to mental health. Problems in the area of mental health have been compounded by serious under-funding as well as the failure to address serious defects in mental institutions. The psychiatric services have always been the poor relation of the health service. When it came to apportioning resources, caring for the mentally ill came low on the list of priorities. Historically, the neglect and lack of innovation surrounding mental illness could have been explained by ignorance and fear. The shift from institutional to community care was one important change but even that was not properly resourced. Today we have no excuse either in terms of lack of knowledge or lack of money. Yet in many ways we are still silent and neglectful at worst and ambivalent at best about the psychiatrically ill. As a society we have been quick to look the other way when the vulnerable have suffered, whether children in industrial schools, women in the Magdalen laundries or the psychiatrically ill in our State institutions.

Probably the most striking example of our failure to face up to the needs of the mentally ill is St. Ita's institution at Portrane. For many years the inmates there suffered in silence. For many years reports were not produced or published by the Inspector of Mental Hospitals on this or any other hospital so that the conditions in St. Ita's and other institutions were hidden from scrutiny. It took brave people such as Annie Ryan to stand up and fight for the rights of those who are unable to speak for themselves. The world she revealed to us was truly grim. It is a tribute to her and the commitment of others like her that much is being done to improve conditions and to ensure good quality accommodation. It reflects well on no Government that it took so long to start to put things right. We cannot be complacent. We should not fool ourselves that everything has been put right.

The long delay in publishing the 1998 inspector's report only served to increase unease about its contents. It highlights a range of serious issues that require our attention. The inspector states that drug prescribing in some locations is often arbitrary and made without regard to appropriate clinical diagnosis. The number of patients, particularly long stay patients, who are on numerous drugs simultaneously, often at high dosages, was striking. In some instances, prescriptions had not been reviewed for a lengthy period. The practice of consultancy in regard to medical note taking, the basics of good medical practice, also came in for criticism as falling below proper professional practice. The carrying out of clinical drug trials – a relevant issue in terms of what we read in the newspapers – without patient permission is also highlighted. There were other matters in the report relating to the lack of privacy and dignity and those in need of geriatric care being placed in psychiatric hospitals because there was no appropriate accommodation for them. There are descriptions of accommodation that do not belong to this era – old Victorian institutions, unsuitable, overcrowded. It is not the good quality accommodation we expect and which these people deserve.

The issues relating to mental health are complex. The Bill concentrates on a particular aspect. In the White Paper there is an acknowledgment, at the end of paragraph 6 of the introduction, that it is only concerned with the Mental Health Act to give greater protection to the civil rights of the small number of people with mental illness who have been detained. Notwithstanding that, the White Paper goes on to say that this should be seen as one of the measures being taken to reform the mental health services. The Council for Civil Liberties has outlined the central issues that need to be addressed in toto, the adequate protection of detention and review of detention, proper provision for voluntary patients, proper criteria for detention and assessment of patients, specific duties to be placed on hospitals in relation to patient care, an independent body to examine conditions in hospitals, protection of the capacity of patients in the right to consent, advocacy for patients and patients' rights, effective monitoring of treatment including the use of drugs, provision of after-care and of anti-discrimination measures. I would add to that list, a specified role for health boards and the right of access to treatment for patients who need it.

Measured against such a yardstick, it is clear that while the reform of legislation is welcome, it does not go far enough. Any changes in law which we bring about now will last for many years so we must achieve a mental health regime which not only matches best practice but stands the test of time. We must go beyond best practice. What is needed is the updating of the law and a programme of expenditure to improve conditions in psychiatric institutions.

I welcome the provision of additional money and I give credit for the improved funding provided by the Department. However, it is not sufficient to overcome the problems which exist. We need to take an integrated approach, particularly in the provision of after-care for the mentally ill. All too often, this is not evident and people suffer as a result. We need to change our attitude towards the mentally ill. Most people who are mentally ill are temporarily incapacitated. The length of stays in hospital denotes this fact with 20% of patients being discharged within one week and 73% within one month.

Those who require long stays in hospital have particular needs and concerns which must be addressed. The inspector's report indicates poor conditions in long stay hospitals. A parliamentary question of mine elicited information about the reality of long stay patients which I found disturbing. One patient had been locked away for 64 years and 70 people had been detained for more than 30 years. Those patients were incarcerated in very different times and without the safeguards which are being applied in this Bill. Some of the reasons for which those people were incarcerated are excluded from the terms of this Bill. These include alcoholism and personality disorder. I am sure many of these patients could have lived outside institutions, and lived much happier lives.

The Labour Party welcomes the establishment of the Mental Health Commission to oversee the standards of psychiatric institutions. The idea of an independent commission is a good and sound one but the commission must be properly funded and resourced. It must also be careful to win the confidence of both patients and staff. Difficulties may arise in the future with regard to the roles of the inspector of mental hospitals and of the commission. The commission will appoint the inspector but there appears to be an overlap which requires clarification.

The establishment of a review tribunal is also welcome. However, we must recognise the flaw which has been referred to by Deputy Shatter. By far the greatest number of involuntary patients are released within a month, which renders the 28 day review practically useless. The White Paper proposed a review after seven days. I accept the Minister's point that this does not compare like with like, but the principle of a seven day time frame has been established and the Minister should incorporate it into the Bill. If we introduce a Bill which does not make a significant change in the terms of protection of those it is intended to protect, we are in danger of window dressing.

I take issue with the composition of the commission. The White Paper allowed for lay involvement but this has been excised in the Bill. To have legal and medical representation alone reduces the value of the commission. George Bernard Shaw maintained that all professions are conspiracies against the laity. It is not the role of politicians to perpetuate the power of the professions but to challenge it and to recognise the contribution of lay people. I urge the Minister not to become part of this potential conspiracy. If it is not challenged it will be perpetuated. The Courts Service is an example of how to do things right. The fact that lay people who are outside the judiciary participate in the new structures running our courts has improved the capability of the Courts Service in ways that would not have been dreamt of in the past. The Minister should move with the times and recognise the contribution of lay people. The lay perspective, the importance of which even professionals recognise, will be missing from the commission and from the decision making table.

The White Paper pointed out that new legislation offered an opportunity for the development of psychiatric services as recommended in Planning for the Future. However, we are only talking about involuntary admissions, which account for approximately 10% of psychiatric patients. We are not simply enacting a new law. We are also repealing the bulk of existing legislation. I am concerned about the rights of those who are admitted to psychiatric hospitals on a voluntary basis. The nature of voluntary admissions in certain circumstances has been questioned in the past. There should be checks to ensure that admissions are fully voluntary. We hear of patients who are told that if they do not admit themselves voluntarily another method will be used. The Bill contains no requirement to ensure that a person is competent to admit himself or herself on a voluntary basis.

The voluntary detention of children is seen as the sole domain of their parents. The health board becomes involved only upon parental failure to act. The Bill refers to children as being aged 18 and under, which seems to conflict with other legislation which defines children as aged 16 and under. The Non-Fatal Offences Against the Person Act, 1997, for example, designates 16 as the age of consent. It is also possible that the Bill does not comply with the UN convention on the rights of the child, which Ireland has ratified.

I hope the Minister will clarify the position of the health boards under the new regime. Under current legislation, health boards are obliged to provide psychiatric care and in-patient services for people with mental illness. The White Paper proposed that a statutory duty be placed on health boards to promote mental health and to provide an appropriate range of services. The White Paper goes on to say, "A legal framework which reflects the new developments in the psychiatric service would give the service a secure foundation and assist in further development". However, no such provision is outlined in the Bill and I would like to hear the Minister clarify the responsibility of health boards. Will health boards have a statutory responsibility for the care of psychiatric patients when this legislation is enacted and is that responsibility for in-patient care only?

The evidence of inappropriate placement or homelessness, where there is no placement at all, of patients who leave in-patient care cannot be ignored. It is estimated that between 30% and 45% of people who are homeless suffer or have suffered from psychiatric illness. Not long ago, the Eastern Health Board was able to say that none of the handful of people who were then homeless suffered from psychiatric illness. It may be that we know more now, or it may be that the situation has changed. Nevertheless, it is deeply worrying that such a large cohort of the homeless population is vulnerable and in need of medical attention. There is concern in relation to the provision for those who voluntarily commit to hospital.

The White Paper states that the Government proposes to define approved centres for the purposes of involuntary admission and that all centres which admit or detain patients will be approved by the Minister. There is a difference in the Bill under which the Minister is not the person who will approve centres. Neither does it confine approved centres to the list of seven contained in the White Paper. The commission will issue approval. Any person who makes an application cannot be refused approval unless the premises do not comply with the regulations provided for in section 65. I am always uneasy about a Bill the implementation of a large bulk of which is dependent on the production of regulations with which we will not have an opportunity to deal in detail. In this instance the regulations are crucial and we do not know when they will be published or what they will contain. A package of legislation is being repealed. There will therefore be an interregnum period while the commission is being established and the regulations are being prepared. How does the Minister see the system operating in the interim?

I am greatly concerned at the exclusion of certain categories from the definition of mental illness. I do not disagree with the principle but those suffering from personality disorders, social deviance or addicted to drugs and intoxicants are excluded. What provision is being made for these categories? What alternative arrangements are being made for them in terms of care and treatment? Under existing legislation persons suffering from these conditions can and are admitted to psychiatric hospitals. There are numerous examples where such patients were subsequently found to have underlying and predisposing psychoses, obsessive or depressive illness to which the condition was a secondary reaction. Does this exclusion extend to patients presenting voluntarily for admission suffering from any of the conditions mentioned?

While the principle is a good one – that we ensure those ending up in psychiatric hospitals are psychiatrically ill – the Minister still has a duty of care to those excluded from the definition. As we are all aware if one has money one can access care in in-patient and out-patient facilities, whether it be St. Patrick's Hospital or St. John of God in the Dublin region or Ais Eirí. If an alcoholic in my constituency is found out of control and very disturbed and in need of in-patient detox treatment the only place to which he or she can go is Newcastle psychiatric hospital. This will not be permitted under the Bill. If a local family doctor is called out and has to cope with a problem such as this do I telephone the Minister? What happens in those circumstances? There is an unevenness in care. In Dublin facilities are and should be developed outside the psychiatric service.

There will be a requirement to make the full range of needed services available in each health board region, including child and adolescent services and eating disorder programmes. There is a tendency to believe that because a service is being developed in the capital, a need is being met but those who do not represent a Dublin constituency will be conscious of the unevenness in care. Patients have a right to access quality services on an equal basis. This right should be supported by legislation.

The "term" personality disorder and social deviance is used in the Bill but not defined. This may cause problems in terms of clarity.

There are a number of specific issues which I will raise on Committee Stage but there are one or two serious omissions. It is reckoned that about 30% of prisoners in Mountjoy Prison have a psychiatric disorder or are psychiatrically ill. One per cent of the prison budget is spent on medical care. This compares with a figure of 6% in England and Wales and 9% in Scotland. It is shockingly low. I am not satisfied that responsibility for the health care of prisoners is being retained under the authority of the Department of Justice, Equality and Law Reform. It should be a matter for the Minister for Health and Children. Not alone are we not providing for the psychiatric needs of those in prison we are not ensuring that those who are psychiatrically ill are kept out of prison when they appear before the courts. I will be extremely disappointed if the Minister does not deal with this issue on Committee Stage.

There are a large number of issues to which I will return on Committee Stage to which I look forward.

Ms O'Sullivan

I thank Deputy McManus for sharing some of her precious time with me. I am my party's spokesperson on equality issues. Although I have the same reservations as the two previous speakers in what it fails to deal with, I welcome the Bill which has finally been introduced. There have been many welcome changes during the years in relation to the numbers detained in large psychiatric hospitals and the way people can be detained. We should pay trib ute to those who have campaigned on the issue. I single out, in paticular, Annie Ryan who with the help of others has campaigned strongly on behalf of those with a mental handicap or an intellectual disability detained in psychiatric hospitals. While this has resulted in many changes being introduced, more remains to be achieved.

I wish to concentrate on the 500 people with a mental handicap or an intellectual disability still being cared for in psychiatric hospitals. This figure was provided by the Inspector of Mental Hospitals, Dr. Dermot Walsh, when he addressed the Association of Health Boards last week on the Bill. As Deputy McManus said, the definition of mental disorder needs to be teased out. It extends to a significant mental handicap. What are the Minister's intentions with regard to the 500 people who are being inappropriately detained in psychiatric hospitals? What provision will be made for them, although I acknowledge that there have been significant changes over a number of years in this regard?

The other area on which I wish to concentrate is people who may be inappropriately detained, for example, people who have suffered head injuries and, what is loosely termed, the young chronically ill. I am aware of people in psychiatric hospitals who have head injuries or other such conditions which do not come within the definition of mental disorder in the Bill. They often do not get appropriate care, such as the various therapies they need. What are the Minister's intentions with regard to such people who are detained in psychiatric hospitals?

I welcome the human rights element of the Bill where people will be entitled to independent review and also that people can only be involuntarily detained in limited circumstances. This aspect has been of concern for a long time because people's human rights were not being looked after in this regard. Individuals could be detained for long periods without any access to a second opinion or an independent hearing with regard to why they were detained in the first place. Such people were often neglected over the years by family and the State.

The overall thrust of the Bill is important but I hope the Minister will respond to the issues outlined by myself, Deputy Shatter and Deputy McManus. The groundbreaking report, Planning for the Future, in 1984 identified a number of areas which are not covered in the Bill. In some ways, the legislation is relatively narrow in terms of what it attempts to address. However, the debate it will bring about in terms of our general approach to mental health will be useful.

Deputy McManus touched on the concern in relation to the number of homeless people who have psychiatric illnesses. While it has been good to bring people out of large institutions, this may have resulted in problems with regard to how people are treated and supported in the community. Much still needs to be done in that regard. More support services are needed for people in the community, particularly those who spent many years in a psychiatric hospital. As the equality spokesperson for my party, my concern is that the Minister would address the question of people with intellectual disabilities who are still inappropriately detained in psychiatric hospitals.

Mr. O'Flynn

I welcome the balance in the Bill in favour of a person's individual rights at all times and in all situations. The main points of the Bill are that there will be one detention order, automatic judicial review, recourse to court approval, informed consent, no drug trial, independent review, no legal formalities for admission and discharge of voluntary patients and approved centres will be registered. In addition, the dreaded PUM – person of unsound mind – system, under which one could be indefinitely detained without automatic review, will be extinct.

The work of the tribunal may appear formidable but in my constituency, Cork North-Central, the north Lee catchment area serves a population of 118,400. In 1997 there were 880 admissions and 896 discharges. A total of 119 of the admissions were on temporary orders under the Mental Treatment Act, 1945, and only six persons had their temporary orders extended. The vast majority of admissions were voluntary. Regarding community services in the same area in 1997, 438 out-patient clinics were held at eight locations. A total of 1,294 patients attended these services while 263 were attending for the first time. One can understand the comparison and the importance of services in the community.

I welcome the new Mental Health Bill, the object of which is to reform existing legislation concerning the involuntary detention of persons for psychiatric care and treatment, to provide for automatic independent review of each decision to detain and to establish mechanisms by which the standards of care and treatment provided in psychiatric in-patient facilities can be supervised and regulated. However, the Bill is just one of the measures being taken to reform the mental health services.

In 1981 the then Minister for Health, Eileen Desmond, appointed a study group which was to examine components, both institutional and community, of the psychiatric services, to assess the existing services and to draw up planning guidelines for the future development of the services. Its document, Planning for the Future, was published in 1984. The main thrust of the report was for a radical shift in the pattern of care of psychiatric patients, particularly in the areas of finance and resources, from an institutional to a community based service with close links between psychiatry and other community services.

The study group recommended a programme to implement its recommendations in all parts of the country. This programme was to be initiated without delay so that mentally ill persons could benefit from an effective and progressive service. To facilitate a community based psychiatric service and to provide particularly for the care of detained persons in such a service, new mental health legislation was essential.

Our Lady's Hospital, situated in my constituency, Cork North-Central, was the second largest psychiatric hospital in the country. It once housed 2,500 patients and, thankfully, it is now closed. The 16 remaining long stay patients and the intensive care patients are currently housed in St. Kevin's unit, which is situated in the grounds of Our Lady's Hospital. There are plans to transfer these patients elsewhere.

Our Lady's Hospital was a landmark outside the western boundary of the city, overlooking the River Lee. It was a place of sadness because of the stigma associated with mental institutions for those who had relatives or friends detained there. We all remember families dumping people in institutions in previous decades. In response to Planning for the Future, a skilfully designed deinstitutionalisation programme was put in place for the patients. This resulted in patients being transferred to community based or specialised services.

Community based rehabilitation programmes must be continued to prevent psychiatric patients from developing institutional neuroses which occurred because of the negative environment that existed in the asylums of the past. A new Mental Health Act to provide for the care and treatment of psychiatric patients in the future is therefore essential.

During my research for this Bill, I considered the historical backdrop to the Mental Treatment Act, 1945. I examined the Vagrancy Acts, 1714 and 1744, which provided for the civil committal of the mentally disordered and created classes of "furiously mad" or "dangerous persons" who could be committed by two or more justices of the peace to places of detention. It was not necessary for them to be charged with any crime before committal.

The segregation of the mentally disordered from society has been termed the "great confinement". This was achieved through the construction of institutions or asylums for the detention of the mentally disordered. Ireland's first asylum, St. Patrick's Hospital, Dublin, founded by Jonathan Swift, was opened in 1757. The Dangerous Lunatics Acts, 1800, 1838 and 1867, provided specifically for the detention of the mentally disordered. These laws remained in force until the enactment of the Mental Treatment Act, 1945, which established the legal mechanism used today for the civil law committal of the mentally disordered. The White Paper is concerned with a new Mental Treatment Act but it should be seen, as I mentioned, as just one of the measures being taken to reform the mental health services.

The proposed new mental health legislation places emphasis on the protection of civil rights of the relatively small number of people with a mental illness who have to be detained for treatment to bring our legislation into line with the European Convention on Human Rights. The Green Paper pointed out that the criteria for detention and the safeguards against improper detention did not conform to those required by this country's international commitments. These relate principally to the European Convention on the Protection of Human Rights and Fundamental Freedom, 1950 to which Ireland is a signatory.

There are six parts to the Bill which is designed to reform existing legislation, repeal the part of the Mental Treatment Act, 1945 concerning the involuntary detention of persons for psychiatric care and treatment, provide for automatic independent review of each decision to detain and establish a mechanism by which the standards of care and treatment provided in psychiatric facilities can be supervised and regulated. The main features of the Bill provide for an independent agency to be known as the Mental Health Commission. One of the main functions of this body will be to ensure the interests of detained patients are protected. Each decision to detain a patient on an involuntary basis and each decision to extend the period of detention will be referred to the commission which will arrange for an independent review of all such decisions to detain to one or more mental health tribunals. In turn, these tribunals will arrange on behalf of the detained person an independent assessment by a consultant psychiatrist. The tribunals will be empowered to order the release of a patient if they consider that he or she does not require to be involuntarily detained. I welcome this provision.

The Bill includes new requirements in respect of obtaining the consent of detained patients for certain types of treatment, for example, electro-convulsive therapy. The Inspector of Mental Hospitals will be replaced by the Office of the Inspector of Mental Health Services. The inspector's annual report will be published in conjunction with the commission's annual report and the commission will retain a register of approved centres in which psychiatric in-patients are treated.

Under the new criteria for involuntary admission, a person may be involuntarily admitted to an approved centre if he or she is suffering from a mental disorder, if, because of that disorder, there is a serious likelihood of that person causing an immediate or imminent harm to himself or herself or to other persons or if, in the case of a person whose mental disorder is severe and where judgment is impaired, failure to admit or detain that person is likely to lead to a serious deterioration in his or her condition or will prevent the provision of appropriate treatment that can be given only by admission to an approved centre.

A mental disorder is defined in the legislation as mental illness, significant mental handicap or severe dementia. The following will be excluded from the definition of mental disorder: personality disorders, social deviance, addiction to drugs or alcohol and perverted conduct. The detention of persons with a mental disorder under the pro posed new legislation will be limited to approved centres.

Section 24 deals with the involuntary admission of children who are defined in the Bill as those under the age of 18 years. In keeping with the approach adopted in the Child Care Act, 1991, in relation to children at risk, the involuntary admission of mentally disordered children is subject to parental consent or an order of the District Court. Where a health board believes a child is mentally disordered and where the parents cannot or will not consent to treatment, the health board may make an application to the courts for an order permitting the involuntary admission of the child for psychiatric care and treatment. An order for the child's detention and treatment may be renewed by the court after 28 days, three months, six months, 12 months and annually thereafter.

I welcome the new procedures governing involuntary admissions, transfers and returns to hospital. Under these, the applicant, spouse or relative will continue to take primary responsibility for initiating an application for involuntary admission and the applicant must be over 18 years. A spouse will be disqualified if in dispute, for example, if a court order has been granted under family law or if he or she is departing or has departed from the marriage. The applicant will be required to have contact with the person to whom the application relates within the previous two days. If a spouse or relative is unwilling or disqualified from making an application, an application may be made by an authorised officer of a health board who is suitably qualified and who is not employed directly in the mental health service. The application will then be forwarded to a registered medical practitioner who will examine the person who is the subject of the application within 24 hours of its receipt. The practitioner shall inform the person of the purpose of the examination unless in his view the provision of such information might be prejudicial to the person's mental health, well-being or emotional condition. Where the registered medical practitioner is satisfied, following an examination, that the person is suffering from a mental disorder he shall make a recommendation in a form specified by the commission that the person be involuntarily admitted. Where, following the refusal of an application, a further application is made in respect of the same person, the applicant must inform the medical practitioner of the facts relating to the previous refusal. I welcome the inclusion of these safeguards in the Bill.

Where a person is received at an approved centre on a recommendation under section 9, a consultant psychiatrist on the staff of the approved centre shall carry out an examination of the person. If the consultant is satisfied that the person is suffering from mental illness he or she may make an order to be known as an "involuntary admission order" in a form specified by the commission for the reception, treatment and deten tion of the patient. If the consultant is not satisfied that the patient is suffering from mental illness, he or she may refuse to make an order.

A consultant psychiatrist or a registered nurse on the staff of the approved centre shall be entitled to take charge of the person concerned and detain him or her for a period not exceeding 24 hours for the purpose of carrying out an examination. An admission order shall remain in place for 28 days and this period may be extended by a renewal order for three months, for a further six months or for periods not exceeding 12 months thereafter. The consultant psychiatrist shall examine the person not more than one week before making the order concerned and certify in a form specified by the commission that the patient continues to suffer from a mental disorder. The consultant must give notice in writing to the patient of the making of the order and must also inform the patient that he or she is being detained or that he or she will continue to be detained under a renewal order. The patient must also be informed that he or she is entitled to legal representation. We have come a long way from the days when people were detained in Our Lady's Hospital in Cork and the key was thrown away.

Responsibility for transferring the person in respect of whom an application for detention has been made will remain with the applicant. If the applicant is unable to make the necessary arrangements, it will be the responsibility of the clinical director to arrange the transfer. If persuasion by an experienced member of the clinical team fails to secure the agreement of the person to come to the approved centre it is proposed that the clinical director may request the Garda to assist the staff of the approved centre to transfer the patient. The Bill proposes that the Garda shall comply with such a request. I welcome this development because, in the past, individual gardaí did not realise they had a role to play in this regard because that role may not have been clearly defined in law.

The Bill provides that the consultant psychiatrist responsible for the care and treatment of the patient may allow the patient to be absent from the approved centre for a specified period and may set certain conditions to such leave. Where a patient is absent from a centre without leave, the clinical director may arrange for the patient to be returned to the centre and, if necessary, request the Garda to assist. Where the consultant psychiatrist who is responsible for the care of a patient is of the opinion that a patient is no longer suffering from a mental disorder he or she shall by order in a form specified by the commission revoke the relevant admission or renewal order and discharge the patient.

Current legal formalities regarding the admission and discharge of voluntary patients will be removed. Authorised nurses in approved centres will be given legal authority to hold voluntary patients, in certain circumstances, up to 24 hours during which time the patient must be examined by a consultant psychiatrist who may hold him or her for a further 48 hours. Arrangements must be made during the latter period for the patient's detention or discharge.

I welcome the review of detention orders. The mental health review board will consist of a psychiatrist and a legal assessor appointed by the commission. The tribunal will review every initial decision to detain a person in a psychiatric hospital and each decision to extend detention.

I welcome the concept of consent to treatment contained in the Bill. As defined in section 55, this is consent in writing obtained freely without threats or inducement. Where it is proposed to perform psycho-surgery on a patient, the patient's consent and the authorisation of a tribunal must be obtained. Electro-convulsive therapy cannot be performed on a patient unless the patient gives his or her consent. Everyone is aware of cases in the past where people were strapped to beds and given treatment they either did not request or which they should not have received. I am glad those days are long gone. Where the patient cannot give such consent the treatment must be approved by two consultant psychiatrists. Where a patient has been on medication continuously for more than three months, the medication cannot be continued except with the patient's consent. Where the patient cannot give such consent, the treatment must be approved by two consultant psychiatrists. This procedure must be followed every three months while medication continues.

Deputy Shatter referred to the adult care orders. According to the Law Reform Commission report, these should be modelled on the Child Care Act, 1991. The proposal to introduce them is welcome. The Law Reform Commission has recommended that evidence be given by a consultant psychiatrist in application proceedings where they appear unnecessarily restrictive and that it may be appropriate to permit evidence to be given by a consultant geriatrician or even general practitioner, who should be given some role in a community orientated protective option. The courts would initially decide on the duration of the order and the mental health review board would decide for or against continuation of the order.

Mr. Shatter

On a point of order, I welcome the Deputy's comments on adult care orders, but there is no provision for such orders in the Bill.

Mr. O'Flynn

I am asking for them to be included. The Mental Treatment Act does not provide for protection of the property of mentally disordered adults except by making the person a ward of the court. The Law Reform Commission recommended that the ward of court procedure should be integrated with detention procedures so that the property of a person detained against his will is automatically protected. When a detention order is made the wards of court office should be immediately notified and a wardship procedure commenced by the solicitor unless there is an enduring power of attorney. This matter should be addressed in the Bill and I urge the Minister to look at it.

Transitional provisions within six months of the Bill coming into operation and the detention of patients in psychiatric hospitals should be independently reviewed. For three years after the commencement of the Act, hospitals and other facilities providing care and treatment for persons with a mental disorder will continue at approved centres. I commend the Bill to the House, especially in view of my experience as a young boy in attending Our Lady's Hospital to visit relatives who were detained there for no sane reason.

Mr. Neville

I also welcome the Bill. It has been a long time in gestation and is a small but significant step towards improving our mental health services, which have been neglected over past decades. It would be wrong to place all the blame for neglect on the Government, but it is in charge. Bigger steps are required to ensure that resources are provided to the mental health services to enable them provide the kind of service those suffering psychiatric problems deserve.

It is now recognised that we have neglected the mental health services and this is reflected in the report of the inspector of mental hospitals when his report of last November revealed a disturbing picture. It is an indictment of the State's treatment of one of the most vulnerable groups – the mentally ill. Those patients have been neglected, ignored and stigmatised for decades.

The inspector expresses his concern at the lack of multi-disciplinary teams in many of the mental health services. It is not acceptable, for example, that one health board with four mental health service centres has no social worker in any of them. This has been repeatedly drawn to the Minister's attention, yet action has not been taken. It is unacceptable that psychological services are poorly represented and, in some cases, non-existent. What plans, if any, has the Government to deal with this? It is unfair to ask the Minister of State to respond. The Minister must have a view and plans to deal with this situation.

At a time of highly developed medical treatment in the general hospitals it is nothing short of discrimination bordering on abuse that drug prescribing in some locations is often arbitrary and made without regard to appropriate clinical diagnosis. The inspector was concerned at the number of patients, especially long stay patients, who were on numerous drugs simultaneously, often on high doses. In some instances the prescription had not been reviewed for some time. Does the Minister accept that medication should be reviewed at frequent intervals and that failure to review it is a sign of serious negligence?

The inspector reports on the increasing number of sudden deaths in psychiatric hospitals, some of which were attributed to drug related effects. I commend journalist Vincent Browne for raising this issue in The Irish Times. Few other journalists paid attention, but it is worth quoting what he said: “The inspector's comments implies that very serious crimes, even manslaughter or criminal negligence, may have been committed.”

Medical note-taking and keeping a medical record is an important tool in the management of modern medical systems. I am very concerned about the inadequacy and quality of medical note-taking in some mental health services. This relates especially to the consultant's input, both on or shortly after admission to hospital, and at subsequent clinical reviews and progress assessments. Surely this approach should not be tolerated.

A key recommendation of the report of the national task force on suicide was that steps should be taken to make the health services, especially mental health services, accessible to the public, particularly the young who may perceive them as being not readily available to address their needs at times of crisis. Psychiatric community services, especially in rural areas, are totally inadequate and are the Cinderella of the health services. There are inadequate day hospitals and community residential facilities for persons with psychiatric disorders. It is unacceptable that in some hospitals as many as half of the acute psychiatric beds are occupied by persons who do not need such a high level of in-patient care. A major reason for this is the absence of appropriate alternative residential facilities.

The service to our fellow citizens who are suffering from mental illness is disgraceful. It has led to the stigmatisation of people suffering from a psychiatric disorder. The Minister must, as a matter of urgency, deal with and respond to this scandal. The abuse of people is horrifying, especially when it is done by the system to the most vulnerable citizens in our society. They deserve special vigilance and care. The way we treat these citizens is a profound indictment on our society and our values.

In 1998, the year for which the most recent statistics are available, 504 people died by suicide, an increase of almost 15% on the previous year. This issue has rightly caused shock in society. Most of those who were suicidal or who died by suicide were under 25 years of age.

Action must be taken to address this problem immediately. Other states have introduced effective suicide prevention programmes and it is urgent that the Government follows suit. We must reduce the levels of suicide and ensure that those who feel suicidal can get help from the State agencies. This help must be readily and easily contactable and available 24 hours a day every week of the year. The recommendations of the national task force on suicide are clear and unambiguous and I call on the Minister and the Government to implement them in full immediately. Other Departments are involved here, especially the Department of the Environment and Local Government and the Department of Education and Science.

In 1998, 504 people committed suicide, compared with 433 the previous year. The majority of people who took their lives were male – 42l as opposed to 83 females. The Government must ensure that the training of medical personnel includes recognition and management of suicidal behaviour as an integral part of such training and continuing education. Health boards should immediately establish a directory of voluntary and statutory services for those at risk of suicide. This should be available to all appropriate statutory and voluntary services and in the offices of general practitioners.

The Government must introduce proper treatment for the mentally ill who are in prison.

In June 1998 the Minister of State at the Department of Education and Science, Deputy O'Dea, announced that a national educational and psychological service would be available to all primary and post-primary schools and to the young who are no longer in formal education. That is important because a higher number of young people who leave the education system early commit suicide than those who remain in the system. He also announced that a new social, personal and health education subject would be introduced in the primary curriculum to deal with issues such as self-esteem and the need to express feelings. When will this be introduced? It is almost two years since the announcement was made. It is important that young people are trained to deal with crises in their lives, to recognise that they are not unique and that they can be dealt with.

It is urgent that assistance be provided to young people who leave school early as there is a particularly high rate of suicide among this group. The Minister should make an order that radio and television programmes which deal with suicide and related issues should display helpline numbers and referral information. The health services, including mental health services, must be more accessible to the public, particularly the young who might perceive them as not being readily available to address their needs.

Adolescence, the period between childhood and adulthood, has gradually been extended during the 20th century. The pace of social and cultural change has never been faster. The life expectancy of most jobs is five years and skills can fast become redundant. Individuals must be more adaptable. What is an opportunity for some is a threat for others. Stresses affect both young men and women, although young males seem to be less adaptable to changes in their status.

Education which is proactive against both suicide and attempted suicide must be broadened, particularly in the case of boys, to encompass the various modern social and domestic conditions. Whereas the physical health of young people might be better in comparison with years ago, the same cannot be said about the social and psychological pressures to which young people are exposed. This is partly due to the increasing instability of family life and a changing sense of per sonal and family relationships. In this context, I ask the Minister to consider the establishment of a committee, task force or group to examine the pressures on young people, to determine the range and size of the problems facing them in modern society and to determine the best methods of addressing them from a social, recreational and educational perspective.

As regards the extension of psychiatric services to the community, the task force on suicide recommends that:

. . . the recommendations of the report on the development of mental health services, Planning for the Future, be implemented in full. In particular, the Task Force recommends the provision of an extensive network of community-based psychiatric services, bringing specialised multi-disciplinary psychiatric services within easy reach and accessibility of all citizens and referral agencies so that psychiatric services are readily available and acceptable to all. This will lead to more frequent and earlier referral of potentially suicidal patients and enable them to receive earlier and more effective treatment.

The task force also endorses the policy outlined in Planning for the Future of establishing acute psychiatric units at general hospitals which will facilitate early intervention for people who attend accident and emergency departments having attempted suicide.

I am extremely concerned about the discharge of suicidal people from psychiatric hospitals. There seems to be no policy to deal with such people. Research in the United Kingdom shows that people who are discharged from psychiatric hospitals are 100 to 200 times more likely to commit suicide in the four weeks after being discharged. I know people who were concerned about their loved ones being discharged from a psychiatric hospital into the community because they were afraid they would commit suicide. I know of two cases where this happened, despite consultations with the hospital. The Minister must examine how we deal with people who are suicidal. There are specific policies dealing with this issue in the North of Ireland. It is sad for someone to say their son or brother will commit suicide if they are released from hospital.

Despite the fact we have the lowest crime rate of any European state, we have the highest level of suicides in prison. Last year six people committed suicide in prison. Prisoners are a high risk group. Dr. Enda Dooley, the director of the Prison Medical Services, stated:

Unfortunately it is inevitable given the complications of the people with risk factors, young male and substance abusers disproportionate with different levels of mental disorder coming from deprived backgrounds. When all these come together in the crisis laden atmosphere in prison then it is inevitable, unfortunately, that on occasions suicide will occur.

What constitutes the prisons' best efforts when we have the equivalent of two full-time psychiatrists for more than 2,600 prisoners?

A report published last November by the European CPT Commission recommended that in-patient psychiatric services for prisoners be reorganised as a matter of urgency. Fr. Fergal McDonagh, head of the prison chaplains, stated:

If a prisoner is lucky enough to see a psychiatrist, a prisoner might be lucky if he saw that psychiatrist for 5 minutes. That would be stretching it I think. Unfortunately, the psychiatric system we have is essentially one where its main function is dispensing or prescribing medication, sleeping tablets and anti-depressants. Counselling is non-existent in our prison system.

Prisoners at risk are kept under observation so they can be checked by a staff member every 15 minutes. Dr. Charles Smith from the Central Mental Hospital does not accept that checking a prisoner every 15 minutes is enough to prevent suicide. He states:

The problem with the routine response of prisons to suicidality is the 15 minute observation. Clearly 15 minutes of observation leaves 14 minutes and 50 seconds of non-observation. So it is not really a good way of preventing suicide on those who are determined. The only way, and it will require a lot of staffing, is eye to eye contact or to make that eye to eye contact more likely in some sort of a ward setting.

Prisoners identified as disturbed or at risk of suicide in prison are sent to the Central Mental Hospital. However, a severe shortage of beds there often results in a prisoner being held in a padded cell in prison.

I will again quote Fr. McDonagh, head of the prison chaplains:

If a person verbalises or uses that language and says that he is depressed or suicidal, the response within our prison system is they are stripped to their underwear, they are taken down to a room that is about six feet by five feet, padded or some of our prisons are not even padded. There is a plastic mattress on the floor and a blanket that is designed that it cannot be torn and used as a ligature and they are left in there and they eat their meals off the floor. Some people might only spend a day in it, but some people have spent weeks in that type of almost like sensory deprivation, especially in the world we live in, it would not happen in a psychiatric hospital across the road. The Central Mental Hospital is the only psychiatric facility available for prisoners.

Prison health care should be of the same standard as health care throughout the community. The difficulty is that we do not accept mental ill health in the same way as physical ill health. A prisoner who is physically ill will be taken to a hospital and treated but a prisoner who is mentally ill will be taken to a padded cell. Why is he or she not taken to a psychiatric hospital and treated the same way as a person with any other illness? People who are psychiatrically ill or suicidal are not a threat to society. There is no threat of escape because of their condition. They simply need treatment.

There is an urgent need for a detailed examination of why there is such a high level of suicides in prisons. There must also be a comprehensive review of how we treat the mentally ill in prison. It is estimated in the US that 10% of prisoners suffer from psychiatric illness. We can assume, therefore, that 10% of our prison population – over 200 people – are also suffering from psychiatric illnesses and are not being properly treated for them.

Cecilia Keaveney

I welcome this Bill. It provides a modern framework within which people who are mentally disordered can receive care and treatment. It is important legislation for those who need such treatment or protection and for those who provide it. The Bill will bring Irish law into line with the European Convention on the Protection of Human Rights and Fundamental Freedoms.

The fact that we can discuss the mental health issue is of value in itself. Too often in the past people with mental illness were hidden away and forgotten. It was considered a terrible stigma and was brushed under the carpet for too long. It is important that we discuss all aspects of mental health. I congratulate the Minister on bringing forward this Bill.

The core provision in the Bill is the establishment of the mental health commission. It will comprise ten members – a practising barrister or solicitor, two registered medical practitioners of whom 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 which promote the interests of people suffering from mental illness. The latter group is becoming more numerous and vocal. Its members deserve a place on the new commission. There is a wide sphere of involvement so the commission should provide adequate representation.

The commission will be a mechanism whereby standards of care and treatment in the mental health services can be monitored, inspected and regulated. This will be of benefit to all concerned and will ensure standardisation of best practice. I have encountered many people in the mental health services sector who work above and beyond the call of duty. When they hear about the establishment of a commission they tend to think of it as an entity to look over their shoulders and that there is an assumption they are not doing their jobs. However, in this instance the commission will assist practitioners in the promotion of high standards and good practice in an area where the recipient of the support is most vulnerable and in need of best practice.

The Inspector of Mental Hospitals will be replaced by the Office of Inspector of Mental Health Services. It will be under the auspices of the commission and both bodies will be independent of the Department of Health and Children. It is a big step. The Minister believes that giving the commission and the inspectorate independent status will be crucial in driving the agenda for change and modernisation in the mental health services, something that must be welcomed.

Among its many important functions, the office of the inspector will be able to review a person's detention. It will be charged not only with assessing acute in-patient services and facilities on an annual basis but also with reviewing mental health services in terms of community residences and day centres. That will give the office a more rounded view of what is going on at grassroots level rather than focusing on a specific area of mental health. Many services fall under the remit of different Departments. Many problems in relation to children, for example, fall under the remit of the Department of Justice, Equality and Law Reform and the Department of Education and Science as well as the Department of Health and Children. It is important, in this instance, that the inspector can review all mental health services and that his reports will be published along with the mental health commission's reports.

Another important responsibility for the inspector is the register of approved centres in which each hospital or in-patient facility providing psychiatric care and treatment must be registered. I do not consider this a threat to people who are currently providing care. It will only ensure the standardisation of best practice. The register will be held in the mental health commission.

Regulations will be made specifying the standards to be maintained in all approved centres, including the requirements in relation to food and accommodation, care and welfare of patients, suitability of staff and the keeping of records. At present, different organisations are being set up to look after people with a mental disorder. The keeping of records and ensuring that proper requirements are followed is most important. The execution and enforcement of the regulations will be the responsibility of the inspector of mental health services.

The mental health issue has gained great momentum within the community. Health boards are reaching out to communities and community groups are reaching out to the State agencies in an effort to promote their plans. This is a tremendous change from the historic situation. I congratulate the people in the voluntary sector for the tremendous work they do and the co-operation they receive from State agencies. It is heartening to see it.

In the past 20 years there has been increasingly obvious movement towards the development of an integrated and community based approach to the care of the mentally ill. There is a need for legislation to keep pace with these advances. Modern Ireland must have a place both in legislation and in the community for people with mental illness. This Bill attempts to enhance the care of such people and to take into account the families concerned.

Given the type of society in which we live, there is a very fine line between what can be termed sanity and what is, for want of a better word, insanity. The pace of life for everyone has increased so much that for us life can get us into situations where our mental stability can be rocked slightly or in a more severe way. Therefore, in a sense, it is a case of there but for the grace of God go I. It is in that sense that it is important developments continue to be made to services and to research and support to ensure that more people, with proper management and treatment, are in a position to carry on normal lives and to contribute, as much as possible, to our society in a positive and fruitful manner.

I acknowledge the tremendous work Deputy Neville does in regard to suicide. I would like to underscore the importance of this subject given the increase in the number of suicides which have and continue to occur, according to the statistics we observe. I agree with Deputy Neville that health services should be accessible to young people in times of crisis.

Recently, I attended a seminar run by the Moville mental health group. People from The Samaritans, Schizophrenia Ireland and many other agencies attended. The Samaritans began their talk by saying they were changing their approach in dealing with people. They said they were going to send more people out and about to deal with cases and that instead of hearing a person at the other end of the telephone after office hours, they would play a message. They pressed a tape recorder which relayed the following message: "Sorry, we are only open from 9 a.m. to 5 p.m. We are unavailable now but if you are feeling suicidal, press one" and so on. There was outrage among the people at the conference. It was a mean trick to play but it was a very good experience for those in the hall. It was not the new approach by The Samaritans but it woke people up to the fact that when someone faces a crisis, they need support, someone at the other end of the telephone and they need facilities. We are talking mostly about in-patient facilitation but we should always remember that prevention is always better than cure. We learned an important lesson in about 60 seconds at that seminar on mental health.

We face more and more problems with substance abuse, which was alluded to by others. Substance abuse, whatever substance, is increasingly altering people's personalities. Individuals who are not necessarily under any other pressure find their personality being changed by the substance abuse in which they are involved. There must be an increased focus on that.

When one considers the horror stories of mental hospitals in the past and the years people stayed in institutions until they were so institutionalised that they could not survive outside the system, I thank God and the Minister for this Bill because those days are truly gone. While they probably served some purpose in the past, there have been great developments since the closure of many of these same units. More effective treatment techniques have helped those in in-patient care. The safeguards to their personal welfare in terms of exploitation or abuse deserved further consideration.

It is was probably a bit naive of me but I did not realise until I heard the Minister speak that the right to consent to treatment had not always been there and that it was not inscribed in law. Under the Bill, the patient must now consent to treatment. Previously, it would have been felt that people were involuntary detained – a sentence that was often not reviewed but in this Bill, there is a focus on improving and modernising the criteria and mechanisms for the involuntary detention. It establishes a system of automatic and independent review of all detentions – a vital focus in this day and age.

It also puts 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. This independent review is extremely important given events in the past. Within 28 days of a person's detention, they have the right to a review. A person's right to be discharged before 28 days is contained in section 27 and they are to be informed when they are to be discharged. Will the families of those detained be informed of when the patient is to be discharged? The discharge of an in-patient without the knowledge of those close to them often causes problems.

The review is extremely important. Reviews will be carried out by the mental health tribunal and it will consist not only of medical but legal assessors. It is important that people who have a mental disorder are treated as people and not as things. I am glad they have the right to legal aid and the right to legally challenge their detention. That offers them a protection which is rightly theirs. However, I ask that the family have some input in terms of being informed of how things are moving and what is going on.

Deputy O'Sullivan spoke about people who, after an accident, suffer a head injury and said they would be in a different category and that resourcing is important. All patients in the mental health area fall into various categories. I have visited my local facilities on numerous occasions and there is quite a mixture of people, including violent, loud, quiet and restrained people. They are often placed in the same facility or in the same room. We cannot expect a violent child or adult who is an in-patient to stay in the same facility or room as a quiet restrained person because that creates difficulties. There are difficulties in terms of resourcing and that is one of the big challenges which remain.

I take this opportunity to congratulate people working in my locality in the mental health area. I would be proud to take anyone to the James Connolly Hospital, which the Minister of State, Deputy Moffatt, recently visited. The work being done there is tremendous. However, the building is old and the Minister should take cognisance of the work they intend to carry out. They are moving towards a bungalow system where people are left to their own devices so that they can develop interpersonal skills and as much independence as they can. It also provides space so that one can keep people of the same type together, which keeps people happy. I commend that group on the amount of work it is doing in the arts. Much more support should be given to recreational facilities for people in these institutions, for the want of a better word.

Therapy is very important and many people benefit from it, especially through music and art. A specific budget should be created, if it does not exist already, to finance these resources and facilities.

There is a nursing unit in Buncrana which needs to be kept open. People believe the mental health unit within it is under threat. I worry about the elderly who care for special needs people because young people with a mental disorder are living longer. Many parents are worried about what will happen to their children when they are not around to care for them.

Perhaps the Minister would examine the Cashel na Cor organisation which cares for people with a mild mental handicap in Clonmany and for elderly people in many day centres. I congratulate the Irish Wheelchair Association on donating a bus to enable children and adults in rural areas to be included. However, a great deal remains to be done in terms of transport.

The most important task is to examine the residential care problem. Granting funding now will ensure a long-term solution. The Minister and his predecessor, the Minister for Foreign Affairs, Deputy Cowen, have done good work, but more must be done to put at rest the minds of parents, especially elderly parents. In the context of our growing economy I would like to think that the next budget would grant funding for the development of residential care units to bring them up to date. Our priority should be to have facilities which reflect the positive moves in medication, social reactions and those made in the Bill. Those who cannot contribute to the community should be given a sense that they are part of it. It must be one of the legacies of the Government that, at the end of its five year term, it can point to the fact that there were positive developments in the provision of residential care.

We should not speak of closeted or forgotten people. We owe it to such people to bring them into the open. We should show that we do not want political kudos for having done that and that we want to treat them as people. I welcome the efforts of the Minister for Tourism, Sport and Recreation and the Taoiseach regarding the Special Olympics. So much of a positive nature is being done that we can only go from strength to strength. However, the resources must be put in place to address this most important issue.

Mr. Sargent

Cuirim fáilte roimh an mBille seo. Táimid ag fanacht leis le fada agus anois tá sé againn. The Bill deals with an area in which I have no expertise. However, as a Deputy for Dublin North, I am aware of and appreciate the work done by the staff and all those involved on a voluntary basis in supporting St. Ita's Hospital. They often make their presence felt in the constituency, be it through the annual concerts they hold, which are always well produced, or in the community where many of them live. I had cause to appreciate recently the generosity of those who work in St. Ita's as some of them gave me a lift during the recent bus and rail strike.

The issue of mental health has been of concern to me in the context of depression, both mild and severe. The Minister of State, Deputy Moffatt, will know this from discussions we have had on St. John's Wort and the Irish Medicines Board's view on the matter. It is an issue which still considerably annoys people but also puzzles them. For example, why are such serious substances as organophosphates being considered by the Irish Medicines Board and awaiting a decision, even though they have been banned in the UK, while the sale without prescription of such a mild product as St. John's Wort is considered illegal? That is an aspect of the mental health issue to which I will refer later.

Old institutions such as St. Ita's and other old psychiatric hospitals now receive investment and I welcome and appreciate that. However, there is a need to redesignate old psychiatric hospitals so that, instead of being seen in the light of the old Mental Health Act, 1945, where all clients are viewed as having a psychiatric illness, they are seen in a more modern light as service providers for people with learning disabilities. That is one of the issues I hope will be discussed further as the Bill makes its way through the Oireachtas. Redesignation is still an issue among people working in the mental health area in that they query whether it is achievable under the new law. I note that Liam Doran of the Irish Nurses' Organisation has called for this redesignation of hospitals and for a clear distinction to be made between the services provided.

Many Deputies will have met nurses, psychiatric and other nurses and students. If we are to have a well developed and well resourced mental health service, we need to take note that the Psychiatric Nurses' Association of Ireland is on a work to rule about pay at present and that student nurses and future nurses will expect, if they are living in a fair society, not to have to pay tuition fees when other undergraduates do not have to pay them. I hope that issue can be dealt with as the Bill goes through the Oireachtas.

I support Deputy Keaveney's point about support for carers. While there have been improvements in the budget and through other means, vast improvements are still required. Carers do not receive half the attention nor half the appreciation society owes them for the intensely difficult work many of them do. Respite care would be a way of recognising much of that work. There is always room for improvement and I hope the Government can deliver on that. I agree with Deputy Keaveney that residential care is an indication of how civilised we are as a society and it is an area which requires vast improvement.

In terms of bricks and mortar, which is an aspect of the Bill which ought to be addressed as much as the definitions and services provided, the maintenance work, which has improved to some extent in St. Ita's in Portrane and on which I can speak with some experience, is still appallingly slow. Notwithstanding the significant media attention that institution received, especially because of the interest shown by the journalist, Vincent Browne, the maintenance work is appallingly slow.

The inspector cited huge areas of neglect over many decades and pointed out that corridors were in poor condition, with plaster falling off walls and so on. There was a recent breakdown in the water and heating systems, all of which points to appalling neglect leading to utterly disgraceful conditions in which people have to work and live. I hope this Bill will provide the necessary political impetus to resolve these problems.

Unit H in St. Ita's was built at the turn of the century in a context more reminiscent of the concept of bedlam where people were packed in and forgotten about by society. There are still 20 people with severe learning disabilities living in one dormitory and day room in this unit. These are very difficult conditions in which staff and clients have to live and work. The former Minister, Deputy Cowen, visited St. Ita's and that was appreciated. The present Minister should also make time available to see the conditions in this hospital and address them based on his observations.

I welcome many of the developments which have taken place. Services provided in the community sometimes meet with fear on the part of members of the public who are not aware of the service being contemplated. For example, a 30 bed unit has been opened in Oldtown, north County Dublin. This unit is working very successfully and has five or six bedrooms with staff and day care facilities which also help people in the community. This is a positive side of improvements in mental health services which, unfortunately, is counterbalanced by atrocious neglect and under investment which must be recognised.

The work of many voluntary organisations often goes unrecognised by people apart from those directly involved. It is important to commend organisations such as the Fingal Mental Health Association, St. Michael's House and Pat Reen in the Fingal workshops in Skerries and Rush. These people carry out very important work and help families who would otherwise be in a very dejected and despairing way given the weight of their responsibilities.

I support the development of an Order of Malta proposal for a day activity resource centre in Balbriggan. This project will require considerable Government support which I hope will be forthcoming. The project has been successfully proposed and negotiated and I wish it success.

Mild and severe depression permeates all aspects of society and most families are affected by it in one way or other. This is the area of mental health which has been clouded in mystery and stigma. The work of Aware has been very important in trying to overcome many of the misconceptions and misunderstandings in this area. In this context, the Minister should look again at the decision of the Irish Medicines Board by which St. John's wort may only be sold under prescription. This is not a cure-all or a treatment but it is important for people suffering mild symptoms of depression.

One Opposition Deputy who is a member of the health committee expressed shock, not at the medicines board's decision but at the number of people using St. John's wort. This indicates that the issue of mild depression is more widespread than many people recognise. Perhaps it is important that this Deputy was shocked into realising this fact and the Irish Medicines Board may have performed an inadvertent service by bringing this issue to people's attention. However, this decision was taken hastily and without regard to the seriousness of other issues such as the use of organophosphates which is still awaiting a decision. Organophosphates are far more dangerous substances than St. John's wort and are used as a sheep dip. However, the two warrant comparison.

There are a number of details of the Bill which need to be discussed. Some of these are minor issues but others are of major consequence to some groups. I question whether we should title the Bill the Mental Health Bill with all the stigma and negative baggage which accompanies the terminology. The areas of the Bill about which I am concerned are the inclusion of mental handicap, the use of the Garda Síochána, the lack of advocacy services, the prospect of the commission's success, the Inspector of Mental Hospitals and the issue of consent.

Section 3 of the Bill deals with mental disorder, and inclusion of the term "significant mental handicap", now called intellectual disability, is not appropriate for the care and treatment of people in this group. Significant mental handicap can be used to include those with a mild mental handicap who live and work in the community setting, as opposed to the institutional settings into which they were first put. Mental handicap has historically been associated with, and is born of, mental illness, its terminology and treatments. However, one is born with a mental handicap and needs the ethos of family support and care throughout life, unlike those with a medical condition.

One is not born with a mental illness and this Bill provides for the care and treatment of specific mental illnesses. The core treatment of a psychiatric disorder or mental illness is not compatible with the care of people with a mental handicap, no matter how significant. Even today we find the inappropriate placement of people with a mental handicap in mental hospitals, 300 at present, and an over use of drugs on people with mental handicap. People included under this Bill will end up as patients in a medical model of care with reception, detention, diagnosis, treatment and cure. Other groups will find themselves wrongly termed as mentally ill.

The power of the Garda Síochána to take a person believed to be suffering from a mental disorder into custody is found in a number of areas. How are gardaí to know what a mental disorder is? Will this be done with the help of an officer qualified in psychiatric illness and training? The level of stigma and negative labelling attached to the arrival of gardaí at a house or workplace does not help in the care and treatment of a person with a mental illness who will have to live and work in those same places after treatment. The use of gardaí in the removal of a person to an approved centre needs to be detailed and changed so that the criminal associations have the least impact on the community standing of families and individuals.

The use of the Garda highlights the lack of community assistance in this area. Is it necessary to use the Garda to deal with a person who has a mental illness?

The lack of advocacy services is important. While admission, referral of admission, review of admission, input from the commission and appeal to the courts are provided for, the lack of advocacy services is a serious shortcoming in the Bill. The lack of provision for such services is a serious deficit in an area where people might be detained against their will, even with the greatest of legal intentions. Independent advocacy services should exist in mandatory institutions, approved centres and similar services, as was recommended in the report of the Commission on Disability in 1996. The mental health commission to be established by this Act may not be strong enough or independent enough to protect at a very basic level. Advocacy needs to take place at a very personal level, one to one, with no strings attached.

I wish the new commission every success. Having had an inspector of mental hospitals from 1945 to the present day, and having seen the obvious failure in maintaining any type of standard, one can only hope an inspector of mental health services employed by the proposed mental health commission will change that. In England there are many non-statutory health groups which lobby for services. It may be argued that in the absence of such a strong lobby in Ireland, some form of non-statutory group participation is necessary in mental health. This is similar to and should be viewed alongside the need for independent advocacy services in mental health.

The definitions in the Bill are unacceptably vague, they are open to subjective interpretation. More detailed guidance on each of the criteria is needed to deal with modern influences. The inclusion of "mental health" is an infringement on the rights of this group of people and upholds the stigma with which they must live. This definition of certain psychiatric problems is used generally by the media; it should be more strictly defined.

I hope the Minister for Health and Children will take up the invitation, as his predecessor did, to visit St. Ita's to see how it operates and the needs it has. The proper funding of such an institution, so it can put behind it the many decades of neglect which are still evident, would be a measure of our commitment to improving mental health services.

Minister of State at the Department of Health and Children (Ms Hanafin)

This legislation has been a long time in the making and will place services for people with mental health problems in a modern framework. People who need psychiatric treatment may need it in their own interests or in the interests of others and this Bill gives us a model by which such people can be looked after. It will ensure the civil and human rights of people who receive psychiatric care and treatment are fully respected and that the highest international standards and norms are followed.

As Minister of State with responsibility for children, I am concerned about mental health and the young. Children are one of the most vulnerable groups in society, particularly in cases of social disadvantage or domestic tragedy, where the child concerned is sometimes left without a parent or guardian willing or able to speak up for him or her. I am pleased the Bill sets out provisions which will ensure that such children, if they are suffering from a mental disorder, will get the care and treatment they need.

Anyone who has dealt with adolescents and children will be conscious of the rates of para-suicide and suicide among the young. There would be very few teachers who have not come into contact with a young person who has threatened suicide or who has succeeded in taking his or her own life. It is tragic to see the suicide figures for children and adolescents. It is the most common cause of death for people aged between 15 and 24 years, more prevalent than cancer or road accidents. That is a cause for concern.

One could only be horrified to see that in 1998, 53 of those who took their own lives were aged between ten and 19 years, 52 of whom were aged between 15 and 19. It is a complex issue and it is difficult to understand why anyone would go down that road. There are factors such as depression and anxieties but such traits must be added to a person's ability to cope. There are other contributory factors. Studies have shown that background and family circumstances are an influence in this traumatic event.

I am particularly worried about the 15 year old to 19 year old age group. The one thing all 15 to 19 year olds have in common is the pressure on them to succeed, be that in examinations or in front of their peers. We should ask ourselves if we are making young people believe, in a time of economic success, that such success is the all important goal. We must teach people that trying is important, that is not necessary to be the best but to be the best a person can be.

Each case is different. Each child who takes his or her own life is a complex person and the more information we have about this issue, the better we will be able to help these young people, particularly young men.

Para-suicide is a cause of concern and money has been made available to conduct research into the issue. A para-suicide, be that person making a definite attempt to take his or her own life, or where there is no intention of doing so, is 20 times more likely to succeed eventually in taking his or her own life. We must pay attention to young people who try to overdose on medication or alcohol or lacerate themselves. That is a cry for help and we must learn how to respond to it.

The Mental Health Bill is concerned with a small group of people who enter the system for treatment and care. The Act defines children as being under the age of 18, unless the person is or has been married. This definition is consistent with that contained in the Child Care Act, 1991. In the existing legislation governing the mental health services, the Mental Treatment Act, 1945, all persons over the age of 16 are treated as adults. By classifying people between 16 and 18 as children, this Bill will significantly strengthen the safeguards surrounding the involuntary detention of people in this age group.

A key principle recognised by the Government in the care of all people with a mental disorder is that the least restrictive form of care should be provided wherever possible. The treatment of psychiatric problems in children and adolescents takes place mainly on an out patient basis and in the community. In a small number of cases, however, children and adolescents may need to be admitted to a hospital for treatment of serious conditions. Under the Mental Treatment Act, 1945, the admission of persons under 16 years of age to psychiatric hospitals or psychiatric departments of general hospitals is limited to voluntary admissions on the application of the person's parent or guardian.

There is general agreement among those familiar with the mental health services that the existing provisions are not adequate to meet the needs of children aged 12 or older who may require treatment for a mental disorder and who may have no contact with their parents or who may not have a parent who is prepared to apply for their admission to hospital.

The Government recognises that the vast majority of admissions of children to psychiatric in-patient facilities will continue to be initiated by the child's parent or parents. It is also recognised that in such circumstances formalities should be kept to a minimum, on the model of a child's admission to a general or a children's hospital. There is a need, however, in exceptional cases for a procedure to allow for the admission of children or young persons to appropriate centres without parental consent.

The Child Care Act, 1991, enables a court to make a care order where the court is satisfied that the child requires care or protection, which he or she is unlikely to receive unless he or she is placed in the care of a health board. While a health board would have the authority to give consent to any necessary psychiatric examination, treatment or assessment with respect to a child who is the subject of a care order under the Child Care Act, it was never intended that this provision would be used as the procedure for the involuntary admission of children for psychiatric treatment. That is why we have included such provisions in this Bill.

The Government recognises that provision for the admission of children without the consent of parents or guardians needs to be made for a small and exceptional number of children with a mental disorder who fulfil the criteria for involuntary admission as set out in the Bill but whose parents or guardians are unable or unwilling to give consent. Such children include those suffering from severe depression, schizophrenia, psychosis or a significant mental handicap who may be a danger to themselves or others and who need treatment in an approved centre. The Government is also aware that there is a constitutional presumption that the welfare of a child is to be found within the family unless the courts are satisfied that there are compelling reasons this cannot be achieved.

Accordingly, this Bill makes provision in section 24 for the admission for treatment without parental consent of a child who meets the criteria for involuntary admission set down elsewhere in the Bill. In the exceptional circumstances where parental consent to the child's admission cannot be obtained, the health board concerned may make an application to the District Court for an order authorising the child's admission. This procedure is in keeping with the approach adopted in the Child Care Act, 1991, in relation to children at risk.

Section 24 empowers the court to direct the health board concerned to have the child examined by a consultant psychiatrist and to have the report of the examination submitted to the court. If the report of the consultant psychiatrist confirms that the child is suffering from a mental disorder, the court can make an order for the child's admission and detention for treatment. The initial court order will be for a period of 28 days and may be renewed by the court for periods of three months, six months, 12 months and annually thereafter. These time limits are the same as those that apply to adult admission orders elsewhere in the Bill.

Section 24(6) is another important provision. It allows the court to give directions as it sees fit on the care and custody of the child during the period when the application is under consideration. This will be a most important consideration in the case of a child or a young person who might be at risk of self-harm or of causing injury to other people.

The Bill contains a comprehensive framework in relation to children, which ensures that, in the exceptional cases, where parental consent cannot be obtained children and young people who are mentally disordered can get the care and treatment they need. In that respect, it is a most welcome addition to the considerable body of existing legislation that protects our children and young people.

The provisions of this Bill will affect only a very small number of children and young people. The treatment of psychiatric problems in children takes place mainly on an out-patients basis and in the community. There has been considerable investment in these services in recent years.

Additional revenue resources of approximately £3 million have been provided since 1998 to enable improvements in multi-disciplinary teams to be undertaken in the child and adolescent services. It is intended that these services will continue to be developed in the next few years. A draft policy document on the further development of mental health services for children and adolescents has been completed. The draft report sets out the objectives of child and adolescent psychiatric services, outlines the type of services provided, highlights issues that require resolution and puts forward recommendations for their resolution. These include the strengthening of multi-disciplinary teams and the provision of residential facilities for the various age groups from younger children to adolescents. The draft development plan was circulated to all health boards for their comments. The views received from the boards raise a number of matters which are being analysed and then the policy document will be presented.

It is important to ensure that a national strategy is put in place to ensure overall services in the area of child and adolescent psychiatric services are provided in a consistent and co-ordinated manner. The Minister intends to establish a working group with the participation of the chief executive officers of the health boards to finalise the development plan. The Department of Health and Children is currently in communication with the health boards in this regard, but in the interim the Department is in discussion in relation to the provision of residential care and adolescent facilities to meet urgent service needs.

The Bill makes important provisions in relation to a very small number of children and young people who require to be admitted involuntarily for treatment without parental consent. It is important that their needs and their rights are protected and met.

In relation to the broader sphere of child and adolescent psychiatric services generally, significant funds have been invested and with the establishment of the working group and the production of a development plan, we will ensure that the services will be further expanded. We need to promote positive mental health. We need to destigmatise suicide and to promote positive attitudes of support towards young people and their families. The Minister and I are committed to facilitating all of this as far as possible.

Mrs. T. Ahearn

I am pleased to speak on this important Bill. During my contribution on the Children Bill, 1999, yesterday I said that we were providing legislation for the most vulnerable children in our society, for whom, in many cases through no fault of their own, life is difficult and has little to offer. This Bill will provide for the most vulnerable people in our society whose quality of life depends not only on what we legislate for them in this House but far more importantly on the services and the back up facilities we provide for them.

We debated legislation this week to provide for two of the most important groups in our society, vulnerable children and those with a mental disorder. The two groups are interlinked in that many children who find themselves before our courts or in trouble with the law end up in our mental institutions, although that is not always the case. I welcome the Bill which deals with standards of care and treatment in our mental institutions. I am pleased it provides that the standard of treatment and care will be monitored, inspected and regulated.

It is regrettable that we debate this Bill under the shadow of 700 psychiatric nurses in hospitals and day centres across the state beginning industrial action over a failure by the Government to agree a promised rate of pay. According to one of today's newspapers, under their work to rule, which will continue for one month and then be reviewed, the nurses in promoted grades are refusing to answer telephones, attend meetings and carry out clerical and administrative duties. One might ask what that has to do with this Bill. I raise it because this Bill is about people with mental illness. For that reason I plead with the Minister to take steps immediately to resolve this dispute because he knows as well as I that patients will lose out as a result of it.

That is not the intention of those in dispute. However, it is what will inevitably happen if the dispute is not terminated. These patients cannot make progress in an unsettled environment where workers are disenchanted and disillusioned with their conditions. The seeds of serious discontent are now sown and it is vital that immediate steps are taken to resolve the difficulty, which I understand relates to a breach of commitments given during the settlement of the nurses' dispute last October. I raise this issue because it has an effect on patients with mental illness.

The Bill speaks about the care and treatment of those will mental disorder. However, the Bill does not deal with the most important need in mental health care, that is, the physical standards and lack of resources in mental hospitals. It is easy for any Government to draft legislation and preach about its aspirations and the spirit of its intentions, but when it comes to directing finances at certain issues, we come up against a stumbling block. I raise this issue in the context of a newspaper article yesterday which stated that the Minister for Finance will once again have to cope with an additional £500 million in the Exchequer in the first three months of this year. This is what is required to deal with the crucial issues of the physical environment, structure and resources within mental hospitals. No matter how well intentioned the Bill is – I agree with its spirit and aspirations – it will all be pointless unless the physical environment within institutions is changed.

It is to our shame that many institutions which care for mentally ill patients are in a shocking and disgraceful condition. I have met with families of patients who find visiting these institutions distressful and upsetting, not because of the nature of their relatives' illness but because of the environment in which their loved ones are compelled to live. These people have no complaints about the staff or quality of care but about the appalling conditions in which they find their relatives, friends or loved ones. Their inability to do anything about this issue is soul-destroying because they know, as the Minister and I do, that the public is not fully aware of these appalling conditions.

We accept these patients cannot seek good conditions or speak for themselves, therefore, they need others to speak on their behalf. Is it the case that nothing will be done in this regard because those who are most affected by the conditions cannot protest? It is an appalling indictment on all of us that the most vulnerable in society, who cannot speak for themselves, are not our priority. It is an even more shocking indictment on us that these appalling conditions exist at a time of excessive financial resources. The staff in these hospitals and institutions do a wonderful job given the appalling conditions under which they work, for which they deserve our congratulations and gratitude.

The Mental Health Commission proposed in the Bill will have a huge responsibility. It will have a major obligation to ensure the spirit and aspirations of the Bill in relation to the treatment and care of those who suffer from mental illness are achieved. The Minister in his speech stated that the commission's primary function will be to promote and foster high standards and good practice in the delivery of mental health. This is not good enough. The commission's responsibility should be not only to promote and foster, it should be to ensure and guarantee proper treatment, care, facilities and physical resources for those suffering from mental illness. Any commission can say it did its best to promote and foster excellent care and treatment but the acid test is whether it was delivered. One cannot provide excellent care and top class treatment if the physical environment is wrong.

I hope on Committee Stage of the Bill the words "promote" and "foster" will be replaced by "ensure" and "guarantee". The Bill must include strong language because many aspects of our mental institutions depend on the Bill guaranteeing what is fundamentally necessary. Change and modernisation will not be achieved if we operate on the basis of just promoting and fostering high standards. Our approach must be stronger and much more definite. In other words, I ask the Minister to ensure there is zero tolerance of anything other than the highest standards, best quality care and improved and modern physical conditions for patients with a mental disorder. We often use the term "zero tolerance" but it should be used in the Bill because we should strive for zero tolerance of anything other than the best for these patients.

Care is not just medical, it must be all-embracing. For that reason, we must do much more research into the lives and daily routine of those with mental disorder who are, unfortunately, confined to mental institutions. There should be activities for these people and we should not allow them to be idle. Their days should be fulfilling and regulated and they should be provided with activities and programmes to which they can aspire. It is not good enough to just provide them with a roof over their heads, with medical treatment or supervision, they must be given a quality of life. Every patient, irrespective of their disability, can obtain satisfaction from something. I ask the Minister for Health and Children to put major emphasis on the quality of life of these patients. This cannot be done by just providing medical treatment, care or sufficient staff, they must be steered towards and provided with positive activities.

I have met many families of people who suffer from mental illness whose stories are very sad, not just because of the illness of their relatives but because visits to them have become a very tough undertaking. Many say that in many mental institutions there is not even a proper room where they can meet their loved ones. The facilities we would consider normal and expect in hospitals and long-term centres are not available in many mental institutions. Families and patients cannot avail of family gatherings or one-to-one conversations in pleasant surroundings in these institutions. This issue must be examined.

I welcome the community based approach to mental illness. Thankfully the day is long gone when people committed to a mental institution were left there to become institutionalised and totally cut off from society. The community based approach is excellent and in most cases works well. The aim at all times must be to get that person to a posi tion if possible, and in many cases it is possible, where they can survive with a certain amount of support and care within a community framework and lead as near a normal life as possible.

In my constituency the health board has bought a residence within residential estates where people can live in a normal environment with support. Sadly there is not sufficient consultation with the local communities. Anybody of right mind would be in favour of community based care for mentally ill patients but they also want assurances and guarantees. The health board should approach this matter openly. Often there is far too much secrecy. After the residence is bought somebody in the housing estate will discover it has been bought for the health board. Rumours start and escalate and before long a group is organised to protest. That is not the true nature of the Irish people. These protests develop because of a feeling of insecurity and the secrecy through which our health boards work when acquiring such premises. That is the wrong approach and I am currently dealing with such a case.

Communities would welcome this type of community based approach if they worked as partners with the health board to ensure the facility works well not only for those who will live in the residence but for the community and their children. Old attitudes die hard. Unfortunately there are still remnants of fear about what will happen. There is no need for this and it could be avoided if there was proper consultation with the community as equal partners. I ask the Minister to raise this matter with health boards given that more residences will be bought in housing estates. It is important to start on the right note. Once there is argument and dispute it is more difficult to resolve the issue than had the right approach been adopted from the first day.

It is important that mental hospitals are used for the purpose for which they are intended, that is, for people with a mental disorder. The treatment, care and regime in those hospitals is for such persons. It is sad to read in the newspapers that a judge, in desperation, has nowhere to put a person with a social disorder except into a mental institution. That is wrong and is as near to a crime as one can get. We do nothing for people with specific problems if we do not have institutions to deal with their particular disorder. It is not good enough to lock them away from society. That is only fostering and encouraging further trouble. Mental hospitals are for persons with a mental disorder and must not be used as detention centres or refuges for those who should not be allowed out either for their own good or the protection of the public. The practice of using mental institutions for such problems should neither be accepted nor allowed.

I am pleased the Bill is patient centred. Too often Bills deal with regulations and formalities and forget the people for whom the service is being provided. I am pleased a patient has a right to agree to treatment, that the involvement of the family is guaranteed and that any decision taken by a consultant psychiatrist to detain a person involuntarily for psychiatric care and treatment will be reviewed by an independent body. I hope we will never again see the day when people will face a life sentence in a mental institution.

I congratulate all those working in the area of mental health, particularly those in the mental institutions in my constituency – St. Luke's Hospital, Clonmel, and St. Michael's Hospital. Every Minister, when visiting a constituency, would do well to call to hospitals that deal with a mental disorder. I do not mean a visit where the meeting takes place in the parlour – with flowers on the table – with senior medical personnel and staff but a visit to the wards to speak with patients. They should get out to the corridors and into the rooms, day centres and the garden and see what is happening there. The Bill will be useless unless there is a huge improvement in the quality of care.

Mr. M. Kitt

I agree with Deputy Ahearn regarding ministerial visits to health board regions and to psychiatric and geriatric hospitals. Successive Governments and successive Ministers have taken an interest in this issue and have visited health boards. I look forward to many more visits by the Minister and Ministers of State to hospitals and day care centres in the Western Health Board region.

I welcome the Bill and congratulate the Minister and his Ministers of State on the work they have done in the area of mental health. The Minister said the existing office of Inspector of Mental Hospitals will be replaced with the office of the inspector of mental health services. The inspector will be employed by the new commission. This reminds me of many meetings I have attended of the Western Health Board where long debates took place on the report of the Inspector of Mental Hospitals. The one fault with the reports was that they were often debated three or four years after the inspection had taken place. I hope the new office will ensure inspections and early reports and early debates on the visit by the new inspector of mental health services.

Some of the policy put forward has been taken from the policy document, Planning for the Future, published in 1984. That document was the blueprint for the development of a modern mental health service and has been accepted by successive Governments as the basis for mental health policy. One of the key recommendations of that document was the development of an integrated community based mental health service to replace the traditional model of care which relied predominantly on in-patient treatment in psychiatric hospitals. A further document, Shaping a Healthier Future, outlined the objectives of promoting mental health, restoring the mentally ill to as independent a life as possible, ensuring that mental health care is comprehensive and integrated with other health services and providing services within the community in sectors close to those being served. I welcome the overall thrust of the Minister's policy contained in those documents.

In line with these objectives, health boards have made considerable progress in providing acute psychiatric units at general hospitals and in setting up day hospitals, day centres and community residential accommodation. These community based services will ultimately replace services which were previously provided in psychiatric hospitals. There were once more than 1,000 patients in St. Brigid's Hospital, Ballinasloe. Over the years that number fell. It passed the landmark figure of 500 and in recent years the figure has dropped even lower. It is widely accepted that community based services provide a more comprehensive service for patients and a much improved quality of life for people who formerly were patients of psychiatric hospitals. The Minister has referred to the fact that the number of patients in psychiatric hospitals and acute units continues to fall. At the end of 1998 there were 5,101 such patients, which is a decrease of 9% on the 1996 figure.

Community care is not always the most appropriate method of care, and in-patient treatment is provided in acute psychiatric units for people who need it. In conjunction with the development of comprehensive community based services, acute psychiatric units attached to general hospitals are being developed to replace large institutions built in an era when psychiatric care was almost entirely limited to in-patient care. There are now 17 acute units attached to general hospitals throughout the country. In-patient care is also being provided in psychiatric hospitals. The proportion of patients being admitted to general hospital units rather than to psychiatric hospitals continues to increase and in 1998 it accounted for one third of all admissions.

In some cases alcoholism cannot be dealt with on a day care or community care basis. In expressing my view that residential care is sometimes needed by a person who has a problem with alcohol, I have occasionally clashed with the Western Health Board. It is sometimes necessary to take such a person out of the home or community environment in order to help his or her recovery in an alcohol treatment unit. We have such a unit in St. Brigid's Hospital, Ballinasloe, where the care and attention given by the staff is second to none. The best people to judge the success of these units are patients who have been treated in them and are now able to cope with their illness and talk freely about the service they have received.

The Minister has spoken of the priority now being given to the improvement of our mental health services and of the funding to be provided. He mentioned the provisions of the Bill and the development of acute psychiatric units associated with general hospitals. I welcome the provision of community based services such as mental health centres and community residences. Many small towns are examining the possibility of establishing appropriate centres and residences for people who have suffered from mental illness. One such town is Mountbellew in County Galway. The Minister also referred to the greater concentration on the rehabilitation of patients, many of whom are elderly, who have been in long-stay wards of psychiatric hospitals for many years. I pay tribute to the Minister of State, Deputy Moffatt, for his work in providing services for the elderly.

To ensure that the pace of development of these services is accelerated an additional £12.2 million was allocated to the mental health service for the year 2000. This represents an increase of more than 100% on the additional funding provided in 1999. A sum of £2.5 million is being provided in the current year to meet the cost of setting up the Mental Health Commission.

This week the House discussed the Children Bill and we recently discussed the Education (Welfare) Bill, both of which are concerned with the welfare of children. It is important that we give priority to the question of child and adolescent psychiatry. There is a need to improve our responses to the mental health needs of children and young people. The Minister has provided an additional sum of £1.378 million in 1999 and a further £1.1 million in the year 2000. This will broaden the child and adolescent psychiatric services by supporting the recruitment of additional consultants and the further development of multidisciplinary teams. Steady progress has been made in developing a specialised service for this client group and each health board now has a dedicated child and adolescent psychiatric service headed by a consultant psychiatrist.

It is important that services are provided as near as possible to the homes of parents or guardians of children receiving treatment. There is no point in having children travel long distances for psychiatric services. Where travel is unavoidable it is imperative that escorts are present on transport for young psychiatric patients and proper safety measures, including safety belts, are provided. There is a need for further development of the child and adolescent psychiatric services. The Minister has said that a policy document is being prepared which will include the identification of areas of particular need. The main shortcomings relate to the lack of in-patient facilities, particularly for adolescents, and priority is being given to this problem as part of the national development plan.

The Minister of State, Deputy Moffatt, is dealing with the question of services, particularly psychiatric services, for the elderly. Old age psychiatric services have been expanding in recent years and the integration of community and hospital based psychiatric services with services for older people is progressing. Additional funding of £3.125 has been provided since 1998 to establish these specialist services in health boards where no service existed heretofore. Schemes such as community alert and neighbourhood watch are very important and the Minister of State's promise to provide fire alarms and security systems for elderly people will be very welcome, particularly in rural areas.

The Minister also referred to the question of suicide and Deputy Dan Neville has spoken about this issue on many occasions. The health strategy, Shaping a Healthier Future, expressed concern at the rate of suicide. In November 1995 a national task force on suicide was established to address the growing prevalence of this tragedy in our society. In September 1996 the task force published a detailed report which contained a detailed analysis of statistics relating to suicide and attempted suicide in Ireland, and a preliminary analysis of the factors which could be associated with suicidal behaviour. The report identified young males aged between 15 and 24 as a suicide risk group.

There has been a positive and committed response among statutory and voluntary agencies to finding ways of tackling this tragic problem. A suicide research group has been established by the chief executive officers of the health boards and resource officers have been appointed in all health boards with specific responsibility for implementing the recommendations of the task force. A sum of £1 million is being provided this year towards a suicide prevention programme in the health boards and research aimed at improving our understanding of the issue. Having information on the groups at highest risk of suicide is seen as a key factor in a suicide prevention strategy. International studies have found that para-suicide is a significant risk factor. Accordingly, £200,000 is being made available this year for the establishment of a national suicide research foundation in Cork and a national para-suicide register.

I was very interested in what the Minister had to say about rehabilitation programmes. He stated that some patients in psychiatric hospitals have been in institutional care for many years. To transfer such patients to a more appropriate care setting in the community a programme of rehabilitation is necessary. The establishment of a dedicated rehabilitation team for planning the future of long-stay patients was recommended by the inspector of mental hospitals in his report for 1998.

The Western Health Board is establishing such a specialist team at St. Brigid's Hospital, Ballinasloe with additional funding provided by the Department. If this pilot project is successful I understand a similar approach will be considered for other hospitals. This is a welcome development and, in conjunction with the acute admissions unit at Portiuncula Hospital, will be of great benefit. Portiuncula Hospital has also received £6 million for other developments. The Western Health Board is assuming responsibility for services at St. Brigid's Hospital from the Franciscan Order. I hope it will be as successful in its efforts in what will now be a public hospital.

I commend the Minister on what he had to say about community services. The growth of alterna tives to hospitalisation must be accelerated through the development of further community based services. An additional £8.4 million revenue funding was provided for the period 1998 to 2000 for the enhancement and development of community based mental health services. This has been used in the main to provide additional medical, paramedical and nursing support staff and to fund improvements in psychology and social work services and the continued development of multidisciplinary teams.

Substantial progress has been made with the establishment of new mental health centres, day hospital and other day facilities in recent years. Additional community based residential accommodation has also been made available. For example, in 1994 the number of community residences was 368 providing 2,685 places. This increased to 386 in 1998 providing 2,871 places. In the same period the number of day hospitals and day centres increased from 159 to 176.

A sum of £150 million capital funding is being provided over the lifetime of the national development plan for mental health services. This will enable the provision of further acute psychiatric units attached to general hospitals and accelerate the provision of additional community based services. The Minister listed the units which are at various stages of development. They include Portiuncula Hospital. A further four acute psychiatric units are under consideration in Dundalk, Wexford, Mallow and Mullingar. The aim of the programme is to provide accessible treatment facilities of high standard and to phase out admissions to older large scale psychiatric hospitals.

The Bill contains a section dealing with the involuntary detention of persons for psychiatric care. The Minister is to reform existing legislation to bring Irish mental health law into conformity with the European Convention on the Protection of Human Rights and Fundamental Freedoms. The provisions of the Bill relate primarily to those patients who require in-patient treatment. The majority of in-patients in acute psychiatric units attached to general hospitals and psychiatric hospitals were admitted voluntarily. Due to the nature of some psychiatric illness however it is sometimes necessary to detain a small number of patients involuntarily for their own protection and that of others. In 1998 there were almost 26,000 admissions to acute psychiatric units and psychiatric hospitals. Of these 2,500 were involuntary. One of the objectives of the Bill is to ensure involuntary detentions only occur when absolutely necessary and are of minimum duration. Another is to ensure the highest standards and best practices are observed in the delivery of all mental health services. To this end the Bill provides new and improved safeguards for psychiatric patients, particularly those admitted involuntarily.

I welcome the establishment of the commission and the fact that the inspector of mental hospitals will be replaced by an inspector of mental health services who will be required to visit and report on each centre at least once a year.

There have been complaints in the past about the quality of buildings in the Western Health Board region. There is one building where renovations are taking place, that is, the Alzheimer's unit, unit 17, St. Brigid's Hospital, which has a hard-working staff. The board is now looking at funding a unit such as the one in Ballindine which was opened by the Minister of State, Deputy Moffatt, and where John Grant is doing tremendous work. Many units in the east have been funded. To ensure a regional balance it is important that similar units are provided in the west.

I commend the Minister on introducing the Bill which I wish a speedy passage through the House.

Minister of State at the Department of Health and Children (Dr. Moffatt)

I thank all the Deputies who contributed to the debate. There is broad agreement on the need for reform of existing mental health legislation. A wide range of issues have been raised in relation to the Bill and the mental health services in general. It is the Minister's intention to respond to each of these in detail on Committee Stage.

In light of the contributions which have been made on the focus of the Bill it is important to reiterate two important points made by the Minister. The Bill will provide a modern framework within which persons who are mentally disordered and need treatment or protection either in their own interest or that 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. This is an important advance and one which will bring mental health law fully into line with our international obligations.

Some of the comments made since the Bill was published in December have failed to recognise that it deals with much more than involuntary admission. It will put in place mechanisms by which the standards of care and treatment in 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 by the office of the inspector of mental health services who will be employed by the commission. The commission and the inspector will operate independently of the Minister for Health and Children and the Department. This independent status will be crucial in driving the agenda for change and modernisation in the mental health services in coming years.

I wish to refer to a number of specific issues raised during the debate. Reference was made to issues raised in the 1995 White Paper and not included in the Bill. With regard to making provision for mentally disordered persons who are wards of court, I am pleased to inform the House that officials of my Department are currently in active discussions with the Registrar of the Wards of Court with a view to preparing proposals which could be included in the Bill before it completes its passage through the Oireachtas.

The issue of adult care orders, which were proposed in the White Paper in 1995 and alluded to by Deputy Shatter, needs further assessment following experience gained in other jurisdictions. Another area not included in the Bill is the treatment of mentally disordered people before the courts and in custody. This is an extremely complex issue which will take some time to resolve. It involves other Departments and agencies. I thank Deputies for their contributions.

Question put and agreed to.