Dáil Éireann debate -
Tuesday, 10 Jun 2003

Vol. 568 No. 1

Private Members' Business. - Mental Health: Motion.

Mr. Neville

I move:

That Dáil Éireann:

– noting the recent critical reports on the treatment of people with mental illness by Amnesty International, the Irish Psychiatric Association and the Inspector of Mental Hospitals;

– concerned that Irish mental health policy and service provision remain out of step with international best practice and that the institutionalisation of the mental health services in Ireland has failed to live up to World Health Organisation standards;

– believing that the high admission and re-admission rates to psychiatric hospitals are due in large measure to the lack of community based facilities;

– concerned at the lack of dedicated psychiatric facilities for adolescents, the lengthy waiting lists for treatment and the lack of consistency in the provision of mental health services throughout the country; and

– deploring the fact that people with intellectual disability continue to be inappropriately accommodated in psychiatric facilities in violation of human rights law; condemns the Government for its neglect of the mental health sector and failure to vindicate the human rights of people with mental illness and for the reduction in the percentage of the health budget spent on mental health and calls on the Government to immediately bring forward a comprehensive package of measures, including appropriate finances, to provide:

– a comprehensive, needs-based, service-user-led review of the mental health care services, promptly and fully implemented, ensuring that they meet international human rights standards and best practice in line with the World Health Organisation 2001 annual report, with an emphasis on community-based care;

– regular quality research in all areas of mental health care needs and service provision, an essential prerequisite for the development of a quality service;

– full financial provision for all areas of mental health care;

– all necessary resources and assistance for the Mental Health Commission in its securing adequate care and conditions for people with mental illness;

– effective action on all relevant recommendations made in the reports of international treaty-based committees, annual reports of the Inspector of Mental Hospitals, and Government reviews and reports;

– a comprehensive system of personal advocacy and an effective complaints procedure to ensure that people with mental illness are assisted in exercising the full range of their rights;

– specialised mental health care for all who need it, including children, the homeless, prisoners, people with other forms of disability, Travellers, asylum seekers and refugees, and other minority or vulnerable groups;

– a public education and awareness campaign to counter the stigma of mental illness, emphasising the rights of people with mental illness; and

– rights-based disability and mental health legislation to give full effect to its international human rights obligations, with due regard to its obligation to enable persons with disabilities to exercise their rights on an equal basis with other citizens.

I welcome the opportunity to introduce this motion and welcome the Minister of State and fellow Limerick representative, Deputy O'Malley, who has responsibility for mental health services. Mental health is one of the most neglected areas of the health services. The Minister for Health and Children has chosen to ignore the great stress, pain and suffering caused by the scandalous lack of resources to deliver a semblance of a mental health service.

Society will be judged on how it protects and deals with its weakest members. Surely among the weakest are those with a psychiatric illness. The State practically ignores them and the mental health services are neglected. I will develop this argument in the course of my speech. I ask the Minister of State to deal with the issues rather than, as his civil servants often suggest, give us a history lesson.

John Saunders, director of Schizophrenia Ireland, has stated:

Mental health care services are in crisis, characterised by decreasing funding, inequitable distribution of resources, antiquated and poorly maintained facilities and poor community support services. This has lead to a situation of low staff morale, insufficient treatment and care programmes and higher involuntary admission rates to hospital.

The internationally respected psychiatrist Professor Anthony Clare stated:

The mentally ill are now the most systematically stigmatised group in our society. They . . . are the lepers of today.

We call on the Dáil to support our motion condemning the Government's neglect of the mental health sector and its failure to vindicate the human rights of people with mental illness. I sincerely welcome the Amnesty International report Mental Health – the Neglected Quarter, which has strongly voiced its concern at the inattention paid by the Government to a series of national and international reports critical of its failure to fully respect the human rights of people with mental illness.

Irish mental health care policy and service provision does not comply with the best practice. This report is one of the most comprehensive investigations and examinations of the mental health services and is a bible for anybody interested in this area. I again congratulate Amnesty International for putting in the time and resources to produce such an excellent report and for making 2003 its year for campaigning for those with a mental illness.

Amnesty International is clear where the responsibility lies. It states that "ultimate responsibility for compliance with international law lies with the Government, not with the individual Government Departments, health boards, Civil Servants or service providers". The House must recognise that the systematic discrimination against people with mental illness is an abuse of their human rights. The United Nations principles for the protection of persons with mental illness and for the improvement of mental health care, known as the M1 principles, were adopted in 1991. These apply to all persons with a mental illness, whether or not in in-patient psychiatric care. They state that all persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person and shall have the right to exercise all civil, political, economic, social and cultural rights as recognised by the universal declaration of human rights.

It also provides that all persons have the right to the best available mental care. The Government is failing to provide this. In fact, Amnesty International has identified seven international treaties of which the Government is in breach. It is a disgrace that the human rights of those with mental illness are not being protected as a result of neglect over decades of the need to invest in facilities for those who have mental illness. The Government has failed to introduce a rights based disability Bill, which is the key to ensuring that the rights to which I have referred are implemented by law.

Prior to the last election an unacceptable Bill was introduced which was not rights based. We were informed in the Dáil that a short period of consultation would take place and an amended Bill would be introduced. One year later, on 13 May, the Taoiseach stated in the Dáil, in response to my question, that "It is the view of those who are authorities on this issue that the Education for Persons with Disabilities Bill should be brought forward and passed first". This was repeated today to Deputies Rabbitte and Kenny. This is an affront to our intelligence and is a recipe for burying the Bill indefinitely.

It is fairly well known that the Minister for Justice, Equality and Law Reform, Deputy McDowell, is not in favour of rights based legislation. Such legislation would force the Government to face up to its responsibilities to the 1,711 individuals living at home with intellectual disabilities who require full time residential service, 861 who require a day service and 1,014 who require a respite service and are being denied. The Government should come clean with these people and their carers and tell them the truth.

In general, our treatment of people with disabilities is often at variance with international standards. The UN Committee on Economic, Social and Cultural Rights, in its 2002 concluding observations on Ireland, noted "the persistence of discrimination against persons with physical and mental disabilities, especially in the fields of employment, social security benefits, education and health" and expressed concern that "the principals of non-discrimination and equal access to health facilities and services was not embodied in the recently published national health strategy".

It is a scandal that there are still more that 400 people with intellectual disability living in totally unsuitable conditions in long stay psychiatric hospitals. The inspector for mental hospitals has, over the years, pointed out the inappropriateness of this both for those suffering from an intellectual disability and those suffering from a psychiatric disorder.

We welcome the fact that the number of people in psychiatric hospitals at any one time has plum meted over the decades. In 1958 there were 21,075 in-patients in public psychiatric hospitals compared to about 4,500 at present. This has been largely due to a change in the approach to psychiatric institutions. In previous decades these were often used to overcome social difficulties and some people were in psychiatric institutions who nowadays would have no necessity to be long stay patients.

There was a certain view that once people had a psychiatric illness they were placed in a psychiatric institution and allowed to live out their days in the institution. Medical advances in the psychiatric area, society's greater understanding of the opportunity to treat those suffering from a mental illness and the policies of subsequent Governments to reduce these numbers have brought about the present situation. The reduction in in-patient psychiatric beds was largely due to the death of long stay patients and, to a lesser extent, to the community resettlement of long stay patients.

In the 1980s, the de-institutionalisation occurred with a move from placing people in large psychiatric hospitals to more a community based model of service provision. However, this process has met with some difficulties, with sufficient resources not being made available by the Government to ease the transition to community care. In 2001 the Health Research Board noted that "the number of admissions to psychiatric hospitals and units has changed little over the last 20 years. In all there were 24,282 admissions in the year 2000 and 70% of these were re-admissions. This exemplifies both the enduring or re-occurant nature of much major mental illness and the need for a greater expansion of community based alternatives to long stay hospital care".

In 2001, the World Health Organisation stated that the institutionalisation process had three essential components in preventing inappropriate mental hospital admissions, namely, the provision of community facilities, the discharge to the community of long-term institutional patients who have received adequate preparation and the establishment and maintenance of community support systems for non-institutionalised patients. Institutionalisation in Ireland has failed to live up to this standard. Ireland has excessively high admission rates to psychiatric hospitals, both voluntary and involuntary, due in large part to the lack of community-based alternatives. There is a shortage of acute beds for those in need of emergency admission due to inappropriate non-acute admissions of those who do not require emergency in-patient care because of the lack of appropriate alternative services.

The 1984 strategy, Planning for the Future, lists seven components of community care which are broadly similar to the WHO specifications. These include prevention and early identification, assessment and diagnostic treatment centres, in-patient care, day care, out-patient care, community-based residence and rehabilitation and training. The Minister must accept it is a disgrace that, almost 20 years after the publication of the strategy, none of these have been adequately provided. I call on him to immediately commence a comprehensive review of the mental health care services to ensure they meet the international human rights standards and those of best professional practice.

Fine Gael's programme, Health of the Nation, states that there is overwhelming evidence that psychiatric services concentrating on rapid response community settings are superior to more conventional services. It is Fine Gael policy to introduce a community-based early intervention service to provide a rapid response for patients with mental illness. This service will see patients in their houses, and other appropriated settings, including general practices, the community base, day centres, or, relatively rarely, hospitals. This will be styled on the hospice home service. The team will be multi-disciplinary including senior psychiatrists, psychiatric nurses, social workers, psychologists, and occupational therapists. The overall philosophy is to try to treat all mental disorders outside hospital in the first instance, with particular emphasis on joint working with other agencies.

While many people with mental illness will be best served by community-based care, for others admission to acute in-patient care is necessary and is the best available mental health care required by international law. In Ireland there is a shortage of psychiatric beds for acute admissions with the result that many are left waiting for the care they need or people in hospital are inappropriately moved. Mr. John Dolan of the Disability Federation of Ireland has stated:

People with mental illness continue to live in acute beds in mental hospitals for no reasons other than the lack of suitable accommodation for them in the community. People are remaining in long stay institutional care for far longer than they require. We continued to abandon people with mental illness in unsuitable and inappropriate institutions.

The 2001 report of the Inspector of Mental Hospitals, published in 2002, highlights that, in particular, older people, people with alcohol problems and homelessness are remaining in institutional care for longer than they require. The report states:

Currently close to 46% of persons in psychiatric units in hospitals are over 65 and in some instances, particularly among the long stay patients, this figure exceeds 50%. Many, but not all, of these older persons now show little sign of behavioural disturbance related to psychiatric disorder and, among the more elderly of them, in particular, their needs and disabilities relate to their age rather than to any psychiatric disorder. Their continued residence in long stay psychiatric facilities is neither appropriate nor best suited to their needs.

The report details a catalogue of substandard hospitals and units, overcrowding and poor living conditions and a failure to comply with the United Nations principles which provide for the right to privacy in patient care. The majority of patients interviewed by the inspector complained of a lack of privacy.

The report highlights a number of concerns. The physical health examination of in-patients, as documented in in-patients records, was often infrequent, desultory and superficial in nature. Given that psychiatric patients are known to enjoy poorer health and have higher mortality than the general population, it is particularly important that this be addressed, especially for long-stay patients in psychiatric hospital or community residence. The occurrence of sudden deaths in psychiatric in-patients due to asphyxia from the inhalation of food or other material, mainly in older patients, reveals a need to train staff in appropriate procedures in cases of foreign body airway obstruction and to provide the care necessary in feeding many older, feeble patients with poor swallowing capacity. Suicides among psychiatric patients at local level are not the subject of any formal audit, and there is a need for local services carefully to audit cases of suicide so that lessons may be learned to make risk assessment and management more potent and effective in the future.

I call on the Minister to immediately address these matters of concern to the inspector. Many of the long-stay institutions were constructed in the middle 1800s and many are totally inappropriate for modern day hospital standards and would be considered a national scandal if general hospital patients were being treated in such conditions. These substandard conditions are both an affront to the dignity of the patients and the working conditions of the staff. They are symbolic of a different era.

All psychiatric institutions in a poor state of repair should be closed down where practicable or refurbished where not. These should be replaced by modern purpose-built hostels for long-stay patients. Acute psychiatric units should be provided in general hospitals for patients in need of acute, short-stay treatment, or similar. Modern special secure facilities should be provided for the relatively small number of long-term, severely-disturbed patients. These changes should include the segregation of younger patients, functional psychotic patients and patients with intellectual disability so they do not share the same ward.

As many as 18% of the child population under the age of 16 will experience significant mental health problems at some period of their development, yet services in Ireland for them are very few. They are difficult to access and there are long waiting lists. The Royal College of Psychiatrists has noted that the lack of dedicated adolescent services reduces the child service ability to treat younger children so that waiting lists for child psychiatry services are lengthened further by the need to respond urgently to adolescents.

Many of the child psychiatric teams currently in place throughout the country do not have the full complement of team members. Psychiatric disorders increase in incidence and prevalence during adolescent years. The incidence and prevalence of deliberate self-harm and attempted suicide also increase with increasing age through the adolescent phase. Epidemiology studies show that psychological disturbance of varying intensity exists in up to 20% of adolescents, yet it is a disgrace that there is a lack of dedicated adolescent psychiatric services. Most areas are seriously short of adolescent psychiatric facilities and in some there are none at all. It is also a disgrace, as I said earlier, that children with mental health needs are placed in psychiatric hospitals. The Government must immediately recognise the difficulties experienced and redirect the lives of children with, or at risk of, mental illness with a comprehensive provision of dedicated mental care services, particularly given the relationship between mental illness and other life difficulties such as homelessness and poverty.

Information on the prevalence of mental illness, and the mental health care needs of Ireland's homeless, and research into appropriate effective responses is very limited. Policy makers and advocacy bodies must consequently operate on estimates and various sources put the proportion of Ireland's homeless suffering from a mental illness at between 30% and 50%. The Government has provided very few specialised mental health teams and outreach services dedicated to this population. Given that the community care services for the homeless are so deficient, with a particular shortage of community-based residential care accommodation, high numbers of people with mental health problems are becoming homeless.

In the European context Ireland is exceptional in the underdeveloped nature of its service to mentally ill people who are homeless. In particular, supported housing is a neglected and under-provided area in Ireland. Additional difficulties exist for homeless people in accessing medical care due to the sectorisation of psychiatric services into catchment areas, introduced on foot of the 1984 Government strategy Planning for the Future which is inappropriate to the needs of the homeless. Strictly speaking, homeless people in need of mental health care should return to their previous place of residence effectively leaving many of them without a service. It is obvious that a system, which operates on the basis of place of residence excludes the homeless. The Government must immediately and adequately address the high level of mental illness in Ireland's homeless population.

Many homeless people remain in hospital over long periods of time. The inspector of mental hospitals in his recent report stated "time and again the inspectorate has been struck by the number of current psychiatric in-patients who are homeless and are accommodated in acute or long stay hospital wards despite being suitable for community residential placement". In its report Health Plan for the Nation, Fine Gael states:

The practice of discharging those treated for mental health who are homeless back on the streets will be addressed. Each health authority will provide specialised hostel accommodation for three months for homeless patients discharged from mental institutions.

The abysmal failure to build adequate and appropriate community psychiatric and psychological services for the mentally ill and unwell people in prison has resulted in mental illness becoming criminalised. People who urgently need medical attention go unnoticed in society and are left unattended for years. Many become homeless. Some die by suicide. Others end up in prison. The Irish Penal Reform Trust estimates that almost 40% of the prison population may be suffering from some level of psychiatric or psychological illness or disturbance. The prison environment is detrimental to their mental health. To say there is inadequate psychiatric and psychological treatment in prisons is the understatement of the year.

The mental health service in our prisons can best be summed up by the use of the strip or padded cell. These cells are small, empty, furnished only with a thin mattress on the ground and a blanket. The prisoner is often left naked and at most with an underpants or night dress. The windows are sealed, thus the cells are inevitably stuffy. If there is a slopping out bucket, it is very smelly. Some prisoners are locked up for 24 hours. These are usually people who are suicidal. Prison records show that 78% of those detained in padded cells are detained for mental health reasons while just 13% are so detained for punishment. Dr. Valerie Bresnihan of the Irish Penal Reform Trust has stated that "to use these cells as a substitute for appropriate medical services is scandalous. Most of all it is an absolute denial of human rights". Dr. Smith of the Central Mental Hospital has stated that the gross overuse of the padded cell for psychiatric disability "is a grotesque way of storing a human being". If I had the time I could give the Minister of State numerous examples of people with mental difficulties who are in padded cells for up to 18 days. In one case the person was in a padded cell for 25 days out of 30 in solitary confinement when international research shows that after three days there is a psychological difficulty with confinement.

The results of a survey of psychiatric services in Ireland, conducted by the Psychiatric Association which was published in March of this year, indicated that psychiatric resources are already overstretched and, rather than being concentrated in areas of greatest need, have paradoxically been developed in areas of greatest affluence. The absence of an up to date national mental health strategy for developing the service is one of the main causes of current inequities in resource distribution. The Psychiatric Association states that the lack of a national strategy has also led to a situation where there is a very limited availability of specialist services. There is an urgent need for forward planning of mental health services in Ireland to avoid ad hoc and inequitable distribution of resources.

Rather than resources concentrating in areas of most need, this survey found that the reverse is true. The number of beds per head of population is widely accepted as a reliable index of medical resources. This survey found that resources were concentrated in the most privileged rather than the most deprived areas. This inequity was most marked in Dublin but was true for the country generally. The survey also found that the number of consultants relative to population levels was significantly reduced in areas with the highest levels of social deprivation, more significantly, the number of temporary, relative to permanent, consultant appointments was greater in deprived areas. Basic specialist services were generally not available outside Dublin and availability within Dublin is based on geographical proximity to special services. There is no neuropsychiatry service available to Irish patients with psychiatric disorders with the result that individuals with brain injury, brain disease or those with a psychiatric disorder as a result of a neurological disease do not receive specialist treatment.

Public services for those suffering from eating disorders are largely restricted to those in the east coast area health board in Dublin. Fine Gael's Health Plan for the Nation states that the need of this group must be recognised. It is Fine Gael policy to train people in the management of eating disorders in each health authority area. A dedicated service should be set up through out-patient and, where necessary, in-patient care.

In the first half of the 1960s, an average of 64 people died by suicide per annum. In the past five years an average of 456 died. In 2002, 451 people took their own lives and about 10,000 attempted suicide. The true figure is higher. If a jumbo jet crashed in Ireland and all the passengers died, the tragic loss would be greeted with horror. An immediate, extensive, and probably expensive, investigation into the circumstances of the accident would be held. The response of the Government to this serious public health issue is to cut the 2003 budget for suicide prevention and research by 40% to €655,000. A total of 379 people were killed on the road last year. Coroners have found that some of these were suicides. This was 72 less than the suicide rate. Yet the contribution to promoting road safety, which is under-funded, is €22 million, 33 times that spent on suicide prevention.

Dr. Connolly, secretary of the Irish Association of Suicidology has stated that "up to 90% of those who take their own life suffer from a psychiatric illness. The introduction of a community-based mental health service will have a considerable effect in reducing levels of suicide and attempted suicide." Finally, as my time is running out, mental health and mental illness are key questions deriving from the value structure of a rapidly expanding modern society like ours. Mental illness is not understood by many, and when a family is touched by one of these illnesses the reaction is often one of stigma, shock and incomprehension. This adds to the suffering both of the victim and the victim's family. Negative attitudes to mental illness need to be addressed. The low level of awareness in the general public of all areas of the service limits the assessing of those in need of the service. The Government should introduce a public awareness campaign through the media on all aspects of mental illness and positive mental health issues.

I wish to draw the Minister of State's attention to the fact that there is no dedicated service for those with personality disorders or with anti-social disorders. It is not appropriate that they are referred to psychiatrists, as they are not mentally ill. Each health authority area should provide a dedicated facility for in-patient and out-patient care staffed with expertise in cognitive psychology and forensic psychiatry-psychology. I commend the motion to the House.

I wish to share my remaining time with Deputies Crawford and Ring.

An Ceann Comhairle

Is that agreed? Agreed.

Mr. Crawford

No doubt whatever time I do not fill will be filled by Deputy Ring.

I congratulate Deputy Neville. Following what he said about those who had been looked after in mental hospitals, it is important that I mention that the move towards keeping people out of long-term care started in my area under Dr. Owens in St. Davnet's. He and the staff have done a tremendous job to ensure that as many as possible are moved out into the community and looked after there. They may go too far at times, and I have had some differences with them over individuals, for we must be sensitive to family needs and the situations in question.

This is the year of the disabled. The Special Olympics torch is on its way to Ireland and will arrive here in the next few days. No doubt when the crowds line up in Croke Park the world media will be there. There will be no one better than our Taoiseach to utilise every camera and photo call to show our involvement in the games. It is marvellous that we have brought the Special Olympics to this country. It is time that our Taoiseach and Government look into their own hearts and souls and ask themselves whether they are meeting their commitments and the needs of people with such problems, ensuring that there is a proper structure for them and that finance for them is not curtailed when it is still available for many other questionable issues.

There is currently a place for a physically handicapped person in the training centre in Monaghan, but there is no funding for a personal assistant to cover it. That used to be dealt with by community employment. When CE was curtailed, we were assured that funds would be provided through the health board, education or some other conduit to ensure that such posts were provided. That young person is not achieving his potential and will certainly be damaged mentally by sitting at home instead of getting proper training. There is a brand-new training centre in Monaghan, set up with help from EU funds. I was fortunate enough to be with the then Minister for Health, Deputy Noonan, when he announced that the money had been provided for that centre. It is helping to train 40 people with different levels of mental and physical disability. There is no doubt that it could train at least 40 more if the funds were available, which would be of great benefit to parents and, more especially, to the individuals concerned, helping them support themselves better.

Respite care is another major issue. When one sees two girls, no longer in the first bloom of youth, being looked after by their 86 year old mother – last year, they were not able to get respite care for them for two weeks to allow their mother a holiday with her only other daughter in England – one feels sore that the Celtic tiger economy cannot cater for such a thing. They could possibly have been facilitated in the St. Davnet's complex, but for all the right reasons the family did not feel that that was the proper place for them. In spite of the difficulties we may be going through financially, I would not like to think that that lady, now 86 years old, who has looked after not only those two but other long-deceased children from birth, would not get the little help to which she is entitled, ensuring that she can get a reasonable holiday to restore her body and soul. That is the type of case.

A total of 207 personnel are now not having their contracts renewed. Those people were looking after the disabled, and I urge the Minister to look seriously at the area. I congratulate Deputy Neville for raising the matter at this level.

Mr. Ring

I too compliment Deputy Neville for putting this on the agenda. The Minister of State, Deputy Tim O'Malley, has a serious job in the Government protecting the people concerned, for they will not be able to march on Dáil Éireann. They will not have the voice or support of the general public and have not had it hitherto. I compliment Deputy Neville and Dr. Connolly in Castlebar for putting on the agenda the problem of suicide in this country over many years when others tried to sweep it under the carpet, not putting the necessary funding in place or discussing the issue.

Many thousands of families have been affected by suicide. As an elected politician, I always know when I go to a funeral home, if I have not heard what the person has died from, that it is suicide. The family does not know whether to grieve, cry or get angry. They do not know where to turn or what the community is thinking about them. It is time that resources were put into mental health. For too long in this country, if people had any kind of mental illness, they were locked away for life. Now they are being pushed out onto the streets, and there is no place for them. They have no middle ground. I am not saying that the mentally ill should be locked up. I believe in what the Government has been doing over the years to bring them out into the community, but there is no point in throwing such people onto the streets if there is not proper supervision and care in place or proper professional help for them. Deputy Neville is right when he says that thousands of people are on the streets every night.

We see where resources have gone, hearing daily about Government jets and €30,000 spent on junkets for members of the Pensions Board. The money should be spent on people with such difficulties as these. I heard the Minister say on national radio that he had visited many hospitals. People are still complaining. We are now in 2003, and we still have facilities in this country not fit for human beings. That should not be allowed. We elected politicians should be ashamed that we are not here fighting for the underprivileged and those who have no one to fight for them.

I listen at my clinics to people whose family members have mental illnesses. They feel that there is no one for them, that they are left alone and that the State has sold them down the river. They think that the next-door neighbours wonder what is wrong with them. Why have we such great sympathy for drunkards that one can go up the streets and everyone will say what a poor fellow he is? He has inflicted that on himself, but the poor person with a mental illness has not done so. We do not say that he or she is a poor devil and ask what we are doing about it and why we cannot help the person or put facilities in place.

I congratulate Deputy Neville and Dr. Connolly for putting suicide on the agenda and bringing this motion before the Dáil. As I said, if we do not discuss it in this House and provide the necessary resources, those people will not be able to march and hold up Dublin city. They will not be out tomorrow holding up the city. Fianna Fáil, Labour Party and Fine Gael Deputies will not go out to meet them, shaking their hands and welcoming them, promising to do what they can. They are forgotten and left alone.

There is nobody to support them. It is shameful for society that we have not put the resources into mental health. We have let those people down. Since the foundation of the State we have locked them up and now we are throwing them out on the street without giving them the necessary medical help. It is wrong that they are out on the street and it is wrong of us not to provide the necessary resources.

The Minister of State at the Department of Health and Children, Deputy O'Malley, has a job to do and he will have to cry foul if he is not getting the necessary resources for these people. If he does not get the money to put professionals in place he will have to say: "This cannot go on. I do not want to be part of a Government that is not putting funding in place."

I compliment Deputy Neville for putting this on the agenda. The cutbacks can affect any other part of society but there should be no cutbacks in the mental health area. Increased funding and professional help should be put in place.

Minister of State at the Department of Health and Children (Mr. T. O'Malley)

I move amendment No. 1:

To delete all words after "Dáil Éireann" and to substitute the following:

– welcomes the Government's commitment to prepare a national policy framework for the further modernisation of mental health services which will take account of recent legislative reform, developments in the care and treatment of mental illness and current best practice;

– commends the action taken by the Government and the former Government since 1997 in improving mental health services, in particular, the further development of community-based services and the development of new acute psychiatric units in general hospitals; and

– acknowledges the need for the further development of services to people with a mental illness over the coming years.

I propose to share my time with the Minister for Health and Children. I am pleased to speak on issues relating to the provision of services to people with mental illness and to outline the measures being taken by the Government in this area. I have listened carefully to the contributions to this debate so far and I fully recognise the need to further improve standards in our mental health services. I assure the House that there is an equal amount of compassion on this side of the House regarding the issue of mental health services. No one person has a monopoly of compassion in this area.

Amnesty International's report, Mental Illness – The Neglected Quarter, which was published earlier this year, highlighted areas of genuine concern in relation to mental health services. These are concerns which the Government shares and fully intends to address.

It would be helpful to begin by referring to the document which has been the cornerstone of mental health policy for successive Governments for almost 20 years. The report, The Psychiatric Services – Planning for the Future, developed the concept of a comprehensive psychiatric service located in the community close to where people live and work. It was envisaged that this would replace the centralised and largely institutional services which were planned at a time when modern treatment methods were not available.

Unfortunately, the rate of progress over the past 20 years in closing down the old hospitals and building up the community services has not been as fast as had been hoped. It has to be acknowledged that, over the years, the 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, adequate funding and support must be provided. I fully recognise that much needs to be done in this regard.

Substantial capital funding under the national development plan has been allocated to the development of mental health facilities. Approximately €190 million is being provided over the lifetime of the plan which will enable the further provision of acute psychiatric units attached to general hospitals and the provision of additional community-based facilities.

The Inspector of Mental Hospitals plays a crucial role in providing an independent and detailed analysis of the mental health services. On the publication of his report for 2001 in September of last year, I was the first to acknowledge that more needs to be done to further improve the quality of our services. Notwithstanding the shortcomings which have been identified, there have been many improvements in the services, which have been outlined in successive annual reports of the Inspector of Mental Hospitals. These relate particularly to the increase in the number of acute psychiatric units associated with general hospitals. In 1983, prior to the publication of Planning for the Future, there were ten such units in place; this has now increased to 19, with a number of others at various stages of development. The number of community residences in 1983 was 111 with less than 1,000 places. In 2001, this had increased to 404 with more than 3,000 places. In the same period the number of in-patients in psychiatric hospitals and units has reduced from approximately 13,000 to just over 4,000. The decline in numbers of new long-stay patients does not necessarily reflect a decline in the incidence and prevalence of psychiatric illness as a whole. However, it is clear that hospitalised prevalence of serious psychiatric illness has declined greatly in recent years. Patients are increasingly being cared for in settings other than in-patient care with less disruption to their daily lives.

I intend to continue to accelerate the growth in more appropriate care facilities for persons with a mental illness with the further development of community-based facilities throughout the country. Substantial additional revenue funding has been provided since 1999 for the enhancement and development of community-based mental health services. This is being used in the main to provide additional medical and health professional staff for expanding services. Again, this commitment of funding has led to considerable progress being made in increasing the number of new mental health centres, day hospitals and other day facilities.

Since coming to office I have visited a number of psychiatric hospitals and have seen at first hand the commitment of professional and nursing staff to the provision of a high quality service. From the outset, I accepted that further investment needed to be made in upgrading or replacing some of the physical facilities and that a greater capital investment was required to provide a community-based infrastructure.

The World Health Organisation's 2001 report, Mental Health: New Understanding, New Hope, was aimed at raising public and professional awareness worldwide of the burden of mental illness and its costs in human, social and economic terms. It is a comprehensive review of all aspects of mental health, from prevalence and treatment to service provision and planning and it concludes with a set of ten broad recommendations for action.

Steady progress has been made in this country over recent years in many of the areas covered by the World Health Organisation's recommendations, for example, in the shift from institutional to community-based care and in the reform of mental health legislation.

The Amnesty report also recommended that a comprehensive review of the mental health services be undertaken. I welcomed that recommendation at the time, because the National Health Strategy, Quality and Fairness – A Health System for You, published in 2001, had recognised the need to update mental health policy to take account of recent legislative reform, developments in the care and treatment of mental illness and current best practice. The strategy gave a commitment that a national policy framework for the further modernisation of the mental health services, updating the 1984 document, would be prepared. An expert group will be established shortly to undertake this work.

Work on a draft scoping document and terms of reference for the group is almost finalised within the Department and I am pleased to inform the House that the recommendations of the World Health Organisation will be among the matters to be considered in the formulation of this new framework. The present Inspector of Mental Hospitals plays a crucial role in providing independent and detailed analysis of our mental health services and I pay tribute to Dr. Dermot Walsh, Inspector of Mental Hospitals, for his Trojan work in this area for many years. The inspectorate has provided both expertise and assistance in identifying problems and outlining the need for improvements. Under the provisions of the Mental Health Act 2001, the existing office of the Inspector of Mental Hospitals will be replaced with the office of the Inspector of Mental Health Services, thus giving the new inspector a much broader statutory remit than that of the current inspector. I understand that the Mental Health Commission is currently recruiting the new inspector and it is hoped that he or she will be in a position to commence inspections in 2004.

In addition to the annual inspections of in-patient facilities which are carried out at present, the new inspector will be required 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 the area of the regulation of standards in the mental health services. The new Mental Health Commission will maintain a register of approved centres, in which each hospital or in-patient facility providing psychiatric care and treatment must be registered. Regulations will be made specifying the standards to be maintained in all approved centres, including requirements regarding 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 Mental Health Commission, through the work of the Inspector of Mental Health Services.

It is my firm belief that this will lay the foundations for achieving a sustained improvement in the quality of care provided in our mental health services. Both the Mental Health Commission and the new Inspector of Mental Health Services will play a pivotal role in this regard. The current Inspector of Mental Hospitals has, however, 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 the 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 would be developed by the new commission to assist service providers in their pursuit of excellence in care delivery.

In the period 1999 to 2002, an additional €70.7 million was invested in the mental health services. In the current year, additional revenue funding of €7.6 million is being provided for ongoing developments in mental health services, to develop and expand community mental health services, to increase child and adolescent services, to expand the later-life psychiatry services, to provide liaison psychiatry services in general hospitals and to enhance the support provided to voluntary agencies.

Priority is being given to the development of mental health services for psychiatry of later life and child and adolescent psychiatric services. Additional resources have been made available by my Department to enable ongoing developments in these services. I recognise that the increasing number of people living to advanced old age will require the development of specialist mental health services which will meet the specific needs of older people. Psychiatry of later life is therefore a key area for development and over €7 million of additional revenue funding has been committed since 1999 to enable a start to be made on the establishment of specialist services in health boards where no such service had heretofore existed. I am committed to the continued development of this specialist service in the coming years.

In relation to mental health services for children and adolescents, I acknowledge that services for this group still require substantial development. However, we have already come a long way. In 1997, there were few child and adolescent psychiatry services available outside the major cities. Now each health board has a minimum of two consultant-led, multi-disciplinary teams.

A working group was established by my Department in June 2000 to review child and adolescent psychiatry provision and to finalise a plan for the further development of this service. The group published its first report in March 2001. It emphasised that the treatment of ADHD and AHKD is an integral component of the provision of a comprehensive child and adolescent psychiatric service. It recommended the enhancement and expansion of the overall child and adolescent psychiatric service throughout the country as the most effective means of providing the required services for this group. It also recommended that priority should be given, in the first instance, to the recruitment of the required expertise for the completion of existing consultant-led multi-disciplinary teams. The report also called for closer liaison and interaction with the education system and other areas of the community health services.

In its first report, the working group also examined the issue of in-patient psychiatric services. It recommended that a total of seven child and adolescent inpatient psychiatric units for children ranging from six to 16 years should be developed throughout the country. It envisaged that the focus of these centres would be the assessment and treatment of psychiatric, emotional or family disorders, including major adjustment disorders, anxiety disorders, mood disorders, eating disorders and schizophrenia. At present, four of these child and adolescent psychiatric in-patient units are at the planning stage and project teams have been appointed to oversee their development. These units will be built in Dublin, Cork, Galway and Limerick.

In addition to the above, the working group has also considered the provision of psychiatric services for 16 to 18 year olds and its report on this important issue was formally presented to me earlier today by the group's chairperson, Dr. Paul McCarthy. I welcome the findings of this latest report. It recommends that priority should be given to the recruitment in each health board area of a consultant child and adolescent psychiatrist with a special interest in the psychiatric disorders of later adolescence. This consultant should have the support of a full multi-disciplinary team. The report also emphasises the need for closer co-operation and liaison between the child and adolescent psychiatric services and the generic adult mental health services. As I said, I welcome this latest report which will serve now as a basis for policy making and planning in this area. I would like to place on record my appreciation of the work of Dr. McCarthy and the other members of the working group.

The working group on child and adolescent psychiatry is now examining the needs of persons suffering from eating disorders and how appropriate services can be developed in the short, medium and long term. The working group has invited submissions from interested parties on how the needs of persons suffering from an eating disorder can best be met and will be preparing its report on the matter over the coming months.

Over the past few years my Department has given special attention to the resourcing of suicide prevention initiatives. As we are all aware, suicide has become a serious social problem that is not confined to Ireland but is a growing global problem. Suicide is now the most common cause of death among 15 to 24 years olds in Ireland, exceeding deaths due to cancer or road traffic accidents. Apart from the increase in the overall rate of suicide, a disturbing feature is the significant rise in the male suicide rate. The most recently published figure from the Central Statistics Office indicates that there were 451 deaths from suicide in 2002. The figure highlights the need to intensify our efforts and to put extra resources in place for suicide research and prevention programmes.

Since the publication of the report of the National Task Force on Suicide in 1998, there has been a positive and committed response among both the statutory and voluntary sectors towards finding ways to tackle this tragic problem. A suicide research group has been established by the chief executive officers of the health boards. Resource officers have been appointed in all health boards with specific responsibility for implementing the task force's recommendations.

The task force recommended that steps be taken to make the mental health services more accessible to the public, particularly to young people. Concern was also expressed at the risk of suicide in older people. Additional funding has been made available to further develop consultant-led child and adolescent psychiatry and old age psychiatry services to assist in the early identification of suicidal behaviour and provide the necessary support and treatment to individuals at risk. Many of the task force's recommendations require continual development, particularly in the area of training and in the development of services relating to suicide and suicide prevention.

Additional revenue funding of €0.655 million has been provided this year for suicide prevention programmes. Therefore, since the publication of the report of the National Task Force on Suicide in 1998, a cumulative total of more than €13 million has been provided towards suicide prevention programmes and for research. This includes funding to support the work of the National Suicide Review Group, the Irish Association of Suicidology and the National Suicide Research Foundation for its work in the development of a national para-suicide register. This Government is fully committed to ensuring that further investment takes place in this area, building on the achievements to date.

The development of advocacy services is a very recent occurrence, but it is another example of the significant improvements taking place in the provision of mental health services. An advocate can be someone who represents and defends the views, needs, wishes, worries and rights of individuals who do not feel able to cope on their own. Advocacy can help service users to participate in and make decisions about their care and treatment. It can be a mechanism for changing attitudes of the public and media towards mental illness and those experiencing it.

The importance of advocacy is far-reaching. Not only does it allow the patient to express his or her concerns but it may also foster recovery by assisting patients to take control of their lives. The power of self-help is a critical factor in any healing process. A sense of being able to share and discuss one's fears and emotions within an understanding environment is invaluable and of tremendous solace at a time of crisis. That is at the core of the advocacy process.

Patient advocacy in the mental health services is still in its infancy. However, some groups have been providing informal advocacy services to patients and families of the mentally ill for some time. In recent years, a national patient's advocacy network has been established, with funding from the Department of Health and Children and various health boards.

The Government has made clear its support of the development of advocacy services by assisting initiatives to provide independent advocacy services. I made available €251,000 in 2002 and an additional €100,000 in 2003 for the development of mental health advocacy services nationally.

Substantial progress has been made in recent years in ensuring that those in need of mental health services receive care and treatment in the most appropriate setting. However, I accept that much remains to be done. The Government is committed to the provision of quality care in the area of mental health, to upholding the civil and human rights of those who suffer from mental illness and to encouraging measures aimed at combating the stigma that is often associated with such illness. Advances in the management and treatment of mental illness now allow many sufferers to live within their own communities, carry on with their lives and continue to contribute to society in a positive and fruitful way.

During my term of office as Minister of State with special responsibility for mental health, I will be endeavouring to secure additional funding for the mental health sector. I will also be overseeing the development of the new national policy framework for mental health. This will devise a sound policy base for the further enhancement and modernisation of our mental health services over the next decade.

The initiatives which I have outlined will reassure this House that mental health services are not being neglected by the Government and that the service shortcomings identified by recent reports are being addressed.

Minister for Health and Children (Mr. Martin)

I thank my colleague, Deputy Tim O'Malley, for sharing his time and also the Deputies who have contributed to this debate. It is fair to say that there is broad agreement on the need for further improvement in our mental health services. Most people would have to agree that people with a mental illness are among the most vulnerable in society. Our health and personal social services, including the mental health services, are first and foremost about people – the patients and their families who receive the services and the staff who provide them.

We live in a society that is patient-oriented. All State services, including the mental health services, must be responsive to this trend. The consumer in the psychiatric service is the patient and his or her family and friends. Just as the power of the consumer has made itself felt throughout the market economy, it is now being felt in the mental health services. The growing advocacy user movement in mental health, which was launched in County Monaghan, is yet another strand to this development, and one which I initiated and welcomed. We now have advocates in every health board area, which is an unprecedented development. It represents a significant achievement particularly for users of the services who have managed to put in place the network which advises decision makers and authorities to influence the development of policy and facilities.

I am determined to continue developing a comprehensive, community-based mental health service. Along with the Minister of State, Deputy Tim O'Malley, I fully recognise that much needs to be done to bring about the necessary improvements and developments. This will involve both investment and reform. I refer not only to reform of structures, but also of the way in which we do things. Having looked at different models in different health boards, I realise that some units and teams have managed to develop models of community care within existing envelopes of income because they did things differently. They had a more team-based approach as opposed to the hierarchical approach evident in some of the more traditional models of delivery. They were not afraid to delegate to other team members or to move to the community setting.

The move to the community setting is obviously influenced by investment issues. There has been a significant move away from the old institutional buildings of the earlier part of the last century. Since the development of the policy document in 1984, there has been a movement towards the development of acute units in general hospitals and a significant decline in the numbers in the institutions or in-patient care. Some of the obstacles and barriers did not just relate to investment; certain practices and work approaches retarded the rate of progress in some areas.

As my colleague, Deputy O'Malley, has already informed the House, approximately €190 million is being provided over the lifetime of the national development plan for mental health services. A significant part of this funding has gone towards the development of acute psychiatric units linked to general hospitals as a replacement of services previously provided in psychiatric hospitals. St. Michael's unit in Mercy Hospital, Cork, and the new unit in Ennis, which is a model of its kind, serve as examples. People talk about the stigma associated with mental health. On visits to Ennis I recall meeting some ten different committees about the major general hospital, but one rarely meets a committee in connection with an acute psychiatric hospital. I was delighted to be able to open the unit in Ennis, which represents a great addition in terms of services. The unit in St. Luke's Hospital in Kilkenny is similar and there are more on the way. They must be acknowledged.

In addition to the 19 acute units already in place, there are more at various stages of development. The funding will also provide for more community facilities such as mental health centres and community residences, which will accelerate the phasing out of the old psychiatric institutions.

Reference has already been made to the need for a comprehensive review of the mental health services. This was highlighted in the national health strategy, Quality and Fairness – A Health System for You. The strategy acknowledged that there is now a need to update mental health policy to take account of recent legislative reform, developments in the care and treatment of mental illness and current best practice. That has followed the consultation process which led to the strategy. People who criticise us for having another review should note that those who use the services and all the representative organisations, through the national consultative forum, pushed for inclusion in the strategy a commitment that we would review, modernise and make more comprehensive the 1984 document. As Deputy O'Malley said, it is intended that a review group will be established shortly to undertake this work.

The enactment of the Mental Health Act 2001 in July 2001 was very significant and I was happy to steer its passage through the Houses of the Oireachtas. The Act represented the first significant reform of mental health legislation in this country for more than 50 years. The Mental Health Commission, which I established in April 2002, is now the main vehicle for the implementation of the provisions of the Act. Its establishment is an important milestone in the development of our thinking on mental illness. Its ongoing work will lay the foundations for achieving a sustained improvement in the quality of care provided in our mental health services. The primary objective of the Act is to address the civil and human rights of the mentally ill.

The purpose of the Act is twofold. First, it provides a modern framework within which people who are mentally disordered and who need treatment or protection, either in their own interest of in the interest of others, can be cared for and treated. In this regard, the Act brings Irish legislation concerning 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 Act 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 detailed work of the Mental Health Commission is a matter for the commission to determine, in accordance with its statutory functions under the Mental Health Act. However, the commission has indicated that one of its priorities over the next few years is to put in place the structures required for the operation of the mental health tribunals. These will operate under the aegis of the commission and will conduct a review of each decision by a consultant psychiatrist to detain a patient on an involuntary basis or to extend the duration of such detention. Recruitment is currently under way for an Inspector of Mental Health Services as provided for by the Act which will help to put in place a system of annual inspections and reports under the auspices of the commission.

My Department also recognises the critical role played by the voluntary sector and emphasises the importance of health boards continuing to support and work closely with voluntary groups. The recently published Amnesty International report acknowledges the funding which is being made available by my Department to support groups and organisations, such as Schizophrenia Ireland, Mental Health Ireland, GROW and Aware, to heighten awareness and develop support services for service users and carers. We have increased funding significantly over the last number of years above and beyond what these groups were used to receiving. This is important because they are powerful moulders and shapers of change of attitude in our society.

I had the opportunity to visit the Central Mental Hospital, the oldest forensic secure hospital in Europe early this year. We have set up a project team to work on a new development there. The estimates of the cost range from €35 million and we are looking at various mechanisms in terms of how it can be financed. We accept that the physical conditions are not satisfactory.

In regard to service agreements, a committee was established to draw up a service level agreement on the admission of mentally-ill prisoners to the Central Mental Hospital. This acknowledges and addresses the issue of delays in the transfer of mentally-ill prisoners to the hospital.

Mr. Howlin

I propose to share my time with Deputy Moynihan-Cronin. I welcome the opportunity to speak on this interesting debate. When I volunteered to speak I did not expect a full press gallery as this is not an issue that attracts attention. Other issues in the health portfolio would ensure a full Gallery, a full press gallery and much more focus. However, there are few issues that are as important as this or that will impact on as many of our citizens and families. I congratulate Fine Gael, in particular Deputy Neville, for his personal interest in this issue which has been neglected in the health portfolio for a long time.

There has been much focus during the last number of months on health issues which, as the Minister knows, are seldom out of the news. Mental health seldom gets the spotlight or interest, a fact acknowledged by both the Minister and the Minister of State. Some would say that mental health is the Cinderella of the service. I know, from my own time in Hawkins House, that the Minister and Minister of State will have heard that point made by umpteen groups and deputations. Society needs to take cognisance of this.

The Fine Gael motion makes reference to a number of recent reports which I have had the opportunity to look through. The only conclusion one can come to on reading those reports is that we are all shamed by the status of mental health services in this first world, developed, wealthy country. I say this as a former office holder in the Department of Health.

Deputy Tim O'Malley is a new Minister of State, only 12 months in this House. In honesty I must say to him that it is disappointing that the response to this well thought out important motion is standard. I know he did not draft it. These responses are brought up on the system and are brought to Cabinet and rubber stamped on the day. However, it would have been refreshing if he had come in and said that he agreed that a lot needs to be done and that there is merit in the motion. He could have said he did not know if he would get the resources to improve things but he would do his damnedest to do so. If he had said that and tabled that sort of a motion I believe—

Mr. T. O'Malley

I did say it.

Mr. Howlin

The amendment the Minister of State proposed commends the Government and everything that happened since 1997 as if nothing good happened before then. There is merit in this House having a little more faith in the nature of debate in the Chamber and in the debate of real issues.

Ireland must face this issue. As a developed and increasingly stressful society, for all generations, we cannot escape the fact that one person in four will experience mental illness at some point in their lives. That is a difficult matter with which each of us must deal.

The Minister of State made reference in his speech to the World Health Organisation 2001 report. That comprehensive and worthy report, Mental Health – New Understandings New Hope, was devoted to mental health issues and was acknowledged internationally. It comprehensively identified the status of mental health services in the world and what needed to be done. It is important that we use the ten key recommendations made by the WHO as a yardstick to judge our performance to date. I know the Minister of State made reference to two of the ten points.

The first recommendation was to provide treatment in primary care. Have we done that? We have begun but have not developed a structured comprehensive way to do it. There is resistance to it and while good in parts it is patchy and non-existent in many places. The second recommendation was to increase the availability of psychotropic medication. I do not know whether this has happened but perhaps the Minister of State will inform us of what progress has been made on that issue.

The report recommends that mental health care be provided in the community where possible. We have made good progress in this area. The bringing of patients into the community did not start in 1997, year zero according to the amendment. I remember receiving a reasoned and understandable letter during my own time as Minister for Health from a woman who occasionally went into deep depression. She was concerned that psychiatric hospitals would all be closed. She wrote and said, "I need a place to go and be mad." She did not want the resource of a community house in the middle of a housing estate. I think what she said was a sane thing to say. We should not have a "one size fits all" policy. We need a variety of responses. There is often an awful response to the siting of community housing. We must get our planning right and ensure that communities understand the need for integration in a structured way. It should not be left to one division of health care providers to establish.

Let us look quickly at the other recommendations. We should educate members of the public. We have certainly not done much in that regard. We have not even resourced voluntary groups to do so. We should involve communities, service users and families in the delivery of care. How well have we done this? We must establish national policies, programmes and legislation in regard to mental health. We have made some progress in regard to new, long-promised, legislation recently but have yet to resource or fully implement it.

We must develop appropriate human resources of which there is not a sufficient supply in place. We must also develop links with other sectors. The mental health service is compartmentalised and not yet fully integrated. The idea of having acute psychiatric wards and reception areas in every acute hospital has been very slow to happen – some ten to 15 years – and, to date, there are very few acute psychiatric wards attached to hospitals.

These issues need to be prioritised and we need consensus to achieve that. Mental health in the community should be monitored and research supported. These are the guideline issues which we need to tackle. We need to measure ourselves in regard to those issues and debate them in the House. My judgment is that on all of these issues, Ireland has a long way to go.

While we can claim to have improved public attitudes somewhat from the days of shame and hiding referred to by Deputy Neville, we are now faced with new challenges and grave issues. There has been much debate in recent months about out of control adolescents, binge drinking, drug taking and, most worrying of all, increased levels of suicide, an issue touched upon by every speaker so far in this debate. It is quite shocking and we should be stunned when the Minister of State tells the House that suicide is now the most common cause of death among 15 to 24 years olds in this country, exceeding cancer deaths and road traffic accidents. Deputy Neville is right to say that if a terrible virus was killing over 450 young people every year, we would spend millions dealing with it to ensure that our youth and our future was preserved.

In a shocking report published in March, the Irish Psychiatric Association found that there was an almost complete lack of adolescent psychiatric services in the State, which is hampering efforts to curb rates of suicide and drug and alcohol abuse. While this may be an over-argued case, it is a shocking statement. The report found that 88% of psychiatric service providers had no access to adolescent psychiatrists, which is an entirely neglected area. The report is there to be read and acted upon.

This is clearly an area of increasing stress. The trauma of meeting families of children who have committed suicide, which we have all experienced, is beyond measure and almost beyond understanding. Suicide leaves a deep wound, and a yawning gap filled with a lack of understanding, hurt and despair. We must do what we can to address it. It must be one of the most awful events for any family to deal with, yet it is now being dealt with by an enormous number – some 451 families last year.

With regard to recent initiatives, the Mental Health Act 2001 established the Mental Health Commission to foster and promote high standards and good practice in the delivery of mental health services. It is unfortunate timing that the legislation for which we have waited so long is coming on stream at a time when resources are being rolled back. The commission, established in April of last year, has still to appoint its inspector of mental health services – the key provision. The Minister of State has informed us tonight that it will happen next year, which is another delay.

Mr. T. O'Malley

I said that it will happen soon.

Mr. Howlin

The Minister of State said that the report would be available next year.

Mr. T. O'Malley

Inspection will commence soon.

Mr. Howlin

I am trying to be supportive. If I were not being supportive, the Minister of State would know it. If I understand correctly, the first report of the new inspector of mental health services will be available next year, and only then will we have a chance to debate it. We need a commitment from the Minister that this will be an annual debate conducted in the House because that is merited.

Mr. Martin

It is provided for in the legislation.

Mr. Howlin

I am not sure a debate in the House is provided for. It might be sidelined into a committee.

There are great deficiencies in regard to services. I was contacted today with regard to St. Ita's, Portrane where there are 230 residents but where there has not been a GP service for some time. Why is that? The Minister should do something about it. Another problem arises in regard to the continuing inappropriate placement of mentally handicapped children in psychiatric hospitals.

A final point which I do not have time to develop but to which I wish to make reference is the scandal of having so many people with psychiatric problems in prisons. A UK study which I have recently considered showed that 50% of remanded males in Britain and 30% of sentenced males had a diagnosable mental disorder. From the figures given by Deputy Neville, I do not think the Irish figures would be dissimilar. We cannot continue using our prisons as dumping grounds for those with mental disorders. This is a critical issue and a critical debate, and it merits a serious response from all in this House.

Ms B. Moynihan-Cronin

I welcome the opportunity to speak tonight although it is unfortunate that I have such a short time to cover a wide range of issues. There was a protest outside Leinster House today by families of children and other people with disabilities, both physical and sensory. I spoke to an elderly mother of one child with a disability. The child has finished mainstream education and will have no place in September. The mother's worry is that if she dies, the only place available for her child will be in a psychiatric hospital.

My father began working as a psychiatric nurse in Killarney in the 1940s. The psychiatric hospital where he worked was a place near which nobody went because it was a dark dungeon. However, he led the way 40 years ago in trying to take away the stigma from the psychiatric hospitals. He also, without great funding being required, encouraged employers to employ those with a disability. A commercial operation was set up in Killarney, which is still going today, where a majority of the employees had a disability. There was no Celtic tiger at the time but that was done.

We have moved a long way from the big psychiatric hospitals to services in the community. However, the Minister of State should not let the community houses become dark dungeons again and should spend some money on them. I visit such community houses because I know many of those working there and many patients. The houses are very dour and dark. A can of paint or a little new furniture would make a huge difference, although I only know of the houses in my own town of Killarney. Funding has been promised for a number of years to provide for brightening them up. This is deserved and would not cost much.

The Minister's speech addressed the issue of facilities for those with eating disorders, from which a huge number of young people are suffering. I am aware of a case where a person from County Kerry is travelling to Dublin twice a week because the required facility is not available at home. They have approached the health board on many occasions for a small sum of money to assist them with travelling expenses but the door has been closed on them. The parents of this girl will beg, borrow or steal to get the money to bring her to Dublin to be cured. If a facility is not available in the Southern Health Board area, patients who must travel elsewhere should be supported. It is not their fault that the facility is not available in their area. I urge the Minister to consider this.

Deputies Howlin and Neville spoke about suicide. I commend Deputy Neville for not letting this issue slide. I also commend him on his work in this area. All Members are aware of people who have suffered this tragedy in their families. However, often in these cases the problem starts small and then escalates. When a person needs treatment for an eating disorder and the facility is not available in his or her health board area, the Minister must ensure such people are given financial support to help them to travel to the facilities that are available in other areas.

Debate adjourned.