Dáil Éireann debate -
Wednesday, 5 Oct 2016

Vol. 923 No. 2

Mental Health Services: Motion [Private Members]

Deputy Mary Lou McDonald

I move:

That Dáil Éireann:

notes that:

- 2016 marks the 10th anniversary of the publication of the Report of the Expert Group on Mental Health Policy entitled A Vision for Change, which laid out a pathway to progressive, modern and recovery-based mental health care in Ireland;

- despite plans for its complete implementation by 2016, much of the strategy is incomplete and many of its recommendations are still to be implemented;

- the crisis in our mental health service has been exacerbated by the failure to implement A Vision for Change in full;

- the current Programme for Government provides no significant detail on plans for the implementation of the reforms laid down in A Vision for Change; and

- there remains no state-wide 24/7 crisis intervention adult mental health service in this State, a major recommendation of A Vision for Change;

recognises that:

- without a 24/7 crisis intervention adult mental health service, the lives and health of people in mental health distress are being put at great risk;

- it is the responsibility of the State to ensure that those who need crisis mental health supports receive that support in a timely and efficient fashion in line with international best practice;

- 66 per cent of all people who are admitted to an Irish acute mental health unit are readmitted within 12 months and Ireland’s 30 day readmission rate is double that of the United Kingdom; and

- the alarmingly high rate of readmissions for mental health difficulties is due to a lack of outpatient community intervention services which are accessible and flexible; and

resolves that the Government must:

- publish within three months, an implementation plan for a seven-day-a-week adult mental health service in every catchment area to be completed within 12 months;

- open recruiting to employ a full complement of staff to provide a multidisciplinary team for these units which can also operate home visits seven-days-a-week;

- provide immediate funding for, and begin the establishment of, a crisis house in every catchment area as an alternative to in-patient care; and

- publish a detailed implementation plan for the full roll out of 24/7 multidisciplinary crisis intervention adult mental health services in every catchment area within 12 months.

I am pleased to move the motion calling for 24-7 crisis intervention mental health services to be delivered throughout the State. Over recent months I have traversed the country, North and South, meeting representatives of statutory bodies and non-governmental organisations as well as families and citizens who have helped to set up awareness programmes, help groups and local community initiatives to discuss issues around mental health and suicide prevention. Of most importance, I suppose, is that I listened to these people. The motion is very much directed by these ongoing conversations and is a direct consequence of meeting such a wide range of people. It reflects the most immediate concern expressed by all of them at the coalface of these issues, many of whom, I am very pleased to say, join us in the Gallery for the debate.

It is clear from our dialogue that we have much work to do in mental health. I could recite a very lengthy list of what must be done. However, the motion on the provision of 24-7 crisis intervention services reflects the most immediate concern of these groups and individuals. We have very consciously chosen to focus on this. I am aware that every deficiency in a service or euro not allocated to mental health causes distress and damage to those with mental health issues. However, the absence of 24-7 intervention services is the point where lives are lost. Lives have been lost.

We know crises do not occur during set hours and there is no timetable or schedule for a crisis occurring for somebody. By their very nature, crises are unpredictable and unexpected. They do not operate on a nine-to-five basis. As things stand, what may a person do if that person or someone he or she knows or loves is experiencing a serious mental health crisis? There are few options out of hours. The person may go to the Garda and many have done so. The person may go to the accident and emergency department. Many have done this and will continue to do so. Neither of these options remotely offers the appropriate care that is required.

I have mentioned before a young man called Ryan Dempsey. I raised his case in this Chamber. Ryan's case epitomises the absolute and immediate need for 24-7 crisis intervention services. Over six months, he repeatedly presented to accident and emergency services because of suicidal ideation or having self-harmed. He was discharged repeatedly within hours. On his last presentation to an accident and emergency department he self-harmed and, having been left in a ward on his own, he died by suicide. Ryan was not a unique case and others like him require psychological help as well as emotional and social support. This cannot be provided by An Garda Síochána and it certainly cannot be provided in a very busy and stretched accident and emergency department. People are left sitting for hours in an accident and emergency department, waiting for help, when they need immediate and special help in the here and now.

I acknowledge the work of mental health services where they exist but these are only available during office hours, five days per week. After hours service provision is still, sadly and disgracefully, the exception in this State. Our mental health services, as currently configured, are not functioning as required. In 2013, 11,000 people presented to accident and emergency departments having self-harmed. It is shocking that statistics indicate that more than one in five is a repeat attender for self-harm. Most are sent home after a few hours and many receive very little care. It is unlikely they will see follow-up.

We need more than general aspirations. We must be focused and get the ball rolling. We need to implement all of A Vision for Change, as that is clearly what all stakeholders and families, among all of us, wish to see. For today, for the purposes of this debate and motion, we want an agreed position on 24-7 crisis care being made available, with an implementation plan within three months and the services being rolled out over the course of 12 months. That is the essence of our motion.

I again welcome the families in the Gallery. I do not know if Fran Dempsey, Ryan's father, is here but I know there are other family members here. They are most welcome and I look forward to a productive and hopeful debate. I also hope there will be universal support for what is a very specific and focused motion.

An Leas-Cheann Comhairle

Deputy McDonald is sharing time with Deputies Buckley, Ellis, O'Brien and Brady.

Deputy Pat Buckley

It is high time this Dáil had a proper and meaningful discussion on mental health and, more important, the services needed for treating mental health. From the many conversations I have had with groups and affected individuals throughout the State, I know the lack of 24-7 crisis intervention services is a major issue that must be tackled.

Many here will be very aware that mental health and suicide prevention is very close to my own heart. Like many other families, I and my extended family have had to go through the trauma of burying loved ones, not once but on two occasions. Over the years I have seen too many of my friends end their lives by suicide. One cannot describe the hurt and sense of loss that is experienced within a family when family members are told that one of their own has died by suicide. Emotions are just sucked from the body and automatically replaced with feelings of hopelessness, sadness, bewilderment and anger. As the eldest of the family, it was I who was tasked with the responsibility of breaking the news to my parents and the rest of my siblings. I did not have the answers at the time to my brothers' deaths and still do not, but surely with better preventative measures and services like 24-7 crisis intervention, many other families could have been spared the same trauma.

Unfortunately, in the past two weeks, I have been made aware of three more people who have taken their own lives. I am also sure that my story is replicated by many families across the country and this is still happening today, as we speak. I have spoken to many coroners throughout the State in recent months and I have heard the same story repeated again and again about a handful of suicides in their localities each month.

A Vision for Change, published in 2006, proposed crisis intervention services and called for a full range of community mental health teams and programmes for adults with mental health issues to be rolled out. It specifically recommended a 24-7 crisis intervention service that would include the capacity to respond in a multidisciplinary way to the specific needs of every individual. This would be done through community mental health teams, if and when they get adequate resources and appropriate staffing. Ten years on and there is still no State-wide 24-7 crisis intervention service for people in need of emergency mental health care in this country.

To where do people turn? At present, their options are very limited. When people take steps to seek help, they are left, along with their families and friends, with nowhere appropriate to go. Often the only option is the emergency department, which is the wrong place entirely for a person in severe mental distress. One family who experienced this is that of Stephen Byrne. Stephen took his own life in January at the age of 20, having been turned away from hospital multiple times and after an attempted hanging while in Garda custody. He took his own life in desperation and hopelessness after failing to get adequate care. Some members of Stephen's family are here today, including his mother Patricia, who is now a voice for her son. She is calling for crisis intervention services to be made available at all times, for which I commend her. I also commend her on her strength and I am very proud to be representing her family and many others. The situation is also unfair on the staff in emergency departments who are not trained to deal with mentally distressed people and who are already under extreme strain due to the failings in our general health care system.

It is clear that mental health care in this country must be taken more seriously. People in distress often feel let down by society and by our health services. A properly functioning mental health care system requires a whole range of supports to operate properly. The community is a crucial part of this recipe and we need fully staffed community mental health teams. Sadly, we are very far short of this at present. The HSE's report, Delivering Specialist Mental Health Services 2014-2015, found that child and adolescent mental health services, CAMHS, staffing was only at half the recommended level.

I urge the Minister of State to take the first step and to invest in mental health. She must start by rolling out the plan to deliver 24-7 crisis intervention services. We have waited far too long already. We need to start helping the 8,708 individuals who presented with self-harm at hospitals nationally in 2014 and some of the 17,000 people who were referred for counselling in primary care in 2015, many of whom are still on lengthy waiting lists. We must also help those who need the help of CAMHS, referrals to which have grown from 8,633 in 2011 to a staggering 13,062 in 2014.

This motion asks for nothing more than what the State has already signed up to deliver. The problem for the Government is that it demands that action be taken sooner rather than later. Let there be no more kicking the can down the road, waiting for reports that will just gather dust. We want no more lengthy lead-ins for half-measures. We must start the process of delivering what was promised ten years ago because with every passing day, the lack of action puts lives at risk. I implore the House to support the motion.

Deputy Dessie Ellis

Issues of mental health and well-being are some of the greatest challenges facing us as a society. The suicide rate stemming from mental health issues has reached epidemic proportions and has well overtaken the road death rate. As a society, we must ask why this is happening, what remedies are needed and where the shortfalls in our system lie.

It is very clear there has been a huge haemorrhage of nurses and front-line professionals. A report by the Psychiatric Nurses Association, PNA and the Royal College of Surgeons in Ireland, RCSI, found that there has been an overall reduction in mental health staff numbers since 2006. The HSE's report, Delivering Specialist Mental Health Services 2014-2015, identifies the fact that staffing in CAMHS was half the recommended level. The mental health service needs more staff, particularly psychiatric professionals, in virtually every area. The current staff do Trojan work, often on their own time and go way beyond the call of duty. Psychiatric care professionals aim to assist in the recovery of people experiencing mental health problems and to promote mental health and well-being. However, understaffing puts the whole system under pressure. It is imperative that service levels are increased and that more nurses and trained professionals are recruited. The availability of services locally, in our communities, also needs to be resourced properly. Were it not for voluntary groups and individuals, I shudder to think how bad things could be. We owe a huge debt of gratitude to all those who give their time, energy and commitment.

There is a huge deficit in our system whereby at weekends or after hours, services are not available. A failure to provide community-based mental health services to replace the institutions that have been closed has led to many falling through the cracks. This motion clearly highlights what is needed from the Government, namely, the provision of a 24-7 crisis intervention service. In terms of staffing, an additional €37.5 million would fund all the positions outlined in the recommendations of A Vision for Change. The provision of 24-7 care would alleviate some of these problems but the process of admission to services also needs to be considered. Presenting oneself to a GP to get a note or to the emergency department is not working; nor is reporting to a Garda station. We cannot treat mental health issues in the same way as other medical issues. Any response to mental health problems must be flexible and capable of providing professional care when people need it, particularly in extreme circumstances.

There is a persistent problem of people presenting at accident and emergency departments with mental health issues being turned away for various reasons. There are many such cases to which I could refer. Indeed, I had the recent experience of seeing my own son being refused admission even though he has had a history of admission to the psychiatric services. This is not the exception but is happening regularly all over the country. The problem of dual diagnosis, whereby people are taking alcohol or drugs on top of their illness is not taken into account and such people are also being refused access to services. This need to be urgently changed and dedicated staff must be provided and trained to deal with it. We need more outreach workers to deal with people in their homes and their communities. The stigma associated with mental health difficulties needs to be tackled. The message needs to go out that help is available and that those in distress must talk to someone - a friend, family member or service provider. People should not bottle it up. It is okay not to feel okay - that should be the message.

Deputy John Brady

In May, Wicklow Comhairle na nÓg conducted a survey to which over 1,000 young people from across the county responded, with 89% of them rating mental health as the number one issue for them. They cited the need for more conversations around mental health, improving services and reducing the stigma around the entire issue. This is a fascinating statistic coming directly from young people.

On Monday of this week, I attended the launch of Be Well Wicklow, which originally started in 2012 as Be Well Bray but has since expanded across the entire county. Be Well Wicklow involves a group of young people from the age of 13 upwards who have taken on the challenge of promoting positive mental health in communities across County Wicklow. Be Well Wicklow is based on three key elements: battling the stigma surrounding youth mental health, learning and sharing the skills that build resilience and ensuring young people's ideas and opinions are central to everything we do. Next week marks the group's annual Be Well week, which will be marked by a range of activities across the county aimed at raising awareness of youth mental health and promoting positive mental health. As part of Be Well week, these young people have designed and created conversation cards, one of which I have with me. The aim of these cards, which will be found in cafés across County Wicklow, is to encourage people to discuss their feelings.

I commend these young people and thank them for everything they have done to engage with this issue. They have shown year after year that they are determined to continue the conversation on mental health. We could all learn a great deal from the work they are doing by taking on the challenge of promoting mental health and thereby inspiring many people throughout the entire county. I would like to wish the members of the Be Well branch in Arklow well with their first Be Well week. A Be Well group is currently setting up in Kilcoole. There are other Be Well groups across the county. Young people are leading the way on mental health in Wicklow. They are setting the agenda. Our job is to recognise the work of these groups and to do everything in our power to support them. I hope groups like Be Well Wicklow will spring up across the entire State. I am delighted that this motion has been introduced by my party. I hope it will receive unanimous cross-party support. In the words of Be Well Wicklow, mental health is not the same as mental illness. Everybody has mental health, and we need to start promoting positive mental health.

Minister of State at the Department of Health (Deputy Helen McEntee)

I move amendment No. 1:

To delete all words after “Dáil Éireann” and substitute the following:

"notes:

— in line with the Programme for a Partnership Government, the Government acknowledges that:

— 2016 marks the 10th anniversary of the publication of the Report of the Expert Group on Mental Health Policy entitled A Vision for Change, which laid out a pathway to progressive, modern and recovery-based mental health care in Ireland;

— the critical importance of prioritising mental health policy and service development;

— the need to increase the mental health budget annually during the lifetime of the Government, building on the substantial additional funding provided for mental health services between 2012 and 2016; and

— the need to further develop crisis and 24/7 responses, building on the investment to date in Acute Units and in supports at community level;

recognises that the Government is committed to:

— continuing to implement A Vision for Change, in a manner which recognises geographical accessibility, in the spirit of both the Programme for a Partnership Government and the Confidence and Supply Arrangement;

— increasing the mental health budget annually during the lifetime of the Government building on the substantial additional funding provided for mental health services between 2012 and 2016;

— completing an evidence-based expert review of the current status of implementation in Ireland and of international best practice in the area of mental health;

— establishing an oversight committee within three months, to oversee the development of a new policy for mental health based on the outcome of the expert review; and

— directing the Health Service Executive to develop a multi-annual approach to the development of mental health services."

I welcome this debate as a chance to restate the Government's commitment to further develop and improve mental health services in Ireland. I have met voluntary, public and private organisations. Unfortunately, I have personal experience of losing a loved one to suicide. I do not think any one person in this Chamber is any more committed to this issue than the next person. We are unanimous on the need to work together to tackle this issue. I welcome the timely manner of this motion, given that next Monday, 10 October, is world suicide prevention day. I am conscious that many organisations and groups are holding events throughout the country. I thank all of those who are making an effort. In my own county, mental health week is being marked by those who are trying to reduce the stigma and to get people talking and raise conversations.

The Government recognises that we cannot afford to be complacent about mental health. That is why the programme for partnership Government includes a clear commitment to undertake to increase the mental health budget annually to try to build capacity in existing services and develop new services. Since 2012, an additional €115 million has been put into our mental health services. That equates to 1,150 new posts. The funding for suicide prevention has increased almost fourfold, from €3.7 million to €11.5 million in 2015. I think this reflects a deliberate decision to try to tackle this issue. Each suicide is one suicide too many. We need to continue to try to bring the figures down. Funding for mental health will continue to increase this year from last year's figure of €785 million to €826 million this year. That is an increase of 5.2%. While I agree that this is not half enough, I suggest that there has probably been more investment in mental health services in the past five years than there was in the previous ten years. This continued investment underscores the fact that this Government is focusing on the modernisation of our mental health services, in line with A Vision for Change, and is aiming to develop mental health policies and services that are, above all, person-centred and recovery-based. I think that is particularly important because for a long time, our services focused on treatment without considering the possibility that people might recover and go on to live, work and have happy and healthy lives in their communities.

It is obvious that financial commitment is not enough in isolation. It must be directed towards what is needed to effect real change. That is why the Government is committed to updating the policy set out in A Vision for Change. This process has commenced with an evidence-based expert review, which is focusing on the progress that has been made in implementing A Vision for Change and is reviewing the current delivery of services in Ireland. This report will take account of international best practice and will inform the next steps in the development of our policy, having regard to human rights, health and well-being. The tender for this review was awarded recently. The report will provide a solid evidence base to determine the policy direction for the revision of A Vision for Change and provide a basis for further service development in this area to help to shape future policy. When A Vision for Change was launched in 2006, it highlighted many areas where attention needed to be increased. A Vision for Change was undoubtedly affected by a number of factors in recent years, including the changed economic context, the constraints on public spending and, most important, the moratorium on recruitment, which probably had the greatest effect. Recent years have seen investment in this area prioritised and significant reforms made.

One suggestion in A Vision for Change was the provision of State-wide 24/7 crisis intervention adult mental health cover. Services are provided to those in need of urgent care. I agree that they are not perfect and we need to continue to improve them. The interlinked components across the services include community mental health teams, which we have been building on. I acknowledge that not all of these teams are full. The staff of these teams are working to the best of their ability. They are able to respond to crises during normal working hours. These teams have established pathways of contact for existing patients, while other individuals can be referred through their GPs. All of the mental health teams keep slots for urgent referrals and emergency cases, for example when people are acutely suicidal or severely depressed. An individual in crisis may present to an emergency department outside of normal working hours. The mental health division has now ensured that all level 4 hospitals have a liaison psychiatric service available on the site of the acute hospital. This service provides prompt assessments in emergency departments. Most level 3 hospitals now have a service in place or one planned. Recruitment is taking place for the planned services. Where a liaison service is not in place, the local service has an alternative arrangement whereby the person is assessed by a liaison nurse, or else the on-duty consultant provides that advice.

While I acknowledge that dual diagnosis is a problem, a clinical programme is being established and worked on. We have appointed a national clinical lead in that area. I hope we will develop that, particularly in our accident and emergency units, as a means of providing additional support. Another example of this is the national clinical programme for the assessment and management of self-harm in emergency departments, which began in 2014. We often speak about suicide, but self-harm is actually an equal if not a greater problem throughout the country. The national clinical programme has trained and deployed 25 senior mental health nurses at clinical nurse specialist level to emergency departments around the country. This facilitates an onsite, rapid response to those who have self-harmed or are suicidal. It supplements and works with the liaison psychiatry services to provide a bespoke response to those who are suicidal or have self-harmed.

There are other measures to note, such as consultant psychiatrists being on call outside normal working hours. This is another example of a service that has been affected by a lack of staff and the moratorium on recruitment. The consultants who are working in this area, together with the psychiatric registrars or senior house officers on duty in acute hospitals, provide an urgent crisis response to people who present to emergency departments. In line with the focus of A Vision for Change on early intervention and community-based resources, approximately half the areas in this country offer a contact point for existing patients within the mental health service seven days a week. This is provided for existing patients who are thought to require additional follow-up, particularly on Saturdays and Sundays when there are no clinics operating.

It is important that we ensure we get the seven day services working as best we can. The 24/7 services need to be our priority and our goal but we need to ensure we can provide a seven day service as well.

The motion specifically mentions crisis houses as an alternative to inpatient care. When discussing this topic we must bear in mind the fact that while A Vision for Change recommends the provision of crisis houses on a population basis, it does not detail the model of care or the specific role or functions of such facilities. Currently, the HSE mental health division is concentrating on the development of a seven day service focused around day hospital and home supports as a priority. It is crucial to match the needs of our population with the services that benefit them most. This approach is in line with the resources currently available to the HSE.

We need to look forward. We must acknowledge that we have a duty to prioritise where and how our services are delivered at present to ensure the provision of safe and evidence-based interventions. However, a good deal of progress has been made. Advances have been made through the implementation of A Vision for Change, including the closure of the vast majority of old institutions, the expansion of community services and funding of specialist areas. I acknowledge the need for continued attention and monitoring to help to ensure that we meet the needs. The review of the implementation of A vision for Change will assist this process, especially in light of the fact that many of the recommendations made in 2006 are based on the 2002 census, when we had a population of 3.9 million. We now have a population of 4.8 million.

We should focus on what is positive as well. Investment in mental health services in recent years has resulted in an increase in the number of staffing levels for adult, child and adolescent community mental health teams. It has helped in the development of specialist services, including those relating to forensics, eating disorders and mental health of those with intellectual disability. Additional investment has also helped us to commit to building a liaison psychiatry service to help develop community mental health services.

Recent data on admission rates from the Health Research Board show a decrease of 20% even though we have had an increase in people seeking services. However, I agree with the comments of Deputies in the sense that we need to continue to see these numbers decrease. In particular we need to focus on the recovery model. Earlier, I emphasised the need for people to understand that they can recover within their communities. This is vital to prevent their relapsing or coming back to hospital with the same problems.

Finally, I am keen to discuss the area of prevention. The programme for partnership Government states that we will establish a youth mental health task force. The task force has been set out. Often we discuss services but until we actually address the area of prevention we will be simply chasing our tails and always playing catch-up. The task force is asking simple questions. How can we align services at national level? How can we align community interaction at a local level? How can we get these strands working together in the best way to help build resilience within our younger people and to ensure they are equipped for everyday life? This would ensure we do not see the same numbers of people needing to or seeking to access these services. Until we deal with these questions, we will always have problems.

While I very much welcome the candid discussion on this critical issue, I call on Deputies to maintain sight of our common goal - ensuring that the mental health needs of our nation are best served. I look forward to the remainder of the debate and everything my colleagues raise today.

An Leas-Cheann Comhairle

Deputy James Browne is next. I understand he is sharing time.

Deputy James Browne

I am sharing my time with Deputy Robert Troy. We have five minutes each. By agreement, we will share the remaining two minutes with Deputy Michael Fitzmaurice.

I welcome the opportunity to discuss mental health in the Chamber. The promotion of mental health and well-being in addition to the provision of services for those suffering or affected by mental illness must be a priority for us all. I welcome the many mental health spokespeople and family members in the Gallery today.

Mental health issues continue to inflict immense damage on our community. Depression, anxiety, addiction and self-harm are profound and great problems in our society and have been for a long time. No family is untouched by mental health issues. For example, we know from an Irish Creamery Milk Supplier Association survey that 51% of farmers have been directly affected by suicide. That is only one section of our society. I have no doubt this is reflected throughout every section of Irish society.

We have successfully confronted dangerous challenges like this before, when people said it could not be done, for example tackling road traffic accidents. We need a similar national platform to address mental health issues.

Suicide is preventable. It was said earlier that it was okay not to be okay and that it was okay to say as much as well. A breakdown in services and access to specialist treatment is all too often a common feature, as attested by the brave families who have told their stories in recent times. More and more, families are stepping out to tell their stories. Our mental health services are under-funded and under-resourced. Disarmingly, the service a person receives can be totally dependent on the county he lives in. A type of post-code lottery applies. We are all too aware of this in my county of Wexford, where the population is ostensibly under the care of Wexford and Waterford mental health services. However, when people present with mental health issues in Wexford they suffer discrimination in terms of a lack of availability of specialist assessment. They are assessed by a triage nurse over the telephone whereas those in Waterford get specialist treatment in person. This highlights the inadequacies, differences and inconsistencies from county to county throughout the country.

Since my appointment as the Fianna Fáil spokesperson on mental health I have had the opportunity to discuss the issues around mental health and access to services with leaders in the field of medicine, practitioners, nurses, other providers, volunteers, sufferers and family members. They have provided me with the necessary information to advance the cause of mental health.

One of the big issues facing patients with mental health problems is that they are seen in overcrowded emergency departments with little or no privacy or confidentiality. They have to wait excessive periods to be seen and they are exposed to constant noise, light and stimulation. Emergency departments should have a designated safe psychiatric area, away from the main emergency department to allow people to get confidential treatment. I will read out extracts from an e-mail sent to me by a lady who came in to my clinic two weeks ago. This lady is available to meet the Minister of State provided her identity is kept secret. She has given me permission to read these extracts. She said:

I took an overdose of paracetamol in an attempted suicide. For about half an hour I felt very dizzy and nauseous. My nose dried up. I could barely breathe and my heart was pounding through my chest. I felt like I was going to be sick but could not get sick, nor could I fall asleep. In fact, my mind was never more alert and was racing faster and faster. I took the overdose thinking I would die fast. But I did not. And I could not take the pain in my chest and stomach any longer, so I went to CareDoc and I was advised to go to Wexford accident and emergency, where I went.

Eventually she was seen in Wexford accident and emergency department and admitted to a six-bed ward. In the morning she woke up in the six-bed ward. She goes on to say:

I was very uneasy about this as I was extremely upset and dealing with a lot of anxiety after an attempted suicide. To have to fix yourself up and not look as if you have been crying all morning as quietly as you can so people can't hear you is very distressing for someone in my situation. Shortly after breakfast the doctors done their rounds. You could pretty much hear what they were saying to each patient as they went around, not exactly everything, but I could still tell you what was wrong with each patient in the room that day. This meant they would hear that I had taken an overdose and this really panicked me.

Eventually she was released from hospital. She was given a referral letter to give to her general practitioner. She told me she never had any contact from the GP. Two days later, she received a bill from the hospital for an overnight stay. It was another two weeks before she got a date for a referral, two months down the line, for psychological services. The bill came first.

I do not hold the Minister of State personally responsible for that individual situation. I realise the Minister of State can relate to that story. However, we must take steps to address these gaps. These are not extremely costly gaps to address either. It simply requires arrangements in hospitals whereby there are proper referral systems. Again, I do not hold the staff in the hospital responsible - they are stressed all the way out the door - but there are simple things we can do. Sometimes we have to get away from the idea of big strategies and reorganisation of the health system. We need to start looking at the simple things that can be done to alleviate people's problems, because these problems have serious consequences.

I want to address the situation with regard to children in particular. In Ireland, one in four of the population is under 18 years of age. Yet, at the end of 2015 the HSE had a total of 600.95 whole time equivalent staff working in children and adolescent mental health services, some 51.6% of the staffing levels recommended in A Vision for Change.

This is insufficient for our mental health services and must be addressed as a matter of urgency. We know that the inadequacy of current provision can have serious knock-on effects. For example, the Mental Health Commission reported earlier this year that the lack of provision of emergency assessment by a CAMHS team in respect of children presenting at emergency departments and adult units is one of the factors contributing to the continuing high number of admissions of children to adult units. The practice of admitting children to adult psychiatric units is one we all want to see end. The provision of a 24-hour emergency CAMHS service in all community health care organisations, CHOs, and the proper resourcing of CAMHS community services is fundamental to achieving this. It will not, however, be possible with such a low staff complement. We need a child-centred approach, the availability of direct access to seven day a week crisis intervention mental health services with outside office hours and specialist telephone support in every catchment area. That is only for a start. Ten years after the publication of A Vision for Change, we have only 75% of the staff required and in the CAMHS only 51%.

Today, I followed up on a situation that I raised during the summer involving a girl who was aged three and a half years when an aunt she was very close to died. She was a lively girl but went into a state of depression afterwards. During the summer, I pointed out that she had been on a waiting list to be seen for 18 months. Last week, she got a letter from the psychological service informing her that it does not cover bereavement. It took 18 months to get a rejection. Yesterday we met Hospice Ireland which told us about the importance of mental health support in end of life situations. It is unbelievable that bereavement does not merit mental health supports. If that is the case, it should be covered. The child turned five a week ago. It is ridiculous that she had to wait 18 months to be told that the service did not cover her.

In the 1980s, approximately 12% to 13% of the health budget was spent on mental health but that figure is now barely over 6%. I am told but I do not know if it is true, the Minister of State might be able to confirm it, that the dedicated section for mental health funding in the HSE will be subsumed into a broader budgetary process. I read that simply as meaning that the HSE is fed up with people in here pointing out that while money is allocated to it for mental health in the budget it is not being spent. This will make it almost impossible to track where mental health spending is going. Will the Minister of State confirm that is the case? We have to track the funding for mental health services.

There is a confidence and supply agreement between Fianna Fáil and Fine Gael to facilitate a Fine Gael minority Government. The preamble to one of the terms in the agreement states that the confidence and supply votes are dependent on the full implementation of the policy principles attached to this document in appendix 1. One of the terms within appendix 1 refers to full implementation of A Vision for Change in the area of mental health. It does not say "prioritise", "facilitate" or "look at" but "implement". I am somewhat concerned by some of the things I am hearing from the Department of Public Expenditure and Reform in the last day or two that suggest mental health services are not being taken seriously when it comes to funding. It is the little things that bring down governments. I am very concerned that the Minister for Public Expenditure and Reform, Deputy Donohoe, and the Department see mental health services as a little thing.

Deputy Robert Troy

I welcome the opportunity to contribute to this debate. I compliment Sinn Féin on bringing forward this important topic in their Private Member’s time. This is the second opportunity in a short space of time that we have had the opportunity to speak to this issue here. I listened to the Minister of State say how we need to address services. Prevention, however, is equally important. It is key to get to people before they become severely depressed or need the services. Earlier this year, it took a national outcry and a debate in this House to force the then Minister for Health to reverse the decision to cut money from the mental health budget. That was before this Minister of State's time. It was not then described as a cut but as a time-sensitive cost saving. While I acknowledge that cut has been reversed, it is worrying that there is no specific commitment in the programme for Government in respect of how much additional funding will be allocated to mental health services annually.

The lack of funding and resources affects a fabulous service - Good 2 Talk - in my constituency, Longford-Westmeath. This service provides low cost counselling services for children and adults. Anybody can turn up with no appointment, no long waiting lists. It has yet to receive its 2016 allocation of funding or the be informed that the funding has been approved. It is operating on a shoestring, on donations and the goodwill of members of the general public who are fund-raising to enable it to provide the service. The Department of Health has approved the group. Will the Minister of State take note and come back to me with the reasons as to why this service is still waiting in October 2016 for its 2016 allocation? Where is the priority there?

I have two letters from families bereaved by suicide. No one knows the problem better than the Minister of State. One letter reads:

I am writing this letter with such anger at the state of the mental health system in this country, it is basically non-existent. I am writing this from personal experience. My dad passed away from suicide not even a month ago. I brought him to doc on call on Saturday the 2nd of July after he had a breakdown that morning. This doctor said he was suffering from stress and depression but sent him home. He presented himself to [ ] hospital on Monday the 4th of July. He told them he was suffering from stress and depression but they were just interested in finding a physical reason for his behaviour. After hours of scans, x-rays and blood tests they concluded there was no physical reason for his condition and sent him home. He was not assessed by anyone from the mental health team.

He attended his GP for the next couple of weeks and was on medication to treat his anxiety and depression. My dad tried to call the [local] primary care centre on Thursday the 4th of August to try to get help but they were on holidays until the 15th of August. He even said himself that there is no help out there for mental health. He was dead the next day.

We are so unbelievably heartbroken and angry that there was no help out there for him especially when he tried to get help. Even in this time of utter sadness, I wonder how many other families go through what we are going right now. I feel deep down that this could have been avoided if someone was willing to help.

In another case, a mother contacted me about her son, who took his own life. I will give a synopsis of the letter by asking the questions with which she ended the letter. She stated:

Why would nobody take my word when I was desperate for help? I explained to the staff that he was taking a knife into his room at night, taking overdoses eg. paracetamol, and had suicidal intentions. Everything was put down to alcohol. I was his Mam for 22 years so I had a better knowledge of [my son] than anyone else [yet] while in [hospital] he never received any counselling.

I have given the Minister of State two examples, but there are many other examples. Unfortunately, the only conclusion we can come to is that our mental health service is not fit for purpose.

The Minister of State has an incredibly difficult task on her hands, but that task will not be made any easier if she is not given the necessary resources to implement the change that must be brought about. A Vision for Change was published in 2006 with a deadline of 2016. It is now 2016 with only 75% of the proposals implemented. I urge the Minister of State to ensure, as the budget deliberations come to a conclusion, that the necessary resources are put in place in order that we can live up to the commitment given and that there is full implementation of A Vision for Change without any further delay.

Deputy Michael Fitzmaurice

I welcome the opportunity of speaking to the motion and I commend Sinn Féin on bringing it forward. There is not a family in Ireland that has not been touched by this issue or that does not have someone close to them who has a mental health issue. The problem is not confined to one area. All Deputies are echoing the need for mental health services. Back bench Deputies are saying that this 24-7 crisis intervention team is needed. As politicians, we get telephone calls perhaps on a Friday, Saturday or Sunday night. Every Member in this House tries to do their best for people, but our hands are tied. What can we say to a person? We can bring them to an accident and emergency department where they may have to wait three, four or five hours to see a doctor, but given the state those people are in, they lose hope. They get fed up waiting. They do not have the patience for it. In fairness, the system in place is not right. Roscommon hospital can bring people in directly for assessment. That should be the case throughout the country. We should not have people waiting four and five hours to be seen.

Yesterday, I got a telephone call from a person I know in the Minister of State's own county who was in a bad state. We rang, e-mailed and got talking to people, but there was nobody who would say it was his or her job. Everyone we spoke to said it was not his or her job. I wanted somebody to call to the person's house to talk to that person and encourage the person to try to get help but, unfortunately, it was the same story. The person was told to go to the hospital and wait for hours.

A review of mental health services in the Roscommon area is due but it is being kicked down the road, so to speak. I ask the Minister of State not to keep kicking it down the road. Regardless of whether it contains bad stuff, she should get it out there because the only way we will solve this problem is to put it in the public domain in order that we can talk about it and try to solve it. The sad reality is that every Deputy in this House is interested in trying to solve this problem. We have had three or four debates in this House but from what I can see, nothing is improving.

An Leas-Cheann Comhairle

I call Deputy Barry who I understand is sharing time.

Deputy Mick Barry

I am sharing my time with Deputy Gino Kenny.

An Leas-Cheann Comhairle

There are eight minutes in the slot.

Deputy Mick Barry

I will start by extending a welcome to the campaigners in the Public Gallery and indicating that we will be voting for the motion.

On 7 May this year, 120,000 people gathered at various locations throughout the State at 4.15 in the morning. They walked and ran five kilometres, crossing the finishing lines of the Darkness Into Light events as the sun came up, raising money for the suicide prevention charity, Pieta House. What is interesting is that in 2009, at the first Darkness Into Light event in the Phoenix Park, approximately 200 people showed up. That is an indication of the growing awareness of this issue in society. The parties of the political establishment have completely lagged behind in appreciating that and in matching it with the funds that are needed.

This week, the world famous musician, Bruce Springsteen, published his autobiography, Born to Run. One of the striking features of the autobiography is the searingly honest and frank description he gives of his battles with depression. On page 528 he puts it very well:

Depression will steal your life. It will take it right out from underneath you by the things you do.

He talks about the effect on him that effective treatment has had, "[It] gave me my life back, which was slipping away between my fingers due to the fact that I couldn't control my anxieties and my neuroses." Bruce Springsteen is a working class hero, but he is a wealthy man now. He has the money to access whatever services he needs. Many people do not have that money, and many in this country do not have access to those services. Successive Governments have let down those people and their families. To illustrate that, current spending on mental health services in the State is €145 million less than it was at the start of the crisis, despite the fact that there are 400,000 more people in the State now. As the motion puts starkly, there is no State-wide 24-7 crisis intervention for adult mental health services.

In his contribution, the Fianna Fáil Deputy, James Browne, said that the programme for Government means the full implementation of A Vision for Change and warned that little things bring down Governments. I would like someone from Fianna Fáil to clarify those points, now or after the debate. What exactly is it saying? Is it saying that if in next week's budget A Vision for Change is not fully implemented and the funds put aside to do that, it will bring down the Government? Is it putting a timescale on that? Words are cheap, and we have seen services cut by Deputy Browne's party, so I am looking for clarification on what exactly is being said.

On 28 April this year, a protest on mental health funding took place outside the Dáil which 500 people attended. It was a small number in comparison with the Darkness Into Light event, but we must remember that Darkness Into Light started with just 200 people seven years ago. What if the 500 who were outside the Dáil on 28 April became hundreds of thousands? What if the 120,000 who participated in Darkness Into Light this year were out on the streets criticising Government and the political establishment and demanding funding for mental health services? If the Minister of State thinks that could not happen, she is being complacent. We need real increases in mental health spending. We need to start with the reversal of all the cuts and the provision of the moneys that were promised over many years for A Vision for Change, and it needs to start in next week's budget.

Deputy Gino Kenny

The crisis in the mental health system appears to be the perennial problem that simply will not go away. It appears to be the sick man of the health service that does not seem to get better. One of the best demonstrations I attended recently was the protest outside this building last spring. The protest, which was organised by the Union of Students in Ireland and Mental Health Reform, highlighted the detrimental cuts to the mental health service and what impact it was having on citizens. At the protests, I listened to a profound speech about a contributor's own daily struggle with mental health and the problems of accessing mental health services when that person needed them most. At the same time, there were stories of hope and human spirit and of fighting against adversity in times of desperation.

Mental health difficulties affect more than half a million people in Ireland. Ireland has the highest suicide rate in Europe among teenage girls and the second highest rate among boys. When people do gain access to mental health services, the lack of funding for psychological and social therapies has led to an over-reliance on the use of medication. The use of medication and coercion in mental health should be minimised due to the potential adverse effects of excessive use. Urgent situations that require a 24-7 urgent response require both a 24-7 community mental health team on call and access to an appropriate emergency department to ensure physical and mental care are assessed in a mental health emergency as they would be in any other health emergency.

A Vision for Change, Ireland's national mental health policy, was introduced in 2006 to detail the number of staff required to provide basic mental health services. When taking into account the increase in population, the required number of full-time posts to implement fully the A Vision for Change policy is now 12,240. However, staffing in mental health services has been cut by 10% during the years of austerity and as of April 2016, only 9,533 mental health whole-time equivalents were employed, which is a gap of 2,687 in the number of staff required. This means that for adult services, staff levels are barely over three quarters of what is recommended by the Department of Health but for children, the position is even worse with only half the staff numbers required in place. The Department of Health's own estimate of the cost of filling the staffing gap is €177 million per annum. Ireland only spends 5% of its health budget on mental health services and it would require more than €800 million to bridge that gap.

People Before Profit welcomes this motion tabled by Sinn Féin. I also welcome what has been a good debate. As a budget will be announced next week, now is the time to right the wrongs of historical underfunding of the mental health service and give citizens a chance to get well again. When carrying out research for this debate, I looked at a PDF copy of A Vision for Change and I wish to read out what I came across on the very first page, because they are the most profound words.

An Leas-Cheann Comhairle

As the Deputy would be depriving other colleagues in the House, I must ask him to conclude-----

Deputy Gino Kenny

It will take 20 seconds.

An Leas-Cheann Comhairle

-----unless someone is willing to share time with him.

Deputy Gino Kenny

It states:

The Greek name for a butterfly is Psyche, and the same word means the soul. There is no illustration of the immortality of the soul so striking and beautiful as the butterfly, bursting on brilliant wings from the tomb in which it has lain, after a dull, grovelling, caterpillar existence, to flutter in the blaze of day and feed on the most fragrant and delicate productions of the spring. Psyche, then, is the human soul, which is purified by sufferings and misfortunes and is thus prepared for the enjoyment of true and pure happiness.

An Leas-Cheann Comhairle

Deputy, you must conclude. You must respect the order of the House. I have been more than lenient.

Deputy Gino Kenny

Can I just finish? It literally is 20 seconds.

An Leas-Cheann Comhairle

You should have started that one minute earlier. There are other Deputies.

Deputy Maureen O'Sullivan

It is unethical and immoral that any budget dealing with mental health or with people with a disability should be cut. I believe those budgets should be sacrosanct and I hope the Minister of State will be able to achieve next week the avoidance of any diminution of that particular budget. Members know what to do, as A Vision for Change tells them, but having a document and a strategy is one thing and implementing it and putting it into action is another. We have the crisis because the implementation has been so slow. The figure for 2013 when it comes to suicide is 10.6 per 100,000, 80% of whom are male and there are significant numbers every year. In addition, homelessness is on the increase and it is known that it is homeless people who are presenting generally with mental health issues. Consequently, it is vital for those working in services for those who are homeless, be it the voluntary housing associations or the local authority, to have the requisite training and skills. This means applied suicide information skills training, ASIST, and counselling skills, even basic counselling skills.

While the motion's proposals are commendable, we again are missing the vital element of prevention and education. In Ireland and in its health system, so much is reactive instead of being proactive and preventative. I think in particular of young people, children and teenagers, as very early on, their parents, teachers, youth leaders or sports managers will be able to identify those who are vulnerable or are troubled, those who are stressed or anxious with suicidal tendencies, as well as those who are dabbling in drugs and alcohol or with eating disorders. The problem lies with what happens when it is identified because all too often, there is no immediate access to a service. In the meantime, the delay leads to further emotional and psychological damage, not to mention economic damage, by the time the person in question may avail of a service. Members must examine what is working and what is making a difference. Many things do that and it is known that in the case of young people who are involved in arts, drama and sports, that all is effective in building self-esteem and resilience.

It is known that people will be anxious and will be stressed but the question is how to deal with it and there is a simple technique called mindfulness. It is not very expensive but is highly effective. Moreover, it is proving to be effective with young people, as well as those who are in recovery from addiction. I will mention in particular groups of foreign-national young people in the north inner city, who I know, and whose status is uncertain. They are dealing with the anxiety of not knowing whether they will be deported. Again, there is the issue concerning tablets and the idea of a pill for every ill from which we really must get away. While I commend the motion and all the amendments that are being tabled, I believe prevention is the factor we are not getting right.

Deputy Mick Wallace

This is a short time in which to cover such a large subject. In the past year, there has been a different level of awareness among Members of this Chamber than was the case previously. People are waking up to how there are some huge challenges in Ireland in the context of mental health. I was made deeply aware of this during the election campaign. Given that County Wexford has the highest suicide rate in the country, I assure Members that we have serious problems in the area. While I do not have time to go into much detail, we must do things differently for a start. It is not working, there is not a good mental health service for those who have concerns in County Wexford and this must change. The Health Service Executive, HSE, must take a much wider look at people's lives and histories. It must promote talking therapies ahead of medication and if medication is being provided, it should never be in isolation from regular talking therapies.

The austerity measures that were implemented in recent years have had a dramatic effect on people with mental health challenges and we are starting to understand there is a strong link between mental health issues and people's social conditions; they are not independent of each other. I am aware, from talking to many of those involved in this area in County Wexford, that it is necessary to make service users much more involved and they must be brought into the fold when decisions are being made about mental health services. This is not being done in my locality in particular and counties Carlow and Kilkenny and south County Tipperary are definitely ahead of us in this regard. They have copped onto this and are involving service users, whereas this is not happening in County Wexford for some strange reason. People who have been brought through the system or who still are using it know what does and does not work better than anyone and it is a mistake to ignore their voices and not avail of their expertise and skills. Obviously, County Wexford needs 24-hour mental health services that integrate peer support workers but it will be necessary to create the care in the community services that were promised but not delivered, as they are completely absent at present.

Deputy Catherine Connolly

This is the third time we have debated mental health issues in this Dáil.

I fully support the motion not necessarily because of its wording, but because it seeks to put pressure on the Government to do what it should do, which is review A Vision for Change.

A Vision for Change, as was pointed out, was introduced in 2006. It followed Planning for the Future in 1984, which was not acted on, and 22 years later A Vision for Change was introduced in 2006. Such was the concern of various bodies at the time that the Government rightly responded and built into that policy an implementation body to ensure that A Vision for Change was implemented. That implementation body sat between 2006 and 2009, and between 2009 and 2012. I will put the comments of that implementation body, and of the Mental Health Commission, in a nutshell. They have repeatedly pointed out that the implementation of A Vision for Change has been slow and inconsistent.

There is absolutely no need to reinvent the wheel. A Vision for Change, which extends to 282 pages, is a most comprehensive document. It sets out precisely what was and is still required. Indeed, among its many recommendations are six I will mention: psychological and social therapies; primary care and community mental health teams in modern buildings; adult education; mental health promotion programmes; adequate and affordable housing given the interconnection between housing and mental health; and formal recognition and support through practical means of the crucial role of family care and carers in the mental health service provision. It is all in the 282 pages.

The implementation body sat for two periods and pointed out that it was not being implemented. The Mental Health Commission also pointed out that it was not being implemented. A Vision for Change ran out in January 2016 and we are still waiting for the promised review. I repeat that there is no need to reinvent the wheel. There is a need to set up immediately an implementation body and there is an absolute urgency to bring the review before us so that we can see that this is implemented.

I come from a city which has just been awarded the European Capital of Culture for 2020. Is cathair dhátheangach í, ach ag an am céanna we have suicide patrols on our streets. That is the level this has reached. I need not preach to the Minister of State, Deputy McEntee, who is fully aware, but repeating anecdotes and talking about the difficulties on the ground lets the system off the hook. We want a new vision for change, we want it implemented and we need an implementation body.

An Leas-Cheann Comhairle

We now have the rural Independents who have eight minutes. I call Deputy Danny Healy-Rae.

Deputy Danny Healy-Rae

I thank the Sinn Fein Party for bringing forward this motion and giving us an opportunity to raise this important matter.

I will start off by asking again that the HSE open Deer Lodge in St. Margaret's Road in Killarney, a purpose-built unit to cater for 40 patients. It cost millions of euro and has been lying there empty for over a year and a half. That is not acceptable. I raised it during the discussions on the programme for Government, I have raised it here at least twice and my brother, Deputy Michael Healy-Rae, has also raised this matter. It is not good enough that this wonderful facility is not operating. It wrongs the people of Kerry, and certainly the surrounding areas of Killarney, that this facility is not available to those who need it.

The HSE is proposing to close down Lantern Lodge in New Road in Killarney and to move those who attend there to Leawood House. Apparently, the facilities that the 18 or 19 patients who attend Lantern Lodge enjoy will not be available to them in Leawood House. I certainly will not accept that, and the people of Killarney and the surrounding area will not accept it.

Mental health issues and depression leading to suicide is a serious problem. People can be born with mental health problems and have depression all their lives and there are others whose depression is caused by pressure and stress. Starting off as children, they may experience stress at school and college, with examinations or whatever, or other family problems. It can be caused by a relationship break-up, the death of someone close to them, financial problems, loneliness and, indeed, rural isolation, which has happened in rural areas in Kerry on too many occasions.

People in very remote places have no recreational outlet. They do not meet anybody anymore. The creamery is gone, the post office is gone, and they cannot have a couple of drinks and drive home because of our stringent laws. I asked for a two-tier system where those in rural areas would be allowed get a permit through the Garda to drive on certain roads after having two or, maybe, two and a half pints. That was not entertained by the previous Government and I do not think this Government is interested in it either.

The Department of Health and the HSE need to up their game to recognise that some people need one-to-one care and assistance because we had a terrible situation again in recent times in Kerry and it is happening too often. Not enough funding is made available in the budget to deal with mental health issues. I am asking that more funding be given to it.

All of us know people who have problems, and maybe new problems, and if they are missing their social scene or not doing the things that they were always doing, we all should recognise it and try to talk to them. The duty of care is to mind our neighbours and we should all try to do better for them.

An Leas-Cheann Comhairle

I understand Deputy Danny Healy-Rae is sharing time with Deputy Michael Collins, who has three minutes.

Deputy Michael Collins

According to the Healthy Ireland Survey 2015, some 9% of the Irish population over the age of 15 has a probable mental health problem, PMHP, at any one time. This equates to approximately 325,000 people, based on Census 2011 population data.

Ireland also has very high rates of suicide. It has the fourth highest rate of suicide among young males and females aged 15-to-19 years across 31 European countries. Despite the high need for mental health supports, they continue to be severely under resourced. I am calling on the Government to protect and sustain existing funding and invest in the continued realisation of A Vision for Change. The Government must fully realise its commitments to mental health, and adequately invest in mental health in order to improve the mental health outcomes of adults and children living in Ireland.

Ten years after the publication of A Vision for Change, mental health services are still not uniformly providing the basic model of care that includes 24-7 crisis intervention, home-based and assertive outreach treatment, with crisis houses, as the norm in all areas. I fully support this motion by Sinn Féin. I recognise that it needs to be implemented urgently.

In the absence of community-based supports, emergency departments, EDs, are often the only option for individuals in crisis, as by their nature crises often occur out of hours. In 2014, the number of people presenting to emergency departments throughout the country following self-harm was close to 10,000. If one is having a mental health crisis, then waiting in a busy ED is not the best place to be. Similarly, if one is waiting for physical care in an ED, waiting alongside people in acute mental distress can make a difficult situation even harder.

I propose that this motion should also include the need for supported living to be provided to those in need as a statutory requirement to allow them to continue on their journey of recovery. There are patients in the psychiatric hospitals who are taking up a bed and are not able to continue on their journey of recovery due to not having anywhere to live once they are discharged. If the HSE cannot provide these units itself, it needs to allocate funding for the services through private health care providers.

There should also be a statutory right to advocacy, as recommended in A Vision for Change. It recommends that all users of the mental health services, whether in hospitals, day centres, training centres, clinics or elsewhere, should have the right to use the services of a mental health advocate. This right has yet to be realised.

Overall, what is needed is an increase in the mental health budget to improve the service. We allocate only approximately 6% of our health budget to mental health care services. We need to increase this allocation in line with international practice. In Great Britain and Canada the mental health budget is 12% of the overall health spend and in New Zealand it is 11%. We need to start treating mental health well-being as an equal of our physical health. Our mental health well-being needs to be looked after and protected in the same way as we look after and protect our physical health.

Deputy Róisín Shortall

I commend and fully support the Sinn Féin motion. There is no doubt there is a clear need to provide dedicated mental health teams on a 24-7 basis in all hospital areas. However, I wish to make one initial point. I am very conscious of the devastating trauma suicide causes for families who have been affected directly. My own certainly was, and I know many families of Members of this House have been directly affected by suicide. It is a devastating experience and we need a very significant response to that.

We also have to view mental health not solely in terms of the devastating impact of suicide but we need to ensure we do not lose sight of the fact that mental health issues manifest themselves in a variety of often interconnected forms. We must be in a position to respond to mental health issues wherever they arise. As such, we must strive for a mental health system in which crisis intervention is rarely the first service with which a person engages. Instead we must be proactive in our approach to mental health issues and design a service which works to address them at the earliest possible stage. To do this, we must move away from the overly medicalised approach to mental health care and ensure much greater access to counselling, cognitive behavioural therapy, CBT, and other therapies, rather than the reliance on medication which many service users report exists at present.

We must also be cognisant of the fact that mental health issues often occur in conjunction with other health difficulties. A study by the UK Department of Health suggested that 75% of drug users and people who use drug services also have mental health difficulties, and the reverse applies as well. For that reason, I appeal to the Minister of State to bring an end to this situation where we are not able to cope with dual diagnosis. The way the HSE operates is that a patient is either part of the addiction services or part of the mental health services but the two are interconnected. We must stop that structural distinction between the two categories of patients. We must also ensure we do not have those barriers between the mental health services and primary care services because, in the main, primary care services should be delivered alongside mental health services. We should not lose sight either of the issue of infant mental health, which is gaining attention and which needs Government attention as soon as possible.

Deputy Catherine Martin

A Vision for Change was launched in 2006. That innovative document inspired hope and was a clear roadmap for a mental health service where our most vulnerable citizens would be placed at the heart of their personal journey to recovery. Ten years later the implementation of this excellent document has been appallingly slow. The tragic truth is our citizens with mental health difficulties have been let down. We need to revisit A Vision for Change and prioritise its full implementation to improve the mental health outcomes for adults and children in Ireland. Such work is vital and every resource should be made available to help those who are unwell or struggling with symptoms of mental ill health, but sometimes it seems the conversation is solely about our response to mental illness. It is time for this country to have a new conversation about sowing the seeds of mental wellness in our schools and communities.

While the Green Party welcomes this motion before the House, we propose an amendment which would merely add to the proposed motion to address formally prevention as well as cure. In our amendment we request the Government to initiate a process of engagement and collaboration with relevant experts on this island and liaise with similar experts abroad to examine current resilience programmes being offered in schools and all other relevant mental health initiatives on offer, to determine their effectiveness, and to design and implement evidence-based intervention programmes at primary and secondary schools that promote resilience and measure the effectiveness of same.

Our young people's sense of self-worth and self-belief are often so fragile that they shatter at the first crisis. Research from the world of psychology indicates that it is possible to teach children to be more resilient. Scientists have identified key traits or strengths that can be harnessed within children and cultivated within school communities that will help them thrive despite adversity and to achieve positive outcomes despite the obstacles they may face. We need to explore and engage with the experts from the world of positive psychology within Ireland and abroad in the knowledge that developing and implementing evidence-based intervention programmes, as outlined in our amendment, will be of critical benefit to our children. Similar initiatives are delivering superb results in countries like Australia, New Zealand, America and closer to home in the UK.

Although some Members have spoken of positive psychology and resilience, I would respectfully bring to Members' attention that the proposed amendment by the Green Party is the only proposed amendment to this motion that specifically addresses prevention as well as cure. Surely we should be willing to embrace formally, at the highest level, the evidence-based approach to mental wellness as well as to treat mental ill health.

Life is an imperfect journey. The reality is that challenges, setbacks and misfortunes are inevitable for everyone. I would ask the Members of this House who have spoken of the merits of this motion to take this opportunity to embrace the new politics we have all heard so much about since February and support the Green Party amendment, because alongside the full implementation of A Vision for Change we need a vision for sustaining mental wellness.

Deputy Seamus Healy

I welcome the opportunity to speak on this motion and to indicate my support for it. A Vision for Change, launched in 2006, was a template for a community-based, progressive and modern mental health care system. Today, ten years later, there is a crisis in our mental health services arising from, and compounded by, the failure to implement the policy set out in A Vision for Change.

The mental health services in my constituency of Tipperary are a case in point and highlight the malaise in the service currently, both locally and nationally. Despite the best efforts of staff, the service is dysfunctional. The Minister of State's predecessor, the former Labour Party Minister of State, Kathleen Lynch, closed the inpatient unit at South Tipperary General Hospital, St. Michael's unit, and transferred south Tipperary patients to Kilkenny and north Tipperary patients to Ennis. That was in 2012. She sold that closure on the basis of a promised quid pro quo that we would have a Rolls-Royce community-based service.

Three years later we have the worst of all worlds. We have no inpatient service, a issue to which I will return, and our community services are understaffed, under-resourced and underfunded. Our community-based teams, multidisciplinary teams supposedly, are struggling to provide a safe service. They are deficient in terms of staff numbers across all categories - nursing, medical and paramedical staff members. The promised provision of a crisis house has not materialised. The inpatient service has been transferred to Kilkenny for people from south Tipperary and to Ennis for people from north Tipperary. That means assessments of patients have to take place in a busy overcrowded accident and emergency department with no privacy or confidentiality. The unit in Kilkenny is overcrowded regularly, there is difficulty gaining admission, and if one gains admission, there is the practice of early discharge. The situation is completely unacceptable.

I call on the Minister of State to implement A Vision for Change immediately, including the 24/7 services, to recruit additional nursing, medical and paramedical staff for the multidisciplinary teams and to reopen St. Michael's unit in Tipperary. I acknowledge the work done by the various voluntary organisations in this area, the community consumer mental health panels, the C-Saw suicide awareness group and others, and thank them for it.

An Leas-Cheann Comhairle

Glaoim ar an Teachta Ó Caoláin. Deirtear liom go bhfuil sé ag roinnt a chuid ama leis an Teachta Tóibín. Tá cúig nóiméad acu.

Deputy Caoimhghín Ó Caoláin

Tógfaimid dhá nóiméad go leith an duine.

A recent article published in The Guardian newspaper indicates how mental illness has soared among young women in England. Causes attributed to this rise include sexual violence, childhood trauma and pressures from social media. Society has changed drastically in the last number of years and the influence of social media on the lives of people is unprecedented. Due to its relatively recent emergence, one cannot definitively say what long-term effects social media will have on young people in particular. It has been widely reported that cyberbullying and constant exposure to unattainable aspirations are having a huge impact on young women and girls and also on young men and boys. It is no wonder, therefore, that a number of studies have pointed to a link between social media and depression, a very worrying correlation and one that must be explored further. We know that other factors such as the growing pressure on our young people to excel academically, poverty and family circumstance are all attributed to the rise of mental illness amongst our young people. However, with the addition of social media use as a recognised trigger for mental health issues it is important that A Vision for Change is implemented in full and immediately. We must ensure there is support to deal with the startling increase in mental health illness amongst our young people. It is absolutely vital, given the information on the situation that applies on the neighbouring island, specifically England. We are no different here. I have raised the issue of cyberbullying and young people's difficulties here repeatedly over many years. Iarraim ar na Teachtaí Dála ar fad a gcuid tacaíochta a thabhairt don rún seo. Gabhaim buíochas leo uilig.

Deputy Peadar Tóibín

I know two brothers living in Meath with serious mental health issues. One brother suffers from significant suicidal ideation. They are living in their father's local authority house at the moment. Their father died recently. They had been caring for their father in recent years but were not registered in the house. There is a major problem with housing in Meath. As a result, the local authority wants them out of the house as soon as possible. This is tearing them apart and is heightening their mental health difficulties.

I know another man in County Meath called John. He drove down the main road between Navan and Kells four years ago at dusk and crashed into cattle that had broken out of a farmer's field. The farmer was not insured; John only had third party insurance. He was left paraplegic as a result of the accident. He is paralysed from the waist down. He has been studying for a diploma. He receives physiotherapy and hydropool services on two other evenings. He gets home around 10 p.m. from his activities on those nights. As a result of cost changes to home help, he will now be refused services after 10 p.m. This 26 year old man is being told he has to go to bed at 9 p.m. every evening. His education, physiotherapy and independence have been destroyed with this effective curfew. As a result of this, there is a challenge to his mental health.

Last month, the HSE closed the 24-hour psychiatric unit in Navan. Two years ago Ardee and Navan had 55 beds between them but the new unit in Navan will see that figure reduced to 46 beds. Those beds are to serve a massively growing population of approximately 300,000 people. Community mental health teams were supposed to be boosted to backfill the loss of service but those personnel targets have not been met. Drogheda is not easily accessible by road or public transport for great swathes of County Meath. The common denominator in these three dire situations is a Government saying one thing with regard to mental health but failing to provide the key financial support to follow through.

Deputy Maurice Quinlivan

I welcome the opportunity to speak on this very important issue and welcome everybody in the Public Gallery. It is great to see so many people here for the debate, especially those who have stayed for the duration of it.

Research carried out by the National Suicide Research Foundation on the impact of the recession and austerity found that since 2007 self-harm and suicide rates have increased significantly. The research also found that where a person lives has an enormous impact on the rate of suicide with two of Ireland's largest cities recording extremely high rates of suicide. My constituency of Limerick city recorded an average rate of suicide of 17 per 100,000 people over a 14-year period. The national average is 11.8 per 100,000 people. On the other hand, the rate of suicide is almost half the national average in affluent areas with an average rate of 6.7 per 100,000 people recorded for the Dublin region of Dún Laoghaire-Rathdown over the same period. Clearly, socioeconomic factors such as unemployment, poor housing, crime, social deprivation, disadvantage, a deep sense of disempowerment and lack of opportunity and life chances result in poor mental health outcomes. Efforts to deal with structural inequality are of the utmost importance if we are to address the issue of mental health. Let us not beat around the bush - poverty causes ill-health in its broadest sense. It goes without saying, and many Deputies have repeated this, that the Government should fully implement the policy outlined in A Vision for Change. It should be implemented straightaway. At the very least, I call on the Minister of State to ensure that voluntary organisations, which do not wait for Government intervention to get going and get the work done, such as Limerick Suicide Watch and Limerick Marine Search and Rescue, are properly resourced and funded by Government.

Deputy Louise O'Reilly

I welcome the families and advocacy groups in the Gallery this evening. I remind the Minister of State that those people are watching us to see if we are serious about the issue of mental health. They are marking our cards and rightly so. I do not know what we will get for effort but the outcomes so far are very poor. I acknowledge the launch of the national task force on youth mental health. The Minister of State is telling us that this will be a community-led task force to take action to improve the mental health and well-being of children and young people in Ireland. It has had its second meeting this week and is expected to continue for the next 12 months. One of the aims of the task force is "to design and provide leadership for changes that get communities working together at a local level and services working together at a national level to improve supports for young people so that every young person in Ireland is supported to build their own resilience and emotional wellbeing." Those are very fine words. When young people reach out, get talking or look for services, irrespective of the supports that communities may provide, the missing link of these services where the State should step in is problematic. They are very often sorely lacking. This is causing serious problems. We should be able to say that the changes that will be proposed by this task force will be implemented. We should be able to say that this task force will work in tandem with the services that the Health Service Executive is providing. The task force and the Minister of State have to bring pressure to bear in ensuring that HSE services are in place to supplement the supports the task force is designing.

Less than an hour ago, the Minister of State said she believes that 90% of mental health needs can be met, dealt with and treated successfully in primary care settings. In August 2016, I received a response to a parliamentary question from the HSE advising me there are no primary care psychology services for the under-18 population of my constituency, Dublin Fingal. It is scandalous and deeply worrying that in an area so populated and where there is massive growth, there are no psychology services available for those under 18. I do not have to convince the Minister of State of the need to resource primary care. She has convinced me that 90% of mental health needs can be successfully treated in a primary care setting. We do not have mental health services in a primary care setting. We have not implemented the recommendations of A Vision for Change. What we have instead is a system that is creaking and people who are crying out and desperate for help.

I urge the Minister of State to implement those recommendations, not in a while but immediately.

Acting Chairman (Deputy Declan Breathnach)

I call the Minister of State at the Department of the Taoiseach, Deputy Regina Doherty, who is sharing time with the Minister of State at the Department of Health, Deputy Corcoran Kennedy, and Deputy Neville.

Minister of State at the Department of the Taoiseach (Deputy Regina Doherty)

The tone of the Sinn Féin motion and the way in which the party has tried to direct this debate are regrettable. What we have been presented with is in stark contrast to the party's actions and activities with regard to the treatment, over many years, of those who have been victims of different activities. It should reflect on how it treats people before it starts pointing a finger as to how others do so.

We have had a cross-party mental health committee in both the Seanad and the Dáil for a long time because there is no one in these Chambers who is not committed to the improvement of mental health services offered to citizens. If we are to believe the statistic that 25% of the people will suffer with some form of mental health difficulty during their lifetime, then there is a possibility that 25% of Members will suffer with mental health difficulties.

Thousands of people in, for example, Dublin, Meath and Wexford have mental health difficulties. It is not something a political party can prove its bona fides on by wearing a badge in a particular month or by introducing motions. It is about the difficulties in our daily lives in our interactions with our families, friends, communities or children. It is how we live. We live helping people on a daily basis. Perhaps the Members opposite should be mindful of that and stop their stunts.

Deputy Pat Buckley

The Minister of State is an absolute disgrace.

Deputy Regina Doherty

The programme for Government, which the Members opposite clearly have not read, states this area is a major priority for this partnership Government. We are making progress. Since 2011, we have added €115 million extra to the mental health budget, which now totals €826 million in total.

Deputy Louise O'Reilly

That is not enough.

Deputy Regina Doherty

I would be the first to say it is not enough. However, we do not have the magic calculator that Sinn Féin obviously possesses. We have to work on the basis of what is in the public purse instead.

The Government is extremely conscious that this is a growing issue. Deputy Ó Caoláin touched on an apt point. Lifestyles and activities are changing not just for older people like me or my parents but also for our children, who have entirely different lifestyles to the one I had at their age. We need to recognise that in the services and the supports we give them. There is not one Member of this House who would form a Government - be it minority, majority or partnership - that would not be committed to providing mental health services. However, there should be no stunts or wearing a badge on a lapel. We live it, breathe it and walk it every day. Members should be more mindful of doing that.

Deputy Peadar Tóibín

The Minister of State should put her money where her mouth is.

Deputy Tom Neville

Before I speak, I am mindful of the sensitivities of visitors and Members who may have been directly affected by mental health issues. We must all be aware of that.

I welcome the establishment of the national task force on youth and mental health in researching how best to introduce and teach resilience and coping mechanisms in children and young people to allow them to develop such mechanisms over their lifetimes.

Changes have taken place in the past decade. Following the introduction of A Vision for Change in 2006, I recall campaigning in several elections in which we spoke directly to people on the doorsteps about mental health and provided pamphlets. Ireland was a different place then and I would get funny looks from those who answered the door when I brought it up. People did not want to talk about it. I welcome that people today bring it out into the open and speak about it. I welcome also that Deputies speak about it because it is not so long ago in this House that they did not, and that was the bottom line.

The stigma needs to be combatted. I have always said this. We had a discussion on mental health at the Fine Gael think-in and we had some thought leaders speak to us. One thing I picked up from the latter is that stigma kills and that we need to combat it. That is a major issue.

I want to bring in some newer avenues to help with mental health, one of which would be through the creative arts and the artistic approach which are quite therapeutic and allow a person to go beyond himself or herself. I would also include the use of data analytics. I know some form of analytics have been put forward in recent years, particularly in the corporate world, to measure work stress, why people are missing work and to measure trauma within work. There is no reason that cannot be diversified to the health sector as well.

Minister of State at the Department of Health (Deputy Marcella Corcoran Kennedy)

On behalf of the Government, I thank all Members for their participation in this debate. I welcome the many constructive contributions which have been made on this topic. Mental health, just like physical health, is relevant to each and every person in our society. It is heartening to see that, regardless of party affiliation, the question of how to best support our citizens’ mental health is at the forefront of all of our agendas. Importantly, this debate has facilitated a range of voices and opinions to be heard.

These debates are key to ensuring we move forward together, and will help us to collectively plan for the needs of our society in this area. In the past decade or so, we have witnessed a crucial shift in the landscape of our mental health services. We have moved from an institutional to a community-based model of care. We have opened up the dialogue on mental health, helping to remove the stigma once attached to it. We have developed a system which focuses not just on cure and treatment but on early detection and prevention. It is true we need to align our services. What is available in one county should be available in another.

I acknowledge the groundwork undertaken by my predecessors in the Department, especially the allocation of €115 million in additional funding in the Health Service Executive’s national service plans from 2012 to 2016. Funding in 2016 will increase from the 2015 amount of €785 million to a projected budget of €826 million, an increase of €41 million or 5.2% which includes the €35 million ring-fenced for mental health. There has been more investment in mental health services in the past five years than in the previous ten. I accept, however, plenty more has to be done.

In line with what was set out in A Vision for Change, which continues to be implemented - although a review process is under way - mental health is increasingly being recognised as something that must be fostered in good times, as well as supported in times of distress. Biological, psychological and social factors are now seen as key elements which need to be approached in an integrated manner if we are to address mental health effectively. This person-centred approach must remain at the core of our modern mental health services. Early intervention and education are essential if we are truly serious about this cultural shift.

As outlined in the programme for a partnership Government, there is a clear consensus that the education system at primary and secondary level in particular is the key to greater awareness, to cultural change, to prevention and to early intervention for the next generation. Measures such as the recently convened youth mental health task force show the Government is focused on improving our nation's mental health and not just in the immediate term. This Administration is investing in prevention that will bring in real and positive changes for the future. As already stated, it is evident this same passion for shaping the supporting structure of mental health services is shared by many in this room.

We will continue to progress the real changes needed in our mental health services in line with our programme for a partnership Government commitments. The Government is committed to the implementation of the national suicide reduction strategy, Connecting for Life, a national strategy for the whole-of-government and whole-of-society approach to work on together. This can be seen in the key co-operation across the Departments of Health, Children and Youth Affairs, Education and Skills, in the Pathfinder programme, as well as the key co-ordination of actions across HSE directorates. The Government will continue to develop all aspects of our mental health services, including infrastructure to benefit the physical environment for both users and staff. A key element is progressing the new 120-bed forensic mental health hospital at Portrane, County Dublin, to replace the Central Mental Hospital in Dundrum. I expect construction will start later this year, depending on overall resource availability, and to have the new forensic hospital operational in 2019.

It is hoped in time to deliver new intensive care rehabilitation units in Portrane, Cork and Galway. We intend to increase the number of staff members available to people seeking treatment. Those students who are graduating are staying and we need to attract more home. It is about letting people know that it is okay to feel bad, that life is full of challenges that sometimes may be insurmountable but, most important, that it is okay to ask a loved one or mental health professional to help them in the same way as if they had a physical injury.

Deputy Seán Crowe

The most important message going out here tonight is that if people need help, it is there. Nobody should have to depend on luck for services but, unfortunately, in some cases, that is the situation. Location should not matter when it comes to the difference between care and no care but, unfortunately, that is the situation in parts of our country. Two weeks ago in my constituency, there were three suicides, one after the other. They involved three young people in one parish in my constituency. One can imagine the impact it had on that area. If there were three separate accidents on the road, what would happen? There would be discussion and extra services. I do not know about any extra services that have been put into my area following these tragedies. That is part of the difficulty.

One person from my constituency who is in the Public Gallery tonight was told by the HSE that there were no funds to run a crisis training course so she went out and got her own funding, venue and facilitators. She has now been told by the HSE that nobody is allowed to self fund to provide these services. Someone make sense of that. I can introduce the Minister of State to the person in question afterwards or write to her about the case. It does not make any sense.

I think we would all accept that this country has improved greatly over the past number of years and we have had a discussion here tonight regarding what needs to be done. I cannot understand it when people show their bravery, and it is bravery. In some cases, they go to the accident and emergency department to look for services but the problem then is that the services are not there and are not suitable in many cases. We need properly trained staff. Am I on my own here tonight? It is incredible that there is no State-wide 24-7 crisis intervention service for people in emergency health care. That is the big question. This debate has been sad and disappointing and an awful element was introduced by the Minister of State, Deputy Regina Doherty. At the end of the day, we need to talk about how we are going to do things differently - that there is a greater awareness, that there will be more resources and that we will do things better. Surely if we can agree on that, regardless of motions or anything else, that will be a good step forward.

Deputy Imelda Munster

It is very frustrating that ten years after the publication of A Vision for Change, we are here tonight with a motion debating the fact that it has not been fully or even nearly fully implemented. This year, we ought to have seen the full implementation of that document. Instead, our mental health service provision is in crisis. Behind this policy lie real lives. Last year, we lost 451 loved ones through suicide, a number that could be higher. Our suicide rate among young people is among the highest in Europe. People are dying because they cannot get the services they need and because of the lack of implementation of A Vision for Change.

It is estimated that around 9% of Irish people over the age of 15 have a mental health problem and I am sure the Minister of State would agree that this represents a staggering number of people. Most of these people can recover if they get the correct treatment options and services but if they cannot get these options and services, it is fair to say the condition of many of them will deteriorate which, in turn, can lead to devastating consequences for their families.

The Government amendment states that it is committed to continuing to implement A Vision for Change and that it recognises the critical importance of prioritising mental health policy and services but we hear that over and over again. The Government says it is committed but we do not see it act on that commitment. The Minister of State has yet to give a date or timeframe for something that is so urgent and critical and that would prevent so much misery and heartbreak for families across this State. It is time for action. Fine Gael has been in government since 2011. It has talked about its commitment but it has not shown commitment and has not delivered. The Minister of State, Deputy Regina Doherty, went off track earlier. In response to her, so far, Fine Gael has refused to provide and fund these services. If the Government can afford pre-election tax cuts in promised budgets, it can afford to fund and provide these services. We are looking for action and delivery in respect of the Government's commitment.

Deputy Mary Lou McDonald

It falls to me to conclude the debate on our motion. I will do so by firstly thanking people for their contributions and acknowledging people who came along. I also want to make it plain that at no stage did I or any of my colleagues set a hostile tone nor would we. Why should we? This issue is far too important for all of us, not just as public representatives but as human beings, for that to be the case.

People have said a lot of things, 99% of which I heartily agree with. Yes, we need to look at the model of care, the social context and the issue of dual diagnosis. I know work is under way in the HSE in that regard. As I said at the beginning of the debate, I could have presented a motion the length of the Chamber with all of the things we need to do and I think all of us would have agreed broadly about the things we need to do but here is the problem with that. Ten years on, A Vision for Change has not been delivered. It would be unfair to lay this at the feet of the Minister of State. That is not the intention of this debate - far from it. However, there is a political accountability aspect in the middle of all of this and we must accept that collectively.

I take a very straightforward view when faced with a massive social dilemma and tragedy. I ask myself what the better option is. Do we need a pat repetition of "we need the delivery of A Vision for Change" and a big long list even though we need this list or do we resolve to start at the start? This is what our motion is proposing this evening. It is not about inviting anybody to make a choice between prevention and cure. That would be an utterly facile thing to do but we are asking people to focus at the sharpest end of this problem. We are asking for us to start at the start - at those times when people in deep crisis are on the verge of life and death choices.

In those moments, in the wee hours, at the weekend or late at night, there are no services. This is the rationale for the focus of the motion on 24-7 crisis intervention.

We do not suggest it is the beginning, middle and end of the picture. We know it is not. However, we argue, and there are people in the Gallery who would argue more articulately than I can and from very deep personal experience, that if we want to start somewhere, this is the place to start. For this reason, we are not in a position to support the Government amendment or the amendment from our colleagues in Fianna Fáil. It is our strong resolve that we do not need a generalised commitment to come from this debate. We all respect each other as human beings. We do not need that again. We need the concrete, cross-party commitment to 24-7 crisis treatment, an implementation plan and the delivery of the plan, as set out in our motion. I appeal to people, in the best of spirits, that we all agree on this point. Let us make it happen and then, my friends, the rest can surely follow.

Amendment put.

Acting Chairman (Deputy Declan Breathnach)

In accordance with Standing Order 70(2), the division is postponed until the weekly divisions on this Thursday, 6 October 2016.