Mental Health (Amendment) (No. 2) Bill 2017: Second Stage [Private Members]

I move: "That the Bill be now read a Second Time."

Before I begin, I wish to make a general apology on behalf of my party colleagues, many of whom are attending the funeral of Deputy Sean Fleming's mother this evening. I welcome the large crowd in the Gallery who are from various sectors of the mental health community, including both representatives and those who have been through the system.

I am pleased to move this Bill which seeks to amend the Mental Health Act 2001. The Bill contains significant changes to strengthen the rights of people when they are in hospital for mental health care. Additionally, the Bill will also support the right of inpatients to make decisions about their own treatment by linking the Mental Health Act 2001 with recent law that affirms that everyone should be presumed to have the capacity to make decisions.

The Thirty-second Dáil convened a year ago this week and since then three mental health debates have taken place. Tonight's debate is the fourth which shows how far we have come as a society and a nation in breaking down barriers and saying "No" to the stigma associated with mental health. It is a step in the right direction but only one on a very long road. I have asked and will continue to ask that mental health be given the same priority as physical health. In that respect, I have written to the Taoiseach seeking the establishment of an Oireachtas joint committee on mental health. I am open to correction but believe that if established, it would be the first such committee in any parliament. If initiated, it would mean that mental health would be debated in the Oireachtas every week.

On 18 May last year, I was honoured to be named by my leader as my party's mental health spokesperson in this Dáil. Not one week has gone by when I have not met or spoken to an individual, family or group who have been affected by mental health issues. I have listened in awe at their sacrifices and in disappointment at the frustrations they face on a daily basis due to a lack of support.

In 2001, the Fianna Fáil leader and then Minister for Health, Deputy Micheál Martin, brought about the biggest and most significant reform of mental health legislation with the Mental Health Act, the first such legislation in over 50 years which radically changed how people with mental illness in Ireland were treated in our hospitals. In 2001, mental illness did not occupy the same space on the political agenda as it does today. The main objective of the 2001 Act was to address the civil and human rights of mentally-ill persons, while also putting in place mechanisms by which standards of care and treatment in our mental health services could be monitored, inspected and reviewed. In addition, the appointment of the Mental Health Commission in April 2002 created an implementation body to ensure that the intention of the Act was fulfilled.

Fianna Fáil, in agreeing to facilitate a minority Government, inserted into the confidence and supply agreement a condition that A Vision for Change would be fully implemented within the lifetime of the Government. A Vision for Change was developed under the then Fianna Fáil Government as a strategy document which sets out the direction for mental health services in Ireland. Since 2001, our understanding of mental illness and the rights of people suffering mental illness have advanced. In particular, we have had the UN Convention on the Rights of Persons with Disabilities, to which Ireland is a signatory. We need to change how we look at Acts of the Oireachtas that affect peoples' rights. They should be viewed as living Acts that can be readily amended and updated as our understanding and knowledge improves.

The Bill before the House today has two core aims, the first of which is to strengthen the rights of patients in key and clearly-defined areas. The second aim is to spur the Government into delivering a comprehensive Bill to address the many concerns of patients in terms of their rights as both patients and human beings, and to bring Ireland in line with the UN Convention on the Rights of Persons with Disabilities. Following Ireland's signing of the aforementioned convention, the 2013 expert group's report on its review of the Mental Health Act 2001 made 165 recommendations for changes to that Act. To date, only one of those 165 recommendations has been implemented. The Government has repeatedly failed to meet its own timetable for updating the Act. At the moment, there is not even a mention of a revision of the Act in the Government's current legislative programme. In that respect, this legislation also aims to compel the Government to do what it does not appear to be prepared to do voluntarily, namely, bring forward a comprehensive Bill to amend the 2001 Act.

I acknowledge that the Bill before the House does not address every issue. There are significant complexities around constitutional rights in such a Bill, including the right to liberty, bodily integrity, autonomy and privacy, as well as other rights. Opposition parties simply do not have the resources available to Government. Additionally, Opposition parties cannot propose Bills that give rise to Government expenditure. However, within those limitations, the amendments proposed today are targeted, significant and will, if enacted, strengthen the rights of patients in care. Enacting this legislation would be a positive step towards achieving the full amendment of the Mental Health Act 2001 in line with the recommendations of the expert group. It would also contribute to the Government's fulfilment of its obligations under international human rights law, including the European Convention on Human Rights and the UN Convention on the Rights of Persons with Disabilities. The Mental Health Act 2001 is currently in compliance with neither convention.

Psychiatric patients, both voluntary and involuntary, need increased protection. We must remember that in terms of involuntary patients, we are ultimately talking about detaining against their will people who have not committed any crime. This is an extremely serious step which involves curtailing peoples' rights. We must ensure that the rights of those patients are impinged to the most minimal extent possible. We must ensure that there are clear deprivation of liberty safeguards and protective measures in place. Of very real concern are those patients who are currently detained ostensibly as voluntary patients but who are in fact incapacitated, compliant patients. Over 90% of patients admitted to institutions each year are voluntary but the protections afforded in the 2001 Act currently only apply to involuntary patients. Some patients are admitted as voluntary patients in circumstances where they may not have the capacity to consent to voluntary admittance. Their capacity may be vitiated for any number of reasons including, for example, dementia. They may not be capable of making an informed decision, they may lose capacity while voluntarily admitted or the relevant information to allow them to give informed consent may not be provided to them and no one reviews their capacity to make such a decision on an ongoing basis.

The proposed amendments to the 2001 Act are in line with the recommendations made by the expert group. Section 2 amends the definition of a voluntary patient, as set out in the 2001 Act. The Act defines a patient as voluntary only if that person is not the subject of an admission or a renewal order, that is, involuntary. In other words, a person is voluntary only by virtue of the fact that he or she is not involuntary. This has led to a situation where individuals who do not have the decision-making capacity to consent to admission are being considered voluntary patients under the law. This section of the Bill provides an unequivocal definition of the term "voluntary patient" by ensuring that only individuals with the capacity to make their own decisions, with support if required, and to give consent to admission would be treated as voluntary under the 2001 Act.

Section 3 eliminates the principle of "best interests" which under the 2001 Act is the primary principle to be applied to decisions under the Act and provides that such decisions shall take into consideration the right to "the highest attainable standard of mental health consistent with least restrictive care [....] equality, non-discrimination and with due respect for the person's own understanding of his or her mental health". This section of the Bill also retains some of the principles already set out in the 2001 Act, including the right to autonomy, privacy, bodily integrity and dignity. This shift from "best interests", which is largely paternalistic in approach and interpretation, empowers people to be equal partners in their own mental health care and treatment. It also values the expertise and knowledge of individuals in understanding their own mental health difficulties and in recognising what is best for them in terms of their own care and recovery. Such principles place an emphasis on the primary importance of autonomy and the right to make one's own choices.

Sections 3 to 5, inclusive, place a strong emphasis on the rights of people to make their own choices.

It aligns the 2001 Act with the presumption of capacity and, if necessary, the provision of support, as set out in the Assisted Decision-Making (Capacity) Act 2015. The presumption of capacity holds even if it is the opinion of others, including mental health professionals, that the decisions being made by the person are unwise. Section 3(6) recognises that the elimination of "best interests", as set out above, will not apply in the context of children and young people under the age of 18.

Section 4 ensures that the principle of consideration of "best interests" will continue to apply to decisions concerning the admission and treatment of children and young people under the age of 18. The best interest principle for children is in line with the UN Convention on the Rights of the Child. The voice of the child must be heard and given due weight in accordance with his or her age, capacity and maturity and with due regard to his or her will and preferences. This is also in line with the UN Convention on the Rights of the Child.

Section 5 amends the 2001 Act to include both voluntary and involuntary patients in the existing provisions relating to the definition of consent to treatment. The consent to treatment provisions currently set out in the 2001 Act do not specify that they apply equally to voluntary and involuntary patients. This section of the Bill expands the definition of consent to treatment and explicitly provides that all voluntary and involuntary patients must give consent to treatment delivered in acute mental health services.

Section 6 amends the 2001 Act by including the words "voluntary or involuntary" in order to affirm that the consent of both voluntary and involuntary patients is required under section 57 of that Act. This section of the Bill also amends the 2001 Act by narrowing the circumstances in which treatment can be administered without the consent of the individual. It provides that treatment cannot be given without consent other than "as a last resort" and in keeping with international human rights.

Ultimately, this Bill is about extending dignity and respect to patients while supporting their right to autonomy. It is about ensuring they retain their voices and have those voices recognised, respected and taken into account. I look forward to the debate on it.

I commend my colleague, Deputy Browne, on the introduction of this legislation. I want to talk about a beautiful young girl from Newbridge, Maxine Maguire, who died by suicide on Tuesday, 7 February last at the age of just 25. She was a much-loved daughter, sister, granddaughter and friend. By all accounts, she was an incredible human being. Maxine had been suffering with an illness for quite some time. When it all became too much on 2 December 2016, she bravely reached out for help and support. Maxine was scared and vulnerable when, along with her family, she arrived at a hospital where she had previously spent some time with the same illness, with depression and suicidal tendencies. It was at this point that Maxine, having plucked up every ounce of courage inside her to get this far, was turned away by the hospital she considered a safe place and by the experts in whom she had placed all her trust. It requires a strength like no other to reach out and seek help when feeling so helpless and alone. Unfortunately, when Maxine sought help in this instance, she was sent home and she received confirmation that she was helpless and alone, that even those who work in this area would not help her, and that she did not matter.

After I met Maxine's parents, I was emailed by Maxine's friend, Aoife Chaney, who told me about the tragedy and heartbreak that unfolded almost immediately. It is very hard to put it into words. Aoife and Maxine's parents would agree that if Maxine had arrived in hospital with a physical illness like a head injury or a virus, she would most definitely have been seen to. I would like to ask a question that Maxine's parents, brothers and friends would want me to put this evening. What criteria are used to decide that the life of a physical health patient is more important than the life of a mental health patient? Maxine was failed by her country's mental health system and was forced deeper into her illness than she had been before, to the point of no return. This is not an isolated case.

Maxine is one of many people who have died at the hands of a life-threatening mental illness. This illness is comparable to many other diseases in so far as it is outside the sufferer's control. The message for sufferers that we hear every day is that they should talk and reach out - that it is okay not to be okay. Maxine's case proves that this is not enough. She bravely reached out and spoke with the most raw honestly and with admirable strength, only to be turned away. It is too late for beautiful Maxine and her family - her parents, Kathy and Robbie, and her brothers, Michael and Robbie. How many more tragedies need occur before something is done? I want to put it on the record that the help Maxine received during the physical part of her illness in St. Vincent's Hospital liver unit and in St. James's Hospital burns unit was second to none. It is a crying shame and an irreparable injustice that it was not until she was dying from a physical injury that was brought about through her negative mental health that our country's health system decided she was important enough to live.

I want to make a general point about mental health. There is huge community activity going on. Darkness into Light walks will take place in a number of places in my constituency this weekend. I could mention many other community and voluntary activities. This Parliament is about the Government. The confidence and supply agreement between Fianna Fáil and the current Government is the basis on which the Minister of State, Deputy McEntee, and her colleagues are in office. The implementation of A Vision for Change is one of the conditions of the confidence and supply agreement. That basically means money needs to be spent on the provision of services. The Minister of State is not spending the money that is needed. Everyone accepts that €35 million is required, but less than half of that is being provided. That is a failure.

Despite all our talk about getting people talking, many of the people who need these services cannot talk and are voiceless. Many of their family members are still afraid to speak even though they should not be. In my view, we cannot continue to support this Government if these and other items are not being delivered. They are not being delivered and cannot be delivered without the provision of the €35 million I have mentioned. If the Minister of State cannot ensure €35 million is spent to provide essential services, someone else will have to do it. We have heard examples of the services that are needed and we will continue to hear such examples. It is simply unbearable. It must stop. We must do our job in this Parliament, which is to run public services, including public mental health services. I commend Deputy Browne on introducing this Bill which will help the individuals suffering mental health problems who are in and out of various institutions and hospitals. I thank the Deputy. I am under pressure because we are running out of time.

I compliment my colleague, Deputy Browne, on introducing this Bill. As Deputy Byrne has said, many of the patients affected by this unseen health issue are voiceless. This Bill sets out to make certain significant changes to strengthen the rights of people when they are in hospital for mental health care. It supports the rights of inpatients to make decisions about their own treatment by linking the Mental Health Act 2001 with recent laws which affirm that everyone should be presumed to have the capacity to make decisions. This includes giving people the supports they need to make decisions.

Many people are affected by dementia and suicide. Deputy O'Loughlin has mentioned a very harrowing case. Unfortunately, children are among those who have taken their own lives. Members of Dáil Éireann have a duty of care to do something about this. This particular Bill certainly reaches out to do that. I hope the Minister of State will take on board the recommendations that are being made in this regard. It is important to acknowledge the great work that is being done by organisations around the country. We are very lucky to have the SOSAD group in the Cavan-Monaghan area and nationally. Those who provide the group's services are available at the end of the phone line to support people in their darkest moments. It is also important to mention the Cycle against Suicide organisation, which is doing terrific work across the country. I had the privilege of attending its talks at Our Lady's secondary school in Castleblayney and at Bailieborough community school in the company of our own ambassador for positive mental health, Alan O'Mara. All of that needs to be supported. This Bill certainly intends to do that. I hope the Government will support it in every way it can.

Ba mhaith liom buíochas a ghabháil leis an Teachta Browne as ucht an díospóireacht seo a thabhairt go dtí urlár na Dála agus deis a thabhairt dúinn an ábhar an-tábhachtach seo a phlé anseo. Is é seo an cheathrú uair go bhfuil an t-ábhar seo á phlé againn le bliain anuas. Léiríonn sé sin cé chomh tábhachtach is atá sé. Tá sé soiléir ó bheith ag plé na ceiste seo le daoine ar fud na tíre go dteastaíonn uathu torthaí a fheiceáil. Tá siad gníomhach amuigh sa phobal chun aird a tharraingt ar na deacrachtaí seo arís agus arís eile i slite éagsúla, cosúil leis an Cycle against Suicide, atá ar siúl faoi láthair agus a bheidh ag teacht isteach i gCorcaigh amárach, agus an siúlóid Darkness into Light, a bheidh ar siúl ag deireadh na seachtaine. Is é bun agus barr an scéil ag deireadh an lae ná gur dhein an expert review group scrúdú ar an ábhar seo. Dhein an grúpa sin 165 moladh, ach níl ach an t-aon moladh amháin curtha i bhfeidhm go fóill.

The expert review group published its report in March 2015 which was carried out in consultation with service users, carers and stakeholders and informed by human rights standards. Out of the expert group’s 165 recommendations, only one has been implemented to date. The pace of reform in mental health services is far too slow.

By the age of 13, one in three young people is likely to have experienced some type of mental disorder. By the age of 24, the rate will have increased to every second person. It is time for action. We cannot keep seeing delay after delay. The energy, enthusiasm and the goodwill to take action is there in communities throughout the country. The Darkness into Light walks, which we will see later on in the week in Inchigeelagh and Ballincollig, and the countrywide cycle against suicide, which will be visiting north Cork soon, are clear indications of the goodwill and the way people want to see action, as well as raising the profile of the issue. This Bill, brought forward by my colleague, Deputy Browne, aims to deliver immediate improvements and legislative protections for adults and children accessing acute mental health services. It is a long time coming.

Molaim an Bille don Teach.

I welcome those listening to the debate in the Gallery tonight. I thank Deputy Browne for introducing this Bill and I recognise the importance he and other Members attach to the need for introducing these changes to our mental health legislation. I agree with them that we need to change our mental health legislation and to do this as soon as possible. We also need to ensure that when the changes are made, they are the right ones and have the intended effect. I welcome the debate this evening, as it affords another opportunity to Members to continue our national conversation about mental health and, in particular, to examine our mental health legislation, which is focused primarily on the processes, safeguards, and protections around involuntary detention and treatment.

From a personal and Government point of view, I want to stress the significance we place on providing and improving services for those in society who are unfortunate enough to suffer from mental illness. We all know that mental illness knows no boundaries. As many Members pointed out, there are many fantastic people working to provide excellent mental health services. In addition to providing the breadth of services required both on a community and hospital level to all who require it, we know there is always more to be done in promoting positive mental health and in reducing stigma. I am glad to see many Members wearing their green ribbons tonight as part of the national awareness campaign about mental health problems. This year, we are developing services around clinical programmes for dual diagnosis, attention deficit hyperactivity disorder, ADHD, eating disorders, perinatal mental health and the development of seven days a week and 24-7 services.

Where the law is concerned, the challenge at times can be the need to keep pace with improvements in human rights standards and medical developments to ensure the legal regime governing mentally ill persons is both responsive and appropriate. In this regard, there must be an ongoing dialogue between politicians, stakeholders, doctors and lawyers to work together to make sure our mental health legislation reflects the correct balance between providing rights for those detained in psychiatric hospitals and providing appropriate protections on the other hand.

We must recognise, however, that of themselves laws do not heal people. Only services and treatment can do that. The law can create a social and regulatory environment, however, that assists medical professionals in delivering their services in a manner that is both ethical and respectful of the rights and needs of the mentally ill.

In 2015, an expert group review of the Mental Health Act 2001 was published. This first significant review was informed by A Vision for Change, our national mental health policy, as well as the UN Convention on the Rights of People with Disabilities, both of which were published since the 2001 Act was enacted. The review provides a clear and complete roadmap for how we amend our mental health legislation for the better. The review, which contains 165 recommendations, is progressive in nature. First and foremost, it sets out to promote and protect the rights of persons with severe mental illness. This is in addition to promoting access to the most appropriate and highest achievable standard of care and support. One of the key recommendations, which I welcomed and which is referred to in Deputy Browne’s Bill, is the move from paternalism and best interests to a service guided by autonomy, self-determination, and respect for the person’s dignity with a presumption that the person is best placed to determine what promotes and constitutes his or her own dignity.

Before we go into the detail of Deputy Browne’s Bill, it is important we recognise that the template for revising the 2001 Act is the expert group review which received broad support on its publication. The Government has already approved the preparation of the general scheme of a Bill to reflect these changes in revised legislation. This work is under way at official level, with the final text of the changes expected to be significantly progressed by the end of this year. There are two significant points I want to emphasise. First, I recognise that stakeholders are keen to see this text sooner rather than later and I understand their wish to see at least some changes emerge more quickly. I share that view, but it is also my responsibility to ensure the changes made are the right ones and have the intended consequences. There is a general acceptance that the changes now being made are significant, complex and so interlinked in many parts that it is entirely appropriate that these changes would be best introduced as a package.

The previous Government did introduce a priority amendment relating to the administration of electroconvulsive therapy, ECT, and medication over three months which came into law in February last year. This was an important first change and the fact it was a relatively stand-alone provision in the legislation allowed for it to be introduced at an earlier stage.

The Mental Health (Amendment) (No. 2) Bill 2017, sponsored by Deputy Browne and published on 23 February, has three main goals. First, it seeks to amend the existing definition of voluntary patient in the Mental Health Act 2001 to include the need for the patient to consent to admission. Second, it seeks to replace the existing principal consideration in the Bill of best interests with several principles including, inter alia, highest attainable standard of mental health, autonomy, dignity and with due respect for the person’s own understanding of his or her mental health. Third, it seeks to link the issue of consent more closely with section 3 of the Assisted Decision-Making (Capacity) Act 2015 which deals with a person’s capacity to be construed functionally. The last two changes relating to best interests and consent closely mirror recommendations of the expert group review of the 2001 Act. The move away from the often paternalistic interpretation of the existing legislation, best identified by the inclusion in the Act of the principal consideration of best interests, is both necessary and welcome.

We all want to see a situation where, in so far as possible, the individual has the final say in what he or she feels is in his or her best interests and that he or she receives the best possible quality of service he or she needs to reach the highest standard of mental health. This change will effectively move away from paternalism and place greater autonomy in the hands of the individual.

While the Assisted Decision-Making (Capacity) Act 2015 was not in place when the expert group reported, nonetheless what the Deputy’s Bill has proposed would be considered to be broadly in line with what the group proposed on consent and capacity. The first change relating to the need specifically to include consent in the definition of voluntary patient was fully accepted by the expert group and is my top priority change at this time. This change is also required to comply with the UN Convention on the Rights of Persons with Disabilities.

While what is proposed is absolutely necessary, there is one significant issue in the Bill I must highlight. If we change the definition of voluntary patient as proposed, then persons without capacity who need inpatient mental health treatment but do not have a mental disorder will not be able gain admission to a psychiatric hospital because they cannot personally consent. A new definition of voluntary patient, which includes the need for consent, must commence only when other changes are introduced to allow patients without capacity to access treatment. In this regard, the Department of Health is in discussions with the Department of Justice and Equality about including new provisions relating to deprivation of liberty in the Assisted Decision-Making (Capacity) Act 2015. This is complex new legislation which will also cover anyone who lacks capacity and is a resident in a nursing home or facility for persons with disabilities or mental illness. The draft provisions being worked on will be introduced on Committee Stage of the Disability (Miscellaneous Provisions) Bill 2016 which has already completed Second Stage in the Dáil.

The expert group review initially recommended that persons who lack the capacity to consent to voluntary admission, often called "compliant incapacitated", should be placed in a new patient category under the 2001 Act to be known as "intermediate". The idea was that such patients would also have available to them all the safeguards available to involuntary patients under the Act. Since then, however, it has become clear that all persons going into residential care who cannot, due to lack of capacity, consent to such admission must have safeguards in place. This is to ensure their rights are protected and that their will and preferences, to the greatest degree possible, are respected as set out under the Assisted Decision-Making Capacity Act 2015.

It makes sense that, with the new deprivation of liberty safeguards being put in place, it offers a better and more consistent route to deal with compliant incapacitated patients seeking treatment in a psychiatric hospital or unit.

It should also be mentioned that whereas the priority amendment to the Mental Health Act 2001 relating to changing the definition of voluntary patient can be put before the Oireachtas in the coming months, any such change agreed by the Oireachtas cannot be commenced until the decision support service to be established under the Assisted Decision-Making (Capacity) Act 2015 is operational. This is because the draft safeguards currently being worked on at official level and discussed with the Department of Justice and Equality envisage a role for the decision support service and, therefore, before such provisions can be operationalised, the support service needs to be in place. A steering group of officials from the Departments of Health and Justice and Equality, as well as the Mental Health Commission and the Office of Wards of Court, chaired by the Department of Justice and Equality, is working on the establishment of the decision support service. A director for the decision support service is currently being recruited but there is no doubt that the establishment and operation of this service will be a complex undertaking requiring significant preparation.

I once again thank Deputy Browne for introducing his Bill. We are all very much in agreement that the changes he is proposing need to be made and I hope he and all other Deputies will accept that the change to be made to the definition of "voluntary patient" must be our priority at this time alongside the associated changes to be introduced under the deprivation of liberty safeguards. This is the focus of my officials' work at the moment and I will be happy to discuss these details further when a suitable draft of the deprivation of liberty safeguards can be made available. I am not, of course, forgetting the two other significant changes proposed by Deputy Browne but when the voluntary patient definition change is agreed along with the necessary deprivation of liberty text, we can then look again at these changes in light of progress made on the general scheme of the overall Bill to revise the Mental Health Act 2001. I am very conscious that other Members who contribute to this debate may have other priority changes that they would like to see take place and I ask that, in raising such matters, they bear in mind that we expect the draft of a general scheme of a Bill to be significantly progressed by the end of this year. As a result of the of the interconnected nature of many of the changes to be made, there is a clear logic in proceeding with the bulk of these changes as part of a single amending Bill. I look forward to Deputies' contributions.

I welcome this Bill and commend Deputy Browne on bringing it forward tonight. The issue of mental health involves so many strands it can be difficult to decide what reforms are most pressing, especially in the context of trying to find potential reform that can be accepted by the House, whose Members do not always see eye to eye and can often seek to find any problem with proposed legislation in order to cast it aside. It was not too long ago that Sinn Féin brought two proposals in this regard. One concerned a €37.5 million investment in mental health services each year from 2017 to 2020 and we also called for 24/7 crisis intervention centres. Sadly, we did not enjoy the same support we see on the floor tonight.

I take this opportunity to welcome members of Mental Health Reform and everybody else in the Gallery. This Government and the House have much work to do on mental health issues and specifically in reforming our legislation to meet the standards of the likes of the United Nations Convention on the Rights of People with Disabilities. Despite signing up to the convention ten years ago, we have not ratified it and we have not sufficiently updated our legislation on the rights of patients to meet its standards. The Mental Health Act this Bill seeks to amend is 16 years old, predating the convention and the A Vision for Change document. An expert review of the Act has been almost entirely ignored by the Government, with just one of the 165 recommendations implemented and no expression of intent from this Government to change that.

We need an overhaul of patients rights and an end to the violation of human rights of patients in mental health services, as well as an end to the paternalistic system that places the final say in the planning of care in the hands of psychiatrists, regardless of the wishes of patients. If the Bill passes this Stage and is ever allowed to make its way to Committee Stage, I would like to see a number of actions being taken. There must be an intense period of deep consultation with those who have experienced our mental health services as inpatients, including those who have been voluntary, involuntary or deemed for whatever reason to not have had the capacity to make decisions relating to their care. These voices must always be central to our policy-making.

In the past, Sinn Féin has called for an Oireachtas committee on mental health in order to focus on these issues, hold hearings and seek expert advice from professionals, service users, their families and advocates. We must work together to develop comprehensive and progressive reform that is not simply the same old way of doing things but with nicer language. We would also like to see an inclusion of a statutory right for all people who enter an approved centre, voluntarily or otherwise, supported in drafting advanced health care directives that place consent and honesty at the centre of care. These must not be empty gestures and should be respected in all but the most extreme circumstances, with the proper checks and balances to ensure this. We also want to see a strengthening of the right to advocacy so that patients, regardless of their status, can seek the support of these services in order to best assert their wishes for their care. The rights of patients should never be seen as an obstacle to care and a system that protects those rights and treats those in its care with this respect will be better for it.

Treating mental health patients with dignity and respect will help to end the stigma which finds four in ten people in Ireland saying they would conceal a mental health issue rather than seek help. It would combat the very high numbers of readmission to inpatient units because if a person feels he or she can seek care and still have a voice heard and respected, with consent sought, it is much more likely that person will seek care before a full relapse happens. Potentially, such people would not require hospitalisation at all.

We need to invest in our services, community health teams and primary care, but we must also invest our respect and trust in the ability of professionals and patients to find solutions to mental ill health without reaching for the old ways of coercion, compliance and detention. I look forward to working with Members to bring these needed reforms to our system and build a service that puts the person at the centre.

I also extend a very warm welcome to members of Mental Health Reform and all our visitors this evening in the Gallery for what is a very important debate at the beginning of this month of May, a month of mental health awareness. So many of us are wearing our green ribbons in solidarity and as a mark of a change that is happening in Irish society, albeit gradually, in which the stigma, secrecy and isolation that are very often around mental health and mental ill-health are starting to lift. We still have considerable work to do to ensure that we get to the destination at which all of us wish to arrive and where we can support positive mental health. We can then genuinely say not alone that it is okay not to be okay but that if a person is not okay, he or she will be okay because services and processes of support will be available. Sadly, as we have this debate this evening and as all of us know, that is not the case. All of us also accept that the State has a major responsibility now to improve patient rights legislation in line with the United Nations Convention on the Rights of Persons with Disabilities. That convention must be ratified.

I thank Deputy Browne for bringing forward this Bill and facilitating this important debate. As my colleague, Deputy Buckley, stated, we regard the Bill to be a positive improvement on current legislation dealing with involuntary mental health patients and those who are currently voluntary but who are deemed to not have capacity. That said, we must understand that the Bill still falls short of the kind of firm rights-based approach needed to meet the standards of the UN convention. The latter is about upholding the equal rights of all people with a disability and this means protecting against the violation of the liberty or ability of an individual to make decisions for himself or herself by arbitrarily declaring such people to be without capacity.

I hope this Bill progresses to Committee Stage.

The Minister said that given the nature of the changes that must happen to the 2001 legislation, it would make sense for that to happen in a single consolidated Bill. That is a very fair point. In that spirit, too, I wish to point to one area that must be addressed seriously, namely, advocacy. Mental Health Reform has consistently articulated the fact that patients in our mental health facilities and psychiatric units are not enjoying their full human rights. In fact, the organisation goes further and says that it can identify concrete violations of those rights. Many things must happen to remedy that. We cannot rest on our laurels. There is no doubt that resources, investment, cash, staff and facilities are core to that, but so too is the area of advocacy. To have that peer support, the voice, the capacity to be heard and the enablement of arriving at autonomous decisions is powerful. Obviously, advocacy services must be independent and fully resourced. They must also be placed on a statutory footing, so that it is not a matter of chance or of good or bad luck as to whether a citizen or patient has advocacy services. It must be a codified, enforceable legal right for every patient.

When the time comes for us to deliberate more closely and to finalise our proposals, I hope the Minister will give due consideration to that matter. I also hope that we can find cross-party support on this area. All of us accept that our services are deficient, that there must be more investment and that we must radically change our legal framework. We agree on all of that, so let us work hard and speedily to give effect to the matters on which we agree. Arís, I thank Deputy James Browne. I wish everybody well during this month. Let us all wear our green ribbons and fly the flag for an honest, compassionate and respectful conversation in which we look after ourselves and each other.

Gabhaim buíochas as ucht an deis labhairt ar an mBille seo. Cuirim fáilte roimh an mBille atá molta ag Teachta Browne agus tá áthas orm go bhfuil mo phairtí ag tacú leis. The Bill contains significant changes that strengthen the rights of people when they are in hospital for mental health care. It is unfortunate, although perhaps not surprising, that to date only one of the 165 recommendations of the expert group report on the review of the Mental Health Act 2001 has been implemented. Furthermore, the Government has repeatedly failed to meet its timetable for updating the Act and there is no mention of revisions of the Act in the Government’s current legislative programme. In that respect, this Bill falls far short of what is required. My party will propose a number of amendments on Committee Stage to strengthen the rights of patients receiving treatment for mental health issues.

It would be remiss of me, when discussing this important topic, not to mention the complete neglect of mental health services by successive Governments. The wider issue of the provision of adequate resources for mental health treatment has not been prioritised by either Fianna Fáil or Fine Gael. This is evident from the fact that neither Fianna Fáil nor Fine Gael supported our calls for 24-7 crisis intervention services. It is also demonstrated by the fact that Fianna Fáil rejected a motion seeking to provide at least €37.5 million in additional mental health funding in the most recent budget.

Having recently hosted a meeting on mental health services in my constituency of Offaly-North Tipperary, I can inform the House that the lack of these services is strongly felt across our communities. People and families are in absolute despair and do not know where to turn. We must address this. There must be a commitment that the vital resources will be provided so that real change can be implemented once and for all. I hope all parties and Deputies in the House will work together to ensure this happens without further delay.

Ba mhaith liom fáilte a chur roimh gach éinne sa Public Gallery, go háirithe daoine ó Mental Health Reform agus an sár-obair atá siad ag deanamh. In the programme for Government, there was a commitment to mental health services under A Vision for Change, which to date has not been delivered or even acted on. Over the years, the State abdicated its duty of care to many sections of our communities. We are very slowly coming to a line whereby we treat all citizens of this nation equally.

This Bill is welcome, as it is a positive improvement on current legislation. However, as usual it does not go far enough. It fails to establish a strong, rights-based approach which should meet the standard set by the Convention on the Rights of Persons with Disabilities, a convention this House must ratify without delay. It also does not provide for strengthening the rights to advocacy or to assistance in making decisions regarding care, and there is no right to an independent second opinion in the determination of capacity. However, any positive change must be welcomed and the amendment changing the definition of a "voluntary patient" to include only people who have capacity to make their own decisions, with support if required, and who give their consent to admission to hospital is an important distinction.

Despite the changes, especially in this regard, if the Government does not support the work of the health services it will still not be enough. Access to and availability of services locally and in our communities must be resourced properly. The work being done on mental health by voluntary groups and individuals is saving this country money and, more importantly, is saving lives. I commend all those who give their time, energy and commitment. At present, however, there is a huge deficit in our system. Services are not available at weekends or after hours on a week day. A 24-7 crisis intervention service for mental health is needed immediately.

This Bill is only the first step in terms of where the State must update legislation either in line with the report of the expert group on the Mental Health Act or in an effort to meet the standard of the UN Convention on the Rights of Persons with Disabilities. We cannot ignore any longer the need to update our legislation.

I will speak in favour of this Bill on behalf of the Labour Party. I congratulate and thank Deputy Browne and his colleagues on bringing it forward. It is very good legislation and it is a matter in which the Deputy has a keen interest and which he pursues consistently. The Bill seeks to integrate provisions of the Assisted Decision-Making (Capacity) Act with the treatment of patients under the Mental Health Acts and I welcome that it has been brought forward.

As other speakers have said, we must confront the stigma of mental health issues in our country. There is no Member of either House of the Oireachtas who does not have an immediate or extended family member who has had to avail of the mental health services in this country, so we must look inward when we discuss this topic. The topic must be front and centre for all of us. In 2015, my colleague and the former Minister of State, Kathleen Lynch, published the report of the expert group on the review of the Mental Health Act 2001. The review, which commenced a couple of years before that, sought to reform and modernise the mental health system in this country, with particular reference to the 2001 Act. Since that Act was introduced, we have had the publication of the A Vision for Change document and the Convention on the Rights of Persons with Disabilities.

The group made 165 recommendations, the bulk of which relate to changes to our mental health legislation. Regardless of party politics, we all know that it will take a number of years to implement many of the recommendations. However, it is taking too long and the timeframe set out simply will not be met.

The Department of Health's own synopsis on the scope of the expert group's findings notes that in particular, the changes seek to move away from the often paternalistic interpretation of the existing legislation to one where, in so far as is possible, the individual has the final say in what he or she deems to be in his or her best interests and receives the best possible quality of service required to attain the highest standard of mental health. In addition, the recommendations provide a practical and realistic way forward, which can ensure that the safeguards necessary for mental health legislation are robust and fully compliant with international best practice, as well as ensuring that those vulnerable people who need care and treatment can avail of it in the most appropriate environment.

The changes envisaged include defining a voluntary patient as a person who has capacity to make his or her own decisions regarding admissions and treatment and who gives informed consent to that admission and treatment. The current Act regards a patient as voluntary only if that person is not the subject of an admission or renewal order. A key aspect of the Bill is amending section 2 of the Mental Health Act to define a voluntary patient as meaning a person admitted to an approved centre who has capacity as defined under section 3 of the Act of 2015 and has given consent to the submission.

In regards to capacity, the recommendation as per the expert group report is that where capacity is, in the first instance, to be presumed for all individuals, where a formal capacity assessment determines that a person lacks capacity, this should now be monitored on an ongoing basis by the treating clinicians to ensure that as soon as a person regains capacity he or she is afforded the opportunity to make his or her own treatment decisions. The Assisted Decision-Making (Capacity) Act 2015 has significant proposals for all individuals in terms of capacity, including the provision of support for a person to make his or her decisions wherever possible and that where mental health is concerned, assessment of whether a person has a mental illness will in future be clearly separated from the assessment of capacity.

This is an important departure from the provisions of the original Act which, 16 years later, is in dire need of reform. Patients, including those suffering from various mental illnesses, deserve the highest possible degree of autonomy in regard to their health. This encompasses privacy, bodily integrity, dignity of all forms, equality and non-discrimination in exactly the same manner as we would expect for all our patients and ourselves.

It is also important that we seek to make available the least restrictive treatment options. The entire sphere of mental health provision in Ireland and around the world unfortunately has been shrouded in great controversy. The notion of a psychiatric institution where people were sent because we could not and, in some cases, did not want to come to terms with the concept that these people were suffering from a medical condition is, thankfully, gone. Sadly, the stigma remains for many people and we need to ensure that we make treatment as accessible as possible without any of the associated stigmas or burdens attached.

The shift in focus towards treatment in the community goes some way towards addressing the problem. However, we need to do much more. There are cases where the most viable treatment option for people with mental health difficulties is for them to voluntarily admit themselves to hospital because under that system, they are likely to be attended to by a multidisciplinary team incorporating psychiatrists, psychologists, psychotherapists and cognitive behavioural specialists. In these situations, we need to make sure that the legislation aids rather than hinders their recovery.

It is incredible and should not matter, but accessing psychiatric treatment as an outpatient can be very difficult even for a person who has a decent private health insurance package. There are still chronic waiting lists for seeing a consultant psychiatrist and the provision of psychotherapy on the public health system is simply not sufficient. Most health insurance plans allow for some inpatient care, usually up to 100 days per annum. However, aside from partial reimbursements for visits to a psychiatrist on an outpatient basis, the costs can be prohibitive for most people who want to receive care privately in the community. This is not even to mention the lack of resources we all are aware exists in the public system.

As is the case in many other areas, it is clear that the private system is picking up the slack because the public system is very much failing. This is wrong. If we had a properly resourced public mental health service it is likely that many people would not have to turn to the private system in the first place for the help they deserve as citizens of the State. It is, therefore, the absence of a properly resourced public mental health service that deprives people of the care they need.

All Members know we are on a long road and have to work together. I do not believe it is in any way necessary to play politics with this issue. We all need to work together, and in that mode I accept what the Minister of State said regarding a comprehensive consolidated Bill being the way to go because it would deal with a multitude of other issues. I want a commitment from the Minister of State on that. It would be worthwhile.

None of us knows how long the Dáil will last but I believe getting the Bill to Committee Stage and starting a comprehensive discussion would be very welcome. Even if the Bill does not pass all Stages, and it is highly unlikely that it will, at least that discussion would have prepared future Governments to introduce the necessary legislation. I ask the Minister of State to use her office to try to get the Bill to the point of being discussed on Committee Stage. That would be forward-thinking and welcome because we have a backlog of Bills on Committee Stage that resembles the M50 car park. The Bill should proceed to Committee Stage because many people in the House would made a valuable contribution to a discussion on the legislation that needs to be changed.

I welcome those in the Gallery; it is good to see them. I welcome Deputy Browne's Bill, which shines a light on mental health services in Ireland. There has been a lot of discussion about mental health services and the accessibility difficulties.

I was elected over a year ago. It is very healthy that we are having a grown-up debate about mental health. It is a sign that the stigma is in some ways being broken down. Things are not perfect by any means but sometimes talking about a problem halves it in some ways. Anything that strengthens patient advocacy and care is paramount in the health care environment. The advocacy for inpatients taking decisions about their treatment is a progressive and welcome change. The definition of a "voluntary patient", in terms of having capacity to consent to admission to hospital, in the Bill is welcome.

It is not clear under the 2001 Act that consent to treatment is required from voluntary and involuntary patients. Replacing the existing principle of best interest under the 2001 Act with assisted decision-making empowers people to be decision-makers in their care. The Mental Health Act 2001 needs to be amended and is clearly not compliant with the European Convention on Human Rights or the UN Convention on the Rights of Persons with Disabilities.

The Government's mental health policy, A Vision for Change, is now ten years old and is out of date in terms of its framework. It is yet to be fully implemented in terms of staffing and funding for mental health services. Resources need to be put where they are needed. People might not want to hear this but the lack of resources for essential services such as mental health is killing people in this country. If resources are not put where they are needed, people will die unnecessarily.

All of us in this country are affected by mental health issues either personally or through family members. We all face the possibility of developing mental health difficulties. I would like to think that if I needed services they would be available but if they were not, I could have a completely different outcome.

That is not acceptable in the 21st century. It is important to go beyond party politics. If one thing comes out of new politics, all of which I do not know that I buy into, it should be people working together for the greater good, better mental health services and in the service of the citizens of the country. That is very important.

I welcome Deputy Browne's Bill. While it is not by any means perfect, nothing in life is so let us work together for a better outcome for everybody because anyone could be in that position. Let us send the message today that nobody is alone and that people who need help should seek it. If it is not there, that is a crime.

I welcome the opportunity to take part in the debate, although I feel I have been repeating myself in the short time I have been in the House. While I welcome the Private Members' Bill put forward by Fianna Fáil and I have no difficulty supporting it, I want to put it in the context that we are here once again. This is perhaps the sixth time since February that we have discussed mental health in the Dáil as a result of a constant campaign of emails, pressure and letters which make us fully aware of how unsatisfactory mental health services are in Ireland.

I have had the privilege in a different life of working in that area and I used my contribution on Leaders' Questions a few weeks ago to highlight the fact that we do not need to reinvent the wheel. A document called Planning for the Future was published in 1984 because mental services at the time were completely unsatisfactory. Fast-forward to 2006 and A Vision for Change was published. I just left the Chamber to get the briefing document on A Vision for Change, which was the report of the expert group on mental health. The briefing document indicated that A Vision for Change was person-centred, recovery-oriented, holistic, community-based, multidisciplinary and population-based. All of this has been set out. I repeat the fact that it was a visionary document and everything was included in it, including the very high suicide rates in 2006 which unfortunately have worsened. Not only were the difficulties highlighted, but the solution was set out. In addition, the expert group said that it did not trust governments and it recommended the establishment of an implementation body. This body was set up for two different three-year periods. I have highlighted this aspect repeatedly and I am not taking particular issue with this Government because it relates to every Government. That is why an independent body, entirely separate from the Mental Health Commission, was set up to monitor it. Every time the body reported during those two three-year periods, it praised the progress that had been made and highlighted the tardy implementation of A Vision for Change between 2006 and 2016. What did the Government do with that information? It disbanded the implementation body because it was telling the truth and stating that the Government was simply not implementing A Vision for Change.

Since I have come to the House, I have heard people speak with the best intentions about a system that needs to be changed, but I take a different view. The vision and the policy are there. Of course, they need to be updated to take account of the complexities of what Deputy Browne proposes in his Bill, but the vision, documentation and solutions are all before the Minister of State. We were told we would get the review practically every month but we still have not got it. The Minister of State has given me a written reply and a timescale, but it has taken constant pressure. I do not know where the fault lies and I am not interested in that at this point. My real point is that it is there to be implemented and, therefore, we must ask why that is not happening. If we are told it is because of cost, that is not accurate because the report of the expert group points out in page 5 the cost of not implementing A Vision for Change. This is something I have highlighted repeatedly. As in the case of domestic violence, there is a cost involved in not doing something.

While I do not want to look at mental illness or services in terms of economic costs, it is important to note the estimated economic cost of not implementing the policy to balance the argument that it costs too much and we do not have the money. In fact, one cannot afford to fail to implement it because it costs the taxpayer more in the long run, not to mention the upset to the people who are not getting proper treatment. The report stated that the estimated economic costs of mental health problems were considerable and amounted to at least 3% to 4% of the GNP across the member states of the EU. The report stated that the total financial cost of mental health issues in Northern Ireland had been estimated at £2.8 billion. Translated to the Republic of Ireland on a pro rata population basis, the economic cost of mental health problems in Northern Ireland suggested a total annual cost here of €11 billion. I ask Members to listen to those figures, which are not mine. We simply cannot afford to fail to deal with the treatment of mental health.

Not only have we failed to reinstate the implementation body, but we are also now aware that of the 165 recommendations made by the other body that looked at this area, only one has been implemented. I know it is difficult for the Minister of State to come to the House to take criticism, as it is for any Minister, but I would have expected her to come to the House tonight to tell us why the other 164 recommendations have not been implemented. She has suggested that some of them are complex and need more study and examination, but not, presumably, the whole 164. Why have they not been implemented? The major additional problem cited in relation to the implementation of change was the lack of staff. Another difficulty has been the interpretation of the document, in particular and to be parochial for a moment, in relation to Galway and Ballinasloe. It was misinterpreted and led to the closure of a brand new unit in Ballinasloe, an issue with which the Minister of State is familiar on foot of representations made to her by Deputies from east Galway. We had to go through the misinterpretation of this wonderful document, A Vision for Change, to justify the non-opening of a modern, state-of-the-art facility in Ballinasloe, leading to extraordinary pressure being put on services in Galway. I welcome what I understand is a review and attempt at least to undo that decision but I do not know how far that has progressed. I mention it in terms of decisions being made for short-term reasons which are costly in the long term. The pressure on the Galway facility is impossible for me to describe. I do not wish to add hysteria or fear, and I have a difficulty with the concept of suicide patrols in Galway city, but people felt so frustrated that they actually resorted to such patrols in order to feel that they were doing something to prevent the high rates of suicide.

All of this was predictable. We need to stop talking and to get answers from the Minister of State as to why the implementation body was disbanded, why the 164 recommendations were not implemented, when the implementation body will be re-established and whether it will have comprehensive powers to monitor A Vision for Change, which remains in place notwithstanding the fact that in theory it ran out in January last year. Presumably it is the same guiding document until a new policy is put in place. Those are the answers I would have expected to hear replies to a year and a half later after having been elected to the House. There should be no more debates on this issue. We should be told what the problems are and then see a cost analysis of not implementing this. The figures have been extrapolated from Northern Ireland, but it is time for a cost analysis here of the failure to implement the wonderful policy that has been there since 2006.

According to the Healthy Ireland Survey 2015, some 10% of the Irish population over the age of 15 has a probable mental health problem at any one time. There is no one in the country who does not have somebody in their lives who has an issue with mental health, whether it be depression, anxiety, stress, alcohol issues and-or drug issues. The Government needs to realise fully its commitments to mental health and adequately invest in mental health and update legislation to improve the mental health outcomes of adults and children living in Ireland.

It is shameful that only one out of the 165 recommendations contained in the 2015 report of the expert group on the review of the Mental Health Act 2001 has been implemented thus far. We need to recognise the importance of treating mental health patients with dignity and place the autonomy back in their hands. The Bill would ensure people received the least restrictive care possible. It strengthens the rights of people when they are in hospital for mental health care and would support the rights of inpatients to make decisions about their own treatment. It must be welcomed.

The Bill would also give children advice on their care when in the mental health service. It recognises Article 12 of the UN Convention on the Rights of the Child. Following on from this, I urge the Government to take action immediately to stop such children from being admitted to adult-only institutions. Communities are doing all they can to raise and improve mental health awareness, which will be seen in places such as Clonakilty, Skibbereen, Dunmanway and Castletownbere this weekend with the Darkness into Light walk being supported by many people.

Mental health patients can no longer be seen as objects. They must be involved meaningfully in making decisions about their treatment and care. Any legislation which seeks to increase the standards of mental health care in Ireland must be welcomed. I urge my fellow Deputies to vote in favour of the Bill.

I thank Deputy Browne for tabling the Bill and stimulating the legislative changes required to amend the 2001 Act. It is important we stimulate these changes. The Bill proposes important changes to the Mental Health Act 2001. It highlights the need to bring forward substantial additional amendments to the Act. The review group on the 2001 Act outlined 165 recommendations, but only one of these has been delivered on so far. I know the Minister has committed to introducing legislation to bring forward many of these amendments. These recommendations are needed to ensure Ireland is compliant with European Convention on Human Rights and the UN Convention on the Rights of Persons with Disabilities. The Bill intends to strengthen the rights of patients in hospital for mental health care, to provide safeguards to their rights to make decisions concerning the type of care offered to them and to ensure there is a presumption of capacity to make decisions regarding their treatment. Only exceptional circumstances should interfere with this capacity. There are quite often exceptional circumstances which do interfere with their capacity to make decisions, and this must be interwoven into the Bill.

It is important that patients are given the support they need to make decisions in an informed way and that all forms of treatment are explained to them in clear and unambiguous terms. It is essential that voluntary patients should have the same protection and oversight as involuntary patients to have their treatment and reasons for admission examined and reviewed. The Bill endeavours to ensure their best interests are additionally guaranteed through the guiding principles of the Assisted Decision-Making (Capacity) Act and by empowering patients to be decision-makers over their own care. It also endeavours to ensure the right to have the highest possible medical care provided and the right to the least restrictive care possible. Patients with mental illness, including dementia, need to be protected and have their rights guaranteed, and advanced directives should be encouraged to have their wishes clearly understood when capacity is lost.

The Bill is intended to copper-fasten the rights of patients who have voluntarily entered care to improve their mental well-being. Informed support and consent must be ensured to underpin patient autonomy and integrity.

I thank Deputy Browne for tabling this very important Bill on the agenda so we can highlight what needs to be done to help people with mental health issues. I have highlighted this in Kerry many times. We have a wonderful new facility which in June will be complete and fully built for two years but is still not open. Public representatives and many others were taken on a tour of this wonderful building. It is a state-of-the-art building but, sadly, it still has not been opened. We have a Government and five Ministers with responsibility for health. I ask one of them to unblock whatever is causing this building not to be opened. We are not giving people with mental health problems the service they require or looking after them properly when this building is not opened. It is to service all of east Kerry and much of north Kerry.

I also ask that the special purpose building to be built at University Hospital Kerry in Tralee be put in place. We have been asked by the people to provide these facilities. I ask again that the building on St. Margaret's Road, which was completed two years ago and is still not opened, be opened right away. Either we have a Minister for Health who is in charge of health and does something about this, or he is not in charge at all. We were guaranteed money to open it in January but it is still not opened. I am afraid it will not be open this time next year if some Minister does not take command and control and states it must be opened and no two ways about it. I have asked many times about it, as has Deputy Michael Healy-Rae, but nothing has happened and it is still closed.

Next Friday night we will have all of the wonderful people out on the Darkness into Light walk to collect funds to help people, and they will do a great service by doing the walk. It is a unified approach because, as Deputy Collins said, every family has been touched by mental health issues or the loss of someone through suicide. I ask the Government to ensure Deer Lodge on St. Margaret's Road, which cost millions of euro and is lying empty, be opened right away and that one of the five Ministers takes charge of it and ensures this happens.

I welcome the debate and commend Deputy Browne. As Deputy Connolly said earlier, we have many debates in the Dáil but, sadly, nothing has changed in many areas. The mental health report on Roscommon and Galway, which was promised in March, has gone on and on for months and months but has not been published. I spoke to the Minister of State earlier as to why it has not been published and she said it is coming near it, but it is a disgrace that it has not been published. Sadly, when we speak about mental health in the Roscommon area, we are closing the day care centres or trying to close them. I am being blunt about it and I am not blaming the Minister of State. The HSE is accountable to nobody. I speak to HSE people. They will tell people one story and do the complete opposite. It is unacceptable how they treat public representatives.

A simple change that needs to be done for people with mental illness is with regard to the fact that at present, if they need to be assessed, they must go to an accident and emergency department. We should have a system whereby they can go to any of the units and be assessed and not be put through 12 or 14 hours in an accident and emergency department.

There are hostels where people feel vulnerable. They do not feel they are able to live on their own, and in various counties at present they are being pushed to apply to the local authority for a house. It is a case of away with them and the community team will be sent out. In many places these community teams do not exist.

I say to all Deputies that we need to be careful and include safeguards. With regard to alcohol, which is sometimes intertwined, people may be trying to help somebody and their hands are tied at present. They cannot help them because every door is closed. I have seen it in my own family. I see it day in and day out.

People, including women and children and husbands, are beating their heads off the wall trying to help someone but there is nothing there to try to help that person who cannot see the situation he or she is in. Gardaí and doctors are afraid to touch anyone in the line of signing the forms or whatever to help people because of litigation. We need to do something. While some will talk about civil liberties and such, unfortunately some people cannot see the place they are in at a given time. We need to make sure we are helping them. I am not one of those who say everyone should be put away. I am not talking about that and people should not get that idea but I have seen myself, when one is trying to help someone, it is like fighting a tide the whole time in the health service, because it keeps saying that until a person is ready to do this, that or the other, it cannot do anything. Unfortunately, people have died because of that system.

I now move to the Green Party and Social Democrats, which have nine minutes. I call Deputy Catherine Martin.

Tá an Comhaontas Glas fíor-shásta tacaíocht a thabhairt don Bhille seo. This Bill put before us today is a welcome step towards creating a modern and patient-focused mental health care system. By changing the definition of consent in the Mental Health Act, we would be changing the provision of services radically. It would be an important step in destigmatising the process of seeking medical services for mental health issues. By giving control to the patient and allowing him or her to have a voice in his or her treatment, we take away some of the fears that face those who are in need of crucial services.

This Bill is not, however, an ending point in the discussion of consent reform or many other reforms that are so badly needed in mental health services. Instead, this Bill should be treated as a springboard for further necessary amendments to the Mental Health Act 2001. For instance, the 2015 report from the expert group set up to review the Mental Health Act 2001 recommended that section 56 be amended to include an understanding of consent wherein consent could be accompanied by the support of a family member, friend or appointed carer, advocate or support decision-maker. This recommended measure, which is not included in the Bill before this House, would be a strong step towards building a truly patient-focused service and creating an atmosphere of holistic support for the patient.

This is just one recommendation out of 165 recommendations put forward by the expert group. However, so far, only one recommendation has actually been implemented by the Government. To make matters worse, no further implementation seems to be on the horizon, as the Government has not placed any of the recommendations on its legislative programme and has failed to meet its own timetable for updating, modernising and reforming the Mental Health Act. This is yet another example of the Government's heel-dragging approach to mental health reform. Why convene an expert group, ask it to review the Mental Health Act in detail and have it publish a thorough list of recommendations if the outcome is a document that is left to gather dust?

Over the past year, I, like so many Members here, have spoken on the topic of mental health in this House. Regrettably, the recurring theme is that of inexcusable delay in implementing recommendations, in funding and in bringing about meaningful reforms. As the Government hesitates in reform of mental health services, ever more vulnerable people are left with services that are simply not up to standard. The Government must instill urgency into its actions. At this stage, many of the various stakeholders concerned are understandably and justifiably sceptical, if not a little bit cynical about words and about cherry-picking reform. Words alone, piecemeal reform and tinkering around the legislative edges are symptomatic of the Government's whole approach to mental health.

While I welcome Deputy Browne's Bill, what is urgently required is a seismic governmental change and new direction in policy approach. There remains no evidence of the Government delivering a proportionate and appropriate response to the scale of this complex problem and ongoing huge challenge. The inaction by this and consecutive Governments is one of the shameful scandals of modern Ireland.

I welcome the opportunity to speak on this Bill. It proposes a number of positive legislative changes. In particular, it will help to ensure that when a person is in need of help, his or her basic human rights are not denied and his or her dignity and care is provided for and protected. The Bill looks to replace the existing principle of best interest under the Mental Health Act 2001 for adults but just as importantly, it seeks to reaffirm support for persons under the age of 16. The terminology, as others have noted, has been interpreted by the courts paternalistically, to the extent where the views of a doctor have been given priority over the views of service users. That interpretation has essentially removed a person's rights. This Bill will bring the Mental Health Act 2001 more into line with the progressive Assisted Decision-Making (Capacity) Act 2015.

The expert group that reviewed the Mental Health Act 2001 made 165 recommendations, as has been said by one speaker after another. Only one has been acted on. We need to have it outlined how the majority of those recommendations will be fast-forwarded. It is all very well talking about consolidation legislation but many of the initiatives in that review do not require legislation. It is critical that people in need are given the help and the authority to make decisions about their own care. The Bill allows for the participation by a person to form a bigger picture of what is best for that person and to guide him or her where that decision-making is needed. No two cases are going to be the same. It is important that there is that flexibility.

I want to draw attention to the issue of youth suicide, on which I have spoken a number of previous times. That is where we really are outliers in Ireland. We have a very significant problem here and have the fourth highest level of youth suicide in the European Union. There is a very good, albeit flawed, strategy called Connecting for Life. A mother came to me and showed me some elements of the report she would like to see changed. She was concerned about the discussions that could happen with a trusted adult, for example, in schools. The parent mentioned that page 115 of that strategy encourages - I underline the word "encourages" - schools to deliver but that does not make this mandatory. She wanted to get across the point that we need to have in-service training for teachers in addition to a module within the teacher training programme. That is not something that needs legislation but which could be done very easily. She made the point that the problem with suicide clusters was that youngsters were talking to each other in language of emotional immaturity and that we need a wider engagement.

We need a structured coping mechanism in schools to provide that kind of engagement. She wants that kind of initiative to be made mandatory as opposed to being encouraged. She made the point that when such an initiative was taken with issues such as teen pregnancy, the HSE made a strong argument that the strategy had worked and there was evidence that the strategy had worked. That mother was someone who had been touched by this because her son unfortunately had taken his own life as a teenager. That was very raw for her when she came to me. She wanted to make sure, as far as she could, that this would not happen to another family and where there were things that could be done, they should be done. It was a simple request for it to be taken up at both in-service training and in the teacher training module. That is not something that would be hugely costly financially but when one looks at the huge devastation in individual families that experience this tragedy or at the ripple effect on the friends of the person who has taken his or her own life, it is inexcusable that something as simple as that is not made mandatory where it can make a significant difference. I hope something like that will be taken on board and acted on.

Mental health issues continue to silently inflict immense damage on our country. The undercurrent of depression, anxiety and addiction is a profound, ingrained problem for society. No family is untouched by some form of mental health issue. Beyond the striking statistics on suicide levels, the affliction of depression is exacting a hefty toll on the day-to-day lives of countless people. We have successfully confronted dangerous challenges like this before. This Mental Health (Amendment) (No. 2) Bill 2017 which Deputy James Browne is bringing forward - I compliment my colleague on the amount of work he has put into this area - seeks to implement many of the recommendations contained in the 2015 report of the expert group on the review of the Mental Health Act 2001. The Bill will deliver immediate improvements and legislative protections for adults and children accessing acute mental health services. The Bill supports the right of inpatients to make decisions about their own treatment, with recent laws that affirm that everyone should be presumed to have the capacity to make decisions. This includes providing people with the support they need to be able to make decisions, and putting the person first.

"Putting the person first" are the four most important words that can be said here today. I am lost for words today. I am in despair, because today in Dungarvan, County Waterford, 16 beds at the Sacred Heart unit in a community hospital were closed. These beds provided vital rehabilitation, long-stay and respite facilities for many patients. We should be opening facilities at this stage, not closing them. It might be asked how I can link this with the Bill we are discussing. We have people with intellectual disabilities, dementia, older parents with adult children with Down's syndrome and dementia, people with mental health issues, and they depended so much on that week of respite once every six months in order for them to be able to continue caring for their loved ones. I find it very difficult tonight. The reason given for the closure of these beds is that in 2017 nursing levels are at crisis point and patient safety is at risk.

I was shocked to see this week in a survey undertaken by the INMO that 85% of all graduate nurses who are training at the moment are considering leaving the country. This morning, during questions on promised legislation, I said to the Taoiseach that a tsunami is coming our way in terms of recruiting doctors and nurses to look after our people. It is a huge issue. The pace of reform in our mental health service is far too slow and this Bill seeks to address this problem.

I am glad to have an opportunity to speak on this Bill, which I genuinely hope will deliver immediate improvements and legislative protections for adults and children accessing acute mental health services. I am appealing to the Minister for Health, Deputy Harris, and the Government to address waiting times, in particular for child and adolescent mental health services. We need increased staffing urgently. There are currently 480 children on the child and adult mental health service, CAMHS, waiting list in the community health care organisation area one, some 87 of whom are priority cases. There is one specialised child psychiatrist in the region who is working 24 hours a week - a retired person. We are lucky that this person is there to deal with these priority cases. Despite his best efforts, he has only seen around 40 children, which really and truly is not fair.

I met six parents last Saturday who have children waiting for these type of services. I understand that doctors had been instructed not to refer any more children because they do not have the staff to deal with them. I know there are ongoing efforts to recruit a full-time psychiatrist, and there is difficulty right across the country on this issue. Whether the pay structure needs to be looked at or something else, something has to happen very soon on this matter. There is no doubt that the area is not given sufficient priority. The families I met are frustrated and at their wits' end. They are under severe pressure. All they want is a roadmap as to where they go, whether that is A, B, C or D. These families cannot even get to stage A, when their children are referred. As the Minister of State knows, unless the children are referred, they do not progress to the next stage. That is the way it is, unfortunately, in the area that I represent. I implore the Minister of State to see what can be done to have these children assessed and to try to help and support these parents, because they are definitely at their wits' end at this point in time.

Every day I hear from family members who are finding it difficult to access mental health services. Despite some excellent services and dedicated staff, the supports are sporadic and not always fit for purpose. There is a prevalence of mental health difficulties in Ireland and we need to start acting on implementing international best practice. Two weeks ago, I was contacted by a friend, a parent who spent 12 hours in Sligo with her child, a 13 year old who was suicidal and who had been systematically failed over a year of self-harm events. It is very hard to stand over anything like this. The next day, the woman and her daughter, bearing a letter saying she needed a bed for assessment, spent a similar time in Galway accident and emergency unit and was turned away. There are no beds for children at the moment in need of psychiatric inpatient help. There are no beds in the whole area. This is what is happening on the ground. I implore the Minister of State to try to deal with these issues. It is not just in my area, but nationally. We should try to understand the hurt and annoyance these parents feel, and the stress they are under. I could see that in my clinic last Saturday when I met these parents. Regardless of cost, this needs to be addressed and addressed urgently.

I commend my colleague on bringing forward this Bill. When a patient is admitted to hospital with mental health problems, he or she is at their most vulnerable, and any Bill that will strengthen their rights has to be welcomed and has to be implemented as quickly as possible. Like Deputy Butler, my county was hit today with the closure of more beds. In a county which has been badly hit in the past number of years by lack of services, it is very hard to take.

I intend to be parochial in what I am going to say. Tipperary has been extremely poorly served as regards mental health services. Two months ago, a delegation met here with the Minister of State at the Department of Health, Deputy McEntee, to try to see if we could get a Jigsaw initiative for our county. No decision has been made as yet on Jigsaw initiatives to be implemented this year. Considering the lack of resources in our county, I implore that Tipperary be favourably looked on for this Jigsaw project.

It is hard to imagine that a county of our size has no psychiatric beds. In the south of the county, patients with mental health problems have to go to Kilkenny and in the north of the county they have to go to Ennis. The difficulty this imposes on families is just not good enough, considering that all these facilities have been taken out of our county. We are told that this country has recovered economically. If that is the case, it is definitely not being shown in the resources allocated to our county.

In my town of Thurles, we have a centre that caters for a catchment area of 34,000 people. The lack of resources and staff in that service is hard to comprehend. Over the past 12 months, there has been no psychiatric counselling available in that mental health centre nor occupational therapists employed. There is no point having a service in name without putting the proper resources into it. We talk a lot about mental health in this House.

Unfortunately, it strikes on every door and hits every neighbourhood and community. Unless we put the proper resources in place, we will not make inroads into the problem. My county has been very badly served in the past number of years, with resources after resources being taken away. We have one of the highest rates of suicide in the country and I implore the Government to look at Tipperary and put some resources in place for mental health issues there, so that we can address this plague which affects modern society.

I am sharing time with Deputy Tom Neville. On behalf of the Minister of State, Deputy McEntee, and the Government, I thank Members for the wide-ranging discussion and suggestions put forward in this debate. This is an important debate which addresses our common desire to ensure that our mental health legislation is as fit for purpose as it can be and meets the highest international standards. There is no doubt that the subject of mental health, in all its aspects, is a priority for all parties represented in the House. Needless to say, when the particular mental health topic is legislation, it is only right and proper that all Members of this House be afforded the opportunity to have their say on how best we can proceed to amend such legislation.

I echo the Minister's earlier comments and thank Deputy James Browne for introducing this Bill. It not only reflects one of the clear priorities for the Government, but is also a strong reminder that stakeholders in the area of mental health want to see progress on the general scheme of the Bill to revise the Mental Health Act 2001. That point has been well made and is accepted on this side of the House. As the Minister of State explained earlier, work is under way in the Department of Health on changes to our mental health legislation, both in the short and medium term. The priority in the short term is to amend the current Mental Health Act 2001 to change the definition of voluntary patient to ensure that such patients must be able to consent to such admissions and treatment.

In the medium term, work is continuing on the general scheme of a Bill to amend the Act on the basis of the comprehensive recommendations of the expert group review of the Act. This is a complex piece of work and it is expected that the finalised text of the Bill will be significantly progressed by the end of the year. The change to the definition of "voluntary patient", which is included in Deputy Browne's Bill, must be accompanied by putting in place appropriate safeguards to ensure that those persons without capacity or a mental disorder as defined in the 2001 Act, but who require mental health treatment, can also continue to access such treatment. The Minister's intention is to introduce such safeguards as part of the deprivation of liberty safeguards also being developed at this time. It is absolutely clear that the two changes must commence simultaneously and because these changes are also required in order to be compliant with the United Nations Convention on the Rights of Persons with Disabilities, this will remain the priority of the Minister of State and her officials.

That, of course, is not to say that the other changes are any less important and the Minister has accepted that these can be discussed further, both in the context of this Bill and in light of progress made on the general scheme of a Bill. In this regard, Members must acknowledge that many of the provisions and sections of the 2001 Act are interconnected, so to make changes on an isolated basis is not always possible. At times, a change in one area is only possible when other related changes are made. That is why it is often better to make such changes as part of an overall package of measures as proposed under the general scheme of the Bill now being prepared.

Members can be assured that the Minister of State, Deputy McEntee, and her officials will review all the comments made here this evening in the context of Deputy Browne's Bill and they will bear these in mind as work progresses on both the short and medium-term mental health legislation objectives.

I commend Deputy Browne on bringing the Bill forward. I believe stigma is starting to break down but we still have a long way to go. It is probably different in different generations and I am very heartened by the fact that teenagers and the younger generation are much more open in the area of mental health. My own age group is not so open and older people are probably less open again. That is not the fault of anyone but is a culturally entrenched belief and we must continue to break it down as best we can. Discussing it in the Dáil is very welcome, as has been said many times tonight, particularly for the people who are watching. I want to be mindful of the sensitivities of people who have been affected by the issue.

This is an all-Ireland challenge. I do not want to be political but the suicide rate in Northern Ireland is the highest in the UK, at 16.5 per 100,000, though that does not take away from the challenges we have in the Republic. There are different complexities in the North but we have to be mindful of it and we have to try to be as apolitical on mental health as we possibly can be, even though politics will creep in at times, as this is in the best interests of our country.

I welcome the development of Jigsaw in Limerick and the mid-west region. We must be mindful that stigma leads others to avoid living, socialising, working and renting and getting employment. People with mental disorders, especially severe disorders such as schizophrenia, have low self-esteem and suffer isolation, while hopelessness deters the public from seeking and wanting to pay for care. On the matter of stigma, people with mental health problems internalise public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment. This is the kernel of stigma and we need to keep combatting it. There is a lack of knowledge, negative attitudes and hostile behaviour.

Why do individuals stigmatise? The website of Aware contains the following:

Sadly, stigmatisation is actually a natural part of the human condition. When one is faced with something unknown, the natural reaction is ‘fight or flight’. In such a scenario, we make decisions rapidly, making general assumptions about what’s going on and filling in any blanks in our knowledge with other information which we do not actually know to be true. We sometimes tend to fill in these blanks based on previous stereotypes.

We must really get behind stigma and understand it if we are to articulate the issue and combat it. The effects are shame, blame, secrecy, isolation, social exclusion and discrimination and we need to focus on that. We need to find the pillars in this area and eradicate stigma. We are starting to eradicate stigma in how we discuss mental health, and particularly in how we discuss it in front of others, and that is welcome, but we now have to eradicate self-stigma so that people are comfortable opening up and approaching the services to speak about their challenges. That is the next phase, something which some commentators have stated in the past six or eight months, but it is a long process.

There are other models which operate in conjunction with the medicinal models. One of these is the creative arts and I am a great believer in what the creative arts can do for mental health. They focus on relationships, meanings and values. Art is therapeutic and art, drama and poetry offer space where meaning can be generated and confidence encouraged. It is open-ended and ambiguous, which helps. How many times have we heard of artists finding inspiration from their own mental health challenges and using them in their art? Creative people bring a different perspective, open-endedness and comfortable ambiguity and these should be used in conjunction with therapy. I am open to correction by people with backgrounds and qualifications in medicine but, following my own research into the subject, I am a great believer in using the two approaches in conjunction.

We have to examine, and keep examining, dual diagnosis, such as of addiction and mental health, and we have to attack it. We need to take advantage of the integration between both and to use the pilot projects which have been done.

Deputy Browne and I are members of the cross-party mental health committee and have seen how these pilot projects are using dual diagnosis in combating addiction and mental health issues. That integrated approach is something that really needs to be addressed.

There is huge complexity regarding the use of alcohol. Those affected may be the loved ones, offspring or partners of those with alcohol or drugs problems. Recreational drug use has increased dramatically in the past 20 years. As a society, we are seeing greater use of synthetic drugs and this must be combatted. I welcome this debate but I must ask that we continue to try to combat stigma in a big way.

I call Deputy Rabbitte, who is sharing time with Deputies Troy and Browne.

I thank Deputy Browne for bringing the Bill before the House. While conversation is important, so is the action which must accompany it. Of the 165 key recommendations, one has been implemented. That has been stated repeatedly during the debate. The one action before us tonight could be the springboard to further actions if the Bill could see its way through the House and into committee for discussion. I call on all parties to support what has come before us. As other Deputies stated, we have all looked for the conversation and sought the opportunity to discuss it further. The people looking in here and those in the Gallery want us to stop talking and to start taking actions. This should be the springboard to bring it further.

Deputy Harty referred to it as a stimulant. Speaking on the plinth earlier, Deputy Browne said it was an opportunity to poke the Government into action. Deputy Butler said that no politics should come into play and that we should all sit down and work together. I would love us all to sit down around the table and leave politics outside the door because people are really suffering. Their lives are in our hands and they are looking to us to come up with solutions.

There are 82 unfilled positions in CAMHS. One of my colleagues said that people are travelling from Sligo to Galway and being refused entry or do not have the opportunity to access it. A previous speaker mentioned that St. Brigid's Hospital was closed. We are talking about the closing of beds in Waterford. Doors are being closed everywhere. As legislators, we do not want to send out the message that we are closing doors on the most vulnerable. We need to tell people that we are here to listen and implement. One of the actions we should take is to vote this through. We should start the conversation piece. We should start bringing it forward.

I welcome the opportunity to contribute. The frequency of debates on mental health matters during Private Members' business in this Dáil indicates the seriousness of the issue. We need to redouble our efforts to promote and tackle the issue of positive mental health. While the Bill acknowledges that nothing stands still, that legislation needs to evolve over a period. This legislation would enhance that which was enacted in 2001. While enhancing and improving legislation is a positive thing and it is what we are here to do, we must also ensure that any improvements in legislation are backed up with adequate resources.

This weekend, many of us will participate in the Darkness into Light event along with tens of thousands of other people throughout the country. That is happening because the State is not adequately funding the services that are needed. There is anecdotal evidence to the effect that because the HSE services are so overwhelmed by the number of people who rely on them, the executive is referring people to community groups. The problems are deeper and more psychological and need more than some counselling services that are provided in the community. Community groups have been punished for the actions of Console. Good to Talk in Longford and Mullingar has been punished because of the actions of Console. When people finally get in-service treatment, no aftercare services are available and they are then referred to the community groups which are overwhelmed.

I understand that Connecting for Life is to be upgraded over the coming months, either by the end of this year or the beginning of next year. We need to seek input from the various community groups that are filling the void being left by the State's failings in order to ensure that we have a proper structure and a proper set of standards across all community groups so that the people who rely on them are getting the best service.

I have listened to the contributions and powerful statements from across the House. Compassion and understanding have been shown in a very constructive debate, for which I thank all my colleagues. There is significant agreement on what is required in mental health, which adds to the frustrations for the mental health service users and providers. Unfortunately, mental health remains a blind spot within the Department of Health.

The Bill is about citizenship. It is about empowering our citizens to participate fully in society and about being able to exercise their rights within society. This means having appropriate law, such as that before the House. It also means being able to access resources and, as Deputy McDonald mentioned earlier, having the advocacy supports so that people can exercise their rights. We want to get to the stage where people with mental health issues feel comfortable saying that without judgment or fear. If they are brave enough to reach out for support, the services must be available to them when they are needed.

It is often stated that one in four people suffers from a mental health issue. In reality, however, the figure is four in four. When family, friends, co-workers are taken into account, everybody is affected by mental health issues. I accept the Minister of State's bona fides in this area. However, the Minister, Deputy Harris, and the Department need to step up and provide the supports mental health needs to make it a priority, to make comprehensive legislation a priority and to make the empowerment of our citizens in care a priority.

The contributions to the debate indicate support for the Bill. However, 140 Private Members' Bills are in the system. I hope this Bill will also be given priority. I acknowledge that the Bill is not comprehensive, nor would that be possible for legislation from this side of the House. However, it makes important changes and I hope it will stimulate the delivery of a comprehensive mental health Bill. I hope the matter will be brought before the committee for detailed consideration as soon as possible.

I again thank all my colleagues for their constructive contributions. I thank Mental Health Reform for its support. I thank the people in the Gallery, those at home who are watching and listening to the debate, and everybody who is affected by mental illness.

Question put and agreed to.