That Dáil Éireann shall consider the Report of the Joint Committee on the Future of Mental Health Care entitled 'Interim Report of the Joint Committee on the Future of Mental Health Care', copies of which were laid before Dáil Éireann on 12 December 2017.
I thank the Minister of State with responsibility for mental health and older people, Deputy Jim Daly, for attending to debate the committee's interim report on the future of mental health care. I also thank the members of the Joint Committee on the Future of Mental Health Care who contributed to the production of the report. The report was unanimously agreed by the committee at the committee's meeting on 6 December 2017 and I am delighted that it is now the subject of a debate in the House.
The Joint Committee on the Future of Mental Health Care was established in July 2017 with the aim of achieving cross-party agreement on the implementation of a single, long-term vision for mental health care and the direction of mental health policy in Ireland. This interim report outlined the committee's proposed goals, work schedule and approach to its work. The committee held a number of initial briefing sessions to inform its work. On the basis of those sessions, the committee formed the view very early on in its deliberations that it is necessary for a permanent Oireachtas mental health committee to be established in order to have ongoing accountability, particularly in the context of funding. The establishment of a permanent committee was the main recommendation in the committee's first interim report.
From the outset, the joint committee identified three main areas of focus, namely, primary care, recruitment and funding.
Since the publication of the first interim report, the committee has gone on to examine these areas in detail and has heard a number of presentations from relevant stakeholders. The committee also requested written submissions from a number of relevant organisations. These presentations both oral and written assisted the committee greatly in the publication and launch of the committee’s second interim report on 26 April.
The committee’s further examination of these issues has cemented the view that a permanent Oireachtas mental health committee is required. The committee calls on the Minister to ensure this happens once this committee has finally reported in October.
The second interim report contains a list of 35 recommendations which it believes need to be acted upon in order to ensure a positive future for mental health care in Ireland. As stated in the report, the order of the three thematic headings is not coincidental. The committee has realised in the course of its deliberations that primary care, which is vital to the efficient delivery of services, is hampered by problems with recruitment, which is tangled in a complex dynamic with funding.
The committee believes that in order to gain a clear picture of expenditure, possible deficiencies and areas for improvement, it is necessary to identify how the funding is being spent within mental health services. However, the committee was dismayed to learn at its first meeting with representatives of the HSE that it was not capable of subdividing mental health budgets in this way, therefore making it very difficult to ascertain what extra funding is required when we do not know how the existing budget is being spent.
Some of the stand-out figures the committee has discovered are as follows. The 2018 budget for mental health is €917.8 million, representing 6.4% of the total health budget and well below the 8.24% recommended in A Vision for Change and the 10% recommended in Sláintecare. In 1984 mental health funding represented 14% of the total health budget while in 2004 it was 7.34%. Ireland's proportionate expenditure on mental health is very low by international comparison which is 13% in Britain and Canada, and 11% in New Zealand.
The incidence of mental health appears to have increased substantially along with the population but the budget clearly does not reflect this. Successive mental health policy documents have advocated a move away for psychiatric hospitalisation. However, while many inpatient beds were removed - a reduction from 12,484 in 1984 to 1,002 in 2016 - the alternative treatment arrangements have not been adequately developed.
Throughout the committee’s deliberations, we repeatedly heard that recruitment and retention of staff are huge issues in the Irish health service, with the HSE using the excuse that health professionals can avail of better working conditions abroad. However, further investigation revealed a poor process of recruitment that would impede recruiting professionals because of the ineffectiveness and inefficiency of the recruitment procedure. If we are to retain the staff that are so desperately needed in the mental health service, the HSE needs to listen to the advice of experts, including staff working on the front line as to how to recruit at local level and how to improve working conditions that will encourage people to remain in their employment. Securing a sustainable flow of clinical recruits, who are incentivised to stay in Ireland’s mental health services in the long term, is probably the single most important challenge to be met by Government and the HSE in order to provide a robust, world-class mental health care service in Ireland.
The most startling gaps in service provision are felt in the child and adolescent mental health services. Representatives of the Irish Medical Organisation told the committee that its GPs describe the situation in CAMHS as “heart sink” and the Irish Hospital Consultants Association directly connects excessive waiting times for assessment in the area with staff shortages. Staffing levels in CAMHS is only at 56% of that recommended in A Vision for Change, a foundational report for mental health service design from 2006.
The committee recommends a number of actions regarding recruitment and retention of mental health staff, including to promote the use of flexible work patterns to retain staff; to amend the Medical Practitioners Act 2007 to allow doctors from other jurisdictions to take up training posts in Ireland; and to review the recruitment process particularly regarding recruitment being carried out on a national level rather than local level.
The practice of admitting children to adult psychiatric units needs to cease immediately by increasing the number of CAMHS beds available nationally. A Vision for Change recognised the crucial role of the primary care sector in mental health care. This report highlights that the current GP contract for the medical card system is now almost 40 years old. There is no provision in the contract for GPs to provide ongoing care for long-term conditions, including mental health conditions, many of which require and benefit from ongoing care.
Most mental health problems are dealt with in primary care without referral on to specialist services. However, significant gaps in the delivery of mental health supports remain. There is a lack of referral options for GPs to counselling, psychotherapy and family therapy or community health teams, resulting in over-reliance on prescribing medication. The Irish College of General Practitioners pointed out that less than €10 million per annum is spent on services such as counselling in primary care and yet more than €400 million is spent of psychotropic medication. The continued use of emergency departments as access points for mental health services is totally inappropriate. Only 60% of the 114 community mental health teams have a seven-day service. Providing primary care in a consistently available setting in which to access mental health care involves increasing staff levels.
Home-based crisis intervention teams should be rolled out nationally as well as increasing coverage to 24-7 mental health services in the community. These can only be increased by significantly increasing clinical staff in the community system.
The committee also recognised the special consideration that should be given to people from minority groups, who can be affected by unique issues. The committee feels it is extremely important for service providers to place a greater emphasis on mental health services for people from minority groups. The committee heard disturbing statistics which quantify the scale of the health and mental health problems which affect people from minority groups. Travellers experience a suicide rate that is six times higher than the national population. Traveller men are living 15 years less than settled men and Traveller women 11 years less than settled women. LGBTI young people have three times the level of self-harm, three times the level of attempted suicide and are four times more likely to experience severe or extremely severe stress, anxiety and depression. Some 56% of LGBTI young people between 14 and 18 have self-harmed and 70% have suicidal thoughts. Challenges are also faced by migrants in Ireland regarding mental health issues and accessing services to deal with them.
The committee found these statistics to be quite startling and has made the following recommendations. Supports and funding for Traveller-specific services should be provided. A specialist health unit should be established for transgender people which would remove the unnecessary reliance on services such as CAMHS for gender dysphoria diagnosis. Mental health supports should be integrated into the health programme for victims of human trafficking in Ireland.
Overall, the committee’s work has shone a light on the glaring inadequacies of the Irish mental health service, and the urgent need for action to be taken, particularly in the areas of primary care, recruitment and funding. I again ask the Minister to give consideration to the committee’s recommendation that a permanent Oireachtas committee on mental health be established.
In his appearance before the committee on 28 February, the Minister for Health said:
I see this committee as having an opportunity to scrutinise in a public forum the working of our mental health services. That is extraordinarily important.
There is much work to be done in this area and the committee is just getting started. The mental health services have some of the most dedicated staff in Ireland who are doing such important work. As any one of us might need these services at some time, we owe it to them and to everyone in the country to keep this important spotlight shining on mental health care in Ireland not just during the time of this committee, but in the establishment of a permanent committee.