Dáil Éireann debate -
Thursday, 10 May 2018

Vol. 968 No. 8

Report on Mental Health Care: Motion

Deputy James Browne

I move:

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 issues 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 from 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 must 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 on 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 healthcare in Ireland not just during the time of this committee, but in the establishment of a permanent committee.

Minister of State at the Department of Health (Deputy Jim Daly)

I begin by thanking Deputy Browne for introducing this motion. I welcome today's debate as an opportunity to restate the Government's commitment to our mental health policy and to the continued development and improvement of our mental health services. I am pleased to have this opportunity to speak on the action that has been initiated, and continues to be advanced, on this issue.

In recent years, there have been welcome changes in the area of mental health. We have witnessed a significant shift in our society's willingness to discuss and address mental health issues. It is now recognised that there is no health without mental health. This has been reflected in the Government's approach.

Mental health has been shown to be a priority care programme for the Government. Since 2012, approximately €200 million, or 28%, has been added to the HSE mental health budget which now totals over €910 million. This extra funding has permitted us to approve about 1,800 new mental health posts over this period. This is a significant investment by any standard and the Programme for a Partnership Government gives a clear commitment to increase our mental health budget annually, as resources allow, in order to expand existing services. Budget 2018 made allowance for an additional €57.5 million for mental health services for 2018. This funding will help us to build on the work commenced in 2017 on the enhancement of community teams for children, adults, later life and mental health intellectual disability services.

A Vision for Change, published in 2006, set out a ten-year policy framework for Ireland's mental health services.

It recommended that interventions should be aimed at maximising recovery from mental illness, building on service user and social network resources to achieve meaningful integration and participation in community life. It was welcomed as a progressive, evidence-based policy document that guided the development of our mental health services towards a new model of service delivery, one which would be service user-centred, flexible and community-based.

A Vision for Change highlighted many areas which were in need of increased attention in the shift from a service with an institutional focus to a community-based service. Implementation of A Vision for Change was undoubtedly affected by a number of factors after 2006, including the changed economic context, public spending constraints and the moratorium on recruitment. However, recent years have seen investment in this area prioritised and significant advances made in the reconfiguration and delivery of services.

In line with A Vision for Change, our focus continues to be on building the capacity of community mental health teams across all areas to facilitate the move from the traditional institution-based model of care to a more patient-centred, flexible and community-based service, where the need for hospital admission is greatly reduced while still providing inpatient care, as appropriate. Progression in other priority areas is also ongoing, such as the continued move towards the delivery of a full 24-7 service, work in the psychiatry of later life, perinatal mental health, ADHD in adults and children and dual diagnosis of those with mental illness and substance misuse.

While much of A Vision for Change remains relevant, its term came to an end in 2016. The Government recognised the need to update the policy in order that we can be assured we are adequately meeting the current mental health needs of Ireland. The establishment of the oversight group was agreed prior to the establishment of the Joint Committee on the Future of Mental Health Care. The commitment to review A Vision for Change policy was referenced in a Private Members' Bill speech on 15 November 2016. In addition, I understand that the review of the A Vision for Change policy is noted in the joint committee's own terms of reference.

With this in mind, the Department published a request for tender in August 2016 for a review and analysis of international evidence and best practice in the development of mental health services, including a review of current delivery of services in Ireland. In September 2016 this external evidence and expert review was commissioned from WRC Consultants as the first step in determining the parameters of a revision of A Vision for Change. This review was completed on 17 February 2017 and provides evidence to inform the policy direction for a revision of A Vision for Change, both in terms of international best practice and the experience of implementing A Vision for Change. An independent chairperson, Hugh Kane, was appointed in July 2017, with oversight group membership finalised in October 2017.

This oversight group is responsible for producing a high-level policy framework which sets out future service priorities. The group is overseeing the development of a refreshed policy for mental health based on the recommendations arising out of the expert review and other documents. The policy review process will also involve consultation with key stakeholders, which is due to take place in the coming weeks. The oversight group is scheduled to have completed its work by December 2018.

Concurrent to the progress of a review of A Vision for Change, on 13 July 2017 the Dáil agreed to establish a new Joint Committee on Future of Mental Health Care. While all-party agreement exists on A Vision for Change, the committee was established with the aim of achieving cross-party agreement on the implementation of a single, long-term vision for mental healthcare and direction of mental health policy in Ireland. Upon establishment, through the terms of reference the committee formally recognised that the Department of Health was simultaneously conducting a review of A Vision for Change. The terms of reference also commit the committee to examining the implementation of A Vision for Change, the current integration of delivery of mental health services in Ireland, the availability and accessibility of services and supports and alignment of services and supports, the challenges in the recruitment and retention of skilled personnel and the efficacy of establishing a permanent mental health Oireachtas committee.

To this end, I would like to recognise the substantial amount of work that has been completed thus far by the committee. The first interim report recognises the need for a collaborative working relationship between the Oireachtas committee and the oversight group and I am aware that a copy of the work plan issued to the committee in March of this year. While not the subject of this discussion, I understand there has been recent criticism about the relationship between the oversight group and the committee. It should be noted that both I and the Minister, Deputy Harris, have appeared before the committee, along with the chair of the oversight group, Mr. Kane. The joint committee has expressed concern that the HSE was not in a position to provide detailed financial analysis on how mental health funding was being spent and I welcome the committee's recommendation that proper systems be put in place without delay in order that detailed information can be made available.

Both the Department of Health and the oversight group are committed to obtaining the best possible future for Ireland's mental healthcare. I know the committee shares this sentiment and vision. It is through working together and supporting each other's work that this outcome will be achieved. Going forward, I hope this is where the focus shall be.

I would ask that today we maintain sight of our common goal of ensuring that the mental health needs of the nation are served in the best manner. The Government continues to be committed to the development of a high quality, person-centred mental health service. I welcome open and positive discussion on this important area and I look forward to the suggestions and constructive comments from the floor.

Deputy Mick Wallace

The interim report is ambitious in its scope but, I would say, cautious in its goals. The proposed staff and service provision increases are a no-brainer and, basically, no mental healthcare to speak of is provided by the HSE. There are three excuses for mental health provision in Ireland: locked up on drugs, drugged in the community and trapped on waiting lists. The report mentions these problems in passing but one gets the sense that the only thing that will change if the report is implemented is that the waiting lists for being seen might decrease.

The report acknowledges the lack of talking therapies available in Ireland and that there is an over-reliance on pharmaceutical interventions, but there is no mention of the problems surrounding these issues or the type of actions that will better this state of affairs. There is no mention of a lack of expertise and help provided by medical practitioners in weaning people off medication and dealing with after-effects. There is no mention of the negative effects or even the usefulness of antidepressants and other powerful drugs that are almost exclusively used alone for long periods with no auxiliary counselling services provided. There is no discussion of the types of talking therapy that need to be expanded, or discussion or evaluation of the types of therapy the HSE promotes at the moment. There is no mention of the fact GPs are allowed to prescribe drugs while the majority of them have zero training in helping people in distress. There is not a word of input from those who have survived the mental health services or who are going through them right now. There is an old saying that has been adopted by those who have survived mental health services, "nothing about us without us", the idea being that no policy should be decided by any representative without the full and direct participation of members of the group or groups affected by that policy.

Last week I spoke here about the dominance of the medicalised model of mental healthcare in the HSE and how GPs and psychiatrists were prescribing powerful antidepressants like they were fertiliser, all without so much as a question about what may be going on in the lives of those in emotional or psychological distress. There is a huge misconception about how these drugs work and around the idea that they work at all. They are nothing more or less than very powerful painkillers. Much like the dominant philosophy one finds in the HSE, they sometimes work on people to remove them from their pain and remove them from difficult and uncomfortable experiences in the short term. When the situation is a crisis, this kind of intervention can have a numbing effect which may help. However, a growing body of evidence is demonstrating that, as a long-term solution, it is not a good approach. Much better outcomes are achieved by helping people through their pain, by being there for the patient and by helping them to build the tools they need to confront their pain and trauma. This approach should be pursued by the HSE but, instead, we have set up a situation where patients are diagnosed with illnesses based on checklists and their pain is outsourced to the pharmaceutical business, while their underlying problems are buried where they cannot possibly deal with them.

What makes the situation even worse is that there are terrible side effects from taking these drugs that can last years. Aside from the fact that the class of drugs called SSRIs are known to increase suicidal ideation, as the clinical trials of the drug show again and again, sexual dysfunction is also a major problem with these drugs, with many people reporting, even after coming off the drugs, that they feel they will never enjoy sex again, which leads to further distress. There is a lot of misinformation, which leads to people continuing to take these drugs and downplaying the side effects.

The best at promoting these products are those in the psychiatric profession. Only two months ago the president of the Royal College of Psychiatrists and the chair of its psychopharmacology committee claimed in England's The Times newspaper that, for the vast majority of patients, "any unpleasant symptoms experienced on discontinuing antidepressants have resolved within two weeks of stopping treatment". This is not true. A formal complaint disputing this claim has been signed by 30 people, including ten psychiatrists, and the president of the Royal College of Psychiatrists has not been able to come up with any scientific research to back up the claim.

It is clear that there are disagreements within the psychiatric discipline about what forms of care have the best results for patients. It is frightening that powerful members of that group will put the lives of thousands of people at risk in order to protect the reputation of the pharmaceutical industry. Coming off antidepressants is extremely dangerous and should be done with the assistance of a professional. The idea of a two-week hangover is a dangerous one. Fortunately, there are other ways to address mental health issues but based on our office's experience with the CHO 5 top brass, and their lack of respect for the people with whom they work, it is hard to be optimistic about progress and reform in this area.

Two years ago, I spoke in the House about Open Dialogue, a mental healthcare approach that has been used in Norway for 30 years with amazing results. It has been successful in curing so-called schizophrenia and other mental health-related diagnoses. The Open Dialogue approach is about person-centred care, where the medical professional is present with people's distress and open to it. Most important, it ensures the person having the crisis is empowered and has the final word about how their care proceeds. The mental health professional goes on a journey with them and is open to going where they are and letting them decide what happens next. The whole system needs to be organised to facilitate this, especially in terms of continuity of care. The same professionals who are involved in the meetings when the crisis first arises are involved through the whole process of care. What we have now is very different because people go from team to team. If relationships are fundamental to care, why have we created a system that is like a conveyor belt? In Open Dialogue, the same professionals must engage with the social network of the person in crisis because the crisis is not just happening to the patient and trained staff must work with them mindfully. It is a whole-system change that puts the patient at the centre of care and empowers them and their social network to move forward together.

In the UK, the NHS is conducting a randomised control trial of Open Dialogue interventions in seven centres throughout the country. They are trying to see if they can replicate the success they have had in Norway and they have trained up to 400 people in Open Dialogue practice in their training centre in London to take part in the trial. We should pay heed to the results as they could be very interesting. To really change the system one needs a system-wide approach and not just a set of interventions and techniques. It is obvious that the system is going in one direction, that is, the medicalised one with the dominance of the notion of brain disorders, diagnosis and medication. This report may be calling for a few different techniques but, unless we change the direction of the stream, very little will change.

I would not lay this at the Minister of State's door. We have a lot of problems in this area. I think he is very interested in the whole subject but he has an incredible challenge on his hands to persuade the HSE to take a different approach. This goes for every section of the HSE. The organisation is a monster that is very difficult for any Minister to get to grips with in a short period of time. I wish him the best of luck with it.

Deputy John McGuinness

I pay tribute to Deputy James Browne on the interest he has shown in this area since his election to this House. I am also aware of the Minister of State's support for change in this area. I served with the father of Deputy Neville who is sitting beside him. Dan Neville also had great interest in this matter at a time when it was not being talked about and he brought great attention to it in the course of debates in this House. He focused on the need for change and I compliment him on doing that.

This report is very timely. Members have put a huge amount of work into it and it needs to be considered fully by the HSE. The implementation of a lot of the things in the report may cost money but it will save lives and will give better quality of life to the family and social network of the individual concerned.

Mention has been made of A Vision for Change from 2006. Unfortunately, that policy change was not followed through with the appropriate sums of money that were required. All over the country there are huge gaps in the service that is delivered at community level. This is further damaging the health of those who are out in the community but have very little support. I meet them regularly in Kilkenny and Carlow and I am sure there are Deputies in this House who also engage with the services in terms of how clients and patients are supported. The time has come for a significant move to be made in the context of funding. We need to examine where A Vision for Change is at. Demand on services is great but the service is simply not there for some people. I have witnessed individuals in distress and deeply depressed and upset over something that has happened in their lives but who cannot access the service. Someone in such a high level of distress needs immediate attention and care but they are told they cannot see a counsellor for six months.

I do not share Deputy Wallace's view on medication but neither am I in favour of the overuse of medication. A balance has to be struck. A lot of mental health issues are being faced by people because they do not have the service. In Kilkenny, the Teac Tom voluntary service is funded by people shaking buckets. It deals with referrals from the HSE as well as other referrals from GPs, or just people who turn up to request immediate support. They can deliver immediate access to a counsellor for an individual but the HSE cannot do it. The HSE tells us there is a wait of several months for such a service but the HSE refers people in distress to Teac Tom. When Teac Tom sought funding from the HSE, however, it was told there was no money in the budget, yet the HSE itself uses the service. Something has to be done to bring private operators, which are delivering a decent service, under the HSE or to allow them to work with the HSE. Their service is far more flexible than what the HSE can offer and maybe it is now time to fund them adequately so that they can pick up the slack when the HSE cannot deliver.

I have spoken to families of persons in distress who have been referred on to hospitals in Dublin but who stay there for the best part of three months. The only thing they get is medication. If it is difficult for them at some point during the day, they are given more medication. Families have taken family members out of such hospitals for fear of the high use of medication where it is not appropriate. I have seen the same patients engage with the community services, as limited as they are, and with the likes of Teac Tom and, over time, they gradually get themselves back to better health.

However, they do not receive the support or access they need in a timely fashion. Many are being moved away from an institutionalised setting, which is fine and is a good idea, but I am concerned that the necessary services are not in place and that they are being substituted by private businesses. I do not know how long the HSE can afford that, but that model needs to be examined in the context of the individuals who are living in community settings, trying to establish a life for themselves but not having the supports they need. I refer, in particular, to young people who are on the autistic spectrum. In terms of being cared for in the community, what plan has the HSE to assist those who are teenagers now but who will become young adults and then adults or those who might be left behind after their parents have died? I do not see the services being developed at the speed necessary to keep up with all those changes. It is a great concern that schools and so on that are funded are now working to capacity. There is no capacity in the system and there is a lack of professionalism within it. There is a lack of future planning for those on the autism spectrum, to whom I specifically refer. I find that quite shocking.

In the context of this interim report, one would imagine that a modern health service would be constantly planning for the next phase. For example, we should look back over the previous two or three years and then establish the plan for the following two or three years, bearing in mind the changes in modern medicine and treatments, including talk therapy and so on. I acknowledge the desire of the professionals in this area to do better and to go the extra mile for their patients, but it seems the HSE and the Department of Health, whichever it is, are incapable of establishing a programme with a review provision every three years. I find that difficult to understand, particularly in the area of mental health. I would say there is not a person in the House who has not been touched in some way, shape or form by the experiences of a person who has mental health issues.

The final point I make relates to our understanding of mental health. One does not know on seeing a person in this House or anywhere else in the workplace whether he or she may have a mental health issue. We have little tolerance of mental health and those with mental health issues in the context of our work in this House. We should have more understanding of the fact that within any workplace there are people with mental health issues who are trying to cope on a day-to-day basis. We need to be far more open in terms of how we deal with each other, be it here or anywhere else, because of the fact that it is deemed to be a weakness if one was to admit that one had a mental health issue. We have to get over that. As public representatives, we should be to the fore in ensuring that is the case. I commend the members of the committee on the work they have done.

Deputy Tom Neville

I thank Deputy McGuinness for his remarks. I agree with what he said about how we approach the subject of mental health and how we speak openly about it. Unfortunately, we have to contend with the fact there is still a stigma attached to it and it is quite prevalent. It is different among different generations or age groups. I am heartened by the response I get from younger age groups, particularly teenagers, when I speak to them about mental health, and I have spoken about that previously in the House. They are much more open about it. The next step is for people who are facing a challenge in terms of their mental health to be able to open up about it. As Deputy McGuinness said, that is what fosters an environment, culturally, where people will feel more comfortable in being able to do that. It is easy enough to talk about mental health, particularly in the third person, but it is still very difficult when it is personalised. That needs to be recognised.

I thank the Government for appointing me to serve on the joint committee. I commend Deputy Browne on the work he has done on this committee and echo his sentiments that the committee should be established as a permanent Oireachtas committee. We have shone a light on this issue in the six months or so that the committee has been in situ. We have turned over many pebbles and uncovered much of what has been going on, brought it into the open and put it in this interim report format.

Deputy Wallace mentioned a number of factors. I do not discount what he said but a more balanced approach is needed, depending on the person's clinical requirements and the type of therapy or mixture of therapies he or she may require. The interim report recommends that a permanent committee be established, which could approach all these issues as it would develop.

Issues highlighted by the committee in its work included management systems, including management information systems particularly around information technology and the way budgets and sub-specialty budgets are reported to those in government who are the budget-holders and give the money over every month. We could not be told about particular sub-specialties. I would refer to a response I got to a parliamentary question on 24 January last, which states:

The HSE's financial reporting systems do not provide for sub-specialty reporting and on that basis we cannot isolate specific spending on children's mental health services. The mental health division is working on a resource allocation/costing model that will allow more detailed reporting on service type when the project is completed.

That is a vague answer from HSE management on that issue. There are no timelines or any indication of when it will happen or where it is in the process. We, as committee members, are trying to get the answer to those questions.

Many of these systems were built ad hoc in recent years and are used as financial reporting systems. They will fulfil audits as they come up but regarding front-end budgetary terms, it is very difficult to see where this money is being spent, particularly where there are needs. We, as decision-makers, need to be able to get that type of reporting structure in place. That was very much highlighted by the committee. It was something of which I was not aware beforehand or in such detail.

Another point concerns recruitment. At our last meeting I proposed we would see an end-to-end recruitment process, in a diagrammatic form, in mental health services and how the stakeholders from all sides come into that. There are anomalies and delays in that process that are not helping with the recruitment of staff. I am not discounting that these are challenging times in terms of recruiting staff. We are in competition with other jurisdictions in terms of our very well educated and strong staff here in Ireland. However, to be able to compete we need to streamline our processes, particularly the recruitment process. We need to see that end-to-end process to determine how we can work more efficiently in that respect.

I have been told that the recruitment process can take more than 12 months. Posts are not advertised or flagged in terms of people who are coming towards retirement age and the end of their career. Those are the tangible solutions that can be put in place straight away as opposed to the longer-term solutions in terms of IT in which a vanilla-type or homogenous-type system would be in place which all the services could look up and which would be electronically integrated. Some of the staff still use paper trails. In terms of systems, it is like driving on a 1980s road when a highway or motorway is needed. Again, that can be achieved as that system is implemented, but we need a long-term plan. Such a plan could be integrated into the Sláintecare report on the future of healthcare and there can be synergy and integration in that respect.

At the outset, it was difficult for us as committee members to see how we would approach this task. There are 21 members from across all parties and the tack we took was to get behind the nuts and bolts of the implementation of A Vision for Change. That is the reason we are seeing the anomalies in recruitment and issues concerning IT systems arise again as well as the other issues outlined in the report.

The Government has made some moves on the issue of mental health. Spending has increased: the mental health budget will increase by €55 million next year. Schools are being resourced with a 300 hour emotional well-being module. I welcome the fact the Minister is working on a single dedicated phoneline and a digital and text service he hopes to roll out. The introduction of regulation for counsellors and psychotherapists will begin soon, which is to be welcomed. Jigsaw has opened in Limerick and Cork, which is a free service for people between the ages of 12 and 25. We are seeing a marginal reduction in suicide figures as well, which I welcome. Obviously the figures are still too high and I have the greatest of respect and sympathy for those who are affected by the issue. I am mindful of that while speaking. We want to move towards a 24-7 service based on that line. Some 112 assistant psychologists and 20 psychologists have been recruited at primary care level. We need to target that area. There is a problem at acute level in terms of waiting lists. The referral pathway has to be tackled, and the Minister has looked at tackling the manner of referral for people who have been left on waiting lists for a very long time. We have to improve at primary care level. We also have to improve mental health awareness and well-being. This issue is similar to the old scenario of the vitamin pill versus the painkiller. It is very difficult for people to engage with vitamin pills to stop the pain in the first place, whereas people will take a painkiller because it works straight away.

We need to start focusing on mental health awareness as a society. It should be promoted through the arts, through sport and community initiatives. We can do small things and make subtle changes which will have a huge, lasting effect for people. In my county there was a drive against suicide a couple of weeks back. The initiative is in its second year. It really connected with young men in their 20s, rural people whose pride and joy is their car. They connected with that drive against suicide, which was phenomenal. It created a sense of community and brought people together. It allowed people to address the issue and to meet people from different backgrounds and communities. These people then formed their own sub-communities. There are subliminal, knock-on effects that result from initiatives such as this. People are able to open up and move forward. These are the challenges we face as a result of the change in Irish society that has occurred over the past ten to 20 years.

I look forward to working with all the Deputies on this committee. We are scratching at the surface at the moment: we need to get into the issue in more depth. I look forward to the next report. The committee will address more issues as we go along, but this report contains the main issues that the committee began with. The committee itself has started to find its feet. It had a shaky start because we did not really know how to approach the issues. I very much hope that this will become a permanent committee to send a message that this area has been neglected down through the years, that it has not been spoken about enough, but that we will give it that profile, shine the light on it and hold people to account in front of an Oireachtas committee.

I am very mindful of the front-line staff who work in this area and thank them for their work. They work in very challenging environments at times, which I have learned from my time in the committee. While I have criticised management information systems and management organisation systems, I do not want to deflect from the fact that those working in the front-line service who actually deliver the service and work on a day-to-day basis, interacting with the patients, are doing a great job, and I want to pay tribute to them.

Deputy Willie Penrose

I extend the apologies of my colleague, Deputy Kelly, who cannot be here to speak on this motion. I compliment Deputy James Browne and the committee for producing this comprehensive and focused report. It is an invaluable contribution to this important area. As Deputy Browne said, it is a very important and vital first step towards addressing an area that has long been neglected and overlooked. It was often looked at as a Cinderella area in terms of budgeting. I recall my colleague, the former Minister of State, Ms Kathleen Lynch, having to fight extremely hard to maintain the €35 million that was earmarked for the area some years ago. She fought to the bitter end and held on to that funding.

On behalf of the Labour Party I genuinely welcome the publication of the interim report of the Joint Committee on Future of Mental Health Care. We are at a critical juncture as we seek to ensure the full implementation of A Vision for Change. The aim of the Joint Committee on Future of Mental Health Care is to engage with all relevant stakeholders and to achieve cross-party agreement on the implementation of a single long-term vision for mental healthcare and the direction of mental health policy in Ireland. We recognise that the Department of Health is simultaneously conducting a review of A Vision for Change, which in my view requires significant repair and refurbishment, with renewed focus and new objectives.

To put the matters in context, we are struggling with a situation whereby children are waiting 15 months to see a psychologist and 2,500 young people are awaiting access to public mental health services more generally. We have a crisis in the provision of child and adolescent mental health services, where patients are placed on lengthy waiting lists because of the serious lack of immediate counselling available. This is an important issue. Recently I discussed mental health with teachers, who informed me that due to an increase in mental health issues emerging in our schools at both primary and secondary level, for example social media addiction, suicidal ideation and the rise of suicide in young people, there is a need for professionally trained school counsellors or psychotherapists. The Government in the UK and Northern Ireland is investing serious sums to make sure that a counsellor is placed in every school. Counsellors are extremely important. They deal with young people who are having suicidal thoughts or who talk about contemplating dying by suicide. It is very likely that we would have a significant decrease in serious mental health issues among young people if we had those services available. It would be a positive, preventative measure to invest in accessible mental health services in schools rather than having to invest in intervention at a later time.

The recent survey carried out by Jigsaw and Headstrong, the My World survey, illustrates that young people need one good adult who they can go to for support or consult at various times. While in schools our teachers have provided that one good adult down through the years, all too often our teachers are stretched and do not have the time or resources to support our pupils in the way they would like to and in the necessary way. It is time to listen to the principals and teachers in our schools. They say that there is a huge need for school counsellors or psychotherapists in each and every school in the country. We should be positive and proactive in that regard.

We spend approximately €910 million annually on mental health services. That only equates to 6% of the total health budget, and in my view it is totally insufficient. It is approximately half of what is required. In other countries 12% to 14% is the norm. We are starting from a very low base. A more radical approach is undoubtedly required. Indeed, the committee has remarked that the most startling service area in which the gaps in provision are felt is in child and adolescent mental health service, CAMHS. The committee views the mental health of children as being particularly important, therefore it is clearly incumbent on the State to ensure a responsive and meaningful service to children, to be provided as soon as they experience any mental health difficulty. Unfortunately, currently this is far from being realised. This is a reflection of particularly low clinical staffing figures in CAMHS. It is disturbing to note the number of young people with mental health issues who have been referred to adult facilities. I have experience of that situation: it is something that has to be addressed in the 21st century.

The Irish Medical Organisation, IMO, told the committee that its GPs described the situation in CAMHS as heart-sinking. There is a direct link between over-long waiting times in the area with staff shortages, the relatively low level of child and adolescent psychiatrists and the general shortage of front-line resources as a result of an unacceptably high number of children on the CAMHS waiting list. The waiting times are too long. It is clear that solving the recruitment and retention crisis with healthcare professionals is going to be absolutely vital and pivotal to building a fair, equitable and available mental health service for all.

We have arrived at an ironic scenario whereby we have a significant number of medical schools, among the highest per head of population of any other country in the western world, and are near the top of the scale in terms of the number of doctors we export and import. It is a truly remarkable and baffling situation. We have to examine seriously why our graduates are choosing to go overseas. We are all aware of why that is the case and we have to try and address that. We are beginning to examine it now. A re-examination of career progression and training opportunities for healthcare graduates is going to be a cornerstone in re-imagining the mental healthcare system that we want to see in Ireland.

I certainly hope that Deputy Browne and his colleagues continue with the excellent work they have done in this area.

We need to move to a space where mental health is treated on a par with physical health. A motion in that regard was debated in the House last week. I think it was a British doctor, Martin McShane who, in 2014, succinctly described the issue of parity of esteem for mental health when he said:

To me parity of esteem means tackling mental health issues with the same energy and priority as we have tackled physical illness.

It is about changing the experience for people who require help with mental health problems.

It is about putting funding, commissioning and training on a par with physical health services.

And parity of esteem is about tackling and ending the stigma and prejudice within the NHS which stops people with serious mental health problems getting treated with the same vigour as if they had a physical illness such as, say, diabetes.

That stigma can be demonstrated like this [what Dr. McShane says next is interesting]: if you fall down and break your hip, an ambulance will be with you in eight minutes to give emergency care at the scene before taking you to A&E. If, however, you suffer an acute psychotic episode in the street, you are just as likely to be attended by a police car and taken to a cell.

We must end the stigma associated so often with mental health. We must raise awareness of the importance of mental health care and recognise the inadequacies of how we have regarded mental health in the past. This means raising awareness within the NHS itself. And we must create parity for mental health care in reality – rather than just issuing rhetoric and paying lip service to it.

I think that encapsulates where matters stand. If an NHS director is saying that in a jurisdiction where the authorities invest more, it is certainly a portent of how we have to raise our ambitions.

I wish to comment on the reference the committee has made to early intervention. Early intervention in psychiatric care is absolutely critical to reducing the severity of conditions, especially in the areas of depression and bipolar disorder. However, the principle is effective right across the board. The committee's recommendation of providing a psychiatric nurse for initial assessment is a welcome first step. This would serve to reduce waiting lists by filtering the people being directly referred to CAMHS and adult services without prior screening. Collaboration on a temporary basis between public and private psychiatric teams would also assist in achieving the goal of early intervention as a more rounded approach is devised.

In order for the aims of the committee to be successfully accomplished, we need to ensure that the stakeholder input outlined by Deputy Browne is continuously focused on and not just paid lip service. Real and tangible recognition must be given. I was concerned to read in the report that the HSE was unable to provide a breakdown of mental health spending by service area at the committee meeting on 22 November 2017. This is just one example of a number of issues raised by the members of the committee. The HSE and the Department of Health need to act prudently in terms of supplying the necessary information to assist the work being carried out. If they cannot do that, how can they plan for the future and bring about improvements?

I am not a member of the committee. Like Deputy Neville, I genuinely hope that a standing committee of the House will be established to deal with this issue. That would be an important step. There is not a family in this country that has not been touched. I spent eight years suffering from panic attacks. Indeed, I was brought out of this House on a stretcher on three occasions and taken to St. James's Hospital. It was a fairly sobering experience. A particular event triggered it and, as a result, I spent eight years suffering, almost crashing a car on one occasion. This is a significant problem. It affects everyone. The people we speak to may well be suffering and they may be doing so in silence, which is the worst of all worlds.

I look forward to seeing the final report when it is published later in the year. Mental health reform is long overdue. I am optimistic that with the help of colleagues here, and with a degree of goodwill, foresight, co-operation and strategic thinking, we can achieve a world-class service that our people expect and deserve. In that context, I again congratulate all the people involved in preparing this report. I hope that it leads to a significant improvement for all the service users in this area.

Deputy John Lahart

At the outset, I want to acknowledge the final comments made by Deputy Penrose. It is that kind of courageous contribution which helps advance the progress of the entire debate on mental health. I also want to acknowledge the work done by my colleague, Deputy Browne, on the Mental Health Parity Bill 2017. It is ironic to think that, in 2018, we are looking at the topic of mental health parity. However, I think we have come a long way.

I also want to acknowledge the role of the Acting Chairman, Deputy Durkan, who was here at the start of the debate and who is always here for the mental health debates. He inaugurated the mental health symposium at the start of this Dáil term. I know there is keen interest in the latter. Like Deputy Neville, I acknowledge the role of all parents, families, guardians, organisations, public servants, volunteers and particularly the front-line services, who keep our people mentally healthy by and large from one end of life to the other. Throughout their lives, they are there at key moments.

It has been stated that it takes a village to raise a child. That is certainly true. I am coming at this debate from a particular angle - acknowledging the value of every other contribution - but I will not incorporate my background because I have a limited amount of time to speak. It certainly takes a village to raise a child but, clearly, as we have seen from many of the scandals in this State over the last number of years, it takes a village to destroy a child. The HSE alone cannot solve this issue. Certainly it has to play a very key and very significant part in this.

I would like to quote, if I may, the poet John Milton. I quote him because of his insight when he said in one of his poems:

The mind is its own place, and in itself

Can make a Heaven of Hell, a Hell of Heaven.

Those words were written 350 years ago. I think they provide an insight that is sobering to listen to today. Mental health is not a new, 21st-century issue. There were wise people and sages around many centuries ago who recognised that people were not only physical beings but also had a mental aspect to their lives that was very significant. That insight is as valuable in 21st-century Ireland as it was 350 years ago.

Clearly, mental health's time has come. Contributions such as those of Deputy Penrose and other Members in recent years, as well as other notable people in society who have helped to ensure that mental health can be talked about in an open way, have been the first wave of recognising that mental health's time has come. Clearly, however, as with any topic, the rubber has to start hitting the road at some point. Public figures have had the courage to come out and let people in wider society know how mental health issues have impacted on their lives. At what point do those disclosures create a real momentum? Will we take action to ensure that in 40 or 50 years, celebrities or public figures do not have to repeat the same kind of personal disclosure?

One of the things that struck me about the debate is that with mental health issues we are always reacting. It always seems to be fire-brigade action. As a society, we are only beginning to discuss the notion of being proactive in respect of mental health. Deputy Neville mentioned sports and things like that, and I will come back to that. That feeds into the notion that it takes a village to raise children. Every aspect of a person's environment and their community is important. One of the aspects that I want to focus on in the limited time I have is the value of mental wealth, as opposed to mental health. I refer to the importance of developing resilience in our community. "Bouncebackability", as the psychologist Maureen Gaffney calls it, is the ability of people to bounce back from the slings and arrows of life.

It allows them to discover they have the capacity to face any difficulty and that there are reserves of potential within human beings which need to be tapped into.

That knowledge, sense of resilience and the ability to bounce back are developed at a very early age. During my childhood, there was a great deal of running wild and free. Nowadays, play and play environments are controlled and it is difficult for children to take risks, be wild and discover they are resilient when they get cuts, scrapes and bruises and bounce back from them. I acknowledge, however, that I have often seen in my own professional and personal life just how fragile human beings are. I do not remotely take that for granted. To some degree, we are all on the cusp of physical illness and potentially on the cusp of mental illness. I have learned about the Irish predilection along the way and heard the phrase "lack of expression leads to depression". The inability to talk is a particularly Irish thing. People like Deputy Willie Penrose encourage people to express themselves. He said that a few minutes ago. If Deputy Penrose can do it, so can I.

Learning to express how one is feeling comes back to what Deputy Neville said. Expression takes many forms. It is not just verbal but can be in sport, the arts and any creative aspect of life. It can be in play, music or drama. From the earliest point in life, children ought to be educated in forms of expression. The ability to express oneself is very much dependent on the environment in which one is raised. Many children in this country, however, are not raised in an environment where the whole village is involved. In many cases, the village may be engaged consciously or unconsciously in keeping them down and fencing them in.

PwC has done a great deal of work on business and mental health in Australia. It has discovered that taking care of mental health is good for business and every $1 invested in mental health by a company gives a return of $2.30. No similar research has been done in Ireland. That is why I refer to the notion that it takes a village. The HSE cannot solve this. The whole community must get involved. We are nowhere close to raising the awareness that every facet of Irish life must be involved. We always talk about schools and front-line services, which are really important, but everyone and every institution in Irish society has a role to play and a stake in the mental health of our people. Work has also been done in Australia on the prevalence of particular types of mental illness in particular occupations. Such work has not been carried out here. They found in Australia that particular types of mental illness are prevalent in specific occupations. They did not look at politics, but they looked at other jobs.

Our pharmacies dispense drugs electronically now, but we have no way to track on a county-by-county basis the prevalence of prescribing anti-depressants or to determine why it might be higher in one county or town than another. Surely, we have the ability to harness that. It may be a question of investing in the technology which can provide the data. Doing so could be hugely valuable. We might discover a wealth of knowledge about where depression is more prevalent and devise policies to address that.

I repeat the phrase I started off with, which was related to Deputy Neville's concluding remarks: it takes a village to raise a child. Equally, it takes a village to destroy a child. Lack of expression leads to depression. Every child in this country must be encouraged and provided with the resources to express himself or herself, whether that is verbally, through sport, art, drama or in any creative way. We must start to develop resilience at that age. That is the kind of thing which leads to a mentally healthy and mentally wealthy society.

Deputy Gino Kenny

I commend Deputy Browne on bringing this motion before the House. It is a very worthwhile debate to have. I commend Senator Joan Freeman on her chairmanship of the Committee on Future of Mental Healthcare and her staff. I have been on the committee since January and it has been an education to say the least. I knew there was a crisis but I did not realise its extent and profundity. It is important not to bad-mouth the health service in which there are some fantastic people at work, but the reality is that there is a crisis. Anyone on the committee will echo what I have to say in this regard. The crisis relates mainly to the retention and recruitment of staff, pay and conditions, waiting times for early intervention, in particular around CAMHS, understaffing and lack of resources. These are endemic problems in our health services.

Deputy Neville made a very important point. Someday, we will have an ideological debate on this issue. I agree that there is a great deal to be said about quality of life and alienation in society. As a socialist, I believe that many issues relating to mental health are attributable to the system under which we live. It is a very competitive and individualistic system rather than a collective one. Collective joy sometimes brings the best out of people. We are social animals. Deputy Neville and I might have that ideological debate over a cup of tea sometime.

I turn to the serious issues around waiting times and pay and conditions. The reality is stark. In 1984, we were in a recession in Ireland but 14% of the health budget was spent on mental health services. In 2004, that went down to 7.3% while in 2015 it went down to 6%. I presume it has increased by 0.5% in 2018 but that is nowhere near the 8.6% stipulated in A Vision for Change or the European level of approximately 12%. There is a disparity of 6% there and people want to engage and seek those services. That is the crux of the problem. When there is a lack of access to mental health services and people must wait to see a psychologist or for speech and language therapy and more serious services, there are deaths. That is the reality. People have been let down by the system and the Government, which is unacceptable. There are people who should be alive today but the system failed them. If more staff and resources are put in place and people benefit from early intervention, common sense suggests that it gives them a chance. It will not save everyone, but it can surely save some.

I do not know if other Members saw the recent episode of the RTÉ documentary series "The Big Picture". It was on CAMHS and the lack of intervention for young people and it was heartbreaking. It should be a flag for all of us here. I touched last week on the RTÉ news item on patients in prison who cannot access the Central Mental Hospital due to a bed shortage. The director of the hospital has said this is completely unacceptable in Ireland in 2018 and I agree.

Finally, there were some very good contributions by organisations such as the Psychiatric Nurses Association, PNA, the Irish Medical Organisation, IMO, Pavee Point, BeLonG To, the Migrant Rights Centre and many mental health service organisations. They have been educational and important. However, the main issue is that this document should not be left to gather dust somewhere. I am sure there are thousands of documents that look and feel great but never see the light of day. The recommendations have to be put into practice, and only the Government can do that. They are the people who can implement this. It probably will not be implemented in its entirety but surely some of the recommendations Members have mentioned must be implemented. Otherwise, we will be talking about this issue constantly, and people will die. People will be let down by the system and they will die.

Deputy Michael Harty

I thank Deputy Browne and Senator Freeman, who pushed for this committee to be established. Fianna Fáil and Fine Gael came together last year and formed the committee, which was a visionary act. I am Chairman of the health committee and there is no way that committee could devote the amount of time the Committee on Future of Mental Health Care can give to this subject. It is a wide-ranging subject and having a stand-alone committee for it is a good idea. The Government should consider continuing the committee beyond its one year remit.

To take up the theme of implementation mentioned by Deputy Gino Kenny, that is my fear about reports. A wonderful report can be produced but its implementation, the final leg of the cycle for implementing change, does not happen. We are beginning to see that with the Sláintecare report. It has been languishing for almost a year and given the evidence we saw this morning, it could be substantially longer before the Government gives a response to it. We have also seen the difficulties with A Vision for Change. It is now ten or 12 years since A Vision for Change was produced yet many of its recommendations have still not been implemented. We must guard against having wonderful reports and then failing to follow through on them.

With regard to mental health, we should speak about mental well-being, as Deputy Lahart said, rather than mental illness. We must build up resilience in our society, particularly in children. Talking about mental health issues and mental well-being in both primary and secondary school will be very important. It is much better to prevent the development of mental health issues before they become so difficult that people must seek help. We should be talking about prevention and self-help to prevent the development of mental problems.

Generally, primary care is the first port of call when mental health issues arise and the majority of cases can be dealt with in primary care. However, there must be access to other services, not necessarily psychiatric services but talk therapies, counselling, social workers and support workers, who should be part of a community mental health team. We have community mental health teams but, unfortunately, those teams are not fully populated. There might be no psychologist, counsellor or social worker and these are important members of a team to contribute to the care of a patient. Medication should be a last, rather than a first, resort. I agree that we tend to over-medicate patients. A contributory factor to that is that patients do not have access to talk therapies and the other supports that should be available to support them. While I would not go as far as Deputy Wallace in his comments, we certainly tend to rely on medication because the support services are not available. It is not that we are over-prescribing for the sake of it. The difficulty is that we cannot get access to the other social services that are required to help people's mental well-being.

There is a lack of 24-7 crisis intervention services. Many people end up in out-of-hours GP services, which soak up much of the pressure. However, some people also end up in accident and emergency departments and unless there is a dedicated psychiatric or mental health service in those departments, the patients get lost. It certainly is not the appropriate place for them. We must examine our 24-7 services and consider helping the general practitioners who are providing out-of-hours services to access support out of hours, and not have people ending up in inappropriate areas such as emergency departments.

The report states that only 56% of the child and adolescent mental health services are fully manned by the various disciplines that are required to deliver such services. That is a damning indictment of the system. Again, it goes back to the failure to implement A Vision for Change. At the other end of the spectrum are the old age psychiatry teams. Only 60% of those teams are fully manned. Again, that is an indictment. If people cannot access the proper professionals it leads to inappropriate treatment for patients.

There is also a lack of integration between primary care and secondary care. I have already referred to counselling. We are also facing a decline in the number of GPs. General practice is suffering greatly at present. There is great difficulty in recruiting and retaining GPs. In addition, the age profile of GPs means that many of them are due to retire over the next ten years. Once that layer of access to treatment diminishes patients will end up in secondary care, most likely inappropriately. Many of the community psychiatric teams are undermanned as well. In some of the community healthcare organisation areas, only 47% of the staff required to man the community psychiatric teams is available. In other areas it is 94%. There is a geographical lottery in that regard.

We must also examine the issue of dual diagnosis of mental health illness along with addiction to opiate drugs, benzodiazepines or alcohol. That is a huge problem. In urban areas, particularly Dublin, if somebody has an addiction problem the psychiatric services do not wish to know, while if one has a psychiatric problem the addiction services do not wish to know. There is a lack of integration and interlinking between those services, which is a huge problem. Another problem is the division of the city. There can be different access to different services on the north side and the south side of the Liffey. People with a dual diagnosis and, indeed, a triple diagnosis where a physical illness is compounding the problem, are very difficult to treat. Emphasis must be placed on that.

I should also refer to alcohol. It is a huge depressant. People in Ireland have a very unhealthy relationship with alcohol. Alcohol precipitates and is part of many of the problems people encounter with their mental health.

Mental health is not just an issue for the Department of Health. It crosses Departments. While it is the responsibility of the Department of Health, the Departments of Housing, Planning and Local Government, Education and Skills and Employment Affairs and Social Protection have a role to play in dealing with people who have a mental health issue.

I will finish by referring to recruitment. There are huge recruitment issues not only in mental health services but across the health system.

This comes down to a number of factors, among them the working conditions under which people are expected to work, quite often because the teams are understaffed and many members of the community teams are missing. The pressure on those teams increases, which makes working conditions very difficult. Quite often they are overwhelmed with the number of patients they are expected to look after, which puts immense pressure on them. This also affects their mental health because they are also subject to the pressures of everyday life. Once the amount of work they have to deliver exceeds what they can comfortably do, they suffer from mental health problems. This puts them off continuing in the service and this is the difficulty - that staff may be recruited but, because of the conditions under which they must work, they cannot be retained. Ireland has become simultaneously one of the greatest exporters of doctors and nurses and the greatest importer of doctors and nurses. Now that our graduates have left the country, we are trawling the world to try to replace them. This comes down to the conditions under which people must work. We have an issue currently with mandatory reporting. There must be mandatory accountability in our health services, whereby people must perform and deliver and management must live up to the expectations of delivering a proper service.

Deputy Dara Calleary

I too compliment Deputy Browne and the rest of the committee, including Senator Freeman, on their work and the report. This Oireachtas has been criticised a lot for its inaction and inactivity, and the brand of new politics is a handy kicking bag for some, but one thing we can say with certainty is that it has brought a focus on mental health like no other before it. I am sorry Deputy Neville has left the Chamber because his dad was a lonely voice on mental health issues for so many years when he was here. So many people have brought that focus to the matter. Deputy Harty's remarks were quite succinct in that they painted the whole picture of the matter and illustrated that this is a primary care issue. The challenges facing our primary care system will not go away. There was a response to Deputy Wallace's contribution on managing the deficiencies in resources through medication because there is no choice in many cases. Deputy Lahart commented earlier on wellness. The Deputy, who has experience in this area, is very passionate about wellness and the broader picture of mental health.

I made a proposal here a number of weeks ago that if we are to change our attitudes as a country to mental health, we must start at primary school level. Many Deputies have spoken about the resource issues, and Deputy Browne has championed the need for 24-7 care and more community care. I often feel that some of the walls that used to surround mental health treatment institutions in the 1950s and 1960s still exist in our minds today in the way we as communities respond to those with mental health issues. Yes, tomorrow night will be amazing. Hundreds of thousands of people all over the world will be out for Darkness into Light, and the community response around the country to mental health issues is local and often led by people working in the services. However, we still struggle with people - colleagues, friends and family - who have mental health issues, and many do not feel equipped to deal with them.

We need to start changing attitudes gradually and to start bringing in, to go back to Deputy Lahart's point, a well-being programme at primary school level. One of the most effective things I have seen in changing this country's attitudes to the environment is the green flag programme. Kids at schools are coming to their less aware parents as champions of the environment. Regarding energy awareness, water awareness, recycling and other things we would not necessarily have done, children are coming home and being the parent in the way we respect the environment because they are learning it and living it at school. Similarly, we need to introduce into schools some kind of mental health and wellness awareness programme in order that children from the earliest age take it as normal to discuss their mental health, just as, if they fell in the playground, they would discuss a graze on a knee or, if they broke a limb, God forbid, come into school with the arm or leg in a cast and everyone would sign it in celebration. We need to do the same with mental health. We need to take into account all the factors that contribute to mental health, including diet and awareness of and participation in sport and athletics, not just academic programmes at school. We need to assure schoolchildren that there will be support and a community response if they encounter mental health issues in the same way that the meitheal of community goes around. As with people who suffer physical illness or some kind of tragedy or trauma within the family, that meitheal should be available and should be a natural response to a mental health issue or challenge. We must start changing the attitude at that generation and taking down these walls that are still in many people's minds, even though the physical walls may be gone, not necessarily out of ignorance, but just out of a fear of the unknown, a fear that people might make things worse by getting involved or fear of an invasion of the privacy we still associate with and attach to mental health conditions.

This is why this report and the work of Deputy Browne, the rest of the committee and all the spokespeople on mental health - I see Deputy Buckley here - are so important. I refer to the awareness of mental health issues being introduced, and awareness of this report, into the mental health budget in particular. Having worked on and negotiated two budgets now, the mystery and the walls that surround the mental health budget are Byzantine. I pay tribute to Deputy Browne and the mental health alliance, who went after the mental health budget like dogs to bones to try to get through those walls in order that next year we will have for the first time a beginning, a proper rolling budget specifically for mental health.

However, there must be accountability for that budget. We must see if services improve on the ground. Users and their families need to see that that money is being used on the ground and not poured into administration or overheads and other costs. It must deliver services and make a change to outcomes. The work that has gone on in this report must change delivery on the ground, and other work will have to change attitudes. Mental health's days of being the Cinderella of the health service need to come to an end. Cinderella needs to go to the ball and marry the prince. If we keep treating the matter as an AOB item in terms of budget and policy, it will continue to lag behind resources, services and community attitudes.

Let this report therefore signify that mental health is now serious. I would like to see the Ceann Comhairle drive to ensure that under Standing Orders a mental health committee will be established forever and that that awareness will forever be there as a legacy of this Oireachtas. Bit by bit, every local authority should establish a mental health committee. There were mental health committees in local authorities decades ago to deliver the service, but now we need to put that back at local authority level, not just at HSE regional level because HSE regions have become completely unaccountable to elected members. Would it not be a good thing that after next year's local elections every local authority established a local mental health committee in its area to bring an awareness to the delivery of services and an awareness of mental health in every local authority area? It is something different and would bring home the message.

Deputy Browne, Senator Freeman and all the other members of the committee - I think Deputy Buckley is on the committee as well - hid down in the basement and did a job many people probably wished someone else was doing. They took it on and they have delivered. It is now up to this Oireachtas and the Government to deliver on the promise of the report and to start actually changing the outcomes in and, most importantly, the attitudes to mental health in this country.

Deputy Pat Buckley

I thank Deputy Browne and congratulate all members and the Chairman of the Committee on the Future of Mental Health Care. As I have said on many occasions in the Chamber, we must keep mental health to the fore. What is so important about doing so? Recently, I was at a public meeting in Tipperary at which more than 250 people were in attendance. It was the harrowing real-life stories of people thinking things cannot get any worse that struck me.

A few really touched my heart. One mother said that she had to have her son sent to jail because there were no mental health services in the area. It must be devastating for a mother to have to have her son sent to jail because of the lack of services. Another man in his 60s had to return to Ennis from Kilkenny having been released from an emergency department because he had no money. I am not inventing these stories and I could go on about what is happening. I commend many of the previous speakers who covered a lot of matters, including dual diagnosis.

I praise front-line staff who are the core of the service and who work so tirelessly and give 100% every day, although many come out of work feeling worthless. We must think of who this issue affects. We are well aware of the marginalised people in society, such as those with a disability, Travellers, LGBTQI, the elderly, the unemployed and children. As I said before, it affects all of us regardless of colour, class, creed or religion and there should be no politics when it comes to mental health and well-being.

The Committee on the Future of Mental Health Care is probably the best committee I have ever sat on. The members of the committee are very strong and committed. We are committed to getting to the truth. If something is broken, we should get to the crux of the matter, look under the bonnet, get into the engine, take off the axle and see what is broken so we can try to fix it. We know in our hearts that this system can be tackled. The situation is heart-wrenching. I deal with it daily in my office and I get emails and texts on my phone about it. Many people are dying in this country and that could be prevented. Many of them could have been treated. Many are suffering from temporary episodes but they have nowhere to go. Last week I asked people where they would go if they wanted a loaf of bread and they said they would go to the shop. I asked them where the shop was and they told me it was in the town. I asked them where they would go if they broke a leg and they said the emergency department. When I asked them where that was, they said it was in the hospital. When I asked them where they would go if someone of 14 years of age or 65 years of age belonging to them had mental health difficulties, they said they did not know because they cannot access the service. Accessing the service is the biggest problem here. It is great having a recipe but if one does not have all the ingredients, one cannot make the cake as it will not come out right.

One of the most startling things recently was the Court of Appeal's ruling on the case of A.B. v. the Clinical Director of St. Loman's Hospital which underlined the drastic need for serious focus on improving the legislation. The court not only ruled that what happened was wrong but that part of the Mental Health Act was unconstitutional and represented a serious breach of duty by the State to protect its citizens. It found that the legislative framework allows involuntary patients to have their detention extended for up to 12 months without an effective or independent review within a reasonable timeframe. All of us as legislators should try to get these things right, and not only the members of the Committee on the Future of Mental Health Care. We have a window of around eight months to sort this out. I have mislaid the figures but I believe there may be more than 65 patients affected by this major flaw in the legislation. This issue was highlighted some time ago by Dr. Shari McDaid of Mental Health Reform who pointed out that the Act is 17 years old and is certainly out of date. The solution is fairly simple. Some 12 months is far too long a period to extend detention of a patient without review and it must be reduced.

I will quote from the recommendations in the expert group review on Mental Health Act from three years ago which were given to the Government led then, as it is now, by Fine Gael.

Section 15(1) of the Mental Health Act 2001 authorises the making of an admission order for the reception, detention and treatment of a patient for a period of 21 days. The order may subsequently be extended for periods no longer than 3 months, then up to six months and thereafter periods of up to 12 months. A number of submissions to the original Steering Group felt that the third time period of 12 months was too long and it was subsequently recommended by the Steering Group to reduce the 12 month period to a period not exceeding 9 months. The Expert Group re-examined the time periods for renewal orders and after some deliberation, it was felt that there was merit in limiting the maximum time period for which renewal orders can be made to 6 months.

It is a nice idea and it all sounds very pretty but the problem is that collectively we need to do the right thing. I appeal to all parties and none on this. I am wholeheartedly committed to the Committee on the Future of Mental Health Care because I believe things can be done better. We are only at the tip of the iceberg but we are getting into it. It is not cut and dried but we need clarity.

Many speakers referred to accountability and responsibility. Of course we need that. Last week a number of witnesses appeared before the committee without prejudice but were threatened by their managers if they told the truth. It is totally unacceptable. Imagine what their mental health was like under that pressure as they strongly and proudly told us the absolute truth of what is happening in the system. The fear of repercussions when they returned to their jobs was at the back of their minds. That should not happen. We need to crack the whip. It is not fair on people with these responsibilities. Excuses can always be found for failures in the service but failures in the legislation are undeniably our responsibility as legislators. I want to flag this issue because it will come up at the mental healthcare committee, the health committee and probably the Department of Justice and Equality in coming weeks.

I now return to where the Committee on the Future of Mental Health Care has reached. It has been an unbelievable journey. We have heard from the most admirable, amazing witnesses, some of them victims. We have heard from front-line staff who broke down. One could not write a book on it, but one could write a piece of history by all of us in this House keeping the committee going. I assure the House that it will bear fruit. Where there is action, there will be an instant reaction. We spoke of prevention being better than cure. Let us not be reactive in society but proactive. It is very simple if we invest strategically and properly. It is about education in schools. We do not give our children the coping skills to deal with life and what will be thrown at them in future. If we invest in it now, the rates of mental health issues will go from high to low. Slowly the emergency rate will fall. Of course, this takes time but eventually we will win. It will require less investment and there will be a better atmosphere and better working conditions. We will have a better country and a better society. We have lost a lot of that. We need to foster respect and empathy for people. I appeal to the House to keep this committee going because it deserves to be kept going and the people need it.

Acting Chairman (Deputy Bernard J. Durkan)

I remind Members that we have 19 minutes left before I bring proceedings to a halt and three speakers left. Members have about six or seven minutes each. I call Deputy Eugene Murphy.

Deputy Eugene Murphy

Less than five minutes will certainly do me because in recent months I have taken the opportunity on numerous occasions to deal with the issue of mental health and, in particular, the situation in my county. The Minister of State, Deputy Catherine Byrne, is here again this evening. She always seems to be here for these debates. I appreciate that because she takes a very genuine interest in this area of health.

I will begin by supporting what Deputy Buckley said. The committee should remain in place in order to keep a focus on mental heath. Since he became a Member of the House, my colleague, Deputy Browne, has given much of his time to studying this issue. Much of his work has been done behind the scenes. He even came to our own constituency and listened to people attentively for three hours one night and took on board their suggestions and ideas. I welcome that.

There have been some welcome changes in recent years. It is good to see a better conversation taking place on this issue. I would like to use a phrase from an old radio programme in the station at which I used to work - "Let's talk". On so many occasions when people are suffering from depression, I find that one of the greatest avenues to support them, or to perhaps bring them out of the deep depression in which they find themselves, is to talk. It might be a very simple conversation. One might go and have a cup of tea with them. It is a very simple thing.

I wish to comment on social media and the effect it has on us. I always refer to text messaging, which, I acknowledge, is very handy, as silent talking, if people know what I mean. Silence can be golden but it can also sometimes be detrimental to the health of people who desperately need to talk to someone. They may be at a very low ebb in their lives and just do not meet a person when they really want to. Sadly, that situation in which they do not meet that person often leads to tragedy. I know of such situations and I am sure that other Members are aware of similar cases as well.

I acknowledge that the mental health budget is improving but I want to discuss the example of Roscommon. The Minister of State is probably tired of hearing me refer to Roscommon. I know that Deputies Browne and Buckley have both spoken about Roscommon and the need to implement the 27 recommendations suggested by the independent review group that published its report in late 2017. I would say again that there has been very little movement on those recommendations. There has been some movement but it is crucial that all the recommendations should be implemented as quickly as possible.

Before I conclude, I return again to my county and the mental health centres there. As the Minister of State probably knows from replying to a Topical Issue matter I raised, the Rosalie unit in Castlerea, County Roscommon, used to cater for 33 people with mild mental disabilities. It now caters for 12 patients and the HSE is refusing to take any more in. The unit is desperately needed. It is a beautiful centre but the HSE keeps telling me and other politicians that these people need the psychiatry of later life care. I beg to differ. The people in that centre have built up relationships and friendships with the staff there. Taking them away from what they are used to is making them unhappy. I keep saying this. We should not be making people or their families unhappy. I worry about matters of that nature. We must get the HSE to understand this. I have difficulty getting the HSE staff in my area to understand it. I acknowledge that some of these people are experts in their fields but I do not think they are necessarily right about the way they handle these situations. This is a matter of concern to me.

That said, what is happening here this evening is good. We must provide the necessary funding. As Deputy Buckley has said, there are some outstanding front-line staff who are doing an awful lot and who want to see the services improve. I will conclude my few comments with the phrase I used earlier - "Let's talk".

Minister of State at the Department of Health (Deputy Catherine Byrne)

I will try to be as quick as I can. On behalf of the Government, the Minister of State, Deputy Jim Daly, and myself, I thank Deputy Browne and everybody who has contributed to today's debate. I welcome the very constructive contributions which have been made by everyone in the Chamber. I also welcome this opportunity to reiterate the Government’s commitment to the development and improvement of mental health services. I have taken notes on some of the issues Deputies raised. If I have time, I will mention one or two of them.

As the Minister of State, Deputy Daly, mentioned in his opening remarks, real and significant developments in mental health services have been initiated since 2012. In the intervening period, approximately €200 million has been added to the HSE's mental health budget, which now amounts to more than €910 million. At a time when health budgets were subject to reductions, investment has been prioritised and increased to develop mental health policies and all connected services. The Government is committed to continuing to progress the real changes needed in mental health services in line with our commitments in A Programme for a Partnership Government.

It is equally evident that this same passion for enhancing the supporting structure of mental health in Ireland is shared by many in this Chamber. The first interim report of the Joint Committee on the Future of Mental Health Care in Ireland clearly indicates the commitment of Oireachtas Members to championing the enhancement of mental health services in Ireland. The report highlights the need for joined-up thinking among policymakers and service providers. I agree that there needs to be greater cohesion and inter-governmental planning when it comes to expanding mental health services in Ireland. It is only by working together that we can deliver on effective mental health strategies and reduce duplication. The committee recommends that a more robust financial reporting system be developed. This is essential to ensure that Government has oversight on how effectively money is being spent on mental health services. Our commitment to seek new ways to further enhance service provision, while also prioritising the updating of our mental health policy, indicates that we take mental health very seriously.

The Government understands that mental health needs to remain a priority. This can be clearly seen in the establishment of the joint committee and the oversight group for A Vision for Change. The creation of these two forums within which to reflect on and progress our mental health services emphasises this commitment. While the joint committee and the oversight group have distinct final aims, there is also shared focus. The first report of the joint committee has set out its aims in a clear and definitive manner. The report identifies the pillars of attention; namely accountability of expenditure, the gaps in primary care, and recruitment issues.

While the difficulties are recognised, we should also acknowledge the positive advancements in this area. The extra funding added to the mental health budget since 2012 has permitted us to approve approximately 2,000 new mental health posts in the intervening period. In line with the commitment to develop early intervention mental health services for those under 18, €5 million has been allocated to primary care. Of this, €3.4 million will fund the recruitment of 114 assistant psychologists in primary care. Of the 114 posts, 111 positions have been accepted and these assistant psychologists have taken up employment. The development of assistant psychology grades will help the HSE primary care service to be more responsive to the needs of children requiring psychological therapies. This should, in turn, reduce the demand on CAMHS and also help to meet the demand from Tusla for psychological support for children in care.

The work of the oversight group will also look at the issues currently facing mental health in Ireland. The oversight group is tasked with refreshing the still well-regarded mental health policy, A Vision for Change, identifying gaps in implementation and updating it to the current mental health context. The oversight group has emphasised the importance of consultation through focus groups and stakeholder groups in the formation of final recommendations. These consultations are anticipated to commence later this month. It should also be emphasised that the formation of the joint committee has been warmly welcomed by the oversight group. The work of the committee will help to ensure that the policy refresh has political support and it will facilitate additional voices from this area as well as examining further areas for attention.

This continued focus of Government on mental health as a priority is essential to ensure that those who require assistance are in a position to access appropriate supports.

The Department of Health and the A Vision for Change oversight committee will continue to work with the Oireachtas joint committee to safeguard mental health in Ireland.

When I came in, Deputy McGuinness was speaking and I wish to comment on one point he made. He said each of us in this Chamber has identified a family member with a mental health issue. A family member of mine had a mental health issue and is continuing to be looked after by the mental health services. Mental illness is a hidden secret in many families and communities. Parents are lost and confused when it knocks on their door. Most of all, they blame themselves for where they went wrong. If they did not go wrong, they ask what happened to make the person end up with such a mental illness. What sinks into one after a while is fear that somebody might take his or her life or do something we cannot predict.

I commend all the members of the committee. I hope it continues to exist.

The Departments of Health and Education and Skills are putting together a well-being programme for schools covering mental and physical health. We have appointed Dr. Donal O'Shea to address dual diagnosis. He is working with a group to examine evening accident and emergency department admissions in this regard. Deputy Harty spoke about how we can deal with this in the confines of an accident and emergency unit rather than by sending people home.

Deputy James Browne

I thank the committee members who worked so hard on the first and second interim reports. It is very clear that party politics was very much left aside. Considerable work is ongoing. I thank, in particular, Senator Freeman, who chaired the committee and brought it as far as it has come. No doubt she will bring the proceedings to a very successful conclusion. With regard to what the committee can do and its fixed purpose, the key to a really successful conclusion would be the implementation of what is contained in the report.

We heard very substantial contributions today from the Deputies, including committee members and non-members. It shows the level of interest in and support for the objective of addressing mental health issues. Even in the term of this Dáil, over the past two years, the quality of the debate has increased from a level of tea and sympathy to one involving a detailed understanding of mental illness. There is a very fine debate now on the issue of mental health in this Chamber, the committee rooms and Seanad.

We heard some very detailed and fine contributions, including from Deputies Wallace, McGuinness and Neville. I never met the former Deputy, Mr. Dan Neville, but his name rings out throughout this building. He made a real contribution. It is fair to say we would not have come as far as we have, or even close to it, without the real groundwork done by Dan in his time. Deputy Tom Neville is following his noble footsteps. We heard a very strong and personal contribution from Deputy Penrose and the Minister of State, Deputy Catherine Byrne. When leaders in society open up about their experiences in this area – Deputy Buckley has done so in the past — they help to destigmatise and normalise mental difficulties.

When I speak to families experiencing issues connected to mental illness, I note that blame and fear almost envelop them. They experience considerable stress in deciding how to deal with that very difficult situation.

Deputy Calleary talked about increasing awareness of mental illness and the supports that exist. This absolutely needs to be done. Intervention is required at the earliest level. From talking to primary school teachers, we hear mental health issues are experienced by children as young as four, five and six. We need to intervene at the earliest stage to make the children aware of what is happening and to give them the coping skills with it. Young people today are being exposed to things at such a young age that it is having a dramatic effect on their mental well-being.

Deputy Gino Kenny talked about the profound crisis with regard to mental health. He also made the important point that there is some fine work being done in the mental health sector. We have fantastic staff in the sector and we must be careful not to terrify people such that they do not seek support to deal with mental illness. Help and support are available, but not enough.

Deputy Harty talked about GPs and the very difficult circumstances they are in. First, there are fewer of them, which in itself is becoming a serious issue. GPs, because they do not have clear pathways and cannot gain access to the supports they need, and in certain circumstances may not even have the training they need, very often have to fall back on medication for sending people to accident and emergency units. The point on medication feeds into what Deputy Wallace was talking about. We probably have an overly medicalised service. Medication certainly has its place but we do need to examine other approaches. Deputy Wallace referred to open dialogue that was very successful when tried in the NHS. We must consider a more holistic, community-based and patient-centred service.

Deputy Buckley talked about front-line staff and referred to the frustration they must be experiencing. We have seen evidence of the stress they are under because they do not have the necessary supports to help.

Very clearly, the dual-diagnosis issue is not resolved. Deputy Buckley has been very strong on this for a long time. He is absolutely correct that the dual-diagnosis misalignment in this country needs to be addressed. Yesterday, we were talking about gambling addiction, which involves an area of dual diagnosis that is probably not addressed. Gambling is dealt with through addiction services. Many mental health issues arise because of gambling.

Deputy Eugene Murphy made very strong points on mental health generally and on issues in Roscommon. He has been constantly raising the scandalous circumstances that arose in Roscommon.

The key will be implementation. I urge the House strongly to support the committee's request that a permanent committee be set up. A number of issues were highlighted that the committee is not dealing with. The committee is limited in both scope and time. A permanent committee will be required. As Deputy Neville stated, we are overturning the pebbles but we need to go deeper and go at it for longer. We are certainly highlighting very many issues. As Deputy Harty, Chairman of the Joint Committee on Health, pointed out, his committee simply would not have had the time to go into the detail. It is worth going into detail.

I thank the members of the Joint Committee on the Future of Mental Health Care. I thank its Chairman, Senator Freeman. I thank the secretariat, including Ms Gina Long and her team, who have been a great support to the committee. I thank everybody who has contributed today. As Deputy Buckley mentioned, the key is keeping mental health on the agenda. That is what we will all keep doing together.

Acting Chairman (Deputy Bernard J. Durkan)

I compliment the Members on adhering to the timeframe.

Question put and agreed to.

The Dáil adjourned at 6.30 p.m. until 2 p.m. on Tuesday, 15 May 2018.