I ask that all leaders have regard to the time allocated.
Leaders' Questions
Yesterday, I brought the Taoiseach's attention a study by Ms Kathleen Ryan in Trinity College Dublin into our child and adolescent mental health services, CAMHS. I referred to how thousands of children and young people are on waiting lists to access psychiatrists and psychologists, as well as how many professionals in the service were finding it challenging, frustrating and disillusioning, that many brilliant people are leaving the service and how there is a collective feeling of frustration among many of those working in CAMHS. The Taoiseach's response was complacent and revealed a certain lack of appreciation of the crisis in our mental health services across the board.
There has been a 10% increase in the number of children waiting to access CAMHS, with more than 2,500 children waiting. There are 350 vulnerable young people waiting longer than 12 months for an appointment which is shameful given their vulnerability. Outside CAMHS, more than 6,500 children were waiting for a primary care appointment in psychology in January 2018 with 1,700 waiting for a psychology appointment for more than a year.
Timely intervention is essential when dealing with vulnerable young people in such circumstances. This is compounded by the 20% increase in the number of children admitted to adult wards. Some 81 vulnerable young people last year spent more than 630 days in adult wards, which is a traumatic experience. The Ombudsman for Children, Dr. Niall Muldoon, recently made a valuable presentation to the Joint Committee on Future of Mental Health Care, outlining young people's experiences of our mental health services. He consulted 25 young people who told of their experiences. He said:
Many of the young people concerned spoke about the length of time it took to access CAMHS and the stark differences in the availability and consistency of the service throughout the country. They described these delays and inconsistencies as being very difficult. They also referenced the distance between the inpatient units and their homes.
He also referred to one young person who spoke of being placed in an adult psychiatric ward which was "an experience he described as traumatic".
When one adds the problems in recruitment to mental health services, there are real issues. Some 31% of psychiatry posts are either vacant or filled only temporarily and there are 500 vacancies in psychiatric nursing. There are concerns for our mental health services. Does the Taoiseach accept that there are major issues in mental health services particularly in access to CAMHS, that many young people are experiencing unacceptable delays in accessing these services and that there are major recruitment and retention issues for professional posts? Will he consider expanding the National Treatment Purchase Fund to address gaps in our mental health services?
I assure the Deputy that I, as Taoiseach, and the Government are very much aware of the shortcomings in our mental services generally, and in CAMHS. We all have constituency responsibilities and are aware of the cases that come into our offices of those waiting for the appointment to access a psychologist or specialist that they very much need. I am also aware that people are increasingly willing to talk about, identify and deal with mental health. It is a big change in our society in recent years, and a very welcome one. There has been a big increase in demand for mental health services by adults and particularly by children. It is not necessarily solely down to an increase in pathology or mental health problems; it is down to a willingness on the part of people to identify the problems they have, to talk about them and to seek help, which is welcome.
On the progress we are making, funding for mental health services has increased considerably. Since Fianna Fáil left office in 2011, there has been an increase of €200 million in the mental health budget. It has increased from approximately €700 million to €910 million this year, and will increase again next year. That is evidence of much taxpayers' money being invested in our mental health services. In practice that means that we recruited an additional 114 assistant psychologists and 22 staff grade psychologists for primary care child psychology services. Of the 114 assistant psychologists, 111 have been recruited and are now in post and of the 22 staff-grade psychologists, 20 are in post. This is a good example of additional staff being recruited and our success in so doing. It also involves a change in model. Part of the current difficulty is that people are often referred to a specialist. This is a problem across our health service, where a patient goes from a GP to a highly qualified specialist, often somebody with a PhD, when people have different needs at different levels and different referral pathways are needed. The introduction of assistant psychologists is a good step forward in this.
The HSE is also prioritising a reduction in CAMHS waiting lists. The total number of those waiting as of March was 2,691, which includes those waiting any length of time, from a long time to those who may have been waiting only a few weeks. The Minister of State at the Department of Health, Deputy Jim Daly, in particular, has directed the HSE to introduce a 24-7 telephone helpline, to ensure better out-of-hours services, and is also piloting a telepsychiatry project in Donegal, which allows people to use modern technology to access the support they need.
We are also working with Senator Joan Freeman. I met her in the past couple of weeks to discuss her legislation, the Mental Health (Amendment) Bill 2016. It will not outlaw children being looked after in adult units but will set out clear legal criteria for when it is permissible. We are keen to work with her in getting that legislation done in the next session.
Three weeks ago, two psychiatrists in the Waterford-Wexford area resigned their posts because they said services were falling apart. I met the Taoiseach's predecessor over the past two years and we went through these issues, along with Deputy James Browne who has monitored the mental health commitments in the confidence and supply agreement. The Taoiseach can quote figures about increased allocation because of demographics or whatever but too many young people are waiting too long to access services, and that is also true of too many children who are in difficult circumstances. When I meet Ministers, they put their hands out and say, "What can we do? There has been a recruitment failure." Some 44 consultant posts were advertised in psychiatry and no applications were received for 25% of them.
No applications were received for child and adolescent psychiatry positions in counties Sligo, Leitrim, Cork, Donegal, Longford, Westmeath, Laois and Offaly. The Irish Hospital Consultants Association, the Royal College of Psychiatrists and the Psychiatric Nurses Association of Ireland will confirm that the recruitment and retention crisis is affecting services across the board. The Government needs to realise that people are waiting too long and it needs to change tack. Senator Freeman has been pursuing legislation for quite some time. If the truth be told, she has been doing so uphill against the system. Too many children and young people have been waiting for far too long. They are suffering as a result. A change of approach is required.
I totally acknowledge that far too many people have been waiting too long to access the services they need. That is true of child and adolescent mental health and of mental health more generally. It is true of our health service generally. The question is what we can do about it. The first step is to provide additional resources, funding and staff. We are using taxpayers' money to do that. Since 2012, an additional 2,000 new mental health posts have been approved and 1,300 of them, or two thirds, have been filled. That is an example of the recruitment that is happening. Perhaps there is not as much recruitment as we need. There have been big improvements in counselling services. I am sure the Deputy is familiar with the Jigsaw service, which has been expanded. I think everyone agrees that this service has brought about a real improvement in mental health services for young people, particularly because they can refer themselves to the service. There are new Jigsaw sites in Cork, Limerick and Dublin, bringing the total number of sites to 13. As the Deputy is aware, we have worked on legislation with Opposition Deputies and Senators, including Independents. A Bill that was proposed by Deputy Browne became law within the past couple of months. We were happy to co-operate with Fianna Fáil to get that through. In the same vein and in the same spirit, we are happy to co-operate with Senator Freeman to get her legislation through. I have had a very good meeting with her on how that legislation might work. I think we can get it through in the autumn session.
It has become clear that the Government has no sense of urgency or seriousness in addressing the CervicalCheck scandal. Instead of pursuing a genuinely victim-centred approach, it has opted to manage and contain the matter. An authentic approach would have put the affected women and their families first in a dedicated and comprehensive manner, rather than in a piecemeal way involving mere words, but that is certainly not happening. Delay and obstruction have been the overriding themes of this scandal and of the Government's handling of this most serious matter. Women are still being forced to go through the courts to access vital information from their medical records. The essential review of 3,000 cervical smear slides has not yet begun. In addition, the final report of the scoping investigation will be delayed. It is important to remember that the scoping exercise was supposed to be a fast and sharp inquiry, mindful of the fact that many of the women in question will become very sick. As we know, women have died. Sadly, some women are now dying. As recently as last Thursday, Fine Gael voted against a Sinn Féin Bill which sought to make open disclosure mandatory. I think that says it all. It says that the Government has not really prioritised this matter and does not really have a sense of the urgency that is required to deal with the issues being faced by these women and their families. To add insult to injury, we understand from campaign groups that women are not being given full and complete information on how to access the €2,000 assistance payment. We are being told that women are being sent into an information cul-de-sac by the HSE and the Department of Health. It has been reported today that only those expenses incurred since 11 May last can be recouped and recovered, which is crazy. The Taoiseach might confirm whether this is true. If it is true, it means that no account is being taken of the considerable expenses and loss of earnings incurred by some of the women who are at the centre of these cases. Yesterday, I raised the imperative of establishing an independent patient advocacy group, specifically for these women and their families. I am raising these issues again today because I am mindful that this is the last occasion on which the Taoiseach will take Leaders' Questions until September. When will the review of the 3,000 smears begin? When does the Taoiseach expect Dr. Scally to report? Will he recall the Dáil, if necessary, when the Scally report is published to establish the commission of inquiry? When will the independent advocacy group for the women and their families be established?
I want to say again how distraught I am, and the country is, that so many women have had to endure the uncertainty and worry that have accompanied the CervicalCheck controversy, on which the Government has focused significantly in recent weeks and months. This has been a difficult issue to deal with. Like the women concerned, Deputy McDonald and everyone else, we did not have all the facts at the outset and we still do not have all the facts. As we seek to deal with this matter, we are often having to change our response on a weekly basis because of the emergence of new facts and new information. We set up the serious incident management team to go into CervicalCheck. It was asked to put things in order and make sure records were provided to women and their solicitors as soon as possible. We established the scoping inquiry and agreed the terms of reference with the Opposition. That scoping inquiry is now under way. Dr. Scally has already produced his first report, in which he recommended that better information be provided to women when they are going for smear tests in order that they understand the limitations of those tests. A consent form which recognises that has already been done. We expect further interim reports from Dr. Scally along the way, as soon as he is ready to give them to us. He has said he is now content and satisfied with the information he is receiving from State authorities and the format in which it is being received. We have asked him to contact the Minister for Health directly if he has any further difficulties. As the inquiry is independent, it would be wrong for me to direct Dr. Scally to end it at a particular point. We should allow him to carry out his independent inquiry as the whole point of an independent inquiry is that the Government does not interfere with it. This inquiry is entirely independent. Dr. Scally has told us he anticipates that he will have completed the report by the end of the summer. We have already agreed that we will proceed to a commission of inquiry in September. We know it will not be possible to answer all questions as a result of the scoping inquiry.
The agreement of the Irish Medical Organisation is in place to give women who are concerned about previous smear tests the option of having repeat smear tests free of charge. Many women have taken up that option. I think it was right to offer this option. A team from the Royal College of Obstetricians and Gynaecologists in Britain, with expert input from the British Society for Colposcopy and Cervical Pathology, has been appointed to review past smears. This team has started its work. It might not yet be examining slides but it is doing its preliminary work and terms of reference have been agreed. We thought its work could be done much more quickly but the experts in the field are telling us it will take longer. It will take up to four months. We have put in place a comprehensive package of health and social care measures. For example, over 400 medical cards have already been issued. If Deputies know about individual cases in which people are having difficulties accessing the €2,000 payment, they should pass on the details of those cases to me or to the Minister, Deputy Harris, and we will look into them. According to the information we are getting from the HSE, difficulties are not being encountered. We understand that many of those payments have been issued. In some cases, there have been difficulties with getting people's bank details etc. I ask Deputies to provide details of individual cases, if they have them, in order that we can follow them up. It is true that it is not possible to claim for retrospective expenses. Expenses can be claimed for going forward. The issue of retrospective expenses will be dealt with in the individual settlements when the individual cases are sorted. As we have said, mediation is on offer in all cases. We cannot stop people going to court. Everyone has the right to go to court if he or she wants to and believes it is in his or her best interests. Mediation is being offered in all cases. A number of cases have been settled by mediation.
The Taoiseach has not told me when the examination of the 3,000 slides will begin. I could also reflect on the Taoiseach's confirmation that the Scally report will be produced in its own good time. I am not challenging the process, which has to be independent.
I would have thought that a Government that understood the urgency and seriousness of these matters would give one direction to Dr. Scally and every agency concerned, namely, to proceed with urgency and efficiency. The Government should resource those carrying out the work so this can be achieved. Members will know that the Scally team had great difficulty in accessing information from the HSE in the first instance. I will not revisit all that.
More importantly, I want the Taoiseach to indicate to the affected women when the 3,000 smear test slides will be examined. When will the commission of inquiry be established? Is it a certainty for September? I want the Taoiseach to tell me what he is going to do about the fact that women still cannot gain access to their medical files. I want him to state how it is defensible, given everything that has happened, that women are still forced into the courts to fight their corner to get their information.
I cannot say for certain when the examination of the slides will commence. I anticipate, however, that it will commence very soon. The scoping and preliminary work done by the Royal College of Surgeons and the British Society for Colposcopy and Cervical Pathology make certain suggestions - for example, that women should be asked for consent. Things were not done properly in the past and we need to do them properly in the future. In that context, it was suggested that if we are to examine women's slides again, they should be asked individually for their consent. It should be borne in mind that it is not just a matter of reviewing their slides but also their entire medical records. What we are seeking for women is not just an answer about their slides but also an answer as to the extent their treatment or prognosis might have been affected. It is a bigger matter than two people just looking at a slide under a microscope. It is probably important to engage women individually, seek their consent for the examination on an individual basis and make sure each woman is briefed and informed of the result of the audit. It is a bigger job than we might have anticipated in May.
The Scally inquiry is independent. The Deputy may not intend to do so but I believe she is questioning its independence by asking the Government to set some sort of deadline. We are not going to do that. We are here to support the work of Dr. Scally. We have asked him to have a sense of urgency in his work. We said we will give him any support he needs. He knows that.
It is intended that the commission of investigation will be established in September. That is, of course, a matter for the Dáil but I believe it can be done in September.
On the medical records, we have set a target of 28 days for any woman who requests her medical records to receive them. It should be borne in mind there are different forms. Some are paper and some are electronic. It is not just patient files. They are held in different places. Some involve X-rays and some involve cytology. It is not as straightforward as it might seem.
I would like to ask the Taoiseach about the high-level report on the Department of Justice and Equality, which was produced by Mr. Ó Ríordáin and which, according to Mr. Pat Leahy, makes some important points regarding accountability and the budget and resources of An Garda Síochána. When will that be published? Will the Dáil get a chance to discuss it?
Why was there no public competition for the position of Secretary General of the Department of Justice and Equality? The latter is a key Department of Government. Everybody believes that most government-related jobs should be filled through public competition. Why was there no competition in this case? The appointee, Mr. O'Driscoll, has a fine track record but we would have expected a public competition.
The justice matter I particularly want to ask about is based on the Central Statistics Office, CSO, report on recorded crime in the year to the end of March 2018. Many people find the contents very disturbing and disappointing. The statistics show a general significant increase in crime across nearly all categories. For example, sexual offences rose by almost 15%, to over 3,000. Attempts of threats to murder, assault and harass were up nearly 14%, to over 19,000 crimes. Robbery, extortion and hijacking rose by 16%, and theft and related offences were up 8%, to almost 70,000 crimes. Damage to property rose by 5%, to over 23,000 offences. Homicides show a decline in this period but, of course, the statistics do not include the terrible second quarter of 2018 in which there seemed to have been an appalling homicide almost every second day.
These figures are published by the CSO as statistics under reservation due to ongoing concerns about the quality of data from An Garda Síochána's PULSE database. What steps is the Taoiseach taking to address this very worrying increase in crime during his period in office and when will the CSO be in a position to publish regular crime statistics without qualification?
These shocking crime statistics are echoed in episodes of appalling antisocial and criminal behaviour in districts of my constituency and the north division of the Garda Dublin metropolitan region. During the Taoiseach's period in office, there has been a significant upsurge in antisocial behaviour, thefts, intimidation, harassment, joyriding and serious drug-related crimes. I have in front of me a petition from 200 residents from a district of the north fringe of Dublin city who are complaining bitterly about the recent spate of thefts of cars, motorbikes and bicycles from their new homes. They are demanding a permanent Garda presence in this vast, new urban district.
In the period to mid-2014, when the Taoiseach was a Minister, the then Government decimated Garda numbers. Every time our local Garda personnel respond - under Chief Superintendent Curran and his officers in the north division of the Dublin metropolitan region - they outline their policing plans but they talk about very tight budgets and the problem of the reducing number of personnel in several districts. The Taoiseach will probably respond with the mantra about having 21,000 Garda personnel by 2021 but there have been no staff increases in the north division of the Dublin metropolitan region, only cuts. There is a report in the media that overtime budgets are being cut by up to 40%. Can the Taoiseach confirm whether this is the case and whether the Garda budget of €1.65 billion for 2018 is adequate?
There has been a generally positive welcome for the appointment of the new Garda Commissioner, Mr. Drew Harris. I welcome his appointment. Will the Taoiseach give him the resources and tools to transform An Garda Síochána from September and to deal with the growing lawlessness that has been a feature of the Taoiseach's period in office?
I thank Mr. Pádraig Ó Ríordáin and his group for the report provided to the Government. We approved it yesterday. It builds on the Toland report and sets out an 18-month timeframe during which the Department of Justice and Equality is to be reformed. It involves dividing the Department into two divisions, one with responsibility for home affairs and the other with responsibility for justice and law reform, with a deputy secretary general heading each and with Civil Service programme managers in the Department to ensure that the Minister's office is kept fully abreast of what is happening in those areas. Quite radically, it involves a real change across the Department, breaking up the work into areas such as policy, operations and legislation. This is very different from the silos we typically have in Departments whereby everything is broken up by policy area. Within each policy area, the person in charge is supposed to be responsible for everything, from legislation and communications to parliamentary questions and policy documents. If what is proposed works, it could be a very good model for the modernisation and reform of other Departments. Let us see whether it works in this Department first.
There is no requirement that all Secretaries General positions be open to public competition. On this occasion, we took the view that it was important that the person who became Secretary General had experience of being the Secretary General of a Department. It is, therefore, essentially a promotion. It involves somebody moving up from being a Secretary General in an important but relatively small Department to being a Secretary General in a much more challenging and complex Department. It is a matter of promotion rather than open competition. The post of Secretary General of the Department of Agriculture, Food and the Marine, which is being vacated as a result of the promotion, will be open to full competition. That decision was made yesterday also.
On tackling crime, there are many things the Government can do and is doing - never mind our target for the future. Since the end of 2016, the number of members of the Garda force has increased by 600 and recruitment continues. We are investing in new Garda stations - modern stations - like the one that can be seen in Kevin Street and the one in Sligo, in addition to some others that are very much going ahead. There is also investment in Garda ICT and vehicles. The current budget for the Garda is unprecedented, amounting to €1.6 billion. It is an enormous budget.
Once again, I have to say to the Deputy - I know he does not accept this - that it is about more than resources. If one wants public services to function well, staff and resources are only part of the picture. Reform is needed. One needs to make sure the resources and staff are deployed in the best interest of those who pay for them and those who use and need to the services. That has not always been the case. It will be very much part of the role of the new Commissioner and his team to ensure that staff and resources are deployed in the interest of the taxpayers who pay for them and the citizens who need them.
When the Taoiseach is walking around the country and when we are walking around constituencies, the one thing that always sticks in one's mind when crime and bad antisocial behaviour are raised, as happens regularly, is that people want to see gardaí - male and female - on the streets.
The visibility of gardaí is missing, and that is a key problem. It is about resources, numbers, particularly on the front line. That must be addressed. We also must have a full discussion of the O'Ríordáin report because apparently it makes important points about accountability and the fact that there is no central accountability in the Department of Justice and Equality. Civil servants and gardaí sometimes have ended up in the same trench together. Garda Commissioner Harris must get rid of that mindset.
I wish to make two final points. Emily Logan, Chief Commissioner of the Irish Human Rights and Equality Commission, recently drew attention to the Lifecycle of a Hate Crime: Country Report for Ireland and said that we are deficient in responding to hate crime. Is that at the top of the Government's agenda for legislation given that she said legislation is required? Finally, I have asked probably 30 times during this Administration for reports on the ongoing investigations of serious white collar crime on foot of the findings of the Flood, Mahon and Moriarty tribunals. When will other Deputies and I get a proper report on the investigation following those tribunals?
The Deputy is out of order. He is introducing extraneous matters. This is Leaders' Questions.
It is all crime. I am talking about crime and the Department of Justice and Equality.
The Deputy could talk about the Great Train Robbery if he wanted.
It is the tribunals. I am talking about crime.
I agree with the Deputy on the first point about Garda visibility. That is what people want. In my community in Blanchardstown and Castleknock people like to see gardaí out on the beat, in cars and on bicycles. The Deputy is right about that. We are increasing Garda numbers and we have 600 more gardaí now than two years ago. More are being recruited all the time and that will facilitate greater visibility. However, it is not just about staff and resources. Things can be done with existing staff levels to increase visibility, such as greater civilianisation. Many gardaí are not out in public where people can see them because they are behind desks and in offices and that has to change. We will need co-operation from the Garda Representative Association and others with regard to civilianisation.
Second, we will need changes in rostering. Gardaí are often not rostered when they are needed, something that can happen in the health service too. There might be many people on duty when it is relatively busy but when it is extremely busy there are not so many people on duty. That may mean asking people to work rosters that they consider to be anti-social, but if we care about society we must have staff in the Garda, the health service and in other areas rostered on duty when society needs them. I hope the Deputy will be supportive of the Garda Commissioner and the Government in making those reforms.
The Taoiseach is commentating again.
I wish to raise mental health services in Tipperary again. My constituency colleagues and I have raised this matter on a number of occasions since the closure of St. Michael's acute psychiatric unit in Clonmel. There are now no inpatient psychiatric beds in north or south Tipperary. Patients in north Tipperary, which was in the old Mid-Western Health Board area, must attend the unit in Ennis while those in south Tipperary, which was in the old South Eastern Health Board area, have to attend the unit in Kilkenny. Both units are overcrowded and substandard and are simply not providing a service for patients from Tipperary. Admissions to the units are being delayed and when patients from Tipperary are admitted they are discharged, inappropriately I believe, ahead of time. There is no consistent follow-up of the patients and it is difficult, if not impossible, for their relatives and friends to support these patients in Kilkenny or Ennis. It is difficult to travel to support family members. Families have been contacting me and other representatives about this issue for some time.
Inpatient psychiatric beds must be provided in Tipperary. We need a seamless service not just in one area but across all areas. There must be a community-based service along with inpatient services. Patients in Tipperary are entitled to a quality service. There has been a significant increase in the number of suicides in the county since the closure of these beds and a number of organisations are demanding that they be reopened. Tipperary's Fight for Mental Health Services has organised many meetings and protests and the Save Our Acute Hospital Services Committee has been in discussions about this with the Minister and the HSE in the south east. It is time a decision is made at the highest level to reopen the beds that were wrongly closed in Clonmel in 2012.
I acknowledge Deputy Healy's ongoing interest in and commitment to health services in the south east. He has raised overcrowding in the hospital in Clonmel on many occasions, and we are making good progress on that, as well as on the mental health services. The move in mental health over the past couple of decades, in line with A Vision for Change which every party has signed up to, is to move away from the residential and institutional model of providing mental health and psychiatric care towards one that is based in the community. Twenty and 30 years ago huge numbers of people were treated in psychiatric hospitals. Over the intervening years we have tried to do two things - to get rid of psychiatric hospitals and move those people into mainstream health care, because mental health is mainstream health care and should never have been treated as something separate, and to reduce the number of people receiving the mental health services they need in a residential setting and move them to a community setting. Most people who have mental health problems do not need to be in hospital. They need treatment and they can get that in the community and stay in their homes. That has been the direction of travel and, broadly, it has been the correct one.
However, on occasion people need to be admitted so we need a certain number of inpatient hospital beds. I am advised that in the south east there is planning permission for, and construction is beginning on, a crisis house for the region. There is a particular focus on Tipperary when it comes to the distribution of advanced nurse practitioners and assistant psychologists - people working in the community who are qualified and can give people the support they need. The Minister of State, Deputy Jim Daly, has visited the area and met with the local representatives. He is giving consideration to the inclusion of inpatient beds in new builds that are proposed for the south east.
I acknowledge the commitment and involvement of the Minister of State on this issue. He has met deputations on a number of occasions and has visited Clonmel to see the services. We have always acknowledged the policy in A Vision for Change which would transfer the majority of services on a priority basis to community services. We have never had an issue with that and have always supported it fully, but there has to be a complete and seamless service. That involves both the community and inpatient beds. We met members of HSE management again recently and they acknowledged that there are at least 20 fewer beds in the area than there should be and that Tipperary would have a priority case for those beds.
A decision needs to be made at ministerial level to reverse the wrong decision to close beds at St. Michael's unit and, instead, to put in place a small number of beds immediately.
I again thank Deputy Healy for raising this important issue. I assure him that we will examine the matter that he suggests. Project Ireland 2040 provides over €10 billion for investment in our health infrastructure, including, buildings, equipment and ICT. As part of this spend, an additional 2,500 inpatient beds will be provided. As part of this expansion and the provision of those additional 2,500 beds, perhaps an appropriate number could be provided for mental health services in the south east. Where new beds are being provided, the intention is to open mental health and psychiatric wards in existing hospitals rather than reopen old psychiatric hospitals, thus mainstreaming mental health, as it always should have been. Centuries ago Descartes or somebody else suggested that somehow mental health was separate from physical health but we all know, although it may have taken us decades and centuries to relearn it, that mental health is intertwined with physical health and it is right that they be integrated again.