Child and Adolescent Mental Health Services: Statements

I welcome the opportunity to discuss the important issue of developing mental health policies and services for young people, particularly child and adolescent mental health services, CAMHS. Promoting positive mental health and well-being is important to us all, particularly as mental health can be a complex and emotive issue. This applies particularly to vulnerable young people who must face evolving pressures and expectations while having limited experience or perspective. Having spent years working directly with young people, I am very aware that they face entirely new challenges that are beyond the experience of older generations. Alongside these are new opportunities to connect and communicate with each other and with services and it is incumbent on us as policymakers to make the most of them. It is encouraging that during my time as Minister of State I have found wide agreement in both Houses of the Oireachtas and among external stakeholders to develop our mental health legislation, policies and services. The Government has consistently prioritised investment in mental health and the HSE has been implementing new or expanded improvements year-on-year. I remain as open as ever to suggestion or constructive criticism that will result in a better CAMHS service. These are often allied to linked improvements around primary care, disability care or early intervention and prevention measures. We must also include enhancements beyond the health system such as those relating to education, justice, childcare or online safety. The best interests and mental well-being of young people must be our first concern in every policy area that deals with them.

The ongoing reform agenda in mental health services has led to much needed change on many fronts, destigmatising mental illness and encouraging open discussion and a recovery focus. Delivering modern mental health services requires adequate resourcing. Beyond that it requires a new outlook to maximise the impact of existing structures and provision. This ranges from addressing acknowledged staff recruitment and retention difficulties to further rebalancing primary care and specialist interventions such as CAMHS. The implementation difficulties we face do not relate to a lack of funding for the key HSE mental health care programme per se. While the fundamentals of our policies and services remain on course, informed by past experience and future needs, there is real scope to do at least some things differently, rather than endlessly expecting more funding to solve problems that can be otherwise addressed. Securing a supply of trained and skilled staff, particularly at consultant level, is a multi-year project and with other countries also experiencing shortages, it is clear an innovative approach is required.

Even in the face of these challenges, developing mental health services remains a priority for the Government and, in line with programme for Government commitments, further investment will continue as overall resources and service pressures allow. Budget 2019 provided an additional €55 million to progress new developments in mental health, which brings overall HSE mental health funding to nearly €1 billion this year. Our aim has been that services become more person-centred, user-friendly, responsive to need and recovery orientated. We have had to respond too, given that demand for CAMHS has increased by over 20% for referrals since 2012. Increasing demands and complexity of cases continue to emerge. A single specialist service such as CAMHS cannot be expected to address all issues.

CAMHS is a specialist clinical service for those under 18 with mental health difficulties that affect their thoughts, feelings and behaviours every day. It is not for everyone nor is it designed to be. Only a small percentage of the population requires access to this service. Some conditions treated in CAMHS include moderate to severe depression, anxiety, eating disorders and self-harm. It has never been a goal to increase referrals to CAMHS. Reducing the number of young people who need this intervention is key, not simply from a resource perspective, but for the sake of the well-being of children and young people. There are now 70 CAMHS teams in place across Ireland. The vast majority of interventions in CAMHS occur in a community setting and this is in keeping with both A Vision for Change and Sláintecare principles and recommendations. Young people with moderate to severe mental health difficulties are referred to specialist mental health services by primary care practitioners such as GPs or psychologists. Specialist mental health services are provided by multidisciplinary teams. These services are concentrated in community teams where only those with needs above that threshold are referred to specialist inpatient settings. Over 90% of mental health needs can be successfully treated within a primary care setting, with a need for fewer than 10% to be referred to specialist community-based mental health services. Of this number, approximately 1% have needs that require inpatient care and nine out of every ten of these admissions are voluntary.

The HSE is committed to ensuring all aspects of CAMHS services are delivered in a consistent and timely fashion, including improved access and reducing waiting lists. In 2015, the HSE introduced a new standard operating procedure for CAMHS. This has helped improve the service overall, including by reducing inappropriate admissions of adolescents to adult units. It has also been a learning experience, prompting services to feed back on how procedures can be improved. On foot of this, a revised standard operating procedure, SOP, is being rolled out. Demographic pressures mean it will always be challenging to maintain the trend of improving access but the HSE is committed to ensuring the admission of children to appropriate units as much as possible and this situation has improved considerably over recent years. The total number of children on CAMHS waiting lists was approximately 2,560 at the end of November 2018. The HSE has prioritised reducing CAMHS waiting lists and particularly the number waiting over 12 months, which was 295 in November. In conjunction with the Department of Health and the HSE, I continually monitor the data nationally to see where further improvements can be made. I have recently spoken to the managers of all the community healthcare organisation, CHOs, and I stressed that I would not be introducing waiting list initiatives because I prioritise real long-lasting reform over short-term solutions. Around 18,000 CAMHS referrals are expected in 2019. Cases assessed by professionals as being urgent are seen as a matter of priority. It is important to point out the figure is an increase from around 12,800 referrals received in 2011. This is a significant additional case load that health professionals are dealing with and is something that is too often overlooked by those who criticise the services. Occasionally, we should all take a step back and look at the very good work being done by the HSE instead of constantly highlighting negative situations because it will not encourage any person to step forward for help at early intervention stage.

There are 76 CAMHS inpatient beds in four acute units nationally with plans for additional beds in the new children’s hospital and the new national forensic mental health complex now being built at Portrane. This is due to open in 2020. I will undertake an on-site visit there on 5 February 2019 and this major capital project is progressing well. The key relevance to the debate today is the fact that a new ten-bed forensic CAMHS unit, the first of its kind in the country, will be provided at Portrane. This should reduce to a great degree the need to send our more complex cases abroad for treatment. As stated, older adolescents can at times be admitted to adult units. This takes place only after efforts to place them in CAMHS units are unsuccessful due to capacity or clinical needs. All admissions of young people under the age of 18 years are notified to the Mental Health Commission in accordance with regulations. All such admissions are also notified to the HSE national mental health service by the regions. It should also be noted that clinicians are not in favour of cut-off points such as a person's 18th birthday. Where inpatient treatment is nearing completion but might need to be continued beyond a person's 18th birthday, consideration may be given by the CAMHS inpatient team to complete the intervention as an inpatient within the CAMHS unit. In such cases, best interest principles must apply. Such principles must take into account the needs of the individual young person who has just turned 18 as well as the other children or young people who are on the unit. HSE national mental health services work closely with local and national CAMHS inpatient services to ensure the clinical needs of the young person are assessed and addressed within the most appropriate setting for the young person and their family.

On 23 January, I convened a meeting with all nine HSE CHOs specifically to review CAMHS. By bringing specialists and managers from across the country together, I am pushing knowledge transfer and co-operative working. The success of day hospital facilities and of nurse-prescribing in respect of attention deficit hyperactivity disorder, ADHD, in some regions was of interest to me.

I will be working with the HSE in order to identify how these initiatives can be expanded.

Another initiative aimed at improving early intervention for young people with emerging and mild mental health difficulties is the enhancement of primary care psychology services through the employment of assistant psychologists. The recruitment of 114 new assistant psychologists is now complete and over 2018 they have become actively involved in primary care teams providing psychological interventions for young people. This major development aims to ensure that young people whose clinical needs are at primary care level receive appropriate intervention, and do not end up on secondary care waiting lists due to lack of appropriate assessment and resources in primary care. Another measure I have brought forward is the training and appointment of ten new advanced nurse practitioners specifically for CAMHS. When these have completed training later this year, they will be directed to areas of greatest service pressures, including reducing waiting lists.

A priority for me is to introduce a new approach to prevention and early intervention in youth mental health care. One obvious and tangible spin-off is not only to provide the level of care appropriate in individual cases, but also to help reduce pressures on the specialist CAMHS service. This initiative has been included in this year’s HSE service plan.

In the context of developing CAMHS, and other initiatives relating to prevention and early intervention, the HSE service plan for 2019 will: continue to implement the recommendations of the youth mental health task force; implement the agreed development of a 24-7 contact line, crisis text line and other e-mental health digital responses; work with sports, community and voluntary groups to develop resilience and reduce demand for mental health services; develop a seven-day-per-week service for CAMHS to ensure supports for vulnerable young persons in line with Connecting for Life; progress day-programme and day-hospital services within CAMHS; develop eating disorder specialist community teams in both adult and CAMHS services; enhance Jigsaw and other early intervention services specific to those aged 18 to 25; enhance access by older adolescents to specialist mental health services and, for those requiring acute admission, their continued appropriate placement and care in child and adolescent-specific settings; and implement the recently developed CAMHS advocacy model. The new funding coming through this year will obviously also be used to enhance existing CAMHS teams, whether acute or community-based.

In the context of pursuing new avenues overall, which will also directly or indirectly benefit CAMHS, we now know from a clear evidence base that many young people wish to avail of information and support on mental health through online channels. While this is not the silver bullet to all problems, the experience of this where is works well in other countries shows significant potential to effectively address many issues here, including benefits for CAMHS.

I have made digital mental health service improvement a key priority. The HSE has embraced this project because the benefits for services are so clear. The digital mental health service encompasses developing online content, signposting of supports and services, and an active listening service based on the provision of text support. This new digital resource will meet significant public mental health need by responding to changing help-seeking behaviours and facilitating the fullest possible range of supports for people experiencing mental health difficulties.

One key initiative is a new website and signposting search tool. The new yourmentalhealth.ie website went live on 10 October last. The public can now find personalised support options through an integrated search tool that generates information on online resources, telephone and face-to-face supports and services relevant to a wide range of mental health issues.

I am sharing time with Deputy Rabbitte. Perhaps the Minister of State's speech could be made available to Members.

I welcome the opportunity to speak on this very important issue of CAMHS. I thank the Ceann Comhairle for arranging this debate and for his continued work in highlighting mental health issues.

Demand for acute CAMHS is increasing. More than 2,500 children are now waiting for a first appointment. Almost 300 of them have been waiting more than a year for first assessments. This is an intolerable wait for children to see specialists. It is a scandal that children and young people are waiting so long for treatment. The failure to give people with mental illnesses the timely help they need is irreparably damaging their lives. Long waits for access to necessary mental health supports can be deeply distressing for people. From childhood to later life, it is vital that mental health support is available for children and young people and their families. I want to put these waiting times into context. In the UK, there is a new guaranteed maximum four-week waiting time for children with more complex problems to access National Health Service, NHS, CAMHS. Recently, there was outrage in Scotland that delays for access to CAMHS had extended to 18 weeks. In Ireland, the wait can be over 12 months.

Why are our CAMHS in such short supply? There are a number of reasons, but they are ultimately caused by the Government's failure to prioritise children’s mental health. There are a significant number of child psychiatrist vacancies. For example, a child psychiatrist travels to Wexford from Galway every weekend to provide cover because for the past six months there has been no child psychiatrist in Wexford, which has a population of 150,000. The conditions within which the CAMHS staff work in are horrific. They are so bad, they in part led to the last child psychiatrist in Wexford leaving. There have been endless false promises about a new facility. The situation is regrettably similar in many other parts of the country.

There are shocking waiting times for primary care psychology. Again, taking my county of Wexford as an example, the wait is three years and no urgent cases are being seen. This means that an opportunity is lost with mental health issues where there could have been an intervention at an early stage and a resolution found. Instead the issue goes untreated and may progress to a more serious issue, necessitating CAMHS intervention which ultimately puts more pressure on CAMHS.

The Government has failed to roll out Jigsaw nationwide. It is an absolute scandal that non-qualified specialists are working as consultant psychiatrists. Children are still being admitted to adult wards in breach of their human rights because there are not sufficient beds in the system. Many of the beds that are there are not operational throughout the year. Children with autism cannot get the mental health care they need. Only 12 whole-time equivalent staff in the whole country work in the mental health disability sector.

As a result of the confidence and supply agreement, an extra €55 million was made available for mental health services and new initiatives in the budget. However, the Government spent almost that amount on agency staff last year.

Whenever the Department was challenged about long waiting lists last year, we were told not to be complaining because there were going to be an additional 4,000 referrals to CAMHS, an increase of 40%. Anyone with the most basic knowledge of CAMHS knew this was a farcical promise. The latter proved to be the case, with only a little over 10,000 people seen - an almost identical number to the year before. Thankfully, that promise is not being repeated this year.

Psychiatric nurses are escalating their industrial action and they have our strong support. They are voting with their feet. The number of vacancies in psychiatric nursing has increased by 40% since 2017. Psychiatric nurses are overworked and highly stressed and the facilities in which they operate are understaffed. Their own mental health is under strain. The Minister needs to engage with them.

Children and young people's mental health is clearly not a priority. What do we know about young people and their mental health? We know that approximately half of all mental illness starts before the age of 14 and therefore it is critical that children get the mental health supports they need as soon as they need it. We know that if we catch mental illness early we can treat it and prevent it turning into something more serious. We know there is a crisis in young people’s mental health. There is a crisis with those young people accessing mental health care. Many vulnerable children under the age of 18, including some who may be suicidal, are being forced to wait unfairly for the care they need and deserve, or are being denied care because CAMHS are overloaded. Our children are being let down.

We also know that with timely and appropriate intervention our children can recover. What are the consequences of the Government’s failure to provide appropriate and timely mental health care for our children? The first obvious point is that they get worse. Like any physical illness left untreated, a mental illness worsens without intervention. This means that when intervention is provided, if it is provided, the condition has become more ingrained, the treatment required is more severe and the recovery period is significantly longer.

While all this has been happening, very often a child’s well-being will have spiralled downwards. His or her ability to participate in society will have been impacted. He or she may find school difficult and may drop out or face expulsion. He or she may become susceptible to criminal gangs that seek to take advantage of his or her vulnerability. He or she may end up in prison or, worse, take his or her own life. Fundamentally, children are being denied their basic human rights to health care so that they can recover and live healthy empowered lives.

None of this is necessary. The Government needs to take urgent action to address the crisis in CAMHS. There are solutions and our children can recover, but this will only happen if their recovery is prioritised. Unfortunately, there is little sign of this happening.

I thank Deputy Browne for sharing his time. I will focus on a major issue with children's mental health and disability teams in Galway. While the figures seem to indicate that CHO2 is brilliant, those figures are distorted. They relate to the intellectual services and the disability services within those. Last April, a meeting was held in Merlin Park to deal with children who were primarily diagnosed with autism, but who are down under the section to do with CAMHS. Some 200 parents attended along with the Galway Autism Partnership, GAP. Every parent in that room was promised that they would be receiving a letter because they were transitioning them away from CAMHS, just as the Minister of State said in his introduction and they were putting them on the right pathway for the intervention.

That does not mean to say that all the children might not have needed some formal level of intervention with CAMHS, but a pathway was being put in place. Regrettably the assessments have only started in the past couple of weeks. Not all of those parents have received a letter to date which is very unfortunate because some people in that room had been waiting for a letter for more than two years. These are parents with children in fourth, fifth or sixth class. They were concerned about them going into first year and what provisions would be put in place for them in the secondary school. However, nearly 12 months later, that letter has not been released, which is very unfortunate.

I see that there is nothing on a six, nine or 12 month waiting list but I know that is not the case and does not reflect the situation on the ground. Before I came in here to speak on this issue, I rang the Galway Autism Partnership group and was told that the assessments are just starting but that they have been outsourced. Parents are not confident at the moment because they are not getting the letters. The group also bemoaned the fact that children with intellectual disabilities are at a disadvantage vis-à-vis children with physical disabilities and that is not right.

As the Minister of State knows, early intervention is key here but that is not what is happening. Children are waiting far too long for the necessary intervention. Intervention should not wait until the critical stage and should be provided through CAMHS. It should be provided earlier through the primary care sector. We must provide more support for primary care services. The Minister of State made reference to e-care and we must do far more to bring primary care practitioners on board. Many primary care units are not capable of providing the intervention that is required. The Minister of State spoke at a meeting of the mental health committee about virtual consultations at primary care centres. That would be a great way to provide relief to families and children but it must be rolled out across the country. It has not reached the west as far as I know, but if it has, I ask the Minister of State to tell me what level it is at because I would positively promote it. Schools should also be told about that service if it is available, but to my knowledge it is not. At this moment in time, as far as parents and the wider community are aware, the only way to get an assessment and support is through CAMHS. We know that the service is short staffed and that there are enormous problems at all levels in terms of providing support.

There is a severe lack of mental health beds for children in Galway. Young children are ending up on adult wards which is totally unacceptable. Dr. Niall Muldoon appeared before the mental health committee and spoke passionately about children's experience of being on adult psychiatric wards. It is shocking to think that we would do that to children. Obviously, they had some problems on admission but they came out with even more problems. Facilities in the new children's hospital are expected to be brilliant but in the meantime we must ring-fence more mental health beds for children around the country. The CAMHS inpatient beds in Galway are for children in 11 counties. We must ring fence more beds.

I welcome the opportunity to speak on this issue today. I thank the Ceann Comhairle for scheduling this discussion and the Minister of State for his input. It is 2019 and I had hoped to be coming in here in a more optimistic frame of mind but I am still disappointed. In his opening remarks the Minister of State referred to investment, recruitment, a lack of funding and so on. I would like to provide a synopsis of the current situation. We still have growing waiting lists for initial and follow-up assessments and we still have a shortage of staff, particularly consultant psychiatrists. We have no transitional services for older teens and young adults and no 24-7 community mental health services. The Minister of State made reference earlier to 76 beds but as of last week, according to a reply to a parliamentary question, we only have 72 beds, of which only 39 are operational. We have gone backwards with regard to beds. In November, 49 out of 74 beds were open which means that we have lost two beds and closed ten since then.

There is a huge difficulty with the implementation of the operating procedures within CAMHS, according to the Jigsaw report commissioned by the Minister of State. The report was very frank and honest but the level of engagement by the service providers with the authors was very disappointing. Perhaps they were over stressed and did not have the time to complete the survey.

An earlier speaker referred to services for children with intellectual disabilities which are actually non-existent. This is so frustrating for everyone. A number of weeks ago, a family was forced to make a young child a ward of court so that the child could be sent to England for help. That is the reality of what is happening in this country. Waiting lists were also referred to earlier. In my own area, there are almost 2,500 waiting for a CAMHS appointment, more than 300 of whom have been waiting for more than 12 months. A full 26% of the total on waiting lists nationally are in CHO 4, covering Cork and Kerry.

I do not want to be negative here. The people who work in the system deserve our respect because they are doing their best. It is understandable that members of the Psychiatric Nurses Association are engaged in industrial action today. Their main concern is not pay but patient safety and a lack of resources. There were 82 young people admitted to adult wards in 2017. In January 2018, there were 623 staff in CAMHS but by January 2019, that figure had dropped by 4% down to 597. Again, we are going backwards.

The Minister of State spoke about funding. While I would not go so far as to describe what he said as disingenuous, it was certainly misleading. He referred to 2018 and an additional €84 million. I have a copy of a presentation given by the HSE in the AV room a number of weeks ago, which the Minister of State attended. In 2018, the figure was €35 million; in 2017, it was €15 million; in 2016, it was €35 million; and in 2014, it was €25 million. The Government is putting information into the public domain suggesting that it has spent additional money and that things are going to get better but that is misleading. The facts speak for themselves in that we are going backwards.

I urge the Minister of State to ensure that the Oireachtas mental health committee is reconvened. We need a vehicle that has the power to hold the HSE and everyone else in the system to account. This is vital if we are to make progress.

The Minister of State spoke previously about the revolving door and said that no child should be turned away. However, there are still major issues with regard to those with a dual diagnosis. Children and young adults are presenting with a combination of problems and are being sent from pillar to post because nobody wants to take responsibility for them. There is no accountability or responsibility in this area.

This is not a personal attack on the Minister of State. I would like to sit down with his advisers to determine where they are getting their information because it is not the same information that we are getting through parliamentary questions and through feedback from the general public.

I have run out of time and will hand over to my colleague, Deputy Mitchell. I look forward to talking to the Minister of State again about the future of mental health care in Ireland.

I welcome the opportunity to speak on this very serious issue. Unfortunately, mental health services in this State are in a very bad way. We have problems with waiting lists, staffing levels and resources, to name but a few. This is having a very direct and noticeable impact on the people who need these

services.

I would like to take this opportunity to tell the Minister of State and the House about a woman with whom I am dealing. Her young son was referred to the CAMHS team in my area. He has attention deficit hyperactivity disorder, ADHD, and oppositional defiant disorder, ODD and threatened to take his own life. One can only imagine how his mother was feeling and what she went through. She was incredibly upset by the whole situation and was extremely worried about her son but was told that she would be waiting for up to a year for her son to be seen by the CAMHS team. That is not good enough.

We have heard from staff who work in this area who speak of being unable to meet the level of demand. Under-staffing and the inability to recruit staff is placing enormous pressure on our mental health services. In my own area, the CAMHS staffing level last year was two thirds of what was recommended in A Vision for Change. We must ask why the staffing levels are so low.

A Vision for Change was published in 2006. Why, 13 years on, are we still facing these issues? The reality is that in comparison with 13 years ago, many more young people are presenting to CAMHS and presentations are generally much more complex. Yet, in 2018, the number of mental health services staff decreased by 4% between the start of the year and November. This is a recurring theme in agencies dealing with our young people. Tusla is another example of where teams are operating with low staffing levels and cannot meet the demands placed on them. What does the Government propose to do to recruit and retain staff? I am concerned, as I am sure is every other Member, that we will end up in the vicious circle of a lack of staff resulting in stress and increased workloads on existing staff and, in turn, an inability to retain staff. We need to break this cycle. The Government needs to examine what initiatives it can take to help.

Mental health services funding and resources, unfortunately, have always been an after-thought. This cannot continue. The Minister and the Government have an obligation to our young people. They need to ensure that adequate funding and resources are available to mental health services and that children, wherever they are in this State, can access treatment and services in a timely manner.

I am sharing time with Deputy Bríd Smith. Mental health issues are the leading cause of disability among young people aged between ten and 24 around the world. According to research carried out by the Royal College of Surgeons for the Health Research Board in 2013, by the age of 13, one in three young people in Ireland is likely to have experienced some type of mental disorder; by the age of 24, this rate will have increased to more than one in two; more than one in 15 young people had engaged in deliberate self-harm; and, by the age of 24, one in five young people will have experienced suicidal ideation. Census 2016 showed that the percentage of people with a psychological or emotional condition increased by almost 30% between 2011 and 2016. This included a 140% increase in mental health conditions among 13 to 19 year old women and an 89% increase among adolescent men of the same age.

According to some reports, shockingly, 15% of 11 to 13 year olds have experienced significant psychological illness. As of May 2018, more than 6,500 children and young people were waiting for their first psychological appointment. Ireland is one of a small minority of OECD countries where young people are more likely to take their lives than older age groups. To address this, there is an urgent need to provide 24-7 access to mental healthcare for young people, including free access to counselling in schools and colleges, and to integrate mental health into the school curriculum. Crucially, there must be a major increase in funding for mental health services and a major expansion of youth mental health services.

I would like to focus on one of the key underlying causes of these issues. I believe that economic inequality, exploitation and the multiple forms of oppression that exist in capitalist societies are a major factor. According to the late social writer, Mark Fisher:

Capitalist realism insists on treating mental health as if it were a natural fact, like weather ... we need to ask: how has it become acceptable that so many people, and especially so many young people, are ill? The "mental health plague" in capitalist societies would suggest that, instead of being the only social system that works, capitalism is inherently dysfunctional, and that the cost of it appearing to work is very high.

It is not an exaggeration to say that being a teenager...is now close to being reclassified as a sickness. This pathologization already forecloses any possibility of politicization. By privatizing these problems - treating them as if they were caused only by chemical imbalances in the individual's neurology and-or by their family background - any question of social systemic causation is ruled out.

The psychologist, Oliver James, also links the increase in mental illness to neoliberal capitalism with its emphasis on individual competitiveness.

The PNA commenced its industrial action today. This is relevant to this debate because, as with the magnificent strike of INMO members yesterday, higher pay for psychiatric nurses is crucial to solving the crisis of recruitment and retention in mental health services. On top of staff cuts, and an ever-growing mental health crisis, low pay is one of the main causes of the chronic understaffing of mental health services and the endless waiting lists. Low pay for mental health workers stems from the wider problem of cuts and ongoing underfunding of mental health services. The Joint Committee on the Future of Mental Health Care found that pay is a significant factor hindering recruitment and retention and, therefore, the problems in the mental health services are at root a problem of insufficient funding. According to the PNA, as of last summer, there were 500 vacancies for psychiatric nurses in the health service but the total number of additional nurses needed to implement the Government's long-term strategy, A Vision for Change, is closer to 2,000. The number of mental health beds was cut from 12,484 in 1984 to 1,002 in 2016. We need a major reversal of the cuts and increased funding in mental health services and, crucially, a major increase in funding for youth mental health services.

I would like to focus first on the now redundant Joint Committee on the Future of Mental Health Care, of which my colleague, Deputy Gino Kenny, was a member. The committee identified that the problem in CAMHS stems from the lack of early intervention, early diagnosis and early assessment. All of us have dealt with cases involving parents who are concerned for their children at an early age and cannot access assessments for them. In one such case, the parents are engaging with the legal system on behalf of their child who is almost two years waiting for an assessment. The future for this young boy if he does not access early intervention will be a lifetime in CAMHS. He will probably end up on medication. Owing to the lack of psychologists, speech therapists and nurses, bed occupancy in CAMHS at any given time is 50%. I know this because Linn Dara, one of the units providing a national service, is in my area and we regularly picket it since 11 of its 22 beds are regularly closed. Young children who do not get early assessments and intervention from psychologists, speech and language therapists, occupational therapists, etc., end up in CAMHS or being medicated. Service users are being failed by a lack of psychologists. Psychologists are walking away from the job in frustration because all that is available to these children is medication rather than the therapies they deserve. We will then treat them as adults with serious mental health difficulties in a system which has utterly failed them.

It is 13 years since a Vision for Change was launched. I think last week was the anniversary of its launch. It is not just this Government but successive Governments, successive Ministers and the Department of Health have failed to implement that vision. Of 108 beds, 50 are usually occupied while the rest of them lie empty. As Deputy Barry said, psychiatric nurses are starting an overtime ban today and will be joining the Irish Nurses and Midwives Organisation, INMO, in strike action in another week and a half. That is not something they do for pleasure, for joy or for the craic or because they are selfish professionals. It is because there is a crisis in our mental health services which the Minister of State - this is not a personal - and those who preceded him have utterly failed in terms of young people. Legal cases will be taken and will force the HSE to deal with this problem.

The new head of the HSE said that the primacy of early intervention is where the problem with CAMHS starts. Ms Anne O'Connor was head of mental health and she now saying that CAMHS is a secondary service but it is the early service that is lacking. I speak for tens of thousands of parents who are distressed, concerned and worried about their children who are not getting the services that they need. We are going to end up with mental health services that are in a continuous crisis situation where if one system fails, the following systems fail and there is no future for people who are in desperate situations.

I do not know the Minister of State is going to address this but I would argue that multiple issues need to be addressed. One of them, crucially, is staffing and the psychiatric nurses are doing something about that and are putting it up to the Minister of State and the Government to pay them properly so that they can retain their numbers and continue to recruit the numbers needed.

I am sure child psychiatrists would love to do something similar and put it up to the Government because they are exiting the service and are voting with their feet by pulling out of the service. It is in crisis. The mental health committee should give the numbers needed to get out of this crisis. That committee should reconvene. The necessary steps must be taken.

It is nearly a year since Dr. Kieran Moore resigned from his position as consultant child psychiatrist in CAMHS in Wexford and there is still no replacement. He specifically cited the working conditions in the CAMHS facility at Slaney House, Wexford, as reason for his resignation. We understood in September that the new CAMHS facility at Arden House would be open in a matter of weeks. In response to a parliamentary question I submitted in November, after no sign of the facility opening, I was told that the new facility at Arden House would be opening in the first quarter of 2019. We now hear that the work required for the new facility at Arden House has only recently gone to tender and that the facility will not be open now until July. I am unsure how we expect to attract consultant child psychiatrist to replace Dr. Moore if we have not improved the working conditions that he cited as the reason for his own resignation.

Approximately half the positions on CAMHS teams nationally have been vacant for a number of years. The staffing levels in CAMHS Wexford, north and south, in 2017 were 48% and 42%, respectively, of the recommended staffing levels in A Vision for Change. Consistently throughout 2018, almost 3,000 children and adolescents were waiting for a CAMHS appointment. The children and young people on that waiting list are waiting for a first appointment, which is their initial assessment, and not for actual treatment. They will then have to endure a protracted waiting period.

The problems with CAMHS need to be seen in context. The pressure on CAMHS is compounded as a direct result of the lack of adequate alternatives. CAMHS has become, as the national director of mental health services in the HSE said, a catchall service. This is a crucial point. CAMHS is a specialist service for the most severe mental health cases but is being swamped by inappropriate referrals because the options in terms of referrals from GPs for children and adolescents who present with mental health problems are so limited and narrow in scope. The waiting list for primary care child psychology services in Wexford are over three years long at the moment.

The over-medicalisation of mental health services is also a massive problem. Public psychotherapy and counselling services for children and adolescents are limited. Places like the Ferns Youth Diocesan Centre in Wexford are doing very good work but there are not enough of these counselling hours available. There are private practices but not everybody can afford them.

A Vision for Change states that the consensus among users and service providers was that psychological therapies should be regarded as a fundamental component of basic mental health services rather than being viewed as additional options that are not consistent consistently available. This is one of the main messages of A Vision for Change consultations, that people want alternatives to medical medication, including access to counselling and psychotherapy. A Vision for Change states that all individuals should have access to a comprehensive range of interventions in primary care for disorders that do not require special specialist mental health services.

There is, as far as I can see, a very broad consensus among almost all mental health service stakeholders that the lack of accessible counselling services is a massive problem and that it is at the heart of much that is wrong with our mental health services. This is one of the strongest messages expressed in the interim and final reports of the Joint Committee on the Future of Mental Health Care. A related issue also highlighted in the committee's reports was that there was an over-reliance on medication as a response to preventing mental health ill-health issues in the absence of alternatives in primary and community care levels.

The Irish College of General Practitioners and the Mental Health Reform Coalition have repeatedly referred to what they see as an over-dependence on medication in our mental health services. The Ombudsman for Children told the Oireachtas committee that children themselves have identified a rush to medicate them in their treatment. I find this an incredible statement. If so many people who work in the mental health services are crying out for talk therapy supports, if this need is so clearly laid out in A Vision for Change and if the national director of mental health services is making similar noises when speaking of the pressure on CAMHS, then why has so little progress been made to make these changes? Perhaps the Minister of State might address this point. It does not seem to be an ideological based position based on the evidence of the of the various groups I just mentioned. Will the regulation of psychotherapy help? Maybe it will. I know many psychotherapists are concerned about how their skills have been ignored so much to date. They are very wary of the proposed tele-counselling model. Tele-psychiatry may be a work around because of the global shortage of consultant psychiatrist but tele-counselling, according to many counsellors, fundamentally misunderstands the nature of counselling and psychotherapy.

While people are crying out for talk therapies, psychotherapists and counsellors are being routinely exploited by the Government's policy of indirectly funding psychotherapists and counsellors via the voluntary and charitable sector. These charities, often funded by Tusla, for example, routinely advertise and recruit qualified accredited and pre-accredited psychotherapists on a voluntary basis and expect them to work for nothing. I can give many examples of this and a number of psychotherapists and counsellors raised this issue with me recently. We have created culture in which psychotherapists are sometimes expected to work for nothing. This is a misdirection of public funds and it only serves to lower the standard of available counselling.

There are at least 5,700 accredited psychotherapists registered with the two main accrediting bodies in Ireland. They will have at least a level 8 honours degree in psychotherapy and counselling. They are experienced, skilled and eager to work but do not fit the HSE's qualification requirements for the grade of counsellor. We have a farcical situation where if someone presents with suicidal ideation, he or she is routinely referred by the HSE to the services of Pieta House, for example. I spoke to psychotherapist this week who works with Pieta House. She regularly counsels such clients who are referred from the HSE, yet she herself does not fit the criteria to work in the HSE itself. Even more bizarre, she is a supervisor of psychotherapy and counselling and supervises therapists who work for the HSE. We need to re-examine the qualification criteria for the grade of counsellor within the HSE to remedy this farcical situation. If we can create the grade of assistant psychologist, we can certainly look again at the counsellor or therapist grade.

I urge the Minister of State to increase investment in talk therapies. The mental health services spend roughly €400 million per year on drugs while some €10 million is spent on counselling. The Minister of State may correct those figures but if they are even close to correct, I am sure he would agree this kind of spending is disproportionate and needs to be addressed.

I am not blaming the Minister of State for all the problems we face in this area and I believe he is genuinely interested in making things better. I listened to his speech, in particular where he said we are perhaps too eager to give out about the HSE and what it is and is not doing. He will have to forgive us, given there are so many problems. Surely he would agree we need to move faster to get to a place where we use more psychotherapy, although I know that is not easy. I know there is an effort to try to regularise the industry in a way that has not been done before, although it has been talked about for over 20 years in these buildings. There has to be an urgency about it but I do not see that. Nonetheless, I am not blaming the Minister of State for that and I am sure he is up against serious obstacles in trying to make it happen.

Only this week, three psychotherapists came to see me to highlight some of the issues I have raised. They are very conscious that, in this House, we change things around and we make things happen in lots of different areas, but it is very disappointing that we have not got to where we want to go in terms of making better use of all the psychotherapists in Ireland, who would make themselves available and who are interested in working. As the Minister of State knows well, there are far more of them than there are psychologists and they are far more available. We need some joined-up thinking. It will mean a massive improvement in this whole area when we get to that point.

As the Minister of State knows, the child and adolescent mental health services, CAMHS, are extremely important. Unfortunately, they are under-coordinated and under-resourced. As many other speakers have said, early intervention is the key, preventing escalation to more serious mental health issues. Intervention may not only involve the individual but may also involve the family, so there are wider issues in regard to adolescent mental health services.

As I said, early intervention is the key and the main intervention is talk therapy, counselling and psychological intervention. As Deputy Wallace said, there is a tendency to the overuse of medication. If one is waiting months or years for treatment, the temptation is to medicate, which is perhaps not in the best interest of the patients. It must be kept in mind that this is due to the difficulty in accessing talk and counselling services. If medication is prescribed, which may be necessary, it should be for the shortest possible time to prevent overdependence on medication. Early access is the key.

The current issues in regard to young people are lack of self-confidence, lack of self-esteem, low mood and low motivation, which carries through into poor school performance. Bullying and peer pressure in school can put severe pressure on individuals. There is also the issue of sexual awareness, social media issues caused by social pressure, the issue of body image which can also be part of social media issues, domestic issues and family breakdown, homelessness and drug and alcohol abuse which unfortunately can be serious issues in adolescence. These are all issues which need to be addressed but they can most commonly be addressed through counselling and talk therapy within primary care and do not necessitate referral to psychiatrists. Psychiatry should be the last resort for adolescent mental health issues.

The other issue is the CAMHS teams, which are under-resourced. Many CAMHS teams are missing vital components. Social workers are very important in CAMHS teams, as are counselling, psychotherapy and, of course, the psychiatrists themselves. The national youth mental health services task force reported some two years ago with many recommendations. One of the recommendations was for a national lead in youth mental health and to have a youth mental health lead in each CHO area. I wonder what progress has been made in that regard. There was also a proposal to set up an interdepartmental team, Pathfinder, which would oversee mental health policy and prioritise youth mental health initiatives. What progress has been made in those areas?

Overall, we must have early intervention and the co-ordination of our voluntary and community sector with our health services. If there is better co-ordination, we will reduce waiting lists and improve early intervention.

I am glad to have the opportunity to speak on this issue. We do not dedicate enough time to this very important issue, which is almost pushed under the carpet despite the serious issues that exist in our mental health services. The mental health service for children and adolescents falls short of what is needed and is failing young people and their families. We have got to a place where, as a society, we have become more comfortable in expressing our concerns around mental health and, in many ways, mental health awareness has never had a higher profile, with sufferers encouraged to seek help. Sadly, currently we have neither the capacity nor the staffing in place to adequately respond to children and their families who are seeking help. This beats all. We need proper investment by the Government in mental health services.

A Vision for Change recommended that 8.24% of total health spending should be directed to the mental health services but we are well below that target, which is not good enough in this day and age. The demand for our mental health services is rising and therefore it is a no-brainer that funding for mental health services must also rise. What is even more appalling is that A Vision for Change identified a progressive decline in the amount of expenditure being allocated to the mental health services, from 13% in 1984 to 7.3% in 2004. Rather than reversing this reduction, this Government and previous ones have flatly ignored this finding, and the Government has continued to cut back on mental health services funding. This is not acceptable by anyone's standards.

Across the water, our neighbours in the UK spend 10% to 11% of the health budget on mental health services. Why are we so behind in regard to investing in our mental health services in this country? This chronic underfunding has manifested in a failure of State agencies to provide adequate mental health services to children and adolescents. The Irish Medical Organisation has stated that good patient outcomes are most likely if patients have timely access to advice, assessment and treatment but, unfortunately, CAMHS is currently under-resourced and is still far below the level of capacity recommended. This means each team is forced to serve a larger population, creating additional pressures on each team and longer waiting times for patients.

The Minister of State is pushing for online services to be available to mental health patients but, in all honesty, if I was a parent of a child who needed to access the mental health services, I would not be jumping up and down if I was directed to go online to deal with the problems through a computer. I would want to meet a person face-to-face to discuss the child's mental health issues and, from there, to come up with a treatment plan. The last thing I would want is to talk to some robot in cyberspace. The Minister of State needs to get real. He needs to concentrate on providing a full service to children and adolescents whereby these children and their families can access real help on the ground and meet with a health professional face-to-face, and not wait months on end for appointments. If the mental health service on the ground is running efficiently and meeting the patient's needs, maybe the Government could then look at investing in some sort of cyberspace app. For now, it needs to look at the service being provided on the ground and to make sure families are being seen to in a timely manner.

I cannot stand here today without mentioning my support for the psychiatric nurses and the other nurses and midwives. Some 6,000 members of the Psychiatric Nurses Association have been left with no option but to engage in industrial action. These nurses will refuse to work overtime today and tomorrow in a dispute over pay and staffing. The Government is putting its head in the sand but it needs to wake up and realise the problems with recruitment and retention of nurses will not go away. The Government needs to co-operate with nurses and listen to their concerns.

I thank the Ceann Comhairle, for allowing time for this vital debate. I will provide some context. I was here, or nearly here, when A Vision for Change was introduced. I had many a battle with the then Minister of State, John Moloney, when he introduced it. We had a vision but that is all we had. There was no funding, no jobs and nothing was put in place. It is the 13th anniversary this year of that ten-year plan. That sums it all up.

I have nothing personal against the Minister of State, Deputy Jim Daly. Deputy Neville is also present. I compliment his father on all the years he spoke about it when it was not popular to talk about mental health. He was a champion in that regard. We all have a duty to pony up and deal with the issue. There is an epidemic of suicide. CAMHS in Tipperary has a waiting list of three to four years. Adolescents are going into the paediatric ward in Clonmel. In fairness to the Minister of State, he helped me as best he could when I discussed a case with him. They were there for between seven and ten weeks waiting to go to the centre in Cork, which has difficulties with capacity. I refer to troubled adolescents who were in the wrong environment and they did not need to be in a paediatric ward but in a special place where they could have someone to talk to. There is a lack of psychologists and psychiatrists. A Vision for Change did not provide one bed in Tipperary. That is what it did for us. It made sure that everyone was sent to Kilkenny, but Kilkenny does not want our patients because the hospital there is overrun with its own patients. Deputy Aylward tells us that every day of the week. That is no disrespect to the people in Kilkenny. People have to travel there in taxis because no bus service is provided. There are significant cracks in the system. It is all a big crack.

Four times as many people are dying from suicide as from road deaths. I do not want any road deaths. There was an horrific incident last weekend. We are putting significant energy and effort into road safety at the moment but I think it is over the top, OTT. Some of the Road Safety Authority, RSA, advertisements on television at the moment are nothing short of a disgrace. They are having a mental health impact on young people. The advertisement that is on the television should not be shown. I have written to the director general, the Minister for Transport, Tourism and Sport and the Taoiseach. It should not be shown because it is impacting on young people's health. Unfortunately, tragedies happen, but four times the number of people die by suicide.

I was at a funeral on Tuesday evening of a friend of mine who was failed by the system in Kilkenny. It was a Tipperary patient who was not looked after. There was another case in Cork of a very troubled woman whose grandfather was a Member of this House. It is so sad. I had a call this morning about a 75 year old man who was a friend of mine. We all get such calls every day of the week. There is an epidemic and we are not dealing with it. The HSE is not fit for purpose to deal with the situation. We talk about A Vision for Change and the ten-year plan, but here we are on its 13th anniversary and we have no plan and we have lost our vision. We will need to get the cataract bus to make sure we have some kind of vision to see what we are doing or where we are going.

I welcome the opportunity to contribute to the debate. I thank Deputy McGrath for mentioning my father in the context of the debate on mental health and where it has come from since 2006. As he correctly outlined, only a handful of people spoke about this issue at the time and we see many more people are elected now, across the political divide, who do so. I very much welcome that.

Nobody is saying the services are perfect or that there is not much work left to be done. The mental health sector was the Cinderella of the health services for many years but a light is being shone on it politically more and more in recent years, in particular with this Dáil following the election of Deputies from all parties and none with a specific interest in this area. That has culminated in the production some months ago of a report by the Joint Committee on the Future of Mental Health Care. Deputy Browne proposed that the committee would be set up, with the support of the Government. A robust report was put together by the committee. Other Members who were on the committee are present. The report highlighted some of the issues involved and the nuts and bolts of the mental health service. I again call for the committee to made permanent. I seek an update from the Government on where we are at in terms of the establishment of the committee on a permanent footing. The Minister of State will be aware that I am pushing the matter hard behind the scenes. I would like to see that happen because I do not want us to take our foot off the gas.

We started to shine a light on A Vision for Change and to investigate its implementation, not only from a political point of view but from the point of view of a management structure. Such oversight is necessary for us as politicians to understand the intricacies of what is happening in the mental health services in order to be able to solve the problems. It is easy to stand up here and make sweeping political statements to get headlines without understanding the nuts and bolts of what is going on behind the scenes. It is incumbent on all of us to educate ourselves as much as possible on an issue such as this which is sensitive, and we must watch our language each time we speak about it. I call on the Government, along with support from all the parties, to put the mental health committee on a permanent footing. That would send a message from the Oireachtas and show that we are taking the issue seriously and putting it on the map.

There has been a reduction in the number of people on the waiting list for CAMHS in the CHO 3 area, which covers Limerick, north Tipperary and Clare. According to the figures from October 2018, the number of people waiting has reduced by approximately 45. The service has had its challenges. The major challenge with CAMHS is the global competition for consultant psychiatrists. That is something we will have to try to resolve. Previous speakers referred to the industrial dispute involving nurses in the PNA. The PNA came before the committee and made a presentation to us. I would very much welcome a solution to the industrial dispute that is going on at the moment concerning the pay agreement. All sides must continue to work towards a solution.

There have been developments in the mental health area more widely across government. For example, in the education sector, 300 hours of well-being classes have been introduced in primary schools. We need to start thinking outside of the mental health area and the health area generally and look to other sectors. I know of private companies and organisations that are introducing mental health and well-being initiatives to deal with stress in the workplace. There is a commercial kickback as people miss fewer days and are more productive at work. That is starting to happen on the ground and I welcome such a development. I would like more of a cross-departmental approach to mental health rather than a narrow approach. More research and collaboration could be co-ordinated by the mental health committee and that could have a knock-on effect. We speak all the time about early intervention, helping people, educating them and showing them how we can put patterns of resilience into place. That could be though sports, the arts or employment. Given that people spend most of their week at work, the workplace is an obvious place to focus. In so doing, we could help people who fall between the cracks or who are in a vulnerable situation. Organisations such as Jigsaw are important for youth mental health. Another important body is the National Office for Suicide Prevention.

The latest statistics I have show that the suicide rate in Limerick city reduced from 21.8 per 100,000 between 2013 and 2015 to 15.4 per 100,000 between 2014 to 2016. I recognise the voluntary groups that operate in this area in Limerick city who do a lot of work with the public and provide intervention on the bridges as well. That should not go unnoticed. We must give credit where it is due. It is a collaborative approach and we must work on it together. We must be mindful of what we say so that we do not send the wrong message. I understand Opposition parties highlighting where they see problems within the service but I do not want to send the message to the public that people cannot interact with the service or that they should not try to access services. I implore people to approach the services if they are in a crisis situation. I also implore them to go to their Deputies, friends, families or whoever else and to engage with the services if they require help. We must be mindful of that.

I know I am over my time. I thank the Ceann Comhairle for driving the mindfulness and mental health initiative within the Oireachtas. There is a saying that charity begins at home. We must not only preach to ourselves but we must practice it in order to send that message out.

I also welcome the opportunity to contribute on this issue. I will pick up where Deputy Neville left off and commend the Ceann Comhairle. He promoted some excellent initiatives last year together with Dr. John Hillery and several others from the College of Psychiatrists Ireland on mental health and mindfulness. I reiterate all of the calls for the cross-party mental health group to be made a full committee of the House. I have been listening to the debate and it is apparent that it is not just an issue for the Department of Health; it involves education, sport, rural affairs and every other Department. If we do not have a single overarching committee doing fantastic work supervising that and monitoring it, then we will continue to have a silo mentality and people will get lost. This is an all-party approach and we need a committee to oversee matters.

I compliment my colleague, Deputy Browne, who since 2016 has brought significant energy to the issue within our party but also in pursuing budgetary allocations. Were it not for his persistence, money would not have been ring-fenced for mental health services this year during the negotiations for the budgets for 2018 and 2019.

One good thing is that there is now a much greater awareness of mental health and much less stigma attached to approaching services for help. However, the services were designed for a different era. They have not caught up with demand or with the change in respect of early diagnosis.

Deputy Neville referred to consultants. We still have a major problem attracting consultants of any discipline to come to Ireland under the 2012 contract introduced by the then Minister, Senator James Reilly. As long as that contract remains in place, there will continue to be vacancies. This is not just an issue for mental health services, it applies across the board and we have to face up to that. There is international competition for healthcare professionals, but we are exporting some of the best trained professionals in the world to Australia and Canada. I spoke to some of them in recent weeks when they were home for Christmas. They want to come home, but they will not do so while the contract to which I refer and the conditions in which they would be obliged to work remain in place. We can fill these vacancies with our people. It will not take a huge amount of money to revisit the issue of the contract. There must be an awakening in the Department of Health in that regard.

The role of social media in childhood and adolescent mental health issues is absolutely extraordinary. I would not like to be a teenager in the current era. It is tough enough to be a teenager at any time, but teenagers today must contend with the ubiquity of phones. During the week, I heard my colleague, Councillor Cathal Crowe, talking about the latest craze on Snapchat. Random fights on school buses are being recorded and posted online. That is having an impact. Pressure is being put on people in a way it never was before in the context of how they should look, how they should sound and to whom they should listen. It is extraordinary. We have to ensure that our services understand and are equipped to deal with this and that professionals within the services have an understanding of the impact of social media on daily lives. Constant and aggressive training and reskilling are needed to keep ahead of these crazy practices. The social media companies can no longer wash their hands of this. We need more than just a Government response. All the social media companies - these are multi-billion euro firms - must invest and take responsibility for the content that goes on their sites.

There is massive frustration among people. It is different in different regions. There is no sense of co-ordination and the CHOs operate like silos. The CHO in my area is facing many challenges but the people on the ground are working incredibly hard. We still have one consultant psychologist post which has been approved but not filled, posts for doctors in training that have not been filled and posts for two social workers that have been approved and not filled. The CAMHS inspection report from July indicates that an additional nine occupational therapists and 18 social workers are required. That is the shortfall in just three counties. I could go through the list. Until we tackle the recruitment crisis in the healthcare sector generally, we can have all the statements, good intentions and support for services that we like but to no effect. We have to fix that first, and then the Minister of State can start building a service that will deliver.

I will finish where I began by stating that the Ceann Comhairle has done a massive amount of work. I encourage him to encourage the Business Committee to place the Joint Committee on the Future of Mental Health Care on a permanent footing. All parties would support such a development. The kind of resources that the Committee on Public Accounts and other committees have must be allocated in respect of the joint committee in order to get it up and running and give it teeth.

Despite what I can only describe as the mantra of the Government regarding additional resources, extra staff, new facilities and so on, it must be clearly stated that mental health services and supports are nowhere near where they should be. The Government states that funding towards mental health services has increased during its tenure to more than €1 billion. This may well be the case but just as with many other areas of the health service, increased funding is not having the effect it should. Staff levels, recruitment and, most especially, retention are under severe pressure.

I wish to place on record my solidarity with and support for all nurses across the State who were either on the picket lines yesterday or represented there by work colleagues. I wish to extend the same good wishes to all our nurses who have emigrated and who, from London, Dubai, Australia and elsewhere, communicated their solidarity with their colleagues. Psychiatric nurses are also due to commence industrial action this week. This is attributable to exactly the same issues of pay and staffing levels. Psychiatric nurses and other staff working in the sector have my complete and unwavering support. I commend them and wish them success in their endeavours.

Early intervention is critical when dealing with mental health issues. It is absolutely essential, just as with any other illness. Early intervention cannot happen if there are extensive waiting lists and a sheer lack of capacity. In my CHO area, CHO 1, which covers my constituency of Cavan-Monaghan and the counties of Leitrim, Sligo and Donegal, there are ten vacant posts. There are 40 young people who have been waiting between three and six months to be seen by CAMHS. Some 38 have been waiting between six and nine months and 17 have been waiting as long as 15 months. This is according to the most recent figures available. A further 145 have been waiting for three months or less. That is a total of 240 who are currently waiting. This reality confirms a serious lack of capacity. There is no other reason for these startling figures. This issue is not political. We all need to work together to address it. The Government must first admit that there is a crisis and secondly embrace an all-party approach to delivering marked improvements. I suggest that in all sincerity. It is in all our interests to work together on improving mental health service provision. Our young people are precious and they need our support. I appeal to the Minister of State to work with colleagues across this Chamber. The issues are self-evident. Let us solve them. We can do that best when we are working together.

Approximately ten days ago, I received an email from a constituent about her little boy, Patrick. Patrick is ten years old and he first engaged with the HSE services more than four years ago. The family feel they have been let down for all that time. In February of last year he was diagnosed with ADHD. At the time, CAMHS suggested an autism assessment. In June he was sent for an urgent assessment to the autism services in Sligo-Leitrim. He has waited since then. The email states:

[W]e would like to ask you to get involved in a situation that is seriously affecting our family. A situation that, if left unchecked, has the potential to end in tragedy.

I have forwarded on to you a complaint that we made to the HSE today. We feel the time has come for the services concerned to stop playing tennis with our lives. Passing the buck continuously between each other achieves no resolution. We all know that neither CAMHS nor Autism Services has the right person in post at present. So they need to fund a service outside of Leitrim to support our little boy.

We feel that if this was the child of any member of government then the case would have been resolved in 7 days, not 7 months and we demand that our children be given the respect and support that is fair.

This family is in absolute despair. That lady has telephoned and emailed me about the situation several times in the past week. I have contacted the services in Sligo-Leitrim. Those services just do not have the necessary person in place. The last thing we heard from them is that Dr. Mark O'Callaghan, the principal clinical psychologist, has suggested that the little boy will be referred to Dr. Yvonne Kelly. There is already waiting list of two months at a minimum to see Dr. Kelly. What are these families going to do? The Minister of State indicated that there are 70 CAMHS teams. How many of those are fully staffed? As far as I can see, none of them are. All of them probably have 50% of the required staffing.

These are serious situations. If that child was at home with a broken leg, would he be left for seven months? No, he would not. He could not be. We need to take the situation as seriously as that. While I absolutely appreciate that the Minister of State is doing everything he can, these families are in a situation of crisis. That mother has written to the HSE. She has said that on 1 February she is going to go public. I spoke to her before I came into the Chamber. She told me to name her and her child. I am not going to do that now. It is time for the Government to realise that we have a crisis in CAMHS and autism services. That is probably true of all parts of the country, but I am particularly interested in the north west. Wherever the money and expertise has to come from, I call on the Minister of State to put it in place now and save these children's lives.

The phrase "child and adolescent mental health services" sounds fine. It sounds promising, as though a service is being provided for young people with mental health issues. We know the mental health issues that young people face. The Minister of State knows it from his own experience and I know it from my teaching and voluntary youth work.

I know the difference a service of support and an individual in a supported setting can make.

The issues I would have seen at second level up to the time I left teaching ten years ago are those that are presenting now at a much younger age. The mental health issues I would have been dealing with at second level are being seen in primary schools now. I am talking particularly about self-harming, suicide ideation, aggressive behaviour, violent behaviour and serious threatening of classmates. That is happening at a time when teachers and principals are snowed under with bureaucracy and endless amounts of paperwork. I would say it is senseless paperwork in many cases in that it is not adding to the quality of the teaching or to the quality of the relationship between the student and the teacher, which is paramount when it comes to mental health issues. It is the principal, the teachers, the guidance counsellor and the chaplain who will be responding to these issues initially, and for quite some time also, while they are waiting on services like CAMHS.

Before speaking on this issue I asked two teacher friends - one at primary level and one at second level - for their reaction to the acronym "CAMHS". From one I was told that the waiting lists are far too long and that CAMHS is more reactive than preventive. They asked what a child needs to do to be guaranteed to see someone in CAMHS in a swift manner. They said that communication with schools leaves a lot to be desired and as the referral is made by the GP the school can be left behind in the paper trail. The other teacher said that CAMHS is very good when the child can be assessed but it looks as if it is over-burdened with every mental health issue. That teacher made the point, which I am aware of also, that there is a gap in services in terms of the hard-to-find services for those between the teenage years and early adulthood. That is the reality.

Another reality is the statistics on the numbers waiting for an appointment. The statistics from August 2018 show 2,453 waiting for an appointment, 169 waiting more than three months, and 313 waiting more than 12 months. Do we have statistics on the presenting issues behind all those figures? I wonder, and perhaps this does happen, if there is a type of triage service that indicates the different levels of urgency behind those particular cases. I acknowledge the target of 72% being seen within 12 weeks.

I saw the report from the National Youth Mental Health Task Force. Its recommendations were sound in looking for a detailed assessment of services and supports currently available to identify gaps and to scope the improvements, but we know about the gaps. Any school or youth project could tell the Minister of State at this moment what those gaps are and can also advise on what exactly is needed.

We hear of the so-called normal mental health issues, and I use that word "normal" very loosely, for young people. We also know the very negative mental health effects on those who are homeless. However, we now have children who are homeless and the normal mental health issues of anxiety and stress are compounded for those young people who are living in hotels and bed and breakfast accommodation. We are shoring up massive problems for CAMHS in the future.

Returning to the point about CAMHS being reactive rather than preventive, I would point to the range of programmes for primary and second levels in the past such as Walk Tall and On My Own Two Feet but they are very relevant today because of the material and the skills they sought to build. I would also point to social, personal and health education, SPHE, and today we are moving into the Wellbeing programme. Those programmes are all worthwhile and effective if the time allocated to them is sacrosanct and the teachers have the skills to deliver them.

I agree with the Wellbeing programme but it must take account of the local area and local issues because there are areas of greater need and greater difficulty. I know what children in the north inner city have been facing, including the violence and the murders they have seen in their community. They see active addiction, people smoking, shooting up and injecting. They see the paraphernalia of drug addiction. Some of them are being intimidated into dealing drugs and some of them have family members who are dealing. Families are being intimidated also over drug debt. The Wellbeing programme must be cognisant of that, recognise the issues in an area or a community and be specific to those areas.

Wellbeing is a preventive programme. I know the demands on the school curriculum. We saw the committee report on relationship and sexuality education the other day but what is needed is a programme in critical thinking that can be applied to any situation or any mental health, relationships or sexuality issue. Wellbeing is also about physical health and physical education and games are important in that respect. None of the preventive measures could help with delays in accessing CAMHS but they could prevent some people having to access CAMHS. The schools and youth projects are picking up the pieces while young people are waiting on CAMHS. They were the youth projects that suffered so many cuts in the past.

Substance abuse service specific to youth, SASSY, is an organisation where children and young people can self refer. Parents and teachers can refer also for those who have addiction issues. I believe we could examine that model and support it even more.

It is about joined-up thinking in terms of mental health issues of young people. I refer to the Departments of Health, Children and Youth Affairs, Justice and Equality, Education and Skills and now Communications, Climate Action and Environment also because of social media.

As the Minister of State is aware, there is an ongoing crisis in children's mental health services. Thirteen years after the publication of A Vision for Change, the services are still completely understaffed. Too many children continue to be admitted to adult units. Waiting lists and waiting times are long and a renewed focus is needed to reduce deficiencies in the services.

The Minister has been a visitor to my county and I know he is passionate about this issue. In my area I have found that the source of the problem is recruitment and the staffing issue. For example, in July last year, the number of vacancies fell from 51 to ten, which was a positive development in the service. However, there are 248 children currently on the waiting list to be seen.

All of us have had different experiences of parents coming to us with their children, some of whom are very young, who need that assistance and intervention. The effects of that spill over into their attendance at school, their ability to go to school which is something most children take for granted. We cannot emphasise enough the importance of proper mental health services within our regions.

An issue that arose was of children being admitted to adult units. I am sure many Deputies are aware of similar problems. I was not really aware of that until parents came to me about it. I refer to one young first year student who was being admitted to an adult service. The parents were more than shocked and as a result they refrained from taking up that hospital bed because they felt it was not the right place for their child and would add to his illness. That meant they had to give 24-hour care to their child at home. They had three other children in the house. I am not sure how they managed that but they were insistent that was the only way to deal with their child's problem because going into an adult bed or unit was not appropriate for the child. We are all in agreement that is not the way to deal with children who suffer from mental health issues.

The number of children admitted to adult mental health units stood at 65 as of September 2018. If this trend was to continue for the remaining months of 2019, up to 86 or 87 vulnerable young children will be inappropriately accommodated this year, a number that will exceed the previous year. The total number so far is greater than that in 2016 and shows that the standards in this area have regressed, having improved for a number of years prior to that. The Mental Health Commission said it is a clear breach of human rights and in terms of a child's dignity.

In 2017, we also saw a 20% increase in the number of children admitted to adult mental health units. That is unacceptable and it is not the right way to deal with this problem. It is also contrary to State policy. It is especially disappointing as there has been progress in previous years and to see that halt, and in some cases reverse, is an indictment of the way we are treating children with mental health conditions.

We are also concerned that the Department of Health does not track the number of times a child has been readmitted to the same adult mental health unit. The A Vision for Change mental health strategy made clear that Ireland needs at least 100 beds for children and adolescent patients to meet the demand. However, the closure of beds during 2017 meant that at one stage just 52 beds were available for children and adolescent patients.

I cannot emphasise to the Minister of State how passionately I feel about this issue. I know the Minister does also, as do many Members in the House. We all know children, be they relations or constituents, whose parents come to us about this issue. It is usually the last chance saloon for them because they have tried all the other options available to them.

School principals are up against it in terms of keeping their students in school because when a mental health issue gets a grip on young people it is very difficult for them to get control. Parents and schools need this support. I cannot emphasise enough the importance of putting the funding into this area and ensuring that A Vision for Change really is a vision for change.

I welcome the opportunity to contribute to this important debate. While there are still many challenges in the area of the provision of mental healthcare, the one positive thing that has happened in recent years is that we are now talking about it an awful lot more freely than we ever did. It has been destigmatised and it is okay for people to talk about their mental health in a way that they never would have. People do not feel vulnerable about doing so. In that regard, I welcome the fact that we have debates such as this on a regular basis in this House. I compliment the work that the Ceann Comhairle has done on this over the past 12 to 18 months. Many Members are contributing to the destigmatisation of mental health in a positive manner. If anything good has come from recent years, that has.

However, as previous speakers have outlined, there are still many challenges. It is not good enough that we can now talk about it as freely as we can talk about our physical health if the supports and services are not in place for the people who have an issue with their mental health and they cannot access help. Previous speakers have outlined the long waiting lists, the fact that adolescents and children are cared for in adult wards and the unacceptable practices that continue to prevail. We need to address that in a meaningful way but we will not be able to do so unless the Government starts to consult the medical profession and deals with the challenges it is facing. If those challenges are not addressed, we will not be able to recruit the relevant people across the various disciplines and services where they are needed.

I compliment the many community, voluntary and not-for-profit organisations working in this area. Without them, the waiting lists would be more severe. I am thinking of Good 2 Talk in Mullingar, which is a free or low cost counselling service if people can afford to give some money. The Minister of State is aware of it and we have engaged on it previously. I mention the challenges and the bureaucratic form filling and procedures that it has to go through every year to get a small percentage of its annual funding from the HSE. I refer to the Transformative College in Mullingar. It comprises a group of people who set up a café where people can go to learn new things and engage with others. It does not even have a permanent home anymore. A café in Mullingar is allowing the college to use its facilities a number of nights a week when it closes. The college is operating on a shoestring. When it goes to the HSE to seek funding, obstacles are put in its way instead of the HSE telling it that it is doing fabulous work and asking how the HSE can help to make things easier.

Before Christmas, I visited the Athlone Institute of Technology. It is a third-level institution with in excess of 6,000 pupils. The level of service being provided there is simply scandalous. A protest was carried out by the students asking for greater supports. This is the time in life when people transition from a family environment where they have the support of their parents to living on their own. If the Minister of State takes anything on board from my contribution, I ask him to consider how dedicated supports can be provided to that cohort of individuals. I am talking about third level students and I am using Athlone Institute of Technology as an example. The Minister of State needs to go back and look at the good work of the cross-party group on mental health. It was an initiative of my colleague, Deputy Browne, and it was embraced by the Government. Unfortunately, it was time specific and the Minister of State needs to look at reconstituting that committee and letting us work together in a collaborative approach to see how we can address the many challenges that currently exist with positive mental health.

CAMHS is an area in which I have taken an interest. Part of my interest stems from an experience I had before I was elected, when I spoke to a community mental health nurse I was representing about an allowance that he may have been due. He asked if I minded him leaving his phone on during the meeting because he had several children in his care who were effectively on suicide watch. I am grateful for that experience in a way because it was something that I had not encountered until that point and I was struck by the fact that this person was trying to provide a service in strained circumstances and was trying to do his best but he was very stretched. It had not occurred to me that this need was there among children and adolescents and I did not know about the extent of that need. I talked to people who provide that service and they are fantastic. The Minister of State will acknowledge that they are working in very strained circumstances. They would like to do more and they would like to provide a real safety net. I know from speaking with people in my community that youth mental health is a particular concern and people want to able to see those services and that safety net provided because they can see that not having those services in place for children can lead to problems in later life. The longer they go without help, the harder it is when that help eventually arrives, if it arrives when they are adults.

There is no one, in this Chamber or outside it, whose life has not been touched by a mental health issue, either concerning themselves, their family, their friends or people in their community. We have become very aware of the scale and disparate nature of mental health illness recently and I say that to refer to my initial point that I was not aware of the extent to which child and adolescent mental health was such an issue, that help was so badly needed and what could be done when it was done right. People are now starting to talk about the scale and the challenge that is posed by consistent and persistent underfunding of services which leads to understaffing.

A cursory look at the state of affairs reveals that the CAMHS service has barely half of the necessary staff needed under A Vision for Change. I recall when the strategy was launched. It was a ten-year project but it is now 12 years' old. It has ceased to have any meaning because so much of it remains unimplemented. Waiting lists for a first assessment have gone through the roof. At the end of October, 2,250 children in my area were waiting to access services, 286 of whom were waiting more than a year simply to access their first appointment. Some 105 of those young people had been waiting in excess of 18 months. It gets to the stage where none of this can be called early intervention because of the length of the wait. It ceases to be early intervention. In my community of Fingal, we only have 63% of the staff necessary for CAMHS with 177 young people waiting for a first assessment. Every expert in child and adolescent mental health says that early intervention is vital to avoid enduring and worsening problems into the future. I do not need to convince the Minister of State of that because he is aware of it but we only have 63% of the staff necessary. I represent an area that has one of the youngest populations in Europe and the number of young people is growing quickly.

That is brilliant but the services are not there for them. We do not have enough people to provide those services.

Mental health issues are emergency health issues. The Minister of State would not expect someone with a physical health emergency to wait over a year for treatment, yet young people with mental health problems are expected to wait. In 2019, we need to see increased and targeted investment from this Government to help those soaring waiting lists and ensure people can access the services they need.

I am glad to be here to participate in the discussion. The comments I will make have been prepared for me by the excellent Emma Smith, a young transition year student, with whom we have had the pleasure of working in our offices during recent weeks. She makes the point that in discussing this matter we must start by recognising that CAMHS has been a vital source of aid for young people who struggle with a form of mental illness, a learning difficulty, a speech issue and so on, and also for their families. It is vital. The level of interest in the debate today shows that.

We must view CAMHS in the context that, thanks to years of austerity, it has been chronically underperforming. It is the young people and their families who are being put under an unbearable strain as a result of that situation. The numbers of people on waiting lists are scandalous. As of September 2018, we know 1,369 young people had been on the list for more than three months, 470 had been on it for more than six months, 241 had been on it for nine months, 222 had been on it for more than a year and so on. In my area, 46 vulnerable young people were left waiting for an appointment for more than six months. That is incredible and a cause for extreme concern. Six months is far too long to leave a young person to suffer, particularly because he or she is at a crucial stage of his or her development and any delay can and will have life-long consequences for him or her. Not only that, but with the services being in such catastrophic disarray, they were putting young people at serious risk. It has been said that 70 children under the age of 16 years died by suicide in Ireland last year. That is devastating. We, as a Parliament, must ask how can we standby and allow this to happen?

Waiting lists are inevitable when staff numbers have been dropping relentlessly. The services are only operating at roughly half the recommended number of full-time staff. We must be honest about that. The staff numbers in CAMHS are down for the same reason they are down in the Defence Forces and nursing, namely, because there is a recruitment and retention crisis. Years of cuts have resulted in staff being seriously overworked and overworked staff who have been kicked around by successive Governments for years do not tend to stick around if they can get out at all. Unfortunately, that is the situation we are in. The Government tells us we are out of the austerity woods but it fails to recognise the importance of the scars that have been left right across our public service. In this case, it is vulnerable children.

We know many regions in the country have next to no professionals. There are only 84 working to provide assessments and treatments for all of Laois, Offaly, Longford, Westmeath and Louth. Worse again, there are only 49 for Carlow, Kilkenny, Waterford, Wexford and south Tipperary, which have a population of nearly half a million people. The chronic understaffing has meant that children are being inappropriately admitted into adult mental health inpatient units. The fact that there were 82 admissions in 2017 is utterly shocking. I cannot imagine how devastating it must be for a child, particularly a sick and vulnerable child, to experience something like that. Worse again, we know that the low levels of staff are inadequately trained, and such inadequately trained staff in inpatient units means that seclusion and physical restraint are becoming normalised, which is an horrific prospect. Children suffering from a mental illness are getting no better treatment than in the Victorian asylums that operated in the past. For those children who are treated by CAMHS, care plans, individually formulated to suit the patient, are time and again overlooked despite the fact that all the evidence shows that these plans are the cornerstone of a successful recovery.

We need to address these shortfalls or an entire generation who so desperately require help and guidelines will be left behind. It is important we recognise that it is not about quantity over quality. Pressure on staff to get people through the system has become immense. A stress on numbers turns cases into quotas. It is no longer about helping a child adequately but instead it becomes about doing as little as possible for as many possible. That is not a solution. This is the institutionalisation of improper care. If the issues with CAMHS are not solved, it will go down as one of our country's biggest failures.

I want to place on record my disappointment that these services are not appropriately staffed with the qualified people who are necessary to deal with the numbers who are turning up for the services. I have seen that at first hand in Kilkenny. In the psychiatric services generally, we can see that there are patients there who have been inappropriately placed because there is no place else for them to go. The centre in Kilkenny city, which caters for a number of counties in the south east, has been overwhelmed by the numbers who turn up for care. When a person in this situation, who requires treatment, counselling and supports, is put on a waiting list, that does not work for them. Something is required for them in real time and that is not happening for them.

When we go down the line into the community services and beyond, we find there are a number of agencies, some HSE and some HSE-funded, that are cobbling together hours of care for patients who need 24-7 care or for children who have a difficulty with mental health issues. That is not good enough. The plan might look okay and appear fine on paper but I have attended many meetings with parents concerning their child or, in some cases, children with the HSE and I am always taken aback by the fact that those on the front line are making every effort, but the plans they are putting in place are unrealistic. The range of services required are not there. Like nurses in general hospitals, I am inclined to believe that for those in psychiatric hospitals or in the department of psychiatry in my area, who are under so much pressure that it not an attractive position any more. They could cope with their own workload but they are trying to respond to a demand from individuals and families they cannot just meet. They do not have the professional capacity to deal with it. It is desperate to see families struggle in circumstances like this and the ports of call, namely, the HSE or the professionals, are simply not there.

Something must be done to arrange appropriate care and to fund it. The only way to deal with it is in the context of acknowledging there is a problem in the workplace for those who are qualified and that there is a problem of under-capacity in terms of the qualified people who are necessary to deal with these issues. In Kilkenny alone one weekend, there were three suicides. There was another funeral today of a young man who died by suicide. All that can be traced back to their younger years and the fact they were neglected in some way as they went through the services. Some fell through the cracks and some did not get the service required. That is an awful reflection on the HSE and its management systems that do not deliver.

The community model of decongregation in some cases and community homes are all affected by this. They do no have the number of professionals required to deal with the cases they have. As a result, the individuals suffering from mental health issues are getting worse.

If they are not treated, they carry it on to the next phase of development of that issue and it becomes deeper and more difficult to deal with.

If we are making these representations to the HSE and drawing these cases to its attention, one would imagine that it would see the pressure that staff are under and the necessity of getting professionals in to make the job better and make a concentrated attempt to deliver the services to the doorstep of the person involved if necessary. In many cases of which I am aware - some of them involved inappropriate referrals to the department of psychiatry in Kilkenny - people turn up for services and are left on chairs and in beds in corridors waiting to be admitted. In two instances, while people were waiting to be admitted, they left the services and others had to be called in to carry out a search-and-rescue mission. That is not good enough. The type of services required to deal with this need to be put in place and available on demand. Unfortunately, that is the way it is with mental health. Will the Minister of State confirm the funding and also indicate how this issue is going to be addressed?

I thank the Members from various parties for their contributions, my officials to my right and the civil servants in the Department who have helped prepare for this and studiously taken note of the contributions that have been made. Rumours of my demise have been greatly exaggerated. On a more serious note, nobody has a monopoly on wisdom regarding the right thing to do in respect of mental health. We all acknowledge that we have come a long way in our recognition of this issue and in our ability to destigmatise and speak more freely about it and the challenges to which it gives rise.

CAMHS is a specialist service within the mental health services. A multitude of other services are available in the context of mental health but CAMHS relates to young people and attracts much attention. As stated earlier, I met the CHO and clinical leads in the nine CHOs in the last ten days. I informed them that I would not run a waiting list initiative and that I would much prefer to deal with the structural challenges that exist within the area of mental health. We have made significant progress in respect of those challenges. I am of the view that meeting them is the key to the future. It would be worth Deputies' time informing themselves and becoming more aware of the changes that are happening. I held a briefing in the audiovisual room in November. I am of the view that it was a helpful exercise; it certainly was for me. It allowed the Members in attendance to question some departmental and HSE officials and get more accurate information. A contribution was made here today which spoke about telepsychiatry and telepsychology as speaking to a robot on a screen. That level of ignorance is not helpful and people should make an effort before commenting on specific initiatives to at least inform themselves. That is not universal but a very isolated incident. I think most people take more care to research what they are talking about.

We have three specific proposals that I hope to advance in the coming year. One relates to telepsychiatry and telepsychology. The latter do not constitute a silver bullet but they offer alternatives to address the recruitment issue because we cannot keep saying we have a recruitment problem. We have to look at new ways of delivering mental health care. The mental health telephone line training will begin on 7 February for the National Ambulance Service. We will have a 24-hour, seven-days-a-week telephone line that will be manned by professionally qualified mental health staff. There is already demand for that with up to 800 calls a month going to the National Ambulance Service which are related to mental health which it does not have expertise to deal with and where sending ambulance is not the answer except in a tiny minority of cases. We will have appropriately trained people taking those calls 24 hours a day and referring people to services. Some 1,027 different mental health services are funded by the HSE but many people do not know where they are or how to access them.

The other fundamental thing we are doing is building a further level of infrastructure underneath CAMHS. We made significant progress on that last year when we hired 114 assistant psychologists and 20 psychologists. We need to continue to build on that.

Deputy Wallace made many interesting points about the over-medicalisation of mental health and the importance of psychotherapy and talking therapies being introduced along with early intervention and support in primary care. We are making significant progress on that to build that level underneath CAMHS. There is an over-reliance on CAMHS. Many people do not need to avail of CAMHS who are being referred to them. There are more appropriate options but, due to the lack of alternatives, people are referred to CAMHS. The key to successfully dealing with the CAMHS waiting lists is decreasing our reliance on it. We will open a crisis text line this year. International evidence has shown that this works well. Young people are much happier and more free to text and will be more likely to do that than to pick up the phone or approach a mental health professional. We have to ensure that we roll that out successfully and I believe we will do so. Those are some of the digital platforms, and we will also roll out cognitive behavioural therapy.

I do not have time to address all of the points relating to A Vision for Change, an extraordinarily ambitious document which was launched in 2006. We cannot forget what happened in the country after 2006 when the economy crashed and a great deal was lost. Much was achieved in the context of A Vision for Change over a ten-year period. If the Sláintecare report achieves anything like A Vision for Change achieved, we will have top-notch healthcare. I will be the first to admit that we have a long way to go. We do not want to have waiting lists. We want more people to reach out for the services and we do not want them to be discouraged by waiting lists. Structural reform is required. There is no quick fix or easy solution.

I thank Members for their contributions. I hope to facilitate another engagement in the audiovisual room in another month or two to which I will invite Members. We can have a further question-and-answer session at that point.. I thank the Ceann Comhairle for his leadership and facilitating this debate.