Mental Health Services Reports: Motion [Private Members]

I move:

That Dáil Éireann:


— the recent annual report of the Mental Health Commission and the report of the Inspector of Mental Health Services;

— the comprehensive nature of the reports and their contribution to building a culture of transparency in mental health services; and

— the recognition and reporting given to improvements, as well as deficits, within the services monitored;


— the findings and warnings from the Mental Health Commission which highlight significant governance and management deficit within mental health services;

— concerns about seclusion, physical restraint and services for young people;

— likely obstacles to the registration of some of the country’s in-patient mental health units without significant improvements in levels of compliance;

— a serious concern with hygiene and maintenance in a significant number of approved centres;

— mental health services where the degree of dirtiness and shabbiness is unacceptable and shows disrespect for patients’ dignity;

— that 70 per cent of approved centres (in-patient mental health services registered by the Mental Health Commission) remained dirty, malodorous and poorly maintained;

— that a number of centres remained unsuitable and not fit for purpose;

— that a significant number of approved centres have, on a consistent and sustained basis, failed to provide the most basic and fundamental aspects of a service;

— that more than 40 per cent of approved centres were non-compliant on the need for individual care plans; and

— that residents in long-term care are not being adequately monitored for serious physical illness and there was widespread lack of access to essential healthcare such as physiotherapy, speech and language therapy, dietetics and seating assessments;

further notes that:

— the Mental Health Commission annual report also highlighted ongoing concerns around child and adolescent mental health services;

— while the total number of admissions of people under the age of 18 to approved centres in 2018 was 408 (down from 439 in 2017), there were 84 admissions of children and adolescents to 18 adult units during the year;

— children and young people in crisis are left with the unacceptable ‘choice’ between an emergency department, general hospital, children’s hospital, or an adult in-patient unit;

— there are only Child and Adolescent Mental Health Services (CAMHS) units in three counties – Dublin, Cork and Galway – and they generally do not take out-of-hours admissions; and

— in April 2019 the number of CAMHS clinical staff nationwide stood at 57 per cent of the level recommended by A Vision for Change;

agrees that:

— while policy creates hope, the evidence gathered by the Mental Health Commission indicates that it is only well-governed, well-managed and well-resourced services that deliver for the public;

— the absence of regulation of State-provided mental health community residences leaves residents open to the risk of abuse;

— there is no justification for some of the low levels of compliance evidenced in the Inspector of Mental Health Services’ report;

— there are significant governance and management deficits within our mental health services;

— it is difficult to see how some of the lowest compliant centres could be registered in the future without significant improvement;

— hope and dignity are key elements of any mental health service and that not all approved centres are providing that, either through the service itself, or the physical buildings in which they operate;

— it is necessary to respect the wishes of service users and their families/carers in facilities such as the Rosalie community psychiatric unit in Castlerea, Co. Roscommon;

— a planned, costed and funded capital investment programme is required to bring a significant number of Health Service Executive (HSE) buildings up to date, make them fit for purpose and ensure that they are registrable;

— the placement of any child in any adult unit indicates a gap in service provision; and

— a child or adolescent’s first introduction to mental health care should not be through a service or building which is not specifically equipped to deal with their needs; and

calls for:

— a system of governance that drives best practice across the whole country;

— measures to ensure that the specialist in-patient approved centres are up to standard;

— the continued movement of the treatment and recovery model to specialist professional community care;

— the introduction of a system of regulation to protect the more than 1,200 people who live in State-provided mental health community residences;

— adult safeguarding regulation to be put on a primary legislative basis;

— a planned, costed and funded capital investment programme to bring a significant number of HSE buildings up to date, make them fit for purpose and ensure that they are registrable;

— an urgent implementation strategy to ensure that the CAMHS services provided match what is recommended under A Vision for Change;

— the recognition of the rights of 16 and 17 year olds to have the equivalent say over their mental health as they currently do over their physical health;

— the establishment of a national advocacy service on a statutory footing for adults and children under eighteen;

— the establishment of a statutory right for patients to information on their treatment;

— the updating of the Mental Health Act 2001 in line with the Report of the Expert Group on the Review of the Mental Health Act 2001 and to include guiding principles for children; and

— the right of involuntary patients to have any advance healthcare directives respected.

I am sharing time with my colleagues. It is unfortunate that I need to propose this motion in respect of the Mental Health Commission's annual report and the report of the Inspector of Mental Health Services with the intention of keeping mental health on the agenda. I hoped there would not be a need for it to be kept on the agenda but the reports indicate that there is such a need. They are comprehensive and highlight some serious areas of concern and failure within our mental health services. They point to a number of positives as well. However, in 2019, some 13 years into A Vision for Change, a lot of these issues are totally unacceptable and unnecessary. They make for stark reading.

One of the key issues to highlight is that of unregulated facilities. Similar facilities relating to disability care and physical health are regulated by the Health Information and Quality Authority, HIQA, but, in terms of mental health, they are unregulated. I am concerned about the potential for serious issues to arise in some of these facilities. There is no reason to fail to have them regulated and assessed. The reports refer to centres being unfit for purpose or unsuitable. We had the first ever prosecution under our mental health services in respect of St. Luke's in Kilkenny, which had to be prosecuted because of the lack of care for some of our most vulnerable people. There is no justification for many of these faults.

I want to focus also on child and adolescent mental health services, CAMHS. As the Ministers of State will know, this is where the 10% of the most acute circumstances arise that affect our young people's mental health services. These services again remain seriously understaffed 13 years into what was to be a ten-year plan, A Vision for Change. Only 57% of staff were found to be in situ. In two areas, CHO 5 and CHO 7, less than 50% of the necessary staff are in place. Similarly, only 7.6% of the necessary staff are in situ in CAMHS for children with intellectual disabilities. There are no staff to care for such children in three areas - CHO 1, CHO 3 and CHO 6 - comprising almost a third of the country. This affects children who suffer from autism or Down's syndrome. Children with intellectual disabilities are four times more likely to suffer a mental health issue and are least able to cope. There continues to be a long waiting list for children, with 2,500 on it. The numbers of children admitted to adult units were 84 last year and 68 three years ago; the trajectory is unfortunately in the wrong direction. I was contacted by a parent whose child was admitted to the Waterford department of psychiatry, DOP, last night and had to be kept on a trolley. He had been on a hard chair all day because not only is there no place in a child unit but there seems to be no place even in an adult unit for him. We have the continued situation of no after-hours access. We have unqualified consultants and we have been waiting a number of years for the Mental Health Act 2001 to be updated; we do not even have the heads of a Bill yet.

On the consequences, in Temple Street Hospital and my local hospital, Wexford general hospital, the number of children being admitted to the emergency department has increased significantly. Suicide remains the greatest cause of death among young people aged between 15 and 24. Antidepressant prescription is increasing because general practitioners, GPs, are seeing no other options and there are no other pathways out there. I am not questioning the bona fides of the Minister of State as I know he is doing his very best but I do not get a sense of urgency from the Government. I do not get the sense that it is prioritising mental health, putting the necessary funds in place or giving him the support he needs. In a country of 4.5 million people, there should not be a postcode lottery. We have a population approximately the size of greater Manchester and there should not be such large differences, even in Dublin, between what someone on one side of a street can access and what someone on the other side can.

A clear implementation strategy needs to be rolled out in order that everybody across the country has equal and fair access to services. The key issues I have highlighted need to be addressed.

Our mental health services are one of the greatest issues of concern to people. There is increasing concern for the well-being of our young people in particular. The tragedies that are visiting them in all too great numbers are a worry, with solutions that are too vague and not properly resourced. The recent annual report of the Mental Health Commission and the report of the Inspector of Mental Health Services make for difficult reading. The reports are comprehensive and contribute to building a culture of transparency in the mental health services. They give recognition to improvements as well as deficits within the services monitored. Nonetheless, the reports highlight many areas of concern and the failures of the mental health service make for stark reading. There has been significant under-investment in mental health services in recent years. This must change. The future of our mental health services cannot be allowed to fall off the Government agenda.

There is also the ongoing crisis in the children's mental health services. Thirteen years after the publication of A Vision for Change, the services are understaffed. Too many children continue to be admitted to adult units. Waiting lists and waiting times are too long and renewed focus is needed to reduce these service deficits. While early intervention for children with mental health issues is critical, for children with an intellectual disability such as autism or Down's syndrome who also have mental health issues, a lack of early intervention is nothing short of cruel. Children and adolescents with an intellectual disability are four times more likely to be diagnosed with a mental health problem compared to others their age. They may find it more difficult to deal with those mental health problems because of their intellectual disability.

I refer to the growth of drug use in our communities. This is both a cause and a result of mental health issues. In my constituency of Tipperary, there is growing evidence of a serious problem in this area and of its direct link to suicide. We need acute mental health beds in our county. We need proper and after hours mental health services in Tipperary. We need a focused attack on the reasons young people are using illegal drugs to mask their problems and we need proper counselling supports for them and their families to get them away from drugs and into a mental health service that is fit for purpose.

I have been working for some time with my colleagues to bring a motion like this to the House. Both Ministers of State, Deputies Catherine Byrne and Jim Daly, have answered questions in the House on more than one occasion in respect of the Rosalie unit in Castlerea, County Roscommon. I am glad that the motion states it is necessary to respect the wishes of the services users and their families and carers in facilities such as the Rosalie community psychiatric unit. The Minister of State, Deputy Byrne, will know from answering parliamentary questions that people in this unit are mildly mentally handicapped. They are mainly old and they have been there for many years. I acknowledge the Minister of State, Deputy Jim Daly, who has come down and has met us. We have had many a hard battle with him but he is a listener and he does try to help. There are 11 people left in that centre, which initially had 33. It has been made clear to us that the centre is closing and a new service will start up. However, throughout this process, families have been forced into a situation that they do not accept.

It is a beautiful building, as the Minister of State knows. It is not a dilapidated building and it is not a condemned building. It has been the home of these people for many years. Despite the best efforts of the politicians and the families, we find that the HSE did not take into account the state of the people, who are vulnerable and need assistance. The Ministers of State will say the clinicians are the people who know and we cannot contradict them but this motion asserts that in such situations, we must have a better way of doing things. I believe the Minister of State acknowledges that point. I will always make the case that it is our job to come into this Chamber to stand up for those who are vulnerable. In similar future situations, I hope we have to look after people in places such as the Rosalie centre. I request that the Minister of State allow the 11 people who are still there to live out the rest of their lives there. They are older people and their families are very happy to have them stay there.

I commend Deputy Browne and others on bringing the motion forward this evening. It is 13 years since the publication of A Vision For Change. Unfortunately, I put it to the two Ministers of State present, Deputies Catherine Byrne and Jim Daly, that nothing much has actually changed. There are still too many children being admitted to adult wards and our waiting lists are still far too long.

In my constituency office in Cork South-West, I recently met the parents of a young man who are at their wits' end and are in an extremely distressed state. Their son should be enjoying college life, life in general, and looking forward to his future. Instead he literally has given up and has thrown in the towel. He was admitted to Cork University Hospital for one week and while this helped him enormously - I commend the staff there - unfortunately there was no follow-up and no plan made for his future. The family are now back to square one with nowhere or no one to turn to.

I know of another patient who presented at a hospital in the last week having attempted to take his own life. The family, understandably, are distraught. Situations such as this could have been avoided if community staff and ward staff were not under so much pressure. It is even more alarming that the two cases brought to my attention in the past two weeks are both young people with families.

What of the welfare and mental health of staff members? From my conversations with these staff members, I am aware that morale is at an all-time low. They undoubtedly are bringing their work home with them and there is no way they could detach themselves from such a predicament. This is very cruel. The matter is not going to go away and it cannot be brushed under the carpet. It needs to be addressed immediately.

I acknowledge Deputy Browne for highlighting the issue and for bringing forward the motion. In its 2018 annual report, the Mental Health Commission highlighted the ongoing crisis around child and adolescent mental health services, CAMHS. While the total number of admissions of people under the age of 18 to approved centres last year fell, there were 84 admissions to 18 adult units during last year. In the report, the commission chief executive Mr. John Farrelly stated that "the placement of any child in any adult unit indicates a gap in service provision". A place that is not equipped for their needs should not be the first introduction of a person in a distressed state to a service.

The long waiting lists for CAMHS stem from the service having barely more than half the staff required. It seems it is not the only mental health service suffering due to problems in recruitment; waiting lists and bed shortages are common throughout the service. It suggests there is a postcode lottery. Tá dúshlán mór ann maidir le sláinte meoin agus an tseirbhís atá á gcur ar fáil, go háirithe do dhéagóirí agus do dhaoine óga. Caithfimid dul i ngleic leis seo, rud atá léirithe arís agus arís eile. Feicimid é arís san tuarascáil bhliantúil go gcaithfimid tabhairt faoi an dúshlán seo le fuinneamh gan a thuilleadh moille.

I thank Deputy Browne for giving me the opportunity to speak on this motion on mental health services. I will begin by complimenting the Minister of State, Deputy Daly, for holding the audiovisual room session with Jigsaw some weeks ago. It was a very welcome opportunity for that organisation to present its stall. It was also welcome for Oireachtas Members to engage with Jigsaw. We acknowledge the wonderful work they do. We need to see that model replicated throughout the State, however that is managed. Deputy Cahill spoke earlier about Tipperary. As long as I have been in the House, we have been talking about Tipperary as a model that needs to be rolled out. Tipperary borders with my native county - we have just a bridge separating us - and mental health issues know no boundaries. Such a service, be it based in Nenagh or wherever, would be very welcome for the people in Portumna to be able to cross the bridge. It would free up a huge gap.

On the motion and the Mental Health Commission, I was very startled to hear yet again that young people being admitted to psychiatric units is on the agenda and that yet again, we are listening to their experiences. We have no idea what it is like to be in those young people's shoes or to be in those particular horrors or what it is like for their mothers, their fathers or their relatives to have to walk away at night leaving their child in an adult unit. I have first-hand experience of knowing what adult units are like. It is soul destroying when one walks away and leaves an adult behind but I cannot imagine what it is like to have to leave a child.

When the Minister of State, Deputy Jim Daly, takes to the floor later, will he please indicate what he is going to do about beds, because it is about beds? Galway has a CAMHS centre but it has only so many beds while supporting 11 counties.

We are fantastic now at talking about wellness and mental health. There is huge awareness around the issue now. People know about it and gone are the days of it being a taboo. People are now able to say that they need help and to ask how they can access help and get support. People are open to the interventions on offer. Parents are open to being told that the best thing they can do is walk away and leave it to the professionals if an intervention is required. They are open to being told they can do no more, they have done the best they can at home but now it is time to let their little ones come in, as the professionals can give them the wraparound supports and by getting that intervention, they can get the young people back on their feet, back into the community, back into school and pushing forward.

It is very hard, however, to do this when there are not enough beds. Parents are very reluctant to avail of getting that next level of support. The reason they do not want to get that next level of support is they do not want to have to walk away, leaving their child in a 50-bed unit in University Hospital Galway. They do not want to leave their child on a stretcher in the accident and emergency department. Why would they? If a child is having a particular episode and thinks the whole world is against him or her, then parents are not going to expose the child to an overcrowded accident and emergency room, while telling the child this is the best they have to give him or her. This mentally scars the children a hell of a lot more. We actually do the child more harm than good. We are not giving them support and we are holding them back by donkey's years compared with where we could bring them. I put it to the Minister of State that early intervention is key. Consider a young child of ten or 11 years of age with attention deficit hyperactivity disorder, ADHD. We are aware that intellectual disabilities and mental health issues are four times more likely when coupled together like that.

We also need to support the staff who really want to help but who are constrained by the facilities around them and by the fact that they cannot give that help. Earlier I spoke with the Minister for Health, Deputy Harris, with regard to primary care settings. I am a serious advocate for it. I appreciate that we have made leaps and bounds since 2012 in the delivery of primary care settings. The first intervention, however, is where it needs to be at. A situation should not have to become acute where the person might need to get into a hospital bed. Early intervention is key, especially when one does it through the primary care centre and setting. One does not need to have all the staff; there is e-health also. We have moved on. We do not need to run around looking for the psychiatrist or psychologist.

We can have that space in a proper primary care setting, where that family are totally engaged, switched on and know what is going on. I was in Australia late last year and I saw exactly how it is done there. Jigsaw is going out there to look at the best ideas. My God, it was amazing when I walked into their rooms and saw all they have done. We can do that too. We are spending the money but we could put that into the primary care centres. It is normal for people to talk about their mental health and well-being. Why would we not integrate that really well within our primary care setting?

I thought the year we spent on the mental health committee in the bowels of Leinster House was a year well spent. It was a year spent trawling through the issues, asking questions and getting to understand not just what has come out in this report, but also the Prison Service and so many other services. It would help any Minister who is in that position to hear it being teased out.

I thank all of the Deputies who have spoken. On behalf of the Minister of State, Deputy Daly, I welcome the motion as it highlights the Mental Health Commission’s role in holding to account our mental health services. The improvement of mental health services is an important priority for the Government. The Government supports the commission, providing funding to it of almost €14 million this year. These reports will help to improve outcomes for service users.

Despite the identified areas of concern, compliance rates have increased over the last two years. However, we acknowledge that further improvement is needed and the Department of Health will continue to monitor progress made by the HSE in improving compliance. I would like to take this opportunity to welcome the new board of the HSE, which held its first meeting last Friday.

It is unacceptable for approved centres to be dirty, and the HSE must ensure that all residents are provided with clean facilities. We all agree they deserve the best and that this is a basic right. Seclusion and physical restraint should only be used for the purposes of treating a patient, or to prevent patients from doing harm to themselves or others. While compliance with seclusion rules is still low, this is improving year-on-year. The same applies to individual care planning. The Government will support the HSE and the commission to work together to further improve compliance in these areas.

The Government notes with concern the findings with regard to the provision of mental health services for children and adolescents. All referrals are assessed on their clinical presentation and need, and those deemed urgent will be seen as a priority. Placement of children and adolescents in adult units should only happen where this is the best care option, bearing in mind all circumstances. The HSE closely monitors such admissions to minimise these. The HSE is reviewing existing levels of service provision and will examine international models of best practice on the most appropriate models of delivery for use in Ireland. As has been said, there are problems in recruiting and retaining specialist staff in child and adolescent services. Efforts are ongoing but there is a shortage of staff at both national and European levels.

The safety and protection of adults who may be at risk of harm is a key objective of the Government. This is why the Government has approved the development of a national policy on adult safeguarding in the health sector, together with any required legislation. Work has been ongoing on updating the Mental Health Act 2001 for some time. The Minister of State, Deputy Daly, is pleased to note that, today, a draft of heads of Bill, based on recommendations of the expert group review of the Act, was sent to the Mental Health Commission for its consideration. This draft represents a detailed and comprehensive piece of work, which aims to improve and modernise certain aspects of the Act in line with international standards. It is important to stress that this is a phase in a process, with the commission likely to require a period of approximately six months to study and comment on the draft heads.

Included in the draft heads are new provisions to allow for regulation by the commission of mental health community residences. I should point out that while such residences are not currently subject to regulation, the commission has the authority to inspect them and recommend improvements which, where possible, the HSE will respond to. In addition, the updated Act will include new text on the provision of information for voluntary patients, given access to such information for involuntary patients is already provided for in the Act. Furthermore, the draft heads include the recognition of rights of 16 year olds and 17 year olds to have an equal say over their mental health care as with physical health.

The motion refers to the Rosalie unit in Roscommon. The HSE consulted widely with patients and families on the provision of alternative care arrangements, as well as taking account of an independent clinical and evidence-based report. On modernisation of care settings, €3 million was allocated for minor capital works in 2018 to help improve mental health facilities. Almost €1 billion was allocated to the HSE’s mental health services for 2019 and funding has increased by over €270 million since 2012. A Vision for Change has provided the framework for mental health policy since 2006. A refresh of this policy is nearing completion and will provide a roadmap for the future of mental health policy in Ireland.

I reaffirm the Government’s commitment to the continued development of a high-quality mental health service for all. While we all agree there is some way to go on this, it is not true to say nothing has been done. The Minister of State, Deputy Daly, has worked tirelessly on many mental health issues since he came into office and I am sure that, in his closing remarks, he will be able to address some of the issues raised by Deputies. We will not be opposing the motion.

I move amendment No. 1:

To insert the following after “advance healthcare directives respected;”:

“- the reinstatement of the post of National Director for Mental Health to provide accountability, transparency and strong national leadership for mental health;

- the development of an information system for mental health, starting with basic indicators so that outcomes can be tracked and monitored;

- a statutory footing for the right to a care plan;

- the publication, before the end of 2019, of a costed implementation plan for the provision of 24/7 CAMHS;

- no freeze on recruitment or overtime for psychiatrists, nurses, psychologists and other essential staff;

- an immediate commencement of the Mental Health (Amendment) Act 2018 in whole or in part so that people’s basic rights are protected; and

- an immediate commencement of the sections of the Assisted Decision-Making (Capacity) Act 2015, relating to Advance Healthcare Directives and the extension of that right, through new legislation, to involuntary patients.”

I wish to share time with Deputies Cullinane, Martin Kenny, Ellis and Ó Laoghaire.

I thank Fianna Fáil for using its Private Members' time to raise these extremely important matters. I would also like to take the opportunity to commend the proposed Sinn Féin amendment, which I believe is very much in keeping with the spirit of the motion and adds positively to it, with policies for which Fianna Fáil has recently expressed support. I thank Deputy Browne and Fianna Fáil for accepting our amendment. We will see the value in these additions, which were developed in conjunction with mental health campaigners.

There are deep-rooted societal impacts on mental health which can only be addressed fully by policies which pursue an end to the economic and political model which enshrines inequality, poverty and isolation. That said, I believe that all in this House, from all political perspectives, can and should agree at least that mental health services deserve investment and that people who use those services deserve dignity and effective care within the service.

I was not shocked at what I read in the Mental Health Commission report because it is something which my work in mental health for many years has made me all too aware of. At the core, this is an issue of rights. We talk about patients' rights in this context but, really, they are simply the rights of all people to care, should they need it. We do not have that system today, as this report and this motion remind us. There is no dignity in a dirty, smelly, broken down ward. There is no dignity in a four-bedroom dorm with no privacy for adults in mental health distress. There is no dignity in a child being placed in an adult ward or, worse still, sleeping on a chair, as has happened for lack of an appropriate bed. Where is the care and dignity when over two thirds of patients do not have care plans in compliance with regulation?

With no dignity comes no hope. There is no hope when long-term patients have no rehabilitation teams, as is the case for 39% of them. There is no hope in waiting lists for care which put lives at risk and see children become adults before an appointment is met. In that indignity and hopelessness, we find staff who have trained for years to dedicate their lives to care being let down by a system and a Government that, quite frankly, undervalues them, overworks them and does not listen to them.

Many things can impact a person's mental health negatively but mental health services should not be one of them for patients, families or staff.

We cannot continue down this road. The solution is not simple or cheap, but the cost of not acting will be greater. We need accountability with, as promised, a new director of mental health in the HSE, a new Oireachtas committee on mental health and a new mental health Act, which enshrines dignity, respect and hope as the right of all who seek care in the services. We demand clarity on the progress towards 24-7 services, with an implementation process that sets out funding and has firm but ambitious deadlines. We need a statutory right to a collaborative and empowering care plan and to advanced healthcare directives for all patients with capacity.

Nurses, psychologists, psychiatrists and other therapeutic professions demand the respect their work deserves, the ability to do that work in Ireland, to live in comfort at home and to safety at work. I ask the House to support the motion and the Sinn Féin amendment.

I support the motion and the Sinn Féin amendment. It is always good to debate mental health services in this House. I want to focus on child and adolescent mental health services, CAMHS, in University Hospital Waterford, UHW, and the lack of facilities in that service.

The south east lost a number of adult psychiatrists over the past number of years. One of them resigned his post because he recognised that the services were lacking and that the building and services in place were not what children who need the supports of a child psychiatrist and CAMHS should get. The Mental Health Commission, on a number of occasions, found that the inpatient mental health facility at UHW was high risk and, critically, that it was non-compliant with regulations relating to the maintenance of records and the use of their selection. It also found in a previous inspection that children and adults were being placed in what it called "a dirty and dusty seclusion room". It was not fit for purpose. We have had reports of children in adult wards, including a report in 2017 of a 16 year old girl who was left in a chair overnight in an adult psychiatric ward and who was horrified by her plight. I am sure her family were as well. All of this demonstrates a lack of capacity in the system.

I do not blame the Minister of State, Deputy Jim Daly, for every problem in the mental health service, no more that I do not blame the Minister, Deputy Harris, for every problem in our health service but there are serious capacity issues. The regulator, in this case the Mental Health Commission, has made it known time and again, year after year, that there are serious problems in terms of capacity, buildings that are not fit-for-purpose, children in adult words and a lack of psychiatrists. Psychiatrists are leaving UHW because they cannot work in that environment. When St. Senan's Hospital in Wexford closed, patients were sent to Waterford for services, but because no additional capacity had been put in place, the Waterford services became overcrowded and patients throughout the south east were told to attend the services in Cork. These people need supports immediately when they are having an episode or when there is a risk to their lives. They need immediate access to services but it is not available to them in most cases. This is the reality for many patients. Much more needs to be done. The Government needs to wake up on this issue.

I commend the authors of the motion and I support the amendment.

Over the past couple of years, I have raised many issues with the Minister of State, Deputy Jim Daly, in regard to mental health services in the north west, in particular CAMHS. He is well aware of the situation there. It is probably at 50% capacity and has been that way for a long time. This is having a major impact on families and young people who run into difficulties. The service is, at best, a skeleton service. Often, nobody answers when people telephone the service.

A gentleman spoke to me recently about his child who is on medication that has to be reviewed every six months. He cannot even make contact by telephone with the CAMHS unit to make an appointment to have that medication reviewed. When he made contact, he was told to contact his GP. The GP told that him that because he did not prescribe the medication, he could not review it. This is the type of problem that exists in our mental health services.

We also have a serious issue in regard to the school-age psychiatrist service. It is non-existent as well. When a psychiatrist is available, he or she is only available for a short time. A child might meet a psychiatrist once a week for six or eight weeks and having built up trust, the psychiatrist is replaced by a locum to do the same job again. This inconsistency is causing significant difficulties.

On adult services, I welcome the proposed new mental health unit for Sligo University Hospital. It is hoped it will be open this time next year. However, there will be 12% fewer beds in that unit than currently exist, which means a decrease in capacity. At the same time, owing to staffing issues, there has not, and will not be, a service in the community. When I talk to officials in the HSE and the mental health services, they say they cannot find staff to fill vacant positions. They are very frustrated with the situation. We need a new focus and a redirection of energy and, particularly, resources to ensure that we provide for the people who need this service, particularly those in the north west and the Sligo region, which is in serious crisis in regard to mental health services. I have spoken to the Minister of State, Deputy Daly, about this and I know he is doing his best but, at the end of the day, somewhere or other there is a blockage in the system that is not delivering for people. That blockage needs to be removed.

I dtús báire ba mhaith liom tacaíocht a thabhairt dom rún seo agus na leasuithe atá againn. We can all agree that the results of the annual report of the Mental Health Commission should give us cause for concern. Unfortunately, it comes as no surprise that there are serious problems in the mental health services. We should be especially concerned about the continuing inadequate service for children and adolescents. It is unacceptable that children under the age of 16 are still being placed in adult units. This needs to be addressed urgently. In general, the services that are available are poor in quality and, very often, vary in standards. Progress in improving these services has been slow or has not happened at all.

We should also be concerned that the existing services are badly funded and are not responding adequately to the needs of the children or their families. These vital services are further constrained by the moratorium on recruitment. We also have a retention crisis in mental health services. I have been told that there are more staff leaving the mental health service than any other area in the health sector. There are insufficient numbers of qualified staff, such as psychiatrists and psychiatric nurses. The Government’s commitment to delivery of a 24-7 mental health service has not been met.

In general, mental health services are available Monday to Friday on a 24-7 basis, but they are not available round the clock on Saturdays and Sundays. There have been many instances of people with suicidal ideation being turned away from emergency departments. The Government gave a commitment that there would be a psychiatrist available these departments on a 24-7 basis. Those who present with mental health issues, however, generally have to wait a number of hours before being seen by a psychiatrist. In my experience, during the time the individual waits to see the psychiatrist their condition may change and improve, which leads to the possibility of him or her being sent home without before being seen by the psychiatrist in their original distressed condition. This can lead to a false analysis of the individual’s true mental state. This also can happen when he or she presents at a Garda station.

There are many other issues I could highlight if I had the time. Staff in mental health services work hard under difficult circumstances. The staff and those who use the services need the best supports and the best facilities in place. Unfortunately, this is not the case at the moment. I commend Mental Health Reform, Dr. Shari McDaid and her team, who have been to the fore in highlighting mental health issues over the years. We are indebted to them.

I recently had a meeting with some of the leadership team of HSE south-southwest.

I asked people on my social media network what issues I should raise. There were others but one of the most common was mental health. It is an issue of significant concern to a wide range of the population. There are significant issues in adult services, with waiting times and the frequency with which people are seen. There was significant concern about the child and adolescent mental health services, CAMHS. Approximately 650 children are on the waiting list in Cork, of whom 115 were waiting for more than one year at the end of last year. There is obviously prioritisation, but it is unconscionable and unacceptable that a child is waiting for more than 12 months to be seen. We are putting people at risk with such waiting times. They are facing difficult circumstances and concerned. Their families are worried and they need to be seen and receive the support they are not getting. I accept that there is increased demand and I am sure it can be said there is a need for a whole-of-government and perhaps a whole-of-society approach, but the way society is developing is causing increased mental health problems. There is also the stark fact that the resources are not available. In north Lee there is a gap. There has been no psychologist in place since early 2017. The team in the south west of Cork is operating at approximately 42% of the strength at which it should be operating under A Vision for Change. The numbers and staff are not available. That is causing the waiting lists people face and the follow-up is not always to the standard people expect. Sometimes people are seen, but it is very rushed. Then they are dissatisfied, which is a serious issue.

I want to give credit where credit is due for the work HSE south-southwest is doing with a new initiative in CAMHS for people with eating disorders. It is positive and I commend it.

An issue has been raised with me anecdotally, for which I cannot provide statistics. We are producing many psychology graduates. The route to becoming a clinical psychologist is very difficult and expensive. To gain the experience and training required, a person often has to engage in an unpaid placement. That issue needs to be looked at since it means that only people from a wealthy background or the very talented can gain that experience. That is a blockage which needs to be examined and removed. Many want to be clinical and consultant psychologists, but it is a difficult route, rightly so to a point. However, there are blockages with which we can deal.

I commend the motion on behalf of the Labour Party. We have tabled an amendment in a genuine attempt to strengthen the motion. The findings made in the Mental Health Commission's report go a long way towards highlighting the significant governance and management problems in services, but the report deals primarily with the top tiers of the pyramid of mental health care services. These should be the services of last resort, but recently they have tended to be the only service delivered, which is a problem. I speak regularly to providers and practitioners on the ground who tell me the same story about people who are forced to present at acute services such as CAMHS owing to the absence of primary care services. In many cases, they have reached a crisis point owing to the absence of early intervention services. We see this not only in mental health services but across all services. Our motion on carers last week was yet another example of the overuse of expensive acute services and the underuse of cost-effective and efficient primary care servoces. We then wonder why Ireland has one of the highest health spends in the Organisation for Economic Co-operation and Development, OECD, yet it has some of the worst health outcomes among advanced countries. The problem is not with the quality of staff in the HSE or overall resources, as evidenced by the current overruns. The problem is that we lack an holistic strategy for mental health services at Government level and a coherent system to match the objectives set out in A Vision for Change.

Young people are experiencing unprecedented levels of anxiety and stress in their everyday lives. Everything has changed in the past ten years. Up to one third now experience mental health difficulties and, shockingly, suicide remains the most frequent cause of death among those aged 15 to 24 years. We need to ask why these difficulties are arising among young people. The increase in inequality is one reason. The evidence shows that unequal societies have greater rates of mental distress. As the gap between rich and poor in society continues to widen, so too does the number experiencing mental health difficulties. There is also obviously a serious social cost.

Perhaps it is better to speak in a language the Government will understand. Economically, the cost of the mental health crisis was put at €8.3 billion by the OECD in 2018. To put it in context, that is approximately half the total health budget. We need a radical change of direction. We need to see expenditure on mental health services not as a cost but as an investment. That is why the upcoming budget should, at a minimum, increase mental health spending in line with what was set out in A Vision for Change.

The amendment calls for a paradigm shift in the delivery of mental health services. We need to move from a reactive approach based on expensive acute care to a preventive and proactive approach based on community-led, cost-effective early interventions. That is the most important thing I will say to the Minister of State, Deputy Jim Daly, and I think he agrees with me. To achieve this, we need an holistic, integrated approach by the Government that moves beyond narrow economic measures to focus on societal well-being. A simple but relevant example is trees in a city. Researchers have repeatedly found evidence of improved mental health from exposure to nature. We all know that a walk in the park reduces our stress levels and improves our mood and mental health. Ultimately, more trees means reduced treatment costs and improved worker productivity. That is just a tiny example. As part of the BusConnects plan, more than 1,000 trees will be felled. Where is the joined-up thinking? Meanwhile other European cities such as Paris are planning the development of urban forests in city centre locations. The Government's approach shows a lack of joined-up thinking in these measures.

We need to redirect spending to primary level interventions that have nipped problems in the bud. Let me give an example. I recently attended a CAMHS briefing which I think the Minister of State may have hosted. This figure was prominent and is worth emphasising. According to the HSE mental health division, 90% of mental health needs could be successfully treated within a primary care setting. That is a fraction of the cost and would reduce the burden on top-tier psychological services.

Let me give another example from another briefing I attended. I recently spoke to representatives from Jigsaw, of which I am a supporter and about which I have spoken to the Minister of State. It provides an excellent early intervention service for young people. Some 71% of those aged 17 to 25 years who came through its doors saw a reduction in the levels of their psychological distress. We have spent a long time trying to roll out these excellent services. I hope there will soon be an announcement of a location for the Jigsaw service in County Tipperary since a decision was made to provide one there. The service has supported more than 30,000 young people and upskilled more than 200,000 adults to foster support of young people's mental well-being. The models are in place and we know that we can produce results if we can expand the services provided. The Minister of State should turn the ship around in the port, let the service be community led and ensure it is facing the community, rather than concentrating on acute services.

Services suffer from the silo effect within the system in which they operate in the HSE. Let us consider, for example, a person who is aged over 18 years who presents to Jigsaw but needs a referral to CAMHS. Under the current system, he or she will need to be sent back to his or her doctor for a referral letter. This means another layer of bureaucracy, a day off work, another €50 to be paid in general practitioner fees, etc. The Minister of State sees where I am going with this. I do not think that is necessary. In reality, the person may never present again to his or her doctor for a referral letter. Is there any way the Minister of State can quantify the number of such events? I am not sure if it is possible to do so, but it would be interesting to know. What is happening is that they will present again later with a more severe problem because they will be lost in the loop.

We should not put bureaucratic or cost barriers in the way of people in mental distress. It should not matter which door a person walks in through. He or she should not have to worry about the convoluted way in which he or she will access services. He or she should just be able to access them. The mental health service should be seamlessly integrated, with different providers having the ability to refer to the most appropriate service in a timely manner.

The Labour Party generally supports the findings by the Mental Health Commission and the implications outlined within the motion, but we believe it is time we moved beyond painting over the cracks. We all know the old adage that prevention is better than cure. It is very simple. Staffing resources and adequate governance must be addressed at every level of mental health care, but as I have repeatedly said, we need to turn the ship around, get rid of bureaucracy and make it face towards the community rather than its current top tier, which is acutely driven. The service does not work to the level required and is also overtly expensive.

I welcome the opportunity to speak on this motion. I could address many issues concerning the mental health services in the Roscommon-Galway constituency but I wish to focus specifically on one issue that is referenced in the motion. That relates to the Rosalie home in Castlerea in west Roscommon. Back in 2015, the Health Service Executive and the then Minister of State with responsibility for mental health, Kathleen Lynch, apologised to the residents of the unit for the manner in which a clinical assessment was carried out without their knowledge or the consent of the next of kin. The assessment was used as a justification for the closure of the long-stay residential unit.

In 2018, a similar clinical assessment was carried out with the same purpose in mind, again without consent. In fact, the next of kin were specifically informed by the clinician that it was not a clinical assessment. The Minister of State, Deputy Jim Daly, stated he was satisfied with the way in which the HSE had handled the situation. In a reply to me, dated 21 June, he stated it was in line with best professional practice. That is not in line with best professional practice. That is not the case and an immediate stay must now be put on any transfer of residents, pending a full, independent review of the treatment by the HSE of the residents over the past four years. The debacle must be addressed once and for all.

I welcome the opportunity to speak on the motion, which I support. This is probably our tenth debate on mental health and, unfortunately, as a previous speaker pointed out, things do not change. That is especially the case in the Roscommon-Galway area where we have had nothing but closures and services being taken away. Day care centres were closed, hostels were closed and then we had the news about the Rosalie unit. This debacle has gone on for four or five years. There has been indecision and families have been treated in an abhorrent way. The manner in which patients and their families have not been given information and things have not been done in a transparent way is disgusting. The people in the Rosalie unit, which is a fine facility, have been there for many years and deserve to stay there. On top of that, we also have a situation in the acute unit in Roscommon in that step-down facilities are not provided. Unfortunately, it seems that people in the services in Roscommon get promoted for closing places. That is what seems to be emerging. They are putting middle-aged people in nursing homes who should not be there.

It is great if one can have the services in the community, but while we talk about it we are not resourcing it or supplying the service in the community. At the same time we are closing the different facilities that made life that little bit easier, be it in Ballaghaderreen, Athleague, Strokestown or wherever else in the county. I ask the Minister of State to have a comprehensive look at what is going on. He should take an overview of what has happened in Roscommon especially and give people dignity and treat them with respect. I do not blame the Minister of State but everything is pushed over to clinicians. They seem to be the saviours of the world. Unfortunately, my reading of it is that families and the patients know more than many of the so-called experts.

I am pleased we are having a debate on this topical issue, which has been debated at length in this Chamber. It is good that we are having the debate today.

The Mental Health Commission's report makes for very sombre reading. About an hour ago I read some of the observations made by the commission. I will refer to four. If they do not worry people, then nothing will. The first relates to physical restraint and seclusion. The report states that just 19% of centres were compliant with the relevant code of practice. The second is that 40% of approved centres were non-compliant with the regulations on the need for individual care plans. The third relates to a shortage of mental health staff, which comes under the narrative relating to the retention of staff. Even more worrying is what was said about 24-hour supervision in approved centres for young people. The commission's observation is that the residences are not regulated and leave residents open to the risk of abuse. The report, to say the least, is unbelievably grim. I do not blame the Minister of State, Deputy Jim Daly, personally, because I do not make things personal. The report is very worrying for young people when they access mental health services.

The observations get worse. The report stated that 70% of approved centres were poorly maintained. Some of them were not even fit for purpose and 40% were non-compliant on the need for individual care plans. Something is dramatically wrong if individual care plans are not provided for the young people in the care of the centres. Nearly 84 children and adolescents were admitted to 18 adult units this year. It is quite incredible that this is going on. The levels of compliance and deficits in care are very worrying. The absence of regulation leaves residents open to abuse. The report makes bad reading for young people listening to the debate tonight. As other Members have said, there is a crisis in the health service and in mental health services in this country. In some ways the staff are trying to do their best, but the lack of retention of staff is having a big effect on the delivery of the service.

In my constituency we received two pieces of bad news about mental health services. The adult mental health services in Clondalkin is due to close and to move to Tallaght. To compound that, the Jigsaw youth mental health service in Clondalkin is also to move to Tallaght. Along with other Deputies from the constituency, I indicated that it was a significant mistake to move Jigsaw from Clondalkin. It is a successful service and it does not make sense to move it to a different area. I hope the decision will be reviewed.

A Vision for Change was visionary in some ways, although it was gathering dust for 13 years. It was visionary to state what we need to have in a mental health service that complies with the 21st century. We are nowhere near that. Having read the observations, the onus is on the Minister of State, Deputy Jim Daly, to review fully mental health services for young people in this country because the report is damning. It is up to the Government to address it.

Progress has been made on mental health issues. I refer to correspondence from Mental Health Reform in which it acknowledges that the Minister of State will send a draft update of the mental health legislation to it in July.

It outlines the work it has been doing on guidelines relating to ethnic minorities and improvements in building a culture of transparency. I feel, having been here for ten years now, that we are saying the same things and going around in circles when it comes to mental health.

The outstanding issue is A Vision for Change and its full implementation. It was so lauded when it was introduced but we are still waiting on implementation. There has been very slow progress on implementing every aspect. There was an independent review mechanism that worked for two terms. We are looking at all this but it has now gone. Where is the independent review?

It is the survivor groups from the institutions who have the phrase, "Nothing about us without us." That could also be applied to those with mental health issues so they can be part of whatever services are being provided.

Yesterday I attended a seminar addressing substance use and misuse in the north-east inner city. The HSE was outlining the improvements planned for health services, covering factors such as a new case management tool and a new inclusion hub where a range of services will be provided. It was using terms such as "outcomes-based accountability" and "ensuring the service is making a difference". This represents a positive way forward but the theory must be applied to individual cases and to the reality. It is as if we know what to do but that doing it is problematic.

An area of need I wish to refer to is dual diagnosis. This is a very real issue for those with both an addiction and mental health issue. When a person presents with an addiction to an addiction service, the service is not provided once it is realised there is a mental health issue. Likewise, when a person presents with a mental health issue to a mental health service and it is realised that an addiction is involved, that is the end of the service. The mental health issue could range from psychosis or bipolar disorder to depression or an anxiety disorder. The difficulty is that mental health and addiction services are not treating people holistically because they are treating the condition instead of the person. I acknowledge there is work and research taking place in DCU, but in the meantime, people with both a mental health issue and an addiction are just not receiving the service they need. The reality is that two thirds of those who have died by suicide had both an addiction and mental health issues.

The last point I wish to make is about child and adult mental health services. The staffing level is 57% of that recommended in A Vision for Change. I once mentioned talking to some teaching friends about their experience of the child and adult mental health services. One said the experience is positive once the child is assessed and is in the service. Another asked what a child has to do to be guaranteed access to the service in a swift manner. That teacher said the service is more reactive than preventive. Of course, the communication leaves schools at a distance because the referral is made by a general practitioner, yet the child is probably attending school and the school is left out of it. As others have said, it is about joining the dots on this.

Unfortunately Ireland has a dark and disturbing history when it comes to the mass institutionalisation of people with mental health problems. It is only in recent history that the State has begun a broad shift away from this model of care. However, according to the Mental Health Commission, the law in its current form is still outdated and outmoded and is not based on a progressive rights-based approach to mental health care. The commission's most recent report highlights significant governance and management deficits within mental health services. Other concerns relate to hygiene and maintenance levels, levels of compliance, the use of physical restraint of young people, seclusion, and 70% of approved centres registered with the Mental Health Commission remaining dirty and poorly maintained.

On upgrading legislation, it is vital that there be reform soon. Advocates have continued to call for legislation to be published no later than the end of this year. Irish legislation is still without key aspects. Specific guiding principles for children are not in the 2001 Act. Individuals do not yet have a statutory right to individual care or recovery plans. Voluntary patients still do not have basic rights to information or advocacy. While those aged 16 and 17 can consent to or refuse physical healthcare decisions, this right does not apply to mental healthcare decisions. Most poignantly in the context of this debate, involuntary patients do not have the right to have their advance wishes about treatment respected, leading every year to the detention of between 2,000 and 2,500 people against their will in psychiatric facilities where they can be forcibly injected with medication, physically restrained by staff and locked in isolation. It is clear that despite reforms made in recent years, the State retains a disproportionate amount of power over individuals with mental health issues. The use of control and coercion must be examined as a matter of urgency.

The Mental Health Commission has repeatedly called for serious attention to be paid to the human rights of mental health service users in terms of capacity and consent to treatment. The main obstacle to greater reform is the fact that State funding has been in crisis, largely due to decades of chronic underinvestment and the inability to recruit and retain staff providing the care. If we decide on everything based on money, we will have serious problems and have them continuously. Waiting lists are long and demeaning. The longer people have to wait to receive mental healthcare, the more problems they face. The commission's annual report also revealed that 84 children were admitted to adult mental health centres in 2018. This is absolutely unacceptable over 13 years after A Vision for Change was published.

Furthermore, the number on the waiting list for child and adult mental health services in Donegal is at an all-time high, with no sign of it dissipating. This is due to inadequate staffing levels. Some are waiting more than a year to be assessed, and that is before they get into the system to receive proper care. We should be at a stage where 24-7 child and adult mental health services are in full effect and fully resourced but we are far from that reality. The current services are not meeting the needs of young people and their families. They have been shockingly underfunded for quite some time. The failure to recruit and retain staff is hampering efforts also, yet the Government does not seem to be doing anything to address this crisis.

Let us not forget the young people in third level education. Record numbers of third level students are receiving counselling for mental health problems, such as anxiety. However, the number of counsellors per student, one for every 2,600, is very low by comparison with the recommended ratio agreed by the International Association of Counselling Services, which states there should be one councillor for 1,000 to 1,500 students. This means students often end up waiting for weeks before they can gain access to a counsellor. The latest figures show waiting times vary, between seven and 40 working days, depending on individual colleges.

One reason for the dire state of our mental health services is ideological. The Government does not believe in the right to healthcare based on need rather than ability to pay. That is the crux of the problem. Instead, the Government continues to invest in a two-tier health system that consistently undermines public services. Despite this, the Government continues to support the structure as opposed to winding it down, and staff are moving away from public care to private care.

It took over a decade for Ireland to ratify the UN Convention on the Rights of Persons with Disabilities. I hope it is not taking another decade to reform our mental health services so the human rights of all those with mental health issues can be protected. The Minister of State must address this on a human rights basis, focusing on the right to treatment and not the cost of treatment. That is the only way to sort this out once and for all. I would love to hear in the Dáil the actual cost of having a health service that is fit for purpose rather than one that meets the arbitrary budgetary figures picked every year for it. That would be refreshing in itself.

With regard to the Mental Health Commission report, particularly in respect of CHO area 3, the mid-west, the acute psychiatric unit in Ennis had a compliance rate of 73% and that in Limerick had a rate of 72%. This is very disappointing. It relates to pressure of work, old infrastructure and staff shortages. I do not believe it relates to professionalism. The shortcomings relate to cleanliness, of course, but also to a lack of dignity, privacy, respect and safety. I refer not only to the safety of patients but also to the safety of staff. The contributing factors are the volume of acute admissions and the lack of inpatient beds. Ireland has 22 beds per 100,000 members of the population whereas the EU average is 70. The Joint Committee on the Future of Mental Health Care recommended that the ratio be increased to 50:100,000 by 2021, and to 70:100,000 in 2023. There is a great need for capital investment to improve our infrastructure. With our improved infrastructure, we will attract staff into our service. Unfortunately, we are not doing that at present.

Not only does Ennis cover the catchment area of County Clare but also the catchment area of south Tipperary since the acute unit in south Tipperary was closed a number of years ago. Unfortunately, the bed complement in Ennis has not increased even though the catchment area has.

Nationally there are 100 vacancies for permanent consultant psychiatric posts. This can lead only to a reduction in services. Some posts are filled by agency staff who are transient locums, and this leads to a lack of continuity and tenure that does not allow the service to develop.

Some posts are filled by agency staff who are transient locums. This leads to a lack of continuity and tenure, which does not allow the service to develop. It is only filling a gap. In other cases, non-specialists are acting up to fill a gap. That is not an ideal solution and not the solution to the staffing crisis. The other issues that pertain are in respect of community services. Community psychiatric services are lacking community nurses, occupational therapy, psychological therapy, counselling and social work support. This also pertains to the Kilrush area, where there is a great lack of staff within the community team. This is unsustainable and also leads to an over-prescription of medication. Instead of talk therapy, we are prescribing medication, quite often unnecessarily.

I thank Fianna Fáil for bringing forward this motion. I thank the Minister of State for being actively interested in County Kerry. He has come down on a number of occasions connected with different aspects of his portfolio. I will welcome him any time he wants to come down. I invite him now because there are other issues with which we want him to deal in County Kerry and I look forward to seeing him visiting as soon as possible. I especially compliment the people who work in the mental health services in County Kerry. I served for seven or eight years on the psychiatric services committee of the old Southern Health Board. During that time I got to know, appreciate and understand the workings of mental health care and all the different plans that were formulated over 15 years. We had A Vision for Change and all of the different models that were brought in regarding how to deal with mental health care and issues arising out of that.

I have one thing to say about County Kerry and the whole country at present. A gap arises in the services where a person is going into adulthood but is perhaps neither a child nor an adult. The Minister of State knows as well as I do that there is a deficiency in the service in that respect. Parents are left in a traumatised state with a young person in the house under their care who is neither a child nor an adult. Those people need very special care and attention. We are failing to give them that care. There are failings in the system and it is not the fault of the people working in the service. It is us as legislators, the HSE and the governance that needs to be addressed to ensure that facilities and services will be put in place to take care of those youngsters and to mind them every day. That is needed because we could lose them in a shot and we do not want to lose anybody. Losing one person is too much. Every county and every family is affected by suicide and similar issues. We want to protect people in those situations.

I also thank Deputy Browne of Fianna Fáil for bringing this important motion forward. I am glad to get the opportunity to speak on this important subject. We all know too many people, young and old, who have lost their lives due to severe mental health problems and suicide. I believe that the HSE and the Department of Health are not at the races at all in delivering a proper service. I compliment the staff working in the services, however. They are working to the best of their ability amid the constraints of the environment with which they have to deal. It is very clear that when an unfortunate person presents at the weekend, in many instances there is no assistance available and that person is then sent home.

That has resulted in the loss of lives and that is not good enough. As Deputy Michael Healy-Rae stated, youngsters from the age of 13 or 14 up to the age of 22 or 23 should not be treated as adults or put into a ward with adults who have a long history of mental health problems. It is wrong to put those youngsters into that environment. We should be striving to get away from that situation. All of our hospitals should be examined and new systems put in place to deal with these scenarios. Some of these young people need one-to-one professional care and to talk with trained psychiatrists. Invariably, those services are not readily enough available. Instead, sedation may be used and that is not good enough. I have gone into someone else's time.

That is so unusual for Deputy Danny Healy-Rae.

I thank the Leas-Cheann Comhairle. It is hard enough to get any time at all here.

Mental health services in west Cork for young and old people leave much to be desired. Only last week, I broke a story I had known about for some time. It concerned our mental health facility known as the centre for mental health care and recovery in Bantry. It is an acute admission unit, which services the west Cork population of more than 50,000 people. The service also has a community mental health team, consisting of community-based mental health nurses, psychologists, psychiatrists etc. In recent weeks, I have spoken about the real facts concerning the conditions in that facility where staff numbers are at an all-time low and the staff members are stretched to the limit. I am blowing the whistle on what can only be called awful management at the centre for mental health care and recovery in Bantry.

There is a major staffing crisis in the unit. The answer to that problem from management was to pull staff from working in the community. The community staff ensure that people stay out of hospital. I am referring to people who need a multitude of different support systems. Agency staff are being brought from Cork city and being accommodated in a local hotel to fill the staff shortages. The morale on the ward has never been worse with many staff going off sick with stress. Those who have spoken to me have no one to turn to. They know that they would be in danger of being sacked if they are traced or their identity becomes known.

Only last week, the Mental Health Commission released a report, which I have to hand, on Bantry mental health services. A drop of 10% in areas across the services has been recorded since another report was carried out in 2017. If we look closely at the report, and I have looked as closely as I can in the time I have had, it is easy to see why. It is simply down to staff shortages. I will be keeping a very close eye on how this issue will be dealt with in future and watching to ensure that no witch-hunt takes place. The wrong that is ongoing in the centre for mental health care and recovery in Bantry should be rectified. The great pressure on the staff should be eased and the happy working atmosphere that used to exist in the unit should be restored.

I know that recruitment and retention of staff in an area like west Cork can be challenging for management. It might help to alleviate the situation if certain steps were taken. Are contracts being offered to each group of students graduating? Are they being offered the opportunity to work in areas like west Cork? Is there a policy to protect community services? Can staff be reassured that if they make a complaint in good faith that they will not be penalised?

I commend Deputy Browne on bringing forward this important motion. I confirm my support for it and for the amendments tabled by Sinn Féin. It is important to state we have come a long way. Both of my parents were psychiatric nurses who started in the service in the early 1930s at St. Luke's Hospital, Clonmel, which was then known as a lunatic asylum. At its height, that institution had more than 1,200 patients. It was a very different place in those days than it is today. My dad joined the service as a warder. There were no nurses in those days. He qualified as a nurse afterwards, as did my mother. Restraint was then the treatment method employed at the time. Indeed, my father often said that he regretted the restraint methods they had to use in those early days.

That generation, however, was also the one that started challenging the whole idea of stigma surrounding mental health. That was the generation that removed the huge walls around psychiatric hospitals. They took down the gates, welcomed in the community and invited it into the hospital. I remember well that there was a local pitch and putt club on the grounds of St. Luke's' Hospital. Members of the public were invited in and patients in turn began to go out into the community. They went on day trips to the cinema and to the circus. Eventually, some patients came to live independent lives in houses in the community.

That was the beginning of community-based services. Staff in mental health services, both past and present, have been exceptional, but current staff are under immense pressure due to underfunding and a lack of personnel. As a result, it is difficult to recruit and retain staff.

It is important to refer to the various volunteers whose work in this area is considerable and valuable. Our area has organisations such as Community Suicide Awareness Workers, C-SAW, the River Suir suicide patrol and Taxi Watch, and there are many others around the country. We should recognise the essential work that they do. They should be supported.

I acknowledge the involvement of the Minister of State, Deputy Jim Daly, his engagement with local issues on the ground, and, in particular, his approval of the Jigsaw project for Tipperary. I spoke to those involved in the project recently. We will shortly meet them to discuss the programme's implementation on the ground.

It is a case of a lot done but an awful lot more to do. The report of the Mental Health Commission as well as the reports on individual acute units are very disturbing, in particular against the background of increasing mental health issues in the community generally, especially among young people where self-harm and suicide are increasing at an alarming rate. The reports are also disturbing in light of the fact that there is a plan for a seamless mental health service. That plan, A Vision for Change, has been there since 2006. Unfortunately, that document is still not implemented 13 years later. It was a far-seeing policy and might have been before its time. It addressed all of the various areas, for example, early intervention, 24-7 services, community care, talk therapies, day care, crisis services, emergency services and acute beds. It is a pity that A Vision for Change has not been implemented. That policy is the key to putting in place good quality health services for the community.

The Minister of State is well aware of it, but I must refer to a particularly difficult situation in Clonmel in Tipperary where services were devastated in 2012 following the closure of the St. Michael's acute unit. When it closed, south Tipperary patients were sent to Kilkenny and north Tipperary patients were sent to Ennis, but those units were overcrowded and not fit for purpose. The Kilkenny unit has been prosecuted and convicted in recent times following a Mental Health Commission report. It is also difficult for south Tipperary patients to be admitted to that unit. Even when they are, they are discharged early. Due to the need to travel, family support is almost non-existent, despite the fact that it is key to helping patients improve and recover. At the time, we were promised a Rolls-Royce community service, but that did not happen either. We now have community teams that are significantly understaffed. For instance, 19 nursing posts and a number of other healthcare professional posts are vacant. We were promised a new crisis house. Seven years later, we appear to be no nearer to it. As other Members have stated, there are particular difficulties in respect of patients with mental health issues attending emergency departments of our general hospitals. Young people are being admitted to adult wards. At one point not so long ago in Tipperary, one third of our paediatric beds were taken up by young people with mental health issues.

These are some of the issues affecting Tipperary. They need to be addressed urgently. The bigger national picture needs to be addressed as well. A Vision for Change should be the foundation for that.

Go raibh maith agat. Téimid ar ais anois go dtí Fianna Fáil, agus tá deich nóiméad acu. Glaoim ar an Teachta MacSharry, who is sharing his time with Deputy Troy.

I might go second, if that is okay.

That is an internal matter.

I welcome the opportunity to contribute to the debate. I congratulate Deputy Browne on his tireless efforts advocating on behalf of patients and the families of those who suffer mental health issues. Not only has he repeatedly pointed out the failures on the part of the Government, he has been to the fore in proposing solutions. For example, last year's Bill would have ensured that greater emphasis was placed on the autonomy of individuals than on the reliance on the principle of best practice as set out in the 2001 Act.

The recent report from the Mental Health Commission is worrying and highlights major deficits within mental health services, including issues of seclusion and physical restraint of young people. Last year, 84 children and teenagers were admitted to adult units. That is an appalling figure by any stretch of the imagination. Last week, there was a debate at the Council of Europe on ending coercion in mental health services and the need for a human rights-based approach. The Commissioner for Human Rights referred to how "a coercion-based mental health system perpetuates the isolation of the very persons who need the support of their community the most, which in turn fuels more stigma and irrational fear". The report's rapporteur pointed to the fact that there was "not enough scientific evidence to prove the usefulness of coercion in reducing harm, whereas there [was] abundant evidence for the harm – and sometimes irreparable harm – that involuntary placement and treatment can cause for patients". We need to reduce the stigma around and barriers to the provision of mental healthcare so that persons are empowered to seek and participate fully in treatment as early as possible.

Staffing levels remain a serious concern. Services in some parts of the country have fewer than half the recommended number of staff required for CAMHS as set out in A Vision for Change. This is simply not good enough. More than 300 people have been waiting a year or more for access to mental health services.

The House is failing on this issue. The Government is abysmally failing this most vulnerable sector of society.

I acknowledge the good work done by many community groups such as Good 2 Talk in Mullingar. Were it not for their work, the waiting lists would be far longer. It is high time to accelerate recruitment and work towards full implementation of A Vision for Change because if we do not, the long-term consequence will be irreparable damage, as stated last week by the Council of Europe Commissioner for Human Rights.

Mental health remains the poor relation in the health service. The health service overall is an omnishambles. Cost overruns were estimated at approximately €400 million based on current figures at the meeting of the Committee of Public Accounts last week at which the director general of the HSE appeared. The Department of Health has always been starved of the resources it needs. That is what leads to statistics such as being 2,671 staff short of what was envisaged in A Vision for Change, a policy that is now 13 years old. We are not taking the issue of mental health seriously enough. The 1916 Proclamation is made a mockery of in terms of the treatment of children. Children are not treated equally. Some are treated far more equally than others depending on whether there is cash in their parents' pockets or they have access to private care. These Houses turn out report after report without any thought of implementation, costs or resources to ensure that we get the services we need.

There are only three or four hospital-based child and adolescent mental health services, CAMHS, units, with none in the north west. We do not have 24-7 CAMHS care, which is unacceptable. The annual report of the Mental Health Commission highlighted that 40% of approved centres were not compliant with regulation 15, which relates to individual care plans. That is shocking in the extreme. Of the 27 centres that continued to use seclusion in 2018, 67% were non-compliant with the rules, while of the 52 approved centres that used physical restraint during the year, just 19% were compliant.

It is a damning indictment of all Members of this House that in each debate on mental health we bemoan the fact that we are failing miserably all people with mental health needs, particularly children. I ask the Minister of State, Deputy Jim Daly, who is present, to be honest with the House and tell us how badly he, his colleagues and officials are being treated in terms of the provision of adequate resources to put the correct governance in place, get an adequate number of staff and attract them from abroad if necessary, although I cannot imagine why we would have a problem recruiting and training our own staff, and ensure that we move to 24-7 CAMHS services as a matter of the utmost urgency along with the provision of a full-time unit in the north west, similar to those located elsewhere in the country.

More than two and a half times as many people die from suicide in this country as die in road accidents. Many of them are young people whose lives are taken away and whose families are devastated as a consequence. It is a national crisis. As my colleague, Deputy MacSharry, stated, continuing care, especially in the area of mental health, tends to be the Cinderella of services. However, it is of significant importance. For some reason, it does not seem to get attention in terms of getting the same amount of finance as other health services or, for example, that has been invested in reducing the horror of car accidents.

Members encounter this issue most often day to day in their clinics, where they are visited by people who are queueing to get into CAMHS. No matter how acute the case may be, the CAMHS list is taken in sequence. One gets on the list and one waits because it only has a fraction of the staff it needs. The reality is that in some parts of the country there are only half the number of staff required to provide the service. We do not seem to be able to understand that this is important and urgent and that the lack of staff is causing ongoing problems. Many people with an intellectual disability also suffer from mental health issues. People suffering from these disabilities and their parents must deal with that horrendous combination. Again, there are not sufficient staff to treat them. People are told that they must wait.

I believe that a stitch in time saves nine. It is far better to treat people as outpatients than inpatients. Obviously, inpatient care is needed, but it should be the last resort. We must question whether we have been penny wise and pound foolish in not ensuring adequate first-call services in CAMHS and other services to try to reduce the number of people who need a full-time residential service. Those who need such a service should get top-class provision. We need to get away from the Victorian ideas and conditions that bedevilled mental health services in the past. Of course, putting an underage person into an adult service should be taboo.

I thank Deputy Browne for tabling the motion, bringing this issue to the House and giving us an opportunity to discuss and debate it. I thank him for his continued interest, as acknowledged by all of his colleagues present, his professionalism, and the very constructive spirit of co-operation in which he has always approached the issue of mental health. It has been welcomed on this side of the House. I thank all those who spoke on the motion. I always find that debates on mental health issues are non-partisan because people's genuine passions come to the fore and, for the most part, they leave politics at the door, notwithstanding the responsibility of Opposition Deputies to hold the Government to account.

I confirm that the Mental Health Act 2001 went to the Mental Health Commission. That is a very welcome step which is long overdue. The Act finally made that journey, which is a step in the right direction.

Many speakers referred to capacity, beds and issues arising in that regard. Obviously, we will not tolerate governance issues, which are unacceptable. Deputy Rabbitte's comments could have been a template for my closing speech. I could not agree more with everything she said, and she said it very well. We can look at capacity. There is nothing more heartbreaking than to see a parent admitting his or her child to a CAMHS unit. It is devastating to witness and we should try to avoid parents having to do so. Deputy Ó Cuív noted towards the end of his contribution that such admissions are to be avoided at all costs. As he stated, it is far preferable to treat people as outpatients than as inpatients. All Members agree on that.

We want to move to a more proactive space. Thankfully, that is happening in the area of young people. Last year, we introduced 114 assistant psychologists managed by 20 psychologists and overseen by ten advanced nurse practitioners. That addition to the primary care service for young people was aimed to build infrastructure at a lower level to help prevent people having to go to CAMHS. I could have decided to carry out an initiative aimed at reducing CAMHS waiting lists and throw a couple of million euro and additional resources at it, but I pulled back and decided to be more proactive and try to get to people earlier and to get intervention working at a lower level. That is why we introduced those staff.

That is working well and capturing many of these issues earlier. Like any initiative in health worth its salt, it will take time to show real tangible results. Despite this, it has been independently evaluated already by the University of Limerick and it is showing significant decreases in waiting times for primary care psychology services for young people. Of course that will have a knock-on impact on the child and adolescent mental health service list. That is to be welcomed.

In the coming weeks we will have a €3 million community fund. It is a small fund initially but it is the first time we have taken some money away from the HSE on the basis that we want to support some of the wonderful initiatives in place in the community. I will be launching the fund this side of September. I hope that €3 million will grow next year to €5 million and then €10 million. Ultimately, that is a sea change and a move away from the more reactive spending of the HSE towards trying to deal with issues more proactively and recognising the work of community groups. We need to support these groups if they demonstrate their work is proactive and preventative in nature. That €3 million will begin in the coming weeks.

One of the most significant tranches of work we have done in the Department in recent times is the refresh of A Vision for Change. We consulted extensively and widely. It is the single most important job because it will determine the policy long after I am in this position and regardless of whoever occupies this chair afterwards. All of us as stakeholders and vested interests will determine the policy. That will go to Cabinet in September. It will be published subsequently. It will set a new direction for us and will be far more outcome focused than the previous version. A Vision for Change served many good purposes but was of its time, some 13 years ago. It needs to be refreshed in recognition of changes and whatever. In particular it needs to be more outcome focused rather than prescriptive like its predecessor, perhaps.

Reference was made to capacity and the opening of the hospital in Portrane. There is much talk of the children’s hospital. There is much negative commentary, and rightly so, as well as much concern around it. Despite this, under the radar the new forensic central mental hospital that we are building is coming. It is a €170 million project. It is on budget and on time. It is being delivered by the HSE to the credit of those involved. Often those in the HSE do not get credit for what they do right when they do it. We will be getting the keys to that in September or October of this year and it will be open next year. There will be additional capacity of approximately 70 beds there, which is a significant contribution to the overall service.

We had 20,000 acute psychiatric beds in the country in the 1960s. Deputy Healy talked about his parents and their time. It was probably before the 1960s when they were psychiatric nurses. I often wondered about his interest in this area, and his background answered that question. Today there are 1,000 inpatient psychiatric beds. We have come a long way. We do not want to let the stick back into that, as it were. We want to avoid that at all costs. That is why we have to put a focus on this work. That will come under the refresh of A Vision for Change. We have day hospitals to allow people to live in their homes at night but to go into day hospitals to receive the necessary treatment. This treatment does not need to be part of a stay-over service.

Deputy Rabbitte spoke about online services and I was delighted to hear her say it. Today I was in Sligo. Deputy MacSharry is gone now but I was there with my colleague, Deputy McLoughlin. I looked at an online pain clinic. The consultants in the pain clinic in Sligo University Hospital are reaching out to their patients online. Patients do not have to trek into hospital to meet the staff. They do not have to queue up, wait for hours or travel for hours. They can literally pick up their handheld devices and speak to the consultants about managing their pain and prescriptions. If they need a procedure, then obviously they have to come in for it, but the initial assessment is done online. That is very positive and interesting. We have several pilots running in the mental health area as well as psychology and psychiatry. Where there are waiting lists, we are writing to people to ask whether they would like to avail of online psychiatry. I have always said that mental health is an obvious service that can be delivered online. I am delighted that Deputy Rabbitte recognises this. This has been done in Australia and it is the future for us.

I have spoken about signposting. I was two years in the job last week. I have spoken about how we have 1,027 services funded by the HSE throughout the country. It is difficult to know the most appropriate service or where to go. People are clamming up, as it were, and joining the wrong queues, and there are long queues too. If people were signposted more effectively and appropriately, we would avoid much of the queueing system. The website is up and running. I appeal to all Deputies to promote it. It is an exceptional website run by the HSE. All a person has to do is put in his or her geography and issue and the website will tell the person the list of services available, whether in person, online, digital or whatever technologies are in place to support it. That is in place.

I am going out to the National Ambulance Service tomorrow morning. A telephone line is to be established. I aim to have it up and running for World Mental Health Day. The line is a one-stop telephone number and it is as recognisable as 999. People can phone in and talk about their issues. An appropriately trained person will be at the other end and will refer the person to the proper service and tell him or her where to go.

Approximately 600 calls per month coming into the National Ambulance Service are mental health related. The service cannot do anything with them. The staff do not know what to do with them. They send out ambulances in many of these cases because that is all they can do, but that is not appropriate. These calls will be captured under this telephone line. Callers will have an appropriate person trained in mental health who will advise them on the service most appropriate for them, explain where it exists geographically and give the details. We have several pilots in psychology and psychiatry.

The substance of the motion relates to the Mental Health Commission. I acknowledge the work done by the commission. I find the body highly constructive. I heard Deputy Noonan speak about the Irish Fiscal Advisory Council one time. He said there is no point in having a dog if it does not bark, as he said in his own inimitable way. It is the same with the Mental Health Commission. We fund it to the tune of €14 million to enable it to challenge the services. I welcome every challenge the commission puts our way. Of course we have to work harder and better for our most vulnerable citizens, some of whom are detained in some of our facilities. They need to have their rights protected. The Mental Health Commission is on their side and we have to support its work and continually challenge the HSE, which is responsible for the delivery of those services. It is not acceptable in any way shape or form that individual care plans are not available for each person or that they are dirty, untidy, unkempt or smelly. That is deplorable and not acceptable on any level whatsoever. I commend the work of the Mental Health Commission. I assure all parties and none in the House that I will continue to support the very important and good work done by the commission.

I thank the Minister of State for his comprehensive outline. I compliment my colleague, Deputy Browne, on the work he has done to date.

The recent report, regardless of what we have heard, highlights many areas of concern. Some of the failures make for stark reading. There is an ongoing crisis in mental health services for children. As the Minister of State is well aware, early intervention for children with mental health issues is critical. Too many children continue to be admitted to adult units. One is one too many. They are already vulnerable or scared and it is far from ideal and potentially more damaging to them to be admitted to an adult unit.

The report states clearly that the first introduction of a child or adolescent to mental healthcare should not be through a service or building that is not specifically equipped to deal with his or her needs. Last year, 84 children and teenagers were admitted to adult units. I have dealt with many cases myself in my constituency of Waterford. One teenager was in a hospital bed miles from home for months on end waiting for placement. Another teenager was admitted to an adult ward and that really proved to be a barrier to his recovery. I find that not only are the children and young teenagers affected, but there is a knock-on effect on the family, including the parents, grandparents and siblings. It would be remiss of me to stand here tonight and not acknowledge the help I have received from the Minister of State, Deputy Daly, in securing the correct facilities for both young teenagers whose cases I have mentioned. I thank the Minister of State for that and for the help that he engaged in both cases. This is the nub of the issue. We can talk about it all night long. There are not enough adolescent beds in the system in the State for these young people. It is very difficult to have to place someone in a mental health institute that is no longer fit for purpose and that is for adults.

The waiting lists and waiting times are too long. I am calling for a renewed focus to reduce these service deficits. I welcome what the Minister of State has said about the new 170-bed hospital at Portrane. I am sure that will make a difference. If there is one thing that we can take from tonight it is that we will do our level best. I know the Minister of State has no wish to put a child into an adult facility. He has told me as much and I believe him. We need to get the message across to the Department and the HSE loud and clear that we will have zero tolerance when it comes to putting a young child into an adult facility. If that is all that comes out of this debate tonight, then it will have been a job well done.

I thank my colleagues for giving us the opportunity to speak on this important issue. Child and adolescent mental health services as an issue have been raised several times.

According to A Vision for Change, the number of staff needed for CAMHS in the community healthcare organisation, CHO, 1 area, which is my area, is 108, and at the moment we are 40 people short. That is creating its own difficulties, and while circumstances have improved over the past number of months, it is still an issue. The Minister of State will be familiar with St. Cecelia's school in Sligo, where there are issues as well. A number of young children and young adults need speech and language therapy. Unfortunately, a member of staff is about to go on maternity leave and the school is finding it difficult to get a replacement. Can something be done to encourage people into that type of work? At the moment, people are not available, and that is causing serious problems. If those young children do not get an opportunity to speak with the help of a professional, they will have no chance as they become young adults.

I welcome the new 27-bed unit in progress at Sligo University Hospital. The Minister of State was there today, and I am sorry I could not be, but I had to be here. A commitment for that unit was given to then Minister, Jimmy Devins, and me ten years ago, and I am glad it is progressing.

As Deputy Butler said, no mother or father wants to have to bring an 18 year old child into a mental institution. I once went with a set of parents when they did it, so I know what it is like and what the parents went through at that particular time. It is devastating, both for them and for the person going into the institution.

Another issue relates to parents of children with severe disabilities such as autism and other types of disabilities. These are young adults aged 18, and they need to be placed somewhere because their parents, who are sometimes elderly, are not in a position to care for them. They are not physically able to do it. I am dealing with a number of cases at the moment in my area. I acknowledge that there is a finance issue, and that it is expensive, but some of those parents are in danger. They are not physically able, because these young adults are physically strong and need to be looked after. I wonder if the Minister of State might examine that. Having spoken to the HSE representatives in that area, I know that it is difficult, and that the money for the HSE CHO 1 area for 2019 has been spent already, but he might examine that.

I thank the Minister of State, the Leas-Cheann Comhairle, and all the contributors to the motion. It arose out of the reports of both the Mental Health Commission and the Inspector of Mental Health Services, which highlighted some of the progress that has been made in mental health, but also many of the deficiencies and unacceptable situations in facilities for people with mental health issues. I thank the Mental Health Commission and Mental Health Reform for their excellent work on mental health over a consistent period. I also acknowledge the important work they do in highlighting issues relating to mental health services to ensure that what we are doing, or are trying to do, will be beneficial to people suffering from mental health issues. Mental health staff acknowledge that they are under significant pressure and that their own mental health can also suffer when there is a serious shortage of staff.

I acknowledge the families and service users who this is all about. I speak to parents regularly, including today in Wexford, who are often dealing with difficult situations, perhaps with their children but sometimes with their parents or other family members. They find it distressing, frustrating, and at times devastating to have to deal with these situations every day. They also experience frustration in trying to access the services they need for their children, who find it difficult to understand or comprehend the situations they find themselves in.

Rates of self-harm are on the increase. That is not the Government's fault. It is a reflection of modern society, and of social media in particular, whether it is from body dysmorphia through Instagram, or bullying. When I was young, if someone was being bullied, it stopped at the school gates or on the way home, but now bullying follows people all the way home, up the stairs, and into their bedrooms. For many young people suffering from anxiety, depression, or bullying, sleep deprivation seems to be massive issue, because they are stuck on their iPads or phones. It is hard for them not to do that, but social media is having a major impact. It is a great experiment in some ways, because no generation before them has had to go through it.

Suicide remains the biggest cause of death among young people aged 15 to 24, and prescription of antidepressants is on the increase. I have no doubt it is being prescribed where necessary, but in the past year, €400 million was spent on antidepressants while only €10 million was spent on talk therapies. The Minister of State is strong on early intervention, but that balance needs to be changed, so we can achieve earlier intervention as quickly as possible. Everything escalates when the services are not there, and children then end up in emergency departments. There has been a significant increase in the number of children attending emergency departments in my county as well. We have to find a way to progress, because we all want the same thing. I do not question the Minister of State's bona fides for one second. He has worked hard in the Department to try to achieve the necessary changes in services, but I sometimes wonder whether mental health is given the seriousness and focus it needs within the higher echelons. More and more money is being put into mental health services but we are not seeing the outcomes we need.

I thank the Minister of State, and all the contributors to the debate. We have used up all the allocated time and many other people would have liked to contribute.

Amendment put.

In accordance with Standing Order 70(2), the division is postponed until the weekly division time on Thursday, 4 July 2019.

The Dáil adjourned at 10 p.m. until 9.30 a.m. on Wednesday, 3 July 2019.