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Dáil Éireann debate -
Thursday, 26 Nov 2020

Vol. 1001 No. 5

Mental Health Parity of Esteem Bill 2020: Second Stage [Private Members]

I move: "That the Bill be now read a Second Time."

For too long mental health has been the Cinderella of the health service. Years of neglect, underinvestment and lack of political will have led to systemic failures in the mental health service. This is a Bill of hope. It is a vital legislative measure that will elevate the plight of people seeking mental health supports to the forefront. The legislation aims to compel a change in attitude towards mental health at the highest level of policy making and governance. A recent incident that caused concern among mental health advocates was when the Government launched its winter plan for health and there was no mention of mental health in the plan. If this Bill is passed, it will be incumbent on the Minister for Health to include a mental health plan in next year's winter plan. If this change of attitude occurs at the highest level, it will filter down into all levels of society and will see the stigma often associated with mental health conditions lessened. We must start to break the stigma once and for all.

The effective integration of mental health services and physical health services is particularly important. A parity of esteem approach to mental health and physical health will provide a holistic, whole-person response to everyone in need of care and support, with his or her physical and mental health needs treated equally. Mental healthcare has suffered from systemic neglect and a lack of appropriate resources over the years. Neglect of people with severe and enduring mental illness has negative outcomes for the individuals concerned, their families and society. This neglect of mental health occurs across the spectrum at policy, institutional, organisational and individual levels. The Bill will place a duty on the Minister for Health to promote health parity and to ensure all organisations in the health system meet parity obligations in respect of mental health.

As I have said numerous times, if one has an accident and cuts one's head, one will receive the appropriate treatment and aftercare when and where one needs it, but if one has a problem inside one's head, one may not receive the necessary treatment. This Bill aims to redress that imbalance. Mental health problems do not simply materialise Monday to Friday or between the hours of 9 a.m. and 5 p.m. and then magically disappear outside those hours. There must be access to a comprehensive, 24-7 mental health service which examines the holistic needs of the person. We heard experts at the Special Committee on Covid-19 Response describe the mental health services as out of date and not fit for purpose, with many services inundated with cries for help.

We need a mental health strategy for young people to provide earlier intervention and support and to reduce the number of adults presenting with mental health challenges later in life. Prevention is better than cure. Before the Covid-19 pandemic, children were waiting up to two years to get an appointment with the child and adolescent mental health services, CAMHS. This is simply not good enough. It is expected that these waiting lists will increase post Covid. When the restrictions were first introduced many people, myself included, thought they would be short-term measures and that we would be back to some form of normality quickly. This has caused people extra worry and anxiety. They are missing family, friends and the like. As a result, people who would not normally have mental health issues have perhaps experienced them for the first time. At present, we are not delivering a comprehensive or adequate mental health service and if there is a big increase in demand during and after the pandemic, I do not know how the system will cope.

I have engaged with numerous stakeholders that have endorsed this Bill, including the Mental Health Commission, Mental Health Reform, Shine and others. I call on all parties and none to support this Bill, particularly Fianna Fáil which has advocated in the past for mental health parity. I hope it will support the Bill today. One of the recommendations in Sharing the Vision states that funding should reflect parity of esteem for mental health compared to other health conditions. The Mental Health Parity of Esteem Bill aims to offer hope for better mental healthcare by ensuring that vulnerable persons with mental illness are cared for efficiently, when needed and on a par with physical healthcare. I ask that the Bill be passed to Committee Stage when it can be teased out and examined further. It must be allowed to progress.

As I said, this is a Bill of hope. It will give hope to any person suffering from mental health problems that he or she will receive the right treatment at the right time. It is very easy to lose hope now, and people need it. They need an assurance that the increase in mental health issues arising from Covid-19 will be treated in a respectful and appropriate manner. In the meantime, the most important thing we can do is be kind to, and respect, each other. It is perfectly okay not to be okay right now. It is normal to feel anxious, frightened, frustrated or worried about things over which one does not have control. People should be kind and reach out if they are not feeling okay. If this Bill is passed today, it will send a clear message to everyone who is or has been affected by mental health, either personally or through family and friends, that we have listened to them, that they are not alone and not only have we listened, but we have acted and put in place the start of a process that will make their quality of life better.

That is the very least they deserve.

It is great to have an opportunity to speak on this Bill. I congratulate Deputy Ward. I also wish the Minister of State, Deputy Butler, the very best of luck in her role. I will be very brief and try to explain to people what parity of esteem means when it comes to mental health. It is defined as valuing mental health equally with physical health, which would result in those with mental health problems benefitting from equal access to the most effective and safest care and treatment. It is about equal efforts to improve the quality of care. It is about the allocation of time, effort and resources based on need. It is also about equal status within healthcare, education and practice. It is about equally high aspirations for service users and equal status in the measurement of health outcomes.

We talk about parity because one of the biggest issues we have had in this country for many years is the stigma attached to mental health. Stigma refers to problems of knowledge, which is basically ignorance, and attitudes and behaviour of discrimination against people. This Bill tries to remove the stigma attached to mental ill health. For many years we have spoken about the fact that with health issues we try to treat the problem, whereas with mental health we will have to treat the person and in order to do that we need wraparound services. I had a very brief meeting with the Minister just before this and we spoke about it. It is about educating everybody when it comes to how we judge people and, more importantly, how we do not judge people.

Taking a parity-of-esteem approach would also enable the HSE and local authority health and social care services to provide a holistic, whole-person response to a problem. The relationship between physical health and mental health is such that poor mental health is also linked with a higher risk of physical health problems and poor physical health is linked with poor mental health, so the parity is there already. In the current Covid climate, we are all aware from the many calls to our offices that people are suffering in so many different ways at the moment. We should do the right thing and make a positive move here today. The aim of the Bill is to include everybody and to accept that, come the exit from Covid, many people will suffer with some form of mental anguish or mental ill health.

The Bill is important because it gives an opportunity for all parties and none to start afresh. Let us go into 2021 putting our hands up and saying we will now accept that we have to treat everybody equally and respect everybody equally. We must give people the care they need. It is very simple. If a person breaks a leg and arrives in an accident and emergency department, everybody knows what their job is and what they have to do. It should be the same when a person is in trouble with a mental health issue. What is important is not to judge people because we do not know what ticks their boxes. With Covid, many people are suffering. Some have lost their jobs. Others have lost loved ones or they are in trouble with their mortgages. We are all individuals and we deal with anxiety and grief very differently. It is about having a wraparound service for each individual and treating the individual and not the so-called pain. We spoke many times about mental health in the Dáil Chamber. I am very optimistic that we can get off on the right foot in 2021, with the agreement of all parties. I would love to see us as human beings standing up and saying we are going to address the real issues and do the right thing.

I did a lot of research recently in the UK, which is probably three or four years ahead of the position here. The system there is working. I do not want to frighten the living daylights out of anyone but, as it stands, the life expectancy of a person with a mental health illness can be shortened by ten to 15 years and sometimes 20 years. It is very important that we treat each and every individual with empathy, respect and non-judgment. If we can bring about parity of esteem and understanding of mental health across the board in this country, we will be doing the right thing. I hope and pray that all parties and none will at least back the Bill to proceed to the next Stage. I hope we can increase people's life expectancy and their belief in the services improving. We know the services are at breaking point at the moment. They are very under-resourced. I would very much welcome if we could all agree on a starting point and a plan to move this issue forward in the coming years. I urge Members to please support the Bill and to do the right thing for everybody.

I commend my comrade, Deputy Mark Ward. He is truly passionate about his portfolio and about attaining parity of esteem for mental health and physical health so that they would be treated equally.

For many, when it comes to our mental health and physical health, it is not just a question of what is wrong with us but of what happened to us. The psychologists say that if we cannot tell the story of what happened to us, it will tell itself anyway in our lives. Looking across this city and State we see people living with the consequences of what happened to them and what was done to them, all too often sometimes by the State. We had mother and baby homes, Magdalen laundries, industrial schools, hubs, hostels, soup runs and people living and dying in tents. A mother in my constituency was afraid to complain about HAP-funded, rat-infested accommodation because there was nowhere else for her to go with her family. Young mothers are taking their lives because of State-inflicted poverty, hunger, homelessness and sometimes the terror of Tusla.

If we are to have a serious conversation about mental health, we need to start with a serious conversation about why so many people are hanging on by a thread. I am a new Deputy and I am shocked when people ring and thank me for just listening to them. Sometimes they cry with relief. It is no wonder our offices are called clinics. Even as a councillor I often had people weeping across the table or down the telephone. One of the things they do not tell us we will need in our constituency offices is a box of tissues because of the pain that some people are in. I refer to people who work but who cannot get a home to rent or to buy. People are in pain because they have a blood platelet count of 435,000 and they cannot get a hospital appointment for a gastroenterologist since last July. They are in pain because their six-year old child needs a specialist interview for sexual abuse and they are waiting since March.

I have older men in my constituency who are living in conditions that are intolerable in a republic. They do not have light, running water, heat or electricity. They cannot wash themselves during a pandemic. Their mental health is really suffering. That is no wonder. They are asking themselves if they ever imagined, even on their worst day, that things would be this bad and that the system into which they have contributed would leave them like this. It is a measure of their own sanity that they question this because the answers to their questions are enough to drive anyone to despair. Society, in its addiction to the status quo, is content, so it is really important that we talk about parity between mental health and physical health. However, talk is cheap and ultimately it is useless. We as a State must look once and for all at what is driving people to despair. It is the lack of a decent home that they can afford, a lack of decent food, a lack of heat when it is cold or the lack of a job with good working conditions.

When they are sick they should have the chance to be treated in a fit for purpose health system and, above all, they should have the chance to be listened to.

People say we should leave our politics at the door when it comes to mental health but we express our politics in how we vote on matters. People expressed their opinion in electing us to the Dáil so it is really important to bring politics into the Chamber, as our voting "tá" and "níl" affects people. I thank Deputy Ward for bringing forward this Bill and I hope it will get support across the House.

I commend my colleague, Deputy Ward, on bringing forward this very important legislation. This Bill rightly puts mental health treatment at the same level of importance as physical health treatment. This principle was enshrined in British law in 2012, demonstrating we are at least eight years behind with our own Irish legislation.

The rationale for the Bill is to place a duty of care on the State to accept the principle of parity of esteem, both for physical and mental health. Earlier this month I raised with the Taoiseach the appalling position of there being no inpatient child and adolescent mental health service, CAMHS, beds in Wexford. Children who require inpatient care for their mental health must travel to Cork or possibly other counties for a bed, or worse, be put into an adult unit. This Bill will bring about a change for good and influence future policies. It will change attitudes towards mental health and the overall well-being of our country.

Another area of mental health welfare that we really need to get to grips with concerns dual diagnosis of people suffering mental ill health and addiction. We all hear and know of people at their lowest point being passed from service to service. As there appears to be no collaboration between services to deal with such individuals, we need to urgently develop best practices and introduce "wet hostels" to support and treat citizens with dual diagnosis. There is no reason shared files, collaborative work and a comprehensive treatment plan could not exist in treating a dual diagnosis of mental illness and addiction.

If we are to have parity of esteem in mental health, we must also take an holistic approach. One such way for this to happen is through the promotion of early intervention and prevention work, as well as the more traditional mental ill health care. A service that comes to mind is the Jigsaw service for young people with mental health issues. It proves a listening ear and gives expert advice and support to young people aged between 12 and 25. It also provides families, teachers and those who support young people's mental health with a wide range of coping and resilience skills. An excellent service such as this should be in every area and accessible to every young person.

In response to a parliamentary question I tabled in July, the south-east community healthcare section of the HSE indicated it was not aware of any plans to develop a further Jigsaw programme in the region in 2020. I urge the Minister of State to recognise the importance of this service and begin planning the investment required for expansion. By supporting and passing this Bill, the House would commit to a noble principle that from now on, the physical and mental health of the nation would be treated as one indivisible right.

It says much and highlights the lack of regard, respect and priority that we display to those with mental health issues that we are forced to bring forward a Bill acknowledging that mental health issues should be held in parity with physical health. I welcome the Bill and thank my colleague, Deputy Ward, for introducing it and giving us the opportunity to begin this conversation on an important societal matter.

I also welcome that today the sub-committee dealing with mental health matters was established and had its first meeting. I thank the Ceann Comhairle for his role in fast-forwarding the establishment of that sub-committee.

Mental health services and supports in this State have always been an afterthought or something that was difficult to access in the past and they are often treated like a dirty secret and something to be buried. In those less enlightened times, the official approach was to exclude, lock away, medicate, ignore and somehow try to forget the people in those services.

Many people suffering from mental health issues face a lack of services across the board and those with mental health issues are also at much higher risk of suffering from addiction, falling into homelessness, being unemployed and being imprisoned for relatively minor offences that lead to jail sentences, and this in turn often leads to a worsening of their condition. Our prisons are certainly not the place to warehouse our mentally ill but many loved ones welcome it, as they believe imprisonment will eventually lead to supports and necessary care for a son, daughter, brother or sister. They believe that if people go into the prison system, an assessment will be made and supports would be provided. We know that in many cases when people are released from prison, they end up back on the streets and without the necessary supports.

We also know prison staff are not trained to deal with these cases and facilities are not designed or equipped for such a purpose. The same could be said of our homelessness services, with dormitory-style accommodation and rampant drug use being the last type of conditions needed by people suffering mental health issues. We know many of the vulnerable homeless citizens placed in these settings go on to develop an addiction or fall deeper into the grip of drugs and alcohol, or they come into contact with dangerous and criminal elements, which only makes their problems all the worse.

What do we say to a parent who comes to us looking for help? We are supposed to be the font of all knowledge and people come to us and look for answers. What do we say to the parent who says he or she has a child or children who cannot speak? These people need support and wait years for an assessment, and for years following an assessment of need they still cannot get support for their child or children. This is happening in my area, which is covered by community healthcare organisation, CHO 7. Waiting lists for supports are getting longer so we can imagine the impact this has on a parent or parents when a child is suffering in trying to make himself or herself understood.

Many of the key staff in this broken system have been seconded to tracking and tracing work for Covid-19, and again I cannot understand the thinking from the HSE that this is somehow acceptable or that these children can be left behind during this Covid-19 crisis. As my colleague stated, Covid-19 will have a lasting effect, with months of lockdown and the stress of working from home possibly only becoming apparent in the months and years ahead. Social isolation is at the greatest level we have seen and gone are many of the escapes that many people need. I am not talking about the pub and a few drinks but sport and exercise have been curtailed and walks or hiking have been curtailed. Friends are at the other side of a WhatsApp group instead of being engaged in human interaction. We know the impact this has, particularly on older people who are isolated and unable to see grandchildren. People could once get into nature but they are now forced to walk on grey pavement under streetlights on dark evenings, depending on where they live. They remain isolated from others.

Our already overly stretched mental health services may not be able to cope with what may come. In my years as a public representative I have come into contact with hundreds of cases of people being tortured by mental health problems. Families have been torn apart because nobody could help when a loved one was seized by a violent or paranoid episode. We all know those stories and we have had parents come to us, crying their heart out, talking about the crisis happening in their homes. We see the figures for domestic violence now and I am sure they are increasing.

Older people often come to us.

Their biggest fear is what will happen to their son or daughter after they die. We have a big responsibility as a society and as Oireachtas Members to ensure the availability of supports. We all know of the worry for parents of children with Down's syndrome, who are living longer these days, or parents of children who cannot speak or communicate and who cannot access supports or education. We have failed those children miserably.

We must acknowledge that mental health is every bit as vital as physical health. We have never done so, regardless of the rhetoric from various Ministers for Health. Our strategy for preserving and improving the health of Irish people must be comprehensive and holistic. We must not just take care of the body but also the mind. We have an enormous responsibility in that regard. Again, I welcome this Bill and thank Deputy Ward for introducing it.

I thank my colleague Deputy Ward for introducing this Bill. It is a very simple Bill, which I hope will have a positive effect on mental health services. We need to place mental health on a par with physical health and improve the provision and quality of mental health services. I have spoken in the House previously about a man whose son was experiencing mental ill health. He felt it would have been better had his son been diagnosed with cancer because at least then there would be clear path to care. Any family that has experienced mental ill health will be familiar with that feeling and this must change. We must ensure that those who are experiencing mental health issues have a clear path to care in order that they can get better.

For too long mental health has been the poor relation of our health services. Sadly, delays in diagnosis and treatment costs lives. These people are not just statistics, they are parents, siblings, children, spouses and friends. It is absolutely shameful that we do not have 24-7 services available to diagnose and treat mental illness. Mental illness does not take the weekend off and neither should the care services. Years of neglect, underinvestment and a lack of political will have left us with a broken system and it is high time it was fixed. Mental health affects physical health and vice versa. We must take an holistic approach.

Covid-19 has had a massive but unseen effect on the mental health of many people and it may be some time before we know the full extent of this. I commend the work of groups like HOPE(D) in Newbridge and the way they have adapted to cope with the challenges posed by the pandemic. They are saving lives but receive no money from the HSE, despite the executive referring clients to them. I want to say to everyone who is struggling in this pandemic that even with the privileged position I am in, there are times when I struggle. It is perfectly okay not to be okay right now. It is normal to feel anxious, frightened, frustrated or worried about things that are outside our control. People should be kind and reach out to one another. They need to know that if they are not feeling okay, they are not alone.

As someone who suffered with mental health issues when I was 16 years old, which is a long time ago, I know that if we do not look after our mental we will be in severe trouble. People do not differentiate between mental health and mental illness. In order to have no mental illness, we need to focus on mental health and teaching people how to keep mental illness at bay. As my party's spokesperson for older people, I am also very concerned about the impact of Covid-19 on people in nursing homes and their families, particularly on their mental health, which is pivotal.

I begin by thanking Deputy Mark Ward for bringing attention to the topic of mental health. The importance of supporting good mental health and well-being has been recognised for some years now and never more than during the current pandemic. The onset of Covid-19 has presented enormous challenges for people's mental health and the Government has responded rapidly by putting additional services and supports in place.

The Government acknowledges the positive intention of this Bill and does not intend to oppose it. Many Deputies will be aware that a very similar Bill was brought forward by a colleague in the last Dáil, Deputy James Browne, who is now a Minister of State. I distinctly remember speaking on and supporting that legislation.

The stated aims of the Bill are to offer hope for better mental health care by ensuring that vulnerable persons with mental illness are cared for efficiently, when needed and on parity of esteem with physical health and to compel a change in attitudes towards mental health at the highest level of policy making and governance. Its main provision obliges the Minister for Health to continue the promotion of a comprehensive health service designed to secure improvements in physical and mental health and in the prevention, diagnosis and treatment of physical and mental illness .

An equal standing within the healthcare system for mental health and physical health is something that we strive for every day. The interdependencies between physical and mental health are well recognised. WHO research suggests that key risk factors for poor physical health and reduced life expectancy are more prevalent among people living with a mental health difficulty than among the general population. For example, people with schizophrenia are more than twice as likely to develop type 2 diabetes when compared to the general population. The incidence of respiratory and cardiovascular disease is also higher among those with a serious mental health condition. Equally, there is a higher incidence of conditions such as anxiety and depression among those suffering from long-term chronic physical health conditions such as asthma and arthritis. The need for a whole-person approach to achieving the highest possible standards of physical and mental health and well-being has been recognised in formulating our mental health policy, as is the need to support the wider psychological aspects of physical health challenges.

While the Government does not oppose this legislation, I have some observations to make on the Bill as proposed. I am offering these with the benefit of having some knowledge of a similar Bill introduced in the previous Dáil. The aims of the Bill are broad. It does not offer any guidance on what parity of esteem would look like in practice. Given the vast spectrum of conditions that influence both physical and mental health, it is silent on what esteem for mental health should be compared to when assessing parity. It does not include specific provisions for how parity of esteem would be achieved, implemented or measured. The Bill's provisions appear different to the narrative in the explanatory memorandum. As currently constructed, it is aspirational but unclear on what it would accomplish in concrete terms.

I urge Deputy Ward to consider these observations in the interest of developing a precise and specific Bill that is easily understood in practical terms. Without that precision, its implications are difficult to predict, and consequently will not be possible to quantify from a financial perspective. I believe this is where the last Bill fell down. I say all of this from a position of experience and in the spirit of the collegiality on matters of mental health that this House has traditionally enjoyed across all parties and none.

I remind the House that the WHO defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity". This is an all-encompassing view of health. It acknowledges that the determinants of health are multifaceted and does not recommend prioritising any one aspect above another.

The Health Act 2004 provides that the HSE shall use the resources available to it in the most beneficial, effective and efficient manner to improve, promote and protect the health and welfare of the public. It also states that the HSE shall manage and shall deliver, or arrange to be delivered on its behalf, health and personal social services. It further states that the HSE shall integrate the delivery of health and personal social services. Deputy Ward's Bill seeks to oblige the Minister for Health to "continue" the promotion of a comprehensive health service designed to secure improvements in physical and mental health. I acknowledge the important role that legislation plays, as Members of this House will know. However, when it comes to health, treatment and services are what we look to for healing.

Funding for mental health services is a priority for the Government. Budget 2021 saw the continued commitment to mental health with increased funding of €50 million, bringing the annual budget to €1.076 billion. This represents an increase of over €365 million or 51% since 2012. The Government is committed to continuing to increase funding as circumstances allow. The Department of Health and the HSE are currently finalising the 2021 HSE service plan, which will be published shortly.

I am confident that this will give a balance of new mental health developments across age ranges and sectors of the population. It will also cover the full spectrum of mental health, from mental health promotion and early intervention to acute and forensic inpatient care. It will also ensure that greater attention is given to improved links between mental health and other services.

With regard to policy, we recently published a new refreshed national policy, Sharing the Vision: A Mental Health Policy for Everyone. The Sharing the Vision policy does not replace that of A Vision for Change but instead updates our approach in the light of evolving and future needs. The implementation of Sharing the Vision is obviously critical to its success and this is a core objective for me as Minister of State. Last month, I announced the establishment of the new national implementation and monitoring committee framework that will drive implementation of the policy. An independent chair for the committee, Mr. John Saunders, has been appointed and selection of the membership is currently under way. Over the 10-year lifespan of Sharing the Vision, the committee will be integral to maintaining the momentum necessary to make the policy a reality and to hold stakeholders to account. Implementation will also be progressed through planned additional investment for the sector under the annual budgets and agreement of HSE annual service plans.

It is important that the implementation of Sharing the Vision is a collaborative process. I intend that the committee and its associated specialist groups will be fully representative and will include strong service user, service provider and non-statutory sector participation.

As the debate here this evening is about mental health legislation, I will take the opportunity to update the House on progress on the review of the Mental Health Act 2001. The Department is currently finalising heads of a Bill to significantly amend and update mental health legislation, taking into account the 165 recommendations of the expert group review, which was partly informed by a public consultation, a comprehensive submission by the Mental Health Commission and Ireland's domestic and international commitments such as those under the Assisted Decision-Making (Capacity) Act 2015 and the UN Convention on the Rights of Persons with Disabilities. The provisions of the Mental Health (Amendment) Act 2018 are also being incorporated into the draft heads of Bill.

There are over 100 sections in the draft heads. The Department has included detailed information under each head to allow for expert input from the Mental Health Commission and the HSE to be provided prior to publication. This will allow the Department the opportunity to address any concerns as early in the process as possible. The draft heads of Bill propose to extensively amend and update existing mental health legislation, moving from what has been described as a paternalistic approach in existing statute to a more person-centred, human rights-based approach. The Department had hoped to submit these heads for legal advice by the end of 2020, however, the Department is currently awaiting further input from the HSE, which is expected in early December, and plans to consider the HSE's submission and finalise the draft heads prior to submission for internal legal advice and to the Office of the Attorney General, as required, in early 2021.

A new part of the Act related to children is being advanced separately, and the Department has approached the HSE, the commission, the Ombudsman for Children and the College of Psychiatrists of Ireland for their expert opinions on the draft heads.

I thank Deputy Ward for introducing his Bill. Work is required to ensure that the final Bill is legally robust, specific and implementable. I hope I have given some useful input on how the Bill might evolve and look forward to hearing the remaining contributions here this evening.

I apologise for not calling on the Minister of State earlier. We have limited time. Deputies Ó Murchú, Ó Laoghaire and Martin Browne are offering.

May I ask how much time I have so that I can adjust my comments accordingly?

I will have to get guidance as to the time available.

I will try not to speak for too long. The Minister of State has provided the World Health Organization's definition of health, which is not simply the absence of disease or a condition. Whatever about the World Health Organization's definition, the reality in our communities and in our health service is that there is not parity of esteem at this point in time. We have to recognise that a societal challenge still exists. Attitudes towards mental health and mental illness have significantly improved in recent years but physical and mental health are not viewed in the same way and that parity of esteem has not been achieved. Deputies, Government and society all have a responsibility to tackle that issue. That is crucially important.

An issue that may, perhaps, be addressed more rapidly is the lack of parity of esteem or of equal treatment within the health service. This can be seen in a wide range of areas. There is certainly no parity in the resources available to mental health. This lack can also be seen when one drills down into community services. My area of Cork is part of the same community healthcare organisation, CHO, area as Kerry. It would be remiss of me not to once again make the point that the numbers on waiting lists for psychology, psychiatry and child and adolescent mental health services, CAMHS, in this CHO area are among the highest in the country. In fact, the number on the waiting list for CAMHS is the highest in the country. That problem has been outstanding for a very long time. There are approximately 2,200 people on the waiting list for CAMHS in Cork and Kerry, 162 of whom have been on it for more than a year. That is absolutely unacceptable. These young people and their families are being left in a crisis situation for far too long.

A psychology position in CAMHS in the Cork north Lee HSE area has had to be readvertised as it was not filled. That vacancy has been outstanding for well in excess of a year. It may well have been vacant for two years at this stage. That is unacceptable and it is a further sign that not enough emphasis is placed on these issues. It is always a matter of being penny wise but pound foolish. It may be questioned whether it is even penny wise. When one fails to deal with things promptly, things escalate, people's issues and conditions become more severe and they need more extensive and more sustained treatment. We have never dealt with these issues at that early intervention stage.

The final point I will make in respect of parity of esteem is that there is an issue regarding discharges from the acute hospitals at times, although not always. I have raised some of these issues with the hospital group in Cork and Kerry. People who have been admitted as a result of mental illness or of difficulties or conditions relating to their mental health are, at times, discharged very rapidly. I appreciate that some of this relates to the severe pressure on our hospitals as a result of the Covid situation but I have come across instances of people who I have fed into the system being discharged in situations which were not appropriate, in which there was insufficient preparation and in which supports were not in place. One person I know of, who was not in the most severe part of their crisis, although they were still in a crisis situation, was left to their own devices and put out onto the street with very little support or guidance. The networks were not there for them. That is an area that needs to be tackled. We would not discharge somebody with a physical condition unless we were confident that they had somewhere safe and secure to go. With regard to parity of esteem, the area of discharges needs to be dealt with.

I will also emphasise once again that the resourcing issues in Cork and Kerry need to be dealt with. The waiting lists are too long. Young people and adults are suffering unnecessarily. Their crises are being extended. It is not good enough.

There are 15 minutes remaining before we must begin the wrap-up. May I clarify whether Deputy Gino Kenny is looking to get in? Yes. We therefore have three Members to speak over 15 minutes. We will proceed with Deputy Ó Murchú, then Deputy Martin Browne and then Deputy Gino Kenny.

I commend Deputy Ward on bringing forward this Bill. I agree with a lot of what has been said about the parity of esteem required in respect of mental health services and dealing with mental illness. I also accept that the issue is not necessarily straightforward. It involves some of the difficulties we deal with every day. There is the question of whether someone has an actual diagnosis. Some people are told they do not have a mental illness but rather a behavioural difficulty. We need clarity. Certain terminology is used quite often. We need the policy to be that there is no wrong door. This means we also need a proper system for dual diagnoses. Given the services and resources we have at the minute, if some of these situations are not clarified and if resources are not brought to bear, all we are doing is putting further pressure on services that are not sufficient to deal with what they are already dealing with.

It is as simple as that. Across the board we have a bad history in this State in respect. We had a history of putting people in institutions and locking them up. We are all aware of the reality of what happened.

At this point, we are not operating best practice with acute beds. I accept not everyone with a mental illness necessarily needs hospitalisation but there are cases where it is required. Excuse me if I am wrong on the exact figure but I am told we operate in and around 20 beds per 100,000 whereas in parts of Europe the figure is between 50 and 70 per 100,000 or higher. This needs to be rectified. I am also told that within Louth and Meath and my local HSE community healthcare organisation the level of bed provision is less again. These things need to be rectified.

We have a situation with regard to mental illness behaviours. These may seem to many people like a mental illness but we are told that, without a diagnosis, what is at issue is no more than behaviour etc. We end up with the Garda dealing with this. Deputy Ward has already spoken this week on the situation. Sometimes our jails are full of people who need acute services but end up in that situation. All this needs to be rectified. We need a holistic approach across the board and we need all stakeholders to be included.

I imagine every constituency office is similar to mine. People appear or we are given issues. The issue may fall somewhere between mental illness, mental health, added disability or other situations and a lack of competence. Sometimes it falls somewhere between mental health services and social care. Really what happens is that the issue falls between the stools. Sometimes we deal with parents who are trying to deal with a child of theirs who is 30 or 40 years of age with many issues. The parents may be in their 70s and may not be fit to cope. We need to look at some element of diagnosis and treatment. We also possibly need to look at assisted living. Where this is not addressed, the pressure goes back on these people. Occasionally, this situation also puts pressure on either the Garda or mental health services. It absolutely fails.

I brought up another fact earlier when I talked to the Minister of State, Deputy Rabbitte, on institutions or congregated settings dealing with disabilities. I believe this happened in the Crosslanes unit in Drogheda recently. I do not believe we have proper screening or testing to ensure staff do not have Covid-19. We had an outbreak and we have difficulty sometimes with this. The public health advice may say people are not close contacts because they are operating certain procedures with masks etc. The fact is that many of our health settings were already under pressure without screening. They will come apart at the seams. I appeal to the Minister of State, Deputy Butler, to look at this situation. I understand that in September or October that was what happened in Crosslanes in Drogheda. I urge the Minister of State to come back to me on that. We need to look at the public health protocols as well as testing and screening at these facilities.

I will be as brief as possible. I will support this Bill. Fair play to Deputy Ward and Sinn Féin for their work on the Bill. It is important that as Deputies and as a society we talk about mental health. There has been a marked difference in the past five years in talking about mental health issues. Sometimes, talking about something can halve the problem.

This is about resources. A Vision for Change was published 14 years ago. The budgetary percentages were not fulfilled to tackle deficiencies in mental health services. The new document, Sharing the Vision, sets out a parameter for fixing the vision. That is important. We have said numerous times in the Chamber that this is about early intervention. When people get intervention early, there are better outcomes. If people do not get intervention, then there are worse outcomes, especially around mental health. The outcomes can be dire and people may simply die. If we can get early intervention for people when they need it, the outcomes are better not only for the people concerned but for society, community and family.

We talk all the time about reform. There needs to be a radical overhaul of the health service in this country. One thing Covid-19 has exposed is the fault line in our health service. Covid-19 has revealed what is probably a new phenomenon in human health. Today, the UN said a global mental health crisis is on the horizon or is in existence. Covid-19 has amplified the anxieties and fears of everyone. It can amplify depression, loneliness and all that comes with it. It is imperative that we reach out to our neighbours and family. These are simple things but they can make a major difference.

The Minister of State, Deputy Butler, has spoken before about Covid-19. It is important that now and in the coming years we look at the effect Covid-19 is having on society. We need to put in place the facilities and resources that can help people get over it. We will get over this pandemic. However, we need to be in a better place not only in respect of our health service but our mental health services as well.

I congratulate Deputy Ward on bringing forward the Bill. I acknowledge his vision and understanding of an area of well-being that, as this Bill suggests, has been left behind in terms of policy decisions and access to care and treatment.

In talking about parity of esteem, it may be worth talking about what represents a lack of parity of esteem. We see this with young people ending up in emergency departments or general hospitals when what they need is tailored mental health supports. In 2019, the Mental Health Commission spoke of how children in need of mental health supports are ending up in general hospitals. The commission said the reason for this was due to an immediate risk to the young person or due to the lack of a bed in a specialist child and adolescent mental health services unit. The report went on to say that children and young people in crisis are left with the unacceptable choice between an emergency department, general hospital, children's hospital or adult inpatient unit. This is one example of how a lack of investment in mental health services results in children having to present at overcrowded emergency departments or general hospitals which are not equipped to deal with their needs.

In 2012, St Michael's inpatient psychiatric unit in Clonmel was closed. The services were transferred to St Luke's General Hospital in Kilkenny, leaving County Tipperary without any inpatient beds. This means that many people in south Tipperary have to travel far from their homes, while those in north Tipperary have to go all the way to Ennis. As well as the distance issue, St Luke's in Kilkenny has a record of overcrowding. That decision denied us a key service. It was a cruel blow to County Tipperary.

Before his departure from office, the former Minister of State, Mr. Jim Daly, admitted that the wrong decision was made to remove the beds from Clonmel. We have been unable to get a similar sentiment out of the current Minister of State. This year I found out that €2 million is being spent on upgrading beds at the same unit, but not for mental health. It seems as though the money is available but only if it is not for the purposes of mental health services. Since St Michael's unit was closed, all we have seen are delays with Jigsaw as well as a delay and a total lack of clarity in the development of a new crisis house in Clonmel. The list of problems goes on for Tipperary. At the same time, while a room has been put aside at South Tipperary General Hospital for people presenting with mental health issues, they still have to go through the emergency department process. All of this shows how mental health services always take the back seat in overall healthcare.

A similar lack of priority has been shown with regard to dual diagnosis for people with mental health and addiction issues. It is widely held that if both issues are not treated together, then it is difficult to get the desired outcome. The HSE has spent €124,586 over a 14-month period and this resulted in the draft model of care.

It went nowhere and the only resource available from that study is a link to the website This shows how, as Deputy Ward put it, mental health is the Cinderella of health services. Organisations such as CARMHA in Nenagh are doing great work in this regard, and I again appeal to the Minister of State to hear what such organisations have to say and see what they do. I appeal to everyone here to support this Bill.

I will finish with a question put to me by a 19-year-old girl from Carrick-on-Suir, and a community work student, who wrote to me about a rising mental health crisis in the south east and the difficulties young people encounter when seeking help. She said:

Deputy in our constitution it states that every child should be treated equally. Yet here we are in 2020 with a multiple-tier health system in relation to mental health. I say multiple because it's not as black and white as it may seem. As a young person struggling, you are asked various questions, depending on your social status and your address. There could be many or no services available in your area. Now please explain to me how we are treating all children equally?

We have a tsunami of mental health issues coming after the Covid-19 pandemic and that must be tackled urgently. I encourage every Deputy to consider this question and to support this Bill.

The Government does not wish to oppose the Mental Health Parity of Esteem Bill 2020. That being said, further clarity is required regarding this Bill. The aims of the Bill are general and aspirational in nature and differ from the background to the purpose of the Bill, as set out in the explanatory memorandum. The Bill does not give any indication of how to achieve its stated aims. While the intention of the Bill is positive, further work is required regarding what the effect of the Bill is intended to be and what the financial implications of this Bill could be.

More generally, there have been many positives of late, with the provision of an additional €50 million in the area of mental health in budget 2021. Of this amount, some €23 million will be allocated to commencing the implementation of many of the short-term recommendations of the new national mental health policy, Sharing the Vision. This includes funding to improve child and adolescent mental health services, CAMHS, and, more specifically, the appointment of 29 whole-time equivalent staff in CAMHS. This increase in staffing can go some way towards reducing the current waiting lists so that children and young people, and their families, can access these supports more quickly where required. It is also essential that these staff are deployed in the areas where they are most required, taking into account that the CAMHS waiting lists vary significantly depending on what area a person lives in.

Mental health should be considered a disability when accessing certain services. This is currently not the case, especially when it comes to allocation in respect of priority on housing lists. I see this issue arising all the time in my clinics. I also refer to the same issue in respect of accessing grants etc. Help is needed in that respect and this is a major area which we must look at. I am passionate about this area and I have raised concerns regarding it. I will continue to raise this at the Joint Committee on Housing, Local Government and Heritage and the Joint Committee on Disability Matters.

People dealing with mental health issues are the most vulnerable people and they matter, as the Minister of State is aware. She is working hard on this issue, and we must ensure people feel that mental health is important. Mental health is an issue we all need to talk about. I recently proposed that Carlow town become a talking town and that our county capital become a place where people can access the help they need at any time without stigma, judgment or obstacles.

I commend Members on this wide-ranging debate. These contributions underline our shared goal of a mental health system that reaches the highest possible standards. Going back to some points, Deputy Ó Laoghaire rightly raised the issue of the CAMHS waiting lists. It is something I have also discussed with Deputy Ward. I am concerned about that issue. The waiting lists are currently at about 2,200 people, but it does vary, as my colleague has just said, depending on where people live. The extra €50 million secured for this area in the budget, however, will mean 29 whole-time equivalent new staff working in CAMHS to drive down the waiting lists. Deputy Ó Laoghaire was also concerned about the Cork and Kerry area. I was informed this week by the person in charge of services there that two new appointments of psychiatrists were made in Cork and Kerry, so that should make a major difference.

Deputy Mythen spoke about Jigsaw, and that leads me on to Deputy Martin Browne's contribution. Jigsaw offers supports for young people aged from 12 to 25 years old. Prior to the onset of Covid-19, it was possible to self-refer, without the need for a referral from a parent, a GP or a teacher. That is fantastic. Jigsaw will open services in Bray in County Wicklow just before Christmas, and services will commence in Thurles just after Christmas. Regarding Deputy Browne's contribution, because it is fair to put things like this on the record, the reason Jigsaw services in Tipperary were delayed slightly is because temporary premises were originally being secured. The great news now, however, is that a permanent premises has been secured. The lease has been signed and there were advertisements in the newspapers this week for seven posts in respect of Jigsaw services in Thurles. There was worry among people living in Tipperary that this might not become reality. Today, however, it is certainly a reality and the sign will be over Jigsaw's door before Christmas, in keeping with the commitment I gave earlier in the year.

Mental health is one of the key priorities of this Government, and it is good that Members have the opportunity to debate these issues. I will set out some of the topical issues in the area of mental health. Many Deputies mentioned the Covid-19 pandemic, and it has presented challenges on an unprecedented scale to our health service, economy, communities and safety. We asked the public to make sacrifices, the kind which would have been unimaginable this time last year. The response to this request has been tremendous and has shown the very best of the spirit for which this country is famous.

However, the pandemic has had a profound effect on the mental health of many people. I hear from members of the public every day regarding the impact of these restrictions. All the Deputies hear the same stories. We have had to make changes in our services. So far, our statutory and non-statutory mental health services have withstood this adversity and I acknowledge the significant efforts of the staff in doing so. Acute inpatient and community residential facilities have remained open, though under necessary protocols. I am happy to state that during the first part of the pandemic, some 85% to 90% of all mental health acute services remained in place. Where numbers have been reduced in some settings, telehealth solutions have come to the fore to protect people using the services and the staff.

Urgent cases determined by clinical assessment continue to be seen across the mental health services, including emergency departments. HSE services have continued to operate at around 85% of pre-Covid-19 levels. GP and hospital mental health services remain open, and people should continue to access these if they are concerned about their mental health. The Mental Health Commission has put in place a risk framework, with contingency plans in every HSE community healthcare organisation, CHO, to mitigate the spread of Covid-19 and to protect service users and staff. The Department has also introduced primary legislation to facilitate the continued operation of mental health tribunals, and this was recently extended to June 2021.

Returning to the subject of this debate, the goal of legislation for parity of esteem for physical and mental health must be carefully analysed to see if that can be achieved. This sets challenges for all of us. Significant thought and effort will be necessary to ensure that it is crafted in a way which fulfils its aims of improving outcomes for all, which is what Deputy Ward is trying to achieve. We must be sure that any changes made are the right ones and are sure to have the effects which are intended. I assure the House that my officials and I will review all the contributions which have been made and bring them to bear in all of our important work in the design and delivery of mental health services.

I welcome the Government not opposing this Bill and I appreciate the support this Bill has received across the House, or perhaps I should say across the convention centre.

I acknowledge some of the points the Minister of State raised and her observations on the Bill. There was a similar Bill previously and I acknowledge some of the reasons which were stated regarding why that Bill fell. This Bill, however, now progresses to Committee Stage. I am happy that it will get the legislative scrutiny it rightly deserves and that it will become legally robust, as the Minister of State put it.

I also acknowledge and welcome the Minister of State's appointment of the independent chair of the monitoring committee for the implementation of Sharing the Vision.

That will help Sharing the Vision move forward. I also call on the Minister of State to ask the HSE to appoint a national director for mental health because that is one of the things that will help restore parity for mental health. The Minister of State's colleague, Deputy Murnane O'Connor, mentioned having different waiting lists in different areas for CAMHS. We need to start moving away from this postcode politics. We need the same level of service no matter what area one lives in or what part of the country one is from. That is another way of restoring parity for mental health.

This week marks a year since I was elected to the Dáil in a by-election. It has been an honour to serve in this House over the past year but it has sometimes been very frustrating as well. Our previous private Members' Bill did not relate to the Minister's remit but it was about community safety. Despite Government Deputies nodding their heads, agreeing with me and saying that legislation was good and valid, it was still voted down. The reason it was voted down was because of party politics and because it was a Sinn Féin motion. I am glad to see that party politics were put aside today and that this Bill will go to Committee Stage. I said in my opening statement that I would work with the Minister of State, who is responsible for mental health, in Opposition, that I would hold the Government to account and that I would propose tangible and real solutions to issues relating to mental health. Today is one of those days when something tangible happens. Today, we did not just speak about change, we acted. We listened to the people who are struggling with mental health issues and acted on their behalf. As has been noted, this Bill is not a panacea for all the problems with mental health services, but it will start the process of making things better.

To all the children mentioned earlier who are waiting for mental health appointments in CAMHS, we hear you. We also hear the parents of those children. To the children who are still being committed to adult psychiatric wards, we hear you. To the man whose story was reported this week, who was left naked in his own urine in a prison cell, we hear you. The voices of those experiencing additional mental health issues due to Covid are being heard today. To those experiencing eating disorders, we hear you. To those who have tried and failed to access services outside the nine-to-five and to anyone who has been affected by suicide, we absolutely hear you. Some people are experiencing mental health issues for the first time, a large number of which are related to Covid, so to anyone who is feeling worried, anxious, depressed, upset or fearful, we hear you today.

The Minister of State and her colleague said that this Bill is broad, aspirational and hopeful. Mental health is such a huge issue and crosses so many spectrums that this needs to be broad. As for being aspirational, we in Sinn Féin aspire to promote real, tangible solutions to mental health issues and we make no apologies for that. We will certainly never apologise for offering hope to anybody. We may all be in the same storm when it comes to mental health but we are not all in the same boat. Parity is the boat that will result in everybody being treated the same when it comes to health problems, whether mental or physical.

I congratulate everyone involved with this Bill. I congratulate Deputy Ward for bringing forward legislation that is very constructive and helpful and the Minister of State for having the foresight to accept it. What we have seen here this evening is democracy working constructively and Members working collegiately together. The more of that we see, the better for all of us into the future.

Question put and agreed to.