Joint Committee on Children, Equality, Disability, Integration and Youth debate -
Wednesday, 6 Dec 2023

Access to CAMHS for Individuals with Dual Diagnosis: Discussion

An Cathaoirleach

We have received apologies from Deputy Murnane O'Connor and Senators Ruane and McGreehan, so there are some substitutions. Senators Flynn and Wilson will substitute for Senators Ruane and McGreehan, respectively. Deputies O'Flaherty and Higgins will substitute for Deputies Murnane O'Connor and Griffin, respectively.

Our agenda item for consideration this evening is engagement regarding access to CAMHS for individuals with dual diagnoses. We will have two sessions. The first must conclude by 7 p.m. in order that we can start the next session. I remind everyone that this is specifically related to children and adolescent mental health services, CAMHS, and dual diagnoses. We are joined at our first session by the following representatives of the Substance Abuse Service Specific to Youth, SASSY, Dr. Gerry McCarney, child and adolescent psychiatrist, and Ms Maeve Geraghty, counsellor. We are also joined by Ms Ber Grogan, policy and research manager, and Ms Neil Moore Ryan, a grassroots forum member, from Mental Health Reform. Our guests are all very welcome. We thank them for coming before the committee. I would like to warmly welcome Neil Moore Ryan, who is an autistic woman and who has lived experience of accessing the services of CAMHS. That is absolutely vital for us. She is a volunteer with the Mental Health Reform grassroots forum. While the committee has an extensive remit, we are always delighted and really appreciative when we can engage with individuals who have had lived experience. Therefore, we really appreciate Ms Ryan being here.

To address some usual housekeeping matters, a reminder again for any member who is accessing the meeting through MS Teams, that the chat function is only to make us aware of any urgent or technical issues and not to make general comments or statements throughout the meeting. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask members participating via Microsoft Teams that, prior to making their contribution to the meeting, they confirm they are on the grounds of the Leinster House campus.

Before inviting our witnesses to deliver their opening statements, I advise them of the following notice with regard to parliamentary privilege. I remind witnesses and members of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her, or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks and it is imperative that they comply with any such direction. That completes our housekeeping matters.

We will have opening statements followed by the usual round of questions and answers. I now invite Dr. McCarney to deliver his opening statement.

Dr. Gerry McCarney

Good evening all. I work with a SASSY team, which works with young people under the age of 18 who have significant issues with drug and or alcohol use. There are some key points in my opening statement. Dual diagnosis means that one person can have a moderate-to-severe mental illness at the same time as a substance use disorder or a behaviour or process addiction. Young people with dual diagnosis may become anxious, depressed, psychotic. Like any other group of people, they can have suicidal ideation, hard themselves, or attempt suicide. They may have significant autism spectrum disorder behaviours and traits, and significant attention deficit hyperactivity disorder behaviours, and they can have problems with eating behaviour just like anyone else.

In the SASSY team, we frequently co-work cases with CAMHS. Young people already under the care of CAMHS will have a severe or moderate mental illness and attend SASSY, where we focus on their substance misuse. The greater the degree of illness, the more likely it is we will co-work a case with CAMHS. Often, if CAMHS assesses a young person and finds signs of substance use disorder, it will refer the young person on to SASSY, within our catchment area. Generally, we have a very good working relationship.

On some occasions, when young people engage in drug use, it means that after assessment by CAMHS they are not offered a trial of medication. There can be various reasons for this. It happens with ADHD in particular. This would be the correct or best-practice approach if the person is using, for instance, illicit stimulants. CAMHS and SASSY may or may not co-work in those cases. The plan with the national clinical programme is to develop the substance misuse dual-diagnosis service, and we would hope to be able to work more cases with CAMHS in these circumstances.

In some situations, CAMHS has not accepted referrals for young people who are currently using drugs. This would mean that they are not assessed by CAMHS, but they can be referred to a service like ours. If it is quite clear from the referral that there is no mental illness, that would be appropriate. In cases where there may be mental illness, though, we would have some concerns. Of most concern are those instances when a person might have suicidal ideation or a history of suicidal threats or self-harming behaviour. Even if the person is using drugs, in that type of case, those behaviours or those ideas should be assessed. In SASSY, we are happy to assess and treat young people presenting with substance use disorder and dual diagnosis and to co-work such cases, but we cannot take on all cases because we are quite a small team with a large catchment area. We do not agree if substance use itself becomes an exclusion criterion for assessment. It is a fact of modern life that a high percentage of young people will experiment with and use drugs and-or alcohol to a degree that is not healthy, and they should have access to mental health services as required.

Autism spectrum disorder, ASD, is considered a disability, and, if combined with drug use, CAMHS could reasonably argue this does not meet its criteria, and I fully understand that. We have certainly held on to cases of people who are on the spectrum, and who had been using drugs, long after they have stopped using drugs because there are very few and very poorly developed services for people who have autism but who do not have a significant intellectual disability. For them, they are vulnerable and fragile but no great service is available to them. This is another issue we have found.

CAMHS sees people up to the age of 18. At times, the length of its waiting list means it might not accept a referral when the difference between the time involved in reaching the top of its waiting list and reaching the age of 18 is too small. That can be a problem if someone is very unwell close to the age of 18. Again, this is something that has come to our notice over the years when people have been referred to us.

An Cathaoirleach

I call Ms Ber Grogan.

Ms Ber Grogan

I thank the committee for inviting Mental Health Reform here today for this important session. I am the policy and research manager and I am joined by Neil Moore Ryan, mental health advocate and member of our grassroots forum. Myself and Neil will both contribute to this opening statement.

As I hope the members of the committee know, Mental Health Reform is Ireland’s leading national coalition on mental health, with over 80 member organisations, working for progressive reform of mental health services and supports in Ireland. According to the Central Statistics Office, CSO, in 2022, there were over 1.2 million young people under the age of 18 living in Ireland, which represents 23.6% of the total population. Ireland also had the highest estimated proportion of children in the European Union in 2021. Thus, the well-being of young people needs to be a central focus for the State.

Our mental health policy defines "dual diagnosis" as the term used when a person experiences both a substance misuse issue and a mental health difficulty such as depression, anxiety or psychosis. Treatment options must address both. Dual diagnosis may also refer to someone who has a mental health difficulty alongside an intellectual disability, autism or both. Key for Mental Health Reform and our members is not to focus on terminology but to move towards services that are tailored to, and revolve around, the needs of children and young people, rather than expecting them to conform to existing structures. Too often, young people end up slipping through the cracks, encountering service gaps that do not cater to their needs or find themselves stuck on lengthy waiting lists, only to discover they have been waiting in the wrong queue or knocking on the wrong door all along.

I will highlight three key areas. I will start with early intervention and prevention. Specialised services alone are not enough to support young people with mental health difficulties, including those with dual diagnosis. It is equally essential to scale up early intervention and prevention services, ensuring where possible that we are preventing the development of more complex and costly mental health difficulties. The voluntary and community sector plays a crucial role in the delivery of these services, including education, talk therapies, helplines and peer support. Appropriate investment in prevention and early intervention services is needed to support children in the community and reduce the need for specialist care. Our recommendation in this area is to invest in early intervention and prevention by providing sufficient funding to the vital voluntary and community mental health services.

Turning to accessing appropriate services, we know that CAMHS waiting lists have almost doubled since 2019. In summer 2023, the figure was around 4,400 children and young people. Concerns about CAMHS have been raised in the Mental Health Commission's independent review reports, as well as in the earlier Maskey report. In February 2023, the UN Committee on the Rights of the Child, which monitors the United Nations Convention on the Rights of the Child, UNCRC, expressed serious concerns about the inadequate and insufficient mental health services for young people in Ireland. The HSE has stated:

Substance misuse services are not provided by CAMHS. The HSE provides two CAMHS consultant psychiatrist-led teams in North Dublin and South Dublin which provide substance misuse services to young people. CAMHS can refer to these services and also receive referrals from them. The service encourages self-referral by the young people themselves.

Mental Health Reform acknowledges the recent announcement of funding for two dual-diagnosis hubs for adolescents with substance misuse issues, but we remain concerned about when these will be operational. Elements impacting on youth mental health span many Departments and, at a service level, a child can be working with several different agencies at once. As such, much improved strategic co-ordination of child and young person-centred care is needed both at policy level and at implementation level. This co-ordination is particularly important in light of the ongoing restructure from nine community health organisations, CHOs, to six HSE health regions. We understand that the aforementioned two dual diagnosis hubs are being funded separately through mental health and then also through the national drugs strategy. We would welcome more information on these points.

Our recommendations are to urgently implement the youth mental health pathfinder project, to develop child and young person-centred care pathways, and to develop a central referral system drawing from the learning from the current pilot in CHO 9.

I will now hand over to Neil Moore Ryan.

Ms Neil Moore Ryan

I will address the voice of lived experience, which is the third area we wish to highlight. As we have seen in the news this year, there are, unfortunately, far too many people in this country who have poor things to say about CAMHS, a place that should be a safe haven for vulnerable young people and children. With this Oireachtas joint committee debate being on the topic of CAMHS and dual diagnosis, which are both pressing issues, particularly currently, I wanted to share my own experiences because I am the expert in my own experience.

I am a 23-year-old autistic woman who was engaged with a CAMHS service from around September 2017 to July 2018. I struggled with self-harm and suicidal ideation and found the CAMHS team was a little flippant with their discussion of it. I very much felt that the members of the team did not take it seriously and thought it was just for attention, an attitude I do not feel is appropriate for people in their position to have. The doctors put me on Prozac, which I was apprehensive about as I had not been on medication and did not want to be on it. However, they made me feel as though they could not engage with me and they would not do the work I wanted if I did not go on it. They raised my dose often. In preparing for this committee meeting today, I spoke with other people who have accessed CAMHS services. Overmedication was a common issue among those people. I spoke to people in preparing for today because every person is unique and every person deserves the best mental healthcare that they need, when they need it.

My voice is important here today because we are not just statistics. There are so many children and young people on waiting lists that I think it can become easy for politicians or service providers to forget that each of the 4,400 children and young people waiting are members of our families, friend groups, communities, schools, sports teams and neighbourhoods. If we are at the point of accessing or trying to access CAMHS, we have already gone through a number of other steps to even get to the point of being on a waiting list. Imagine the hurt it causes to then be turned away because you also have autism, or an intellectual disability, or a substance misuse issue.

I thank the committee for inviting Mental Health Reform to speak. I also thank the people who spoke to me about their experiences. Ms Grogan and I very much look forward to this evening's conversations. We are grateful to the committee for examining this important topic.

Senator Tom Clonan

I thank our guests for coming in and giving their evidence. I am very sorry to hear about Ms Moore Ryan's experience. I will ask a question but, unfortunately, I will then have to leave because I have a committee meeting in committee room 1, which is running at exactly the same time. My apologies for that.

A couple of weeks back, Mental Health Commission representatives were here, including its chair, Dr. John Hillery, and the new Inspector of Mental Health Services. They both agreed, on the record, that CAMHS were in "failure" - that was the word used - and is failing our young people. That seems to align with the experience Ms Moore Ryan set out, and what I hear from the many representations I get through my office. There is a recurring pattern in those representations, one of which is that it is a bit of a lottery as regards where people live and, if they get access to a team, whether the team is led by a consultant with higher specialist training. I emphasise that, generally speaking, there is no criticism of front-line clinicians. The sense there is a failure rests on an acknowledgement that there just are not enough properly qualified people with the higher specialist training that is necessary to put this service in effect, effectively.

This question is for all the representatives. We have been told by the CEO of the HSE that Progressing Disability Services for Children and Young People is in failure. We have been told by the Mental Health Commission that CAMHS is in failure. Is there anything that the witnesses could recommend to the committee as a step that could be taken? They are the experts, they are on the front line and they have the lived experience. Is there anything we can do? Is there a pathway, roadmap or example of best or good practice in another jurisdiction they can point to and say that is what we should be doing?

Ms Maeve Geraghty

The SASSY and the YoDA teams, which are the dual diagnosis adolescent teams in Dublin, work very well. When young people come to our service, we are able to assess whether they have mild, moderate or severe mental illness and get them the treatment they need accordingly. What is very clear is that it is only available in a very small catchment area and is not available nationally. It works well because we really listen to young people. We are psychiatric-led but we also have child and adolescent psychotherapists who are trained to listen to what young people are saying, rather than jumping to conclusions and diagnosing or dismissing just because it does not look good on paper. We also see young people within two weeks of referral to make an assessment and to prioritise. Having the counsellors available gives us the opportunity to listen because many young people feel that they are not actually listened to. It works and is effective but is only available to a small number of people because we have a tiny team and it is not available outside Dublin. There are good role models for something that works and needs to be made available nationally.

Senator Tom Clonan

What CHO is that service running in?

Ms Maeve Geraghty

CHO 9.

Dr. Gerry McCarney

On what would help, I am not sure that splitting disability services off from CAMHS worked. I am not sure disability services had developed to a sufficient degree to offer a service that was sufficient. Previously, people went to mental health services, regardless of mental illness or disability, to be assessed, to identify what intervention might help and then to seek support. There is now a lot of confusion about which service people go to and whether it is there, which is not helpful.

On substance misuse and dual diagnosis, the national clinical programme for dual diagnosis is timely. It is great that there is some action at last. To be fair, we have had a lot of support, particularly from the Ministers of State, Deputies Butler and Naughton. The two new hubs are not new. They have been working for some time as substance misuse teams. They will continue to do so, as well as trying to do more on dual diagnosis. They will see people who do not have an illness, as well as those who do and have substance misuse issues. The plan is to have two more hub teams, one in Galway and one in Cork. Those teams would have this hub-and-spoke model, where the four hubs will cover their own catchment area but will also be in a position to offer more support virtually and some face to face. It will certainly be virtually to areas outside the catchment area so the expertise can travel more easily and be available. To do that, however, we need to have these spokes. That means we need to have a skeletal team at least. The skeletal teams that were envisaged consisted of a clinical nurse specialist and a counsellor in each CHO area. There were nine CHO areas and now, with regionalisation coming down the track, that will be six. We have to see how that will reconfigure but the plan was, regardless of where people lived, that there would be a person to refer a child, if he or she were using substances.

We are trying to expand that potentially into process addictions, which are essentially gaming and gambling. Gaming, particularly for younger people, is an issue. Gambling is probably an issue but we are not sure of the extent of it, especially if it takes place over the phone rather than through going to shops and so on. We are very conscious of that in trying to develop that service. In the strategic implementation group, SIG, for the drug and alcohol strategy, we put in eight new action points in the mid-term review, one of which was the development of a national substance misuse service for under-18s that would be cohesive, well governed and supported. We hope to develop that so there is a real service out there that will see young people regarding their drug and alcohol use, and their process or behavioural addictions, and be able to look at the dual diagnosis aspect so we can maybe take some of the pressure off CAMHS, depending on how well we are developed. One of the issues is recruiting people. It is great that funding is being made available to recruit but people are not always there. We have had difficulty in recruiting for certain disciplines. Having different disciplines offers a different skill mix. That is very important but if the people are not there, or they are not coming forward to join the service, then the posts cannot be filled. That is a challenge.

On making the service better, CAMHS has been under-resourced for a long time. It has improved over the past few years. There is a lot of frustration that it cannot do better but, when it has half-teams, it has been a challenge. I was chair of the Faculty of Child and Adolescent Psychiatry for three years and I heard a lot of that, even though I was not working in a CAMHS post as such. There is a lot of willingness to improve things. Recruitment is one way of doing that, but it is also about looking at how we work and how we co-work between different services. That will help, as will looking at referral criteria and services underneath the moderate to severe. Other services were developed, such as community psychology, and other agencies were supported, such as Jigsaw, etc. CAMHS then focused on moderate to severe illness, but there are a lot of people who are in distress who may not have a moderate to severe illness but could receive support. We need to look not just at CAMHS but the other funded organisations to see how they are fitting into the picture because they need to work cohesively to offer a proper service for people.

Ms Ber Grogan

On that point, I will say what Ms Moore Ryan said. If someone is already in CAMHS or accessing CAMHS, that person has gone through a series of referrals, and has gone through difficulties and experiences.

We in Mental Health Reform would say what the Government has been saying about other areas for years, which is that prevention is better than cure. The funding should go to early intervention and prevention. Funding for mental health is an investment rather than a cost. The longer term return on financial investment is worth it, never mind the return as regards the human costs associated with young people experiencing mental health difficulties. Early intervention and prevention services are provided by many of our members in the community, in schools and in community organisations like Jigsaw, Pieta, the ISPCC and A Lust for Life. There are loads of services offering these early intervention and prevention services so why would we not invest in them? They got nothing in budget 2024. There was a very disappointing announcement of 68 new posts for CAMHS in budget 2024 but no increase in funding for organisations in the community and voluntary sector even though demand for their services has gone up exponentially. Why are we trying to fix the later pieces when we should be looking at what is happening earlier?

Obviously, recruitment is an issue. I know Bernard Gloster is coming before the committee later. It would be great to find out if the recruitment embargo also applies to mental health. We have heard that it does but that there is a derogation for disability, allowing for some posts in that area to be filled. If that embargo applies to mental health services, that will have longer term impacts in years to come.

I was thinking about what would have happened if all of the policies and recommendations that have been made over 13 years or more had actually been implemented. In 2017, there as a national youth task force working on a youth pathfinder project. Its recommendations have not been implemented. There are some great recommendations in Sharing the Vision and there is some really good work happening but there is no new development funding in budget 2024. Bits of the progress that have been made are going to stall and that is going to impact on children and young people. I do not know if Ms Moore Ryan has anything else to add.

Senator Tom Clonan

I will ask one more brief question before I go. Is there a jurisdiction elsewhere that the witnesses look to and say "this is how we should be doing it"?

Dr. Gerry McCarney

I worked in the UK and saw the same issues that we were having.

Ms Ber Grogan

May I come in on that? We recently launched new domestic leave legislation. Ireland is one of the first countries in the world to do that. Why can we not be the world leader in mental health services and supports? The reform of the Mental Health Act is happening. It is on the list for priority drafting for this session. Nowhere is doing this perfectly. We have looked to other countries for inspiration but we now have this opportunity. Let us lead. When we look at all of the things that have happened to children, young people and people experiencing mental health difficulties over the years, it is clear we owe it to them to now become world leaders in human rights.

Today, I was at the Mental Health Commission's launch of the World Health Organization's QualityRights e-training, which is on human rights and mental health. It is free. It would be amazing to see it rolled out across the HSE. The committee might mention it to Bernard Gloster when he comes in later. The Mental Health Commission brought An Garda Síochána, the Prison Service, the HSE and loads of other stakeholders together for this morning's launch. The World Health Organization's first paper on this training came out today and shows that it is already making an impact on front-line service providers with regard to capacity, decision-making, basic human rights and person-centred care. There is free training that could be rolled out tonight if someone wants to sit at home on a Wednesday evening to start it.

Senator Tom Clonan

I thank the witnesses very much and again apologise that I have to go. It was great to see Ms Moore Ryan and I wish her continued good health and recovery. I thank her very much for coming in because I know it is not easy.

Deputy Patrick Costello

My experience of CAMHS is mostly as someone referring people to them. My biggest frustration was, to be blunt, the gatekeeping that happened a lot. If there was a suggestion of substance abuse, CAMHS would shut down and not take the person. Where there was a suggestion of disability, CAMHS would shut down and not touch the case. Ms Grogan made the point that people who are engaged with CAMHS have been on a waiting list for a long time. However, there is also a whole cohort of people who never make it onto that waiting list. It is important to name them.

Dr. McCarney touched on the community services. An answer I got quite often was that issues were emotional or behavioural and that community services were more appropriate. There is a disjointed system in which there is never an obvious service to refer people to or assistance in making that referral. As has been said, it is a case of waiting at the wrong door. That is my own frustration with CAMHS but we are dealing with dual diagnosis and, where there are two things going on, the situation is much more severe.

I will pick up on a few things. For clarity, is it the case that YoDA and SASSY are the only services of their kind in the country at the moment?

Dr. Gerry McCarney

They are the only teams in the country where the clinical lead is a specialist child and adolescent psychiatrist who has a special interest in addiction. There are many services around the country, in every CHO area, that work with young people who are using substances but they are the only two operating at that level. They are considered a tier 3 service in the four-tier system. I will give a simple view of the four-tier system. If you have experience or expertise in either mental health or adolescent development and substance misuse, you are tier 1. Tier 2 is where you are working specifically with young people like that. I am sorry; tier 1 is where you are working with young people but do not have that experience, tier 2 is when you have experience in one of those areas and tier 3 is where you have experience in both. Those teams have experience in young people's mental health and adolescent development but also in substance misuse. Tier 4 refers to residential treatment. There is one place in Ireland for that.

Deputy Patrick Costello

Dr. McCarney talked about the hub and spoke development model. I have been taking notes because, as Ms Grogan has said, Bernard Gloster is on his way in and we will ask him about these matters. Dr. McCarney made reference to the interest group, the special group to carry out the midway review, the new recommendations and the hub and spoke model. When was that recommendation made?

Dr. Gerry McCarney

Which recommendation is that?

Deputy Patrick Costello

Dr. McCarney was talking about a recommendation in respect of this hub and spoke model and developing the system so that there would always be somebody to be referred to in the local CHO.

Dr. Gerry McCarney

A couple of things have been happening simultaneously. The national clinical programme is under mental health. That was developing a dual diagnosis programme. There have been previous clinical programmes. The programme on early onset psychosis is one that comes to mind while the programme on eating disorders is another. The programme for dual diagnosis has been under development for the last few years. That comes under mental health in association with the College of Psychiatrists of Ireland. That was agreed this year. There is an adult service part but there is also a part for under-18s. The team I am part of was identified as the pilot. This team and the YoDA team are the two existing teams at tier 3 level. We will work in unison to try to develop that and the plan is to have two further teams, in Cork and Galway.

Halfway through the lifetime of the drug and alcohol strategy, there was an interim review. The national oversight committee was reconstituted and it was broken up into strategic implementation groups to look at various aspects of the strategy. I was tasked with chairing the group dealing with the part relating to young people and prevention. We identified eight action points. The fifth related to the development of a national service for under-18s. This dovetails very well with the national clinical programme. The main difference between the two is that the national clinical programme is about dual diagnosis while the under-18s service is about dual diagnosis and those using substances who do not have an illness.

It is both. That is what is happening in reality. What was the last part of the question?

Deputy Patrick Costello

I will come back to it because I am conscious that I am running out of time. I have one or two quick questions for Ms Moore Ryan. She talked about overmedication and the flippant responses from some clinicians. I have experienced that as a referrer but obviously it is a lot easier because I am not the one looking for help for myself. I appreciate that it is very different to be on the receiving end. Ms Moore Ryan talked about the overmedication when she was in looking for help. Did the clinicians respond? Did she complain to them about it? Did they respond in any way? Was there willingness to understand her perspective? Equally, does she feel the services had an understanding that she had two things going on, that is, the autism and the mental health challenges?

Ms Neil Moore Ryan

I will speak on the medication first. I actually did not want to be on medication. I asked not to be put on it but I was very much made to feel I would not be engaged with if I was not put on it. I actively said that I did not want to be on medication and they put me on it anyway. They were happy once I was on it. They just upped my dose from then on.

In regard to the autism, I got my CAMHS documents recently and there was a note stating that they thought I might have autism from my very first meeting with them. I am pretty sure I brought it up with them but it was never brought up again. I never knew they were concerned about that in that first meeting until I got my own papers back. As far as I was concerned, they had no idea or any suspicions even though I brought it up myself.

Deputy Patrick Costello

The diagnosis was before that and Ms Moore Ryan told them-----

Ms Neil Moore Ryan

No, I was diagnosed as an adult.

Deputy Patrick Costello

Okay, sorry.

Ms Neil Moore Ryan

I had my suspicions from personal experience.

Deputy Patrick Costello

I think I am out of time. I will come back in again later, with the Chair's indulgence.

Senator Mary Seery Kearney

I am rushing from another meeting so that is why I am not there in person. I did not want to miss my slot. I thank the witnesses for their opening statements and their contributions so far today. I also thank them most sincerely for the ongoing work they do. Ms Grogan has been particularly brilliant to me personally on a couple of things I needed to run past her.

The Fine Gael Parliamentary Party met with Families for Reform of CAMHS recently. That group put forward some stark statistics and they are reflected in much of what the witnesses have to say this evening. There is this idea that a key worker and a clear care plan must be provided for every child under the remit of CAMHS. The statistics from Families for Reform of CAMHS members show that for 72% of those children, there is no key worker or care plan. Only 12% of the children in those families actually have a key worker and a care plan. Do the witnesses concur with those figures? Could they describe the consequences that arise from the failure to have a key worker and a care plan?

Ms Maeve Geraghty

I can speak to this from my previous role in the child care system, where I was in the voluntary sector working with children in the care system for 23 years. There are a couple of things that made it almost impossible to get children seen. One is that GPs were the only ones allowed to do a referral. We might get them a GP for the first time and the GP would not have a notion of who they were, except for their name and date of birth, but they were the only ones able to do a referral. The referrals were led by us but the GP would write them. It was hard to even get on the waiting list. We had our own key working system within the community. The community connect very well with each other, including with SASSY. We were able to get some direct referrals into SASSY where we did not have to go through this whole system of going to a GP first and then through the CAMHS gatekeeping system. We should have direct referrals.

The other problem was that even where CAMHS was half interested in looking at a referral, it would not phone the people who knew the young people but would just take the referral from the GP, who would not always know the young person. If CAMHS had some sort of system where it actually spoke to the referrers, the adults who actually knew the young person, it would then be able to get a better idea of what it was dealing with and whether it was the best or most appropriate service. Often we would never get that far. That would be a problem.

I very rarely got somebody into CAMHS so when we did get somebody into CAMHS, they were generally referred out. Trying to get a key worker or a care plan is very difficult and then the young person gets lost in the system because they do not know where to go. Jigsaw would say they are too high-profile for its service and CAMHS would say they do not reach the threshold for its service. There is a huge gap between Jigsaw and CAMHS for young people who just do not seem to fit the criteria for either.

If a young person is using drugs, both Jigsaw and CAMHS are reluctant to see them. A lot of the young people I have worked with over the years would be self-medicating because they have waited so long to get help that they cannot get the help. Weed is very good for anxiety as far as they are concerned and alcohol and other substances can help them get away from their own internal dialogue, or depression and anxiety. Illicit drugs work when you cannot access the services. Once people start using illicit drugs that are useful to them, they fall into the pattern of getting out of the mainstream and into the margins where it gets very dangerous because then they are dealing with drug dealers and people you do not want your children dealing with, because they are trying to self-medicate. Getting to the door is the problem. Once someone is in there, then of course having a care plan and a key worker would be really great but it can be hard getting to that door first.

Senator Mary Seery Kearney

Did Ms Grogan want to add to that?

Ms Ber Grogan

I will, briefly. First, I thank the Senator for her kind words and continued support of Mental Health Reform in the work we do. Ms Moore Ryan has summed it up really well as regards a care plan being devised and having a key worker. That is the person you would discuss treatment options with, and dosages if it is about medication or what other treatment is available, such as talk therapies. We are talking about having a consultative relationship, or just being told what to do. We all know from our own experiences which of those is going to have a more positive outcome for the person. Under the Assisted Decision-Making (Capacity) Act, which the Senator did a lot of work on, for people over 18 there are decision support arrangements and laws in place but 16-year-olds or 17-year-olds are still excluded from that, which is why we need urgent reform of the Mental Health Act. We would say that key workers and care plans are absolutely vital to supporting a person and to empowering them in their own experiences.

Senator Mary Seery Kearney

Where it occurs, it is useful, but how much of a say does that young person have in that care plan? Is it handed to them or do they co-create it?

Ms Ber Grogan

The guidelines and operating procedures say the plans should be co-created and that it is best practice to have them do that. In preparing for today's meeting, Ms Moore Ryan and I looked at the Mental Health Commission's independent reports into CAMHS and into the nine individual CHOs. Part of the problem that was mentioned earlier was the postcode lottery. If you have a team that works really well and is co-creating with the young person, and listening to them and taking their views on board, as is the young person's legal human right, the outcomes will be better.

It is also their legal human rights. Then the outcomes will be better. It is, however, patchy across the services. There is not that standardised level of service across all of the CHOs. This is why we have consistently asked for the reinstatement of a national director of mental health, which is also in the programme for Government. We have also had some meetings directly with Mr. Bernard Gloster. We do not agree that there is not a need for a national director. We welcome the new youth mental health office but we believe that high level strategic accountability is needed.

Senator Mary Seery Kearney

I thank the Chair. I will come down to the committee room now.

Deputy Sean Sherlock

I thank the witnesses for being before us today. For me the key phrase around CAMHS is always "getting into CAMHS". There is this constant battle of getting into CAMHS. In advocating for families or for people who need access to services, I characterise CAMHS as like a silo with no windows and no door. Whatever the governance structures are or how it operates, my perception of how it operates is very much within this. It seems to exclude more people than it lets in. That has been my first-hand experience as a typical constituency TD, and that is what we all are here effectively. I am a great believer in breaking down silos, in seeing cross-collateralisation from the community and from the lived experience of people such as Neil right up to psychiatrists, psychologists and everybody else who needs to work within the system, and of building out an infrastructure that ensures that where a person has a need, there is a door through which they can go. In saying this, I am not saying anything that has not already been said.

I want to try to get a deeper understanding of the substance abuse service specific to youth, SASSY, and the youth and drug alcohol service, YoDA. I am reliably informed by my Dublin colleague that YoDA is on the southside and SASSY is on the northside. We are going through a bit of a "Star Wars" phase at home at the moment and I am reliving past glories. I have to say I am thoroughly enjoying it. It seems to me there is something inherent within that SASSY and YoDA model. I say this because at the moment I have a situation of a young person presenting with a dual diagnosis that is not related to addiction - I will not say too much more beyond that it is not addiction related - and we are trying to get that poor kid into CAMHS. He has been excluded just for want of some sort of an assessment so that his mother, in this instance, can take the next step on his behalf. We are banging our heads off the wall. This is us as TDs doing it. It is really internalising what his mother is going through on behalf of her own son. I am fearful for the woman at this stage because it is a traumatic experience for her.

Have we arrived at this situation because of these silos? Is it because certain types of professions are protecting how they operate and not wanting necessarily to collaborate? Is it as simple as saying there are not enough front-line people in the system for the it to work? Perhaps the witnesses could tell me because it seems the SASSY and YoDA models are a good starting point, and Deputy Costello also spoke about the hub and spoke model. There is something in these. If we could roll that out, even in spite of the shortages of front-line staff, it has been my experience that people will travel to access services if they are not immediately available within their own geographical location. They are desperate to get access to services. If, at the next meeting, we are going to push back against Mr. Gloster on this one, is the right question to ask when a YoDA and a SASSY model are going to be rolled out throughout the country? Will the response to that be that we have the community network teams, we have CAMHS, we have the progressing disability services, and we have pathways to this and pathways to that?

I am genuinely not being cynical because we always work to try find solutions. Forgive me if I am being long winded. In my experience the HSE is excellent at processes and it is excellent at devising strategies. It is absolutely brilliant at answering parliamentary questions. I can give the committee chapter and verse on how many children and young people are waiting for access to CAMHS because I have a list as long as my arm of replies to parliamentary questions. Until we get to the point where the HSE is strategically solving the issues and giving attention to the SASSYs and the YoDAs of this world, where it is addressing everything in the mental health reform and is giving due recognition to people like Neil, then we will be having this conversation again in five years' time. Can I get the witnesses' real and raw perspectives on this? It would help me in the next step of this process here in committee.

An Cathaoirleach

A vote has been called in the Dáil. I suggest that this will give the witnesses an opportunity to think about those questions. We will suspend the meeting while the vote is ongoing, and when we come back, the witnesses can answer those. Then we will have one more speaker.

Deputy Sean Sherlock

I will conclude by saying, and this could be a wrong perception, that sometimes psychiatry has too much power. Disavow me of this notion I have. Neil's experience has really touched a nerve with me. I am grateful to the witnesses for their perspectives on this, especially on the agency the person has and the rush to medicalising or prescribing. It is my perception, and disavow me or correct me if I am wrong, that we are overprescribing in this country. Maybe we need to tilt it back to the person having agency over his or her own pathway.

Sitting suspended at 6.27 p.m. and resumed at 7.20 p.m.

An Cathaoirleach

I apologise for the long delay. Given that we have run so far over time, I will ask that we get written replies to the questions. I will allow Deputy Ó Murchú to ask his questions and he, too, will get written replies.

Deputy Ruairí Ó Murchú

There will probably be considerable repetition in the sense that many members have dealt with issues constituents have raised with them regarding CAMHS. One issue is that the service operates in a silo. Another is whether dual diagnosis relates to autism generally or to people who have substance abuse issues. The witnesses' comments on SASSY and YoDA were incredibly interesting.

In my area, a number of positions have not been filled in CAMHS, the adult mental health services and disability services. The problem is there has never been a proper conversation about accepting what the service can provide to people and how it can provide the best bang for our buck as part of workforce planning, including ensuring the necessary staff are recruited. We need to find the best means of doing that. I do not think we have had those conversations. That is really what I am saying. I will put the exact same question to Mr. Bernard Gloster.

Ms Bernie Grogan

I will say only one thing because I know we are short on time. Mr. Bernard Gloster and Dr. Amanda Burke are due to appear after this session. Mental Health Reform acknowledges the amount of work they have been doing since they have been in post. We have a lot of hope for the changes and restructuring they are going to bring. Mr. Gloster has been really accessible to our members and we are looking forward to meeting Dr. Burke. We are hopeful they will bring about change.

An Cathaoirleach

That is great. I apologise to the witnesses but, unfortunately, votes in the Chamber sometimes clash with committee meetings. This has been a very good session. In particular, we very much appreciate hearing from Ms Moore Ryan. I am conscious that there could be people who are looking for help right now. There is a HSE helpline. People can text HELLO to 50808. It is important that whenever we discuss this issue, we also note the supports that are on offer. I thank the witnesses very much.

I propose that we publish the opening statements to the Oireachtas website. Is that agreed? Agreed. We will suspend for a few minutes while the next witnesses come in.

Sitting suspended at 7.28 p.m. and resumed at 7.32 p.m.

An Cathaoirleach

The agenda item for consideration at this session again is engagement regarding access to CAMHS for individuals with dual diagnosis. Mr. Bernard Gloster, chief executive of the HSE joins us in this session along with Dr. Amanda Burke, child and adolescent consultant psychiatrist and national clinical lead for child and youth mental health and Ms Mellany McLoone, chief officer, CHO Dublin north city and county, who are all very welcome to this meeting.

Obviously we had a lot of dealings with Mr. Gloster when he was CEO in Tusla and he has not been before this committee since his new role. We wish him the best of luck with everything in that role. Issues were raised in session one of the meeting to which Mr. Gloster may wish to refer, if he was listening in to that or through follow-up correspondence if that is more convenient.

Going to our own housekeeping matters, as we have a vote at committee, we have to finish at 20:30 so I have to ask people to be really brief with their questions. In regard to parliamentary privilege, in advance of inviting our witnesses to deliver their opening statements I want to advise them of the following in relation to parliamentary privilege. I remind witnesses and members of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her, or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks and it is imperative that they comply with any such direction. I now invite Mr. Gloster to deliver his opening statement.

Mr. Bernard Gloster

I apologise for the rescheduling that had to happen because of my diary. I want to recognise that with committee members and thank them for the welcome back. There are times when I wish I was back here all the time. I always found this to be a very supportive committee and one in which constructive work is done.

I am conscious that this is my first committee appearance since the incidents in Dublin two weeks ago. I take this opportunity, as this is the children's committee, to express my support for and indeed my good wishes to the families of the children who were caught up in that incident. I have obviously been closely connected to it because of our involvement. I express our good wishes to everybody who was affected by those incidents.

I thank the committee for the invitation to meet today to discuss access to CAMHS for individuals with dual diagnosis. I am joined by my colleagues Ms Mellany McLoone, chief officer of CHO Dublin north city and county and Dr. Amanda Burke, executive clinical director for mental health in the CHO 2 area up until recently. She is a consultant child psychiatrist on the specialist register and has just taken the first new national role of a dedicated national clinical lead for child and adolescent mental health services. I am grateful to her for taking that role and for the experience she brings to it. She will assist the committee this evening in some of its deliberation. I am also supported by Mr. Ray Mitchell and Ms Sara Maxwell from my office.

The range of services and supports for children and young people is extensive and is provided in acute and community settings. The HSE also works with and funds a number of providers in the voluntary sector to support the provision of services to children and young people. There has been an increased demand for mental health and disability services over a number of years, which has led to challenges for access including waiting times and sometimes disjointed pathways. It is of concern to me that at times, our patients and their families face challenges in accessing our CAMHS and our disability services and the following is indicative of our approach to attempting to resolve some of those challenges. The HSE has prioritised targeted service improvements to streamline referrals and to ensure patients get the right service at the right time. These include the national policy on access to services for children and young people with disability and developmental delay, which is designed to ensure that children are directed to the appropriate service based on the complexity of their presenting need; joint working protocols between HSE primary care, disability services and CAMHS to make the referral process between services as easy as possible for families and clinicians to navigate; and the child and adolescent mental health services operational guideline, which was published in June 2019 and highlights the importance of joint working or shared care with other agencies, including HSE primary care, children's disability network teams, CDNTs, and other agencies supporting children and adolescents such as Tusla, the Garda and the education services. In addition, the model of service for CAMHS-ID provides a framework for the development of specialist mental health services for children and adolescents with an intellectual disability, so that they can access services in the same way as their peers.

The final report into CAMHS was published by the Mental Health Commission in July this year and the findings have been accepted in full by me and by the HSE. Together with the Maskey report and the findings from HSE-commissioned audits on prescribing practices, adherence to the CAMHS operational guidelines and service user experiences, these findings are directly contributing to the HSE’s programme of work to improve services. Some of those improvements include piloting a standard autism assessment approach and protocol for use across all parts of the health service; piloting a central referral mechanism within CHOs for all specialist community paediatric services in the area. This will provide a single point of access, a more integrated service user journey and help to eliminate the practice of multiple, parallel referrals to different services; implementing a child and youth mental health improvement programme led by a dedicated national office with Dr. Burke and a dedicated assistant national director leading that service and separating it from our adult mental health services. This arose from the Mental Health Commission’s review of CAMHS, and our own internal audit of prescribing practices.

The model of care for dual diagnosis, namely, coexisting mental health and addiction, was launched jointly by the Minister of State, Deputy Butler, and the Minister of State, Deputy Naughton, in May 2023. This model of care outlines specialist services to support individuals with a dual diagnosis including specialist services for adolescents aged between ten and 17 years. The roadmap for service improvement for disability services for children and young people was launched by the Government and the HSE in October 2023 and aims to ensure children are referred to the most appropriate service; reduce the waiting time for children and improve outcomes; optimise use of voluntary and private disability service providers for assessments and interventions; improve the HSE’s legislative compliance for assessment of need, AON; and improve staff retention in CDNTs by being good places to work. Many of the 60 actions contained in this roadmap are already being progressed.

Assessment of need compliance continues to be a challenge, which remains a concern for me.

Some 7,612 applications for assessment of need were received in the most recent four quarters, the highest number of applications received in any 12-month period since Part 2 of the Act was commenced as far back as June 2007. A revised assessment of need standard operating procedure incorporating guidance on completion of clinical assessment was issued in July. The HSE continues to explore all options, including additional procurement from the private sector. Assessment of need administrative and assessment hubs are now in place to streamline assessment of need processes. It is important to note that children do not require an assessment of need to access a children's disability network team or primary care service.

A number of service improvements are being introduced to improve access to services for people with autism. A programme board with representation from persons with lived experience of autism is leading out on agreed priorities, including a programme of awareness raising to provide better information for autistic people and their families to improve access to services and support, for a better understanding of autism and to provide guidance to clinicians and service providers. It also aims to build professional capacity and competence among key professionals working with people who experience autism, including piloting the implementation of a tiered model of assessment. In addition to the measures outlined above, it is my intention to see the HSE, at all levels, increase and enhance our joint working with other sectors with responsibility for the well-being of our young people, including education, youth services and Tusla. I wish to place on the record of this committee that I recognise that our services are not anywhere near up to the par we want them to be. Substantial plans are in place to get there but it is complex and difficult. For some time to come, I envisage that we will continue to see young people experiencing challenges in our services.

An Cathaoirleach

I appreciate those comments and Mr. Gloster's words on the committee. We had a good working relationship with Mr. Gloster in his role in Tusla.

Deputy Patrick Costello

To be brief, for my first question, I will ask for a follow-up in writing to the committee instead of an answer now. The model of care was launched earlier this year and there are the CAMHS operational guidelines from 2019. Is there a review process? Does the review include consultation with the public and service users? A written note to the committee would be fine.

One issue is gatekeeping of CAMHS. We spoke about the challenge of getting a referral. Once a referral has been accepted, there is a waiting list but even having the referral accepted is a huge problem. There is also an issue related to exclusion, which we heard about in the first session. If there are other issues, CAMHS can decide to exclude people, saying that is not its service and it is not right. Whether it is gatekeeping or the disjointed pathways, ultimately, a young person who is vulnerable and in need of help is left with no service. I want to know what is being done to prevent that gatekeeping and exclusion and to ensure people are getting the help they need.

Another issue is overmedication. If all you have is a hammer, every problem looks like a nail, as the old saying goes. By the time young people are whittled through these exclusions and gatekeeping and end up being seen by CAMHS, quite frequently, medication is all that is offered. We heard in the earlier session that service users felt they were overmedicated, resisted medication and were basically told that if they did not take the medication, they would not get a service and that was the only service it could offer, essentially. What is being done about exclusions, gatekeeping, overmedication and disjoined pathways? They are all linked, to a degree.

Mr. Bernard Gloster

I will ask Dr. Burke to comment as those are fairly clinical questions.

Dr. Amanda Burke

On the question about disjointed pathways, we acknowledge there have been difficulties accessing CAMHS. This year, we are working on a single point of access which will mean any young person with a mental health difficulty will be referred through a single referral point. Their referral will be triaged by a team of clinicians which will not just include CAMHS, disability and primary care but also our partner agencies like Jigsaw, Pieta House and, we hope, Tusla. We will pilot this so that the young person, their family and the referral agent do not need to worry about where they send this referral. They send it to one place and then it is up to the clinicians to decide which is the most appropriate. When the referral comes in, it will be date-stamped. For example, if it was sent to CAMHS, seen by CAMHS and CAMHS said it did not meet its criteria, the young person would not be penalised. They would be redirected to the most appropriate service. The waiting time will not be any more. We hope that communication will be done in a network area. We will develop relationships with our partner agencies so it will be more efficient. Young people will not be referred to lots of different agencies or wait for so long. There will also be inter-service collaboration. I listened earlier and it was said that people are not talking to each other. If there are weekly team meetings in which you discuss the matter, that will help the whole process. We are quite excited about that. It will take a bit of time. We will pilot it first and then mainstream it.

Deputy Patrick Costello

What is the timeline for the pilot?

Dr. Amanda Burke

It will start next year. One area is fairly well developed in the administrative triage system but we need to put clinical triage at the back of that. That will be the Dublin area first and there will be another pilot site outside of Dublin. I know we are short on time so I will move on to the issue of overmedication. I was listening earlier and I would like to apologise to the service user who had a bad experience. A young person should not have that experience in CAMHS. We apologise. If they want to contact us after, we will talk to them about their experience and I hope we can learn from it. We had a prescribing audit and the results were very positive. We did not find any evidence of overprescribing. Notwithstanding the results from County Kerry, which obviously were unacceptable, we did not find generalised overprescribing, which is good news. What the Deputy spoke about is prescribing in isolation. Some CAMHS teams do not have access to the psychological or talking therapies they need. We would never prescribe medication unless warranted but it should be prescribed in conjunction with talking therapies. We have waiting lists for those. The new youth mental health office is looking at innovative ways to tackle that, one of which may be outsourcing some talking therapies while we build capacity in our teams. We were lucky to get some new development funding this year. We will target that funding towards talking therapies in the multidisciplinary teams.

Senator Mary Seery Kearney

I pay tribute to Mr. Gloster. As head of Tusla, he was extremely accessible and fantastic. I wish him well in his appointment in this role and hope it continues in the same vein. The Fine Gael Parliamentary Party met the parents' group, Families for Reform of CAMHS. The group is growing in numbers daily. It is quite substantial. It gave a submission to this committee. It did a survey of its members - a substantial number, not 30 people but a very substantial number of children and families.

While the HSE denies that there is any discrimination against autistic children, we strongly believe, based on our experience, that the exclusionary clause in respect of autistic children is often being used against them to not offer supports or a differential diagnosis. That rather than diagnosing an anxiety disorder or acknowledging self-harm or suicidal ideation as part of a mental health issue, everything is linked back to autism so as not to have to offer supports.

[...]

Some of our members mentioned support being withdrawn once a diagnosis of autism was disclosed and others raised concerns that turning away autistic children is being used as a way of reducing waiting lists and refusing referrals. Many members said that CAMHS explained away anxiety and-or depression as just being part of ASD, rather than acknowledging and offering support for the mental health issues being experienced.

We spoke with these mothers who came in to us. One of them happened to be a social worker. They are not isolated cases. We can talk about the woman who gave evidence in the last section of this and say it is an isolated case of over-medication or the offer of medication. However, in these instances, it is not. This is a pattern of behaviour in the context of dual diagnosis. Why is it happening? How on earth is it acceptable and how is not being picked up on and dealt with?

Dr. Amanda Burke

We recognise that there have been deficits across the board in services relating to autism. It should not be up to parents and families to determine what is the appropriate service. That is our job. We recommend that autism-specific supports be provided within either primary care or the CDNTs. If someone with a moderate to severe mental health difficulty was accessing those, then they had to move over to CAMHS. There was, so to speak, a ferrying over and back going on. I will outline what we are going to do about this. We have an autism protocol that has been piloted in two areas and that is now being rolled out to four. We hope it will become mainstream early next year. The protocol says that young people would access their autism supports either in primary care or the CDNTs but that their CAMHS supports would be provided in conjunction with these. People do not attend one service or the other, they can attend both. This takes away the possibility of being transferred from one service to another. Ideally, CAMHS support would be within reach into the CDNTs. The person stays with the team they are comfortable with and CAMHS consults with them.

Pieces of work could happen within CAMHS, but there is absolutely no exclusion for people with autism from CAMHS. The CAMHS operational guidance is very clear that if a person has a moderate to severe mental illness or autistic spectrum disorder, they come under the responsibility of CAMHS, so they can attend both services. The pilot programme has provided good insights, and hopefully these problems will decrease.

Senator Mary Seery Kearney

That leads to two follow on questions. The first relates to recruitment. At present, there is a recruitment freeze in the HSE, but disability services are exempt from this. Are CAMHS services exempt?

The CDNTs are hugely under-resourced. I have talked to some of the members of those teams over the years and found that many are of the opinion that parents amplify, exaggerate and dramatise their situations. I have heard comments to the effect that the parents expect their children to be fixed. I am appalled by this attitude. Parents need to be treated with tenderness, kindness and respect in these situations. There seems to be a dismissal of parents in some instances. I am concerned that this is a pervasive attitude within the teams

Mr. Bernard Gloster

I do not disagree with those sentiments. I would be misleading the committee if I said anything other than that there is a very varied culture across our health and social care services. It is rooted in a historical, paternalistic culture of professionals knowing what is best for people. Thankfully, we also have some very progressive members of our workforce who do not subscribe to this view, so I think there is a sea change happening in respect of the issue. I would never uphold a position where we become judgmental of people because they are unhappy with the service we provide. Even if we cannot or do not believe it is appropriate to provide what they believe they want, that does not mean they should be treated as if they are troublesome.

Senator Mary Seery Kearney

Is there a complaints mechanism?

Mr. Bernard Gloster

Yes, there is.

Senator Mary Seery Kearney

Is it effective?

Mr. Bernard Gloster

Sometimes that does not work because when people have a fundamental distrust of us they do not trust the complaints process either. I have met many families who feel that way. At times, professionals might be frustrated with the position a parent might keep advocating. I made the point recently in an interview that I am paid to be frustrated whereas parents are not. Parents are anxious about their children and they will go to the ends of the earth to find a way to address that anxiety. Even when saying no, our job is to be compassionate and kind.

Regarding recruitment, the Senator is correct, disability is exempt from the recruitment pause in most grades, other than management administration. This is because disability is now also a separate Vote, and because the shortfall below the funded target is so significant. Unfortunately, CAMHS is not exempt from the pause for the few weeks left in the year except for consultant doctors and graduate mental health nurses who can be recruited. On a positive note - and I have commented publicly on this - there will be 2,200 additional new posts for the health service next year. I am delighted that not all of that figure is destined for acute-centric posts. Some 70 posts are specifically directed to CAMHS. Those posts will be protected, recruited for and filled. There is no doubt that the health services is able to recruit better than it did before, which is good. We are losing fewer employees that we did before, which is also good. However, there comes a time when we are at full complement for what we are funded to do. I have made the distinction many times. That is what we are funded to do, it is not what we are saying we need. We would always look for more but we have to demonstrate some level of control in spending what we have.

CAMHS will be recruiting again in January. I will give a brief description of the service in terms of its recruitment and staffing volumes. I have worked in the health service for a very long time. I remember when the first CAMHS consultant was appointed in Limerick where I was based. This was one consultant for three counties and he had a secretary. There are now six consultant-led CAMHS multidisciplinary teams in that area. It has significantly expanded from its beginning, but that is not to say that we do not need to do more. I want message to go out from the committee in response to parents that I will not lead a health service which treats people as if they are problem because they advocate for their children.

Senator Mary Seery Kearney

I thank Mr. Gloster for the directness of his response.

Deputy Sean Sherlock

I want to acknowledge the role of the HSE in bringing forward the project for the extension of Mallow General Hospital and the fact that there will be 12 beds available in the new extension there tomorrow. I want to acknowledge the project team, the contractors and the team at the hospital itself who have done a great job in bringing the project to fruition. It will have a massive impact on our community in north Cork and further afield.

I will stay with Cork and CHO 4 because this is the area I represent. This is the first time ever I have heard anybody from the HSE publicly acknowledge the issues with CAMHS. I want to acknowledge that. I have been around for a quite a long time. Whenever we sought to have referrals to CAMHS, it operated, to my mind, as a silo with no doors or windows. It was very hard to advocate for individuals and families. We have a major issue in CHO 4, with 720 children waiting for access to CAMHS. For people seeking primary care psychology services for mild to moderate mental health difficulties, I am not saying services are non-existent, but they are extremely difficult to obtain.

What words of comfort can the HSE give to people in the CHO 4 area? In fairness, the HSE is absolutely brilliant at replying to our parliamentary questions in supplying figures, which allows us to compare and contrast between CHOs but CHO 4 is arguably a bit of a basket case in terms of waiting lists. I am not being verbose about that and I contend that the lists in CHO 4 are always too high. I want to hear when we will see the new psychologists coming in and output from what our guests have told us here tonight. We have been told that a pilot scheme is being put in place, etc. but that will take some time but CHO 4 is in an extremely acute situation based on the figures that I have cited here tonight, which the HSE supplied. I need to give some comfort to the families whom I represent that there will be access to primary care teams for psychology services, in particular. Not very long ago one family, for whom I am an advocate, received a dual diagnosis that was non-addiction related for their loved one, so my experience of CAMHS is completely the opposite of what I have been told here tonight. The family was told very specifically that "No, you cannot have access to CAMHS." By God, we are fairly good at beating down the door when we need to and got access. Thankfully, the people who heard the case were reasonable but that is not the universal experience of people. We are a good bit along the road now. I understand that Mr. Gloster is in the job a relatively short time. To be fair to him, he has always been a straight shooter as far as I am concerned. I need to see more psychologists in CHO 4 and better primary care teams, CDNTs and CAMHS. The experience of the family interfacing with CAMHS needs to be qualitatively better and enhanced. We cannot wait for a pilot scheme to work, to see how the research is used and learnings translated. I contend that it needs to be translated now.

Mr. Bernard Gloster

I will let Dr. Burke deal with the specific of the CHO 4 in Cork piece. Not to add to the problem but I want to start with the acknowledgement of the problem first.

The Deputy's point has been very well made. He has been a long-time advocate of an issue that I would have a huge concern about, which goes beyond CAMHS. The children who require specialist services in Cork and Kerry need a better response from us. Our assessment of need waiting list, which the Deputy has rehearsed many times, far outstrips what other parts of the country were doing. The approach to responsiveness to children with complex needs, be they disability or mental health, seems to have come from a different place and has not always got the type of attention it needs, despite many very good people.

CHO 4 for CAMHS is divided into three areas. There is south Kerry, which clearly has had very specific challenges because of Maskey. We will live with the clout of that for some time. I spent a few hours with the team there and had a pretty sobering conversation. I spent time in north Kerry where there is an audit and I met a young man who was one of those over-medicated people for many years. He ended up requiring surgery because of the impact the over-medication had on his body and he is a person with autism. On the Cork piece, I do not know when exactly a psychologist will arrive. For us the post is not so much a question of money but getting psychologists and keeping them. My colleague will talk to the Cork piece.

Dr. Amanda Burke

Yes. Last week, I was in Cork and Kerry. We looked at team functioning, equity of access and why some teams work one way or another. Consistency is a challenge for us and the national office would like to bring forth consistency.

Deputy Sean Sherlock

Do we need a standard culture across the board?

Dr. Amanda Burke

We do have a standard operating guidance.

Deputy Sean Sherlock

We do not have a standard culture and governance, which is the problem as far as I am concerned.

Dr. Amanda Burke

Yes, I know exactly what the Deputy is talking about. I would advocate very strongly for the clinical directorate model, which would be that all teams work under one clinical directorate. We have a clinical director post in Cork-Kerry that we are trying to fill at this time for CAMHS. We were not successful in the last filling but we will certainly roll that out.

We are looking at wait list initiatives in terms of the people who have waited the longest. One of the initiatives that have been put in place in Cork is an ADHD wait list initiative which is headed up by a new consultant. It took a while to get them in place. They have been a little bit affected by the recruitment pause to the end of the year but I hope they will be in full force next year. That is a streamlined pathway for people with ADHD.

We, as a national office, are looking at outsourcing some of these ADHD assessments through treatment purchase abroad as well to reduce the numbers again. We are acutely aware of the issue and the Deputy is right that it is a big challenge in Cork-Kerry but we are trying to tackle it.

Deputy Sean Sherlock

Does Mr. Gloster wish to say a few words about Mallow General Hospital?

Mr. Bernard Gloster

I spoke too early when I said that I missed this committee. I am absolutely delighted to see the progress in Mallow. I genuinely want to say that I think the public representatives across all parties have been exceptionally supportive and, indeed, patient with us in respect of that. Up to 40 new beds will open for Mallow, and I think there are more to come and more to do.

From the end of this week, I will be appointing six regional executive officers to manage the entire health service, which will do a lot of the integrating or what we might call "knocking of heads together" be that CAMHS or hospitals. There will be one for Cork and Kerry, which will be for all acute and community services. I will not say the old Southern Health Board but the Deputy knows what I am talking about.

Deputy Sean Sherlock: I do.

Mr. Bernard Gloster

Mallow has a very bright future.

Deputy Ruairí Ó Murchú

There are a lot of positives here. On some level everyone has stated their points, and the difficulties that people have had, about CAMHS being a particular silo. Sometimes I put that down to the fact that there was no capacity in the services, and people could not deal with what they were dealing with, so on that basis they were happy enough, if they were in a CDNT or primary care, to offload CAMHS knowing that CAMHS would not take them and CAMHS was happy enough to offload people back. Obviously such a situation is unacceptable but it has happened so it is just a case of finding the means to bring that to an end.

Most parents, when dealing with an issue, such as anxiety, want a strategy to deal with the issue as it concerns their child. On some level, parents do not particularly care where an issue is dealt with. Therefore, what is needed is an element of flexibility rather than rigid rules and an attitude of there being no room at the inn. I think we all buy into the idea of no wrong door. Everybody perked up when they heard mention of "a single point of access and triage". That is a pilot scheme but what is it for? Our guests have talked about the autism protocol, the two pilot schemes and how the scheme will become mainstream. Please give some information on that.

Dr. Amanda Burke

The Deputy has mentioned different things. The autism protocol is well developed. We have encountered a few teething problems though not specifically on the CAMHS side and more on the disability side with Fórsa but we are working through those. Next year in the first quarter I anticipate that that is going to be ratified and rolled out.

Deputy Ruairí Ó Murchú

Will it be rolled out across the board in quarter 1, done and dusted?

Dr. Amanda Burke

Yes. With regard to the single point of access, we have been looking at various national and international models. We want to do is look at them here and tease them out before we roll out the scheme completely. Again, there is a pressure on it.

Deputy Ruairí Ó Murchú

Will that be a single point of access for everything?

Dr. Amanda Burke

Yes.

Deputy Ruairí Ó Murchú

Will dual diagnosis as regards disability be dealt with?

Dr. Amanda Burke

Yes.

Deputy Ruairí Ó Murchú

Will dual diagnosis as regards drug taking or whatever addiction or other issues be dealt with?

Dr. Amanda Burke

Yes, absolutely.

Deputy Ruairí Ó Murchú

What is the timeline?

Dr. Amanda Burke

Again, we are hoping to stand it up in the first quarter of next year, at least in one area, and then roll it out. We acknowledge and agree with the urgency on this so it is a real priority for us.

Deputy Ruairí Ó Murchú

I get that the HSE still needs to test it.

Dr. Amanda Burke

Yes.

Mr. Bernard Gloster

Just to say, that is as opposed to pilots. I get a bit frustrated with pilots, to be honest, because we could open an airline with the numbers of them we have.

Deputy Ruairí Ó Murchú

I might use that line.

Mr. Bernard Gloster

To be fair, what Dr. Burke is talking about has serious efficacy because we are talking about creating a "No wrong door" principle for children. If we do not test that properly and roll it out too quickly, we will get it wrong and will have to go back and retrofit it. I have every confidence we will do this quickly, test it and push it on.

On the autism protocol, I am satisfied that is now at a point where it is mandated. When it is mandated that means it is not an optional piece to do or not do; it is mandated and therefore must be done. That is what the protocol will be.

Deputy Ruairí Ó Murchú

I said I would put a question to Mr. Gloster in the final part. We are all aware of the issue with the CDNTs and primary care and what positions remain unfilled. With the best will in the world, even if we got workforce planning correct in the morning, we would not have the right number of psychologists, occupational therapists, speech and language therapists and whatever else. How do we plan for the numbers we have while trying to increase the other numbers to fill those positions? How do we provide the best bang for buck on the basis of unfilled space? That is using the private sector, technical fixes and whatever can be done. We all know that the earlier the intervention, the less is the need for more costly or nuclear options being required later.

Mr. Bernard Gloster

I will ask Ms McLoone to respond as she has the lived experience of managing a full team that is fully functioning and operating very well and dealing with the challenge of trying to fill teams across different parts of north Dublin.

Ms Mellany McLoone

In response to the Deputy's question, there is no single solution to resolving this. It involves quite a number of things. The important point to acknowledge is that, especially with our children's disability services, a huge amount is done through our voluntary provider colleagues. They are an integral part of what we are doing. It is also extremely helpful that we are exempt from the derogation. On one level, we are hopeful that will positively benefit children's disability services. We are also looking at new models of care, which relates to the Deputy's exact point about bang for buck. For example, could we look at more group therapy?

Deputy Ruairí Ó Murchú

Would that be in school as well?

Ms Mellany McLoone

It would not necessarily be in schools but with the children's disability network teams. I am referring to looking at more group therapies so we can provide a service to the population more quickly. To be fair, speaking on behalf of all the CHOs, we have absolutely exhausted the private sector. The one cautionary point I would make, to be fair to all the health and social care professionals who work in the service, is that they really want to maintain the standard of service, so where we are outsourcing we want to ensure the service provided is of similar quality as it would be if people were receiving it from the HSE. That requires a level of clinical governance. As Mr. Gloster alluded to in his opening statement, there is quite a robust roadmap.

The other point is that over the past 12 months the development of the community healthcare networks, coupled with the children's disability networks, is in itself enabling far more integrated work. I certainly find that in my CHO. People are located together and there is greater trust and communication-building. All those things are supporting a more integrated system. It sounds very simple but it is not easy. At the front line where the teams are providing that service, there is a really strong willingness for them to do that.

Deputy Ruairí Ó Murchú

We all want to see that. I have overused the term but it is about bang for buck. The difficulty is that when families are waiting, sometimes they are expecting somebody to come in on a white steed to save the day when that is not necessarily something that can be done. It is about working alongside the families an at earlier stage and then we all learn strategies-----

Mr. Bernard Gloster

What we did very recently was advertise to the entire country and to any organisation involved in providing supports to children and families that if they felt they had a credible offering to families of children with a disability, they could list with us and we will fund them to provide the service to children who are waiting for the fuller range of our disability service. In that way, families are at least getting some support while they wait for the full service. That could be equine, music or play therapy, but these are ways of supporting children while they are in that very protracted waiting period.

Deputy Ruairí Ó Murchú

It all makes a difference.

An Cathaoirleach

The Deputy is out of time.

Deputy Ruairí Ó Murchú

I will be very quick. My own wee lad is autistic and because my wife was involved, we got some ADHD supports that made a considerable difference. Those supports provided her and others with an element of community and backup. The schools, both primary and secondary, have been brilliant, so I never rule out their involvement.

Mr. Bernard Gloster

Absolutely.

Deputy Ruairí Ó Murchú

I will ask the question and maybe the reply will have to be in writing.

An Cathaoirleach

We will have to get a written reply.

Deputy Ruairí Ó Murchú

We all understand the human rights ethos that is built into mental health services, whether CAMHS or adult services. Unfortunately, from time to time, we come across people with severe difficulties who are a danger to themselves and others. With all the human rights-based legislation and so on, we do not necessarily have a means for dealing with that. I appreciate that is a bit of a curveball to throw.

An Cathaoirleach

Yes, which is why the Deputy will get a written reply. We are running out of time and I want to ask one or two questions as well.

Mr. Bernard Gloster

That was a very broad question.

An Cathaoirleach

Yes.

Mr. Bernard Gloster

The circumstances of those presentations are as far as they are wide. It is a very legitimate and fair question, so I promise the Deputy I will ask Dr. Burke to take it away and, as a consultant psychiatrist, to give the Deputy a considered response. We will put the social care response with that. I promise we will do that in a couple of days.

An Cathaoirleach

I thank Deputy Ó Murchú.

I will ask about two issues. The pilot programmes sound fantastic. Is there consultation with people who have lived experience? The first session the committee had with Ms Moore Ryan was invaluable for us to learn. Consultation would be very important. Mr. Gloster was saying he wants the executive to get it right the first time so it does not have to go back and retrofit. Is there consultation and, if so, what does that look like?

I have another very basic question. It has been said here that if people have autism or another diagnosis, they should still be able to access CAMHS. However, that is often not what they read in the letters they receive. What practical advice do the witnesses have for people in that situation or for us, as elected representatives, when we come across that? What is the next port of call?

Mr. Bernard Gloster

Before we get to the advice, I will address the consultation piece. In the six or seven months I have been in post, I have established a process. I have met Mental Health Reform twice and done two very long engagements with the group where it then goes away and reflects with its member organisations and comes back to me with challenges, questions and issues. I then present it with challenges as to how it can help us as well. Separate from that but cutting across it, just last week I had my second engagement with the Children's Rights Alliance. That is something I started which I have carried on into the health service, because obviously children have lots of health needs. The alliance has given me position papers on responding to children in particular circumstances, such as children in emergency homeless accommodation and so on. The alliance also advocates very strongly around autism, CAMHS and disability services. At an organisational level, therefore, I am very much saying we have to front-face the people we serve and include them in prioritising the issues, but also designing the response. I do not know specifically in the pilot if there is a service.

Dr. Amanda Burke

There is not specifically one in the pilot as yet because it has not been fully designed, but we have been doing a lot of work on getting service user feedback. There is a piece of qualitative research coming out from UCC and it will be published at the beginning of January. It is on wide service user engagement on the experience of CAMHS. We also have service user engagement within the office and it is looking at how it will engage widely with service users and get the voice of the young person as well as the family. In individual models we will be bringing in user engagements. We will definitely incorporate that in the pilot but it has not been fully designed yet.

Mr. Bernard Gloster

The advice to public representatives responding to parents who present with needs-----

Dr. Amanda Burke

I apologise; I missed that one. As somebody said earlier, they should not be turned away. We have robust systems whereby, if someone feels they have not been dealt with fairly, they can come back in with a complaint through Your Service Your Say and that will be looked at and responded to. We are saying clearly that young people with moderate to severe mental illness do belong to CAMHS. Some people may not meet those criteria but it behoves the services to say where their needs should be met.

An Cathaoirleach

That is exactly the key point. People want to know where they can or should go.

I apologise that we were a little rushed but I think we nonetheless had an opportunity to ask the questions. I propose we will publish the opening statements on the Oireachtas website. Is that agreed? Agreed. I thank Mr. Gloster and everybody-----

Mr. Bernard Gloster

If I could just say, the invitation is there to this committee, in its role of dealing with children issues, if it would at some point like to discuss the totality of health services for children. That would be very good because it would join up all the dots, right the way from the GP to the paediatric ward-----

An Cathaoirleach

Mr. Gloster might regret saying that.

Mr. Bernard Gloster

It is just an open offer to the committee. I would be very happy to do that because it is an important part of its agenda.

An Cathaoirleach

Mr. Gloster will be glad to know we are currently looking at our work programme for next year, so that comes at a good time and I thank him for the offer.

I again thank all the witnesses and our members. We will suspend to allow the witnesses to exit before we will resume in public session for the taking of deferred divisions.

Sitting suspended at 8.22 p.m. and resumed at 8.31 p.m.