Joint Committee on Future of Mental Health Care debate -
Wednesday, 22 Nov 2017

Funding and Budgeting of Mental Health Services: Health Service Executive

Chairman

I welcome from the Health Service Executive, Ms Anne O'Connor, national director of mental health services, Mr. Stephen Mulvany, chief financial officer, Mr. Jim Ryan, head of operations and service improvement, mental health division, and Ms Yvonne O’Neill, head of planning, performance and programme management, mental health division. On behalf of the joint committee, I thank the witnesses for their attendance. The format of the meeting is that Ms O'Connor will be invited to make a brief opening statement, which will be followed by questions and answers.

Before we begin, I draw the attention of witnesses to the position regarding privilege. Witnesses are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if they are directed by it to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable.

Members should be aware that, under the salient rulings of the Chair, they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

I remind members and witnesses to turn off mobile telephones or switch them to flight mode. Mobile phones interfere with the sound system, make it difficult for parliamentary reporters to report the meeting and adversely affect television coverage and web streaming of the proceedings. I advise witnesses that submissions and opening statements will be published on the committee website after the meeting. I invite Ms O'Connor to make her opening statement.

Ms Anne O'Connor

I thank the Chairman for the invitation to attend today's meeting. Members will have received a separate briefing document which sets out details on mental health finances and governance.

As outlined in the 2017 HSE mental health division operational plan, the mental health division remains focused on providing and developing mental health services across the country. The overall HSE budget has increased year on year since 2014. Currently, the mental health budget accounts for 6.2% of the overall HSE budget. Mental health funding is allocated to the HSE in a context where this is agreed on an annual basis through the national service planning process. This, in turn, is agreed and approved by the Department of Health and the Minister of State with responsibility for mental health.

The mental health division acknowledges that a broad range of services support the mental health and well-being of the population. Specialist mental health services are provided through child and adolescent mental health services, CAMHS, general adult mental health teams, psychiatry of old age teams and the national forensic mental health service. Each of these multidisciplinary services treats moderate to severe mental health disorders. However, specialist mental health teams are only one part of a larger health system that addresses the mental health and well-being of the population. This whole system includes services at primary, secondary and tertiary care levels. Specialist mental health services sit within the secondary and tertiary care levels. Community teams are supported by day hospitals and inpatient units, where necessary. Examples of primary care services include general practitioners, clinical psychologists, speech and language therapists, etc.

The HSE also provides counselling in primary care, CIPC, and the national counselling service, NCS, as well as funding a number of agencies to provide psychological supports to the population. In addition, the National Office for Suicide Prevention is an integral part of the HSE mental health division.

The mental health division is committed to improving specialist mental health services and working with HSE primary and social care and our community partners to develop a comprehensive range of services to support the mental health of the population. Actions in this regard include increased recovery orientation of all mental health services; a focus on quality and service user safety; developing a range of service improvement initiatives focused on meeting the needs of our most vulnerable, for example, mental health in intellectual disability, homeless populations and dual addiction and mental health needs; and promoting positive mental health via an integrated mass media campaign, Little Things, which had 1.5 million page views in 2016 and is now being developed for priority groups.

The mental health division has a clear focus on best practice and improving outcomes, as set out in our clinical programmes. In addition, we are focused on youth mental health where, among other initiatives, €5 million has been allocated to primary care to recruit 120 assistant psychologists to develop early intervention services for those aged under 18 years.

Staff recruitment in mental health continues to be a significant challenge, resulting in the underdevelopment of mental health teams in certain areas which then impacts on access, targets and waiting times. The lack of availability of suitably qualified staff also contributes to inadequate out-of-hours services.

Regionally, the nine community health organisations, CHOs, have responsibility for the delivery of community health care services in their areas of responsibility. While the chief officer of the CHO has overall responsibility, the head of service for mental health, in conjunction with the executive clinical director, is responsible for the delivery of mental health services in the CHOs. The forensic mental health service operates on a national basis. Through monthly performance engagements with the nine CHOs, the mental health division has a clear line of sight on service delivery in each area.

The mental health division remains committed to the development of high quality, integrated mental health services in a spirit of partnership with service users, families and other key stakeholders, as part of a whole system approach to the mental health and well-being of the population. The recruitment of a sufficient number of skilled staff and the development of equitable access to services continue to be key priorities for the mental health division.

Deputy Michael Harty

I thank the witnesses for attending today's meeting as we commence our deliberations on mental health services. As a general practitioner, I will address this issue from a practical point of view and focus on primary care. The great difficulty faced by general practitioners is that while we can access community health teams, many of these teams are lacking certain professions. For example, many are experiencing serious difficulty recruiting psychologists and in many other teams psychologists, community health nurses, social workers and occupational therapists are also missing.

As the document submitted by the HSE states, 90% of mental health issues are dealt with in general practice and primary care.

For the 10% of people who are referred, there is a problem in accessing services because we do not have a psychologist and not everybody needs to see a psychiatrist. In fact, few people need to see a psychiatrist. General practitioners look after many patients themselves but when they refer patients, it is quite often for psychological assessment or else they are referred to CAMHS. The patients do not need medication. They need assessment and, probably, talk therapy or occupational therapy. Those services are not available, perhaps not because there is no funding but because there is a difficulty in recruiting. Perhaps the witness will address those issues.

The Sláintecare report, which was published last May, includes a reference to mental health reform. If we are to reform our health service, that would obviously include mental health services. The difficulty with Sláintecare is trying to get legislative backing and political buy-in in order that the HSE and the Department take responsibility and there is accountability and responsibility for delivering or not delivering health services. We should continue to refer to Sláintecare when considering our mental health services because it contains a roadmap for improving such services.

There are many social determinants for health issues, and particularly mental health issues. These cut across the Departments with responsibility for housing, education, transport, health and social protection. We must examine how those Departments are helping to deliver a mental health service to our patients.

As I said initially, talk therapy is the outstanding deficiency in our community mental health services. We just cannot get to people for talk therapy. A great deal of medication is prescribed, almost definitely unnecessarily, because we cannot get access to psychological services, cognitive behaviour therapy and so forth.

Finally, there are budgetary gymnastics every year whereby the allocation of extra money to mental health services is €35 million. However, €20 million is not spent because the HSE cannot recruit people or for other reasons. It is unclear how that money flows into the following year. Perhaps Ms O'Connor will address that matter.

Ms Anne O'Connor

I could not agree more with many of the points the Deputy made. We are acutely aware of psychological services and we have been seeking to improve them. This is our third full year of having a division dedicated to mental health. We have done a great deal of work on the core infrastructural aspects, looking at what exists for mental health in Ireland and how we can improve our various specialist services. However, in the past 12 months we have really realised, not that we did not already know, that there is a very significant gap at the early intervention stage for all ages. We are commencing an initiative with the under 18 year olds, with €5 million, to improve access to counselling for them in primary care. That relates to the recruitment of 120 assistant psychologists and a number of qualified psychologists. They will work with those under 18 years of age and keep them away from the mental health services, if I am honest, by providing that first line of defence and early intervention. This is something for which there is huge demand. I am not sure how we will get to the stage of meeting all the demand. We are starting with the under 18 year olds because we believe that is a huge gap and that we have young people bouncing into CAMHS as a result of that gap.

In terms of talk therapy at a broader level, we have the national counselling service and CIPC within that. This has sat slightly outside the mainstream services and we are now looking at embedding it within each CHO so that we have an approach to adult counselling services within CHO areas that is more integrated with all the other services. We are also considering bringing in a specialist lead to head up a programme of improvement around psychological interventions. Part of our difficulty is that there is such a wide range of psychological interventions. There are different types of service provision in different areas and there are different types of therapies associated with different clinical programmes. We are looking at what we should be providing for everybody everywhere. An initiative is starting on that and we will soon try to get a lead for it.

Sláintecare promotes a shift to primary care and early intervention. There is funding within that listed for counselling in primary care, psychology in primary care and a number of specialist mental health services. The mental health division has a clear focus on embedding recovery in all our services. The only way we will be able to address the mental health of the population is by ensuring sufficient access at primary care level in order that people can be kept well in their communities and, ideally, not need mental health services and by ensuring that they receive high-quality and efficient interventions when they do need to access those services. That is what the division is committed to and our work is very much planned in that way.

There is an accountability framework within the HSE whereby there are performance contracts in place. Every chief officer has a performance contract with me, as the national director for mental health. In turn, I have one with the deputy director general. The heads of service for mental health are now also held to account within their areas. They are the people who are charged with operationally managing mental health services in their geographical patches.

The social determinants for health are acknowledged. We see that clearly. All the evidence suggests that we must do more on specific groups. Within Connecting for Life, a number of vulnerable groups are identified as priority groups, such as those who are homeless, Travellers, LGBTI people and others. We are focusing on those with the range of interventions listed in the operational plan. Social protection is an issue and we are already working with the Department of Employment Affairs and Social Protection on some of our initiatives. We have an initiative under way to examine individual placement and support, IPS, and supporting people in employment. We face a challenge in respect of mental health because people are often penalised in a way for going back to work-----

Chairman

I am sorry to interrupt but we must stick strictly to the time limits. We have gone over seven minutes. I remind the members that this meeting is about funding. We have invited Ms O'Connor to attend next week to discuss implementation of services, so we should keep focused on questions about funding.

Deputy Tony McLoughlin

I welcome the witnesses and thank them for attending. I have a number of questions. The witnesses have provided figures on the allocations for mental health funding. I live in the CHO 1 region, which includes Sligo, Leitrim, Donegal, Cavan and Monaghan. The figure for that area is €73.6 million. Can the witnesses give a breakdown of this per county and per the different services in the region? Also, is the funding for CHO areas linked to population? What are the reasons for the CHO 1 region being the lowest funded in the country, considering its size and geographical spread?

Ms Anne O'Connor

I do not have a county breakdown of the allocation with me but we can get one for the Deputy and send it to him.

We have endeavoured to look at population in terms of how we allocate resources. Obviously, there is a historical allocation to services across the country. Since the division was introduced, we have been able to look at funding on a national basis for the first time. Prior to that, it was done on a geographical basis and we were never in a position to look at how one area compared with another. We have sought to do that over recent years in terms of matching resources to populations. There are different reasons for areas having more resources. For example, an area that had a number of old psychiatric institutions tends to have more resources available historically.

I will have to get the details of the population breakdown for CHO 1 but throughout the last few years we have looked at how we can increase the resources into those areas that are below average. We have used a deprivation rating scale, the Haase and Pratschke scale, for looking at how we can build population and demographic factors into resource allocation. That model is used within the HSE. We are incrementally trying to grow the areas that have been under-resourced, but we have a way to go on that. Ultimately, we have services that have been well funded historically and we cannot simply turn off services in areas where they exist. We must try to rebalance over time.

Chairman

Does that answer the Deputy's question?

Deputy Tony McLoughlin

I wish to get a breakdown of each county.

Ms Anne O'Connor

We will get one to the Deputy.

Deputy Tony McLoughlin

When I referred to the geographic spread, I was referring to the area comprising Donegal, Sligo, Leitrim, Cavan and Monaghan. The funding for that area is €73.6 million, but perhaps we can go into that matter later.

As mentioned, the child and adolescent mental health services, CAMHS, particularly in the CHO 1 region, operate at a critical stage in service delivery. Children must wait a long time to access the service and many have been turned away. Why? I have met many parents of children who have experienced the same, as have, I am sure, parents in other parts of the country. Are the delays and lack of service caused by funding constraints or an inability to recruit skilled staff to work in the region? If so, what efforts has the HSE made to address the problem? Is addressing the matter a priority for it? Is the problem being caused because psychologists who have no experience of treating children are not being considered for these positions? Is the recruitment practice developed centrally or by each CHO unit individually?

Ms Anne O'Connor

I shall comment initially and Mr. Ryan will then comment.

In respect of CAMHS in the CHO 1 region, we have had a problem in the past couple of years in the Sligo-Leitrim area. That has been a recruitment issue in that we have been unable to recruit a consultant psychiatrist. Mr. Ryan will update the committee on the matter. The HSE is committed all of the time to recruiting staff for CAMHS. As I mentioned in my opening statement, there are ongoing recruitment challenges, particularly in the recruitment of consultants, nurses at certain grades and psychologists in some areas. At any one time we try to recruit about 1,000 staff for mental health services. A number of efforts have been made to manage the waiting list in Sligo-Leitrim and we have considered ways to support services in the area by using personnel from other areas. We have worked very closely with the services in the area to see how we can improve the position. There is a very good and detailed action plan in place for the region on which Mr. Ryan will comment.

Mr. Jim Ryan

There is a self-improvement plan in place, particularly for the Sligo-Leitrim region because there is a waiting list of over 12 months for CAMHS. The figures I have received today show that 40 people were waiting at the end of September, while 25 were waiting at the end of October, which represents a significant decrease. We hope to have eliminated the waiting list by the end of the year. The improvement is due to the employment of a consultant in the past few months who has focused specifically on the 12-month waiting list. We have also considered the practices followed by each of the teams to make sure we conduct our business in the most effective way possible.

In respect of child and adolescent mental health services, CAMHS, one of our major objectives is to reduce waiting lists and increase access at inpatient level and the level of CAMHS teams. We expect to eliminate the 12-months plus waiting list in the CHO 1 area by the end of the year. We will do so in such a way that the waiting list will be significantly reduced from now onwards.

Chairman

Deputy Tony McLoughlin asked for a breakdown of the figure of €73 million on a county basis. Did he also seek a more definitive breakdown of how the money was spent?

Deputy Tony McLoughlin

Yes.

Chairman

I ask the delegates to note the additional detail sought.

Ms Anne O'Connor

We can give the Deputy a breakdown on a county basis. By way of an observation of how we access funding, we do not have a view which drills down into very specific services at cost centres. We can give a breakdown on a county basis or based on the old integrated service areas, ISAs.

Deputy Tony McLoughlin

I am unhappy with that answer. I asked for details on different services in the region. The national director and her officials in the HSE should have the information available and know how much money is spent. If €73.6 million has been spent in my region, as an elected representative for it, I should know exactly where the money has been spent. Every member should be able to tell his or her constituents how much money has been spent.

Mr. Ryan mentioned the recruitment of a psychologist. Is the position temporary?

Mr. Jim Ryan

No, it is not. We are trying to recruit a psychologist on a permanent basis.

Deputy Tony McLoughlin

Is there a psychologist employed in a permanent position?

Mr. Jim Ryan

No.

Deputy Tony McLoughlin

There is no point in Mr. Ryan flippantly saying a person has been appointed on a temporary basis and is doing the work. I have been told in my constituency office on a weekly basis by the parents of young children who have tried to access CAMHS that they have been turned away, a situation that I am sure is replicated all over the country. Mr. Ryan has confirmed that a person has been appointed on a temporary basis. Why has no one been appointed on a permanent basis? Does the HSE have enough funding to recruit someone to the position on a permanent basis?

Mr. Jim Ryan

Yes.

Chairman

Deputy tony McLoughlin's time has elapsed. I have noted his request that the national director of mental health services answer his question in the coming week.

Ms Ann O'Connor

Yes.

Deputy Tony McLoughlin

I have more questions about costs incurred.

Chairman

The Deputy is way over his time.

Deputy Tony McLoughlin

In all fairness, I am here as a representative of the people.

Chairman

I know.

Deputy Tony McLoughlin

I have relevant questions to ask the delegates. As one of the lead speakers, I would like more time, particularly as a few members cannot attend. I, therefore, ask the Chairman to be flexible.

Chairman

May we come back to the Deputy's two questions after we hear from Deputies Tom Neville and Catherine Martin? I agree with him that we must avail of this opportunity to ask questions and that we need transparency and answers from the delegates.

Deputy Tony McLoughlin

That is the reason I am here. We have discussed the issues of funding, resources and where money has been spent. I wish to ask more questions that are relevant to the debate.

Chairman

I will allow the Deputy back in later.

Deputy Tom Neville

With the permission of the Chair, I propose to engage in a rapid fire question and answer session with the delegates.

Chairman

Yes.

Deputy Tom Neville

How much money did the HSE receive for the development of new services in 2016?

Ms Anne O'Connor

The HSE received €35 million in 2016. The information can be found in the tabular statement in the pack supplied.

Deputy Tom Neville

I thank Ms O'Connor. How much of the €35 million was spent on the development of new services?

Ms Anne O'Connor

My colleague, Ms O'Neill, will answer that question.

Ms Yvonne O'Neill

The sum of €35 million was allocated on a recurring basis for the development of new services. In 2016 we recruited staff on a phased basis because we could not-----

Deputy Tom Neville

My time is limited. How much of the money was spent on the development of new services?

Ms Yvonne O'Neill

There was a combination of new services and other-----

Deputy Tom Neville

What was the figure?

Ms Yvonne O'Neill

I do not know it off the top of my head.

Deputy Tom Neville

All right.

Ms Yvonne O'Neill

I can establish the figure and revert to the Deputy with it.

Deputy Tom Neville

Yes. Was there money left over?

Ms Yvonne O'Neill

Yes.

Deputy Tom Neville

Where was the remainder of the money spent?

Ms Yvonne O'Neill

It was spent in the development of mental health services.

Deputy Tom Neville

In the development of existing services.

Ms Yvonne O'Neill

Partially. We have invested in infrastructure. As the Deputy will be aware, under regulations we are inspected. Therefore, we would have some minor capital. Some of the funding would have been in that direction.

Deputy Tom Neville

For existing services.

Ms Yvonne O'Neill

Yes.

Deputy Tom Neville

Was the HSE plugging holes in existing services?

Ms Yvonne O'Neill

It was improving existing services.

Deputy Tom Neville

Who authorised such expenditure?

Ms Yvonne O'Neill

The Department, the Minister and the national director for mental health services.

Deputy Tom Neville

What is the name of the person who authorised where the money would be spent?

Ms Yvonne O'Neill

The money is spent directly under the national director and the Department of Health.

Deputy Tom Neville

The national director for mental health services.

Ms Yvonne O'Neill

Yes, in agreement with the Minister and the Department of Health.

Deputy Tom Neville

I want to know about the decision-making process involved.

Ms Yvonne O'Neill

That is it.

Ms Anne O'Connor

On the critical outlay, every year when development funding is allocated, there is a proposal that goes to the Department of Health. We decide what the priorities and work with the Department on them. The Minister of State at the time was involved in the discussion and we received approval from the Department to proceed with our initiatives.

On development funding, we have invested in clinical programmes. When we receive approval in a year it is often for the recruitment of staff, but we do not recruit within that timeframe because the process takes longer to complete. We receive approval from the Department to use the money to improve infrastructure while we recruit in order that the money does not move out of the mental health service. The allows us to keep the money within the area.

Deputy Tom Neville

The HSE uses some of the money to plug holes in its infrastructure. How much money does it need to run the service properly?

Ms Anne O'Connor

In improving infrastructure we prioritise safety. In improving our environments we prioritise audits of acute units and the like. We seek to provide a better space, particularly in acute units. Without doubt, there are some poor facilities in the mental health sector. There has been very significant investment in such facilities, but, unfortunately, I cannot give the figure.

Ms Yvonne O'Neill

Up to 2016 we spent €11 million in development funding. In 2017 we helpfully received €3 million of recurring expenditure that will allow us to invest proactively. That means that we can invest on a proactive rather than a reactive basis.

Doing that allows us to plan for the infrastructural development.

Deputy Tom Neville

Has there been an audit done of the services?

Ms Yvonne O'Neill

We have about 2,500 services. We do not have an active audit of all 2,500. However, our CHOs submit plans to us for their priorities and that is where the investment funding goes.

Deputy Tom Neville

Is there no specific top-line figure or timeline that would fix the HSE's infrastructure problems?

Ms Anne O'Connor

Work is under way from an estates perspective on a ten-year capital plan and mental health is being captured in it. It includes refurbishing and replacing existing facilities and the building of new ones. There is a figure for that and we can get it.

Deputy Tom Neville

I want to go back to recruitment. How much time do I have?

Chairman

The Deputy has two and a half minutes.

Deputy Tom Neville

There were problems with recruitment in 2016. New moneys have come through in 2017. What plans has the HSE made to build a pipeline, knowing money was coming through for 2017, 2018 and 2019?

Ms Anne O'Connor

There are a couple of initiatives that we started last year relating to nursing. The mental health division now funds undergraduate and postgraduate nurse training. We have had significant difficulties in nursing particularly in the east coast where we have nurses who train and work in Dublin for a couple of years and then go home, wherever home is. We have been very challenged on the east coast. We have been funding a postgraduate nursing course in UCD. The first year of that is now complete. We have also completed the first year of an additional undergraduate programme, which is an extra 70 places. We are into the second year of that and we will have another intake. The mental health division has invested significantly in nurse education, which is uncommon. We are also working very closely with the College of Psychiatrists, looking at how we can improve training. We have invested more in psychology training too.

Deputy Tom Neville

I am conscious of my time. I do not mean to interrupt the witness.

Ms Anne O'Connor

That is fine.

Deputy Tom Neville

Could the witnesses furnish with me with the figure for the recruitment target in 2016 versus the number of people recruited and the position for 2017 compared with the target?

Ms Yvonne O'Neill

There is a summary of that in the documentation provided.

Deputy Tom Neville

I understand that but if I could have it broken down as simply as that it would be very helpful.

Chairman

That is noted.

Deputy Catherine Martin

The witness said the HSE had invested significantly. Could I have that figure? Can the witnesses provide a breakdown of expenditure on out-of-area placements and agency staff in 2013, 2014, 2015, 2016 and 2017 please? Can I have a breakdown of last year's mental health expenditure in CAMHS, general health and old age psychiatry by community health care organisation? If there is no time to answer all these questions, I would like the answers in written form.

Chairman

Absolutely. We will follow up on that.

Deputy Catherine Martin

Will the division please provide a breakdown for the 2018 mental health budget, including the 2018 development funding? Will the witnesses let me know how and why these areas were identified for investment? The 2017 HSE mental health operation plan commits to reviewing existing out-of-hours services, exploring ways to improve 24-7 crisis intervention arrangements and considering pilot sites. It makes commitments on the development of out-of-hours mental health supports being included in the HSE mental health operation plans since 2014. In February of this year, the then Minister of State with responsibility for mental health services, Deputy Helen McEntee, publicly stated that work was under way on a roadmap for the development of out-of-hours access to mental health services. Has the HSE completed this work? When did the HSE complete the work? When will the roadmap be published? Has a budget been identified for its implementation?

Has any funding been allocated to the exploration and design of evidence-based psychological resilience building programmes in our schools, even on a pilot basis? There is extensive research from other countries showing that certain strategies taught in schools can leave children less vulnerable to mental illness. This is not to take away from the well-being policy being implemented in the new junior certificate. Are we being specific about psychological interventions based on psychological research, which indicates that early intervention is key? Has any consideration been given by the HSE to establishing a team of appropriately trained psychotherapists or psychologists dedicated specifically to schools? There are some teachers who are trained as psychotherapists. NEPS is under-resourced and such a team would take the pressure off it. Has any research been done on this by the division? Has a budget been identified to implement this?

Chairman

Before Ms O'Connor answers, perhaps we can leave the question about the creation and implementation of the roadmap until very last or to next week when the witnesses return. The funding questions that Deputy Martin asked-----

Deputy Catherine Martin

In that case, if my last question is being moved to next week, I will ask a different question on funding. Could I have a breakdown of expenditure in the following areas in the past three years: mental health and intellectual disability, dual diagnosis of addiction and mental health difficulties, mental health services for people experiencing homelessness, and mental health services for minority groups?

Ms Anne O'Connor

In terms of the breakdowns, from our systems we can tell the Deputy what development funding has been assigned to the priority areas the Deputy mentioned. We do not have a single national financial system so we are limited in terms of the detail. There is transparency in services at a local level. We are working towards a community costing model which will allow us to have a national view and a breakdown of the figures. It will be on CAMHS initially. There is other work going on in the HSE in respect of a single financial system, which Mr. Mulvany may be able to talk about.

In terms of resilience in schools, work has recently been completed by the youth mental health task force in partnership with the Department of Health, the Department of Education and Skills and many other bodies. There was also a pathfinder initiative which looked at the need to enhance well-being in schools. That is seen as a matter for the Department of Education and Skills and the recommendations of the task force will go to Government fairly soon. The HSE does not provide services in schools in that way.

Chairman

The Deputy asked about the funding for 2016.

Deputy Catherine Martin

I am also concerned with working towards a national view. We need a national view. What exactly does Ms O'Connor mean when she says the HSE is working towards the national view? It worries me that the witnesses are saying that services within schools are a matter for the Department of Education and Skills because there is a huge problem with the lack of joined-up thinking. There is a need for Departments to communicate and link up with each other. One cannot say that the issue of children suffering with mental health issues belongs in one box, which is the Department of Education and Skills, and that the HSE can take a hands-off approach. It is not acceptable. The HSE must take responsibility for it.

Ms Anne O'Connor

I am not saying that at all. I am saying it is part of the youth mental health task force that we all participated in collectively. There are a number of recommendations and some are assigned to the Department of Education and Skills and some to the Department of Health. It does not mean we will not be working in partnership, but there is an acknowledgement that the intervention in schools is an issue for the Department. We do not employ psychologists or provide teams to schools but we have psychologists working in local services that link very closely with schools. Many members of our CAMHS teams go into schools on a very regular basis but we do not have a dedicated team.

We work very closely in the HSE across the primary care, health and well-being and mental health divisions. The role of the mental health division is very much around very specialist mental health services. The health and well-being division has far more engagement in schools intervention. We are looking at that as the full pathway for mental health for young people.

Mr. Stephen Mulvany

National visibility of financial information on mental health is a work in progress for the HSE. I will focus on what we can provide. By using our system of health accounts, we can say what the total spend is in each given year across the country. We can also tell the Deputy the total spend by LHO, as they were formerly, and by CHO, as they are now. The LHOs were smaller divisions. We can give that information. We can also identify who all our staff are. We can tell what the output is, including the clinical membership of each of our community teams, whether they are general adult, psychiatry of old age or child and adolescent teams. We cannot yet run a report that tells us all of those figures across every CHO on a push-of-a-button basis.

As the committee probably knows, investment in ICT for community services and mental health services has been significantly lacking in recent years. The same has been true in terms of financial information systems in the health service. Thankfully, we are now investing and have been supported to invest in our financial information systems and that will be rolled out over the next three or four years. My division is not waiting for that so work has been done to map the individuals on those various teams in order that, as part of the community costing project mentioned by Ms O'Connor, we can actually establish sufficient reporting capability. We are a year or so away from being able to do that readily. This does not mean that we cannot-----

Chairman

I think there will be more questions about that issue. In other words, the fact that we cannot drill down to see how money is actually spent. I will go on to the next batch of questions. I will call Deputy McFadden, Deputy Buckley, Deputy Carey and Senator Kelleher to ask their questions. I call Deputy McFadden.

Senator Gabrielle McFadden

Senator.

Chairman

Senator McFadden.

Senator Gabrielle McFadden

That is okay.

Chairman

I have promoted the Senator instantly.

Senator Gabrielle McFadden

I am happy where I am. I thank the witnesses for attending. I found the opening statement to be very vague. There is nothing in it to tell us what is happening in mental health services. It is all very vague and I must say that I am very disappointed with it. We constantly hear that we need more resources and funding for mental health services yet when someone is asked, they cannot drill down into where the money is going. Almost €1 billion is provided for mental health every year and yet only €90.2 million has been allocated to my area, CHO 8. When Deputy McLoughlin asked the witnesses, they could not tell him where the money relating to his area goes, which is really bizarre in this day and age, particularly when the Government is constantly being called upon to provide more money for mental health services. I would like to know where the money is going. Does the money that goes in actually get to the service user? I would really like the witnesses to outline specifics in order that the committee can see how the taxpayer is getting value for money. Are there data relating to outcomes which indicate whether we need doctors, more psychologists or more nurses? Are there data which show that there are certain areas of our mental health services that are underperforming? If there are, we need to know what they are and what can be done to fix the problem.

Regarding recruitment, I welcome the 120 assistant psychologist posts. This is very good because it gives young psychologists an opportunity to gain experience and will also help in primary care. How many of those posts have been filled? I was shocked to hear the witnesses say that up to 1,000 needed to be recruited at any one time. Could the witnesses outline the specific ways in which the HSE is trying to do this? What is happening such that the HSE cannot recruit psychologists or nurses? What plans does it have to address this difficulty? I would like specific answers to those questions instead of the vague answers in the opening statement.

Chairman

Could the Senator's last question concerning recruitment and the breaking down of funding be deferred until next week? Would that be all right? It is such a very serious question. Several people have spoken about recruitment, which will be the subject of next week's meeting

Senator Gabrielle McFadden

It does involve finance so it should be answered. I want a very specific answer. I do not want a vague one.

Deputy Pat Buckley

I thank the witnesses for coming before the committee. I listened to a few members already and I am conscious of the time. I am extremely angry and disappointed. We came in here today to talk about funding and there seems to be a lot of tangents and people running off left, right and centre. Correct me if I am wrong, but are the witnesses telling me that no audit of mental health spending was carried out in recent years?

Ms Anne O'Connor

No. Just to clarify-----

Deputy Pat Buckley

I welcome Mr. Mulvany because his is the first name I have heard that has something to do with finance and, therefore, please God, he will provide some accountability. He mentioned work in progress. What is the spend in that regard? We can tell him what is the spend. I want to know where that spend is going in each CHO area, how much is actually being spent on the services for people who need them and how much has been diverted into the maintenance of buildings and so on. This mental health spend was supposed to be used to supply services to patients.

Has the HSE ever had to use development funding in the past to cover deficits in any of the services, particularly mental health services? If so, there is obviously a knock-on effect. Has this delayed the money being used in the places in which it should have been spent? If so, there must be a huge underlying gap in the services. If the money is not going into the services and as we are dealing with funding, can we receive a breakdown? Where is the money going? There is an officer for financial responsibility in each CHO. Are there financial officers in each CHO who can be held accountable and who we can bring in and of whom we can ask similar questions? We need to get to the bottom of this matter. As one of the Senators said a while ago, almost €1 billion of taxpayers' money is going into a hole and we are not getting straight answers. If I or anybody else here had spent €1 billion and could not say where we had spent it, I am sure we would suffer the consequences. As a result, we need those answers. I appeal to the witnesses. Can we get them and also a breakdown in respect of each area?

Chairman

Two more members have questions to ask before the witnesses can answer. I reassure members that we are taking note of every question they are asking and will ensure that they are answered.

Deputy Joe Carey

I thank the witnesses for attending. There needs to be transparency in terms of where money is spent. I would like to get a breakdown of each CHO in terms of the personnel employed in each area and what they do and of the services delivered. I note that 80% of the money spent in mental health goes on staffing so, obviously, that is where the money is going. I also note what the Chairman said about recruitment. I welcome the fact that the HSE is working in conjunction with some colleges trying to support courses but I feel more work should be done in that area. In terms of trying to produce skilled personnel, do we have enough college places and are there enough people coming out of college who can fit into the system where there are huge gaps?

Deputy McLoughlin referred to Sligo-Leitrim in the context of shortcomings relating to CAMHS. I am from County Clare, which is in the mid-west. Are there shortcomings in terms of recruitment there? What gaps exist? What are the HSE's plans to address the recruitment of staff in that area?

Chairman

Again, we must stay focused on funding. We are taking note of those questions about recruitment and they will be presented to Ms O'Connor next week.

Senator Colette Kelleher

I thank the witnesses for their presentation. The HSE's operational plan for 2017 states that its vision is to support the population to achieve its optimal mental health and that its mission is to promote and protect the mental health of the population, to provide effective services to those who need them, making best use of existing resources, and to seek to continuously improve those services, making best use of the resources available. The HSE has set five goals, which include reducing loss of life by suicide, integrated services, timely services, the views of the people the HSE is there to serve, mainly those who are seeking support with mental health issues, and trained and engaged staff. My question is a simple one and it relates to a budget. How would the witnesses rate the HSE's delivery out of ten against that mission, that vision and those goals to which I have just referred? In capital terms, what budget does the HSE need in order to get to ten out of ten for people?

Ms Anne O'Connor

I might ask Mr. Mulvany to answer the finance-related questions.

Mr. Stephen Mulvany

I will try to address some of the funding questions. There is absolutely an audit of mental health spending. We have an internal audit, so mental health is just as likely as any other service area to be subject to an internal audit that would yield a report with recommendations, actions and follow-up. Separately, we are held accountable through external audit by the Comptroller and Auditor General, and again mental health is as likely as any other spending area to be subject to external audit by the Comptroller and Auditor General. There is audit and accountability around mental health funding. Our annual financial statements cover the total cost of mental health spending and those statements are audited, with the report coming through the Committee of Public Accounts to this House. It is part of the accountability line. We are also accountable to the Department of Health and we publish a financial and activity report every quarter that includes mental health detail, although I accept it is not at the level sought by Deputies.

To answer the question of whether we know where the money goes, we do. Perhaps I was not articulate enough in demonstrating that we do not yet have a system that allows us to run a routine report and gather separately all the child and adolescent mental health services, CAMHS, or all age costs. On a monthly basis we produce data that allow us to see outputs. A Deputy asked that question but I will let colleagues speak about outcomes, as we are a little bit away from reporting outcomes. We can see outputs in terms of activity that is going through community-based teams. We can see the number of people being admitted to CAMHS units. We can see what the money is doing, measured by limited enough ICT data that we have around activity. We have measures of activity for all our community teams across the different specialties.

We have periodically examined how many clinical staff we have in each clinical team across the various community health care organisations, CHOs. There is a head of finance in each of the CHOs and it supports the management team, including the head of mental health services and the executive clinical director for mental health. There is greater visibility at a local level and we can, as required, gather specific data on most of the different ways people might want to examine the mental health spend. We have not yet got the capacity where that is all sitting in a single system with a single reporting tool in order that we can run routine reports readily. That is the subject of many discussions in different committees in this House and I am thankful it is being addressed. There is investment going into financial systems in the HSE. The HSE is 12 years in existence and still does not have a single integrated financial or human resources system. It certainly does not have a single integrated mental health system or electronic health record, EHR, for mental health.

We set out each year our requirement for both capital and revenue. Deputy Harty asked a question at the start that I did not get a chance to answer but I will do it now. In the A Vision for Change plan, one of the strongest elements was that it sets out a requirement that is population-based. Regardless of whether people want to update the specifics inside, it sets out a resourcing requirement for both staff and units in terms of physical capacity. I disagree with one comment that was made in that part of the provision of mental health services goes on in buildings that must be up to standard and safe. We must house the staff that we are trying to recruit.

Chairman

Could I interrupt? The members have asked specifically about the breakdown of funding, so you should give a very specific answer.

Mr. Stephen Mulvany

The very specific answer is we do not readily have that information now. We can seek to provide it as much as is possible. That will take some time. We will go through the transcript and establish the different numbers of views that members have before assessing how feasible it is to produce that and over what timescale. The specific answer is we do not have the systems to do that. It is not that we do not want to do it. It is also not the case that we are not able to tell what are the outputs delivered from the money.

Chairman

It is not satisfactory.

Mr. Stephen Mulvany

It is the reality.

Deputy Pat Buckley

I thank the witness for the answer but it is mind-boggling. If I had been running a business for 12 years, I would have the books balanced and I would know exactly what money was going in or out. I cannot find words to describe this. These are totally unacceptable answers. We have a responsibility as a committee and we are trying to get this off the ground. We need to start from the bottom up. I will reiterate this, as more than €1 billion is being spent on mental health services and we cannot get a straight answer for even one CHO or CAMHS element. The witness cannot say that a certain amount is being spent.

I understand about upkeep and so forth, but we are not looking at that. We want to know how much was spent in 2016 in CHO area 4, for example. We want to know what the money was spent on and where it was spent in county areas. Was it spent on CAMHS, who spent the money and who authorised it? We need to get to the crux of the matter because we have a job to do.

Chairman

Is Mr. Mulvany able to answer the question?

Mr. Stephen Mulvany

I am not and today I have answered the question as best I can. The answers are not deliberately vague but they provide the reality.

Deputy Pat Buckley

He does not have them.

Mr. Stephen Mulvany

It has been explained.

Chairman

Will you be able to come up with the answer?

Mr. Stephen Mulvany

We will be able to provide a level of information in a breakdown below CHO level for 2016, for example, but it would not come from a system that would allow us to produce it quickly. The Deputy asked who would authorise it and that relates to a series of different questions. We will seek to do what is practical. Whether the reality is accepted or liked, it is the reality facing the HSE. It has only this year secured the investment necessary to invest in a single information system.

Chairman

It is an extraordinary answer. I will have to stop Mr. Mulvany now as four other people-----

Mr. Stephen Mulvany

I presume it is accepted that it is the factual answer.

Chairman

That is fine.

Deputy Fiona O'Loughlin

I extend my welcome to the four witnesses we have from the HSE. I am sure the witnesses will accept that part of our role in this committee is to scrutinise accountability in mental health services with respect to delivery. This refers to funding, staffing and implementation. I know we will deal with implementation next week. Funding also relates to staffing and, in considering this, we will look at the gaps in mental health services. This is about us doing our work in making recommendations. It is regrettable that the budget could not be broken down into specialties like CAMHS, as has been mentioned. Mr. Mulvany mentioned that this might be something we could get. It is not just about being accountable to us as members of a committee but being accountable to the people we represent. There have been various crises involving mental health, so if we could stand over levels of investment in different areas, it might be easier to ascertain the gaps and what we need to do to be able to help with them.

I note the €35 million in additional funding committed to mental health that was held back by the Department of Health in 2016. Was that funding released? It is important to know if money is being held back by the Department when services could have good use for it. My colleague, Deputy Martin, has referred to the link with education, and as part of this a report was produced by a committee on mental health in schools. We made 20 recommendations, one of which was that there should be collaboration between the Minister of State with responsibility for mental health issues and the Minister for Education and Skills. I would like to know Mr. Mulvany's views on that. There is another link with education.

We have had some questions on the planned recruitment and if young people when they are leaving school could look at areas that are available. That needs to be worked on with the Department of Education and Skills. I ask the witnesses for their comments on that aspect.

CHO7 has been allocated €87.5 million. I appreciate that the allocations to the different CHOs are historical. Society has changed so much in recent years and we need to be able to stand over it in a far better way because some of the areas have different types of challenges that change from time to time. Even though that might seem like a significant amount of money for Kildare and Wicklow, I am conscious that towards the end of the old health board system that area had the lowest spend on mental health per person. I do not know whether the figure tallies with that.

Chairman

Before I call Deputy Corcoran Kennedy, I remind the witnesses to include Senator Kelleher's query in their response.

Deputy Marcella Corcoran Kennedy

I thank Ms O'Connor and her colleagues for coming in this afternoon. On a housekeeping matter, there have been some requests for follow-up information. I ask that this be sent to the secretariat which can then circulate it to all members of the committee. It might be easier than trying to identify specific answers for individuals.

Chairman

Absolutely.

Deputy Marcella Corcoran Kennedy

The overall health budget is €14.6 billion. I understand €5.5 billion of that budget goes to section 38 and section 39 agencies. How much of the mental health budget goes to section 38 and section 39 agencies? Is that included in the figure for each CHO area? Does each CHO have a specific budget within its funding amount for the section 38 and section 39 agencies that are relevant to the mental health area? The total amount allocated to each of the CHO areas is €793.9 million. The opening budget in the mental health division operational plan is €838.6 million. What happens to the difference of €44.7 million? The Revised Estimates allocate €906.6 million for mental health services. Is the HSE operating on that figure or on the lower figure of €838 million? What are the plans for the difference?

Senator Máire Devine

The HSE was established over a decade ago. Why did nobody put a red alert on the lack of specialty financial reporting, in this case obviously mental health and CAMHS? Do the witnesses not find the lack of financial report accounting for sub-specialties unacceptable?

The biggest problem in the health services is recruitment and retention of staff. Every year we were told that an extra €35 million was coming to the mental health budget. There were sighs and disbelief that it would occur and that we would actually see it working on the ground. Why do we not plan for recruitment and retention? The HSE has plans but they have not worked. There was €20 million this year and €20 million last year. The Roscommon services returned €18 million supposedly because they could not spend it. They could not recruit the staff, meaning that the HSE spent it in other areas. Is there no planning for getting a bunch of money together and really going after recruitment and retention? That is where our services are falling down and it is why the HSE, in particular mental health services, is in such a mess.

The money seems to go into the black hole of agency staff. Is there a figure for mental health spending on agency staff to patch up our inpatient and outpatient services? While the beds in Linn Dara in my area have reopened, it was closed for a long time, which was unacceptable for our young people. If another €35 million or €40 million is allocated next year to recruitment and retention, it will not happen because we are not encouraging our nurses who are leaving the country because of the terms and conditions and the chaos in the services they are trying to provide. Why do we not ring-fence the budget? Why is it spent elsewhere? That is the crucial point in understanding why we are failing in the health services. Do the witnesses not find the lack of financial reporting unacceptable and that nobody said what is going on here because we do not have those figures?

What is the difference between employing the 120 assistant psychologists in the primary care teams and what Jigsaw has offered, which is 90% funded by the HSE? That also targets those aged under 18 years.

Deputy James Browne

I wish to take up what some other speakers said about the opening statement. I sat on the Committee on the Future of Healthcare and I sit on the Joint Committee on the Eighth Amendment of the Constitution. While I am glad the witnesses from the HSE are here, this document gives us no insights. It is the kind of answer we get at the start of the reply to an oral parliamentary question. In future we expect far more detail and much more insight. The concern is the lack of insight. Are the witnesses satisfied that an effective accountability system is in place? Does the HSE have measurements to assess how much is being spent, where it is being spent and what are the outcomes? How much is being spent on external placements? From what budget does that come?

Over three years, €17 million was returned from Roscommon. Cuts were made without any reference to safety or quality assessment. Has that ended? The Roscommon report recommended that budgeting be delegated down to lower levels. Does the HSE accept that recommendation from the Roscommon report?

Chairman

I ask Ms O'Connor to answer all those questions, after which I will call Deputy McLoughlin.

Ms Anne O'Connor

Mr. Mulvany will answer some of the questions relating to finance and I will answer others.

Deputy Browne asked about accountability and performance. It is important to state that we know where money has been spent. We have access to a whole raft of reports that are produced every month. It is just not broken down by specialties in the way the Deputy is requesting. The HSE has a system of financial accounting that is quite extensive. Any local manager, CHO manager or the division can look into these accounts and see exactly where money has gone. It is inaccurate to say we cannot see where money has been spent; it is just not categorised by specialty in mental health in the way the Deputy is seeking.

Regarding accountability around reporting, we have monthly performance meetings with every chief officer in the country. Finance forms part of those discussions. It is important to balance that with the equally important discussion on quality and safety of services. Ultimately money is related to service delivery and we need to ensure that services are also safe, etc. There is accountability within the CHO dealing with monthly performance. I am also held to account every month in terms of the balanced scorecard in the HSE service plan looking at the metrics that include finance and HR metrics. There is a clear line of accountability right through the system in terms of governance and as Mr. Mulvany mentioned, we are also accountable on an external basis and appear before this and other Oireachtas committees.

On external placement, the cost in 2016 was €40 million. It goes to external placements which are funded from the mental health budget and relate to people who have a specific need that is not met within our own services. Some of the costs could be nursing homes or they could be in very specialist facilities for people. Out of area placements were mentioned previously. They are not all out of area placements, they are just placements that are provided by another provider. That cost has grown by about €10 million in the last three years. It is a growing cost and something that we seek to address through a service improvement initiative, looking at how we can provide better services to people with complex mental health difficulties.

The retraction of funds for Roscommon is a topic that has been well covered previously. The money that came out of the Roscommon budget was never spent on mental health. It was money that had been coded to mental health that was going elsewhere in the system. With the establishment of the mental health division we were able to see that and examine how to use it for mental health. CHO2, where Roscommon sits, is still one of the more highly funded areas in mental health. Kildare is the most poorly resourced part of the country, and it has suffered as a result of not having a psychiatric institution. There is no great legacy value in that area in terms of resources.

We mentioned that our budget was 80% plus pay. There is very little in our core budget that we are able to move around unless we stop employing staff in certain areas. That would mean ceasing to provide services in certain areas.

Our flexibility in recent years comes from our development funding. That allows us to develop initiatives in areas. We seek to look at the areas which are most in need of services. Page 6 of the document on funding which we supplied to members has a list of the types of investments that have been provided in each of those years around our development funding. We have developed new teams across all specialties and opened new acute units in Cork, Drogheda and other places.

Chairman

Once again, we are straying from the funding aspect.

Ms Anne O'Connor

I am talking about where the development funding has been used, in relation to the question about where development funding had gone. It has gone into those initiatives. That is where it has been spent.

Chairman

Is Ms O'Connor saying that Mr. Mulvany will be able to answer the question about funding, is that correct?

Mr. Stephen Mulvany

On the sections 38 and 39 question, that funding is within the total budget of the mental health service as typically reported. The figure is around €77 million for section 38 and section 39 bodies combined which includes suicide prevention.

The budget for mental health in the 2017 service plan is €867.8 million. We do not have a final budget for 2018. The service planning process is still under way. The draft figure is about €918 million, but that is subject to the service plan being finalised.

Agency spend is in excess of €30 million. I think it is €35 million. Typically, though not always, it is on medical agencies. That is the area where we have the greatest difficulty but there will be some parts in other areas. We can provide more information on that if required.

On budgeting down to lower levels, the HSE's financial regulations allow and provide for budgets to be delegated to whatever level is deemed most appropriate. There is no principle issue with delegating budget and responsibility further down.

On whether we feel we have effective responsibility, if the definition of effective responsibility is having that split specifically by all those different specialties, then we do not because we do not have that split. Given the constraints of the systems we have, we would say that yes we do have effective accountability. There is nothing to be complacent about, and it can always be improved on. Do we know and do we agree and have we been saying that the HSE required a single integrated financial system, since before it was even established? Yes, we absolutely have. We have also said that it requires a single HR and electronic health records system. This year we secured funding to sign a contract to actually implement a single national financial integrated system and we expect to get the same in the area of HR. In the meantime, we are progressing with what we can, which is the community costing exercise, so we can take different views at a CHO level if required. It is something we wish to do but we have a subspecialty view of what the outputs are per month, per team, for all the clinical community teams and for all the outputs in terms of what is going through our residential units. That visibility, in terms of the accountability question, is there. We do not have all the information that we would like to have but we are working to get it.

Chairman

Can Mr. Ryan answer Senator Kelleher's question?

Senator Colette Kelleher

It related to weighting performance about stated goals and then, second, how much is needed to achieve the optimum performance. They are two simple questions but no one has attempted to answer them.

Mr. Jim Ryan

We review our operational plan on a quarterly basis. Every quarter, for each line such as child and adolescent mental health, peer support workers, we review our performance against our plan. At the end of the year, I have to internally account for our performance against the plan.

Senator Colette Kelleher

Is the HSE at 100%, 70%, 60%?

Mr. Jim Ryan

Each is not necessarily new. It is a multi-year approach. It rarely takes less than one year in order to be able to fully implement any of them. There was reference to 7/7 services. We have started the roadmap which one of the members mentioned earlier. We will have completed it by the first quarter of 2018, including recruitment.

It is difficult to give an overall mark out of ten because there are various elements and we are at different stages in the different projects and initiatives which we are implementing. I am not trying to evade the question but that is what we are trying to do. Our operational plan is our bible for the year. It is what we said we would do and it is what we are trying to implement.

Senator Colette Kelleher

I will put it another way. Does Mr. Ryan think that we have a good mental health service for people in Ireland?

Mr. Jim Ryan

I was in Norway recently and many of our new initiatives are ones which they would like to follow, such as peer support workers. Many of the things that do not get as much publicity, such as Advancing Recovery in Ireland programme, our framework for recovery, are things on which we are leading internationally. Where we struggle is the recruitment of key staff, as we mentioned earlier. That is not due to a lack of desire but the ability to be able to do it.

Senator Colette Kelleher

Then Mr. Ryan would say that we are a model of good practice in our mental health service.

Mr. Jim Ryan

I did not say that. I said we are working towards the best model we can achieve given our resources and our staffing levels.

Senator Colette Kelleher

What resources does the HSE need then?

Deputy Marcella Corcoran Kennedy

Are we not going to have the same rules or are there different rules?

Chairman

We were trying to clarify something but we will have to move on.

Senator Máire Devine

He did not answer about the budget. I did not get a clear sense about that.

Deputy James Browne

I asked a question about whether the HSE accepts the Roscommon recommendation that budgeting should be delegated downwards to lower levels.

Chairman

Can we have an answer to both those questions?

Deputy Catherine Martin

There is also the question of agency staff from 2013 to 2017.

Mr. Jim Ryan

I do not have a figure for the last two years. The latest figure is €35 million, which I gave earlier. I am not familiar with the specifics of the report which the member mentioned. My colleagues might care to comment but what I said was that our financial regulations allow for the idea of delegating budgets to whatever level is deemed appropriate so there is no issue in our internal approval process. It is down to the practical implementation of that measure. I cannot comment on the specifics.

Ms Anne O'Connor

I would very much welcome the recommendation. It is in all of our interest to have everyone as accountable as possible. Where anyone is incurring a spend they should be accountable for making those decisions.

Chairman

Can someone answer Senator Devine's question?

Ms Anne O'Connor

Was that on the recruitment and retention of staff?

Senator Máire Devine

Ms O'Connor knows this already but I need to really stress that our health service cannot function without staff. We have been bled dry of staff. There was an effort to take away the €20 million that was supposed to help with recruitment last year and this year, which in itself is not enough. Are there any intelligent financial plans to staff our health service? Otherwise, we might as well give up.

Chairman

We are talking about funding again.

Senator Máire Devine

It is about having a plan and prudent housekeeping. Any housekeeper would do the same. Where one sees a shortage, one goes after it.

Ms Anne O'Connor

Funding for recruitment is not the issue. The issue is availability and the market. Internationally, there is a common pattern, unfortunately, when it comes to medics and nursing in particular. We know that we lose many of our medics post-qualification to other countries. We struggle to get them back not only in mental health but across the board. We know that we lose people in nursing as well. We have embarked on several initiatives, including overseas recruitment campaigns. We have had all manner of events in Ireland hosted to try to attract staff. We have had staff attending international conferences to try to attract new staff. We have tried just about anything. If there are any other ideas that we have not tried, we would welcome hearing about them. We have a continual programme-----

Senator Máire Devine

I have many ideas.

Chairman

The question was whether the HSE has ring-fenced the funding for recruitment.

Ms Anne O'Connor

The funding for mental health is ring-fenced.

Chairman

Deputy Browne, was your question answered?

Deputy James Browne

Yes.

Deputy Tony McLoughlin

My questions are for Mr. Mulvany. Mr. Mulvany remarked that there is a person with financial responsibility in each of the community health organisation areas who reports to him.

Mr. Stephen Mulvany

Will I answer the question now?

Deputy Tony McLoughlin

No, Mr. Mulvany can answer it afterwards. These officials report to Mr. Mulvany. Earlier, I asked for a breakdown of the different services in the various regions and the associated costs. Can Mr. Mulvany elaborate on the answer?

We referred to the Jigsaw programme and the plans for the programme to be rolled out nationally. We can see the benefits.

Earlier, I referred to the waiting lists for child and adolescent mental health services. I am not happy with some of the answers on CAMHS in my area because many people have not been treated or looked after. I want to get some statistics and facts. I hope the HSE representatives present will be able to furnish me with the facts and data on the funding spent in each of the regions. I am concerned about community health care organisation area 1, where there is a lack of funding. There is a plan in the coming years for a 25-bed mental health unit at Sligo University Hospital. What are the HSE plans in the coming three years? Can the officials give me an indication of where we are going?

Mr. Stephen Mulvany

We have nine heads of finance, each of whom works in the nine community health care organisations. They do not report to me but to the chief officer of the community health care organisation. That is seen as the appropriate accountability line. The idea is that the man or woman who is responsible for the service has the necessary supports. The head of mental health services for the locality and the head of finance report to the chief officer for that area. The name of the individual in the area in question escapes me.

Deputy Tony McLoughlin

It is John Hayes.

Mr. Stephen Mulvany

I was asked about the different services and the breakdown. We have undertaken to go away and identify what we can practically provide as quickly as we can provide it with reference to the sub-specialty breakdown by community health care organisation. In practice, we do that by engaging with the nine heads of finance. We seek to work with them and their local legacy financial systems to pull together the data as best we can. My key point was that it is not readily available in a report in a single system. We are perfectly happy to source the data and provide the committee with them in whatever way is practical. It might take one or more steps. We will provide any information that can reasonably be provided.

Deputy Tony McLoughlin

These people are reporting in to Mr. Mulvany. I am unsure of the answer but perhaps Mr. Mulvany can help. How can he adjudicate on it? The HSE gets something close to €1 billion for the mental health service. How can Mr. Mulvany identify the funding that the services need if those responsible have no breakdown of the various areas or of what money is being spent and where it is being spent? How many staff are involved? Will the officials elaborate on the number of staff in the various areas? Mr. Ryan stated earlier that the HSE does not have permanent staff in these areas. Some of the officials are saying that the HSE cannot get the staff. Why are we not getting the staff for these essential services?

Mr. Stephen Mulvany

As I said earlier, those individuals do not report to me. They report to people who work for the HSE overall. The organisation, across all its divisions, has a capacity and process to work out each year what resources are required for the following year and for longer periods. The process is hampered by the systems we have, but we have to get on with the reality of it. Each of the divisions will engage with each of those nine community health care organisations to figure out what they require to run the service as it exists today as well as the development funding they will seek for new services or the expansion of existing services. The process runs every year and, within its limitations, it is reasonable process. That is how it happens. The fact that the financial officer does not report to me directly does not interfere in the process in any way, good, bad or indifferent.

I was asked about recruitment and another question. I will ask my colleague to answer those questions.

Chairman

We are going to deal with recruitment next week. There are some more questions about funding. I hope the members do not mind if I ask some questions as well.

Deputy Tony McLoughlin

I asked a question about the new unit at Sligo University Hospital. Will Mr. Ryan address that question?

Mr. Jim Ryan

The question relates to a 25-bed replacement unit in Sligo.

Deputy Tony McLoughlin

What is the update?

Mr. Jim Ryan

The update is that it is progressing. It is included in the capital plan. It is on course.

Deputy Tony McLoughlin

When is it due for completion?

Mr. Jim Ryan

I will find that out exactly for Deputy McLoughlin. I understand it was for late 2018 or early 2019.

Deputy Joe Carey

Mr. Mulvany mentioned that €77 million went to section 38 and section 39 organisations. How many section 38 and section 39 organisations are under the remit of the HSE?

Mr. Stephen Mulvany

Approximately 100 organisations.

Chairman

You are saying that you cannot give us the details. Deputy McLoughlin spoke about the Sligo area and referenced a figure of €73 million. The officials can say how much went to each county but not what each county spent on children's mental health services etc. Is that correct?

Ms Anne O'Connor

No, we cannot state it in that way.

Chairman

If we brought the person responsible from community health care organisation area 1 before the committee, would that person be able to break it down for us?

Mr. Stephen Mulvany

What we are saying is that we cannot do it today. We are saying that we do not have a system to allow us to run a report.

Chairman

Answer my question. Let us suppose we brought the chief finance officer from CHO area 1 before the committee. Let us suppose we brought Mr. Hayes before the committee. Would he be able to break down the figure for us?

Mr. Stephen Mulvany

If you brought him before the committee, and he and his team knew the specific questions, or if we did what we are suggesting, that is to say, we go and seek as much information as we can from the nine CHOs, package it and provide it to you, the outcome in either case would give you the answer. It is entirely a matter for the committee members in respect of who they bring in.

Chairman

What level of breakdown will the HSE be able to provide?

Mr. Stephen Mulvany

We are clear on what the committee is looking for. The committee wants to know how much was spent in CHO area 1. In fact, the committee probably wants to know how much was spent in the counties in CHO area 1 under the headings of CAMHS, old age and general adult.

Chairman

Can we have a breakdown of that? We are looking for data on all the CHO areas. The members represent many areas. At the end of this session, after I ask some more questions, we will put a specific question or questions to enable you to come up with answers on the CHO areas.

Mr. Stephen Mulvany

We will take those away and provide as much information as we can as quickly as we can. Whatever we cannot provide, we will see whether we can work on it.

Chairman

I understand the service plan states that 90% of mental health needs can be successfully dealt with and treated in a primary care setting. Do you have any idea of the figures, Ms O'Connor? If 90% of mental health issues are in primary care, what percentage of the mental health budget goes to development or delivery?

Ms Anne O'Connor

Historically, the mental health budget did not go into primary care. Now, we have allocated funding. We have allocated funding to primary care and early intervention in respect of Jigsaw. Jigsaw funding is now in excess of €9 million and heading towards €10 million. This year we have allocated €5 million for counselling and primary care for those under 18 years, as I mentioned.

Chairman

Do you have an overall figure that you can provide with a breakdown for primary care?

Ms Anne O'Connor

We can certainly look at that.

Chairman

Does Mr. Mulvany have any idea how much was spent on agency staff?

Mr. Stephen Mulvany

We have answered that question twice. It is €35 million. From the systems we have, we can break down the spend by county by total for mental health, by the different categories of non-pay expenditure, such as drugs, cleaning, washing and so on, and by the categories of pay expenditure. We can also say how many people are employed per county and what the output is against many performance indicators. We could fill the room with the data we have. The data which we do not have but we want relates to how to take a service view of that at a sub-specialty level. We are working on that. I would not want people to leave the meeting thinking that we do not have a lot of information about where the money goes, that we are not audited or that it is not accounted for because that would be unfair to the staff working in this area.

Chairman

What else are members to think given that Mr. Mulvany said there is €73 million in the CHO 1 area and he cannot break down what was spent?

Mr. Stephen Mulvany

That is not what I said. What I said will be available in the transcript.

Deputy Tom Neville

As regards the IT systems that were mentioned, we have established that a certain amount of the €35 million will go to plug holes rather than be spent new development. We do not yet have the exact figure for that. We have established that there has been no audit of systems to understand to where the money used to plug holes goes annually. It is done on a priority basis year by year. Given that A Vision for Change is being implemented and new money is being invested every year, has there been any forward planning as regards recruitment and the recruitment backlogs, the IT system and what it is compromising and whether the difficulties in the IT system and recruitment are related? If the IT system difficulties relate to recruitment issues, why is the money that is being used to plug holes - which was being used as new money - not used to develop the system? It seems that staff cannot be found or recruited but a certain amount of money is being handed back every year instead of being used to improve the recruitment process. I understand the witnesses may not be able to answer my question today but I would like the answers by the next occasion on which they appear before the committee, and, in particular, if recruitment is to be addressed.

Ms Anne O'Connor

We do not hand money back.

Deputy Tom Neville

It is used to plug holes, it is not left as new money.

Ms Anne O'Connor

In the first year while we are recruiting we use the money for other things. There is a lead-in time for recruiting staff. If we have our development funding we go through a process with the Department to get approval to proceed with certain initiatives, we will not get those staff in the door within six months.

Deputy Tom Neville

I understand that a pipeline has to be built.

Ms Anne O'Connor

There is a pipeline. Under our recruitment licence, we are tied in to the national recruitment service. The mental health division is part of the HSE and there is a recruitment licence in play. We have to follow certain procedures in regard to how we recruit staff and that takes time. That recruitment process is constantly in being, whether it is to do with new developments in terms of the development funding or just replacement staff. We have a lot of churn in our service because people move around. As we develop new services, people move around.

I have mentioned nurse training. A pipeline for nursing in particular is one initiative.

Our funding is prioritised around key service development. For example, if we have a series of clinical programmes, we look at our population of vulnerable groups and safety. Safety is a key guide for us in terms of our services. The metrics are in our monthly reports. Our performance report is published every month and is visible to everybody in terms of how we are performing against all the metrics. It is transparent and available for anybody to look at every month.

Senator Jennifer Murnane O'Connor

I am very much in favour of funding to heighten awareness and more needs to be committed in that regard. The HSE ran a media campaign for the Little Things initiative. The campaign is being developed for priority groups and its website had 1.5 million page views in 2016. Those groups are looking for funding. What level of future funding has been allocated for them? A lot of the page views were by people looking for services they needed. There are priority groups. What is the HSE going to do in this regard? Many people accessing the website were very concerned by issues.

How many of the 120 assistants for whose recruitment €5 million has been allocated to primary care have been recruited to date?

It is very confusing that there are nine regional CHOs and there does not seem to be a budget for them. A local authority gets its budget every year and works through it. I could give many examples of cutbacks in my area of Carlow-Kilkenny. Who is responsible for the cutbacks? Who is making those decisions? If the CHO does not have a budget, who decides to cut the services - such as weekend and overnight services - that I know have been cut?

Ms Anne O'Connor

On page 3 of the finance document the Senator will see-------

Senator Jennifer Murnane O'Connor

I have been coming and going from the meeting so apologies if I have missed something.

Ms Anne O'Connor

The budget for every CHO is set out on page 3 of the finance document. Each CHO has a very clear budget it is monitored against on a monthly basis. There have been no cuts in mental health.

Senator Jennifer Murnane O'Connor

There have been cuts in services.

Ms Anne O'Connor

Mental health funding has not been cut.

Senator Jennifer Murnane O'Connor

Services have been cut.

Ms Anne O'Connor

A cut in a particular area may be because of overspending elsewhere in that area. However, budgets do not move between areas. It is important to say that when a budget is assigned to a CHO, that is the budget. We do not take it away and give it to somebody else.

Senator Jennifer Murnane O'Connor

If a CHO wants extra budget funding, would such be allocated if they need services?

Ms Anne O'Connor

If they want extra funding, they go through a process in terms of development funding. Development funding is where we have the flexibility to give extra funding to services on an annual basis in line with the initiatives we agree with the Department of Health, whether for a clinical programme, the development of a new unit or whatever. Organisations can put that into their annual proposal. The budget is assigned.

The recruitment of assistant psychologists is an initiative driven through primary care and the interviews took place last week. It is a significant initiative that has not been done before and its lead-in time was quite significant due to agreeing on the job spec etc. and working with the Departments of Health and Public Expenditure and Reform on that. We have a couple of other initiatives. The Senator mentioned the Little Things campaign, and we are now doing tailored campaigns for priority groups. We are also looking at how we support those priority groups. For example, we have a significant service improvement initiative in respect of homeless people and new mental health co-ordinators for Travellers that is commencing in each CHO area, so we are promoting and supporting the service delivery for all priority groups at a CHO level. In terms of our investment, we are gradually covering all of the priority groups as set out in Connecting for Life, which guides the work we do in many mental health services.

Senator Jennifer Murnane O'Connor

Is there funding available?

Ms Anne O'Connor

There is.

Senator Jennifer Murnane O'Connor

Will every group receive funding? Some groups have applied for funding and are still waiting to receive it.

Ms Anne O'Connor

Is the Senator referring to organisations when she uses the word "groups"?

Senator Jennifer Murnane O'Connor

Yes, absolutely. Organisations and groups that have sought funding. As I have said, awareness is crucial but so is funding. I appreciate that Ms O'Connor said that funding is available but there is definitely a lack of funding. Every CHO has its budget but extra funding is needed by services Ms O'Connor cannot give figures for that today. I did not realise that budgets have been given for each area but can we have breakdowns that are more accountable for what we need in the future? Some organisations and groups are constantly looking for funding. Does Ms O'Connor have a list of what is needed and what is not needed?

Ms Anne O'Connor

We have a list of organisations we fund, many of which are funded at local level through a CHO. A very small number of them are funded at a national level.

Senator Jennifer Murnane O'Connor

A very small number of them.

Ms Anne O'Connor

It is important to say that we are looking at our agencies. Our interest is in growing services, not organisations, so if an existing organisation is seeking funding we look at how its service delivery fits with the overall objectives for mental health, and we have a service arrangement with every organisation. If there is a need for additional funding, it is discussed through that process. That is an accountability measure in terms of how and what we fund and how we monitor what organisations are spending their money on.

Senator Jennifer Murnane O'Connor

I thank the witness.

Deputy Marcella Corcoran Kennedy

Ms O'Connor mentioned that €77 million is allocated to the section 38 and section 39 agencies. Would she be able to provide a breakdown of where that is going and perhaps show us whether it has increased year on year over the past ten years or so? Can she distinguish between local and national level?

Are they in that group of section 38 and section 39?

Ms Anne O'Connor

Yes.

Deputy Marcella Corcoran Kennedy

If Ms O'Connor could distinguish that, it would be great.

Ms Anne O'Connor

We have two section 38 organisations only in mental health: St. Vincent's Hospital, Fairview and St. John of God's. The others are all section 39. It is no problem to give the Deputy a list of those.

Deputy Marcella Corcoran Kennedy

A breakdown of the amount over the period would also be good. It is a significant amount, almost three quarters of a billion, that is going out. If we add in the agency spend, we are up to quite significant money.

Ms Anne O'Connor

It is also important to say that we are finding that a lot of our funded agencies are experiencing the same difficulties as us around recruitment. That is a new development. They are not able to get staff in the same way, either.

Mr. Stephen Mulvany

We would not want to encourage further proliferation of organisations, as Ms O'Connor has indicated. There are a lot of organisations being funded and, while some of them do very good work, the last thing we want is more and more organisations seeking to start off in an unco-ordinated fashion. We can talk about what individual organisations are looking for. I am sure a new organisation could emerge in most counties in most months of the year. We are looking to develop the services but not necessarily to develop individual organisations, although there is always room for targeted investment.

Deputy Marcella Corcoran Kennedy

I hope the Chair will forgive me if I make another point. I am going a little bit off the finance side of it. We are frustrated at the delays in the recruitment but we can also appreciate the fact that one cannot just magic people up. I want to acknowledge the pressure existing staff are under. If we cannot recruit people, those who are there already are under huge pressure. It is important to acknowledge the great work they are doing. If we are probing here today, it is out of concern for them as well as everybody else. We want to be sure that they and the people who need the services get them in as timely a manner as possible.

Deputy John Brassil

I apologise for being late. If I ask questions that have been asked previously, I ask the witnesses to forgive me. Is the HSE having difficulty with recruitment?

Chairman

That question was asked. Next week we are having Ms O'Connor in to address recruitment specifically.

Deputy John Brassil

The future of health care committee found that some of the hospital groups were recruiting per hospital group. As a result it was a better process. I would suggest that the community health organisations consider that approach because it produces better results.

For the myriad section 39 organisations that are out there, does the HSE have a methodology by which it can measure their input, effectiveness, value for money and so on? Is there some metric by which they can be held accountable for the money they get? There are various organisations doing wonderful work that could do with much more money. However, I am also aware that there might be organisations of which we might question where they fit in on the spectrum. That is something that might be improved upon.

There is an accountable officer for each CHO. In Cork-Kerry, it is Ger Reaney. If I understand correctly, Ger is responsible for the delivery of the service. He is also responsible for disability. Is there a need for an accountable figure more specific to mental health? I am casting no aspersions on anybody. It is just such a huge area. Trying to cover that plus disability and a few more legs as well might be an impossible task for any individual.

On the drugs spend, some anti-psychotic drugs are very expensive. They are distributed to the HSE's general pharmacy or medical cards set-up. Are those figures included in the mental health spend or are they part of the general overall drugs spend? It is a big figure and a lot of money but I am not sure it is the right place for it to be included.

Ms Anne O'Connor

In terms of the governance piece, I share the Deputy's concern about the chief officer and the breadth of the responsibility. They have now all got heads of service. Within Mr. Reaney's area there is a head of service for mental health, another one for primary care and another one for social care. There is quite a strong management team in each of the nine community health organisations and there is a very senior person there dedicated just to mental health. They are surrounded in turn by a team that includes the executive clinical director, directors of nursing, etc. The governance within the CHO has become a lot more robust and there is a dedicated management structure around mental health in each of the nine community health organisations. That might allay some of that concern.

Mr. Mulvany might wish to address the question about the drugs.

Mr. Stephen Mulvany

There is about €10 million of drugs within the mental health budget and the mental health spend. I would imagine that is largely the residential facilities. The vast bulk of mental health related drugs are prescribed in general practice or at least renewed there, issued in community pharmacies and paid for through the primary care reimbursement service. That is a further €80 million which is outside of the mental health budget which the members have laid out in front of them. If we added it to the mental health budget, it would bring it up by a further 9% or 10%.

Deputy John Brassil

I am glad it is not in that figure because it would leave the mental health section with a lot less money to do what it needs. It is also relevant when we are looking at the percentage spend on mental health. It should be included in that if that is what it is spent on.

Mr. Stephen Mulvany

It would bring the spend up to 6.9% as referenced in the document we circulated.

Deputy Catherine Martin

Is there a timeframe for the breakdown the witnesses are going to provide to us? Will we have it for next week? Will it include mental health and intellectual disability dual diagnosis, homeless and minority groups? The witness has said that information is not readily available today, which beggars belief. With respect, when they were coming in to this committee dealing with funding, did the witnesses not foresee that we might want that information? Surely this is not the first time this information has been sought. I would say practically every member here has submitted parliamentary questions and written to the HSE. I really am struggling with how the witnesses were not ready for that today. Even in this Dáil, have the two Ministers of State who have held responsibility for mental health sought that breakdown from the HSE at any stage? Have they asked where that money is being spent and how?

Mr. Stephen Mulvany

To answer the Deputy's first question, no, it will not be possible to provide that next week. We will read the transcript. A number of Deputies have looked for specific pieces of information. We will go and engage with the nine CHOs and see what can be provided as quickly as possible. We will not seek to delay the process. If necessary, we will give the Deputy something in the interim within a short period.

In terms of coming here today, we came with the financial information that we have. Initially, I think I got a couple of days' notice of this meeting, which became a week and a bit. It would not have been practical to produce that in a general way. Now at least we have a better sense that there are different flavours of what people are asking for. One of the Deputies wanted to know who authorised all of the spend, which is a slightly different, totally reasonable question. We will take this transcript, put it together as best we can, and then we will reply. It is not that we do not have a lot of information.

Have previous junior Ministers asked the question? I have no doubt that they have and we will have provided the best information we had at the time. My main point is that it does not readily exist in a format such that one simply runs a report, which is how we all would agree it should exist. We will have provided a variety of information to Ministers over the years in terms of either new posts or total posts in these various sub-specialty areas. Even some of the areas the Deputy mentioned herself, we will just have to dig out and see. The homeless piece is a further sub-specialisation in terms of the overall answer. We will provide what can be provided. We have a lot of information. There is a lot of audit and accountability. There are budgets. We would not want people to think there are not budgets to manage the service, although there might not be available data.

Chairman

Before I pass the witness on to Senator Devine, can I just pull him on what he has just said? He said he only had a couple of days notice. I have made four requests over the last year looking for a breakdown of the mental health budget.

I have in fact received an email from the Minister's assistant, dated 24 October and responding to my request for a breakdown. I will quote directly from this email: "[U]nfortunately there is no sub-speciality reporting available from the financial systems and therefore I cannot provide this information for any year until such systems are enhanced." Is Mr. Mulvany telling me that he does not know how each community healthcare organisation, CHO, is spending its money? Are they not accountable to Mr. Mulvany as chief financial officer? Do they not provide his office with a breakdown of every single penny that they spend each year? I think I am reflecting Deputy Catherine Martin here in saying that I find this to be absolutely extraordinary.

Mr. Stephen Mulvany

I ask the Chairman to clarify whether that is a statement or a question. If it is a question may I answer it?

Chairman

I have been asking this for the whole meeting and I am still not getting a clear answer.

Mr. Stephen Mulvany

I have to say to the Chairman that I do not believe that to be a fair reflection of what I actually said to her.

Chairman

I am quoting an email from the Minister's office.

Mr. Stephen Mulvany

I know what I know. The Chairman asked me a question and told me that it was amazing that I did not know something. I have told her what notice I got for this meeting and I am now telling the committee that we can account for what is spent in the different areas. That is a fact. The issue is that we cannot readily account for it in the particular way in which both we and the committee would like to, that is sub-specially. We comply with the obligatory accounting requirements, including those of the Department of Health, and we are audited every year. As I stated before, we provide information under 26 headings of non-pay expenditure and 11 main headings of pay expenditure and we can break all of this down by county. The issue is being able to provide this information in what I would describe as a service-line reporting fashion. Our systems do not yet allow us to provide us that level of information or that view on the information. I point out to the Chairman, however, that this is not the same as saying that we cannot account for the money. That is not a fair reflection of what we are saying.

Chairman

Deputy Catherine Martin asked for a timeline on this. What is the timeline for giving us that information?

Mr. Stephen Mulvany

We can come back next week to give a sense of what we can provide by when. I have been very clear that we cannot provide the information that has been sought within a week because we will have to take out the transcript and engage with the CHOs in question. It is much more practical to say that we will give an interim view to the committee within the next three or four weeks. Until we actually do the exercise we cannot know how long it will take.

Senator Máire Devine

Everybody in the HSE is under pressure, be they the witnesses before us today or the front-line staff. Picking up on the Chairman's comments, was no alert sent? I have a response here to a Parliamentary Question on planning performance and programme management. Many committee members have asked this question of the HSE, as have NGOs, and I know that Mental Health Reform is here today. I myself received this response in October. Surely some alert must have gone out somewhere if the HSE received 30 or 40 communications stating the importance of this matter and how much we need to focus on it.

Can the witnesses comment on whether allocating just over 6% of the overall HSE budget is adequate for our mental health services? This allocation stood at 14% in the early 1990s and is currently at 13% in Britain and in many other countries in Europe and further afield. I would also like a comment on the decision to shut down the six-bed high dependency unit in Tallaght Hospital at the end of this month. This is due to staff shortages but I would also like to know about the implications on the budget. I worked in high-dependency units for a long time and I know that shifting from such a unit to a general ward requires far more supervision and far more so-called "specials" for very volatile individual patients in the form on one-to-one, two-to-one or three-to-one nursing. This brings in both the dignity of nursing that patient, as the nurse is with them 24-7, but also extra demands on the budget of that hospital as it has to provide extra special services to ensure risk safety in the aftermath of the decision to shut a custom-built high-dependency unit. Will Tallaght Hospital be penalised when it goes over its allocated budget, or will the HSE give it extra money because this arises from a HSE decision?

Ms Anne O'Connor

In response to the question of funding percentages for mental health, Sláintecare places that allocation at 10%.

Senator Máire Devine

Yes.

Ms Anne O'Connor

We would obviously like to keep moving upwards. We are part of an environment and part of a wider health system. With regard to the Tallaght unit, I cannot comment on the actual closure but I would like to clarify for Senator Devine that we do not penalise in such circumstances. The reality is that bed closures as a result of staffing shortages do not arise because there is no funding.

A reference was made earlier to Linn Dara. The straw that broke the camel's back in that case, for example, was that even the very specialised agency that sometime supplies us with staff was unable to find any. We could not get staff; the agency we normally go to for staff could not get staff; and therefore the unit had to close for an interim period. None of us want people to be nursed in inappropriate settings that do not best meet their needs. That is not in anybody's interests so we always strive to have the right facilities open for people, particularly those with a higher level of need. There are times, however, when we just have serious staffing crises around manning a roster on a given day.

Senator Máire Devine

It is a question of the dignity of patients and of the staff working with them.

Ms Anne O'Connor

I agree with the Senator.

Deputy Tom Neville

I have some questions here for forward planning for next week. With regard to the €35 million of new money for 2016, where was that money, once furnished, used to plug holes and where was it used in new development? I do not just want a top-line figure here, I would like a breakdown of exactly what holes were plugged with that figure. I understand that there could be time restrictions here but there will be both short wins and long wins when it comes to getting figures together. Perhaps some of the figures we requested could be submitted by next week - the top-line figures, perhaps - so I ask that the witnesses keep that in mind. I understand that some of the other figures may take longer to get, in which case I ask the Chairman that we be facilitated in inviting the stakeholders back if we need clarification on some of the answers. I would be grateful for that because this is a learning process for all of us, and the answers that may take some time to be supplied to us will obviously lead to follow-on questions.

In anticipation of our discussion next week of the recruitment issue, I ask that the stakeholders furnish us with some extra information around some of the recruitment challenges that were articulated today. I further ask that this be provided under a number of different heading, including for example, talent pool; systems; location; job description; career progression; working conditions; qualifications; experience; and decision-making timelines and processes. If the stakeholders could have some information for us on that next week we could then start to tease out the anomalies within those headings rather than scratching at the surface. This would save time for both us and them as we would not have to invite them back in again to get clarification on answers that might take time to submit. This might be helpful.

Chairman

That would be very useful. I thank the Deputy. Is that all right with Ms O'Connor?

Ms Anne O'Connor

We will have to take this request away with us. We have a national recruitment service that looks after all of our recruitment so we will have to see what information we can get from them.

Deputy Tom Neville

It would save us having to ask the questions next week only for the witnesses to say that they need to go back to check. We are going to try to pre-empt that.

Ms Anne O'Connor

Yes.

Chairman

I would also like to request a breakdown of the budgets for the children's mental health services in each of the CHO areas. I would like to find out how much was allocated in each CHO area and how it was spent. Are there any further questions?

Mr. Stephen Mulvany

We have been asked for every individual sub-speciality, which is totally reasonable, and all of the committee members want to see the breakdown of the budget and spend across the nine CHOs. I have been very clear, however, that we will not be in a position to provide that by next week.

Chairman

That is all right, I am not waiting for next week.

Mr. Stephen Mulvany

I thought that the Chairman had said next week.

Deputy Tom Neville

What I was saying was that some of those figures might be available to provide to us next week.

Mr. Stephen Mulvany

I think that is unlikely.

Deputy Tom Neville

What about the top-line figure on how much was spent in 2016 or clarification on whether €10 million or €15 million or €20 million was spent on new services?

Ms Anne O'Connor

Just to clarify, the Deputy is talking about the development fund for 2016. That is a different matter entirely.

Deputy Tom Neville

That was my question; I was not talking about the total budget. If we can get this information then we can move on a lot more quickly.

Ms Anne O'Connor

We can provide the information on the development funding. That is fine.

Mr. Stephen Mulvany

Absolutely.

Chairman

There was also a request for information about last year's recruitment funding.

We will go through our own questions and see what that was about. I call Deputy Buckley.

Deputy Pat Buckley

I thank the Chairman. I will be brief. Mr. Mulvany thinks I have a vendetta against him, but I do not. The witnesses spoke earlier about the chief financial officer of each individual CHO. Is there a possibility that if there is harmony within the CHO, the two officers can set their own budgets and request additional development funding? What I am trying to get at is the following. If the two officers in a particular CHO decide they need extra funding which they wish to draw down through the development fund to staff a CAMHS unit fully and if they can encourage staff in, can it be done?

Mr. Stephen Mulvany

First, I do not think at all that the Deputy has a vendetta against me. We are happy to answer questions and to be accountable. I will refer to how the process works and some of my colleagues may also want to comment. Each CHO, including the mental health part, can, within reasonable parameters, spend its mental health budget. I was going to say "as it sees fit" but it is in line with the overall framework that is set down. As such, we are trying to move more to a recovery oriented model and development funding. We have to fund the existing base services, but some of those can be described as "legacy" or as "legacy modes of practice". We are trying to move away from that. They are part of the overall process. The CHO officers get an input and engagement from my colleagues here around what is required for the next year and an overall figure is reached. My colleagues must agree that with the Department. Within that, they can spend. They cannot just decide they need more or want more and are, therefore, going to spend more. That would just be-----

Deputy Pat Buckley

If they could realistically plan ahead, they could say that they had confirmation that in two years' time, they could retain a fully staffed CAMHS unit team, for example. With wages and other costs, they would say they needed X amount. Can that be done if the will is there within the system?

Ms Yvonne O'Neill

That is the type of process we are involved in annually to look at how we build our submission for funding to Government under the Estimates process. As such, we have direct engagement with our CHO mental health colleagues and talk through the specialties. For example, one might take the relocation and opening of the Linn Dara CAMHS acute unit. We engaged with our CHO colleagues to look at the cost of that service. They were able to say they could reasonably bring the beds to X if they could get funding for Y. We brought that to Government as part of the programme for Government funding process and are now able to allocate the full cost of the operation of the Linn Dara service within the CHO 7 budget. That is exactly as the Deputy has outlined and it is the process we fulfil each year as part of the annual Estimates and budget allocation process. As Ms. O'Connor outlined, it is also part of the performance reporting process. On top of the additional funding we secure for Linn Dara to allow it to be operational, we ask on a monthly basis if it is there yet. We know by development post, as Deputy Neville asked, what they have been allocated and whether those posts are in place. Where, for example, it has not been possible to recruit staff to those posts, they may be incurring overtime or special costs, as Senator Devine outlined. In that case, we will say that the funding can, in the interim, plug holes, to use the member's term. That is the type of application of funding. It is for direct mental health service provision and it is working with the CHOs and services to determine their priorities for that. The exact process Deputy Buckley outlined is the one we are involved in; annually in terms of service planning and budget allocation and monthly in respect of performance management.

Chairman

I do not know if, on the back of that, Ms O'Neill can answer the following. Did Mr. Mulvany say that the manager of each CHO had the facility and ability to allocate the budget to whatever it is within the CHO area? If so, is the manager the person who decides how much is allocated to children's services? Is that how it works?

Ms Anne O'Connor

We are implementing A Vision for Change, which I know we are coming to next week. As such, we are on a constant journey to try to increase the number of community child and adolescent psychological teams, old-age teams, liaison teams and adult teams. It is all set out and we are on a particular road map to implement the policy. We have a view and are able to see within each CHO where it is in terms of what it should have in its area. We know how far from A Vision for Change norms it might be or even from the national average and we know which areas are worst off and best off, etc. There is a plan in place for the business we are in and what we have to try to achieve. They can spend money in line with the operational plans. We have a national service plan and an annual operational plan and each community health organisation has its own operational plan which is a "drop-down" from the national plan. There is a very clear map set out.

Chairman

As such, it is not their own decision to say what can go-----

Ms Anne O'Connor

It is to a certain extent, but they cannot go off and simply develop some unrelated service which is not set out as a priority for the mental health division. They are funded to provide certain things.

Mr. Stephen Mulvany

The chief officer has a head of mental services and a head of primary care. The chief officer cannot decide to spend the mental health money on something that is not mental health.

Chairman

What about allocations specifically for child mental health services?

Mr. Stephen Mulvany

The head of mental health services and the chief officer can propose, in their engagement with my colleagues here, spending additional money on child mental health services. If they get agreement for that and it is in line with policy, they can make a decision. As Ms O'Connor is trying to make clear, we are trying to foster local accountability and decision-making but it is within the overall policy framework. That means they have to meet the major priority needs first. What they propose must make sense. I used to be involved directly in this division and I note that my colleagues are trying to encourage local services to make the right decisions and to feel some ownership and empowerment in that regard. However, it is not laissez-faire. It is not possible to say it was put into child care and into elderly care if it is not the most obvious priority.

Ms Anne O'Connor

We mentioned MHID and dual diagnosis. There are areas that we can see are priorities nationally which might not necessarily be identified by a chief officer as a local priority. Nevertheless, we know we should have MHID services in all areas. We get into that discussion on a monthly and yearly basis.

Deputy John Brassil

I have a final question on the tables on the CAMHS spend. The average spent is approximately €4 per capita. In CHO 9, however, it is up to €4.28 and in CHO 8, it is down as low as €3.58. There seems to be a large anomaly.

Ms Yvonne O'Neill

What table is that?

Deputy John Brassil

It is table 1 - population served by community health services.

Ms Yvonne O'Neill

It is just the population served.

Deputy John Brassil

My apologies, it is just a statistic. I understood it to mean something else.

Chairman

The session has not been easy for any of us. All we are trying to do is identify what is missing and what needs to be looked at so that we can do something together to improve mental health services in Ireland. I thank the witnesses for attending and for the information they have provided to the committee. We will ask the witnesses to return as soon as we get the figures from them.

The joint committee adjourned at 4.20 p.m. until 10 a.m. on Thursday, 30 November 2017.