A Vision for Change: Update from Health Service Executive

Chairman

I welcome Ms Anne O'Connor, who is the national director of mental health services; Dr. Philip Dodd, who is the national clinical adviser and group lead; Mr. Jim Ryan, who is the head of operations and service improvement, Ms Yvonne O'Neill, who is the head of planning, performance and programme management; and Mr. Liam Hennessy, who is the HSE's head of mental health engagement. On behalf of the committee, I thank them for their attendance today. The format of the meeting is that the witnesses will be invited to make a brief opening statement, to be followed by a question and answer session.

Before we begin, I draw the attention of witnesses to the position in relation to privilege. I ask the witnesses to note that they are protected by absolute privilege in respect of the evidence they give to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a 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 they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or 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 House or an official by name or in such a way as to make him or her identifiable.

I remind members and witnesses to turn off their mobile phones or switch them to flight mode. Mobile phones interfere with the sound system, which makes it difficult for the parliamentary reporters to report the meeting and has an adverse effect on television coverage and webstreaming. I advise the witnesses that any submission or opening statement they make to the committee will be published on the committee's website after this meeting. I now invite Ms O'Connor to make her opening statement.

Ms Anne O'Connor

I thank the Chairman and the members of the committee for inviting us to attend this morning's meeting. I am joined by Dr. Philip Dodd, Mr. Liam Hennessy, Mr. Jim Ryan and Ms Yvonne O'Neill, all of whom work in the mental health division. Members will have received a separate briefing document which sets out the details of the implementation to date of A Vision for Change and other service improvements that are currently under way. The document sets out in detail the progress made in respect of each of the relevant 209 recommendations. Other briefing documents that were supplied to the committee last week set out details of the governance of mental health services and provided an overview of the 2017 budget. Other reports that are available to the committee were published as part of the HSE annual planning and performance cycle.

The report of the mental health policy expert group, A Vision for Change, was published in 2006 and subsequently adopted as Government policy. This progressive, evidence-based policy document proposed a new model of service delivery which would be centred on the service user, flexible and community-based. It has contributed significantly to the development of mental health services in recent years by providing a policy and rationale for the delivery of standardised services. The implementation of A Vision for Change was initially constrained by the lack of the recommended investment in the post-publication recessionary years. While consistent investment has been made available since 2012 through programme for Government funding, the inability to recruit some key clinical staff due to early retirement options for nurses and international competition for some specialist consultant staff has frustrated efforts to improve services at a faster rate. The summary points I am making are detailed in the separate briefing document that has been provided.

The implementation of A Vision for Change initially focused on the core building blocks underpinning mental health services, including the reconfiguration of community mental health teams within recommended population catchment areas. The level of whole-time equivalent staffing recommended in A Vision for Change, adjusted for the latest 2016 population, is 12,354. The actual staffing level last month was 9,767, which represents almost 80% delivery of the recommendation in A Vision for Change. General adult mental health teams are now based on populations of 50,000. Nationally, we have reached 76% of the staffing levels recommended in A Vision for Change. In addition, we have put in place 69 of the 79 recommended child and adolescent mental health teams and 30 of the 48 recommended psychiatry of later life teams. There are insufficient staffing numbers in some of these teams, resulting in 56% achievement of the recommended staffing levels for child and adolescent mental health teams and nearly 61% delivery of the recommended staffing levels for psychiatry of later life. We continue to use development funding to increase the staffing levels on existing teams or to create new teams, while also implementing recommendations on other specialist teams including mental health, intellectual disability and rehabilitation. All of this is outlined in detail in the briefing document that has been submitted.

A Vision for Change describes a framework for developing and promoting positive mental health, including suicide prevention, across the entire community. The National Office for Suicide Prevention, established shortly after the publication of the policy, has driven the strategic direction for suicide prevention. Initiatives to date include the appointment of suicide resource officers in local communities, suicide crisis assessment nurses in general practice, funding of agencies for direct counselling and support services and more recently through Connecting for Life, the commitment to interagency working and the development of local suicide prevention implementation plans. Additionally, the development of the self-harm clinical programme and the appointment of nurses in emergency departments nationally to deal with cases of self-harm have been progressed.

A Vision for Change places significant emphasis on the need to involve service users and their supporters at every level of service provision. Within the mental health division, we have developed a national office dedicated to engagement with service users and their families and increased mental health engagement capacity within the nine community health care organisations. We have developed a national recovery framework to ensure that a recovery ethos underpins all service delivery. In 2017, we employed peer support workers in our services for the first time.

The policy recognises that most mental health treatment and care is delivered in primary care settings. Specific initiatives to date include the development of the counselling in primary care service and national counselling service, the funding of over 100 assistant psychology posts to expand psychological interventions to children and the funding of innovative youth-friendly mental health organisations like Jigsaw. The policy also recommended that community mental health teams should offer multi-disciplinary, home-based and assertive outreach care and a comprehensive range of medical, psychological and social therapies across the lifespan. Recent initiatives here include the development of seven day mental health services, the funding of home-based treatment teams and assertive outreach teams, the provision of modern evidence-based therapeutic programmes and the development and implementation of the early intervention psychosis clinical programme.

A Vision for Change sets out recommendations for best practice in the delivery of recovery and rehabilitation services for people with severe and enduring mental illness and other significant needs such as forensic mental health, homelessness, substance misuse and eating disorders. Initiatives here to date have included development of specialist rehabilitation services, mental health services for people who are homeless, the clinical care programme for eating disorders and the deployment of forensic mental health teams in all prisons.

Significant capital development has taken place since the publication of the policy. Over recent years, new units have been built for children in Dublin, Galway and Cork. Adult units have been developed in a number of locations, including Cork, Drogheda, Limerick, Galway and Killarney. The refurbishment of many units across the country has also been provided for and construction work has now commenced on the new national forensic mental health facility in Portrane which will provide 170 forensic beds including forensic child and adolescent mental health services, CAMHS, and forensic mental health intellectual disability, MHID, services. Notwithstanding these developments, it is estimated that in excess of €500 million in additional funding is required to meet all future mental health infrastructure requirements.

Since the publication of A Vision for Change, the mental health division has also responded to a variety of emerging wider mental health issues including the development of appropriate perinatal mental health services, the development of a clinical programme for ADHD in adults and other initiatives. Additionally, since the establishment of the division in 2013, there has been an emphasis on improving services using a programmatic approach to ensure implementation of sustainable change designed to modernise mental health services, including over 25 service improvement projects.

A Vision for Change has been a valuable policy guiding the continued development of and investment in mental health services. Consideration now needs to be given to adapting the approach taken to date to support integration and the implementation of more recent policies. The HSE looks forward to contributing to the review of A Vision for Change, recently initiated by the Department of Health, and also to maximising the opportunities identified in Sláintecare for responding to mental health needs as part of a wider societal and whole-of-Government approach to health.

Chairman

I thank Ms O'Connor for the trouble she went to in providing us with those documents this week. It was a very comprehensive report which looked at exactly what was achieved and was transparent about what was not achieved. I appreciate the trouble that she and all the witnesses went to. The format here is that the first four speakers will have seven minutes each to ask questions and get answers.

I echo the Chairman's words and I thank the witnesses for their work. It is much appreciated. The more information we have, the more we can work on. I have a number of questions I will open to all the witnesses. My first question has been partly answered but I will put it to the witnesses. What are the key reasons for the difficulty in recruitment and retention of mental health staff across the country? How can such challenges be addressed and what measures need to be put in place? One of the briefing documents that we received earlier deals with some of it but it has me slightly confused. It states that funding provided to mental health is ring-fenced for mental health, yet on the next line it states money that is unspent in respect of recruitment is allocated to the improvement of mental health infrastructure. I can understand that but it also then mentions agency staff. We have a major issue with recruitment and retention. We have been over and over this, even in the Committee on the Future of Healthcare. The HSE has told us that it cannot get staff, yet there does not seem to be any problem in getting agency staff. Why can the HSE not start to recruit these staff directly? Is there an issue with contracts?

That is just one issue. I have a couple of other questions which I will put to the witnesses which relate to recruitment. Is there an issue with salary conditions and pay rates in Ireland? If there is, why can we not address that and do what is being done in England, where packages are being enhanced so that staff can actually be recruited and retained? I know it is a challenge but we will have to break the mould and start somewhere. There was also an issue with out-of-hours access. An initiative was mentioned here last week. What was the initiative the witnesses were talking about? There was an initiative for community mental health services. How many in the country are operating on a seven day week, if any? An issue close to my heart goes back to preventative measures, which is that prevention is better than any cure. Does the HSE have a plan to roll out the 24-7 access to crisis mental health services in every area in the country? We are all looking for an update on the development of the new clinical approach to dual diagnosis. The Minister of State, Deputy Jim Daly, was here a couple of weeks ago and mentioned the possibility of a one stop shop, or, as he called it, the no wrong door policy. Has that been flagged with the HSE? We have spoken about it among ourselves here. We need a pinch point where everybody in the country has at least one access point and service can be distributed to wherever it is needed.

There was a worrying piece in the media last week or the week before stating that over 600 people left emergency departments who were in crisis. Do the witnesses have numbers of people who were either highly intoxicated or under the influence of drugs who were refused admission to the acute section of the services? Is it possible to get those numbers? Is a record kept? Primary care is the main issue here. It goes back to the bottom-up approach. It is a similar issue to what I said a while ago about people trying to access counselling services. The waiting lists are so long that people are being discouraged and, unfortunately, left behind. Does that go back to recruitment? Does it go back to the lack of service when assisting general practitioners, GPs? GPs are normally the first port of call. No matter what ailment one has, a person will usually go to a GP first. Another issue which I saw last night and see many nights, and which is not only prevalent in Dublin but countrywide, is that of homeless people. What steps, if any, are taken to assist people who are homeless? If they are taken in and assessed as having mental health issues, is there a follow-up or are they just assessed and left back out? Is any accommodation or assistance at all offered? It is heartbreaking and soul-destroying to see these people.

Most of these people are in a bad place, temporarily. I am also concerned about mental health service provision to people in the criminal justice system. Not everybody is aware of services in their local communities. Information is key and there appears to be a lack of support in this area.

Ms O'Connor mentioned in her opening statement that 90% of these issues should be addressed through primary care. The words "should" and "can" are two very different words. I would prefer to use the word "can".

Chairman

The Deputy has one minute remaining.

I am almost finished. Ms O'Connor also stated that an additional €500 million in funding is required to meet future mental health infrastructure requirements, which concerns me in light of my earlier comment regarding the ring-fenced money that has been already spent on infrastructure and the lack of spend on recruitment and retention that needs to be addressed.

I welcome the Sláintecare report which hopefully we will have an opportunity to discuss at a later stage.

Chairman

I remind members that the seven minutes allocated is for questions and answers.

Ms Anne O'Connor

The Deputy has asked many questions, some of which I will address and I will then ask my colleagues to address the others. In regard to agency staff and recruitment, which we addressed last week, we do have agency staff and we try to recruit them but, unfortunately, they do not all want to work. The flexibility that is granted by working as an agency staff member is very different. We have tried to offer contracts to agency staff but not all of them want to take them up. There is no issue around funding. We have to keep our services operating and so we staff what we can with existing staff and we then seek to recruit agency staff. It is not only the HSE that cannot recruit as agencies are now also struggling to get staff, which is something not previously experienced. I referenced at our last meeting that we had to close beds in a CAMHS unit in Linn Dara. The reason this is so bad this year is that the agency could not get staff either. There is a general shortage of the staff we need. This has been the experience not only of the HSE, but across agencies and our funded partners over the past year to 18 months. There is a wider recruitment issue that is hitting the health sector because we are operating in a global international market for staff. It is worth noting - this was referenced in one of the responses given earlier - that in Ireland we have very fairly highly trained mental health staff. Not all countries specifically train nurses in mental health. Our nurses are, therefore, very attractive to other jurisdictions. Only about three or four countries have dedicated mental health training for nurses. Our nurses go abroad. There are massive recruitment campaigns going on in the UK that are offering very attractive packages which are very difficult to compete with.

In regard to packages and pay scales, these are not within our gift. We were involved in the Bring Them Home campaign last year, which was an international nursing recruitment campaign. We got a very small number of nurses arising out of this very big initiative that involved representative bodies, the HSE, the Department of Health, etc. There was a package agreed as part of that campaign but it did not cut it for us. To be honest, some people would not come home for what they were being offered. Also, the HSE is locked into the public pay frameworks and it cannot decide to pay anybody outside those agreements. This is an issue we work with every day, and it is broader than mental health and the HSE. I hope that answers the Deputy's questions on the agency and recruitment issue regarding the conditions. I also point out that when we were having difficulties recruiting consultants, we worked with the Public Appointments Service to survey consultants abroad to determine why they were not coming back to Ireland. The feedback we got was that they were all aware of the posts that were available. There was no lack of information in that regard. It was not just an issue of pay but the environment in which they would be required to work, rosters and lack of facilities, etc. It is a bigger issue than just pay.

Mr. Ryan will respond later on the seven day services and out-of-hours service because he is leading in that area and Mr. Dodd will respond to the questions on dual diagnosis and the accident and emergency aspect. In terms of primary care, most mental health is dealt with in primary care. We could argue about whether there is sufficient capacity in primary care to support GPs. We know that capacity does not exist from a psychology perspective. It is for this reason that we are investing in the 120 assistant psychologists for under 18s. There are not enough avenues for the GP to take and GPs say that they are obliged to refer people to specialist mental health services even though they know that, for example, counselling might be what they need. The national counselling and primary care service operates for people with medical cards only. Anybody who does not have a medical card does not have access to that service. We fund agencies to provide different kinds of counselling on our behalf, to which there is variable access. I mentioned last week that we are looking at a national initiative around improving access to psychological therapies and talking therapies. We are bringing in a clinical lead to do that piece of work. We have a variety of types of counselling across services. I accept there is an inequity in different areas in that there are some types of services available and not others. We want to have a standardised approach to how we do the talking therapy side of things. We are also conscious that we need to develop services in general in primary care because it is not all about counselling. For example, with young people it might be about speech and language therapy, occupational therapy or something that is not a mainstream mental health requirement.

In regard to homeless people, we have specialist services to meet need in this area. As mentioned on page 29 of the document on homeless services, which was provided to the committee, there are specialist teams for people with severe mental illness, one on the north side of Dublin and the other on the south side. There is a similar service in Cork and another in Waterford. These services are for people who have long-term mental health conditions. We know that GPs deal with people but there is a gap in the service for people who have become homeless and do not have a severe mental health illness but are at risk of developing it. We are conscious of that gap and we are well advanced in our work with the NGO sector and other services on putting in place a stepped care model to support people with mental health illness. We are looking at how we can provide a more aggressive and assertive outreach model to people who are homeless to prevent them from developing greater problems. This work is under way as one of our service improvement initiatives.

I will ask my colleague, Mr. Ryan, to comment on the forensic services. We currently have in-reach in all of our prisons. This has been a significant development over recent years. The Central Mental Hospital Dundrum will soon move to Portrane. We have staff going into every prison and we have different initiatives in certain prisons. In regard to infrastructure, there is always a difficulty in this regard. A significant amount of HSE funding is being spent on the new children's hospital, which is the second largest capital development. The forensic hospital is the largest mental health capital development ever. We know that we have other facilities that are not meeting their requirements. We are regulated and environment is a key concern for the Mental Health Commission. Some of our units that were developed in the 1990s are struggling to meet compliance. We have a constant improvement programme. Deputy Buckley mentioned the need for money to remain in mental health services. If he were to ask people working in mental health services about the spend on infrastructure, they would say that one of biggest differences for service users was the improvement in their environments. We have a long way to go on this and if we really want to improve our service model, we need to develop better day hospitals and nicer units. We are lucky in that we have a footprint in many of the new primary care centres as they develop but there are still lots of gaps around the country. I will hand over now to Mr. Ryan.

Chairman

As we have only a couple of minutes remaining I would ask the witnesses to be brief.

Mr. Jim Ryan

I will be brief. In regard to 24-7 services, we started with 7-7 because we wanted to do service provision in a way which would allow us to see to where the evidence would point. Earlier this year, we did a trawl of the 114 general adult community mental health teams and we found that 60% of them were providing a seven day a week service, which meant we had a 40% gap. We then identified that to meet that gap we needed an additional 50 whole-time equivalents. We sought funding from the programme for Government, which we received. We then consulted with local areas on what professionals would be required.

We have that information and we are recruiting those 50 posts to be in place by the end of quarter one in 2018.

There have been questions on the roadmap. That is what it means. We expect to get that information because we will have a suite of key performance indicators to see what value it has brought to a Saturday and a Sunday service. Has it reduced people having to attend emergency departments? Has it reduced people having to go back into hospital? We want to trial the evidence before we look at moving on to a 24-7 basis. At the moment, we do not have a model of care which we could stand over. There is a lot of information here. Briefly, that is the situation in regard to the development, on what we would see as a phased basis.

The second item that was raised was around forensics in the Department of Justice and Equality. In the Central Mental Hospital we have 12 forensic psychiatry-led teams. Most of those are operating in prisons. In all the Dublin and Leinster prisons we have a forensic psychiatrist, social worker and nurse who are working within the prison system. They are treating prisoners who have a mental illness and who, at that time, either do not have to come into the Central Mental Hospital or who are on a waiting list to come in. It is an attempt to try and provide care where the prisoner is located if we cannot get them into Dundrum. The 93 beds tend to be full all of the time and there is a waiting list.

Those teams operate on a year-round basis. We are also expanding that to Castlerea. There is a limited service in both Cork and Limerick and we are trying to enhance that as we speak. We have both the posts and the funding for it. It is a question of making sure that it integrates with local services.

Chairman

I thank the witness.

Dr. Philip Dodd

On the issue of self-harm and how it is managed in our emergency departments, our clinical programme for the management of self-harm was launched in 2015. In 2016, we began a process of recruiting clinical nurse specialists to be placed within emergency departments across the country. Approximately 16 of the levels 3 and 4 emergency departments in 2016 were staffed and began to implement the clinical programme. Towards the end of this year we have it in place in 24 of the 26 levels 3 and 4 emergency departments. We have recruited 36 clinical nurse specialists across the country. With regard to what was recently presented in the press, the National Suicide Research Foundation has been publishing data on self-harm as part of its self-harm register for the last number of years. It has quoted a percentage of 13% of people as leaving emergency departments without assessment.

In the data that we have collected in the 16 emergency departments for last year, we found a rate of 9.9% leaving emergency departments before assessment. However, 231 of those individuals were actually referred to the general hospital for treatment or the on-site psychiatric hospital, bringing the rate down to 7.2%. That suggests that where the clinical programme is in place, it is significantly reducing the number of people who present with self-harm but leave hospital before assessment. That is what we are hoping to achieve. If we compare those figures to international figures, in the UK a 2013 study found that approximately 40% of people presenting with self-harm to the UK emergency departments were leaving before assessment.

We do not have full data from across the country yet because this is a relatively new clinical programme. We are not trying to measure anyone leaving hospital prior to assessment, having presented with self-harm. We are trying to achieve a measure of every individual being offered assessment. Our international data, and even our Irish data, suggest that the performance of this clinical programme is improving that outcome.

With regard to dual diagnosis, based on A Vision for Change, the policy document outlines that the vast majority of supports to people who present with addictions should be provided within primary care services. A Vision for Change very much delineates the relatively limited role for secondary and tertiary level mental health services in the support of people who have primarily got a mental illness presentation and an addiction presentation. The divide between that designation of how a person needs to be supported is not a concrete designation in that the way in which the policy has been rolled out across the country actually means that many mental health services are placed within primary care. The National Drug Treatment Centre in Dublin is funded and developed through primary care but actually has a number of mental health teams as part of it.

Our clinical programme has just started. We have a national working group that has been set up in the spirit of co-production along with other service users and service users' representatives. What we hope to achieve from this clinical programme is very much developing a model of care within our mental health services and developing clear pathways of care for people who present with significant mental illness complicated by addiction problems as well.

Chairman

I thank the witness. I am aware that 20 minutes have gone by.

I will be very brief on dual diagnosis. The review of the implementation of A Vision for Change in November 2017-----

Chairman

Deputy, we are going to have to cut it short. It is 20 minutes.

------says that specialist community teams designated to address complex, severe substance abuse or mental disorders have not been developed.

Chairman

Perhaps the witnesses could answer that at the end of the session.

How many adult teams do we have in place in Ireland? What actually constitutes the team? How many people make up a team? What would be meant by an adult or a children's team and a fully staffed team? I will ask my questions one at a time so as I keep within the timeframe.

Ms Anne O'Connor

In terms of-----

I mean fully staffed. That is all I want to know, the number.

Ms Anne O'Connor

The actual number of a fully staffed team is seven I think.

Seven makes an adult team and seven makes a children's team. Is that the case?

Mr. Jim Ryan

Seven makes an adult team and 13 for child and adolescent mental health services, CAMHS, teams.

I thank the witness. Of all the teams that the witnesses listed earlier, how many teams are in place? How many suicide prevention teams are in place in Ireland? Just the number please

Ms Anne O'Connor

We have 114 adult teams.

There are 114 adult teams.

Ms Anne O'Connor

We have 69 CAMHS-----

Are these all fully staffed now?

Ms Anne O'Connor

No.

What is the number of fully staffed teams?

Ms Anne O'Connor

Staffing comes and goes on a team all of the time. We know the percentages. In terms of-----

A team is not a team unless it is complete. How many fully staffed teams do we have?

Ms Anne O'Connor

In terms of-----

In adults and children?

Ms Anne O'Connor

In terms of today, I could not tell the Deputy how many teams are fully staffed today. We have staff coming and going. We know the number of teams that we have. We know that within CAMHS we are at approximately 50% of staffing. We know that in general we have-----

I want actual figures. Can the witness provide the information to the secretariat?

Ms Yvonne O'Neill

I can clarify that in the documentation provided, appendix 5 shows every adult, child and psychiatry of old age team, the numbers of current wholetime equivalents today and the percentage of A Vision for Change recommendations.

I have a specific question. How many fully staffed teams are there throughout Ireland and what are their exact locations?

Ms Yvonne O'Neill

I will answer that. In appendix 5-----

Is that the appendix that I am looking at? That has wholetime equivalent as 332. Is that the case?

Ms Yvonne O'Neill

It is appendix 5. It is a condensed table. There are three separate ones. It lists general adult, psychiatry of old age and it shows the name of the team, the population, the number of wholetime equivalents and the percentage achieved of A Vision for Change.

Chairman

Can we clarify that again for Deputy Rabbitte? Who in that team is available? The witness knows that many CAMHS teams do not even have a consultant psychiatrist and therefore the team is obsolete.

I do not mean to put Ms O'Neill on the spot but if she can find that-----

Ms Yvonne O'Neill

It is in the pack. There are a lot of data in it.

I have decided with the HSE that I am going to drill down into questions. What I need to know are concise answers in regard to how many fully fledged teams there are nationally.

Ms Anne O'Connor

That appendix covers every team in the country.

That is okay, it will answer for the next day. We have dealt with 24. Mr. Ryan has answered this. How many seven day mental health services are there? Seven is what he has said. Is that the correct figure nationally?

Mr. Jim Ryan

Nationally, we have 114 teams. Of those 114 teams, the analysis indicated that 60% had a seven-over-seven service that includes home-based treatment, assertive outreach and a nurse-provided service.

The figure for seven-over-seven is 60%. Is that correct?

Mr. Jim Ryan

It is 60% of the 114 teams. We expect to bring that figure up to 100% by the first quarter of 2018.

How many of those have a home-based therapeutic team?

Mr. Jim Ryan

We defined what we meant by a weekend team. It depended on whether the team provided home-based, assertive outreach or nurse-provided services. They were the three criteria to be met.

How many of them reached that level? Was it 60%?

Mr. Jim Ryan

Exactly.

How many teams are in place for the early intervention psychosis clinical programme?

Dr. Philip Dodd

The early intervention clinical programme has not been launched yet. We have started to recruit staff for two or three demonstration sites. We will recruit those posts in the first quarter of 2018.

Where are the sites?

Dr. Philip Dodd

We are selecting them based on waiting criteria within the next week.

We are talking about it but we have not launched it. Has the HSE gone to recruitment of staff?

Dr. Philip Dodd

No.

There has been no recruitment of staff. Can the HSE provide us with the list of the 25 services for improvement projects listed in the presentation earlier?

Ms Anne O'Connor

We can certainly give the committee the list of the projects. It is in the pack in appendix 15.

That is perfect. I need to ask some more questions on dual diagnosis. Can Mr. Dodd explain dual diagnosis? Let us suppose a patient presents to a general practitioner primarily with addiction problems but there are underlying mental health issues. What does the GP do with such a patient?

Dr. Philip Dodd

Currently, it depends on the primacy of the problem. If the primacy is the mental health presentation-----

I am referring to an addiction presentation with underlying mental health issues.

Dr. Philip Dodd

In general, referral to primary care addiction services is the first route.

Let us suppose a GP wants to make a referral to the hospital in Galway. I am from Galway, so it is primarily a matter of Galway for me. Unfortunately, we do not have an admissions policy at the moment where there is dual diagnosis in University Hospital Galway. The HSE representatives have referred to Dublin and so on. How can that be addressed? What is the policy in this regard?

Dr. Philip Dodd

The Mental Health Act 2001 precludes involuntary detention of an individual with only an addiction problem. That is the first issue. That is why it is not appropriate for people who only present with addiction problems-----

I said it was an addiction with an underlying mental health issue. The person would already have been to mental health services.

Dr. Philip Dodd

Does Deputy Rabbitte's question relate to admission to hospital?

It is not only about admission. I have in mind referral for assessment.

Dr. Philip Dodd

Does the question relate to referral to a community mental health team?

Dr. Philip Dodd

Many existing adult community mental health teams will assess the individual for mental health support needs. Some teams throughout the country have embedded addiction counsellors, but that has not been rolled out as part of a programmatic approach. That is what we are-----

Do we have one in Galway?

Dr. Philip Dodd

I will have to check.

Can the HSE provide us with a list of where referral bases are in place at the moment and where addiction counsellors are in place throughout the country?

Ms Anne O'Connor

The committee should note that this is part of the clinical programme. The clinical programme is scoping what is available. There are different versions, but most mental health teams currently deal with people who have addiction problems as well. The difficulty for us is that they do not all have specific addiction counselling.

This is one of the challenges for us in developing the services. It is important that people do not come to a mental health service simply to access addiction counselling. Such people need to be managed in primary care. That is what we are trying to develop with our colleagues in primary care. The idea is to have that first line of defence in primary care, where there is access to addiction counselling and mental health supports.

I suppose the reason for my line of questioning is that it is an issue in the west. Initially, some people present with an addiction and an underlying or established mental health problem.

In 2014, St. Brigid's Hospital in Galway was closed. Since then, we are operating out of a 45-bed unit in an out-dated excess-capacity hospital in Galway that is not fit for purpose. Is there a capital budget for expansion or reopening of beds?

Ms Anne O'Connor

We have a new unit that is built on the site of the hospital in Galway. We are hoping to open it early next year. This new development has been completed. There has been significant capital investment. That will replace the current unit.

How many beds are in it?

Ms Anne O'Connor

It is a 50-bed unit.

We are matching 50 beds with 50 beds. At the moment we have a 45-bed unit. We are gaining five beds. That is still not meeting the needs for the rest of the county or surrounding areas. Are there further steps to address a mental health capital infrastructure plan in the west?

Mr. Jim Ryan

A Vision for Change refers to 15 beds per 100,000 people. At the moment, many areas are operating with 20 beds per 100,000. We need to try to ensure that the beds we have are used for those who require them most. I will try to answer the question directly. We are trying to stay within the policy, which refers to 15 beds per 100,000. The policy also refers to the development of a range of community services. Previously, we discussed early intervention and so on. The bed numbers are actually above those set out in A Vision for Change.

Chairman

Thank you for keeping to time. I will comment on that point. As we know, A Vision for Change is now 11 years old. I do not think it took into account the growing population. Whether the figure is 15 beds or 20 beds per 100,000 people, the number is insufficient. Perhaps that is something that the expert review group can examine. Senator Devine is next.

I thank the witnesses for their presentation. I have some quick-fire questions. The HSE representatives referred to 90% of mental distress or ill-health being dealt with in primary care. The primary care team will be seen to be led by the GP. How involved are GPs in this? What information and encouragement is being fed to them? Primarily, the work of the primary care team is to promote well-being in order that we do not get to the crisis stages. The idea is to have early intervention.

Has the HSE engaged with An Bord Altranais to discuss the possibility of the board altering its criteria for registration in this country? We know at least 100 nurses have attempted to register but have been refused because of the strict criteria on the educational and experience modules. This needs to be revamped. Experienced nurses were turned away. They are now in other services but we need them in our services, as the members of the deputation know.

My next question relates to estimating the number of people in the Central Mental Hospital and the number of people in prisons. The number of those with mental health issues has sky-rocketed. I know the deputation addressed this earlier. Reference was made to the Central Mental Hospital, where the 93 beds are always full. I know there is a waiting list as well. Has the ten-bed facility in Dundrum reopened? I raised this question last year. Have the difficulties been sorted out? Did the HSE get the staff?

Has the HSE ever thought of allowing or employing psychiatric nurses to sit in the courts and Garda stations? A successful trial along those lines took place in London. Obviously, the idea is to get mental health issues at the first level of presentation along with some crime or alleged crime.

What contracts are the HSE offering to staff now? Are they flexible? The deputation referred to flexibility. Are they permanent? Do the contracts encourage and set out a career path or opportunity? Does a nursing contract have a clause to the effect that by so many years the employee will be eligible to become a clinical nurse specialist or advanced midwife practitioner? We know those roles can take a heavy workload from the mental health multidisciplinary teams. That is the way we need to proceed with experienced staff.

Has the HSE looked at the unsuitable environment of accident and emergency departments? I imagine we all agree on this point. While the GP might be the first port of call, where is the first port of call after 5 p.m., at weekends and out-of-hours? These are times when the greatest prevalence of mental distress is seen or is at its height. Has the HSE looked at alternative models for emergency services to be offered with particular emphasis on people in mental distress?

Will the witnesses name the 40 areas which do not offer services seven days per week?

Ms Anne O'Connor

I will answer some of the Senator's questions before handing over to Mr. Ryan. We are in violent disagreement about the whole primary care issue. We all want primary care to be better resourced to deal with mental health and we are doing a great deal of work with the Irish College of General Practitioners, ICGP. We have a project which is examining specifically the physical health of people with mental illness because we know that the physical health of people with severe and enduring mental illness is very poor and their life expectancy is much lower than average. We have a significant amount of work under way with the Irish College of General Practitioners looking at improving physical health and ensuring general practitioners are trained and work with us in this area.

I referred to the whole of society and integrated approach to mental health. As I may have mentioned last week, we are firmly of the view that we need our specialist services to be very specialised and very good but we are at a stage where, with A Vision for Change having set a particular model for us, which is great, we need to do a substantial amount of work in primary care. We know people do not have sufficient access, general practitioners do not have sufficient supports available for people and so forth. We are committed to addressing all aspects of this and working with the ICGP. General practitioners are also represented on the Connecting for Life cross-sectoral group. We are at one in our view on that issue.

In terms of well-being, Healthy Ireland is guiding much of what we do. Using Healthy Ireland, Connecting for Life and A Vision for Change, we are trying to drive a number of initiatives to promote positive mental health. Historically, the mental health division has not focused on mental health promotion. However, we have done a significant amount of work in this area in recent years through the National Office for Suicide Prevention. This includes running the Little Things campaign. We are also working with colleagues in health and well-being in primary care to look at a variety of models around messaging, mental health promotion and general population approaches to mental health.

The Department of Health engages regularly with An Bord Altranais and the HSE engages with the Department. The Department recently negotiated a change in respect of advanced nurse practitioners under which it is no longer the site that is approved and so forth. There are a number of obstacles and the Department is engaging extensively with An Bord Altranais. We do not engage with it directly because we go through the Department.

In terms of contracts, we try to be as flexible as we can. We send out all sorts of messages around staff coming to work for us. If the issue is one of working part-time, we try to hold on to staff and try to recruit them on any basis in terms of the hours they will be available for work. We work within the broader public sector, however, which means certain limitations apply to contracts and it is not necessarily within our gift to offer anything. Nevertheless, we try to be as flexible as we can.

In terms of accident and emergency models, we are examining this issue very intensely. There are two groups of people in the mental health services. The first is those who are known to the services and may have been in our units. They will have attended teams, experienced a crisis and often return to an emergency department. We are not happy that this is occurring and we believe other models are available. We are examining models used in the United Kingdom, for example, and in 2018, we intend to develop one site where people will be seen in a different way.

Part of the challenge we face is that A Vision for Change specifies that people should present to emergency departments. We have to manage the policy and the feedback we receive from everybody. Our priority is the group of people who are known to mental health services. The challenge we face is how to provide a service where people can be properly assessed. The statistics show that people who have a history of mental health problems are not always fully screened in respect of their physical health when they attend an emergency department. There is always a risk that we treat people differently because they have a mental health problem and we miss a physical health issue. We have to be careful about that. There will be lots of protocols to work out in terms of how a facility should work.

The second group of people are those who are not known to the services. These individuals will have to visit emergency departments until we find a different approach. Hopefully the review of A Vision for Change will help in that respect but current policy dictates that we take a particular approach. I ask Mr. Ryan to address the issue of prisons.

Mr. Jim Ryan

On the forensic service, forensic staff carry out 4,000 screenings of remand prisoners every year. Every prisoner who is remanded is assessed from a psychological and mental health perspective. One of the issues we have is that there is no legislation in place for what is known as the court diversion scheme. Recommendation 15.1.2 of A Vision for Change requires the introduction of legislation to enable us to do this in a more formal way. We are doing it somewhat informally and we divert people who do not need to come into the prison system but may need to be more connected with the mental health service. I hope that answers the question.

On Senator Devine's question on seven-day services, I will circulate the information to the Senator as I do not have the list with me. I will send a list of all the teams to the Senator.

I also asked a question on beds.

Mr. Jim Ryan

We secured funding and renovated a unit for an additional ten beds. The difficulty is that we cannot staff the unit at the moment. The new hospital will have 170 beds when it opens in 2020. This will assist in addressing the waiting list. Forensic bed numbers in Ireland are still below the international average.

Mr. Ryan referred to a figure of 93 beds. Is the correct figure not 83 beds?

Mr. Jim Ryan

No, it is 93, of which 83 are for males and ten for females.

At our previous meeting, I was shocked that the witnesses were unable to tell us where the €1 billion in annual funding for mental health services is spent in the various community health organisations. We heard today, however, that additional funding of €500 million is required. I do not understand how the witnesses can arrive at that figure.

On recruitment, we heard that money was not an issue. People working in mental health services tell me, however, that part of the problem in terms of staff retention is conditions, including the management and organisation of their workplaces. Who develops the rules and procedures for running a department? Some front-line staff argue that the buck is always passed and there are too few front-line staff. People decide to pass on problems because they believe it is not their job to deal with them. This passing of the buck causes great stress among front-line staff. It is not appropriate that they have to work in such conditions and I would not blame any member of staff for leaving their job. Who is responsible for management?

We heard there are teams in place nationwide but not all positions have been filled. How many management teams are in place? Have all the positions on those teams be filled? I suggest that all the positions on management teams have been filled and all the front-line positions are not being filled.

I accept what Ms O'Connor said on agency staff. How much would an agency nurse earn compared with a nurse employed directly by the Health Service Executive? Why are the mental health services unable to recruit psychologists? Will Ms O'Connor outline the pay and conditions for psychologists compared with pay and conditions for psychiatrists? What are their salaries and how much would psychologists and psychiatrists earn in the United Kingdom? I suggest that psychiatrists are paid much more than psychologists. We need to recruit more psychologists and more talk therapy and less medication is required. I also suggest psychologists in the United Kingdom have better pay and conditions than psychologists here. We need to address this issue. We must also stop constantly asking for more funding.

According to the opening statement, HSE psychology services have traditionally been underresourced, yet Ms O'Connor was unable to tell the joint committee where the €1 billion in annual funding was being spent. The service is now asking for a further €500 million in funding. We must stop focusing on how much money we do not have and focus instead on delivering value for money for current funding.

At our last meeting, I asked for data on clinical outcomes in order that members could identify which areas are performing well and which are underperforming or underachieving. I have not received a reply, although I thank the witnesses for the other documents they submitted to us with the replies. I ask for specific answers to the questions I have asked.

Ms Anne O'Connor

I will first address the Senator's question on the €1 billion allocation. As we clarified at our previous meeting, while we can say where every euro goes, we cannot provide the information in the format in which the Senator sought or give a breakdown in expenditure as between child and adolescent mental health services and adult mental health services. We can provide reports setting out precisely where all the funding has been spent, however.

I apologise for interrupting, but supposedly €90.2 million was to be put into CHO 8, my area. Is Ms O'Connor able to tell me to the penny where that €90.2 million is going, in each county, town and service?

Ms Anne O'Connor

We can run financial reports that identify where every euro goes. The difficulty is that our system does not capture the information on CAMHS, general adult psychiatry and old age services, as we discussed on the last occasion. The point was made that we were unable to do so for audit purposes for the Comptroller and Auditor General and so on.

Ms Anne O'Connor

I clarify that we can say exactly where all of the money goes. I do not want anyone to think we cannot.

Chairman

Can the committee be given a breakdown?

Ms Anne O'Connor

We can send financial reports for every area, but they are voluminous.

If, for argument's sake, I was to ask exactly how much was put into Athlone town in CHO 8, Ms O'Connor would be able to say exactly how much was being put into the town and how much each service was receiving.

Ms Anne O'Connor

No, not in the case of towns. We do not provide services on the basis of geography but for populations. We would be able to say how much was being put into a specific service. For example -----

Yes, but Ms O'Connor does not know how it is being spent.

Ms Anne O'Connor

No, we do.

That is the point we are getting at and what we need to get to the bottom of because we do not know where the money is being spent.

Ms Anne O'Connor

No, I am sorry; we do know where it is being spent. We absolutely do, but because of the nature of our systems we cannot capture a breakdown of the information on CAMHS. In the last session we went into detail on our financial systems.

Chairman

Will Ms O'Connor provide the committee with the data she is in a position to give us, by area? The chief financial officer has also agreed to capture every single euro. Ms O'Connor has said she knows where every euro goes. Will she confirm that the chief financial officer will provide the committee with this information?

Ms Anne O'Connor

Yes. We also received questions yesterday, arising from the financial discussions on Tuesday. On Tuesday evening we received the questions that we have answered today. The finance questions were received by us yesterday.

Chairman

The problem is that the answers are still too global; there is not a sufficient breakdown of where exactly the money was spent and how much.

Ms Anne O'Connor

We will provide the committee with financial reports for every CHO. I reiterate that they are very detailed.

Chairman

Will Ms O'Connor continue with her response?

Ms Anne O'Connor

The reason we can say it is in excess of €500 million is that we have made ten-year capital projections across the HSE, although they are not specific to mental health services. The need for capital health funding has been a significant topic of discussion and within it we have captured the requirement for mental health services. That is how we derived the figure.

Before I ask Ms O'Neill to speak about recruitment and pay, I will refer to how a department works. If one takes acute units in hospitals as an example, there is a line management structure in which the nurses report to a clinical nurse manager at a particular grade who reports to an assistant director of nursing who ultimately reports to a director of nursing. The governance paper we provided at the previous meeting sets out the governance structure for mental health services. Each area has a head of service for mental health, at least one director of nursing - there are several directors of nursing in each community health organisation - and an assistant director. There is, therefore, a tight governance model.

Everyone is a professional and has his or her own professional standards. Passing the buck would not be acceptable to any of us. Everyone has his or her own personal responsibilities and ultimately we have a governance perspective on services. We hold the management teams to account - the chief officer and the heads of service - and each CHO has its own management team. There is not a variety of management teams, but there are many types of mental health team within an area. The management teams are not significant. There is generally a head of each discipline. For instance, there are a number of directors of nursing; there will be a manager for the occupational therapy service, one for the social work service and one for the psychology service and that would be it. The lack of middle layer managers in any of the allied health professional grades provides a challenge for us. There is a very flat structure for the allied health professionals. The nursing service has directors, assistant directors and different grades of clinical nurse manager, but the allied health professionals do not. One often has a single manager with a variety of basic grade and senior staff. We are trying to look at management teams.

Psychologists and psychiatrists are different staff. A Vision for Change sets out the construct and make-up of a multidisciplinary team. All teams are led by a consultant psychiatrist. It is included in A Vision for Change and we work with it. There is at least one, possibly two, consultant psychiatrist, depending on the size of the area involved. There are non-consultant hospital doctors, psychologists, occupational therapists and so on, but they are from different disciplines who train in a different way and have different qualifications. Even within the psychology service, there is a breakdown, with clinical and counselling psychologists. Part of our challenge is that A Vision for Change specifies a clinical psychology service. We believe there is a significant role for counselling psychologists in primary care and employ them in the national counselling service. We are looking at how we can employ more throughout the services we provide. Again, we are working with a policy that has set a particular direction, but it is being reviewed. We hope some of these matters will be addressed.

I ask Ms O'Neill to speak about agency staff and so on.

Ms Yvonne O'Neill

When we move a nurse from an agency arrangement to being directly employed by the HSE on a permanent arrangement, the value to us is 16%. We constantly seek to convert any member of staff on a temporary or agency arrangement to being a permanent member of staff where we have such vacancies. It is worth noting in response to Senator Máire Devine's question about flexibility that we also re-employ retired nurses to the maximum of their pre-retirement income in order that it does not impact negatively on their superannuation. That gives them the flexibility they seek. They are making decisions on a work-life balance based on their terms and conditions and do not want a permanent arrangement.

I forgot to ask about something. In the mental health division operational plan for 2016 a sum of €2 million was allocated for the development of specific services to enhance the supports available to those who were homeless. In my area Midlands Simon Community does amazing work with persons who are homeless who have underlying mental health conditions. The HSE provides it with about €48,000 annually, a figure which should be reviewed, as it is not sufficient for Midlands Simon Community which has been deemed to be the best agency based on value for money achieved per service user. Better value for money could be achieved by putting money into agencies such as Midlands Simon Community which not only houses people but also teaches and helps them to deal with their issues.

Chairman

Will the Senator leave the answer to that question until the end, please?

Will the HSE look at it?

Ms Anne O'Connor

The service approval model I mentioned will map what is happening and what needs to happen.

I thank Ms O'Connor.

I wish to follow on from Deputy Anne Rabbitte's question on appendix 5 which I have before me and in which a breakdown is given. There are 114 general adult teams with staffing levels based on population and placed against the recommendations made in A Vision for Change. Has the HSE told us the number of positions that have yet to be filled in the 114 teams?

Ms Anne O'Connor

Yes.

On which page is the information? I cannot find it.

Ms Anne O'Connor

Appendix 5 includes some detailed tables which show the number of posts - clinical whole-time equivalents and the percentage in the context of A Vision for Change.

For the last meeting the HSE provided a table with answers which was very helpful for me. I was grateful to receive it. Will it do something similar for the next meeting? Can we get figures for the 114 teams, the numbers in each and the numbers of positions that remain to be filled?

Ms Yvonne O'Neill

Sure.

I want to know what the actual position is, rather than the percentages. Can we get an indication of how many full teams are available and where the deficiencies are? Does that make sense?

Ms Yvonne O'Neill

There is no problem in doing that. It is only a calculation; we have given the percentages. It will not be a problem to give the numbers.

If that could be done, it would be fantastic.

Chairman

We need to know who is part of the teams. It is no good saying there is a team of eight people when the psychiatrist is missing.

Ms Yvonne O'Neill

I can supply that information. We record the data in a monthly return.

Ms Anne O'Connor: I mentioned th

In 2013 I believe €500,000 was to be invested in information technology systems. When the HSE examines the requirements in terms of business functions, with which stakeholders does it consult prior to putting them in place?

Ms Yvonne O'Neill

We have a working group which includes representatives of all stakeholders, staff and services. We develop a specification in terms of requirements.

Does the HSE consult exterior stakeholders such as Government bodies?

Ms Yvonne O'Neill

The submission has to go via the Department of Finance which assesses the specification. We consult and report on the position on the ground and the proposal goes to the chief information officer of the HSE. There is a clear process for submitting it to the Department of Finance.

There is no exterior interaction with end users.

Ms Yvonne O'Neill

We make market soundings whereby we bring in current providers and staff look at existing systems.

That is not my point. I am referring to business functions and interactivity, not user ability. We are asking for figures on CAMHS and other things, but we cannot get them because the systems cannot produce them. Their functionality is not conducive to giving us reports. If we are investing in IT systems, we need to ask what the communications process is between the functional users and those who put the systems together. The HSE has hiring numbers for CAMHS, but if it can hire and knows how many positions it needs, can it not produce a report on how much that would cost?

Ms Yvonne O'Neill

Yes and we include an approximate calculation in the submission. We receive returns from teams every month and input them into basic Excel systems which allow us to determine how many staff we have which enables us to calculate the current cost of those staff and determine what the gap is with reference to A Vision for Change.

Is it not easy enough to give us the figures for which we are looking for CAMHS?

Ms Yvonne O'Neill

The information is limited by what we collect on the provision of general adult community teams, CAMHS community teams and psychiatry of old age teams. It does not extend across the spectrum of mental health services.

A sum of €850 million is being spent and I am trying to get a breakdown. I am in the dark on many of the areas in which money is being spent. We received a figure of €5 million for community health care services and are looking for a breakdown of the functions involved. I cannot interpret the nitty-gritty of the details the HSE gave to auditors as I do not have the qualifications to do so. The stakeholders consulted when these IT systems are constructed may need to change. Our report may propose that end users such as this committee be consulted in order that we can be given the scripts and other reports made available. We are building IT systems that I, as a politician accountable to the people, cannot interpret. It is only specific experts within the system who can interpret them and I depend on these stakeholders to be able to do so. There is also a need for exterior consultation. If we put money into the construction of new systems, we need them to be able to spit out details, in real time, of business functions if we ask for them.

Chairman

That is agreed and noted.

The flexibility of agency staff is attractive but on account of the positions not being permanent, it was not so attractive for the purpose of covering maternity leave contracts. There seems to be a conflict.

Ms Yvonne O'Neill

The position is different for different staff. Older nursing staff are being brought back through agencies after they retire, as they are allowed to do once they are aged 55 years. Our agency problem is not with allied health professionals as largely they have permanent posts. However, as we have a large female contingent, we have high maternity rates. We have a lot of young and newly qualified staff in this category.

Ms O'Neill mentioned negative media reports and the negative perception of mental health services. A recent report stated the HSE was having a problem in recruiting. Ms O'Neill answered questions about pay and conditions of staff and said there was a perceived lack of educational development in mental health services vis-à-vis their counterparts. What has the HSE done to combat the negative perception of mental health services? What campaigns has it put together to address the issue?

Ms Anne O'Connor

We are constantly working to address the issue of stigma in mental health services and fund a number of initiatives in that regard such as SeeChange.

That is not my question. I am asking about the negative perception in the media which blocks people from being recruited.

Ms Anne O'Connor

We have funded a number of initiatives. Recently in the north west a lot of work was done in publicising child and adolescent services. A team attended an international conference and did a lot of promotional work on what it was like to live in the area. The mental health division is part of the wider HSE and there are certain ways of working that are common across the HSE, within which we must work. We are trying to work with our services in promoting the areas within which they operate. For example, one can recruit a panel of 100 nurses but in recruiting a team to work in County Kilkenny or County Donegal, for example, we can show how it works and what the lifestyle is in either area. We are trying to change the way in which we promote areas in order that it becomes real and about living and working in a particular area.

Does the HSE use exterior agencies to do this or is it done internally?

Ms Anne O'Connor

We do it ourselves.

Chairman

The remaining members have literally three minutes each.

Because of the turmoil this week, I only got to see the report yesterday. I do not know when it arrived, but it contains a lot of interesting and good information and I would like a little more time to digest it. Perhaps we might return as a committee to a few of the issues raised. There is a lot of information included in the appendices which needs to be scrutinised a little better. On page 43 is shown the posts needed to meet the recommendations made in A Vision for Change: 477 in general adult services; 460 in CAMHS; and 200 in the psychiatry of old age service, giving a total of 1,137. How many of these posts have been funded? Does the HSE have the money to fund them? How many could it fill right now and how many would be left to be filled for which funding would be needed? Deputy Anne Rabbitte made the good point that a team of seven was small and that if one was missing, it greatly inhibited the team's ability to deliver. It is very difficult to deliver an effective service in such circumstances.

The HSE probably has a number of teams which have been fully filled. What is their output? If the HSE could determine the outputs, it could work out what the increase would be in creating new teams. If it focused on specific areas, it could increase output in this way and achieve the targets set. If it did not achieve its targets, it would have to ask why. The committee is also trying to achieve this.

Chairman

That is the only question the Deputy can ask if he wants to receive a reply as we have run out of time.

The Psychiatric Nurses Association and the RCSI engaged in a detailed review. The HSE also carried out a review.

What was put forward was positive. I am aware of ten areas where there are deficiencies. I would like to analyse them further and determine what is needed, such as how many high-observation beds are required. I would like a timeline within which improvements can be achieved. I would like targets and key performance indicators to be set. We could then begin to break through and determine what is needed to improve the situation over a certain timeline. If we achieved that, it would be great, but if we do not we need to determine why.

Chairman

I ask Ms O'Connor to be quite brief.

Ms Anne O'Connor

In terms of the performance of teams and numbers of people, in a performance report we look at the number of clinical people and how the team performs every month compared with other teams. We have that information every month and feed it back to teams. It is fair to say that it is not always the case that teams with vacancies are performing poorly. We have teams that are fully staffed which do not necessarily perform. The other challenge in mental health is that we have one of each discipline. If an occupational therapist is missing, nobody else can do that job. Nobody else can be a social worker. That is a challenge. Ms O'Neill can discuss funding.

Ms Yvonne O'Neill

Reference was made to page 43 of the documentation provided. It shows the current number of whole-time equivalents, WTEs, in post. In addition, we have the approved funding for the unfilled post, which, we have clarified, is ring-fenced. When we receive programme for Government funding for expanded teams, we recruit personnel for the teams and the money remains ring-fenced. If the additional funding available for posts was added, the number would probably go up by another 5% across the teams. There are approximately 300 to 500 unfilled posts. We do not need funding, we just need to recruit people.

In our calculation, we noted that the number of staff paid for through agencies is not reflected in the WTE numbers, but it is equivalent to in the region of another 1,000 WTEs. That is across all services, including community, acute and inpatient provision. There are 9,500 WTEs currently in place and the adjusted population calculator in A Vision for Change stated that we need approximately 12,500. Posts funded by agency add another 1,000. We are actually at about 11,000 in terms of the numbers in A Vision for Change. The Deputy is correct: all of that should be put together and gaps determined. To be fair, that is the level of analysis and work we are doing around improvement projects.

Chairman

There are two more members who want to ask questions.

What I am going to say will not make me popular, but I am coming at this from a different angle. I am not qualified in mental health. I happened to be my party's spokesperson on health in the Seanad when A Vision for Change was introduced. I challenged and welcomed it, and thought it was a huge move forward. On many occasions, I have seen a change in patients or friends of mine.

I admire psychiatric nurses for the work they do. It is a job I simply could not do. I was the only Government Deputy in Roscommon-South Leitrim from 2011 to 2016. The accident and emergency department in Roscommon closed and we wanted to build three different facilities. There is a mental health facility in Roscommon hospital. We approached it and said we wanted to build an urgent care centre, a rehabilitation unit and a palliative care service for the Mayo-Roscommon hospice. The total cost of the development would have been €20 million. We wanted to use the six or seven acres of land that were available and offered to pay for a new mental health facility. We waited six or seven months but were then told that it would inconvenience patients and staff. Five years later, people are complaining that the Roscommon mental health facility is not fit for purpose.

We had to build an urgent care centre over what was the endoscopy unit. We are now building around the mental health facility at the back of the hospital. A rehabilitation unit for the west of Ireland is being built. There may be issues with staff but services should be about patients. On local radio, I called on management and staff to work together. At 6 o'clock one morning I received 20 phone calls from psychiatric nurses. Those in any other occupation who engaged in such behaviour would be taken to court. In fairness, I explained to them that I did not say what was alleged. Psychiatric nurses have a tough job and represent their patients, but they should not target politicians. The action was unprofessional and nasty. The people involved should have known better.

I know what the witnesses are going through. Issues should be highlighted. Mental health should not be a political football. This should be about the patient. How have services improved? What the Chairman is doing today is vital. What happened to me stopped me from getting involved again because I was scared. People in the Psychiatric Nurses Association who should have known better told lies to their staff. When I explained to them that what they alleged was not what I had said, they understood my position. These people should have known better than to ring a politician at 6 o'clock in the morning. I would not do the job the witnesses do for anything.

Chairman

Does the Senator want them to respond?

I want them to respond. Have things improved?

I second what Senator Feighan said. I live on the other side of the constituency wall in Portumna. I was in contact with some psychiatric nurses who felt very aggrieved by what happened with management staff on the Roscommon side.

Ms Anne O'Connor

In our document, we reference the importance of having a recovery. Mr. Hennessy can speak as our head of engagement. Things have improved. We are fully committed to putting service users at the centre of what our business is about. Mr. Hennessy came into post a year ago as our head of engagement with service users and family members. He is driving the service user agenda. We now have an area lead for engagement within each community health organisation and the critical thing is that for the first time this has allowed us to have an equal voice for service users at our management table.

Mr. Liam Hennessy

I am a service user, possibly the only one at the table today. In other occupations, that might have been seen as possible barrier to employment but, in the case of the HSE and the mental health division, it was actually a requirement in order for me to take up the post. The post was about putting in place structures across the country which would allow service users and their families to be involved in the delivery of services, as well as monitoring services as they are rolled out. Local structures have been put in place by the nine area leads across each CHO, which the national director referenced.

The curious thing is that, even at this early stage, we are starting to get feedback from the structures. The national director emphasised in public that this would not be just about consultation because it has been done in the past and largely ignored, or at least that is the perception of some service users and their families. The national director has emphasised very publicly that this is a two-way process. Services will be obligated to respond to the issues raised by service users and their families.

Chairman

I thank Mr. Hennessy.

I would like some clarification. I spoke about budgets two weeks ago. They are confusing. It is important to get figures from the nine CHOs and break them down because cuts are happening even though we have been told that is not the case.

One of the transition and transformation requirements is that hospitals must close in order to free up resources to provide community-based care. Recently, in my own area of Carlow-Kilkenny, St. Dympna’s in Carlow closed, as did St. Brigid's in Galway. The witnesses gave all the figures, although those figures only go up to 2016. In Carlow-Kilkenny, people now have to go to St. Canice’s. I am a firm believer in having community-based services. Does the HSE believe that, by closing all these hospitals, it is providing the service that people need? We have to accept that there are long-term patients but there are also short-term patients who need to go into hospital for, say, a month or two weeks. We need to get clarification on that because it is a major concern for people.

Regarding CAMHS, there is only one pilot under way, which is an advocacy project in CHO area 2. When is that to be rolled out to the nine CHOs? It is fine to say “We are working on it” but this is needed now. I have a concern when the HSE keeps saying money is not a problem. Every area is affected and we all need to make sure this happens in all of the areas.

On homelessness and housing, the witnesses say that the HSE is working through local authorities for people who need to go back into houses, which is excellent. What measures are in place? Does the HSE buy or rent houses? I know from dealing with people that there are many who are renting but who are confused and do not want to stay where they are. Who decides where they go? Is the HSE buying or renting houses and what agencies are involved in this? I ask that the witnesses clarify those three issues.

Ms Anne O'Connor

On bed numbers, we are implementing policy in the context of A Vision for Change. As a result, the numbers are set out. The model is about closing institutions and having acute units, etc. The gap that exists is more to do with the absence of other supports. It is not about having lots of beds everywhere because people should be at home and supported to live at home.

In terms of advocacy, this has gone to tender. The CAMHS advocacy project has been extremely complex in that advocacy for children is very different to having advocacy in place for adults, for all sorts of reasons. We have gone to tender for an external agency to run that. That tender is out and we hope to commence that initiative at the end of this year, although I am not sure of the date as we have to do the pilot piece first to see how it works.

On housing, we do not buy or rent houses. The whole ethos is about people living in their own homes, having their own front doors and their own tenancies. We are working with housing agencies, for example, the Housing Association for Integrated Living, HAIL, and with local authorities. We have a very significant project under way as part of the policy relating to housing transition, which is about moving people into their own homes and being supported. As the health service provider, our role is to support people from a health perspective in their own homes and we work with local housing agencies in that regard. Obviously, the housing environment has impacted upon that but we have divested ourselves of many of our low-support hostels. We previously had people living in health-owned housing, which is really not appropriate in the current age. We have given many of our properties over to housing agencies and local authorities for them to have proper tenancy arrangements with people.

I thank the witnesses for their presentation. One of the first things that jumped out at me in terms of the transition and transformation chapter is that the HSE's mental health division was established in 2013. We can see, therefore, that a considerable amount of work has been done in the past four years in delivering on A Vision for Change, although it will be very challenging to progress that.

I am interested in the prevention side and, in particular, whether the HSE has provision for research into how to deal with the evolution of social media. I am very concerned about the impact this is having on young people. Where is that kind of research catered for within the HSE's budget or how does the executive conduct that type of research? I would have thought it would be crucial for the delivery of services to try to understand how to prevent difficulties in this area. I know the Healthy Ireland framework would be a big part of this.

Section 38 and section 39 agencies obviously do vital work across the country. I am trying to figure out how the HSE can ensure fair access across the country to the services that are provided. One could be lucky enough to live in an area where there is a very active agency whereas that would not be the case in another area. I am trying to establish how the HSE is going to ensure there is an evenness of services or equality of access to those services across the country, regardless of where they are located. If the HSE can provide a list of the section 38 and section 39 agencies and the funding they receive, it would be very helpful.

Ms Anne O'Connor

We have a social media campaign, Little Things, which is broad mental health messaging that we are now adapting specifically for CAMHS and other groups. The HSE has quite a good digital media department and we are doing a lot of work with it in looking at how we can develop a better presence in terms of mental health supports and access. At the moment, at the request of the Minister, we are looking at having a single type of portal and IT access on mental health. The work that goes on in respect of promotion and prevention really sits within the health and well-being division. Just today, the HSE has launched a new Twitter tag in the context of health and well-being for schools, so there is a whole Twitter feed that is going to push out health promotion and health and well-being messaging to all the schools in the country. That has been a very significant initiative. From a mental health promotion perspective, we are part of that and there is a mental health promotion officer working with the health and well-being division.

With regard to the section 38 and section 39 agencies, we will send the Deputy a list. We covered that at the last meeting so we have that information available.

Ms Yvonne O'Neill

The last published annual statements are for 2016 and at the back of that document there is a list of every funded agency and how much is funded. However, we will separately provide that as part of the financial data.

Chairman

Is that satisfactory, Deputy?

Chairman

I did not get my tuppence ha'penny worth as I did not get to ask my questions. I am sure the witnesses will be glad to know that we have run out of time. I once again thank Ms O'Connor for what she provided yesterday. I am struck by the vastness of the HSE's remit - it is absolutely enormous. I think the members and I are struggling a little so, before the witnesses came in this morning, we loosely agreed that we are going to focus on three areas, namely, primary care, funding and recruitment. We see this as three modules, so we will be asking the HSE to come back in every now and then to help us to see where we are at, what the baseline is and what we are achieving.

I see Deputy Rabbitte wants to come in.

Certain dynamics might have changed from this morning's meeting. It will be a question of assessing the responses we get back in order to determine our baseline.

Chairman

Yes. What I was going to add is that we have a private meeting next week at which the members will decide on and confirm this. While all the other information is obviously crucial for the future of Ireland, there is only a certain amount we can do. We are in a very precarious position this week and all of it could have gone down the Swanee, so we are definitely going to focus on the three areas.

Again, I thank all of the witnesses for coming in and for answering so many questions. We will let them know what we will be focusing on after next week.

The joint committee adjourned at 12 noon until 2 p.m. on Wednesday, 6 December 2017.