Mental Health Services: Discussion

Chairman

I welcome Professor Joyce O'Connor, former chairperson of the expert group on mental health policy; Dr. John O'Brien, vice president of the Irish College of General Practitioners; Dr. Brendan O'Shea, director of the postgraduate resource centre at the Irish College of General Practitioners; and Dr. Brian Osborne, assistant director of the mental health programme at the Irish College of General Practitioners. On behalf of the committee I thank witnesses for their attendance today. They will be invited to make a brief opening statement and this will be followed by a question and answer session.

Before beginning I draw attention to privilege. Witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and 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 their mobile phones or switch them to flight mode as mobile phones interfere with the sound system and make it difficult for parliamentary reporters to report the meeting. Television coverage and web streaming would also be affected.

Any submission or opening statement made to the committee will be published on the committee website after this meeting. I invite Professor O'Connor to make her opening statement.

Professor Joyce O'Connor

I thank the committee for the invitation to attend today's meeting. I am here in a private capacity, as the Chairman noted. The members are all aware that A Vision for Change was published in 2006 and it has since provided the framework for mental health policy. It is unusual in that the policy has been accepted across parties and everybody sees that A Vision for Change is the policy framework. As we all know, the big problem has been in implementation.

Today I will consider the framework for the delivery of mental health supports and services, and in doing so I will deal with three matters for discussion. The first is the wider view of mental health supports and services. The second is the establishment of an interdepartmental group at national level that would deliver locally; it would be a cross-governmental working group. All of us are in the community health care organisation areas and we can influence what is happening in these areas because we live there. Although the issue is national, it is also local and it affects everybody. The third area on which I will speak is the Mental Health Act 2001, particularly the amendment of the Act to include the idea of an approved clinician. I will speak to that later.

When speaking about mental health services, we must take a wider look as it involves both supports and services. In the documentation there is a diagram from A Vision for Change and the members are familiar with it. It highlights the matter. Community support, primary care and mental health services are outlined but the vast majority of people, or 90%, are seen within that big area. It is where GPs and primary care comes in and people with mental health difficulties use them for help. We need to create a public awareness and shared understanding of what is mental health. This is about mental health supports and early intervention at an early stage. It is about delivery for mental health services. Mental health is a continuum, as we all know, and we can all get into difficulties. We do not necessarily need mental health services but we need early intervention. If we are lucky we get it from family, friends or community but we can also get it from GPs, who are the gatekeepers of services and support. In creating a shared understanding of mental health, we will have the key to the delivery of effective services. It will help young people and adults to assess services. If we have a prevention model, we will be able to do our work much more effectively. We know from international research that 75% of all mental disorders have already begun under the age of 25. The early intervention is important.

Within the GP service and community there is an array of elements. I will leave my colleagues to speak for GPs and primary care, and I am sure they will do it more effectively than I can. There are other people in the community, including nurses, psychologists and counsellors. There is an array of people in that community. One of the problems - with due respect to colleagues - is that not all GPs know about these services. They do not have the time but they are still the gatekeepers. We need to consider how we resource GPs and that community service. In the wider group of mental health elements, there are a number of issues to be considered. We are beginning the process.

As political leaders in this area, the members can make this happen. We need consultation and advocacy at an early stage. We need awareness and training for GPs, teachers, youth leaders and communities. This includes members of the GAA, rugby and soccer, as well as all kinds of organisations that meet young people. We need to examine how to be more effective with online mental health supports, which are really important. I do not know if the committee is familiar with reachout.com, which is geared towards those aged between 18 and 25. It is for young people having difficulties rather than young people with severe and disabling disorders.

We need to promote families and support them to promote mental health among their young members. We must also support schools and third level institutions.

If we have that within the lower section to which I referred, and I believe many of these services are in place, we need to ask ourselves how we align supports and mental health services and provide access to them. What do we need? We have the building blocks in the community but we need to change the system. I will cite the example of the child and adolescent mental heath services, CAMHS. We all know given the prominence of the issue in the public domain that there are waiting lists for CAMHS. These waiting lists are symptomatic of a system that is fragmented, with referrals for support often inappropriately going to CAMHS. If we spent all our time and effort eliminating waiting lists, we could do so but they would return after a month. We must ask, therefore, what is wrong and the answer is the system. We know, for example, that five of the nine community health organisations, CHOs, do not have waiting lists of more than a certain time. What is needed, therefore, is effective leadership, co-ordination and teamwork, close to full staffing and no recruitment problems.

While members may be aware of this, I was surprised to learn that almost 100,000 staff support young people in different way. They are funded by the Government for mental health supports and services and almost €300 million is spent on youth mental health. This is all documented very well in the Pathfinder report. There is also no single policy for youth mental health or a single Department responsible for it. The focus has not been on local circumstances or areas. What do we need? The joint committee can make a major difference in this regard. We need a system change because while the blocks are in place, the system is not working effectively. We need an interdepartmental working group consisting of representatives of all the Departments and agencies, as well as non-governmental organisations working in the community. This national body could deliver mental health services effectively by providing national co-ordination. Locally, a liaison person would be in place who would help signpost in each CHO area all the services and supports available in the area in question. He or she would also work with general practitioners and identify gaps in services locally.

Some members may remember the severe jobs crisis the country experienced in the early 1990s when unemployment in certain areas stood at between 30% and 40%. At that time, the Department of the Taoiseach brought together representatives of the relevant Departments, agencies and communities to address the issue of jobs. This was a highly effective approach and I suggest we adopt a similar strategy in the area of mental health, taking an overarching, a cross-departmental and an across-Government approach. While there is another approach, it would take longer implement. We should start, therefore, with the area based approach. There are legal requirements in the Public Service Management Act 1997 but the changes required could be made over time.

I suggest that we have a liaison person in each CHO area to co-ordinate the provision of supports and services and identify gaps. These individuals would work to standard operating procedures and there would be appropriate communications protocols, standard assessment processes and co-ordination of the services. This approach would cut waiting times immediately and standardise referral processes. People who badly need mental health services would have access to them, while all others would be directed to general practitioners and community services. There would be an appropriate intervention at a time, place and pace that is appropriate for the person and it would be much more effective. While these changes are under way, systematic change is needed to make a real difference. The importance of interagency co-ordination cannot be overstated. I ask the joint committee to consider this proposal.

My third point relates to the Mental Health Act. I refer specifically to the emphasis placed on the consultant psychiatrist in the Act and the consultants' contract. This is viewed as an impediment to multidisciplinary working. However, a review of the Mental Health Act in 2015 did not recommend introducing the role of "approved clinician" but proposed instead that the matter be considered again. I ask members to consider the introduction of the role of approved clinician, which has been introduced in other countries very effectively. It has been in place in the United Kingdom since 2007, for example, and could be introduced here through a statutory instrument.

There is good evidence that multidisciplinary working can be achieved and lead to approved outcomes. It is not possible to become an approved clinician overnight and a person must complete extensive training and do considerable work to achieve this designation. However, there is also a supporting training programme which has been developed in the United Kingdom. It is known as the choice and partnership approach or CAPA and has been used in Australia, New Zealand, Canada, the United Kingdom, Malta and Belgium. I understand its use here has commenced. The value of the programme is that it enables people from different backgrounds to work together more effectively. While I do not have time to discuss it in detail, at the end of the process an administrator makes appointments for all team members without consulting them. This means the diaries of all team members are put together. This approach has been highly effective in other countries.

I ask the Chairman and members to help make the changes I have set out. The first step would be to make a statement about the wider view of mental health supports and services to help people to understand the complexity of this issue. It is also a simple issue, however. Most of us are at the lower level to which I described and any of us could need help at an appropriate time. However, we will never get it if we have to try to access it at the high level. Members should help people to understand this. This does not require money but belief and commitment.

I ask the joint committee to propose the establishment of an interdepartmental working group to create policy at national level which would be delivered locally. As such, members would know what was happening in their respective areas. They would know what services were available and what could be delivered. This would be very powerful as it would mean everybody could effect change.

The final change would be to amend the Mental Health Act to introduce the role of an approved clinician. I thank members for their attention.

Chairman

I thank Professor O'Connor for her presentation which was wonderfully explained. I invite representatives of the Irish College of General Practitioners to make its presentation.

Dr. Brian Osborne

With the permission of the Chair, Dr. O'Brien and I will share responsibility for delivering the presentation. The Irish College of General Practitioners, ICGP, thanks the Chair and members of the Joint Committee on the Future of Mental Health Care for the invitation to reflect on the development of general practitioner led primary care as it relates to mental health. The ICGP is a professional body for general practice, with more than 4,000 members and associates and 690 general practitioner trainees.

General practitioners are at the heart of the health system. Every day, thousands of people all over the country see their family doctor without any waiting time and receive quality attention and care. Between one quarter and one third of such consultations include a mental health component.

Over 90% of mental health care takes place in a general practice setting. To ensure we can continue to provide that cradle-to-grave service for a growing population with more challenging conditions, and address our retention and manpower crisis, we urgently need to commit to greater resources and a new contract to further develop GP-led primary care.
A large proportion of these daily interactions are driven by the mental health needs of people attending. Maintaining quick and easy access for people to generalist health care professionals in the community must be an overarching objective in the future expansion of primary care, enabling people who are well known to each other in a personal sense to engage collaboratively to address the needs of people attending, in their own communities, and to assist in building their resilience. As general practice services are not associated with any particular health condition, stigma is reduced when seeking mental health care from a general practice team, making this level of care far more acceptable and accessible for people and their families.
The work of general practice is prevention and earlier intervention. Our values relate to lifelong personal medical care, wherein people choose and are enabled to attend a doctor or nurse who they know well, and who knows them and their circumstances well, and where mutual confidence is to the fore down the years and across the generations.
In this submission, we demonstrate what the expansion of GP-led primary care means with respect to mental health, what the challenges are, and what our legislators need to do to ensure general practitioners can continue to be at the heart of a reformed health service. It is the view of the Irish College of General Practitioners, ICGP, that unless adequate capacity is built in GP-led primary care, the remainder of primary care, the secondary care sector, and the broader health system will never function safely, efficiently or effectively. Collectively, we need to undertake a realignment from a hospital-focused system to a more balanced system, where much more care is delivered in communities.
In addition to grave difficulties in secondary care as a result of chronic underfunding of GP-led primary care, there are separate intractable difficulties regarding the way secondary care is delivered in the Irish health system, and it is not the task of primary care to fix these. These difficulties in secondary care relate to an over-reliance on non-consultant hospital doctors, NCHDs, working exclusively with public patients, and a continued failure of secondary care to embrace electronic medical records and administration. Poor communication and a lack of integration between general practice teams, primary care health professionals and secondary care lead to reduced efficiency and effectiveness of the whole health system.
Protracted and grave difficulties are evident in critical bottlenecks in emergency departments, waiting times for most public hospital services, sub-optimal health care outcomes, perceived and actual gross inequalities access, and in well-identified system risks arising from poor continuity of care, which will all continue as the inevitable consequences of a hospital-centric health system, where decades of systematic under-resourcing of GP-led primary care are also clearly evident.
Specialist services in a hospital-centric model will continue to be unable to safely or effectively address present volumes of clinical workload. Much of this workload is best addressed in the community setting, delivered by teams of GPs and practice nurses working in a generalist service, based in practices adequately supported by administrative staff and allied health professionals, with access to focused educational supports, so that more of the mental health care needs of most people can be addressed in the community, closest to where people live and at the most
appropriate levels of cost and complexity. Timely and equitable access to essential and valued specialist care, where necessary, is an integral part of developing an effective overall system.
There is strong international consensus around developing a health system based on strong GP-led primary care. Development of universal access to strong primary care delivers substantial benefits to all citizens, and must now be considered relatively inexpensive, in terms of whole-system health care costs. With respect to mental health, increasing the numbers of GPs and practice nurses, and training and retaining them, is important so that there is adequate capacity to meet the rapidly evolving demand from a growing population. The importance of easy access for people to GPs as point of first contact and early intervention is broadly agreed internationally.
In recent years the ICGP recognised that over-medicalisation has become more apparent in the health system, characterised by a continued and almost exclusive focus on technical, hospital-based medical care. We also question the extent to which the Irish health system supports talking therapy. We accept that we spend over €1 billion on drugs, a large proportion of which relates to psychotropic drugs, when we spend less than €10 million per annum on services such as counselling in primary care. We rely on a GP-led primary care sector which is seriously understaffed.
Initial steps towards achieving a health system based on GP-led primary care must be the immediate reversal of resource cuts introduced under the financial emergency measures in the public interest, FEMPI, legislation, and the replacement of the present general medical services, GMS, contract with one which addresses the needs of people who attend GPs and their practice teams for ongoing medical care.
These two issues, FEMPI and the GMS contract, are constantly to the fore in communications between our college and the GPs who are college members, GP trainees and practice nurse colleagues. GP-led primary care is at present delivered by approximately 3,700 GPs and 1,700 practice nurses. In health systems which are considered more effective than ours, such as those of Scotland, Canada, the Netherlands, Australia and Denmark, there are more GPs and practice nurses who work uniquely with a truly generalist and holistic approach.
In Ireland, at present we have approximately 64 GPs per 100,000 population. They are unevenly distributed, with fewer than 40 per 100,000 in three counties. In Scotland and Canada, the number is between 90 and 100 GPs, with an effective ratio of 0.8:1 between GPs and practice nurses. The view of the ICGP is that we need to plan for a population of 5 million, with corresponding increases in GP and practice nurse numbers. The acute and outstanding needs of rural practice, and practice in deprived areas, must be supported appropriately and urgently, with serious thought given to geographical and deprivation weightings in funding. GP-led primary care is a key support throughout the lives of Irish citizens, supporting them from before birth to end-of-life care and grieving. Every day, people who are troubled by mental health problems attend GP-led teams, with large volumes of care provided by GPs, through mild and moderately severe spectrum mental health conditions, including unipolar and bipolar affective disorders, suicidality, obsessive-compulsive disorders, acute anxiety, phobias, post-traumatic stress disorder, personality disorders, the full spectrum of addiction disorders, methadone maintenance and the psychoses and for ongoing support over years in body image disorders, dementia and post-partum depression. In caring for people suffering from these conditions, general practice has done so without the levels of inequality regrettably associated with most secondary care services. However, during the decade from 2007 to 2017, GP-led primary care has been allowed to weaken to an alarming extent.

Dr. Brendan O'Shea

We are making a case for stronger primary care. Why is generalist care important? Generalist care is important because people are complex and they rarely present with single issues in real life. Generalists deal with the totality of problems people experience and present with, addressing them with regard to their physical, psychological, social and existential context.

If people are funnelled into specialised services for common problems they will quickly become frustrated with dead ends at every step, and such a system grinds to a halt around these dead ends. It is the view of the ICGP that this phenomenon is substantially at the heart of the phenomenon of over 650,000 people on public waiting lists at present.

Failure to grasp this reality results in serious problems in responding comprehensively to the range of problems people with their health. We strongly recommend that legislators recognise the difference between generalist and specialised care, and take effective steps to increase capacity in generalist primary care in communities, as opposed to our historic focus on specialised secondary care.

I will now outline the connection between generalist care and mental health. The ICGP is at present committed to collaborating with the HSE, and all other relevant stakeholders, in assisting in the development of better care for people with long-term illnesses. In the long term, the ICGP supports free primary care at point of access, fully resourced in communities, as critical for success in this objective. We recognise this as an essential, socially redistributive undertaking in our unequal health system.

The ICGP recognises the importance of mental health as a key prognosticator across the range of all common long-term illnesses, and this, together with more effective end-of-life planning, are areas which we have identified as key points in reorientating our historic focus on specialist-orientated hospital care. The people we care for with diabetes and heart failure have better outcomes if underlying depression and anxiety are detected and treated earlier and more systematically. This takes more time on the part of GPs and practice nurses to deliver. However, GP teams are currently critically short of time.

I will now quote a patient representative at an ICGP faculty consultation on regional diabetic care.

In all the care I’ve ever gotten for my diabetes, nobody ever asks me how I am! How am I feeling? It’s all about my HbA1C, the weight, the blood pressure, and the tablets.

The question of how someone is feeling is very important. We want time to address that with people.

Having sufficient numbers of GPs and practice nurses to switch on fully the practice of brief interventions in respect of mood, alcohol, better eating habits and stress handling is essential. General practitioners are highly and consistently accessible to families, parents, carers, children and adolescents. Turnover within general practice teams is exceedingly low, good continuity is evident in the provision of service over years and decades, and there is a high level of contextual knowledge in general practice teams which is simply absent in most instances in mental health teams and elsewhere within the health system.

What more can GP-led teams do? The ICGP is at present committed to delivering actively key national strategies, including Healthy Ireland, Making Every Contact Count, Sláintecare and Forwards Together. We believe we have good policies. We are collaborating actively with the National Office of Suicide Prevention, NOSP. In our elaboration of chronic disease management, we will be advising that mental health and end of life planning be reflected across all the main disease centres. It is not good enough to talk about diabetes and heart failure without looking at the attendant mental health issues that arise in these populations. In 2018, we will be rolling out another national programme of education for GPs and practice nurses on suicide prevention and deliberate self-harm, in collaboration with NOSP. However, we urgently need more GPs and practice nurses so that there is time for more, and earlier, talk therapy.

It is a most pressing concern that increasing numbers of rural practices and practices in deprived communities are closing. Elsewhere, the composition of practice teams is changing. They are very slowly getting bigger, accommodating the personal needs of younger GPs, who are more likely to work part time, and who will not work 60 or 70 hours per week as the current generation of older colleagues have done. In the context of these larger practice teams, the ICGP supports the idea of basing sessional allied health professionals, particularly in psychology, counselling and life skills coaching, in practices. We advise that the most appropriate skills mix be determined at the level of the practice with reference to the specific needs of the community. The ICGP is supportive of the role of more involvement by allied health professionals, but is impatient at delays in this roll-out and remains acutely concerned at the overall shortage of GPs and practice nurses.

In respect of GP-led teams and primary care teams, the ICGP is concerned about the experience of GPs with primary care teams, PCTs. We fundamentally agree with the advice that there needs to be greater networking in the middle and bottom parts of the pyramid. However, we have a lot of difficulty carrying out that networking. The people in the primary care teams do not have working email addresses. They do not have electronic medical records. They are not adequately connectable. We understand that there is a lot of activity in communities but it is not evenly distributed. Some of our colleagues are carrying out research on social prescribing and they are ensuring that their practices are more tightly networked to the services that are in communities. This all requires time on the part of general practitioners and practice nurses who have heaving waiting rooms.

We must look at primary care teams because so much has been put into them by the HSE during the past decade. Research conducted by the ICGP indicates that while over 70% of GPs are well disposed towards this type of networking and towards primary care teams, fewer than 13% of GPs surveyed reported positively on their experiences for the reasons I have given. While all individuals working in GP-led teams engage in full electronic communication, as I have said, most members of HSE primary care teams do not have functioning email addresses and utilise paper-based records.

GP-led teams have, as far as funding constraints have allowed, developed services relevant to people who attend them, but this occurs on an unsystematic and uneven basis, especially due to manpower shortages. The reality regarding mental health care is that most psychiatric illness is cared for in the general practice setting. Further investment here will enable better and earlier prevention in the middle and bottom parts of the pyramid, with less expensive intervention. However, it needs to be recognised that in Ireland, GP-led primary care is relatively and dangerously under-resourced. We are not short of policy. We have implementation deficit disorder.

Dr. John O'Brien

Increasing the numbers of GPs and practice nurses and providing additional sessional inputs from relevant health care professionals will enable better prevention, earlier detection, more immediate care in communities and a shift in mental health care from psychiatric outpatient departments, OPDs, if adequately resourced. Focused transitional funding is essential for this to happen, to increase training and improve retention for GPs and practice nurses. Legislators, administrators and patients can all be confident that given the highly computerised nature of general practice-led primary care, any additional resourcing can be supported by agreed full system de-identified data analysis. Stakeholders can thus be assured that funding is tied to agreed activities. This process is already well established in general practice in terms of the PCRS and Heartwatch data returns, and in the primary care research network activities.

It is the view of the ICGP that the financial emergency measures in the public interest, FEMPI, legislation has destabilised general practice, especially in rural and deprived communities. Within the NHS and many Commonwealth health systems as well as the Scandinavian and Dutch systems, the proportion of health spending in primary care is in the order of 8% to 11% of the total health spend, whereas in Ireland the proportion is in the order of 3.7% to 4%, less than half of the spend in the systems I have just mentioned. This striking historic under-resourcing of GP-led primary care in Ireland is an important rate limiting factor in improving mental health care for individuals and families at this point.

The ICGP is confident that given adequate resourcing for GP-led primary care, substantial improvements can be achieved in the experiences and outcomes for many people with mental health needs who use our health service. The college is closely aligned with best international evidence and with our own national policy framework. First must come the stabilisation of GP-led primary care through relevant and essential investment in building capacity, following which we can confidently implement key policies and continue to make real and positive differences to people who rely on the Irish health system to deliver their essential health care, particularly mental health care.

We have identified a number of action points for the committee to consider. The first is addressing the instability in general practice arising from cuts in funding under the FEMPI legislation. This is sometimes construed as GPs looking for money for their own sectoral interest. This is money for the people who come in to see us. It is so that we can provide the service we need to provide to these people. It is not for us. Second is replacing the present GP contract with an evolving contract to support the primary care needs of all citizens. Third, we call for the use of deprivation and geographical weightings to address the greater health care needs of deprived and rural areas. Fourth is extending the use of electronic medical records and administration beyond general practice to the whole health system. That is a very important component of the integration that is badly needed to avoid waste within the system. Fifth is the provision of adequate sessional allied health professionals in GP-led primary care, especially counsellors and psychotherapists. Sixth is to review and appraise the functioning of primary care teams, increasing input from mental health practitioners. Seventh is ensuring that mental health is effectively reflected across all evolving chronic disease programmes. Mental health does not exist in isolation but is co-morbid with a whole load of other conditions. Eighth is to increase the numbers of GPs and practice nurses towards 5,000 whole time equivalents of each. This is important to provide the time people need to articulate and have heard the problems with which they are presenting in primary care. Ninth is to stabilise staff turnover in all psychiatry services, reducing dependence on non-consultant hospital doctors for service delivery.

What we are trying to address here is the frustration that patients feel at seeing different staff on subsequent iterations of their care within secondary care. It is a common and big problem. Tenth, we should critically appraise care pathways in all psychiatry services, which at times appear profoundly disjointed, often because of resource problems or staffing problems, but which have the net effect of deflecting those who need a service from getting it.

Chairman

I thank all of the witnesses for their input. I would explain to them that we have a speaking rota where the members have seven minutes to ask questions and receive the witnesses' answers. I will start off with Deputy Neville.

I welcome the witnesses and thank them for coming in today. I will take it chronologically. I will field the questions first and give the witnesses a right to reply then.

Professor O'Connor mentioned nine community health organisations, CHOs. She stated that five CHOs do not have waiting lists over a period. What was that specific period and where were the five CHOs? Professor O'Connor spoke about the choice and partnership approach, CAPA. Will she elaborate on that for me? I was trying to listen and take notes. I would like greater elaboration on how that model is more advantageous than what is currently in place. Professor O'Connor spoke of the need for interdepartmental working groups. Does she see that overlapping with any working groups that may be present already at a higher level within the system, because the last thing we want is overlap? We are seeing some overlap in places.

I thank Dr. Osborne for his presentation. He mentioned there is a reduction in stigma when patients are assessed by a GP team or by a GP. Will he elaborate on the factors behind that? Are there studies behind that assertion and specific evidence on that?

Dr. O'Shea stated that 13% of GPs do not have working email addresses.

Dr. Brendan O'Shea

On a point of information, only 13% of GPs positively reported with respect to primary care teams. Primary care teams are not working for general practitioners.

Dr. O'Shea spoke about email addresses not working. Was there a percentage?

Dr. Brendan O'Shea

To the best of my knowledge, at present 100% of other people in the primary care team do not have email addresses. They do not use electronic medical records. They are contactable, for brief windows of time, by phone. Otherwise, it is paper communication. It is incredible that, throughout most of the secondary care system in all of the expensive acute hospitals, they are still working with paper-based electronic medical records.

The witnesses have studies done on that. Last week or the week before, we asked the service provider, the HSE, about the IT system and electronic communication. We were told a certain portion of the new funding of €35 million would be for what was referred to as service improvement - I use the term "to plug holes" - and we still have no figures around that. Now I hear even something as simple as email addresses, a technology that is roughly 20 years old, is not set up for members of staff. What is coming back at us repeatedly is IT systems and IT. We have a huge hangover from PPARS here. There seems to be a fear of tackling the IT issue within the health service, perhaps because of what happened in PPARS long before my time here. We need to get the figures from the HSE on the areas of IT that it is concentrating on with the new funding that it cannot spend in that period. We are told that the HSE uses a priority rota every year but we cannot see what that priority is. Now we hear that we have no email addresses for staff in areas of primary care.

My final question relates to FEMPI. Dr. O'Brien mentioned that FEMPI has destabilised general practice, particularly rural practices. Is FEMPI the only reason the sector is experiencing shortages? If the FEMPI measures were reversed in the morning, would there be a significant increase in the number of people trying to take up the profession? If not, what are the other factors that may be affecting this as well?

Chairman

I remind the members that there will be many questions asked. I ask witnesses to keep their answers as precise as possible.

Professor Joyce O'Connor

I thank Deputy Neville for his questions. I will answer directly on the real problem with waiting lists. The figures that I have are for July 2017. At that stage, urgent cases were seen within 72 hours, 73% of referrals were seen within three months and the total number waiting more than 12 months was 366. There were five CHO areas that did not have any waiting lists in excess of 12 months.

Does Professor O'Connor have the names of those CHOs?

Professor Joyce O'Connor

I do not have all of them. The reason I am hesitating is that those numbers can change. The real problem with these waiting lists is these could have been the waiting lists in July, whereas the waiting lists in September have changed and the numbers have changed. Therefore, these are not reliable. They are all to do with effective leadership in the CHO area, effective teams working together, a full complement of staff and recruitment. The point I was making was that addressing the waiting list is not the issue. It is addressing the system.

That brings me to the Deputy's third question, if I could take it, about the interdepartmental working group. As far as I know, that idea of a cross-departmental agency-NGO working group does not exist. It would be something new that would help focus and address the issues to which my colleagues have referred in a local area. Such a working group would operate on a national level with a mandate, and there would be a liaison person within each CHO area who would document all the services, look at the gaps, see what is needed, create a referral pathway for those who need mental health supports, and then, if necessary, patients could be referred on to mental health services. For example, if we were walking down Kildare Street today and I tripped, I would be sent to St. Vincent's or St. James's where I would see a triage nurse and maybe get an X-ray. I would not see a consultant orthopaedic surgeon unless I had broken my ankle. The problem is that the system is geared towards the specialist services rather than towards GPs. I am suggesting that each CHO area would have that liaison person.

From what I understand, and Professor O'Connor may correct me if I am wrong, there are five CHOs performing better than the others.

Professor Joyce O'Connor

Yes, absolutely. If I can get them for the Deputy-----

Chairman

I would remind Deputy Neville that he has run over his seven minutes and there are more answers required here as well.

Professor Joyce O'Connor

I can get information on what is happening at present for Deputy Neville. He asked about CAPA. CAPA is a training programme for staff from multidisciplinary areas to work together. It is based on staff understanding their roles, having respect for one another and learning to work together in an appropriate fashion. It is an extensive programme and it is very effective. It is evidence-based. It shows that if staff are trained effectively to work together in multidisciplinary teams - my colleagues here referred to different models of care and in this model of care, everybody has a position - no one person is above another. They work together and they work on their particular expertise and resources at an appropriate time and place.

Chairman

Does Deputy Neville want something further?

No, that is fine. I am conscious of my time.

Chairman

All right. Would Dr. Osborne briefly answer Deputy Neville's question?

Dr. Brian Osborne

With regard to the stigma, I do not have the references to hand but I will be happy to send them to the Deputy. There is a large body of international evidence that mental health care is best delivered in primary care. One of the reasons for this is stigma. It is stigmatising if patients, especially younger people, are seen attending psychiatry services. In addition, general practice and primary care offer what is known as the primary care advantage. The general practitioners and practice nurses develop longitudinal relationships over time and build relationships and trust, so patients are happier to come back rather than seeing a different doctor or different health care professional at each visit.

Dr. Brendan O'Shea

Deputy Neville raised the FEMPI cuts and asked if everything would be all right if they were reversed. It will not. FEMPI has taken out more than 38% of funding under the medical card system, which has had a profoundly destabilising effect. It must be reversed so practices can begin to recruit more doctors and practice nurses. There is also a need for a contract. The current contract is 39 years old. It is frightening to read it. As our finances have become more squeezed over the past decade, all practices have had to examine everything they are doing in an increasingly tight way and have had to make difficult decisions about what they cannot care for. I do not have time to spend 30 minutes with an adolescent or 45 minutes with somebody who has just had a diagnosis of colonic cancer to explain it. That is causing our younger colleagues, in particular, to feel very bitter and twisted about it. I do not wish to work in a system that is operating so tightly. We are not looking for more money for general practitioners, GPs and practice nurses. We are looking for more money for more GPs and more practice nurses. There is a difference.

We have some reservations regarding the flat team approach. The primary teams have been set up as a recent example of the flat team approach. They have rotating chairs. It does not work. There is a place for clinical leadership. General practitioners are specialists. We are senior clinicians and the only senior clinicians en masse who are on duty after 6 p.m. any evening. We are community stakeholders. We live in towns and neighbourhoods where we are visible and accountable. We have that continuity aspect. It is not just FEMPI cuts but a better contract.

Chairman

Thank you for that. I will have to move on. I call Senator Murnane O'Connor.

I thank the witnesses for their opening statements. GPs do a great job and it is not easy. I compliment them on that.

I read the report and it referred to the Irish College of General Practitioners having a ten-year plan that contains 14 recommendations. The ninth recommendation refers to building access to primary care mental health services. Representatives of the Department appeared before the committee a few weeks ago and they told us that funding is not an issue. How is the Department working with the plan in the 14 areas that must be addressed? This is crucial from the general practitioners' point of view.

Second, since becoming a member of this committee I have tried to meet various groups. Do the witnesses believe that people who suffer with depression and who do not have a medical card will not visit GPs because they cannot afford it? That was the main issue I encountered when I met the various groups. Can something be put in place and what would the witnesses recommend? Money is the biggest issue there.

I also met some youth groups during the week particularly with regard to child and adolescent mental health services, CAMHS, and I was shocked to hear about a particular school that had applied for DEIS status. This week there was an announcement and more than 257 schools did not qualify for DEIS. If one is attending a non-DEIS status school, one does not qualify for some of the counselling services because one is not attending a DEIS school. That is unacceptable. The schools I dealt with are non-DEIS schools and they have been fighting for counsellors for the last few years. I could not believe it.

I understand that the south east is the only area conducting a self-harm intervention programme, SHIP. It is for young people who self-harm. I met several groups on this issue. The biggest issue is that one can only access that programme if one is over 16 years of age. Many of the people who tried to attend the programme were under 16 years of age and they were told they could not go into the programme. I cannot believe it. Can a system be put in place for younger people under 16 years of age? Many of the young people who went to this group were much younger than 16 years of age and they were just turned away. I was shocked when I met them.

I met many groups because I knew I was due to contribute this week and I wanted to get information on my area of Carlow and Kilkenny. I was shocked to discover from the list that Kilkenny has the lowest number of doctors at 37.

Dr. Brendan O'Shea

Yes, the lowest three counties.

Carlow is the same. I am aware of people in Carlow trying to access doctors. It is not the doctors' fault and I do not blame them. It is just that there are not enough doctors. A group from Carlow met a group from Holland recently. The main issue was that 18 years of age is the cut-off for services when one is young. Then one is an adult. However, in most countries they are provided up to 25 years of age. That is a massive issue for young people. One cannot access services from 18 to 25 years of age. We now have what is called transit, where one is caught if one is over 18 years of age. One must go to adult services, whereas one can get into the system if one is under 18 years of age. Who is deciding the age groups? Can this not be revamped? This is crucial. I was trying to look up information today and I saw that yesterday 73 requests for crisis information were received by Youth Suicide Prevention Ireland. That is unreal. People are crying out for help. There must be a better system in place.

I agree with the witnesses that it is all local. It is about one's own area, knowing one's patients and trying to access these services. It means everybody working together. Perhaps the witnesses could respond to the issues I raised. I was speaking to Senator Kelleher this morning about a family friend I was trying to help a few weeks ago. Her daughter was trying to commit suicide and she was put into hospital for two nights because she was on suicide watch. She came home but what services are there for her and her family? These are the areas that I believe are crying out for help. I hope the witnesses can give me some answers on the different areas I raised because I will be referring back to the different groups I have consulted. I am shocked at the number of groups that do not qualify for different services, yet we are told there is funding available.

Chairman

We are pushed for time. Can Dr. O'Brien respond to that?

Dr. John O'Brien

There was a great deal in that contribution. To start with the funding for mental health services in primary care, we do not see a great deal of evidence of it. We see a great deal of under-provision and extraordinarily long waiting lists. Primary care counselling has a waiting list of four to six months and the waiting list for primary care psychology in my area would be 18 months. It varies around the country depending, much of the time, on social deprivation.

On the affordability of general practice, I take the point that being faced with having to pay for the service is a deterrent. There is no question about that. This is a historical matter and not of our choosing. We would prefer it to be different. However, patients who have a medical card will consult twice as frequently as people without a medical card. If one has a system that is groaning in terms of its capacity to deliver by virtue of the numbers of GPs for 60% of the population, which is the amount without a medical card, and if one increases the consultation rate there by two there will be serious capacity problems. While we are in favour of this type of thing, it must be phased in. One cannot just magic it out of the air.

The Senator also raised the issue of suicide. Suicide is a major concern. Some 500 people commit suicide per annum and it is just awful. In fact, I was speaking to a GP during the week who works in a very deprived area. She told me about the case of a 20 year old whom she had attended. She had been looking for services for this person since the person was in third class.

The person never met the criteria for CAMHS or Tusla and when the family was ready to engage with family therapy, there was a waiting list for that so it never happened. All these deficiencies are within the system. We are failing people, most particularly vulnerable and poor people. The FEMPI legislation measures took their greatest toll among the section of the community that is paid for by the State, that is, the urban deprived and rural communities. It is not an accident that it is where the choke points are now. I was asked if GPs will come walking into practice if we fix FEMPI. The answer is they will not. It is much harder to fix something than to prevent it from breaking. The fixing will take some time. We would want to get on with it fairly sharpish because we are looking at a situation that is destabilising.

Professor Joyce O'Connor

I agree totally with what the Senator said. It is very frustrating because people do not know. That is why having a liaison person in each area who actually does that is really important. I agree with my colleagues here but there are other people in the community who can be used and whom people do not know about. We have to address that.

The other thing, which the committee can follow up, is that the national youth mental health task force report was published on Tuesday. In each of those areas, it has given a timeline and outlined the people who are responsible. Believe it or not, some of the timelines start next quarter. I think everybody would agree we have tonnes of reports but the problem is following up and seeing what has been done. This report has a timeline and people who are responsible. It is absolutely crazy that education is not in that mix and that there are not counsellors in this area. The report addressed that. We need to see that it is implemented. A Vision for Change was set up in 2006 and we are still talking about it. This complements it. We should look at this report and ensure it is contained in it.

A national phone line has been set up for people with severe mental health issues. Has anybody tried to use it? The number is 8255. It creates a referral pathway. If the person mentioned was at home he or she would ring 8255 and would be given the name of somebody in the local area. There is no question that there are funding issues. Our colleagues can go through that in detail. The emphasis should be put on the local. Members should look at their local areas and see what is there and ask if it is being communicated. There are a lot of NGOs getting money from the State and they are focused on different things. The Minister can tell them what they are getting their money for and what they have to do but they are under-utilised. They could work with GPs. It is not just GPs; there are other community resources that would also help.

We all know the problems but we also know what the solutions are so we have to ask why it is not happening. Everybody wants it to happen.

Chairman

We will come back to Dr. O'Shea. There will be a lot more for him to add at the end of the conversation but I need to move on with the questions.

I thank the Chairman and welcome Professor O'Connor and the members of the Irish College of General Practitioners, ICGP. I thank them for coming in this morning. Since we are dealing with the primary care module this morning, I will concentrate on that. To give the witnesses an opportunity to answer my questions I will limit them to a minute if I can. Professor O'Connor referred to an approved clinician at the beginning. Will she expand on that role? Will she address the issue of general practice, early intervention and the GP as a gatekeeper? The appropriate initial referral, or no referral as the case may be in many cases, is the first act which will direct people to the proper person and will substantially reduce waiting lists if people are referred appropriately. I am in the happy position of being on first-name terms with all the mental health personnel in my area and I can pick the phone up and make a priority referral at the drop of a hat. Depending on electronic referrals is fine but a personal phone call is the best referral system I can think of.

Will the witnesses address the issue of social determinants of health and mental health and how it ties in with the inverse care law where the people who need care most get it least? Will the witnesses talk about talk therapy because there is serious over-medication in mental health care, which is probably a reflection of the lack of talk therapy services that are available? The most recent report on health care reform is the Sláintecare report, which covered the entire health service. Sláintecare has the nuts and bolts of how we should attract people into our service and how we should populate our primary care teams, particularly our community psychiatric teams. Will the witnesses address those issues? We know the answers and the solutions but the problem is the implementation. How do the witnesses believe we can implement change?

Chairman

Who would like to answer that?

Professor Joyce O'Connor

We can implement change because we know what we need to do in each area now. We need to put a system into primary care. We need to get all the resources working together and put in one or two liaison officers in that area who will work with GPs and utilise all the areas of health care. I agree that GPs are the gateway. People go to GPs for help so that is a very practical way of doing it. We should insist that all the actions in this report that are starting on 1 January 2018 are implemented. We should follow this through. They are specifying they will do certain things and they have to be done.

The HSE has no information system. We do not know who gets care, what happens and what the outcomes are. It is a priority for it to set up an information system. In the commercial world, they say data are money. Data are knowledge. We do not know what is happening. That is absolutely critical.

The approved clinician is somebody who goes through a process of training and development. Using their expertise they are made the responsible clinician in certain situations. The approved clinician would work in this area. For people who are in CAMHS, the consultant psychiatrist would probably be that person because they are dealing with severe mental health disorders. It gives other people in the team the capacity to make decisions and to move things on. At the moment, the consultant psychiatrist has to sign off as the responsible clinician for all cases. Having an approved clinician is working very effectively in the UK where they have the process and training.

In tandem with the choice and partnership approach, CAPA, a multidisciplinary approach would make an enormous difference because the appropriate people would be seeing people at a different level of intervention and they would be able to sign off rather than always waiting for a psychiatrist. The issue is it clogs up the system. Psychiatrists, who are very well qualified, could then spend their time dealing with really serious cases, which is why they are in psychiatry. Other people, such psychologists, nurse practitioners and counsellors could become approved clinicians. Is that clear?

Chairman

Will Dr. O'Shea contribute at this point?

Dr. Brendan O'Shea

Deputy Harty mentioned Sláintecare and the key points coming from it. In key respects, the ICGP is very supportive of the approach taken by Sláintecare.

We would welcome a shift of care and treatment into communities and community-based services.

On the issues raised by Senator Murnane O'Connor relating to the system of referrals and gating people into age categories, that is, in its totality, care rationing. We feel the greatest and most obvious way to address that is to increase capacity in general medical care so that more can be done at a lower level of cost and complexity so that the right care is provided by the right person at the right time. If enough practice nurses and general practitioners, GPs, are evident, that is the space in which much of that care can be delivered.

We have to be strategic because we cannot do everything and cannot act on all the suggestions. It is the view of the Irish College of General Practitioners, ICGP, that a really important suggestion to act on is this issue of capacity in GP-led primary care. It will solve a greater proportion of most of the problems. If one has the manpower on the ground, one will be able to co-ordinate and signpost issues.

There was a question on gatekeeping. Gatekeeping is critically important for the health system but it is not a politically attractive word. Signposting and care co-ordination are also issues. Care co-ordination is a key skill set of general practitioners and practice nurses. If one has more general practitioners and practice nurses, it is more likely that one will have the co-ordination one is looking for.

Dr. Brian Osborne

I thank Deputy Harty for his questions. It is important to acknowledge that a huge proportion of mental illness can be managed purely with talk therapy. It is much more effective if it is delivered at an earlier stage. As Dr. O'Brien referred to, there are long waiting lists for counselling, primary care and psychology. There are restrictive practices in talk therapy, especially with regard to child and adolescent mental health services, CAMHS. As general practitioners, we can refer patients appropriately, when needed, to psychology and primary care. They are referred back to us and we are advised to refer to CAMHS, which then tells us to refer to primary care. The patient and his or her family are caught in the middle. It is frustrating for patients, families and GPs.

Dr. Brendan O'Shea

On the whole system, secondary mental health care has a substantial amount of funding but in primary care and with regard to international figures, GP-led primary care in Ireland is seriously underfunded. We are spending a lot on health care. It is a question of how we are spending it and where we are putting the funding. We have unashamedly made a case for more general practice and nurse practitioner-delivered care. I hope we have made a convincing case. We believe that a strategic investment in a subsystem that is already electronically enabled will give the best outcome after the spend.

Professor Joyce O'Connor

I will add to that the better use of resources that we are already funding through the NGO sector. Many NGOs get funding. We should look at how that funding is used. That could complement what the committee is doing.

Chairman

Does that answer Deputy Harty's questions?

Yes. Will the witnesses address the inverse care law and the people in areas who most need care getting the least care?

Dr. John O'Brien

The inverse care law works on the principle that poor people have greater problems with their health. The GP that I was talking to during the week told me that, last year, there were 20 people in the practice who had died. Of that group, four were over the age of 60. That gives an idea of what happens when people are poor. They get more ill, more illnesses and they get them earlier in their lives. They usually have a multiplicity of illnesses. This feeds into the financial emergency measures in the public interest, FEMPI, matter because those patients are covered by the general medical services, GMS, contract. The funding going into GMS following the financial emergency measures has resulted in them being unable to get the same amount of time and attention from their GPs because the funds are not there to employ the extra staff necessary to deliver that. If we take that a little further, the service in west Dublin for psychiatry only has two psychiatrists. It has lost one psychiatrist. It operates with locum staff. Several key staff members are missing for a variety of reasons, including maternity leave and not being replaced. The waiting lists have expanded there and now run out to five months for routine matters. It is not routine because 90% of routine matters are dealt with in general practice. If people get beyond a general practitioner, it is far from routine. If we bring it into the mental health domain, the poorest section of the community with the greatest degree of problems gets its resources delivered at the same rate as the rest of the community when it needs more than the rest. If there are twice the mental health problems in a deprived community, then twice the amount of mental health services are needed in that community. That is not what happens and as a result people get much less the poorer they are and the more they need.

I am absolutely shocked to find the lack of embracing of modern technology. I am a politician. I have 30,000 emails and the phone is on 24 hours a day. I do not have the same engagement but every practice and every professional has to upskill. I am shocked at such a simple issue. Anybody can phone me, 24 hours a day. I do not mind. I feel that if GPs are not prepared to upskill with modern technology, it is a huge reflection on general practice. The witnesses can answer me in a minute, but we are talking about the deprived. To me, the new deprived people are middle Ireland. I was at a doctor last week and the waiting room was full. It cost me €45, which I do not mind although I wish I had a medical card. It cost me €45 but it is the same for mothers, although thankfully there is no cost for children under six. I feel that middle Ireland is the new deprived.

To me, primary care has been an issue. I take consolation in the fact that the witnesses mentioned Commonwealth countries. I believe we should embrace more Commonwealth countries. I find that twice as much is spent in Commonwealth countries. In the last ten years, we have embraced primary care centres. I see in my own town of Boyle that one is opening in January, as well as in Ballymote and Claremorris. It is the way forward and care has to be GP-led. There are not many areas around the country now in which we do not have a primary care GP-led centre. Do the witnesses have a view that we should do more?

We are talking about mental health, which has become a political issue. If we were in Opposition, we would probably use it as well. We need more GPs to come out and say what is right with the system. Sometimes, we are happy when we are miserable. My involvement with the health care sector has been absolutely wonderful, including at my local GP. We sometimes need to stand back and have people such as the witnesses, as honest, independent, professional health care providers, to articulate what is good. Unfortunately, that does not sell newspapers. If something is wrong, we absolutely have to deal with it but the witnesses are in a position to speak. People sometimes do not believe politicians but doctors have the trust of the general public. What is happening here today is wonderful.

Sometimes, we need to articulate what is positive.

Chairman

Dr. O'Shea is anxious to get in.

Dr. Brendan O'Shea

I apologise for getting agitated. I shall breathe deeply. It is really important to be clear that the only part of the Irish health system that is uniformly electronically enabled is general practice. In all of the acute hospitals, they are scribbling on paper records, bar the maternity hospital in Cork. Notwithstanding the billions which have been spent in the acute hospitals system, they are not computerised. The other parts of the primary care team which are not GP led are not electronically enabled. We engage with our colleagues in the Office of the Chief Information Officer and understand that they will all have email in the early part of the new year, but it will then be 2018. It is really important to be clear about that. The only part of the health system from which the members as legislators can get reliable big data is from my colleagues and I and our practice nurses. That is the first point.

The second point, which I am delighted to make, is that Senator Feighan is right that we need to be positive about the things that are working. The members are getting good health care because we are the affluent. Julian Tudor Hart is a Welsh general practitioner who stated that the people most in need of a service were least likely to get it. In a corollary to his law, he said this impact is most likely to occur in societies where there are untrammelled commercial interests at work. That is Ireland. That is the image of private, for-profit health care and private clinics. The people we feel most agitated and anxious about are the deprived people attending our surgeries. With respect to the wish to have a medical card, the position of the Irish College of General Practitioners is that we regard easy access to primary care and general practice as a really important social benefit. We are in favour of extending free-at-point-of-delivery primary care in principle, but it must happen on a phased basis and in a way that does not break our services. Our services are at breaking point.

What are the good things we have done? In the Irish College of General Practitioners, we are collaborating as closely as we can with everybody, including the HSE, the Department of Health and the Minister and it is difficult. Senator Murnane O'Connor asked about the contract and our engagement with the Minister. There have been a lot of promises and there is an absolute wagonload of policy but getting the deals done is incredibly slow and people are dying because of it. To go back to the positives, we understand within the college that large numbers of our very young and bright medical undergraduates are interested in going into general practice. We have had an increase of 58% in the number of young doctors applying for our national GP training scheme and have increased the number of places to over 200 this year. In Ulster, however, they have 110 places for a population of 1.1 million, which they think is not enough. I hope I have touched on some of the questions.

Chairman

Does Dr. Osborne want to add to that?

Dr. Brian Osborne

It is perhaps more important to talk about primary care teams than primary care centres. Where the activity takes place is a secondary concern. Building all these new primary care centres does not mean one extra patient will be seen. With the financial constraints the country appears to have, it is more important to invest in human resources than buildings. General practitioners may own their surgeries or be in long-term leases. There are financial constraints that will limit them from jumping from one building to another. In some areas such as Country Roscommon, the HSE is trying to charge Dublin rents. There are huge issues around centres, but the teams are more important. Everyone does not have to be in the same building but they need to be in contact, ideally by electronic communication.

Chairman

I thank Dr. Osborne. I want to clarify something that was explained to me by Dr. O'Shea a few weeks ago. Primary care does not mean a building as such. It means a domain, as Dr. Osborne explained. We will take a batch of questions from four members next. When the fourth member is finished, I ask the witnesses to answer.

I welcome Professor O'Connor, Dr. O'Shea, Dr. Osborne and Dr. O'Brien. I sat on the Committee on the Future of Healthcare and it is an honour to sit on this one. The witnesses are a breath of fresh air. One of our biggest issues has been honesty, accountability, responsibility and leadership. Professor O'Connor mentioned it all in her opening speech. What struck me was something that is a huge issue in any part of the health system. She said the need was not for money because we have the services. She said changes can be made through statutory instrument, that we do not need money and that the issue is how the system is actually run. GPs are the first point of contact and we have all used their services. The biggest point to get across while people are actually listening is that we need the Minister for Health and the Minister of State with responsibility for mental health and older people to listen to people like the witnesses who are straight, honest and at the forefront of what is happening. Prevention is better than cure and it can be done at a very low cost. I listened intently to the witnesses and their documents, which I have read, and submissions have probably been the best we have received in the past 12 months. This comes from all parties and none. I can feel the witnesses' hunger, belief in what they do and drive. These things are achievable but someone has to grow up here. I liked the witnesses' honesty in that regard. I appeal to everyone here; let us grow up, go back to whoever we are dealing with and say this has to happen.

I have been a mental health advocate for 14 or 15 years but today is the first day I heard of the 8255 number. I am disgusted and angry that it is not in the public domain. I am blown away on that one.

Chairman

Does the Deputy actually have a question he wants to pose?

I do not actually have a question today. I just want to commend the witnesses' on their honesty. I have 40,000 questions but we do not have time for them. We need these discussions, so well done.

I bid the witnesses a good morning. The Minister of State, Deputy Jim Daly, mentioned that number a couple of weeks ago when he was here. I had not heard it myself. It is a great facility.

It has been said by everyone that mental health services are best delivered in a primary care setting. I accept that. I have the height of respect for GPs. Some of my best friends are GPs. In their submissions, the witnesses mentioned funding several times, for example, "Further investment here will enable better and early prevention" and "Adequate resourcing for GP-led primary care is necessary. Improvements can be achieved and experiences and outcomes for many people with mental health can be improved". It is all about resources. I feel very strongly that there should be a clinical psychologist in every primary care centre. Some of the witnesses said they did not have the manpower on the ground or the time to listen to people for more than a few minutes. I feel very strongly that I would not go to a GP in these circumstances. I would not go to a psychologist with a throat infection. I would prefer not to be seen in a primary care centre by a GP but rather by a clinical psychologist. There should be a clinical psychologist available in every primary care centre just as there is a GP. That is a way forward. One would walk into a primary care centre and make an appointment through the receptionist with one's psychologist rather than with one's GP. That would free up the GP to look after people with throat infections and allow psychologists to do what they are trained to do. Some of them will have studied for nine and ten years to get a doctorate in clinical psychology. That is a very important thing and it would alleviate waiting lists and a lot of the pressure GPs face.

I agree with Professor O'Connor about the liaison person. There are many services on the ground and many NGOs, and nobody knows what is going on. Some services are running in parallel and some areas have no service.

It would be of a significant benefit if there was a liaison person in every county.

We talk about money all the time. I cannot believe the email situation. I know somebody in a primary care centre who spent several hours one afternoon trying to put their name and address on the bottom of their email in Irish because they were instructed to do so by the HSE. To me, that is a huge and utter waste of finances. Over €1 billion is going into mental health every year but nobody knows how it is spent. The reason nobody can get this breakdown is because the figures are not electronically linked which is outrageous. Will the witnesses give their opinions on the provision of psychologists in primary care?

I thank Professor Joyce O'Connor, Dr. Brendan O'Shea, Dr. John O'Brien and Dr. Brian Osborne, who have various titles and accomplishments. It seems to me that the pyramid that Professor Joyce O'Connor presented needs to be turned on its head, which we can do in our report. We often start either here or there when what we need to do is turn it on its head. That is where most people are and where the prevention and early intervention can take place. Even graphically that is an important message for the committee.

Professor Joyce O'Connor made clear recommendations on what the committee can do. My colleague, Deputy Harty, spoke about approved clinicians. Will Professor Joyce O'Connor give more details about this proposal? The committee can explore it in greater detail because it seems to be a practical proposal. It would also be good to hear more about CAPA, the choice and partnership approach, because it seems to be practical.

Will the GP witnesses give more detail about the weighting for deprivation and rural communities? Are there models we can examine on how that weighting might be done? The poorer one is, the more stressed one is and the more likely one is to suffer poor health and poor mental health. Have the witnesses any suggestions for further exploration of this area?

Senator McFadden spoke about clinical psychologist provision. I am struck by how we spend €1 billion on drugs but €10 million on counselling and primary care. That would seem to be a proportion which we need to invert. Will the witnesses point us in the direction of those who might help us to understand such an inversion? It would be better to see €10 million spent on drugs and €1 billion spent on prevention. That money is in the system but it might be spent inappropriately.

I thank the witnesses for their presentations which informed me a bit more.

Going back to the IT debacle, the national children's hospital is due to open in Rialto. At its core, it will have IT. Another submission from the hospital would be important. That will be the benchmark for the future and will not involve retrofitting. I cannot believe there is not a WhatsApp group, for example, or other simple method to keep people in contact with each other.

The queues for outpatient departments in mental health services are heart-breaking. We need to shift that fundamentally back to where people belong to and their local areas. Most people, particularly younger people, when faced with an enormous queue will walk out and not avail of the services. The €1 billion spent on medication and medicating policies are issues which we need to talk about at this committee. I find them dubious at times but certainly up-ended.

The common problems being drawn into specialised services which are adding to the waiting lists were brought up. We are dealing with well-being and the majority of people. It is not mental ill-health such as psychosis or an enduring mental health issue. We need to turn primary care centres and GP practices into well-being hubs which will involve early intervention. We are trying to do away with stigma but well-being is a much more acceptable word for everybody from the four-year old child to the elderly person. We need to take this on board because the majority services are required for people in crisis. We all go through crisis but do not have to be labelled mentally ill as a result. We just need to strengthen our resolve and get supports to allow ourselves come to solutions to get back on track.

Professor Joyce O'Connor

There is a common theme coming through many of the questions.

Senator McFadden's point about psychologists links in with the approved clinician area. They are trained and equipped to intervene at an early stage and can refer an individual. That is the point I was getting at when referring to the availability of clinical psychiatrists and counsellors, as well as other types of therapists and interventions, in local areas. Whether these would be in a GP clinic is another matter, but it is important they are in a local area where they can be accessed. An approved clinician, which is what a clinical psychologist would be, will be able to sign off or refer an individual. We need to look at what is available in the community, use the expertise of a range of professionals in the mental health area and not underutilise them.

CAPA means people have to work well in teams. The primary care team could well do with an intervention from CAPA where they are trained to work with one another effectively, recognise their expertise and what they can contribute. Dr. Ann York is involved in CAPA and it is available in three centres in Ireland. We can certainly send on information about that to the committee after the session. It gets people to work well together.

The lack of communication is the one issue about which every member spoke. There is a real issue about electronic communication but there is also an issue about recognition of others' expertise and being able to communicate effectively. The area of IT is absolutely critical. Data are important in every other area of life. People are making businesses out of it. The fact we have not got a connected information system is bad. The good news is that it does not take long to remedy it if there is a willingness to do so because one can leap over old technologies quickly. However, it needs that investment to ensure the system is in place.

If someone was meeting in two or three years, he or she would have all of the data to hand. He or she would know who they were seeing, where they would be seeing them, the outcomes, what the effective therapies were and who in the system was working, including GPs, counsellors and nurses.

On the comments made by Senators Colette Kelleher and Máire Devine, this is about well-being. We all go through difficult periods and need to talk to a GP and a psychologist to work through the issues. I ask the committee to start creating an understanding about mental well-being, mental fitness and mental health services because the public needs to know that services are available at that level.

Dr. John O'Brien

I thank Senator Gabrielle McFadden for her contribution. There must be an awful lot of throat infections because it is all people seem to think I do. I wish it was the case, but it is a little more complicated than that.

We teach our registrars and trainees that general practice is holistic, encompassing the biological, psychological, social and existential problems people bring with them and they are multiple. They include loneliness, grief and financial problems, among many others that will not be found in a medical textbook. We have a continual relationship with patients over many years. It is an iterative engagement that builds relationships and forms emotional capital which can be drawn down at the times people are in trouble. Psychology, counselling and psychotherapy are extremely important resources for us to have at our disposal, but it is not always the case that people are ready to attend those services at a given time. Very often there will be a "Will I? Won't I?" dilemma because it is painful for them as they are exposing themselves in attending a professional. We should not fragment general practice. One of its great strengths is as a central, holistic place into which everything feeds. Any problem can be heard or dealt with, although perhaps not concluded. Other agencies can also feed into it. If services are to be added to general practice in the form of psychologists and counsellors, they will be important.

A meta-analysis was conducted in the United Kingdom which demonstrated that psychological intervention soon after a self-harm episode reduced the risk of reharming by between 30% and 40%. We deal with and contain problems while the waiting lists are being worked through. That is not good as it leads to a deterioration in problems and a greater requirement for more expensive services that might be available in the secondary care system. If the problem can be tackled in the place of least complexity and the guns are brought to the front line, one is likely to have a greater impact. As a country, we spend the same as the OECD average, but we do not spend or divide it up well. Earlier people were harping on about the FEMPI legislation. If the State persists in investing 3.5% to 4% of national income in general practice, I am afraid we will end up with the same results. If someone has pyrite in his or her house, the basement should be fixed, not the attic. We are in the basement.

I thank the delegates for attending and appreciate them giving of their time. Many of these issues were addressed in the past. Am I correct that Professor O'Connor was chairman of the previous expert panel in 2004?

Professor Joyce O'Connor

In 2006.

The fact finding mission started in 2004 and a substantial 288-page document was produced.

Professor Joyce O'Connor

That is correct.

While we offer accolades for all of the good words that have been uttered at this meeting, they were all committed to paper 13 years ago. As a member of the Joint Committee on the Eighth Amendment of the Constitution, I am stickler for profiling people and conducting research. Page 15 of the document mentioned the need for multidisciplinary teams, to adopt a recovery perspective, to formalise links between specialised mental health services and for service users to be viewed as active participants. There is nothing new in this. In her opening comments Professor O'Connor said we should again consider an expert group or putting people into different positions, but the groundwork has been done. A Vision for Change was an excellent document, but how the HSE approached it might not have been best practice in the long run and it is coming home to roost.

I am my party's spokesperson on children. Professor O'Connor mentioned the numbers on waiting lists up to the end of July, but I have figures to the end of September when there were 2,333 children waiting for a referral for their first appointment, of whom 861 had been waiting for longer than three months. The list goes on, with 521 waiting for more than six months. What direct access do GPs have to make a referral? They need to know the baseline because nobody is in a better position than a GP to make that assessment and an early intervention. We all know what "acute" means and GPs are in the best position to identify it. It is when children need to be transferred immediately to CAMHS. Why are there roadblocks to prevent early intervention? That issue falls at the door of the HSE. How is it being addressed?

I thank the delegates for attending. I apologise as my voice is failing. I read their submission with interest. We previously discussed at the Committee on the Future of Healthcare the critical role played by GPs and the primary care service at all levels to try to get the health service back on an even keel. The ratio of GPs is 64 per 100,000 people. It needs to be 90:100,000. How can it be achieved? Are there sufficient students in the universities to move to the IGCP for training to increase the ratio? How can Scotland achieve it but not Ireland?

The submission refers to primary care teams. Only 13% of the GPs surveyed reported positively on their experience of such teams. Why is that? I would have expected the figure to be much higher. What can be done to improve it? Everything goes back to trying to deal with as much as possible at primary care level. That would go a long way to solving many problems across all areas.

A significant number of section 39 organisations deal with mental health issues.

While many of these organisations are doing excellent work, what is the experience of the Irish College of General Practitioners, ICGP, in this regard? Do the organisations integrate well with primary care teams and general practitioners? Does each organisation know what the next organisation is doing? Do they refer back to the ICGP? Can we do anything to improve that scenario? I received a query this week from a person who works in this area. Her suggestion was that where possible, these organisations should all be located in one building with shared receptionists and shared costs to try to get the HSE better bang for its buck. I am interested in the view of the ICGP on that suggestion.

I thank the witnesses for their presentations. From everything they have said, I can hear how committed they all are to public health and I wish to acknowledge that.

Earlier, Deputy Rabbitte referred to how Professor O'Connor was involved with A Vision for Change, which was published in 2006. My focus to a major extent is on mental health well-being and the health promotion side of things. Has Professor O'Connor seen any change in young people who present suffering from anxiety and so on because of the various things that can go wrong as a result of exposure to social media? It is only in the past six or seven years that social media has taken off and become a major part of the lives of young people. I am concerned about the amount of young people, including primary schoolchildren, who are now experiencing mental health issues. It is incredible to me as a mother. I often ask myself how I would manage the social media business if I had young children now. I am keen to hear the views of Professor O'Connor.

I am interested in the impact that alcohol has on mental health. I do not think we do enough taking about the negative impact it can have. It is a lovely social lubricant - no one is being prohibitionist - but we need to inform our people about it as well. I know front-line general practitioners do this but I am keen to hear from the witnesses as to whether we are doing it enough. The HSE's askaboutalcohol.ie website is fantastic but are we doing enough to get the messages out?

We now have new communities coming in. They include people who have come from countries where certain practices are the norm such as, for example, female genital mutilation, child marriage and so on. Attendant problems can result. How do general practitioners manage that? Is the college training GPs to recognise if someone has been subject to these practices? Such people would have all the trauma associated with them and this can have an impact on their mental health. Is there an associated training programme now? It is only in recent years that we have begun to deal with people coming from countries such as Sudan or wherever. Is there a programme for GPs or practice nurses to enable them to know what to look for if people come in?

Chairman

I would like to be the fourth person on this batch of questions. I have two brief questions. We see a high number of referrals to the emergency room for people who have suicidal ideation. Do they go on their own bat to the emergency room or do GPs refer them? If GPs or those in the emergency room are the only people who really operate outside the nine-to-five system, how can they support the person who has suicidal ideation?

The ICGP representatives referred to the negotiations with the HSE and the possibility of a change of contract. Can the GP representatives inform us of their position with the negotiation with the HSE? How is it developing? Is there any timeline for it?

Dr. Brendan O'Shea

I will go in reverse order and take your questions first, Chairman.

The Chair asked about referrals to the emergency department. People who are being referred to the emergency department under these circumstances absolutely do not want to be there. Often, the general practitioners who have to send them in do not want to send them in there either. Under the current system, they go from an experienced general practitioner into an emergency department, which is often exceptionally busy – that is the polite term for chaotic. The person in question waits and is then seen by a junior hospital doctor. Frequently, there is no specialist on-site. There is specialist backup by telephone. That is the system we are stuck with and with which we operate.

As for the contract negotiations, we are not good at this. The last contract was negotiated 39 years ago and there is no memory or process of any of that. As for where the process is at, we met the Minister for Health, Deputy Harris, shortly after his appointment in August 2016. We had assurances that there would be progress on the contract. Regrettably, we have made the contract negotiations very complicated for ourselves because there requires to be a detailed alignment between the Department of Finance, the Department of Health, the HSE, the college, which is the standards-driven body, and the GP representative organisations. Other important people are involved, including the Irish Practice Nurses Association. We have made this very complex. The job the negotiators have to do is exceptionally difficult. To answer the question, as far as we can understand it the negotiations are progressing very slowly in a relatively opaque manner and in a manner that is of concern to those of us who are particularly focused on patient care. This touches on some of Deputy Brassil's points on building up the system. As each year goes by, a further percentage of our young trainees emigrate. They will not work in a work system that is operating the way it does.

Deputy Brassil asked how we build capacity and what can we do. How do we get to 90 GPs per 100,000 of population? The college has increased the number of places on the national training scheme from 154 five years ago to up to 200. The college is ready and able to expand training, subject to funding and building in training capacity. We believe that, subject to funding, it will be possible to increase capacity. This year there has been a marked increase in junior hospital doctors applying for places on the national training scheme. We are positive in that regard.

If there is a new contract, it will make a difference. At present, 17% of each class of graduating GPs leave straight away. They leave to work in Australia, Canada and the UK. GPs in these countries have equality, electronic health care and appropriate processes of referral. GPs in these countries do not have to send their patients into chaotic emergency departments and they are paid reasonably well. If we have a better contract, there is a prospect that the groups who have emigrated in recent years may come home and that we would be able to retain more of our well trained and well qualified general practitioners.

There is another element to fixing the problems that relates to the capacity for practice nurses. I am keen to highlight the situation of practice nurses in the health system at the moment. They do not have uniform access to maternity leave or educational leave. They have no career progression pathway. In general terms, their terms and conditions are significantly limited relative to their colleagues in the hospital setting. We have 1,700 practice nurses who work incredibly effectively. They are all electronically enabled. It is known exactly what they do, but it is very difficult to recruit younger nurses to expand capacity at present. However, if we can equal the playing pitch between practice nurses in hospitals and in general practice, then we are confident that we will be able to increase the numbers of general practice nurses. That would have all manner of attendant benefits that we have referred to already.

Chairman

Does anyone else want to answer a question?

Dr. John O'Brien

Apropos the capacity side of things, it is actually more pressing even than the information committee members have before them. Some 15% of GPs are over the age of 65 and 25% are over the age of 60 years. We have a demographic cliff looming ahead. Much of what we are talking about today is urgent. We cannot simply continue talking like this. It is urgent.

Is 70 years of age the mandatory retirement for GPs?

Dr. John O'Brien

It is 72 years of age for GPs.

Is that another issue? I am asking the question because 72 years of age is young.

Dr. Brendan O'Shea

The college is examining this. We have older GP working groups within college. We are looking to extend. Dr. O'Shea is correct in saying that there is a demographic cliff towards which we are proceeding. Certainly, the college is open to the idea.

We understand that many college members who are older are interested in working, provided that they can be supported in that, so that they will not be dealing with heaving waiting rooms but will be able to assist and help out. We are open to all of those suggestions.

Dr. John O'Brien

We are open to all solutions but we need to see there is a problem. It is also the case that when people have worked very hard in the system for very many years, at 65 years of age they want to go. That needs to be taken on board. Even though they can stay until the age of 72 years, a proportion of them are unlikely to want to stay until they are 72 years.

On the issues of suicide and an emergency room, the UK had a national confidential suicide inquiry and the upshot was that the intervention of a 24-hour crisis team was the single intervention to have the most impact on suicide rates. We need to be focusing on how we do things as much as anything else. If we are to have such crisis intervention teams, they need to be specialist delivered or closely led. They cannot be, as Dr. O'Shea said, a junior hospital doctor being called an expert. That is not true. That is one side.

The other issue is the impact of social media. I agree that it is a significant problem. I do not know how any society is getting to grips with it at present but I think it is a major problem and it boils down to bullying and a range of other things that are very bad. We will see a greater increase in the level of childhood mental health problems coming forward. It will come to us in the first instance.

We have an ambivalent attitude to the abuse of alcohol. We are amused and horrified by it in equal measure. There are two aspects, one of which is that GPs and all health care professionals need to be banging that drum on an ongoing basis, but I also think we need a wider discourse as a community as to how we might address it as this is peer driven. When a person's friends are drinking heavily, so is that person. That is the way of it. Young people in particular engage in binge drinking. It has an impact on mental health, liver disease and I could go on and on. Very valid points were raised.

On the issue of ethnicities and how GP practices are coping with different social norms, I think GPs are dealing with it. I do not know that we have an overarching overall policy. There are different aspects, and some will fall into women's health education which is quite extensive in the college. As I said earlier, a GP takes all comers and takes all problems and addresses them accordingly. GPs have a continuing medical education programme and would have an awareness of the various problems that people in the community are experiencing.

Chairman

Deputy Rabbitte is still waiting for an answer.

I am waiting for two answers, one in respect of a child who presents in a crisis and how he or she can get the acute intervention with a CAMHS team. Second, I addressed a question to Professor O'Connor on her earlier contribution, which has already been identified, and why we have not delivered on it. The roadmap, A Vision for Change, was set out in 2004, but looking at what has been put in place in terms of the CAMHS teams, not one of the teams at this time is above 58.7% of the fully resourced team envisaged in that brilliant document, A Vision for Change, and this happens to be in the CHO 3 area. The HSE has approached the implementation of the policy in the wrong way. The HSE did not put the teams in place before it decided to withdraw services. The HSE withdrew services, such as St Brigid's psychiatric hospital in Ballinasloe, and funnelled them into Galway or Roscommon hospitals, which were not prepared, and then it fell back on the GP services to deal with mental health. I want to understand what the expert group on mental health policy is taking from its document to address mental health?

Professor Joyce O'Connor

I accept that a lot of what we said and what we are saying now is still relevant. The key to it is the delivery of services. I will talk about the HSE. We identified in our document the key area and where the attention needs to be focused. What has happened is that in each area, there is the possibility now of intervening appropriately in each CHO area to free up this group in the mental health services to deal with people who need their care. There are people on the list who should be more appropriately linked there.

To address the issue of early intervention, there is a need to have an overall multidisciplinary body set up at national level with all the Departments, not just the HSE, but I would like to see the Departments of Education and Skills and Children and Youth Affairs and Tusla to take responsibility for this area so that the interventions therefore will be more effective.

To revert to Deputy Neville's question, the areas that have worked more effectively are those that have effective leadership, work well in a multidisciplinary team, have the full complement of staff and do not have recruitment problems. That is clear.

I think part of the way of addressing it in terms of implementation is to work on this area in terms of early intervention.

I could not agree more with Professor O'Connor, who mentioned Tusla, but Tusla does not have a fully functioning ICT system, so when we talk about Tusla social care workers or any other workers, they have no way. There is also a data protection issue because they are not currently sharing information with An Garda Síochána or with the GP service.

Professor Joyce O'Connor

I am sorry, but Tusla has worked out a protocol with the HSE in terms of working in service.

Is it in use at this moment?

Professor Joyce O'Connor

My understanding from the HSE is that it is in service. What I am saying, and Deputy Rabbitte is absolutely correct, is that is it not crazy that we are in this committee room in 2017 discussing a document on which there is an agreement on the policy but we are falling down in its implementation? We know where the blocks are. As a committee, members could write what will make a difference because they can intervene. There is no joined-up thinking. One of the fundamentals of A Vision for Change was integrated services and integrated supports and services and that is only beginning to happen. If that is done, it will make an enormous difference. There is a way of doing it, starting next week.

I could not agree more with Professor O'Connor. One of the problems when a child presents at a GP practice is that the only recourse for the doctor is to refer the child to the child and adolescent mental health service, CAMHS, which must refer the child on. Why can the GP service not make a direct referral to the youth advocate programme, YAP, or whoever is identified as a provider?

Professor Joyce O'Connor

Exactly. That was what was suggested, namely, that in each of these areas, the NGOs that are being paid for by the State through the taxpayer could work with the primary care teams and the GPs. The GPs do not have the capacity to deal with all interventions. They could not possibly do so, and Deputy Rabbitte is honest enough to say that. Therefore, patients can be referred to these other bodies. Section 39 organisations, to which Deputy Brassil referred, are in place but they are not aligned with the policy. What the Minister can do is say to them is that if they are being funded by the State, this is how they must work. They should not work off their own bat.

At the moment, if a patient in Galway presents to a local GP, that patient has to be referred to CAMHS.

Professor Joyce O'Connor

He does not have to be. It is their decision.

I am talking from experience. I am working with people on the ground and I can tell Professor O'Connor that it must go through CAMHS. CAMHS operates the referral system and it decides at what stage an intervention is made.

Professor Joyce O'Connor

That is a roadblock.

We are trying to identify and get around roadblocks for young people and their parents and to see if we can get the correct early intervention so that when GPs make the referral to acute services, the services are available. We also need to stop it going through the one channel.

Professor Joyce O'Connor

Absolutely. I do not know why that is happening but I accept it. However, it is not what should be happening and it is not the right way. If we had a liaison officer in the CHO area the GP would liaise with him or her and they could refer the patient on. That is where the approved clinician comes in, with clinical psychotherapists able to deal with people at an appropriate level and the right time and place to work effectively with the person who needs the help rather than channelling up through a system in a way that was not envisaged and should not happen.

Chairman

One of our aims is to create the roadmap, hand it to the Minister and ask him to implement it. The case in Galway to which the Deputy referred, in which the patient was referred to CAMHS and outsourced from there, is a little bit unusual and should be investigated.

Dr. Brendan O'Shea

In all the cases that need to be referred, a spectacularly effective thing to do is allow more care to be delivered in a general practice setting.

Professor Joyce O'Connor

But not just in the general practice setting - it should be in a community setting so that all the burden is not on general practitioners.

Dr. Brendan O'Shea

Absolutely.

Professor Joyce O'Connor

There are other people in the picture with whom we could work effectively.

Dr. Brendan O'Shea

Practice nurses are critically important, have incredible potential and are incredibly cost-effective but we have a tiny number of them in the Irish health system relative to other, more effective, health systems.

Professor Joyce O'Connor

There are public health nurses as well.

Dr. Brendan O'Shea

We have no idea what public health nurses are doing.

Professor Joyce O'Connor

We could use them as a resource.

Dr. Brendan O'Shea

We certainly could but we do not know what they are doing because they operate in a de-identified, non-data-driven environment.

Professor Joyce O'Connor

Absolutely. We can agree on that. I accept the point about social media and I think it is a big issue. A very interesting conference on technology and well-being was held recently. I will send the data on it to the Chairman. It addressed some of the issues and people are becoming more aware of their implications. To turn this on its head, however, people are also looking at the power of technology to intervene earlier with young people. They are using the ReachOut.com model that was used in Australia and has been very effective. In Australia, there are 1.6 million users and researchers have been able to gather data and look at who is using them. Surprisingly, young people aged between 18 and 25 with suicide ideation often used it positively to help them. E-mental health and technology can also aid GPs in the area of early intervention.

The new communities can be addressed in the education area and if the necessary support was there it could act as an early intervener because they are seen on a day-to-day basis. A joined-up interdepartmental and inter-agency system, in which local community GPs and NGOs work together, is more likely to pick up early intervention issues so that a case does not have to be really severe to get attention.

Dr. Brian Osborne

It is not just the GP and the practice nurse in the general practice setting as there is also on-site sessional talk therapy and Senator Devine mentioned well-being hubs, life skills coaching and counselling, all of which can be delivered in a general practice setting.

I have been a bit parochial because I know a lot of GPs in Galway. There are wellness centres in Galway, as well as positive talk therapy. It is being done really well.

Dr. John O'Brien

I work in Castleknock, an affluent area in Dublin, and within my practice there are three psychotherapists, although they are not there all the time. One of them is a child psychologist. If I need to access a service I can do so and I can do it reasonably quickly. I also have a talking relationship with the individuals who come. Three miles up the road in Mulhuddart, I have a good friend who does heroic work but she has psychology waiting times of 18 months, CAMHS waiting times of a year and CIPC waiting lists of five months. GPs will find the water level and if the service is needed they will be on the lookout for it. They will ask each other who does what and where it is and they are scrounging around to find whatever they can for the individuals concerned. This is bearing heavily on the poor and deprived and they are the people we are failing.

Dr. Brendan O'Shea

This is the inverse care law at work. There was a question on deprivation weightings which we did not address. We can wait for as long as we like for the new general practice contract - and I do not know if it will ever happen - but in the current system the same payment is involved for one of Dr. O'Brien's affluent cases in Castleknock and one of his or Dr. McGinnity's medical card patients in Mulhuddart. A mechanism exists, at the flick of a switch in GMS under the primary care reimbursement system, to put in community deprivation weightings. The HSE has the technology to do that and it can use Health Atlas Ireland for this as it has information about background levels of deprivation in communities and can map the pre-existing resources. When they do this, all the places like Mulhuddart light up so without any new contract they could crank up the payment level and Dr. McGinnity would get €227 per year for looking after a medical card patient, rather than the current €156 per year. I refer the committee to the work of our colleagues of the Dublin Deep End group, which is a group of GPs including Dr. McGinnity and Professor Susan Smith, for more information about this. Deprivation weightings would be very easy to switch on without a new contract if we had the will to do it.

Actions could be taken to ensure more practice nurses and GPs. We fully subscribe to the idea of connectedness in the middle and bottom part of the pyramid and the general practice sector will move rapidly in this respect, though we have doubts about the ability of the HSE to move rapidly on anything.

Chairman

I thank the witnesses for their input, which will contribute to our very important report on primary care. We are indebted to them for the invaluable information they have provided. We will let them know how we get on.

The joint committee adjourned at 12.30 p.m. until 10 a.m. on Thursday, 18 January 2018.