Community Health Care Organisations: Discussion

Chairman

I welcome the witnesses from the community health care organisations, including Mr. John Hayes, chief officer, and Mr. Padraig O'Beirne, area director of nursing for Cavan-Monaghan mental health service, from CHO area 1; Mr. Tony Canavan, chief officer, and Mr. Liam Fogarty, head of finance, from CHO area 2; and Mr. Bernard Gloster, chief officer, Dr. John O'Mahoney, executive clinical director, and Ms Niamh Doodey, business manager, from CHO area 3. On behalf of the committee, I thank them for attending the meeting today. The format of the meeting is that each chief officer will be invited to make a brief opening statement which will be followed by questions and answers.

Before beginning, I draw the witnesses' attention to privilege. Witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they 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.

I remind members to turn off their mobile telephones or to switch them to flight mode as mobile telephones interfere with the sound system and make it difficult for parliamentary reporters to report the meeting. In addition, television coverage and web streaming would be adversely affected.

Any submission or opening statement made to the committee will be published on the committee website after this meeting. I invite each of the chief officers to make their opening statement.

Mr. John Hayes

I thank the committee for the invitation to attend today's meeting. I am the chief officer for the community health care organisation, CHO, which covers the five counties of Donegal, Sligo, Leitrim, Cavan and Monaghan. I have attached maps of the area highlighting the main towns and mental health service delivery locations in appendix 1 of my submission. I am responsible for the overall management of community health services in CHO area 1. I am joined by Mr. Padraig O’Beirne, area director of mental health nursing services in the Cavan-Monaghan area and chairperson of the inter-agency steering group which developed the suicide prevention strategy, Connecting for Life, for that area.

The total population of CHO area 1 is 391,281. It is a largely rural area with a low density population and is challenged by relatively high levels of deprivation, a higher percentage of the population with medical or general practitioner, GP, visit cards and limited transport provision compared to national norms. The CHO was established in 2015 and merges Donegal with Sligo-Leitrim and Cavan-Monaghan to form a singular area with four divisions, namely, primary care, social care - which encompasses disability and older people - mental health, and health and well-being. Acute hospital services in CHO 1 are provided by two hospital groups, the RCSI hospitals group and Saolta University Health Care Group.

The organisation and delivery of mental health services in the area are underpinned by national policy, including A Vision for Change. Mr. Leo Kinsella is the head of mental health services in CHO 1. Each geographical area has an integrated area management team chaired by the executive clinical director and includes area directors of mental health nursing, allied health professionals and service user representation. The main building blocks of the service are consultant-led multi-disciplinary teams including inpatient, day services, day hospital and residential care; specialist child and adolescent teams; general adult psychiatry teams; psychiatry of old age teams; specialist teams such as community rehabilitation and psychiatry of intellectual disability; and mental health services encompassing primary care, including counselling in primary care, CIPC, suicide prevention supports, youth mental health, Jigsaw, bereavement support and so forth.

In terms of CHO 1 capacity and funding compared with the A Vision for Change recommendations, I have included in my submission the data already provided to the committee by the national director for mental health. I draw the members' attention to the particular challenge regarding child and adolescent mental health services, CAMHS, in the area. For the CAMHS teams servicing the population, we have just over 51% of the clinical staff recommended in A Vision for Change. Regarding the resources for mental health services, I have provided the key staffing data at December 2017. In all, we have 940 whole-time equivalents working in mental health services across the five counties.

In the spreadsheet provided, I have divided the budget for CHO 1 into Sligo-Leitrim, €24.651 million; Donegal, €25.778 million; and Cavan-Monaghan, €23.501 million. Of the overall CHO 1 budget for community health care, 19% of the budget is apportioned to mental health services and within that, some 8.4% is for child and adolescent mental health services.

There are two major capital projects ongoing, one of which is in Blackwater House, St. Davnet’s Campus, Monaghan. This project consists of the redesign, refurbishment and extension of Oriel House to meet the needs of the Blackwater patients. Planning permission has been granted and it is expected that this capital will be completed by the first quarter 2019. There is also a new acute mental health unit to be developed in Sligo. This project will consist of a new build unit on the site of Sligo University Hospital with a target completion date of the third quarter of 2019 with an estimated cost in the region of €11.9 million.

I have included some additional information in the appendices around the keys facts of the demography, health infrastructure and some key developments of the posts and location of centres where mental health service are provided.

Mr. Tony Canavan

My name is Tony Canavan and I am the chief officer for CHO 2 which includes counties Galway, Mayo and Roscommon. I thank the Chairman for the invitation to attend the committee. I am joined by Mr. Liam Fogarty, who is head of finance for CHO 2.

I will describe the mental health services provided in CHO 2. I will outline some of the opportunities that are arising currently for our services and some of the challenges that we have been facing in recent times.

Chairman

I am sorry but it is important that we can hear Mr. Canavan and there is a mobile phone causing interference with the sound. Perhaps it is Mr. Canavan's own phone. Will all members and witnesses ensure their mobile phones are on airplane mode or certainly not near the microphones please?

Mr. Tony Canavan

I apologise. I shall briefly outline some of the general direction that we hope our services will take over the coming years.

CHO 2 covers a population of just over 453,000 based on the census from 2016. As outlined by my colleague, the CHO 2 is an administrative structure within the HSE through which all social care, primary care, health and well-being and mental health services are delivered. Essentially, this includes all health services in counties Galway, Mayo and Roscommon outside of the hospital services, which in our area are provided by the Saolta group.

CHO 2 is one of nine community health care organisations. There is a direct line of governance between me as the chief officer and the national director for mental health services. In this way, our mental health services in Galway, Mayo and Roscommon are integrated as part of a larger, national governance structure. The total budget for CHO 2, incorporating all services, in 2017 was €457 million and we employed approximately 4,500 staff across all services.

The mental health services are a very important element of the services that we provide. In total, 1,296 staff were employed in our mental health services last year across a range of grades. The breakdown of this information has been provided to the committee in table 1 of my written submission.

Last year, approximately 20% of all expenditure from CHO 2 related to mental health services, some €99 million for the year. The allocation to our mental health services has increased steadily over the past three years from €92.5 million in 2015, to an increase in 2016 and the spend as I have just outlined for 2017.

Mental health services are provided across a range of settings including inpatient facilities located in all three counties with a total of 125 beds, community-based residences, day hospitals and day centres. In addition to these services, we also have the child and adolescent mental health services, CAMHS, inpatient facility located in Galway city which meets the needs of the population from Donegal and down through the western seaboard as far as North Tipperary. This unit is located in Merlin Park in County Galway. Details of the types and numbers of centres are provided in table 2 of my written submission.

Over the past ten years, in particular, 25 community-based teams have been established across CHO 2 delivering services in the areas of general adult psychiatry, child and adolescent mental health, psychiatry of later life and mental health intellectual disability, MHID. As such the mental health services in CHO 2 can be said to be largely community based with the support of required inpatient facilities. This reflects a change of approach over the past 30 years from one which was previously heavily reliant on inpatient care that focused on illness and centring around large institutions such as St. Mary’s in Castlebar and St. Brigid’s in Ballinasloe, to an approach now focused on community-based delivery and is steadily working towards a wellness model as provided for in A Vision for Change. Table 3 in my written submission provides an outline of each of the community mental health teams we have across the four service areas.

There are opportunities arising for us. In 2016, we completed the development of a primary care centre in Castlebar, which will become a base for one of our community mental health teams. We will shortly complete a similar centre in Westport, County Mayo and we have planning permission to develop a community health team base in Tuam, County Galway. We are also in the process of completing the development of a new 50 bed inpatient unit on the grounds of Galway University Hospital and minor capital works are taking place across a range of facilities in Castlebar and in Roscommon. All of these investments are designed to create further opportunities for us to develop our community-based services that integrate well with other more general health services. This is an important factor of the services we are trying to develop.

We are, however, facing challenges. Recruitment of qualified nursing and medical staff continues to be a significant issue for CHO 2. Subsequently, these difficulties lead to a reliance on services provided through agency staff and the cost and other issues associated with this approach to employment.

While great progress has been made in developing our services along the strategic direction outlined for us in A Vision for Change, there is still a lot of work to do in this regard. We have a highly skilled and motivated workforce that is receptive to the process of continuous improvement, but there are cultural impediments within our services and the communities we serve that we need to overcome if we are to continue to modernise our mental health services. In recent years, the mental health services have led the way in involving service users in the design and delivery of services. I say this in the context of the health services generally. We expect this to develop even further and are very optimistic about the outcomes this involvement will have for our services overall. The importance of integrating our mental health services with other vital services such as primary care and social care cannot be over emphasised.

I thank the Chairman and the committee for their time today.

Mr. Bernard Gloster

I thank the committee for the invitation to attend today. I am joined as a witness by Dr. John O’Mahoney, executive clinical director for mental health services in HSE mid-west community health care organisation, CHO 3. My colleague chief officers have introduced their witnesses and I can advise the committee that we did consult to ensure a mix of some different roles in the make-up of those attending the committee today.

I am the chief officer of HSE mid-west community health care, referenced in previous HSE national submissions to the committee as CHO 3. I am responsible for the overall management of all health services, excluding acute hospital care, in the mid-west. Specific to this committee, the mental health service of the mid-west is one of four service divisions which make-up community health care. The service in the mid-west is part of a national system of nine CHO areas and with regard to mental health I refer the committee to the evidence already given by the national director for mental health and her team in recent months.

The HSE mid-west area covers Clare, Limerick and North Tipperary with a population of 384,998 according to the 2016 census, representing a 1.5% increase on 2011. The mental health service in the mid-west operates as one service with single governance for the service.

The service has one head of service reporting to me as chief officer, one executive clinical director and one area director of nursing. They are supported by an expanded management team in the disciplines of psychology, occupational therapy, social work and management, reflective of the multidisciplinary nature of modern-day mental health services. While there are some county-based aspects for logistical reasons, all operational parts point to one mid-west system with some services shared. The mental health service in the mid-west operates mainly across three specialist domains of general adult, psychiatry of later life, and child and adolescent mental health services, CAMHS. It would perhaps assist the committee to summarise these services, and I have expanded the detailed metrics in the appendices provided.

There were 786 whole-time equivalents employed in mid-west mental health care at the end of November 2017. The mental health service in the mid-west has a dedicated budget, and in 2018, this is set at €66.988 million, having grown from €58.923 million since January 2015. The general profile divide is in the order of 80:20 pay and non-pay. Thirteen community mental health teams form the core of service delivery for the majority of service users. Working in a multidisciplinary approach, these teams receive referrals, mainly from primary care general practitioners, GPs. The 13 teams are in 11 locations. There are two teams in north Tipperary, four in Clare and seven in Limerick. There are three psychiatry of later life teams, of which one is based in Clare, supporting also north Tipperary pending the further development of a fourth team specific to north Tipperary. Two are based together in Limerick. There are six CAMHS teams, of which one is based in north Tipperary, two in Clare and three in Limerick. There are two rehabilitation teams, one of which is based in Limerick and one in Clare, increasingly providing a mid-west focus. Small, discrete teams provide other supports, with one liaison team based at University Hospital Limerick, one forensic team and one mental health intellectual disability service.

The HSE mid-west hospital group has inpatient and residential supports for people according to their need and notes that the desired outcome is to have the least possible dependency on beds and the greatest possible support for people in their own communities. The former large institutions of the old psychiatric hospital era are now out of use for residential services in the mid-west. The mid-west has 81 acute beds with a plan for a further eight which are already built as high observation beds. There are 49 beds for psychiatry of later life, providing some element of intermediate but predominantly long-stay care. A further eight houses are staffed on a 24-hour basis. These provide a high level of support to people with particular needs associated with enduring mental illness, while another 16 houses are not staffed on a 24-hour basis, consistent with the level of independence and self-sufficiency of the residents.

On specific initiatives, in 2017, the HSE mid-west mental health service led and produced a detailed action plan, Connecting For Life, which is inclusive of the three counties and involves 41 key stakeholder interests. The service has developed the advancing recovery policy and secured a specific service reform fund to support and embed the approach across all teams. Strong progress is being made in the area of service user engagement, particularly in the design of services, since the appointment of a full-time lead for engagement.

The HSE mid-west hospital group's mental health service, like other areas, has challenges, many of which arise from the transition of historical models of the institutional era to the modern-day best practice approaches. The rapid expansion of multidisciplinary teams, coupled with economic factors, has presented a challenge in the areas of recruitment and retention, reflective of the wider international health service arena. The demographic pressures in some instances add to the demand, either in volume or complexity, reflected in various ways, perhaps most recently commented on in respect of CAMHS. These pressures lead in some cases to waiting times which would not be desirable. The services are operating to a comprehensive operational plan each year which strives for incremental improvements in response to those challenges.

That concludes my statement and I have included information in the appendices. I am grateful to the committee for its consideration of these matters.

Chairman

I thank Mr. Gloster. I call Deputy Tony McLoughlin.

I welcome Mr. John Hayes and Mr. Padraig O'Beirne from CHO 1. I represent the constituency of Sligo, Leitrim, south Donegal and west Cavan, so that is the area I will focus on. I thank Mr. Hayes for his opening statement. I have a number of questions to put to him. Is he confident that that constituency area and indeed the whole CHO 1 region has been operating to the best of its capacity with regard to the levels of mental health care provision over the past four years? The provision of CAMHS in the CHO 1 region is a major concern for me and has been highlighted on numerous occasions. Would it be wrong to say that it has been operating in a state of crisis for the past while? As of this month, 204 children await an initial meeting with a psychologist. These children have eating disorders, are self-harming, have ADHD and many other issues. Sixteen of these children have been waiting for more than a year to meet a psychologist and six have been waiting for longer than 15 months. This is not acceptable. Why are these shocking waiting times being allowed to happen and how can we stand over these delays? Mr. Hayes, as chief officer for the CHO in this area, might explain what progress we are making and how we intend to overcome the statistics that I have in front of me. Has he discussed staff recruitment? I know that is an issue because some of his colleagues have been in before and spoke about funding and staff recruitment. I welcome the recent appointment of a number of staff there in recent weeks. The lack of funding affects the ability of CHO 1 to provide better mental health services to the public. Mr. Hayes has rightly outlined that the area we represent is very vulnerable. There are many issues in many rural areas. Will Mr. Hayes comment on those questions?

Mr. John Hayes

I will deal with the CAMHS issue first because there is no doubt that at the end of 2016 and in early 2017, we had a particular problem in the Sligo-Leitrim area with the lack of CAMHS consultants. The approved number of CAMHS consultants in the area was two and one person resigned at the end of 2016, then the second resigned in early 2017. At that point, we initiated an action plan to address some of the immediate issues that arose for parents. I have met some of the groups of parents and some of the young people. We reviewed the options available with them. Some immediate action was taken by employing a half-time consultant from Belfast, providing for access outside the area and commencing a process with general practitioners and other people in the area who provide support for mental health to young people. The main focus of the work, however, was on recruitment. We successfully recruited two consultants in June and, from that period to date, we have 2.5 consultant psychiatrists working in the CAMHS.

At the beginning of January 2017, there were 400 people on the CAMHS waiting list across CHO 1. At the end of December, that number was down to 204. In the Sligo area in particular, we have 36 young people on the CAMHS waiting list as of the end of December 2017, which is an 83% reduction from January 2017. That was the lowest month.

At the moment, the Sligo east team has the shortest waiting list across CHO 1. All 16 people on that waiting list have been on it for less than three months. I suppose we want to acknowledge the difficulties. We have worked with GPs as well. If they are concerned about a young person, they can make direct contact with a CAMHS consultant four days a week to discuss the case. If the CAMHS consultant cannot see that young person immediately, advice and support is directly provided to him or her. We can show considerable progress in addressing the issue. However, there is a fundamental issue with recruiting permanent CAMHS consultants. I think that is reflected in CHO 1. We are trying to address the issue. We sent a team to a conference on child and adolescent mental health services in Geneva as part of our recruitment drive, particularly with a view to addressing the issues in Sligo and across CHO 1. A number of consultants are interested and we will interview them in February 2018.

Chairman

Have the Deputy's questions been answered?

Mr. Hayes has suggested that additional staff will be employed in February or certainly over the coming months. This is vital for the CHO 1 area. How many people are we talking about? Funding is a big issue. This major issue has been debated at various meetings on numerous occasions. I am concerned about the amount of funding required to have successful mental health services in the CHO 1 area.

Mr. John Hayes

I drew attention in my submission, or an attachment to it, to the benchmarking of the CHO 1 figures against the targets in A Vision for Change. CAMHS on the ground is operating at approximately 51% of the recommended level of clinical staff for the service. A further 44 clinical staff would be required across the five counties to bring CHO 1 up to the targets for the CAMHS set out in A Vision for Change. As the Sligo-Leitrim area is currently operating at a level between 51% and 53%, it is representative of what is happening across CHO 1. Our immediate recruitment challenge does not necessarily involve funding per se. It involves getting consultant psychiatrists, in particular. We have less difficulty than the eastern area in recruiting psychiatric nurses. Our main challenge is in recruiting consultant psychiatrists. We are endeavouring to address that issue. While we have had some success to date, until there are permanent people in full-time employment, there will always be a sense of vulnerability due to the possibility that they might leave and move on.

Chairman

What proportion of the CHO 1 budget is allocated to CAMHS services? When Mr. Hayes spoke about the projects that are coming up, he said it is hoped that a new 26 bed unit will open next year. How can that happen if there are such problems with recruitment? When Mr. Hayes spoke about overall staffing levels, he said that the CHO 1 area has 941 whole-time equivalent staff. Given that he can really only account for 156 staff for the general adult teams, 46 staff for the CAMHS teams and 35 staff for the psychiatry of later life teams, it seems that 702 staff are not accounted for. When it is not possible to get staff, what happens to the money that is allocated for recruitment? I have asked a few questions. Mr. Hayes's answers might be of interest to Deputy McLoughlin.

Mr. John Hayes

If we cannot get staff, we apply to the national division for approval. In 2016, we did some work to upgrade infrastructure. We also employ locum consultants. They cost significantly more to employ than HSE-rate consultants. The additional cost to the system of employing locum and agency staff is considerably higher.

Chairman

Does Mr. Hayes have a breakdown of that?

Mr. John Hayes

I can provide the overall figure. The additional cost to CHO 1 of employing medical staff would be approximately €800,000. I can get a full breakdown of that.

Chairman

Yes, please. How much money is allocated to CAMHS?

Mr. John Hayes

The budgets are normally broken down across the categories of medical, nursing and support staff, as opposed to the teams.

Chairman

Okay.

Mr. John Hayes

We can give the committee a good indication of the percentage of the budget we get that is devoted to CAMHS. In our area, approximately 8.4% of the mental health budget is devoted to CAMHS.

Chairman

Just over 8% of the overall mental health budget is for CAMHS.

Mr. John Hayes

Yes.

Chairman

Okay. I find that extraordinary. Does Deputy McLoughlin have any further questions?

No, I am fine. I might come back in later in the meeting.

Chairman

I call Deputy Rabbitte.

I represent the Galway east area, which extends from Portumna to Headford and from the bridge in Banagher to Kinvara. That is the area I will focus on. While I appreciate that the CHO 2 area covers all of counties Galway, Mayo and Roscommon, I will focus on my area when presenting my views on this issue. Mr. Canavan has said there are 25 community teams. How many additional community teams would be needed to have the full allocation?

Mr. Canavan also said that CAMHS beds have to service an area from Donegal all the way to Galway, Roscommon and Mayo. Is that correct? If so, does it include Sligo as well? How many counties are the CAMHS beds in Galway for? How many CAMHS beds do we have in Galway? Are there plans to expand the number of CAMHS beds in Galway? Are there plans to expand the number of CAMHS beds throughout all the other counties I have mentioned?

I do not see Youth Work Ireland Galway on the list of section 39 organisations that has been submitted to us. Maybe Mr. Canavan can clarify for me whether it is on the list. If not, will it be on it?

Will Mr. Canavan revisit the capital projects he named so that we can get a clear outline of what is planned and the time schedules involved? I did not hear him mention Toghermore House. What is the status of Toghermore House?

I have a specific question for Mr. Gogarty. I have been looking through the accounts. Will he explain the expenditure of €7.9 million on dental? What exactly does that cover? The nursing bill came in at €20.3 million. I am trying to understand why €7.9 million was spent on dental and €20.3 million was spent on nursing.

I will come back in after Mr. Canavan and Mr. Gogarty have answered those questions.

Mr. Tony Canavan

The Deputy's first question related to the number of community teams.

We have the correct number of teams for our area but they are not all fully populated yet. There may be deficits within teams but we have the correct number.

How many of the 25 community teams are fully filled?

Mr. Tony Canavan

We use the numbers provided in A Vision for Change.

Let us be clear for the benefit of the people who are listening to proceedings. Am I correct in saying that there must be 23 staff on a community adult mental health team?

Mr. Tony Canavan

It varies. For example, in County Mayo there is an excess of five people on the general adult team in Ballina, but we are short of people in Belmullet and Castlebar. In fact, we are short of people for most of our teams. We only have 90% of what was recommended in A Vision for Change in terms of the adult teams.

Mr. Canavan has drilled down into the figures. I mentioned east Galway at the beginning of this meeting. Am I correct to note that the Portumna-Loughrea and Portumna-Ballinasloe units are short one member on each of their teams?

Mr. Tony Canavan

The Portumna-Ballinasloe unit has just over 87% of the allocation stated in A Vision for Change and is short two whole-time equivalents. Loughrea has a team that, at 117%, exceeds the provision stated in A Vision for Change.

How many of the 25 community teams specified in A Vision for Change are full?

Mr. Tony Canavan

The reason I am slow to answer is that three of the adult teams exceed what was provided for in A Vision for Change.

Mr. Tony Canavan

The teams have more members than what was provided for in Vision for Change and the remainder have very slightly less than what was provided for in A Vision for Change.

Is Mr. Canavan telling me that the 25 community teams are full?

Mr. Tony Canavan

No. Is the Deputy asking specifically about the adult teams?

Mr. Tony Canavan

There are not 25 adult teams.

I asked how many of the 25 community teams were full. I want to know because when I perused the list, I noted the following: a shortage of 10.6 mental health support workers and a shortage of 8.9 nurses on the adult teams; CAMHS has a shortage of 10.3 consultant psychiatrists and 9.7 nurses; and psychiatry for old age services has a shortage of 10.2 mental health support workers. Reading between the lines it looks like not all of the teams are full.

Mr. Tony Canavan

As I said clearly at the start, all of the teams are not full in the context of the measurement against A Vision for Change. Some of them exceed the allocation. There is a shortfall in staff in the general adult service, CAMHS and psychiatry for later life.

How many of the 25 teams are full?

Mr. Tony Canavan

Out of the 11 general adult teams, three of them are in excess and the rest of them have a shortfall. In terms of CAMHS, all of them have gaps. In terms of psychiatry for later life, one out of five is in excess and all of the rest have a shortfall.

Do 21 teams have a shortfall?

Mr. Tony Canavan

Correct.

Am I correct to say there is a shortfall in staff in 21 of the 25 community teams throughout CHO 2?

Mr. Tony Canavan

That is correct.

I thank Mr. Canavan for the clarification. I ask him to discuss CAMHS beds.

Mr. Tony Canavan

The CAMHS beds are located in Merlin Park and serve counties Donegal, Sligo, Leitrim, Mayo, Galway, Roscommon, Clare, Limerick and Tipperary. We receive children from all across that region.

How many beds are provided?

Mr. Tony Canavan

There are 18 beds.

How many counties do they serve?

Mr. Tony Canavan

Nine counties. It is possible for a child from some other part of the country to be referred to our facility, if required.

Does Mr. Canavan, in his professional experience, feel we have enough beds?

Mr. Tony Canavan

We have gone through a period of constant excess demand for the beds. We seem to have got on top of that demand over the past three years and manage it better. That indicates there is a better balance between the need for inpatient beds and the number of beds available. It is difficult to say definitively whether that is adequate. At present, there is a good match between the demand for the beds and the number of beds available.

When referring to CAMHS beds, we are effectively talking about a CAMHS bed for a child, for example, in Donegal. To clarify, a CAMHS bed facilitates anybody under the age of 18. Would it be better to provide CAMHS beds in the locality, in Sligo General Hospital or in places closer to home? Would closer proximity not facilitate better recuperation? Let us be mindful of the long distances that families must travel to get services. For example, a family from Donegal must drive for three hours on poor roads to reach Galway to engage with staff in the CAMHS unit and, most importantly, their child.

Mr. Tony Canavan

I will call on one of my clinical colleagues to answer after I reply. First, it is not possible to provide beds in every single location. Second, it is not the bed that is important but the quality of the staff and clinical team who provide care to the patient. It is difficult to provide such a service in many locations. The decision to centralise the service in a relatively small number of locations probably matches that view.

Like many of our services, there is a need for greater focus on the provision of care in the community, as pointed out by my colleagues, and in people's homes as opposed to providing inpatient care. For example, it is possible that the vast majority of the CAMHS requirement for people in Donegal, if we deem the county to be one of the furthest away, are provided in Donegal. It is better for the very small number of people who require inpatient care that it is provided in Galway. I do not know if there is a more qualified answer to that.

Chairman

A final question, Deputy.

I wish to make a comment. Mr. Canavan's reply does not fly for the simple reason that 21 community teams are inadequately staffed. Therefore the support is not in the community. When was the last time CHO 2 Galway conducted a recruitment campaign to recruit more staff?

Chairman

That must be the last question from the Deputy.

Mr. Tony Canavan

Our recruitment for staff in mental health services is ongoing and includes medical staff, nursing staff, adult health professionals and a whole range of staff. We had difficulty recruiting medical staff, particularly around Mayo, and nursing staff throughout, especially Galway and Roscommon. There is an ongoing recruitment of staff for mental health services.

Chairman

Let us move on. I call Senator Feighan.

I am glad of an opportunity to discuss these very important issues with the witnesses today. I seem to straddle two or three different areas. As my colleague, Deputy Tony McLoughlin, has adequately asked questions related to County Leitrim, I will raise issues related to County Roscommon. I understand that the witnesses do a very difficult job. It is an emotive and complex situation for the workers, the service provider and the service users. Not everyone could equip themselves to work in the sector.

I am all for saving money. Anybody who works in the public sector should be lauded for their work. Sometimes when people in the public sector see a pot of money, they decide to spend it. I like to see various Departments consider the funding that they have received and utilise it across the system. The three-year rolling budget is more beneficial and definitely helps the witnesses to conduct their work in every department. Unfortunately, the recent history of the mental health service in the county has led to a damning report being published last September. The report showed that the HSE prioritised cost-cutting over meeting the needs of valuable service users.

The 44-page report was truly a damning indictment of how mental health services are run in the county and it was highly critical of the leadership at all levels within the HSE. The report was carried out by three senior experts from the Northern Ireland health care sector. Almost €18 million in funding between 2012 to 2014 was returned by Roscommon-Galway HSE. Was damage done? I understand this is what makes headlines but are there any positive aspects? Is there anything the witnesses feel the report did not cover? Are there reasons for the return of this €18 million in funding? Was it returned to some other area where it was used to positive effect? I seek an answer to that question.

Mr. Tony Canavan

The report the Senator referred to was a review commissioned by the national director for mental health services. It was commissioned in 2015 and published in September 2017. The reason for the report was there were concerns about the quality and appropriateness of some of the services that were being provided in Roscommon at the time. As the Senator correctly pointed out, a three-person team from outside the jurisdiction came in to look at it. It is fair to say the team reported and called it as they saw it. Unfortunately it did not make for very comfortable reading. They were critical of many aspects of the services being provided in Roscommon at the time. They were particularly critical of the way services were led. It referred specifically to funding that was described as having been returned to central HSE. Some confusion has arisen about the funding. It is just over €17 million for the three-year period from 2012 to 2014. Most of that funding came out of County Galway. Galway and Roscommon were at the time, and to some extent still are, a single administrative unit as far as the mental health services are concerned. When that report referred to those moneys being returned, they were moneys from Galway and Roscommon. It is reasonable to say that most of those moneys went out of the Galway budget. It is also fair to say, because it is said in the report, there were opportunities lost. When that funding was lost, there were opportunities lost to counties Roscommon and Galway to advance the process of implementing A Vision for Change and continuing to improve the services. I agree with it; it is true. It is also important to look at the funding position in the context of what was happening generally in the health services at the time when a lot of services were being curtailed and cut back for cost reasons and in the context of what has happened since. In my opening statement I referred to the fact the funding base across CHO 2, which includes Roscommon, has increased year on year in 2015, 2016 and 2017. We are hopeful it will continue to increase in 2018. It is difficult to find something positive in that report. It was a very critical report of the services overall. I am optimistic about what can come out of it. What can come out of it is we can change the way we deliver our services and the way we make decisions within the service on our priorities. We have established an implementation group around that. It has been working actively on it since September of this year since the document was published. I am very optimistic we will make significant headway as a result of it. This report will have been worth it if it shines a light on things that should not have happened or should not have been done in the way they were and if we take that on board and make the changes that are necessary going forward.

Do I have a few more minutes?

Chairman

The Senator has one minute left.

The same report produced 27 recommendations on how to improve Roscommon mental health services. How many of those have been implemented in the short term, if any?

Mr. Tony Canavan

The first commitment we gave in September was to produce an action plan. The action plan essentially outlines the specific actions we will take on each of the 27 recommendations. It is fair to say there have been actions taken on all of them at this stage. One recommendation has been entirely completed at this point because it referred to something specific that had to be done immediately. All of the other recommendations tend to be of an ongoing nature and we will be working on them throughout 2018 and probably throughout 2019 as well. Each step along the way and each action will be clearly defined in the plan that was completed on Tuesday of this week, which will be made available to people who will be able to see and track the progress we are making. We will be making headway very shortly.

Chairman

Before we move on to CHO 3, how much money is allocated to CAMH services?

Mr. Tony Canavan

Just over 11% of our allocation for mental health services in CHO 2 is for CAMHS.

Chairman

It is 11% of the overall mental health budget. Deputy Rabbitte asked Mr. Fogarty the question about dental services.

Mr. Liam Fogarty

The category the Deputy refers to is non-consultant medical staff. They are known as medical-dental. That is a term we use in the HSE. There is a category of non-consultant medical staff who are categorised as medical-dental. We did not have any dental costs.

That is how it appears from reading the report.

Mr. Liam Fogarty

The category is medical-dental, which is described as non-consultant doctors.

Chairman

Before I pass him on, I will ask Mr. Canavan about the CAMHS budget. Was it all spent? What does the CHO do when it does not spend all of the budget? Is it returned to the HSE?

Mr. Tony Canavan

I am smiling because not only did we spend the budget, we spent €7 million over the budget. It looks like we will be overspent in 2017 across all of our services, including CAMHS.

Chairman

We still want a breakdown of how the budget has been spent in all of the CHO areas, more specifically than has been delivered to us. I will move on to CHO 3.

I thank each chief officer for their presentation. I welcome in particular Mr. Bernard Gloster, Dr. John O'Mahoney and Ms Niamh Doody. There is a bit of a theme in the issues that have been raised. I will focus on the CAMHS in the mid-west. Will Mr. Gloster give us an overview? There are significant challenges. We have been given figures on staffing arrangements and there are gaps there. One of the boxes is headed "VFC". Will Mr. Gloster give us an explanation for that? I welcome that in Clare, the county I represent, a consultant will be appointed to the CAMH service. It was a particular challenge over many years. There was someone working there in an agency capacity. It is good to see that is happening. There are significant challenges. What measures are taken to improve access and to deal with age-appropriate services and the waiting list? What type of waiting list is there? I will allow my colleagues, Deputies Harty and Neville, to raise issues on that.

I went to the launch of the Connecting for Life strategy. I compliment the witnesses from that region on the lead-up to that day and the involvement of all the stakeholders across the region in communities. How is the implementation of that plan going? Have the witnesses received any updates from different community sector involvements in it? The budget has increased by €8 million over the past three years to a total of €66.988 million in 2018. In light of the significant funding given by Government in recent years, what are the main achievements in 2017? What are the priorities in 2018?

Mr. Bernard Gloster

On the CAMHS overview, I will not repeat everything in the appendices, but the Deputy pointed to the six teams we have. The VFC column shows the percentage of the team that is filled measured against what A Vision for Change indicated would be the optimal for the population at the time.

Members can see that they are quite variable. That is consistent with CAMHS teams generally across the country because of recruitment challenges and so forth. However, they are quite variable, running from 41% of the A Vision for Change recommendation up to above 81%. That is a general overview of the teams. The CAMHS across the mid-west have approximately 50 whole-time equivalent positions occupied out of a total workforce of 786 in the mental health service. There has been quite an amount of focused attention on the service in the past couple of years.

With regard to managing age-related issues and pressures, I will let Dr. O'Mahoney comment on that momentarily. However, a very significant concern for us at any point is when children are waiting, particularly for over 12 months. On the balance side, I tend to emphasise to people that the mid-west area, since it had its first CAMHS, has moved to operating a 24-hour service through the emergency department at University Hospital Limerick. There is a CAMHS consultant on call every night. That mitigates the concern in what one might call the milder categories of referrals and shows that the focus is on the crisis and emergency. Ideally, we would get to a much better position of early intervention that would avoid children having to go on a waiting list and waiting for 12 months to be seen. That is probably the biggest concern we have, and we do not shy away from it being a factor for us.

The age-related factor is a particular issue. People who are familiar with mental health legislation and policy will understand that there was a point in time when children were seen up to 16 years of age, after which they were seen in the adult service. The trajectory now must be to ensure there is a CAMHS sub-speciality for people under 18 years of age. Dr. O'Mahoney can comment on progress in achieving that.

Dr. John O'Mahoney

As my colleague said, we have a 24-hour emergency service. The service is operated from 9 a.m. to 5 p.m. in each area and after 5 p.m. it is located, as are most emergencies in the mid-west, in University Hospital Limerick, where a consultant, a NCHD and crisis nurses are available.

With regard to 16 to 18 year olds, only one of all our CAMHS teams is not in a position to manage all the 16 to 18 year olds. It is in Nenagh. All the rest of our teams manage the 16 to 18 year olds. As Deputy Carey pointed out, we now have two CAMHS teams in Clare, which is within decimal points of the A Vision for Change requirement. They account for 117,000 people. We were lucky enough to be able to attract a consultant psychiatrist and, as a result, we have now attracted other allied health professionals. The difficulty we have with recruitment is a difficulty that exists both nationally and internationally. We are competing with other countries to recruit people. I spent 19 years of my professional life working abroad and I have been back here for 12 years. In fact, I ended up in my current position because I felt that I might be able to put whatever experience I had gained abroad to use in helping us to adapt to providing a service for a small nation with limited resources.

Notwithstanding Senator Feighan's comments about the public purse, there is no getting away from the fact that 6.6% of general health funding is less than half of the funding in all northern European countries and a third to a quarter of that of most of those countries. As a result, we have difficulty filling our teams. When I meet colleagues of mine who are working abroad and ask if they will come back they ask, "Will I have a full team?". I tell them we are getting there, but they are the difficulties in recruitment and retention. One of two colleagues I worked with in Limerick has been doing one of my former jobs in Canada for the past six years, probably better than I did it by all accounts. These are the recruitment issues we face. It is about morale and ensuring we have these teams. While A Vision for Change is the benchmark, in some ways it may have been a little aspirational. Nonetheless, if one compares the amount of funding and the number of staff we employ with their equivalents in the rest of northern Europe we are far behind. That creates difficulties and there is no way around that.

Mr. Bernard Gloster

I will reply briefly to Deputy Carey's other two questions. The team of 40 stakeholder agencies that put Connecting for Life together has formed an implementation group for the strategy. As there is a multi-agency or multi-stakeholder approach to Connecting for Life there is an oversight process whereby the agencies meet and each agency accounts for its stewardship of the actions it signed up to. In the mid-west it is a three-year plan and in late 2018 there will be a full mid-plan review for the public to see. I said at the time of the plan's publication that we would have to be held to account by it - we could not just produce a lovely report on the day and the process was over. It was just the start.

On the question about the budget, the Deputy is quite right. Certainly in my time as a health service manager there has been a reasonable increase in the budget over the last couple of years. It has been very welcome. In terms of what that has helped us to do, I can give the headlines. I worked in the health service when there was one CAMHS consultant. I now have six teams, albeit they are at various stages of development. We have refurbished the acute unit for psychiatry in Limerick to a very high standard and we have been able to build eight high observation beds there. I have approval and development funding for approximately 24 posts to open those but I am faced with an immense challenge both in the industrial relations arena in securing agreement and in the recruitment arena in securing the people. I believe the mental health service is fundamentally different from what it was, although it has huge challenges. One of the hallmarks of it for me was in 2016 when we closed the last bed in the last of our old psychiatric hospitals.

I welcome the witnesses, particularly Bernard Gloster and Dr. John O'Mahoney from CHO 3. In fact, the mid-western hospital group, for want of a better term, and the CHO 3 coincide. The mid-west is one of the few areas where the hospital group and the CHO coincide, which makes management perhaps a little easier.

Deputy Carey has spoken about the CAMHS. There is a lack of key community care personnel in various areas. It varies from a shortage of 30% to 11%. In west Clare there is a shortage of psychologists, social workers and occupational therapists. There are many key areas where there is a gap in the service. Will the witnesses comment on that? In addition, will they comment on how that impinges on suicide prevention and services for drug and alcohol addiction, which is a huge problem?

I note that the total number of whole-time equivalents is 786. Perhaps the witnesses will indicate how many whole-time equivalents are required. There is a breakdown in the various areas in the submission. With regard to acute beds, the acute psychiatric unit in Clare also covers north Tipperary. That puts a huge amount of pressure on the acute beds for Clare and the mid-west. Perhaps the witnesses will comment on how that is working and on the shortage. I believe they mentioned there is a shortage of eight.

With regard to cognitive behaviour therapy, which ties in with key personnel being absent, how is that being delivered? Also, how does that tie in with over-medication? As a practitioner I find there is a great deal of over-medication in psychiatry.

Perhaps that is a reflection of not having enough talk therapy and counsellors in the system. Will Mr. Gloster comment on his connection with the voluntary bodies in the mid-west? What connection is there between the statutory and the voluntary bodies? With regard to dementia services, I know there is a challenge in respect of inpatient beds for dementia and separating dementia patients from patients who have very challenging behaviour. Mixing the two together can impinge on patient care. Does Mr. Gloster have unspent funds which must be returned because he is unable to employ personnel? It seems to be a recurring theme that the Minister announces an extra €35 million for mental health services every year, but €15 million is returned because it has not been spent. Is that a reflection on not being able to recruit?

Mr. Bernard Gloster

I thank Deputy Harty and certainly will attempt to capture all the questions he has asked. On key personnel, I may take that as one question with the issue of vacancies in the current 786 whole-time equivalent positions. I will start from there because that is the real profile on the ground. Of the 786 whole-time equivalent positions that we had at the end of November, we had just under seven vacancies in the medical profile, 27 in nursing, 12 in what we call allied health professionals, which would include psychology and the therapies, and 16 in what we call general supports. Dr. O'Mahoney might comment on the clinical impact of that at the end. The impact is partly mitigated in various ways. For example, out of a nursing profile of 366 there are 27 nursing vacancies. We cover an average of 16 of those vacancies with agency staff, so we spend the money arising from those vacancies on agency replacement to mitigate the risk. We also spend it on health care assistants when we cannot get nurses. That is the profile of the 786 staff and the current vacancies.

Psychology is a particular pressure for us. At the present time we have three basic grade psychology vacancies from our normal routine posts and two and a half senior psychologist vacancies. So in total we have five and half vacancies in our regular posts in mental health. We also have a number of vacancies in development posts which we have yet to fill. In terms of what we have on the ground, we have five and a half vacancies. The difficulty for us which I see on the profile is that a number of those in psychology posts will be taking maternity leave this year, which will result in very significant vacancies. The reality is that the replacement rate for clinical psychologists just does not line up with the attrition or absence rate. We have spent a considerable amount of money developing new training places on the doctoral programme in the University of Limerick and in the National University of Ireland, Galway. I manage the funding of both of those programmes for the HSE. We do everything to capture those recruits coming out, but invariably people make lifestyle choices - they travel and so on. Psychology is a pressure, there is no disputing that. Dr. O'Mahoney can talk about that in the context of other disciplines involved in the therapy.

On the acute beds, as I said there is a total of 89 beds. I have eight beds built for high observation at present which we are hoping to open. We now have the indicated and approved resource that we need to do that, which is 24 whole-time equivalents. We are having some difficulty nationally as well as locally in coming to an agreement with the relevant representative organisations as to what they would consider acceptable. That is presenting us with a challenge. The second challenge will be recruiting the numbers.

The Deputy is quite right about the bed situation in north Tipperary. Acute patients in north Tipperary now come predominantly to the acute unit in Ennis in Clare, and occasionally to Limerick. They were previously served from south Tipperary, which is a different community health care organisation, CHO, area. That is because of the old county-based mental health system when the big hospitals were in operation, a system which pre-dated even the health boards. The unit in Clonmel closed and, in accordance with A Vision for Change, it moved its direction to Kilkenny while ours moved back to the mid-west. Based on A Vision for Change, if everything was right and proper, 89 acute beds would be adequate for the population based on the measure. However, with the demographic changes we are now experiencing, A Vision for Change would have to be revised and we would need more than 89. We need more than 89. In the general sense there is a pressure on them because not every other part of A Vision for Change has been implemented. The other dependencies of A Vision for Change cause pressure. The 89 beds in the mid-west are very busy. The acute unit will be in Ennis. There is no getting away from that.

On the voluntary sector, we have a number of partner organisations under section 39 of the Health Act 2004. We do not have a heavy dependence on them as service providers, but we have a huge reliance on them as support for what we do and as support for people who have been using our services for quite some time. There are some exceptions which would be considered to be direct service providers in supporting either suicide prevention or response to suicide. The agencies we give the greatest amount of funding under section 39 of the Act are Limerick Youth Service, at just over €100,000 a year for youth mental health, and the organisation GROW. We spend just under €1 million on section 39 funding across the profile.

On dementia, the Deputy is quite right that we are very challenged in respect of the demographic profile in that regard and the separation of the different categories within that. He will be familiar with a particular unit in St. Joseph's Community Hospital in Ennis which has traditionally been managed by the elderly service as a dementia facility. We are now just in the final stages of recalibrating that to be led by a consultant psychiatrist specialising in later life. The Deputy will be familiar with him, Dr. Reynolds. He will take over the management of those beds. That will delineate their use differently and we will then be challenged in other parts of the older person sector to respond to the other types of dementia presentations.

The Deputy asked about the return of funds. I do not return funds. I tend to use them. For the last three years particularly we have had a very important rule set in the HSE, which is that divisional money comes as divisional funding and is measured in that way. My money for older persons, therefore, is measured on my spend for older persons. My money for mental health is measured on my spend for mental health. It is not the case that it can be moved around Billy to Jack. I cannot decide tomorrow to spend mental health money on something like a new primary health care centre. I do not have returned funds. I was close to a break-even position last year in respect of mental health, but all of the money I have in the mental health budget is exclusive to mental health and is all spent in that profile. That has increasingly been the position for all of us.

Chairman

We are going to have to speed up a little bit here. I thank the witness. Is that all right Deputy Harty?

Mr. Bernard Gloster

Dr. O'Mahoney was just going to make one brief comment.

Chairman

Will he make it very briefly?

Dr. John O'Mahoney

Very briefly. We are also about to open the psychiatry of later life headquarters in what is essentially an elderly campus. They are moving in. We also have approval for the appointment of a psychiatry of later life consultant in north Tipperary. A team is already being built there. There is a state-of-the-art facility just about to open in St. Joseph's Hospital.

I thank the witnesses for coming today. I will try to be brief and not go over what was already mentioned. I thank the witnesses for the information they have brought in. First of all, I have a couple of quick observations in respect of child and adolescent mental health services, CAMHS, particularly in the Limerick area. In A Vision for Change, the figure for staffing in Limerick west is 41.2% whereas for Limerick east it is 74.5%. Will the witnesses give me a brief breakdown of the geography? Where are the lines within the county? Is Limerick east the city? Is there a break between the city and the county? Will they outline why there is such a challenge in west Limerick as opposed to east Limerick? Positions were filled on the east Limerick side in September, if I am not mistaken.

Obviously the development posts are new positions for a new service. From my calculations - and I hope the witnesses will correct me if I am wrong - 70% of those posts have been outstanding from 2014 onwards. If they are not able to provide it today, can the witnesses send me a breakdown of vacant backfilled positions at a later date?

I want to try to get an overall view of posts outstanding, be it development posts and backfills of current vacancies.

I would like the officials to elaborate on funding. It was stated that this service is allocated 6.6% of general health funding. Is the kernel of the argument that they are finding recruitment is constrained by national wage agreements and salaries? I am hearing about the challenges around recruitment but I am not hearing any specific factors. Do the difficulties arise from the location of the jobs, the position being offered or are other jurisdictions targeting consultant psychologists, nurses and so on? I would like to get a breakdown of the recruitment challenges to see where we can try to close the gaps. I agree that we face challenges in recruitment but I would appreciate if the witnesses could articulate specific issues that we could pinpoint.

On budgets, the witness said quite rightly that the budget does not go back to the fund but that it is spent on mental health. When the senior management appeared before the joint committee on a previous occasion, I could not get an answer from them on what happened when money allocated for a new post was not spent because of the failure to fill it. I was told that the money would go to spending on service improvement. I was trying to push for information on whether this money was going into the IT system or where the service improvements were. Would the witnesses give me a general overview of that service improvement, when it is outside recruitment, and also how one arrives at setting the priorities for the area where the service improvement should be made. In 2016, when the money was allocated, it would not have been known how much would not be spent. How does one arrive at the decision?

Mr. Bernard Gloster

I thank Deputy Neville for his questions. In respect of backfill recruitment, and I will provide the Deputy with a specific list of the actual posts subsequent to the meeting, in terms of the global figure of 786, we are running a recurring deficit in terms of filling jobs of 50 to 60 posts. The breakdown is right across the spectrum, with probably the largest number of unfilled posts being in nursing.

On the child and adolescent mental health service, CAMHS, teams, CAMHS east, CAMHS west, CAMHS central, the reason that one sees in the appendices a population of 47,000 between those three teams and a combined actual staffing of just under 25 personnel is the origin of the service. The service started with one consultant in 90 O'Connell Street in the city centre and then it grew to two and so on. While there has been expansion, they consolidate and share their focus. They started out originally as the city team and many of the expanded teams have moved to a new base at Punches Cross in Limerick. There is a lot of cross-sharing of the resource. CAMHS west tends to refer to Newcastle West and that direction and CAMHS east is towards Kilmallock and Doon.

On utilising the money in our budget, traditionally money for development posts is given when the post has been filled. In other words, the post would be filled and then the money would be drawn down. In more recent times, however, the money has been front-loaded and has been given upfront, as our national colleagues told the committee. Some of the money would be used on mitigating risk for vacancies. For example, in 2017, we spent approximately €4 million on agencies for mental health in the mid west. The most significant element of expenditure was on doctors, followed by nursing. We would use money to mitigate risk. We would use money by agreement with the national division. We might decide to target a particular initiative, but as a once-off cost, so that when we come to fill the post, we would still have the money to fill it and we would not end up with a recurring cost. The once-off cost could be on anything from supporting additional training and development to doing a targeted waiting list initiative. If an additional psychologist or consultant was identified as being available through an agency and we had some spare capacity in the run rate of our funding, I might say to Dr. O'Mahoney that if we could attract that person for three months through the agency, perhaps we could take them in to shave off what we are worried about on the waiting list. That is an example of a service improvement. Equally, we can do something on IT. Our IT system is a very old system. It has served us very well but we will have to make modifications to it. I think IT has a patient administration system.

My colleague Dr. O'Mahoney may wish to add to what I have said on the CAHMS teams.

Dr. John O'Mahoney

Deputy Neville asked about moves from the west Clare team. We have a new team set up in Clare and it will suit some of our people who have commuted from Clare to work in west Limerick to relocate. We are constantly facing a retention battle within our services. We are competing with other areas to attract people, but we also have to deal with urban drift. It is more noticeable in Clare. Deputy Harty will be familiar with this, whereby north Clare is essentially being partially depopulated and our services are located in Ennis. The same will occur in Newcastle West, which is on the border with Kerry, and I am well aware that the Kerry CHO is having the same difficulty attracting people. We will have transfers from our area to theirs because it suits people's personal lives and they know they can do it because they are a scarce resource. Retention of staff within our areas is a problem, never mind retaining the overall numbers.

I cannot get away from the fact that we are competing with the United Kingdom, Canada and Australia for staff across the board, not just doctors but also nurses and psychologists. Very often it is pointed out to me that it is about salaries, but it is not all about salaries but also about working conditions and working as part of a team. I meet colleagues of mine who are working abroad. I am almost schmoozing them trying to get them to come back to Ireland.

This is anecdotal evidence, obviously, and while I am not disputing what Dr. O'Mahoney is saying, I am asking all stakeholders if there are any studies or statistics on this? We heard from the CHO area 1 that the problem is in recruiting consultant psychiatrists and in CHO area 3 the problem is trying to recruit nurses. There differences between the CHOs show that it is not just an international factor but also local. Are there any studies on this? It may not be Dr. O'Mahoney's remit and may be a step higher. From a HR point of view, are there any studies on this or does Dr. O'Mahoney know of any?

Dr. John O'Mahoney

The HSE has a national workforce plan and has published the figures.

I am not after figures. It is the reasons.

Dr. John O'Mahoney

The reasons are that we are competing.

I am more interested in the specifics. Dr. O'Mahoney mentioned working conditions but can he be more specific on the conditions, or does he have specific information around the team working that drills down into it?

Dr. John O'Mahoney

It is very simple. Most people who go into these professions are interested in caring for people and in doing a proper job. They may be working in a team where they know what has to be done but they do not have the resources. While I am on this point, I will respond to a question the Chairman raised. We have a range of staff who offer talk therapy, such as nurses, occupational therapists, psychologists and doctors trained in CBT and other talk therapies. The problem is that if there are only four people in a team, one has got to cut one's cloth to suit the measure and see the people who are most unwell or most deserving of care.

It becomes frustrating for people to not be able to do their job. The best example is that a consultant psychiatrist in Britain will typically have half the catchment area size in terms of population compared with a consultant here. That consultant would have a fully populated team. I am not trying to beat the drum to death but these are the facts. The members can speak to my colleagues about it. At this stage we are almost net exporters of health care professionals. When I worked abroad, I always had colleagues-----

Chairman

I am going to have to move on.

Dr. John O'Mahoney

That is the best answer I can give.

Chairman

Were all Deputy Neville's questions answered?

Chairman

Okay. We will wrap up but I have some questions. What is the percentage allocated to the child and adolescent mental health services, CAMHS?

Mr. Bernard Gloster

I genuinely would not want to mislead the committee on the breakdown of the money. I will provide it to the committee.

Chairman

Okay. Who makes the decision on how moneys are allocated to the different divisions? Who makes the decision in each area what mental health services for children would receive? Will the witness give a brief answer?

Mr. Bernard Gloster

With respect, it is not a question that I might make a decision tomorrow to CAMHS X amount and adult services Y amount. It comes pre-determined by the posts already approved as the driver is 80% pay. If I have an approval in development posts this year for ten jobs and four of them are for CAMHS, the decision is made thereafter that 40% of the budget is for CAMHS.

Chairman

Everything is still very foggy. As a committee, we are very concerned about mental health services for children. On 7 December last year we asked the witnesses to provide us with a breakdown of the percentages. Will they have this when they return? Mr. Canavan mentioned that 11% of the budget went to child health services.

Mr. Tony Canavan

Correct.

Chairman

We want a breakdown of how that was spent last year, whether it was in recruitment or disability, for example. We want the amounts rather than percentages. I ask that each of the witnesses provide that as soon as possible. That is it for today and I thank the witnesses for coming before us. I really appreciate the time taken to travel to Dublin.

Sitting suspended at 11.52 a.m. and resumed at 12 noon.

Chairman

I welcome to the meeting from CHO 4, Mr. Ger Reaney, chief officer and Ms Sinead Glennon, head of mental health services; from CHO 5, Ms Aileen Colley, chief officer, Dr. Stephen Browne, executive clinical director for mental health, and Mr. Michael Morrow, head of finance; and from CHO 6, Ms Martina Queally, chief officer, and Ms Antoinette Barry, head of mental health services. On behalf of the committee I thank them for their attendance today.

The format of the meeting is that each chief officer will be invited to make a brief opening statement which will be followed by questions and answers. Before beginning I draw the witnesses' attention to privilege. Witnesses are protected by absolute privilege in respect of the evidence they are to give this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any persons or entity by name or in such a way as to make him, her or it identifiable. Any submission or opening statement made to the committee will be published on the committee website after this meeting. I invite each of the chief officers to make their opening statement.

Mr. Ger Reaney

I thank the Chairman and members of the committee for the invitation to attend the committee today. I am the chief officer of Cork-Kerry community healthcare, which is referenced in the documentation provided by the national division as CHO 4. I am the principal responsible officer, responsible for all HSE-run or HSE-funded community-based services in the counties of Cork and Kerry. I am joined Ms Sinead Glennon, who is the head of mental health services in Cork-Kerry community healthcare. My colleague chief officers, Ms Colley and Ms Queally, will introduce those accompanying them. As with our colleagues who addressed the committee earlier, we have tried to ensure a mix of different roles in the teams attending today across the CHOs. All responsibility for mental health services in Cork and Kerry is under Ms Glennon as head of mental health services. There are separate management teams in Cork and Kerry for historical reasons each of which includes an executive clinical director and area director of nursing along with an area director of nursing for child and adolescent mental health services in Cork.

Specialist mental health services are developed in collaboration with the national mental health team and delivered in line with national policies, frameworks and priorities. As I am conscious of the committee's time, I do not propose to go through much detail on the make-up of services and the various teams. Suffice it to say that Cork-Kerry, as with other CHOs, has a mix of adult and CAMHS teams, psychiatry of later life teams and a mix of acute units and other residential units. They are set out in our statement and in the appendix. Mental health services in Cork and Kerry have a strong focus on recovery and co-production whereby initiatives are developed jointly by service users and staff. We have consistently sought to emphasise community-based services, including home treatment services, thereby reducing reliance on acute type services.

Referrals to specialist mental health services are usually through GPs. Specialist mental health services work closely with many other health and social care services. The introduction of community health care networks, as referenced in the Sláintecare report, will support stronger integration between specialist mental health services and other health and social care services in each local area.

Cork-Kerry community healthcare mental health services employs 1,468 staff across a range of disciplines set out in table 4a in the appendix which we forwarded to the committee. This represents an increase of 23% in overall staff numbers since 2012. The increase in staffing shows the impact of the programme for Government investment in mental health from 2012 onwards, which has impacted on the staffing in adult mental health teams and in CAMHS teams; additional staffing to open new acute units at Cork University Hospital, CUH, and Deer Lodge residential unit in Killarney; and also the development of specialist services for psychiatry of later life, mental health services, people with intellectual disability, suicide and self-harm prevention, as well as services for homelessness, rehabilitation and forensics.

Like many of our colleagues in other parts of the country, we experience recruitment challenges, particularly in child and adolescent psychiatry, non-consultant hospital doctors, nursing and psychology. We recently established a task force in our CHO comprising HR and medical personnel to focus on recruitment into child and adolescent mental health services. We can expand on that later. Notwithstanding these challenges, we recruited 170 new staff who started in Cork-Kerry mental health services in 2017. At the end of December, there were 28 vacancies, excluding a number of development posts which we have yet to fill. The budget for specialist mental health services in the area is €118.3 million, representing an increase of just under 15% since 2015.

One of the committee's headings is primary care. Obviously, the majority of mental illness is treated in primary care, in particular by GPs. We support that through the counselling in primary care service, which provides counselling for people with medical cards referred by GPs. We can give further details on the location and volume of that. We have also been developing a psychology service in primary care through recruiting seven additional psychologists and 16 additional assistant psychologists. Five of the seven psychologist posts have been filled, as have 13 of the assistant psychologist posts.

The next section outlines a number of achievements, and given time constraints I will not dwell on them. They refer to a number of acute units, the Jigsaw service in Kerry, which also commenced in Cork in 2017, a number of initiatives in suicide prevention and also mental health engagement.

In 2018 we will develop a liaison psychiatry team in University Hospital Kerry, a CAMHS liaison service in CUH in 2018; an additional CAMHS consultant in Kerry with a special interest in liaison and the mental health needs of children with intellectual disability, complete the refurbishment of the acute adult mental health unit in University Hospital Kerry, establish a specialist forensic team working with Cork prison, establish a child and adolescent mental health services eating disorders team, establish a specialist perinatal service in Cork University Maternity Hospital, and introduce advanced nurse practitioners.

As with other areas, we face a number of challenges in addition to the recruitment challenge. We experience waiting times for child and adolescent mental health services due primarily to recruitment issues and the absence of certain staffing levels. We are working through a detailed comprehensive enhancement project led by a clinician in our area, with a number of short-term and long-term measures to improve that. We are also prioritising that area for development funding which has been allocated to us at the end of 2017. Access to the CAMHS inpatient unit can be a challenge depending on demand. The unit has fluctuated between 14 and 18 beds depending on medical staffing. We are also conscious that suicide rates in Cork and Kerry are high, although they have reduced in recent years. They are a particular focus through our connecting-for-life plans. As with other CHOs we are experiencing high-cost external placements where we need to refer individuals to external agencies for services.

That concludes my opening statement and I would be happy to answer any questions members have later.

Ms Aileen Colley

I thank the Chairman and members of the committee for the invitation to attend the committee today and the opportunity to provide them with information on the mental health services in the south east. I am the chief officer for CHO 5, and like my colleagues, I am responsible for the overall management of HSE services excluding the acute hospital services in the south east. I am accompanied by Dr. Stephen Browne, who is the executive clinical director for mental health services, and Mr. Michael Morrow, who is the head of finance for CHO 5.

CHO 5 covers Carlow, Kilkenny, south Tipperary, Waterford and Wexford, an area with a total population of 510,333, which has had a net increase of 2.6% since 2011.

The greatest increases were in the older age groups, particularly those aged 65 to 74 years, with the greatest decreases in the younger age groups, particularly those aged 25 to 34 years. There is a further breakdown in the appendices.

In health service analysis and planning, we are cognisant of many factors, including the age groups, gender, social determinants of health, deprivation indices, housing and so on. All these indicators have an impact on the demand for services in our area and a potential impact on expected outcomes for our population.

Nine CHOs are the delivery arm of the HSE national operation plan and the mental health plan, implementing care in alignment with key performance indicators, national policies, clinical standards and operating procedures.

Community health care organisation, CHO, 5 like the other CHOs are standardised as such in that we have a governance structure that devolves under four care groups, primary care, mental health, social care, and health and well-being. There is an alignment in both the governance, that is, to and from the national office to the CHO and then in the local clinical service delivery across the four care pillars. This is achieved by agreed key performance measures, across care group representation at senior management through to population alignment, where the clinical teams work in areas, averaging populations of 50,000 people.

The term mental health describes a health status that can range from positive mental health through to severe illness. Hence the requirement to provide services from a stepped care model from population health such as information through to specialist mental health services. The specialist mental health services are provided to a particular group in the population. Like my colleagues in the south east, we have seven child and adolescent mental health services, CAMHS, providing secondary care, specialist services for young people up to 18 years who have severe and complex mental health disorders.

We have 17 general adult mental health teams and five psychiatry of later life teams, servicing people in different settings, including outpatients, acute day services and in the individual's home.

The south east has six approved centres, including two acute adult units and four psychiatry of later life units. Community mental health services are delivered by a range of multidisciplinary teams and that is within a sectorised population based approach.

As the statutory service provider, we work with our voluntary partners to ensure the meaningful engagement and involvement of the service users in its design and delivery. Integration is achieved through collaborative working between and across primary care, acute services and mental health. The integration is further enhanced through co-location as appropriate.

The mental health teams with a total staff of 1,187 staff are organised to provide inpatient, residential and community services in centres as set out in the table in my presentation and also in appendix 3.

In line with the stepped care model we have roles and teams that provide prevention, early intervention and other supports, such as suicide prevention. The regional suicide resource office co-ordinates activities in suicide prevention, intervention and postvention in CHO 5. One of the key responsibilities of the office is the development and implementation of Connecting for Life - Ireland National Strategy to Reduce Suicide 2015-2020. The latest launch was in Carlow on 7 December 2017.

Under the national counselling services, the south east has three services: counselling in primary care, self-harm intervention programme and national counselling services south east. There is a further breakdown in the appendices.

The development of a recovery focused model in CHO 5 has been an ongoing priority. The recovery college in the south east was officially launched in 2017 and offers focused education which is designed to complement existing community mental health services by utilising an education approach which has a positive effect and impact on the mental health and well-being of people who utilise the services. The introduction of an area lead and five peer support workers to represent the views of service users, family members and carers was a significant step also in 2017.

The budget and actual spend on mental health services in CHO 5 is summarised and one can see there has been a 14.6% increase between 2012 and 2017. CHO 5 remains committed to the delivery of a high quality patient-focused service. However, as my other colleagues acknowledge, there are challenges to achieving this objective. There is an increasing demand for services for children and young people across the spectrum of promotion, prevention and early intervention right through to tertiary level inpatient care. We will be continuing a strong focus on this area throughout 2018 and beyond. Similar to all areas, recruitment and retention of staff, especially for medical and nursing staff remain a challenge. We continually assess, analyse and monitor our operational plan, key performance indicators and the feedback we receive to target change and address our challenges through resource management and best practice.

That concludes my opening statement. There is further information in the appendices. I thank the Chairman and members of the committee for the opportunity to make this presentation.

Chairman

I thank Ms Colley and invite Ms Queally to make her opening statement.

Ms Martina Queally

I thank the Chairperson and members of the committee for the opportunity to attend today’s meeting. I am the chief officer of HSE community health care east which is referenced in your documents as community health care organisation, CHO, 6. Community health care east describes the same geographical area as that covered by CHO 6, incorporating the former local health offices of Dublin south east, Dublin south and Wicklow. I am joined by Ms Antoinette Barry, the head of service for mental health in CHO 6.

I have submitted appendices to accompany this opening statement which provide detailed information in respect of the governance of mental health services, finance, human resource and service delivery.

As chief officer, I have overall responsibility for the management of HSE community services. As well as mental health, this includes primary care, social care and health and well-being. In line with the community health care organisations report 2014, the area is divided into the eight community health networks, CHNs, shown in the appendices. The community mental health services are delivered primarily by 11 community health mental health teams and work is under way to realign these 11 teams to our eight community health care networks. This will include some realignment with our colleagues in CHO 7, who will address the committee in the near future. This is a really important step in fully integrating our services in line with Sláintecare 2017 and as outlined in the community health care organisation report. This is an important step as to what Ms Colley described earlier in terms of stepped care.

The population of community health care east is 383,000. However, the population covered by mental health services is more than 400,000 due to the aforementioned boundary issues. In addition, we work with colleagues in CHO 5 to provide acute adult inpatient mental health beds at Newcastle Hospital to facilitate easier access for patients in the Gorey area.

In community health care east, mental health services are provided by a combination of direct provision by the HSE and under contract through a service arrangement with St. John of God in its clinics at Cluain Mhuire and Lucena. The HSE provides adult mental health services in Dublin south east and Wicklow and St. John of God, Cluain Mhuire provides adult mental health services in the Dublin south area. St. John of God, Lucena provides child and adolescent mental health services, CAMHS across community health care east and to part of CHO 7.

There is a clear governance arrangement for mental health services in the area. Ms Antoinette Barry is head of service for mental health and reports directly to me as chief officer. The executive clinical director and the area director of nursing in turn report to Ms Barry. There is one mental health executive management team for the overall area which includes senior clinicians and administrative managers and also includes senior manager from St. John of God. All governance and management systems are in line with HSE policies, including quality and patient safety and national financial regulations and so on. I have included a map and a detailed organisational structure in the appendices. There are 560 whole-time equivalent staff employed in our mental health services at the end of November 2017.

Under the programme for Government, a total of 50 additional posts have been approved since 2012. Of these 17 are filled and the balance are in the process of recruitment. A further breakdown of the information is provided by discipline and by team in the appendices.

Recruitment and retention of nursing staff has been a significant service challenge for our area. The main reasons cited by staff in exit interviews are accommodation cost and commute times. We have tried to address this challenge in a number of ways. The introduction of the higher diploma in mental health nursing initiated by community health care east with UCD has been very successful with 38 nurses completing the programme in January 2018, 12 of whom are contracted to work in this area. A further 38 nurses will commence in February 2018, 14 of whom will be contracted to this area. We are continuing to work with UCD as our academic partner to increase the pool of candidates available to us through increasing the number undertaking undergraduate and postgraduate training.

There is a detailed finance breakdown in the appendices but the overall budget for 2017 was €56.86 million. As outlined earlier, mental health services are provided through a number of specialist areas by multidisciplinary teams. We have 11 general adult community mental health teams, two old-age psychiatry teams, nine CAMHS teams, one mental health intellectual disability team and one eating disorder team. We also provide liaison psychiatry to St. Vincent’s University Hospital, St. Michael’s Hospital, St. Columcille’s Hospital and the National Maternity Hospital. These are the three main acute hospitals and the maternity hospital in our area.

In 2018 we will extend the current seven out of seven out-of-hours response for general adult community mental health services, which exists in part of our area, and it will cover the Wicklow primary health care area. We have received approval for four additional posts to cover that and it is a significant improvement. We continue to prioritise co-location of our community mental health services with primary care centres. Centres are planned for Dún Laoghaire, Stillorgan, Bray, Greystones and Arklow. Mental health services are already co-located at Wicklow since 2015. In 2018, a Dublin south-east team will co-locate with primary care services at Churchtown.

Community health care east has a total of 89 adult acute care beds, a breakdown of which is provided in the appendices. In line with national policy, we are developing a plan that will address the number and location of acute beds to ensure all our beds are provided at the most appropriate location. The plan will be costed and will require capital investment. Child and adolescent patients access acute inpatient beds in the Linn Dara unit in Cherry Orchard, Ballyfermot, and the St. Joseph's unit in Fairview. In addition to acute care provision, a range of continuing care, rehabilitation, transitional care beds and community residential places are provided across community health care east. A breakdown is given in the appendices.

We have a number of service improvement initiatives. A mental health recovery committee established in 2017 and was awarded €1.3 million by the service reform fund and €30,000 by Advancing Recovery Ireland, based on a successful proposals to re-orientate services towards recovery. In line with the national clinical programmes, we have established a programme at St. Vincent's University Hospital for the assessment and management of people presenting to the accident and emergency department following self-harm. We are also progressing the implementation of the national clinical programmes for the specialist areas of eating disorders and perinatal mental health. Two suicide resource officers have been appointed to support implementation of the local Connecting for Life action plan, launched in March 2017. A local Connecting for Life oversight group has been established. I am glad to say it has good stakeholder engagement at a cross-sectoral level, which is really important for successful implementation.

A mental health engagement lead was also appointed in February 2017 and he established the community health care east area forum for mental health engagement. In line with the Healthy Ireland policy and the evidence of the need to promote general health and well-being of mental health service users, a significant target for us, we have a number of initiatives that support patient recovery. I will not go into the detail of these but they include Woodlands for Health, which promotes physical activity in outdoor spaces; Kickstart to Recovery, which is a group engagement involving physical activity through football; The Mindful Melodics Choir; and Choices for Health, a lifestyle programme. These are important intersectoral initiatives and require a solid partnership working at a cross-sectoral level. They are focused on health and well-being, particularly in a holistic approach to health and mental health recovery of service users. As a leadership team our emphasis is on continuing to place our service users at the centre of the development of our service, with particular emphasis on recovery and reorientation towards community services.

Chairman

We will start questions with CHO area 4. We will take questions from Deputies Brassil and Buckley, as well as Senator Kelleher.

I thank the witnesses for attending the committee today. I will get straight to the questions as time is limited. I want to get the maximum from the time allocated. A Vision for Change indicates the recommended team size for adults is 23, for a child it is 13 and for the elderly it is 12. The witnesses mentioned their teams so do they reflect those figures? Assuming that is the case, the deficiency in the adult section is 25%, in the child section it is 46% and in the elderly section it is 40%. The staff numbers are smaller than they should be in all three areas. If we got the staffing numbers to the level prescribed by A Vision for Change, would we address, by and large, deficiencies that currently exist in our mental health services in CHO area 4?

The document refers to community and mental health staffing levels. I note that in some areas it is greater than what is needed but in other areas it is less than what is required. Killarney, for example, has 1.3 times the staff needed. Why are these not rearranged so there is no surplus in any area and deficits could be reduced? I would like an explanation as to why that is the case and what can be done to address it. There is also the matter of recruitment. Is the national recruitment service of the HSE responsible for all recruitment? Is that how it operates? I am speaking personally but I do not see how the recruitment process is visible. Are we advertising at recruitment fairs, for example, or what way are we going about this? Do we go to London and other international destinations to try to get people back here? There were several attempts by the National Health Service in the UK to target people, offering our graduates extra training to get them over there. We need to do something similar. If we are doing it, I am not aware of it. We would like to see more of it.

There is the matter of integration of primary care, specialist mental health services and the various organisations that work in this area. Are the witnesses satisfied that such integration exists and if they are not, what do we need to do to improve it? There are a number of organisations dealing with suicide prevention and mental health services in general. I am not convinced the work they do is linked with specialist mental health services, nor am I convinced that specialist mental health services are linked with primary care. As a committee, we must focus on this to help medical professionals achieve better results.

Somebody might present to me at the weekend if I get a phone call on a Saturday or Sunday night. We are elected representatives and often people see us as the first point of call. Is there an emergency number I can use to say I have a specific acute case that requires immediate assistance? This is so I do not have to tell somebody to come back to me on Monday morning. That could often be a crucial 24 or 48 hours.

Unfortunately, there was an incident in my home town last year, around September, which ended very tragically. I would have liked to have had services whereby I could have asked the person to contact a certain person who might have been able to help him or her. I did not, and that may be as much my fault as anyone else's.

Are the suicide crisis assessment nurses, or SCANs, as they are known, operational everywhere? If so, what is the link between the SCAN and the primary care services, and how do we get the message out there that this person exists in the community and his or her services are available? I am sure those services are much needed.

I refer to the issue of dual diagnosis, whereby people present not only with mental health difficulties, but also with addiction difficulties. I have come across situations whereby people are told that if they have an addiction, until they are clean they will not be seen. It does not work that way. A person with addiction difficulties and who has mental health issues needs immediate care. Trying to get him or her clean might be the very basic action needed and might set him or her on the road to recovery. I would be interested in Mr. Reaney's comments on that matter.

I note the suicide rate in Kerry is now 17 per year. Is this below or above the national average? What is being done in Cork and Kerry to try to get that down to the national average? I would prefer if there were no suicides at all, but they are a reality.

The last question I have concerns issues surrounding counsellors. There are many counsellors, or people purporting to be counsellors, but what level of qualification do the community health care organisations look for? Are jobs available for people with honours degrees in counselling services, a level 9 or level 8 qualification, particularly in hospital or community? If so, how do I direct someone looking for employment and looking to offer their services to the system?

Chairman

The Deputy has gone way over his time.

I am sorry about that. I thought I was being very efficient.

Chairman

It is fine. I probably should have said at the beginning that we are trying to contain contributions to seven minutes each. I ask Mr. Reaney to answer the questions as quickly as he can.

Mr. Ger Reaney

That is a very comprehensive range of questions. I will do my best to be brief.

Regarding the targets in A Vision for Change and how our teams compare, I agree with the Deputy's analysis of CAMHS teams. I think we are closer to the indicative figures for CAMHS in A Vision for Change than for adult services overall. We are at just under 90%. Approximately a third of our adult teams have the staffing they should have in terms of A Vision for Change. I should say, though, that A Vision for Change specifies an indicative staffing for a population of 50,000. Many of our teams have populations different from the 50,000 level. What we have, therefore, is analysis that is mathematical and does not necessarily take into account the mix of roles within the teams or local factors, whether geography, deprivation or whatever else. As for where some areas are over and some areas are under target, Killarney, which is the south Kerry team, is an area where the population is significantly dispersed and where significant travel is required to reach Cahirciveen and Waterville, whereas Tralee's is a more concentrated population. The variation between the teams is probably justifiable.

To respond to the question about whether it would be sufficient if the numbers in A Vision for Change were in place, it would be significant progress. It would be the realisation of a target that was set ten years ago at this stage. That target was designed to build up community services and minimise the requirement for individuals to attend acute units. Whether or not it would be sufficient would have to take into account factors to which my colleagues and I have referred regarding increasing evidence in modern society of pressures. This would probably require a greater buildup of services in primary care, to which the Deputy also alluded, and I might come back to that. Our initial target is to focus on achieving the targets in A Vision for Change, but I know that a review of A Vision for Change is under way and I suspect further development on those targets is required. Our current priority is the child and adolescent mental health service, which is furthest away from those targets, and some of the specialist services, which we are building up in terms of old age, mental health, psychiatry and rehabilitation teams.

We do recruit to the NRS, and we recruit otherwise as well. Our recruitment challenges are in particular areas of psychiatry, most non-consultant hospital doctors and psychologists and specialists nurses. We have 12 nursing vacancies out of a total pool of close to 400 staff. That is not a huge number at a given point in time but, regarding child and adolescent psychiatry, as my colleagues would have outlined to the committee in the morning session, we are working within both a national and an international shortage. We advertise those posts in The BMJ. More importantly, we follow up through individual contacts because the child and adolescent medical community is relatively small and, rather than do recruitment fairs, we feel this is probably at this stage a more effective process, and we are being successful. Our difficulty in Cork and Kerry is that we had a number of retirements coming quite close together and we have also had a number of people who are not Irish nationals and who moved to other countries. We have been quite successful. We currently have 1.5 positions to fill. We are confident of filling one of those positions and the other position will be advertised shortly.

Mental health services are one of the biggest users of psychology. In Cork and Kerry we employ nearly 100 psychologists, including some assistant psychologists, and we have recognised and led the way, working with UCC, in addressing what is a shortfall in training. Working with UCC and the HSE nationally, we have put in place a doctorate programme in psychology which will produce the first graduates in 2019, I think. That is our future plan for that area. In addition, our psychology department would be seen as being quite proactive and quite attractive to work in, but we are working within a pool which is not quite large enough.

I outlined the position regarding primary care earlier. We will go through in a little more detail some of the services that are available at primary care level. Key among these is the counselling primary care service, which is a national service. We provide that across 30 locations in Cork and Kerry, so it is locally accessible and GP-referred. It is fixed-term, usually six to eight sessions, and can be extended if necessary. We have two SCANs who cover three of our mental health teams in Cork and we are employing one nurse in Kerry from 2018. That service requires further development. The service is well integrated with GPs. Referral is made by GPs, and the nurse carries out an assessment, determines what form of service is required and provides feedback and information to the GP afterwards.

I have referred to our psychology service. Our primary care psychology service in Cork and Kerry has been under-resourced for some time and we have been proactive in negotiating with the national primary care division funding to improve this. I outlined the numbers earlier - seven psychology positions and 16 assistant psychology positions, the majority of which we have now offered to people.

The broader area of integration is a good one, and I feel there are opportunities for closer integration between mental health services and primary care services and between mental health services and other services. Some of this concerns building up our staffing, having more counsellors available through our counselling and primary care service, having more SCANs available and building up our community mental health teams, but also the structures. I referred earlier to community health care networks, with which members will be familiar from the Sláintecare report. They provide a format for closely integrating primary care services with other services, including specialist mental health services. I would be happy to elaborate on this should the committee require me to do so later on.

Regarding emergencies, no more than the Deputy, I have got the phone call late at night as well. Our preference, depending on the emergency, is to talk to someone's GP. The call that I took involved establishing whether the matter needed to be dealt with immediately or whether it could wait until the following day, and we established contact with the person's GP the following day.

If a service needs to be dealt with at night, we currently have seven over seven nursing service across most of the area and will have it across all of Cork and Kerry from April 2018 so that will be a port of call in an emergency. If an emergency occurs at night, the service that is available is the local emergency department. I appreciate that this is not the ideal service but we have built up liaison services, particularly in both of the major Cork hospitals, at medical and nursing level in recent years to ensure that this experience is as effective as possible.

In respect of dual diagnosis, it is hard to comment on the individual case discussed by the Deputy but I would not believe that normally addiction should be the reason that somebody would not be able to engage with mental health services. We have a strong addiction service in Cork and Kerry that is separate from our mental health services. Traditionally, it would have been within the mental health services but it works very closely with mental health services. We are seeking funding through our social inclusion budget nationally for a specialist consultant post involving a psychiatrist with an interest in addiction services. There are strong links there are and I am happy to discuss any individual cases that undermine that with the Deputy later.

The Deputy's next question related to suicide and the initiatives in place to address that. Obviously, suicide is an issue that is broader than mental health services. The health services have a role in providing a lead in the area but addressing suicide, be it in Cork, Kerry or across the country, requires society as a whole to work together. Obviously, members will be well aware of the increased profile and freedom to talk about mental health issues and that the national HSE "Little Things" campaign through social media and traditional media is significant. Locally, we have two plans, one for Cork and one for Kerry. They have 72 actions and multi-agency plans agreed with the local authority, the Garda and ourselves. We have suicide awareness officers who work on two fronts, one of which involves building community resilience working with communities and schools to raise awareness and building that community awareness and capacity to minimise the risk of suicide. We have trained 12,000 people in the SafeTALK programme, which, again, builds that level of capacity. The second focus for the suicide awareness officers is being there as a response when a suicide affects a family or particularly if there is more than one suicide in a community. We work with our psychology department in putting in place a number of resources to avoid what can be seen as a cluster effect at times.

The counselling we employ through mental health services is through the counselling and primary care services. That is provided through a third party agency at the moment which employs those counsellors. I cannot tell the Deputy the exact accreditations they use but there is an accreditation form. I am well aware that national accreditation standard will be set with CORU for counselling shortly. The Jigsaw service, which we fund, employs counselling psychologists but the counselling resource we employ directly would be psychologists and assistant psychologists. I think that answers the majority of questions.

Mr. Reaney might send me on the details of the counselling recruitment service. I thank him for his comprehensive answers. I will probably talk offline because I do not want to take up so much time but one third having the staff means that two thirds do not have it so there is a big challenge there. This committee should focus on setting a target for getting all the areas to full staff levels. If we succeeded in doing that alone, we would have done a very good job. I asked a question about the link with primary care and Mr. Reaney gave a very professional answer that there is work to be done there. There is probably very good work but that is a huge area in which we really need to improve. Sometimes it is the system. It is not the fault of any one person. In respect of improving it and the link between those services, if we did everything we could as a committee to work towards helping the CHOs achieve that, we would be doing a lot of good work.

Chairman

I must speed the Deputy up. There are two more members who want to speak to witnesses from CHO 4.

I am finished.

I thank the witnesses for coming here today. I will try to be brief as possible as I have a lot to include in a couple of minutes. Listening to the presentations today, the two things that really get to me, and I do not envy the witnesses' job, which is an extremely difficult and challenging one, are CAMHS and teams. A soccer team has 11 players while a rugby team has 15. It goes on and on. We have listened to many presentations today and we have buckets that are half empty. We have buckets with no assets but we all have buckets. I have 11 or 15 buckets on my team. Can we get the breakdown in each CHO of how many CAMHS teams are actually there, how many are fully staffed, how many are understaffed and, more importantly, how many are overstaffed? There does not seem to be an over-emphasis on a common sense approach. We listened to one presentation from witnesses from CHO 3 or CHO 2 which said that one team is 118%. These are percentages. We want to talk about people and staffing, that is, psychotherapists, psychologists, etc. Why is there no common sense approach? If there are three people on a team that is overstaffed and another team is understaffed by two while another is short one person in the same CHO area, why can we not move people around? Is it down to contractual issues? Why are we over staffing some areas while we are told we cannot fill other areas?

The second issue that leaves me feeling really aggrieved is retention. We are talking about recruitment. The HSE seems to be very good hiring agency staff to fill the deficit and can afford to pay the agency staff more money than its own staff to fill the gaps. To me, this is criminal when it comes to wasting funds. Why can we not sit down with the unions and hash this out? I can understand on the consultant side of it that it may be not a shortage internationally but probably the fact that we are so weak on recruitment because of the wages structure. My next point, which I have flagged with the Minister, goes back to teams. I will use Cork and Kerry as examples. If we need nine teams in Kerry and ten in Cork, why can we not fully staff them and show that it works? I know somebody has to lose out. I am just using them as examples. By fully staffing them, we will cut down on the stress within the system because everybody, even the nurses, are stressed. I have spoken to nurses who have left work crying. Surely we can harmonise the system where those who work in the system will stay in their jobs. Everything in these areas seems to be either half empty or half full so there is no harmony in any of these areas. They seem to be totally broken. Many questions arise. What is the level of decision-making in each area with regard to budgeting and even thinking outside the box? Have they the power to do that? Has anyone in any CHO area told the Minister "I'm short two to fill a full complement of a team and I think this will work"? Can the witnesses do that? These are hard questions. This committee is here to drive this on and assist them. Have any community mental health youth leaders been appointed in any CHO because there are major issues coming down the road with cyberbullying? This is another thing that will come up over the next couple of years so let us nip it in the bud.

I am conscious of time. How much longer do I have?

Chairman

The Deputy has approximately two minutes.

Deputy Brassil mentioned visibility when it comes to recruitment. Can we go into the schools? Perhaps that has been done. Can we get packages, work with unions and say to people that when they qualify in five years, they will work in specific CHO areas and outline the opportunities they will have, along with wage structures, increments, information on where they can improve and so on? I do not see any forward planning to retain staff or give them a chance to improve. That is why we are losing a lot of very good staff from the country. It is not always about money. I spoke to a very good friend at Christmas two years ago and he cried because he wanted to work and pay his taxes here at home but he could not afford to live here. He works in Australia now and he still hates it. I have so much to say on this but I will stop there and send Mr. Reaney an email.

Chairman

I thank the Deputy. I call on Mr. Reaney to respond and ask him to be as precise as possible.

Mr. Ger Reaney

There is a range of good questions. On the numbers per team, unfortunately I cannot answer the question about overstaffing versus understaffing because none of my CAMHS teams is overstaffed. I gave an answer earlier about adult services. They are indicative figures based on a population and they do not take into account a number of other factors. However, we know that does not arise in respect of the CAMHS services. We have prioritised this area this year for the development funding, which we negotiate with the national team. We will add 7.5 posts to our CAMHS service across Cork and Kerry.

On the question of whether one fills a full team or goes partial, our sense is that we continue to try to address the most important deficits. We have met with our teams as part of our CAMHS enhancement project, led by one of our psychologists, and identified within those teams what the profile is of people presenting, what are the key skills that would make the most difference to them and we prioritise the posts based on that, so that we can achieve the maximum effect.

On agencies, we use them for medical staffing when we cannot get staff in any other way. It is very much used as a last resort.

How can the agencies recruit agency staff and pay them and the HSE cannot?

Mr. Ger Reaney

Because medical agencies pay higher rates than we pay and they charge us for that.

That is what I am saying about wasting money. We cannot pay the same as agencies but when those agencies hire staff, they charge the HSE more than what they are paying the agency staff. It is a double standard. There is triple the standard pay difference between agency staff that are well capable of working within the system and probably want real jobs. It is not Mr. Reaney's fault but I want to make the point. There is huge waste in this, even in recruitment and retention. We will never fill this if we have a private sector that is 47% of nearly all the CHOs. It is even the case with CAMHS, which seems to be filled by agency staff. Is that correct?

Mr. Ger Reaney

In our area, we have one medical post filled through an agency. I mentioned money but some people like to work with the agency. Not everyone wants to settle down to a job.

I understand that because of the atmosphere and the better rights. We ask the questions to get the answers so that the public know too. It is about supporting CHOs as well as supporting us. We all want to do things correctly and we hope to have a proper system for everybody.

Mr. Ger Reaney

Beyond medical agency staff, the other area in which we use agency staff to a significant degree is nursing. In most cases, that is for temporary positions so they may be covering vacancies for maternity or sick leave or they may be placed where we need additional staff for a short period due to particular needs of people in residential centres, for example. Most of the positions that we are filling are not permanent positions. We currently have 12 vacancies in our nursing area but we could have up to 40 positions filled through agency. The rest would be temporary short-term positions. There could be a vacancy in east Cork this week and next month it may be in west Cork. It is difficult to fill those vacancies with regular staff, although we continue to explore ways in which we can reduce our agency staffing because of the premium cost that we have to pay on that.

The Deputy mentioned the idea of putting in place teams that are fully staffed. I mentioned that one of the initiatives in 2018 will be an eating disorder team. Since we wrote our submission to the committee, we received confirmation that we will be a pilot for an early intervention team for adults. Both of those teams will be fully put in place. That provides an opportunity to test the Deputy's thesis. These are coming on the back of clinical programmes. To some extent, it also addresses how proactive we are or otherwise in addressing deficits. For various reasons, including the fact that we have consultants working as part of the clinical programmes nationally, our area has been quite proactive in working with our national team and seeking to be a pilot site or initial developing site for both of these areas. Both will be put in place, subject to recruitment, as full teams.

A question on the power of decision-making was also put to my colleagues earlier. We start each year with the service we have. While we have the capacity to move funding from adults to children or from residential to community in theory, that is based on the extent to which we can reduce the need and the service in one area to build it up in another. It is not always that easy to take away a service that is needed in one area in order to fill a need - which may be greater - in another. Where we do have decision-making authority entirely is in respect of new funding. That decision-making is done in co-operation with our national teams. Approval for 90% of the posts relating to development funding in recent years was based on local decisions. Usually, a national framework is put in place in order that we might prioritise the CAMHS service this year or specialist services for older people another year, but we will prioritise where those staff go. I assure the committee that the decision-making, in as far as it can be in an overall national framework, rests with me and Ms Gleeson and her management team.

I understand that the youth health service lead will be advertised early this year, hopefully in the first quarter. If we can get more details on that, we will provide them to the Deputy.

On workforce planning, I would like to get the contact details for the Deputy's friend in Australia before I leave this meeting. We would be very happy to talk to that person about a position. We are coming out of the period when there was a recruitment moratorium. It is only about three years since that was in place. Some of the overhang from that remains in the minds of certain staff. We are working hard to create an atmosphere where people feel valued. We have development programmes in all our staffing areas, including nursing. Staff have the opportunity to study for postgraduate qualifications and specialise in areas in which they are interested. We try to line that up with the service need. That is good workforce planning but we have some way to go. We have increased the number of nurse training places at Institute of Technology Tralee. All of those who wanted to work in Kerry have been offered jobs there. Similarly, those trained at UCC have been offered jobs in Cork. We have a level of forward planning. It is not perfect but it is something that we develop further year by year.

I thank Mr. Reaney. I have many more questions but I will leave it there.

Chairman

I thank Mr. Reaney. We will move on to Senator Kelleher.

Mr. Reaney and I worked together around disability issues in a previous life. It is nice to meet Ms Gleeson. The briefing was really clear - the main document and its appendices - so I thank the witnesses for that. I also welcome the ethos around recovery and co-production which they have outlined. It is important to have principles and values guiding decisions.

I live in CHO area 4. I have worked in that area with Cork Simon Community, where were big issues with addition and dual diagnosis, in the Cope Foundation where there was a focus on disability but also a significant interface with people who had mental health issues, and then in Alzheimer's, which is another area that takes us into mental health issues.

I was informed by the hearings that Senator Freeman chaired on child mental health and some of the questions I ask will reflect that. In preparation for this meeting, I have also made contact with teams on the ground. Dr. Karen O'Connor gave a very good presentation on the home-based team. This is an excellent service to prevent people being admitted and it also plays a role in respect of early discharge. I am also due to meet people from Arbour House. Some of my questions will reflect these things.

When I met Dr. O'Connor, she spoke of how access to counselling at primary care level would prevent over-medication and inappropriate referral to secondary care and that recruitment and retention of staff in other parts of the mental health service - including cover for maternity leave and sick leave - have a huge impact even on teams that are working well because they pick up the slack for problems in other parts of the system. Dr. O'Connor also commented on the out-of-hours service or the lack thereof and the postcode lottery.

The home-base team is working well but it does not cover all areas. The boundaries and silos were also an issue which came up all the time in the child and adolescent mental health hearings. People are falling through the cracks. I have some specific questions on these issues. In their experience, do the witnesses believe that the CHOs have the right mix of skills? We have spoken about vacancies but do the CHOs have the right kinds of people? With regard to the waiting lists, as of October 2017 there are 748 children waiting with 222 of those children waiting for 12 months. Where does Mr. Reaney expect to be this time next year in terms of those very unacceptable waiting lists? Does CHO 4 have proposals around family therapy as a core part of the CAMHS teams? This would seem to be something well worth considering. What are the CHO 4 plans for this? How is the CHO 4 helping to prevent people falling through the cracks? For example, if a person in COPE has a disability as a primary diagnosis but also has mental health issues, which often happens with people who have Asperger's or autism, how do people on the ground work to look after this person? It is the same with silos. If a person with dementia is under the age of 65 where does he or she get access to psychiatry services? How does CHO 4 make sure that people do not fall through the cracks of dual diagnosis?

With regard to the suicide rates of 14.7% in Cork city and 17.1% in Kerry, do the witnesses know the reasons the rates are so high in these areas and where does Mr. Reaney expect to be this time next year in this regard? Obviously, he is not in control of all the factors around suicide but where would he see the efforts to reduce those rates in Cork and Kerry?

Chairman

I thank Senator Kelleher. For the purpose of clarification for our visitors, there was a fast exit by some of the committee members as they had to attend a vote. They will be back.

Mr. Ger Reaney

I thank the Chairman. The Senator asked if we have the right people. I believe we have the right people. We need more of them, as we already outlined to Deputy Buckley. The posts as identified in A Vision for Change are the priorities for us in order to build up those teams. There are particular posts within those priorities that will bring their own value. These are our priorities. I will ask my colleague Ms Glennon to cover the query about the CAMHS waiting lists and the work we have under way. I made reference to a CAMHS enhancement project. This waiting list is certainly our number one priority at the moment.

That is good to know.

Mr. Ger Reaney

That waiting list is not acceptable. There are factors around it. In particular, we have had a number of consultant vacancies. As we fill one vacancy another person retires. This has had a significant impact along with the high number of referrals. Ms Glennon will go through some of the steps we have in place for the short term, medium term and longer term, which we believe will address those waiting lists. These will also address the family therapy issue.

The Senator made reference to people falling through the cracks and to the silos. I will address these points separately. The Senator spoke of her own background in the intellectual disability services. This is an area for development for us. We have appointed a relatively new intellectual disability team over the last two years to support the consultants who are already there. We are also in the process of recruiting for a similar post in Kerry. We are aware that there is work to do in the context of how that team works closer with the agencies to build on the existing relationships and to ensure there are a consultant and staff assigned to each geographic area. We are currently working through that with our teams.

On the issue of needs of people over the age of 65 who have dementia and Alzheimer's, we have developed the psychiatry of old age team. Cork and Kerry would traditionally have been quite strong on general adult community mental health teams, and not so strong on specialist teams, including mental health teams and psychiatry of old age teams.

I asked about the services for those aged under 65. That is the issue.

Mr. Ger Reaney

Is that for people with an intellectual disability?

No, for people with dementia. There is a significant number of people who fall through the cracks because they do not fit in to the silos.

Mr. Ger Reaney

That is a fair point and I apologise if I picked up the Senator's point wrong. We had a meeting recently with our head of social care and with Ms Glennon because many people with dementia are treated by geriatricians. We are putting in place a process with our consultant colleagues in both the psychiatry of old age and with geriatricians, to ensure we have the correct pathways. My experience is that people do get to the right place but at the moment it may take a little bit longer than is ideal. With the growth in dementia, it is an area we cannot be complacent about.

I fully endorse Senator Kelleher's theme on silos. We need to be constantly conscious of this area. I refer back to the community health care networks as being the most comprehensive way to have a local structure for a population of 50,000, and where primary care is linked closely to all the other services, therefore facilitating those services in talking to each in a better way. The current structures do not support that as well as they should. My colleagues and I are very anxious that we can move on with the roll out of the community health care networks. Ms Glennon will address the issues relating to CAMHS.

Ms Sinéad Glennon

As the Senator has mentioned the CAMHS waiting lists have hit a high and there are unacceptable wait times. The November data that was supplied to the committee has 748 children in total on the waiting list, 222 of whom are waiting more than 12 months. As Mr. Reaney said, we started a CAMHS service enhancement project. We have nominated a dedicated lead to that project who has a clinical background as the principal psychology manager. This lead person has been working very closely with the teams to develop their own plans as it is not a one-size-fits-all. It depends on other local services and it depends on the geographic area. We have made very strong improvements with some of the teams, especially with team C. It peaked at 209 earlier this year. These are the December figures because we do not yet have full figures for this year so far, but it is now down to 146 on the total waiting list. Team B is another example. It peaked at 100 in August 2017 and is now down to 66 on its list. It is a very concerted piece of work with the team and developed by the team, to improve it ways of working to look at what is the best possible mix with the needs of the child and the family, and also with the team members available. We acknowledge that in some of our teams there are just not enough staff on the ground, particularly when one factors in maternity leave and so on. Seven and a half additional posts have just been signed off as part of the development funding of the national team and these posts have been targeted towards the teams with people waiting more than 12 months and they are specifically identified to disciplines that the teams have said would make the most difference. We are confident that over the next 12 months there will be a considerable improvement in CAMHS.

The Senator spoke of the family therapists. We have a number of these posts across the system but we would like to have a lot more. The training piece is quite lengthy. In some teams we have one person who is trained in family therapy. If that person leaves the team we also lose that skill. As part of the CAMHS enhancement project, we are trying to develop co-ordinated team-based training plans that we will collate up to one CHO-wide training plan to identify training needs over the next years, and to potentially bring the trainers into our area rather than having people travel elsewhere for training.

Our rates of suicide are above average. It is an issue especially in Cork city versus Cork county. Kerry also has rates that are higher than the national average. Both counties peaked in 2012. The Senator asked why this is. The honest answer is that I do not know. There is strong research linking unemployment and suicide figures. Obviously, it is a multi-factorial piece. We have strong structures in place following the publication of the Connecting for Life plans. The Kerry plan was published at the end of May and the Cork plan was published in July. There are dedicated project teams, a steering group and a number of work streams. There is a lot of involvement from community and voluntary agencies. The community helped us to write the plans and there was wide-spread consultation across the two counties. The plans are very much focused on what can be done internally, be it social prescribing, better links with first responders, better ways to identify people who are potentially at risk and targeting services towards them.

We are very fortunate in Cork to have the National Suicide Research Foundation. We work very closely with Professor Ella Arensman and her team there. They have conducted a very in-depth observational piece of work over the last years where they interviewed families who were bereaved by suicide. The team tried to gain better insight into the whole picture around the time that led up to the suicide or other various links. Our work is usually informed by research and this brings a great strength to the area also. Quite often the figures we have around suicide are a little bit behind; we must wait for coroners' reports, for example. The National Suicide Research Foundation is working to implement a real-time data system, which would give us improved visibility over potential emerging trends and we would not be reliant on anecdotal evidence. Often the media reporting is inflated; it is not the true figures.

With regard to the CAMHS waiting list, where would CHO 4 like to be at the end of the year?

If Mr. Reaney cannot answer that today, I ask that he forward the information to the committee in writing because it would be helpful for us to know.

In terms of the increasing rate of homelessness and the crisis in that regard that all present know exists, to what extent have the services provided by organisations such as Cork Simon Community that are co-located or funded by the HSE kept pace or held their own with the increase in homelessness? I refer, for example, to the community psychiatric nurses, CPNs, and psychiatrists based on Anderson's Quay. I would like some reassurance on that issue because there is such a correlation between homelessness and mental ill health issues.

Chairman

I thank the Senator. Does Mr. Reaney wish to reply?

Mr. Ger Reaney

We hope or intend that nobody should have to wait longer than 12 months. The only caveat in that regard that is the issue of consultant vacancies. As I said, we have short, medium and more long-term measures to put in place a resilience such that even in the event of somebody retiring or being sick we would be able to minimise the impact on those waiting for a long time. As regards homelessness, I earlier neglected to say that we are putting in place an additional homelessness consultant who will work in Kerry and Cork and provide an outreach service in Kerry.

The health funding provided to agencies such as the Simon Community has not kept pace with the increase in homelessness. Although the Government has a significant programme in terms of housing, it is a challenge for all of us to keep the health aspect properly funded. We are working with Cuan Mhuire on an initiative there which we shortly hope to bring to fruition.

If Mr. Reaney writes to the committee in that regard, it will be able to support that initiative.

Chairman

Before we move on to CHO5, I wish to ask Mr. Reaney how much of his mental health budget goes towards mental health services for children.

Mr. Ger Reaney

Some 11%. The figure for 2015 is €12.5 million.

Chairman

We would like a breakdown of that. We have asked other CHO areas to provide the same. We are asking all areas to provide a breakdown of how the children's mental health budget is spent, such as disability, etc. We need that breakdown.

Mr. Ger Reaney

The Chair means a breakdown------

Chairman

A breakdown of the figures, not percentages.

Mr. Ger Reaney

The breakdown between adult and child and adolescent------

Chairman

No. We want to know what budget was spent last year or the year before on mental health services for children, how it was allocated and how the decision was made that children's services would get 11% and by whom. Mr. Reaney earlier said it depends on need but all present know that children's mental health services are in an appalling condition. Who makes the decision that 11% is enough?

Mr. Ger Reaney

As my colleagues and I outlined, we do not start each year with a zero budget basis but, rather, with a number of services in place for adults and children. As we outlined, we have prioritised child and adolescent services for development posts and are continuing to do so this year in terms of 7.5 additional posts into teams and also an eating disorder team. The scope for decision making is around what additional------

Chairman

What happens if it is not spent? Does the money then go elsewhere?

Mr. Ger Reaney

We will spend it. Absolutely.

Chairman

Even if people cannot be recruited.

Mr. Ger Reaney

There are other pressures within child and adolescent services. People sometimes need to be referred outside the area to other services and that can also be a draw on funding.

Chairman

Finally, before we move on to CHO5, there are many discrepancies regarding the number of teams that Mr. Reaney has in CHO4. According to the figures provided, there are 1,468 staff or people working for Mr. Reaney in CHO4. We cannot account for 1,105 of them. Are there many absent employees, are they working in other areas or hospitals or are some not working in mental health but still classed as Mr. Reaney's employees?

Mr. Ger Reaney

I think I can answer that. We have given a detailed breakdown of the staff in five teams and if that is not sufficient detail we can give more. We have not given a breakdown of the remainder of the staff, who are in various acute units and residential units which, because they operate 24-7 365 days a year, tend to need more staff. If we have one nurse in a community working on a team 9 to 5, to run a similar position in a 24-7------

Chairman

Perhaps, rather than telling me now, Mr. Reaney could forward that information to the committee. We will send a letter asking for specific details to all witnesses. I thank Mr. Reaney. We will now move on to CHO5. I call on Senator Murnane-O'Connor.

All the representatives of the CHOs seem to be outlining the same problems such as the recruitment and retention of staff. That must be addressed because mental health is becoming a more serious problem. As I have said at previous meetings of this committee, awareness and working with the families of those with mental health difficulties are issues that are not being addressed.

To take the example of Carlow, which is my area, along with A Vision for Change there are child and adolescent mental health services, CAMHS, and the self-harm intervention project, SHIP, which is a programme being run in the south east to address self-harm by those aged between 16 and 25. However, some younger teenagers need to access that service, which has a waiting list. I have been in contact with the relevant CHO in that regard. Some people who have come to me are on a waiting list and badly need to access that service. It frightens me to think that we have such a service - which is on trial only in the south east, although it is hoped that it will be rolled out across the country - but some teenagers who want to access the service and address self-harm issues are told they are on the list and will have to wait. It is the same with CAMHS, which also has a backlog in that area that needs to be addressed.

Those who live in Carlow are very lucky because they have Carlow regional youth service, which is an independent body that provides great services. The CHOs seem to be using such organisations. Last year, one of its services, Folláine, provided counselling for 140 young people. It charged young people €2 because there was such a need for the service. The Carlow regional youth service has 14 other projects that provide services to the young people of Carlow. It is an excellent project. It has projects in disadvantaged area and works with liaison officers and the Garda. Last year, it worked with over 5,000 children. Some €20,000 was recently allocated to the structure and providing help but that does not go far enough. That organisation provides a very good service and is always looking for money. It finds it very hard to get money but is dealing with areas in which children from the ages of 12 to 24 are crying out for help. I read in Ms Colley's submission that there is increased demand for service for children and young people and I agree that there is. We need to consider that area into the future. It is a great service. I appreciate that €20,000 was allocated to it some weeks ago and the service was delighted with that but we need to look at putting far more money into such areas because everyone will have to work together with the HSE into the future.

The recruitment of staff is a massive issue. Last week in Carlow I went to a meeting about A Vision for Change. It was the first such meeting held and was part of the HSE local forum. I am sure such meetings are being rolled out across the country. I was very taken aback at that meeting. I have learned that friends, carers and family members who support people are key to this issue. However, only six other people turned up for the meeting.

There are issues here. We went through the whole booklet, which was excellent, and great work can be done with it, but we realised that people are not aware of it. People are not aware of what is available for them out there. If families, users and their friends are not aware of a system's existence it cannot work. That night one of the users present said that there was an occupational therapist, OT, he or she had been working with in St. Dympna's. St. Dympna's wanted to keep this particular OT on, but it was told that this person could not be kept on because of a lack of funding. Anne, who managed the health department, had told us that there was funding in place for the various areas. I learned a great deal that night. I do not know what kind of response the witness is getting, but this is a good programme that nobody was aware of. I only heard by chance because someone I know was going, but otherwise I would not have known it was on. This is something we all need to work on. Every area needs to use this. Perhaps the witness can comment on that.

Another issue that I am sure the witness is aware of is St. Luke's psychiatric unit, which has 44 beds but which had 52 patients last weekend. It was on local radio in Kilkenny all last weekend. Some of the patients had been left on the couches in the TV room. That is a disaster. People were very angry over this. I have spoken to people and their families. I want to know if extra units are going to be built. We had St. Dympna's, which provided a great service. Now the bulk of our services are in Kilkenny, which caters for south Tipperary, Waterford, Wexford and Carlow. Our capacity is too small and we are not able to cater for it. It is a massive issue. Is there funding, going forward, to build new units? We need them. I can understand that everyone is doing their best. We are here to highlight things in our own area. Are there any plans to build more units to ensure that we never have a situation like this again?

Chairman

I will stop the Senator now.

I have one more question. I want to ask about the day centre. There are day centres in all areas, but I can only speak for Carlow. We have Aiséirí and the involvement services. I am going up to meet a group next week. Is a certain amount of funding allocated to these services every year? I understand that every year they are looking for different things and they are told that the funding is not there. I have a list which I did not bring, but I will provide it when we meet again. The service is constantly looking for funding. Is there a programme there for day services for funding or for works that need to be done, or indeed for the OT I mentioned, who St. Dympna's wanted to keep on and which it felt it needed? It boils down to staffing, recruitment and funding. I will come back and address some of these issues, but these are the queries I have for my own area that I would like some answers to.

Ms Aileen Colley

I will start with the forum. It is a new matter in the 2018 plan. In the opening statement we referred to the area lead, the six peer workers and the Recovery College. That is linked into ensuring that the people who utilise our services, who we provide care and support to, have a voice in determining how our services are developed and how they would like to see them delivered. I take the Senator's point that an awareness campaign is very important. It is essential, because we want this engagement. It was the first meeting of the year, and it is a brand new programme. There was a meeting in Carlow, and then another in Kilkenny this week. I am very happy to take the Senator's comments and suggestions back. She will see the forum developing over the course of the year. I note that it uses social media and radio, but we need to make sure that we are getting the contact points out and encouraging people to turn up and have that voice. Sometimes that is about permission. People have to feel that it is a safe environment to come to and add their voices to. We received €1.6 million in service reform funds, which will specifically look at supporting people under the headings of housing, employment and training, and that is linked to the Recovery College, which will also be linked to the forum.

In terms of the Senator's other questions, it is much the same as has already been said about Cork and Kerry. Recruitment and retention is one of our priorities. We have all of the data - we have provided it to the Senator - which we look through and ensure that we can allocate appropriately. For example, 33% of the development posts we had were targeted towards child and youth mental health services. There is a recognition that child and youth mental health services need to grow and must be supported. In my opening statement I referred to a step-care model, which is really what we have been discussing today. The importance of primary care, GPs and the voluntary organisations was alluded to, in terms of the regional youth service. We have provided money for that. We have also worked with Tusla and the local council to decide how that support can be given. For us it is about trying to provide wrap-around services, making sure that people get the service at the level they require. The Child and Adult Mental Health Services, CAMHS, is a specialised service. It is trying to ensure that the people it is involved with get what they need as quickly as possible and that they can get it easily.

The Senator asked about the self-harm intervention programme, SHIP. There are three people on the list for SHIP in Carlow, and we take that very seriously, given the type of service that it is. We have a director of counselling services that works closely with both primary care and the mental health team. That team spans both services. When a person comes through SHIP their care can be returned to the GP, or if multi-disciplinary care is needed, hand in hand with the specialist services, those referrals are made. We are piloting that in the south-east. An evaluation study is available, if the Senator would like to read it. It has already been published. We are now in the next round, and SHIP is now available in all counties in the south-east.

St. Luke's was mentioned. The events of last weekend were very unfortunate, when there were 52 patients and only 44 beds. We do have an emergency protocol which is used to bring a situation like that under control as quickly as possible. Nobody wants people on extendable couches or chairs. It is very difficult for the patient and their families but also the staff involved. We recognise that. I am happy to say that by 6 p.m. that evening there were 44 beds occupied, through emergency measures implemented throughout that day. Since then we have had ongoing management plans and have sought to address that. It is difficult to always keep the number to 44, because there will be times where it is under 44, times when we have exactly 44 and of course times when there are more than 44. The Mental Health Commission is one of the regulatory bodies, and we are very conscious of that. Most important, we work for the comfort and safety of the patients. A management plan is in place there.

In terms of beds, 44 beds are available in both Kilkenny and Waterford. We use some beds from CHO6 as well, which I believe was referenced in the statement. Vision for Change is something of an indicator. We must take cognisance of the fact that we have had a 2.6% growth in our population. A Vision for Change was published ten years ago. We must also look at the indices in terms of social determinants of health, etc., and what that means for our area. Dr. Browne might speak on this as well.

However, our team takes it very seriously and it is looking at it analytically as well as from the care perspective, that is, in terms of clinical pathways of care, what is the most informed best practice, so that we can plan ahead.

At this point in time we do not have any commitment on the capital plan for new acute units in the south east. We do have it for other things. For example, in Waterford, we will have 20 beds as part of the rebuild of St. Patrick's and we will have beds coming into Clonmel but not for an acute department of psychiatry.

I will hand over to Dr. Browne.

Chairman

Before Dr. Browne answers, another Deputy wants to ask questions on his area. If it is necessary for him to add to it, great. If not-----

Dr. Stephen Browne

I suspect I will answer the questions he will ask.

Chairman

Probably.

Dr. Stephen Browne

Therefore, it might be of value to consider the issue of bed provision from the national, regional and local perspectives. I draw the committee's attention to the submission of the Irish Hospital Consultants Association. This contains an interesting graph which indicates that, pre-2008, the per capita bed provision in Ireland was above the European norm.

Chairman

Is Dr. Browne speaking about adult capacity?

Dr. Stephen Browne

Acute psychiatric bed provision was above the European average until approximately 2008. Then there was a sharp decline and we are now well below the European average. Most European countries spend between 10% and 12% of their health budget on mental health. We have spent around 6% in the past number of years. A Vision for Change, when costed in 2006, suggested that to staff to the norms recommended would require the allocation of 8.4% of the health budget to mental health. A Vision for Change set a standard for acute bed provision of 16.7 per 100,000 population. Most psychiatrists would say that is an unfortunate underestimate. The current national average is 22 inpatient beds per 100,000 of the population. In CHO5, the average is 18.3. If one were to take 18.3 from 22 and multiply it by 5.1, the population of CHO5 being 511,000, we find CHO5, compared to the national average, has an underprovision of 18 beds.

Chairman

I will stop Dr. Browne there. Perhaps Deputy Browne might ask the witness questions directly relating to that. Would Deputy Browne start his round of questions, please?

To confirm, I think the population figures were updated in the 2016 census, but were the percentages in A Vision for Change also updated?

Dr. Stephen Browne

The rates given in A Vision for Change are per 100,000 of the population, so it is a static figure. When population increases, there will be an increased need. I also draw the Deputy's attention to Planning for Health, a copy of which has been provided. This shows that, due to pure demographic variables, it is estimated there will be an increased pressure on bed availability for mental health throughout the country over the next number of years of 0.9% per annum.

How many CAMHS inpatient beds are in CHO5?

Dr. Stephen Browne

Zero. The national plan was to establish a 20-bed unit in Éist Linn for CHO4 and CHO5. If the Deputy would like the figures and percentages of admissions, I can provide them as well.

How many CAMHS acute admission units are in CHO5?

Dr. Stephen Browne

None.

When Dr. Browne refers to CAMHS approved centres, is that a reference to inpatient beds?

Ms Aileen Colley

The statement was about the community teams. We have no inpatient beds whatsoever.

As part of the plans for the new national forensic mental health hospital, is it intended to develop intensive care rehabilitation units? That is, there would be one for the west and one for the south and they are looking at the midlands. For HSE South, that would include Waterford but not Wexford. Is that correct?

Dr. Stephen Browne

We have made a submission for what is called a slow stream rehabilitation unit. One of the problems with A Vision for Change is that it never took cognisance of the fact that there would be what are called new long-stay patients. These are patients who, due to the severity of their illness, require an admission to a psychiatric hospital for a year or longer. In 2004 it was postulated that by 2011 there would be no new long-stay patients, but that has not happened. Since the first quarter of 2013, there have been 416 new long-stay patients nationally, of which, fortunately, only 29, or 6.3%, were in the CHO5 area. In order to ease the pressure on acute inpatient units, it would be ideal to have a regional slow stream rehabilitation unit for these new long-stay patients who require ongoing inpatient care but not necessarily in an acute psychiatric unit.

Would that be different from the plans, under the national forensic mental health hospital, for intensive care rehabilitation units?

Dr. Stephen Browne

It would be. That is dealing with a specific cohort of patients who, by definition, required input from the national forensic service.

The HSE is developing plans for one for HSE South. Has Waterford looked for that unit to be located there or is it expected to go to Cork?

Dr. Stephen Browne

We are not involved as this is a national forensic mental health service initiative. CHO5 would be separate to that.

Therefore, the decision would be made at HSE South level, if one likes, as to where they want to locate it.

Dr. Stephen Browne

I presume it would be made at a national division level and, therefore, if there is an agreement that there will be what we call a super-regional forensic PICU, which is an intensive care unit, or a rehabilitation unit, we would be seeking protocols for admissions to that unit when appropriate.

Is there any Jigsaw unit in the south east?

Ms Aileen Colley

No, there is no Jigsaw unit in the south east. There have been conversations about it in south Tipperary and in other counties. As it is a national organisation, our national division will lead out on the conditions that are required in terms of planning for the Jigsaw sites. At the moment there is already agreement for the forthcoming year and we are in conversations with our national colleagues. However, at this point in time, we do not have a Jigsaw unit. We have other providers that are similar to Jigsaw but would probably not have the same remit. For example, Squashy Couch provides similar services in Waterford.

Chairman

We have to be out of here by 1.50 p.m.

I have only two or three more questions.

Chairman

We still have-----

I am sorry. I see Senator Máire Devine wishes to contribute as well.

Chairman

I am sorry she has been there for so long, not getting a word in.

What are the total numbers of mental health teams for all sectors? How many are fully populated?

Ms Aileen Colley

The breakdown in the appendices shows the general adult teams. There are 17, but the list is shorter because, for example, in some bigger places they will be broken up into smaller subsets of teams. There is an analysis there not just in percentages but in terms of the whole-time equivalent, WTE, gap. Taking on board what was said earlier about CHO4, we have a good analysis. In terms of our adult provision, we are at nearly 77% of what is in A Vision for Change. We still have a gap of approximately 49 clinical staff to go for adults.

There is a variance between our counties and local populations of 50,000. That is the comment that is really important. We range in population groups of 50,000 but sometimes, given the way people work with GPs or on foot of where they live, some of our teams have population groups which are larger or smaller than that. We need to reflect that. The other reason it might appear in our area that there is overpopulation compared to the area of another team is that there are legacy issues where we had people employed in acute services or longer-term facilities which have been closed on foot of deinstitutionalisation. In the context of development posts, we analyse that and prioritise the counties which need to come up to an effective level by having a complete team for the area.

Can Ms Colley put a figure on the total number of mental health teams there is meant to be? For example, we know that in CHO 2, between CAMHS, adult and old-age services, mental health and intellectual disability, there are meant to be 25 teams in total but only four of those are fully populated. Can Ms Colley give a figure on how many mental health teams there are meant to be and, of those, how many are fully populated?

Ms Aileen Colley

For CAMHS, none of our teams is fully populated. It is the same as CHO 4. In the general adult service, there is one team in particular which is populated - in fact, it is overpopulated - but the rest are underpopulated. For the psychiatry of old age-----

Dr. Stephen Browne

In reference to the overpopulation, one will see, if one looks at CHO 5 for general adult, that it will range from as low as 36% in west Waterford to south Tipperary where it is 130%.

Chairman

I am sorry to have to stop Dr. Browne. This is information the witnesses have provided already and I will show it to Deputy Browne afterwards. We really must finish up. I feel very bad that we have CHO 6 here but have not even gone near them yet. If there are more questions, can they be addressed directly to Ms Colley?

According to the figures, only one mental health team is fully populated. That is the takeaway point.

Chairman

That is it. I reassure the members that we will follow up with questions but also that we will probably be inviting the witnesses back again. That is a reassurance for the witnesses and the members. I ask Senator Devine to address CHO 6.

I thank the witnesses for their patience and for the comprehensive presentations and appendices provided. I come back briefly to the emergency overcrowding protocol. We are taking risks when we look at who to put on leave, who to give extended leave and, in particular, who to discharge. I acknowledge that it is an emergency protocol, but it is risky for clinical staff.

I am known for my brevity and will not go on too long. The moratorium was damaging to staff but the insulting graduate nurse contract offered several years ago has created a damaging legacy in the context of trying to recruit staff. Issues with the recruitment of nursing staff in the east seem to be much more prevalent than elsewhere nationally, which is saying something. It is a problem for every CHO area, but in particular for the east. What contracts are being offered to staff? What is in them? Are they flexible? We spoke about agency staff and their cost. Some agency staff do not necessarily wish to become full-time employees or to sign a contract. Are we flexible enough? At one stage we were saying that if someone could offer four or more hours, that person should contact us. I do not know if it is less than that now. What flexibility, educational opportunities and opportunities for advancement are there, in particular in nursing where one has CNSs and ANPs and where we could run a nurse-led health service at a much reduced cost?

Of the budget, perhaps 80% goes to payroll with 20% going to different services and infrastructure. What is the breakdown between front-line clinical staff and the back-up support staff who are so important but who are providing administration services? I tie that in because I want to know if we have plans, and if so, how advanced they are in the context of the paucity of IT and its use, which has been startling to the committee. IT is a low priority but if we train enough people, we will need fewer in the long term. We would have a lot more continuity and care would be easier to access, as would records. The gap in whole-time equivalents in CHO 6 is verging on 50% in some instances. I do not know if I am reading the statistics right and stand to be corrected.

Linn Dara has been a bugbear of mine as the Chairman will know. It is open. How many beds are operational there? I have harassed two Ministers at least over the last several months and eventually the facility has opened. What are the waiting lists like, including Fairview and the CHO 6 area?

Is the budget based on population or the historical location of asylums? Has that changed and has the position been modernised to refer to what is needed according to the population? What is the budget for section 39 bodies, including Jigsaw and those which offer services on the ground, including CAMHS in particular? Are there contingency plans for the proposed strikes on Valentine's Day? What is the breakdown of the budget for section 39 services? The spirit of A Vision for Change must include value for money. What do the section 39 services provide in that context and how much value do we have in terms of outcomes? Can we measure outcomes or do we just allow the services off to provide what they believe they need?

Chairman

I must ask the Senator to wrap up as the witnesses will not have enough time to answer.

I commend the HSE on its new community initiatives. We must get community ownership of mental well-being. I refer not to the serious end of what we need in terms of wrap-around mental health services but to community well-being, in particular SafeTALK, Assist and all the other initiatives. We need to promote them to empower communities to look after each other.

Ms Martina Queally

We have particular issues in Dublin. As I said in my opening statement, exit interviews with nurses demonstrate that it is most acute among nursing staff. Exit interviews show that the cost of living in south Dublin is high, including the cost of renting and housing. That is definitely a problem, not only in terms of recruiting new candidates for our workforce but also in terms of retaining staff who want to purchase homes, start families and all that good stuff. We have had a number of initiatives as we have not been successful through national recruitment for our area. We have established a specific project under the area director of nursing. It is a special project group to look at local recruitment.

I was asked about the postgraduate and undergraduate programmes. There have been undergraduate nurses all of the time, but we never had a particular undergraduate programme in our acute units and community services with UCD. We have now established that with UCD. We will attempt to grow our workforce, which is very important. The postgraduate programme has been very successful. A lot of the general nurses who do agency work have gone on to that postgraduate programme, which has been really worthwhile. People in mental health nursing retire quite young and we are fortunate that some come back to do agency work, which has kept services safe. Some of the people doing agency work are very experienced. However, we are too reliant on them.

I am glad to say that because they are so experienced we know we have a safe service. This is a very important message for the public because mental health services can be high risk areas so providing a safe service is very important.

With regard to the contract, to be honest local recruitment has been based on temporary contracts and this has been a disadvantage. Our work with HBS under this project will allow us to recruit people to permanent posts. We hope this will improve our situation.

We are developing expertise in our advanced nurse practice and clinical nurse specialist teams, and encouraging people not only to enter our service but to develop a career with us is really our aim. Under Mr. Walsh, the area director of nursing stewardship, we are looking at advanced nurse practice programmes in CAMHS and old age psychiatry in a number of other areas, and we hope to develop these shortly. We did not get any in 2017 but we hope to be on the advanced nurse practice programme in 2018. We have a number of clinical nurse specialists. The CAMHS waiting list is high in Dún Laoghaire, and we are looking at nurse prescribing and advanced nurse practice to free up medical time so we can improve the waiting list. This is very important also.

We have a focus on service improvement in existing nursing posts and how our current staff is deployed to best effect. That is in answer to the question on A Vision for Change being value for money. It is difficult to pinpoint outcomes, but through our focus on the recovery of patients in mental health services we will be looking at, hopefully, shorter length of stay, fewer admissions, people remaining in the workforce and being in close contact and fully functioning in their own communities. This is very important in terms of our ethos and our focus on how our services are developed and run.

In terms of the breakdown of pay and non-pay, our non-pay is slightly higher than it is in the rest of the country. This is because of the number of contracted services we have. It is close enough to 70:20 but it is slightly different. It is not quite 80:20 but it is close enough.

With regard to the gaps in our teams, I gave an outline of the A Vision for Change gap. It is correct to state none of our teams is at the level of A Vision for Change. Our adult teams run at approximately 47.5%, and our child and adolescent humans at approximately 60%, of what A Vision for Change states. This is a position we want to change.

Chairman

I apologise for interrupting. We will ask specific questions of each CHO area and follow up on Senator Devine's questions.

Ms Martina Queally

With regard to Linn Dara, our information is 22 beds are open. We do not directly manage it but we have access to those beds and 22 of them are open.

Chairman

Obviously I did not manage this meeting too well because everyone spoke for far too long. I ask Ms Queally to forgive me for delaying her for so long at the end.

I thank all of the witnesses. We really appreciate their time and effort. We will follow up with questions on specific needs with regard to what the committee is looking for. As I stated, we are seriously disturbed about the services for children and we want to address them.

The joint committee adjourned at 1.55 p.m. until 1.30 p.m. on Wednesday, 24 January 2018.