Joint Committee on Future of Mental Health Care debate -
Wednesday, 24 Jan 2018

Community Health Care Organisations: Discussion (Resumed)

Chairman

I welcome the witnesses from the community health care organisations, including Mr. David Walsh, chief officer, and Dr. Brendan McCormack, executive clinical director, from CHO area 7; Mr. Pat Bennett, chief officer, and Ms Anne Kennedy, head of finance, CHO area 8; and Ms Mary Walshe, chief officer, and Ms Angela Walsh, head of mental health services, CHO area 9. On behalf of the committee, I thank them for attending the meeting. 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.

Members should be aware that under the salient rulings of the Chair, they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. I ask members and witnesses to ensure their mobile telephones are switched off or placed in flight mode as they caused considerable disturbance with the broadcasting equipment last week. Mobile phones interfere with the system and make it difficult for parliamentary reporters to report the meeting. In addition, television coverage and web streaming may be adversely affected.

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

Mr. David Walsh

I thank the Chairman and members for the invitation to attend today's meeting. I am joined as a witness by Dr. Brendan McCormack, executive clinical director for mental health services. I am the chief officer of CHO area 7 and I am responsible for the management of Health Service Executive services, excluding acute hospital care, in this area. I report to the national director for community operations.

CHO area 7 includes County Kildare, west County Wicklow, most of south County Dublin and most of the Dublin City Council area south of the Liffey. The area had a population in 2016 of 697,000, an increase of 33,175 or 5% on the 2011 figure. A total of 43% of the population are below average on the deprivation indices.

The mental health service reports to me through the head of service. There is one executive clinical director and one area director of nursing. The mental health management team also includes allied health professionals and service user representation. A separate management structure is in place for the Kildare area, with a clinical director and director of nursing reporting directly to the head of mental health.

The mental health service in CHO area 7 operates across a number of specialist domains, including general adult, old age, child and adolescent, and mental health of intellectual disability. The general adult services are community oriented, with an emphasis on delivering secondary care in the community. The access team provides mental health services to the homeless population in south Dublin. In addition, a perinatal service is provided to the Coombe hospital. Rehabilitation teams are in place in Kildare and Tallaght, with recruitment under way for a team in the St. James’s sector.

The HSE national counselling service, NCS, provides counselling to adults who have experienced childhood abuse. The counselling in primary care service, CiPC, delivers short-term counselling to those with mild to moderate mental health issues who have been referred by their general practitioner. The service is currently available to general medical scheme, GMS, card holders only.

In total, there are 905 whole-time equivalent staff, WTEs, employed in mental health services in CHO 7. That is outlined in the appendix to our statement.

The mental health service in CHO 7 has a budget of €93 million in 2018. That has increased from a budget of €74.69 million in 2012. The budget is split between pay and non-pay expenditure by a ratio of approximately 70:30.

There are 12 general adult community mental health teams, which form the core of service delivery. These include three teams in the St. James’s sector, four in the Tallaght sector and five in the Kildare and west Wicklow sector. Referrals are mainly from primary care GPs and provide a range of interventions, often long term.

There are three psychiatry of later life, POLL, teams, and hospital liaison services are also provided. There is one rehabilitation team in each of the Tallaght and Kildare services, with a third to commence in the St. James's sector in 2018. A Vision for Change recommends that mental health services for people with an intellectual disability should be provided by a specialist team. Under the chairmanship of Dr. Brendan McCormack, a new management team, including the HSE and voluntary agencies, is in place to oversee this development. These will be catchment area-based services.

The HSE Linn Dara child and adolescent mental health service, CAMHS, has seven community mental health teams. They are supported by an adolescent day hospital team based at Cherry Orchard. However, services in Tallaght, Templeogue, Rathfarnham, Crumlin, Drimnagh and Walkinstown are provided through the Lucena Clinic service, which is under the governance of CHO 6.

There are 132 adult acute inpatient beds in CHO 7, with access to another ten beds in Midland Regional Hospital at Portlaoise. Some 52 beds serve the Tallaght sector, 51 beds serve the St. James’s sector and 29 are in Naas. There are eight hostels catering for 100 residents, and an additional 70 low support and medium support places are also provided. The 24-bed Linn Dara CAMHS inpatient unit is one of four inpatient units in the country. It also has an integrated school.

The CHO 7 mental health engagement area lead was appointed in 2017 and sits on the management team. There are local monthly forums in place across the CHO. These structures will be developed further in 2018. Learning from the views and experiences of service users, family members and carers ensures they are central to the design and delivery of services.

There are three resource officers for suicide prevention. Our Connecting for Life action plan will be launched next month. Work will continue to reduce the levels of self-harm and suicide in close collaboration with statutory and voluntary partners. Approval has been given for five additional posts in 2018 to develop a seven-day service in the St. James’s sector. That will mean that all sectors in CHO 7 have seven-day cover.

In addition, funding has been provided in 2018 for 16 assistant psychologists and four staff grade psychologists.

A regional specialist community eating disorder team for child and adolescent patients will commence this year. Work is also ongoing on a new attention deficit hyperactivity disorder, ADHD, clinical care pathway service in south-west Dublin. The new children’s hospital is located within CHO 7 and includes 20 mental health beds, eight of which will be for eating disorders. The operational arrangements for these beds are currently being worked through.

Recruitment and retention of staff is a significant challenge in CHO 7. Many staff members commute long distances. Shortages of medical staff have led to agency usage. Nursing recruitment particularly impacts on all services. The physical infrastructure for many of our services is poor. Capital planning to replace the Lakeview unit at Naas General Hospital is currently under way. St. James’s Hospital's acute mental health unit is currently being refurbished. A lack of long-term care options creates pressure on acute beds and the cost of private placements is significant for the service.

Other priority developments for the service include a home-based treatment team for Kildare and enhanced rehabilitation services in Dublin South-Central. I refer also to the need to further develop psychiatry of later life services. Bids have been submitted for additional funding in 2018 to address these areas.

That concludes my statement. I have also included some information in the appendix to my written remarks. I am grateful again to the committee for its consideration of these matters, and I am happy to assist further in any questions.

Mr. Pat Bennett

I thank the committee for the invitation to attend today. I am joined by the head of mental health services at CHO 8, Ms Siobhán McArdle. Ms Anne Kenny, the head of finance, is also in attendance. I am the chief officer of the HSE midlands, Louth, Meath community health care organisation, referred to in documents submitted to the committee as CHO 8. I am responsible for the overall management of all HSE services in the area, excluding acute hospital care.

The HSE midlands, Louth, Meath CHO area covers six counties, namely, Louth, Meath, Longford, Westmeath, Offaly and Laois. The region has a total population of 619,281 per 2016 census figures, which represents a 4.5% increase on 2011 figures. While the CHO has the fourth largest population when compared to other CHOs, it has the highest number of children and young people.

The CHO was established in 2015 and comprises two previously separate health service areas, the midlands and Louth-Meath. The mental health service of the CHO is one of four divisions which make up the community health care portfolio. The other divisions are primary care, social care, including for older people and those with a disability, and health and well-being. Acute hospital services in the CHO region are provided by three different hospital groups, namely, the RCSI Hospitals Group, the Ireland East Hospital Group and the Dublin Midlands Hospital Group. Those hospitals are referred to in the appendices attached to the documentation submitted.

The mental health service in the midlands, Louth, Meath, CHO operates as two service entities, with shared governance for the overall service operating through the office of the head of service, Ms Siobhán McArdle, who reports to me as chief officer. There are two executive clinical directors, Dr. Maurice Gervan in the midlands and Dr. Emir Niyazi in Louth-Meath. There are also two area directors of nursing. All mental health management teams in the region are multidisciplinary in membership and include occupational therapy, psychology, social work, speech and language therapy, dietetics and most importantly, service-user representation. This reflects the multidisciplinary nature of modern mental health services. A broad range of services support the mental health and well-being of the population of this CHO. Specialist mental health services are provided through child and adolescent mental health services, CAMHS, general adult mental health teams and psychiatry of old age teams across the region.

The mental health service in our CHO has made a strategic commitment to embed recovery within everything we do. This vision will be achieved collaboratively using the expertise of people with lived experience, HSE staff, non-governmental organisations, NGOs, local authorities and other stakeholders relevant to the experience of the recovery journey.

There is a total of 1,081 staff employed in the midlands, Louth, Meath CHO mental health service. Services are provided through multidisciplinary teams. This is consistent with best practice and in line with government policy as detailed in A Vision for Change.

The mental health service in the CHO has a budget exclusive to mental health services. In 2018 this is set as €95.517 million, which represents an increase of 21.3% from the 2015 budget of €78.735 million. I know that the Chair was anxious to get figures on CAMHS that I had not included in the report. I have them now and can provide them. The CHO's budget for CAMHS is €11.6 million. That represents 12% of the mental health budget for the region. The mental health budget represents 18% of the overall CHO budget.

The programme for Government development funding has been provided to the CHO to develop the new acute mental health facility adjacent to Our Lady of Lourdes Hospital in Drogheda and to develop child and adolescent community mental health teams across the CHO along with general adult community mental health teams.

There are 17 community mental health teams providing services to the general adult population with moderate to severe mental health disorders. Five of the teams are fully staffed per A Vision for Change. The remainder are operating with approximately 70% of recommended staffing levels. Again, I have included this information in the appendices. Recently opened primary care centres in Mullingar and Kells provide accommodation for community mental health teams alongside their primary care colleagues.

There are five psychiatry of old age teams in the CHO providing community-based and residential services to older people with mental health difficulties. In this service, only one of the teams is operating with less than the recommended staffing levels. Specifically, that is the service in Meath. There are 11 child and adolescent mental health teams in the CHO providing community-based services to children, young people and their families. The service currently operates with only 60% of the recommended members of the multidisciplinary team. The development of the CAMHS teams is ongoing.

Specialist mental health services are provided through a range of specialist teams, including teams for mental health intellectual disability, rehabilitation and recovery and liaison services. It is important to note that the developments in this area have been slow, and there is a need for further investment and development of these services.

Community teams are supported by day hospitals and inpatient units where necessary. There are 116 acute beds provided in three inpatient units in the midlands, Louth and Meath. Ten of these beds are used to provide services to people from Kildare, as Mr. David Walsh mentioned. There are 108 continuing care beds in three approved centres in the region, including services provided by psychiatry of old age. In addition, the service supports people with high, moderate and low-support needs to live in the community. Services work closely with local authorities and housing agencies to support those with housing needs.

The mental health service is responsible for the provision of counselling in primary care, CIPC, and the national counselling service, NCS. The CHO funds a number of agencies to provide supports to the population in the area, for example, Mental Health Ireland. There are three resource officers for suicide prevention in the CHO who co-ordinate activities in respect of suicide prevention. This office is the first point of contact for those affected by issues associated with suicide and self-harm.

I will now speak on some of the specific initiatives we have been working on and our achievements in recent years. The mental health service appointed an area lead for mental health engagement in 2017. It is important to acknowledge that this individual has been the leader in encouraging user engagement with services. We are committed to ensuring that service users, family members and carers are central to the co-production, design and delivery of mental health services. This builds on the foundations laid by the mental health services consumer panel in Louth-Meath.

Our CHO has been successful in securing moneys from the service reform fund in order to refocus existing services to a recovery-based model. Our three-year plan will facilitate the advancement of recovery initiatives and the enhancement of employment opportunities and will allow support service users to transition from accommodation by the HSE.

The CHO is committed to the full implementation of Connecting for Life, Ireland’s national strategy to reduce suicide. The launch of our CHO Connecting for Life plan will take place in March 2018. This multi-agency plan has been developed in partnership with service users, family members and carers across the region during 2017. The plan was informed by a public consultation process involving staff, members of the public and key priority groups.

The CHO has been allocated additional funding to develop and enhance community-based seven-day mental health services for existing users of the services provided by general adult community mental health teams. This is a positive development through which service users can access appropriate services at the weekend instead of presenting at accident and emergency departments.

One of the challenges we face relates to the difficulty of securing sufficient recurring funding for a number of services in our CHO. The programme for Government funding is used to develop and implement A Vision for Change. Given that the policy A Vision for Change is now over ten years in existence, it does not reflect changes that have occurred in HSE community health care in recent years. There is a challenge in funding services not described in A Vision for Change. Funding does not cover the additional cost of employing agency staff while waiting for permanent staff to be recruited. Non-recurring funding for 2018 is €5 million or 5.2% of the budget.

The three areas that are being discussed today have experienced the highest increases in population due to being in or on the commuter belt. There has been significant and consistent population growth in the CHO in recent years. This has created a corresponding increase in demand for all services, particularly CAMHS, across the region. All teams are working to ensure that targets relating to waiting times for services meet national key performance indicators.

My colleague, Mr. Walsh, has already discussed recruitment, so I will address clinical accommodation. The rate of capital investment in permanent clinical accommodation has not kept pace with staffing increases in our mental health teams across the region. Delays in the development of primary care centres in key urban areas have resulted in an over-reliance on leased or shared accommodation. This gap impacts on productivity and staff retention.

Specialist mental health services for adults and children with an intellectual disability are underdeveloped in our CHO. The service welcomes any additional investment in these teams to ensure equitable access to mental health services for children and adults with an intellectual disability.

I thank the Chairman and members for their attention and for their interest in the mental health services in CHO 8. I acknowledge the strong commitment of all staff working in the mental health services and in the national division who support us. Through them, we are committed to providing safe, high-quality, recovery focused person-centred services. My colleagues and I are happy to assist with any questions or clarifications members may wish to raise.

Chairman

I thank Mr. Bennett. Before I engage with CHO 9, may I clarify one point. Mr. Bennett said that €11 million was allocated to CAMHS last year or the year before, is that correct?

Mr. Pat Bennett

Yes, it was allocated to CAMHS last year.

Chairman

Is that allocation for CAMHS or for mental health services for children in general?

Mr. Pat Bennett

It was for CAMHS.

Chairman

When we revert to Mr. Bennett, perhaps he might indicate the overall figure for children's mental health services. I now invite Ms Mary Walshe, the chief officer of CHO 9, to make her opening statement.

Ms Mary Walshe

Good afternoon. I thank the Chair and members for the invitation to attend. I am joined by Ms Angela Walsh, head of service for mental health in CHO 9.

I am the chief officer in CHO Dublin north city and county, which is the best description of the area, rather than a number. Similar to my colleagues, I am the accountable officer for the provision of community services. I am committed to integration between primary and secondary care. We work closely with acute hospital services in a co-ordinated way around the assessed needs of the client. This is done in conjunction with Beaumont Hospital, Connolly Hospital Blanchardstown, the Mater Hospital and the Children’s University Hospital, Temple Street.

CHO Dublin north city and county is one of nine community health care organisations in Ireland and is responsible for providing care services to a population of 621,405 within the geographical district of Dublin north city and county. I have included details of the area in appendix 1. There are high levels of need within the inner city as a result of socioeconomic and ethnicity reasons. The population of CHO Dublin north city and county has seen an increase from the last census of approximately 6.9%. One of the fastest-growing constituencies in Ireland is Dublin Fingal and the Dublin City Council area has experienced a population increase of 4.8%. Population growth has been a considerable factor in increasing demand for services in recent years and presents a significant challenge in the context of service planning and delivery in Dublin north city and county.

From a governance perspective, as chief officer, I work closely with the national director of community services, Ms Anne O'Connor, and her team in implementing the national priorities. This is managed through a series of performance meetings with the national divisions. As head of service for mental health, Ms Angela Walsh chairs the CHO mental health management committee, which has representatives from all disciplines to ensure there is a wide range of expertise who can represent the views of service users, carers and family members. The governance structure is in appendix 3.

I will expand further on service provision for CAMHS. In CHO Dublin north city and county, there are eight child and adolescent mental health teams providing mental health services through assessment and treatment at outpatient clinics and in the day hospital. These teams are operating, as set out in A Vision for Change, staffing levels at an average of 66.5%. The CAMHS inpatient 12-bed unit, St. Joseph’s, is operated by St. Vincent’s Psychiatric Hospital in Fairview. The CAMHS consultants provide 24-7 cover to the inpatient unit of the latter and to the emergency department at the Children’s University Hospital, Temple Street.

There are 20 general adult mental health teams providing mental health services to the population. Four of the 20 adult teams are fully staffed as set out in the policy A Vision for Change and the remainder are operating at an average staffing level of 65%. General adult acute inpatient care is provided in four locations, with a total of 125 beds.

There are two psychiatry of old age teams in CHO Dublin north city and county. These teams are operating at 53.3%, as set out in A Vision for Change. There are 12 acute assessment beds - six in the Aishlin centre at Beaumont Hospital and six in St. Vincent’s Psychiatric Hospital, Fairview.

There are a number of day hospitals, eight general adult, one CAMHS and three psychiatry of old age day hospitals with service user led recovery-based hubs within CHO Dublin north city and county. In addition to the day hospitals there are sub-specialist services including four rehabilitation psychiatry teams and three liaison psychiatry teams reaching into Beaumont, Connolly and the Mater and one homeless community mental health team.

We have one a mental health intellectual disability service, which is operated by the HSE's St. Joseph’s service in Portrane in partnership with two section 38 agencies, providing assessment and treatment to clients attending their services. It is important to note that St. Joseph’s intellectual disability service, although providing mental health and intellectual disability, MHID, services is funded through national social care. I have given significant detail on the totality of the bed capacity for continuing care in appendix 4.

The overall staffing for CHO Dublin north city and county mental health service is 1,232 whole time equivalent as at November 2017 census. The single biggest challenge for mental health services in terms of recruitment is mental health nursing. Since 2013 there has been an average of between 35 to 45 whole time equivalent on-going vacancies that remain unfilled in mental health nursing across all services.

The overall budget for CHO Dublin north city and county mental health services in 2017 was €114.458 million, which included an allocation of €14.233 million for St. Vincent's Psychiatric Hospital, Fairview, the section 38 service provider. The allocation for 2018 has been increased by €2.6 million, or 2.35%. The budget for the mental health is provided in appendix 6. I am aware the committee wish to have some level of details on funding and this is the best breakdown we can give in terms of CAMHS, general adult community mental health and psychiatry of old age. I can discuss that further if they so wish.

CHO Dublin north city and county received programme for Government funding of more than €2 million since 2013 for recruitment to posts under A Vision for Change and new developments in line with the HSE clinical programmes for mental health.

These additional posts have been welcomed in enhancing service delivery with a focus on recovery.

I will address the challenges and opportunities for a moment. The population growth within my and my colleague's area has resulted in an ongoing increase in referral rates to child and adolescent mental health services, CAMHS, which brings a significant challenge in terms of our ability to meet the resultant timelines. In response to this, a robust quality improvement plan commenced in CAMHS in my area in 2017 to focus on children who were on the "greater than 12 months waiting list". That list has been eradicated and we are now focusing on further lists. This remains a continuing focus in 2018.

As Mr. Bennett alluded to, capital development is critical. Having appropriate infrastructure to support the effective delivery of service is paramount. A detailed capital plan has been devised to meet the growing demand on services over the next five years in my area. A significant number of our mental health teams are co-located or are due to relocate to primary care centres, which leads to a better interface with GPs and our other colleagues in primary care.

We have been awarded €230,000 from the service reform fund. It is intended to utilise these funds to assist service users to maximise their recovery and support them in seeking employment. This fund will also support service users to articulate their views and fully participate in mental health management teams.

A strong focus for us in 2018 will be on the Connecting for Life strategy. The implementation plan for our area is in its final draft stage and is due to be formally launched in the first quarter of this year. There are two resource officers for suicide prevention who provide information and support, as well as co-ordinating suicide prevention initiatives in the community. I am happy to say there has been a reduction of 50% in the number of suicides in my area between 2006 and 2015.

CHO Dublin north city and county is committed to providing a high-quality, standardised, patient-focused service that best meets the needs of the population we serve. We support integrated health services that meet the diverse health and social care needs of the community and treat each person according to his or her needs. We work with all stakeholders in our area, both statutory and non-statutory, to achieve high-quality health and social care services to ensure that our service users are supported to recover from their mental health illnesses and are treated with dignity and respect. A key focus for our area is positive engagement with service users, families and carers, who can assist us in planning and developing services into the future.

I thank the committee for the invitation to address it. I have included some information in the appendices. My colleague and I are happy to assist with any question or clarification members may wish to discuss.

Chairman

I thank Ms Walshe. Regarding the questions and answers session, we have asked committee members essentially to represent the witnesses' areas.

I apologise to members for last week. I let the meeting get out of hand. We overran by an hour. That was my fault. Can we try to have a bit of discipline, through me, this week? It will be seven minutes each. We will start with Senator Devine, who will ask questions relating to CHO 7.

Senator Máire Devine

I am usually brief but do not quote me on that. In the interests of brevity, I will only ask questions, although I can make statements. I thank Mr. Walsh and Dr. McCormack for their briefings on CHO 7. The Chairman will discuss the issue of money, as not being able to discover what the budget is has got us around this table numerous times. I will ask different questions. Some are specific to CHO 7 while others are more reflective of an opinion.

The main issue that I raised almost every day in the Chamber last year was that of the closure of Linn Dara. Is it fully operational now and what impact had its closure on the waiting list? There are 93 young people on it. Is that worse or better? There has been a knock-on effect. The organisation worked hard to reduce waiting times to 12 months, but the six-to-nine-month and nine-to-12-month lists must be worked on now. The closure had an impact on those as well.

There are three suicide prevention resources officers. Where are they based? Are there measures of outcomes and successes? Ms Walshe stated that CHO 9 saw a 50% reduction with just two resource officers, which is commendable and the right way to go. Are there data on how effective they have been?

My next question is on IT. We have been debating reform and Deputy Neville and I attended a committee this morning where IT systems were discussed. "IT" seems to be a scary term in the world of mental health services. Are there plans for a state-of-the-art IT system? It would cut back on administration and be efficient. There could be apps that members of the general population could click on to find out where their cases stood. The national children's hospital is planned to be high-tech in that regard. A new system could be piggybacked on the state-of-the-art IT system that the Department of Children and Youth Affairs is tendering for in respect of affordable child care services. Perhaps CHO 7 could learn from or buy into that success. It is a large area of work, but it is the area of the future and will make everything much more manageable in the health services and guide front-line workers.

A Vision for Change is done and dusted but it has never been implemented in its entirety. Adult services and, to an extent, old age psychiatry are steady enough even though there are many vacancies. The Ombudsman for Children has stated that A Vision for Change's chapter on children - chapter 10 - is at the back of the book and no one really gets that far. We give up half way through. In the witnesses' opinion, would it be better for us to develop A Vision for Change or a stand-alone sister policy in respect of children?

Our urgent care model is accident and emergency. That is usually the only way that people in distress can attend out of hours. Could other models of care throughout Europe, the US and Australia be considered? There is a different approach to urgent care in Australia, in that it is semi-separate from the accident and emergency system and is not caught up in it. It is dedicated to those in mental distress. Considering it would be good.

We used to have many rehab units and A Vision for Change did not foresee the need for medium-to-long-term care. Mr. Walsh alluded to the potential need for more units. Are there plans in that regard and how many more would be needed?

I am curious. Perhaps I am just being suspicious, although I am not normally. Dr. McCormack is heading up a group comprising the HSE and voluntary agencies to develop a mental health and intellectual disability team. It will be an in-house team run and directed by the HSE, as opposed to section 39 and voluntary agencies. Will Dr. McCormack comment on this matter? I might be reading too much into it.

In light of the discussion that the Oireachtas and country will have over the next few months on the sexual and reproductive health of women and girls, does Mr. Walsh believe that dedicated mother and baby facilities need to tie into an overhaul of sexual and reproductive health services for women? While the Coombe hospital provides access to a neonatal doctor, there is not a single bed in the country for mammies and their newborns.

Chairman

I thank Senator Devine and ask Mr. Walsh to be as concise as possible with his answers.

Mr. David Walsh

I thank Senator Devine for her questions. The inpatient waiting list for the Linn Dara service is currently three.

Senator Máire Devine

Only three?

Mr. David Walsh

Yes. The list in the appendix refers to those awaiting outpatient appointments in the community. The Linn Dara unit is currently fully open. As of today, it has 23 residents and while it has a maximum capacity of 24, I am advised that due to the mix of patients it is currently deemed to be full with those 23. Work is ongoing and in particular, the reconfiguration of teams in Kildare and Lucan this year will help us to address the longer waiters for community outpatient appointments. We expect that those 23 patients who have been waiting for more than three months will be addressed in the coming months because obviously that is too long.

Two of the three suicide resource officers are currently on duty and one is on leave. They cover the entire CHO. I will ask Dr. McCormack to elaborate on their work on the Connecting for Life programme once I have answered the other questions posed. In terms of IT systems, there is a huge gap. The mental health division is currently working on a programme to introduce a comprehensive IT system that cuts across all of our community services including mental health and primary care. The aim is to improve the ability to communicate between GP, community mental health and acute services. The IT gap has an impact on our efficiency but there is a project under the auspices of the project management office of the mental health division which is examining it and we all support that.

In terms of A Vision for Change for children, as people within the service delivery system we implement the policy that comes down to us and we welcome any direction on policy. I will ask Dr. McCormack to address the question on urgent care. Regarding rehabilitation units, CHO 7 is an area that did not have major institutions in the past so it does not have huge resources that can be reconfigured into newer forms of service. For that reason, we have spent quite an amount of money on placements with other agencies, including private nursing homes and private long-term care facilities to try to address our needs. The appendices contain details of our hostels but there is a gap there in terms of meeting the needs of chronic, long-term patients. I understand that the mental health division intends to source a resource during 2018 that may help to address that but we would see it locally as a very significant gap.

I will ask Dr. McCormack to talk about mental health and intellectual disability. In terms of mother and baby facilities in the context of mental health and motherhood, we provide a perinatal service in the Coombe Hospital but that is an area that needs to be further developed. As a medical practitioner, Dr. McCormack would be better placed to talk about that.

Chairman

Before Dr. McCormack responds I would remind him that there is another committee member who wants to ask questions about CHO 7 too. In that context, I ask him to be as concise as possible.

Dr. Brendan McCormack

I thank the Chair and Senator Devine. I will begin with the question about the suicide resource officers. There is one officer based in the old Meath Hospital campus in the centre of Dublin and the other is based in Kildare. The third officer is currently on leave but will also be based in the Meath Hospital site. Does that answer the Senator's question?

Senator Máire Devine

I was seeking specific details on outcomes and successes. Has there been a reduction in suicide levels in CHO 7? Does Dr. McCormack have that data?

Dr. Brendan McCormack

We can provide statistics on the local rates. Locally there has been an increase in suicide rates in some pockets and areas which is quite a concern. This has been a focus for the suicide resource officers as well as the local teams. Most of those cases were people who had not been in touch with the mental health services which is of particular concern.

Senator Máire Devine

Could Dr. McCormack provide a graph to give us an idea of the suicide patterns in the area?

Dr. Brendan McCormack

We will provide that to the committee. The Senator also raised mental health and intellectual disability. Here we are referring to the development of a new service which is being driven nationally. A national steering group was set up under the mental health division. Resources have been provided for the last three to four years with a view to establishing community based teams for each catchment area for people with intellectual disabilities. Until now, such services have been provided on an ad hoc, somewhat haphazard basis and have been provided mainly by the voluntary agencies.

Senator Máire Devine

On that point, I want to welcome the fact that such services are now back with the HSE. I welcome the fact that service provision is back in public ownership and that there will be more stringent checks and balances in place. That said, I am not criticising the voluntary agencies.

Dr. Brendan McCormack

Some of the services have been excellent in some areas but absent in other areas. What we are hoping to do is provide a consistent and equal service across the board.

Senator Máire Devine

A national service, so to speak. That is great.

Chairman

I thank Dr. McCormack but will have to cut him off there. Deputy O'Loughlin is next.

Deputy Fiona O'Loughlin

I have two small housekeeping points I would like to raise. First, would it be possible to get documentation more than 24 hours before our meetings? I am the chairperson of the Joint Committee on Education and Skills which meets on Tuesdays. It is quite difficult, in that context, for me to be able to read the documentation in detail in advance of other committee meetings. My second point is that I will have to leave in about 20 minutes to speak in the Chamber on education.

Chairman

That is fine.

Deputy Fiona O'Loughlin

My remarks are also related to CHO 7. I want to acknowledge the opening statement from Mr. David Walsh and thank him and Dr. McCormack for attending today. I also want to acknowledge Mr. Walsh's willingness to engage on issues in the area on an ongoing basis which is very much appreciated. I am going to try not to repeat any of the points made by Senator Devine but there may be some degree of overlap.

I thank the witnesses for the documentation provided and the huge level of detail therein. That level of detail was something we were seeking from national representatives. In terms of finances, I am particularly interested in the ratio of pay to non-pay items. Obviously we need to have the best of professionals and that must be acknowledged. We must also ensure that there are other elements at play. We must also acknowledge the very difficult job that all of the witnesses have in terms of providing a sustainable and highly standardised system across the whole area.

We are dealing with a society where there are very diverse health and social needs within all our communities and within the communities the witnesses serve, particularly in the area of mental health. We must examine preventative measures and areas where early intervention and acute intervention are needed. There are many levels to be considered. I would put a great deal of focus on preventative measures in terms of work that can be done by community organisations working with schools and helping community organisations whose volunteers do a great deal of work. I would mention the Hope (D) service, with which I am sure Mr. David Walsh and Dr. Brendan McCormack are familiar, which does a great deal of work before people reach a crisis point, the Samaritans, which have their regional base in Newbridge and which does incredible work, and the Mojo service, and I have seen at first-hand the terrific work it does.

Senator Devine asked a question about the suicide prevention officers. I am particularly interested in how they do their work in terms of suicide prevention. I welcome the fact that funding is being spent on the Lakeview unit in Naas. That is badly needed and I would like to hear the timeline for that.

I would like one of the witnesses to tell me about the monthly local forums that have been established, and I am particularly interested in area 9. The sharing of the views and experience of service users and families in trying to identify the gaps that exist is hugely important and will help in designing the best delivery systems we can have.

From having spoken to constituents and friends of mine, I would acknowledge that the whole area of eating disorders is a major one in terms of mental health issues. I note a regional team will be commencing this year. That is to be welcomed but I would like to know how the roll-out of that will happen, and we need to make sure that it will have an impact in every area. I would also mention the home base treatment team and it is good to note the priorities that are emerging.

The child and adolescent mental health service, CAMHS, is one of the areas about which I have a concern. I genuinely regret to say that I do not hear many positive comments about CAMHS. I am always conscious when we are dealing with professions and public servants that it is not good for mental health for public representatives to start to give out about them because everybody must be respectful of one another.

However, I have genuine concerns and I would mention the experiences of three random constituents of mine. One parent contacted me advising their child has been in the system for ten months and that they rarely get to see somebody and they have never seen the same person twice. There is no consistency across the service. That is very wrong. We all know what it is like to have to build up trust with a young person. The fact that different professionals deal with the young person every time is not right and that certainly should not be way the system works.

Another parent contacted me whose child who was attending school and was deemed to be too severe for CAMHS and they were completely caught out. Luckily in that case, the matter rectified itself in a number of months. I also spoke to a parent who was desperately trying to do the best for their only child. They said that they would pay for private assessment as there was such a long waiting list to get an assessment but they were told by CAMHS that if they went privately for the assessment they could not come back into the system. I highlight those cases-----

Chairman

Would the Deputy be able to consolidate the questions she wants to put to the Mr. Walsh?

Deputy Fiona O'Loughlin

Yes, I will. Briefly, I would like a breakdown of the costs involved in paying locum and agency staff. With respect to the waiting list for CAMHS, the waiting time in my area is average but we need to be able to improve the waiting times. Does community health care organisation, CHO, 7 ever return funds to the HSE? I know that happens in some cases. The witnesses have outlined their priorities for 2018 and they might indicate if there are any more of them. They referred to having a team in place to deal with older people. I am glad some improvement has been made on the day care centre in Monasterevin. Day centres provide a vital place for older people. Do the witnesses have a timeline in that respect?

Chairman

I call Mr. Walsh to reply and I ask him to be as concise as possible.

Mr. David Walsh

I thank the Deputy for raising those issues. Regarding agency staff, the total spend last year on agency staff was €8 million and, of that, €6.3 million related to general adult services and the rest was across child and adolescent and psychiatry later in life services and that is split between nursing and medical staff. Agency nursing staff costs are very high and growing. It reflects the problem we have in recruiting and retaining staff within the service. For example, we have got 184 service development posts since 2012 and we have filled 143 of them but we have only 34 more staff because we are leaking more staff out the backdoor. That is a real issue.

That leads into the Deputy's issue around consistency. If a child or an adult comes back for their next appointment and they do not recognise anyone who is there, that is a problem. In terms of the medical staffing, that has begun to stabilise even though the problem has not been completely addressed but with the nursing and allied health professionals the high rate of turnover remains a problem.

On the question of CHO 7 giving back money, we generally do not. In 2016, we overspent by in or around €3 million and, in 2017, having got much more support from the mental health division, we came very close to breaking even, but the difference was in or around €100,000 or €150,000. That reflects the fact that we have more than 14% of the population but we only have 10% of the budget. That is an immediate stressor within the system.

With respect to the psychiatry of later life services, the service in Kildare only started in the past few years and it is building. The Deputy will note that from A Vision for Change figures. They are very low in terms of the psychiatry of later life services. In terms of the figures across Tallaght hospital and St. James's Hospital sectors, the professionals within them provide a very good service but they are still very much below the bar in terms of A Vision for Change targets. With respect to Monasterevin, I will broaden it out beyond Monasterevin and point out that we need to make better use of all our health care facilities beyond having merely a 9 a.m. to 5 p.m. service. I expect to have a firm design around Monasterevin that I would be happy to share with the Deputy over the next month or so.

Deputy Fiona O'Loughlin

I thank Mr. Walsh for that.

Chairman

We will move on to CHO 8. The two members who will be questioning the witnesses are Deputy Corcoran Kennedy and Senator McFadden. I call Deputy Corcoran Kennedy.

Deputy Marcella Corcoran Kennedy

I thank all the witnesses for coming in. The discussion has been very helpful. This is a very important committee. Many people have different perceptions of this area but we are learning increasingly more from the evidence that is coming through and that will help inform the document we will produce at the end of this process. What is very clear from all the people who have presented in recent months is the level of commitment that exists to help people who are experiencing mental health difficulties. There is no question about that existing at every level.

I have an observation and a number of questions. I welcome the area lead on mental health engagement.

Will the mental health youth lead be appointed? If so, when? What will the remit be? I am very interested in the area of youth mental health. We talked about A Vision for Change but social media have suddenly appeared on the horizon and have become a significant issue in a very short space of time. This was not really addressed in A Vision for Change and I perceive the role of the youth mental health lead to be important in this regard. Art therapy has potential for young people. Would this be considered as part of the remit of the youth mental health lead?

Reference was made to the challenges associated with agency staff and to how the costs were not reflected in A Vision for Change. Roughly how much is being paid out at any one time for agency staff?

A point was made on the lack of primary care centres. Mr. Bennett noted their slow development is preventing the delivery of the kinds of services they want to provide. Linked to this is the number of nurses listed, which stands at 510. How many of these are suicide crisis assessment nurses? Are they linking in through the general practitioners and primary care centres? How is this achieved?

My next point is on the capital requirements. Along with facing primary care centre difficulties, do the representatives face difficulties regarding the provision of specific houses that people might require, depending on their mental health care needs? They may not be able to function on their own. Is planning an issue where there is a desire to put in a particular facility? Are there objections on the part of locals who may not understand what the witnesses are trying to achieve?

My next question is on an issue that is somewhat specific but has come across my desk recently. It concerns the psychological disorder Prader-Willi syndrome. It is not very prevalent in the population. Are the education and medical systems tuned in sufficiently regarding this disorder? There is a difficulty in accessing services because the disorder may be considered more physical than psychological. Perhaps there is more emphasis on the physical.

Mr. Pat Bennett

The Deputy welcomed the area lead and user engagement. It is a really important role. The lead is based in Louth-Meath and she has been working across the area. She has been involved in the Connecting for Life strategy and in local fora. We can give the Deputy more detail on that, including on consultations in which she will be involved.

On the youth mental health lead, I understand we do not have funding for 2018.

Ms Siobhan McArdle

I believe it is a development in that there is a national commitment to there being youth workers to broaden out the area lead for young people as part of the mental health engagement brief. In each of our CHOs, we have not yet got the funding for that but we understand it is a 2018 commitment. We would welcome that.

Mr. Pat Bennett

I absolutely agree that art therapy is important and significant. It is provided on an ad hoc basis in a number of areas, where it has made significant improvements. It is a medium through which people can feel very comfortable communicating.

In 2017, the agency cost was €7.8 million for CHO 8. That points to the significant challenge that exists. We listened to all the hearings last week on recruitment challenges, particularly on the medical and nursing sides. I refer to significant money for ourselves because we are paying one third more than what we would be paying our own staff. There are significant costs involved here. That is a major issue.

On the primary care centres, there has been good progress. In some areas we are waiting for planning permission or for the developments to be completed. We sometimes have to lease premises, which is not ideal. The idea behind the primary care services is to improve the integration of services and the linkages with general practitioners and the other services. Again, however, there is a significant move in respect of a number of centres, including that in Tullamore, which should be ready in the first quarter of next year. I can give members an updated paper on the development of the primary care centres right across the CHO. I will be happy to do so after this meeting.

On the suicide nurses or scan nurses, there are two in our area who link with the general practitioners and the primary care centres. They also link with the hospitals. Can Ms McArdle elaborate on the scan nurses?

Ms Siobhan McArdle

The scan nurses and suicide crisis assessment nurses project was established as a pilot project. It is specific to Laois-Offaly and our CHO. In addition, we have delivered self-harm nurses, who work in emergency departments in our acute hospitals. We have seven in total across the midlands and Louth-Meath. Therefore, across the whole six counties, we do have access. There are different pathways but we work very closely with our GP partners and acute hospital services to ensure there is good integration with the community mental health teams in any of those areas.

Mr. Pat Bennett

I will ask Ms McArdle to deal with the capital requirements in regard to housing. We work very closely with the local authorities. I am not aware that significant issues have arisen in obtaining planning permission.

Ms Siobhan McArdle

Specifically in mental health, we do not have issues in respect of planning. We have had some infrastructural developments in the midlands. Some of our high-support need houses have been redeveloped. Part of our service reform fund policy concerns enhancing housing options for people with mental health difficulties and working closely with local authorities and housing agencies to ensure it is not just the HSE that is supplying housing but that people can be given sustainable tenancies like any other member of the public, such that they are not defined by their diagnosis and can live in the community. We do not have experience in our area of people objecting because we are working more closely with the local authorities to ensure people are living full lives in the community. It is just about getting tenancies. There are no special accommodation requirements for somebody with low or medium support needs. It is just about getting housing and sustaining it through tenancy support. Obviously, for people who have continuing care needs, we provide a higher number of beds together, although not in a complicated setting. The individuals live in the community and are supported by support workers, who ensure people are engaged in community settings.

Mr. Pat Bennett

On the final question, on Prader-Willi, I will ask Dr. Brendan McCormack to make a comment.

Dr. Brendan McCormack

As far as I know, there is not a specific service for people with Prader-Willi syndrome. For those who need a specific service, there is a service gap. I understand this is being considered at national level. The former national clinical lead, Dr. Margo Wrigley, has been considering this at national level. I understand there will be some recommendations. I could be corrected on that. I have had some discussions with Dr. Wrigley on this. I am happy to look into that a bit further and provide information later.

Deputy Marcella Corcoran Kennedy

The issue of staffing has arisen at a number of our meetings here. I notice that the CAMHS team has 60% of the recommended staff members. For another of the teams mentioned, the figure is 70%. Is this attributable to the population increase or qualified staff leaving? Alternatively, is it attributable to the fact that we are not directing enough young people who are making decisions on careers into the very valuable and important career in question? Do we need to be considering this? Is it a combination of everything, such that we should be considering connecting with the education system and career guidance teams, suggesting the various levels? Is that part of it? It must be so frustrating to be bringing in agency staff continually when one would much prefer to have full-time staff and make better use of the funding.

Mr. Pat Bennett

The Deputy is right. It is not just a population issue. This is both a national and an international problem, particularly in regard to consultants in the child and adult mental health services, CAMHS, but also specialised nursing staff. We are working with universities in terms of placements, looking at post-graduate programmes, etc. Some of it is around lifestyle choices. When people finish training, many of them want to travel and see some of the world. Some of it is to do with the fact - one of our colleagues mentioned this last week - that our systems are underdeveloped and therefore people might not want to come into the environment without having a full multi-disciplinary team around them. There are a number of challenges there and for us to grow services, we will have to make sure we have permanent staff in place. The previous speaker mentioned the inconsistency of people turning up and seeing a different person every time. That is very difficult because to get that connection with a young person in particular takes time and energy, which can be lost. There are a number of factors. It is not always about wages and conditions, even though that is a factor. There are other factors as well.

Deputy Marcella Corcoran Kennedy

Finally-----

Chairman

Very briefly.

Deputy Marcella Corcoran Kennedy

I want to say that mentalhealth.ie is an excellent website. It is a marvellous first point of contact. We all have a responsibility to try to highlight, in terms of parents who might be concerned about their children or anybody who is a bit below par, the fact that there is a great deal of information available. I very much welcome that and will certainly promote it. Do the witnesses find that that type of technology is a good way of accessing the general population in terms of trying to help them almost in their own homes because things have changed to a huge extent? I was talking to a parent recently who gave me an example of her child who was connecting with the counsellor online. That was marvellous because the parent did not have to drive the child somewhere, and they were able to connect. That is a tremendous step forward in terms of efficiency and all sorts of cost savings, as well as benefit to the individuals.

Mr. Pat Bennett

In terms of the future, this generation is very comfortable with technology, much more comfortable than me. My own children will often look up stuff online with regard to illness and other difficulties, so the Deputy is absolutely right. It is time-saving but it is also more comfortable for them in terms of the engagement process. It is very important in terms of developing that. As Senator Devine said earlier, the development of a good IT system is vital. That is one of the real positives of social media. One of the criticisms expressed over the years was the negative impact of social media on people's mental health but this is positive in terms of that type of professional engagement and support.

Chairman

I will move on because there are more questions for the witnesses.

Deputy Marcella Corcoran Kennedy

I thank the Chairman.

Senator Gabrielle McFadden

I thank the witnesses for being here and giving of their valuable time. I acknowledge their offer of information, help and support. Not wishing to be parochial, although I will be, it is very good to get that offer because the people in the first group we had in here from the national office were not very forthcoming or nearly as helpful.

Senator Máire Devine

The Senator is very polite.

Senator Gabrielle McFadden

I am trying desperately to be polite. I acknowledge the offer of information and support.

Deputy Corcoran Kennedy raised the issue of staffing, which was one of the questions I intended to ask, in terms of CAMHS only working at 60%. She highlighted the possibility of that being for various reasons. I will not ask the same question she asked but I have two other questions on that. First, what proportion of the 120 assistant psychologist positions allocated by the Government in last year's budget for this year will come to the community healthcare organisation, CHO? Have they been advertised and how many have been filled? If they have not been advertised, why not?

Also, on staffing, I presume the problem is not all about salaries. One of the comments made to me by two members of staff, not in our CHO but in a different one, was that there is not enough support or consideration for the staff's own mental health and well-being. People are finding that they are very overworked. Email and IT facilities are great but people find that in using email they can off-load their work onto somebody else. They may think their job is done but it is piled on to somebody else. That was a comment from two members of staff from a different CHO but it probably is an issue that affects staff in our CHO and I would like to hear about staff in that regard.

In their opening statement the witnesses said the service had been allocated additional funding to develop and enhance community based, seven-day mental health services. Can they tell us more about that and what it actually involves on a day-to-day basis? I had a case some years ago of a lady who on three occasions had her husband drive her to present herself as being suicidal to a facility in CHO 8 and she was sent home each time. She did not even get past admissions. That was outrageous. I had her husband on the phone telling me he was doing a 24-hour watch because she said she was suicidal. That is not good enough. That happened in 2015. What does it mean when the witnesses say they have been allocated funding to develop and enhance both the community based and in-service?

Regarding finance, €95 million goes into the service. It shocked me that when the witnesses were before the committee on the other occasion they could not tell us how that money was spent. I am very curious about money that is paid to other organisations that provide a service on the service's behalf to people who need it. Some of them are excellent people who do exceptional work way beyond the call of duty but for illustration purposes, if I were to say to the witnesses that €100,000 was paid to Organisation X to provide a service, could they tell me exactly how much of that €100,000 reaches the service user and how much of it is lost in corporate events and other things that go on in organisations, including in the Health Service Executive?

I have many questions but I will conclude on this one. Appendix 4 has a table outlining the 1,081 staff, which includes medical, which is self-explanatory, and nursing. Specifically, what is general support and patient and client care, and how do they benefit the service user on a day to day basis? The witnesses can then have the rest of the day off.

Chairman

Not quite, Senator. There are other-----

Senator Gabrielle McFadden

When they are finished answering my questions.

Mr. Pat Bennett

I thank the Senator for the many good questions. The assistant psychologists come under the primary care services. I am sorry I do not have an answer for her on that but I can certainly follow it up. That is funded under primary care.

Senator Gabrielle McFadden

That is probably a fault because if that comes under primary care and the witnesses are responsible for mental health services, there is no linked thinking in that regard.

Mr. Pat Bennett

Yes.

Senator Gabrielle McFadden

That is something we need to examine in the future.

Mr. Pat Bennett

That is not to say they would not be working across both, but they are funded under primary care. However, we can certainly follow up on that, get the information and revert to the Senator.

Senator Gabrielle McFadden

I would like that.

Mr. Pat Bennett

On the support for staff, I could not agree more with the Senator. Staff are stressed. The non-filling of positions in recent years and positions disappearing has had a huge impact on them. There is an employee assistance service within the service but it is the responsibility of managers as well to support their staff. We would encourage staff to go to managers with particular difficulties they might be experiencing. Many of them are not work related but to do with outside work because of the other pressures in life. The Senator is right, however, that it is something we need to put in place because mental health staff are users of mental health services as well. There is a reality in that respect. The Senator has made a very good point and she has put into my psyche the need to be a bit more forthcoming on that issue because it is very important. I will have a look at that.

Regarding the seven-day mental health service, I will ask Ms McArdle to take that question.

Ms Siobhan McArdle

Across the CHO we have a seven day service but it is at a basic level for all service users who access our rehabilitation and recovery services. For clients who have enduring mental illness, the rehabilitation and recovery teams provide weekend supports.

However, we are conscious that the service needs to be extended to all people who attend our general adult or community mental health teams. There is national recognition of this as well. The Midlands, Louth, Meath Community Healthcare Organisation has a home-based team skeletal service in the Louth-Meath area. The funding allocated in 2017 will be used to enhance the service in that part of the CHO. In addition, the funding allocated will be used to open day hospital services in the midlands to allow service users who access day hospitals during the week to have access over the weekends.

That is a welcome development. It will mean that if someone wishes to contact or access the service, he or she need not turn up at an admissions unit or emergency department. The person will have contact with staff who are familiar with the care of that person and the case. The staff will be available to assist these people over the weekends or assist their family members.

The staffing allocation is a small amount. We would like to see the home-based service rolled out throughout the full CHO area. We would also like the day hospital model to be rolled out throughout the rest of the CHO area. It is a work in development but it is most welcome.

Mr. Pat Bennett

The last question from the Senator was on the grant to voluntary organisations. The formal answer and process is that we have service level agreements with the organisations under which they outline budget requirements for the year. Normally, 11% or 12% goes towards administrative costs and support. Most of the rest should be on direct services.

Several of the groups we fund in mental health are advocacy organisations. Much of their work is on campaigns, advertising, promoting and networking events. They are not real service deliverers in the sense of mental health services; they are advocacy organisations. There is an ongoing monitoring process with these organisations. I suppose we could be more forensic than we have been, to be honest. We need to look at that. However, the service level agreement is the template we use for the grants.

Senator Gabrielle McFadden

I have three comments.

The first relates to something that should not but does happen to public representatives. This is where a person comes to us who is suicidal. I advise these people to go to their general practitioners, GPs. The GPs send them to hospital and the hospital sends them home. What should a politician do in that situation? Where should I send someone? The person I have in mind was sent home three times from a hospital and is suicidal. What is a person physically to do in that situation?

Is there assessment of the outcomes in respect of the other organisations used by the HSE? If the CHO gives €100,000 to an organisation, is an assessment carried out at the end of the year to see what outcomes emerged and what value for money was achieved?

I will give the HSE representatives a half-day after my last question. Can they explain some of the references in appendix 4, for example, "general support" and "patient-inclined"?

Mr. Pat Bennett

The question relating to suicide is very difficult. The idea is that the person would be clinically assessed and the decision would be made by a clinician. It is difficult to say after that. It is a decision that the clinician has to make. It is a professional judgment.

Dr. Brendan McCormack

Part of the 2018 project for the Connecting for Life strategy is to enhance the signposting for people in that situation. That is part of the action plan nationally but in addition, each CHO area has a localised version.

Mr. Pat Bennett

I will address the last two points on the organisations we fund. We carry out assessment at the end of the year on outcomes. We go through a process and that informs the decisions around funding for the following year.

The reference to "general support" staff includes porters, catering and housekeeping. The reference to "patient-inclined" care includes health care assistants and multi-task assistants. Again, I would be happy to give a list to the Senator after the meeting.

Senator Gabrielle McFadden

That is fine. I was simply seeking a layperson's explanation.

Chairman

We will move on to CHO 9. Sadly, the member from this area is not present. Consequently, I will ask some of the questions. I will be aided by Deputy Buckley and Senator Devine. I will start off with particular questions about funding and recruitment. I may also extend the questions to the other CHO areas.

I wish to advise the witnesses that we will be giving them specific questions we would like them to follow up through correspondence. I said the same to the CHO area representatives before the committee last week. While I have so many things to ask, I will be brief and perhaps you can reply in black-and-white with brief answers, if possible.

My first question is for Ms Walshe. You have spoken about how in particular you have a difficulty in recruiting psychiatric nurses. I have noticed one thing about all CHO areas. You referred to serious difficulties in recruiting medical and clinical staff. What are the others doing? Ms Walshe referred to 1,232 employees in CHO 9. There is another figure of approximately 944. What are they doing? Ms Walshe may not be able to answer me but I have put the same question to all the CHO areas. We need a breakdown. If the CHOs cannot recruit, what are they doing?

Ms Mary Walshe

I wish to clarify a point on the numbers. I acknowledge there is a discrepancy between the figure of 1,232 and the figure in A Vision for Change, which relates to the community mental health teams in the community. We need to give the committee a breakdown of the staffing in the approved centres, because that is where the significant discrepancy arises. It looks like we have all these staff and people may ask where the rest of them are. Significant numbers are in residential centres. For example, I have four approved centres, including the Ashlin Centre in Beaumont Hospital. There are acute beds in St. Vincent's Hospital, Fairview, the Mater Misericordiae University Hospital and Connolly Hospital. There are child and adolescent mental health service beds in St. Joseph's unit in St. Vincent's Hospital. The discrepancy relates to the numbers in the community teams. One figure for numbers of staff relates to our approved centres and those in psychiatry of old age.

Chairman

If we specifically asked you that question, can you all provide that breakdown by correspondence, including administration staff and long-term absenteeism? I am sure the all the CHO areas have that as well.

Ms Mary Walshe

Yes, absolutely. We have absenteeism for all our areas.

Chairman

There is another problem I keep coming across and I am not getting a clear answer on it. I am sorry for picking on Ms Walshe but it is simply that she is responsible for the area on which I am focusing. What is the managerial structure breakdown for each area and overall? I have asked for an overall managerial structure from the top down. Who does what? Who are officials reporting to? Who is accountable?

Ms Mary Walshe

I am the accountable officer for the totality of the budget within CHO 9, Dublin north city and county. The budget is over €650 million. From that perspective, I have a delegation from the national director in respect of the total accountability. I am the accountable officer for both the oversight of that spend and the management of more than 6,000 staff within the area. Ultimately, I operate delegation further down to the heads of service. For example, Ms Angela Walsh, who is on my left, has the delegation of responsibility in respect of the total management of €114 million in mental health services. It is similar for primary care and social care. The appendix I supplied has the structure within my area, including the heads of service, their names and who reports to them. The detail of who sits on the mental health team under Ms Walsh is in appendix 3.

Chairman

We will look at that.

Ms Mary Walshe

We have governance within the CHO area and governance and management structures within that.

Chairman

Can you indicate the structure if we go upwards?

Ms Mary Walshe

I report directly to Anne O'Connor, who is the national director for community services. We have monthly performance meetings to review the totality of my accountability in respect of finance, human resources, activity, quality and service-user experience. Particular performance reports and so on have to be viewed in that context.

Chairman

You are being really clear and concise and I appreciate that. I have two brief questions and then I will pass on to Deputy Buckley.

Ms Walshe stated she is responsible for the overall budget. When she allocates money towards children's mental health services, does she make the decision? On what is it based? Is it based on an assumption of having three child consultant psychiatrists in a given year? How do you allocate funding? If is the worst-looked-after area in all our mental health services, why is the allocation of funding so poor?

Ms Mary Walshe

There are historical base budgets and additional development funding has come in since 2013. The determinants for that are related to the national service plan and the priorities within the relevant divisions. Currently, the budget is defined as in the total budget and then there is a breakdown for mental health, primary care and social care. No funding is transferred within any of those divisions. The allocated mental health budget is set at an 80:20 mix, or thereabouts, regarding pay and non-pay. Those are fixed because the staff are based in child and adolescent mental health service, CAMHS, general adult, mental health intellectual disability, MHID, and so forth.

The issue concerning developments is based on the priorities in the national service plan and the additional development funding. We have significant engagement with the national division in determining our bids. We may look for 20 new development posts. Some of those may be between CAMHS, psychiatry of old age or general adult. One is making the determinant in some ways depending on the activity and the data one has. For example, we have eight CAMHS teams and 12 networks. We have responsibility to provide service to 145,000 children under 18 years of age in my area. The ideal would be that a network should be providing services for primary care, mental health and older persons and people with disabilities within that area. We are in a little bit of a better position than my colleagues in that we are at 66% regarding A Vision for Change and ideals with regard to the make-up of the CAMHS teams. We put in a bid every year and it is determined in the negotiation with the national division as to what is funded.

Sometimes we get funding for posts which we are not able to fill. For example, it could be for an occupational therapist, OT, in MHID when we would be more successful if we had a social worker. Sometimes one has to have that level of flexibility to determine where one feels the priority could be met. We have been lucky in our area. We had a difficult past 18 months when we had significant deficits and had to use agency consultants for CAMHS. We spent over €5 million on agency staff last year. We are fortunate that many of our nursing deficits are filled by overtime, which gives a level of safety in that one has experienced staff doing overtime. While it is not ideal for their health and well-being, at least we have stability on the safety side of the service.

Chairman

The committee is certainly focused on children's mental health services. We have asked for a breakdown but we have been given percentages. We will be writing to all the witnesses for the actual breakdown of the 11%, what it means in monetary terms and how it is divided. We were a little bit surprised we were not provided with the monetary figures. Anybody who has a business and has been given money from a bank must supply details on how it has been spent, down to the last penny. The witnesses may have given the committee an overall breakdown but they did not give a detailed one. It is important. How can we ask for more money for CAMHS when we do not know what the HSE is spending or paying for?

We are actually here to help. We are not trying to poke holes in the provision of mental health services. We are trying to see what is wrong. This is the first time there ever has been a committee on mental health care service provision. The witnesses should not see us as the enemies. We are genuinely here to aid the officials. I am sure they are just as frustrated as we are.

Ms Mary Walshe

I come from a clinical background. From my perspective, my colleagues and I welcome the opportunity to present to the committee. If I can speak on a personal level, I think nobody in this room has not been touched by a family member’s mental health.

Deputy Pat Buckley

I am in good form today and I agree with the Chair on working together to get services right. I thank the witnesses for appearing before the committee.

Today, I want to highlight some of the good news. The good news is normally not one of the best sellers when it comes to any part of the health service. We cannot be negative all the time. I welcome the approval of five additional posts for 7/7 services in the CHO 7 area. I also welcome the fact an extra 16 additional psychologists and four grade staff psychologists will be appointed in this area. A positive step in another area, CHO 8, is the appointment of an area lead for mental health engagement. It is first time in 11 years that we actually have seen a 50% reduction in the number of suicides, which is to be welcomed.

Today is not pick on Ms Mary Walshe day. However, she spoke about having eight CAMHS teams. Instead of breaking them into percentages, is there 11 or 12 on a team or is it index-linked to specific areas? Last week, the committee heard one team was at 113%, another at 97% and another at 18%. If one team is oversubscribed, can one not take from that to bring the other teams up to be fully staffed?

The committee is not anti-agency but there is an issue around retention and recruitment. Ms Mary Walshe made a valid point earlier about paying overtime and having stability in a team. A team needs to be fully staffed. One needs harmony and happiness in a system with everybody working with each other. We have seen that there is friction between permanent staff and agency staff. There is no harmony. It aggrieves me that we have a problem with the hiring and retention of staff but we can still afford to take on agency staff. We cannot afford to pay our own staff more and give them a better package to retain them in this specialist job but we can pay more to agencies. It probably is twice as much because the agency staff get a higher fee and the agents are paid more. How are we going to move away from that? Do we have to revisit the whole area of staffing and new contracts? If we are to train people in this area, must we ensure they have a guarantee that they will have a proper secure job, properly paid and possibilities of promotion? There does not seem to be harmony in this area. In most of the CHOs, 49% are HSE staff and the rest is made up of agency staff. It does not seem to work.

Ms Mary Walshe

Our first port of call from a nursing perspective to ensure safety and stability in a team is overtime. We have to monitor that because we also have the European working time directives regarding hours of work. We also have to ensure that staff health and well-being is looked after. We appreciate it when experienced staff put themselves forward for overtime. Due to the cost of living in Dublin, staff living within the Dublin circle tend to do some shifts on overtime.

From that perspective, we really welcome that and the team appreciates that. It is important that we look after staff health and well-being. We had a staff health and well-being week in November. It was very well attended by staff. They really appreciated the fact that we acknowledged it. Mindfulness courses that were offered were booked out. We appreciate that it is really important.

In respect of nursing in particular, we have produced the numbers relating to increasing the student numbers. Someone working in London has a London weighting. We do not have that in Dublin, which would acknowledge the increased cost of living in Dublin, such as housing. This may need to be looked at not just for nursing and the health service but the public sector in general. It is something that may be helpful to retain people in Dublin because people are moving outside it to buy housing. Even though our colleagues in the other areas are picking up very experienced staff, the fact is that there is still not enough for even down the country. It is a problem in Dublin. Someone working in London has a London weighting, which may be something that needs to be looked with regard to retaining experienced and skilled professionals within the public service. We have looked at recruitment abroad to ensure that nurses meet the register requirements from a mental health point of view. They are not there in mental health nursing in comparison so they will not be eligible to register on the nursing register. That is an issue whereas our acute hospitals and other areas have been able to recruit from India, the Philippines and so on. That is all being reviewed and looked at as well.

We have put additional funding into ongoing education and training because that does retain staff. People do want to do higher diplomas and masters. A number of nurses in our area are doing PhDs and we have encouraged and supported that. Again, it is about retaining skilled people and valuing them within our service. We have had Christmas campaigns at the airport in our area because it is very close to us. We have done all the local recruitment. We have done what we can to retain it. As Mr. Walsh has said, we got more than 111 development posts over recent years but it only resulted in 83 whole-time equivalent additional on the census in 2017, so it is an ongoing piece. We have lost quite a lot of senior nurses from the system because they could retire at 55. That has been closed off but we have lost quite experienced nurses from the system because they were able to retire at 55. That has just changed but we have certainly lost quite a lot of people over recent years. I might defer to Ms Walsh with regard to the queries on the teams.

Ms Angela Walsh

The answer is that it is an average of 16 whole-time equivalents per 50,000 of population. As Ms Walshe outlined, we are trying to reconfigure our teams to the health and social networks, which will align them to primary care, so we have some legacy teams where we had full staffing and we are dividing the population, so that piece is what is causing the irregularities when one looks down at the percentages as per A Vision for Change. That will be a fluid process because as Ms Walshe also said, our population increased in 2016. We think we have the population right and then it increases so we will need more staff. Sometimes that can reflect in us looking like we have fewer staff than are required.

Chairman

Can I jump in before I throw it back out? As a chief executive or the chief manager, how much autonomy does Ms Walshe have? She mentioned that she had a lovely week for her staff, which is a brilliant idea and totally essential. Did she take it upon herself to do that?

Ms Mary Walshe

It came from the director of HR as an initiative. That is primarily done within the resources. We have counsellors and we also utilised services like MABS coming in to give a lunchtime talk because there are many other trials and tribulations people go through. It was our initiative.

Chairman

My question was whether it was area 8's own initiative.

Ms Mary Walshe

Yes.

Chairman

This is going to sound awful and I do not mean it in a critical way. Some areas seem to be a bit better - more efficient - or something is working a bit better than in other areas. Is it down to autonomy or is it down to resources?

Mr. David Walsh

Each of the CHOs is on a point of finalising its own Healthy Ireland plan under the health and well-being banner. Within that, a piece of that is centred on our own staff. We did not run something as sophisticated as that described by Ms Walshe in CHO 7 but we do run wellness clinics for staff fairly regularly using our own psychology staff and sessions to help people deal with stress. The Healthy Ireland plan is putting a structure around it but before that, it was up to each area to do its own thing.

Chairman

In general, are CHOs are autonomous? Can they make overall decisions?

Deputy James Browne

My question is a follow on from that put by the Chairman. Members of the Committee on the Future of Healthcare and this committee have seen that some areas have really good best practice in some areas but it seems to be almost like silos in that it does not seem to spread to other areas. Do people in the different CHOs talk to teach other about best practice or does it have to go up the chain and back down again? How does that work?

Mr. Pat Bennett

We have standard operating procedures across services that are about bringing about consistency and equity across services. As chief officers, we meet every month to ensure consistency among ourselves. Again, we are working off best practice and our best practice guidelines nationally as well, so there is consistency around that. The Deputy is right. There have been differences in the past but things are far more integrated now across the system. The likes of standard operating procedures help us with regard to having a measure. There has been significant improvement in that area and it is something we are going to continue to develop. It is an evolving process.

Chairman

We will now hear three very short questions from Senator Devine and then we can call it a day.

Senator Máire Devine

They are more comments than anything. The Dublin weighting is probably a problem. We have been pushing it as a union for a long time but the Minister for Finance is not listening to us very well. Tony O'Brien's yellow pack graduate nurses and his quote "we forced them out" are significant. They never got over it because he never apologised for that. In respect of getting generic nursing training, there was a threat to psychiatry in its specialty. That has abated for now but I understand the problem internationally because many countries would have generic training nursing, although the research shows it is very poor for psychiatric patients.

One Deputy, or it might have been one of the witnesses, spoke about going into the colleges. We are waiting for the new children's hospital and its recruitment process and strategy. They are actually going into the schools so it is catching fourth or fifth year students prior to their making decisions on what they will study. It will take at least 15 to 20 years to regenerate the nursing and medical staff we need because we are losing them now. They are dropping off like flies. I know the unions will probably come after me and I will never be allowed to join the union but I have a comment about the reconfiguration of the entire restrictive practice of professional assessment and diagnosis. At the moment, it involves the consultant psychiatrist. Perhaps we should throw out those kinds of ideas out and look at what a team means and what responsibilities and skills a person needs to produce an assessment, diagnosis and treatment plan. We are moving a bit away and taking in nursing involves nurse prescribers and advanced midwife practitioners but we need to open our brains. I know people will not be very happy. People will feel they are left on contracts but we are going to have this significantly for at least the next generation so maybe we should think outside the box. Not everybody needs a consultant psychiatrist to make a diagnosis.

Chairman

Does anybody want to answer that because that is a very relevant question, certainly about psychiatrists?

Ms Mary Walshe

Dr. McCormack might have a view on it.

Dr. Brendan McCormack

I do not think this is the place.

Chairman

Is it not? Okay.

Dr. Brendan McCormack

I note from the interim report of the committee that there is a list of potential stakeholders or expert witnesses that the committee may yet invite. They would be far better able to speak to that than I am.

Chairman

In fairness, it is relevant for the impact that it includes Dr. McCormack and the teams as well. If a psychiatrist is absent, missing or sick or if a post is not filled, it has a domino effect.

Dr. Brendan McCormack

I am not in disagreement, necessarily, with the approach. Other jurisdictions use other approaches and certain team approaches work well. Indeed, it works within our services as well. In child services, for example, some diagnoses are carried out by people who are trained in autism. The use of the autism diagnostic observation schedule, ADOS, is an example. A person trained in the use of the ADOS protocol who is a psychologist or psychiatrist can make the diagnosis. That is an example of interdisciplinary work. Models exist here and in other countries. We have advanced nurse practitioners. That area could potentially be developed further. They have the ability to make diagnoses, depending on their specialty. Certainly, that is something to be looked at.

Chairman

I thank Dr. McCormack. I thank all the witnesses for attending and for taking time out to be grilled by the committee for the past two gruelling hours. Their time has assisted the committee in the production of our next report. I thank them for that.

The joint committee adjourned at 3.30 p.m. until 10 a.m. on Thursday, 1 February 2018.