Mental Health Services: Discussion

Chairman

We are now in public session. I would like to welcome from the Psychiatric Nurses Association Mr. Peter Hughes, general secretary, Mr. Niall O’Sullivan, national vice chairperson, Ms Caroline Brilly, industrial relations officer, and Ms Aisling Culhane, research and development adviser. On behalf of the committee, I would like to thank them for their attendance today. The format of the meeting is that they will be invited to make a brief opening statement which will be followed by a question and answer session with the members who will have seven minutes each.

Before we begin, I draw witnesses' attention to the situation in relation to privilege. Witnesses are protected by absolute privilege in respect of the evidence they give to the committee. However, if they are directed by the committee to cease giving evidence 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. 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 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 entity by name or in such a way as to make him or her or it identifiable.

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

I wish to advise witnesses that any submission or opening statement made to the committee will be published on the committee website after this meeting. I invite Mr. Peter Hughes to make his opening statement.

Mr. Peter Hughes

I thank the committee for the invitation to address the committee on the future of mental health care. As general secretary of the Psychiatric Nurses Association, I would like to highlight my concerns in relation to the future of mental health care in Ireland. The inadequacies and underinvestment in the current provision of mental health services is something the PNA has consistently drawn attention to and I would hope that the interest of the committee in this area will help to address the many gaps in the mental health services that exist throughout the country.

In 1984, the first major mental health policy, Planning for the Future, was published, recommending the development of community services to coincide with the closure of hospital beds. The closure of a large number of beds occurred but very limited community services were provided, as outlined in the table in my submission.

In 2006 A Vision for Change was published with recommendations to close more beds and develop comprehensive community services. The policy envisioned an active, flexible and community-based mental health service where the need for hospital admission would be greatly reduced. It would require substantial funding but there was considerable equity in building and lands within the mental health system, which could be realised to fund the plan. The report recommended that steps be taken to bring about the closure of all mental hospitals and to reinvest the resources released by these closures in the mental health service.

The report, An Impact Evaluation of "Vision for Change" (Mental Health Policy) on Mental Health Service Provision, phase 1, 2016, which was commissioned by the PNA and completed by the faculty of nursing and midwifery of the Royal College of Surgeons in Ireland, RCSI, aimed to explore the extent to which the principles and practices enshrined in A Vision for Change have been realised and implemented over the past decade. While the study participants identified a multiplicity of prerequisites for the full implementation of A Vision for Change, their top priorities were identified as: comprehensive staffing and resourcing of community-based services; the provision of 24/7 crisis home care teams; the development of crisis houses; developing alternatives to hospital admission; the establishment of rehabilitation assertive outreach teams in all mental health services; and regional intensive care units to be established as per A Vision for Change.

The PNA-RCSI study 2016 clearly shows that 76% of beds were closed but only 30% of the community services were provided. The table in my submission outlines the reduction in beds since Planning for the Future. In 1984, there were 12,484 beds; in 2004, just two years prior to A Vision for Change, there were 4,173 beds; and in 2016, there were 1,002 beds. In percentage terms, between 1984 and 2016, there was a drop of 92% and between 2004 and 2016, there was a drop of 76%.

It is very evident that the necessary agreed closure of inpatient beds has not coincided with a well-developed and resourced comprehensive community-based alternative in line with the national policy. As outlined in the table in my submission the stark reduction in funding coincides with the timeline of both policies, clearly indicating that both policies have been used as cost-cutting measures. The findings indicate that there has been a significant failure to implement national policy and clearly indicate that this failure has a very significant impact on the quality of mental health services and care available to the public. The report concludes that unless the community-based mental health service is fully staffed and resourced the system will continue to malfunction and fail to meet the needs of its users, people with mental health needs and mental illness, an already vulnerable cohort in society.

The table in my submission indicates the mental health budget as a percentage of the health budget. In 1984, coinciding with the table in my submission, this was 14%; in 2004, it was 7.34%; and in 2015, it was 6%. A Vision for Change estimated it would require a budget share of 8.4%, at a minimum.

In the UK and Australia, the mental health services percentage of the health budget is between 12% and 14%. It is imperative that the mental health budget as a percentage of the health budget is significantly increased. Research would show that one in four people develop a mental health problem in their lifetime equating to 25% of the population, yet only 6% of the health budget is allocated to mental health.

Another key factor in the lack of service development is the crisis in recruitment and retention of psychiatric nurses. In December 2016, HSE figures showed that there were 885 psychiatric nurses over the age of 55 and 867 nurses between the ages of 50 and 54. Under fast accrual potentially 885 psychiatric nurses may retire immediately, while a further 867 may retire within the next five years, a total of 1,752, which equates to 34.2% of the mental health nursing workforce. The headcount as of September 2017 was 4,746. These figures would suggest that there are 374 vacancies but a recent survey of PNA branches suggests vacancies are closer to 500. Services with high levels of vacancies are: the Tallaght-St. Loman’s service, Dublin, with 43 vacancies which equates to over 20% of the whole-time equivalents, WTEs; St. Joseph’s, Portrane, with 58 vacancies, which is over 20%; Waterford with 26 vacancies, which is over 19%; and Louth-Meath with 34 vacancies, which is over 16%.

When the service developments outlined in A Vision for Change and not yet implemented are factored in, the requirement for additional nurses reaches more than 700. A Vision for Change recommended between ten and 15 nurses per assertive outreach team. Calculated on the basis of one team per 100,000 population, this requirement alone would equate to 675 nurses where there are 45 teams with 15 nurses per team. Figures from the Health Service Executive revealed that by August 2017, only 93 new staff had been recruited in that year to date, despite soaring demand in all areas of the mental health services and the HSE's admission that 1,963-new posts had to be filled if the level of staffing required in A Vision for Change was to be achieved.

I will provide some examples of the impact of nursing shortages on service provision. In May 2017, 50% of the admission beds in Linn Dara child and adolescent mental health services, CAMHS, in Dublin were closed until the end of October. This meant 11 of the 22 beds at the facility were closed as a direct result of nursing shortages as the service was short 50% of its nursing complement. A Vision for Change recommended 100 CAMHS beds nationally. Following the closure of beds in Linn Dara, bed numbers nationally declined to 52 and currently stand at 63.

The construction of the new national children's hospital is a welcome development. The new hospital will have 20 beds for child and adolescent mental health, eight of which will be dedicated to a service for eating disorders. However, considering the difficulties in recruiting and retaining nursing staff in the child and adolescent mental health services, this development will also create some challenges.

As a result of the failure to provide assertive outreach teams and intensive care rehabilitation units, ICRUs, more than 16% of beds are occupied by patients who were admitted more than six months previously. As a consequence of the 76% reduction in beds and the lack of community services, significant demand on beds has resulted in bed usage reaching 120% in many areas. To give an example of this excessive demand, service users in Waterford and Kilkenny regularly resort to sleeping on chairs because beds are not available. This means a person admitted during the day may be informed that he or she will have to spend the night on two chairs in a corner. Also in Waterford, service managers proposed to suspend parental leave and cancel annual leave for four weeks over the Christmas period owing to nursing shortages.

The Tallaght-St. Loman's mental health services have 43 nursing vacancies. As a consequence, the assertive outreach team, which should have 45 nurses as per A Vision for Change, had 13 nurses last year. This figure has since declined to eight. This is a vital service for those with an enduring mental illness if we are to ensure that service users can live as independently as possible in the community. The diminution of this service will ultimately result in an increase in the number of admissions among this client group. As a result of staffing shortages, the same service proposed to close its six-bed high observation unit at the end of December 2017. This is a unit for those with an acute mental illness who require a higher level of observation.

In County Kerry, the home based team recommended in A Vision for Change has been disbanded. St. Joseph's intellectual disability and mental health services has 58 nursing vacancies and relies heavily on overtime and agency work. This has a significant impact on the continuity of care for clients.

I will refer to some examples of challenges in recruitment. The figures presented in the submission show the purchasing power parity ratio, PPPR, in main destination countries for Irish nurses. Based on the staff nurse salary minimum point of the scale, the hourly rates using the PPPR are 27.13 in Canada, 21.10 in Australia, 16.66 in Ireland and 19.87 in the United Kingdom once the high cost area supplement available in Britain is factored in. Moreover, all nurses in the UK commence employment on the second point of the salary scale in recognition of the nursing degree qualification and are recruited to areas where the high cost area supplement automatically applies.

According to the Department of Health, the top five destinations for Irish nurses emigrating are Australia, the United Kingdom, the United States, Canada and New Zealand. The Nursing and Midwifery Board of Ireland found that a total of 1,343 nurses and midwives sought certificates of current professional status in 2017. These documents verify qualifications and are sought by nurses when they intend to work overseas. They provide a strong indication of a nurse's intention to work abroad.

The UK has 24,000 nursing vacancies and the figure is expected to increase after Brexit. Mr. Jim Campbell, director of the World Health Organization's workforce department, speaking at the global forum on human resources for health in Dublin in November 2017, raised concerns that, post-Brexit, the UK may try to fill gaps left by migrant health workers from the European Union by attracting nurses from Ireland under the traditional UK-Ireland bilateral agreement. The UK is offering packages such as €8,000 relocation costs, which is more than five times higher than the figure offered in the HSE's Bring them Home campaign. They also offer educational opportunities, low cost accommodation and a 37.5 hour week. Mental health nurses are in significant demand in the UK and other countries and services in these locations are offering relocation and incentive packages to attract Irish nurses. The HSE Bring them Home campaign in 2015, which offered a relocation package of €1,500, attracted only six psychiatric nurses to return to Ireland.

Domestically, St. Patrick’s Hospital, Dublin, starts all graduates on the second point of the scale. A welcome package of €3,000 is also on offer, with €1,500 paid after six months and a further €1,500 paid after 12 months. Nurses in St. Patrick's Hospital work a 37.5 hour week and are not subject to the pension levy.

The work environment for psychiatric nurses is characterised by overcrowding, staff shortages, the failure to implement service developments as per A Vision for Change, poor job satisfaction, workplace stress, a lack of cohesion and continuity of care, an unsustainable workload, an acuity of symptoms among service users due in part to a lack of community development, a lack of career opportunities and incidences of violence and aggression. These factors help explain poor nurse retention rates.

There are also significant delays in the HSE recruitment process, which can take between four and six months to complete.

At a time of recruitment crisis, these delays are inefficient and unacceptable. Authority needs to be delegated to the community health care organisation, CHO, areas to speed up this process. In the UK, the professional qualifications of the nurse are recognised, with the first point of the nurse’s scale higher than the maximum of the HSE scale. In the UK, the nurse is recruited at the same level as the therapy grades - physiotherapists, occupational therapists, podiatrists etc. In Ireland, the nurse is treated as a lesser professional than the therapy grades.

Please note the comparative salaries. A staff nurse on the first point of the scale earns €29,122 whereas someone on the first point of the therapy grade scale earns €34,969. There is almost €6,000 in the difference. The midpoint for a staff nurse is €37,129 whereas it is €43,191 for someone in a therapy grade. The 12th point of the scale for a staff nurse is €43,754 while it is €48,851 for someone in a therapy grade. The long-service increment for a staff nurse is €45,086 compared with €51,033 for someone in a therapy grade. When one factors in that those in therapy grades work a 37 hour week while staff nurses work a 39 hour week, there is a difference of 20% in their hourly rates. It is the view of the PNA that the staff nurse scale must commence at a point equivalent to that of therapy grades. Having regard to the comparable minimum qualifications, that is, an honours degree, and the role and responsibilities of the posts, the salary scale for therapy grades should be applied in its entirety to nurses. The development of the staff nurse scale in this way would enhance recruitment and retention.

The mental health service is in dire need of psychiatric nurses and other professionals who will join and stay in the public system after qualifying. One of the most significant consequences of the recession and of the decisions of Government in cutting public service pay, introducing the graduate scheme and enforcing a recruitment embargo was the creation of a culture of graduate emigration. For those who were unable to emigrate or who chose to remain at home, the private sector continues to offer exciting and financially rewarding opportunities.

The current crisis in nursing is forecast to get significantly worse over the next few years. Should the Public Service Pay Commission fail to recommend remedial pay measures, then the chance for this country to resolve this crisis will be lost for a generation, with horrendous implications for the delivery and development of mental health services and patient care.

Chairman

I thank Mr. Hughes. The information he has just given us is really depressing. I call Deputy Gino Kenny. He has seven minutes for questions and answers. We would like to keep this as tight as possible.

I thank Mr. Hughes for his presentation. This is probably the most damning document I have seen in the two years I have been in the Dáil. It is even worse when one sees it in black and white, word by word and statistic by statistic, because behind every statistic is a person who has been neglected and left behind by the State. It is damning beyond belief. I can only imagine the morale among psychiatric nurses at the moment. It must be on the floor when one considers their pay and conditions. It is damning of our society that this has been allowed to happen. Some people do not want to hear it, but the reason that these decisions are being made and that this document has been produced is that people and governments have made political choices. They have to live with themselves. Some of them do. They can live with themselves while neglecting people like this.

I want to clarify some elements of the presentation. On inpatient beds in mental health services, it seems that a shocking amount of mental health beds were lost in that 30 year period. Will Mr. Hughes clarify that? I am sure there is some sort of proper answer. In Linn Dara in the area in which I live, 11 beds were lost in the child and adolescent mental health services, CAMHS. It is just not acceptable. Sometimes one runs out of adjectives. Things are so accepted and routine. What really drives me mad is that politicians have reached a crescendo speaking about mental health services and trying to bring them together, but when it is put in black and white it is terrible to see. Obviously pay and conditions are pretty bad in comparison with those of other grades. I acknowledge the work of psychiatric nurses and nursing staff. We do not want to play down their role because they are on the front line. Will Mr. Hughes clarify these issues, particularly the loss of beds, the other units which have closed and the mental health spend?

The spend is crucial to the whole issue. A Vision for Change advocates that 8.24% of the health budget be spent on mental health, but we are nowhere near that. People can say that there were years of recession, but the economy is on the up, as people are saying, and that should inform the percentage we expend on mental health. This will keep going on and on until we address it politically and deal with front-line staff. It is great that Mr. Hughes has brought this issue in here. Will things change? I hope so, but they will only change if political choices are made. If they are not made, we will still be here in five years. A Vision for Change was ten years ago. Have most of its recommendations been implemented? Very few have. Reports just gather dust. It is a damning report. I am sure that many people were neglected and let down by our mental health service over that period. It is a shame that this is ongoing, that it has happened and that it probably will happen.

Will Mr. Hughes address those issues, especially pay and conditions, the loss of mental health beds and what can be done? We do not want to come out of here depressed out of our minds. We want to say what can be done logistically and collectively, even though I have said that these are political choices. Something like mental health is so serious that we try not to be political about it, but sometimes we have to be. These are choices. As a country, how do we address the issues I have just outlined? How can we right the terrible wrongs outlined in this document?

Mr. Peter Hughes

The reduction in bed numbers resulted from the closing of the large institutions. We had almost 12,500 beds in 1984. As I said, the Government policies in 1984 and 2006 were both intended to close beds and introduce comprehensive community services. Our research shows that in the ten years since A Vision for Change was published, over 70% of beds were closed and only 30% of the community resource was put in. With the closure of the large institutions, the money raised from the sale of lands and the staff resources of the institutions were supposed to move to the community to provide comprehensive 24-7 crisis services, outreach services and intensive care rehabilitation units. Those never materialised. As we see, in the same timeframe, the percentage of the health budget allocated to mental health services decreased. Had the budget even stayed at 13%, as it was in 1984, we would probably have an excellent mental health service.

I started my career in the early 1980s in St. Brendan's Hospital when there were 12,000 beds in the system. There is no longer a hospital on the St. Brendan's site, although a new unit with 52 beds has been built on it, and development of community services in the area has been minimal. At that time, we were told nothing could be done with the old hospital because it was an old Victorian building. It is now a state-of-the-art Dublin Institute of Technology complex. I live near the area, and when I walk through the site, I cannot believe the transformation that has taken place. When people lived in the building, it was an absolute disgrace. It is now a beautiful place as a result of investment. While a brand new unit has been built on the site, there has been, as I stated, very little development of community mental health services.

Psychiatric nurses initially embraced A Vision for Change. The result, however, was the removal of beds from the system without an alternative being provided to the hospital mission. That is the sad part of it. We are now being told there is no budget available, yet there are still opportunities. For example, there are lands available in places such as St. Senan's hospital in Wexford, and Portlaoise. Why can the revenue raised from the sale of these lands not be reinvested in mental health services? This was done on a smaller scale in the St. Loman's-Tallaght service where I also worked. When part of the land of the old St. Loman's hospital campus was sold, a sum of, I believe, €28 million was ring-fenced for mental health services. As a result, the primary care centre in Ballyfermot now also provides mental health services and two new 17 bed hostels have been built. Resources were provided when money from sales was reinvested. The problem, however, is that the cost of living in Dublin, among other factors, makes it difficult to attract staff to work in the service.

It has been suggested that the Department is unable to spend its mental health budget because of difficulties with recruitment. What is Mr. Hughes's response to that suggestion?

Mr. Peter Hughes

The Department could develop resources. There are also ways of attracting staff to work in services. What is happening is there is a continuous flow of the work environment, meaning the more one works short-staffed, the more frustrated and demoralised staff become. We must create a good working environment and also address the pay issue. I cited the example of a private service in Dublin. Other private companies are paying newly qualified psychiatric nurses €25 per hour, which equates to approximately €50,000 as a basic annual salary. Nurses only need to move to the United Kingdom and they will receive a relocation package of €8,000.

We must consider providing subsidised accommodation. We made a proposal, as part of a pre-budget submission and separately to the pay commission, to include some subsidised staff accommodation in Portrane where the new national forensic hospital is being built. While I am not an expert in construction, add-ons to major construction projects do not cost much. One could impose conditions on staff moving into subsidised accommodation, for example, requiring them to move out after a maximum of five years. This proposal, if implemented, would attract staff.

As I outlined, there are 58 vacancies in the Portrane service and almost 30 vacancies on the mental health side. It is difficult to attract people to work in that area. The majority of those who work in the forensic mental health service live on the southside of Dublin or in County Wicklow. If these staff are expected to move to Portrane, we must consider the provision of subsidised accommodation or some sort of allowance. We must also address the pay element.

Is Mr. Hughes aware of a model elsewhere in the world where accommodation has been provided for hospital staff?

Mr. Peter Hughes

In the United Kingdom, the NHS is building 20,000 units for staff as we speak. I spoke about the closure of the old institutions and the development of new services. Staff accommodation was provided in the era of the old institutions. Around three years ago, what was known as the nurses home on the new Dublin Institution of Technology campus was demolished without a replacement. Before demolishing a building, why not wait until we are ready to build on the site? This building could have been utilised for staff or homeless accommodation or another purpose. The site now lies empty. Subsidised accommodation was, therefore, provided in the past. We could add some staff accommodation to major construction projects. These units could be provided to staff for a specific period at a subsidised rate, particularly in the large cities.

I noted yesterday in a slightly different context that the Health Service Executive is planning to knock down a state-of-the-art building constructed only ten years ago in Wexford town to make way for a car park. I understand the sale of St. Senan's hospital in Enniscorthy will generate substantial revenue. Was a commitment not given to retain income from the sale of old Victorian hospitals in the mental health services?

Mr. Peter Hughes

Yes, these moneys were to be reinvested in services but that has not happened. That is the reason we lost resources and do not have community services. The resources that operated in these institutions were not moved out into the community and the money generated from the sale of lands was not reinvested. It was partially reinvested in the new unit in the Grangegorman site and I also gave the example of investment arising from the sale of St. Loman's hospital. Apart from these two cases, the money has not been reinvested elsewhere. Our Lady's hospital in Cork is another example of a large site which, if sold, could generate significant funding for mental health services.

How would Mr. Hughes describe staff morale?

Mr. Peter Hughes

It is very low and this has been a problem for some years. As I stated, psychiatric nurses embraced A Vision for Change and many of our members were excited about the prospect of services moving into the community. This has not happened, however. It is demoralising for nurses to have to tell patients they must sleep overnight on a chair. These patients have contacted the mental health services seeking help because they are experiencing mental health distress. Telling these patients they must sleep on a chair only increases their distress and is extremely demoralising for staff.

Is there evidence of nurses moving out of the psychiatric side of the nursing profession?

Mr. Peter Hughes

They are moving to different services, either private services or psychiatric services in the United Kingdom where they have more educational opportunities and the cost of living is lower. They are leaving the services.

Another development that will take a long time to repair was the decision in 2012-13, when the graduate scheme was introduced, to tell psychiatric nurses with a four-year honours degree who were just about to qualify that they would be paid 80% of their salary the following year and 90% the year thereafter. Many of this cohort of graduates emigrated and the message coming back from them is that they will not return. The only reason any of them would return would be if the salary on offer made it worthwhile to do so. These nurses were highly disenchanted when they left and it will be very difficult to persuade them to return.

Would it be fair to say that nurses are highly educated, trained and professional and this is not reflected in the types of work they do and the pay they receive?

Mr. Peter Hughes

The Irish training model for psychiatric nurses is up there at the top, which is why there is such a demand for them in Australia, the UK and Canada. Those are probably the three main places that really want Irish nurses. When they go abroad, Irish nurses get promoted very quickly and they get into specialist posts. There is a lack of specialist posts here. There is no 24-7 community crisis service which nurses would embrace. Their prospects are being stunted. As I said, they are working in overcrowded and understaffed admission units that are very hard for them to attend.

It is shocking that to this day children continue to be admitted to adult wards. Mr. Hughes spoke about patients having to sit on chairs overnight, but children have to do it in adult units. It happened in Waterford before Christmas. It is simply shocking that it is still happening today.

Mr. Peter Hughes

Absolutely. In 2011, the Mental Health Commission code stated that no children were to be admitted to adult units. We saw the 2016 figures where one in seven CAMHS admissions were to adult units. It is unacceptable. Whatever about a child being admitted for one night, my understanding is that two children were in a unit in Waterford for six weeks just coming up to the Christmas period. We highlighted our concerns regarding a child who was admitted last May or June and slept on a chair that night. An adult unit is a totally inappropriate environment for children, but we are operating with just 63 of the 100 CAMHS beds promised 11 years ago. The demand for those beds is a lot higher than 100. We are trying to get 100 beds but that is probably not sufficient because the community resource was not put in place. We have few fully functional multidisciplinary teams in CAMHS. We have four day hospitals nationally where there should be 15.

We have not put the alternative to hospitals in place, yet the latest figure shows that almost 3,000 children are awaiting assessment. If we do not address child and adolescent mental health issues, they will come into the adult system. We need to intervene as early as possible in mental health. We see all the time that the numbers are growing. Currently, the statistics are that one in two of those aged under 25 years of age will have a mental health problem. That is unbelievable. One in four people will have a mental health problem in their lifetime, yet we are investing 6% of the budget in an area that needs to cover 25% of the population.

Chairman

I will have to stop Mr. Hughes there.

The HSE informed me this week that it does not keep any records of how many times the same child has been readmitted to adult units. It is shocking that it does not know.

Chairman

It is also difficult to find figures on how many children present at accident and emergency rooms throughout the country. For some reason that figure is not kept either.

I thank the witnesses for attending this afternoon to help us with the important report we will produce. Some of the challenges associated with our nurses qualifying and going abroad were highlighted. What does Mr. Hughes see as his role and the role of anyone involved in the service in creating the impression that this is a good place to work? If we could retain people, it would take the pressure off. As I listened to some of the previous commentary, I thought that an 18 year old listening to it would not go into the profession. There must be a gap in terms of selling it as an attractive career for people. How is that gap to be filled? Today's topic is on recruitment. If we want to recruit, we need people to graduate. Therefore, how will we get young people in? How would they look at this and say it is an attractive career?

Mr. Peter Hughes

There are a sufficient number of people applying for the undergraduate programme but they may be using it as a route out rather than a route in. They qualify and then get to see what it is about and the lack of progression within the service. For instance, we have approximately 20 advanced nurse practitioner posts for the whole of the mental health service, and clinical career progression is stunted. At 18 or 19 years of age people might believe this is the career for them, but sometimes it is difficult to retain them in the service. We retain some but we need to create an environment that retains them, that is, we need to create an environment in which units are fully staffed and not overcrowded, practitioners are given the resources to treat their patients with dignity, and community services are there as an alternative to admission to hospital.

Mr. Hughes said that there are 20 advanced nurse practitioners. Does he think that there should be more? How many more should there be?

Mr. Peter Hughes

We should have advanced nurse practitioners in many areas. Primary care would be a good example. We should have an advanced nurse practitioner in every primary care centre. We should have them in the hundreds. We also need more psychiatric nurses in primary care. There are very few psychiatric nurses in primary care.

How many advanced nurse practitioners in mental health services should there be?

Mr. Peter Hughes

There should be at least one in every primary care centre throughout the country. We should also have advanced nurse practitioners in each service, whether that is early intervention, home-based care or otherwise. It should be in all the different areas.

Is the industrial relations dispute between the HSE and mental health nurses ongoing?

Mr. Peter Hughes

There is a dispute in Kilkenny at the moment on understaffing and overcrowding. A ballot result is due tomorrow from the services in Waterford. It is the same issue. Services in Kilkenny and Waterford are admitting patients to chairs or beds in corridors. We had a campaign in 2016 on recruitment and retention and, while some positives came out of it, two years later the issue is not resolved. A lot of temporary nurses and graduate nurses were made permanent and we increased the number of undergraduates. We also got a postgraduate course up and running. A feasibility study has been completed on those who have a degree in psychology or social science etc. moving into psychiatric nursing by way of possibly a two-year course to get an honours degree in psychiatric nursing. During that time, we examined with the HSE all avenues to recruit and retain, but unfortunately while it has had some impact, it has not been sufficient. We still have almost as many vacancies and this is just to stand still. If we were to develop the service as it should be developed, we are short approximately 2,000 nurses. We are short approximately 500 nurses to have services as we stand.

What would be the first thing Mr. Hughes would do to address the crisis in mental health services to which he referred?

Mr. Peter Hughes

As part of the agreement on our 2016 recruitment and retention campaign, a subgroup was established to examine the provision of 24/7 crisis intervention services. We were part of that group and continued to push. We wanted to have four pilot sites - two urban and two rural - for a one-year period, after which they would be evaluated with a view to rolling them out, but we could not convince the HSE to opt for them. We agreed the model of crisis intervention and that there would be pilot sites, but we could not get agreement on when the pilot scheme should start. We wanted it to start in the last quarter of 2017, but there is no date for when it will start. That is an issue. If there is no starting date, getting a pilot scheme up and moving will be difficult. The HSE's attention was on implementing and building on the seven-over-seven services. We are in favour of seven-over-seven services, but the four pilot sites could have been run in conjunction with them. There would not have been much of a resources issue. We should have seven-over-seven services within 12 months, but we would have known where we stood in the provision of 24/7 services. It was a lost opportunity. I hope we can establish the pilot scheme in the next few months.

We are trying to ensure we will consider everyone in need of mental health services. The more we learn at this committee, the more we realise we need to focus, for example, on ethnic minority groups, young people and people with dual diagnoses. In order to equip nurses to deal with everything involved, do they receive additional training if they need it or does it form part of their normal training?

Mr. Peter Hughes

The standard training provided as part of the honours degree programme covers much of it, but many nurses continue on to further education, including higher diplomas and masters degrees in fields as broad as mental health nursing or community mental health nursing. That further education covers many of the aspects in question. We do not have an issue with the type of training provided, as our nurses are sought all over the world.

Chairman

I thank Mr. Hughes.

I thank Mr. Hughes for his presentation. I will ask direct questions to which I want short answers.

How many psychiatric nurses are trained every year in Ireland?

Mr. Peter Hughes

Approximately 400. Since 2017, the number is 420.

We will stay current. How many nurses are expected to be lost this year?

Mr. Peter Hughes

In 2018, 800 are eligible to retire. I believe I gave a figure of 875.

In 2018 approximately 800 will retire.

Mr. Peter Hughes

No. That is the number who can retire. Some of them may stay on for an extra year, but currently they are eligible to retire.

Regarding the 420 who are in training, the process only started in 2017 and they will not qualify until 2021. There is an attrition rate of between 10% and 12%.

I will rephrase my question. How many psychiatric nurses who are in training will come on stream in 2018?

Mr. Peter Hughes

At the time they started, the number was only 290. Therefore, I suggest it will be approximately 250.

In Mr. Hughes's experience, how many nurses do we normally lose annually to retirement?

Mr. Peter Hughes

Based on anecdotal evidence, probably between 400 and 500.

Is that a conservative figure based on the fact that there are more than 800 who are eligible to retire this year?

Mr. Peter Hughes

Yes.

We can see the gap straightaway.

Mr. Peter Hughes

Yes.

As in this session we are dealing with recruitment, how would Mr. Hughes advise the Government to address the matter? It will be a number of years before we will be able to match retirements with recruitment. Is it the case that it will be 2020 before we will be able to make them match?

Mr. Peter Hughes

It will be much later than that.

When does Mr. Hughes think-----

Mr. Peter Hughes

The number of undergraduates only increased in 2016 when it rose by 60. It then rose by a further 70. The postgraduate scheme, with its 38 nurses, is another route into nursing.

I will stay focused on graduates. In Mr. Hughes's view, when will enrolments match retirements?

Mr. Peter Hughes

To stand still without further development, it will be a further five or six years.

How would Mr. Hughes advise the Government or policymakers to address the matter?

Mr. Peter Hughes

One element would be the postgraduate scheme. A qualified nurse can take a one-year postgraduate course in psychiatric nursing. We could expand the scheme regionally. We need to consider conducting a feasibility study of others with degrees moving into nursing. That would more than likely entail a two-year training scheme.

Many nurses who entered the service after 1995 and have been on a PRSI class A stamp are now retiring. When they do, they cannot work again as otherwise, they will lose their supplementary pension. The Government could examine that issue. It would be a short-term, stopgap option for a number of years, but it might solve the problem.

Or would it create a larger problem in the long run?

Mr. Peter Hughes

I do not believe it would. We always want new graduates to be employed, but given the dire straits we are in and how people who are fit and willing to work some hours are retiring, we should use that resource, although those who will start to retire in the next few years on a class A stamp will not be able to do so. Those who retired in recent years were mostly on a class D stamp and could work 19 hours.

Were Mr. Hughes to advise the HSE on how to accelerate the recruitment plan, the operation of which in the United Kingdom has gone well, what would he say to make it attractive enough to bring people back home?

Mr. Peter Hughes

I would say the word "salary".

Would Mr. Hughes mention relocation packages or anything like them?

Mr. Peter Hughes

Yes, but the €1,500 package only attracted six people. My understanding is that nine applied but only six took up positions. We need to consider the provision of subsidised accommodation and educational opportunities and show that there is a career pathway as a clinical nurse specialist, an advanced nurse practitioner and so on. A combination of many elements is needed, for example, a relocation package, plus salary and subsidised accommodation.

The Minister has appeared before us and we have heard many reports from the HSE. I am being told in one ear that funding is not an issue, yet, in the other, I am being told that mental health services are in crisis. I am trying to match the two in order to determine what could be done to address the crisis. Obviously, we are not recruiting and training enough people annually. That will be the downfall. Does Mr. Hughes agree that we need to increase recruitment numbers via the CAO and so on?

Mr. Peter Hughes

If we are to get people in, we will have to create the environment for them. We need to consider the provision of subsidised accommodation, etc. Regarding resources, I outlined our proposals for 24/7 services and four projects.

That is very interesting and I would love the witness to expand on it.

Mr. Peter Hughes

Why can that not be resourced? It has been said there are resources. Here is an example of where we were told that we cannot do that at the moment until we create the seven-over-seven services. I still believe the two could be done in tandem. That is a start. Then people would look at these projects and say well at least we are going in the right direction toward comprehensive community services that do not finish at 5 p.m. If nurses in the UK and Australia see those type of developments, because they are working in those type of developments, they may be encouraged to come back. It might be enough to attract back some of those disenchanted graduate nurses getting paid the 85%.

Have the 24-7 and the seven over seven proposals been circulated to us?

Chairman

It has not and it was one of the things I was going to ask Mr. Hughes. Will he send that to us and we will circulate it among the members?

Mr. Peter Hughes

The report that we have?

Chairman

The proposal, yes.

Mr. Peter Hughes

Yes, we will do that.

Chairman

We are out of time Deputy Rabbitte.

Can I ask one last question? It relates to the four houses versus the 15 day houses. Where are they located in the country?

Mr. Peter Hughes

Is the Deputy referring to the day hospitals?

Yes, the day hospitals. Where are they located?

Mr. Peter Hughes

I am not 100%-----

Chairman

We will find that out for the Deputy. I have to stop Mr. Hughes there because we have to be out of here as another group is coming in at 3.30 p.m. We are going to ask questions in groups now. We will hear from three members who put questions before after which the witnesses may respond.

I have a quick question. What is the difference between psychiatric nurses and mental health care workers? If we think about nursing we think about a medical model. Psychiatry is not a medical model from a nursing point of view. Why can that gap in recruitment not be served by mental health care workers? The witnesses can answer that now if they want but I am going to Deputy Neville first.

I am one of those who emigrated during the crash and came back after four years. I have done my stint in the UK and Australia. I was a recruitment consultant when I was away, so I have a background in the area. I think it is simplistic to say salary is the reason people do not come back. I think it is a much broader term than that. I accept it is a factor. However, I also stress in terms of salary that we have to look at living costs as well. Costs are a lot higher for someone living in London or Sydney than for someone living in Limerick. That has to be put on the table as well when we are balancing that argument.

Are there any statistics around what length of time people worked in the services before they left, or do they come out of college and leave? That is an important point. In respect of Brexit, has there been any increase in interest in people from the UK looking to work in Ireland, given that they would remain in the EU? Are there any applications? Are there any statistics on people from other jurisdictions, who would have trained in other areas, and have come to work in Ireland?

We are all aware of the difficulties in recruiting people into the public services. However, the facts and figures presented by Mr. Hughes are of extreme concern. We could hear a pin drop we were all so taken aback. The word demoralising has been used but I would suspect it is heartbreaking for health professionals to work in a situation where they are reduced to saying that a chair is a bed. They are highly trained professionals.

If we look at 34% being eligible for retirement in five years, we are facing a mental health time bomb. I refer to 500 vacancies in psychiatric nursing and 1,343 trained nurses and midwives having sought certificates of current professional status because they are going to go overseas. It is incredible. However, if people are working in a system with low pay, appalling working conditions and they are undervalued, why would they stay? They are so valued abroad.

It is obvious that the issue of pay and conditions needs to be addressed and quickly. Do the members of the PNA reference any other barriers or disincentives? I refer to people in Waterford being told that parental or annual leave may have to be suspended. Are career progression, cost of living and work life balance issues that come up? What can be done to address those issues? What services and supports are in place for our mental health professionals? I refer to the stress they face in their working conditions and the burnout they may feel.

I want to go back to something Deputy Neville said about why people emigrate and do not stay in the profession. We can increase our training numbers as much as we like but we are in a global market. We can train 1,000 psychiatric nurses. However, that does not mean 1,000 psychiatric nurses are going to stay in our health system because it is dysfunctional.

What structural change does the PNA see as necessary within the health service in general and the mental health services in particular? I refer to recruitment and retention. As Deputy Neville said also, I do not think that it is all salary. It is career progression, job satisfaction, and being valued within the service. There is huge problem of demoralisation and demoralised staff are quite inefficient in the service that they deliver. We have looked at this and all these issues in the Sláintecare report. There needs to be structural change within the HSE to demand accountability and responsibility but also to put in supports for staff. Bricks and mortar are important but the human resource in our health service is the most important part.

What supports, as Deputy Martin asked, are there to value a staff member and to prevent them leaving the service? Many people leave the service and there is no exit survey to ask why. If there was an attrition rate in a commercial company that we have in our health service, one would wonder what was wrong with that company that was allowing so many people to haemorrhage. What structural changes does the PNA see in the HSE that could stop this?

I express an interest, being very closely aligned with the PNA. I welcome the witnesses. I am delighted to see the response around this table. We have been raising this issue for years and have not got this message out of how desperate the situation is in our mental health services.

I want to go back on a few points. I talked a lot in past committee meetings. I disagree with Deputy Neville. We live with the legacy of the yellowpack offer now. The nurses forced out at that time will not come back. They will not come back under any circumstances. It is to do with Mr. Tony O'Brien never saying sorry. Those nurses are in Australia and the UK. I disagree as well with Deputy Harty that it is global. Global goes both ways. Why are we not getting people from other countries and not necessarily our Irish nurses back? Something is lacking. Pay is one part of it, along with accommodation. However, I also refer to educational opportunities and using the skills that we have.

I wish to talk about generic nursing when it was mooted. I know the Chair has asked that question about other health care workers filling the gap. The Government wanted to scrap psychiatric nursing in its entirety some years ago and just have generic nursing. We fought really hard for it.

Research from around the world, in particular in Australia, shows that services for psychiatric patients have decreased and there is a lack of expertise, which has a negative effect on the experience and chance of recovery for patients.

A home-based scheme with outreach teams has operated in Cavan-Monaghan for a while. The initiative has led to a 72% reduction in the number of admissions to psychiatric hospitals. The 24-7 service has tried to replicate that success throughout the country. It would be great if people were a lot more knowledgeable about the home-based scheme.

I want to say to Mr. Hughes that if any business anywhere is 120% over capacity, then health and safety should be called in. Can the Health Information and Quality Authority, HIQA, be called upon to resolve this matter? Unfortunately, one cannot do so because morally one cannot shut down services, and in some cases they have been shut down. If an organisation in any other sector was 120% over capacity, it would be deemed dangerous.

Chairman

This part of the meeting has run over time. Therefore, I ask Mr. Hughes to answer the questions as efficiently as he can.

Mr. Peter Hughes

Deputies Neville and Harty asked similar questions. They highlighted the fact that it takes more than a certain salary to attract people back. I think a salary can act as a huge incentive. As Senator Devine has said, the graduates who were part of the graduate scheme would have some reservations about returning home. I hope that we will get them back. We must develop services, make them attractive and provide promotional opportunities. I also wish to mention subsidised accommodation, but we cannot provide same.

Earlier I spoke about the purchasing power parity, PPP, ratio in different countries. Ireland is below the PPP ratio. One can talk about the cost of living in cities like Sydney and London, but when one applies the PPP ratio, in terms of an hourly rate, one can see that Ireland is still below. Ireland does not measure up to the other countries in that respect. In other countries one has greater purchasing power or one's money goes further. That is one element.

Deputy Catherine Martin mentioned services in Waterford, how demoralised the staff there are, and people sleeping in chairs. There has been very little community development in the area but it is not the only one. The alternative to hospital admission is to constantly keep pressure on bed capacity in the area. Waterford now takes all admissions since the psychiatric unit in Wexford closed bar a small number of admissions from Gorey upwards that travel to Newcastle. There are extra pressures now. As has been done all along, beds were closed quickly without resources being allocated to communities.

I know I have harked on about a 24-7 service. In Australia a 24-7 service has been provided for 30 years and the UK has had one for the past 25 years, but this country does not have even one such service. This country is way behind. Years ago I worked in Australia as part of a team to provide 24-7 care. This country does not even have a service that resembles that and the closest we have is a few home-based teams. Senator Devine referenced the scheme in the Cavan-Monaghan district, which has proved successful. Has the scheme been replicated anywhere else in this country? No. The relevant authority seems to have adopted the view that the scheme worked once but it will not work anywhere else. That seems to be an issue.

We go to services and look for any developments as per the national policy document, A Vision for Change, or the next version of same, but the providers can say they do not believe in the model. We need the national policy to be applied consistently and standardised. We should roll out schemes nationwide that have been proven to work. That is why I have called for a 24-7 service to be rolled out in two rural areas and two urban areas on a pilot basis. If the scheme works, it can be rolled out nationally and, therefore, become the national standard.

Chairman

The committee will write a letter to Mr. Hughes and his organisation seeking answers to a few questions, which will help us compile our report. Deputy Harty mentioned the exit programme. I ask Mr. Hughes to ask his members to answer why they left. Another major matter is absenteeism and he could ask them about that too. Absenteeism may be caused by stress related issues.

I also want the letter to include a request for supports to be provided to staff who suffer from stress or burnout.

Chairman

Yes.

One of my questions was about how many people left and whether a survey was conducted on the topic. Did people emigrate when they graduated from college? Did they emigrate after a specific period?

Chairman

The Deputy has asked very good questions.

I wish to highlight that other factors, apart from salary, affect whether people decide to return. The management structure and work practices have been mentioned as examples.

Chairman

If Mr. Hughes cannot answer those questions now, we can add them to our letter to him. Also, Deputy Martin asked how staff are cared for.

Mr. Peter Hughes

I can answer part of that question for Deputy Martin. I do not have the information to hand that is necessary to answer the questions posed by Deputy Neville. All other disciplines working in multidisciplinary teams have clinical supervision and protected time to share for one hour once a month, but psychiatric nurses do not. Even though reports recommend clinical supervision and protected time be provided to psychiatric nurses, it does not happen. Psychiatric nurses do not have protected time once a month to talk to a peer supervisor or clinical supervisor about some of the stresses of the work such as difficult clients, cases or circumstances. That does not happen.

Is it that they are supposed to get it and do not get it or is it that they are not even assigned that time?

Mr. Peter Hughes

It is not assigned.

Chairman

We will ask that question and seek greater detail in our letter. I asked Mr. Hughes to describe the differences between mental health care workers and nurses, especially from a medical model point of view, etc. I will include my query in the letter too.

I am sorry for rushing the delegation but we have invited another group of people to attend this afternoon. I appreciate the delegation coming here today. They have stunned all of the members here with their replies. I hope anybody who has listened in or will listen later will be moved by the struggles that psychiatric nurses are all going through.

Mr. Peter Hughes

I thank the Chairman.

Chairman

I suggest that we suspend the meeting for a few minutes to allow the next delegation to take their seats.

Sitting suspended at 3.40 p.m. and resumed at 3.45 p.m.

Chairman

I welcome, from the Irish Medical Organisation, Ms Vanessa Hetherington, assistant director, policy and international affairs, Dr. Matthew Sadlier, consultant psychiatrist, and Dr. Ray Walley, general practitioner. On behalf of the committee, I thank them for their attendance here today. They will be invited to make a brief opening statement which will be followed by a questions and answers session.

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

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

I remind members and witnesses to turn off their mobile phones. It is very important that they put their phones on airplane mode because it causes havoc with the system.

I advise that any submission or opening statements made to the committee will be published on the committee's website after this meeting. I invite the IMO to make its opening statement.

Dr. Matthew Sadlier

On behalf of the Irish Medical Organisation, I thank the Chair and the Joint Committee on the Future of Mental Health Care for the invitation to discuss the difficulties in the recruitment and retention of medical staff to our community mental health services.

Mental illness represents a significant and growing burden of disease. It is now estimated that half of all people will experience a mental illness in their lifetime, and approximately one in five working age adults suffers from mental ill health at any given time. Mental health issues have been shown to have serious and detrimental consequences with people suffering from chronic, enduring mental health problems having shorter life expectancies by between ten to 20 years. Prevalence of mental health disorders in children and adolescents is also growing with studies showing the prevalence of diagnosable mental disorders as one in six in young teenagers. Mental health disorders in childhood are a strong predictor of mental health disorders in later life. Good outcomes are most likely if children and young people have timely access to advice, assessment and treatment.

Recruitment and retention of medical staff is a major issue across our health services including within our mental health services, specifically. The recruitment and retention of psychiatric consultants and non-consultant hospital doctors is a significant concern. This lack of recruitment leads to variations in access to services with excessive waiting times for outpatient assessments, high usage of locum staff with consequent impacts on budgets and continuity of care, and access to child and adolescent mental health services has reached a critical point with under-resourcing and difficulties recruiting and retaining medical staff leaving young people and their families particularly vulnerable. In 2016, the Mental Health Commission reported that the most cited challenge facing Community Health Organisations was the recruitment and retention of staff across all specialties with particular difficulty in recruiting consultant psychiatrists in child and adolescent psychiatry. While HSE figures suggest that general adult community health teams across the country operate at 78% staffing levels, psychiatry of old age teams at 58% and child and adolescent mental health teams at 53%, the sharing of staff, overtime hours worked and the filling of key consultant positions by locum staff render the full extent of understaffing difficult to quantify. The HSE, in its quarterly performance report from July to September 2017, highlighted difficulties in the recruitment and retention of skilled medical staff as a significant challenge to the provision of mental health services with high agency costs having a significant budgetary impact on community healthcare organisations. In particular, the HSE highlighted recruitment and retention of medical staff to child and adolescent mental health teams as a key factor contributing to waiting lists in excess of 12 months in CHO 1, which comprises Donegal, Sligo, Leitrim, Cavan and Monaghan, and CHO 3, which is the mid-west, including, Clare, Limerick and Tipperary, CHO 4, including Cork and Kerry, and CHO 8, including Laois, Offaly, Longford, Westmeath, Louth and Meath. It also highlighted recruitment and retention of staff as contributing to difficulties reducing the number of children admitted to psychiatric units.

Only 67 child and adolescent mental health teams are in existence out of the 95 recommended in A Vision for Change with many not working at full capacity. Just 66 inpatient child and adolescent beds are available, a figure that falls far below the 100 beds that were required as a matter of urgency in 2006. Since 2006, there has been a population increase of approximately 200,000 of those aged less than 18 years, an increase of approximately 21%, generating even greater need. Furthermore, inpatient beds are available only in the major urban centres of Cork, Dublin, and Galway. This often places treatment options far from the homes of patients in more remote areas of the country. No inpatient beds for child and adolescent mental health services exist in the country's north west, south west, south east, or the midlands, nor in the State's third most populous city, Limerick. Where referrals are required for patients in these regions, they must be sent to facilities which are already under pressure in Cork, Dublin, or Galway. If we are serious about putting mental health on a par with physical health, serious action must be taken by the HSE to address the recruitment and retention crisis affecting both consultants and non-consultant hospital doctors in our health services.

It is little wonder that the health services in Ireland experience pronounced difficulties in recruiting and retaining medical staff when both remuneration and working conditions lag significantly behind those available elsewhere in the English-speaking world. Independent research on the emigration of health professionals from Ireland has found that “much recent emigration has been driven by dissatisfaction with working conditions in the health system and uncertain career progression opportunities, aggravated by austerity-related staff reductions, salary reductions and taxation increases". This research also indicated that the overwhelming majority of those who leave do not plan to return to Ireland, and experience superior working conditions, training, professional opportunities, and pay abroad. Simply put, no solution can be found to the staffing issues within the mental health services without services that are appropriately resourced to deliver patient care in a safe environment; competitive remuneration of consultant and non-consultant doctors compared to international levels in English speaking countries; adequate clinical and other supports; increased educational and training supports; and enhanced and improved work-life balance.

My colleague, Dr. Ray Walley will address the issues of general practice.

Dr. Ray Walley

General practitioners, GPs, are often the first point of contact for those suffering from mental illness. International best practice suggests that the majority of emotional and psychological problems, such as anxiety disorders and mild to moderate depression, can be adequately managed by GPs in the community without referral to specialist mental health services.

The value of psychological therapies, including counselling, cognitive behavioural therapy, psychotherapy and group therapy, is widely recognised in the treatment of patients with mental health issues. There is increasing evidence that exercise is effective in the treatment of mild depression and anxiety. It is recommended in A Vision for Change that all individuals should have access to a comprehensive range of interventions in primary care for disorders that do not require specialist mental health services. Failure to provide adequate counselling, psychotherapeutic and occupational therapy services and support in primary care can therefore lead to an over-reliance on drug therapy or unnecessary referral to equally under-resourced specialist mental health services. Current counselling in primary care services are provided to adult medical card holders only. Meanwhile children and those entitled to a doctor visit card are left reliant on the private system where the cost is often prohibitive and where the regulation of counsellors and therapists is only now being introduced.

Our GPs describe the situation in our CAMHS as "heart sink". Young patients with serious mental health and behavioural problems face long delays for assessment, with urgent access only available through emergency out-of-hours services or emergency departments. With insufficient resources allocated to general practice and limited access to supports and psychotherapy services in community or primary care, referrals to CAMHS are increasing. At the same time, pressures on CAMHS have raised the threshold for acceptance and patients are increasingly referred back to the GP without assessment and where options for treatment in the community are limited.

The IMO is calling for sufficient resources to be allocated to general practice with direct access, on GP referral, to publicly funded counselling, psychotherapeutic and occupational therapy services and supports in the community.

Chairman

I wish to explain to the witnesses that we have two lead speakers who will have seven minutes each to ask questions and then we will have questions from the rest of the members. I will start with Deputy Gino Kenny. Not yet? We can move on. Would Deputy Rabbitte like to ask her questions at this point?

The Chairman can let the other speakers go first because we had the first round the last time.

Chairman

Perhaps I could jump in, if members do not mind, and start with a few questions. Dr. Walley used the words "heart sink" and this is my first time hearing that term. The word is that GPs tend to refer straight to CAMHS which could be causing some of the bottlenecks around the country. I asked this question of the previous group and Dr. Sadlier may be able to answer this. We have talked about psychiatric nurses, mental health workers and CAMHS teams who have to be led by psychiatrists. Is there no other solution? If there is no psychiatrist, for example, if he or she is out sick or on maternity leave, that team comes to a standstill. Is there another way to resolve this? Can we not have a team that can assess children in particular, and if there is a very serious issue, then have the consultant psychiatrist deal with that matter. Perhaps Dr. Walley can answer one half and Dr. Sadlier can answer the other half.

Dr. Ray Walley

Does Dr. Sadlier want to start with the psychiatrist one?

Dr. Matthew Sadlier

There is a model out there involving agencies. Jigsaw, which works in my area, is the one I am most familiar with. I give the caveat that I am not a specialist child psychiatrist. I am an adult psychiatrist. Our statutory mental health services were designed at a time when mental health services dealt with what we would now call severe and enduring mental health problems, specifically issues of schizophrenia, learning disabilities and severe levels of illness. We are now dealing with issues of mental health as opposed to mental illness, if we can make that distinction. Issues of distress and anxiety have moved into the realm of the treatment zone as psychotherapies in these sorts of things have advanced and have been found to be beneficial in these areas.

Is there a middle ground between primary care and specialist secondary psychiatric care? There can be and there are models that have worked elsewhere in the world. However, for that to happen we would need to have very well-defined referral pathways. We would need to have very well-defined middle-ground services with staff with adequate qualifications and adequate definitions of roles, which can be a problem in areas of non-statutorily defined roles such as nurse and doctor. That is the difficulty with that middle-ground area.

At the moment people are generally seen by the specialist services initially. This is certainly the case with adults. Where we would see those over 18, these are in the teenage years, but the later teenage years. We would divert some patients to wards if we felt they were not suitable for secondary services. We have two choices. We can run a service where patients get screened at the highest level of expertise first. Then the specialist services will, for want of a better word, and I apologise, keep some people within their services and divert some people to services of a lower level of complexity or whatever terminology one wishes to use. Alternatively, we can run a service at the lower level of complexity, as the Chairman is intimating, whereby they see the people first and then pass on. The concern about that is when somebody has a serious problem, are we putting in another stage before the people with the most serious illnesses get the treatment they most require?

Chairman

On that issue, 3,000 children are on the CAMHS waiting list. If there were some initial assessment, it might get rid of 90% of that waiting list. I thank Dr. Sadlier for his answer. I will ask Dr. Walley a different question. Is he aware that the GPs are in negotiation with the HSE over a new contract?

Dr. Ray Walley

Yes. I am involved in them.

Chairman

Mr. Walley is involved in them. As this has been going on for so long, what is stopping the progress?

Dr. Ray Walley

Will I take the heart sink stuff first?

Chairman

Yes. Mr. Walley can start with heart sink and then I will pass on to the other members.

Dr. Ray Walley

I am just making sure the quote is correct. We are saying that the child and adolescent mental health service is heart sink and not that the patient is heart sink.

Chairman

I know.

Dr. Ray Walley

There can be terminology used in training whereby one has a heart sink patient. However, we are saying the service is heart sink. Over the past three, four or five years there has been an improvement in the pathway methods in regard to child and adolescent mental health. I agree with the Chairman that we are on a learning curve as well because much of the service is not there. For example, only in recent years have we had things like a more defined early intervention team service with, it is hoped, support from speech therapy, occupational therapy and all the other therapies. In some cases we would have sent people into CAMHS, but we were generally given feedback to direct them in a different way.

We recently had an email debate about CAMHS among our GP committee which highlighted that it is very difficult for even the moderate and severe patients whom we are referring in to get seen. I know of two cases in north Dublin in the past seven days. Obviously, I have to be careful about the details. One of them was very young - under ten years - and one of them was young. Basically, the GP in question discussed the case with the child and adolescent mental health consultant in the daytime and the advice was to send that case to Temple Street hospital, meaning that we could not get an appointment for a very severe case because they were under so much pressure. The same happened with the older child. These cases were identified as needing to see a psychiatric service.

I agree with the Chairman that at the start of this referral system, since we were learning what to send and what not to send, there probably was an over-referral. However, I cannot say it is there now. Automatically, we have somebody coming in. These are children. Automatically, we feel for the family and for the patient. We know automatically that the patient is on a long waiting list on a referral pattern. Basically, such a patient will get a knock back. If I make a referral, I know there will be at least one knock-back letter.

Then one is trying to engage with someone to say this is where we are going and some might come in but that is not a service. They are very stretched with what they have. Some of our referrals come from school principals who are already dealing with these issues and are involving the allied services within education and they are stretched too. Four or five years ago I would have agreed that there was over-referral because we were learning the system but not now. It has not been an agenda item on the contract.

Chairman

When Dr. Walley states it has not been with whom does he mean?

Dr. Ray Walley

In dealing with the HSE and the Department of Health mental health is not an agenda item on the contract because the same deficiencies and difficulties are the case in general practice, which is the first port of call. That is the case be they within child and adolescent mental health or physical health where we have a staff deficiency, an aging staff and a recruitment and retention problem. That is rumbling away like Mount Vesuvius but it will explode. There are 666 general practitioners, GPs, over 60 years of age. Where I work, in the north inner city, if there is a child or adolescent with mental health problems there are usually lots of co-morbidities in that family. We are dealing with many different issues. There is no evidence of funding in the contract talks. Whatever happens as a result will have to be phased in because of the potential workload of co-morbidities that we are not addressing, the aging GP population and the recruitment and retention problem in general practice. Everything that has been said about psychiatry applies to general practice. There was a withdrawal of 40% of funding for general practice through the financial emergency measures in the public interest, FEMPI, cuts when most businesses run at a 30% turnover. That was a 40% cut before costs were taken into account and our costs are stable.

Chairman

Before I pass on to Deputy Harty I want to throw in another point. Our committee is focusing on three things, one happens to be primary care. We have been advised that 90% of cases can be dealt with at primary care level. We are very interested in seeing what the problem is and we are told there are ongoing discussions about the contract between GPs and the HSE. One of the Deputies said earlier that funding is not an issue, according to the HSE. Is there something else that is preventing this?

Dr. Ray Walley

There was no evidence of any funding in the last budget, unless somebody is hiding it and not telling us all about it.

Chairman

When was the last time the GPs and the HSE sat together to talk about this contract?

Dr. Ray Walley

Two weeks before Christmas.

Chairman

They are no further on.

Dr. Ray Walley

We have had behind the scenes talks.

I thank the witnesses for coming in again. We sat for 11 months to discuss reforming the health service in general, resulting in the Sláintecare report. Issues such as this have been raised in that report. It is eight months since the report's publication and it does not look as if it will be accepted as an implementation blueprint for reforming our health service. Those are the indications we are getting from Government.

In the absence of a broad plan such as that, what do the witnesses see as the first step in reforming our health service? We are speaking about recruitment and retention here. Recruitment and retention of GPs is very important for the mental health services because generally we are the first port of call. We will deal with most of those patients ourselves or refer them to a community psychiatric team, which should consist of a psychologist, a social worker, maybe cognitive behaviour therapy and a community psychiatric nurse, all the components make up a community team and many do not exist. The posts are not filled. Those places are vacant. We spoke with the Psychiatric Nurses Association earlier and went through various reasons why people are not staying in the service. They reckoned salary was the main problem. I would think career progression, job satisfaction, being supported in their job and the morale of staff are problems. They should be valued members of staff yet there does not seem to be a lot of support for them. What do the witnesses feel is needed in respect of recruitment and retention of GPs, the allied services and consultants and non-consultant hospital doctors in psychiatric services?

Dr. Matthew Sadlier

As someone who has worked in the health service for 19 years I would say it is a question of improvement not reform. We have had so many reforms that I sometimes do not even know who I am working for. I started working under health boards, then the HSE, then pillars, then community health care organisations and integrated service areas. It is a question of incremental improvement to the services rather than another broad scale reform of the services. That is my first visceral reaction.

To improve the services we have A Vision for Change for mental health care. I would argue that mental health care has led out the Irish health care service for a long time. There was an inspector of mental hospitals a long time before the Health Information and Quality Authority, HIQA, was ever thought of to inspect general hospitals. We have had reports on how the mental health care services should be organised since the late 1960s. There was Planning for the Future in the 1980s and A Vision for Change in 2006. It is a question of implementing the reports that are there. The structures in A Vision for Change are excellent. We divide the country into catchment areas. There is a service that is accountable for every area, with community mental health care teams, whether for adults, old age or children. The difficulty is in staffing those teams, the recruitment and the retention.

I cannot overstate how much damage the 30% cut to consultants' salaries, which was introduced unilaterally in 2012, inflicted on the Irish health care service. It was felt by trainee doctors at the time as a direct assault on them. We had experienced FEMPI cuts and cuts for new entrants across the public sector and various changes in terms and conditions but this one cut was imposed on one grade for reasons that nobody could really understand. Nobody could work out what due diligence was done at the time or what were the expectations of this. Since then we have gone from a system where consultant staff were easy to recruit. The first consultant interview I ever sat for was in early 2012 and there were 37 applicants for three consultant posts in north Dublin. There are now 22 vacant consultant posts and nobody applying for them. That problem has not been solved. There are three different salary scales for consultants. People see that as a direct assault on them, their training and their expertise and they are unwilling to take a job where they will be working side by side with somebody who has the same level of expertise and responsibility and is expected to deliver the same workload but at a significantly different rate of remuneration. Nobody would take up those jobs in a private company.

There are other issues in respect of funding training and education for non-consultant hospital doctors, NCHDs. They used to have a training grant but now they have to self-fund a lot of training which is becoming more expensive. They have to pay for various things out of their own salaries. That could be improved by comparison with Australia and Canada where our doctors are going. We work in an English-speaking health service and compete with New Zealand, Australia, Canada, the United States and the United Kingdom. Other countries seem to have done better on issues regarding training and education and work-life balance.

Junior doctors here are still expected to work outside the European working time directive limits and we have difficulty in applying the maximum 24-hour shifts. Junior doctors will not put up with such conditions any more when they can get better conditions in other places.

GPs are the first port of call for patients. The ICGP was before us prior to Christmas and it said the crisis in the Irish mental health care service is also a crisis in general practice. Do the witnesses agree with that? There is constant talk of the need to build up our primary care services but I do not understand how our GPs are going to have the capacity to protect or care for patients who present with mental health difficulties. It was said that GPs aged over 60 now accounted for 30% of the workforce and we do not know if these will be replaced. Before Christmas, we were told there were only 37 GPs in Kilkenny, 38 in Longford and 41 in Kildare and that last year was the first year ever that ten places on the GP training scheme were not filled. We need them but we cannot recruit them, never mind retain them, so what is the solution?

Dr. Ray Walley

There is a little bit of good news, which is that there was an oversubscription for training posts for the first time ever because the union and the college are doing what they are supposed to do. The State is also doing what it should do and there is a good campaign, the Be a GP campaign, which got people interested. The majority of the workload is done by GPs with a medical card contract, and there are only a small number of private GPs, just 266 out of a total of 2,540. It is 40 years since Professor Barbara Starfield looked at best health care systems and found that, in the general practice-led European system, mainly in the form of the NHS and the Dutch system, morbidity rates and rates of medical complication were inversely proportional to the number of GPs.

The emphasis of general practice is continuity of care. One knows one's GP and can talk to him or her. Much of the service is from cradle to grave and that is still the emphasis of good health care systems. In America at the time, and it is still the case, there was one cardiologist to 10,000 people but its mortality and morbidity rates were atrocious for a First World country. The American health care system remains the system which one must not emulate. It costs a fortune and one gets very little out of it in the way of reduced mortality and morbidity.

The idea was to have GP-led teams. In my practice there are eight staff, including three GPs, one practice nurse and three secretaries. As a business, we run on a 30% profit margin but under the financial emergency measures in the public interest, FEMPI, we had a 40% cut in funding, meaning we automatically had to let staff go. We had to constrain the practice to ensure we did not go bankrupt. For the first time in the history of this State, 120 middle-aged GPs left the country with their families. It is unheard of, but I remember a politician saying that doctors had always emigrated, a very flippant comment that just irritated people. The cuts are still in place and, as a result, general practice has not been able to employ more staff. It is now worse because the people who come off the training schemes are emigrating and it is difficult to get locums. It is difficult to get holidays and that brings more stress to the system. We are not as far gone as some European countries and we could still resuscitate the system.

I have no problem with blue-sky thinking but what I really want is evidence-based medicine, and my patients deserve that. Blue-sky thinking is experimental but it costs a lot. As a vocationally trained GP, my prescribing costs less than that of somebody who is not vocationally trained. The system is based on managing a budget in an appropriate way and that is what happens in a practice. The Irish College of General Practitioners provides organised continuing medical education. We have the same programme, curriculum and methodology so that we treat people in the same way, although we all have different personalities. Anything else is blue-sky thinking and I am concerned that it will cost more money if we do not fund what we should fund.

The health care system to copy is the Dutch system because they have developed general practice over 30 years. They provide 10% to general practice and 10% to community care and they have 85% of their beds full at any one time. They rotate and do not have problems with elective surgery. I am sure the system is not perfect but it is the system to emulate. They retain all their staff and have no training problems. It is not exorbitantly expensive like the American system, where consultants and GPs can earn eye-watering money. Dutch doctors are paid reasonable rates and they retain their staff. The system works and the population is happy. We are at Olympic standard when it comes to producing reports but we are at bronze medal level, or even at the bottom of the heap, in implementing things. We implement nothing. Patients in rural and urban deprivation often have a lack of reading and writing skills and cannot defend themselves. We pay a fortune to fix these people because most of them are public patients. If we carry out preventative medicine and save a person's life by persuading them to have a smear test, it is cheaper than if they get cervical cancer later on. It is straightforward but we do not seem to get it.

Ms Vanessa Hetherington

Health systems that have good primary care systems have taken decades to build up and it does not happen overnight. There is no reason we cannot build up our primary care system in an incremental fashion with a clear plan. With a clear strategy and proper resources, we will attract people back. At the moment the emigration rate of newly qualified GPs or consultants is huge, but if we commit to building up our primary care system, they will come back. They have suffered severe cuts, and while there are negotiations, there is no clear commitment of resources so they are considering their options. They look at their colleagues and decide they do not want to be stressed out, so they look at their options elsewhere.

Dr. Ray Walley

The Dutch spent 30 years developing community care and general practice. The problem with primary care is that a lot of people do not know what it is. Professor Barbara Starfield wrote about primary care physicians, which are an American phenomenon, but we are GPs and the equivalent in the Netherlands and the UK are also GPs. It is important not to use opaque terminology.

The key thing is that if there are enough GPs, morbidity and mortality rates go down. Clinicians are decision-makers on the basis of evidence-based medicine, their training and a continuous review of the literature. If the system is not led by clinicians, there will be more medication use.

The majority of those who come to me with a cough have a viral illness and do not need an antibiotic. I have the training and experience to be able to say this and they understand and accept it. When a person has been a patient of a particular doctor for five years, he or she builds a relationship such that he or she believes what the doctor has to say.

The global market is ever decreasing. Ten years ago when a person who had been working here for five or ten years decided to move abroad, it was a big step but now, owing to the increase in air transport services and IT connectivity with people being able to keep in touch, it is much smaller. They may appear to be soft issues, but they are the things people weigh up when deciding if they should leave. They are the issues I took into account when I last left Ireland. By comparison, when I left in the 1990s, email was only coming on stream. While we have to deal with competitiveness, salaries, the provision of accommodation and so on, psychologically it is now a lot easier for people to leave. It is also a lot easier for them to come back if we can get it right. Whereas previously when a person left Ireland, he or she was gone for 20 or 25 years, it is now a lot easier for him or her to come back. Based on what I have heard today, it appears that competitiveness is now more intense. When a person left Ireland 20 years ago to move to Australia, it was a big move, but it is not as big anymore. Connectivity is such that one can travel from Australia to Dublin, via Dubai, in 24 hours. I have made that journey myself. The issues with which we are grappling today are not huge.

Reference was made in the opening statement to high agency costs. Perhaps the delegates might elaborate on whether outsourcing to agencies is eating into the budget too much and also on the over-reliance on medicine?

Dr. Matthew Sadlier

The issue of agency costs is linked with the 30% cut in consultants' salaries. As we cannot fill consultant posts, many of the vacancies at that level are being filled by staff recruited through an agency which pays the doctor at a particular rate. I do not know the amount, but I do know that it is higher than the salary paid if the doctor was taking up a HSE contract at the normal level. Also, a levy is paid to the agency on top of what is paid to the doctor. The 30% cut in consultants' pay is probably costing the health service more because it has led to increased use of agency staff. As I said, because of the additional fee paid to the agency, agency staff are more expensive. It is happening across the board. We can only speak about doctors, but I know that it happens on the nursing side also. At junior doctor or NCHD and consultant level we have to take in agency staff because we are not able to recruit doctors on the standard contracts because they are deemed not to be attractive enough.

Chairman

On the point about the financial difference between the 30% cut and the cost of hiring agency staff, is it possible to get that information?

Dr. Ray Walley

We can probably access the data, but at times they are a little opaque.

Chairman

I know.

Dr. Ray Walley

It is probably an issue for the Comptroller and Auditor General.

The issue was discussed at the meeting yesterday of the Joint Committee on Health. There is a premium of 20% to 33% in hiring agency staff as opposed to a salaried staff member which reduces the amount of money available to supply the service.

Has there been a change of culture or work practices on the part of young general practitioners who have come into the workforce? For example, do they want flexibility to work with agencies in order that they can work only two or four days per week, as opposed to taking up a full-time job and remaining in it for, say, 20 years?

Dr. Matthew Sadlier

In the case of hospital based doctors, my area, there is an element of what the Deputy suggests. Agency contracts provide doctors with flexibility in working hours and maintaining a good work-life balance.

Would they make more money working for an agency?

Dr. Matthew Sadlier

Yes; they make more money working for an agency and also have more flexibility.

But fewer benefits and less job security.

Dr. Matthew Sadlier

Yes.

There is a trade-off.

Dr. Matthew Sadlier

They have less security and as they do not pay into the pension fund, they have fewer long-term benefits. At certain times of their lives some doctors like the concept of being able to work for two months and take a period off, etc. Agency contracts provide that flexibility.

It was mentioned that 30% of the workforce were approaching retirement age.

Dr. Ray Walley

One quarter of the general practitioner workforce are over 60 years of age, of whom 260 are over 65.

It was mentioned that the middle cohort of graduates left Ireland during the recession. Is there now a gap in the middle or is the gap wider than that?

Dr. Ray Walley

The average age of a general practitioner in Ireland four years ago was 52 years. At the time the average age of a general practitioner in Australia was also 52 years, which was looked upon as being old. Markets like Australia then began to aggressively incentivise people to move there. There is a difficulty in all countries in which English is spoken because they have an ageing medical workforce. What can now be done in the health care sector is more complex. People are also living longer. There are statistics which show that a person aged over 70 years has so many comorbidities he or she requires more inputs by a doctor and so on. All of the countries in which English is spoken are incentivising medical personnel to move and remain there. I am a trainer under one of the general practitioner training schemes. The modern day graduate is no different from the majority of those who are still working here, but what he or she wants is a work-life balance. When a GP experiences a 40% reduction in turnover, the only person from whom he or she can get more is himself or herself. As a result, he or she ends up arriving at work before the staff and leaving after them. He or she will also take on fewer locums and assistants and do more of the work himself or herself. Many practices have closed. I know of one in which the GP employed an assistant who he had hoped would replace him when he moved on, but that practice has closed and the assistant has moved to Canada. Only about 15% of practices in the country are operated single-handedly. We moved to a double partnership and then to operations comprising three or four doctors. We need to move to having practices that will have the least referral rates to hospitals. The most expensive is an average practice with two to three GPs because they know their patients. The problem is we do not use evidence based medicine. Ireland is no different from Britain which, following the Second World War in which a swathe of people were killed, had to bring people in from the colonies. It had to incentivise people to move into areas of deprivation and rural areas. It had to design contracts in a certain way. However it is done it will be expensive, but we have to do rather than talk about it.

Chairman

I am sorry to interrupt Dr. Walley, but I must allow Senator Máire Devine in at this point.

We know about the loss of nursing staff and this is probably due to the austerity cuts. There are other factors but those cuts happened ten years ago and that is when we started haemorrhaging staff. They were severe cuts which went to the core of the service. There was no foresight and the service shot itself in the foot. We and in particular the kids with mental health issues are living with that today.

Previous witnesses said that if there are applicants the recruitment process takes too long. It is too cumbersome and wrapped up with a lot of red tape. They ask if the community health organisation, CHO, areas, did the recruitment directly would that significantly improve and speed up the process. I am not sure whether the present witnesses can comment on that.

The observation was made that in 1984 there were 14% entering the mental health area but now it is 6% yet the statistics here show a rise of 21%, at least in those younger than 18 years, since A Vision for Change came into being. Mental health disorder in children and adolescents is growing with a prevalence of diagnosable mental disorders in our young people aged between one and six. That scares the living bejesus out of me. I do not believe our teenagers have such a high incidence.

Dr. Sadlier described the serious need for wraparound services which are important for the enduring, chronic mental illnesses, schizophrenia, bipolar, and that sort of stuff. The Chairman touched on well-being and how we deal with that as opposed to putting the teenagers on this train that takes years to get them to a treatment they do not need but will need by the time they get there. The idea is to have well-being ambassadors in communities. Our well-being has to be community-led and owned. How do we do that? Dr. Sadlier asked who falls through the gaps, who is responsible and accountable when a person in serious need is missed. There has to be a way to figure this out because we cannot continue to label one in six of our teenagers as mentally unwell. They have issues with well-being and some have issues with mental health. That will develop into difficulties.

I am cynical about the influence of the Diagnostic and Statistical Manual of Mental Disorders, DSM. How often is it referred to? It has grown since 1957 from 106 diagnosable mental health problems or illnesses to over 300 in its last publication. On the back of it there is what I believe is disease-mongering. It is in the interests of big pharmaceutical companies to have more diagnoses available so that they come up with a pill that will hopefully deal with some of the symptoms. We have got so far in diagnosing to death all our foibles, all our sense of spontaneity and human traits that we need to separate them. They are not problems unless they are causing the person who is living with them, or those around them, problems. There has to be a much easier and more compassionate way to consider everyday difficulties that we all encounter as human beings, and to mind our children and make sure they get the well-being service wrapped around them, not necessarily the medication, the diagnoses and the waiting on the train for the wraparound mental health services. We need to have much more community ownership of this. Society needs to say it and not the DSM or big pharma guys. That is my soapbox speech.

Before the witnesses came in the Psychiatric Nurses Association, PNA, gave a presentation and we were all shocked, except Senator Devine who has worked in that field. It was beyond bleak.

All our hearts sank when the state of the mental health services was shown in black and white and staff morale. It was shocking. The narrative is that the neoliberal agenda has done terrible damage to the health service in Ireland and the front-line staff, like us, have to pick up the pieces. The witnesses say that the failure to provide adequate counselling and psychotherapeutic and occupational therapist services in support and primary care can lead to an over-reliance on drug therapy. There is an over-reliance on anti-depressants. The number of people who come into my office and say they are on anti-depressants is incredible. I am sure they are telling the truth. There is an over-reliance on opiates as well. Can Dr. Sadlier comment on that and on drugs, particularly for children and particularly ritalin?

I have one last question which is probably not relevant to this debate and Dr. Sadlier does not have to answer it but Deputy Harty and I have had major debates on this issue. Could he comment on the present debate about the use of medical cannabis in Ireland?

Dr. Matthew Sadlier

Regarding the interviews and the interview process, when a post is coming vacant for predictable reasons, usually retirement, the person has to retire before it can be approved to be advertised. That process could be tightened up and improved. I am not an employment lawyer but employing somebody is difficult in the modern era when one wants to be fair and impartial. The CHOs could probably do a faster job but will everybody be treated fairly? The Public Appointments Service, PAS, does the recruitment for the public service to allow for a more transparent and fair process. That is the problem, although I hate to use that word. I am not an expert in that area but the point about retirement could be tweaked such that posts could be ready to be rolled out at the time the person would retire.

We do not use the DSM.

Dr. Matthew Sadlier

The Senator will be delighted to know we use the International Classification of Diseases, which is a World Health Organisation, WHO, document. The DSM is published in America by the American Psychiatric Association.

I do not think from an academic perspective that we have over-medicalised mental health but when that distils down to treatment sometimes, yes, it is unarguable. When we say one in six teenagers and 50% of the population have a mental disorder some of that is phobias. While I do not wish to be dismissive of people with those problems, it is not as serious as schizophrenia or illnesses like that and treatment is usually relatively straightforward and recovery rates are quite high. They can be treated sometimes outside statutory services. The Senator is absolutely right that we need to have sensible referral pathways and guidelines towards the treatment of these disorders. There is an element of public information regarding the use of antidepressant medication.

As Dr. Walley said on the subject of antibiotics for illnesses, people tend to feel their problem is not being validated if they do not get a prescription for an antibiotic. Public information is necessary to persuade people that not every problem requires medication and that alternatives are available. Psychotherapy is often recommended but I would also recommend occupational therapy and a good study was done by the mental health service in north Dublin, where I was working, and the FAI into running a football programme. It involved kick start football training one day per week and was found to be incredibly effective. Such interventions, on the part of organisations such as the FAI, the IRFU or the GAA, have a community and social involvement and that can help.

Opiate services are our Cinderella services and we have called for drug detoxification units for a number of years, because they are lacking at the moment. Detoxification is the hardest thing to achieve, especially for people who have difficulties with alcohol, opiates or benzodiazepines, and withdrawal often needs medical management, which specialist drug detoxification units would aid.

Dr. Ray Walley

I agree with the point that people are not allowed to be different any more. Some of my patients are just different and it would be very boring if everybody was the same. As their GP, they have known me for a long time. I give them the same advice about exercise and diet and the majority are not on medication. Because they are given this advice by a professional, they are very relaxed about it. Nuffield, a non-governmental organisation in the UK, looked at this issue following allegations that more prescribing was taking place and it decided that it was a good thing, as it meant people came early with mental health issues and that is what we want.

There are criteria under which one prescribes medication and one takes people off after a certain length of time but modern life is tough. There are difficulties and that results in mental health issues. They have been particularly evident during the ten years of the financial crisis in Ireland and the UK. Professional journals provide evidence that the increase in prescribing was not unique to Ireland and the UK but also happened in America. People are better educated and come to primary care and GP-community care more easily so we are giving more medication but we are also taking more medication away. We are trying to get people to be more exercise-conscious because that can lead to a massive improvement in mental health.

I am a GP in the inner city and there is a lack of opiate services, with only 35 detox beds for a country of 4.7 million people, which is crazy. Ritalin is a controlled drug and is consultant prescribed, meaning GPs do not prescribe it without it being reviewed by a clinic. I am an interviewer on one of the HSE panels and we are often lucky to have applicants because there are many posts for which there are no applicants. I trained in the UK and came back to apply for my post in north Dublin as one of 72 applicants. I came in at No. 4 but the people ahead of me were older and decided not to come back. We train excellent graduates which other countries want. Companies trying to recruit for the UK, Canada or wherever do not come here to interview potential GPs or consultants. They go to Australia instead, as they can meet more Irish young doctors in Australia, New Zealand or Canada than here.

Dr. Sadlier will give his opinion on cannabis. As a GP who has been qualified for 30 years, I am concerned about the legalisation of cannabis as it is a major carcinogen, with a higher tar content than cigarettes. It is especially dangerous in the adolescent brain and while there are medical uses for medicated cannabis, as somebody working in a deprived area I can say that evidence-based medicine is not there. If there is evidence-based medicine and there are uses for it, it would need to be reviewed.

Dr. Matthew Sadlier

In my time working in general adult psychiatry I would say that one quarter of my inpatients were there because of cannabis. From a mental health perspective, it is probably the most destructive drug out there. There has been growth in people smoking cannabis, the plant of which has 154 psychoactive ingredients. It is more than likely that some are effective and can be used in the treatment of illnesses. Digoxin, a heart drug we all use, comes from the foxglove plant but I would not advise people to pick foxglove leaves to chew, nor would Dr. Walley or Deputy Harty. Cannabis should be dealt with like any other medication. When a distillative cannabis is found to be effective for treating an illness it should be licensed in the same way as penicillin or any other medication. I do not see the sense in making an exemption for cannabis herbal products. If an evidence-based product is found and passed by the same drug regulations as apply to every other pharmaceutical agent, then I would have no problem with it.

This committee will produce a report at the end of the year which will try to improve our mental health services. Leaving aside the question of recruitment, which is the topic of today, what needs to be done? Is it about money? Is it about political will? Is it about structural change in the HSE or the Department of Health? Is it about implementing known plans or is there something else that needs to be done? How would the witnesses grade the respective options? If one asks someone in the HSE or the Department of Health something, they will ask how much it is going to cost. Everything comes down to money but we have to decide how we spend the money.

Dr. Matthew Sadlier

I am a practitioner on the ground and I know how much things cost. The one reform I would like to make to the health service is to introduce electronic patient records. There is no difference, in information technology terms, between walking into our clinic now and walking into it in 1890.

Chairman

Is that an issue with the HSE? Why is it the case?

Dr. Ray Walley

There has been no capital investment in the last 30 years and IT systems are provided for by way of capital investment.

Dr. Matthew Sadlier

I am not expert in law but existing provisions around confidentiality, security protection, data protection and so on will have to be amended if we are to have a system that is functional. There is no point having a system in respect of which the data protection requirement is so high it is unusable, but equally we do not want a system that can be easily hacked and so on. If my credit card provider can move from the swipe card to the chip and pin card within six months, why can the health care service not do things faster?

Also, communications between hospitals and primary care providers needs to be improved. When a patient becomes ill and calls an ambulance he or she may be taken to the Mater Hospital or Connolly Memorial Hospital, Blanchardstown. The patient could also choose to make their way to either hospital on their own or with a friend. If that patient has a long history of illness, in respect of which the records are held at another hospital, or if he or she has recently had an investigative procedure carried out at another hospital, to get those records I have to sign four consent forms. That needs to change, taking into account data protection requirements.

On the question of what one thing would change my life as a practitioner on the ground, I think improved information systems could generate huge efficiencies in the mental health service and across the physical health service. From our perspective, recruitment and retention of staff is an issue. I think we also need to have a conversation around health service staff being dealt with in a separate way to other staff in the public sector.

Ms Vanessa Hetherington

If we are to be able to recruit and retain health services staff we need to resource our health system so that they can practise in a safe environment. As stated in our opening statement, we are competing with other English speaking countries and we are losing doctors to countries where they are treated with much greater value, they are given the resources they need to carry out their work and they are provided with clinical supports and work-life balance. We have begun addressing acute capacity and we now have the Sláintecare report. We now need to begin addressing how we can recruit and retain our doctors and other health care professionals in the system.

Dr. Ray Walley

Within general practice, 99% of practices are fully computerised and 24 million consultations occur every year. We are fully computerised because we are contractor-led practices and we understand the efficiency of computers. We get our blood tests back quickly and as the service improves in terms of reading referrals we can do more of that online. A lot of the services do not do that. Computerisation has been GP led because we are contractor-led.

Chairman

In other words because GPs are contract led they have the autonomy to set up their own software.

Dr. Ray Walley

We could do so prior to the reductions under the Financial Emergency Measures in the Public Interest Act. The problem now is that everything is contracted as a result.

Dr. Matthew Sadlier

On Sláintecare and the movement of the mental health services community, every year large numbers of people are referred to mental health services but their problem is a physical health problem, such as hyperthyroidism and so on. The move of mental health services to the community has to be done in tandem with movement of information systems from hospitals to the communities. In a service in which I worked previously, which was based in a community centre, we had to wait for blood results to be posted to us. It is important that there is the highest level of computerisation associated with the movement of health services to the community.

Dr. Ray Walley

I lost a family member to emigration. If we lose people to emigration we will not get them back because often many of them will have delayed having a family such that when they move to the new country they then have their children and decide to remain in that country for another five years to get naturalisation there and then they do not return. Very few doctors who emigrate return.

Chairman

Deputy Walley made an interesting point about the recruitment of Irish clinicians in Australia. We will include that proposal in our report. We are grateful for of the information provided today and will factor it into our report. The committee will do all it can to ensure changes are made in primary care.

I thank all of the witnesses for their attendance.

The joint committee adjourned at 16.56 p.m. until 1.30 p.m. on Wednesday, 7 February 2018.