A Vision for Change: Engagement with Department of Health Oversight Group

We are now in public session. I welcome Mr. Hugh Kane, chairman of the Department's oversight group for A Vision for Change, Dr. Fiona Keogh from NUI Galway, a member of the oversight group, and Mr. Tom O'Brien, from the mental health unit of the Department of Health. On behalf of the committee, I thank everyone for attending. The format of the meeting is that witnesses will be invited to make a brief opening statement and this will be followed by questions and answers.

Before we begin I draw the attention of witnesses to the position in respect of privilege. Witnesses are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter and 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 asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Members should also 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 any official by name or in such a way as to make him or her identifiable.

I remind members and witnesses to turn off their mobile phones or switch them to flight mode as they cause havoc here. I also advise witnesses that any submission or opening statement they make to the committee will be published on the committee website after this meeting. I invite Mr. Kane to make his opening statement.

Mr. Hugh Kane

I thank the Chair and members of the joint committee for inviting us to today's meeting. I recognise the work the committee has completed thus far. The members of oversight group, including me, have read with interest the two reports published by the committee.

As I indicated during my previous appearance, the work of the Oireachtas Joint Committee on the Future of Mental Health Care and the oversight group share many of the same concerns. The work of the oversight group has, in the first instance, concentrated on assessing A Vision for Change, our national mental health policy, to determine what changes are needed to this foundation to refresh it in today's context. While the term of this policy came to an end last year, many of its recommendations helped to shape our current mental health system and remain at the heart of effective and appropriate mental health services. With this in mind, it was important to take a considered and staged approach to this work. In line with the oversight group work plan, consultation is taking place will continue in the coming weeks and feedback will be incorporated into the final report. This approach is similar to that taken by the joint committee, which has heard from different stakeholders over the course of its work. It is with interest that the group has observed the insights provided by the committee meetings. Our group will consider the stakeholder feedback in our discussions as we deliberate on how best to include it as we proceed.

My purpose this evening is to share with the committee the work of the oversight group of which I am chair. While I am sure members are familiar with the context within which the oversight group was created, I will nonetheless begin at the initial stages of the group. A Vision for Change was published in 2006 and set out a ten-year policy framework for Ireland's mental health services. It recommended that interventions should be aimed at maximising recovery from mental illness and building on service user and social network resources to achieve meaningful integration and participation in community life. It was welcomed as a progressive, evidence-based policy which guided the development of our mental health services towards a new model of service delivery, one which would be service user centred, flexible and community-based.

A Vision for Change highlighted many areas which were in need of increased attention in the shift from a service with an institutional focus to a community-based service, and many of the recommendations are still valid today. However, A Vision for Change came to an end in 2016 and preparations for a review and updating of policy have been under way since early 2016. The initial step was the commissioning of an evidence-based expert review in September 2016. This looked at the implementation of A Vision for Change and how future policy and services could be improved. The review provides evidence to inform the policy direction for a revision of A Vision for Change, both in terms of international best practice and the experience obtained since the adoption of the policy. It presents a broad overview and mapping of evidence and developments in the mental health area that are helpful in guiding policy development and practice in Ireland. Coincidentally, the report was published on the same day as the joint committee was established in July 2017.

In October 2017, the Minister for Health established the oversight group which was tasked with producing a high-level policy framework setting out future service priorities. I was honoured to be appointed by the Minister to chair the group. In considering the appropriate membership, it was decided to keep the group small, efficient and inclusive of leaders in the area to ensure a clear focus on the task of producing a refreshed policy in a timely manner. The oversight group, in line with its terms of reference, is overseeing the development of this refreshed policy for mental health, based on the recommendations arising out of the expert review and other relevant contributing documents. Work is scheduled to conclude in December of this year.

The oversight group engaged in a detailed consideration of current policy actions and recommendations.

It established a number of subgroups to focus on specific areas of attention, including child and youth mental health, the mental health of the over-65 age group and examination of policy outcomes. The outcomes subgroup focused on how outcomes can operate as a paradigm shift within the system to work better and more efficiently and to serve the service user in a better way, drawing from existing research and practice. The oversight group has determined that its work will have a focus on developing measurable outcomes within an outcomes focused framework.

An ecological framework will also inform the refreshed policy. This approach focuses on both population level and individual level determinants of health and interventions. It is acknowledged in much recent research that health is determined by influences at multiple levels, such as public policy, community, institutional, interpersonal and intrapersonal factors. An evaluation of the current context and how that relates to A Vision for Change and other current mental health related policies was also deemed necessary. This document examines whether specific actions have been implemented and, if so, to what success. The evaluation also examines whether specific actions have been implemented through other policies in this area and considers whether actions are still relevant if they are not implemented. I understand this is the document the committee referred to in its second interim report. A preliminary report has been received and is tabled for discussion at the next meeting of the group which takes place tomorrow. Following this meeting, the researcher will be asked to finalise the report. When this final version is received it will be shared with the members of the committee.

I also note that the committee has referenced engagement with the Department of Health as an area for action in its second interim report. As mentioned in my letter to the committee last December, the oversight group agreed to report further to this committee when the initial part of our deliberations was completed. As members will have seen in the oversight group's work plan furnished to the committee in March 2018, these deliberations have taken place mainly within the oversight group up to this point. While we have not been in a position to share working documents, I reassure the committee of our shared goal and the oversight group's ongoing commitment to this goal.

We are currently engaged in a stakeholder consultation process and we have just left the first advisory group meeting this afternoon. For this part of the process two half-day meetings have been scheduled - one today and the other, which was due to be held in June, will be in September. At these meetings we will gather input from mental health clinical experts who currently work in front-line services and service user representative organisations. It has been important to the group that the positive aspects of A Vision for Change would not be lost. The group is attentive to its mandate which is to complete a refresh of A Vision for Change. The oversight group is working on developing a framework document that will both guide the stakeholder process and assist the oversight group to work within a shared vision. Stakeholder feedback received is extremely important to us and it is hoped that all relevant information received will inform the recommendations in the refreshed report.

While the final domains have yet to be decided, it is anticipated that the following five domains will be considered: social inclusion and recovery; prevention and early intervention; access, co-ordination and continuity; improvement and innovation; and accountability and transparency. Outcomes and specific actions will then flow from these domains. Enablers that exist will also be explicitly recognised, as it is important to note what has contributed to the positive aspects of current service provision in order to ensure it continues. Wider public consultation is also set to take place in Dublin, Cork and Sligo in August. All of this feedback will be incorporated into the work of the group, with the group ultimately producing "an updated draft policy framework which sets out current and future service priorities within a time-bound implementation plan". The feedback from these stakeholder sessions and the working document mapping recommendations against current context, alongside any other completed items of work, can be provided to the committee once available.

The oversight group acknowledges the good work completed by the Oireachtas committee. In several of our meetings it was agreed that the existence of the Oireachtas committee was a very positive development because its work would assist greatly in ensuring that the policy refresh would have political support. The oversight group is clear that the terms of reference ask it to focus on refreshing policy. Policy determines outcomes for individuals in need of mental health support and shares a vision of what good mental health outcomes should be. This differs from the work of the joint committee, whose focus is on service improvement, staff shortages and funding. There is certainly a role for both groups and working together will result in a real shift in prioritising mental health in government, resulting in positive changes in policy and service provision.

Once again I thank the committee for inviting us to today's meeting. I will be happy to take any questions.

Thank you, Mr. Kane. Before I call on members for questions I will address a point Mr. Kane made which I find somewhat disappointing. He stated:

The Oversight Group is clear that the terms of reference ask it to focus on refreshing policy. ... This differs from the work of the Joint Committee, whose focus is on service improvement, staff shortages and funding.

I have to clarify this. The committee's remit is not to be a sideshow to a process taking place within the Department of Health to decide the future of mental health policy. In its terms of reference this committee is tasked with reaching cross-party agreement on the direction of mental health policy. We are, therefore, the primary body in existence for setting this agenda. Our task is to provide a vision for the future of mental health care in Ireland and we will do that in our final report in October. To be clear, I view this committee's remit as encompassing the oversight group's remit. We are not working in two separate areas. It is important, therefore, that the oversight group's work feeds into our work and that we are fully aware of the group's activity and the information available to it. Otherwise we might find ourselves at cross purposes, and the oversight group's efforts will not be fully effective if they cannot be adequately reflected in our report.

The procedure now is that members will have seven minutes each to ask questions and receive responses. I will start with Deputy Harty.

I thank the witnesses for attending. I wish to clarify the status of the oversight group. I have looked at the membership and I note it is not entirely a HSE group. It is an independent group with people drawn from many disciplines, including members of the Irish College of General Practitioners, ICGP, and Dr. Shari McDaid of Mental Health Reform. It is quite a broad group, not just the HSE.

Mr. Hugh Kane

Absolutely.

Will Mr. Kane outline, for my own information, how the membership of the group was chosen? He can see that there is a little tension between this committee and what the oversight group is doing. We are trying not to overlap to a great degree but at the same time there is a lack of communication between the two groups. I wish to clarify where the oversight group is coming from because Mr. Kane said in his opening statement that we were doing two separate things. Will he outline the separation of those two functions?

Mr. Hugh Kane

The oversight group is an independent group and I am an independent chairman. Our terms of reference ask us to report back to the management board of the Department of Health. Regarding how the group was chosen, we were looking for people with competencies in the area of developing policy and people with an understanding of mental health systems and how management systems work. We identified a group of people based on those criteria.

I was before the committee last October just as we were beginning our work. I regret, and it is unfortunate, that there is a sense that we are doing different things and that we are not on the same side in terms of what we are trying to achieve. The particular work we were tasked with in our terms of reference was to review A Vision for Change and to come up with a refreshed version of it. The focus of what we are doing is on the next period, being cognisant of what happened previously and what is currently happening. Essentially, that is what we were asked to do in our terms of reference.

This committee is working in a linear fashion and we have produced two interim reports. Will the oversight group produce an interim report on how it is progressing?

Mr. Hugh Kane

Probably not, although we will produce outputs as we go along. There are some ongoing issues. One is that we are a voluntary group and all of us have other day jobs. That mitigates against us being able to get together as often and to do work as required, so that is a particular challenge.

The focus of work during our first three meetings was deliberating on this complex area of mental health and what would be a good way to approach the development of a refreshed A Vision for Change. We spent a good bit of time deliberating, thinking about and discussing among ourselves the direction in which we would go.

When I was here on the previous occasion, I noted that the oversight group decided to take an outcomes-focused approach rather than focusing on outputs and that we would examine the issue in the whole other context I outlined. Considerable thought and deliberative time went into that. As we are an independent group whose members are drawn from many different backgrounds, we engaged in a considerable amount of discussion to reach consensus and agree on the best way forward. In respect of trying to write a report based on that kind of deliberative approach, nothing really comes out of that because one goes through a process and we work as colleagues, share ideas, argue the points backward and forward and move on. That took a particular amount of time.

We were anxious to establish the current status of all the recommendations in A Vision for Change. We contracted an external group to do that particular task. Obviously, when we were trying to determine what was in and out of scope in terms of the work we were doing, we felt this was a fairly key piece of work. We received a draft report in at the end of February on that work. This identified what was finished, what was not finished and why it was not finished, what else might be missing and whether changes had taken place in other areas that we needed to add to our work. We decided to hold that piece of work while we moved on to developing the overall framework we are using to look at the development of policy. Again, in looking at that framework, we spent a good bit of time looking at other jurisdictions that have used an outcomes approach and the places where it has worked really well. A few moving pieces are starting to fit together. We are at the point where we have a draft framework into which we can build a policy. That is what we consulted extensively on today with the people we met. We will work on that kind of framework. Tomorrow, we must finish the piece of work with the consultants who carried out the work on A Vision for Change to identify the gaps and the final pieces that need to be done. Once that is done, that becomes an output and, as I said, we will share that with the committee.

Mr. Kane says the group has begun meeting stakeholders.

Mr. Hugh Kane

Yes, we met the first group of stakeholders this afternoon.

Did the group not meet any stakeholders between October 2017 and today?

Mr. Hugh Kane

No.

How often does the group meet?

Mr. Hugh Kane

We meet every month. We have had six meetings since we began.

As Mr. Kane can appreciate, we meet every week and we are going through a large amount of work. Is one meeting per month sufficient? Does the full membership attend meetings of the oversight group?

Mr. Hugh Kane

Generally, that is the case because we try to synchronise our diaries when we meet. We have busy lives and members come from different parts of the country, which is a particular challenge. In between the monthly meetings, different groups have been working on different pieces of work to bring back to us.

In its deliberations so far, what has it found to be the main inhibitors for implementing A Vision for Change? What are the barriers to implementation? We have been through this with the Sláintecare report and we have identified barriers to implementation. What barriers has the group found in its deliberations? We have looked at three primary areas, namely, primary care, recruitment and retention and funding. Perhaps Mr. Kane would like to comment on that.

Mr. Hugh Kane

We decided to adopt an outcomes-focused approach because we felt that a fundamental question on which we needed to be clear concerned the objectives we were trying to achieve within the mental health service. Before we looked at other issues, the fundamental question for us was what we were fundamentally trying to achieve in the mental health services. That is what we viewed as critical and it is where we focused.

Part of the issue with A Vision for Change was that when one looks at the original report, the first four or five chapters were where much of the vision and future thinking were set out. The final chapters focused very much on the resources and inputs required to deliver the report. In our judgment, when one reads any reviews of A Vision for Change, one can see they tended to focus on the resource inputs rather than the other cultural issues or different ways of working that have been implemented. That has been our starting point. We have not looked at inhibitors per se because we have been trying to identify particular enablers within the system that will enable this policy to move forward in a particular way. That has been the focus rather than inhibitors.

Before we hear from Deputy Rabbitte, I will comment on Mr. Kane's comment that members of the oversight group all have busy lives and, therefore, it is difficult to meet. The group meets once a month, which means it has held about six meetings in seven or eight months. For something so important, surely the group making important decisions on refreshing A Vision for Change should not be voluntary. How much did it cost to bring in consultants to help the group?

Mr. Hugh Kane

I was appointed by the Minister who appointed the group so its status and membership are matters for the Minister rather than me to comment on. I do not know if I have the detail on what we spent on the review of A Vision for Change. If I do not have it with me, I will provide it to the committee.

I thank the witnesses for their presentation. I will follow on from where Deputy Harty left off. Mr. Kane spoke about what the group is trying to achieve. What is the group trying to achieve because I could not figure it out from his presentation? What is the focus?

Mr. Hugh Kane

We have been tasked with producing a refreshed version of A Vision for Change. Within that, the route we have taken is that we think that a future policy should really be outcomes-based. Internationally, there is strong evidence that this is a good way of bringing about fairly fundamental reform and change in services, particularly in terms of the people who access services. In terms of our particular piece of work, we are building a framework for the new policy that will look at things like the vision we are trying to achieve and the values that should underpin that. We are trying to identify the key domains and areas under which we would group the particular pieces of work. Underneath that, we are trying to identify the key actions that need to be taken to deliver that. We are looking for enablers. This involves multiple stakeholders. It is across Government and many different stakeholders. One advantage of using a framework like this is that once there is agreement on the outcomes we want to achieve, we are able to approach other colleagues and stakeholders to see what actions they need to take to deliver on the outcome that has been agreed at policy level so there is-----

All of a sudden, I have seen a clear blue light for the simple reason that we take a bottom-up approach. We meet every single week and we meet stakeholders who come before us. We are meeting stakeholders with regard to primary care, recruitment and retention and funding. To be fair to the Chairman and the clerk, every week, groups of people appear before us and we sit for two or three hours. The oversight group is putting structures in place. This is where I am somewhat disappointed. I thought the committee would be given feedback from the work the oversight group was doing every month so that we could hook on to its framework from the stakeholders that were appearing before us. Was the request that this group would give us a monthly report not one of our asks last November?

Yes, we asked for a monthly report.

Has this happened?

I do not know why that has not happened. I appreciate everything Mr. Kane has said. As I said, a clear blue light has appeared but it is a pity the committee and the oversight group are not working in tandem. While we are very different, we should be feeding back from our stakeholders. The Psychiatric Nurses Association, the Irish Prison Service and service users have appeared before us.

The committee is doing good work but the oversight group is not seeing any of that other than what it sees in the reports we produce. While the group is beginning to meet stakeholders is it possible that we could marry the stakeholders together to ensure outcomes? We work best when we are working together. How does Mr. Kane think we can support this process going forward, and how can we enable the group's outcomes for the next number of months while this committee is in place?

Deputy Rabbitte is correct. The witnesses have access to the committee meetings every week and access to those who give testimony every week. We are baffled as to why the committee cannot have an interim report from the oversight group. I apologise to the Deputy for cutting in on her contribution, but perhaps Mr. Kane will answer her questions.

Mr. Hugh Kane

I referred earlier to producing a monthly report. The group's initial discourse was based on a consideration of issues, especially when the group was forming. The first three meetings of the group were about trying to clarify its focus and be clear about the approach we were going to take, how we were going to do the work and what our main focus would be. This is an important process given the different stakeholders involved. Writing about that process could mean a two-line report.

On the other work for A Vision for Change we were delayed a bit when we went to do it. We felt it was critical to determining the scope. We have made a quantum leap at this point in so far as we have that work on A Vision for Change nearly completed and we have done an international trawl on outcomes. We have developed a framework that we will be happy to share with the committee. This allows us to start to hang the pieces together.

The consultation process we are engaged in looks at the framework and tries to find out from people what are the most important outcomes to aim for, how should they be grouped and what are the best actions to do that. When we have this information, we will be able to slot in and use much of the information gathered by us and the committee in a way that makes sense to us all.

We were involved in a great deal of thinking and discussion around stuff, and trying to present that when nothing was emerging.

I can understand that. I understand why there would have been three meetings and conversations where the oversight group was trying to find its footing, no different to ourselves here. Other than Deputy Harty, who comes from a medical background, we are elected representatives. The group has work to do to be our enablers so the committee can give the group indications for outcomes. If I have one request from today's meeting, it is that the oversight group would forward its reports to the committee. Perhaps the committee could focus on who is coming before it. Ultimately, we want the best workable vision. We are with the stakeholders as they come before committee. The oversight group has the knowledge that the committee does not. The group must share that knowledge with us to ensure the best outcomes. It might eradicate any tensions but we have to work together for the best outcomes, particularly for the next six months.

Mr. Hugh Kane

We have some information that is at a stage we are willing to share. It is reasonably well thought out but it is a work in progress. We will have a committee meeting tomorrow. The work on A Vision for Change can be shared with the committee as soon as it is completed. We have a draft framework that we would be happy to share. We are at the stage some outcome from our thinking that would be helpful and we would be happy to provide it.

That would be welcome.

Who will be consulted in the consultation process that the oversight group is about to engage in?

Mr. Hugh Kane

We discussed this in great detail. Traditionally, a consultation process would start with an advertisement in a newspaper and written submissions would be made. We were particularly interested in hearing from people and their families who are in services and who have used services. This process is often not as accessible in the same way as access to professional groups. The idea behind going around the State is to invite people who are from that background, because it is important that we hear their voices and facilitate that discussion, along with others such as professional people, and other organisations and agencies that work in the area. We hope to consult based on our framework, to try to get some support and some grounded suggestions from people. We had our reference group meeting today and we plan to meet again in September. We will schedule to have these three meetings around the countryside to-----

Regarding three meetings, how did the group come up with the locations? Dr. Fiona Keogh is looking at me now and thinks that I want to know why Galway was left out. However, I want to know why the locations were not chosen based on the CHO areas. Why was it not broken down that way? Why were only three locations use? I ask this because we talk about A Vision for Change and how it failed in Galway and the closure of St. Brigid's Hospital. I would love the oversight group to meet people in Galway to hear how the loss of that service has impacted the area. How was the decision made to hold consultations in three locations? Why could an additional four meetings not be held to make the process all-inclusive?

Mr. Hugh Kane

We were trying to cover geographical areas. Sligo was to cover the north and north west, including Cavan and Monaghan. There are transport links to Dublin, which facilitated the east. The Cork meeting could cover the south. We had a discussion about whether to go to Galway and, on balance, we determined that Sligo would work better because it was nearer.

I do not want to disenfranchise an area, but Mr. Kane can see where I am coming from.

Mr. Hugh Kane

Sure.

Representatives from all the CHOs have been before the committee. They were forthcoming and gave us their time. I ask Mr. Kane to widen the consultation to ensure communities are not left out. Using three locations is too narrow. That is not a criticism. Reference was made to the child and adolescent mental health service, CAMHS, but Galway is one of the areas that has the required 22 CAMHS beds. That is still not enough but that process needs to be reviewed. I ask that the oversight group would link in with the Chairman on this.

Mr. Hugh Kane

I will talk to colleagues about that tomorrow.

When the Minister, Deputy Harris, appeared before the committee on 8 November 2017 we asked him to ensure that we would receive not only a copy of the oversight group's work plan, but also monthly updates. Was that request made by the Department of Health?

Mr. Hugh Kane

Absolutely, but the issue was that if I was to write a monthly report to the committee, there would not be sufficient substance to assist the work of the committee. That was the only reason. Part of our issue when trying to come up with a work plan is that the group was in its formative stage and while we could have filled out a sheet, we wanted to make sure that we came up with a plan that we felt we could achieve and which was workable for us. This was the motivation. We were not trying to avoid talking to the committee or to keep out of the limelight. We were in a phase of deliberation and consultation. Writing a report based on that would not have been particularly helpful to the committee.

I respect that the witnesses are volunteers. I am a little bit cross with the Minister because A Vision for Change had been reviewed and has been refreshed. What is the next "R" in this process? Perhaps it would have been nice if someone had told the committee that the oversight group did not have the work plan and so on.

I thank the witnesses for attending. I am disappointed. We are not here to pick on the witnesses but when other members and I approached the committee's work with a vision and a mission. This was to be an implementation committee and that is why we have focused on interim reports and I am disappointed.

It was my view at the time, and probably that of others, that by running two parallel committees, they would never meet in the middle. That is what seems to have happened over the past several months.

In his opening statement, Mr. Kane stated that in 2016, A Vision for Change came to an end but it had not. We have had reviews and the next one will be to sex it up but it will not provide answers.

Mr. Kane spoke about evidence-based proposals. We have had so many stakeholders inform the committee that they have an evidence-based proposal, namely, the Sláintecare report. By the way, today is its birthday. We had the life experts in the Seanad tell us how the system is not working. Mr. Kane said he is currently engaged in a stakeholder consultation process. We will have to move away from consultation to implementation. The experts are telling us that it is difficult to access mental health services. Fancy information campaigns on TV and so forth can be run, but I am hearing day in, day out on the ground about the difficulties people have accessing mental health services. The first point of access, GP services, are swamped. One might not even get to see a GP now. We should not have have more of these reviews. Instead, we should have a committee such as this to take the first six pages of a report's recommendations and implement them.

Mr. Kane said in his opening statement, "While we have not been in a position to share working documents, I would like to reassure the committee of our shared goal and the oversight group's ongoing commitment to this goal." It is ongoing because there are two planes flying parallel to each other and will not meet. It is like asking a bank manage to cash a "Thank you" note. I am not being disrespectful to the witnesses. I am angry and disappointed with the Minister. I was excited at the start. I believed that if we could work together and achieve something positive, the people who would benefit would be those who needed these services most. While there has been excellent work done since the committee started, the subs are warming up on the other pitch and might never get a game.

First, we need to achieve access the services. We will hear about lack of staff and recruitment and retention. If that is the case, then we should roll out pilot projects. We know where systems are working well and where there are problems in the State. I was recently at a meeting in Tipperary attended by 200 people who were protesting about the lack of availability of mental health services. Up to 220 shoes were displayed at the meeting, each one representing somebody who had taken his or her life since 2012. That is in one county. Surely, that is a red flag and there should be some pilot scheme to address this.

Mr. Kane referred again to evidence-based proposals. We have heard from all the experts and documents have been published. Can we not ask the Minister to take a different view on this? Can we not have an early intervention system to deal with a problem in a certain area of the country and then roll out it out in other areas?

There is a high incidence of cancer in certain areas which are then targeted. There are high instances of youth suicide in certain places which are targeted. In Dublin as many mothers and young women are dying by suicide as fathers and young men. Surely, that has to be red flagged. I am aggrieved that we keep talking about coming up with a plan but it is then claimed more evidence is needed. The evidence is available. We are heading towards a major crisis in mental health services. There is a shortage of up to 500 staff in the system. There will be 1,700 retirements in the next five years but there is no plan to replace them and begin a recruitment drive. I do not mean to be condescending but I am trying to flag that we must be realistic. If this is not working now, can we start thinking outside the box to implement a system that will work instead of just talking about it?

Mr. Hugh Kane

We have a little piece of the jigsaw on which we are working. A service is operating every day that is reforming, making changes, supporting people as best it can and responding to issues.

I take the Deputy's point about implementation. The work with which we have been tasked is to design a mental health system that better meets the needs of the people. That is what we are struggling with. At the same time, we know there are challenges and issues every day that the delivery system is operating on. Our work has a future focus on what might be a more efficient or effective way of delivering.

While I thank Mr. Kane for the answer, it worries me. I am not trying to be disrespectful. The oversight group and the committee are trying to predict and plan for the future. We can predict that in the next five years there will be a massive shortage of staff. In five years, we will ask how did it come to this and how can it be addressed. Can we not nip this in the bud? Can we investing in GPs and primary care now in order that in five years we may not have to provide for a crisis in secondary or acute care?

Mr. Hugh Kane

Absolutely. We have work to do on workforce planning, as well as on access to primary care. I accept there are significant operational problems in the system. As we are not involved in the day-to-day management and running of the service, we have been asked to take a different focus. There are people working hard on the points the Deputy mentioned every day of the week.

The witnesses are charged with refreshing and reviewing A Vision for Change. I am blue in the face, however, from talking about documents which go nowhere. A Vision for Change is 12 years old. Psychiatric nurses were excited when it was first launched because we had an input into it. However, it was realised it was just used as a fiscal scalpel towards services and not the rolling out of up to 70% of community services. How can this be refreshed by the oversight group if its recommendations were never implemented in the first place?

I get disheartened because the issue rolls on with report after report with no action. When we established this committee, we said it would be a committee of action. However, it is just rolling on with talk and reviews. I apologise if I seem to be giving out but it is frustrating and action is needed. Earlier the Seanad debated the Seanad Public Consultation Committee report on children's mental health services, which was produced under the stewardship of the Chairman and we called for her Mental Health (Amendment) Bill 2016 to be enacted as soon as possible to stop children being nursed in adult psychiatric units.

It is possible but there is no political will to do it. That is an action that is doable but we are not even getting timelines. There are lots of barriers but there is a significant amount of legislation that could be enacted. I am sorry for ranting.

Professor Harry Kennedy from the Central Mental Hospital was here last week, along with witnesses from the Irish Penal Reform Trust and others. He was of the opinion that we should scrap A Vision for Change but I disagree with him. I do not think we have the right to scrap what is a decent document that requires implementation. He believes the document does nothing to address the issue of prisoner mental health, the rise in psychosis among prisoners or the fact that our prisons are becoming our new mental institutions because of the closure of so many long-term mental health facilities. I asked Professor Kennedy to be proactive and to write to the oversight group for A Vision For Change. I also urge the oversight group to write to him. He is a very able individual with some very useful ideas. However, I urge the oversight group not to take up his idea of scrapping A Vision for Change and starting again because we do not have the luxury of the time to do so.

A lot of research has been conducted by the Royal College of Surgeons in Ireland in collaboration with the Psychiatric Nurses Association, whose members have on-the-ground experience. A study was published in recent years which showed that 73% of the recommendations in A Vision for Change had not been implemented. I was very cynical when the oversight group was set up because I thought it signalled more of the same. I hope that the oversight group is using the evidence provided by the aforementioned study as guidance in its work.

I was quite impressed with the oversight group's work plan, which is just like the care plans that are drawn up in hospitals. It identifies the problems, the objectives, the dates and how we will get where we want to go. I would love to see all of the boxes filled out and ticked off. There was a suggestion that five town hall meetings would be rolled out across the country, which I welcome. I recommend the use interactive materials at those meetings and urge the oversight group to invite questions from participants and to get their feedback, either directly or through applications like Mentimeter. It is important to reach out to as many people as possible. Most importantly, I urge the group to hurry up and to carry out its work quickly.

Mr. Hugh Kane

One of the items on our agenda tomorrow is the issue of prisoners. That is on our radar and I am glad to hear that Professor Kennedy has raised that matter with the committee. We hope that our framework document will become fairly comprehensive over time, with a lot of detail included. The document should have a beginning, a middle and end and we hope to take that approach. In terms of our consultation, anything that we can do to make it smarter or better will be considered. I thank the Senator for her suggestion in that regard.

Yes, Mentimeter is a good way to engage.

Mr. Hugh Kane

We will take a look at that.

I am dismayed at the lack of progress because every day that passes is another day during which people who need it do not get support. We had fantastic presentations on prisoners and mental health from a range of different people recently. They described the scale of the mental health difficulties for people who are locked up, who have no safe place to be and who cannot escape their surroundings. It was quite shocking. Every time this committee meets a new group, we are shocked. We had members of the Traveller community before us and were shocked at the statistics that they presented to us. We listened to people who spoke about human trafficking and were shocked at what they told us. These are not ordinary, small problems. They are huge problems and the scale of the challenge cannot be overstated but the sense of stasis is overwhelming. I have a number of specific questions on the work plan. Action 8 refers to reducing the over reliance on prescription medication by increasing investment in counselling and talk therapies. The response refers to the HSE having commenced "a service improvement initiative". When one hears such a response, one feels that the issue of talk therapies has disappeared into a black hole. The document refers to access to talk therapies being examined where clinically indicated. We already have evidence and know that talk therapies are valuable in terms of helping people to address problems. When I worked with the Simon Community in Cork we had walk-in therapy sessions with approved counsellors. We did not get a penny for that service from the State but provided it using fundraised money. We did not commence research with a view to producing a report. People were coming to the sessions and disclosing historic abuse issues that they needed to address. We did not tell them that they had to get sober first. If they were inebriated on the day in question, we told them to come back the next day. That service is still in place. Simon did not wait for reviews or examinations. I want a commitment from the oversight group that it will move forward on action 8.

In the context of action 22, the rate of mental ill health and suicide among Travellers is exponential, shocking and a disgrace to us all. Again, we do not need more reports on this. I see that nine grade 7 mental health service co-ordinator posts were created. Are those posts all filled? Are all of those co-ordinators in place? They were being recruited in October 2017, as I understand it. While to me, that is a bee in a bear's belly in terms of addressing the issues, I wonder if even that much has been done.

Given the exceptionally high rates of mental ill health and suicide among Travellers, including young people, the €1.5 million in dormant accounts funding is no more than crumbs from the table. While it is welcome, it is nowhere near the kind of concerted, mainstream effort and funding needed.

Action 27 refers to integrating mental health supports into the health programme for victims of human trafficking but once again we have mention of a review. We are talking about people, mostly women, who have been trafficked into this country and who have experienced enormous trauma. We had a presentation recently outlining the experience of trafficked women in particular. What needs to be reviewed?

While I accept the bona fides of the witnesses here today, it seems that we are dealing here with a cesspit of bureaucracy that is disconnected from reality. We saw the same with CervicalCheck, where good people in the system were disconnected from real people. Part of our job here is to listen to people and to connect with them. The oversight group does not seem to be able to respond in a way that is not about reviewing or kicking the can further down the road. I ask the witnesses to provide further details on actions 8, 22 and 27. I also ask them to provide details on training. Training is referenced in the work plan but how many people are receiving training?

Mr. Hugh Kane

I am at a little bit of a loss because the actions referred to by Senator Kelleher are not actions or responses from our group.

I understood this to be the oversight group's work plan.

Mr. Hugh Kane

No, these actions and responses are from the Department of Health and the HSE

Can the oversight group take these actions on board in the context of its own work plan?

Mr. Hugh Kane

Yes, absolutely. There are issues here that are on our agenda, including prisoners, Travellers and ethnic minorities. These are all being considered as part of our work.

There is no sense of urgency about this. That is the point I am trying to make. I do not much care whether the work is carried out by the Department of Health, the HSE or some other unit. I just want to see a sense of urgency around doing the work.

Mr. Hugh Kane

We have terms of reference and a work plan. The actions and responses in the document to which the Senator refers are from other bodies. I will ask Mr. O'Brien to respond.

Mr. Tom O'Brien

We provided this documentation to the committee in order to assist it in the preparation of its interim report and to give the committee some sense of the situation in terms of actions and responses. Some of the responses from the HSE are still only draft responses. In terms of action 8, the Minister and the Department are working very closely with the HSE to ensure that digital texting and digital online interventions are being progressed. The Minister hopes to be able to make an announcement in October, during mental health week, on launching some of those interactive digital tools.

It does not go anywhere near what the Senator says but at least she is not waiting for the report here to be finished. There are some actions proceeding as we go through the few months ahead.

I thank Senator Kelleher. When I look at Mr. Kane, I think of the term "don't shoot the messenger". I know it is quite difficult today for him to listen to this and there is a sense of quiet anger but our anger is not directed at Mr. Kane. I wish to clarify that.

Mr. Hugh Kane

I appreciate that.

Senator Kelleher and others mentioned the review of A Vision for Change and the refreshing of the review. When a new committee is set up, does nobody question the Minister on whether it is a lovely exercise in kicking the can down the road? Really and truly, it is. The last time Mr. Kane was here he mentioned that the report would be ready by the end of the summer. It has now been put back to the end of the year in December.

Mr. Hugh Kane

We hope to finish in November.

Our report comes out in October. How does that make sense?

Mr. Hugh Kane

There is no point in me saying I will have it by October if it is not achievable. The target date for us is November. If we are ready before that and we have other stuff to share in the interim that is of assistance both to the committee and us, we can certainly share it.

This is where there is a disconnect.

Mr. Hugh Kane

Sure.

It is why it just does not make sense.

I apologise for being late as there was a rally outside relating to people with cervical cancer. It was fairly moving, as one might imagine. We accept the witnesses have major challenges ahead in their work. I am not long on this committee. There is a credibility issue with the work being done because of the work already done but which has not been implemented. That is a problem. We are picking up from the groups coming in that the structures seem to be all over the place. There does not seem to be great co-ordination. Services seem to be dependent on where a person lives, so if gaps exist, something needs to be done. I hope that is on the agenda. It is wrong that if a person lives in a particular area, that person cannot access services. The Ireland that allows such things should be gone, as far as I am concerned. Similarly, if I do not come from a wealthy background, those services should still be available to me and my family.

Where do many of the families looking for that help go? It is the biggest problem we face. They normally go to politicians like us and we are probably the worst people to go to. Some will go to their GP and so on but there is a gap in the knowledge. These are simple problems such as who to contact at a service level. The answers are not available to us so if they are not available to us as elected representatives, how can they be available to Joe Citizen? These are the simple issues that could be life-changing for people. I wish Mr. Kane well but as well as anybody like him on a committee, there is a major responsibility on the Minister to explain why the recommendations of predecessors were not carried out. Before taking on a new role, Mr. Kane must be clear in his own mind that he is not wasting time and ticking boxes in the same way. This committee is sitting down and coming up with recommendations but I hope they will not sit on a shelf.

This is not an attack but I am looking for a sensible way forward. I hope more committees will adopt such an approach. I am interested in Mr. Kane's views.

Mr. Hugh Kane

The Deputy mentioned the gaps in access and we are looking at such matters. It is interesting as one of the pieces of work we commissioned was an examination of A Vision for Change to see what has been implemented, even partially, and what is still relevant. We thought it was a fairly fundamental starting point for our work and it is something we have just completed that will be helpful. All of us on the committee are interested in trying to make a difference and do something. It is why we do this. No more than the members, we get a bit frustrated and we want action for many reasons.

Last week Professor Harry Kennedy was in but he is on record as saying he is breaking the law and not complying with court orders. It is another scandal like the scandal being raised outside the gates today. Will we be the first to criticise the service providers coming to us and saying that resources are not there? There are gaps in the service and someone must follow through the work we are doing.

I have a couple of questions for Mr. Kane and I am seriously keeping in mind not to shoot the messenger. However, I would like some answers. Deputy Harty spoke about the committee being independent but there is a large number of HSE people on that committee, including from the National Office for Suicide Prevention. I presume Mr. O'Brien is representing Mr. Canning.

Mr. Tom O'Brien

That is correct.

How can the witnesses not be biased if the majority of the committee are from the HSE? Mr. Kane used to be with the HSE too.

Mr. Hugh Kane

Yes. No matter what group of people comes together, we all bring baggage and bias.

The HSE has much baggage.

Mr. Hugh Kane

Whether one works in the HSE, the Dáil or as a milkman, we all have bias to deal with. I take the role of independent chair very seriously and I want to ensure bias is not in the room, as much as possible, and everybody's voice is heard and contributions are valued. No matter what group of people I bring to the room, we all have a bias. As chair, my role is to be aware of potential bias and if somebody makes a point that I see as coming from a position of bias, I must challenge it. There are many very strong and talented individuals in our group. It will be open and challenging. We will not have stuff going through on the nod and there will be much dialogue, discussion, disagreement and arguing of points. As independent chair, we will evidence our independence and thought process in such a way.

The purpose of the work today and over the summer is to test some of the ideas in the process. Just because somebody works or does not work in the HSE should not lead to the person being branded as not being an independent thinker. As chair I can say I have a fantastic group of colleagues who work really hard and go the extra mile. There are certainly enough people in the group to ensure that if there is a bit of bias, it will be sought out.

I am sure you chair it exceptionally well but if Mr. Greg Canning, a principal officer at the mental health unit, is on the committee, it will be coloured.

Mr. Hugh Kane

It is unfair to pick out a particular member. I am aware of from where everybody comes-----

I did not just select him but I mentioned the HSE. I said three quarters of the committee are from the HSE.

Mr. Hugh Kane

There is a major element that would challenge issues in our committee. If people are in any way trying to block us or inhibit movement in a particular way, the committee would not stand for it. It is dynamic.

I am happy to hear that.

Mr. Hugh Kane

Hand on heart, I can give that assurance.

I absolutely believe Mr. Kane. There were stakeholders in this morning.

Mr. Hugh Kane

This afternoon.

I understand that the witnesses will engage with them again for another half day. How many stakeholders appeared today, and who were they?

Mr. Hugh Kane

The number was in the high 20s.

Mr. Tom O'Brien

There were 27 today and a large number of apologies were received. Approximately 50 people who signed up could not make it.

How many groups did they represent?

Mr. Hugh Kane

We had a good balance between service users or their families and the professionals working in the field. For instance, there was representation from social work, social care, psychiatry, psychology, general practice, counselling, occupational therapy, nursing, service users, speech and language therapy, dieticians, education, the Irish Advocacy Network and peer support workers. There was a broad range of representation and we sought to ensure everybody had equal access. We achieved a good level of agreement. People found the specific task we are doing a little challenging. There was broad representation today and the group will meet again when we have more detail on the area on which we are working.

I suggest the group looks back at the public consultation stakeholders and service users who testified to their lived experiences over two full days.

Mr. Hugh Kane

That is really valuable to us.

As there are no further questions, I thank the witnesses for their attendance. It is much appreciated. We view them as the messenger and we are very respectful of them.

Mr. Hugh Kane

Absolutely.

At the same time, we must ensure we are not kidding ourselves.

Mr. Hugh Kane

I thank the Chair and committee members for meeting us today and ask them to accept our bona fides. We fully accept the bona fides of the committee. We are working towards a common purpose.

I thank Mr. Kane.

Mr. Hugh Kane

We will submit the documents to the committee and appear again as soon as the committee wishes.

The joint committee adjourned at 6.55 p.m. until 1.30 p.m. on Wednesday, 13 June 2018.