Developments in Mental Health Services: Discussion

The purpose of this morning's meeting is to meet Mental Health Reform and the Inspector of Mental Health Services regarding developments in the area of mental health services. On behalf of the committee I welcome the representatives of the Mental Health Commission: Ms Kate Frowein, senior regulatory manager; Dr. Susan Finnerty, Inspector of Mental Health Services; and Ms Rosemary Smyth, director of standards and quality. I also welcome, from Mental Health Reform, Dr. Shari McDaid, director; and Ms Kate Mitchell, senior policy and research officer. I thank them all very much for attending.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to 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, persons or entity by name or in such a way as to make him, her or it identifiable. I also advise the witnesses that any opening statements they have made to the committee may be published on the committee's website after this meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

Dr. Susan Finnerty

I welcome the opportunity to make this submission. The Mental Health Commission is the regulator for mental health services in Ireland. We are an independent statutory body that was established in April 2001 under the Mental Health Act 2001, under which the role of the inspector is set out.

Some 90% of mental health services are delivered in primary care settings. A further 10% are delivered within specialist mental health services, including community residences. Under the 2001 Act, the statutory scope of mental health regulation is limited to inpatient services only, which are estimated to make up less than 1% of mental health services in Ireland.

The joint committee has sought information on developments in mental health services in the State. The basis of this report is taken from recent inspection findings as well as information compiled by the commission as part of our ongoing monitoring of compliance and receipt of quality and safety notifications from services. While the scope of the commission’s regulation is limited, we nevertheless closely monitor developments across the broad range of mental health services in Ireland, including acute adult mental health services, rehabilitation, continuing care, child and adolescent mental health services, forensic mental health services, and community mental health services. As a general comment, it is evident that the provision of mental health services is inconsistent across the country and lacks proper integration. For example, a young person in need of mental health services in Galway will be able to access a vastly different range and level of services than a young person in Waterford. Similarly, a person in Cavan-Monaghan or Sligo-Leitrim will have access to mental health rehabilitation services, while a person in Donegal will not, even though they are in the same community healthcare organisation, CHO, area.

The commission therefore welcomes the implementation of Sláintecare, which envisages a system of integrated care provision based on need rather than on location, age, or diagnosis. We hope that this will finally realise the goals included in A Vision for Change, which set out Government policy 13 years ago in 2006. We understand A Vision for Change is undergoing a review and refresh, and we look forward to seeing the revised policy.

In regulated services, we have seen a number of positive developments. We have seen an overall increase in the national average compliance with regulatory requirements, from 74% in 2016, to 76% in 2017, to 79% in 2018. Progress is slow but is consistently trending in the right direction. For the most part we have seen good engagement from services in working towards compliance and implementing the judgment support framework, the Mental Health Commission’s quality framework. There have been some notable improvements. For example, the department of psychiatry in Roscommon University Hospital has gone from being 52% compliant with regulatory requirements in 2017 to being 83% compliant in 2018. Another marked improvement was seen in St. Brigid’s Hospital, Ardee, which went from 64% in 2017 to 93% in 2018.

We have also seen some improvement in fundamental aspects of care provision such as medication management, individual care planning, and consent procedures for involuntary patients. These are positive developments but are not consistent throughout the country. There is work yet to be done to ensure people receive the same consistent high-quality care and treatment no matter where they are located. There has been ongoing progress towards decommissioning outdated and unsuitable buildings for the provision of inpatient services. In 2006, 17 approved centres were operating in inappropriate institutional settings. By 2019, only three remained, with two due to close by 2020.

We do, however, have ongoing concerns. The commission continues to highlight concerns relating to the physical infrastructure of mental health facilities and premises. Inspection reports have consistently identified concerns relating to the overall suitability of premises to meet patient needs, concerns relating to the physical safety of premises, and concerns relating to the maintenance of the premises, including basic repair works and cleanliness. In 2018, 70% of regulated services were found to be non-compliant with the regulatory requirements relating to their premises. It is unacceptable that in 2019 we still find service users in long-stay units living in dormitory-style accommodation and in units where one shower is shared between 20 people, and to find units which are dirty and in disrepair. This does not respect the basic privacy and dignity of service users.

It is the position of the commission that there is no therapeutic benefit to the use of restrictive practices such as seclusion or physical restraint. These practices should only ever be used as a last resort where there is a serious and urgent safety concern. Despite this, physical restraint was used in 81% of all approved centres in 2018 and 97% of acute adult services. Seclusion was used in 42% of all approved centres in 2018 and 65% of acute adult services. We are concerned that there is a lingering complacency in the use of these practices. In many services, these practices are accepted and commonplace. Such practices directly affect a person’s human rights to liberty, autonomy and bodily integrity. We have seen little real engagement in the proper scrutiny and reduction of these practices by the mental health services

In a recent report, I highlighted serious concerns regarding the provision of general health services to persons with severe mental illness in continuing care approved centres. People with a severe mental illness will die, on average, 20 years earlier than the general population for largely preventable reasons unrelated to their mental illness. Following a review of ten services across the country, I highlighted inadequate and inconsistent monitoring of patients’ physical health needs and inadequate and inequitable access to essential healthcare services. The commission has sought a national response from the HSE to address these serious concerns.

I also have concerns about the provision of specialist rehabilitation and recovery services for people with enduring mental illness. This can be summarised as a lack of appropriate housing for people to move to more independent living; too few rehabilitation teams - we only have 48% of the number recommended by A Vision for Change; existing teams which are poorly staffed; and a lack of localised community and inpatient specialist rehabilitation units. We have a large number of people who are still residing in institutional care who, with rehabilitation and recovery services, could live more autonomous, satisfying lives as part of their own communities.

While the statutory scope of mental health regulation is limited to inpatient services, as inspector I have the statutory power to visit and inspect any premises where a mental health service may be provided. Over the past three years I have been undertaking a systematic review of all 24-hour nurse-staffed community residences in the State. There are 118 such community residences across the nine HSE community healthcare organisation areas, accommodating more than 1,200 service users. The residents of these services are often in long-term accommodation and the community residence is their only home. They represent a large number of potentially vulnerable adults with enduring mental illness whose voice is rarely heard.

The community residences are often poorly maintained, too big, institutionalised, restrictive and at times not respectful of service users’ privacy, dignity and autonomy. Many residences were in poor physical condition, with 19% of those inspected in 2018 requiring urgent maintenance and refurbishment. A significant number of people living in these residences should, with appropriate support, move to smaller, less institutionalised accommodation. These units remain without regulatory oversight or safeguards, despite the number of units and vulnerability of service-users accommodated in such units. Over a number of years, the Mental Health Commission has called for these residences to be regulated. Regulation would allow the commission to enforce changes where deficits and risks are found, protect the human rights of people living in these residences and help mental health services to provide care and treatment in accordance with best practice standards.

At the end of 2017, I reviewed the provision of child and adolescent mental health services, CAMHS. This review highlighted a number of concerns about the provision of the services nationally. These include: poorly staffed community teams - overall the staffing in 2017 was 60% of that recommended in A Vision for Change; the number of young people admitted to adult units, which the commission had continued to raise as a concern across a number of years; the variation in funding for CAMHS across the CHOs, which varies from €40 per capita in CHO 5 to €92 per capita in CHO 2; the lack of out of hours emergency CAMHS both for assessment and for inpatient beds; and waiting times of up to 15 months for non-urgent outpatient appointments with CAMHS teams.

The commission recommends national oversight and governance to address the ongoing concerns within regulated mental health services, noting that the ongoing and widespread nature of the concerns points to systemic issues that will not be addressed with a solely local or regional focus. The commission recommends that the revised national mental health policy, A Vision for Change, should reflect the aims set out in Sláintecare, in particular a focus on the provision of integrated care based on need, not on location, age or diagnosis. The commission recommends putting proper regulatory safeguards in place to uphold the human rights and ensure the safety and well-being of persons in specialist community-based residential mental health services, that is, 24-hour nurse supervised community residences. The commission recommends the establishment of an out-of-hours mental health service for young people in crisis, including a clear pathway for their families and loved ones. The commission recommends the proper provision of funding ensure there are adequate services for persons with severe and enduring mental illness, including appropriate accommodation, general health and rehabilitation services. The commission recommendations the prioritisation of funding to ensure all accommodation in residential mental health services - approved centres and community residences - are safe and fit for purpose.

I thank Dr. Finnerty and invite Dr. McDaid to make her opening statement.

Dr. Shari McDaid

I thank the Chair and the members for inviting Mental Health Reform to come before the committee to discuss developments in mental health services. We welcome the attention that is being given by the committee to the area of mental health. By way of background, the prevalence and impact of mental health difficulties is significant and growing. At any time, one in ten adults in this country has a mental health difficulty, while almost 20% of young people aged 19 to 24 and 15% of children aged 11 to 13 have experienced a diagnosable mental health disorder at some point in their young lives. The number of people disabled by a mental health difficulty is also growing at an alarming rate, with a jump of almost 30% in the numbers reporting a level of mental health difficulty that was disabling between the censuses of 2011 and 2016. Importantly, such difficulties can be more debilitating than most chronic physical health conditions. For example, people with mental health disabilities are nine times more likely to be outside the labour force than the general population. This is the highest proportion for any group of individuals with disabilities.

The cost of mental health difficulties is enormous, with figures suggesting it may amount to as much as 4% or more of GDP in some countries. This would equate to approximately €12.4 billion based on Irish figures. To put this in context, a research study on the cost of childhood overweight and obesity estimated the total lifetime cost in the Republic of Ireland to be €4.6 billion per annum. Untreated mental health difficulties contribute significantly in terms of cost. It is imperative that mental health is recognised and afforded appropriate priority within the wider health agenda to reflect its significance in contributing to the burden of disease in Ireland. This will require a substantial increase in mental health funding, including in budget 2020, both to sustain existing levels of service and to develop new mental health services and supports.

I would like to draw the committee's attention three major issues of concern this morning, namely, governance and accountability in mental health services, protracted delays in reform of Ireland’s Mental Health Act 2001 and the implementation of national mental health policy. It is very important to acknowledge the positive developments that have been achieved across the mental health system at local, regional and national levels. Mental Health Reform recognises the dedicated work of Government, its agencies, public representatives, direct service providers, and the community and voluntary sector. These achievements include the development of clinical care programmes in areas such as self-harm, eating disorders and early intervention in psychosis; the introduction of a national framework for recovery in mental health; and the pilot of advocacy services in child and adolescent mental health services. Some positive developments that have been initiated at the primary care level include the introduction of assistant psychologists, the expansion of Jigsaw services and the piloting of e-mental health supports. Mental health has also received significant attention in the Oireachtas through Seanad and Dáil debates and, most significantly, the establishment of the Committee on the Future of Mental Health Care.

While all of this progress is welcome, it has taken place in the context of new challenges. The mental health system suffers from a severe lack of capacity in the face of increased demand, which has pushed the mental health services to breaking point. While efforts have been made in recent years to make up for some of the losses, the old adage of mental health as the Cinderella of the health services is clearly evident in the continued under-resourcing of mental health services and supports. The shortfalls in mental health service delivery are further reflected in the lack of out of hours crisis services for both adults and children. We are disappointed that despite the recruitment of new staff as part of a planned roll out of seven day services across adult community mental health teams, only four additional areas are reporting a seven day service. In April, HSE mental health confirmed that there is no planned date for completion of the cost and implementation plan for providing seven day child and adolescent mental health services. Not only are the child and adolescent mental health services not able to provide 24-7 support around the country; there is not even a date for producing a plan to see how that can happen. A participant of Mental Health Reform’s national My Voice Matters consultation noted that “outside of office hours [there is] no professional to turn to when in crisis- at the weekend for example. [It] makes no sense that people in this day and age still have to go to A&E as [a] first resort. [It] doesn’t help the patients’’ The inspector for mental health services has recently reported “appalling standards” in certain mental health inpatient units and the Mental Health Commission has recently published a report on the lack of physical health care monitoring of individuals in a number of inpatient services across the country. There are myriad other gaps in mental health service provision, including a lack of resources in CAMHS, which has a fundamental impact on access and quality of care. As of September 2018, in the most recent figures we were able to identify, almost 2,500 children were on the waiting list for CAMHS, of whom over 12% were waiting more than 12 months. Lengthy waiting lists also exist in primary care psychology and there are significant challenges for particular client groups to getting access to mental health services, including those experiencing homelessness and those from ethnic minority communities.

We are also deeply concerned with reports from service users of poor quality in mental health services.

Our national My Voice Matters surveys found that over 40% of service users indicated that they had a poor experience of HSE mental health services. Almost 40% indicated that they were not involved as much as they would like in decisions about the medication they take. Two thirds reported that they did not have a written recovery or care plan developed with their community mental health team. Among family, friends, carers and supporters, over 70% were dissatisfied with the extent to which HSE mental health services had considered their support needs. We draw a direct link between the resource issues and the experience of the quality of the services capable of being provided.

In terms of governance and accountability, we acknowledge that between 2013 and 2018, there was an increase of approximately 20% in the mental health budget and of 28% in mental health spend. Despite such progress it is important to acknowledge that it still has not brought us to the same level of funding that was being provided in 2008 before any implementation of A Vision for Change had taken place. Investment in mental health services continues to fall well below international standards. In 2019, just 6% of the total health budget was allocated to mental health, representing an ongoing trend in recent years of significant underinvestment. Sláintecare recommends that mental health spending increase to 10% of the overall health spend.

A report prepared for the Department of Health by the Work Research Centre identified that a comparative positioning of Ireland internationally suggests that the percentage resource allocation to date is lower than in some of the countries with better developed and better performing mental healthcare systems. The data available indicate levels of allocation of between 10% and 30% in countries such as Sweden, the Netherlands, Germany, France and the UK. Recent developments to invest in Ireland's forensic mental health services and the introduction of the service reform fund in the HSE, including the national roll-out of an evidence-based approach to supported employment for people with severe and enduring mental health difficulties, are welcome. However, investment in mental health services and supports must continue and must be increased on a much greater scale to effectively improve the mental health outcomes of Ireland's population. We recommend that public expenditure be increased to 10% of the health budget within ten years to be in line with international standards on mental health funding as a proportion of the overall health budget.

In addition, there continues to be no national mental health information system to report on the full extent of resources, provision, quality and outcomes for community based mental health service delivery. For example, there are no data on the number of people in community mental health services who have an individual care plan, the number of individuals offered a talking therapy, the wait times for such therapies within mental health services and the employment and housing outcomes for people using the mental health services. Mental Health Reform has been calling for such a system in budget submissions since 2013. It is unacceptable that more than 13 years after publication of A Vision for Change there is no information system to account for the almost €1 billion in public expenditure on mental healthcare each year.  We recommend that an interim system for gathering key performance information on the mental health services be put in place as a matter of urgency.

We note that the restructuring of HSE governance and accountability structures in 2018 led to the dissolution of the HSE's mental health division and the abolition of the post of national director of mental health. Despite the appointment of senior management officials responsible for leading on mental health operations and mental health service planning and strategy, it must be considered that the dissolution of these structures within the HSE on mental health may have an adverse effect on driving the reforms necessary to ensure the delivery of a modern, recovery-focused mental health system that adequately protects the human rights of adults and children. We recommend that the post of national director for mental health and the mental health division be restored to ensure coherent leadership in mental health at national level and clear authority and accountability for a distinct, national mental health budget each year.

With regard to mental health legislation, we have consistently advocated for reform of the Mental Health Act 2001 in line with the expert group recommendations on review of the 2001 Act, to ensure that people have their rights adequately protected when they go into hospital for mental healthcare. The Minister has recently announced that the general scheme of the Bill on reform of the 2001 Act will be complete in June 2019 and ready for the Mental Health Commission's consideration. Given the lengthy delay so far and noting that the expert group's report was published in March 2015, we are asking for a date for publication of the full reforming legislation before the end of 2019. It is also of fundamental importance that the Mental Health (Amendment) Act 2018, signed into law by the President in May 2018, is commenced as a matter of priority to ensure that those small but significant changes can be made immediately to the 2001 Act. This includes that people are encouraged and supported to make their own decisions about their mental healthcare.

Implementation of the national mental health policy is a concern. Significantly, the oversight group tasked with reviewing Ireland's current national mental health policy is due to complete its work and the publication of its report is imminent. In accordance with the terms of reference of the group it can be expected that there will be a much greater focus on early intervention and prevention, mental health in primary care, improved access to mental health services, the development of services to appropriately meet the needs of particular groups of people, such as individuals experiencing homelessness, people from ethnic minority groups and those engaged with the criminal justice system, and the social inclusion of people with mental health difficulties. It is an understatement to say that many stakeholders were disappointed with the pace of implementation of A Vision for Change. It is imperative that the revised mental health policy is supported by a costed and timelined implementation plan and the establishment of robust monitoring and review mechanisms.

I will conclude this statement with the comment of one of the participants in the My Voice Matters survey: "It has been seven years since my first contact [with the mental health services] before I have gotten the help I need which I do feel the course of time waiting made a lot of things worse in my life". I thank the committee for its time and I look forward to members' questions and comments.

Thank you, Dr. McDaid. Our first contributor is Deputy Murphy O'Mahony.

I welcome the witnesses. It is great to see, yet again, a full panel of female witnesses, which is extra welcome.

The Darkness Into Light walk, which was held recently, brought the issue of mental health to the fore. As a result of that walk, people were sharing their stories more frequently than they normally would have. I acknowledge everybody who took part in the walk and those who organised it. What do the witnesses think can be done to decrease the stigma of mental health issues? Have they any ideas on how something could be included in the education system, particularly in national school, whereby a child growing up to become an adult realises it is okay not to be okay and would never think otherwise? Obviously, the wheel turns and those young children will become adults, so it is a win-win situation in that people will feel better and it is cost effective because it will not cost the health system as much for treatment and so forth. That is my first question.

There were many questions in both submissions. Do the witnesses often meet the Minister of State, Deputy Jim Daly? What are his answers to those questions?

Dr. Susan Finnerty

On the question of stigma, much has been done to decrease the stigma. My concern is about stigma surrounding serious mental illness. That has not been tackled as enthusiastically as it might be.

People who have a serious mental illness and may need inpatient care from time to time, or who need help with vocation and accommodation, experience stigma. It is to do with a lack of education about mental illness, especially serious mental illness. People do not realise that those who suffer from a serious mental illness recover and can, and do, live lives in the community the same as any other citizen. The way to tackle that is through more education and publicity around the fact that it is okay to have a mental illness, they are like other illnesses in that they can be treated and people can live lives the same as the rest of us. That is my feeling on it.

I had not thought of that stigma about serious mental illness. When I think of mental illness, it is the lower form of it rather than the more serious end I am thinking about. Dr. Finnerty's suggestion that there is still much stigma with serious mental illnesses is interesting.

Have our guests any ideas for the educational system?

Dr. Shari McDaid

I will first answer the Deputy's question about whether we have meetings with the Minister of State, Deputy Jim Daly. We do meet him and we have requested to meet him soon particularly about the findings of the My Voice Matters surveys, which give a national picture of people's experiences of mental health services. We are awaiting a date from the Minister of State in that regard.

I will ask my colleague, Ms Mitchell, to answer the questions about stigmas and schools.

Ms Kate Mitchell

I thank the Deputy for her question. In terms of the broader question around stigma, some fantastic initiatives are happening at national and local levels. This month sees the green ribbon See Change campaign which has done fantastic work in raising awareness around, and promoting positive attitudes towards, mental health.

Research shows that attitudes towards severe mental health difficulties are still very much lagging behind. We can see that through research carried out quite recently by the National Disability Authority. Members of the public are not as comfortable working with, or living beside, people with mental health difficulties in comparison with individuals in other disability groups. We still have a way to go in challenging attitudes towards more severe mental health difficulties. Measures need to be taken to better support employers in recruiting and retaining people with mental health difficulties and local authorities in placing individuals in secure housing and so on.

Some wonderful work has been carried out by schools, teachers and principals in promoting the mental health of students and ensuring their mental health needs are addressed. We need to see that happening at a national level through national protocols and processes. National guidelines were produced for both primary and post-primary schools in 2013 and 2015, which promoted mental health and well-being. There have been concerns about the lack of implementation of those and lack of resourcing and training for teachers and so on. The key point is that schools really need to be adequately resourced and their staff trained and supported to push that forward.

Dr. Susan Finnerty

My colleague, Ms Rosemary Smyth, will answer a question.

Ms Rosemary Smyth

I will respond to the Deputy's second question about meetings with the Minister. The board and chief executive officer of the commission meet the Minister on at least an annual basis and meet the officials from the mental health division in the Department on a quarterly basis. We addressed all of the matters we have raised today at our last meeting with the Minister. He advised of commitments in relation to staffing including putting assistant psychology posts into primary care and looking for consultant psychiatrists because we are finding those posts difficult to fill at the moment. Those were the Minister's priorities.

We also raised the governance issue with him prior to the appointment of the new director general. We spoke about the structures and, as Dr. McDaid said, we advocated for a national director for mental health and the national offices to be put back in position. We found that unit and the national director very helpful from a governance and accountability perspective and it is not as effective in the absence of that office. We addressed that with the Minister at our most recent meeting and he advised that he will allow the new director general to find his feet before discussions take place about that.

As Dr. McDaid said, we are expecting the legislation in June and very much welcome it. We have had two welcome legislative changes in recent times. One removed the unwilling treatment of people who are detained. People are no longer forced treatment against their will and we welcome that from the perspective of safeguarding and human rights. The most recent legislative change removed 12-month orders, so people can no longer be detained for that duration.

We table Vision for Change at all our meetings with the Minister. We have asked to be consulted about the refreshing of the policy and look forward to receiving a draft of that.

I have a few specific questions. Dr. Finnerty mentioned young people in need of mental health services in Galway and different areas. Why is there such disparity between places? How can that happen?

Dr. Susan Finnerty

Interestingly, Galway has the highest funding at €92 per capita. Areas such as CHO 5 have the least funding.

Is it all down to money?

Dr. Susan Finnerty

It is. The teams have to be filled.

Dr. Finnerty also said that people with a severe mental illness will die, on average, 15 to 20 years earlier than other people. What are the reasons for their deaths that are unrelated to mental health?

Dr. Susan Finnerty

They are mostly cardiac problems. Monitoring is really important because somebody can be prevented from developing cardiac problems. By monitoring things such as waist circumference, body mass index, BMI, or bloods and so on, one can stop the development of cardiac problems if one gets in early enough. That is the difference between treating somebody proactively and someone ending up in an intensive care unit.

Many people come into my office who are trying to access child and adolescent mental health services, CAMHS, and it would be great if something could be done to make them easy to access. I again stress the importance of 24-7 access. Mental illness does not only hit people during office hours. It would be really good if we could get a date from the Minister for when all of that will kick off.

I thank all our witnesses for coming in this morning. I join with my colleague in saying it is a refreshing and welcome change to have an all-female panel. People will be jumping onto Twitter now to give out about me saying that. They had better preface that by showing examples of them giving out on occasions there has been an all-male panel. People do not give out about that. I welcome the all-female panel and the witnesses are all very welcome.

Reference is made in the Mental Health Reform submission to the piloting of e-mental health supports. Britain is using a crisis text line, Shout, which comes from an American-based model. I have concerns about e-health in general. I am not convinced of its merits but I have very particular concerns regarding e-mental health and e-mental health supports. I would be interested in our guests' views on e-mental health as a back-up when there are other services on offer and, in particular, on abandoning traditional services in favour of online supports. If we give someone an app, that is not the same as offering him or her real support. It is not going to where the person is at; it is simply fending off a problem and not actually dealing with it. I would be interested to hear our guests' views.

Dr. Shari McDaid

Mental Health Reform has been looking at e-mental health or digital mental health in recent years because we are the Irish partner for a cross-north-western Europe project to explore this. Mental Health Reform wanted to be in that role because we are in a position to open up the discussion about digital mental health, to explore the pros and cons involved and to facilitate knowledge sharing so people, in the professions as well as service users and service providers, can be fully informed. There is a basis for figuring out what that role should be. What we are seeing in the evidence is that it is effective, particularly in a blended therapy approach. What we mean by that is that digital mental health support is a complement to the support that is provided by a mental health professional. Particularly in primary care, one could think of a digital mental health support as being book-ended by an initial consultation with a mental health professional and then follow-up with a mental health professional. In between, however, we are getting pretty good evidence that the online programme, particularly online cognitive behavioural therapy, CBT, is something people can do. In addition, the mental health professional is always informed as to how he or she is getting on in the programme. The information is available in order that the mental health professional can see the progress.

What does it do? First, it makes the mental health support much more accessible to people wherever they are. This is a significant issue. For example, I have heard of situations where, for example, mothers with young children find it very helpful to be able to access a mental health professional online because it is very difficult for them to get organised and have the opportunity to go to an appointment on their own. For people where stigma is an issue, digital mental health can help them to access support whereby they do not have to go onto the high street and into a clinic that says "mental health" on the storefront. We think there is potential. We are really interested in exploring that and discovering how to ensure that it is done in a safe way and on the basis of good practice. We held a joint seminar with the Psychological Society of Ireland last year to make sure that we are all learning about the appropriate way to bring digital mental health into the system.

The difficulty I have is not that there may not be a place for it in a functioning mental health system but that we have a dysfunctional mental health system and the supports do not exist at the moment. This is something I have recently taken an interest in. My worry is that this is a cheap way of offering support. It is, obviously, always going to be less labour-intensive and all of that. Dr. McDaid stated that a person may not want to walk down the high street and walk into a shop with a sign up advertising "mental health supports". However, those supports are not there so that option is not there either. It is not that people are saying that there is a range of supports available to them and that they wish to choose the one that is being offered online. My concern is that people are saying there is literally nothing available. They want to talk face to face with a person and to be the one who walks down the street and goes through that door. They are actively seeking help but all they are getting is an app.

Dr. McDaid makes a very relevant point that this may be appropriate where it is book-ended by professionals, where they are available. My fear, and my understanding, is that these crisis text lines do not necessarily deliver this type of support. As the studies go on, there will be evidence that they operate as a complement to services, which is not necessarily a bad idea, but if they are the service itself, they will be wholly inadequate. In a space where we have difficulty recruiting and retaining staff, this becomes nearly an outsourced way of doing it. That is where my concerns would lie.

Dr. Shari McDaid

As stated, I do not think it should become a substitute for mental health professional care. We have to look at what people who might need that help want, whether they are what we call mental health service users or people with low-level mental stress who are looking for early intervention. We have to look at what they want and their preferred options. Many people will still want to see someone face to face but some will feel more comfortable with a digital or online option. It is about creating that choice for people.

Ms Rosemary Smyth

First, the commission welcomes telemedicine and has done so, and it has advised the Minister in the context that it is not filling a gap, that the appropriate resources need to be there to refer people on and that the services need to be enhanced. It is not to fill a gap without having the full support structures in place. Second, it is most important that those who are providing the service are regulated either by an oversight body like ourselves or a professional regulator, so there is governance and oversight of such a service.

Would it make sense that these services should be put to one side for the moment in favour of developing the more traditional services? Telemedicine is quite new. I have to put my cards on the table and state that I do not like it, although that is my personal opinion. I would prefer to see a doctor or mental health professional. In the absence of services being developed, I would caution against going down the road of telemedicine. Every person who has spoken has said it is okay and it might be positive as a complement to existing services. The difficulty I have is that if we go down that road before we build up the other services, it will become increasingly less likely that we will develop the other services and we will simply have the idea that what was intended to be the complement to the services becomes the only service. I caution against that. I ask that we park that for the moment and focus solely on the development of the services that are so lacking.

I live in north County Dublin. The waiting times there for children to access a person face to face are running up to 30 months. I would be nervous that families who are in crisis, and getting further into crisis as the wait goes on, would simply be offered an app or some version of telemedicine without the additional support and then, because all the staff are under pressure, the box is ticked to indicate that the supports are in place. There is a space for the telemedicine service or the e-mental health support to complement existing services but, in the absence of existing services, I do not believe the telemedicine model will work or be effective. It is not intended to be the service; it is intended to be the complement to the service.

Dr. McDaid makes a very good point that mental health service users should be consulted and their opinions should be sought, and the service they want and need should be delivered for them. However, my fear is that the service will be developed because it is cost-efficient and is much cheaper than another version of it. That is where the focus will go and it will no longer be on making up the deficit.

Dr. Shari McDaid

I cannot see it as an either-or. I think we have an estimate that 300,000 adults in Ireland will have a mental health difficulty at some level over the course of a year. Our counselling and primary care service has capacity to see 11,000, less than 10% so we need both and we need both urgently. We need to build up the digital mental health supports and the options for using them throughout the mental health system but we need to do it safely and in a way that recognises the integral and vital role of mental health professionals in our mental health system.

Absolutely. I have one very brief question that relates to attendance at accident and emergency units. I know because there are people in my constituency who have come to my office because they have had to bring a loved one to an accident and emergency department. The person does not have a physical ailment but he or she literally has nowhere else to go so the only door that is open to him or her is the accident and emergency door. It is the last place these people want to be. Could the witnesses talk about the impact of this? As a former trade union official, I represented nurses, many of whom were in accident and emergency departments, and I know the impact it has on staff. These are people who want to do their best but might not have the training to cope with a person who is experiencing mental health distress and who finds himself or herself in an accident and emergency unit. Could the witnesses describe the impact on the individual? I know the impact on staff members is horrendous but the witnesses might be able to describe the impact on a person who has to go to an accident and emergency unit. What happens to the person after he or she presents at an accident and emergency department, which we all agree is the last place the person wants to be and the last place he or she should be but in some instances, is the only place where he or she finds an open door?

Ms Kate Mitchell

Deputy O'Reilly raises a very important question. Mental Health Reform has carried out consultations in different parts of the country for a number of years. It is one issue where we heard consistently from people who use the services when they experience a mental health difficulty, family members and mental health professionals and what we have heard echoes what Deputy O'Reilly saying, which is that when somebody is in mental distress, he or she is in crisis and an accident and emergency department is the last place he or she wants to be. It is not an appropriate environment. It can be quite distressing. It can be very noisy and chaotic and in many situations, the person is waiting for an extremely long period of time to be seen by a mental health professional. In some cases, people will leave before they get the support they need, which can lead to tragic consequences.

Mental Health Reform has been advocating for out-of-hours mental health services. We received a commitment from the Minister of State with responsibility for mental health to roll out seven-day-a-week services in all parts of the country for adult mental health services. Recruitment has been completed for about 36 of the 48 posts required to deliver on that roll-out, with an additional eight posts accepted but the implementation of this 7-7 provision is slow, so it is important that we see the implementation of that as a matter of priority. In many areas of the country, there are no 7-7 or 24-7 mental health services for children and young people, who must go to an accident and emergency unit when they are in mental distress and crisis. Often when they go to an accident and emergency department, they do not get to see a child and adolescent mental health professional but are seen by an adult consultant psychiatrist. Many families and children have to wait quite a considerable amount of time to get that crisis support. We would say that there needs to be a roll-out of 24-7 services for children and young people. It is really important that this is implemented as a matter of priority.

Dr. Susan Finnerty

I agree. With regard to after hours, in nearly all places, it is the accident and emergency department people arrive at. There are some services that do provide an eight-to-eight or seven-to-seven service and there are few that provide a limited seven-day service but it is very limited. The other difficulty in some places is that when people do come to accident and emergency departments and are seen by the psychiatrist, the units to which they would be admitted are full. This leads to all kinds of difficulties such as people staying long periods of time in accident and emergency departments and people being discharged from accident and emergency units when it may not be the best thing for them. During office hours, in most cases, there are day hospitals or areas where people can come and see somebody in an emergency so that they do not have to go to an accident and emergency unit. In some places, there are home-based treatment teams that will go out and assess somebody in his or her home but it is very patchy and inconsistent across the country.

It is. In a scenario where one can schedule appointments and only hit that crisis between 9 a.m and 5 p.m., even at that, someone is still not guaranteed that he or she will get the service he or she needs. This is unscheduled care no matter which way one looks at it and having a nine-to-five service is no use to someone at midnight. It is very regrettable not just for the patient but also for the staff, who can do nothing for the patient, and is something that must be worked on.

I call Senator Colm Burke - sorry, Deputy Durkan.

I will defer to my colleague from Munster.

More senior first.

I welcome our witnesses and thank them for their reports. Regarding the variation in terms of spending across the CAMH service, particularly the €40 to €92 per capita variation, is that caused by a local need or investment in outdated services or structures? What is the main cause of that? There is a significant difference - more than double - that needs to be addressed because if that is a symptom of what is happening across the board, it is a serious problem.

Dr. Susan Finnerty

It is difficult to know exactly what is causing it. The service in Galway is a particularly proactive service that has developed a number of good practice initiatives such as advocacy. It has an emergency bed and other beds in that region and has developed the services very well. That in itself attracts people to come and work in that service. CHO 5 finds it particularly difficult because it cannot get staff to work in that area, which down the line decreases the chances of getting people - either allied health professionals or consultant psychiatrists - to come and work in the service. The service in Galway is a very established one going back many years and has attracted funding in order to maintain that whereas the CHO 5 area would be a new service that does not have beds and finds it very difficult to get inpatient beds for CAMHS. There are a number of factors.

To what extent has any review been carried out with a view to addressing that imbalance? For example, I have an idea as to why staff cannot be found to work in CHO 5 but I would like to hear it more graphically. There should be no patchiness in the system. It should be equal across the board. We need to know what the cause or causes are and if there are particular causes, which I think we know, we must address them. Can we do that?

Dr. Susan Finnerty

The reasons for this rest with the HSE. The Mental Health Commission does not fund the services. The decisions on how to fund and provide the services belong to the HSE.

When there is a huge imbalance such as this, to whom do we apply? I am not asking Dr. Finnerty to make a comment or criticise the HSE, far from it and I would be the last to do so as the Chairman well knows, but we need to know precisely, starkly and graphically what the issues are.

Ms Rosemary Smyth

The provision of services is a matter for the commissioners of child and adolescent beds, which in this case is the HSE. A considerable number of years ago, the commission conducted a review and the result indicated there were enough inpatient beds within our jurisdiction for CAMHS and that the problem lies in community services, whereby care and treatment that could prevent people warranting admission are not available. We have spoken about waiting lists and waiting times. It then comes to the point in time when people do need admission.

The commissioners made the decision on the structures and where to locate the CAMHS units. They are located in Galway, Cork and Dublin, including in St. Vincent's Hospital in Fairview. These were decided by the commissioners. Only three of the units provided by the State take in those aged under 16 years of age. Again, this is a reduction in the number and capacity. The commissioners decided on the age groups that would be admitted to these units. With regard to the lack of provision, the commission has repeatedly requested that the provision of 24-7 out-of-hours services and community services be developed.

Are we to assume the various regions have a huge amount of autonomy in the degree to which they develop the service or fail to develop the service? What do the witnesses recommend to address this issue? I emphasise there should be no patches in the system that are not capable of delivering and dealing with the issues.

Dr. Susan Finnerty

Obviously we recommend equitable access for everybody in Ireland to adequate CAMH services and that the funding is equitable so the provision of service is not based on postcodes whereby, as I pointed out, somebody in Galway gets a better service than somebody in Waterford or other areas. We certainly recommend equity in funding and equitable access to the services.

Dr. Shari McDaid

I want to point out again the importance of having a national director with authority over the budget for the entire mental health service, keeping in mind we only had a national director for mental health from July 2014 until 2018, which is a relatively short time in which there was an officeholder in the HSE who could look at spending throughout the entire country and prioritise spending based on need, deprivation levels in certain areas and trying to rectify historical legacy imbalances.

Is this happening?

Dr. Shari McDaid

It is less likely to happen now because we no longer have a national director and decision making on the budget is more devolved and is moving towards being more devolved to the regions. This is the concern about the new structures in the HSE.

The HSE is the overall co-ordinator of where the money is spent and the basis on which it is spent which, presumably, is good investment to improve services and to address issues insofar as patients are concerned.

Dr. Shari McDaid

Ultimately, it is the account holder and should be responsible on a national basis but our concern is that the structures now in place do not really facilitate this very well because there is not the same level of accountability as there was when there was a national director for mental health who was responsible for the mental health budget.

Dr. McDaid is saying this is an urgent need.

Dr. Shari McDaid


Some years ago I saw a report on the number of children aged between ten and 13 admitted to accident and emergency departments having self-harmed or having had a mental breakdown. Some of these children were admitted more than once and some had a tragic ending. To what degree does the system as it is now interact with these children, identify them and try to protect them and provide the type of services that they require? They may be in a difficult home situation. There may be addiction involved and a variety of issues contributing detrimentally to their particular situations. In these circumstances, what do the witnesses see as being the most immediate and urgent intervention to address the issues?

Ms Kate Mitchell

I thank the Deputy for his question on this fundamental issue. The figures on presentations of self-harm continue to be significantly high among our younger population. A HSE national clinical care programme has been introduced on self-harm presentations to emergency departments. This has been in operation since 2014. I believe it has been expanding to each emergency department throughout the country. My understanding is that 24 emergency departments now have a dedicated self-harm specialised clinical nurse in post, with the aim of expanding this to the three paediatric hospitals. As far as I am aware, this issue is being addressed to some extent through the self-harm national clinical care programme. It will be very important to continue to review the programme and monitor it to ensure it is being implemented effectively.

Is that being done?

Ms Kate Mitchell

There was a recent review of the self-harm clinical programme and I believe there were mixed reviews on how it was operating in various hospitals. It will be important in the future that there is consistency and standardisation in how it is rolled out throughout the country and how it is implemented in various hospitals throughout the country. There are certainly other measures that need to be put in place. It is not the full solution. For example, there is a requirement for more out-of-hours services and crisis services for children and young people to support that need.

Dr. Susan Finnerty

With regard to the age range the Deputy gave of children aged between ten and 13, if a child of this age comes into an accident and emergency department with self-harm or suicidal ideas, it certainly needs a response from the child and adolescent mental health services. The difficulty, as Ms Mitchell and I have said, is this it is not available in every area. Obviously this is concerning and we recommend an out-of-hours CAMH service available for accident and emergency departments so children who present, particularly at that age, are picked up by the CAMH services.

I am interested to know the degree of interaction through schools, GPs or by whatever system, whereby children and their families can have access to the required level and quality of service to address this specific issue before the situation reaches an accident and emergency department. To what extent do we have this in place? From my dealings, and I am sure everybody here can point to similar dealings, I can point to cases where this did not take place, where there was a void and, as a result, there were tragic consequences.

To what extent do CAMHS identify children through the schools and offer them support, reassurance or whatever is required? I will ask two further questions before finishing.

Dr. Shari McDaid

I will make a comment in reply to the Deputy's questions. Clearly, CAMHS are very under-resourced. They have approximately 56% of the recommended number of staff. Inevitably, those services retrench. They heighten the criteria for admission because they feel that they cannot cope. There was also a major increase in demand - it is believed to have been 25% - for CAMHS.

Ms Kate Mitchell

Between 2012 and 2016.

Dr. Shari McDaid

That is a perfect storm - an increase in need and inadequate resourcing. In the face of that, staff will increase the threshold at which people can access mental health services. Ironically, it may be more difficult now for CAMHS to do the kind of outreach and interaction in schools that they should be doing than might have been the case ten years ago. The Deputy is correct to state that it should be happening. If a school has a concern about a child, it should find it relatively easy to contact CAMHS and get advice, support and guidance on whether the child should be referred, but we do not get a sense that this is routinely available across the country. I am just pointing out why that might be the case. It is not enough simply to blame CAMHS and say that they should be more open. There must also be adequate mental health support throughout the system - within the school, in primary care and in CAMHS.

There is a significant difference in the degree to which funding is available in some areas. Where one has double the funding of an area that is under pressure, there is a gap in the system. Information exists, and I would like it to be made available to the committee. Could we have a report on the extent to which CAMHS in areas that are underfunded are meeting, failing to meet or for whatever reason unable to meet targets compared with those areas with different funding chains?

Dr. Shari McDaid

We would welcome the HSE being asked for that. The committee should bear in mind that the HSE used to publish an annual report on CAMHS but, as far as I am aware, it is no longer producing those reports annually. We would welcome it if the committee requested that the HSE get back into the practice of publishing the annual report on CAMHS.

Of my two final questions, one relates to medication, particularly for children and adolescents. As a child grows older, a parent - especially a mother - can have a concern about restraints and the child not taking medication or being supervised in that regarding to the extent that he or she should be. The progression of the child's condition may be a contributory factor. How do we reassure the parent that the child is safe when seeking treatment or while in respite care? We need to reassure parents so that the State is seen as a helping, supportive and fair instrument for dealing with their children's conditions.

My final question is on housing and a matter that we have all encountered. Adults, including young adults, may have been sleeping rough before being referred to what used to be called sheltered housing, although it is no longer sheltered to the extent that it should be. We must try to ensure that the person is in an environment that is supportive and does not undermine his or her self-confidence and self-esteem and where the person and his or her family can feel that they can rely on it for the best possible treatment.

Dr. Susan Finnerty

I will answer the second question first. As I mentioned in my submission, we have concerns about the residences that are supervised over 24 hours. We would like to see them respecting the autonomy and dignity of those residing there, both through how they treat the residents and through the environment in which they live. In 19% of such residences, the environment is unsatisfactory. Something needs to be done about that as a matter of urgency. Since the residences are also large, there is a tendency for people to become institutionalised, lose their independence and stop being part of the community. That is why the commission is anxious that these residences be regulated. While I can inspect them, we cannot enforce action because the Mental Health Act does not allow us to do so. We recommend that they be regulated, as that would help us to ensure that those residential places were suitable for people, be they young or elderly.

Regarding the Deputy's first question, it is difficult to reassure people about medication, its effect on someone or how the illness will progress without knowing the circumstances of that particular person. The clinical team is best placed to do that. In such cases, every effort should be made for people to communicate with the treating team and for the family and young person to be involved in his or her treatment.

I thank Dr. Finnerty.

I thank our guests for their presentations. It is important that we acknowledge the work, dedication and commitment of everyone working in the mental health services, which is a very demanding area.

I wish to raise a few issues, some of which have already been touched on. I will first address CAMHS and my experience from dealing with parents who have come to me about the issue of medical practitioners. I know of a case where someone would have had access to a consultant within a short time if he had just lived a half mile up the road, but there was no medical consultant in his own area. I do not understand the geographical boundaries that are being used to determine who a person sees. If someone is in the wrong area at the wrong time and there is no consultant, that person might have to wait anything up to 18 months to see someone. I have had to deal with such a situation. The parents of a 16 year old had to monitor their son non-stop for those 18 months. CAMHS would not get involved until he was assessed. If there is not a consultant, I do not understand why some other process is not in place to ensure that a case is handled. The parents ended up taking their son to an accident and emergency department, but he was sent back home without an additional care plan being put in place. This issue needs to be addressed. Why are there geographical boundaries? We do not have that type of boundary in maternity services.

Why do we have it with adolescent mental health?

The second issue is the growing challenge that we will now have to deal with of people who are non-Irish and who have come to Ireland without the kind of traditional family support that one might see in Ireland. I had a case recently, for example, where a non-Irish girl had been in Ireland for approximately 12 years and had no family in Ireland. She was in rented accommodation and had serious mental difficulties. The landlord got her GP to see the girl because she would not go to the GP herself. The GP's response was to contact me as a public representative for the area but four weeks later she was still not getting help. I got on to the public health nurse, who told me she could not attend the girl unless she is requested to do so by the GP or somebody else in the HSE. There were four weeks during which there was no action but eventually the landlord took a recording of the person because she was going downhill very fast. Only when played the recording did the GP go to see the person. The person in question was admitted to psychiatric services for eight weeks but is now back in the community and in the same residential accommodation. The landlord has told me the person must leave by 30 June but I cannot source a back-up service. This is one of many problems where we have many non-Irish people who, unfortunately, will end up in a position without backup from a family. We will end up with people like this on the street. What do we need to bring about forward planning with this matter?

The third issue relates to balancing of cost. I had a case of mid-30s person and, in fairness, the HSE was doing its best. It had to apply two care assistants to the person in question because assistants working on their own had been assaulted. A package was done to provide care for the person in the community and the cost was €130,000 per annum. There must be a way of dealing with a case like that, where a person has good and bad days but the assessment is the person should be out in the community as opposed to being in a more definitive care position.

The fourth issue concerns the lack of information. I know a guy for a long number of years and I spoke to his family recently as I received ten or 20 emails per day from the person. The person is now under the care of mental health services. The family has distanced itself from the person because of difficulties, and the family is convinced that the use of illegal drugs over a long period caused a long-term mental health problem. We are not getting the information out there that the use of illegal drugs can lead to mental health issues. There is not enough information out there for young people in particular. I have come across a number of cases where people have been in perfect health before getting into drugs and they now have long-term mental health problems, with no road back. How is it proposed to deal with this? Must we put much more information out there? Where do we start with such a process?

Dr. Susan Finnerty

The Senator asked about a position where there is no CAMHS consultant in a certain area but there is one ten miles down the road, for example. There have been some difficulties over the past few years filling posts for CAMHS consultants, and there have been occasions when in certain areas there has not been a consultant available to provide a service. Sometimes they will cross over from another area or community healthcare organisation to try to pick up any of the emergency cases. I know CHO 5 ran into some difficulties with that and the services from other areas went through the waiting list, with urgent cases being seen and so on. That was not ideal at all and the difficulty was in recruiting a consultant psychiatrist. The posts had been approved. Dr. McDaid has done some work on the topic of non-Irish patients.

Dr. Shari McDaid

The point on forward planning was very well made. We have been calling for some time now for the mental health services to develop a programme of cultural competence for staff in bringing about a culturally sensitive service. This will have to apply to mental health care delivered in primary care as well and it is about ensuring the system is equipped to support people from different ethnic communities and new communities coming to Ireland. That extends not just to developing a level of staffing competence in providing services to people from diverse cultural backgrounds but also to planning for services that have adequate capacity to support individuals in distress in those circumstances. That is really where the Senator's story hints at a failure to adequately plan for a new situation in Ireland, which is a more diverse community. I would welcome it being a priority within the HSE for them to plan for services that can provide support for people from ethnic minority communities coming into the country. It will probably need to do that in partnership with other services around the country, such as the direct provision system. There needs to be communication and collaboration between those who organise direct provision and mental health services.

Dr. Susan Finnerty

There was a question about the expense of cost packages and how it should be based on need. There are a number of people who have very complex psychiatric needs and they require very expensive packages for care. They are either treated outside this jurisdiction or else the care is provided by a private company with the health care assistants or mental health nurses providing care for them. It is expensive but there is no facility in Ireland currently where people with such complex needs and high staffing requirements can be treated.

The point is that this person is in the community and the argument is whether this is the correct decision. The cost of keeping the person in the community is very high. A number of years ago, that person would have been kept for a substantial period in more permanent care but that seems to have totally changed. The argument put to me is the person in question is not suitable to be in the community. Members of that person's family have suffered injury after being assaulted, as have care workers. There is a concern as to whether this was the right decision.

There seems to be a reluctance to keep a person in more clearly defined care. Referral into the community is the preferred option, but the appropriate support services may not be available. Even where they are, there can be a difficulty in finding staff and then with the cost of staffing.

Returning to the CAMHS issue and the geographical divide, I still do not accept that because there is a boundary half a mile up the road from a person's house he or she should have to wait ad infinitum.

My other question is about the definition of "urgent care". I think a 16 year old teenager who is borderline in respect of self-harm, or whatever the issue might be, requires urgent care. However, the system seems to be telling parents that it is necessary to go on a waiting list to see a consultant and that CAMHS cannot become involved until a full assessment has been made. Something has to change. Geographical boundaries should not apply. If one consultant is not available, some process should be set up immediately to ensure no one will be left in limbo. The family to whom I am referring were left in such a situation. Other families in the same area are caught in the same dilemma. No assistance was being offered for a long time. That issue has to be dealt with.

Dr. Susan Finnerty

I agree. Anybody who needs urgent care should be assessed by a consultant psychiatrist or the CAMHS team.

On the geographical areas, the HSE has divided the country into community health care organisation, CHO, areas, within which there are various sectors. I am not sure how strong the boundaries are between each team or CHO. However, anyone who needs urgent treatment and intervention should be seen. There should be no question of telling someone that is not possible because he or she lives in a certain area. That is unacceptable.

We would be in a right mess if we were to apply the same rules to maternity services. We seem to accept these rules in the mental health service, which does not make sense to me.

Ms Kate Mitchell

I will comment briefly. This issue highlights the gaps in staffing in the mental health service. A consultant psychiatrist might be not available in one area, but there may be one available a few miles down the road. There is a waiting list in the particular catchment area, which highlights the need for enhanced efforts to recruit the required consultant psychiatrists. There is also a need to focus on the recruitment of allied health and social care professionals. We need an increase in the numbers of psychologists, social workers and occupational therapists in order that children and young people and their families can access services when they require them.

The argument being made in the particular case was that CAMHS could not become involved until a full assessment was made by a consultant. If a consultant is not in place in a particular area, surely there should be some intermediate action?

Ms Kate Mitchell

The legislation, the Mental Health Act 2001, defines a consultant psychiatrist as the clinical lead for a service and he or she must be in place to make the assessment. That is the position set out in legislation and policy. If the committee is to look at the issue, it will need to examine it in the context of the existing legislation. There are other jurisdictions, the United Kingdom for example, where a consultant psychiatrist is not required to make the assessment and take on the role of clinical lead. That is not the case here.

The problem in this case is that there are consultant psychiatrists in the particular area, but they do not deal with adolescent mental health issues. No one is taking responsibility. The question arises as to who is in charge in the area once an adolescent mental health consultant is not available. Who takes responsibility when such an issue arises? Mental health consultants do cover the particular geographical area, but they do not deal with adolescent mental health issues. There is buck passing going on. No one is taking responsibility, even though the person concerned is living in the area.

Ms Rosemary Smyth

That brings us back to the point raised by us and the representatives of Mental Health Reform. I refer to the governance of and accountability for the service. We cannot see it happening and would like to see the issue being addressed so as to rule out the possibility detailed by the Senator. There should be an individual who could be held to account for the care and treatment of a child or adolescent in such a situation, but that is not the case.

Turning to the point made by Ms Mitchell concerning the legislation, it only pertains to children who require involuntary admission. They must be assessed by a consultant psychiatrist. A very small proportion of children are admitted under section 25 of the Mental Health Act 2001. We advocate that an assessment be undertaken by any member of the team whenever a child or an adolescent presents at an emergency ward or elsewhere. As Dr. Finnerty stated, such a presentation should be regarded as an urgent need and the child or adolescent addressed by a consultant.

Will someone comment on the connection between mental health problems and the abuse of drugs?

Dr. Shari McDaid

There have been concerns for a long time about the separation between addiction services and mental health services. It is helpful that the Senator has brought up this broader point about the evidence increasingly showing that certain illegal drugs seem to have an association with severe mental health difficulties. I refer, in particular, to psychosis, where there seems to be a link with certain drugs. We need to get out that message. One of the issues on which we are not focusing enough is the prevention of mental health difficulties. We may never be able to cope with demand if we do not put more effort into prevention and educating people about how they can prevent mental health difficulties.

The Senator's point is well made. However, a challenge often arises with people who have a history of addiction or misuse of illegal substances when they present with a mental health difficulty. Too often in our system they are turned away from one service or another. They are told that they have to sort out their addiction issues before they can be seen in the mental health service or vice versa. It is probably more often the case that a person ends up in addiction services when he or she also needs mental health service supports. Those supports are not being deployed in an integrated way. I hope that failure will be addressed in the revision of A Vision for Change. I do not think that policy was very helpful. It seemed to conceive of addiction issues and services as being separate from mental health difficulties, unless there was a clear mental health difficulty prior to addiction. I hope the next mental health policy will recognise much more that substance and alcohol misuse often feature among those with mental health difficulties and that holistic support is needed.

Does Dr. McDaid accept that we need to instigate immediately a health information campaign to highlight this issue? Recently I came across someone in the maternity service. She was pregnant and cocaine was detected in three out of four tests. She was using cocaine, despite repeated warnings that such drug use would cause problems. We are not getting the message out.

Dr. Shari McDaid

The evidence needs to be communicated clearly in order that people can understand what they are getting into when they take these risks.

I apologise for not being able to be here sooner.

If I touch on something that was dealt with earlier, the witnesses may give me short shrift and need not go through it again. I have some generic questions. Can the witnesses name one or two critical issues, areas or services that are outside the health services and that have a significant impact on the people about whom they are concerned? On prevention, which Dr. McDaid just mentioned, we have the analogy that it is better to prevent people falling into a river than to be trying to pull them all out in time. Are we spending too much effort on trying to save people, as it were, and not enough on keeping them well most of the time? I am not suggesting that resources be taken from one and given to the other.

I also have a couple of questions for the Mental Health Commission. It was great to see the executive summary it provided with the bullet points. The summary states that there are some good things happening. It also sets out six areas, forensically but briefly, where there are serious issues. It states that "basic and fundamental aspects of care and treatment in regulated health services continue to be lacking", that there is "lingering complacency around restrictive practices", and that a large number of specialist community health teams remain without regulatory oversight. It cites a lack of rehabilitation supports for people with enduring mental health services; the whole issue of the physical health needs of people with enduring mental health needs; and the provision of child mental health services in the community. I want to focus on the second last item. What is the interaction in respect of general health, disability and other conditions? How might that be dealt with differently? The drugs thing was almost a parallel issue in terms of trying to slice and dice people.

The Mental Health Commission is the regulator of mental health services. It is also there to protect the interests of people admitted and detained under the 2001 Act, which is quite a critical and long overdue provision. It is, dare I say, therefore locked into people who are in services or who are on the cusp of being so. We have heard it set out eloquently by Senator Colm Burke. What has the commission to say about people who are not in services and should be?

Turning to Mental Health Reform, it sets out three major issues in the first page of its presentation, governance, accountability and protracted delays in reform of the 2001 Act. We hope we do not have to wait as long as from 1945 to 2001 to get the next Act and get things moved on. Reference was also made to implementation of the national mental health policy. I refer to the United Convention on the Rights of Persons with Disabilities. Will the witnesses comment briefly on what it requires, what Ireland has said it is going to do and how this relates to A Vision for Change and the Mental Health Act? The second page of Mental Health Reform's presentation states "the Irish mental health system suffers from a severe lack of capacity in the face of increased demand which has pushed the mental health services to breaking point". What is actually meant by that? When is that going to happen if something does not change?

Dr. Susan Finnerty

I will address the general health question first. We touched on it a little earlier. The main point is that people with a serious mental illness die ten, 15 or even 20 years earlier than those who do not have a serious mental illness. In the main, this is due to preventable factors.

It need not be.

Dr. Susan Finnerty

That need not happen. That is the point. The preventable ones are the cardiovascular illnesses, heart disease and stroke. It is very easy to monitor this and pick up very early if people are showing signs of physical health problems like that. In the same way that we go to our doctor for our lipids, weight and so on, people who have serious mental illness and are on medication need to have the same. We found that in a small group of inpatients, this was not happening. We also found that access to essential healthcare, such as dietetics, physiotherapy and speech and language therapy, were not ether either.

Is it that they are not there or that people are not connecting with them?

Dr. Susan Finnerty

They are not provided. These are inpatients. They are not provided for them. They cannot access the community and they cannot access this as inpatients, so they fall between two stools.

If they were in the community, they could go to their GPs if they were minded. It is a different dynamic.

Dr. Susan Finnerty

They could go to their GP, who could refer them for physiotherapy. While there might be a long waiting list, they would eventually get it. With inpatient continuing care units, that may not be the case.

Ms Rosemary Smyth

I will follow up on the regulation of mental health services. The Senator is right that our remit extends only to inpatient services in respect of enforcement and compliance of the services. We register them. Our remit does not extend beyond that, although the inspector has the right to visit anywhere a mental health service is delivered. We have no enforcement or powers beyond that. We have advocated and have recommended today that our powers be extended. It would give us more powers in being able to look and to address many of the members' questions, which we are not able to answer because we do not have the full picture of a pathway of a patient through mental health services. We are only looking at the 10% of people who are inpatients. We do not have oversight of the rest of the mental health services, where the majority of them are delivered. This is a deficit. There is no oversight of a patient's journey through mental health services provision.

The protection element is a very important piece of work. We see ourselves as safeguarding those who are the most ill and who require involuntary detention. Through our offices, we establish the tribunals to ensure their rights are upheld. It has been a very welcome provision for the people who have to go through that process that they are afforded those rights and protections.

The Senator asked about the critical issues outside of the health remit. Does he mean matters in the jurisdiction of other Departments?

I was thinking of something that might not be in the health basket but nonetheless has an impact.

Dr. Susan Finnerty

One organisation I would think has had an impact is Jigsaw. It provides primary care services for young people.

They have had quite an impact. They work with CAMHS but provide a walk-in service and support them through whatever journey they are making with their mental health issues. They have been able to provide a primary care service which the HSE may have had difficulties providing.

Dr. Finnerty has made a great recovery.

Dr. Susan Finnerty

I thank the Senator.

Dr. Shari McDaid

The two critical areas outside the health service which have a huge impact on people recovering from a mental health issue are housing and employment. Many people who have a mental health difficulty would identify themselves that if they could just get adequate housing, it would help them to recover. If they could just get support to help them into the daily routine of employment or participating in the community, for example, as a volunteer or parent, this would be as important for their recovery, if not more so, than some of the medical treatment they will receive. They are not alone in thinking that because the evidence on the impact of having secure housing and employment is very good. For instance, when we see in the social welfare system that about 50% of people on disability allowance identify mental health as their primary concern, we know that we do not have a well functioning mental health system. It should not be the case that people who have a mental health difficulty and want to work do not routinely get the support they need to get back into work. We welcome the national roll-out, under the service reform fund, of support for people with severe mental health difficulties to get back into work. That is a pilot programme and needs to be mainstreamed. In housing, no one should be in an inpatient for the sole reason that he or she cannot get housing. That is a very inefficient use of resources, yet it is the case in inpatient units around the country. We have seen evidence of this.

Another area which may not be as closely related to what would help people recover but is nonetheless symptomatic of the weaknesses in our system is the extent of mental health difficulties arising for people who are in the prison system and on remand. Between 40% and 60% of people on remand have a diagnosable mental health difficulty and between 5% and 10% of people in the prison system have a severe mental health difficulty. That is not the appropriate place to recover from a mental health difficulty. It will not help them to recover. We need to look closely at the supports in the prison system and ensure that people in the prison system who are experiencing mental distress get good quality supports and all the support they need to ensure their mental health difficulty does not reduce their ability to get back into the community.

I would like my colleague, Ms Mitchell, to answer the question on the UN Convention on the Rights of Persons with Disabilities, UNCRPD. While people with a mental health difficulty do not always identify for themselves as having a disability, that convention has many powerful messages and commitments that can positively impact on people with mental health difficulties.

Ms Kate Mitchell

It is clear that Ireland is currently out of compliance with the UNCRPD in that the Mental Health Act 2001 is not in line with the convention or the European Convention on Human Rights. The Government acknowledged this in its roadmap for ratification of the convention. This is evident in several parts of the Mental Health Act, for example, voluntary patients do not have basic rights to information on their estimated length of stay in hospital. People who are inpatients detained under the Mental Health Act 2001 do not have a legal right to an advance directive by which they can, when they are well, set out their wishes and preferences for their treatment. The advance directive then comes into effect when they become unwell. People who are detained under the Mental Health Act 2001 are the only group of individuals who are excluded from that right to a legally binding advanced directive. We are also out of compliance in not having individual care planning on an statutory footing and the lack of statutory rights around advocacy services and supports. Many provisions in the Mental Health Act 2001 require reform and must be updated urgently to ensure we are in compliance with international human rights standards, including the UNCRPD.

On A Vision for Change, it is clear that many aspects of the policy have not been implemented or implemented to full effect. This was evident in Mental Health Reform's most recent national consultation of people who use mental health services. For example, for 13 years, the national mental health policy has stated that all individuals accessing mental health services would have an individual care recovery plan. More than two thirds of respondents to the survey reported that they were not aware of having a written care recovery plan. The national mental health policy explicitly states that people should have access to key working but many of the people using the services report that they do not have access to that kind of support. A similar issue arises with regard to service users being listened to or involved in decisions on medication. There is a significant gap between what is in the policy and what is happening in practice. The revised mental health policy offers a very positive opportunity to address some of those issues. We need to ensure implementation of the revised policy and one way to achieve that is to cost a timelined action plan to ensure there are robust monitoring review mechanisms in order that we do much better this time.

As Deputy O'Connell was not here earlier, I remind her that we will have a pre-legislative scrutiny meeting with representatives of the Department at 12.30 p.m.

I thought that was the first matter for discussion. My target is to conclude by 12.30 p.m.

I hope I will not go over ground that has been covered. Reading the opening statement last night, governance and accountability in the health service stood out. I sit on the Joint Committee on Health and the Committee of Public Accounts which have discussed CervicalCheck and the national children's hospital project. Key to fixing all this a change in governance structure, which is a magic wand that is waved at us when something goes wrong. Overspends in hospitals are one issue but if the witnesses have a serious concern about governance and accountability in mental health services, the net effect of poor governance are the catastrophic instances of people dying prematurely. Will the witnesses outline their experience of how bad governance or weakness in governance can have catastrophic impacts on patient outcomes?

On the devolution of powers to regional bodies, Deputy Durkan, the Chairman, Deputy Harty, and I sat on the Sláintecare committee at which we discussed community health organisations and having proper boundaries among the hospital groups.

Are the witnesses saying to us that we need a national director of mental health steering this from the top and then filtering down that direction to the organisations? Coming out of this committee, we want to make it clear what the witnesses want because if bad outcomes have catastrophic impacts on families and on people's lives then we have to act because it is not an accident. This is an emergency as far as I am concerned.

For the doctors and the medics present, when there are gaps in funding or staffing, how does it affect their approach to treatment and their approach as professionals? I cannot outline every permutation of a situation but are consultant psychiatrists and teams ending up in situations where, for example, they see person A at 14 years of age and they want to carry out a considered pathway of care for this particular individual but because the resources are not there, they have to go to the tier 2 or the tier 3 of the treatment where they decide that they do not have cognitive behavioural therapy, social services, clinical nurses or psychiatrists so they will just medicate in a holding situation? I am a pharmacist by profession although I do not practise anymore. Is it a case that people, young or old, are getting suboptimum treatment to keep them in a holding position? To what extent is that happening?

The increased demand was mentioned and I find that concerning. In some ways it is good because people are recognising that there is an issue and perhaps openness towards mental health is the reason for that. Maybe it is just that there are more conditions or there are more presentations but it is very concerning if there is an increased demand. Although I can see that the budget has increased, it has not increased at the same rate.

Dr. McDaid or Dr. Finnerty spoke about the threshold and how that makes treating medical professionals feel they literally have to nearly triage the level of emergency. I do not want to get into the witnesses' personal lives, but in terms of going home and sleeping at night when they are looking at that threshold and that funding, are they lying there in bed wondering if that person should have got over the threshold and if they have made the wrong decision? Are they being forced to make suboptimum decisions because they just have to prioritise the services to those who are most at risk?

I refer to the institutionalisation in residential care reference mentioned by Dr. Finnerty in response to Deputy Durkan's question about homelessness. Trinity College Dublin has a longitudinal study on growing up in Ireland and I read some findings that were brought out at the start of the year. There were negative effects from the recession on children and families and their mental health. I cannot remember the detail but I am sure that is the case because it is a well constructed study. I mention the people living in direct provision; 13 years ago I was working in Athlone with the Lissywollen site as a pharmacist and I cannot believe those people are still there as I was telling them it would be over soon. Can anyone quantify the long-term effects on those people's mental health? In this scenario 13 years have been taken out of people's lives - they have been deskilled, the ability to have a home has been taken from them and there are other issues affecting women with children who are particularly vulnerable. Is this the inquiry of the future? That is what I am getting at here.

I want to finish off my questions and then I will take the answers. The next bit I want to speak about is the separation of addiction and mental health and international best practice. I have heard anecdotally in the real world that people cannot see a psychiatrist until they stop taking drugs. Is it normal in other jurisdictions to stream these two illnesses or conditions? It does not seem in any way logical. If a person is taking drugs because he or she is self-medicating for an underlying mental health issue and then he or she comes off the legal or illegal drugs, he or she is in limbo and his or her mental health needs are still not met. Perhaps the witnesses could expand on that and maybe outline what the best way is of sorting this out.

Another issue that came to me as I have been sitting here this morning is that I have a bit of legislation going through the Dáil, and we will be looking at it here in the committee, about the regulation of the advertising of fake cures and treatments for people with cancer. On the influence of social media on vulnerable people who have mental health issues, some people are so bad that they will target people who have stage 4 cancer and tell them that by standing on their head and rubbing cat's urine into their hair, for example, it will cure it. Is this happening across mental health and psychiatric units? Is there any market out there that the witnesses know of or that they have come across? That is just an aside I thought of this morning out of personal interest. Is there a notable social media influence, a negative impact and a targeting of people with mental health illnesses with rogue treatments or suggestions that big pharma is out to get them? Is that prevalent these days and is it an issue in providing care? Do people drop out of the services because somebody on the Internet is going to fix them and not the professionals?

Has Dr. Finnerty recovered?

Dr. Susan Finnerty

I have recovered, thank you. I might answer the question about doctors and how they feel about gaps in funding and treatment. I am a psychiatrist but like the Deputy I do not practise clinically and have not done so for some time. On gaps in funding and treatment, consultants have told me about the worries they have about how to provide a service for people when it is basically not there. An example of that might be to take somebody who has a severe and enduring mental illness, who is in a continuing care unit and who is capable of moving to more independent accommodation. There may be a small rehabilitation team who want that person to move on and who have provided the best they can but there is no housing for them to move into, no employment or vocational training for them to move on to and not enough support in the community for them to live a more independent lifestyle. That person stays where he or she is within the continuing care unit despite the fact that the doctors and the team feel that this person could move on. That person's life is affected by the fact that there are gaps in services and funding.

At the other end of the spectrum the same thing happens in CAMHS services as well. A person who may be assessed by a consultant or by one of the team may be unwell but there might not be any accessible beds in the system at that time for that young person to be admitted. That is where the Deputy's point about sleepless nights and worries comes into it because that young person may be unwell and, as was mentioned, the parents have to look after that child because there is no accessible place for that person to go. Yes, doctors worry, other team members worry and families worry about that.

Dr. Shari McDaid

I will take the questions the Deputy has raised around governance and accountability and link that to the question she asked on the experience of gaps in services.

We have been clear that we believe the absence of a mental health information system and the dissolution of the post of national director in the office of mental health within the HSE are negative for adequate accountability. A good example of this is the statement the HSE made in the service plan this year. The plan stated clearly that the HSE will have to essentially make choices about providing services to some people and not providing services to others because mental health services did not get the full funding that they needed. The HSE is essentially saying that it has to ration services. That is how the statement translates. It means the HSE will have to make choices that some people with get mental health treatment while others will not because the mental health services will not have adequate funding for the year based on what those responsible know the demand will be. The real tragedy, as has been pointed out, is that when people do not get mental health treatment their mental health deteriorates and they get worse, sometimes with the worst of outcomes.

Moreover, we do not know, and we have no way of knowing as far as I can tell, how much this is going on or who is being helped and who is not or what those decisions are. A good example is in emergency departments. We have a self-harm liaison service and admissions through accident and emergency departments. We know people who are admitted through accident and emergency departments get help but we do not know how many people are turned away from accident and emergency departments. That information is not kept, so we have no idea how many people have showed up at accident and emergency in distress but who have not gotten any service.

That runs throughout the mental health services. We do not know how many people are helped. We do not know how many people go into mental health services who feel they need a holistic range of supports but maybe only get one type of support but not the others they need. We have some indications from our survey of people who have used mental health services. They say they have got talking therapies. The findings were encouraging in that more people said they were getting talk therapy than we had expected. However, it is still the case that many people say they only saw one mental health professional. Many say that within the mental health services their experience is of medication being the predominant mode of treatment.

We really do not have robust consistent regular transparent information about what is going on in our mental health services and of course that is concerning. We have hundreds of people living in high-support accommodation and medium and low-support HSE accommodation but we do not know the quality of the service they are getting apart from the inspection reports that have been done on an informal basis, so to speak. We do not have those services regulated.

I will say what I have said to the committee in the past. It is an urgent priority to get better quality more transparent information about what is happening in the delivery of our mental health services so that we can then attest to whether people are getting the services they need.

There was a question on the separation of addiction and mental health.

I asked about international best practice.

Dr. Shari McDaid

Ms Mitchell can answer that.

Ms Kate Mitchell

I thank Deputy O'Connell for raising that question. It is a fundamental issue. We hear consistently of adults and children not getting access to mental health services because they have a dual diagnosis of mental health difficulties and addiction. My understanding is that there are practices in operation in other jurisdictions that focus highly on integration between addiction and mental health services and co-location of addiction counsellors on mental health teams. I gather that is proving effective. Within the Irish context there has been a pilot involving integration between addiction, mental health supports and co-location of addiction counsellors on a mental health team. This is the "no wrong door" approach piloted in north Tipperary. It proved positive outcomes in terms of people being able to access the services they required as well as showing marked improvements in their mental health and well-being. We really need to look to these kinds of initiatives in Ireland in terms of what is working. We need to look at rolling them out at a national level. However, it requires a multi-pronged approach in addition to co-location of addiction counsellors on teams. That is happening in certain areas but it is certainly not happening everywhere. There is also a requirement to increase the capacity within community mental health teams to support people with addictions. That applies across the disciplines. We need to increase capacity and adequately resource addiction services so that they can provide low-level mental health support.

We also need formal processes and protocols to ensure collaboration and integration between addiction and mental health services. It requires significant investment attention and focus to ensure we see progress in this area.

Dr. Susan Finnerty

I wish to add to that. I suppose I am around a long time. When I started, addiction counsellors were on mental health teams. There were usually one or two addiction counsellors. That has continued in some areas to this day. We believe that addiction, whether it is the cause of the mental illness or because of the mental illness, needs to be addressed in a holistic way of looking at people to try to help them. There certainly has been a move to silo it. That ties in with what I was saying about physical health.

Why would anybody do that? Dr. Finnerty has been around a long time - those are not my words. Why are they doing this if it is internationally seen as not ideal and if we have a pilot that says we have a better way?

Dr. Susan Finnerty

I think it is probably because A Vision for Change saw the two areas as distinct. It took the view that treatment of addiction problems should be in the community and outside mental health teams. That approach has continued. I hope that innovative change, review and refreshed thinking will see that looked at again. I hope to see more holistic and person-centred treatment. Ideally, addiction counselling, physical health and other areas would be part of that care pathway.

Hundreds of people are in high-support HSE units. Is their progress not being quantified? Do those people not have care pathways? Someone mentioned that there was an absence of care pathways. Does that even apply to the people in high-support HSE care? Do they not have care pathways?

Dr. Susan Finnerty

The care pathway for people who are in residences like that is really through rehabilitation and recovery. Their acute need has gone and the idea is to move them on. They do not have care pathways because there are not enough rehabilitation teams, and the teams that are in place are poorly staffed. Only 48% of the teams recommended in A Vision for Change are in place.

Even if a care pathway was put together and it recommended rehabilitation in a given way, the services do not have the people to implement. Is that the case?

Dr. Susan Finnerty

We do not have the housing for it either.

A pathway will set out how to fix it for a person but then we cannot do it for them.

Dr. Susan Finnerty

We neither have the housing to do it nor the vocationally trained staff to do it.

Those people have to stay where they are.

Ms Rosemary Smyth

We were asked about the Government's accountability and devolution from the perspective of the Mental Health Commission. Since the commencement of the 2001 Act in 2006 we have seen several iterations of governance structure within the public sector. We do not see similar structures in the private sector, which we also regulate. We have gone through several people who are responsible. There have been occasions when we did not know who was responsible and accountable, although the Act provides for a registered provider or proprietor. In the case of the public sector, this is the director general of the HSE, who devolves down the function.

That can be devolved down to anybody the director general deems fit to be considered for the role, and it can be at different levels of authority. The person does not always necessarily have the remit over funding, for example. Therefore, he or she does not really have the authority to exercise any change within their remit. I was asked for an example of that. It can be clearly seen in the inspection reports and the levels of non-compliance within the different CHO areas. Even within the CHO areas, the disparity of compliance levels within the regions will be seen. It is one service that is provided by one provider and the question must be asked why in one area a service can be compliant and people can receive a good quality service while down the road people are not receiving the same type of service, despite the fact that it is the one governor and the one commissioner of that service. This is why we ask and advocate for a national office for mental health with oversight of and responsibility for the delivery of mental health services.

We would also advocate in the area of regulation. The Act and the regulations do not provide for us to have oversight of governance arrangements, which would be unlike our sister regulator, the Health Information and Quality Authority, HIQA, and also unlike other jurisdictions that have such statutory regulatory oversight for governance.

The Act refers to a responsible, accountable person, but there are no actual qualifications set out for that person, nor are parameters set out for who they are. Is Ms Smyth saying that they do not have to be from a medical background?

Ms Rosemary Smyth

That is correct.

This person can be anywhere on the governance structure within the HSE.

Ms Rosemary Smyth

The Act refers to a named person and the registered proprietor-----

Ms Rosemary Smyth

-----and there is the clinical governance where the clinical director has set responsibilities. Corporate and clinical governance do not always necessarily meet up. This is another issue that needs to be addressed.

The person actually making the decision could be below the pay grade-----

Ms Rosemary Smyth


It is very poorly thought out.

Ms Rosemary Smyth

The Health Act lays out very clear provisions for the registered provider of designated and residential services, whereas the Mental Health Act has nothing laid out around the fitness of persons in charge of or running an approved centre.

That is reassuring.

Before we conclude I have a few questions on compliance for Dr. Finnerty, and Ms Frowein might like to comment. Reference was made to regulatory compliance improving by some small percentage points year on year. What are the areas with non-compliance?

Ms Kate Frowein

On inspection, the inspectors are required to look at all regulations, codes of practice and statutory rules. We have a very comprehensive data set spanning across a number of years that allows us to take a risk-based or intelligence-led approach to identifying concerns. Across most of the areas there is improvement. As Dr. Finnerty has said, it is slow and modest improvement. There are some areas, however, where improvement is lacking. That would be in areas such as unsuitable or unsafe premises or cleanliness of the premises. There could be issues around privacy, medication - which is still low - and staffing and staff training in particular. We continue to have concerns around those areas. As my colleague Ms Smyth has pointed out, we do see high compliance in some parts of the country and in some sectors. There is no explanation as to why in some areas or in some CHOs compliance should be so much lower when it is the same provider.

Perhaps they are not Nightingale wards anymore, or perhaps they still are, but what are the regulations to govern accommodation that is shared by patients? We have very strict regulations around housing in the housing sector, but are there regulations for accommodation in hospitals?

Ms Kate Frowein

There are regulations but they are broadly stated, such as the furnishings and fittings have to be suitable to the number of residents or that the overall environment needs to meet the needs of residents. It is very broadly stated and there is a lot of room for interpretation within that. As Dr. Finnerty has pointed out, we do not believe it is suitable that people continue to be in dormitory-style accommodation, especially for long-term accommodation. There is, however, no regulatory prohibition on that.

On recruitment and retention, during the hearings of the Committee on Future of Mental Health Care, we learned that to recruit a nurse, the service has to go through 25 steps between deciding that a nurse is needed and actually having approval for the nurse. If there is any gap in those 25 steps the approval may be delayed and it could be up to 18 months before a service could recruit a nurse. Is this an issue given that recruitment is national rather than regional? Sláintecare includes a proposal for regionalisation of services, one aspect being that regions would have autonomy in the recruitment of staff. Is it an issue that recruitment and retention is too centralised?

Dr. Susan Finnerty

I am not aware of the exact number of steps involved or how long it takes to recruit, but on inspections it is certainly fed back to us - and we see it - that a post may have been approved for up to six months but there is no sign of the person coming. This does not just apply to nurses. It also applies across the board into the allied health professionals.

I am aware of community psychiatric teams that are very poorly populated, not just in CAMHS, and that do not have a psychiatrist, perhaps have not had a psychologist for several years and have half a social worker and half an occupational therapist. This leads to a reduction in services, prolonged waiting lists and poor outcomes for patients, unfortunately. Senator Colm Burke spoke about the lack of consultants making decisions. Unfortunately, we now have non-consultant hospital doctors who are filling the gaps, and not just acting up to consultant level. It may be that the non-consultant hospital doctor is the only person who can man an outpatient department. This is not satisfactory. How can we overcome that?

Dr. Susan Finnerty

That is very difficult to do. The non-consultant hospital doctors are doctors in training to become psychiatrists or to become GPs. The level of training differs. One could have a person who has just started his or her training or a person who is finishing the training making those decisions, taking outpatients and so on.

On the recruitment of consultants, it is very difficult to recruit consultants in an area where there are no consultants, if the committee gets what I mean. In an area where there is an active service, where teams are well staffed and there is good training and continuing professional development then one will tend to attract the consultant psychiatrist. We can see this around the country. In areas where teams are poorly staffed or where there is long-term difficulty in recruitment of consultants, one finds that retention is also a difficulty.

I am aware that when teams are poorly populated, those team members who are left standing burn out much quicker.

Dr. Susan Finnerty


As a result it is almost like a spiral. That team disintegrates quicker due to the lack of support. Staff who work in psychiatry, and in other areas of medicine, do not have adequate support from the HSE to allow them to work effectively and efficiently. They burn out much more quickly. Are there any moves within the HSE to put in additional supports to support staff?

A member of staff is a fantastic resource to have. To allow such people to burn out and leave seems to be very uncaring on the part of the employer.

Dr. Susan Finnerty

The HSE appears to be very willing to allow staff to go on for further training. We are back again to the spiral. The difficulty is to release the staff for training because they do not have enough staff. It is a spiral. As we do not have the critical mass of staff, it is very hard to retain those who are there without introducing motivating factors. Even when motivating factors such as training are introduced, staff find they cannot be released. It is a big problem.

I have come across many children who are in distress for many reasons. However, they do not necessarily need the services of CAMHS. They do not need a psychiatric service; they need a much more supportive service. However, CAMHS tends to be the catch-all for everyone in distress, which then blocks appointments and places for people who are in genuine need. Is there a way to direct people to a more appropriate service other than CAMHS? Talk therapy is generally what these adolescents need. Unfortunately, however, talk therapy is very difficult to get. That also goes into adult psychiatry. Owing to a lack of talk therapy, cognitive behaviour therapy, occupational therapy and all the other therapies to help people with mental illness, the prescription pad is the easy way out. I believe a considerable amount of unnecessary medication is prescribed because the other support services are not available. How can we address that?

Dr. Susan Finnerty

That is true. I am hopeful that the assistant psychologists in primary care will address some of that need, even though there are not many of them. I mentioned Jigsaw. Young people can go there to get that kind of support where a serious mental illness is not involved. I have been told by nearly all the teams in CAMHS that they are absorbing everybody with any mental health difficulties. They sit on waiting lists, meaning that people with serious mental illness cannot be assessed and treated. Triage is going on and some areas have managed to get their waiting lists right down, but there are very few community services for the less seriously ill and there they sit on the waiting lists.

Dr. McDaid mentioned the urgent need for the 2001 Act to be updated. What areas are most important and need to be dealt with most urgently?

Dr. Shari McDaid

First would be regulation of the community residences. It is deeply concerning that people are in HSE-supported accommodation that is unregulated. I do not think any other residential services within the health service continue to be unregulated. In light of what we have seen in other parts of the health service in that regard, I believe that would be an urgent priority. We should ensure people have the right to make decisions about their own mental health treatment. Removing the exclusion of people with mental health difficulties, who are involuntarily detained, from the provisions under the advance healthcare directive is a priority. People who lack the capacity to make decisions should have their rights protected and there should be oversight of their circumstances. People lacking capacity under the current law can still be considered a voluntary patient and therefore there is no tribunal and no requirement for independent oversight as to the reasons they are in hospital. That is a very significant concern.

In all circumstances there should be the right to advocacy support. We have the right to a lawyer in the context of a tribunal, but we do not have the right to the kind of representative or peer advocacy to ensure that everyone who is in hospital for mental health care has the support they need to make their voice heard and to be supported to address concerns they have about their treatment.

Those are some of the priorities. Voluntary patients can also be quite vulnerable when they are in hospital. I am concerned that there is no legislative requirement to provide voluntary patients with information. People who are voluntary patients may often not even be sure about their status and whether they are voluntary or involuntary. They will not necessarily know about the provision of an advocacy service or other rights they may have when they are in services. Ms Mitchell might point out anything I have missed.

Ms Kate Mitchell

Dr. McDaid has pointed out the main provisions. I would also stress the importance of placing individual care and recovery planning on a statutory basis. People should have a legal right to that kind of care and recovery planning. The legislation should contain specific children and youth principles, so that there is particular consideration for the voice of the child, with children and young people being involved in decisions about their care and treatment. We specifically need to address the issue of age of consent when young people go into hospital for mental health care and treatment. Currently 16 and 17 year olds are not presumed to have capacity to give consent to admission or treatment. It is really the only area of the health sector where that exists. In every other area of the health sector, 16 and 17 year olds have a legal right to consent to their healthcare. That area also needs to be updated urgently.

As our health system improves and as the population ages, dementia is a growing problem. Given the need to deal with patients with dementia who can no longer live at home, are there plans to develop specific dementia services within our health services? People with chronic psychiatric illness are often housed or accommodated along with people with dementing illness. There can often be difficulty in managing those two groups. Are there any moves to provide specific dementia services within our psychiatric services?

Dr. Susan Finnerty

There are some already. Some of the approved centres are specifically for people with dementia and provide specialist services under the auspices of the old-age psychiatry teams. I cannot think offhand how many there are at the moment. A large part of the old-age team is dedicated to dementia care.

Is that being specifically funded?

Dr. Susan Finnerty

No. It comes under the mental healthcare budget.

Dr. Shari McDaid

I do not have the information on the dementia service. More widely, there is a need to ensure adequate mental health services are integrated in the implementation of Sláintecare. Sláintecare is relatively light on mental health. There was a rationale for that insofar as there was an anticipated review of A Vision for Change. Such a revised framework needs to be fully part of the Sláintecare implementation. It needs to be perceived as part of Sláintecare implementation. The Sláintecare reforms will not work if mental health is not integrated into them.

I give the example of the new GP contract.

The new GP contract, about which I have only read in news reports, refers a lot to support for chronic diseases. We know, for instance, in the case of diabetes care, that it costs 50% to 75% more to care for someone with diabetes when the mental health aspects of the disease are not being addressed. I encourage the health community to look out for mental health as an issue in the implementation of all the health service reforms. Unless mental health is integrated in all of those locations, the system will be far more expensive than it needs to be.

Ms Rosemary Smyth

I wish to follow on from what Ms Mitchell said about the reform of the 2001 Act. We concur with everything she said and agree that all of those areas need to be addressed. In addition, as I outlined to Deputy O'Connell, the registration section of the Act needs to be addressed. Part 5 of the Act is taken from nursing home legislation from the 1990s and needs to be amended in order that it is fit for purpose in the context of a modern mental health service and the registration and regulation of same in the modern era.

There is much public debate at the moment on the decriminalisation of cannabis. We are all aware that cannabis can cause serious mental health issues, precipitate psychosis and demotivate young people because of its side effects and addictive qualities. Should the decriminalisation of cannabis be promoted or resisted?

Dr. Susan Finnerty

I take the Chairman's point that cannabis can be associated with serious mental illness but people with serious mental illness may go on to self-medicate using cannabis or similar drugs. In making a decision to decriminalise cannabis, one would have to look at the evidence very carefully and weigh up the risks on a population base. Certainly on an individual basis, in my past life, I saw people who had major difficulties because of cannabis use. It needs to be thought about very carefully.

Can I ask a question on that?

Yes, of course.

Is work being done by the College of Psychiatrists of Ireland to study other populations and approaches in places like Portugal, for example? Is anyone looking at the Portuguese model and the impacts on the population? Do the witnesses have any information on that? Is it their professional opinion that if there were magical powers within a particular compound that has been around for generations, they would have been noticed before now? I am concerned by many of the claims being made for cannabis. I am very much in favour of a compassionate approach to drug use in respect of the links between addiction and mental health but some of the claims being made are such that patients would not need any other tablets if they had access to cannabis. That is the narrative at the moment but many of us are concerned about the erosion of the good work that professionals such as the witnesses have done over the years. As with our discussion of the Kardashian effect last week, we are concerned that some celebrity's opinion is considered equal to a body of evidence. I find that concerning not just in this case but in every case of medical treatment.

Dr. Susan Finnerty

I do not think cannabis is a treatment for mental illness. I have no expertise at all in any of the other illnesses for which cannabis has been suggested or linked with so I could not answer the Deputy's question. All that I know is that there is an association between cannabis and serious mental illness which is why we need to be very wary of decriminalising it.

I thank Dr. Finnerty.

That concludes this part of our proceedings. On behalf of the committee, I thank Ms Kate Frowein, Dr. Susan Finnerty and Ms Rosemary Smyth from the Mental Health Commission and Dr. Shari McDaid and Ms Kate Mitchell from Mental Health Reform for their attendance.

We will now go into private session to get an update from the Department of Health on the CervicalCheck tribunal.

The joint committee went into private session at 12.36 p.m. and adjourned at 1.14 p.m. until 9 a.m on Wednesday, 12 June 2019.