Workforce Planning in the Mental Healthcare Sector: Discussion

In our first session this morning we will hear from representatives of the Mental Health Commission on workforce planning in the mental healthcare sector. On behalf of the committee, I welcome from the Mental Health Commission, Mr. John Farrelly, chief executive, Dr. Susan Finnerty, Inspector of Mental Health Services, and Ms Rosemary Smyth, director of standards and quality assurance.

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

I invite Mr. Farrelly to make his opening statement.

Mr. John Farrelly

On behalf of the Mental Health Commission, I thank the Chairman and members for the opportunity to address the Joint Committee on Health. I am joined today by my colleagues, Dr. Susan Finnerty, Inspector of Mental Health Services, and Ms Rosemary Smyth, director of standards and quality assurance. We are pleased to be here today to discuss workforce planning.

The commission is the regulator for mental health services in Ireland. We are an independent statutory body established in April 2001 under the Mental Health Act. The commission’s mandate is to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to protect the interests of persons admitted and detained under the 2001 Act. In addition, under the provisions of the Assisted Decision-Making (Capacity) Act, the commission is responsible for establishing the new decision support service to support decisionmaking by and for adults with capacity difficulties.

At this juncture, it is important to point out that 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.

Although the Inspector of Mental Health Services can inspect all mental health services, there is effectively no regulatory oversight of the majority of services that are delivered outside of inpatient facilities. We welcome the work of the Minister of State with responsibility for mental health and older persons, Deputy Jim Daly, to facilitate change in this area by commencing a process to amend the current Mental Health Act.

The principal functions of the Inspector of Mental Health Services are to visit and inspect regulated services, that is, approved centres or acute units, annually to assess compliance with the regulations, rules and codes set out by the commission; to visit and inspect any premises where mental health services are provided; and to review the quality and safety of mental health services in the State. Following every inspection, a detailed report is produced and published by the commission. The inspector also reports annually on themed inspections carried out each year. For example, in the past two years, the inspector has reported on child and adolescent mental health services, CAMHS, 24hour supervised community residences, the physical health of people with severe mental illness, and mental health rehabilitation services. While we do not have regulatory oversight of these areas, the fact that the inspector visits and we publish the report creates a transparency about the reality of life for people who are receiving our services.

As a general comment, it is evident that the provision of mental health services is inconsistent across the country. The services lack proper planning, resourcing and integration to ensure each geographical area receives the same level of quality and care.

Regarding mental health policy, in a wellorganised health system, policy is set by the Government on foot of a political mandate. It is then implemented by the relevant stakeholders or service providers. Implementation is monitored against agreed metrics using a data evidence based approach and reviewed and evaluated on a regular basis. The Irish national mental health policy, A Vision for Change, has been in place since 2006. Its core concepts, which are admirable, are recovery, person centred services, partnership, user and family involvement and the delivery of multidisciplinary, communitybased services. However, the commission has referred on numerous occasions to the absence of any independent monitoring of A Vision for Change, a situation that has remained unchanged since 2013. The commission strongly advocates that any reviewed or refreshed document should include and consider modern evidenced based approaches to service transformation, leadership, workforce planning and development. It should learn the lessons of the years since 2006 in terms of the application of policy.

At the highest level of our mental health services workforce, it is both noteworthy and disappointing that the Health Service Executive removed the post of national director for mental health. The removal of this core leadership position sent out a clear and unambiguous, although perhaps unintended, message that mental health is not a priority. It is also evident to the commission that this has negatively impacted on the delivery of services nationally. That it was permitted to occur, in addition to the slow, ad hoc and unmonitored implementation of A Vision for Change, is disappointing.

In terms of resources, Irish mental health services have significant resourcing challenges, not least in staffing. To make progress in these areas, adequate funding is required. The commission welcomed the additional funding allocated by the Government to mental health services in 2019. However, we are conscious that the current level of expenditure on mental health is still less than the target set out in A Vision for Change, which was a document from 2005.

As will be discussed in more detail, the commission is cognisant of the continued difficulties in maintaining and increasing levels of adequately trained staff. The HSE’s workforce planning document, published in October 2018, outlined that the mental health workforce is at 76% of the levels recommended in A Vision for Change. Interestingly, the main data findings indicate that community staff, which is where our vision was to be, account for only 27% of the overall workforce in mental health. Based on our inspections, we are aware of the serious effect that a lack of adequately trained staff has on the quality and quantity of services. Given the labour intensive, human oriented nature of mental health care services, it is imperative that the mental health service budget be increased to at least the level outlined in A Vision for Change if full and effective staffing is to be provided in mental health care teams across the country.

Research clearly indicates the economic returns and benefits of investing in mental health supports and the effective training of staff, as well as the enormous cost of limiting investment, both on the health and the economy of our country. If we are to put in place modern community services and move out of the shadow of institutional care, workforce planning and change management are key.

Additional funding is fundamental to changing workforce practices and development. However, there is also a need to change how the State uses existing funding to redevelop services. Creative and innovative approaches, improved team working, building up community services and changing work practices are having an impact in certain CHO areas, while others appear to be stagnant and trapped in a closed loop of unhealthy logistical and clinical practices from the traditional institutional system. The mental health services in the country that are of the highest quality have adapted by changing their approaches and practices. Some services have recruited and trained mental health support workers to undertake nonnursing duties, which has allowed for the further development of specialist nursing roles. Nursing staff in some services facilitate additional specialist outpatient services, for example in early intervention and homeless services. These services contribute to reduced admissions to inpatient facilities, shorter stays and early discharges. As a result, the pressure on the staff in approved centres is also reduced. Lack of these community services has the knockon effect of longer lengths of stay for people in inpatient services, which has resulted in overcrowding in some facilities. Another key development is the use of the voluntary sector in providing services to people with psychiatric illnesses in nonresidential community care. That is often forgotten. If we are to move into communities in the future, it will not be with just the HSE. It must also be with the voluntary sector and the people who are at the coalface.

In countries with highly developed mental health services, clinical workforce planning is rooted in and supported by prudent and decisive strategies and programmes. While these may exist in Ireland, it is not evident to the commission that governance, leadership development and transformation strategies link to or drive workforce development our mental health services. It is disappointing to observe the continued lack of development of rehabilitation services in Ireland.

I want to talk briefly about performance management, development and support, PMDS. This is often forgotten about but it is critical to enable a service to develop and function. Following on from public service agreements, PMDS is now common practice across the civil and public services. It is a process for establishing a shared understanding about what is to be achieved and how it is to be achieved, and an approach towards managing people that increases the probability of success. If we are to transform our health services, it is an essential aspect of governance and management to facilitate individuals and teams to link performance to policy and operational plans. The commission is aware that in 2012, the HSE introduced a formal performance management system to fulfil the terms of the public service agreements. However, the commission has found very little evidence of this approach in practice. The commission has reservations about the success of any national policy, workforce initiatives or plans that are not underpinned by an appropriate performance management framework.

We inspect approved centres in the context of regulation 26, which relates to staffing. The most common reason for noncompliance within regulation 26 over the three year period was subsection 4, which relates to training. We also look at skill mix and the number of staff. That does not raise its head as much as staff training. The regulation states: "The registered proprietor shall ensure that staff have access to education and training to enable them to provide care and treatment in accordance with best contemporary practice." Essentially, many approved centres were noncompliant with this because not all health care professionals were up to date with mandatory training in, for example, basic life support, professional management of aggression and violence, fire safety and the Mental Health Act 2001.

The past number of years have been difficult in the context of providing and maintaining a high-quality and safe mental health service for our people. However, we have ample opportunity for the future lives of those people suffering with mental ill health to transform our mental health service, if we put in place, fund and implement the right policy. The end goal for each and every one of us must be to move out of the shadow of institutional care by creating modern, wellstaffed community services in the areas where people live and can be close to their families and homes. The commission recommends that any workforce planning should be aligned with national policy to ensure that the system as a whole develops, innovates, and transforms. The Department of Health and the HSE should reinstate the national director role for mental health to ensure dedicated, senior level executive oversight and accountability. The transformation of our mental health service must be evidencedbased, connected to and underpinned by a performance development and support system. I thank the committee for listening. We will be happy to take any questions.

I welcome our guests and thank them for their work to date. I want to address their role and remit in regulation. Mr. Farrelly stated that the commission's remit extends to only 1% of mental health services across the country. Who regulates the other 99%?

Ms Rosemary Smyth

The Mental Health Act only applies the regulations to inpatient services. Some 65 are currently on the register. The inspector is entitled to visit every other mental health service but the legislation does not provide for enforcement, so there are no powers, following our findings, to enforce, close down or attach a condition. We are using moral authority at present to bring about changes, mainly in community residences. Other services are not regulated as such. We visit them but no body currently regulates them.

Is it not extraordinary that 99% of our mental health services are not being regulated with proper policies being enforced against them? The Mental Health Commission produces detailed inspection reports of inpatient units. We often see very serious breaches of regulation and policy within our institutions. What risk do our guests see in the context of services that are not being regulated at all?

Mr. John Farrelly

To be fair to the mental health services, a light is shone on them more than on most other health services. Our acute hospitals, maternity hospitals, etc., are not regulated at all, notwithstanding everything that has happened. At least there is scrutiny and rigour regarding the acute services. We are beginning to find that the currency of beds in acute services is a thing of the past. We need to get into the currency of people, who live in communities, not institutions. I have regulated charities and was previously a regulator in HIQA. I think the mental health service is developing in such a way that it is transforming in the community but the regulation and law have not caught up. The idea that regulations will keep people safe is a faulty concept. What will keep people safe is the staff and others who look after them. From our perspective, in the review of the Act, we would like to be able to regulate the entire mental health service.

Does Mr. Farrelly agree that the regulations should be extended to cover all mental health services?

Mr. John Farrelly

Yes.

Mr. Farrelly referred to the role of director of mental health, which was stood down a short while ago. I hear consistently across different aspects of mental health services that this has had a detrimental impact on the delivery of services within the mental health sector. The commission has called for the role to be re-instated. Have the witnesses seen, in practical terms, a real impact from the loss of that director from the top table?

Mr. John Farrelly

As the chief executive of the commission, I have definitely seen an impact. Previously, when in HIQA and the Charities Regulator, having access to people at the highest level effected change because there was significant competition for resources. Ms Smyth can speak to the fact that without a leader at the appropriate level, mental health services tend to get pushed to one side.

Ms Rosemary Smyth

The funding is driven from the national level. When we identify areas of non-compliance and breaches of regulations, particularly in the context of premises where significant resources are required to rectify the breaches, it is really from a national level. When we are addressing it at a local level we cannot get the same response; we get a response to the effect that "We do not have the money, we do not have the budget." It has to go to national level. When the national director was in post as the regulator and person responsible for registration and enforcement, we could definitely see a difference and see impact driven down to the local levels. Once that post was removed, it was very hard to engage with the appropriate people to ensure action plans were being put in place to ensure compliance.

It was put to me by somebody in the mental health sector that the consequence is that policy and operations are almost separated out. When a director was there, he or she could knock heads together if things were not joining up across the country. Would that be fair to say?

Ms Rosemary Smyth

Yes.

Mr. John Farrelly

That is a fair comment. I know there is Sláintecare, transformation and so on. However, I just ask a simple question as to who is in charge and who is running the show and the service. When we ask that question of the HSE, it is very hard to get a clear answer. That is nothing to do with any individual. When we go to the trouble of creating a national policy which comes from the top down, I do not understand who decides we are not going to apply it. That is worrying. If people had gone to the effort of communicating with others to create a national policy and then there was just an ad hoc approach whereby someone decided we were not going to apply it, that would not be good enough from my perspective.

Very good. I just want to touch on the issue of the appointment of non-specialists as consultants. This was not mentioned in the opening statement so I hope our guests do not mind me raising it. I refer to the big issue whereby people who are not qualified in psychiatry are being appointed as consultants. What impact is that having? The President of the High Court has stated that this is scandalous. He has reported the situation to the Attorney General and a number of other bodies. What is Mr. Farrelly's view on that? What is its impact?

Mr. John Farrelly

In terms of impact, I will defer to Dr. Finnerty and Ms Smyth. We have mental health tribunals where we work to vindicate the rights of people who are detained. We would not allow any consultant on those tribunals unless they were on the specialist register. Just to be clear, we would not employ someone to vindicate people's rights unless he or she was on that specialist register. In terms of the health service and whom it employs, I will ask Dr. Finnerty to come in.

Dr. Susan Finnerty

It is of concern that doctors who have not completed their specialist training are being appointed as specialists in mental health. The training to become a psychiatrist is long and very detailed. To put somebody who has not had experience into psychiatric care management and have him or her leading a team is concerning. We would call for any consultant psychiatrist who is appointed to have the relevant training. One would not appoint a surgeon who did not have the relevant training.

That is it. To qualify as a specialist, doctors go through extensive training. Even in terms of leadership, it was described to me how a person who had to have a nurse help them to put an IV in one week was leading an entire team the next week. That just seems absolute madness.

Ms Rosemary Smyth

In respect of our tribunals, because we do not have the non-specialists, what we are seeing is an increase in the number of cases in which procedures are not being applied correctly for people who are detained involuntarily, the most vulnerable people using our mental health services. That results in orders being revoked unnecessarily and, as a result, people are having to go through the whole process again or are perhaps undergoing early discharges without receiving appropriate treatment. From that perspective, it is quite concerning that the most vulnerable people who are using the mental health services are not afforded an appropriately qualified person to manage their care.

As well as being a breach of human rights, that would strike me as something that would be extremely stressful for people who are already vulnerable and in a difficult situation.

Ms Rosemary Smyth

Absolutely.

I want to raise the Health Research Board, HRB, statistics on psychiatric units and hospitals. It may be a bit of a quirk but in the 2018 HRB report, in respect of admissions for children and adolescents, it is stated that while its statistics are in respect of every child under the age of 18, the Mental Health Commission is restricted by the 2001 Act and only includes children under 18 who are not married. It must be somewhat unhelpful to be putting statistics together when different arms of healthcare within the State are using different metrics, aside from the fact that it would seem quite anomalous and somewhat archaic and something that should be changed at this stage.

Mr. John Farrelly

I agree with that. It does not cover the fact that young men and women, children and adolescents, should not be accommodated in adult units, whatever definition we apply. Compared to our nearest neighbours such as the UK or Scotland, on our evidence base and statistics and how we judge things we are definitely a little bit behind the curve in Ireland. We are more than happy to work with any agency to ensure that statistics for the public are good and correct.

Ms Rosemary Smyth

That pertains only to those who are involuntarily detained, not to children more broadly. In 2018 there was only 18 involuntary admissions of children so it is a very small number that we are talking about.

I will allow Deputy Browne just one more question. He will get in a second time.

According to the HRB, County Donegal has an admission rate of 484 per 100,000 while County Monaghan has a rate of 187 per 100,000. Donegal has two and half times the admissions as Monaghan while the two counties are relatively close to each other in terms of population. Monaghan also has the highest suicide rate, according to the National Office of Suicide Prevention. I also hear that Monaghan has pretty decent community mental health care. Can we extract any correlation or causation? Why would one county have admission rates that are dramatically higher than those in another county, while that other county has very high suicide rates? Is there anything we can take from that or is it more dangerous than anything to be looking at the statistics like that?

Dr. Susan Finnerty

It is an interesting point. Donegal and Cavan-Monaghan currently are in the same CHO area so the governance would be the same. Not all people who die by suicide actually get to the psychiatric services. They usually attend primary care services. One aspect that could be looked at is how they access the psychiatric service, whether there is open access for people who are mentally ill and who are suicidal. It also points to an element for which I do not have any figures, namely, primary care facilities and resourcing in those areas. We would be looking not only for general practitioners but also for counsellors, psychologists and so on based in community care and primary care. That area might be explored. Unfortunately I do not have the answer.

Perhaps the point is that we need to do more research as to why we have those statistics; maybe there is a lack of explanation.

Dr. Susan Finnerty

We do need to look at primary care provision of mental health services for people who do not reach the threshold of serious mental illness but still have difficulties from time to time.

I thank our guests for their contributions. Is Mr. Farrelly confirming that no consultant who is not eligible to be registered on the specialist register will act in a tribunal? Is he confident he can exclude those people legally who are practising as consultants but not entitled to be entered on to the specialist register?

Mr. John Farrelly

We would not look at it as excluding. We believe that a person needs certain competencies and capabilities in order to protect and vindicate the rights of the 2,000 or so people who are involuntarily detained. To do that, he or she must have this specialist qualification.

That is excellent. It was mentioned that the spend is still below the 8.24% of the target in A Vision for Change. What level is it at? Would the 8.24% target be considered a gold standard or the average? What would be considered as an international best practice target?

Mr. John Farrelly

A Vision for Change is out of date and it would not be the gold standard. I cannot give the Deputy the exact figures for finances and mental health because it is hard to track it. Someone might get the money but might not be able to spend it. It is how it is spent and, as we go out into the community, realising that it is not always doctors, nurses and GPs but the next frontier for people in terms for not-for-profits.

However, it was stated that it is below 8.24%. Obviously, Mr. Farrelly knows what it is.

Ms Rosemary Smyth

It is 5%.

Accordingly, an international best practice target would be in excess of 8.24%. What would that figure be?

Dr. Susan Finnerty

In the region of 16%.

We are pretty far behind.

Ms Rosemary Smyth

It was at that figure back in the 1980s. The mental health budget was gradually cut year on year.

Successive Governments have chipped away at it ever since the 1980s. With regard to the suppression of the post for national lead, who is currently driving national policy in mental health?

Mr. John Farrelly

It is hard to ascertain. We know that there is a group of stakeholders refreshing A Vision for Change. Ultimately, one imagines that the Government, through the Oireachtas, enables the Department to drive through a policy. Policy should be owned at that level. Then the HSE and the different agencies should made accountable and funded according to that policy. It is confusing as to who owns the policy. Even A Vision for Change was not necessarily set out by the HSE. There is a weakness in that regard. It is difficult to know who owns it. There is a board of the HSE. As far as I am concerned, the accountable people for implementing it must be at that board level and making sure things are happening. When one looks into mental health services, it is hard to get clarity and accountability of who is in charge and who is governing them.

Yet Mr. Farrelly is confident enough that we need to work a bit harder on PMDS. Who would Mr. Farrelly see as the person who would drive that?

Mr. John Farrelly

It was supposed to be introduced in 2012, with the idea that it was going to be rolled out at a particular level. It is happening pretty much everywhere else to some degree. It is a tool to support people. One has a policy, then operational plans and the individual attached to it and supporting it. That should be driven out by the leadership. It should just be happening.

We have just established that there is no person in a position of leadership, however. Does Mr. Farrelly see this being driven at local level?

Mr. John Farrelly

Just to be clear, I would not want to just target the mental health services. I do not believe our health service in its entirety has grasped the concept of PMDS. I am not sure it is culture within the HSE or Tusla. It is not just mental health services.

From my background and previous work, I have a fairly detailed knowledge of PMDS, particularly development aspect of it. There are a number of factors involved. Clearly, it is unfair and unreasonable to expect that staff will participate in PMDS in a situation where many of the failings are the result of understaffing and under-resourcing. It is tough in that environment. It is also extremely hard to do the development section of PMDS when one is under-resourced. If one does not have enough staff to cover one’s roster, one most definitely cannot release staff to get the necessary training.

People are signed up to PMDS via the national wage agreements. There is an element in that which has to be properly resourced, however. There is much work that has to be done in advance of the health service being ready to properly engage. PMDS can be incredibly positive but it is an exercise in finding out the failings of an organisation. An individual cannot be responsible for that. A site or a community health nurse is not responsible for the fact they are operating off a team which is less than 50% of what it should be. If one tries to do PMDS with that individual, it is tough. There items in his or her job description that they just cannot get to do because physically one does not have the time. When one gets to the development aspect of PMDS, it is tough to do that.

Mr. John Farrelly

It is the same for many people in the public service. Everybody else has managed to give it a go since 2012 across the different areas. It is interesting that it seems to be absent. From our perspective, the idea of connecting everybody together is important as it is not just individuals but teams. Particularly when one is under-resourced and struggling, that is the time one meets a couple of times a year with one’s manager to connect on what is achievable and not.

One of the first pillars of Sláintecare implementation this year was to look at that area which was due to happen either in this or the previous quarter. I appreciate that it is difficult for people. However, unless one gets that time to think about things and connect them, one will always be scrambling. It is tricky but it is not meant to be draconian tool.

There are particular staffing issues in the health service. We would be ignoring the elephant in the room if we did not mention them. I do not think one can make a direct comparison. The Public Service Pay Commission specifically focused on issues relating to the health service in view of the challenges and difficulties around recruitment and retention, a nice way of saying that the health service is understaffed. It is not fair to the men and women working in the health service to draw a direct line comparison with people working in other sectors of the public service. That comparison does not exist on a like-for-like basis. Before one would talk about PMDS, one would have to address the issue of the chronic understaffing which is evident in the mental health services and right across the health service. It would make any issue relating to PMDS exceptionally challenging. This is not because individuals do not want to engage with it. From my experience, which is fairly extensive, healthcare workers actively want to engage in PMDS but there are issues with time and so forth. It was stated community makes up less than 27% of the staff in the mental health service. One hears about the postcode lottery. Does that leave areas where cover is just not there?

Dr. Susan Finnerty

Yes, it does. The variation in funding and staffing across the country is quite stark. Just taking the CAMHS, child and adolescent mental health services, in particular, services in community healthcare organisation, CHO 2, Galway, Mayo and Roscommon, were funded €90 per capita. In CHO 5, it was only at 45%. There does not seem to be any particular reason for this. Sometimes, it appears that he who shouts the loudest or puts forward a better business case tends to get the staff. It is a postcode lottery as to what access to services one gets.

I welcome our guests and thank them for their presentations.

I will follow up on my colleague's last point. I was a member of the health board and learned a few lessons there, some which have stood to me in good stead. There is a presumption that the rule prevails across the country. There should be no changes from one area to another. The same conditions arise, perhaps to a greater extent in some areas depending on its social and economic make-up. Will Dr. Finnerty comment on whether the seriousness of the discrepancies between one area and another is creating a problem for the delivery of mental health services?

Dr. Susan Finnerty

I looked at rehabilitation services last year. The provision of rehabilitation services are very important for about 14% of people who suffer from serious mental illness so that they may live in the community and reach their potential. Some CHO areas do not have a rehabilitation service. What services there are are scant to say the least. That means people do not have access to that essential service and they are languishing in highly supervised residences and acute units. That example is quite stark. I looked at the child and adolescent mental health services, CAMHS, two years ago. Its staffing is only 60% of what it should be. In some areas there are good, accessible CAMHS and in other places there are not.

Are any efforts being made to spread the availability of rehabilitation services evenly throughout the country, proportionate to demographic demand?

Dr. Susan Finnerty

At a local level, there has been needs-based assessments but I am not aware of any overall nationwide assessment of what is needed to provide a rehabilitation service. It tends to be a knee-jerk reaction. There will be people in acute services who need rehabilitation, which is provided in the private sector a long way from their homes. That is not ideal. There have been some moves by the HSE to provide other agency services and staff such as housing officers or individual placement and support, IPS, which is the placement service for people looking for jobs, and that has started to be rolled out. There is some recognition that maybe the nursing or medical model does not always work and we have to look outside the box.

If we were to bring about some change in that area, what should we do at this level? What can Dr. Finnerty do at her level to co-ordinate the efforts with a view to addressing those particular deficiencies?

Dr. Susan Finnerty

I can report on that area, and have done so, and then the commission can look at what is being done about it and what improvements have been made and so on.

Mr. John Farrelly

That is the key challenge. We have closed down many of the institutions but we have not necessarily replaced them and thought about the community services. If a new policy develops and goes through the political system, people should be held accountable for its implementation and they cannot decide what not to implement. There is a plan there. A model such as Sláintecare, but with some sort of a module around mental health because it tends to get forgotten about, seems to work where people are held accountable.

Another thing that would be useful in the political system would be an agreed approach around reviewing the Mental Health Act and getting that through. It was a good policy. The problem was its ad hoc implementation.

The mental health services were always regarded as the Cinderella of the health service. Has the system improved in its favour or have things gone the other way in the past ten years? I ask mindful that we have incurred the most serious economic crash in our history and that two things came together as demand increased and resources decreased. That was very difficult to manage and still is. All the indications suggest that the estimates to date are way short of what will be required. We must bear that in mind when we deal with this. Have things improved or deteriorated in keeping pace with the rest of the health services?

Mr. John Farrelly

Ms Smyth will come in with more detail, but the statistics show that things have improved for some citizens, depending on where they live, and have similarly disimproved for others.

We need better dispersal of what we have.

Ms Rosemary Smyth

From an inpatient perspective, where we regulate, we can use our enforcement powers, which we have done in the ten years since the Act commenced. We no longer have large institutional buildings. They have all closed down and we have modern mental health services now. That is an improvement for those who have to use the acute inpatient services. There is also reform of the legislation so that anyone who has been involuntarily detained has an automatic right to review, which is very positive. I would reiterate the point on the lack of parity in service provision in the community, CAMHS and rehabilitation. Outside inpatient services, service provision is patchy, in that it is good in some areas but needs to be improved elsewhere.

How does the service become aware when children need attention? Do the referrals come from school medical examinations? Are they from reports from An Garda Síochána or some other source? Some time ago, I asked a parliamentary question on the number of children aged between eight and 13 years who had attended at emergency departments having self-harmed or attempted to do so, and did so repeatedly. How do these cases come to the attention of the service and can the service provide the necessary attention?

Dr. Susan Finnerty

It is important to remember that CAMHS treats people who are seriously mentally ill. There is a whole population of young people who require some form of counselling or support but not necessarily in CAMHS. The Minister of State, Deputy Jim Daly, has put counselling psychologists and assistant psychologists into primary care, and that would be the first port of call.

The investment in primary care is key for young people, whether it is Jigsaw or psychologists in primary care, counsellors or social workers at that level. That will allow the CAMHS teams to deal with children such as those described by the Deputy, with repeated self-harm, depression, early psychosis and so on. That is where the investment is needed.

On community services and adherence to medication programmes, one of the problems that I found over the years was an unwillingness in some cases to comply with medication requirements, which resulted in reversion and so on. How satisfied are the representatives here that adherence to medication programmes is respected and fully followed through in the community?

Dr. Susan Finnerty

I would not have that information.

Mr. John Farrelly

We do not actually regulate the community. Regarding one of the things that emerged from the research about medication, one can see the number of people who go on antibiotics and fail to complete the programme. It is not about adherence, rather it is about an individual citizen who has paid or whose family has paid taxes for years. If this person becomes unwell, he or she seeks treatment. If something is properly explained to a person and that person is given a choice, he or she usually goes along with a programme. Adherence is not so good if a person only gets two or three minutes and the medication and its side effects, such as putting on weight, are not explained. Most people would admit that medication that is now available has come a long way and has advanced in recent years, but it is moving to an idea where someone is not actually having something done to him or her. Rather, he or she is being provided with a service that he or she must understand and be part of. That movement is beginning to happen.

One thing I have found with regard to medication for children and young people is that, in some cases, a parent may feel that the medication has an adverse effect on the child or teenager and decides not to pursue it. To my mind, this is a very false economy. I would like to see a more uniform process applying in all cases so that there would not be peaks and valleys in either the quality of the services available throughout the country and the quality of attention given to individual cases, particularly in the case of young people who, very often, decide to withhold information as to whether they are taking their medication. That has been my experience. I would not have dealt with as many cases as the witnesses would deal with but I deal with a fair number of them. I would like to be reassured about that in terms of continuation of their medication programme.

In respect of the commission's remit regarding the inspection of inpatient services, it has come to my attention on a number of occasions that there is substantial overcrowding in acute services, which has resulted in a loss of dignity and privacy and a very unsatisfactory perception of the treatment people have received in acute services. Will the witnesses comment on that because some services have been amalgamated? For example, mental health services in south Tipperary have been amalgamated with mental health services in Ennis. I understand that this has led to substantial pressure on beds and admitting patients and led to subsequent overcrowding.

My second point concerns presentations to general practice and, going back to Deputy Durkan, who is the source of referrals. In general practice, one is left trying to filter things that need to go to CAMHS, namely, serious mental health issues and those that can be dealt with counselling or other services. Unfortunately, the number of team members missing from CAMHS teams is substantial. For example, there may not be a psychologist or a team may only have half a social worker, as it were, or lose a community psychiatric nurse, who may be on holidays or maternity leave and may not be replaced. In many cases, CAMHS teams other than the psychiatrist - the backup personnel - are not there because the teams are understaffed. It then falls to the GP to decide if an issue is a serious one, in which case he or she will send it to the psychiatrist in CAMHS, or whether it can be medicated by himself or herself. There is pressure on GPs to medicate themselves because the backup talk therapy and support services are not there. In some cases, there may be unnecessary medication because the alternative talk therapies are not there. Is there a sense that there is overmedication because of a lack of the other supports that should be there within community psychiatric services?

Regarding recruitment and retention of staff, one of the findings of the report of the Oireachtas Committee on Future of Mental Health Care was that there was a disconnect between the HSE centrally and front-line needs at ground level. A total of 25 steps needed to be taken before a staff member could be recruited. It is to be hoped, with the new Sláintecare proposals, there will be a regionalisation of services so the number of those steps will be reduced substantially so that a staff member can be recruited in a relatively short time. Will the witnesses address this point? What engagement does the commission have with Tusla regarding children's problems and child services?

Dr. Susan Finnerty

Regarding the overcrowding in some units, it is interesting to note with regard to where someone lives in the country whether his or her local psychiatric unit tends to operate at over or under capacity. There are examples of both. The Chairman mentioned Tipperary and the south east. Two psychiatric units in that area have closed - St Senan’s psychiatric hospital in Enniscorthy, which was an old asylum but had an admissions unit, and St. Michael's unit in Clonmel, which was an acute psychiatric unit. What has fallen behind is the development of community services in that area. While the number of beds has been reduced, community services such as home-based treatment teams have not been put in place. The area has crisis houses but they tend to get blocked up. Admissions tend to be much lower in Cavan-Monaghan, which has well-developed community services, and services do not operate at over capacity. The key is the development of community services, not necessarily more beds. It involves stopping people getting into acute units and not being able to be discharged. Rehabilitation, which I mentioned earlier, is an example of that. Without developing rehabilitation services, people will become long-stay patients in acute units and will block beds for people who need to come in.

Mr. John Farrelly

The Chairman mentioned teams not being staffed. He painted a picture with which we would be familiar. GPs tell the commission about being left with a dilemma about how to care for a patient, including the risk. That comes back to community services and planning. We seem to be stuck in accident and emergency in this country but other 24-hour wrap-around services are available to a GP. This was all being done 20 years ago in other countries but we seem to be consumed with inpatient beds as opposed to developing the community services where people want to be treated. We need to be clear. Nobody wants to go to a psychiatric inpatient unit. If care was available in his or her area, particularly in rural areas, he or she would access it. The State must be commended on Jigsaw. This is not the HSE but is funded through the HSE and the State. Many of these services, such as Pieta House, are born out of gaps because the services are not there, so we need to identify the gaps and see how we create the momentum around that in communities.

We do not have full visibility regarding overmedication. From working with various doctors and nurses, I think we are fairly clear in Ireland that medication is used appropriately. We have a fairly professional and good workforce.

I can understand it in an emergency, but generally that does not seem to be a major issue.

Some of the medications have side effects, particularly weight gain. We met Tusla recently to discuss the potential of a memorandum of understanding. We just put one in place with the HSE, which is a risk-based protocol.

What about recruitment and retention?

Ms Rosemary Smyth

We have been pointing out to the committee that the length of time to fill posts is an issue. It can take six months to fill a post. From working with the services experiencing overcrowding, one in the south east that has received a derogation from that because of the pressure from our organisation over overcrowding. This particular service in the south east has 50 vacancies. It has been permitted to recruit directly to fill those posts. It filled some consultant posts in recent weeks, which has helped. It will also get some additional nursing posts. For example, to help with the overcrowding, it had set up a service involving four nurses on the team to do preassessments. They only work from Monday to Friday. They were able to manage the overcrowding from Monday to Friday but then it peaked again at the weekend because they did not have the resources for that time.

Is the recruitment problem down to lack of finance or lack of applicants?

Ms Rosemary Smyth

Both. There is a lengthy process to get sanction to fill a post. Obviously, the funding comes with that and there has to be appropriate funding for it. There are issues in attracting people to the services, particularly in attracting CAMHS consultants to more rural parts of the country. Dr. Finnerty can elaborate on this.

Dr. Susan Finnerty

Many factors are involved in recruitment to approved posts. The people appointed to posts in areas such as Donegal and Kerry are working in isolation. For example, an occupational therapist would need to travel quite some distance to meet colleagues or to attend conferences and so on. As Deputy O'Reilly said, people who work in those jobs want to develop themselves and so on, but they can be very isolated in some areas. It becomes a vicious circle: the less staff the service has, the less likely it is to attract. It can also be hard to retain the people who are there. It is not quite as simple as having the posts and advertising; there are other factors.

If a team is understaffed, those who are still standing are more likely to burn out pretty quickly.

Dr. Susan Finnerty

Absolutely. They then get frustrated and want to move somewhere where there are-----

More supports.

Mr. John Farrelly

This is just anecdotal. We have many consultant psychiatrists helping us in the tribunals. The leader is the consultant psychiatrist. Where there is a vacant post, teams tend not to build up as quickly. Those teams tend to build up where is a committed consultant. If they move on to something else, during the period they are not there, there is a tendency for the team to not do as well.

There is an added value to having a long-term person in post to generate advancement in the team and in the area.

Mr. John Farrelly

A geographical area with a senior clinical leader committed to the area will tend to do better.

I am glad I have the opportunity to discus this important issue. I welcome the witnesses and thank them for their help. Many families and communities in Kerry have been ravaged by mental health issues, resulting in suicide and the loss of family members, which has rocked families and communities to the core. We are sick and tired of the Government talking up the financial improvement in the country. If it has improved the country's finances, this has not been shown in the mental health services in Kerry. We are at a very low ebb at present and there does not seem to be any accountability for what has happened.

A couple of years ago - I had not been long a Deputy - a 20 year old presented in a local hospital. I will not name the hospital because I do not want to personalise healthcare workers who are doing their best in the conditions in which they have to work. This young man was in a very bad state on a Friday. He was being released and the family was so concerned, they came on the phone bawling crying to me. They said they could not imagine how they were to take care of him for the weekend or who would be responsible for him because six years earlier, his father had committed suicide in the back yard. They were very upset. Luckily enough, I got to talk to a particular nurse in that hospital who was not dealing with mental health. I ensured he was kept in there for the weekend and the following weekend. That man is perfect to the world today.

Another whose grandmother contacted me was mot so lucky. It was the same kind of story. He went in there for the weekend feeling very down. He was let out on that Friday and he is no longer with us. That family are very upset because they feel he could have been saved.

Life is so important. I had an uncle who said, "There's only the breadth of your nail between being dead and being alive." In cases like this we are losing people. We have lost so many through suicide. There was a lot of talk about a Bill that went through recently to save lives on the road, but we must try to save lives in whatever area it is, and we are not doing it. A few years ago, three boys committed suicide while in care, which should not happen. It is shameful that happened and it was not so long ago.

I read a report Mental Health Commission report by Dr. Finnerty. In respect of services in Kerry and Cork, it stated that while there are supposed to be seven dedicated rehabilitation and recovery teams in the team, there are just two poorly staffed teams in place to cover a population of 680,000 people in both counties. The report stated that to deal with demand the HSE was using an out-of-area service, a model that has been strongly criticised internationally.

Dr. Finnerty also said that in the course of her research she spoke to several people with enduring mental health illness who were frustrated and angry and were stuck in a system that was not meeting their needs. Because of the unmet need for rehabilitation, many people with enduring mental illness have repeated admissions to inpatient psychiatric units and are then discharged, only to be re-admitted when things breakdown again - the so-called revolving door of admissions. The short-sightedness of not providing adequate mental health rehabilitation services, from both a human rights and a financial viewpoint, is quite astounding.

Dr. Finnerty said that in some cases patients were moved away from their homes and local treatment teams for up to two years. The commission has asked the HSE for an action plan to address the concerns raised in the report. Only two poorly-staffed rehabilitation teams are in place to serve a population of 689,750, though the A Vision for Change mental health strategy states that a minimum of seven is needed. According to A Vision for Change, 70 nurses are required but only six are available. Some 340 people in Kerry and Cork are living with mental illness in institutional care, which is considered a high proportion of the population. Major capital spend is needed for one 24-hour-----

Could the Deputy please turn off his phone?

I apologise. Major capital spending is needed for one 24-hour supervised residence in Kerry. I appeal to this committee, the Minister for Health and the Department to provide this service in Kerry because it is not available when it should be. There are no services at all on the weekends. Staff also have relatively little training in areas that are recommended for people with severe enduring mental illnesses, such as cognitive behavioural therapy for psychosis, cognitive remediation, family therapy and social skills training. I thank Dr. Finnerty for raising and highlighting this issue. I am glad of the opportunity to support her on it. We must work together and do more because the Minister for Health clearly does not recognise the need for mental health services, which are required and deserved by the people of Kerry.

Could Dr. Finnerty comment on that?

Dr. Susan Finnerty

I have looked into the rehabilitation services nationwide and what the Deputy says is accurate. Unfortunately, poor services are not isolated to that area. Donegal, for example, has no rehabilitation service at all. However, the population of more than 600,000 has only two rehabilitation teams and many people are in some type of institutional care, whether hospital or community residences, from which they cannot move on. As we said earlier, access to services is a postcode lottery.

Can I just add in support-----

The Deputy may ask one more question.

Deputy Durkan raised this issue as well. I am concerned about the kind of universal treatment received by people with mental health issues. They all seem to be given the same kind of antidepressant that slows down their movements, which is very upsetting for the parents of 16, 17, and 18 year olds. They immediately recognise that this is the same treatment given to people in their late 30s or 40s, and are slow to take it up a second time when they see the effect it has on their children. It impedes them from going forward when something raises its head again. Would more one-to-one care deal with that differently, rather than giving people antidepressants at the weekend and sending them home, saying they will be all right? We know what happens then.

Dr. Susan Finnerty

There are various means of treating somebody with a mental illness. When people are seriously mentally ill, psychotic or suicidal, sometimes they need medication for a period of time to get over that hump. The other talking therapies, and support in the community and so on, should kick in at that stage, but that does not always happen because the services are understaffed. People may stay on medication for longer than they should be. Certain groups of people need to stay on medication to keep them well and functioning in the community.

I thank Deputy Healy-Rae. We will now return to Deputy Browne.

Jigsaw published some startling facts yesterday. That organisation does fantastic work and needs additional funding to expand because it is meeting a need that is not otherwise being met. It allows self-referrals, which is important. It stated that the number of children being prescribed psychiatric medication has increased by nearly 500% over the past decade and Professor Brendan Kelly said that the recruitment crisis in the HSE is a factor in that. We learned from the Joint Committee on Future of Mental Health Care last year that the HSE spends approximately €400 million a year on psychotropic drugs but only €10 million on talk therapies. The work of the witnesses highlights the lack of rehabilitation units, and I know from talking to families that one of their biggest issues is with children and adults being shown the door once they are patched up in a psychiatric unit. There are no supports in place for family members on how to deal with a situation, or supports for the patients in terms of aftercare plans and rehabilitation. Ultimately, they often end up spiralling downwards. Between 65% and 75% of all admissions to inpatient mental health units are readmissions, which is anecdotally due to people not getting the right supports. There is a debate about whether we rely too much on the biomedical model versus a biopsychosocial model. What are the thoughts of the witnesses on that? Medication has an important role and doctors only prescribe it when needed but it is often needed because doctors have few alternatives to offer people in a very desperate situation.

Mr. John Farrelly

A Vision for Change was quite successful in closing down the big institutions. While it also developed a relevant number of community services, the big challenge is to transform those, or else we would be having this conversation every year. We need community services that are not just led by doctors and nurses, because no matter what medication people are on, they will still want to talk to someone. They need education to comply with their medication and understand what it is about. The key for us is applying a policy that allows us to get to Ireland. Ireland has a good opportunity in this area because we are so small compared to other countries, and, therefore, we have the capability to set up these services. There has been a policy drift and its application has not occurred for various reasons. We have gone through a major recession and have heard many other reasons, but the policy must be applied in the Department by the HSE and it must be held to account. I assure the committee that wherever we are given the relevant regulations, we will regulate and create transparency.

Ms Rosemary Smyth

I agree with that.

Dr. Susan Finnerty

The Deputy asked about distressed young people arriving in emergency departments with nowhere else to go. There is only one CAMHS emergency bed in the country, and that is in Galway.

None of the other units will take somebody as an emergency. What is happening is that when the person is in the emergency department everybody is ringing around trying to find a bed and if the risk is great the person ends up being admitted to adult units. The lack of emergency beds in CAMHS is quite stark.

In a recent incident in Waterford a 16 year old boy spent 40 hours in the emergency department at the weekend, 24 hours of it on a chair. He also suffers with autism so he spent most of the time with a blanket over his head because the bright lights, distress and the movement around him were very stressful for him. Not only was that an outrageous situation, but it is also striking than when a consultant child psychiatrist could be located the psychiatrist had to contact every child inpatient unit to try to find a bed, fill in forms and applications and give reasons. That is an outrageous waste of the time of a consultant child psychiatrist at a weekend. Surely there should be a bed manager or a single point of application.

Dr. Susan Finnerty

There is a co-ordination group that meets every Monday either by teleconference or in person. The group looks at who is waiting for an inpatient CAMHS bed and tries to match a CAMHS bed with the patient. Usually that is quite successful. The emergency is the problem, that is, the Friday or Saturday night when a young person is in distress and arrives at an emergency department and there is nowhere for the person to go.

Mr. John Farrelly

We have facilities around the country and we are developing primary care facilities. When considering the future, there is no reason that those facilities could not be open 24 hours a day. People are coming back to the same point, which is what parents, children and people are looking for. In fact, when we did our road shows in Galway a group of service users told us about setting up a cafe. They are looking for a safe place and the GP is looking for a safe place. We are so caught in the shadows of institutions that we do not seem to have the creativity or the policy oversight to say we are going in a particular direction.

Another issue that consistently arises is the lack of integration between CAMHS and primary care or psychiatric services and primary care. I am aware from talking to some managers that a lack of integration is probably to put it too loftily as very often they do not even talk to each other. How do we address that? What is the impact of the complete lack of integration between the different aspects of the HSE or have the witnesses dealt with that?

Mr. John Farrelly

Research needs to be done. The centre of our attention should be the patient or the child and mapping the services they receive. The Deputy mentioned Tusla, for example. There are some very good people working there. One can look at the National Educational Psychological Service, NEPS, and the educational services in the Department of Education and Skills. It is the idea of co-ordination. In Ireland, we always seem to think in a particular way, even in our strategic thinking. In other countries there is a trust for mental health that is as big as our mental health services. It is led that way, and then integrates. The idea of inter-sectoral and cross-sectoral approaches has always been a challenge in Ireland, but it is something that must be thought about and worked through.

Dr. Susan Finnerty

I can give a small example. We looked at physical care for people with mental illness who were in hospital and we found there was a lack of integration. People with mental illness were falling between the stools of acute hospital care, where they were unable to access services such as physiotherapy or speech and language therapy, and they were not part of the community so they were not able to access it there. They were not getting access to these services. Anecdotally, a number of acute units in acute hospitals found it quite difficult to integrate with the overall hospital so it is difficult to get physicians and surgeons to come and see patients in the ward. The patients must go to an outpatient appointment even though they are in the same hospital building. It is improving, but there is that them-and-us attitude.

The last issue is accommodation. Providing accommodation to patients in the mental health services was transferred a couple of years ago from the HSE to the Department of Housing, Planning and Local Government. In fact, when I was told that, I contacted one of the county councils and it was news to the housing section in that county council. People there had never received any information about it, and I do not believe they have since. Something I deal with almost weekly is the situation when a person is being discharged from an inpatient unit. He or she has been patched up and shown the front door. Often the person has other issues as well. The person may or may not have an addiction. The council will say that it cannot put the person into the usual emergency accommodation, which is often bed and breakfast accommodation and is not suitable. However, it has no other suitable accommodation. The person either ends up homeless and spirals back downwards or ends up in emergency accommodation, basically a room over a pub or the like which will not help the person either. Is there a plan for providing suitable accommodation for people with mental illness? There does not appear to be.

Dr. Susan Finnerty

There is a move by the HSE to appoint housing officers in each of the CHOs and some of them are in place at present. The services work closely with voluntary agencies such as HAIL Housing, Respond Housing Association and the like to provide accommodation. One of the big difficulties is that there is a very large number of what we call 24-hour supervised community residences. There are at least 113 of them housing approximately 1,300 people. A number of those people do not have to be there. I refer to rehabilitation again because if the rehabilitation teams were in place they could move out to more independent living. This would free up facilities that are owned by the HSE, in most cases, for development in homelessness services, rehabilitation services and so forth. That issue must be addressed. Since we are discussing workforce planning, there is a large number of nurses in those supervised residences who could be employed in the community offering services to people with either acute or enduring mental illnesses. It takes 12 whole-time equivalents to staff one of those community residences and we have 113. A significant number do not need to be there. That would free up housing for more acute crisis houses and so forth. It must be examined in the context of what the HSE is currently providing as well as looking to the housing authorities.

My advice to families or patients is that the only way it seems possible to get accommodation resolved for somebody who is leaving a psychiatry department is to refuse to leave the hospital under any circumstances until it is resolved. If one walks out the door it becomes almost impossible but if one refuses to leave, the department will find some way to resolve the housing situation.

Dr. Susan Finnerty

Yes.

Thank you, Chairman.

Before calling Deputy Durkan, I wish to make a comment. The biggest change in psychiatric services over the past 30 or 40 years has been the closure of our institutions. That was a dramatic change. Has there been a satisfactory progressive development of replacement services?

Are they improving year on year and is there a momentum developing to deliver the community services that are absolutely necessary to replace those institutions? My memory of 30 to 40 years ago is of a psychiatric nurse being a person who turned up in a white coat to bring somebody for admission. That is now a thing of the past and we have wonderful community psychiatric services. Is there a progressive realisation of the development of those services?

Mr. John Farrelly

If there is, it is not being driven in a co-ordinated way across the country in accordance with a policy or plan. People who work in mental health tend to be compassionate people who want to make a difference. If one looks across the country services are basically ad hoc, scattered and slow. There is a tendency for people to concentrate on inpatient services where regulation does not help. The concentration should, however, be on the community. There are improvements but one could not say that they are necessarily directed from the centre in an organised way.

A further question arises on dual diagnosis in respect of homeless people who are perhaps living on the streets. They generally have not only mental health but addiction issues. There seems to be a separation of services where if one has an addiction one receives addiction services, but if one has a psychiatric problem, one is dealt with by the psychiatric services. There is quite a siloed disconnection between those two services. How can that be bridged?

Dr. Susan Finnerty

I remember many years ago when we developed our service that we had addiction counsellors on the team. They would deal with people who had a dual diagnosis. I am only aware of one addiction counselling service in the midlands. It tends to be farmed out to other services and there may not be the greatest connection between them. Instead of being seen as a whole person, people are being hived-off to different services for what should be a person-centred, holistic care. I do not believe there is any move to provide addiction services within mental health teams.

Ms Rosemary Smyth

Two of the larger independent providers provide those addiction services as part of their overall mental health care. The commission is looking at this at the moment. I am working actively with the HSE to identify the types of services referred to by Dr. Finnerty. A great number of services are bought in by the HSE. Our exercise with the HSE at the moment, which we have also discussed with the mental health unit in the Department of Health, concerns what type of service is being provided within those services. Our role of statutory oversight of those services operates with a view to bringing those services under the umbrella of mental health services and appropriate regulation. We are looking at this piece of work at the moment.

Briefly, do our witnesses have a means of comparing the standard and quality of our mental health services here with those in adjoining jurisdictions and, in particular, throughout Europe? Where do the best services apply? How do they do this comparison? How do we compare? What are their staffing levels like? Presumably, our eyewitnesses attend professional conferences at European and international level. Are their services as good or are they way off the mark?

What are the levels of suicide in various other European countries? From the information that our witnesses have been able to glean, how do we compare? I have an idea of what the answer to that is but I am looking for confirmation of that. How do these countries address this issue in comparison with our services? Can we do more or are we doing the best we can?

Ms Rosemary Smyth

I will address this from the perspective of standards and quality assurance and how we ensure that all of our regulatory framework is in line with European and international standards, with the European convention and with best standards. We recently conducted an external review of our regulatory framework and it was found to be quite robust. We compared seven jurisdictions, four within Europe, New Zealand, Australia and Canada. We were unique in being the only jurisdiction that has a stand-alone mental health regulatory framework. We were ahead of other jurisdictions and are the only jurisdiction that has specific rules on restrictive practices such as seclusion and restraint. The Act and these regulations only apply to such inpatient settings and facilities and do not have application for the wider sector. From an assurance perspective, as a regulator, our standards are robust in how we regulate and we have that affirmation from our external review.

On how we keep ourselves up to date, we are a member of a group of international regulators, which most European countries are a part of. We meet annually to discuss various topics. The restrictive practices topic is one that comes to mind and it is very strong in that agenda, together with inclusion of service users. That is something that this group have again looked to Ireland for assistance and help on as we have been seen to be the leader in including service users in our planning, in preparing our documentation against which we regulate.

On staffing levels, we look to other jurisdictions. Workforce planning came up in the Joint Committee on the Future of Mental Health Care, as well, in that is there is no benchmark on what should be the appropriate staffing levels within mental health services. The UK, in its National Institute for Health and Care Excellence, NICE, guidelines, provides some guidance on acute units and what the staffing should be there. We defer to those guidelines and have our standards at what we think should be the appropriate number of people on these units.

On the levels of suicide, that is something we cannot really comment upon, because sudden and unexplained deaths are reported to us but the determination is not made by us as to whether it is suicide. That falls to the coroner. We are, however, working with the National Office for Suicide Prevention. Dr. Dodd has recently taken up post as the clinical lead there. We have met with him and are looking to do some joint work on international standards and the reporting of suicides, because there are many areas that could be developed in a better way here and learnings to be taken. This is something that we intend to pursue with the National Office for Suicide Prevention.

I thank Ms Smyth.

I thank Ms Smith for her reply. Is it not necessary on an ongoing basis to keep in touch with the standards and the quality of services available elsewhere in order that we do not slip too far one way or the other, but more particularly, in order to be able to address the areas of particular deficiency and thereby provide a better quality of service? How often would such references be made by the Mental Health Commission and would such interaction happen to enable such an exchange of views with those in other jurisdictions? I believe the figures on the levels of suicide are available right across the European Union. Can the commission give the committee any indication on the extent to which it can focus on that issue, with a view to identifying the worst case scenario, improving it insofar as we are concerned here, and providing an improved quality of service?

I thank Deputy Durkan for the questions.

Mr. John Farrelly

The key issue is that we have quite a limited statutory remit and we have to apply our resources in the inpatient acute units. Everything we do beyond this eats into a resource for which we are not necessarily funded. I assure the Deputy we read everything that comes out, for example, the latest report in the UK on overcrowding and overcapacity of inpatient beds, and map them across. With regard to suicide prevention statistics, an office has been put in place by the State to concentrate on this. Unfortunately, from our perspective we must concentrate our resources on protecting the approximately 2,000 people detained against their will. We concentrate on the 1%. We would love to have the statutory remit to expand and look at the 10% and get the appropriate funding to do this from the State.

Notwithstanding the absence of a statutory remit, surely it is indigenous to what the Mental Health Commission is doing, particularly with regard to identifying the need for community-based services? Is it not necessary for the commission to expand beyond its remit in an inquisitorial role to identify the best and worst of the most serious issues?

Mr. John Farrelly

We do this and the Inspector of Mental Health Services, Dr. Finnerty, has done more than any previous inspector to expand the remit. It all takes up resources and money and we do stretch people internally because we appreciate that everyone must stretch to deliver it. As an example, if people want to invest directly in a higher level of research, planning or investigation, it all costs money.

I note what has been said but I emphasise and underline what I have been saying with a view to increased attention in this area.

I understand the Mental Health Commission's remit covers inpatient acute units and patients detained against their will. Does the commission have information on how we compare with international standards with regard to access to child and adolescent mental health teams?

Dr. Susan Finnerty

The UK system has difficulties in the same way as we do. It has difficulties with the recruitment of staff and building up teams. It also has difficulty in providing inpatient beds. At present, its main worry in all areas of mental health is the provision of out of area services, which also happens here. Somebody in Donegal would probably be provided a bed in Galway but it could be anywhere else. The child and adolescent mental health beds for people in Limerick are in Galway. It is a problem. It is probably not as vast as it is in the UK but it is a difficulty.

Even accessing the service can be difficult. I am a GP and if I see a teenager who may be depressed or have an anxiety disorder, and I am sure the Chairman will agree with me, I send the patient off and refer him or her in good faith. Often the team reviewing the referral states it is inappropriate. One professional doctor refers somebody who genuinely needs help and the referral is undermined. Sometimes doctors are accused of not even having seen the patient and that they discussed the situation with the parents. That is disgraceful.

I have said numerous times in the Seanad, and I have spoken to the Minister of State, Deputy Daly, about it, that access for GPs to a 24 hour emergency phone line to the child and adolescent mental health service with regard to very vulnerable teenagers would be a solution-driven pragmatic approach. It would not be abused. I would probably use it only once a year if I had a case involving a suicidal teenager, instead of sending him or her to the emergency department or having to admit him or her to the adult mental health unit in Castlebar. That unit does great work but it is a dreadful place, particularly for a young person. Undermining referrals from GPs is not good because there is a breakdown of communications between the mental health and community teams. A 24 hour emergency phone line would probably be beneficial and prevent admissions to the acute units.

Dr. Susan Finnerty

One of the problems, and we spoke about it a bit earlier, is the fact there are no child and adolescent mental health emergency beds apart from one in Galway. What happens is that doctors refer people to the accident and emergency department and spend considerable time ringing around trying to find a bed. The doctor usually fails and that teenager is admitted to the adult acute unit. Added to this is the problem that community child and adolescent mental health teams are poorly staffed. In my most recent report, I estimated they were staffed at approximately 60% of what is recommended in A Vision for Change. I also made the point that some areas are better resourced than others. I gave the example of Galway, which is particularly well-resourced in comparison with other places, such as the south east, which has only €45 per capita-----

Does Dr. Finnerty have a comment on the fact that child and adolescent mental health teams undermine professional referrals from GPs that are sent in good faith after assessing a child? The GP would not refer the child to the mental health services unless he or she had a serious concern. Often GPs receive a letter stating the referral was inappropriate and asking whether the doctor had seen the patient. That is totally unacceptable. It happens on a regular basis in Mayo. It undermines the entire service being provided. It also undermines the patient's relationship with the GP because the parent is often copied in on the letter. They have had the courage to come in with the child to disclose whatever needs to be disclosed to the doctor. They trust their GP, with whom they have a long-term relationship. The doctor makes a referral in good faith and then a letter is received by the doctor, with the parent copied in, stating the referral was inappropriate. I do not know about this. People are falling through the cracks. Mental illness that is not dealt with in children and teenagers does not go away, it just manifests later. A review of the structures regarding referrals and accepting referrals needs to be undertaken.

On this point, I have the numbers of the consultants on the child and adolescent mental health team in my area. Because I have experienced what Senator Swanick has mentioned I try to make contact with the consultant to discuss the case to make sure I am heading in the right direction. Quite often, the consultant responds and sees the patient but if he or she felt it was more appropriate to go in a different direction I would-----

If an appropriate referral is sent in it should be accepted in good faith. This is the problem. People are falling through the cracks. They are being referred to psychological services when they need psychiatric services.

The point I am making is we have siloed thinking and we need to have a much more integrated service with better communication between primary and secondary care to identify the correct pathway. It is not that anyone is second guessing the doctor's judgment; it is trying to navigate through the system in the most appropriate way.

I understand that and I understand there are manpower problems. I totally understand all of this. I understand they are not second guessing clinical decisions. I am only concerned about the patients and I am afraid people are falling through the cracks who should not be and they are not getting the appropriate services. Sometimes the way the child and adolescent mental health service communicates to families can be seen as flippant to the concerned parents of a teenager who might be in trouble.

That perhaps requires a review.

Mr. John Farrelly

Some other countries have metrics to look at for access, what happens, timelines and different things. We are quite informal in Ireland and there is no one monitoring or accounting for that. People slipping through the cracks is something that we hear about continuously from professionals, families and everyone involved. We are building primary care centres and it should not be the case that the only alternative to a general practitioner is an accident and emergency department in order to ensure someone is safe. We must build our community services so there are hubs to which people can go 24 hours a day.

On behalf of the committee, I thank Dr. Finnerty, Mr. Farrelly and Ms Smyth for coming in this morning and giving their expert evidence. We will now suspend the meeting until our next witnesses have taken their seats.

Sitting suspended at 11.20 a.m. and resumed at 11.46 a.m.
Deputy Louise O'Reilly took the Chair