Review of Mental Health Services: Discussion

I will shortly call on Mr. Rogan to make his opening statement but, before I do that, I will introduce the witnesses. I welcome them to our meeting this morning. They will be presenting remotely on our review of mental health services. I would like to say at the outset that the committee members and I intend to give priority to this important impact which is even more important in the demanding times of the Covid-19 pandemic. Today's meeting with Mental Health Ireland and Jigsaw will give an opportunity to members to assess the gaps in services and the amount of work that needs to be done by this committee. We appreciate not only the work that our witnesses are doing on behalf of vulnerable people but also the opportunity they are giving to committee members to engage in the area of mental health.

I welcome to our meeting the CEO of Mental Health Ireland, Mr. Martin Rogan, and Ms Gina Delaney, development officer of Mental Health Ireland. I also welcome, from Jigsaw, the National Centre for Youth Mental Health, Dr. Joseph Duffy, CEO, and Mr. Paul Longmore, acting clinical director. Before we hear the opening statements from our guests, I need to do some housekeeping. I will point out that there is uncertainty if parliamentary privilege applies to witnesses giving evidence from a location outside the parliamentary precincts of Leinster House. I ask our guests to note that the constitutional protection afforded to witnesses presenting in person in Leinster House may not extend to those presenting remotely. No clear guidance can be given on whether, or the extent to which, the evidence given is covered by absolute privilege of a statutory nature. Therefore, if a witness is directed by the Chair to cease giving evidence on a particular matter, he or she must respect that direction. Is that understood? Okay.

I am told that Mr. Rogan is having difficulty coming in. I will call on Mr. Duffy to make his opening statement. He is welcome here this morning.

Dr. Joseph Duffy

On 12 March 2020, Ireland entered uncharted territory. In the face of the global pandemic, public health advice forced many to rethink how we live our lives and for Jigsaw, it forced us to rethink how we continue to be there for young people and those around them.

As Ireland’s primary youth mental health charity, Jigsaw has, for 14 years, established a track record in advancing young people’s mental health and developing supportive communities by providing a range of primary care services and supports. From the start of this public health emergency, we were adamant this would not change. On 12 March, while we announced the temporary suspension of our face-to-face services, paused the ongoing roll-out of our post-primary school initiative One Good School and postponed all our community work, our commitment to being open for business remained. A collective effort has seen us rethink how we operate and develop a full range of services to support young people aged between 12 and 25. We also want to support their parents and educators.

From early on, we were acutely aware that Covid-19 and the measures taken to contain it had the potential to negatively affect our young people’s mental health. The ongoing restrictions, though necessary, took aim at our collective need for closeness in personal relationships with family and friends, for autonomy and control, for direction and a future to aim for. Those are all key components of positive mental health.

In response, we looked to develop a wide range of supports and services aimed at harnessing the opportunities that technology affords with our expertise and experience, a union that, to date, has offered real and tangible supports to many young people across a range of platforms. We have continued to support young people through a broader service offering across phone, video and online services. In-person services resumed on 20 July. We have developed a wide range of e-mental health supports and services and our offerings to communities and schools across the country have expanded.

What have we learned due to the impact of Covid-19?

Given the evolving nature of the pandemic, arriving at a concrete answer is a challenge. Research carried out nationally and internationally all points to increasing levels of psychological distress, disconnection, anxiety and depression, but it will take a while to have long-term and fully rounded research. The World Health Organization nevertheless reported that 93% of 130 surveyed countries, including Ireland, show a decline in access to mental health support and an increase in demand for mental health services over the past six months. We know from work done by Young Social Innovators that 47% of young people fear the long-term impact of Covid-19 on their mental health. We also know from the Irish Youth Foundation that 53% cent of young people are feeling anxious, stressed or depressed. Recent research published by the Department of Children and Youth Affairs, How's Your Head, shows that the Covid-19 crisis had negative effects on young people’s health and well-being, especially among marginalised groups. The most common negative effects related to the mental health of young people.

In addition, Jigsaw's data show that even in the past two months there has been a 25% increase in referrals to our clinical service and a 400% increase in traffic to our online services and supports. We have been able to support almost 10,000 teachers who have downloaded mental health training courses in the past six months. There have also been a quarter of a million page views of our online support, jigsaw.ie.

However, Jigsaw has seen a year-on-year increase in demand for support from young people, not just as a result of Covid 19. During this time, we have connected directly with young people, their parents and those who support them. What we are hearing is a real cause for concern. There is significant isolation, uncertainty and fear, which are leaving many people without the core elements that support their health and well-being. There is a lack of connection with those around them that is leading to high levels of anxiety, low mood and psychological distress. There is a significant amount of uncertainty, leading to a growing sense of hopelessness and particularly fear for the future. There is concern and worry for parents and family members in the fast-emerging and real sense of loss for young people. Behind each statistic is a young person. Regardless of the data and the theory, we know there is terrible loneliness for a 14-year-old with nobody to talk to. There has been much anxiety for all those who came through the leaving certificate year and now face the prospect of attending college remotely or not at all. What is clear is that many, especially those who are already vulnerable, sad and in distress, will emerge from this crisis with poorer mental health.

The past six months have provided a major lesson for Jigsaw. One of the things that is highlighted is the need for new and fresh perspectives on how we, as an organisation, and the nation respond to support the mental health of young people and those around them. Ireland has long needed more focus on mental health and more funding for this sector, and not just as a result of Covid 19. The trusted mental health supports and services that are currently in place are needed now more than ever. Jigsaw has a central role to play in this vital support infrastructure, now and into the future. We want to be in a position where we are able both to maintain and to accelerate our services in response to what is an escalating situation.

As we look forward, Jigsaw strongly believes that mental health promotion and prevention need to work hand in hand with therapeutic interventions. Jigsaw’s work in communities adopts a holistic approach that kick-starts new conversations, encourages a deeper understanding and broader knowledge of youth mental health and fosters collaboration. All are key areas in supporting, complementing and expanding our clinical model and contributing to the achievement of the outcomes we want to see in prevention, promotion and early intervention. We are increasingly aware that new ways of working are feasible and that digital interventions must be central to our future thinking. We are seeking to augment our e-mental health by continuing to work with our multidisciplinary team across the clinical area. Lastly, Jigsaw is seeking to increase our clinical teams to cope with the increasing demand. We are fully committed to Sláintecare and support the primacy of providing accessible and timely care in the community. However, this is a challenge. By growing our front-line staff numbers, we are aiming to create a flexible pool of trained clinicians to deploy to the areas of greatest need across our network of services as well as furthering the integration of our clinical offerings across in-person, telephone, video call and online modalities. To do so, we need greater financial investment in our work.

We believe such increased investment will enable Jigsaw to consolidate our work in creating a new and evolved blend of service offering across in-person, video, telephone and online services. That will make a significant difference in creating a more responsive front-line mental health service, reducing wait times across our services, alleviating pressures further up the line in terms of specialist services and supporting our work in communities. Given the ever-growing demand for mental health services and supports, and a world that has changed like never before, with the right political will we must grasp the opportunities at hand to address the challenges before us. At Jigsaw, we believe that now, more than ever, there is an unparalleled opportunity for us to embrace health and well-being and to be the pioneers of a national movement that will support healthier communities for generations to come.

As an organisation fully committed to working with the committee and supporting the Government agencies, we thank the committee for the opportunity to meet this morning. While the current cost of the Covid-19 pandemic to individuals, families, schools, communities and society at large remains uncertain, it is clear that we all have a part to play. At Jigsaw, we are fully committed to playing ours and I hope the committee will continue to support our ambitious plans.

Mr. Martin Rogan

I thank the committee for the invitation to address it today. I am pleased to join the committee on behalf of Mental Health Ireland.

There is no health without mental health, as in the UN declaration. In recent decades we have seen the use of the term "mental health" expand well beyond its original and previous connotation of mental illness and psychiatry. Irish people now apply the term across a much broader range of life experiences, including overwhelming stresses, life adjustments and well-being issues. It is used in a less stigmatised way today. Mental health services have been through a period of extraordinary change and reform over recent years, but significant concerns relating to service access and capacity persist. We have experienced a pendular swing from the 1980s when it was largely a bed-based service to having now the lowest bed-to-population ratio in Europe, approximately half the European rate. This has been quite challenging for everybody involved. Such a model can only really be contemplated if there is very robust and strong investment in community-based mental health services. This has not been our experience to date.

As a country, we have experienced radical social change over the past two decades, with lifestyle changes, different constructs in families and work patterns, demographic and social changes, greater diversity and new expectations. In fact, personal satisfaction and well-being are now considered the new determinants of success. The term "mental health" attempts to encompass a broad sweep of human experiences, from life satisfaction, well-being, stress and distress to mental illness through to full psychiatric illnesses. To date, we have looked to an under-resourced psychiatric model to extend itself to respond to the full spectrum of these needs. This is neither an appropriate nor sustainable model. We must step back and apply the right solutions in the right context for the right person at the right moment.

The recently published Sharing the Vision: a Mental Health Policy for Everyone proposes that we address the needs of the whole population, and this is the sensible approach in providing properly resourced, more responsive services for people with the most significant mental health needs. The WHO recommends that every state should dedicate 12% of its health budget to mental health spending. In Ireland, it is less that 7%. That is going to be a stark reality that will be difficult to avoid no matter how we approach this conversation. Despite the extraordinary commitment of staff working in the services, it is unrealistic to expect that they can deliver the full range of services when they have less than 60% of the resourcing that is recommended. Our mental health services are imaginative each day, but they cannot be imaginary. We must be plain and honest with each other in that regard.

The additional pressures associated with the Covid-19 pandemic have uncloaked underlying tensions and some of the fragility that people live with daily. We have had strained social bonds, overstretched families, people living in insecure housing, precarious employment, long commutes, inadequate childcare provision, drug and alcohol misuse and financial uncertainty. These additional stressors have opened up fractures in many instances. Supporting mental health can be difficult at the best of times, and these certainly are not the best of times. A healthy society seeks to address proactively many of these concerns. Chronic stress corrodes not just physical but also mental health. At a societal level, it can instil division, hostility and cynicism, eroding the quality of life for all citizens. The uncertainty of Covid-19 has overwhelmed many, and the crushing effects of isolation have been very difficult to bear, especially for those already dealing with loneliness.

We know that loneliness is a particularly damaging phenomenon at individual and societal levels.

At Mental Health Ireland we have two primary roles, promoting positive mental health and well-being across whole populations and supporting individuals in their journey towards recovery. We do this in a variety of ways. We work with our network of volunteers and staff and with peers, peer educators and recovery colleges right across the Republic of Ireland. We work very closely with the HSE mental health services and a range of partners within the mental health sector and in other sectors.

This Saturday is World Mental Health Day. The theme is Mental Health for All: Greater Investment, Greater Access. It is really important that our new national policy perfectly echoes this sentiment and calls for additional investment. It does not mean more of the same. It seeks to advance a different, more hopeful and inclusive agenda, hence its title, Sharing the Vision: A Mental Health Policy for Everyone. This new policy is a comprehensive and impressive declaration of intent, but it must be more than that. Unless it is backed with investment, the momentum and enthusiasm for implementation will very quickly be lost. It must be monitored via political oversight as well as through the structures described in the policy itself. There is a huge risk that it could disappear without trace unless we monitor it very closely.

Mental Health Ireland and our colleagues in Mental Health Reform and other agencies would certainly welcome the establishment of a special mental health subcommittee of the Oireachtas Committee on Health. This would really help to focus on, capture and celebrate the progress as we fulfil the objectives of this policy in its full implementation.

We know that Irish people are concerned about mental health, and not in a self-serving or selfish way. There is a genuine concern for ensuring that all citizens are treated fairly, equally, effectively and respectfully. This has to more than just a faint hope. We frequently hear the words "mental health" being bandied about. There is sometimes a lot of chatter in this space. We need to follow through with action. People who use services and their families have been disappointed before. Now they want to be seen, heard and listened to. Talk is cheap but talking therapies are not. We need to respond to this in a credible way.

When promoting positive mental health and well-being, Mental Health Ireland pursues three strategies, namely, strengthening the individual, strengthening communities and removing barriers to good health. Our work is supported by the HSE and very generous public donations. There has been an enormous groundswell of people who want to become involved, contribute and be active in this area. We welcome people who wish to do that as volunteers.

Research shows that investment in the mental health of our population does not just raise quality of life for individuals. It builds better communities, promotes independence and brings economic benefits too. The London School of Economics suggests that there may be an eightfold return on each euro of investment. We have been very economically successful in many ways, but our burgeoning economy is of little value unless all of the people benefit from, enjoy and share in that success. We cannot return to slavish routines, stressed and unsustainable lifestyles and inequality. We can do better, and as a community and society, we can make very active decisions which will promote mental health for all of our citizens.

In the past seven months, we have witnessed the best that Irish people can bring, pulling together, protecting one and other and reawakening community bonds. If we can retain some of that spirit, we can do really well. The challenge of Covid-19 has reminded us that personal health and well-being is not a solo pursuit. It is a shared exercise built on cohesion, collective effort and mutual respect across all life stages.

Providing high-quality uninterrupted community-based mental health care is a challenge, particularly in the context of Covid-19. Many services have had to be reduced. We really believe that these are essential services. We need to create more innovative and adept workarounds so that people who genuinely depend on these services are not left behind. We must overcome the challenge of providing continuous community-based services and supports in the context of Covid-19. We also know that peers and family members want to contribute. More than half of our organisation's staff are people with lived experience who want to share their unique insight, contribute to understanding and assist other people on their journey to recovery. This is a much more hopeful message than those of the past.

However, we also know that Irish mental health services are patchy and unevenly resourced. There are significant differences in spend per capita between one county and another, or indeed between one community healthcare organisation, CHO, and another. We must ensure that every citizen has his or her right to recovery fully realised in every county of our country. Uneven investment has restricted timely access in some parts of the country and discouraged innovation and modernisation in others. It seems an unusual thing to say, but an abundance of resources has caused services to become stuck. The weight of resources is causing inertia. Services' agility in moving forward and accepting better and more modern practice has sometimes been limited. We need even distribution of the available resources. We know they will never be adequate, but let us at least be fair.

We also know that timely access to service is critical. Delayed interventions risk lives and miss opportunities for recovery. When someone is acutely unwell and needs to see a psychiatrist, psychiatric nurse, occupational therapist, social worker or psychologist, no substitute will do. We also know that the new policy opens up new opportunities to welcome new talents and skill sets. A much more diverse workforce could include new skills in the areas of employment, supported housing, education, training, life skills and community integration. In the past, we were inclined to look to health professions to fulfil all of these functions. We need to use our health professions in a more targeted and deliberate way. Sharing the Vision invites us to do that.

We have also learned from international colleagues. I spent two hours last night talking to colleagues in the US, Canada, Australia, New Zealand, the UK and Sweden. They spoke about the corrosive effects of what are described as "diseases of despair". For example, for three consecutive years, life expectancy has decreased in the US for the first time in history. The loss of life expectancy has been attributed to poor mental health phenomena, often manifested as drug and alcohol use, obesity and suicide. These are eroding the huge gains that have been made in healthcare in recent years. We cannot allow our country to go down that path. We must learn from the experiences of others to avoid this.

Our new mental health policy is a very confident statement.

I ask the speaker to begin to wind up his remarks. He has gone way over time.

Mr. Martin Rogan

I will come to a close now. The new policy is less fixated on inputs and much more focused on outputs and outcomes for people who use services and their families and communities. This is why Mental Health Ireland is fully committed to realising all the objectives in the new policy.

I would like to address the comparison which was made at the end of that presentation between this country's mental health services and those of other countries. We need to modernise and set standards. As I see it, our problem is that we have come from the institutional care approach of the 1980s to supposedly creating a place where the cases of those with mental health problems can be developed and they can receive care, treatment and attention. That has not happened to the extent that it should Does this vision for the future anticipate the provision of the required care and attention, having particular regard to the fact that we are dealing with people who have mental health problems?

Mr. Martin Rogan

I am happy to take that. As Deputy Durkan said, we saw in Planning for the Future in 1984 and A Vision for Change in 2006 really sensible plans that would put us on a par with our international peers. In 1960, we were spending about 23% of the health budget on mental health. Today, it is less than 7%. That means we need to have well-focused commando-based community mental health teams with all of the disciplines in place. The recession meant that was not possible. There was significant loss of staff through retirements and they were often not replaced due to moratoria. There has been significant movement in the past number of years on this but there is still quite a distance to catch up.

In the Deputy's county of Kildare, there was not a history of psychiatric service because the people of Kildare were previously serviced in west Dublin by St. Loman's and in Carlow by St. Dympna's Hospital at that time, which meant a mental health service had to be built from scratch. It meant it was a dynamic, community-based service but it is a thin veneer when we look at the population shape and see that the ratios are seriously out of kilter. There is a real opportunity in this context to look again and see that every citizen has equal share of the per capita spending on mental health. Counties like Kildare would very much benefit, as would County Meath, where there has been significant population growth that has not always been matched by investment in mental health services.

Dr. Joseph Duffy

I would like to comment further on Deputy Durkan's question on international comparisons. Ireland is one of the three leading countries in the world in terms of supporting youth mental health, along with Australia and Canada. This has been significantly supported, as has our work in Jigsaw, by the HSE and the new document Sharing the Vision encapsulates that focus on early intervention and prevention. Those things are hugely important in terms of building on and the other element - and we will probably get into this in further conversation - is about the funding and the gaps in the continuity of funding. There is a willingness to support young people early on. We have a huge amount to learn. We are more advanced than they are in the UK and in certain parts of America. There is a great deal of international experience we have benefitted from.

In that case, our goal should be to set an example that could be copied worldwide. We are a small country and we can give closer personal attention to the patients and have direct access to information from those at the coal face. My experience in recent times, even though the services are trying their best, is that a patient goes into hospital and is discharged in the middle of the night at 2 a.m. or 3 a.m. onto the street. There is no place for them to go and they end up sleeping on the street, in a doorway or in a railway station to the detriment of their health. As a first step, we need to tackle that. Much of the homelessness that we see around the city originates from mental health problems and difficulties and feelings of loneliness, no help and nowhere to go.

I thank the witnesses for the presentations. I will deal with the issue in the presentation from Mr. Rogan. He said we have an opportunity to open up and employ a more diverse workforce with a range of new skills. The reason I raise this extremely important issue is the lack of connectivity between various State agencies. I will give two examples. In one example a Cork City Council property was badly damaged by a tenant. The person ended up in mental health services, and then when they were discharged from mental health services, they had nowhere to go. The second example is that I was outside the Simon Community services in Cork a number of months ago and there was a girl there at 11 o’clock at night. She had been discharged from Limerick Prison earlier that day with nowhere to go. These people have ended up on the street and there is a lack of connectivity between State agencies and the mental health services. How can there be more connectivity between different State agencies? Mr. Rogan spoke about the diverse workforce with a range of new skills. Perhaps he could talk a bit more about what can we do urgently to deal with those issues where people fall between a number of different stools and end up with no support?

Mr. Martin Rogan

It is an important message. In the past, the mental health service provided a whole range of things beyond the mental health service, including housing, and that is no longer within the brief. The expectation is that other arms of Government would come together. The HSE, the Department of Health and the Department of Housing, Planning and Local Government work closely on the needs of people with disabilities and part of that relates to people with mental health needs. We have seen scenarios where people, through an episode of acute illness, lose their existing accommodation or become alienated from family members. I dealt with a case just yesterday on this topic. We have seen a number of agencies, including our mental health associations, which have stepped into the breach, working with local authorities and with capital assistance grants, for example, the Cork Mental Health Foundation provides a lot of housing to people who would otherwise find themselves homeless and in distress. As the Deputy said, a number of people by virtue of the complexity of their mental health issues, often compounded by drug and alcohol issues, find themselves homeless, step away from services or are lost to the service. In the prison population, we see in Ireland that significant numbers of people, 7% of the Irish prison population, have a diagnosis of a psychosis and are often imprisoned for relatively venial but recidivist public nuisance issues but really their need is a mental health need and a wraparound approach.

Sharing the Vision embraces that approach of all the agencies working in tandem and more closely together and not trying to displace each other and working with housing authorities because that is their expertise. However, that expertise does not extend to mental health care. How does that collaboration work more affectively? We see the same in relation to training, employment and education. There are bridges being built there which are effective but we have a lot more work to do.

Ms Gina Delaney

There is a huge message of hope when lived experience is brought into the workplace. It is important we have that message of hope that somebody who experienced housing difficulties and got support is now able to support others in that area - for example, somebody who was in prison and got support and is now able to support other people who are going through similar experiences. When we have lived experience in the workforce it helps to convey the message that there is hope and that a person can recover and be in a role where they can provide support.

How can we fast track that connectivity? We are not doing enough in that whole area. Now more than ever because of Covid we need to deal with this particular issue.

Mr. Martin Rogan

During the Covid period, people have been very creative in this in terms of upgrading hotel space and, with other agencies, a wraparound programme. That has made a fundamental change. The housing first approach is needed. Particularly in the community-based services, the person needs stable accommodation. The most basic human needs must be met. One service user said he needed a roof over his head, some food in the fridge, a job to go to and a date for Saturday night. Mental health services do not deal with that fourth heading, generally, but these are basic human needs and it is difficult to provide a mental health service to any individual whose human needs of belonging, safety and shelter are not being fully met. At a local level, mental health services are trying to engage with local authorities and often that is a good relationship with it can be patchy and be built on personal relationships. We need a stronger policy view on that and the new policy supports that.

Ms Gina Delaney

It is around innovation as well. Many groups and organisations have been able to do a lot of strong, effective work online. We need to be innovative and encourage innovation so that work can continue. There is a large number of good inter-agency committees that work to implement recovery and the recovery framework and there are regional forums where we have lived experience and mental health service providers working together to progress mental health in our local communities. Covid has put a lot of things on hold but can we be more innovative? Can we support that to keep going through this so we continue to see progress?

I wish to ask one final question about those aged between 14 and 18 years. There are quite a lot of gaps and new challenges in that area so how can we work better to deliver a service for that age group? I am wondering what we need to deliver from the various agencies, to ensure that those in the 14-18 age group in particular, can get access to services in a timely manner.

Dr. Joseph Duffy

The 14 to 18 years age group is a key group, because there are some young people there who need support with their parents, and there are also 17 year olds and certainly 18 year olds who are able to access the support themselves. What is needed with that group is to be able to provide a range of supports, and one of the things that we have been able to do over the last number of months is to provide that support, some of it initially on an anonymous basis. Doing a live chat through Jigsaw online has been a very useful way of doing that, because one is allowing young people to have direct access and support themselves. The other part of it is the provision of support for parents, and we are able to do that through a 1800 number for parents, so that they are able to get that support. The other key element to it is working with other organisations, such as Mental Health Ireland, on mental health reform, and working within the sector and with the HSE to look at how health services and supports are co-ordinated. A huge amount of work has been done during the Covid-19 pandemic in terms of an awareness of what each other is able to do and trying to harness resources with it.

Another issue, particularly with that 14 to18 year old age group, is that of consent. Consent for young people for mental health supports is different from consent for physical health supports. It is something that has been discussed in committees before, but it is an area to be looked at.

As the members can see, things are a bit disjointed in respect of who is to speak and so on. If the speakers could ask a particular question of the organisations represented here today, it might help. I am trying to be as flexible as possible but we do have to be out of this room at a certain time. I call on Deputy Ward.

I am thankful for the opportunity to speak at the committee today; I am not a member of the committee but I am very passionate about mental health. I will speak for a few minutes and will leave ample time at the end for both Mental Health Ireland and Jigsaw to respond.

I have recently taken up the role of mental health spokesperson for Sinn Féin, and I have worked in community mental health and addiction services on the front line for many years. One sees the problems at community level, but when one gets to this level, one sees it as being the result of systemic failures that have happened over a number of years. That is starting to bear fruit in the sense that we can see really how bad it is getting. This pandemic has really shone a light on the systemic years of under-investment, mismanagement and other issues; it is quite worrying.

The share in division that is coming up does not lack ambition, but it is political will that is required, as well as the resources to back it up. To go back to a point that was made earlier, tomorrow I will be initiating a Mental Health Parity of Esteem Bill 2020 at First Stage, to bring mental health up to the same parity as physical health, which is important. The idea of having a subcommittee on mental health is one of the things that can deliver that parity. I do not think that it will be sidelined. I think it will shine a light on mental health and will enhance the input of this committee and the subcommittee into mental health going forward. It is a good idea and it is to be welcomed.

As Dr. Duffy is aware, Jigsaw is an organisation about which I am passionate. The first Jigsaw was established in my own area of north Clondalkin, less that 100 m from my own front door. It was born out of a spate of youth suicides in the area, many of whom were children of friends and neighbours of mine. I know how innovative the organisation is trying to become with its use of technology, but I am concerned, because the face-to-face service of sitting down in a room with someone should not be replaced. Are there any plans to reintroduce face-to-face services at some level? This virus is not going anywhere for the foreseeable future and we are going to have to learn to live with it. While I do welcome the innovative use of technology, I still feel that there is a need for face-to-face services. As Dr. Duffy mentioned, behind every statistic there is a young person, and some of those young people would benefit from face-to-face appointments rather than the use of technology. It should also be noted that there are some young people who cannot access technology where they live or they may not not be allowed to access it. If they were able to access face-to-face services, they may feel more free to speak.

I was very taken by the Mental Health Ireland statement that the State has moved from an entirely bed-based model in the 1980s to having one of the lowest bed: population ratios in the OECD. The statement notes: "This model should only be contemplated where there has been a strong and sustained investment in services. Unfortunately, this has not been our experience to date." I know it concerns monetary issues and resourcing, but what changes would Mental Health Ireland like to see at policy level, given that it has stated "it is unrealistic for mental health services to be able to function properly with less than 60% of the recommended funding"?

My final point relates to lived experiences, particularly people in prison, as previously mentioned. In some of the prisons at the moment, prison link workers deal directly with people with mental health and addiction issues, in other words, those with a dual diagnosis. These prisoners have to choose between having a professional service visit that will help them to stop reoffending and be a prodcutive member of society when they are released from prison or having a family member visit. That is not good enough and it is that joined-up thinking that is missing.

Changes can be very simple. I have submitted parliamentary questions and I have spoken with the Minister in the Dáil on this issue, but I still have not received a clear definitive answer, as to why it is not happening. I am not asking the witnesses to answer why it is not happening, but I want to highlight one of the issues that we have in mental health and addiction provision that would help people going forward. I think the witnesses have 50% of the time remaining to respond.

There are five minutes remaining.

I might jump back in. The Chairman knows what I am like.

The Deputy will not jump back in, in the five minutes that remain. Who wishes to respond first?

Dr. Joseph Duffy

I will respond to the Deputy's questions to Jigsaw. I thank him for his continuing support of Jigsaw in the Clondalkin area. I want to reassure the Deputy that Jigsaw made a decision to introduce video and phone services as quickly as possible, when face-to-face services were suspended in March. We had phone services operating from March and video services operating from April. We reintroduced face-to-face services on 20 July, which was part of the previous phase 4 of the Government roadmap, so each of the Jigsaw services around the country now offers face-to-face appointments. We know that they are prized by young people. We hear from them all the time about why they want to come for a face-to-face session. They want to do so because they might not have the space or technology at home, but also some of the issues that are leading them to come to Jigsaw might arise because of their particular home circumstances. That is something that we have operating at the moment and we plan to continue it. I wish to acknowledge the tremendous work that has been done by our staff in the services across the country in 12 areas. They have really maintained the services and support, and we plan to continue to do that.

We do face significant challenges, because obviously we need to maintain social distancing and some of our buildings are not very suitable for doing that. However, we have tried to allow for that, and we are using space in the national office in doing so. We will continue to provide video and phone services. We know, for example, that in Donegal, some of the young people from Arranmore are really pleased to be able to use video and phone services because it means that the services are much more accessible to them. The same is true in places like Kerry and Cork, but what is also important is maintaining the face-to-face services, and that is something that we will commit to continuing to do.

Does Mr. Longman wish to respond?

Mr. Paul Longmore

Dr. Duffy has probably said most of what needed to be said. To echo Deputy Ward, there is no replicating face-to-face service provision and we in Jigsaw have, since March, sought to be imaginative and creative in the multiple ways we offer young people access to support. We think that in order to be accessible to young people in particular, we have to offer a number of ways in, hence we are offering a service via face-to-face, phone, video call and also online from live chat. The way that is breaking down currently is that roughly 50% of our services are being offered through face-to-face appointments, 30% by video call and 20% by telephone. What this tells us is that there is no one-size-fits-all. Different young people have different needs and in order to take account of their unique circumstances and the unique challenges they are facing, we need to offer a number of different ways and we need to be adaptable and flexible in how we offer our service. There are certainly some young people whose preference and need is for a face-to-face service and also, clinically, where we feel they require a face-to-face service-----

Mr. Longmore is going over what his colleague said. I would appreciate it if Mental Health Ireland could come back in for the last minute. I appreciate Mr. Longmore’s input and thank him.

Mr. Martin Rogan

To clarify, at Mental Health Ireland we are not in any way nostalgic about going back to a bed base. Nobody wants anyone to be in hospital, whether it is an individual or a family member. We can provide much better services in the community but they need to be properly staffed with properly equipped teams. Innovative options like community cafés, sometimes called crisis cafés, are currently working with the HSE in CHO 2 in the west of Ireland to develop this innovation, and that is described in the new policy. The Deputy can see that, within a matter of weeks, we can innovate and provide the services people would wish for. Certainly, if a person needs to be hospitalised, that needs to be available quickly and fairly across the country. We have lots of options and more creative ways of working with people in their own home and in the community so they do not become alienated. While it is an area we want to develop more, it requires staffing and resources.

Much of the policy in the last while seems to suggest mental health issues stop at a certain time of night. We need 24-7 access to emergency mental healthcare because it is greatly needed. I thank the witnesses for their responses.

I see other members nodding their heads on that last point. I call Senator Clifford-Lee.

I thank the witnesses for their presentations and contributions to date. It has been widely acknowledged that the pandemic has had a very large impact on women in this country, and that spans from the impact of domestic violence levels to the burden of home-schooling and domestic duties, all while trying to work from home. However, there is a particular cohort of women that have suffered terribly, and that is the women who have been pregnant and have given birth during the pandemic, or who will do so over the next period of time. I have heard from hundreds of women who have had to attend appointments alone, who have gone to scans alone, who have been given very tragic news alone, who have miscarried alone, who have been told there is no heartbeat alone, and who have given birth with very little support from a partner and had to go through traumatic births and recoveries. Then, when they are discharged from hospital, they are in the community, possibly far away from family, and not able to access community supports.

My question is whether any assessment has been done on the mental health impact of the pandemic on this particular cohort of women who have been pregnant or have given birth during the pandemic. Are there any international studies on that cohort of women? What supports can be put in place to deal with this situation for these women as we learn to live with the virus? Considering the current restrictions, what can be done to improve the situation?

Mr. Martin Rogan

The Senator has raised a very important issue. At all significant life events, in recent years we have moved towards being very independent and solo, and that is not a realistic way for us to live our lives. In fact, the changes to nuclear families have been quite challenging, and certainly a huge event like childbirth or someone running into difficulties during pregnancy should never be faced alone and a person should be supported fully.

On the point in regard to domestic violence, I was talking last night to colleagues in New Zealand and I discovered it has a system for people experiencing domestic violence which means they can have up to ten days paid leave. New Zealand, which we often consider a utopia, has a very high level of domestic violence but at least it acknowledges that more than we do here.

Some of the necessary public health responses around Covid have worsened the situation of people who are in difficulty, as Dr. Duffy alluded to earlier. Sometimes people using technological approaches need to be in a safe space or a private space to be able to avail of that. If a person who is challenging or who has coercive control is present, the other person simply cannot avail of the service in that context.

I am not aware of the research, but I can certainly make inquiries of our international colleagues on the particular mental health impact for people travelling through a pregnancy or recent childbirth.

Can Mr. Rogan suggest possible changes that can be brought about to improve the situation for women?

Mr. Martin Rogan

There is obviously a logistical piece. It is important we understand that public health precautions are designed to be protective in terms of protecting the individuals and other patients in that situation, and this is why people have been invited for single appointments. Other methodologies can be used whereby the partner can join in by telephone or video link, such as we are using here today, which can minimise the sense of isolation the person feels at hugely traumatic moments. The services will do their utmost to do that but it is certainly a very live challenge in the context of Covid.

Ms Gina Delaney

As a fellow woman, I feel the need to say that while childbirth seems a relatively short period of time in somebody's overall life, that experience, whether it is positive on the whole or negative, stays with a woman for life. In those instances, perhaps we could have services where, if it is safe to have the delivery at home, we could encourage that where possible. If not, I do not have an answer other than to say a woman should have support and have a loved one with her.

It is very clear from the experts I have spoken to, and the witnesses have confirmed it today, that it is very important for people to have support at this very important time. Sometimes it is not something that can just be forgotten about very easily and a very difficult experience will impact on that family for the rest of their lives. I thank the witnesses for their contributions and for all the work they are doing at the moment.

I would like to echo that and I thank the witnesses very much for all the hard work they are doing at such a difficult time in the country. I have a question around maternal healthcare and perinatal mental health because it is an area of great interest to me. To add to that conversation, the witnesses might know that outcomes are significantly better, not just the long-term impact in terms of mental health but also with regard to the immediate impact of childbirth, when women are given support from partners.

That follows into an area that speaks to both groups here today, which is around how Covid is impacting young people. I was sent an interesting video last week by Dr. Ray Nethercott, who is a consultant paediatrician in Belfast, of a child being handed a horse chestnut and being told it is coronavirus, and then running away screaming. It has been widely shared on social media as a kind of a funny thing, but he sent it to me because he is very worried about the pressure on both small children and adolescents around the Covid crisis. My specific question is whether the witnesses think we are doing enough to communicate the public health messages to children. I see other countries have specific media strategies and communication campaigns around speaking to children, given Covid is impacting their lives so specifically and having a big impact on their school and home life. Are we doing enough to talk to children about what Covid is and what the health advice is, or are we focusing our health messages too much on adult communications strategies?

Dr. Joseph Duffy

I will reply first. The Deputy is correct. It is important to think about how we focus our messages. Some of the feedback we have had within Jigsaw from our youth advisory panel, especially in the early stages of Covid-19, was that the messages were given through mainstream media, including the newspapers and terrestrial television. Much of the feedback was that this is not where young people are at. They need those messages through social media in a way that is more directed to them.

There needs to be particular messages directed to younger children. Children have extraordinary capacity when it comes to learning, sharing and understanding, as do adolescents. However, it is important that the messages are tailored to the audience. Much of the time we rely on parents to do this. Now that children are back at school, they will be with their peers. It is vital to think about how they are spending the majority of their day and what messages they are getting, especially in the area where I work, which relates to adolescents and young adults. This is about the messages that are given to them through social media. We need to think about positive ways to do that.

There is considerable negativity around young people at the moment. What they should experience at this point in their lives is a sense of striving for independence, but this has been greatly curtailed because they do not have the ability to make new networks of friends and so on. This is really important in terms of thinking about how we continue to build their resilience. Clinical staff and those working in the services are greatly impressed by the adaptability young people are showing in being able to come to services through telephone and video and the support they are able to give to each other. It is important to involve them in the conversation and to have this conversation with them. We need to involve children of all ages in these conversations. It is a particularly important topic and one we need to address now.

Mr. Martin Rogan

This is really important for young children too because the natural instinct of parents is to shield, protect and not frighten young people. At the same time, parents need to give a rational understanding. Young people will absolutely sense quickly that things are amiss. They may ask why they cannot see their grandparents anymore and why visits are being curtailed, etc. It is important that parents walk through what this means in a responsible and age-appropriate way. I have seen this with my grandchildren and we certainly saw it at an early stage in this pandemic. We were using the language of virus, vaccine and masks in a frightened way. It was designed to be protective but that can be unhelpful and unnerving for young children. Open communication is important and we need age-appropriate messages that parents can share with children and that can be included on daytime television and social media platforms. These can explain what this is about and the sensible things that children can do. They can explain why things have changed and how they can respond to that.

Certainly, we have seen friendships form in preschool and the return to school has been positive. It is about building these relationships and allowing young people to make sense of the new context we must live in at this time. It is a well-made point and one to which Mental Health Ireland would be happy to contribute. We do extensive work with families and young adults. Certainly, with young children some age-appropriate messaging would be helpful.

Ms Gina Delaney

I agree. For young people especially there is so little control in their lives. They have to go to school and they have to do their homework. They ask what they have control over. Now we find ourselves in a pandemic where everything is curtailed. Even decisions that were somewhat within our control are now outside of our control. Understanding this is really important for young people. Mr. Rogan will probably take that away from today and we will have another conversation around young people and the messages we have to get out to them.

Mr. Martin Rogan

Basically, we have to map out the issues that are in our areas of concern. Often these can be frightening and we may have no control over them. Then we map out what we have control over in terms of exercise, washing hands, being careful and avoiding crowded spaces. These are the things we can usefully deploy in our own space. There is differentiation between this and the broad approach found on daytime television, where all news is heavily built on an unsettling message around Covid-19. It is a question of what is in our area of concern versus what is in our area of control. That is really helpful. It gives a sense of agency, decision-making and choice to which young people can respond.

Does Mr. Longmore wish to come in?

Mr. Paul Longmore

I think in general we look to adults to provide emotional and psychological containment to children and young people. We should be cognisant of the fact that in society at large at the moment there is heightened emotion and considerable anxiety. People generally are unsettled. That communicates itself to children and young people. There is a possibility that adults are a little less able to provide that containment to children and young people because they are so busy managing the impact of Covid-19 on their lives and their own struggles. I echo what Dr. Duffy said. Teenagers and young people in their early twenties are within the age range of Jigsaw. Where they are connected to the public discourse what they are hearing is leaving them feeling somewhat vilified and scapegoated. That is really unhelpful. We have to be understanding of the unique developmental stage where young people in their teens and early twenties are. It is almost their job to strive for independence and autonomy and to push boundaries a little. That is what they need to do to establish themselves and to find their identity. Rather than blaming and publicly shaming young people, we should look to engage them more and be a little more understanding about the specific impact of these restrictions on them in their lives. That would be more helpful.

I completely agree with Mr. Longmore. I do not believe we can continue to try to blame teenagers for doing what teenagers do while the rest of us are not doing what we should be doing. Moreover, I do not believe it is possible to shield children anymore from the reality of Covid. I have small children. I know it sounds strange to suggest we could make cartoons about coronavirus because it is a rather bleak subject, but I would like to see stronger, age-appropriate messaging from the HSE geared towards that age group. I am unsure how much longer I have.

The Deputy has run out of time.

I have more questions but unfortunately I have run out of time.

There may be an opportunity to come back in at the end. We might get back to the Deputy in a second time.

I thank everyone for their contributions. There is no doubt the past seven months have been challenging for everyone in the country, regardless of age. Covid-19 is grim when it comes to our physical and mental health. The consequences are yet to be quantified in terms of what it has done to the national psyche and to people's personal health.

There is a paradox in all of this. On the one hand, we have seen the extraordinary solidarity that has been shown by people in looking after neighbours and all the other things we have all been doing for a long time. Yet, the paradox to the whole Covid situation is the isolation it has brought. That isolation can be very difficult. The lack of access to services can really compound the impact on the well-being of people and their mental health. We are all cognisant of that.

I have a question for Dr. Duffy relating to young people accessing Jigsaw at the moment. What is the average waiting time for a young person who is seeking a consultation, whether it is remotely or in person? The reason I ask is that before I came to the meeting today several parents told me that the average time to get some sort of consultation with anyone in Jigsaw, especially in the Dublin West area, was four months. I hope the Jigsaw representatives can clarify this. These people were told that was the waiting time. I suggested that could not be right because early intervention is crucial.

Dr. Joseph Duffy

I thank the Deputy for his support for Jigsaw. The wait times at the moment range from four to more than ten weeks. The reason is that we have particular demand in certain areas. We have demand in areas of high population, including Dublin South-West, Cork, north Fingal and Dublin city. We have two things available at the moment that we did not have available previously. We have a 1-800 freephone number that can be accessed by young people and parents. That is available countrywide. That will get an immediate response in speaking with a clinician. In addition, if the person leaves a name and contact number we will ring them back. We do that promptly.

The second thing that is also available is live chat, as my colleague, Mr. Longmore, mentioned. That is available five days a week, and on Tuesdays and Thursdays it is available from 2 p.m. until 8 p.m. That service provides direct support from a clinician. The difficulty we have is that demand far outstrips capacity. At the moment, given the limitations we have in respect of Covid-19 and physical buildings, we are trying to provide as much support as we can. We have clinicians working remotely and we also have some clinicians working from our national office, where it is possible to socially distance and provide space and support, and they can offer video support.

When a young person contacts the service and is given a waiting time for an appointment, if that appointment is ten weeks away it will often be brought forward because of cancellations by other young people and because of our availability. That is probably the furthest out that people would be seen. We are trying to support people and see them much sooner. The real difficulty we have is that we have reached capacity in certain services. We need increased resources to be able to support more young people. Insofar as possible, what we have tried to do where we have a shorter waiting time in a service or some capacity with staff is to use those staff to provide support by video and phone. For example, staff in Galway are providing support to some of our Dublin services and staff in Offaly are providing support to our services in Meath. That way of trying to be as flexible as possible is greatly important. Apart from the impact of Covid-19, there has been a significant year-on-year increase in referrals to Jigsaw. We also know that September and October are peak times for referrals, so we are doing everything in our power now to provide as much accessible support as we can.

Mr. Paul Longmore

To add to those comments and provide some figures regarding what Dr. Duffy said, we looked at the period from July to September in recent years in respect of increasing demand. We saw an increase of 22% in referrals to Jigsaw services between 2018 and 2019 and an increase of 25% from 2019 to 2020. What we are looking at is not specific to the impact of Covid-19, although that may be exacerbating some of the difficulties that people are experiencing. There has always been a problem, however, whereby our capacity has been far outstripped by demand for our services. We are doing everything we can to try to offer young people as timely a service as possible, and we are putting in additional routes to support, such as live chat.

Fundamentally, however, those waiting times being experienced in some of our services are unacceptable to us as well. I know Deputy Gino Kenny feels aggrieved by this situation, and so do we and the Jigsaw clinicians. We really want to be offering timely support to young people, and a waiting time of four months is not what we aspire to. Our aim is to offer timely support to as many young people in Ireland as we can, so we would welcome any way in which the Deputies could support us with additional resources to enable us to bring those waiting times down.

In theory, it is probably correct that there could be a waiting time of up to ten weeks to get a consultation.

Dr. Joseph Duffy

There could be, unfortunately.

I am not criticising Dr. Duffy, but that is absolutely shocking. That is incredible. I refer to a waiting time of ten weeks for someone to get some kind of consultation or intervention. There is something seriously wrong there, and it concerns resources. For somebody in a crisis situation to be waiting ten weeks means that we have a serious problem on our hands.

Mr. Paul Longmore

It is important to state that for people in a crisis situation, Jigsaw might not be the right service to support them at that time. That is because we work in the mild-to-moderate primary care level service. We do, however, endeavour to connect people presenting to us in crisis to a service that can support them immediately. We work very closely with our colleagues in the mental health services and in HSE community health teams, with GPs and with other service providers. If somebody does present in crisis, we will look to connect him or her with the service that he or she needs very quickly, so that he or she receives the required support in the moment.

Ms Gina Delaney

It is a continuous conundrum with the services. We want to provide a recovery-focused, human rights-based approach to our mental health services, but with the existing under-resourcing we find ourselves providing people with waiting lists instead of the services they need. I was trying to access an advocacy service for someone recently and I was told it would be 28 days before that could happen. I could not fathom that situation either. How is it possible to talk to someone about something important that happened 28 days ago? It is sadly the case that something that important will still be important after those 28 days, and the issue will have been impacting that person's mental health even more. When we refer to the impact of the Covid-19 pandemic affecting people's mental health, we must ask what steps we can take. It might involve analysing what services people need. I refer to Jigsaw, talking therapies and advocacy services. If we analyse exactly what is available, including the statistics on the rise in levels of mental health issues, we can find out if it is possible to fill that gap. The answer is most likely "No", but we need to do that analysis to see what we can do.

Our next speaker is Senator Hoey. The Senator has seen how things have been working, with short questions and an indication of who the questioner would like to reply. I call Senator Hoey. It is her session.

I thank all the witnesses for their presentations. It is very useful when other people ask questions, because I can tick off things I wanted to ask myself. There is a benefit to listening to other people's questions.

We are aware of the challenges that isolation and lockdown have posed to many people. It is probable that nobody in Ireland has escaped all the challenges. I want to focus on those groups in Irish society that have not traditionally had the best access to mental health supports, even before the onset of the Covid-19 crisis. I am thinking of those living in rural communities, especially farmers, and the complexity that comes with geographic isolation and also difficulties with access to broadband. I know Mental Health Ireland is working with Teagasc and the IFA on this aspect.

I am also thinking of those people in direct provision centres who have already come through trauma. Isolation and fear in direct provision during the lockdown have dramatically exacerbated the existing situation. I am also thinking of young LGBT people, who may not yet be out to their families, or those who are out but not accepted by their families, and I include sexual orientation and gender identity in that area. I am also thinking of the Traveller and Roma community. Tomorrow is the first National Traveller Mental Health Day, and there is a commitment in the programme for Government to develop a Traveller and Roma mental health action plan.

The witnesses in their presentations mentioned innovation and different ways to try to reach people, and how it has been necessary to try to find ways to do that during the lockdown and the Covid-19 crisis. Will the witnesses outline some of the supports they have been able to provide, and those they would like to be able to provide, in innovative ways to any or all of the groups I have mentioned? What actions, resources or supports do the witnesses think that the Government needs to put in place specifically for those groups I have mentioned? I pose those questions to both sets of witnesses. The question regarding young LGBT people may be one that the representatives from Jigsaw Ireland could look at, and then the representatives from a Mental Health Ireland could address the issues regarding other groups.

Mr. Martin Rogan

That is an important point. It has been recognised that some groups have always had significant difficulties accessing services, for a variety of reasons. Sometimes social stigma has been involved and sometimes access, particularly regarding the farming community, which is predominantly male-based. Primary care services may also not be used sufficiently. That is why Mental Health Ireland has been working with Teagasc to develop a "Coping with the pressures of farming life" programme, which includes information on mental health and self-care, as well as farming tips. This approach has been taken up by our colleagues in Northern Ireland and also overseas. We need to go beyond that, however, because that only deals with a certain region and a certain element. I refer to our network of our development officer team, our trainers, our recovery colleges, our volunteers and mental health substation.

We were not, unfortunately, able to participate in the National Ploughing Championships this year, as the event had to be cancelled. Returning to a point made by Deputy Gino Kenny a moment ago, isolation is really corrosive. We know that being isolated or lonely has the same health impact on people as smoking 19 cigarettes a day. I not quite sure why it is 19 and not 20. Nobody would ever recommend that people improve their health status by taking up smoking, so isolation is a really important factor. We need to understand what barriers are involved in this area.

As we mentioned earlier in the context of our promotion of positive mental health and well-being, this is about strengthening the individual and strengthening communities, and the farming community has been really powerful and really supportive. We have worked with district vets, and many other others, to make sure that relationship is in place. Last year, in particular, when there was the fodder crisis, the mental health aspect and impact from that was very important. We need to be innovative and get out into communities, and meet people in marts or anywhere the farming community meets. That is especially challenging in the context of the impact of Covid-19.

I previously chaired the Traveller health group in Dublin and the members of the Travelling community also have significant needs. People with significant mental health needs often present quite late, and with quite florid and challenging psychiatric presentations.

We have been able to work with Pavee Point, and in a co-production. It is really important that we recognise the wisdom and expertise that resides within the Travelling community and among primary care workers within the Travelling community so that the message lands well and is fit and not alien to their culture, ethos or ethnicity. We have worked very closely with Pavee Point and Exchange House to develop resources in that space for Travellers, with Travellers, by Travellers, bringing the mental health expertise and an evidence base but making sure it is absolutely culturally appropriate. These are really important elements.

We are also very conscious that Ireland is a more diverse country now so there are people from many different cultures and diverse backgrounds and indeed people taking refuge here. We have worked over the last years with the National Office of Social Inclusion, working with people who are in direct provision centres as well. There are very significant and well-recognised challenges for people who have lost control of their own decision-making, their sense of agency and autonomy, while travelling through that process. We certainly try to respond in a very direct way, translating into different languages. More than just being linguistically competent, it needs to be culturally competent so that the person can recognise themselves in that space while getting the benefit of expert mental health inputs as well.

Dr. Duffy might want to speak about the work we have done in the LGBT community. It has been really helpful. We are active in the Pride movement as well. Dr. Duffy might have been more active in that space.

Dr. Joseph Duffy

I will ask Mr. Longmore to take this.

Mr. Paul Longmore

There are a couple of fundamental ways in which Jigsaw tries to be as accessible as possible to all young people that might make a particular difference to minority groups. One is that young people do not need any professional referral to access the service. That takes away a hurdle and makes the threshold easier for young people to access our services. The other thing is that our services are free. An awful lot of counselling and therapeutic services are run on a private basis and people have to pay for them. Offering a free service where young people can self-refer or parents can refer a young person is very helpful in terms of accessibility. On a local level, a lot of our services develop relationships with, for example, local Traveller groups and faith-based groups in order to build bridges with particular communities and signal our openness and our desire to reach out to all young people within a particular catchment area. We have had certain joint projects at a more national level with BeLongTo, for example. A number of our services are involved in local Pride events every year, all of which signals to young people from a diverse range of backgrounds that Jigsaw is accepting and welcoming of them, sees their uniqueness and wants to support their mental health in that.

I was thinking about the role the mental health subcommittee might play in identifying what needs to be done, working with groups like that in terms of the people who are falling through the cracks. I am deeply concerned that the particular groups I mentioned are going to continue falling through the cracks. It will be important for members to bear those groups in mind when we are looking at that subcommittee, as well as being mindful of the work that the witnesses are doing. It is about how we can reflect on that to really try to get those people who may fall through, so that we try to create a bit of a safety net for them.

I thank all the contributors. My first question is for Dr. Duffy. It is fair to say that Covid has fast-tracked the change to non-physical consultation from face-to-face engagement or just a chat. Is this likely to increase access and use because it is easier for some teenagers and young people not to have to physically walk through a door to avail of services? I understand others say that nothing can replace face-to-face interaction and I understand the flexibility issue as well.

What relationship does Jigsaw have with the child and adolescent mental health services, CAMHS? Is there a mutual relationship between them? Dr. Duffy mentioned September and October as peak times for engagement. Is that coming into the winter period? Is it the return to school? Are there particular triggers for young people to reach out such as family change, family strife, a change of home, people moving to a different county, a new school, starting secondary school, or a bereavement? Are there particular triggers that are very evident?

I would like to ask Mr. Rogan about access to mental health facilities. We have a wonderful new facility in the grounds of University Hospital Galway. It is a very impressive building and I was there at the opening of it. I understand people have to present to an emergency department to get referred. Is this the case nationwide or is it a peculiarity here? Perhaps it has even changed. It was brought to my attention at the time. The other thing we hear a lot in respect of the budget is the spend of 7% versus 12% in international comparison. We hear that as well with GPs and in terms of primary care. We would all like to see the organisations' budgets increase but if they increased on a percentage basis, other sections of the health service would reduce on a percentage basis. Obviously the witnesses want extra funding. Perhaps we could ask the secretariat to look at that analysis in respect of the percentage spend in Ireland on the different sectors versus other areas. It is something that comes up.

Dr. Joseph Duffy

I will respond as briefly as I can. Certainly having multiple modes of access to Jigsaw through phone, video or face to face does make a difference. For some young people who might be socially anxious, to start by video makes a big difference and then part of their therapeutic progress might be to come into a session face to face. For young people who are at a physically distant location, in some of our services we operate satellite clinics and supports. It really varies. Having multiple ways in which young people can connect with Jigsaw is only going to help and it is something that the young people and clinicians want to continue. It is not just a Covid phenomenon. We are going to continue to do it.

The second question was about our relationship with CAMHS. We have a really positive relationship with about half of the CAMHS teams. That stems from local relationships and the support we have from the HSE to have standard operating procedures so we can make direct referrals to CAMHS. In respect of about the other half of the CAMHS teams, we cannot make that direct referral but have to refer the young person back to their GP who must make the referral to CAMHS in turn. That really is a blockage in terms of care. We have talked to the HSE and the inspector of mental health services and a lot of people around it. It is something we would definitely like to see improved. There has been a real willingness on the part of many teams to support that.

The third question was about peak times in September and October. The pattern over the years has been that when young people get settled back into school, they see it as a new year and it is time then to begin to address something. That might be prompted by their parents or a teacher. One of the significant things it is prompted by is the transition into secondary school or from secondary on to third level. It is important in terms of those transitional times of their lives. It is a key time of year when people are thinking they need to get things resolved or get some help before Christmas. Someone in a new class or school might want to do that. When we were talking to young people in April and May a number of them were saying that because they were at home and not being bullied, they did not have all of those social pressures. They felt they were doing okay now and said they might come back to us in September. There is a group of young people who will continue to access supports because of the very nature of being back in school. It is a natural time. We see some lesser peaks around March and April, which is the time of mocks and leading into exams. It very much follows the pattern of a young person's life throughout the year.

Mr. Martin Rogan

On the question about emergency departments, as the Senator said there is a very fine new unit open at University Hospital Galway. This is mirrored across the country with acute inpatient units happening in acute hospitals. There has been significant capital to achieve that. The question is whether an emergency department is the best place for a person who is in distress, feeling overwhelmed or in a crisis. Nobody believes that. Ideally people using mental health services would be coming through general practice. It is probably not always understood that about 35% of all occasions of GP care, which is about 6 million occasions of care every year, relate to a mental health need. Some 90% of mental health issues are progressed and supported through primary care with about 10% being referred forward.

Ideally, that should be in a community mental health centre, which centres are often now housed in tandem with a primary care centre, but for crisis admissions or, say, a person who may have overdosed or suffered lacerations, the emergency department is the point of presentation out of hours. This is described in the new policy as a community café or a crisis café. I am talking about a place where a person who does not have either physical health or other overwhelming issues, for example, drug or alcohol issues, can be received and safely managed, and there are protocols in place for that. It is a place where the person can steady themselves and be properly received, and if a referral to an emergency department is required, they can be supported in that role. If inpatient admission is required, that can be arranged there as well. We have feedback from individuals and family members who persuade a family member in distress to go to an emergency department but he or she simply cannot contain a four-hour or five-hour wait. Such people often leave before being seen.

There are very good data on this in respect of the National Suicide Research Foundation. Every year in Ireland, approximately 12,000 people present to emergency departments following an episode of self-harm. In terms of the figures, it is estimated that 60,000 people who self-harm do not present to the emergency department. It is important that the person is managed, sustained and made safe, particularly if there is an issue around a laceration or perhaps overdosage. That happens in an emergency department. Drug, alcohol or behavioural issues can compound that presentation. Most people who leave a mental health service will never be admitted but we need to have timely, ready access. If a person uses community services and needs admission, he or she should be able to go from the community mental health centre to the inpatient unit that is expecting to receive that person for admission.

With regard to budgets, where we have unevenness, and primary care is a huge portal for people who use mental health services, it is very important that a range of services are available and that there is capability and capacity in primary care. It is not our intention to seek a massive mental health budget or say that in all instances people need to come to a psychiatric model of service, but we definitely need to rebalance programmes because where the mental health service is inadequate, people need to present in other fora. That is often the emergency department or the criminal justice system. The persons are often known to gardaí, end up in the prison system or have drug or alcohol issues. The need does not change. It is the route by which the person gets to resolve his or her problems. It is often the case that by the time the person is seen by the mental health service, there is a lot of unravelling, family discord and torn relationships which could have been addressed at an earlier point. As Dr. Duffy and Mr. Longmore referred to earlier, they often present in young people rather than adolescents. An emergency department, ED, is not the preferred place but we do not want to get to a place where people with mental health issues are debarred or unwelcome in the emergency department. They need the same parity and access to service, be that in primary care, EDs or any other aspects of physical care.

We also know that the physical health profile of people with mental illness is poor and that their lives are often foreshortened by between ten and 15 years. Indeed, some studies suggest it is by up to 20 years. This is often people who find themselves outside of health screening, women's health and men's health services and a range of other cancer screening-type programmes. It is very important that a person with a mental health need has a strong relationship with his or her GP and that good continuity of care and avails of the mental health services that are most beneficial to him or her.

Mr. Paul Longmore

Is there time for me to add a brief comment?

A brief comment, please, as we are way over time.

Mr. Paul Longmore

A number of the questions reflected a concern about people falling through the cracks in mental health services. That is an understandable and real concern. For people using mental health services, they can at times appear to them to be disjointed and difficult to navigate. To go back to the idea of communication and close co-ordination among the child and adolescent mental health services, CAMHS, Jigsaw and other primary care level services, that co-ordination is essential to make sure that people do not fall through the cracks. We need much more of a joint approach. Better co-ordination between the different levels of care and the different care providers is vital to make sure that people do not fall through the cracks.

The next speakers are Deputy Lahart, Senator Black and-----

Will I be given a few minutes?

The Senator will have an entire slot.

I cannot stay because I have another commitment.

Would Deputy Lahart mind if Senator Conway spoke next?

I will be very brief. There are three components to the question I want to ask. The first, on the effect on children, was asked by Deputy Hourigan. Senator Hoey highlighted the area of rural isolation, which was the other aspect I wanted to talk about, but I do not believe in repetition so I thank them for that.

I would like the witnesses' observations on the third issue, which is the number of NGOs which do great work in the mental health area. Do they believe that within the current NGO structure there is more room and opportunity for co-operation? Could some of the organisations come together and pool their resources and perhaps have a more focused approach? Is that a body of work that could be carried out in terms of research and perhaps a report on it by the subcommittee on mental health if we go ahead and set it up?

Mr. Martin Rogan

It is a well-made point. At the most recent count there were more than 1,000 agencies active in the mental health and suicide prevention space in Ireland. That can be a bewildering array for a person in distress and in difficulty and it is not always clear which agencies have the firepower, sustainability and skill sets to support them in their needs. There is an opportunity to rationalise and to come together.

We are also very mindful that, at a community level, when there has been a distressing incident such as clusters of self-harm, that mobilises people who want to do something. Our role as national organisations is to work with that sentiment and translate it into credible and sustainable programmes and tasks. Much of that is evidence-based. At Mental Health Ireland, we have developed programmes, for example, with Professor Margaret Barry in NUI Galway, to develop an online programme to train people in mental health promotion. There are many very well-intentioned but ill-founded initiatives in this space. At best, they are a distraction, and while well-intentioned, they just do not have the firepower or the evidence underpinning-----

If I may interrupt because I am conscious that I am eating into another member's slot, that is the nub of my concern in that there would be a tragedy within a community and, out of that, people set up an organisation with the best intentions but which does not achieve the purpose of its establishment. I believe that the conversation about reforming that needs to come from the witnesses' sector. We cannot be seen as the big, bad politicians who create an environment where that is not acceptable or where it is seen as encroaching. I refer to proposals coming from the sector on how the aftermath of a tragedy can be properly channelled. I can name many organisations that were formed as a result of a tragedy. I could not question the motivation or the intention of those who formed them but one would have to wonder if they achieved the purpose for which they were set up.

Mr. Martin Rogan

In the area of self-harm, the policy framework is called Connecting for Life. That title is very deliberate. It is about connecting, coming together, taking that energy and working very closely to develop that. I am sorry about the background noise. It is also about ensuring there is a vision and the HSE being very clear about the services it is commissioning, that they are well structured and, through charity regulation, that they have proper governance arrangements in place and can sustain themselves to support people at a vulnerable time for people with significant mental health needs.

I will have to try to get one of those bells we heard in the background that I will be able to ring when the speakers go over time.

I thank the contributors. It has been a very rich session. I had been listening to it and came down for this slot. We will have to come back to it because it is one of those important issues. In response to a number of the comments the witnesses made, it strikes me that some of the messaging around adolescent and youth mental health ought to be directed at adults, especially in terms of cutting them some slack. As a constituency Deputy, residents and residents associations often give out about teenagers gathering or prowling. That is the kind of language they use but we all did that.

I am always very taken with the language. When one asks whether there is an end result to this gathering and prowling, one is told it very often just amounts to gathering and prowling. It is not prowling, obviously. Occasionally, there are antisocial elements but they tend to comprise a very small minority. Some of the messaging needs to be directed that way. Last Sunday, Dr. Tony Bates was, as always, particularly good in describing the space the generation in question finds itself in. Despite some of the commentary on the figures, one can safely make the evidence-based statement that younger people are a little more resilient than others where Covid is concerned by virtue of their age. That is not to say that there are no exceptions. The young may be very concerned about their parents or grandparents, however, and may experience awful guilt, worry and anxiety if socialising for fear that they will bring Covid home. They may not fear for themselves - the majority do not - but they fear for family members whom they know or feel are vulnerable. This is a pretty weighty thing for a teenager.

I could talk for an hour based on what the witnesses said, as could my colleagues. The primary care system works really well. What is the position on an ordinary teenager who does not present to a GP and consequently does not end up in the services? How does the mental health message get through to such a person? I refer to someone who may be struggling a little and looking for a little advice.

On loneliness, for decades it was difficult for someone to say he or she was depressed. Thank God, we have moved beyond that. If someone said he or she was depressed, it was as if there were a great parting and people drifted away from him or her. I believe it is much more difficult to express a feeling of loneliness. We have to challenge that. When someone says he or she is lonely, people begin immediately to stand off as if it were a spreading disease. Loneliness may be felt by every generation, from the very young to adults. I am interested in hearing the witnesses’ views on that.

With regard to the figures on self-harm, how does self-harm manifest itself physically among those from 15 to 24 years?

Maybe my next question could be responded to in writing. I am really interested in hearing the witnesses’ views. It was mentioned that there is a large number of agencies in the mental health sector and that there is an opportunity for rationalisation. I am glad this was raised. How would rationalisation work? I am particularly taken with the language used around firepower. I am aware of what is being suggested but could it be explained because it will be on the public record? Some agencies have the firepower, in other words, the backup and resources, particularly human resources, to deliver. It is important that the witnesses qualify the statement that while some of the organisations are well intentioned, they may not be operating according to an evidence base and may be without the firepower. This is a very important message for the public to get.

Dr. Joseph Duffy

I will respond to the first question and then hand over to Mental Health Ireland. On messaging, the Deputy may be asking about the average 14 year old who may have some concerns or worries and about how the message gets to him or her. Within Jigsaw, we did strong work with schools, under our One Good School programme, to support young people. There is a large body of evidence emerging that suggests peer support and influence make a genuine difference for young people in getting the message out. There is a point to be made on accessing support directly online without a referral, as my colleague, Mr. Longmore, mentioned. One of the main initiatives on which we have worked with the FAI, Rugby Ireland, the GAA and the Ladies Gaelic Football Association concerns the One Good Coach programme and mentoring process. It is about being available in the community and being able to support young people. It is amazing to learn from young people where they hear the message. It might be from an advertisement by one of our corporate partners, such as Lidl. Young people are open to and receptive to listening to the messages.

I will hand over to Mr. Rogan to respond to the last question.

Mr. Martin Rogan

Isolation and loneliness comprise a major issue. There has been a stigma associated with acknowledging or recognising that one has become disconnected. This is not unique to older persons or those who have experienced a bereavement. We are aware, for example, that many migrant workers in Ireland have no social networks. They go to work, go back to their accommodation and go to work again the next morning. They are not in any way connected to their community. They are often quite isolated. There is a sociological phenomenon known as anomie whereby people just do not feel connected in any context. They appear to be at the centre in their workplace, GAA club or family but never feel a sense of belonging or connection. That is really harmful to mental health and very closely associated with self-harm. Increasingly, as is recognised with political radicalisation, people often derive a sense of belonging from getting involved in very extreme groups with unique views. It is not necessarily their preference but it is where they are made feel at home and welcome. This is a real challenge. I have been at meetings with Interpol on how people can become susceptible to being radicalised because they are disconnected and do not identify with their natural community. Covid shone a bright light on this. It is evident across all life stages.

With regard to the potential to rationalise the number of agencies in the mental health space, I want to be very clear that I am not in any way disparaging of the absolutely genuine commitment of people who want to respond and reach out in a helpful way in their communities. Mental health, however, is a technical discipline. There is a scientific base, and people bring an empathetic understanding as well as an information-based understanding. Where there has been a tragedy, people often come together and want to respond, which can prevent further tragedies, but the question is whether an organisation has the necessary skill set, organisational shape and the staff to sustain it. One may end up with a multiplicity of small and fractured agencies, and it can be difficult for a person with an acquired disability, be it oneself or a family member, to know which agency is best able to help.

At national level, there are about ten agencies that the HSE funds and supports. They have a branch structure right across the country. They include Jigsaw, Aware, Grow Ireland, Samaritans Ireland and Mental Health Ireland. There is a range of agencies that are very well established and properly supported by the HSE. That is not to say that we are at the end of history because there will always be space for innovation, but there is also space for evaluation and ensuring the impact can be measured and that there is value for money. We do not want a replication of chief executive officer roles, head offices or photocopiers, for example. Much energy can be lost in that emergence. The new policy is clear about this. We need to raft-up and work more closely together. We need to be much clearer about our role, focus and intention. In our organisation and strategy, we have been clear that our role is promoting positive mental health and well-being and supporting people in recovery. We have a suite of programmes and projects that fit absolutely in that space. We collaborate very closely with Dr. Duffy and his colleagues in Jigsaw and a range of other agencies in the mental health sector and beyond. It is an acknowledged role. We would certainly welcome an open and adult conversation about this. We certainly would not be found wanting. Mental Health Ireland was established in 1966 and has a presence throughout the country. We would be very happy to assist anyone who wants the conversation.

I thank the witnesses for their presentations, which were excellent. I also thank them for their great work.

I want to speak specifically about the impact of Covid-19 on mental health. The scale, speed and nature of the Covid-19 pandemic are beyond anything that most of us have experienced in our lifetimes. The mental health issues associated with the pandemic are likely to surpass any previously experienced so it is vital that we get ready for them and work on the recommendations on how to prepare for a significant increase in mental health services demand.

I want to mention the groups of individuals who may experience certain mental health challenges brought on by the crisis.

They include the vast number of people who have lost their jobs or who are at risk of losing their jobs; individuals who have been separated from loved ones, or those who have lost loved ones to Covid-19; healthcare workers and first responders who are operating under tremendous stress; children and young people because they cannot socialise with their peers; parents of children and young people who are struggling; women who face a heightened risk of domestic abuse; older people; and individuals with pre-existing mental health issues. The list goes on. It is beyond my own comprehension sometimes. I am concerned.

I am aware that the Tánaiste and the Taoiseach have both said recently that mental health is really important at this time. They have highlighted it in many of their speeches. Fiona Coyle, CEO of Mental Health Reform, has said:

The Government says it understands how important mental health is. Yet, its Winter Plan did not include mental health. Now, just days remain to Budget 2021. €30 million is only enough to deliver a standstill, stay-as-you-are service level for mental health. That wasn’t good enough in good times. With COVID-19 now placing huge pressure on our people and our services, at least €80M will be required on Budget Day.

I have a few questions that I will throw in together and perhaps Martin and Joseph will respond. Why do the witnesses think that mental health is not prioritised, particularly in the Covid pandemic and the winter plan? Waiting lists were extremely high before the pandemic. Some 10,000 people were waiting for primary care psychology services and 2,000 children were waiting for child and adolescent mental health services, CAMHS. How is Covid-19 likely to impact these waiting lists and what can be done to address this?

Sharing the Vision has addressed an important exclusion in mental health services of people with addiction, but there is no sign of implementation of a no-wrong-door approach for a dual diagnosis. With signs that drug and alcohol use are on the rise due to Covid-19, what will be the impact of our poor service provision on people?

I know I have thrown in a lot there and that we do not have a huge amount of time. Unfortunately, because I am an Independent I am at the end of the committee. I will have to fight that with our Chairman at some point. I have thrown in a lot but the reason I ask is because we need to prioritise mental health. This is why the subcommittee is absolutely vital.

Mr. Martin Rogan

As Senator Black has pointed out we are in a completely unprecedented uncharted space. We get that. There has been quite a degree of movement and unsettling right across the population. Ireland is a small island so we have interacted with international colleagues. For example, we know that since January, 28,000 papers have been published on Covid, but just 26 published on the impact of Covid on mental health. There is a lot more work to be done in understanding this. Some of it is anticipatory anxiety. These are people who have not been touched by the situation but are fearful of it. There is also the issue of isolation, which we referred to earlier, and the loss of social contacts. Mental Health Ireland has seen a particularly stark aspect whereby due to some of the necessary precautions, some of the natural, organic coping mechanisms that a person would include in this or her life were removed. These include sports activity, culture, choir practise, and other social contacts. When they were removed the person suddenly began to decompensate. To visualise this, imagine the game Ker-Plunk, where one takes out the cocktail sticks. We remove some coping mechanisms and get by, but sooner or later the wrong one will be taken out and a person can get a very dramatic effect. We see people presenting with anxiety, depression and quite fearful beliefs for the future.

We have also had the opportunity to work with some US colleagues, including Joshua Morganstein and Brian Flynn. They are experts in the whole area of mental health and disaster management. A big concern for them is that the duration of the crisis makes it so difficult for people to cope with. These gentlemen are dispatched when there has been a huge weather event, a school shooting or a terrorist event. They guide people through the mental health sequelae of these events. They recognise that the duration of the Covid experience is an issue. We do not know yet if we are mid-way through it or towards the end or towards the start. This makes it difficult to pace ourselves in that space.

We also do not expect to see people presenting with significant psychiatric need. There is a certain regularity, and even at times of war and conflict, levels of serious mental illnesses such as schizophrenia, depression and bipolar conditions, remain remarkably static. However, the quality of life, and the experience of people in the wider population can be seriously undermined by Covid. We see this in very subtle ways in domestic strife, irritability, loss of productivity and a sense of being overwhelmed. This is why broad, community-based models, which have responded to tragedy and difficulty, are a natural, organic coping mechanism. It is important that we do not interfere with these mechanisms, that we support them and do not try to displace them in any way. It is a very important piece, and something we are closely monitoring.

I shall now turn to the new funding and the funding applications. We met with the Minister of State, Deputy Mary Butler, recently. The Minister of State referred to the winter funding and said that while mental health was not explicitly mentioned, it is a component of community-based services. In next Tuesday's budget it will be really important that there is a significant piece so that we can begin the exercise of implementing the new Sharing the Vision model. If we are overlooked and if the existing level of service cannot be maintained, or if there are some additional costings associated with working in the context of Covid, that would be hugely disheartening for the 1,200 people who are active in bringing together the document called Sharing the Vision. As an exercise in co-production, in building trust and relationships, and for the momentum needed to implement this, it is absolutely essential there is a strong signal next Tuesday in the budget. Otherwise we will just have faint praise and empty rhetoric, which is simply not good enough for the people who need services and for our wider population, who are really unsettled at this time.

Dr. Joseph Duffy

When we think about mental health in Ireland, traditionally it has been out of mind, out of sight and out of town. The large psychiatric hospital model of care is a really strong legacy. It is hugely important that mental health is valued. The work of this committee, and the idea of setting up a subcommittee, are hugely important steps. Ireland also has an opportunity, as I said earlier, to lead the way, especially in early intervention and prevention work. This is the work we do in Jigsaw, the work done in health promotion with Mental Health Ireland, and the work done through Mental Health Reform in looking at the sector. There are a number of agencies that work incredibly positively. I hope we can end on a positive note. There is a lot of work, a huge amount of commitment there, and a huge amount of innovation in what we can do. We need significant backing from the Government in funding for this, and for the funding to be put on a consistent and year-on-year basis.

Ms Gina Delaney

It is also important that we have co-production in everything we do. Any groups that are set up, such as the Oireachtas mental health subcommittee, will need to have lived experience, family member experience and NGO representation on all of those groups. This is where it can be ensured the committees hear the voice of actual experience. This can then influence services. Having co-production and lived experience as part of everything we do will make sure that we influence things in the right way.

Mr. Paul Longmore

As referred to in the preamble to Senator Black's question, the scale of the challenges can feel a little overwhelming for us. In the face of that there may be practical and tangible actions we can take. We can look to see what is working and what has worked well within our system, and then look to put the resources in to offer those things at scale. This includes working very much with communities. I do not think we can do this without engaging whole communities. The days of addressing mental health difficulties purely in individual clinical settings are behind us. We need to see what has worked, what works well, what we have evidence for, and then put our money where our mouths are to offer these things at scale. We know the demand and the requirement for mental health services is only going to increase.

We will finish on that note. I thank the witnesses. We got a sense of the challenges facing many families and individuals. I do not know if we captured the desperation and difficulties being endured by many families at the moment. There is a huge challenge still there in how to access services, where to go, where to go in a crisis and so on. We can all accept that in the past we have let down those people who have looked to politicians for supports. In their contributions the witnesses spoke of the amount of resources being only at 60%. This is 40% still needed. That is the message, if there is one at all, with regard to the budget.

To sum up, will the witnesses clarify their specific asks of the committee?

Maybe the two groups could respond to that in 30 seconds. They might also take up the invitation from Deputy John Lahart and write to the committee to put forward in more detail what areas they think the sub-committee should look at. If the groups take 30 seconds each, they might sum up for us.

Dr. Joseph Duffy

What is very important is that we think about mental health as a system of care. In Ireland, we have had very traditional models in our heads, so we would see Jigsaw as being at the early intervention side and see that long-term term care is at the other end. It is very important that we understand that and then fund it appropriately, and look at what is the evidence base and where we can be international leaders in this regard. With regard to the sub-committee structure, it is a question of looking at the evidence and asking agencies to produce the evidence, which would be very illuminating, and it is very important we are able to do that. There is a lot of work to do but there is huge energy from people to be able to do that work.

Mr. Martin Rogan

It is important to say that much of the work is contained in the Sharing the Vision document. There are some 100 recommendations so there is a risk this could be considered overwhelming, which is why it is broken out into short-term, medium-term and long-term goals. It is very clear about having a strong implementation of that approach and that it has the confidence to take on these challenges. As we have seen this morning, there is a huge willingness and a huge political interest in this area, but it is now time for action. We need to move beyond discussion and debate. We can have our disagreements and we can have our view, but let us disagree and then commit. We know what Sharing the Vision is proposing, we know what people in the youth services want, what families want and what communities want. The option now is to get on and do that.

I am very encouraged. I have worked in the area of mental health for approximately 35 years and this is one of those seminal moments where we can make a real change. The prospect that we can treat our way out of this is not realistic. We need to look again at how Irish people live their lives, whether that is conducive to their health and whether it supports their good mental health. I am confident we can do this.

I thank all our speakers. The committee will adjourn until Wednesday, 14 October, when it plans to get an update on Sláintecare.

The joint committee adjourned at 1.32 p.m. until 11.30 a.m on Wednesday, 14 October 2020.