JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 22 Apr 2004

Mental Health Services: Presentation.

Acting Chairman

I welcome Dr. Kate Ganter, chairman; Dr. Brendan Cassidy and Dr. Stephen Browne of the faculty of adult psychiatry; Dr. Harry Kennedy of the faculty of forensic psychiatry; Dr. Oonagh Bradley of the faculty of child and adolescent psychiatry and the faculty of learning disability; Dr. Margo Wrigley of the faculty of the psychiatry of old age, and all from the Irish College of Psychiatrists. I invite Dr. Ganter to commence the presentation on the current and future implications of the continuing lack of resources provided for mental health services.

I draw the attention of those present to the fact that while members of the committee enjoy absolute privilege, this privilege does not apply to witnesses appearing before the committee. Members are also reminded of the long-standing parliamentary practice that they should not comment on, criticise or make charges against a person outside the House, or an official, by name or in such a way as to make him or her identifiable.

Dr. Kate Ganter

We thank the Chairman and members of the Joint Committee on Health and Children for agreeing to meet us and affording us the opportunity to share the concerns of the Irish College of Psychiatrists about the deficits in mental health services. We propose to illustrate to the committee the deplorable state of the services.

This year only one area in psychiatry received an increase in budget - the much needed funding for the development of forensic services at the Central Mental Hospital. No other service received an increase. This is in contrast to other specialties in acute hospital settings.Funding for the mental health service dropped from 11% of the total health budget in 1997 to 6.6% in 2003. The level of increase in funding of psychiatry is the lowest of all the medical specialties. Why is this happening when the reports of the mental health inspector show that there are major deficits in the service and make recommendations for the development of community services and the full establishment of multidisciplinary teams?

Mental health is a serious public health issue. Although mental ill health affects one in four of us during our lifetime and causes more disability than lung problems, the development of services is neglected year after year. Members of the committee may not be aware that four of the ten major causes of all disability are due to psychiatric conditions: unipolar depression - the most frequent, bipolar disorder, schizophrenia and obsessive compulsive disorder. Alcohol use is also on the list. The burden of psychiatric illness has been underestimated for too long. According to the World Health Organisation, psychiatric conditions account for 19% of total disability and 10% of people with a severe mental illness die by suicide.

Planning for the Future, published in 1984, recommended the development of multidisciplinary teams but this suggestion has not been implemented. The Irish College of Psychiatrists has called for the Higher Education Authority to develop the postgraduate training of clinical psychologists. Just over 20 places are available, even though it is recognised that at least 50 are needed to keep services at the present level, regardless of the need to produce a sufficient number of trained clinical psychologists. About 100 places are required annually to ensure their skills are present on each clinical team. The Irish College of Psychiatrists has asked the Department of Health and Children to develop psychotherapy by establishing consultant psychotherapists, given that no such posts exist in Ireland. The inspector of mental hospitals, the Irish Psychiatric Training Committee and the Irish College of Psychiatrists agree that psychotherapy services and training are of paramount importance. Such training is mandatory for basic general training, as well as higher training, but almost all areas of the country are unable to meet the required standard.

The results of a recent questionnaire sent to all consultant psychiatrists demonstrate that there is a strong negative correlation between team size and the rate of psychiatric admission in each of the health board areas; that there is a significant correlation between the size of the clinical team and the number of non-drug treatments provided for patients; that the size of clinical teams differs significantly between health boards, that there is a fourfold difference in personnel numbers between the most and the least resourced team; and that there is an inequality in the development of multidisciplinary teams between health board areas. Psychiatric services are under-resourced. The research I mentioned shows that the size of the psychiatric team influences outcomes, whether patients are admitted to hospital and offered a full range of treatments. Some 83% of consultants have no access to a psychotherapist, 76% to a family therapist and 33% to an occupational therapist.

There are inequalities in the funding of mental health services across health boards. Urban areas receive half the funding per capita of rural areas, on average, but urban areas have twice the rate of severe mental illness compared to rural areas. While €100 per head is provided for 100 ill people in an urban area, €200 per head is provided for 50 ill people in a rural area. The Irish College of Psychiatrists wishes to make clear that it is not saying rural areas are adequately funded but that they are not as badly funded as urban areas.

The long-term neglect by the Department and politicians of mental health services has been highlighted in Mental Illness: The Neglected Quarter, a report produced by Amnesty International Ireland. Although reports such as, We Have No Beds, have been published, little has been done to implement the numerous recommendations which have emerged. Mentally ill patients comprise a vulnerable and marginalised group which is stigmatised in society. Such inactivity further compounds these problems.

The review of acute bed capacity specifically excluded psychiatric beds. Therefore, the agreed 3,000 extra beds do not include any psychiatric beds. A Department of Health and Children study has shown that 45% of acute psychiatric beds in the ERHA region are blocked. In some cases, beds are provided in facilities that are poorly maintained, badly lit, cold, damp and outdated. I am sure that if one were to visit any of the facilities, one would be shocked. There are inequalities between health boards. There are 50% fewer beds per capita in the eastern region than in the rest of the country. There are 2.4 times as many community residences in non-ERHA areas as there are in the ERHA region.

The second report of the working group on child and adolescent psychiatry which examined the deficit in services for 16 and 17 year olds was published in June 2003. Although the report highlighted the need for the development of services, no money was made available in the 2004 letters of determination. Families have started to publicise this dreadful gap in service. When adolescents require a psychiatric service, they generally require it immediately.

The Irish College of Psychiatrists recommends that a service be provided for those between the ages of 14 and 18 years. The working party's first report recommended the establishment of seven units to provide a total of 144 beds for those under the age of 16 years. There are approximately 20 beds in the whole country. When those between the ages of 16 and 18 years are included, it is clear that an extra 80 beds are required, or a total complement of 224. These figures speak for themselves.

Services for children under the age of 16 years are compromised by the lack of adequately resourced outpatient multidisciplinary teams. As a result, the waiting period in some areas is more than one year. There is no national database. We recommend the establishment of a database in line with a recommendation in the second report but no funding has been set aside for this initiative.

The Irish College of Psychiatrists agrees with the second report's recommendation that all mental health services - child and adolescent and adult - should be managed under a single management structure in each health board area, or region as may be the case in the future. Specialist services should come under the same management structure. There are many good reasons a single management structure is needed, the principal of which is that it would enable easy transition across services and access from one service to another.

Although there is a higher prevalence of mental illness among people with an intellectual disability, there is a lack of awareness and recognition of the need for mental health services for them. Mental health services are poorly developed and resourced, with large variations across the country. No health board has an adequate number of multidisciplinary teams with the specific remit of assessing and treating mental illness among such persons. There is a need for a catchment area based mental health service to promote the development of a multidisciplinary mental health team, providing for psychotherapies and a range of treatment settings.

While progress has been made in developing specialist mental health services for older people, there is no service in substantial regions of the country such as counties Kildare, Wicklow and Kerry and most of County Cork. The longest established and busiest services in Limerick and Dublin need full resourcing of multidisciplinary teams, including additional consultant psychiatrists.

Forensic services are poorly developed outside the Central Mental Hospital. Some 20% of people in prison and 8% of those on remand are mentally ill. Some 5.8% of sentenced prisoners are psychotic during a six month period. There is a need to address severe and enduring mental illness among such persons and to develop humane secure psychiatric services with fewer mentally ill people in prison.

It is right that there is growing concern in communities about the problem of drug and alcohol use by teenagers. There is a need to deliver an integrated, comprehensive national response to the problem. Specialist adolescent addiction services are required. Many of the targets in our excellent national drugs strategy which covers the period from 2001 to 2008 specify responses to drug and alcohol use by young people. However, we need the funds to deliver on the strategy's targets. There are 12,000 heroin users in Dublin. There is also considerable abuse of other drugs, including alcohol. The health of the nation is burdened by the problems associated with substance and alcohol abuse. Evidence shows that there can be significant savings to society when effective interventions and therapies are promoted and made available. The under-funding of such services makes no financial or medical sense.

The chairman of the Mental Health Commission estimates that there will be over 3,000 annual hearings at the mental health tribunals as a result of involuntary admission. All of the cases in question will be acute. We are already understaffed and the implementation of the Mental Health Act 2001 will create a further burden. The Mental Health Commission has made public the fact that its lack of funding is slowing progress. If we are not funded at local level, the work entailed in complying with the Mental Health Act 2001 will remove services from other patients.

As I said, 6.6% of the health budget is spent on mental health services, compared to 13% in the United Kingdom. The increase in the budget is by far the smallest in the last five years for any programme under the Department of Health and Children. Overall growth in the non-capital health budget between 1990 and 2001 was over 300% but only 131% for psychiatry. During the Celtic tiger years, 1997 to 2002, the increase in overall new capital expenditure was 120%. For psychiatry, it was 74%. When adjusted for inflation, the overall increase was 72% but only 36% for psychiatry. Quality community-based care costs as much as in-patient care. While outcomes are similar, they are better socially and vocationally. While the move to community care will not save money, it will provide a slightly better outcome.

The national treatment purchase fund and waiting list initiatives have never been available to mental health patients, even though there are many areas of psychiatry in which there are waiting lists. Child and adolescent psychiatry is one such area in which there is a waiting period of one year and more. In a number of health board areas many are waiting for psychotherapy where it can be provided. The clinical psychologists and psychotherapists who provide such services are thin on the ground. Of 400 clinical psychology posts funded, 180 are vacant. As described, it is difficult to recruit qualified staff as an insufficient number are being trained. More recently, the cap on manpower numbers has meant that when someone vacates a post, he or she is not replaced, regardless of the needs of the service. This reduces the breadth of treatments available within each specific catchment area and produces inequities across areas. Recruitment problems are outlined in the document circulated to members.

While we acknowledge the financial constraints under which the Government operates, we do not seek high cost technology. Our aim is simply to restore equity and provide the staff who can make a difference to the lives of a large number. We welcome the fact that a Minister of State has specific responsibility for a mental health services brief. We also welcome the establishment of the expert group. The Department should note that we require specific representation at the management advisory committee as the chief medical officer and his assistants do not deal with mental health issues. We suggest that either one of the assistants to the chief medical officer or the inspector of mental health services should have a specific brief for mental health at the committee.

In summary, we have 17 recommendations. We recommend that all mental health services be managed and funded under the directorate of the national hospitals office. There should be specific representation at the management advisory committee by one of the assistants to the chief medical officer or the inspector of mental health services. The funding level of 6.6% of the total health budget must be reviewed. The cap on manpower numbers relating this to specific service need should be removed. The inequity in services, including bed provision, across health boards and regions should be addressed. The Department should fund and develop inpatient units for children and adolescents and adolescent services. Psychotherapy services, including consultant psychiatrists in psychotherapy, should be developed. The Department should fund innovative schemes supported by the health boards and regions such as DETECT. Resource services for prisoners should be provided.

Mental health services for people with intellectual disabilities should be funded and developed, as should such services for older people with mental illnesses. There should be greater investment in alcohol and drug treatment programmes. Multidisciplinary teams in all age ranges and specialist services should be developed while a database for services for children and adolescents should be established. Specialist adolescent addiction services must be developed while services should be provided through the national treatment purchase fund and the waiting list initiative.

Acting Chairman

Before opening the floor to members, I convey apologies from Deputy McManus, the Labour Party spokesman on health, who cannot be here today. I welcome the Chairman, Deputy Batt O'Keeffe, who will be taking over shortly.

Deputy O. Mitchell

I welcome the delegates and thank Dr. Ganter for her presentation which was absolutely damning. It mimics presentations we have had heard on all specialties. When one considers the 17 recommendations made, it appears every aspect of this specialty is underfunded. While there are dozens of questions I would like to ask, I will concentrate on a few.

I am a little surprised by the first recommendation that mental health services be placed under the aegis of the national hospitals office when the trend is to remove people from hospitals. At least, that is what I understood to be the objective.

With approximately half of the psychiatric beds blocked, one can see there is a major crisis. Was the decision to take patients from residential care, particularly in the institutions, made without adequate preparation in terms of sourcing alternative accommodation in the community? As a public representative, I hear from many distraught families about mentally ill persons who are not receiving treatment and have nowhere to live. I am sure the same is true of other members. While the housing problem has nothing to do with the Irish College of Psychiatrists, solving it forms part of treatment. I would like to hear the opinion of the delegation on this.

The problem with manpower shortages does not simply involve money. There is an insufficient quantity of trained staff. Is that where we should concentrate our efforts? Is addressing this issue the key to providing services? In considering the 17 recommendations, should one start with training? I understood there had been an increase in the number of training places for psychologists but I may be wrong. According to the Minister, the number has doubled. Is it the case that clinical training places are unavailable?

While many worrying points were made, a significant one was that medication was being used instead of one-to-one treatment by a psychologist or psychiatrist. Patients are being given tablets because there is no one to give them anything else. There are dozens of questions I would like to ask but these points are enough with which to go on. What should be our priority? Where should one start?

Deputy F. O’Malley

I thank Dr. Ganter for her presentation and agree with Deputy Mitchell. To read the document provided is shocking. Mental health is a difficult issue which people do not understand. It is very complex. It touches many of our lives and families but due to stigma is not openly discussed. Due to its complexity, in many ways I am loathe to ask questions which may be simplistic. The range and breadth of the specialisms of the delegates alone astound me.

The facts and figures are appalling. Mental health was always neglected, largely because those who suffered were put away and left isolated. With the provision of care in the community, we have had to open the doors and consider different ways to provide treatment. The funding level of 6.6% of the total health budget is atrociously low. As a public representative and member of the Joint Committee on Health and Children, I did not realise the share of the budget was that low. Today's presentation has been very valuable in highlighting this fact to those of us who should know the how poor is the proportion of the budget.

I was surprised to hear there were waiting lists. It would not have occurred to me that the national treatment purchase fund could be used to address certain types of mental illness. If there are waiting lists, why is it not being used? I am sure there is no provision which prevents it being used to deliver treatment for psychiatric illnesses. Presumably, patients require a great deal of intensive care close to where they live, making it unsuitable to send them away.

Has the list of recommendations Dr. Ganter outlined to the committee been costed? The cost is always the bottom line with the Government. It is particularly the case with issues as complex as mental illness that economics and costs are not the priority. I would be interested in hearing what the costs might be as we need to know what the bottom line is to improve services. I thank Dr. Ganter for her presentation.

Deputy B. O'Keeffe took the Chair.

Chairman

I apologise for being late. Will the representatives also address the relationship between mental health, acute treatment and community care? Throughout the presentation, the sector is described as the Cinderella of the health service which does not get its fair share. Will Dr. Ganter address the issue of returning people with mental illness to the community? Perhaps the emphasis on this approach has been the reason for the decrease in the need for acute psychiatric beds. How does this approach impact on the delivery of psychiatric services?

Dr. Ganter

The first question asked was the reason we recommend that mental health services be placed under the directorate of the national hospitals office. We thought long and hard about this issue and our position does not mean we are moving away from our wish to be a community based service. It is often not recognised that it is an acute specialty, an issue not addressed fully in the paper due to time constraints. Although we work in the community, we also work within the hospitals structure in acute units. I hope nearly all of our acute services will be located in general hospitals in the next few years, rather than stand-alone specialist units. That is the direction in which we are moving.

The vast majority of those treated live either in their own homes or residential settings. The difficulty is that moving people from acute hospitals such as old psychiatric hospitals has resulted in a reduction in the number of beds defined as acute; hostel and residential placements are still required for a certain number of these patients who in many cases will need to spend a significant portion of their lives in such facilities.

Another reason for deciding to come under the aegis of the national hospitals office relates to our view of how working in the community fits in with the hospital model proposed in the Hanly report which envisages a network of major hospitals surrounded by local hospitals. Similarly, we operate comfortably in local hospitals surrounded by satellite clinics. We envisage working primarily in this kind of setting, from which we will move out. My colleagues in general adult psychiatry will speak to this issue further.

I envisage that the model I have described, with its strong links to primary care, will increasingly become the model for physical medicine, although not for surgery. Cystic fibrosis, chronic lung disease and chronic cardiovascular services will operate within this kind of model. In future, therefore, greater attention will be paid to the way we operate and the structures we have developed in our services. I believe they will offer a blueprint for the future for other medical services - the main reason for our recommendation as regards the national hospitals office.

We also believe our services could get lost if we were to move to the community setting. I will not go into more detail on that issue because we could discuss it for a lifetime. Dr. Stephen Browne will now address questions on residential and adult psychiatry.

Dr. Stephen Browne

There were approximately 20,000 patients in psychiatric hospitals 30 years ago. This number has dramatically decreased through de-institutionalisation. The issue facing us now is how to deal with incident cases, that is, new cases of a condition identified. There is a concept known as the new long-stay patient. This means that in a service which looks after about 100,000 patients per annum one or two patients will require long-term care in a psychiatric institution, hostel or group home. One of the difficulties we have identified from the survey of public psychiatrists we carried out in 2002 is that 35.6% of them had no access to a high support hostel, 47.5% had no access to a medium support hostel while 44% had no access to a low support hostel. These figures relate exclusively to those who have no access. The partial access available to others may not meet the needs of their patients.

We carried out the research to highlight two facts. If there is inequity between health boards in the development of multidisciplinary teams, one of the fundamental questions to arise is what effect such inequality has on patient outcome. For the first time, we have been able to show that admission to hospital is not based purely on an individual clinician's threshold for admission. Given that some psychiatrists admit many patients to hospital with others more community oriented, admission is not solely a product of the number of beds at one's disposal. We have shown that multidisciplinary teams have an independent influence on determining admission rates between individual health boards. This influence persists when one controls all potential confounding variables, including deprivation indices and rates of provision of hospital beds.

The second point the research highlights is that multidisciplinary teams vary dramatically throughout the country. Because of the correlation between a team and the number of non-pharmacological treatments provided, we asked whether we are giving drugs when we should be giving talking therapy. This was shown not to be the case.

Psychiatric illnesses have their aetiology in biological, psychological and social factors. Therefore, our treatments are biological in the form of medication, psychological in the form of talking therapies such as psychotherapy, and social, which involves addressing issues within the family, homelessness and so forth. The basic fundamental components of a multidisciplinary team are a doctor, nurse, psychiatric social worker, psychologist and occupational therapist. The problem is that 20% of public psychiatrists do not have access to a psychologist and this figure does not include those who have some access. This means, for example, that a public psychiatrist could find that a catchment area of 100,000 which has four or five general adult psychiatrists will have just one psychologist. A person working in such an environment would technically have to indicate on the survey that he or she had access to 0.2 psychologists or 20% of one psychologist. The figures we cite refer to those who have no access to a psychologist but many psychiatrists have access to far from ideal levels of psychology.

As regards access to social work, 13.6% of respondents have no access to a social worker while 30% have no access to an occupational therapist. In terms of my treatment of my patient, I will devise a treatment plan which addresses his or her pharmacological, psychological and social needs. If I do not have the other members of the multidisciplinary team available to me, I am somewhat stymied in the treatment I can provide. If I have far from ideal access, I have to put the patient on a waiting list, which means he or she must wait for long periods to get access to a psychologist. In the treatment of depression, for example, the evidence shows that pharmacological therapy plus psychotherapy is better than either therapy alone. That is not to say, however, we give drugs and do not provide talking therapy. We try to treat patients in a holistic manner with an understanding that we are trying to address a medication, psychological and social need. The problem is we sometimes do not have access to the psychological and social treatments required.

Deputy F. O’Malley

Is mental illness preventable? If so, what can be done?

Dr. Brendan Cassidy

Certain aspects are preventable. One of our recommendations is early intervention for the treatment of psychosis. Research shows that the only indicator that shows how somebody with a psychotic illness, for example, schizophrenia will get on, is how long he or she has been unwell before he or she sees a doctor. The average is approximately one year or just over it. The shorter the period, the better they will do. That is the main determining factor.

In Australia and Scandinavia early intervention teams have been put in place to educate teachers, general practitioners and families to identify children at risk and have them seen early. The East Coast Area Health Board, with the child and adolescent service as well as the Cluain Mhuire service, put together a proposal to start such a programme in Ireland. While it was supported by the ERHA, it was turned down by the Department. It is policy in the United Kingdom that every area is to have such a team in place. However, we have turned down this innovative structure which covers all areas of psychiatry: adult, child, voluntary services, GPs and statutory services. Certain aspects are preventable and outcomes can be improved.

In response to Deputy O'Malley's question on the national treatment purchase fund, the Department measures waiting lists according to procedures. It does not measure them to see a specialist or counsellor but to have an operation or procedure done. If one is on a waiting list for over a year to see a consultant child psychiatrist, for example, this is not measured. Therefore, one does not have access to the treatment purchase fund.

With regard to how the fund can be used in psychiatry, as Dr. Browne said, we have plenty of individuals for whom we can provide pharmacological treatment. We would like to have certain talking therapy or psychotherapy available to complement this but we do not have the staff. Private psychotherapists and psychologists are available in the community. Why can we not buy eight or ten sessions for the individuals concerned? I cannot see the reason varicose veins are considered more important than depression.

Equity between services is what is at the heart of the matter. This demonstrates the inequity and the exclusion of mental health at departmental level. That is the message we need to get across. In the 1960s and 1970s inspectors of mental hospitals used to attend meetings of the management advisory group in the Department but they have not done this for the past 20 or 30 years. As the chief medical officer does not have responsibility for mental health, there is nobody shouting for mental health at departmental level. They are outside the game, the reason mental health is last in line all the time. We need somebody at high level meetings who has a specific responsibility for mental health services.

The issue of nursing home beds and bed blockages in hospitals was also raised. Some 20% of acute hospitals beds are blocked by persons who require long-term care, yet the report in the eastern region states 45% of beds in general psychiatric hospitals are blocked. There is an outcry when the figure of 20% is referred to but we hear nothing when the 45% figure is mentioned. Money was provided last autumn to provide nursing home care for patients in acute hospital beds, none of which went to psychiatry, in particular old-age psychiatry; it all went to medical and surgical facilities. It is important that we keep this in mind.

What committee members have heard from us is what will be heard from patients and their families. The same will be heard from GPs, nurses, social workers, psychologists, the Mental Health Commission and Amnesty International. Everybody is saying the same thing. This is not self-interest or professional self-interest. Indicative of this concern is that Amnesty International chose the issue of mental health as its first ever project based in Ireland - it usually deals with international issues - and its report is extremely valuable. I had the feeling when we met its representatives that it attributed much of the problem to psychiatrists but when it had completed its consultations, it was clearly of the view that the problem lay with the Department and that political neglect was responsible.

In regard to community care services, acute treatments and beds, as Dr. Browne said, up to now community care services have been removing patients from institutions in order to place them with appropriate services where they are treated. In recent years community care has revolved around the options that present when a GP refers a patient with an illness. We look to see if a bed is available or if we can provide care in the community that avoids disabling him or her and making him or her dependent by admitting him or her to a hospital. We cannot do this in every area because it relies on manpower and multidisciplinary teams. The options are provided by our home care teams which are up and running in certain areas through which nurses visit a patient's home once or twice a day. Patients can be brought on a daily basis to acute day hospitals staffed by nursing, medical and other staff. Such facilities have to be available 24 hours a day, including weekends. They are available to some extent but not in many locations.

When we talk about early intervention being the policy in every area in the United Kingdom, assertive outreach and crisis intervention teams are the others wanted. We do not have a crisis intervention team anywhere in this country. If there is a crisis in the middle of the night, there is nothing available until a patient is admitted, instead of having a team available which can deal with the matter and follow the person at home for the following two or three days. Once a person is admitted to hospital, everything is much slower as the staff are not available to deal with the matter. This disables patients and creates a dependency which is not in his or her best interests in the long term.

The big factor about community care is that it does not cost any less than what we are spending on beds. It does not give better outcomes in terms of illnesses but does improve a person's occupational, vocational and social skills and outcomes. It also has a higher rating among families and users as a more acceptable treatment method.

Dr. Browne

I wish to add one or two points to what Dr. Cassidy said. On the alternative to hospital, a place in the community where one would treat patients with the aim of keeping them at home and out of hospital, 27% of public psychiatrists have no access to a day hospital and of those who do, 22% rated the premises as either inadequate or totally inadequate.

One may hear of the concepts of home care and assertive outreach which can be effective but they are no more effective in treating a condition than routine hospital care. They offer marginal improvements in the individual's social and vocational occupation and quality of life. However, they are resource-intensive. The recommendation would be that one member of a team carrying out home based or assertive outreach work would look after 12 patients. If I were to apply this to my service, my time should increase by a factor of 20 or 30.

Chairman

We will not go down that road. We are trying to come back from it.

Dr. Browne

It is important to make the point: alternatives to hospital are not cheaper. Some say they are more expensive.

Dr. Oonagh Bradley

We have heard a lot about primary prevention of mental illness but secondary prevention is an important component. In regard to children, adolescents and those with an intellectual disability and a mental health problem, we are losing an opportunity to prevent secondary difficulties posed by long-term enduring illness and disabilities because many individuals do not have access to treatment either because they are on long waiting lists or because there is not a specific mental health service which can cater for their needs. It is important to remember this.

Deputy Neville

I thank the Irish College of Psychiatrists for its presentation. Psychiatry and mental health services have practically been ignored rather than supported. Representatives of the Irish Diabetic Association recently appeared before the committee. While we accept it is an area which is underfunded, the relevant figure is 10%. However, the relevant figure as given the by college for mental health services is 6.6%. They treat 25% of the population at some stage in their lives, which puts the matter in perspective.

We have been informed that one of the catalysts for changing the health service is the Hanly report. What was the delegates' input into the report and what output does it represent in terms of their recommendations for improving mental health services?

I heard one of the delegates say at some stage that they had 400 patients under their care. How could one adequately serve 400 patients suffering from psychiatric illness? Will the delegates outline the proportion of patients to each psychiatrist and how they cope with such high proportions?

The Mental Health Act 2001 deals with involuntary admission and related issues. When Deputy Mitchell and I were involved with the Bill in the Dáil, it was obvious that substantial investment was needed to ensure the procedures to protect those admitted to hospital involuntarily were in line with the requirements of the European Union. This investment has not been made. How can the Act be implemented without funding to put in place the necessary personnel?

Will the delegates comment on the fact that the level of suicide has become eight times greater in four decades? Up to 500 now die by suicide per year. In addition, 10,500 presented at accident and emergency units last year because of suicide attempts. Is there an estimate of the number who did not present at such units but who were treated by their general practitioners or those who did not present at all? Is there any way of establishing the true figure for those who attempt to commit suicide?

There is a perception that psychiatrists are slow and sometimes reluctant to communicate with concerned families to discuss their concerns. In general medicine, if somebody breaks a leg, consultants do not seem to have any problem telling the whole story. Even if somebody has cancer, nobody has a problem telling the mother, father, brother, sister, husband or wife of the patient about it. Why are psychiatrists so reluctant to open up in the same way?

Senator Glynn

I welcome the representatives of the Irish College of Psychiatrists and fully agree with them on the terms they used. Perhaps the phrase "Cinderella service" was not mentioned. Nevertheless, it has traditionally been a feature. However, having spent some 30 years in the psychiatric service, it would not be fair not to recognise that significant improvements have been made. It is safe to say much has been done but that there is a hell of a lot more to do.

One of the great misconceptions over the years was touched on in the 1994 report, Planning for the Future, of which I believe Mr. Liam Flanagan was one of the authors. It is a marvellous document in its own right but the misconception that originated at the time still persists. There is a belief that devolving psychiatric services to the community leads to a cheaper service. While it leads to a better service, it does not lead to a cheaper service. There was a debate at a health board conference during which the then Minister for Health and Children stated the hospital service was dearer than community care but Dr. Alan Maynard, a health economist from York University, clearly stated community care was better but dearer.

A number of events occurred around that time, as a result of which we are now suffering. First, a number of small nursing schools were closed. This ensured there was no intake into the psychiatric services for a number of years and that the age profile of many of the serving nurses became unacceptable. This is freely admitted by the profession, although it has been partly reversed, certainly in the case of the Midland Health Board. We started nurse training with a first intake of over 30 students.

The number of community residences established varies from health board to health board. In this respect, the Midland Health Board has been reasonably successful. St. Loman's has a department of psychiatry of later life. We also have child and adolescent psychiatry services. However, there has been a drop in the resources allocated to the psychiatric services, about which I have received representations from former colleagues. This is pertinent when members of health boards are formulating their service plans. When the allocation is made to the relevant board, it is then a matter for it to determine how it is spent. Unfortunately, the psychiatric services have not come out at the right end.

Chairman

I have to cut in because——

Senator Glynn

These are the points that need to be made.

Chairman

——we are subject to time constraints. The Senator should limit his contribution to questions on the presentation.

Senator Glynn

I will be asking questions. Why is the level of inappropriate occupancy of beds so high? Why are certain patients lodged inappropriately overnight and fully accepted by the staff of the various psychiatric hospitals, thereby preventing appropriate occupancy of beds by acute psychiatric patients? Why has the number of intervention beds in community residences not been increased? With the closure of psychiatric hospitals, there must be a corresponding facility provided in acute general hospitals. In many cases, this has been provided but in many more such a facility is pending.

The representatives mentioned local authority houses. Where patients have gone through the resocialisation programme in the various settings of the psychiatric service, the relevant local authorities have not responded in the way they might have in rehousing them. There have been some successes but not near enough. The number of community residences outside the ERHA region is greater. Why is the position so bad in the ERHA?

Is enough being done to exhort people to train as psychiatrists? I am delighted to see that one of the delegates' recommendations is that all mental health services should be managed and funded under the national hospitals office. I never agreed with the inspector of mental hospitals. To have such an inspector is to continue stigmatising psychiatric illness. It should form part of an overall directorate. I commend the delegates on this recommendation.

Deputy Cowley

I apologise because I must leave at 11 a.m. I am very pleased to be present as I have great admiration for the work of the Irish College of Psychiatrists.

As a GP for many years, I have seen at first hand the need for the mental health service and its deficiencies. The document laid before us is truly shocking. It shows that the level of funding has dropped from 11% of the total health budget in 1997 to 6.6% in 2003. This is amazing considering the gross deficiencies which have been pointed out. We have all these reports and recommendations, yet money is not spent to implement them. Therefore, what is the point in producing more reports?

The observation in the report that 45% of acute psychiatric beds in the ERHA region are blocked and that it is a question of freeing up beds is pertinent. A Green Paper on psychiatric services showed that the majority of long-stay patients in psychiatric hospitals - defined as greater than one year - are over 65 years of age and could be supported in the community if there was a place available for them. That is a terrible indictment of the system, although I acknowledge there is a move from the ancient, crumbling and decrepit institutions referred to in this shocking report towards brand new units in acute hospitals. Despite this, there are problems.

While I have great time for the work which our colleagues in the psychiatric service do, the scheme initiated at Mayo General Hospital was held up for two years because those involved looked for disturbance money. It the required the expenditure of €1 million in disturbance money before patients could avail of the service. The same happened in Carlow and will happen across the board in a service starved of money. A sum of €1 million was paid to staff to move a few yards down the road - the two hospitals in question adjoin each another. This is disgraceful given the money needed in the service.

Some 20% of prisoners are mentally ill, a terrible figure. If money was invested in the service, would we have so many in prison at such a huge cost, both in humanitarian terms as well as to the Exchequer? It seems to be a case of penny-wise and pound-foolish.

What is damning is that the Mental Health Commission has highlighted the lack of funding. When the Mental Health Act is implemented, the crisis will get worse.

Other members referred to the value of community care. If it cost twice as much, it would still be worth it because people want to be cared for in the community. However, in St. Brendan's unit in Mulranney we took in a number of psychiatric patients who were managed well in their own communities with support and ingenuity. In this context, sheltered and voluntary housing have a large role to play, as do communities where great work can be done.

Senator Henry

This is an appalling document. However, we already knew what the position was and no matter what warm feelings and sympathy we express to the delegation present, we must take some of the blame. I know that Senator Glynn passed some of it to the health boards but we pass the relevant legislation, which includes the Mental Health Act, even though we are well aware that the necessary resources will not be made available. The explanatory memorandum to the Criminal Law (Insanity) Bill currently before the Seanad states there will be no financial cost apart from the cost involved in setting up the examining committee. This is ridiculous because all legislation costs money. However, we must realise there are no votes in the issue because it does not matter how badly mentally ill persons are treated, the problem is hidden and not discussed publicly. This is a serious problem.

Every issue covered in the report can be described as very urgent. Those involved in the area of child psychiatry have been in contact with me to highlight the long waiting lists, even for violent children to receive treatment. The situation is dreadful at the Central Mental Hospital which cannot be knocked down because there is a preservation order on it. At the same time there are seriously ill persons in our prisons. There are also people with intellectual disabilities who are not mentally ill but still being cared for in mental hospitals. What on earth are they doing there in this day and age?

I have been trying to find out the numbers in the various health board areas considered so seriously ill - some have criminal records - that they have had to be transferred outside the jurisdiction for treatment. When I raised the matter on the Adjournment in the Seanad a few months ago, the Minister for Health and Children said he could not give me the figures but would ask the health boards to communicate with me. To date, I have received just one reply from the Midlands Health Board. It is costing hundreds of thousands of euro to send patients outside the jurisdiction to be treated. Is any effort being made to look at the cost of providing proper treatment here?

In a recent article in The Irish Times Eithne Donnellan indicated that there were grave worries about the lack of secure places in psychiatric hospitals. How are we to introduce the Criminal Law (Insanity) Bill if we do not have the physical facilities required to deal with the people concerned? It is not just the Department of Health and Children which is involved; the Department of Justice, Equality and Law Reform also needs to look at the matter, as does the Department of Education and Science in terms of the lack of training for clinical psychologists. The course in Trinity College was nearly cancelled last autumn at very short notice, even though we were spending more on advertising abroad for clinical psychologists. It is bizarre.

We will have to take some of the responsibility for what is happening because we are supposed to be at the centre in introducing legislation and organising the health service. In 1994 I managed to have the report of the inspector of mental hospitals discussed for the first time ever in either House of the Oireachtas. We need pointers as to which problems we should tackle first because there are no votes in the issue of mental health. We will try to give the delegation as much support as we can because we are very concerned about the matter and recognise how serious the problem is.

Dr. Ganter

I would now like to respond. There is a rather long list of questions.

Deputy O. Mitchell

Before Dr. Ganter replies, perhaps she could respond to my earlier question, also raised by Senator Henry: on what should we focus? Should we focus on training? If we could leave here and do something for the delegation, is that the issue we should be highlighting?

Dr. Ganter

Using Mr. Hanly's model of 300,000 in an area, the focus is on ensuring there is a sufficient number of clinical teams across all specialties, in other words, for all of the age groups about which we have been talking. These should be real, unlike those to which we have referred with few of the other disciplines involved. They should also extend to mental health services for people with an intellectual disability who have been neglected in terms of their mental health needs. The focus should be on funding such teams. In this context, we need a strategic plan which fits in with the need for training which is focussed. We have been trying to highlight the fact that we are not just talking about funding and resources but having the correct strategy and structure in place. There is an opportunity, in the context of the ongoing health reforms, to ensure this is done correctly for once.

Those who work in the mental health service are dispersed. We come under different structures. For example, some of us are funded through the psychiatry programme and others through the children's programme. Under one programme, there can be an organised and well constructed service to cover all ages and specialisms. However, the Irish College of Psychiatrists believes this is a political non-runner in the Department of Health and Children and not among the main players. It is not a costing issue but about an attitude in seeing mental health as a major health issue. In the United Kingdom it is predicted that by 2010 the second greatest cause of morbidity will be mental health problems, after cardio-vascular diseases. It is not just about disability; it is also about morbidity within the general population. We can get the committee more detailed figures, if it wishes. There must be a focus for future mental health teams to cover all age groups in all areas, not simply a consultant dealing with a patient on his or her own with the aid of a community nurse.

We want to encourage innovative approaches such as the DETECT programme referred to by Dr. Cassidy but it is difficult in present circumstances to introduce new ideas when there are spending constraints. It has been mentioned that one consultant team and partial team can have up to 400 patients which is ludicrous and detrimental to the patients' well-being. Psychiatrists, nurses and administrators are doing their best but the situation is impossible. Managing time to even address this committee is difficult. Those working in the sector get bogged down and burnt out. The problem is compounded when large numbers of patients are taken on. Within our community, people are much more aware of the need for services which they are demanding.

I will hand over to one of my colleagues to discuss the figures on suicide.

Dr. Cassidy

I said I had approximately 400 patients but the figure is closer to 480 with a staff complement of one community nurse, one social worker, two junior doctors who are changed every six months and will be working on a shift basis from August, and one third of a psychologist. Several colleagues have informed me that they the same number of staff but with 600 patients.

Chairman

A GP will have up to 1,000 patients under his or her care. However, when Dr. Cassidy speaks of 400 patients under his care, is he dealing with them at the same time? Do patients come and go within the system?

Dr. Cassidy

When I took over 18 months ago I went through every open case file to discharge patients not actively receiving a service. I reduced the figure to 480 who were actively attending some part of the service such as outpatients department, day centres——

Deputy Neville

Were they expecting to see Dr. Cassidy every time?

Dr. Cassidy

Yes. Lack of continuity in seeing a consultant is a complaint made by families and patients. However, physically, I cannot see all of them.

Changing junior doctors every six months is also frustrating for patients. It is frustrating for the junior doctors, too, because by the time they get to know a patient, they have been moved on. Whereas a GP has patients who come to him or her occasionally, in my case patients are actively receiving a service.

The Hanly report is another example of psychiatry being forgotten. In the east coast region there are three adult psychiatry services, including the one in which I work which covers Blackrock and Dún Laoghaire, an area with a population of 175,000. In Newcastle, the service covers a population of approximately 100,000. The Vergemount service which is moving to St. Vincent's covers approximately 100,000 people in the community care area from Ringsend to the Merrion Gates. The Hanly group never contacted any one of these services.

Deputy Neville

Was this confirmed as part of Mr. Hanly's brief?

Dr. Cassidy

Yes, he had to be chased up on the matter. Psychiatry is the third largest specialty in terms of the number of consultants working within it. At local level, in county hospitals, when one takes away tertiary specialties, psychiatry is the second largest. No contact was made with any of the services mentioned or with the child services.

Dr. Ganter

When I was a member of the steering committee of the Hanly group, I tried to bring psychiatry within its remit. However, mental health services are always treated separately, as is psychiatry. In so doing, people focus on acute services such as accident and emergency departments. While psychiatric services are included, they are not perceived in the same way; they are seen as a little piece of the overall picture. It was difficult, therefore, to get the steering committee to give greater consideration to psychiatry.

Another reason for the limited reference to psychiatry in the report lies in the notion that psychiatry services operate differently. As I said, we do not. Increasingly, secondary medical services are operating in a similar way. It is unfortunate that psychiatry is always treated differently and forgotten.

Dr. Cassidy

I understand the Hanly steering committee did not make contact with psychiatry services; that contact had to be initiated by them.

Dr. Ganter

That is correct.

Dr. Cassidy

My point, therefore, is that the Hanly steering committee did not initiate an examination of what psychiatry services were available.

Senator Feeney

Was Dr. Ganter representing psychiatrists on the Hanly steering committee?

Dr. Cassidy

She was representing the IMO. The Hanly group did not work through its steering committee for representation. It met local services and service providers and forgot about psychiatry. We initiated contact and met with it to make a number of presentations. We were proactive in addressing the imbalance and a number of our concerns were taken on board.

The Hanly report recommended the centralisation of services, the antithesis of the way in which psychiatric services are developing; they are now more community-focused. It was recommended that there should be one unit in the East Coast Area Health Board, covering every patient from Arklow to Ringsend, in St. Vincent's Hospital. No recommendations were made, however, on how to deliver psychiatric services in the community; this matter was left to the expert groups. For the east coast region the report recommended that a 160 bed psychiatric unit should be built in St. Vincent's Hospital - a new asylum, again marginalising and stigmatising those with a mental illness.

The psychiatric services want to come under the management of the national hospitals office. If services will now form a large part of each regional hospital, this makes senses in the fight for resources. If we do not fight for them, we will be forgotten again. One has to report to one of 32 community offices, then one of the four regional offices and, finally, the Health Services Executive. There is one direct reporting line in the national hospitals office. The community sector is referred to as the non-acute sector. As Dr. Ganter pointed out, considering some of the patients involved, it should be described as acute. Labelling us as non-acute undermines the service.

Senator Glynn's health board made an acute unit available in Mullingar which was taken over by the medical services because psychiatric services were not included in the same programme fighting for resources.

Senator Glynn

That was in Portlaoise

Dr. Cassidy

There is no funding in our budget this year to establish the tribunals provided for in the Mental Health Act. If they are introduced, there will be a large administrative commitment with extra paperwork and IT, resulting in the loss of more clinical time. What services does the Minister for Health and Children wish me to cancel to implement the Act? Instead of upgrading mental health services, the Act is reducing and demeaning existing services through the lack of funding. The Minister should please tell me whom he would like me not to see in order that I can fulfil the requirements of the Act.

Dr. Browne

As regards suicide, obviously the first point that one would wish to highlight is that it is a tragedy for any family. However, I would like to put matters into context. Individuals with a psychiatric illness have a standardised mortality rate which is much higher than that for members of the general population. It is not purely due to suicide. For example, individuals with schizophrenia have a standardised mortality rate between two and three times that for matched controls. They have a higher incidence of cardiovascular and respiratory illness. Unfortunately, up to about 10% or 15% of individuals with serious mental illnesses will end their lives by suicide. Since the introduction of pharmacological treatments, the evidence has been that the mortality rate has decreased for illnesses such as schizophrenia and manic bipolar affective disorder. However, there is obviously still a major challenge for us.

Approximately 12 years ago the UK Department of Health issued a document entitled, The Health of the Nation, for which it set a target that within ten years it would aim for a 10% reduction in the rate of suicide in the United Kingdom. At the same time the United Kingdom mirrored what we did, which was to reduce spending on mental health services. The suicide rate actually increased. Approximately two years ago the Royal College of Psychiatrists wrote to the UK Department of Health highlighting that the only way to influence the suicide rate materially after ten years of attempting to meet the target was a ground-up approach to improving basic services.

The 1997-98 study of suicide in Ireland showed that only 47% of individuals who had committed suicide had ever seen a psychiatrist. This does not mean that they were in contact with one at the time. The evidence from the national confidential inquiry in the United Kingdom into suicide and homicide indicates that only 25% of those who commit suicide in the United Kingdom are in contact with a psychiatric service in the year before their deaths. One must ask the reason people do not avail of such services. There is a variety of reasons, including stigmatisation and how people perceive the role of psychiatrists. As a psychiatrist, I would argue that a possible fundamental issue is the fact that, when people come to us, we do not have the services that we would wish to provide for them. That is the fundamental point that we would like to make today.

Senator Glynn

I asked two questions.

Dr. Margo Wrigley

I wanted to comment on one of the issues mentioned by Senator Glynn. It was more specifically to do with the fact that there had been improvements in the service. From the point of view of psychiatry of old age, there have been increases in the numbers of consultants. In 1996 there were four but we now have about 20 in post. Therefore, there have been improvements. The downside is that people seem to assume that, once there is a doctor in post, the service problems have been solved. In psychiatry of old age we have the same problems of inadequate resources and facilities, no teams and so on. The most glaring example was the Tallaght service set up in 1998, where the first community nurse was only appointed in 2003 until which date the doctor was not able to operate in the community.

Let me return to the issue of acute hospitals and how we lose out. It has certainly been the case for us in psychiatry of old age in respect of which there was a review of services for elderly people carried out a few years ago. While community care and the geriatric medicine services were invited, the psychiatric services were deliberately excluded, even though we asked to be involved. The result has been, in my area, that the number of consultants has increased from 1.3 geriatricians ten years ago to five, yet I still work single-handed. That is what is happening because we are not part of acute hospital care services.

Dr. Kennedy

I would like to respond to a point raised by Deputy Cowley. About 20% of those in prison have a mental illness. Let us focus on those with severe illnesses such as psychosis. The figures in Ireland are about the same among the sentenced population as in other countries but they are between two and three times higher among the remand population. There is, therefore, a serious problem unique to Ireland in the number with psychosis remanded to prison. Overwhelmingly, they are young men with schizophrenia.

Members might expect me to say there are not enough forensic psychiatry services in Ireland. There is not, they only function as part of a whole mental health service. What one gets when one examines the cases turning up in prisons is evidence of gaps around the country in particular areas. For example, if one develops a great many community services and does not have beds, people end up in prison, since the few who do not fit that model are young, difficult men, often with schizophrenia and a comorbid drugs problem. They are the orphaned groups, a sign that the whole system is not hanging together. We, therefore, need a comprehensive service which caters for everyone, particularly those with the most severe illnesses. It is a very sad comment on idealism if that ideal that people like a community service results in there not being sufficient community beds to prevent people ending up in prison. That is what is now happening in Ireland.

Chairman

Is there a high percentage of ADD cases in prison?

Dr. Kennedy

Very little systematic research has been done. The natural history of attention deficit disorder is that it gets better in late adolescence. In a small proportion of cases other problems, particularly to do with substance abuse, kick in. This becomes the next stage for a minority. It is true that in the prisons substance abuse is probably the most common reason for incarceration. I will give members an idea of how our work is driven. Since there are so few of us working in the prisons, we are obliged to concentrate on those with the most severe mental illnesses, schizophrenia and bipolar affective disorder, which used to be called "manic depression". Far more such persons are remanded to prison in Ireland than in other similar countries. This reflects gaps in a comprehensive service.

We badly need a modernised secure psychiatric service. The hospital in Dundrum has been condemned twice by the committee for the prevention of torture because of the state of the building. Our staff are very committed and hard-working. I do not suggest that building large numbers of secure hospitals is the answer. However, a well-integrated, comprehensive service with services for young people, acute mental illnesses and the elderly will prevent people ending up in prison. This requires a careful, evidence based model and a substantial increase in the resources devoted to mental health services. Otherwise, more and more young people with psychosis and schizophrenia will end up in prison.

Dr. Ganter

I thank members once again for listening to us. They are all very interested in what we are saying, and we very much welcome the fact that they have heard us. We have highlighted what has been happening in mental health services in recent years. Developments can help. We are talking from an evidence based approach. We know what can work and ask that members listen to us and do something about it.

Chairman

We are grateful to the representatives of the Irish College of Psychiatrists for coming before us and outlining its concerns, particularly about the lack of resources, and drawing attention to a very vulnerable and dependent section of society. The presentation will be passed to the Department of Health and Children. We will ask the Minister to respond to the inadequacies as outlined and come back to the college.

The joint committee adjourned at 11.20 a.m. until 9.30 a.m. on Thursday, 29 April 2004.