I welcome from Bodywhys Ms Catherine Joyce, communications officer, and Ms Jenny Kelly, board member, who will make a presentation which will be followed by questions from committee members.
Children with Behavioural Problems: Discussion with Bodywhys and HSE.
Our understanding was that one of us would speak from a parent's perspective. I will make most of the presentation, while Ms Joyce will verify some points.
That is fine.
I wish to outline my personal experience and the issues that arose for us as a family during the course of that experience. My daughter developed bulimia when she was about 15 or 16 years old. We had no idea about eating disorders at the time. This happened 16 years ago and matters have improved since. The problem was bewildering because we did not know what to do and could not ask anybody about it. However, we were very fortunate, as we had a very good general practitioner, but I have since learned that this is not common practice. GPs need training in eating disorders. Because such disorders are relatively rare, they are not yet covered as part of professional training. We need to overcome this problem.
Our GP first referred me to a dietitian because he was conscious that there were real stigma issues arising. We did not wish our daughter to become engaged with the mental health service at the age of 16 years because we did not know how it would pan out. However, visits to the dietitian did not work and she was later referred to a specialist psychiatrist who saw her over a number of months. She was eventually admitted to St. Patrick's Hospital for the first time.
Part of the problem was that we did not know what had sparked the eating disorder because the cause is very different for everybody. However, my daughter made me aware much later that while she was in school, the message she was getting from the teachers was that she was not very good and would not get into college. She actually had mild dyslexia, which had not been spotted. When she went from primary to secondary school, she ended up in the bottom stream, where she was with a class of people who did not want to work and had no interest in work, which she did — people with eating disorders are very conscientious and hard working. Her confidence was very much eroded in that setting, where she met teachers who had more or less written off the class. We have a major job to do in the area of education.
Our personal feeling at this time, as with many parents, was that eating disorders are different from many other mental health conditions. If one's child develops a condition like schizophrenia, no blame is attached whereas with eating disorders, parents can be blamed for the condition or, if not, they tend to blame themselves. There is also the issue of stigma and how to protect one's child and deal with this issue in regard to her school and friends, which is difficult.
We were very lucky at the time. When she was hospitalised we had VHI cover and she was able to access a specialist unit. At that time there were only two main specialist units, in addition to a public unit in St. Vincent's Hospital which had just three beds — this is still the case today. We were lucky to be able to get that kind of instant help. I understand there is a waiting time of about 18 months at present for the specialist unit at St. Vincent's, where the psychiatrist has recently retired and no replacement has been appointed. People deteriorate if there is a long waiting time.
The specialist programme of hospitalisation did not work for my daughter, who had many admissions and problems later. While that is not to say we were not very grateful for the treatment she received, I would like to highlight a couple of points. When she was admitted there was virtually no contact with the family. Her psychiatrist was always available to us but she was discharged to us at weekends and following the programme without any guidance on how to treat her. We were never asked to report back on how the weekend had gone. I would have seen us very much as a team. I believe the services need to be built up in a way that includes far more team-building between health professionals, families and carers.
Many things have improved but they have not improved enough. Another point that arose for us concerned an episode in the hospital, probably during her second admission. She had a very good friend in the hospital who committed suicide during the night. She was very distressed by this and I got permission to take her to the removal and the funeral. Following the removal I brought her back to the unit. She was very distressed by everything she had seen and was very quiet. She was also prone to self harm. I said to the nurse: "Please keep an eye on her for this evening. It is going to be difficult."
I came back the next morning to discover she had been admitted to the locked ward in St. Patrick's Hospital. She had self-harmed during the night and the response was that, for her own safety, she be admitted to the locked ward. This was an unsuitable environment for a 17 year old because there were people there who were extremely ill. One woman kept coming to the foot of her bed and asking her if she was dead yet. It seemed to us like a punishment was being inflicted and that there was no understanding of her situation. After being discharged, there were periods when she had to receive counselling. Fortunately, we were able to pay for that. For many people, however, this is not an option and it is difficult to access such services as a public patient.
Another issue that arose for us is that there were times when she would be in an extremely bad state at home. There was one particular incident where she became virtually catatonic in a corner of her bedroom. We knew she was in serious danger. It was a Friday evening, however, and I could not access my GP. Nor could I avail of assistance from St. Patrick's because the psychiatrist there had gone off duty. There was nobody to whom we could speak.
There is no emergency service for people with mental health difficulties. An accident and emergency department was not appropriate in our case and we had few options. We were on the point of having her committed after making I do not know how many telephone calls. This, however, would have implications down the line. It is a serious step to take. When one is that desperate, however, one will do anything to keep one's child alive. That becomes the main priority. I make a plea for emergency services.
I have merely given an outline of some of the issues we faced.
Ms Catherine Joyce
Some aspects of the service have improved since the period to which Ms Kelly refers, particularly in terms of recognition of family inclusion. Most services now show an awareness of the importance of family therapy and the involvement of family members in the recovery process. Other than that, however, little has changed in front-line services. Many of the recommendations in A Vision for Change would go a long way towards improving front-line treatment for people with eating disorders. It is a question of having a timeline for when those recommendations might be implemented and of securing the necessary finances and resources.
I thank Ms Kelly for her moving account of her daughter's difficulties. I hope she has improved.
She is doing well at the moment. She is 75% to 80% well and is coping with life.
A worrying issue raised by Ms Kelly is the lack of access to services at weekends and other out-of-hours times. We have heard this before in regard to patients with mental health problems. There are sometimes disastrous consequences when people cannot access services. We must take this issue up seriously with the Department.
It is worrying to hear Ms Kelly speak of the dissociation between herself and the hospital services her daughter required. It was she who was expected to look after her daughter at the weekend. It is unsatisfactory that parents in such situations are given little instruction and that no inquiry is made on a Monday morning as to how their child has fared. This is another example of where services must urgently be improved.
I also was concerned because many of these young people, it is generally girls, seem to run into trouble in their teens at school, frequently during the transition from primary to secondary school. While the association with streaming is new to me, its examination might be significant. It destroys people's confidence to feel they are not perceived to be as valuable as they had always thought. I do not know how many secondary schools operate total streaming for children at present. I had the experience whereby one child went to a school in which streaming only took place for three subjects, while the others went to a school in which all subjects were streamed. I thought the school in which only three subjects were streamed, which included higher mathematics, Irish and so on, was much better than the one in which the sheep and goats were divided strictly. Members should ask questions of the education system and can contact the Department of Education and Science in this regard.
The waiting list for St. Vincent's Hospital sounds terrible. A period of 18 months is impossible.
I am unsure whether that period is for admission or just to see someone at present. However, the important point is that it has a very long waiting list. Those with bulimia become much more entrenched in that behaviour. However, those with anorexia deteriorate further, the illness becomes more entrenched and consequently more difficult to treat. In terms of the best use of resources, the prognosis is much better for those who receive early treatment and those affected will need fewer services.
Ms Kelly's daughter was in her mid-teens. Was any effort made to continue her education? Could anything be done in this regard when she was in hospital?
Yes, she sat her leaving certificate examination in St. Patrick's Hospital. She had crashed out of her leaving certificate year to go into hospital at Christmas. When she came out, we were able to send her to the Institute of Education. I cannot emphasis how important it is to have some money when one has an eating disorder. We were able to provide this.
Was Ms Kelly's daughter keen to sit her leaving certificate examinations or was it a parental wish?
She was keen to do her leaving certificate and she went into the Institute of Education. However, she crashed out again there and ended up sitting the examinations in St. Patrick's. She received virtually no further schooling from when she entered hospital to when she sat the examinations.
Did she work on her own?
Yes. She received some grinds in hospital. Moreover, a teacher from the institute used to go in and do it free of charge.
Ms Joyce might be in a better position to answer my next question. I have attended Bodywhys meetings and one is told frequently that such children have been overweight in the first instance. Is this true? It is becoming clear that many more children are overweight at present and we could be facing a highly serious problem.
Ms Joyce
The experience of each person who develops an eating disorder is highly individual and it is not necessarily the case that such people had issues with weight as children. Obviously, some did so and perhaps the manner in which it was dealt with had an impact on their self-esteem that subsequently made them more vulnerable to developing an eating disorder.
Dealing with obesity and with childhood obesity in particular is about trying to emphasise the need to build self-esteem and to focus on healthy lifestyles, healthy eating and so on. However, when promoting this, one must be mindful both of the psychological impact this might have and of the psychological factors that might play a part in that obesity.
In respect of adult obesity, of those who present at the weight management clinic in St. Colmcille's Hospital, approximately 25% either have diagnosable binge eating disorder or have elements of it that would not necessarily classify them as having full binge eating disorder. There is a great need to understand the psychological process that might contribute to someone becoming obese. This must be examined, particularly in obesity prevention campaigns aimed at childhood obesity.
We must remove the sensationalism and not focus on good or bad foods. The implication is that if one eats certain bad foods one is a bad person and it can be perceived as such. It is about fostering good self-esteem and finding physical activities children enjoy and promoting a healthy lifestyle for them. Schools and education also play a part in terms of prevention through fostering a sense of self-esteem, teaching children good coping skills and providing them with confidence in their own abilities to cope with their worlds and lives.
I sympathise with the fact that parents are blamed. Many television programmes and articles in the press state the mother or father was always on a diet or should have been on a diet. These must be unhelpful.
These are extremely unhelpful. Dieting is dangerous and 90% of eating disorders begin with and are triggered by a diet. Other issues come into play but the behaviour is typically that someone who has an issue will go on a diet. Initially, the diet makes them feel good and people tell them how wonderful they are and comment on how well they look. This encourages them to go further and further and all of a sudden they are caught in this. The message must go out that diets do not work. The prevalence of diets, the sexualisation of young girls and the fashion industry feed into an eating disorder, and body image issues.
Is the banning of models of a certain size by the fashion industry useful?
Ms Joyce
We are always careful to state that the media and fashion industry do not cause eating disorders. Eating disorders are mental illnesses and various factors come into play in their development. Fashion and the media are unhelpful because they promote certain body ideals and body image is often promoted as being equal to success and happiness in life. The messages sent out can have an extremely negative impact.
The ban on a BMI lower than 18 sends a message. However, focusing on a certain BMI also sends the same type of message as focusing on weight. In the UK, an obesity prevention strategy was worked out whereby the helpline number of Overeaters Anonymous would be placed on women's clothes over size 16. This is not helpful and stigmatises women of a certain BMI. We must remove the focus from weight and size and promote health, self-esteem and good positive body image.
We receive many requests from schools but do not have the resources to respond to them. Last year, we produced a CD-ROM called "i-figure" which examines these issues for SPHE classes. It does not focus on the signs and symptoms of eating disorders but on body image and positive self-esteem. It also focuses on building media literacy skills so one can unpick media messages, learn to see them for what they are, have a rational response to them and remove the element of believing that if one is a certain size one will be happy.
I welcome the delegation and I thank Ms Kelly for her moving presentation on her situation. I wish to speak about treatment facilities. When I was in practice we had basic facilities only. Is the unit at St. Vincent's still in existence?
Yes.
How many beds does that unit have?
Three beds are allocated specifically for eating disorders. This is an adult service.
Are other inpatient beds provided specifically for the treatment of eating disorders?
Private beds are available. The two major eating disorder programmes are provided in St. Patrick's Hospital and the St. John of God Hospital, both of which are private facilities. People living in the catchment area of Blackrock can access the eating disorder programme in the St. John of God Hospital through Cluan Mhuire. St. Patrick's Hospital has told us that it can take public patients provided their general practitioner makes a submission to the local health board for funding. However, capacity is by no means sufficient. Having said that, only a tiny proportion of people with an eating disorder require hospitalisation. However, they all need GP care, counselling and to undergo cognitive behavioural therapy and other similar therapies. The latter services are not always readily available and, in many ways, much harder to access.
Are hospital beds available outside Dublin?
Ms Joyce
No public beds have been specifically allocated for the treatment of eating disorders. There is a treatment programme in St. Anne's Children Centre in Galway but I believe it is private.
In Ms Kelly's presentation she made reference to the clearly horrendous nature of emergency provision. What would she envisage as an appropriate emergency response? Would she consider it necessary to have an on-call help register?
Something of that nature is needed in order that one can call and explain the situation. An emergency admissions procedure not involving committal would also be beneficial.
Will Ms Kelly clarify that point?
If somebody is distressed and needs to be admitted to hospital, one way of doing so is by means of committal. That, however, gives rise to longer term implications. The person concerned needs easy access to somewhere he or she can be reasonably confident of safety. If somebody has a medical emergency, he or she will go to a casualty unit and, if the emergency is serious, will be seen quickly. There is no equivalent service for those who experience mental health problems. We need to address this issue in some way. While it is for the powers that be in the HSE to decide whether emergency services should be provided through an individual service which a patient is already accessing or by other means, there is certainly a need for such services.
Ms Joyce
If the recommendations contained in A Vision for Change were implemented, they would increase the number of public beds nationally to 24, with particular emphasis on the treatment of eating disorders. That would go a long way towards addressing inpatient treatment. Many of the recommendations made in the report would answer the gap we are highlighting, particularly with regard to multidisciplinary teams in each HSE region with specialist expertise in dealing with eating disorders which could filter information and advice on treatment to community mental health teams. Such an approach would allow services to be more community-based and provide a focal point in each catchment area with specialised expertise in treating eating disorders. There would be an impact on the entire area because, while the specialist teams would not necessarily become the focal point for extreme or difficult cases, they could help local mental health teams to deal with any issues that arise. They could also make a significant contribution to addressing the issue of access to emergency care.
Has a presentation on A Vision For Change been made to the HSE?
Ms Joyce
A Vision for Change informs the HSE's strategy.
How many men have eating disorders and is the figure rising? Part 2 of the Mental Health Act 2001 which took effect in November last year recognises 16 and 17 year olds as children. Has it had any effect so far? Ms Joyce spoke about the need for specialised services at St Anne's in Galway and Warrenstown House in Dublin to ensure no person under 16 years would be admitted to an adult mental health facility. Will she update the committee on whether there has been any movement in that regard? Does the delegation know the schedule for implementation of A Vision for Change?
I am sorry I missed the beginning of the presentation because it sounds like it was very moving. I have had discussions with people about their problems in this area. Ms Kelly said people living in Blackrock could access services at St. John of God Hospital but does that only apply to people living there? I have spoken with a person in Shankill, although I am sure the delegation cannot answer me directly.
Eating disorders strike me as similar to homelessness which does not simply involve the absence of a shelter but much wider problems which need to be dealt with. Do people with an eating disorder recognise that a mental illness is involved? If they do not, is that part of the problem?
Ms Joyce said three public beds were available. I am interested to learn whether they are exclusively for persons with an eating disorder. How do they work? If a person is fortunate enough to access one of those beds, for how long will he or she occupy it? What is the length of treatment? An eating disorder is not as simple as it sounds but a mental illness which manifests itself in one's attitude to food and body image. Is it wise to allocate specific beds for people with an eating disorder? The general mental health services should be available for that purpose.
I saw a headline in the newspaper today about obesity. Bodywhys is conscious that the problem concerns not just people who do not eat enough but those who eat too much and that a healthy attitude is required. It is important to teach children in school and promote a positive personal body image to instil confidence. If one has confidence, it is taken for granted but it is terrible to lack it. It is vital to respond to requests from schools to stop the onslaught of insecurities which lead to an eating disorder. I am sorry to hear Bodywhys cannot cope with the requests it receives. It should be identified as a priority to reach out before the problem develops. Ms Kelly indicated that a tiny proportion of people who have this illness need hospitalisation. The presentation pointed out the absence of support for families. What support services are available?
Can people overcome this or is it a chronic illness that requires treatment and which one must live with forever?
I thank Ms Kelly for her presentation. I am surprised to hear that there is no cover at weekends, because people do not get sick by appointment. As far as I am concerned, this seems like an operational joke. Is Ms Kelly referring to the psychiatric services?
Yes.
I worked in the psychiatric services for many years and there was always a consultant psychiatrist on call at weekends. The situation that has been outlined is unacceptable and I wish to protest against it in the strongest possible manner. This is an operational matter that must be addressed as a matter of urgency.
I understand everything else Ms Kelly said as I worked and dealt with the people she mentions in my own career. I strongly support what is stated on page four of the presentation regarding short-term recommendations. A dedicated four bed unit with medical facilities in a general children's hospital for acute eating disorder cases is sought as is Health Service Executive funding for inpatient and outpatient care at St. Patrick's Hospital and the St. John of God adolescent programmes, to manage less acute cases.
When I practised my profession I visited a psychiatric hospital in Leicester which had a dedicated eating disorder unit that worked very well. On another occasion a young lady who was studying for her leaving was admitted with a problem not dissimilar to the one experienced by the witness's daughter. These problems are not new and questions regarding the lack of cover for consultants in the psychiatric service at weekends must be answered.
I have been looking at the critique on the recommendations of the task force that is supposed to look after issues relating to psychiatry and it is clear that the situation is impossible. I knew this already because I have used the service for patients. One can examine the HSE guidelines for primary care teams on the management of eating disorders but there are no primary care guidelines on the management of eating disorders. Issuing guidelines to general practitioners and practice nurses on dealing with eating disorders through primary care will be difficult and will not be achieved in six months. The strategy, A Vision for Change, is over a year old and the matter is going nowhere.
The quotes from Wexford on the community mental health team are interesting. The community mental health team there can hardly deal with acute, serious psychosis in adolescents, never mind issues regarding eating disorders among adolescents. The team is downplaying the problem by saying it is under resourced. It is grossly under resourced and cannot deal with acute, serious psychosis in County Wexford so I cannot see it dealing with eating disorders. This matter has been totally ignored by the HSE and nothing is happening at primary care level regarding patients with eating disorders.
Am I correct in saying that St. Patrick's Hospital has capacity in its eating disorders unit to look after patients with such illnesses and the HSE has made no effort to contract any of these beds?
As far as I am aware that is the case. I attended a talk recently in St. Patrick's. I am aware it takes in public patients but a GP must apply for a patient to be taken in, although many GPs are not aware of that.
Even if they do so, it is not a case of applying; rather they have to fight tooth and nail to try to contract one of those beds. I went to St. Patrick's to talk to the people there on this issue. I am aware it is a private institution but to be realistic about this, we need to speed up the process. If one thing could be done within the next six weeks, it would be to get a service level agreement with St. Patrick's. In regard to all the other issues the representatives mentioned, such as beefing up the primary care teams and the community mental health teams, they cannot be achieved within a 12-month period as it is not possible to do so from the point of view of providing the necessary resources and manpower.
From reading through this document it appears that nothing realistic is being done. Most of the positive aspects outlined are covered by a very small level of funding, which the representatives have received to run TV and public awareness campaigns. However, the real issue is to implement some of the proposals outlined. That is the job of the HSE and the Government. We should make it clear that has not been done. We should focus on these matters. I gather St. John's does not have the same sort of capacity as—
It has an 8 bed capacity in terms of the eating disorder programme it runs.
It has the same capacity as St. Patrick's in terms of acting urgently to take up capacity in the private sector to deal with this issue.
It runs a specialist eating disorder programme. These programmes are only for people with anorexia. St. Patrick's will take in people with bulimia but St. John of God will not.
What three measures would Ms Kelly ask the HSE to introduce in the immediate term, which could be done within a three month period?
Ms Joyce
The Deputy is correct about the need to put in place a service level agreement with St. Patrick's and the way in which it could be assessed would need to be made transparent, particularly to primary care teams and GPs. In terms of emergency care, that needs to happen. Ideally, the approach should be in the direction of what we were saying about multidisciplinary teams. In regard to the implementations proposed in A Vision for Change, we need a timeline for that, an outline of how and when that will happen, and we need to be made aware of that.
It is important to point out that the HSE provides our core funding as against the notion that it only gives us a small level of funding for certain campaigns. We applied for our core funding from the HSE to be increased last year to expand our support services. We find it difficult to manage because of the presence of such blatant gaps in the provision of care, especially emergency care and how best to provide that care. Even if beds were allocated in public hospitals nationwide, there is the issue of how to staff such provision, which is time-consuming and would need to be worked out.
In terms of providing emergency care at St. Patrick's, it is necessary to access private treatment, if there is any, in the Dublin area, including in St. John of God, and to make applications to work that out. In terms of outpatient care, perhaps it would be possible to work out low cost counselling or subsidising counselling within private treatment areas to ensure that the public health care system has support in trying to deal with the numbers approaching it. Primarily, it is important to make the way one can access care in the public health care system transparent, as it is difficult to know how to go about it. I am still unclear as to the processes in place in most of the HSE regions, and they vary depending on the HSE region one is in. Therefore, it is necessary to clarify what processes are currently in place, providing a timeline and the resources to make serious headway on implementing the recommendations.
Have the representatives a notion as to why Dr. Mary Darby has not—
I interrupt the Senator as I want to bring in Deputy McManus on this round of questions and then I will call the Senator.
I apologise for being late. I have had experience in my constituency of trying to help people access St. Patrick's. The process of going through the HSE is difficult and stressful. I recommend that, following this meeting, the committee should write to the HSE and ask that it establish some type of standing arrangement. The capacity is there. I have visited the unit in St. Patrick's and it is a fine unit. Obviously, St. Patrick's must pay the bills, so there is also the question of funding the unit. The HSE should be able to ensure that people in desperate need can access what is available. My experience is that the process is very stressful for the family and can be quite slow. We should write to the HSE about this matter.
A sum of €750,000 is being spent on the development of a national centre for treating eating disorders. It compares unfavourably to the €160 million that was spent on a failed computer system. We appear to be back again to the black hole of how the HSE operates. It is a mystery to our guests and to us. It is also a mystery to many people working within the HSE. It is extremely disappointing that what was supposed to be health care reform, to make the system work better, simply has not worked. It has created layers of bureaucracy, with many bewildered people inside and outside the system. We are aware of what the delegates are experiencing, although that is not terribly helpful.
There is one area which is central to meeting the need. It does not involve hospitalisation but involves therapy, helping people to alter their behaviour, counselling and providing that type of expertise. In the delegates' experience, does that primarily require people who are trained psychologists or is it a service that can be provided by psychotherapists who are trained to deal with eating disorders? The area of providing such supports is very fluid. There is no regulation, it is not structured and many people are accessing counsellors who, perhaps, have no proper training or have training that will cause more problems. Do the delegates have a clear idea of what is required in providing those services, presumably through the HSE, to ensure people can stay in the community and learn how to deal with their difficulties? That would be a cost effective way to treat what is a mental disorder.
I remind members of the committee that we are meeting with representatives of the HSE immediately after this discussion.
Why has Dr. Mary Darby not been replaced? Everybody knew she was due to retire. Is this related to the common contract talks?
Ms Joyce
I will start with the question about eating disorder problems among men. It depends on the eating disorder. In the case of anorexia, the ratio is one in ten; for bulimia, it is one in six; and for binge eating disorder it is 50:50 between men and women. The overall international statistic would be one in ten, but that can be broken down according to each eating disorder. There are other related issues that do not come under the eating disorder diagnosis but include muscle dysmorphia, exercise bulimia and so forth. There are plenty of issues that affect men as much as women.
It is a serious issue for men. Whatever about the stigma experienced by women or teenage girls, it can be really difficult for teenage boys or men to even acknowledge to themselves that they have an eating disorder because it is still seen as either a female issue or a gay man issue. There are layers of stigma they can internalise or which they perceive they will experience if they acknowledge that they have an eating disorder.
The Senator also asked about Galway and Warrenpoint.
I asked about specialised services for children under 16.
Ms Joyce
As far as I know, they are general psychiatric units but eating disorders account for part of their work. They treat adolescents with eating disorders. The child and adolescent units have been established to provide an important service. Obviously, if young people with any sort of mental illness end up in adult psychiatric care, it adds to the stress and trauma they are going through. I do not know a great deal about St. Anne's, although I know they take children and adolescents with eating disorders, as does Warrenpoint.
It is important to be aware that eating disorders are different from most other psychiatric illnesses in that they have a physical aspect to them as well. A person may be treated in the eating disorder unit, either in St. Patrick's or in St. John of God, and if they deteriorate badly and need feeding they will be transferred to a general hospital where they may come under the care of somebody who has no particular expertise in eating disorders. If people are fed too quickly or at a pace they cannot cope with, that can compound the problem. It is such a complex issue.
Part of that question concerned Part 2 of the Mental Health Act, which came into effect last November and recognised 16 and 17 year old people as children. Has that had any effect so far?
Ms Joyce
It will have an effect when services are revised and a greater range of services is available. As regards child and adolescent services that are currently available, it is important that adolescents aged 16 or 17 should not to be shunted into adult psychiatric care before they are ready. This is particularly so at a point when adult psychiatric care is not equipped to deal with the issues they are going through. It may add to the trauma of their experiences within the mental health services. When the recommendations have been implemented, there should be a cross-over so that at the age of 18 people can be transferred across services, whether they are outpatients or inpatients. Up to the age of 18, it is important that people are treated as adolescents. Many of the issues they experience include coping with change. If they are put into adult psychiatric care too soon it obviously will not help their recovery.
I will now move on to Deputy Fiona O'Malley's questions. She asked whether people with eating disorders recognised that they have a mental illness. That depends on the individual but very often they do not. We are therefore always careful about saying publicly, or to those who access our services, that this is a mental illness. It can make people feel alienated and can put a label on their experience that they would not necessarily assign to it. For the purpose of services, etc., it is important to recognise that it is not just about food but is also a mental illness and there are various facets to it. It is important how one frames that in terms of the people themselves, by following their lead on how they experience it and what they feel about it.
The length of an average stay depends on the person involved. The difficulty with an eating disorder is that it is a very individual experience. Some treatment options will work for some people but not for others. It comes down to which treatment programmes people are in. Some people find one method or approach to be fantastic, while others may hate it and it will not work for them. It is a question of providing options.
It is hard to administer, is it not?
Ms Joyce
It can be very hard, yes. In terms of inpatient care it can be anything up to three months. People can then come in but go out and may have to return later. It depends. The difficulty with inpatient care is that it is often accessed by people who are severely underweight and whose health is seriously at risk because of the medical consequences of their behaviour. As regards regaining their physical health, if they are fed too quickly and one does not deal with the psychological or emotional aspects of the condition, then—
It is not going to work.
Ms Joyce
—it is a fruitless exercise. When one sends them back out they will soon return because they have not dealt with the underlying issues. It really depends on how people respond to the treatment.
I refer to access to wider mental health treatments. People can be treated within the mental health area. Again, the recommendations come to the fore. The idea is for people to access community mental health teams and that expertise and knowledge of the particulars of eating disorders will filter down to community mental health teams so they will have an awareness and knowledge of them. It is quite difficult because there are so many facets. One must deal with, and focus on, the medical and physical consequences but there is also the emotional or psychological impact or the underlying issues. Nutrition, diet and family therapy are added factors. We need a multidisciplinary approach which must be available so that community mental health teams can access information and knowledge.
On our inability to cope with all the requests we receive, it would be great if we could do all the talks we are request to do. We have talked to the Department of Education and Science about working with the social, personal and health education, SPHE, inspectorate taking a top down approach. We would start with the inspectorate and perhaps provide training for it. We already provide training for SPHE teacher groups which request it. We try to focus on that. That top down approach flows through the school and education system. It does not have to come from outside but is part of the system. We are building that awareness. Anything schools do in terms of health, health education and physical education should be informed by an awareness of teaching life skills and coping skills and an awareness of eating disorder prevention.
I refer to support services on an outpatient basis. It is about providing options which would be readily available to people in the public health care system. In terms of private care, if one has the resources, one can find what treatment works for one because one potentially has the resources to try psychotherapy, psychology, psychiatry and cognitive behaviour therapy, CBT, and to stick with whatever works. There needs to be an awareness of that in the public health care system so there are options, whether low cost counselling subsidised by the HSE or fully provided by it. It must be about the options available to people.
In terms of consultant care over the weekends, perhaps the HSE would be better placed to outline the current situation.
We will ask that question in the next session.
Ms Joyce
All the points Deputy Twomey raised were valid. Emergency care is needed. A service level agreement with St. Patrick's makes it easy to access that treatment option. That is key to emergency cover in the interim while we do not have the full services we need.
As I said, public outpatient care needs to be about the options, providing low cost counselling options and making it easy for people to access them. The procedures must be made clear in terms of who one goes to first and how he or she refers one on so that everyone, including primary care teams, are fully aware of what is available and how to access it.
Has any scientific analysis been done to see what actually works? If somebody is not clear about what he or she wants, he or she could end up spending much time shopping around and, in a sense, playing the system. What analysis has been done so that one could say to someone what would work in his or her case or at least enable one to tell him or her where to start rather than leaving it wide open?
Ms Joyce
In terms of bulimia and binge eating disorder, cognitive behaviour therapy has been proved to work most effectively. We are careful about what we say to people accessing our services because they will not work for some people. One does not want to compound feelings of failure in a person or give the impression that he or she is not responding to a treatment to which others have responded. We are careful with regard to not referring people for particular treatments. We merely provide them with the relevant information.
International research has proved that cognitive behavioural therapy, CBT, has worked in respect of bulimia and binge eating disorder. Anorexia is more difficult to deal with. Research is being carried out at Oxford to try to develop an enhanced CBT treatment for it. The difficulty is that this is an inexact science and it really depends on how the individual responds to the treatment he or she is accessing. CBT is used in respect of bulimia and binge eating disorder, while inpatient treatment and psychotherapy or psychiatry are used in treating anorexia.
Senator Henry inquired about Dr. Mary Darby. I am aware that Dr. Caroline Maher has been appointed on an interim basis. She has held the position for six months and, as far as I am aware, will be in place for a further six. I presume the recruitment process is ongoing. I do not know why arrangements were not put in place before Dr. Darby left.
This is a matter of concern because I understand 78 consultant posts in this area remain unfilled, half of which have not been advertised. I do not know why that is the case.
A number of these issues are more relevant to the HSE. Members will have an opportunity to raise them with its representatives when they come before us later. We have had a good exchange of views with the representatives from Bodywhys. I thank them for their presentation and we will see what we can do to progress matters.
Sitting suspended at 10.37 a.m. and resumed at 10.41 a.m.
In this part of the meeting we will discuss the issue of parents with children who have behavioural problems. I welcome witnesses from the Health Service Executive. They are Mr. Martin Rogan, assistant managing director of mental health; Dr. Ian Daly, consultant psychiatrist and chairman of the expert group on mental health; and Dr. Brendan Doody, child and adolescent psychiatrist and clinical director. I invite Mr. Rogan to begin the presentation.
Thank you, Chairman, for the opportunity to address the committee. I will introduce my colleagues. Dr. Ian Daly is clinical director with the west Dublin mental health service and chair of the HSE expert advisory group on mental health. Dr. Brendan Doody is acting clinical director in the child and adolescent mental health service and a member of the HSE expert advisory group.
We will respond to the presentation by our colleagues in Bodywhys and we have circulated a document on that subject to members of the joint committee. The document includes the relevant excerpts from Vision for Change, the report of the expert group on mental health policy.
Eating disorders are extraordinarily complex. Members have heard the very human experience of individuals and families. The need to develop specialist services for people with eating disorders was identified in the health strategy 2001. Eating disorders pose a considerable threat to the health and well-being of adolescents and adults in the western world. Eating disorders have the highest mortality rate of all major psychiatric disorders. This results from medical complications of the illness and from completed suicide. The relevant rates in adolescent girls has increased in recent years and are estimated at 0.5% to 1% for anorexia nervosa, 2% for bulimia nervosa and 4% to 5% for partial presentations of these syndromes. The peak age of onset is during adolescence and the result is often chronic and significant associated morbidity and mortality.
The diagnosis and management of eating disorders present an ongoing challenge to clinicians. The frequent onset in childhood and the often secretive nature of the condition highlight the need for early detection and intervention. The current level of service struggles to provide an adequate response to the needs of this group, who are often admitted to medical wards, due to medical complications arising from malnourishment.
Eating disorders are a complex medical and psychiatric disorder associated with significant morbidity and mortality. The two main sub-groups are identified as anorexia nervosa, characterised by severe calorific restriction, and bulimia nervosa, where binge eating alternates with behaviour such as vomiting, laxative use or dieting and exercise designed to counteract the additional calories consumed. There is a peak onset in adolescence and the conditions often run a chronic course, occurring at a time marked by significant and important development tasks in physical, social and cognitive spheres. The presence of chronic illness at this point has significant impact on many domains of a child's development.
The mortality rate for eating disorders is higher than for any other psychiatric disorder. Estimates of mortality, which vary depending on the methodology of studies, are approximately 5% per decade. Apart from the high mortality rate, morbidity includes problems in reproduction, osteoporosis, continuing low body mass and major psychiatric comorbidity, particularly depression. More than half of the adolescents presenting will also meet the criteria for either depressive or a similar anxiety disorder. Studies in the past 20 years appear to suggest there has been an increase in the incidence and prevalence of eating disorders. Groups such as Bodywhys have done a significant amount to raise the level of public awareness and recognition in that regard.
On treatment principles, treatment of anorexic patients must be based on a comprehensive, detailed assessment of both mental and physical status. A decision is then made on whether treatment on an inpatient or outpatient basis is most appropriate. An increase in the number of clinical cases has not only affected admission rates to psychiatric units, but also to paediatric medical wards. It is clear that medical needs in a severely emaciated patient require intensive medical treatment. However, it can be extremely difficult to provide the necessary psychotherapeutic milieu in such an environment. Inpatient treatment in a specialist unit offers the attraction of a wealth of accumulated experience in treating eating disorders. However, patients with such disorders can be effectively treated in units that treat a range of psychiatric disorders. Working with parents is an integral part of the intervention programme for young people. Outpatient programmes are increasingly considered as a treatment option involving specialist teams. We work jointly with community teams.
On the presentation of conditions, a family may ask for help because of the patient's loss of weight, refusal to eat, vomiting or amenorrhoea. The family unit is often under considerable stress by the time help is sought. Patients may present with syndromes of binge eating, purging or laxative abuse. The diagnostic features of eating disorders are more common in females than males.
With regard to sub-conditions, the common features of anorexia nervosa are as follows: weight loss or failure to gain weight during pre-adolescent—
Does Mr. Rogan intend to read his full presentation?
Mr. Rogan
If possible, but I can give a brief overview of the general points.
Please do so.
Mr. Rogan
Our document gives details on anorexia and bulimia nervosa and introduces a differential diagnosis of depressive disorder and physical illness, including tuberculosis, AIDS, endocrine disorders and inflammatory bowel disease. It describes the importance of working with families and patients in terms of their information and knowledge of the condition, its import and safe management, as well as the self-care associations, etc. This is a particular challenge with younger people in giving them a full understanding of the import of the condition. We stress the importance of general management and advice for patients and families.
My colleagues can speak more effectively than I can on medical treatment and the medications used. Occasionally, anti-depressant medications, for example, fluoxetine, are used to reduce the frequency of bingeing and vomiting, but they are not a cure. No psychoactive medication has a proven effect in the case of anorexia, but some anti-depressants may be beneficial.
Liaison referral is important as regards close working relationships between primary care and community child and adolescent teams, as well as our adult teams. In recent years we have been involved in a project with the Irish College of General Practitioners which has developed an on-line training programme and resource pack which was launched by the HSE on 6 February. It gives guidance and advice to general practitioners on the recognition of the most commonly seen conditions in primary care in respect of anxiety and depression. It also provides good guidance on the provision of counselling in a primary care setting. The previous speaker talked abut the importance of accessibility to good quality counselling, something to which the HSE is committed. The resource pack also provides guidance on referral pathways. This complements the on-line ten module training programme for general practitioners in mental health, including a module on eating disorders.
Our presentation document also provides information on bulimia nervosa and services for children, as described in A Vision for Change, which document was launched in January 2006. In May that year the management team of the HSE adopted the document in its entirety and established an implementation team which meets each month. Its next meeting is due to be held next Wednesday. It has identified a number of programmes for development.
With regard to the allocation of new funds this year to deal with eating disorders, the HSE will invest €750,000 to reinforce the centre in the Elmount unit at St. Vincent's Hospital. Reference has been made to the fact that the consultant psychiatrist is retiring and that a locum is in place. It is intended to have a formal post with a special interest in eating disorders. Dr. Darby brought significant expertise as a result of her personal interest in that area. We wish to formalise that. She also had a number of staff who developed particular expertise in this area. We intend to develop a second unit in the South Infirmary in Cork. Each HSE area will become self-sufficient over the next number of years. Each of them will have a full multidisciplinary team with a special interest in eating disorders. They will work in collaboration with other adult and child and adolescent teams. They will support a number of dedicated beds in each region. A number of references have been made to the use of private beds. The HSE has funded the use of private beds in some instances. We need to bear in mind that one cannot spend funding more than once. If one invests in the private sector, one may have to defer one's development in the public sector, unfortunately. The public sector services may be closer to the homes of those affected. Sustained contact and integration with families in the service areas is absolutely essential in this regard.
Where does that fit in with the Minister for Health and Children's policy on co-located hospitals?
Mr. Rogan
I think the Deputy will find that St. Patrick's Hospital is not co-located.
I was referring to the general point that Mr. Rogan was making.
Mr. Rogan
I was not making a criticism. We think individuals should avail of primary care services in the first instance. They should then use community-based services, if appropriate, before getting a clinical assessment and recommendation from the local health manager if that is necessary. The manager may think it is appropriate to refer individuals to other services. We prefer to develop these services within the context of the HSE so they can be fully integrated. We have embarked on that process. We fully acknowledge that we are coming from a low base. A diagram from page 153 of Vision for Change is reproduced on page 7 of the document we have submitted to the joint committee. The diagram describes the process whereby an individual who is recognised as having an eating disorder goes to see a general practitioner who may initiate treatment which may be successful. If the treatment is unsuccessful, the individual's case may be referred from primary to secondary care services, usually in the form of community-based mental health services. We are engaging in significant investment to increase the capacity and capability of community-based teams, some of which include providers of family therapy services and people with a particular interest in eating disorders. The most complex cases are referred to the national centre, which provides tertiary care services. We would like to reduce our current dependence on the private sector. We will use this model.
It is important to recognise and understand eating disorders. People have sometimes held the unsympathetic view that young people with eating disorders are somewhat self-absorbed. Such an unhelpful approach can cause people to defer their presenting for treatment. It can feed into the quite secretive nature of the condition. The HSE works closely with Bodywhys and other agencies to promote public understanding of the condition. It educates people about it through the media and through school programmes like SPHE. It provides core funding for a number of the agency's initiatives. We are pleased that Bodywhys has been an active member of the Alliance for Mental Health, the Irish Mental Health Coalition and, most recently, the National Service User Executive, which was launched in early February under chapter 3 of A Vision for Change. A number of representatives of Bodywhys accompanied the staff from the HSE who travelled to the UK in recent days to examine services there. We are keen to ensure that those who use our mental health services have an active role in designing and evaluating the services. Bodywhys has been a strong ally of the HSE in that regard. We intend to extend our service level agreement with Bodywhys quite significantly this year. Some meetings have already been arranged to that end. My colleagues, Dr. Daly and Dr. Doody, might like to comment on these issues.
Perhaps we will take some questions on Mr. Rogan's initial presentation.
Most people who are employed in the health service, including the staff of the HSE, have the best possible intentions as they do their work each day. I sometimes leave documents like the one that has been circulated to the committee lying around at home. When my wife, who is a working general practitioner, picks them up and reads them, she asks what planet we are living on. Problems are encountered on a daily basis when one tries to get treatment for people with eating disorders. As I said to the last delegation, most general practitioners do not know anything about treating eating disorders. Page 7 of the document before the committee relates to a minor case that was brought to the attention of a general practitioner. In minor cases of anorexia nervosa or bulimia, patients are provided with some additional, mainly moral, support of the sort that anyone could provide. Such cases never go beyond the general practitioner as they are not complex and do not give rise to other issues. According to the presentation, the next treatment level involves a child and adolescent mental health team, but this service does not exist. Anyone reading the document presented would get the idea that if a general practitioner considered a case complex, the patient would be referred to the child and adolescent unit and be seen. It is suggested that if that does not work, the person will be referred to an inpatient unit. I do not know when Mr. Rogan last tried to get somebody into an inpatient bed, but it has not been long since my practice in County Wexford attempted to do so. It was a bloody nightmare to say the least.
To sign someone in as an involuntary admission to a psychiatric hospital and properly care for someone with anorexia nervosa are the two most difficult things a general practitioner can be asked to do on a day-to-day basis. If one is unfortunate enough to have an adolescent requiring treatment for anorexia nervosa who also has psychiatric symptoms which require involuntary admission to a treatment centre, one cannot use the Mental Health Act to obtain treatment but must obtain a court order. That is the sort of day-to-day issue with which some general practitioners have to deal in more complex cases. There is no assistance for them in a ridiculously structured system which cannot meet the demands of the 200 complex cases which present nationally every year. These patients are in great need of the assistance of properly structured health services, which do not currently exist. The Mental Health Act itself represents an obstacle to obtaining proper care for patients by dragging people through the courts to get orders where treatment is required.
The services to which Mr. Rogan referred are either non-existent or delivered piecemeal nationally. There should have been a serious acknowledgement in the eight-page presentation that the services being set out did not exist. According to the document with which we have been presented, for the small number of children and adolescents who require specialist input above and beyond that provided by the child and adolescent CMHT or inpatient unit, there will be a national centre for eating disorders in the new children's hospital at the Mater. Even if provision is made in the shortest possible timeframe, another five years will have passed before we see a national children's hospital at the Mater, regardless of Deputy Harney's grandstanding and tough talk two months before a general election. It will therefore be at least five years before a proper inpatient national centre for eating disorders is provided. In the meantime, the child and adolescent community health teams will be completely inadequate. We should stop talking about training general practitioners through modules on this and that. There are approximately 2,500 general practitioners nationally, most of whom have enough cop-on to know when a patient requires more specialised treatment. We would like to see the specialised treatment made available in a realistic manner rather than to hear pie-in-the-sky presentations.
I feel the utmost dread when I hear a general practitioner say he or she has just come across a 16 year old with serious eating disorder problems. When the doctor contacts the community mental health team, whose hands are tied as much as those of general practitioners, he or she will find there is very little it can do for the adolescent who may need inpatient treatment. The analysis applies to private patients as well because these problems are complex and having the wealth to throw money at them will not necessarily help someone. If a family does not have private health insurance and access to St. John of God or St. Patrick's, however, the problem becomes a living nightmare. That should have been acknowledged in the presentation and it is the reason I asked about a service-level agreement with St. Patrick's.
An agreement would be a ray of light we could offer families in the short term. In the next three to four months, the HSE should adopt a service-level agreement with St. Patrick's and take five or six beds to ensure that there is some semblance of a chain of treatment from general practitioners through community child and adolescent psychiatric units and beyond. The Bodywhys document shows how inadequate the service is in County Wexford and across the country. The HSE must, as a priority, ensure there is a semblance of a chain of treatment for patients. This is not currently the case. I am not attacking Mr. Rogan but it must be acknowledged that the position on the ground is disastrous.
The two most difficult tasks facing general practitioners are signing a person into a psychiatric institution against his or her will and trying to secure treatment for a person with an eating disorder. They are difficult for different reasons. We do not like signing persons into psychiatric units because it is a complex process which removes the rights of individuals. In the case of persons with eating disorders, the problem is that services are not available. Eating disorders are as life threatening as suffering a heart attack or being diagnosed with cancer.
I first became aware of this issue when a lady came to my office and informed me of the case of her 18 year old daughter who, unfortunately, suffers more from behavioural problems than eating disorders. I was shocked to learn that when her daughter eventually ended up in jail, having been brought there by her mother, the Prison Service did more for her than the health service. This reflects the reality on the ground.
At one stage, having committed her daughter to an institution in the south east, the lady received a call from the centre in question asking her to remove her then 17 year old child from the unit because she was causing such hassle. The reason she was committed in the first instance was that she was causing dreadful problems at home. The child's mother slept fully clothed with car keys and a mobile telephone in her hand in case she was attacked by her daughter during the night. She was hit on the back of her head while driving a car and had a frying pan thrown at her. It was a horrific case and every mother's worst nightmare.
I am sure when the lady in question conceived her child 18 years earlier, she never thought this problem would come down the tracks. She has consistently pointed out to me the need for supervised residential care for people aged 17, 18 or 19 who have behavioural problems. Unfortunately, it is not possible to cope with these young persons in the home but these cases are not considered sufficiently serious to have them placed in an institution. That is the difficulty faced by the lady to whom I refer.
Last year, I asked a question about the number of behavioural psychologists. I understand the south east does not have a behavioural psychologist. I am not certain of the position in the rest of the country. I received a long reply from the HSE in September last informing me that while there was no recognised grade of behavioural psychologist, there were different categories of psychologist. Clearly, specific posts must be created for behavioural psychologists. I ask members of the delegation for their views on this matter.
When and where will the additional 80 beds become available? I note they will be for children and adolescents and that a national centre for eating disorders will be established in the new national children's hospital. I have major concerns about the capacity of the proposed new hospital to meet the needs of children. Although there are currently 480 beds available for children in Dublin, the new hospital will only have 380 beds.
In recent days, we learned of a case of a six-week old baby who waited in pain for four days to access a bed in Crumlin hospital. No parent or child should suffer in this way. The proposed new children's hospital will be built without a sufficient number of beds, even allowing for changes in medical treatment. The HSE proposes to establish a centre in the hospital which will, I presume, have some of the 80 inpatient beds mentioned. This would further reduce the capacity of the acute hospital to provide services for children. I ask the witnesses to elaborate on this issue. How many beds will become available? Where will they be located? If there are any concerns about the provision that is being made in that centralised hospital, it would be important that they are put on record.
I thank the group for attending and for its presentation. I do not easily use the word "mythical" but it is appropriate in terms of what we are being told Dr. Daly and others should do with a child with eating disorders. Like Senator Browne, I have had the unfortunate experience of a psychiatrist contacting me to ask what she was supposed to do with a child of 12 with eating problems who she felt was suicidal. No professional person should be contacting a public representative to see what on earth can be done to get a bed for a child somewhere. This is deplorable.
I have been hearing about these mythical beds for two decades. Nothing has happened. I have also heard about the beds that were supposed to be in general hospitals for the same length of time yet nothing has happened in that regard. Nothing will happen in five years time because it will not be considered a sufficient priority for this hospital which, as Deputy McManus stated, already looks as if it will be pretty small for the services that are being included there.
For as long as I have been in medicine — which is four decades — mental health services for children and adolescents have not improved. I do not expect to see any improvement in the next five years. It is terrible when we hear someone like Ms Kelly who spoke earlier about the fact there was no access to any help at weekends. Forgive me for putting it like this, but this is mythical.
We will return to the HSE. The flavour of the debate is evident. People do not believe the situation can be improved within a five-year period. Perhaps Mr. Rogan would begin by addressing the issue of non-existent weekend cover.
Mr. Rogan
It is not intended to be misleading or mythical in the programme and plan, as described in A Vision for Change. I accept we are coming from a very low base. In its broadest sense, mental health has not always received the priority we would like it to receive. In 2006 and 2007, there has been significant new investment in mental health but in the years prior to that we have almost been in retreat in terms of the per capita spend on mental health. There is no doubt we are coming from a very low base. I would not pretend the case is otherwise.
In 1997, there were approximately 30 child and adolescent teams compared to the current 45 teams. The HSE has committed to introduce eight new teams every year for the next five years. That will increase our capacity by 40 new community-based child and adolescent teams. The HSE also intends to commission four 20-bed dedicated child and adolescent units in Dublin, Cork, Galway and Limerick. We are coming from a very low base. We are meeting again tomorrow with the service planners in regard to the National Children's Hospital at the Mater about the mental health requirements, not just in terms of bed space but also in terms of space for the outpatient department, OPD, and accident and emergency services.
It should be recognised that the current three hospitals destined to move to the Mater Hospital are currently providing many of these services in a paediatric context and they will be transfusing with that service.
There are no services for treating eating disorders.
Mr. Rogan
They provide services to a number of young children with eating disorders in the nearest most appropriate context, especially at Our Lady's Hospital for Sick Children in Crumlin, where a particular interest has been developed in this area in terms of the mental health services at that hospital. Each of the hospitals has a liaison presence in regard to mental health and they frequently work with children who have comorbid presentations in terms of their physical health needs as well as their mental health needs.
Are they included in the 20 beds?
Mr. Rogan
I beg the Deputy's pardon, I do not understand.
There is reference to 20 beds here and a further reference to 80 beds.
Mr. Rogan
The four 20-bed units the HSE is developing are mental health beds but within the existing children's hospitals, which are moving to the Mater Hospital campus, there are also a number of children with mental health needs, concurrent with their physical needs, and those services will travel with them.
So the 80 beds are not new beds?
Mr. Rogan
We are creating 80 new beds.
This is HSE-speak. If there are beds in the existing paediatric hospitals that are dedicated for this purpose and there will then be beds dedicated for this purpose in the new children's hospital, they are not additional beds, they are simply a transfer of beds. Which are they?
Mr. Rogan
The beds currently used at Temple Street Children's Hospital, Tallaght Hospital and Our Lady's Hospital for Sick Children in Crumlin will move to the new national children's hospital.
Are those included in the 80 new, additional beds?
Mr. Rogan
No. Beyond that there are mental health beds, 80 new beds for 20 bed units. It is also important to point out that St. Anne's in Galway, which was referred to earlier, a HSE-operated facility, and Warrenstown House in Dublin are also doubling their capacity for children under the age of 16.
In 2006 we allocated €3.25 million and in 2007 we are spending €7.95 million, which amounts to 150 new whole-time equivalents. We are on a steep curve in terms of developing our capacity. We are conscious that a quarter of the Irish population is under 18 and their mental health needs are significant. They have been recognised and we have described a significant investment in terms of capital and new resources and skills.
Where will the four 20-bed units be and when will they be provided?
Mr. Rogan
The unit in Dublin will be in St. Vincent's Hospital in Fairview, which is close to the Mater Hospital campus. In Cork, it will be located in Bessborough, which is coming out of the local authority planning process at the moment. In Limerick, it will be on the Dooradoyle campus and in Galway on the Merlin Park campus. These units are progressing, there has been a significant investment in each of them, and they will require 60 to 65 staff each — another 250 staff.
We are working with our colleagues in the education sector to ensure that all of the skills required for community-based teams and our inpatient services are available to us. It is a focused, fast moving and high investment programme. If the document was in any way misleading, I apologise but it describes where we are going next. We are tuned into that.
We are undertaking an exercise in each of our child and adolescent teams throughout the country to examine team completeness. In some instances teams may only have 60% of the key personnel so as well as there being insufficient numbers of teams, the teams themselves are sometimes insufficient. We are looking at waiting list management reduction techniques and we are working with colleagues from Britain in staff workshops in this area. There must be new capacity but it must also be effective and efficient. Improving access from primary care to the most appropriate point of treatment is essential for us. This must be an achievable and realistic programme.
There is a number of services, including St. Patrick's and St. John of God, where we have service level agreements for provision of community based services. We keep the area under review but it is important to point out that both of these units are often fully subscribed so there is no additionality available at those campuses. Many of the patients there are already referred through HSE services and, in some instances, part-funded on that basis.
I contacted St. Patrick's and it was indicated to me that there is capacity available there and a service level agreement would be possible.
Mr. Rogan
I have met the clinical director and managers at St. Patrick's, with whom I have a close working relationship. We are looking at the area because if we invest in option A, we may have to forgo option B and we must be alert to this. It is under active review and I will come back to the Deputy on it.
Senator Browne mentioned the experience of a woman and her 16 year old daughter. There is no doubt but that it is an extraordinarily difficult situation. Not every child with a behavioural problem has a mental health problem behind it. We have opened up a relationship with the Department of Education and Science, which has a programme for schools behavioural services. Of the 753 post-primary schools, 50 will be involved in phase one of a pilot project on child misbehaviour in school that presents difficulties. We hope to collaborate closely with the mental health service where a mental health issue is recognised and documented.
The NEPS programme is being developed to bring in an additional 30 psychologists. We have a close working relationship with our colleagues in the Department of Education and Science. Within the HSE's palliative services are child care services. We have frequently been actively involved in these cases. Placing someone in residential care should be a late option. It would be useful if we had other steps along that stairs. Other colleagues from the HSE would be more expert on this point.
On the grades of behavioural psychologist, the HSE recruits clinical psychologists to work in our services both in community-based and specialist services, predominantly mental health and addiction services. We will extend the number of clinical psychologists in training. Under the old structure, it was not viable for each health board to create a formal relationship with each of the four universities, UCD, TCD, NUIG and UL. The HSE has been able to work closely with the universities and maximise the number of trainees. Our ambition is to get to a figure of 50 trainees per year so that there are 150 trainees across the three-year cycle for clinical psychology. Many of these will have specialist skills in behavioural therapies as would other disciplines. Many of our nursing staff or medical staff would also have particular interests in certain areas. It is an area in which we need more capacity and capability.
While beds are an important component of our service, in isolation they can be quite limited. It is important that we have throughput, upstream and downstream options before a person requires to be admitted to a bed.
In the past there were many ambitious plans for mental health care but often the resources were not available to activate them. A Vision for Change describes at least €150 million in new revenue over the seven-year cycle of its implementation. We are already on course with the first two years of the programme. A capital programme of €796 million has been put in place to complement it. Most of this will be extracted from the value of existing lands owned by the HSE which are no longer required for facilities. The process has begun and the estates section is disposing of these lands and re-investing in mental health care facilities. There is a real opportunity with real resources and a strong plan that has universal acceptance.
No one would be happier than me if something happens.
Mr. Rogan
I think the Senator might be second to me on that one. There is sustained investment in both our adult and young people services to improve capacity. I accept it can be frustrating for our colleagues in our community-based mental health care teams in that they see significant needs in treatment but do not feel they have the full capacity to meet it.
There is nothing acceptably real in place. It is a product of history and structure. Psychiatric hospitals were general reception places for the administrative care of people who did not function well in society. They were not specific places of treatment for specific conditions.
When Planning for the Future was inaugurated in 1984, its main drive was to replace the institutional system with a community-based system. It was largely a geographical solution trying to get community teams in place to provide comprehensive care in the regions. Given that Ireland was a relatively poor country at the time, there was no money to move beyond that position.
We have become a wealthy State but our infrastructure has been poor in meeting the level of demand where we can provide, on tap, sophisticated, delineated and specified treatment programmes for various conditions. It is a real problem that does not have an immediate solution and will take some years to resolve.
The great benefit of A Vision for Change is that it has focused perceptions around this issue. It will continue to generate consensus among all parties involved in developing mental health care services. There are considerable difficulties around this point. Most of the funding in psychiatric services is sunk in the old structures. It is very hard to move those moneys into new structures and systems. We are a relatively small country, so we do not have large numbers of specialist training programmes or schools for people to gain access to them. As Mr. Rogan said, we must first set them up and then try to develop them.
If we use a private service facility, that will almost certainly redirect funding from the aim of putting in place a longer-term structural solution in a public facility to such conditions as eating disorders. As members are aware, there is not the same flexibility in transferring cash in the mental health sector. The perception is that a great deal of money has been invested but that it is stuck in the old structures. Practitioners would like a great deal of extra bridging money to link the old and the new experiences. Getting it is a real challenge, however.
I am not trying to be negative in this regard. We are very much focused on trying to develop a programme, but we may need some time to deliver it.
This is profoundly depressing. I remember the Planning for the Future document when I was a girl, approximately 30 years have elapsed since. This is terrible news, and the community teams are not yet in place. We are still unable to transfer money from the old structures to the new ones. We have been told the same thing for at least ten years, and the rate of progress is akin to molasses flowing in January. It is really terrible that it should be so slow. It would make one depressed were one not already suffering from depression. I remember Liam Flanagan and Barry Desmond launching the programme. To hear that we have made so little progress since is dreadful.
Planning for the Future proposed general-purpose, generic community mental health teams, and in this case we are talking about more specialised teams focused on such conditions as eating disorders. That development of a specialist focus was not envisaged in Planning for the Future; it is only A Vision for Change that has articulated that. I hope that the document in question will drive the process.
There are not many members present to listen to the witnesses, so I will not torture them about it. However, are the community teams in place everywhere?
Perhaps we might focus on the specialist teams rather than the issue of institutions.
This is terrible news.
Have timeframes been specified?
As Mr. Rogan said, some 40 new community or child and adolescent teams have been planned specifically for the next five years, and that change is currently being implemented. However, there are certain difficulties regarding the employment process.
When will that process begin?
It has already begun.
What progress has been made to date on putting the teams together? A period of five years was mentioned.
Yes.
What year did it begin?
In our area we advertised recently — or we have at least submitted the business cases for those teams.
Dr. Brendan Doody
There is increasing recognition that serious disorders that may surface in adulthood have their onset in adolescence. There is also greater acknowledgment of the need for services and education so that problems can be detected at an early stage when intervention will be more effective. Despite our recognising the importance of early intervention regarding adolescent mental health problems, when those problems have surfaced and been picked up, services have not been adequate to meet the needs.
Once again, we reiterate that child and adolescent mental health services are starting from a very low base. The document A Vision for Change mentions 98 community teams providing services for those under 18, but there are currently only 45 such teams in place, and those may have only 60% of their recommended multi-disciplinary complement. That means that we have a third of the recommended service level. Inpatient services for children and adolescents have contracted over the past ten years. In other words there were more inpatient services ten years ago than currently. There are a number of different factors as to why inpatient services contracted partly as community services developed. There has been an expansion in community services which drew on the nursing expertise, in particular, within inpatient units. The difficulty is that the service expanded at the expense, sometimes, of inpatient services.
The treatment model is such that the young person and the family need to get the most appropriate treatment at the time it is needed. That may be from the community mental health team to the local inpatient unit, or perhaps an input from a specialist team may be required. A model exists, but we are a long way from it being in place. Child and adolescent mental health teams differ from adult services in that they see eating orders as part of their core business. They see that the multidisciplinary team has necessary skills to meet the needs of young people presenting with eating disorders in the majority of cases. However, these teams also need to know they have backup and access to inpatient facilities and services when needed. I work as a consultant in an inpatient unit. There are just two inpatient units for children and adolescents in the public service, at present, and one in the private service. The public service has a capacity of only 12 beds, between our unit at Warrenstown, Blanchardstown in Dublin and the one at St. Anne's in Galway.
We take referrals from all over the country, from Wexford to Monaghan. We struggle to meet the demand that exists for inpatient services. We also experience young people with eating disorders who will often be referred as part of their assessment for medical investigations. They are on medical wards because of these investigations. There is difficulty, then, in moving them on to inpatient services. This is my experience because I work, also, at the children's hospital in Tallaght. Trying to manage such children on a general or paediatric ward is far less than ideal because, while medical needs are being met, a particular therapeutic milieu must be provided for young people with eating disorders. Staff on general and paediatric wards believe they do not possess the necessary skills because it is an area that requires skill, expertise and confidence as regards working with these young people. Children are on paediatric wards because there is no ready access to inpatient facilities. We are also aware that on occasion young people have actually gone abroad to access inpatient services.
We talked earlier about the proven interventions when it comes to eating disorders. A critical part of any intervention or treatment programme for young people and adolescents is the importance of the involvement of family therapy. Family work is very difficult if the child is being treated at a significant distance from home or in another county and this can have a very disruptive effect on the young person. Then there are the problems involved in integrating the child back into the home, community and school.
Eating disorders in young people tend to occur at a very critical time in their physical, social and psychological development. It is of paramount importance that the child is integrated back into his or her normal environment as soon as possible. What is laid out, therefore, is a comprehensive model of services that needs to be in place to meet the needs of young people with eating disorders. We are a long way from having the necessary services in place. Some of the difficulties can be practical in nature, as Mr. Rogan said, with regard to looking at multidisciplinary teams. It is not just a case of appointing a consultant psychiatrist. Again, we have to look at training adequate numbers of consultant child and adolescent psychiatrists and other members of clinical teams, psychologists, nurses, social workers, trained family therapists and so on. It is a matter of not only looking beyond particular disciplines but achieving the proper skills mix within teams. We need a community mental health team to meet the needs not only of children with eating disorders, but also of other children. It needs a range of skills that can be accessed. Community teams will struggle because they state they do not have the range of skills and personnel required to treat young people with such disorders. Treating such persons is very intensive, time-consuming work that requires the necessary personnel. It is very difficult to embark on a treatment programme when one does not have the necessary personnel to deliver it.
I wish to make a helpful suggestion. Could the centre for eating disorders not be located in the children's hospital in Tallaght? It does not have to be a very big unit. We would then be five to ten years ahead of schedule, rather than having to wait for that great hospital in the sky.
Dr. Doody
It forms part of the development. If we look at the geographical locations of the 80 additional beds, Dublin is seriously under-represented. Of the 80 beds, 60 are located outside Leinster. This means only 20 can be allocated in Dublin. This is particularly bad for the south Dublin and mid-Leinster area. I have been involved in the National Children's Hospital in Tallaght. The board of the Adelaide, Meath and National Children's Hospital has adopted a policy to develop an inpatient unit on site in the hospital in Tallaght. Time is not on our side. We are meeting consultants on Friday. I met consultants on Monday who are working on the project for the new national children’s hospital and made it clear that we needed to develop an inpatient resource. There is also an immediate need to provide what we can in a shorter timeframe.
Tallaght Hospital and St. James's Hospital, in conjunction with St. Patrick's Hospital and Trinity College, have instituted a CBT degree training programme, of which four of our staff members are in their first year. It will have specialist training modules, including on eating disorders. Four staff members will start the programme every year. It is a programme for upgrading the skills base of staff in the service. We will be in a position to have skilled staff for interventions in treating conditions such as eating disorders. It will be an ongoing programme. We have a second programme for the treatment of people with other behavioural problems and problems of identity and relationships. It is a two-year programme and the first group are about six months away from completing the course. These programmes are university based, not just one-off informal teaching programmes. They will upgrade the skills base of our staff and mean that structural programmes will appear in time. We have started from a low base and it is difficult to access finance. However, the process has started. We hope the programme will be accessed by other health care facilities to increase the skills base of their staff.
If anyone anywhere was enthusiastic about this, it would be worthwhile for the sake of patients to get going with it.
Dr. Doody
I recently appeared before the board of the NCH where I was berated for the lack of progress on developing an inpatient unit. The hospital in Tallaght, uniquely in Dublin, has an adult general hospital, a paediatric hospital and adult mental health facilities located on site. With regard to the need for a comprehensive service, the liaison service had presentations to the National Children's Hospital in Tallaght last year in 105 cases of deliberate self harm in those under 16 years of age. There has been a very significant increase in the numbers for the under-16 age group. The age limit at Tallaght is 16 whereas at the other hospitals it is 14.
There is a concern with regard to the new children's hospital's cut-off age limit. If we raise the age from 14 to 16 or higher, the number of young people presenting with acute mental health problems to that facility will increase significantly, which has significant implications for the hospital and the demands on it.
The new Mental Health Act has 18 as the cut-off age.
Dr. Doody
It has long been recognised that the cut-off age between child and adolescent mental health services and adult services is 16 years, which goes back to the 1945 Act. It has also long been recognised that the needs of the older adolescent group were not best met within adult services, which have a different developmental perspective. There was a mismatch between the needs of this group and what adult services could provide.
The faculty of child and adolescent psychiatrists in the Irish College of Psychiatrists has long been concerned about the needs of this older adolescent group, which have been neglected. This group presents particularly often with very acute eating disorders. The Vision for Change document has clearly enunciated that the policy for this group of 16 and 17 year olds should come under the remit of child and adolescent services.
I was involved in the child and adolescent inpatient forum and the two documents published at the end of last year which considered how child and adolescent services would incrementally take on the mental health responsibility for this group. However, I come back to the fact one is dealing with existing services which are poorly resourced for the needs of under 16s. It is important we look to the mental health needs of all those under the age of 18 and that we do not develop services for one age group at the expense of another.
This applies also to children presenting with other conditions. It is important that those children whose needs are such that they require a service have that service available to them. If there is a highly under-resourced service, as may be the case in Wexford, it will spend all its time dealing with emergencies and crises — this is the only capacity it will have. On occasion, an intervention at an earlier stage would prevent a crisis occurring but if there is no capacity to intervene earlier, the service will always deal with extreme crises. We must recognise that children who are suicidal are acutely unwell.
We must consider developing inpatient community services with all of the various disciplines, and make sure that when we get resources the required people are available to be recruited. The Vision for Change document highlights the significant manpower implications. We need to plan not only financially or with regard to the locations from which staff will work but also with regard to training so each of the multidisciplinary teams has the range of skills on board to provide a comprehensive service.
I have one concern with the Vision for Change document, namely, its costing. When we did the sums with regard to implementing the child and adolescent aspects — the under 18 aspects — of that document, we found there was a cost approaching €90 million. Given the entire document is costed at €150 million, we would very much hope it is deliverable but we are concerned that adequate costing has not been made, that the document's recommendations will not be delivered and that the service will be blamed. In other words, although we will provide the amount of funding that was allocated, I am of the view that the costing is significantly inadequate to realise the services laid out for implementation.
The Minister will not be pleased if that comment of Dr. Doody's is quoted on the front pages of tomorrow's newspapers.
Dr. Doody
We must be clear about the cost involved in putting in place the necessary services. This comes back to the issue that the percentage of the budget that is spent on mental health services has shrunk significantly from more than 12% ten years go to some 7% now. The Mental Health Commission stated in its previous document that a certain amount of the health budget should be ring-fenced for mental health services.
The HSE estimates it will cost €90 million to provide these services. I have some concerns about what Dr. Doody said. He made the point that the necessary personnel are not in place and that planning is inadequate. The Minister, Deputy Harney, keeps saying that half the paediatric beds in Tallaght Hospital are empty. A physical structure is therefore already available to provide services immediately. How soon could the necessary personnel be put in place there? If, for instance, a decision were made tomorrow to designate Tallaght Hospital as the national eating disorder unit for children and adolescents, how quickly could the required staff be installed?
I am irked to some degree by the points the delegates made about funding. In regard to the service level agreement with St. Patrick's Hospital, for instance, they claim there is no money for delivering the public service component of its mental health services. This same concern does not seem to arise, however, in regard to the National Treatment Purchase Fund, the budget for which has doubled in recent years. Some concern has been expressed that the working of the fund may affect surgical training, but nobody is making the argument that a service for children and adolescents with mental health problems cannot be provided immediately because we are focusing on public development in the long term. Nobody is saying that when it comes to operations for varicose veins and gall stones.
It is a separate funding source.
I do not see that as a reason. If the National Treatment Purchase Fund can be used to deliver varicose vein operations, it can certainly be used to provide for adolescents with mental health problems.
There are plans to move the acute psychiatric unit at St. Vincent's Hospital in Fairview to the new Mater Hospital development. The former sees its future role as very much a community mental health service provider. How realistic is it that we will see a 20-bed unit for child and adolescent mental health services in Fairview in the next five years? How much effective discussion has gone into this proposal? Is it No. 46 on some agenda? St. Vincent's Hospital has a totally different viewpoint as to how it will develop in the future. Is this simply another exercise in moving bundles of papers?
Is the Tallaght plan an immediate option? We should assess the options realistically and begin to take action. This is the type of issue the delegates should take back to their political masters to counteract all the raiméis we hear from them every second day.
Mr. Rogan
We have been involved in detailed discussion of the situation at St. Vincent's Hospital in Fairview and it is much further up our agenda than No. 46. We expect that approximately eight beds will be introduced there later this year in a refurbished site that will become the forerunner of the 20-bed unit. One of the issues to consider in developing a child and adolescent unit is the educational needs of young people. The footprint for such a unit is significant and we must examine how that can be best accommodated. This is not by any means a pipe-dream.
We will have a meeting with the management of Tallaght Hospital tomorrow to consider the opportunities that already present at the Tallaght campus and how they can best be realised. The implementation of the Mental Health Act has focused minds in regard to the difficulties experienced by people at 16 and 18 years of age. There is a growing body of evidence in respect of the early identification of other mental issues that may require subsequent lifelong programmes. For example, both Dr. Daly and Dr. Doody have been very closely involved in developing models for the early identification of quite severe and significant psychosis into the future. Consequently, the relationship between our child and adolescence service and our adult services cannot be tectonic, whereby one simply steps over one's 18th birthday and suddenly becomes an adult.
If one is trying to treat someone on the front line, it is exactly like that.
Mr. Rogan
This is what must be improved.
The services might consider a patient's date of birth and state the matter is out of their jurisdiction at that point. Alternatively, they might note the patient will not reach his 18th birthday for another three days and although he may be walking around with a big, bloody knife in his hand, one is obliged to wait for a court order before being able do anything about it.
That is the reality on the ground. While I hate to be cynical in this respect, the position may be grand from Mr. Rogan's perspective. However, he should consider the scenario in which one is summoned to some person's house, outside of which are two squad cars, three ambulances and a group to match, and someone at the other end of the phone is asking for the exact date of birth. It is exactly like that. Someone decides that one has contacted the wrong service or that one needs a court order before being able to do anything about it.
There is a need to wake up in this regard. I will not dismiss such issues because I dealt with a similar matter recently and it is incredibly frustrating for those involved. I refer to those who work in the hospitals in the south east, as well as the doctors, gardaí, ambulance personnel and families who are involved in these cases.
Mr. Rogan
I am very familiar with this area and my professional background also keeps me alert in this regard. We must get away from such scenarios. They often relate to highly limited resources and using such resources in a finite way. As for the capacity in our child and adolescence service and our adult services, since new funding became available in 2006, permanent positions are beginning to materialise in terms of advertisements, etc. As we will have 18 new adult teams, capacity should be much improved. When one builds bridges across an age divide, it is useful to have someone on the far bank building towards one. Capacity will rise in our adult services and child service. It is important not to have a digital divide between child and adolescent services and their adult counterpart. It is important to collaborate effectively in the hand-over of those who may require longer term care.
To return to the subject of eating disorders, such continuity of care is absolutely essential.
The witnesses should respond to the question on personnel. How soon can—
Dr. Doody
The document, A Vision for Change, was very good in terms of considering the important issue. If we want to develop services, we require proper manpower planning. As the Deputy noted, this is not simply about money as it also pertains to having the money and training people in order that they are in place. We must consider inpatient services and, in this context, inpatient resources pertain to the recruitment and employment of nurses. We have found the Dublin factor definitely is in play. It is much easier to recruit nursing staff for positions outside Dublin, as is the case across all nursing specialties. In respect of child and adolescent mental health in particular, the roles are highly specialist in nature and hospitals in Dublin must recruit nursing staff from abroad. Consequently, the ability to access nursing staff with the necessary skills for working in inpatient child and adolescent mental health units is more problematic.
This is a challenge. However, simply because it is a challenge does not mean that we should not work hard at building up and recruiting. I say it is a challenge rather than being impossible and a number of the factors that make it challenging are not unique to mental health services. As for recruiting nurses to mental health services, there are difficulties in recruiting nurses to meet shortages in all nursing specialties. However, given the number of graduates who are emerging, one hopes the position with regard to nursing graduates in mental health services will improve. While we have gone through a period that has not been very good with regard to numbers, that situation is definitely improving. I am sure Mr. Rogan can respond in this respect. While it will be challenging, the future availability of nurses to work in such units should constitute an improvement on the position that obtained in recent years.
Dr. Doody is beginning to speak like a politician. I still do not know how long this will take.
Dr. Doody
It is somewhat like beginning by stating that if we have—
If we decided to create a national eating disorder unit in Tallaght, finding personnel would be a problem as it was with community care mental health teams. These teams are piecemeal throughout the country which is a problem with regard to training people to fill them. If I were the Minister for Health and Children I would cut this conversation short by simply asking for a realistic timeframe in which to establish an eating disorder unit in Tallaght and obtain the personnel to staff it. We are going to India and the Philippines for nurses and South Africa for radiographers and occupational therapists.
Dr. Doody
The first question is whether the physical resource of a building is available or whether one must be built.
There is a building available which is a start.
Dr. Doody
The next factor is to develop the team. I imagine a one and a half to two year timeframe is realistic and reasonable.
That is not too bad. It is a significant improvement on five to ten years. We should definitely go for it.
That is for Mr. Rogan to take away.
I thank the delegation for its presentation and for staying longer than one hour. We appreciate it.
The joint committee adjourned at 11.52 a.m. sine die.