JOINT COMMITTEE ON HEALTH AND CHILDREN (Sub-Committee on the High Level of Suicide in Ireland) debate -
Friday, 25 Jul 2008

High Level of Suicide in Irish Society: Discussion.

Chairman

I am pleased to welcome Dr. Siobhán Barry, director, Cluain Mhuire Services; Dr. Patrick Doorley, national director of population health, Health Service Executive; Mr. Geoff Day, director, National Office for Suicide Prevention; Mr. Fergus McGrath of the Reach Out project; and Mr. Seamus McNulty, assistant national director of primary, community and continuing care services, Health Service Executive.

I draw attention to the fact that while sub-committee members have absolute privilege, this same privilege does not apply to witnesses appearing before the sub-committee. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable. I call on Mr. Doorley to make his presentation.

Mr. Patrick Doorley

Suicide is a societal problem. Although there are specific influences in individual cases, including alcohol, mental illness such as schizophrenia and so on, broad suicidal trends in many countries are influenced by societal factors such as changes in law and so on. Our role in the Health Service Executive is one of leadership and co-ordination. Members will see from our presentation that we are trying to engage with various elements in civil society, including local communities and non-governmental organisations, to work together to tackle this major public health problem. My colleague, Mr. Day, will outline the statistical information in more detail. While Ireland's rate of suicide is average, or slightly above average, in comparison to that of other European countries, our difficulty is our rate is fifth highest in terms of youth suicide. We take this public health problem extremely seriously.

Reach Out, the national strategy for suicide prevention, was developed some years ago. Each year the Health Service Executive has been trying to advance as much of that agenda as possible. Mr. Day will provide the sub-committee with a brief update under each specific heading and action, as set out in the strategy. My colleague, Mr. McNulty, will answer questions on mental health services. Our objective is to co-ordinate a mental health promotion approach with a mental health treatment approach. Both have an important role to play.

I ask Mr. Day to make his presentation, after which we will be happy to take members' questions.

Mr. Geoff Day

We welcome the opportunity to engage in this discussion with the sub-committee. The seventh report of the Joint Committee on Health and Children was an important document for us and built on the work in which we were engaged in the development of the Reach Out strategy. Suicide prevention has a relatively short history in Ireland, given that suicide was not decriminalised until 1993. Therefore, some of the difficulties arising from the stigma associated with suicide prior to 1993 are still with us.

Three major reports have been prepared since which set out the direction for action and investment. These are the report of the national task force on suicide published in 1998; Reach Out, a National Strategy for Action on Suicide Prevention, published in 2005; and the Joint Committee on Health and Children's seventh report on the high levels of suicide in Irish society published in 2006 under the chairmanship of Deputy Moloney. The 1998 report was followed by the establishment of resource officers for suicide prevention; the provision of year-on-year funding for suicide prevention activities, amounting to €4.5 million by 2005; the establishment of the national suicide review group which I had the privilege of chairing for some years; and the allocation of funding for the ongoing work of two extremely important organisations in the field, namely, the Irish Association of Suicidology and the National Suicide Research Foundation.

Following the launch of Reach Out in September 2005, the Health Service Executive established the National Office for Suicide Prevention, NOSP. Its function is to co-ordinate suicide prevention activities, consult public organisations on future suicide prevention initiatives and commission and develop new services for suicide prevention, where appropriate. It employs six staff in offices in Dublin, Cork, Galway and Ardee. It has an annual budget of €4.5 million, comprising additional new moneys made available in 2005, 2006 and 2007 and money transferred from the former health boards to meet the historical funding arrangements of the Irish Association of Suicidology and the National Suicide Research Foundation. An additional sum of €l million was made available in 2006 to fund 20 projects through the dormant accounts fund administered by Pobal. The NOSP was involved in drawing up the criteria for selection of those projects. A second round of suicide-specific funding of €1 million will be made available later this year.

It is worth saying that although the NOSP did not seek bids for funding in 2008, many organisations submitted completely unsolicited proposals to the office. A total of 26 bids was received from a range of organisations totalling €3.8 million, which gives an indication of the need and commitment, particularly in respect of voluntary organisations, to develop specific suicide prevention initiatives

In respect of suicide data, suicide numbers and rates rose dramatically during the late 1980s and 1990s, peaking in 2001 at 519 suicides which represented a rate of 13.5 per 100,000 population. As Dr. Doorley said, this is probably average for the rest of Europe. Since 2001, the number of suicides has remained at just under 500 per annum, although it is probably too early to say whether the dramatic rise of the past two decades has reached a plateau. I suppose we all hope it has and that it is heading down but it is too early to read that from the data. Data on suicides in 2005 by year of occurrence is now available from the CSO. This indicates 481 suicides and a rate of 11.6 per 100,000 population; therefore, the rate of suicide has declined, although the numbers remain stable at around 480 and 490.

Of most concern to us is that Ireland now has the fifth highest rate of youth suicide in the European Union. Suicidal behaviour remains a major public health problem in Ireland. Every suicide is an individual tragedy for the person concerned, his or her family and community. Whatever we do in terms of our strategic approach, we must never forget that this is an individual tragedy. Dr. Doorley mentioned risk factors for suicide. They include alcohol and drug abuse and depression remains a major factor. Suicide trends over time in Ireland and many countries are also influenced by major social changes, particularly those which result in less social cohesion.

We are lucky here in that we have collected data in the past few years on form 104 which is completed by the gardaí. A research project was initiated and reported earlier this year. The research indicated a level of under-reporting of suicide which it was estimated could be at least 6%. We have nearly complete data on self-harm presentations through our accident and emergency departments since 2002. This is probably one of the best sets of data across Europe and has been collected by the National Suicide Research Foundation. The number of presentations for self harm has remained stable at around 11,000, of which 21% were due to repeat acts. We know that repeated self harm is a very strong indicator for completed suicide.

Targets for reduction in suicide and self harm have been agreed with Government since the production of the committee's report. The targets are to reduce the level of suicides by 10% by 2010 and, perhaps as importantly, to reduce the overall rate of repeated self harm by 5% by 2010 and to further reduce it by 5% by 2016. The programme for Government includes a further target of reducing the rate of suicide by 20% by 2012. These targets are in line with those adopted by our immediate neighbours in Northern Ireland, Scotland and England

The implementation of the actions in Reach Out can only be achieved through collective action by Government, statutory and voluntary bodies and individual communities. It is, therefore, everyone's problem. Many high-level commentators have made that point. The role of NOSP is to co-ordinate activities and this has been achieved by a combination of actions, including the NOSP annual forum; meetings with funded projects to monitor progress; ongoing discussions with voluntary groups at national and local level; regular meetings with HSE resource officers for suicide prevention; ongoing dialogue with the Departments of Health and Children, Education and Science and Justice, Equality and Law Reform; and the involvement of many agencies on a partnership basis.

The health service has a statutory obligation to report on suicide prevention activities to the Houses every year. The annual report was previously compiled by the suicide review group, but this role has been undertaken on behalf of the HSE by the National Office for Suicide Prevention since 2005. We will complete our report this year and we hope the Minister will present it to the Houses on 10 September, world suicide prevention day.

Since 2006, the NOSP has been working closely with colleagues in Northern Ireland on joint suicide prevention initiatives. The Northern Ireland strategy, Protect Life: A Shared Vision, was launched in 2006 following consultation with us and many other organisations. A ten-point plan was agreed the same year and an update on the plan was recently reported to the North-South Ministerial Council. The NOSP and the Department of Health, Social Services and Public Safety in Northern Ireland will continue to develop existing and new initiatives in this area.

It is important to stress the new areas of work since the publication of our reports. New technology as a means of communication has developed rapidly and is now one of the primary means by which young people communicate. If we are to reach those particularly vulnerable young people, we need to use their form of communication. We have already been in discussion with our Internet safety board about its role and the implications for suicide prevention. We accept the Internet is both a positive and a negative means to convey messages about suicide.

We have read the conclusions of the Byron report in the United Kingdom which makes recommendations in three areas, namely, reduce the availability of harmful and inappropriate material in the most popular parts of the Internet, control by parents and ICT suppliers to manage access to material and build resilience, particularly among young people, in order that they have the confidence and capacity to determine what is harmful themselves. We are working on a number of specific projects related to the use of technology and I am pleased that Mr. Fergus McGrath is in attendance, as he may be able to assist us all in this process.

We have our own profile for the Your Mental Health campaign on Bebo, the social networking site used by thousands of young people. The profile has had more than 35,000 hits and made 1,400 friends. The response from young people is almost entirely positive. The site is moderated by our staff to provide advice and to ensure no inappropriate content is accepted. We are working with the search engine company Google, the European headquarters of which is based in Dublin, to support voluntary organisations using the most up-to-date technology to interact with young people in particular. Google has also made some changes to its search approach, primarily led by representations from Samaritans in order that help services are advertised on the first page of Google. However, having examined the site today, not all parts of Google do so. Hence, we have some work to do.

Many organisations in Ireland are already using technology to reach young people, either by way of information or by on-line counselling. The NOSP and others have established the Technology For Well Being group, which is looking to co-ordinate and develop our approach to using this medium. We also provide funding to a number of groups using technological approaches as well as those using traditional help lines.

We work primarily to the recommendations set out in Reach Out. We hope to commission an independent review of Reach Out and the work of the NOSP in the near future. The NOSP has also taken into account the recommendations set out in the Oireachtas report on suicide. We have supplied for the committee's consideration a brief update on the recommendations, with the relevant cross-reference to Reach Out where appropriate.

Our key achievements include making some improvements in our self-harm response through our accident and emergency departments, establishing the HSE Your Mental Health campaign, setting up Headline, the media monitoring organisation, undertaking a significant review of bereavement services, researching the risk and protective factors for those affected by institutional abuse, researching data collection on suicide and self-harm and working with the Coroners' Society of Ireland to establish a pilot project to collect better data. We have established two primary care initiatives to fast-track responses to self-harm and suicidal ideation and we are funding some work with Travellers and the lesbian, gay, bisexual and transgender community. We are also funding the work of a number of voluntary organisations working in suicide prevention. As the Chairman knows, we wholeheartedly support the work of the successful world congress on suicide prevention which the Irish Association of Suicidology hosted in Killarney in autumn 2007. It was an opportunity to listen and contribute to the world debate on suicide prevention.

The challenges are many and I refer to some of them. It is important that we maintain the suicide prevention profile with the public and the Government. It is important also that we present the arguments internally for developing suicide prevention services within existing HSE resources. We should present the case for new and sustained investment to the HSE through the Government. We should support the vital and important work undertaken by voluntary organisations and communities, from within which many strong initiatives come. We must continue to support them. We must also seek to change public attitudes to mental health in order to create a more supportive society. We must recognise that young people, in particular, have different ways of communicating and that our approaches should respond to them. We need to ensure research findings here and elsewhere can be made applicable. Where possible, we will collaborate with our colleagues in Northern Ireland, elsewhere in the European Union and worldwide in order to learn from and contribute to knowledge on suicide prevention

Mr. Fergus McGrath

I have been invited before the sub-committee because I submitted a proposal on Reach Out. Members have a copy of my proposal and I will talk them through it. It is being submitted by eolach.ie, a computer-based education and training provider located in Clonmel, a company I set up four years ago. We specialise in providing mental health related educational material by offering on-line courses in general psychology and drugs and behaviour, both of which were written by me. We also provide an on-line stress education and training product, which I developed, for the workplace as part of an employee’s overall health and safety programme and-or personal development. As well as using our website for the provision of academic courses, it can also be used as an educational and administrative resource that can assist in the implementation of the national strategy for action on suicide prevention 2005-14 and subsequent strategies.

I completed a BSc in psychology at the University of East London which I followed with a higher diploma in computer science at UCC. My aim was to fuse psychology with computer science. At the time I was not sure how I would do it but this is the result. The eolach.ie website will be used as a one-stop-shop to incorporate and support all of the suicide-related services in the State - educational and otherwise - with regard to the national strategy. It will also act as a social network for persons at risk and their families, as well as for members of the public.

The proposal will facilitate cross-Border co-operation as per strand two of the Good Friday Agreement. It supports the vision and guiding principles of the national strategy for action on suicide prevention 2005-14 and traverses all four levels of the plan - the general population approach, targeted approach, responding to suicide and information and research. It is based on a successful pilot intervention study in Germany - a four level community-based intervention programme for depression and suicidal behaviour which was designed to contribute to early identification and the improved care of depressed patients and those who engaged in deliberate self-harm, as well as the prevention of suicide. The study used four levels of intervention - general practitioners, acute groups, community facilitators and the public. Due to its success, the European Union is partly funding further research into its effectiveness in 16 regions across Europe, one of which is Ireland.

We propose to use the four levels of the study and include two others, mental health services and administrators. We also propose to use the Internet to support and co-ordinate it. To clarify, the German study was not internet-based and had four levels. My proposal is internet-based and has the four German level plus two more. The six levels will be general practitioners, acute groups, community facilitators, the general public, mental health services and administrators.

The major feature of this proposal is the incorporation all of the suicide-related services in the State and possibly on the island. In doing this, we hope to provide an innovative, integrative and systematic approach to address the increase in depression, deliberate self harm and suicide in Ireland at different levels. This will be achieved via the eolach.ie website which will act as a focal point for all parties who have an interest in or are affected by depression, deliberate self harm or suicide.

For this to happen the eolach.ie website will host separate areas for each of the six levels mentioned. Individuals from each level will have password-protected access to the areas of the website that contain material of relevance to them. Alternatively, everybody accessing the website could have access to all of the content irrespective of their level. This can be discussed further down the line.

These areas will be populated with the following material, resources and activities: personal password-protected user accounts for each user; suicide-related educational material of relevance to each of the six levels; a glossary of key terms associated with the educational material, the entries to which can be searched or browsed in several different formats; an audio facility where users can listen to the educational material and narrated Power Point presentations that can provide information in a dynamic manner.

As an educational resource it will also have a wiki facility that allows users to engage in user-driven, participant-centred communal education or research. A wiki is a web page that anyone can add to or edit. It enables documents to be authored collectively and supports collaborative learning and or collaborative research.

A "Latest News" section will ensure that users of the website are kept up to date with topical issues of relevance. It will be similar to a newsletter. An "Upcoming events" section will publicise upcoming events of relevance. In a "Recent Activity" section users can see a list of changes that have been made on the website since their last log in. This will prevent users from having to trawl through the entire website to see whether changes were made to anything they may have added.

The website will have discussion forums where users can discuss relevant issues with their peers in an asynchronous manner. Postings can include attachments and can be sent to users' e-mail addresses if required. In social forums users of the website can discuss non-work related issues or issues not related to the topic at hand. There will also be a chat room where users of the website can engage in real time synchronous discussion.

A personal mail facility will allow users to send and receive mail via the website. This could replace the standard e-mail address system used by many organisations and people. It is a case of clicking on a user's profile and sending him or her a mail. It is easy and very user-friendly. A display of current users will indicate who is logged in at any time and the idea of this is to facilitate communication, which is a core aspect of this proposal.

We can have quizzes that are automatically scored once submitted. These could be used as educational fun activities, as can automated crosswords where the clues and answers are all mental health-related. A list of participants will facilitate communication.

Chairman

I ask Mr. McGrath to summarise the remainder of his presentation because time is limited.

Mr. Fergus McGrath

Very well. Users of the website will have the option of completing on-line courses. Members of the public who do not have access to computers in their own homes may be able to access the website in youth cafés, substance misuse centres and so forth. A core aspect of the proposal is the potential to assimilate suicide services on an all-Ireland basis, thus fulfilling elements of the Good Friday Agreement. In that context, the Internet is the ideal tool for cross-Border initiatives.

The website contains many features of social networking websites - even though it is not strictly such a site - thereby making it more attractive and engaging for young people, in particular. Links could be provided to other social networking sites such as Bebo and so forth. It may also be possible to include a link to the Samaritans or the HSE, if the latter was to devise a service similar to that provided by the Samaritans. It is possible that material could be devised and sent to schools through the website. Our general psychology course is being used as a transition year activity; therefore, we already have a presence in schools.

If this model is successfully implemented, there is no reason it cannot be used internationally, albeit on a larger scale. I am open to suggestions regarding amendments or changes to the proposal, as well as to having a more general discussion on the matter. At a later stage I wish to assimilate all mental health aspects, including the national drugs strategy, the clinical psychology service and so forth, under one umbrella because of the strong links between them. The cost is negotiable. In fact, it may even be a cost-saving measure if used properly. I have a demonstration package which some members may have seen. If not, I strongly urge them to take a look at it. Access details are provided on page 6 of my presentation.

The proposed measure can act as a co-ordinating structure for all of the suicide-related activities under way in the State, which is its key benefit.

Chairman

I thank Mr. McGrath.

Dr. Siobhán Barry

By way of introduction, I am the clinical director of a publicly funded mental health service, working in south County Dublin. I acted as a consultant to the committee in the preparation of a previous report on high suicide rates in Ireland.

Senator Mary M. White

I apologise for interrupting, but could we deal with the individual presentations as they are made?

Chairman

Members can pose questions, once Dr. Barry has finished her presentation.

Senator Mary M. White

That is fine.

Dr. Siobhán Barry

By way of general comment, it is good to receive an update. Strategies scheduled to run for several years can be derailed quickly, unless they are reviewed on a regular basis.

Mr. Day spoke about the primary function of the National Office for Suicide Prevention being implementation of Reach Out. In that context, it would be helpful to the committee if the 29 areas earmarked for "phase one actions" in the document were commented upon by Mr. Day today. Actions were indicated in September 2005 and it was anticipated that they would be taken and completed within a short timeframe. It would be helpful for the sub-committee to investigate whether these were delivered or if obstacles had arisen. It would also be helpful if we knew on an annual basis the budget of NOSP. The percentage breakdown of the office's budget was given in its annual report for 2006, which was published in September 2007, but it would be useful to know the percentages as well as the total amounts spent on research, media activities, training and so on.

The sub-committee would benefit from an understanding of the links between the work of NOSP and the psychiatric services in terms of putting in place A Vision For Change. I question whether the diversion of funds from mental health services, which the independent monitoring group described as running to €21 million over a two-year period, has had an impact on the work of the office. I would like to know whether the HSE staffing embargo and restrictions on travel, hotels and facility hire has had an effect on training people in the community, particularly with regard to the emotionally charged type of training conducted through the Applied Suicide Intervention Skills Training programme. I would also like the committee to inquire into the current number of suicide resource officers. The NOSP's first annual report set out a figure of 11 officers but I understand the number is now eight, of whom only five are employed in a permanent capacity. That appears to be a regressive move.

The association between suicide and alcohol use, particularly among young people, was mentioned. It appears that the Department of Justice, Equality and Law Reform is attempting to address this issue within its own sphere of influence but I wonder at the health services' response, particularly in regard to access to treatment. Questions arise regarding the provision of services and whether data are collected on people from eastern Europe, given that the rates of suicide in that region are high relative to Ireland. We already know that people who emigrate from Ireland have a high rate of suicide. I would like to know whether data are collected by the CSO or through Form 104.

While I am interested in Mr. McGrath's proposal on the Internet as the ideal tool, this needs to be tempered by an awareness of the degree of isolation that is innate to the medium. While the Internet may provide information, many people who self-harm or end their lives by suicide appear to have an alarming degree of social isolation. Further forays into the Internet must be balanced by realism.

Senator Mary M. White

I thank everybody. Dr. Barry spoke about issues which come within my areas of interest. I spoke earlier to Dr. Doorley about the 11 suicide prevention officers who are supposed to be in situ around the country. Apparently, three positions are not filled. For anybody in the Visitors Gallery who does not know, suicide prevention officers are dedicated to bringing down the rate of suicide in the community. One of the positions in County Kildare has been publicly advertised. I spoke with Dr. Doorley in Leinster House about two months ago and pleaded with him to fill the positions as a matter of urgency. It should be a priority for the positions in Cavan, Louth, Meath and Monaghan, as well as other areas where there is no suicide prevention officer, to be filled.

It is possible we could have an unfortunate tragedy in the areas where there is currently no suicide prevention officer, namely County Wicklow, Dún Laoghaire, south Dublin, counties Louth, Meath, Cavan and Monaghan. A tragedy occurred in the south east and no suicide prevention officer was in place.

My research in the past year indicates that we have an epidemic of suicide in Ireland. I would add another approximately 120 on top of the official figure; I included these undetermined deaths which in other countries would be added to the official figure. There is another figure of road traffic accidents that are suicides. I put the figure at 613 as against the official figure of 493. We have a crisis and the area of self harm and repeated self harm must be dealt with seriously.

During the week Dr. Ella Arensman indicated we were unique in Ireland in that we did not have special procedures for treating people who turned up having committed self harm. The National Suicide Research Foundation, based in Cork and headed by Dr. Arensman, produces state-of-the-art statistics and registrations in the area. It is probably one of the top groups in Europe for registering deliberate self harm. If 20% of people who self harm repeat the action, we have a crisis. If 8,500 on average turn up for treatment out of approximately 50,000 who self harm, it appears that most people who self harm do not go to accident and emergency departments or general practitioners. What will we do about this?

A sense of urgency in Dr. Doorley's office to put in place suicide prevention officers is required. I will keep at this issue until people are put in these positions as I feel a sense of responsibility to people in the areas in question. I will not let go of the matter until suicide prevention officers are in place. Ideally, every county should have a suicide prevention officer. As a lay person, I know we will always have suicide with us and in the overall scheme, the proportion of people dying from suicide is not large. I have studied the matter in the past 12 months, although I am a politician and policymaker rather than a scientist. From my reading of state-of-the-art academic studies, I believe many people at risk of dying through suicide could be helped. The act leads to serious trauma to society, families, communities and friends. For every death by suicide six people consequently suffer serious trauma throughout their lives.

I record my admiration for the work of the Chairman, Deputy Neville, on this matter, his personal initiatives during the years and his efforts to put the issue of suicide on the national agenda. He drove the change in legislation in 1993 that made it no longer a crime to commit suicide. Everyone who knows me in this room knows that I am not in the business of flattery but I would also like to laud Mr. Day. The HSE is privileged and lucky to have a man with his experience and dedication to this cause involved in the area.

As a business person, I do not understand why these positions cannot be filled. As I said to Dr. Doorley previously, 113,000 people work in the HSE, which has an annual budget of €14.5 billion. Why are there not two or three people in the system who wish to change jobs? I could go on about this for a week but I will not. My priority is to have these positions filled and see an improvement in the response of the HSE to people who turn up at hospitals having suffered self harm.

Chairman

Perhaps when the delegation deals with this it could also address the issue, raised by Dr. Barry, relating to the permanence of the suicide resource officers.

Senator Phil Prendergast

I too thank the delegation for today's informative presentation. I have a great interest in young people and the statistics relating to them in terms of suicide in Ireland are horrific. In my previous career as a midwife I visited schools to speak on sexual health, sexually transmitted infections and crisis pregnancies. In the course of my work I met young people who expressed suicidal thoughts relating to situations that they felt they could not handle. This is relevant to the general area of being a parent with teenagers and experiencing the pressures that go with managing things on the scale in which they occur nowadays.

Mr. McGrath is from Clonmel but I assure the sub-committee that a cosy arrangement has not been cooked up as I did not know him before contact was made. He heard me on the radio talking about this committee and I tested his proposal, through the eolach website, on some young people, including my son of 17 years of age. They felt that the website could be useful because young people tend to use websites like Bebo and I thought that he should have some input in this committee.

Do the delegates agree that funding for suicide prevention seems to be abysmally low? Psychiatric services are undergoing a significant review because there is a move towards relocating people who were in old-style psychiatric hospitals. This is occurring in Clonmel. I am speaking about my own area but I am sure that this is reflected nationally. The management of services for people approaching the end of their lives is being examined. A great deal of land is owned by the HSE.

A commitment was made by Professor Brendan Drumm that the €12 million that would be realised through the sale of lands in Clonmel would be reinvested in mental health in the area. This is something about which I feel strongly. It could be of great use. The people before the committee today have significant experience in the area of suicide; do they feel there should be a pilot programme to see how we can improve services and progress this important issue? I am not saying this programme should be in Clonmel, it could be in any area of the country.

Deputy Edward O’Keeffe

I welcome the delegates. As somebody from rural Ireland with an interest in this problem - it is an acute problem in my area, which is Cork - I would like to know how effective suicide prevention officers are. Suicide is sudden and happens instantly. We are moving into a crisis in the economy worldwide and recessions usually bring a high level of suicide because people get into debt with banks and the pressures of life rise, although they are felt also during good times. What advice does one give to people who are in debt and are at a crossroads in their lives? That is a real issue. My colleague, Senator Mary White, with whom I am very friendly, has been a great help in the area of suicide because, like the Chairman, she has done much work in this area using her own resources. I admire people who do this.

Among young people, a substantial number of car accidents are suicides but this is not identified. We have heard mention of drugs, drink and so on, but it is quite easy to get drunk or take a drug overdose and have a car accident. How much work has been done with regard to the connection between car accidents and suicide? I believe any accident in which a car hits a large truck, which is a way in which many accidents happen, is intentional rather than accidental. Such accidents are not always investigated by the Garda to a sufficient extent to determine the cause of death. I have seen accidents in which a car and a large truck were involved and there was no doubt in my mind that they were intentional. Some people say that because no note was left with an explanation, it cannot have been suicide, but this is not necessarily the case. This should be investigated, because there is a high level of car accidents involving young people between the ages of 18 and 25 years.

Chairman

I wish to raise a few issues, the first of which is suicide statistics. The recent provisional figures for 2006 give a total of 409. The National Suicide Research Foundation in Cork has carried out research which shows that the statistical return, known as Form 104, is not universally used. In fact, based on this research, I calculated that around 50 suicides were unreported. In addition, there were 66 undetermined deaths in the same year. We must also take into account deaths which were not identified as suicide such as those mentioned by Deputy O'Keeffe, including some car accidents and drownings. Some experts put the total at around 600, as Senator White said. What is the reaction of the delegates to this? We are hearing a total of 400 to 450, yet many people are saying it is really 600. If we do not know the extent of the problem we cannot begin to deal with it. We need to know its extent.

Our remit as a committee is to examine the seventh report of the Oireachtas Joint Committee on Health and Children on the high levels of suicide in Irish society. I thank Mr. Day for the report with which he furnished us. I went through it in great detail and it appears that subgroups were set up to consider most of the recommendations. For example, the first recommendation was simple - to have appropriate support, in the form of trained professional suicide prevention officers, in communities at local level. A health and education liaison group was to be established immediately in July 2006. I understand a sub-group was set up to examine the matter. Another recommendation was to appoint a national co-ordinator in the education sector to work in partnership withe HSE staff. The report asks that outline tenders be accepted by August 2006. Now there is a subgroup considering it. For around 95% of the 33 recommendations, working groups have been set up and strategies are being prepared, mostly on the advice of this committee which was accepted by the Government in a debate in the Dáil on 26 October 2006. This is not a matter of committee policy, but of Government policy. There was a two-hour debate on the matter in the Dáil on that occasion which fully accepted the report of the Oireachtas Joint Committee on Health and Children.

The budget this year for the National Office for Suicide Prevention is €3.05 million with the intention of having improvements introduced. I have a copy of the relevant parliamentary question and the reply of 29 April 2008 stating that money was provided for the implementation of Reach Out, the national strategy for action on suicide prevention. I am sure it is intended to cover our recommendations also because there is no question of extra money being provided.

In Northern Ireland a similar office was set up which received £3 million for a population of 1.6 million. If we equate that with the figure here, the National Office for Suicide Prevention should have a budget in excess of €10 million. In addition, £3.5 million was provided to set up a helpline in Northern Ireland. Many committee members are of the strong view that there is not a proper commitment to fund the National Office for Suicide Prevention.

Senator Mary M. White

Hear, hear.

Chairman

Many of the initiatives set out in our document have not been acted on because the resources have not been supplied. That is why the Oireachtas Joint Committee on Health and Children set up this sub-group to investigate the matter. Judging from the report submitted to us, there is much discussion and consultation and sub-groups have been set up but no action has been taken in two years. That is my interpretation and I would like to hear the delegates comment on it.

Dr. Patrick Doorley

I have some broad comments and Mr. Day can supply many of the details. I shall start with the point the Chairman made. It is important to note that the budget and the activity of the National Office for Suicide Prevention form only a small part of the activity of the HSE in the area of mental health promotion. Suicide prevention is essentially about mental health promotion. To offer an example, the health promotion service in whose premises the suicide resource officers are located has a staff of more than 200. They conduct mental health promotion in communities and schools as part of their overall work. That is accepted as a good approach.

Chairman

With all due respect, that work was done before Reach Out was established. It does not build on the crisis identified by the putting in place of Reach Out. Before the sub-committee made its recommendations or Reach Out made any such recommendations, all those services were in place, as were the €8 million mentioned and the suicide resource officers.

Dr. Patrick Doorley

We have enhanced these services and maintain very strong links with the Department of Education and Science. We have training programmes for teachers in respect of developing health promotion in schools. Within that context social, personal and health education can be explored, with specific modules that focus on different aspects of health promotion such as mental health promotion. The HSE has health promotion workers who work in and with local communities, doing much the same work as the suicide resource officers. We are doing a great deal and Mr. Day can give the details concerning what Dr. Barry mentioned in her talk. We would certainly like to be able to do more. What we are trying to do, and what the Government expects us to do, is to use the money we get to the best effect. The strategy is very evidence-based. In other words, we are doing what appears to be the best thing to do by following the example of countries that do this work well.

Mr. Geoff Day

I will pick up on some of those issues. I take the point that some of this work is taking time, but I stand over the fact that we have initiated a significant number of actions since the office was established. I draw the sub-committee's attention to my summary in which I indicate that we have made improvements to our self-harm response in accident and emergency departments. It is perhaps not as good as we would like it to be long-term, but we have made some investments that will prove to be more effective. We have established the HSE's mental health awareness campaign which, from its evaluation, has had a significant impact in changing attitudes. As we know, campaigns need to be sustained over time to ensure a long-term impact. Under the ASIST programme we have trained nearly 8,000 professionals in the last three to four years, although in my report I said the figure was 5,000. We have developed a number of programmes. For example, we have initiated two pilot projects to fast-track referrals from general practice for persons who report with self harm - one in Dr. Barry's service in Cluain Mhuire, south Dublin, and another in County Wexford.

I do not dispute the fact that we have work to do, but the work of the office is about trying to take action on proposals. It would not be right for me at this stage to go through the 29 actions referred to by Dr. Barry. They are covered every year in our annual report. As I understand it, it is the only part of the HSE which has a statutory obligation to produce a report for the Houses of the Oireachtas. The report examines the action areas identified in Reach Out. We will do so in our report to be issued on 10 September. A review of the work of the office and Reach Out would best be undertaken by somebody outside the office - either by an independent academic organisation or another appropriate body.

I wish to clarify the annual budget. Some €3.55 million has been provided for suicide prevention measures since publication of Reach Out in September 2005. We originally costed the first phase of Reach Out, covering roughly the first three years of the programme, at €5.5 million. That information is in the public domain and I have restated it on a number of occasions. We also inherited some moneys from the health boards which were used to fund two major organisations - the Irish Association of Suicidology and the National Suicide Research Foundation. We have a working budget of €4.5 million. As Dr. Doorley said, however, it is clear that other parts of the HSE make a significant contribution to suicide prevention, not least the mental health services, an issue on which Mr. McNulty may wish to comment.

Deputy O'Keeffe asked how effective resource officers for suicide prevention were. It is sometimes difficult to measure their effectiveness. We know they support communities in crisis. When there were tragedies in Monageer, Clonroche and in County Mayo, the resource officers for suicide prevention worked with local communities and supported health staff with their specialist knowledge. They have an effective role to play.

The Deputies and Senators who commented on the issues about numbers have a point we must accept, namely, there are hidden suicides. Some 6% were identified in the Form 104 research as being potential suicides. We know from international evidence that anything up to 6% of road traffic accidents could be suicides. I worked in the then North Eastern Health Board for a time where I managed the ambulance service and the comment Deputy O'Keeffe made about those type of accidents is correct. I recall the chief ambulance officer telling me on one occasion that he saw the outcome of a road crash and had spoken to the driver of the lorry who said he was convinced that the man sought to take his own life by driving into his vehicle. We know that road traffic accidents could be a factor and the international research tells us the figure is 6%.

Chairman

Would that be single occupancy vehicles?

Mr. Geoff Day

Yes, single occupancy vehicles.

Chairman

Not all road accidents.

Mr. Geoff Day

Yes.

Dr. Patrick Doorley

To be precise, the latest figures suggest a total of 51 single motor vehicle accidents, and they would be the most suspicious. Approximately 24 of those would involve men under 30 years. As Mr. Day said, approximately 6% is an estimate, and we accept there is some under-reporting. We have been discussing this issue for a long time with--

Chairman

The most serious issue is not completing the Form 104, which is an issue for the Department of Justice, Equality and Law Reform.

Dr. Patrick Doorley

Yes. We accept it is not entirely satisfactory. The figures available to us are very useful in terms of trends. We know the problem is not getting worse. We hope it is getting better but it is difficult to be sure about this. There are always difficulties with international comparisons. That is the case in every area, whether it is death rates or sickness rates. They are not perfect but at least in terms of the trend they are not unreasonable over the longer period; inferences can be drawn. We will examine these figures. We are open to having people with expertise in this area to try to get a better estimate of the true figure and, if necessary, adjust what we publish.

Mr. Geoff Day

To add to what Dr. Doorley said, we are funding a pilot project this year with the Coroner's Society of Ireland. The coroners are aware there are issues around the decision made as to whether a death is by suicide. We have put a proposal to the coroners to run a pilot project, which will collect more data on family and individual circumstances, that might begin to address some of the members' concerns, as expressed by Senator White, about the numbers. That might help us get a more realistic picture of the real number and may lead us to conclude that we must change the current reporting system. As was said earlier, however, it is important we have accurate data. It is important to collect accurate data for the future on which to make planning assumptions and I would be reluctant to rush head long into a new data collection system until we were clear about what we wanted to collect and the basis on which we were collecting it.

I want to make two other points, one of which concerns a point Senator White made about the target for the repetition rate of self harm. As I said, we know from the international evidence that repetition of self harm is a strong indicator of potential for future suicide. When we agreed with the Minister for Health and Children on targets for a reduction of suicide, we also suggested we should seek a new target many other countries do not have, which is a 5% reduction in the repetition rate for self harm from 20% or 21%. The reason is very clear. It would be wrong for us to seek to reduce the number of self harm presentations to accident and emergency departments. We ought to have a target of increasing them. This is because we know from some of the international evidence, particularly from the United Kingdom, that the number of unreported self harm episodes is perhaps four or five times the number reported. We want to encourage people to come forward having self harmed, rather than keeping it private, with all the dangers that incurs. That is why we set the target of reducing the self-harm repetition rate, which is the real measure of whether we are being successful in stopping potential suicides.

Chairman

Before Senator White makes her contribution, in his next round of answers, Mr. Day might respond to the issue of suicide resource officers. That is the point Senator White raised. Dr. Barry referred to the impact of the HSE's staffing embargo and travel restrictions, with which Mr. Day might also deal.

Mr. Geoff Day

Yes.

Senator Mary M. White

I wish to revert to Dr. Doorley's reference to vacancies for suicide prevention officers. We had a meeting here about two months ago and he said then exactly what he has said today. This topic is a passion of mine and my eyes have been opened as to how much suicide and self harming there is in our country. He said he would look at the possibility of health promotion people taking up those positions. The Programme for Government clearly set a target for a 20% reduction in the national suicide rate by 2012. The National Office for Suicide Prevention should set out a business plan for how it intends to achieve this reduction. It should report annually on this. People in the regions should be able to identify a national suicide prevention officer working in regional communities. I apologise for being antagonistic about it, but has anything changed since Dr. Doorley and I met here two months ago? I would just like to know if jobs have been filled in these three areas.

Chairman

Dr. Doorley might take note of the questions because it speeds everything up.

Senator Phil Prendergast

I apologise if my contribution is somewhat disjointed but I have not been a member of this committee for very long. How many adolescent psychiatric beds are there in the country now? I am aware that there is a long waiting list for such facilities. Earlier we questioned what effect the embargo has had on the appointment of officers. Horrific though the suicide numbers are, it is the end game and we should talk more about how to prevent those statistics from rising in addition to analysing how and why suicide occurs.

Did Mr. Day say he would have an independent review of how his office was run?

Mr. Geoff Day

Yes.

Senator Phil Prendergast

If his is an area of expertise why would he need to have such a review? I am sorry if this question appears to be somewhat cynical and apologise if it is inappropriate, but will such a review be of much benefit? Will it hold up the process and entail a diversion of funds that could be better employed elsewhere? I am not posing the question mischievously, but simply to know the answer.

Chairman

I do not want to be confrontational but I have absolute respect for Geoff Day and the work he does. I know what he does and have known since the office was set up. I have no hesitation in saying this.

In regard to my question on the implementation of the recommendations of this report, we have heard about a figure of €3 million being made available to reduce suicide. The Government accepted this report in the Dáil following a two hour debate, which was the time given by the former Taoiseach, Deputy Bertie Ahern. Implementation of the recommendations of this report will cost €60.09 million. That was costed by the previous committee. If €3 million is being provided for the implementation of the recommendations of this report, how can they be implemented if they are costed at €60.09 million? I accept there were suicide prevention initiatives before this report came out. However, we are talking about the implementation of Reach Out, this report and, to a lesser extent, A Vision for Change.

Dr. Patrick Doorley

Every year we seek money from the Department of Health and Children in the Estimates process. We must try to make the best of what we get. All health services could use more money. However, there are restrictions on funding, staffing and even on clinical staffing and we have had to ask people to do more with the same resources and sometimes with even fewer resources. I do not see that changing, given the current climate.

In regard to the suicide resource officers, we in the process of recruiting one.

Senator Mary M. White

What about the other two?

Dr. Patrick Dooley

In regard to the other two suicide resource officers, recruitment is difficult in the HSE, even for clinical staff. All I can say is that we will look at what we can do there. I repeat we have health promotion staff who are conducting mental health promotion programmes. It is virtually the same function in the community. They are interacting with schools, local communities--

Senator Mary M. White

Will Dr. Dooley write to me with their names and their areas of responsibility?

Dr. Patrick Dooley

I will.

Senator Mary M. White

My document and the appendix refer to vacancies. When people ring from around the country, say, the local garda or the teacher, or whatever, I would like to be able to tell them who is the key person. I was able to give the name of the person on radio Limerick this morning.

Dr. Patrick Dooley

I apologise. I thought it had gone out to you.

Chairman

I wish to deal briefly with the permanency issue. I am not saying people who are transient are not committed but permanent suicide resource officers--

Dr. Patrick Dooley

These are permanent HSE staff.

Chairman

All eight of them.

Dr. Patrick Dooley

They are permanent staff.

Chairman

They are not permanent resource officers.

Dr. Patrick Dooley

They are not permanent resource officers but that is the way with many senior staff and it does not mean there is not a commitment to keeping those posts.

Mr. Seamus McNulty

I wish to respond to Senator Prendergast's comments on acute beds for adolescents because it is referred to in A Vision for Change and in recommendation No. 14 in this report. Until now there were only 12 beds in the HSE for acutely ill children in St. Anne's in Galway and in Warrenstown. The number will increase to 30 beds this year. There are four interim beds in Galway which have been commissioned since the beginning of March. Eight beds in Dr. Steeven's in Cork and six beds in St. Vincent's Hospital will come on stream in the fourth quarter. That will bring the total number of beds to 30 in the current year.

Construction will commence on a 20-bed unit in Cork and a 20-bed unit in Galway in the autumn. Therefore, by the end of 2009, we will have approximately 50 of the 80 beds recommended in A Vision for Change, which was over a seven to ten year period.

In regard to consultant child and adolescent psychiatrists, 12 posts were advertised recently and the selection process for those posts is under way. When they are in place, there will be eight additional teams. There are 47 in place nationally and it will bring the total complement to 55. When they are fully in place, the annual cost of funding those will be an additional €18 million.

Dr. Barry referred to the issue of the HSE's embargo on training. I reassure the committee that it does not apply, for example, to assisting all those in what we consider to be clinical training to support frontline initiatives.

On the issue of the sale and reinvestment of the asset value of properties associated with the large psychiatric hospitals, I confirm that the HSE is committed to this and, as the committee may be aware, it is working on plans for the decanting of the service in Clonmel, for example.

Chairman

Last year ASIST programmes were cancelled because they were not allowed to use a hotel and Mr. McNulty is telling me now they will not be interfered with. Does he accept that last year ASIST programmes were cancelled?

Mr. Seamus McNulty

I am not aware of that. There is a great deal of accommodation available within the HSE and there are community facilities around the country. We do not always have to go to a hotel to deliver programmes.

Chairman

There is a strong view that the people who attend those courses should have a level of service that a hotel can provide.

Mr. Geoff Day

I shall answer that specific question about ASIST programmes. We answered a parliamentary question on this issue. There were seven ASIST programmes cancelled in 2007. They were cancelled primarily because we were asked to move them from hotels and we could find no suitable alternative accommodation.

We have maintained the same level of ASIST programmes this year by using other facilities, often in community-based locations. It is important to stress that while the ASIST programme in the early years focused on training HSE staff, it has focused in the past couple of years on training those in communities. While the difficulties around staff being allowed to travel might apply to administrative staff, they have not applied to those clinical staff who would deliver the training in our communities. I am not aware that we have had to cancel any this year and the programme is running as it has done for the past three or four years.

I will pick up on two issues. I apologise to Senator Prendergast for not being clear about the review and evaluation. I was speaking specifically, not about the office but about the evaluation of Reach Out and the way in which we collectively deliver the actions in Reach Out. It is normal practice for that work to be evaluated by an independent person. I am satisfied that the work of the office is such that it does not need to be evaluated, but it is right that the process in which we are engaged - whether we are delivering the actions as agreed and in the right way, are having an impact and making a difference - is evaluated by somebody outside the HSE.

The Chairman is correct on the issue of funding. The report which was accepted by the Houses of the Oireachtas costed the measures in this programme at €60 million. If one breaks them down, it is clear that €40 million of that is to develop the child and adolescent service about which Mr. McNulty can speak eloquently. There is a separate level of investment going into this. We are not comparing like with like.

There is a reference in the document to €5 million going to public works. That money does not come to the HSE. There is a costing of €10 million for alcohol-related initiatives. We all agree that the task force report on alcohol sets a marker down for the important work we need to do in the HSE and elsewhere in terms of the prevention of alcohol abuse. That leaves €5 million for --

Chairman

That aspect was practically ignored, but it did come to the fore in the report. It is an issue for us.

Mr. Geoff Day

Absolutely, but I am trying to compare like with like. The other suicide prevention measures in the Oireachtas report amounted to €5 million. I accept that the level of funding being allocated to the National Office for Suicide Prevention is less than one would anticipate, but it is not that far off what this committee called for. It is important to make that clarification rather than compare the €60 million in this report with the €3.5 million to €4.5 million being made available. A significant amount of other resources go into the HSE, not least into child and adolescent services and mental health services, that should be counted if one is trying to compare like with like.

Deputy Charlie O’Connor

I wish to be associated with the welcome extended to all our guests. It is important that we remember that this is the second coming of this sub-committee. This is because the problem has not gone away; perhaps it never will. The comment was made earlier that single vehicle crashes are often very upsetting for families who deny that these are cases of suicide. It is important we understand that suicide is a complex issue.

The delegation should be aware that Oireachtas Members are frustrated by the situation. I speak from the Government benches, but it is important to point out that even at local level we find ourselves battling against the system, which, forgive me, can be difficult to accept. As some may know, I live in Tallaght where we have been fighting for some time for the appointment of a suicide nurse to Tallaght Hospital. On a number of occasions I and other colleagues have also raised the issue of funding for the Travellers' youth project in Tallaght, something which Mr. Day knows about and supported. These are two issues of concern that could be duplicated throughout the country. We had to take on the system and try to get simple improvements in these two areas. However, even in times of recession, these initiatives should be funded and dealt with without difficulty. This sub-committee will never be able to make progress if we cannot tick off the accomplishment of such issues.

Senator Mary M. White

Hear, hear.

Deputy Charlie O’Connor

All committee members and guests would agree with that and we must start from that position. I often make the point at committee that much good work is done through interaction with the visiting delegations to the committees. My experience comes from the Joint Oireachtas Committees on Social and Family Affairs and Health and Children. Often delegations leave our meetings frustrated, because we are still dealing with issues they raised when they return a year later. However, the other day a group came in and applauded a committee on making progress, which was good.

Where issues are identified in the non-political atmosphere of a joint committee, there is an expectation that we will deal with them. This is clearly the aim of this sub-group. We are examining the report produced by a number of members and accepted by the Oireachtas. We have found that many measures have not been dealt with and that the crisis is as big as ever. None of us believes we can solve the problem, but we do not want to stand still and do nothing. I hope today will be a start as far as our guests are concerned and that we will make progress and continue working on the more serious issues. When we make our next report, we must urge that the issues be dealt with.

I understand there are significant demands on the health service and that Professor Drumm's office receives representations and lobby groups every day on all issues. It is clear that suicide is a societal issue. We are all familiar with cases of suicide. It is important that all of us understand this nettle has to be grasped. I do not wish to sound patronising to the Chairman but reference has been made to his work and to the work done by Senator Mary White and I note Senator Prendergast's interest in this issue. We are committed and we want to make progress and I hope all our guests understand this and help us as much as possible.

Chairman

I wish to conclude this meeting within the next ten minutes.

Senator Phil Prendergast

I will be brief. I wish to make a general point. When I worked with the HSE we carried out a survey of all the staff working in the system. My specialty was midwifery and the survey also included those working as paediatric nurses, oncology nurses and theatre nurses. The psychiatric area is currently undergoing significant restructuring and many of the people working in this area have skills which could be used. I would recommend that staff within the system could be regraded or trained to work in a different direction. With regard to Mr. McGrath's presentation, could such a system be piloted or used in the future? I do not expect a straight answer to those questions but I wished to make the comments simply because in my view a system such as that proposed by Mr. McGrath is probably cost-neutral or would cost very little. There is a wealth of psychiatric specialties among staff which is not being utilised. There is room for changes to be made on a cost-neutral basis and this should be considered.

Senator Mary M. White

I propose that the committee should invite Dr. Doorley to return to the committee in three months' time to see what progress has been made in the reduction of the suicide rate in the country. The programme for Government sets a target of a 20% reduction in the national suicide rate by 2012. Does Dr. Doorley think this will happen? I refer to an article by Dr. Ella Arensen in The Irish Times on 22 July. She stated that unlike many other European countries, Ireland has no standard guidelines for the assessment of deliberate self-harm patients who present at accident and emergency departments. It seems hospitals should have guidelines such as those in other countries.

Dr. Siobhán Barry

I refer again to the Reach Out document. Certain "phase one actions" were to be completed within approximately three years and we are now very close to that three-year mark. There are a total of 29 recommendations for action. While people often think ticking boxes is not a very worthy exercise, it is often a very good way of ensuring one is on course. There is no way that Reach Out can be implemented to its phase two level, which will require partnerships with other organisations, if phase one has not been completed. Phase two has 57 recommendations. There should be some process by which the 29 actions should either have been delivered or the obstacles to their delivery should be cleared.

There has been a certain amount of discussion about reviewing the work of the National Office for Suicide Prevention, which was to be commissioned in late 2007. It is now 2008 so we are already off the rails in this regard. It begins to worry me when things start getting delayed within such a short timeframe.

Mention was made of the importance of mental health promotion in the prevention of suicide. That is what one would intuitively feel. Unfortunately, there is not a strong evidence base to support it. I draw the attention of interested parties to the Health Research Board report of March 2008, written by Dr. Dermot Walsh who is the former Inspector of Mental Hospitals. He prepared an excellent report on suicide, attempted suicide and prevention in Ireland and elsewhere. Dr. Walsh is not known as a man who pulls his punches. At the end of the report he states: "There is little will to progress the preventive measure with most potential to impact on youth suicide, the implementation of the recommendations of the Strategic Task Force on Alcohol." Of all the things, that is the one with the strongest evidence base. It will take the action of the Department of Health and Children to implement its own strategic task force report.

Chairman

To develop Senator Mary White's point, when do the delegates envisage crisis nurses being available 24 hours a day seven days a week in hospitals? Is there a target date for this? We have the constant criticism of people causing self harm or being in difficulty outside of working hours with nobody available to deal with them as they do in 60% of our hospitals in normal working time.

I ask Mr. McNulty or Dr. Doorley to comment on the fact that of the €51 million allocated to A Vision for Change for 2006 and 2007 only €27 million was spent on areas for which the Minister clearly stated she had allocated it. She made a strong statement to this committee and to me that she felt what happened was wrong. She stated she was having discussions with the HSE and was not allocating any extra money in 2008 because she was not sure it was going to be used for the purpose she intended.

Dr. Patrick Doorley

I ask Mr. McNulty to answer that question. I might take the other ones. Some important points were raised before it.

Mr. Seamus McNulty

Funding of €26 million was made available in 2006 and €25 million was made available in 2007. Some 57% of the 2006 funding has been put in place and 74% of the 2007 funding will be in place by the end of this year when we put the acute interim beds in place and the consultant psychiatrist. The full-year cost will be an additional €10 million going into 2009, which will ensure that nearly 100% of the 2007 funding will be committed by the time we have the full-year costs of those investments fully rolled out.

Chairman

The Minister intended that money to be spent in the year for which she allocated it. She has clearly stated that to us.

Mr. Seamus McNulty

That money is being expended on that to which it was committed by the Minister. In response to the point made by Senator Prendergast, as the HSE closes hospitals, staff will obviously take up new roles for which they are skilled and will be upskilled to take on new roles as suggested by her.

Senator Mary M. White

As I must take a flight from Dublin Airport shortly, I would like to hear Dr. Doorley's response.

Chairman

We will finish with this. I do not believe we will glean much more information.

Dr. Patrick Doorley

I am conscious that the committee is anxious to finish. On the evidence base for the interventions--

Chairman

Dr. Doorley can have as much time as he likes.

Dr. Patrick Doorley

We are very well aware of the evidence base for all the interventions. There are no randomised controlled trials to show that many of these things actually work and it is only over a long period that one sees this. The one that is most strongly evidence-based is alcohol. The HSE has been very active about that in encouraging the implementation of all the recommendations of the task force. We have put information on our website about the harm and so on. On the question of the evaluation, I must be very careful that we are not unintentionally misleading the committee. We will do an evaluation. It will be outside the National Office for Suicide Prevention but not necessarily outside the HSE. We have skilled staff who can carry out this task efficiently. We do not propose to commit massive resources to evaluation.

Senator Mary M. White

Will the target of reducing the incidence of suicide by 20%, as set out in the programme for Government, be achieved?

Dr. Patrick Doorley

While it may be a little unfair to describe target setting as guesswork, it is an inexact science. Nevertheless, setting targets motivates people to try to achieve them. I honestly do not know if we will reach the target to which the Senator referred but we must do our very best. Although it may be too early to undertake a review at this stage, one of the reasons for having one is to ask whether the target is over or under-ambitious. That is the only way to deal with long-term targets.

Senator Mary M. White

Given that Ireland has the seventh highest rate of youth suicide of the European Union member states, is it not a priority to set a target to reduce its incidence?

Dr. Patrick Doorley

Yes.

Senator Mary M. White

I have a problem in this respect, as one cannot achieve anything unless one sets targets and develops strategies to achieve them. Members of the sub-committee who are determined to do something about the high suicide rates in Ireland are frustrated. The delegates, as the persons charged with achieving the Government's target, must be up-front with us. No one else has responsibility for this issue.

Dr. Patrick Doorley

The Senator wants us to be up-front. We will need to consult a number of people to set a target. It is difficult to say with confidence that we can deliver on the target. We would have to set a long-term target and review it in three or four years to determine whether it was over or under-ambitious and whether we needed to do more. Nobody can tell the sub-committee that we will reduce the youth suicide rate, as there are many influences outside our control. Our job is to show leadership and work with communities, schools and other actors which can--

Chairman

Programmes in other countries have achieved considerable success.

Senator Mary M. White

That is my point.

Dr. Patrick Doorley

We have examined them.

Mr. Geoff Day

I will reply to the Chairman's important question about responding to crises. There are two elements to the issue, one of which is the crises faced by those who present at accident and emergency departments. Our target is that by the end of this year every accident and emergency department will be able to provide a specialist response. The question remains whether this will be created from within internal resources, the more likely scenario, or new resources. We have been in discussions with Mr. McNulty and his colleagues to try to realise this objective. This type of service does not necessarily need to operate 24 hours a day, seven days a week. One must bear in mind that 40% of those who present at accident and emergency departments having self harmed also have alcohol in their system. According to most clinicians, it is wholly inappropriate to try to treat such persons for anything other than the initial presenting problem. One cannot do any long-term therapeutic work with them. This must be done within a few days of the event but not immediately. Our target will be to provide a specialist response in every hospital.

The wider issue of our response is one which the Health Service Executive is examining. We will welcome the recommendations of the inquiry into the Monageer tragedy because it could tell us a great deal about what we need to do. The two responses to crises are different. One is in the community where we need to do more, especially by way of the social work service. In the other, the psychiatric service, our response is very clear. A psychiatric service is available 24 hours a day, seven days a week which general practitioners can access at any time of the day or night.

The focus of the Chairman's concern is accident and emergency departments. We have an ambition to ensure every accident and emergency department will have at least one specialist. I hope this will be enhanced over time.

Mr. Fergus McGrath

I will briefly address the concern raised by Dr. Barry about the Internet and isolation. One of the objectives of the proposal I outlined is to reduce the levels of isolation being experienced. The Internet can be used positively by developing on-line communities and social networks which develop a sense of belonging. I hope by doing this such networks and communities will prevent suicide and deliberate self harm.

Chairman

I sincerely thank all the delegates for attending and for their presentations and replies which have been informative. We accept the limitations on their ambitions in terms of what they wish to achieve in their work. It is our duty to ensure information is placed in the public domain and that we use our role as legislators to assist them in whatever way we can.

The sub-committee adjourned at 3.45 p.m. sine die.