Mental Health Services: Mental Health Reform

I remind members, witnesses and those in the Visitors Gallery to please ensure their mobile telephones are switched off for the duration of our meeting as they interfere with the broadcasting of proceedings even when in silent mode. They also interfere with members of staff.

This morning's meeting is divided into two sessions. The first is a meeting with representatives of Mental Health Reform from which I welcome Dr. Shari McDaid, director, and Ms Kate Mitchell, policy and research advisor. As members know, Senator John Gilroy is the committee's rapporteur in the area of mental health and will present a report in due course. We look forward to a very good discussion today on the priorities for the mental health service in Ireland. Mental health issues have a huge and profound impact on people's lives in all parts of society. We look forward to hearing from Mental Health Reform, which promotes and prioritises mental health services. I thank Dr. McDaid and Ms Mitchell for attending the meeting on behalf of a very powerful advocacy agency which campaigns for improved mental health services.

I remind witnesses regarding privilege. Witnesses are protected by absolute privilege in respect of the evidence they are to give to the committee. However, if they are directed by the committee to cease giving evidence in relation to a particular matter but continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence.

You are directed that only evidence connected with the subject matter of these proceedings is to be given and you are asked to respect the parliamentary practice to the effect that, where possible, you should not criticise or make charges against any persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of a long-standing parliamentary practice and ruling of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the House, or any official by name in such a way as to make him or her identifiable.

As we will have two parts to our meeting, is it agreed that we will conclude this section by 11.15 a.m. at the latest? Agreed.

I invite Dr. McDaid to make her opening remarks.

Dr. Shari McDaid

I thank the Chairman and committee members for inviting the representatives of Mental Health Reform to appear before the committee. Some of the issues we will discuss were contained in our pre-budget submission which was circulated to the committee.

Mental Health Reform is the national coalition of 48 NGOs interested in working towards improved mental health services and implementation of the Government’s mental health policy, A Vision for Change. There is no doubt that in recent years there have been positive developments. However, the reality is that despite the appointment of 727 staff in the past three years, at the end of July there were just 63 more staff in the mental health services than there had been at the end of 2012, and still almost 1,000 fewer than in 2009, showing that the huge losses the mental health services incurred in the early part of the recession have yet to be made up, never mind increasing the staffing the levels that were envisaged to provide the holistic service set out in A Vision for Change. The scale of the challenge before us is clearer when one considers that full implementation of the policy would entail having 12,482 staff and as of July we had fewer than 9,000. It is in this context that I would like to outline our perspective on the recent progress made on the policy.

In our view, recent years have brought some significant positive developments. For the first time in the modern era, the national public health service has a leader at the head of the mental health services who sits at the senior management table, with a national director for mental health and a distinctive mental health division within the HSE. The Government had ring-fenced funding amounting to €90 million to develop specialist community-based mental health services and for suicide prevention between 2012 and 2014, and a further €35 million has been allocated for 2015. We certainly appreciate the additional investment. However, it is important to understand that much of this funding has gone to replace staff leaving the service, so that the net increase in funding up to the end of 2013 was quite marginal.

As in prior years, we are concerned that the HSE has delayed recruitment of staff under this year’s allocation so that the funding of €20 million allocated under budget 2014 is not likely to be spent this year. On a positive note, the proportion of non-medical staff, including social workers, occupational therapists and psychologists, within the mental health services has more than doubled since 2009. This is very positive as it reflects the strong desire expressed by people who use mental health services to have access to a less medicalised service and access to more complementary or non-medical supports.

The HSE’s recent decision to mainstream its culture-change project, Advancing Recovery in Ireland, on a national basis provides a basis for driving the culture change needed within mental health services towards a recovery-orientated service that works in partnership with service users and family members. The appointment of someone with personal experience of using mental health services as a member of the national management team for the mental health division is also a very welcome symbol of how service users need to be at the centre of planning.

However, Mental Health Reform is very concerned about the continued gaps and very real strains in the mental health supports available for people across the country. We still do not have in all parts of the country the model of 24/7 crisis intervention within the specialist mental health services that was set out in the policy. Not all services are providing home treatment and there are very few crisis houses to provide alternatives to inpatient beds. This is unacceptable in a context where we still have upwards of 500 people each year taking their own life, the majority of whom will have had some contact with a health professional during the previous year.

The waiting list for child and adolescent mental health services is still too high. In July 2,757 children and adolescents were waiting to be seen by CAMHS. Although this was a 2% decrease on a year earlier, it still means that quite a large number of children are waiting to be seen. There are also too many children and adolescents being admitted into adult wards. The most recent information from the HSE shows that for this year out of 158 admissions up to the end of June, 53, which is more than a third, were to adult units. This is despite the fact that under the Mental Health Commission’s code of practice, no child under age 18 should be admitted to an adult ward, save in exceptional circumstances.

We are also concerned about the large increase in the numbers of homeless people being admitted to inpatient units. The information for 2013 is that 245 people of no fixed abode were admitted to inpatient units, an increase of 40% on 2012. We are concerned therefore that the wider housing crisis is having a very real impact on people with mental health difficulties.

We continue to be concerned about staffing shortfalls, as mentioned earlier. In order to fully implement the policy, the HSE would need 12,482 staff. As of the end of July of this year, there were fewer than 9,000 posts and the services were short 231 doctors and 567 nursing posts. More than 1,000 nurses have been lost to the service since 2009. The combination of the moratorium along with the wider difficulties of the levels of remuneration for people taking up positions as nurses and doctors are clearly impacting negatively on the ability of the HSE to recruit and retain staff for mental health teams.

We are also concerned that mental health services in primary care are not able to cope with demand. We have been told by the HSE that there are waiting lists for the new counselling in primary care service. This is a service which is intended to be available free to medical card holders by referral through their GPs. It was only initiated nationally in July 2013 and as of the end of August 211 people were waiting between three and six months for an appointment and 70 people had waited more than six months. Clearly, timely access to a counselling service is vital to give GPs confidence in referral and also to make it an effective early intervention.

Despite recent positive developments, there are still huge challenges to bringing about the type of primary care and specialist mental health services set out in A Vision for Change. These challenges reflect the continued vulnerability of mental health services within the overall health system and the need to have sustained political will in order to redress decades of neglect.

I thank Dr. McDaid for her presentation. She has outlined it as it is. There are clearly grave challenges in terms of funding. We must accept that governments need to work within certain parameters. For many years mental health was described as the Cinderella of health services. There was clearly insufficient commitment in any programme for government to ensure there was enough funding. When we saw the cutbacks even though there was ring-fencing of funding it was only ring-fencing in name and did not really translate into guaranteed committed funding year-on-year. Obviously we have seen the exodus of health professionals over recent years creating further problems. That is the backdrop to where we are in terms of trying to provide mental health services in our communities throughout the country.

Dr. McDaid referred to child and adolescent mental health services. Many adolescents are still being admitted to adult units even though we all know it is wrong from a clinical point of view as well as from the point of view of an individual's rights and entitlements. Have we made much progress in that area? I know there are ongoing developments. Have we gone much further down that road to ensure that we do not have adolescents attending adult psychiatric units, for example, and being admitted to adult psychiatric services?

Some general practitioners have expressed concern to me - as I am sure they have to others - about the new counselling and primary care service. The view appears to be that if we do not address this particular problem quickly the result will be people again being admitted through the emergency departments of our hospitals. Is that something about which the witnesses would be concerned?

It was stated that we have sufficient social workers. There is one area where I believe there may be a break in the chain, namely, secondary school career guidance counsellors. There has been a huge reduction in recent years in the number of guidance counsellors in our schools. Is Mental Health Reform aware of any difficulties in this area? People often say that vulnerable people should be seen by a general practitioner. A vulnerable child whose general practitioner is the family general practitioner may not wish to speak to him or her. Are there other avenues open to vulnerable students, who previously would have spoken to their career guidance counsellor and so on, who may have been camouflaging their difficulties for some time and may not want the family to know about them. In the witnesses' experience, are there any difficulties in this regard?

I join in welcoming Dr. McDaid and Ms Mitchell to this meeting. I wish Ms Mitchell every success in her new role. Wearing my hat as Sinn Féin spokesperson on health, mental health is of huge concern to me. I am the Sinn Féin representative on the all-party group on mental health. I commend the representatives of each of the parties and Independent voices represented here for their input in this area over the past number of years. Without the help of Mental Health Reform and Lara Kelly we would not have been as proficient as we have been in drawing attention to some of the critical areas that need to be addressed.

That said, the Mental Health Reform presentation made this morning is alarming and distressing. Despite all our best efforts at highlighting the importance of properly resourcing our mental health services, in excess of 2,700 children are awaiting access to child and adolescent mental health services. While there has been a 2% decrease on the data for the last year, this is not good enough. When presented with such stark relief it is very alarming. We will have an opportunity during the second part of this meeting to address some of these points with the Minister of State with responsibility in this area, Deputy Kathleen Lynch, the Minister for Health, Deputy Varadkar and representatives of the HSE. I would encourage colleagues to reflect on some of the information shared with us by Mental Health Reform.

On homelessness, it was stated that 245 homeless people were admitted to inpatient units last year. Data for this year are not yet available. However, 245 is a significant increase on the data for 2012. This information indicates a connection that needs to be recognised and addressed and not only through mental health services. Homelessness in all of its dimensions needs to be properly addressed.

On staffing levels in the mental health services, the position that should apply under implementation of A Vision for Change is being missed when there are fewer than 9,000 people providing a service for almost 12,500 people. I know from personal experience, having met and conversed with the services in my own area, that the people involved are giving heroic service in terms of front line provision, in particular the community mental health teams. Their role in all of this must be acknowledged and commended.

Roll-out of the new counselling and primary care service across the country is unequal. There are huge gaps in access to and the availability of counselling supports in terms of mental health needs. Having highlighted some of the most salient points made by the witnesses, I would like now to put some questions to them. The Minister for Public Expenditure and Reform, Deputy Howlin, referred in his budget address to the Dáil immediately following the address by the Minister for Finance, Deputy Noonan, to new staff recruitment and in this regard mentioned psychologists and counsellors for the mental health services area. There was no detail of this in the subsequent contribution of the Minister for Health, Deputy Varadkar.

The Deputy must conclude.

Does Mental Health Reform have any indication of that likely recruitment and how quickly it might come to pass? The allocation for this area in 2015 is €35 million. It has been highlighted today that the lesser sum provided in the current year will not be fully employed. We had a commitment from the Minister of State that the shortfall for this year of €15 million would be provided in addition to the €35 million allocation for next year but that has not happened. Perhaps the witnesses would set out the likely negative consequences of that failure to adhere to the commitment that was contained in the programme for Government in 2011.

The witnesses might also elaborate on the Mental Health Commission's needs in terms of fulfilling its functions as set out in its pre-budget submission. Reference was also made in the agency's pre-budget submission to the need for extension of free primary care to all who require long term mental health treatment. As part of Sinn Féin's effort in its preparation of an alternative budget, I attempted to have that costed by the Departments of Health, Finance or Public Expenditure and Reform but they were not able to do so as they have no information in relation to the current number of people who require mental health services, never mind projections in this regard into the future. There are major problems in this area.

I, too, welcome Dr. McDaid and Ms Mitchell. It is helpful to us as Oireachtas Members when organisations come together. I have a few questions arising out of today's presentation. While I can speculate the answers to those questions I am interested in hearing the responses of the witnesses. It is difficult for us to know how we are performing given that the last review of the monitoring group of A Vision for Change was in 2011 and published in 2012. The Minister has said that there will be no more reporting and that other mechanisms will be put in place. However, there is no other mechanism which allows us or the State to assess its progress. Progress is not reported in any other way, other than, perhaps, the CAMHS reports.

We are still getting the annual CAMHS reports, which is a tribute to those concerned although I do not like what I am reading. However, it at least shows us where we need to focus attention. I am very concerned about the absence of a reporting mechanism.

I am concerned about children being placed in adult psychiatric wards. I very much support the witnesses' position that no child under 18 should be admitted to a ward of this kind, except in exceptional circumstances.

Several years ago it was agreed that no child should be in an adult ward. I do not know why this is occurring and tried to establish why the practice persists. Anecdotal evidence gleaned by me shows that some units are determining themselves that they will deal only with certain cases or conditions, such as eating disorders. There is no national co-ordination. Thus, when a place is being sought for a child, services are deciding locally the cases they will deal with and not deal with. I refer to children in need. It is unacceptable that we cannot deal with the more difficult, complex cases. Surely it is for these that we have a health system in place. Surely it is when the issue is complex that a child should be put into a ward. It is not a treatment but part of a process. When this part of the process is required, the appropriate beds need to be in place.

On the issue of CAMHS, which I mentioned, I was interested to see that the Royal College of Surgeons in Ireland has expressed concern that we have the highest rate of mental illness in Europe among those under 25. We need to be cognisant of that when dealing with children and young people.

I am concerned about the waiting lists and will certainly be bringing this up with the Minister at our subsequent meeting. I am concerned also about the experience of teachers and social workers. When referring cases, they are not getting the responses they wish for. In fact, social workers have told me that when they refer a case of a child in care to CAMHS, they are basically told, "They are in your care now; they are out of the community and you should look after them". For me, the very reason for having CAMHS was to address this. It is for this reason I felt CAMHS should be moved into the Child and Family Agency. Do the delegates believe that would be beneficial? Is it a position they support?

I am concerned about the triage process for determining priority because it has a masking effect. Children are often medicated and other options are given such that, by the time a child is seen, we do not always know the position. The age in question is such an important one developmentally. Saying three months or one year has an effect on a child's educational and social development, in addition to other critical aspects. We know it is during the teenage years that children are most likely to present for the first time. That we are not dealing with the issue causes stigmatisation later in life.

Having read about this matter in preparation for this meeting and our next, I noted two issues, one of which is awareness-raising and the other of which is the action taken. Over recent years in particular, NGOs have increased the level of awareness-raising. I question, therefore, why the State needs to focus on this area. Perhaps it should be supporting the NGOs in focusing on awareness-raising and focus itself on delivering the mental health services for people in need of them. We are raising awareness but the service is not available when requested. We ask people to talk and present, yet the service is not in place for them. Therefore, I have a huge question about this. While it is nice for the State to engage in awareness-raising with the NGOs, it should ensure the services are in place.

Dr. Shari McDaid

I will respond to the questions one by one.

Deputy Kelleher started off by talking about funding and the fact that there has been investment. The challenge has been that, despite allocations of funding at budget time, the issues with retaining staff in the service and the slow process of recruiting new staff have meant the numbers have just not increased; that is the bottom line. It is a case of a boat with a hole in it wherein one keeps trying to throw the water out. The services are leaking staff all the time. This is the case because there are attractive retirement packages. The age profile of the nurses in the mental health services is such that a generic provision meant to lower the overall number of health service staff has affected mental health services much more heavily than others. This has not been dealt with. We are now at a point where, for the first time since 2006 and the publication of A Vision for Change, we are facing severe difficulties in providing enough nurses to staff acute wards and provide community services so people do not end up in acute wards. I refer to services such as day hospitals open seven days a week. These have to be staffed by nurses. If we do not have enough nurses, we cannot provide the crisis support required to prevent people from ending up in hospital. Right now, we are really in danger of moving seriously backwards with the agenda in A Vision for Change because of the difficulties with staffing.

Interestingly, the difficulty employing consultants is part of the reason CAMHS is not doing as well as it should be. It has had severe difficulties in recruiting specialist consultants to fill teams and man inpatient wards.

With regard to the admission to wards of children and adolescents, we have actually gone backwards this year. This is of severe concern. Steps were taken to increase the number of beds. There was a maximum increase of approximately 56 beds earlier this year. This then decreased by ten over the summer, resulting in fewer than had been anticipated. In the context of A Vision for Change, there should be 80 beds. This was based on a smaller population so we really need more now. We are in danger of moving backwards rather than forwards.

With regard to the counselling in primary care service, it was asked whether difficulties in meeting demand mean people end up in hospital. That is a possibility although the service is really geared towards people with mild-to-moderate mental health difficulties, not those in a severe crisis. The intention is that, by catching people early, they will not end up needing specialist mental health services and potentially more severe treatment down the line. It is so important that general practitioners have a place to refer patients to because we hear time and again that people have felt over the years that all they are offered on going to their general practitioner is medication. They do not necessarily want medication alone; they want other types of supports. The service needs to be built up much more and we need to consider creative solutions. If we do not have dozens of psychologists available, we need to consider creative solutions drawing on the expertise of NGOs and other types of providers so as to meet the need.

The reality in Ireland is that there are very strict referral criteria for child and mental health services. Basically, a general practitioner must make a referral. There are some sound clinical reasons for that. This is understandable but, in recent work we did examining procedures, we learned there is more flexibility in other jurisdictions, including the United Kingdom and Australia. Therefore, we believe there is scope for more flexibility, as in allowing concerned teachers and social workers to have easier access.

The Jigsaw services comprise a positive development. I refer to open community centres that young people can go to. They are more youth-friendly than other services. They are not medical or general practitioner surgeries but centres to which people can go to talk to somebody if they are concerned about their mental health.

Those seem to be working well and there is investment in rolling them out more widely this year.

I thank Deputy Ó Caoláin for his kind words about mental health reform. We work hard to essentially draw together the concerns, issues and good practice around the country. We will keep trying to do that. I will speak to the homelessness issue and the relationship between the housing crisis and what might be happening in mental health services. One of the concerns drawn to our attention this year in particular is the difficulty in being able to discharge people from acute wards because of a lack of housing availability. It is shocking that despite a major push towards community-based mental health services, we might have people ending up in an institutionalised setting in an acute ward longer than they need to be there because there is no appropriate housing option in the community. That concern arises because of the housing crisis.

We were asked if we had any information on where the 2015 allocation will go but we do not. It is correct that this was not specified by the Minister of State, Deputy Kathleen Lynch, in the joint announcement about funding. We expect there should be some information about that in the HSE's national service plan or the mental health division's operational plan. There is still a major shortfall to be made up. We were asked about the negative consequences of the €15 million shortfall and I can allude again to staffing shortfalls. We are not in a position that we have so many staff in mental health services that we cannot think of what to do with more; we are in the opposite position, as services are under strain. Even with multidisciplinary staff, although it is positive that the proportion has doubled, the numbers of staff are still well below needs according to A Vision for Change. There is plenty of scope for further investment.

There was a question about the Mental Health Commission, which has been impacted by the moratorium to the extent that it was having difficulty filling some of its inspection and other senior management posts, meaning it has been difficult for it to fulfil its functions, particularly in having multidisciplinary input into its inspections. We want to know that the Mental Health Commission can fulfil its remit, as it is the main means of accountability for how well mental health services are fulfilling legal obligations.

I thank Senator van Turnhout for her kind words about our organisations. She expressed concern about the absence of an independent reporting mechanism. I agree that we are in a position without regular annual reporting, which is against the recommendations of A Vision for Change, either internally by the HSE or externally by an independent body. That puts us in a very difficult position. No voluntary organisation has access to the information that might be obtained by having an official mechanism for reporting. I agree that there is a need for a robust but efficient reporting mechanism, which should not be overly onerous on services but which should give the required information. I did not allude to a difficulty in my statement but it is mentioned in successive pre-budget submissions. We asked for an information system for mental health services over previous years and were told initiatives were under way to improve the position. There has been a modest improvement this year, with some activity data for the adult mental health services that we have not had before but it falls far short of what is provided for the child and adolescent section.

We are very disappointed the development of an information system is not progressing at a better pace as we simply do not know the level of need for mental health services. It is very significant that we have not had a national survey on the psychological well-being of the population since 2007. Right through the recession we have not had a data source on the national levels of need. It is very welcome that the Royal College of Surgeons in Ireland has produced data on child and adolescent need which is pointing to the higher levels in Ireland, and we can only suspect what may be the higher levels for adults as well, given the economic strain that people have been under. Both of those elements are very important.

Why are children still being admitted to adult wards? We have spoken about the reduction in the number of beds and there is also a need for good training for staff. The HSE's restriction on training has had a very direct impact on the adequacy of the inpatient child and adolescent mental health services. Staff who do not feel equipped to respond to children with very complex needs or behaviour will resist children being admitted to wards. We need to shift towards investing in training for staff so they can respond appropriately. Interestingly, that extends to services where we need training in how to work with adults with difficult behaviour as well so we can have less use of seclusion and restraint.

We were asked if non-governmental organisations, NGOs, should see more investment in order to provide awareness training. There is a need for a combination of public sector investment and work with NGOs. A partnership approach is probably correct and I would like to see much deeper investment in community development initiatives for mental health and well-being. Sustained community development work will bring about a shift so that fewer people will develop mental health difficulties at an early stage.

As six other people wish to contribute, I ask members and others to be brief as we must conclude by 11.15 a.m.

I thank Dr. McDaid for the comprehensive presentation. In fairness, it outlines the positives and where there is a need for action. With regard to staff shortages, the witness indicates that over 12,000 people are required. Will she indicate where is the shortfall between the 9,000 people and the 12,482 people? Per head of population, is the 12,482 figure comparable with what is available in the UK? The witness spoke about the shortage of doctors, with a shortfall of 200, and there is also a shortfall of 500 nurses. Is this a result of action not being taken by the HSE to recruit or is it because people are not available? The number of doctors mentioned is quite high, so does that take in both consultants and junior doctors? Is there a major problem in the area? How can the issue be tackled?

There is the issue of homelessness, and the witness has pointed out the lack of services for homeless people. What could be done immediately to address the problem? I am referring particularly to something that could be done over the next two to three months, especially as we are approaching Christmas. The issue is highlighted at that stage more than any other time of the year.

What do the witnesses believe could be done to deal with the issue in order to fast-track some action?

I thank the witnesses for the presentation. I have one or two questions, one of which Senator Burke alluded to, about the shortfall in staff numbers outlined in A Vision for Change. It was said that up to July there was a shortfall of approximately 3,000 staff. I am concerned about the 567 nursing posts that have not been filled. I accept dealing with people with mental health issues requires highly skilled professionals. The work is very intense. Are agency nurses employed in the mental health sector?

It was said that 212 people are waiting for between three months and six months and another 70 are waiting for more than six months. Is there a breakdown of their specific geographic location? I read that 34% of children are still being admitted to adult psychiatric services in hospitals. I echo the comments of other speakers that it is absolutely scandalous. We must examine the situation as a matter of urgency. It was said that some of the 500 people who took their lives had contact in the past year with health professionals. Is there a percentage available? Is it 20% or closer to 80% and where does one get such figures?

I fully agree with what was said about homelessness. People seek housing on a regular basis. Depression and anxiety about where to go in the evening are among the main problems that arise. Many people end up sitting in accident and emergency departments and they develop many other problems there in addition to the reason for which they are admitted. Alcohol abuse is one of the main problems I encounter among the people I deal with who experience homelessness. In my area there are two houses where homeless people can go in order to drink. Not all areas in Dublin have such a facility as they seem to be concentrated in certain parts of the city. That is a real problem because I meet people who regularly come from other parts of the city to the inner city in order to be facilitated in wet hostels. Some homeless people would not have to go to accident and emergency departments if they could be facilitated elsewhere. I accept that is a broader issue but the situation must be examined.

I have had some dealings with community-based mental health services as part of primary care services through relatives of people who suffer from their nerves. All of them have said the service in the community is excellent and that people are well looked after. It is a huge comfort to families that their relatives can be seen in the community rather than them having to travel. It is good for communities to know that people suffer from mental health issues and that people should not be stigmatised as being affected with some kind of plague. Most families in this country have someone who suffers from depression, anxiety or other mental health illness and we should not hide the fact in a closet and pretend it does not exist because it does. One of the things that has helped families to cope with the mental health illness of a family member is the availability of a community-based service.

I welcome the witnesses and thank them for their good work. Reference was made to the shortfall in the number of psychiatrists. Even if the shortfall were addressed, where would we fit in an international league table of psychiatrists per head of population? For most specialties in medicine we are way off the bottom of the charts. I am sorry to catch the witnesses on the hop and I understand if the information is not to hand. What is our ratio of psychiatrists per head of population compared to the United Kingdom, which tends to be second worst in the world among OECD countries for most specialties, and in comparison to an average figure for continental Europe?

This is a specific and technical question. Does Dr. McDaid have any sense of the provision of liaison psychiatry services? I do not know where this fits in the planning for psychiatry services. A great deal of the demand for mental health services comes via other doctors and other illnesses. People develop complications that require psychological care, which I find is often very hard to access.

Could Dr. McDaid also give me a sense of the average waiting time for treatment? I refer to somebody who has a routine psychiatry request from a GP for an outpatient appointment that is not felt to be life threatening; if, for example, somebody has an addiction issue or personal issues which are not felt to put the person in the way of self harm. Approximately how long does a person wait to get seen?

My query relates to the question asked by Senator Crown about waiting times. I am aware of a lady who tried to take her life. When she contacted the hospital where she was to see a psychiatrist, she was told it would take eight weeks. Her family was obviously very upset. In spite of that, the doctors in the hospital were able to ring her and tell her to come in as they had a bed for her. I do not understand how a long timespan would be given and then the doctors could change their minds within 24 hours.

Reference was made to a national coalition of 48 NGOs in the context of Mental Health Reform. Following a previous presentation I inquired how many groups were involved in suicide prevention and I did not get an answer. I was told that between 350 and 500 groups were in existence. Could the witnesses comment on those groups and what they are doing, given that we have been told there are 48 groups in the national coalition?

Twice this week I have been contacted by school principals who are extremely worried about adolescent children in their care. They want to know where they can go and whom they can get to see. It is not that the children need to be admitted to hospital but they need help. I am aware that when one rings the local support services, one gets an answering machine but one never gets a call-back. Nobody seems to answer the phone. Why is that the case? The support group is based in the locality but it does not respond to people.

I thank Dr. McDaid for her presentation. I apologise for being late. I have read it in the meantime. Could she provide a view on out-of-hours social worker access? Actions speak louder than words.

The National Office for Suicide Prevention advertised recently for ten suicide prevention officers nationally. Our assessment is that 40 are required, at least one per county and significantly more for larger counties such as Dublin, Galway and more populous areas. Has the organisation done an analysis on the cost of mental health versus the funds allocated to it, including indirect costs such as the impact on affected families in terms of reduced output and what may be termed "presenteeism"?

I thank Dr. McDaid for her excellent presentation. My problem is that coming last, most of the questions have already been asked. Suicide is my main concern. Every family in this country has some experience of suicide. I am concerned about whether the money is going to the right place. As Deputy Mitchell O’Connor outlined, there are so many agencies around the country but I wonder whether the money is going to the right agencies. A total of €90 million has been spent on mental health in the past three years. In fairness to the primary care centres, they are doing a fantastic job. Most of the money has gone towards the replacement of staff. I refer to social workers, psychiatrists and occupational therapists. They are very important people in combatting mental health issues. The Government is taking mental health very seriously and has ring-fenced €35 million for next year.

Two weeks ago in my area of Dundalk the son of a family who contacted me was knocked down by a car and there is nothing they could do about it. If people are suffering from mental health problems and are thinking about taking their own lives, I am sure there must be some early indications.

This is something we can prevent. Is the money going to the right places? Is it following the patients? The money allocated is considerable. Some €90 million has been allocated in three years, €35 million is to be allocated for 2015 and I hope that the Government allocates more. Are we doing enough to help prevent suicide?

I welcome the delegates and thank them for their presentation. When one sees it all presented in this way it is very shocking. I want to make one point regarding the shortage of doctors and particularly nurses. I find this hard to understand that there is such a shortage of nurses when nurses are emigrating to find work. I know nurses who could not get employment here. I find it difficult to get my head around that.

I have only one question to put to the delegates. In terms of A Vision for Change, is the situation getting better, standing still or is it getting worse? When people come to my clinic, as they would call to other members' clinics, I find I am getting stressed trying to access services on their behalf. I can only imagine what that does to the people who suffer from mental illnesses.

Dr. Shari McDaid

I will respond in the order in which questions were asked. Senator Colm Burke asked where the staff shortages are but I do not have exact figures with me. He asked me a number of questions around figures and I would be happy to forward them to him after the meeting as I do not have all those figures with me. The staffing numbers, to which we refer when we mention a shortfall are the numbers that were developed by the expert group. In all of the international information on good practice that is available, there are not necessarily figures indicting that X number of doctors, social workers or occupational therapists are needed because it depends very much on the population, its needs, specific make-up in terms of, say, disadvantage and its age profile. We have a particularly young population and we might need more child and adolescent mental health services than other jurisdictions. It is not easy to do a straight like-for-like comparison in terms of this is what is provided elsewhere and this is what we should have. What we have is what the expert group came up with. This is the expert group appointed in 2014 to develop the mental health policy. It gave its considered and consensus views on what the staffing levels should be, and that is what we are working off now.

The percentage of the health budget that goes to mental health services in Ireland is still only about half of the percentage of the health budget that goes to mental health services in the UK. We must recognise that we are coming from a very long legacy of decline in spending on mental health services. In the 1980s, 13% of the health budget was spent on mental health and it is now down to 6% or 6.5%. I would have to check the most recent budget and once we have the HSE service plan for next year we will have a clear indication of where it is at for 2015. We still have a long way to go and for all the reasons I outlined earlier it has been very difficult to get an increase in spending because of the difficulties in recruiting and retaining staff.

Deputy Colm Burke wanted to know whether the difficulties in recruiting the staff arises from action not being taken by the HSE or from it not being able to recruit. It is a combination of both. On the one hand, the HSE has been very slow in deciding where it wants to spend the money. We know it is only as of September of this year that it was able to say that this is exactly where it wants to spend the 2014 allocation. We hope it will be in a much better position to know where it wants to spend the funding for 2015 but that is the third successive year the funding has been delayed, in part because the Health Service Executive has been slow to determine where to spend it. On the other hand, we have to take account of whether the recruitment package is attractive enough to get people into the service. That is a wider issue across the health service.

Deputy McLellan asked the reason we would have a shortfall of nurses but psychiatric or mental health nursing is a specialist discipline. We need people who are particularly trained in mental health nursing and, generally speaking, it has been difficult to recruit nurses.

Deputy Catherine Byrne wanted to know if there are any private agency nurses involved. My understanding is that to make up deficits agency nurses are used, but I do not know the extent of that at this time. I do not have a breakdown of that. We would have to go to the HSE to get a breakdown of the where we are at in terms of the waiting lists in the counselling and primary care service but if that would be helpful, we would be happy to seek that information. The Deputy wanted information on the fact that the majority of people who take their own life will have seen a health professional. I would have to double check that. I believe it comes from research carried out by the National Suicide Research Foundation but I will confirm that because I would like to be sure of the information I am providing.

I would agree with the Deputy that as we have travelled around the country, and we hold four public meetings every year to make sure we are hearing what is happening to individuals trying to access services and their family members, we have heard of good services being provided and the difference a good service makes. Where an individual has good access to a mental health nurse in terms of having their telephone number and being able to ring them whenever they are concerned, or where the mental health nurse gives a family member their telephone number directly so that they can access that kind of follow-on support after discharge from hospital, that is very valuable and appreciated and can work very effectively to keep well and out of hospital. I agree with the Deputy on that.

Senator Crown asked for some specific information, which I would be happy to provide at a later date. The numbers in A Vision for Change were set out by the experts involved in developing the policy, therefore, that is the basis upon which we are saying that there is a shortfall of psychiatrists. However, there is scope for looking at those numbers again with regard to Ireland's population to see if they need to be improved upon. The Senator asked about routine procedures referral by general practitioners into mental health services and the waiting period in that regard; I hope I am correct that this is what he asked. To clarify, if someone goes to a GP with an addiction they will not be referred to mental health services because there is a separation of services in Ireland between mental health and addiction services. That is a difficulty in that many people with mental health difficulties also have addiction issues that need to be addressed. That is something that needs to be examined.

In the adult mental health services I believe the target being worked towards in terms of people being seen is 12 weeks. That can be seen on the HSE's published information on its performance monitoring reports. It is working towards a target of 12 weeks, which is the reason it seems to take a long time to get access. However, this is the first time we have had a target and we need to consider now whether that target will be adequate. When a GP refers someone into a specialist mental health service he or she generally has significant concerns about that individual because only people with severe mental health difficulties are referred to the mental health services.

On the other hand, we need to provide more support to GPs in order that they feel more capable of responding and providing mental health support to individuals, both those at risk of developing a more severe mental health difficulty and those with mild to moderate difficulties. We are looking to some of the clinical care programmes being developed in the HSE to improve the supports to be provided to GPs. For instance, there are plans for an early intervention in a psychosis clinical programme within the HSE. A key function of that programme is to improve the consultancy support for GPs in order that where they are concerned that someone might be developing psychosis, they are quicker to refer the person to the mental health services but are also more able to provide a range of supports. The early intervention psychosis programme has been discussed for a couple of years and it needs to be implemented.

I think I have answered the question from Deputy Mitchell O'Connor about the waiting list for adult services. With regard to the number of suicide prevention organisations that have arisen in response to suicide in local communities, there is a difficulty with the co-ordination of those activities. We are looking to the new suicide prevention - what I hope will be a mental well-being framework as well - to address better co-ordination of the local initiatives on suicide prevention. It is widely recognised that while people initiate local programmes out of very sincere desire to improve the situation, there will be a better impact overall if those supports are co-ordinated throughout the country. We need to see in the new suicide prevention framework what specific actions will be taken by the National Office for Suicide Prevention to improve the co-ordination of those initiatives.

On the question of why support groups might not be available, co-ordination would help with that. With the launch of the Little Things campaign - I am wearing a Little Things badge today - the Samaritans have a phone number which is 116123 for people to call which has been provided to the Samaritans by the National Office for Suicide Prevention. This is a way of getting the message out to the public that there is a centralised highly skilled service available for individuals who are feeling like they are in danger of harming themselves. This initiative will be helpful.

In reply to Senator MacSharry about out-of-hours social worker access, the mental health policy sets out that every community mental health team should have a 24-7 intervention arrangement. It does not specify what that arrangement should look like. We consider it should be a combination of the seven day a week day hospital with telephone access to acute wards with good family education in order that families will know how to respond to a person in crisis, as well as home treatment in order that families are supported by intensive home treatment where a family member is going through a crisis period. Those are some of the components we would expect to see in a 24-7 service.

With regard to the ten suicide prevention officers being recruited, I do not have the exact number of existing suicide prevention officers but these ten would be additional-----

There are ten officers. We thought there was a need for 40.

Dr. Shari McDaid

On the question of the cost of mental health versus the funds allocated, mental health costs the economy about 2.5% of GDP every year. The funds specifically allocated to mental health are approximately €700 million. A significant disparity exists. I refer to an initiative undertaken in the UK which we have not considered as yet in this country where it has been decided that mental health needs to be given parity of esteem with physical health in allocating the budget. That issue has not even been broached in this country but in the UK they have grasped the nettle and decided that the only way to address the decades of underspending on mental health is by having a concerted effort to have parity of esteem on spending.

Deputy Fitzpatrick asked whether the funding for suicide prevention is going to the right agencies. My reply to Deputy Mitchell O'Connor links in with that question in the sense that we need better co-ordination of the funding on suicide prevention and we need it to be going to evidence-based interventions on suicide prevention. We need to see that change coming out of the new suicide prevention framework.

Deputy McLellan asked about the strategy, A Vision for Change, and whether we are getting better, getting worse or standing still. I am very hesitant to call it in that way because we have a very disparate system where parts of the system are moving forward and parts of the system are falling backwards. Those parts of the system that are moving forward are still scattered and are still in some ways the exception rather than the rule. The number of services which provide home treatment are still in the minority. I refer to the number of services adopting a recovery orientated progressive approach and which are reaching out and pushing social inclusion for people with mental health difficulties, but these services are in the minority. While those services are to be commended on how they are driving things forward, it needs to be much more consistent throughout the country. We also need to remember that there are particular disadvantaged communities which have received very little attention to date in A Vision for Change. When I say disadvantaged I mean people with intellectual disability for whom the services have not been given attention since A Vision for Change was published in 2006. I am talking about people from ethnic minority groups and I include the Traveller community for whom the services recommended in A Vision for Change have not been given attention. I refer to people with eating disorders where the eating disorder service has not yet seen any significant developments since the publication of A Vision for Change. My overall assessment is that I commend those areas where it is doing better because in every place where it is doing better there are individuals who are getting a good quality service and it is making a real difference to their lives. I would not rest easy, however, until everyone in the country has that level of service.

I thank Dr. McDaid and Ms Mitchell for their attendance. I thank the members for their participation.

Sitting suspended at 10.48 a.m. and resumed at 11.30 a.m.