Mental Healthcare at Community, Voluntary and Preventative Levels: Mental Health Reform

It is lovely to see the witnesses, who will both be joining the sub-committee remotely. They will review the way the community and voluntary sectors cope as a first line of defence in tackling mental health issues. From Mental Health Reform, I welcome Ms Fiona Coyle, CEO, and Mr. Ray Burke, senior communications and advocacy officer.

Before the witnesses give their opening statement, I wish to point out to them that there is uncertainty as to whether parliamentary privilege will apply to any evidence provided from a location outside of the parliamentary precincts of Leinster House. Therefore, if the witnesses are directed to cease giving evidence in relation to a particular matter, they must respect that direction. I call on Ms Coyle to make her opening remarks, although we are having connection problems with her.

Mr. Ray Burke

I am happy to make the opening statement in place of Ms Coyle.

I would like to start by thanking the sub-committee and the Chair for inviting Mental Health Reform to appear before it today. Mental Health Reform is Ireland’s national coalition on mental health. With more than 75 member organisations, we provide a platform for our members to work together to drive progressive reform of mental health services and supports in Ireland.

I would like to start by saying that Mental Health Reform warmly welcomes the establishment of this Sub-Committee on Mental Health, which we feel will play a critical role in examining mental health at this important historical moment in Ireland. This year, 2020, has been a year of unprecedented challenges, both for our citizens and for our mental health system. It has also been a year of opportunity, with the launch of an ambitious new mental health policy, Sharing the Vision. The establishment of this sub-committee recognises the urgent need for a focus on the new context facing our mental health system and our society more broadly. We see this sub-committee as a critical instrument through which the Oireachtas and the Government will be accurately informed to make the right leadership decisions regarding mental health services.

Covid-19 is a mental health emergency as well as a physical health emergency. Not alone does the threat of contracting and spreading this virus instil fear and anxiety across our population, but the public health restrictions and our broader approach to the virus have also had a profound impact on people, increasing social isolation and loneliness, and undermining the social and cultural supports on which we have come to rely. This profound sense of loss and dislocation represents a societal trauma that will have a severe cost that will be felt in the weeks, months and years ahead.

In Ireland, we are already starting to see an indication of the impact of the pandemic on people’s mental health. In a survey of our member organisations in April 2020, 76% of respondents said they had to withdraw mental health services they usually provide due to the Covid pandemic. This is despite a significant increase in demand – Jigsaw, for example, has reported a 50% increase in demand for its services. In terms of statutory services, the HSE has said recently that traffic to its mental health website was up 490%, with more than 800,000 visits between March and July.

While the mental health need grows, more and more people are coming forward for support. However, what is very clear is that our mental health system is not adequately prepared to cope with any significant increase in demand. In fact, our mental health system was struggling to cope with demand long before the pandemic hit. For example, the number of referrals to child and adolescent mental health services, CAMHS, increased by more than 40% from approximately 12,800 in 2011 to 18,100 in 2019. Despite this, nationally, CAMHS is at less than 60% of recommended staffing levels.

More than 2,000 children are currently waiting for their first CAMHS appointment. The challenges faced by CAMHS today are just one example of a system that has not received the level of prioritisation, resources and political leadership needed to deliver for our citizens.

Mental Health Reform believes there are very clear actions that will help to achieve the progressive mental health system that our country deserves and should aspire to. These can be achieved through investment in and full implementation of our new national mental health policy, Sharing the Vision. However, three overarching areas must be addressed.

First, we must substantially increase investment in our mental health services and move to gain greater accountability and transparency over the mental health budget. Members will be aware that Ireland's national mental health budget currently stands at €1 billion. The World Health Organization, WHO, recommends that mental health spending should be 12% of the overall healthcare budget and Sláintecare recommends that mental health spending should be 10%. In 2020, however, Ireland's mental health budget was approximately 6% of the overall health spending. While more investment is needed, we also need to make wise investment. The development of an appropriate, electronic mental health information system based on key performance indicators will assist in driving transparency and accountability in the development and delivery of mental health services. It is not acceptable that more than 14 years after the publication of A Vision for Change, the previous mental health policy, there is no national information system to report accurately for performance and mental health expenditure in Ireland.

Second, we need to re-establish a dedicated lead for mental health within the HSE who will report directly to the CEO. Mental Health Reform believes that the decision to disband the HSE’s national office for mental health, along with the role of the national director for mental health, was a significant backwards step in driving oversight and accountability for expenditure and the development of services across our mental health system. While we understand the need for reform of HSE structures and governance, we know that to drive forward the changes that are needed in mental health, which are decades behind where they need to be, a role of this type is essential. This needs to be re-established.

Third, we believe that a greater political focus on and scrutiny of mental health in Ireland is very important. While this subcommittee represents a significant step forward in that area, we are eager to see mental health become a more prominent feature across all relevant committees and debates in the Houses of the Oireachtas. This means holding the Minister of State with responsibility for mental health and older persons and the Minister for Health to account at a granular level on both our mental health budget and the delivery and implementation of national policy.

I thank the members for their time. My colleague and I look forward to answering any questions, if Ms Coyle has managed to re-establish her connection.

I thank Mr. Burke. Would Ms Coyle like to come in at this point?

Ms Fiona Coyle

I thank the committee for having us here today. I also thank Mr. Burke for jumping in. My Internet connection in the house dropped there for a few moments. I apologise for that, but this is one of the new challenges we face in this new context. I look forward to answering any questions the committee may have.

It is good to see Ms Coyle and Mr. Burke. It is good to be able to put a face to the voice. I have spoken to Mr. Burke a number of times on the phone and I thank him for being at the end of the phone. As the spokesperson on mental health for Sinn Féin, I have worked in the community on front-line mental health services and addiction services over the years. Having come into this role, I have really seen the frailties in the mental health services, including the obstacles and difficulties people have in trying to access the right mental health services when and where they need them, and at different levels.

Mr. Burke referred to CAMHS, which I am very passionate about. Perhaps Mr. Burke could expand more on that. It is a no-brainer to put resources into early intervention. I am not just throwing out platitudes, but prevention is much better than cure. If we can get early intervention to help young people to deal with whatever mental health needs they have at an early age, it can help to build resistance and they are less likely to come back into mental health services as they get older. In pure economic terms, never mind the human side of it, this would be money well spent and money well saved. Will the witnesses give their views on how they think we would be able to improve the CAMHS service and how to get early intervention in earlier? How do they think we could get better outcomes and how could we track these?

Reference was also made to the €1 billion budget for mental health. The figure has been thrown around for a number of years by different Governments. If one goes back in time, however, the budget in 2009 was, I believe, €1 billion. It has not increased at the same level as the health budget over the years. As mentioned in the opening statement, Ireland's mental health budget is down at 6% of overall health spend, while the WHO recommends 12% and Sláintecare recommends 10%. We have to get there incrementally. I do not think the system would be able to take a doubling of the mental health budget straight away. It is something that will have to be done incrementally as we build the services up.

My next point is a bit of a plug. I have initiated a Bill in the Dáil today, the Mental Health Parity of Esteem Bill 2020. I have spoken to representatives of Mental Health Reform about this and I thank them for their support. The Bill has the support of all the stakeholders out there. I have done a fair bit of research on it. The idea behind the Bill is, basically, what we are talking about here: to elevate mental health to the highest level of policymaking and the highest levels of government so that every kind of health intervention would have a mental health aspect. The Minister for Health went through the whole winter preparedness plan for the HSE recently and there was not one mention of mental health in the plan. This is what I am talking about. The Bill seeks to elevate mental health to the same parity of esteem as physical health. Hopefully this will lead to benefits such as a 24-7 emergency access for mental health. What do the representatives believe the benefits of this would be and what would it look like? How do they see this being rolled out in the community? At one stage, Ireland had the most beds per capita in Europe for mental health and we have now gone to one of the lowest. In order for that system to work, we need to bring community care up at the same time. I do not believe that this has happened. I would appreciate an opinion on that too. I thank the Chairman for letting me in.

Ms Fiona Coyle

I thank Deputy Ward. I will address some of the Deputy's questions and then my colleague will come in.

The point on CAMHS is very valid. The data speak for themselves. It is very difficult to talk about our mental health services without talking about staffing. Our mental health services are based on staffing. CAMHS in particular is an area with great understaffing, with some of our CAMHS services at 60% overall across the country. This means we are not running the services at the level they should be at. It is also very important that we look at mental health, as the Deputy noted, as a consortium. It is about providing the person with the service in the community at a time when he or she needs it.

While Covid has impacted all generations and every individual in the State, I would like to refer to a survey undertaken by the Department of Children, Equality, Disability, Integration and Youth with SpunOut.ie, in which younger people said that they have felt undervalued and unfairly scapegoated while they have been making sacrifices during the pandemic that had not been taken seriously. What came across in the report, and what we are saying more broadly for the population but especially for young people, is that mental health is not just something for the Department of Health to deal with. It is not just a health issue and it needs to be mainstreamed across all areas including in the Departments of Education and Social Protection. We need to ensure there are a variety of supports and services available to young people to support them in their own mental health journeys.

Mental Health Reform has asked, and continues to ask, for the prioritisation of investment in staffing, which we know needs to be done in the weeks and years ahead.

In regard to parity of esteem and the winter plan, this is something that Mental Health Reform came out very strongly on. We have a huge opportunity at the moment for our members. Never before has mental health been under such a public policy spotlight. As a country, we understand the impact that Covid has had and is having on both physical and mental health. It is great to see that mental health is being discussed and to see the establishment of this committee and other initiatives. However, that must be followed through with action. On the winter plan, an individual I spoke to, who accesses services regularly, was quite disappointed and felt it was just as important to keep those with mental health difficulties out of hospital during the winter as those with physical health difficulties.

On the issue of 24-7 services, this is something Mental Health Reform and its members have been campaigning on for many years. All of us in this space know that anyone can have a mental health crisis at any time. A mental health crisis does not occur between the hours of 9 a.m. and 5 p.m. and it is fundamental that there are out-of-hours supports for those who need them.

Whenever we talk about mental health services, it is very important that we always talk to those who are accessing the services, and that their views and experiences are brought back into the type of services we are developing. Mental Health Reform last year launched a report entitled My Voice Matters. As part of that, we spoke to more than 1,200 people who have lived experience, and to their families and carers, to understand their experiences of Ireland's mental health services and supports. One of the key findings that came out of that report was that, of those participants who, unfortunately, had to go to emergency departments to seek support for their mental health, 49.3% disagreed that they got the support they needed. That fact alone shows the need to invest in 24-7 services and supports, because this is what people need and deserve.

Perhaps Mr. Burke would like to comment further.

Mr. Ray Burke

Deputy Ward referred to the proportion of the overall health budget that mental health represents. If we look back as far as the 1980s, mental health was about 20% of the overall health budget. Unfortunately, in the 1980s, we were spending that money on things that were not very progressive and were spending it on large inpatient, asylum-type facilities that were unacceptable. We have moved very much away from that model to a more community-based model of mental health services. In that shift, however, we have moved to one of the lowest bed-to-population ratios in Europe, as far as I am aware, and we are half of the ratio of countries like Germany. In order for a system like that to work, and Deputy Ward hit the nail on the head in this regard, we need a really strong community mental health service and mental health provision, and we just have not seen that. As the budget since the 1980s has dropped off, we have not seen the investment in community mental health services. That is where we are today. We have moved from 20% of the overall health budget in the 1980s to 6% today, with an overall mental health system that needs investment. We could have retained much more of that money and invested it wisely over those years to have a much stronger community mental health system but we just do not have that today. There is a serious need for investment. If we look at countries of similar size to Ireland, such as New Zealand, for example, it is spending approximately 12% of its overall health budget on mental health and our closest neighbours in the UK are spending more than 10%. While it is not everyone's favourite yardstick to look at the proportion of mental health within the overall health budget, by virtually any measure, mental health services in Ireland are lagging behind other countries in Europe. There is a need for improvement and investment in those areas.

To follow up on what Ms Coyle said on the issue of 24-7 services, Deputy Ward asked how this would be rolled out. It was our firm belief that a first port of call would be a seven-day-a-week mental health service for adults and children. We understand that is being rolled out at the moment for adults but it is extremely slow. Realistically, no plans have been made clear to us by the HSE or the Government in regard to a 24-7 mental health service for children. This is a huge deficit in our system that needs to be addressed. It was clearly marked out in A Vision for Change, the previous mental health policy, and it is clearly marked out again in Sharing the Vision. It needs to be prioritised. The absence of 24-7 services means people will end up in emergency departments outside of hours, for example, at 8 p.m. during the week or at any time over the weekend. That is an extremely distressing place for someone in a mental health crisis to be, possibly needing to tell their story again, to re-traumatise themselves and to go through the whole process of explaining their personal history, and that type of thing. It is not acceptable and needs to change. It needs to be prioritised very urgently.

It was remiss of me earlier not to congratulate Senator Black on becoming Chairman and commend her on all the hard work she has done in getting this committee set up. I thank her for that. It is really needed.

Reference was made to young people, who are really getting a bad run of it, especially within the media, and the spotlight is on them. The vast majority of young people are compliant with the regulations. As with everything, there are always a few exceptions but everyone is then tarred with the same brush. I can understand this. I am a father myself and I know how difficult it is for young people at the moment. I have sometimes used the example of my 14-year-old daughter, who will leave her bedroom and come in and listen to the Taoiseach talking, to see what the new restrictions are. That shows how much of an impact this is having, because she wants to see how the restrictions are going to impact on her being able to meet her friends, play football and access school. While she is there, she is on her WhatsApp group with her friends, and they are back and forward on it. It really is getting into the psyche of young people. As I said, the vast majority of young people are really adhering to the rules.

The witnesses mentioned the issue of accident and emergency. In my past role, I have sat with people in accident and emergency. Mr. Burke described perfectly how difficult and demoralising it is for people while they are there. They are not getting the privacy and the hearing they need. The staff in accident and emergency are doing the best with the resources they have, but some people are not trained to deal with mental health issues as they arise.

Ms Coyle mentioned the 49% of people who were not happy with their treatment in accident and emergency, and I would have thought the figure was a bit higher. There is also the issue of after-care. Much of the time, what happens in accident and emergency is that people are seen but there is no follow-up in the community, as the witnesses mentioned. That needs to happen, especially in the area of dual diagnosis. Many people are falling through the gaps when addiction services and mental health services do not meet.

I thank the Chairman for allowing me to come back in. I thank the witnesses for their statements.

To follow on from Deputy Ward, I congratulate the Chairman warmly on her appointment, which is most appropriate, given the work she has done over many years, in particular in recent years. Having worked with her in the Seanad, I know her deep commitment to this work and this particular issue.

I welcome the witnesses and I listened to their contributions with interest. Mental Health Reform represents 75 organisations and I have no doubt that each one of those organisations has a very strong commitment to the work it does. However, I have had a view for a long time that one of the problems in the whole area of mental health is that there are too many organisations.

Each of them has laudable objectives and commitments. However, because there are so many it creates a disjointed approach, as opposed to having a clear, unified approach. With the best will in the world, all the various organisations will have some tangents in terms of how they go about achieving their common goal. To extend that to the voluntary sector, I have seen many examples over the years where, as the result of a tragic situation, a foundation or charity is formed that provides good services but often it is based on a local tragedy or a commitment among local people. My view is that there are too many organisations, as opposed to having a select few organisations that all the funding would channel through and which would have a clear, unified voice. I am interested in Ms Coyle's thoughts on that.

Ms Fiona Coyle

I thank the Deputy for raising those points. In terms of the membership of Mental Health Reform, our members represent a diversity of interests and areas. Some are delivering mental health services in partnership with the HSE and the State, some are working on delivering homelessness services, some are working on disability rights and children's rights and some are working on specific interest group areas, such as ethnic minorities or the LGBTI+ community. Overall, the value of civil society and of the community and voluntary sector is that many of these groups developed out of a failure of the State to provide services and supports. We are saying today that there still is an unmet need out there in delivering mental health services and supports.

The importance of the role of the community and voluntary sector in delivering services is recognised in our new policy, Sharing the Vision. Many of our members are working to ensure the voices of those service users are heard, that they are receiving advocacy support and that the State is held accountable for ensuring the rights of service users are being upheld.

On Covid, the journey we have gone through over the last number of months has been an important turning point in the relationship between the State and the community and voluntary sector. As in all sectors in Ireland, the restrictions were challenging to our members. They rose to that challenge and managed to continue to provide services, either by going online or adapting their service model in a time when there has been growing demand from service users and when the organisational challenges in terms of funding and staffing issues were severe. A majority of our members are reporting increased demand for their services. We know there is a need there and these organisations are filling the need. Our organisations, especially at community level, try as much as possible to work together and co-ordinate.

There are many different supports out there but that is because the need is diverse and each individual's mental health journey and the types of services and supports they need may be individual to them. It is our perspective that the community and voluntary sector plays an important role in the delivery of services. It has been strongly outlined by the Government and in various policy documents. I hope that answers the Deputy's questions.

The diversified nature of it is interesting and we will be delving into that. This subcommittee wants to achieve something. We would not be here otherwise. We will have to do a report because our purpose in meeting is to make recommendations to Government. Is there any best international example Ms Coyle suggests we should look at as an example of where we should be trying to get to in terms of the level of services she would like to see or the structure or shape of those services? Is there any country in Europe that springs to mind where we should interview the people in charge of mental health in that country to see how they do it?

Ms Fiona Coyle

This year has been one of opportunity. We launched a new mental health policy, Sharing the Vision. As part of the development of that policy, the oversight group that was part of the development process looked at mental healthcare systems and models in other countries. It is our view at Mental Health Reform that we have the roadmap. Sharing the Vision is a transformational document if it is implemented. It is similar to its predecessor, A Vision for Change, which was welcomed across the board as a roadmap or pathway along which we should be moving our mental health services and supports.

What we need to do is mapped out there but it would be beneficial to look at why we did not achieve that with A Vision for Change. Why did we have a plan that was full of potential but did not deliver for the people who needed it most, namely, the services users and their families and carers?

My colleague, Mr. Burke, spoke about other countries who are investing more funding and more money in this area, which we agree is a significant first step in ensuring the services are to the level needed. Much of that work has been done in the development of the policy and there are many examples in there that could be transformational. Does Mr. Burke want to talk about some of the countries he mentioned and the different elements that could be useful?

Mr. Ray Burke

I thank Senator Conway for his questions. It is tricky because Ireland is unique in many ways. I echo Ms Coyle's comments that we have a strong plan in Sharing the Vision, which builds on A Vision for Change, and we really need to get on with implementing this policy, learning from the mistakes of the implementation of A Vision for Change, investing adequately and driving this forward. That is the best vision we will have.

It is difficult to compare Ireland to other countries but there are countries that do certain things well. We can look at Scotland, for example, or at the level of community care in France. There are strong mental health services in places like Canada. Once or twice a year we link in through an international initiative with different countries across the world to speak about our mental health services and systems and this is where we find interesting, innovative initiatives coming through. Those are some of the countries but the big caveat is we are in a unique situation because of our population size and because of the inheritance of our health system from the UK and the development of that over a century.

I will come in on the Senator's previous question. I know he has an interest in this because I believe he asked this question to our friend and colleague, Mr. Martin Rogan, in the Joint Committee on Health a couple of weeks ago.

The Senator has identified a really important area. I very much support what Mr. Rogan said at that time, which was that we really need, first of all, a very clear vision from the HSE on its commissioning process and what it would like to see in the community and voluntary sector, good governance structures and regulation at charity level. This is a double-edged sword, however, because we also really need to support community activation, citizen engagement and peer support. How do we marry these two things? There is a very clear need to support communities. Reference was made to organisations that emerge from instances of suicide clusters. How do we support community healing, activation and engagement while also making sure that the adequate level of training is in place to ensure safe service provision? Senator Conway has identified a really important area, and I thank him for that.

To sum up and to develop that very briefly, we are a small country and if we pull on our resources smartly we can achieve a lot. I am on the board of directors of a couple of disability organisations and I see the overlapping taking place in the sector. I am somewhat new to the whole discussion on mental health. I look forward to learning from and engaging with the sector. We may develop this going forward. I thank the witnesses for their time and the engagement. It is much appreciated.

I echo the comments congratulating the witnesses on getting this set up. It is long overdue. I am only new to the whole system, but it is really significant that they have managed to get this set up. I hope it sends a very strong message and is not seen as this being dealt with elsewhere but that the body of work that comes out of this leads to real and effective change. I thank both witnesses for being here. I will try not to overload them with questions. I was furiously writing notes and thinking about things as I was listening.

We talk a lot about CAMHS and the impact it is having on young people not being able to access mental health services. When we talk about young people not being able to access mental health services, I do not know that people think about what that means as a lifelong consequence for those people. Not to put the witnesses on the spot and ask for their predictions for the knock-on impact of this on a young person's life, adulthood and reaching various milestones, but if a young person cannot access these vital services, could the witnesses briefly outline a picture of what that means for that person? Perhaps it is optimistic thinking from some people that the mental health difficulties just fizzle away as people get older - perhaps that happens - but I genuinely think people do not think beyond what that means for that individual. What are the lifelong consequences when that person cannot access these services?

Yesterday was International Day for the Elimination of Violence against Women. In the past week we have seen a lot of talk about online harassment and abuse. We have the Labour Party Bill dealing with online harassment and bullying, which I hope will pass. Do the witnesses have any commentary to make on this? We talk a lot about funding for the mental health sector, but what needs to be done legislatively? We have that Bill coming forward, for example, but are there legislative gaps the witnesses see that we need to fill in? Obviously, there is a funding gap - that goes without saying - but is there perhaps a legislative one somewhere that we need to consider as well?

Do the witnesses think people are more or less likely to come forward with mental health difficulties due to Covid? I do not know that we have ever had such a collective experience that has impacted people's physical and mental health but also such an individual and isolating experience. There is a narrative of "we are all in this together", that if we put our best foot forward we will all be fine. Do the witnesses think that that will have an impact on people? We constantly say "talk about it" and so on, but if everyone is saying we are all suffering so we just have to pull ourselves together, do the witnesses have a concern about how we will get people to be able to feel safe in talking about how this has had an impact on them? Do the witnesses have any concerns that the "best foot forward" narrative will impact people talking about their mental health?

Reference was made to the system being potentially overloaded coming down the line. I wonder about that. From a workers' rights perspective, I am acutely aware of the precarious nature of the work in this sector which, I would hazard a guess, is mostly down to funding. I know that a lot of charities rely on the goodwill of the experts donating and volunteering their time. That has an impact on the service when people are working in a precarious area. We talk about student nurses, the precarious nature of their work and not treating them well, and then student nurses looking at ways to get out. Could the witnesses offer any commentary on the impact of this precarity on people being able to participate? It is so crucial to be able to retain the workers we have.

Finally, the Government launched the Keep Well campaign about a month ago. Perhaps I am just not terribly clear on it but, from what I can see, there does not seem to be a timeline, a strategy or outcomes associated with the campaign. Perhaps I just cannot find them online. It seems to be more just a web page. Could the witnesses offer some commentary on that? This is supposed to be our national mental health strategy for Covid. Do the witnesses have any comments on the Keep Well campaign?

I apologise for landing an enormous number of questions on the witnesses.

Ms Fiona Coyle

I thank the Senator for her questions. They are all very relevant. I will speak about her comment on the lifelong consequences for an individual. The message that has been clearly coming across over the past decade is that everyone has mental health, that recovery is possible for everyone and that everyone is entitled to his or her own mental health and well-being, whatever that may be. I will talk in more generalised terms because each individual's journey is unique to him or her, but we see the international data that early intervention can alter the journey an individual can have. For example, one of the recent pieces of research that has come out concerns early intervention psychosis, on which we have a national clinical programme. As one can imagine, for a young person who has psychosis to get intervention at that early stage could completely change the outcome of his or her life. Raising awareness of prevention is therefore really important. Ensuring that people get access when they need it can alter their journey. To bring it down to economic costs, if one invests in and supports people early in their mental health difficulty, they may not need such intense support going forward. That has an economic impact. It also has an impact not only on the individual but on his or her family, school community and community at large. Ensuring we get support to people is therefore important not just for the individual but for his or her family and communities as well. I hope that answers that point.

Yes, urgent reform of legislation is needed. I will leave that to my colleague, Mr. Burke. We have been waiting for legislation for years now and we hope it will come through shortly.

As for stigma, I think there was a great hope at the beginning of the Covid crisis when more and more people were talking about mental health. I think it is fair to say that people understand now perhaps more than ever that mental health can be influenced. It has a social element to it. There are social determinants that influence all our mental health. That has come across very clearly during Covid, but what we have been hearing back from individuals, in particular individuals who before Covid may have been living with more severe and enduring mental health difficulties, is that we need to be careful that Covid does not become a more stigmatising period. There is a widespread narrative out there about looking after one's mental health, going for a walk or listening to a podcast, and I think that is part of the Keep Well campaign as well.

However, what we are hearing back is that we are not giving people permission to say that even though they have tried everything, they still need support. People are feeling guilty that it may be due to them that they are not doing the right things, while the reality is that many people might need additional support. That is okay. As a society, we must embrace that and say to people that it is all right to reach out, to pick up the telephone, go to their GP or that they might need additional support down the line. We have been noting that. There is a great opportunity to reduce the stigma at present, but we must ensure we are being inclusive, that we are recognising that mental health is a spectrum, that people are at different stages, which is okay, and that it is okay for people to reach out and to need support.

We do not have information on the "Keep Well" campaign. It is an initiative of the HSE and the Government so we do not have access to the plan, but we can refer back to the committee on it.

In terms of the community and voluntary sector, the Senator's comment is correct. Many of our member organisations are reliant on both State support and the generosity of the Irish people through fundraising. We have seen this year that an economic shock can impact the services our members are delivering and implementing. Our members make every effort to ensure that the needs of their staff are being met and that supports are available.

I will hand over to Mr. Ray Burke to discuss the Mental Health Act and legislation.

Mr. Ray Burke

I wish to respond to some points raised by Senator Hoey, and I thank her for her questions. She first asked about the consequences of untreated mental health difficulties over time. One example, which the Senator will know well, is the consequence for students who are not able to access mental health services and supports when they need them. We know that there is serious underinvestment in mental health services and supports at third level. The Senator will know this because she served as president of the Union of Students in Ireland, USI, when the youth mental health task force report was under way and published. There is serious investment required and the consequence of students not getting the mental health supports they need, perhaps at examination time when they are under massive pressure, could be very significant. It could result in somebody dropping out of college altogether or in more serious consequences. We have seen examples of that in the media over the years. We are very concerned that people do not get access, which is the Sláintecare principle of the right service at the right time. If one is not getting the right service at the right time, things can get complicated down the road requiring much more serious and costly interventions. We must avoid that if at all possible.

The Senator asked if people are less likely to come forward during the pandemic. We have seen evidence, and our colleagues in the HSE have suggested, that people with existing mental health difficulties are less likely to come forward during Covid-19. There is a serious concern that the difficulties of those people are becoming worse as a result of isolation, loneliness and other factors and that they are not getting the support they need when they need it. Again, this is related to timely access to services. The Senator raised a very important point that has to be explored further.

Her other question was about whether services would be overloaded. There is evidence of this, and it draws from studies on international crises. Colleagues in the HSE have said that the fourth wave of this crisis will be the largest and the longest, and that it will be a mental health wave. It is very worrying. We need to be investing now in mental health services for what is being called the largest and longest impact of the Covid-19 crisis, the mental health impact, but we are not seeing that. As we have said consistently over the last number of years, even before Covid-19, our system is not able to meet the demand being placed on it. When we are starting on the back foot and now this crisis has emerged, we must move quickly, right now, to prepare ourselves for what experts are saying will be the largest and longest impact of this crisis. We are not seeing that happen quickly enough.

Regarding mental health legislation, our Mental Health Act is not in compliance with international human rights law, for example, the UN Convention on the Rights of Persons with Disabilities, UNCRPD, the European Convention on Human Rights and the UN Convention on the Rights of the Child. It has been found to be unconstitutional on several occasions and we have been waiting many years for the draft legislation to reform this Act to be brought forward. There was an expert group review of the Mental Health Act in 2015. It recommended approximately 183 changes to the Mental Health Act. Since 2015, we might have seen about three of those changes made, often forced through because of cases that emerged and constitutional challenges to the law. It is critical, but it has been pushed back by successive Governments. This draft legislation must be published urgently. The law must be reformed urgently. It was promised that the legislation would be published last year and, most recently, we were expecting to see it this month. That is probably out of the window now because of Covid-19. Where is the legislation? It must be published and brought before the Houses to be debated. We need it. While we wait for the legislation people's rights are not being protected adequately and that is unacceptable.

That was a comprehensive answer. I like this committee when we get stuck into things. I thank the witnesses for that.

I thank the representatives of Mental Health Reform for attending the meeting. I will make a number of points and some of them might appear to be contradictory. I congratulate you, Chairman, on your initiative and appointment as Chairman.

I have one reservation and I have had it since the start. When I started my life in professional politics in 1992, I worked for a Minister of State who had been appointed by the then Taoiseach, Mr. Albert Reynolds, as Minister of State with responsibility for women's affairs. It is a dim and distant time that has passed. I do not like the separation of mental health from health and I do not like the idea that we are still establishing a sub-committee so we can ensure it gets dealt with. I look forward to the day when we have a Minister for well-being or something similar that encapsulates the health area and that we automatically assume this area incorporates the mental health area, or that the mental health area incorporates the health area. That ought to be one of the primary objectives. How do we go about removing the gap we always have with the separation of the two? It happens in emergency departments. One must be triaged to ascertain whether one is a mental health patient or one has another emergency, and one is sent a certain way. In fact, sometimes people will want or require a holistic approach, and there have been many developments in that regard.

I practise as a psychotherapist and I worked with businesses. Private secretaries have done a phenomenal amount of work as has the public sector on bolstering employees. I wish to emphasise some of the good things, and I am not doing it because I am a member of a Government party. I believe it is a better way of looking at things. I found the life being sucked out of me in the past ten or 15 minutes, and I mean that in the best way. There is massive investment by employers in employee resilience. Some might say they are just ticking boxes because they have a duty of care to their employees, but others are incredibly enthusiastic about it. I also see that they get a bang for their buck from it. Productivity improves when one looks after employees and one creates incentives for them and are mindful of their well-being. Obviously, the corollary is true as well.

A PricewaterhouseCoopers, PwC, report from Australia and New Zealand seven or eight years ago showed this virtuous circle. The more those countries invested in health, including mental health, the more health premiums reduced because there were fewer claims. That was a large carrot for their finance ministers and health insurers. They knew that, if they invested in mental health, it would result in a reduction in claims and payouts. It was a holistic view of well-being that covered health and mental health.

Deputy Ward and I were councillors on South Dublin County Council. When speaking to constituents, I would see both sides of the story - housing officials behind their desks stressed up to their gills and housing applicants feeling like they had been treated unsympathetically and unempathetically because their circumstances in life had not been taken into account. There should be a whole-of-government approach to issues.

The witnesses have not focused on resilience. The positive story to date has been the enormous resilience of people in the face of the pandemic. The Spanish flu of the late 1910s was followed by the Roaring Twenties when people partied for a decade. It was followed by the greatest depression the world has ever seen, but I can see people finding out in a year or so the ways in which we have all been diminished by the pandemic. I mention resilience because that is the main factor - bouncebackability. It is important to accentuate that, in the teeth of considerable adversity, many human beings find incredible reserves within them that they did not realise they had to face issues. We could hold them up as examples as well. There are positives.

I will make my next comment as a Government representative, although I was not a member of the party in the previous Government. Something the witnesses have missed is that the role of these Governments in the past ten months has been awe-inspiring in terms of the resources they have placed at the disposal of every Department and local authority. They have fulfilled the social contract. There are gaps everywhere, for example, in hospitality, mental health and event management, but the Governments have kept the show on the road and not let the issue of resources get in the way.

We reopened schools because of the recognition that doing so would be fundamental to the mental health of society and the mental health and development of children. I have visited many schools in my constituency in the past month. A tiny, almost negligible minority of children have not returned to school. I accept that there are a number. In most schools I visited, great efforts are being made in the form of home delivery of meals under DEIS 1, in some cases by school principals and vice principals. The mental health committee needs to tap into this recognition of people's situations. It is a narrative that shows the greatness of human beings, their constant regard for one another, their keenness not to forget the kid who cannot come to school because his or her parent has an underlying health condition or because of some other situation, and the system's response to ensure people are not left behind. We should capture the DNA of these actions. They say a great deal about us and I do not want them to be forgotten. I am not making this as a political point. Many people moved heaven and earth, and are still doing so, to make these things happen. We need to recognise that.

When called on, the State responded. There were holes, but the responses of some other countries have been appalling. There is an invisible social contract between the State and the citizen where the latter should be looked after when trouble happens. The State has stood up, but that is not to say that it has got everything right.

I grew up in a generation where people took to bed with their nerves. That was how it was described, but there were many mental health issues in the background. We have moved a long way from that.

I have read and accepted everything the witnesses have submitted. I had a conversation with South Dublin Chamber this morning. The witnesses could not have covered everything at this meeting that was mentioned in their submission, but South Dublin Chamber is concerned about self-employed people and sole traders, entrepreneurs who are busy trying to keep their shows on the road in normal times. Even in recessions, sole traders will try to create new work and consolidate existing work. In the pandemic, however, they have been told they cannot work. The enterprising things they have done to keep their shows on the road are no longer available to them as options. They are not members of the Irish Small and Medium-Sized Enterprise Association, ISME, or the Small Firms Association, SFA. They tend not to be on LinkedIn. They have no connections or networks. South Dublin Chamber has discovered that they are suffering a great deal of stress because reaching out was not part and parcel of their day-to-day activities. We can forget that the self-employed and others involved in enterprise suffer stress, too. They need to be part of the conversation.

Speaking from my professional background, I mentioned in a Dáil contribution that we tended to associate loss with the loss of a loved one. All of the literature shows that loss extends beyond that to, for example, status, health, job, pets or things. The most underestimated response to loss and grief is anger. There is a great deal of anger and pent-up loss, hurt and emotion in society. People are not even aware of why they are angry. There is work to be done on this matter. It is a legitimate, justifiable and perfectly human response to get pissed off when we lose control of our circumstances in life. People can be taken aback by the anger they feel, but it is a natural response and should be included in the holistic approach.

The Minister for Health, Deputy Stephen Donnelly, mentioned something when updating the Dáil on Covid approximately six weeks ago and it could be helpful if the committee drilled down into it. He spoke about the establishment of a county volunteer corps. I was interested in the idea and have submitted a couple of parliamentary questions to find out what it entails. I have never heard of the like in Ireland before. If I have the concept right, it seems to be a corps within counties of people who want to volunteer their help in many different ways. It presents an opportunity in the context of mental health and well-being. It might be helpful if we examined what the Minister had in mind and what contribution we could make to framing the conversation.

During an update on the Covid situation, I made the point that we needed to give people hope and have the State do something for Christmas. As an off-the-cuff remark, I said it would be great if we had a great Christmas light display. I was trying to tap into people's need for a bit of colour in the run up to Christmas. Some people on social media interpreted that as being all I had to offer. I only had two minutes to make the contribution. One individual commented that what would give him them hope would be the reintroduction of a mortgage suspension over the period. We can make many interventions, but the practical one is often the one that makes a difference to people's mental health. If I did not have to pay a bill or if it would stay suspended for a time, I would sleep at night.

I look forward to the committee's work. The role of social media is being mentioned in every conversation.

Many of our younger generation are getting answers or looking for advice on social media and there is some really good stuff there. I often see Bressie's content on Instagram and other really inspiring things but there is also quite destructive content, as we have seen in recent weeks.

I hope this is the start of a conversation about well-being, of which mental health is a really important, equal part. I thank the witnesses for their paper which I read with interest. I look forward to engaging on this.

Ms Fiona Coyle

The Deputy raised some really important points for the committee and I thank him for that. He spoke of not seeing mental health as a stand alone item and its importance as a topic that has relevance not only for health but for several areas across society and across a large number of Departments. We are in a space of opportunity, which I think the Deputy was saying. It is not all negative. Many good things are happening. It is an opportune moment. We know the system is not delivering for everyone but we have an opportunity this year to use the momentum and focus that is there to drive change and have mental health discussions in areas where they were needed before but they did not happen. That is important.

The Deputy spoke about investment and the private sector. There is more research on this and many companies are investing in the mental health and well-being of their staff and it is the same for a country. The cost of mental health difficulties is enormous. Some figures suggest it is about 40% or more of GDP. In an Irish context that is costing €12.4 billion annually. It is important to view the funding into mental health as an investment rather than a cost on the State. The current level of investment is not where it needs to be. We need to put a plan in place for how we will get to that international standard mark. We have all agreed that Sláintecare will move towards 10% but this is a really key investment. Early intervention will bring economic returns.

Many good things are happening around the country. When I speak to our members, I hear about the amazing work being done by people and organisations. Unfortunately there is something of a postcode lottery in Ireland. The type of services a person will receive is reliant on where he or she lives. We are all in the same storm at the moment but we are not all in the same boat. It is really important to recognise that some demographics are more at risk of mental health difficulties. The pandemic has shown the huge impacts of social detriment such as living in poverty, living with a disability, or being from an ethnic minority group; these all impact on people's individual resilience. It is not that being born into a particular group in society makes a person less resilient, it is more the stigma or discrimination, or lack of basic rights, not having enough money to pay for basic food. All these takes a toll on an individual's resilience. Recognising that many positive things have come from the current pandemic and there are huge opportunities there, we are operating in a system that was not meeting the needs of many of these vulnerable groups before the pandemic. The pandemic is inadvertently impacting more on those groups, so we need to ensure that the supports are in place.

The Deputy spoke about other areas but we are under time pressure. I wanted to make those points and to urge the committee to take the opportunity to reflect on them.

Mr. Ray Doyle

I am really encouraged by Deputy Lahart's comments. Overall, I took the message of hope and recovery from it which is what our mental health services should be about. No matter what challenges a person faces in his or her life, there is a range of options which will support him or her in whatever recovery means to him or her, whether that is a return to work or simply being able to leave the house. Our mental health services should be inspired by what the Deputy said about hope and recovery and I could not agree more. He is completely right in saying that Ireland has come so far in the development of its mental health services compared to the early part of the 20th century, even until the 1980s, the distance we have travelled is incredible. We need to acknowledge that and the brilliant work being done around the country. I thank the Deputy for his remarks.

I welcome the speakers from Mental Health Reform. I reviewed its opening statement and got to hear some of the earlier contributions. I was going to ask the witnesses opinions on access to acute services, in particular. St. Brigid's Hospital was in the area I am from. It dated back to the period when there was more institutionalisation. There is more treatment in the community now. Mental Health Reform represents more than 75 organisations. GPs are the first line of defence. They can access counselling for people who approach them with mental health issues. How is that performing?

I am thinking of people who reach acute stages of needing care. People are going from Ballinasloe to Galway city to patrol the rivers there. What are the services like for people in acute situations? There has been much Government investment into mental health recently.

Ms Fiona Coyle

I thank the Senator for raising that really important question. There is a challenge of accessing mental health services at the primary care level. When an individual presents to a GP and may need additional support, the GP will refer them on, perhaps to primary care psychology. Our submission refers to the waiting lists. By the end of 2019, 7,000 children and teens were waiting to see a psychologist, an increase of more than 20% in one year. People may not be getting the timely access to the services that they need. That delay at primary care level needs to be addressed.

As my colleague, Mr. Burke, said, Ireland has gone on a real journey in relation to its mental health services but we know that access to acute care is fundamental to a person's recovery.

For us, it is about looking at the spectrum that is there. It is wonderful to see a community come together to mind those people whose mental health is stressed and to try to assist them. However, we should ensure that people get the timely access they need where they are, so that we will no longer need to see those types of services in the various cities in which they operate. Mr. Burke might wish to speak a little more about the challenges for the acute services.

Mr. Ray Burke

One thing that strikes me about the acute services concerns the Mental Health Commission and compliance with the regulations. We need to see improvements in that area. The Mental Health Commission has been very strong in driving reform. What stands out in particular is the availability of care planning for inpatients. Care planning is one of the essential ways for inpatients to have choice and control over their mental health treatments and have their voice heard in an inpatient setting. Compliance with care planning is not at an acceptable level. That needs to be improved, as does staffing at acute levels. While figures vary between community healthcare organisations, nationally approximately 70% of the recommendations set out in A Vision for Change have been implemented. There are some issues of understaffing.

We did a survey of people who were accessing mental health services, in particular inpatient services. We could provide some of the findings of the report to the committee. We learned that people do not feel they have choice and control over their treatment in hospital. That is worrying and concerning and speaks to broader issues about human rights. Care planning is one of the ways to achieve this and, as such, compliance needs to improve in that regard.

We are also concerned about one of the pieces that emerged in the report, namely, the focus on medication as part of treatment. Medication should be one of a range of different options for people when they are receiving inpatient treatment. Care planning has a role in that but we also need a range of professionals to be available to people in hospital to provide more choice over treatment. We are not seeing that at the moment. Those are the main points that strike me about acute care.

Ms Coyle spoke about the waiting lists and long waiting times to access experts such as therapists or counsellors in the HSE and the allied healthcare professional sector. What is her opinion about using technology in some way at an early stage or for it to be combined with face-to-face, person-to-person care? I accept what she said about a centred approach. Given that we are dealing with a backlog and that timely intervention is so crucial, I am thinking in particular of e-health. There is an allocated budget for e-health within the HSE. What are the views of the witnesses in that regard and in what ways should we be trying to progress it, while keeping the voice of the person who is going through a crisis at the heart of the process?

Ms Fiona Coyle

I thank Senator Dolan for that very important question. E-mental health is something Mental Health Reform has been working on for the past three years through an EU-funded project. The provision of e-mental health has great potential to deliver better and more timely services to individuals. Covid has moved the e-mental health journey forward. We are seeing more openness to these services from practitioners and service users alike. The one caveat I add is that while these services need to be explored, we have very little evidence at the moment to show if they are fit for purpose or serve the individual at an equivalent level as a face-to-face appointment. We need to gather more evidence on that before we move forward.

The second issue that has come up frequently relates to access and the digital divide. Not everyone has access to the tools - broadband and the Internet - required to access the services. A study by Accenture earlier this year showed that one in four people in Ireland feel they are not able to access the digital world. Mental Health Reform is conscious that the number is probably higher for people with mental health difficulties, who are more at risk of being from lower socio-economic backgrounds. Some of our members include Pavee Point and the Traveller Counselling Service. They note that there is very poor access to the Internet among the Traveller community. They have been facing significant barriers in accessing services digitally or using e-mental health tools. While there is great potential, we must take time to reflect on what we are doing and how we are doing it. There are also questions about regulation that will need to be looked at in due course. E-mental health is definitely an opportunity and an area that we need to invest resources in to explore its potential benefits.

Given that we are in the middle of a pandemic, there is an opportunity to deliver care when it is needed in a timely way, especially when the need is acute. It is important that we use all the weapons in our armoury. I thank the Chairman for the time. I very much appreciate it.

I thank Senator Dolan. I thank all members for their fantastic engagement and the wonderful questions, and the great answers from our witnesses.

I will ask a few questions as we still have a little time. A key investment is to get professional help to people with mental health issues in a community setting. This is something in which I have a specific interest. It is clear that GPs do not currently have the supports available. Have the witnesses looked at the make-up of fully functioning community mental health teams? What should we ask for from the Minister who has promised to provide those teams?

Ms Fiona Coyle

I thank the Chairman and members for their questions. Support at community level is fundamental. The previous mental health policy, A Vision for Change, outlined what the composition of community mental health teams should be. We know there are major barriers throughout the country to getting the correct staff for these teams. This time, where we are prioritising mental health, may present an opportunity to address some of the more structural issues facing mental health services and health services across the board in terms of recruitment and retention of staff. How will we ensure we recruit and retain the correct staffing levels in these teams?

We have fewer staff in our mental health services in 2020 than we had in 2015 and 2016. Staffing is something that we have highlighted and will continue to highlight as a key barrier that needs to be addressed if we are to move towards the mental health service that is outlined in the new mental health policy, Sharing the Vision. I understand, and we have been told by the Government, that the staffing levels and composition of community mental health teams outlined in the previous policy remain relevant in the new policy.

Would Mr. Burke like to come in there?

Mr. Ray Burke

There are two important areas in terms of the community mental health teams. The first is whether we have the required number of teams available in each community healthcare organisation, CHO, and the second is what staffing levels are within those teams. While the overall number of teams might be much closer to what was envisaged in A Vision for Change, the staffing level on each team can vary dramatically and that is a key aspect of the matter. The new mental health policy, Sharing the Vision, is less prescriptive about the types of professions that are needed and is more focused on the strengths that are available in a local area. Issues of staffing and retention were drilled into by the Joint Committee on the Future of Mental Health Care, including making sure that we are getting people into posts quickly, following best practice and that we are efficient in that area. A critical element of the broader puzzle is making sure that recruitment is as efficient as possible and that people are getting into posts where they are needed across the country.

In his opening statement, Mr. Burke identified the need for electronic mental health information. What commitments have been given to the community and voluntary sector to develop the architecture that underpins mental healthcare provision? Does the HSE actively engage in development it?

Ms Fiona Coyle

We feel an important step would be to develop an information technology system that would help to work towards understanding needs and how services are being delivered. That commitment was actually in the previous mental health policy, A Vision for Change, which is more than 14 years old. We understand that various efforts have been made over the years to look at putting in place the type of system that is needed but from what we are hearing back, certainly in the first lockdown phase of responding to Covid-19, the information and files of a lot of people accessing our services are still on paper and in various offices. That gives an insight into the level at which we currently are in our mental health services. We need, as a priority, to look at building an information system that will be able to give us the data that we need to make wise investment decisions to ensure people are getting the help that they need.

Mr. Burke has previously engaged with some of the ad hoc initiatives and he might be able to give more information on that.

Mr. Ray Burke

The information system is critical. As Ms Coyle said, it has been promised for several years and we have not seen anything produced. We really need to know, for example, what are the outcomes for people who go through community mental health services. An information system of that style would help us to understand where we can generate efficiencies and we need to look at that aspect. It seems that without clear data that will allow us easily map the journey of someone through our mental health system and report on it, things are difficult. That needs urgently to be brought forward. I believe it was another recommendation of the Joint Committee on the Future of Mental Health Care and we have not seen it pushed forward significantly.

Another aspect of the IT infrastructure that is important, especially during the pandemic, is that we are hearing from staff in statutory services that they do not have sufficient training or simply do not have access to the level of technology needed to transition quickly away from face-to-face services during these challenging times or at least to help support ongoing service delivery. The availability of laptops, tablets, phones and broadband is patchy across the country. If we want to be able to provide a service to somebody who is unable to come in for a face-to-face meeting, the staff might not have the training or the technology to facilitate it. People might not be able to use that technology. There are huge challenges now, during the pandemic, as regards the availability of sufficient information technology systems that we really need to look at.

Questions are also being raised about the efficacy of different mental health therapies delivered online such as cognitive behavioural therapy, CBT. There are also questions there that need to be answered and investigated further.

I am interested in the previous question asked by the Chairman. Without holding up the meeting, perhaps Mental Health Reform could provide us with a short paper on that general digital architecture. I am fascinated as to why it would be useful. What are positive examples of where it is applied in a useful and productive way? Where are the gaps? What is the international experience? Where have interventions been positive and where are there question marks? I am particularly interested in EU funding because I know nothing about it. I do not want to put too much work on our guests but if they were even able to send a link or two, it would be appreciated.

I wanted to get the thoughts of our guests as to whether we are training enough people to go into professional roles. Are some of those who we train attracted elsewhere, specifically to the public sector, because they do not see a bright future in their profession?

Ms Fiona Coyle

That is a concern across our health services. It comes back to my previous comments about recruitment and retention of staff. We hear from some of our members, particularly those who work more with allied health professionals, that some of our services require quite specific training. The HSE put in place a staffing strategy in 2018 and considerable work went into it. It needs to be implemented. Staffing is not an area that we focus on but Mr. Burke might have more to add.

Mr. Ray Burke

I do not have much to add to what Ms Coyle has said.

We have come to the end of the first meeting of this subcommittee. I thank our guests from Mental Health Reform for coming in. I believe this committee is badly needed to work alongside the Joint Committee on Health. We need to highlight mental health issues specifically around the impact of Covid-19. I have no doubt that now, more than ever, people are feeling isolated, disconnected from community and almost frozen. People are struggling to engage with a future that can sometimes feel quite bleak to many people and the financial burdens seem insurmountable and threatening now more than ever.

It is having a terrifying impact on the people of Ireland. Our duty from here on out, therefore, is to create a framework that is facilitated by open and indepth discussions so that we can plan for a much brighter future going forward. I appreciate the witnesses and members engaging today. We will keep in touch with Mental Health Reform and we will keep the engagement open going forward.

The joint committee adjourned at 10.41 a.m. until 9 a.m. on Thursday, 3 December 2020.