Joint Sub-Committee on Mental Health debate -
Thursday, 3 Dec 2020

Access to Mental Healthcare at Primary Level: Discussion

Chairman

This morning's meeting focuses on access and continuity of mental healthcare at primary level.

I welcome our witnesses, all of whom will be presenting remotely to us to discuss access and continuity of generalist mental healthcare at primary level. I welcome, from the Irish Medical Organisation, IMO, Dr. Denis McCauley, chairman of the GP committee, and Dr. Sumi Dunne, member of the GP committee, and from the Irish College of General Practitioners, ICGP, Dr. Diarmuid Quinlan, medical director, and Dr. Brian Osborne, assistant medical director. I thank them all for presenting to us and for their opening statements which raise serious concerns for a vulnerable section of the population who are very unwell.

Before we hear their opening statements, I need to point out to the witnesses that there is uncertainty as to whether parliamentary privilege will apply to their evidence provided from a location outside of the parliamentary precincts of Leinster House. Therefore, if the witnesses are directed by me to cease giving evidence in relation to a particular matter, they must respect that direction. I call on Dr. McCauley to make his opening remarks.

Dr. Denis McCauley

Good morning. I thank the committee for the invitation to give evidence today. I am the chairperson of the GP subcommittee of the Irish Medical Organisation.

I thank the Chair and the committee for the opportunity to discuss the impact of Covid-19 on the demand for mental healthcare and access at primary care level.

There is no doubt that the present Covid emergency has had significant psychological effects on the population of Ireland. There are escalating reports of common mental health problems and more marked neuropsychiatric disorders associated with the Covid-19 pandemic. These can arise from direct effects of infection and of long Covid syndrome, with enforced isolation and quarantine and with the additional stressors such as acute or abnormal bereavement, job losses, interfamilial tensions and sudden impoverishment. These additional pressures can present as acute psychiatric diagnosis or an exacerbation of previous psychological or psychiatric issues, domestic violence, or increased levels of alcohol or drug use.

General practice is generally the first point of contact with the health services for patients suffering with mental illness. Approximately 50% of GP consultations have some element of psychological input, while 25% of GP workload relates directly to managing mental health symptoms including anxiety symptoms, depressive symptoms and addiction. International best practice suggests that 90% of emotional and psychological problems can be adequately managed by GPs in the community, without referral to specialist mental health services. Unfortunately, the system in Ireland does not support this approach.

Currently there is no funding allocated for mental healthcare in general practice. Neither A Vision for Change nor Sharing the Vision sufficiently recognises the role of general practice in mental healthcare while none of the funding allocated to mental health services factors in GP-based care.

The greatest burden of mental ill-health lies within the medical card population but presently GPs consult with patients with mental health illness with no formal contract in place other than acute care provision under the current GMS contract, which was subject to a decade of financial emergency measures in the public interest, FEMPI, cuts.

The recent agreement between the Irish Medical Organisation, the HSE and the Department of Health to reverse those FEMPI cuts imposed on general practice is welcome. However, a standard clinical programme for mental healthcare in general practice should be negotiated similar to the chronic disease management programmes funded in the recent GP agreement.

For GPs, evidence-based psychological therapies, including counselling, cognitive behavioural therapy, psychotherapy and group therapy, is widely recognised in the treatment of patients with mental health issues. In 2006, A Vision for Change recommended that "All individuals should have access to a comprehensive range of interventions in primary care for disorders that do not require specialist mental health services." However, access remains poor.

Access to counselling in primary care services, one of the only services that is available to us, is restricted to adult medical card holders only and excludes patients with moderate-to-severe psychological problems, long-standing depression, anxiety, behavioural problems or personality disorders. Those excluded are reliant on the private service, which is often not available and is quite expensive.

The incidence of mental health disorders in children and adolescents is growing with studies showing the prevalence of diagnosable mental disorders in one in six young teenagers. Mental health disorders in childhood are a strong predictor of mental health disorders in adulthood, but good outcomes are most likely if children and young people have timely access to advice, assessment and treatment. Jigsaw provides early intervention services for young people with a range of walk-in and online mental health supports for young people and their families. However, for children with more complex mental health and behavioural issues, access to specialist child and adolescent mental health services is poor.

Recent figures from October of this year show that there are 2,229 young people with serious mental health and behavioural problems on a waiting list for an initial assessment by a child and adolescent mental health services, CAMHS, team of whom over a third have been waiting for longer than six months.

A recent report published by the HSE mental health division found that staffing levels at the end of 2019 in our child and adolescent mental health services were 57.5% of the levels recommended in A Vision for Change. Approximately 15% of child and adolescent psychiatry posts are unfilled while a further 20% are filled on a temporary basis.

Failure to appropriately resource mental healthcare in general practice and provide adequate counselling and psychotherapy services in primary care can, therefore, lead to an over-reliance on drug therapy. At the same time failure to adequately resource specialist mental health services in the acute sector means that for many patients the only way to access services is through emergency out-of-hours services or through already stretched emergency services.

The IMO recommendations are: investment in a clinical programme of care for mental health should be negotiated between the Irish Medical Organisation, the Department of Health and the HSE similar to the chronic disease management programmes funded in the recent GP agreement; investment in publicly funded counselling and psychotherapy services and supports in the community, accessible on GP referral - many practices have available rooms, which could facilitate these services and would defragment the management of mental health conditions; appropriately resource specialist child and adolescent mental health services to ensure timely access for vulnerable young patients; address the difficulties in recruiting and retaining consultant specialists across the health system; and build our capacity in both the primary care and acute settings in tandem.

I thank the committee for listening.

Chairman

I thank Dr. McCauley. The sound is not great but we were able to read his presentation as well. I now call on Dr. Quinlan to make his opening remarks.

Dr. Brian Osborne

I will make the opening remarks, if that is okay.

Chairman

I thank Dr. Osborne.

Dr. Brian Osborne

I thank the Chair and the committee for its invitation to attend today. We welcome this opportunity. I am a GP in Galway and I am the assistant medical director with the Irish College of General Practitioners, ICGP.

The ICGP is the professional body for general practice in Ireland. General practice teams deliver continuing personal medical care provided by generalist healthcare professionals, including GPs, practice nurses and a growing strand of practice based allied health professionals in the fields of psychology and counselling.

When well supported and adequately resourced, GP teams can engage systematically in activities known to prevent and care for a range of mental health issues and medical conditions. This is achieved using brief interventions in relation to alcohol and tobacco use, lifestyle interventions in the context of exercise and stress management as well as delivering continuing community based care.

The Covid-19 crisis has had profound economic, social and educational impacts. Countries that are more unequal suffer with higher levels of mental illness, including drug addiction and anxiety. The social determinants of mental health are hugely significant.

Supporting mental health, lives and livelihoods should be the role of every Department, and not just the Department of Health.

In April, researchers from Ireland released the first wave of the Irish Covid-19 psychological survey, a multi-wave study running throughout the Covid-19 outbreak, to better understand how people are responding to, understanding and coping with the pandemic. Initial results suggest that mental health problems are common: 41% reported feeling lonely; 23% had clinically meaningful levels of depression; 20% had clinically meaningful levels of anxiety; and 18% reported clinically meaningful levels of post-traumatic stress. Women seemed to be experiencing more anxiety whereas men were experiencing post-traumatic stress at a higher rate.

In May, the UN launched a report, Policy Brief: COVID-19 and the Need for Action on Mental Health, which highlighted that those most at risk were front-line healthcare workers, older people, adolescents and young people, those with pre-existing mental health conditions and those caught up in conflict and crisis. Even when the pandemic was brought under control, grief, anxiety and depression continued to affect people and communities.

Every day, thousands of people all over the country get to see their family doctor without any waiting time and receive quality attention and care. Around one quarter of such consultations include a mental health component. Over 90% of mental healthcare takes place in a general practice setting. GPs are the first port of call for many experiencing mental health difficulties, including symptoms of depression, suicidality, anxiety disorders, addiction problems, eating disorders and behavioural symptoms. Furthermore, GPs provide physical and psychological supports to those persons with lifelong mental health conditions, such as schizophrenia. People with severe mental disorders have a higher prevalence of many chronic diseases and are at a higher risk of premature death associated with these diseases than the general population. There is a reduction in life expectancy of ten to 25 years among patients with severe mental disorders. The excess mortality among this group largely relates to cardiovascular, respiratory and metabolic diseases. Since general practice services are not associated with any particular health condition, stigma is reduced when seeking mental healthcare from a general practice team, making this level of care far more acceptable and accessible for people and their families. General practice is one of the few parts of the health system that has remained open and accessible throughout the Covid-19 pandemic. The traditional model of general practice has had to change. We now consult patients by telephone and video, or in person with appropriate precautions.

Not all parts of the health system, particularly the mental health system, are as accessible as general practice. Access for children and their families to CAMHS can be problematic. There are restrictive referral criteria, waiting times can be long, and children's conditions often worsen while they are waiting to be seen. A particular problem in the service arises when children are between 17 and 18, when they fall between child and adult services and referrals are rejected by both services. To state the obvious, this is detrimental to the care of these patients.

Access to psychology and primary care is haphazard. Again, there are long waiting times. For example, there is an 18-month wait for the service in Galway at present. Counselling in primary care, CIPC, has seen increasing waiting times, and the service is limited. The following problems preclude a patient from accessing the service: moderate to severe psychological problems; long-standing depression; severe anxiety; behavioural problems or personality disorders. Where are these patients supposed to gain access to psychological supports?

Many improvements have taken place since the publication of A Vision for Change in 2006 but, as Sharing the Vision acknowledges, there is much more to be done in developing stronger mental health supports at community and primary care levels. Mental health services, like general practice, should be accessible for all. General practice provides care for over 90% of mental health conditions without the need for secondary care input, and GPs have a pivotal role in providing first and ongoing care for these patients. General practice needs to be supported in caring for these patients, with greater access to talk therapies, including on-site sessional talk therapy in a general practice setting, addiction services, improved integration with primary and secondary care, and upscaling of digital technologies, in mental health services in particular.

The physical healthcare of patients with mental health conditions, including severe and enduring mental illness, should be led by the patient's GP. A properly funded, integrated, structured programme of care for these patients needs to be implemented as a matter of urgency.

Chairman

I thank Dr. Osborne. Before I call on our first speaker, I remind members that they should be brief because it is likely that all members will want to participate in this short session. We will proceed according to a rota, if that is acceptable.

Deputy Mark Ward

I thank the witnesses for their honest opening statements. I have a few things to say, and I will ask a few questions as I go along. If both witnesses could respond at the end, it would be fantastic.

As the witnesses said, Covid-19 has brought the frailties in mental health services right to the fore. Any frailties that existed have been brought out kicking and screaming for everybody to see. It has been a difficult time for people, particularly those with a history of suffering from mental illness. It has also been very difficult for those suffering from mental illness for the first time because of Covid-19. Since I became spokesman for mental health, my office has been inundated with people looking for advice.

I worked in mental health and addiction services in the community for numerous years but I am not a doctor. The first bit of advice I always give a constituent is to contact a GP. Mental illness is really a matter on which people need guidance. In this regard, it was worrying to hear about the difficulties GPs are having in referring patients to the appropriate services. I would like to see tangible steps taken. What is the one change at policy level that would make the witnesses' job easier and make it easier for patients to gain access to the services they need?

I was taken aback by one of the recommendations on access to counselling. I believe it was made by the IMO. Sinn Féin had an alternative budget that would make GP referrals to counsellors free of charge. The witnesses have a very simple solution in their document. Many GPs have additional capacity in their buildings in which they could have a counsellor on site, be it for one or two days per week. That would really work. What are the barriers that would prevent this from happening? Is there anything we can do to make progress on this?

I was on to CAMHS. We all know about the poor access to CAMHS. It was mentioned by the delegation. That there are 229 young people waiting for an appointment with CAMHS for over six months is really frightening. As we know, prevention is better than cure. If young people are given access to the appropriate services at a young age, they are less likely to need access to adult acute mental health services when they get older.

Dr. McCauley stated 15% of child and adolescent psychiatry vacancies are unfilled while a further 20% are filled on a temporary basis. Is there a difficulty in attracting staff into adult mental health services or is there a difficulty with retention, or both?

Dr. Osborne stated the life expectancy of a person with mental illness is between ten and 25 years lower than it is for others. Could he give reasons for that? Is it because of lifestyle, diet or the lack of exercise? My asking this is not victim-blaming because I understand that it is hard for people suffering from depression even to get up out of bed and wash themselves.

I was at a launch a couple of years ago when I was mayor of South Dublin. Two GPs in Jobstown, Tallaght, had started an initiative on green prescriptions. It was called "social prescribing". Is this something GPs seek to do? Is it beneficial? I refer to where a GP refers the patient to an initiative in the community, such as a men's shed or local walking group, to prevent isolation and help with socialisation and all the other elements.

I always find that testimonies put the flesh on the bones of a story. It was good to see testimonies included in the ICGP's opening statement and in the document provided.

There is a 22-year-old woman suffering from postnatal depression and suicidal thoughts and there have been no services in eight weeks. I presume that because there is no service for such a person in the period, she may be contacting her GP in that time. What pressures are being put on GPs because services are not available for that person? Is it taking GPs away from other work they could be doing? There are many questions and bits and pieces but I would appreciate it if the witnesses could answer what they can.

Dr. Denis McCauley

I will try to answer the first couple of questions and Dr. Osborne might deal with the others. One should remember that we attempt to look after 90% of almost psychological illnesses in general practice, with the other 10% going to the hospital. When we treat a psychological illness, we generally like to have three options. They are talking therapies and medical therapies or a combination of both. In general practice we do not have access to any talking therapies. We have spoken about counselling in general practice and the waiting list is quite long, and it is very restrictive. Currently we have no talking therapy access at all really.

We should have three treatment strategies but unfortunately we just have one. We have no access to any cognitive behavioural therapy, dialectic behavioural therapy or group therapy. When it comes to common psychological illnesses, or the 90% we are supposed to look after, we have no counselling services at all.

Normally we like to have three options before prescribing for perhaps a third of cases. However, we must prescribe for nearly the majority of cases and give them supportive psychotherapy within our own time in general practice. It is something we are not resourced to do but we must do it because there is no other option. I would like access to counselling in general practice that is evidence-based, given by proper counsellors, resourced and free for the person to attend. We would also like resources to be put into general practice to allow us to do the work we are doing. We are doing it as best we can but this is not the best that could be done.

There was a question on attracting and retaining staff. There is a pay differential between entry consultants who are joining now and established professionals. A child psychiatrist joining a team now would see the psychiatrist who was there before him or her being paid 30% more, which is a disincentive to start. I spoke to our local service provider today, who said the work is very stressful because of chaos, pressure and safety issues within the CAMHS, and because people are working overtime with severe cases and they cannot look at cases that are not obviously severe but which could develop into a severe case or a tragedy.

The wage differential is huge and everybody has said it will change but the sooner that happens the better. It is the number one issue. As people are so overworked and only 50% of staff are available in the CAMHS and adult services, they are working at a level that is probably dangerous and there is an associated risk. People will not feel comfortable and they will leave.

I hope that answers the first few questions. I will pass over to Dr. Osborne to handle the other matters.

Dr. Brian Osborne

I echo Dr. McCauley's comments. Access to talk therapy to which general practitioners can refer patients is crucial. Counselling in primary care, CIPC, is a very limited service for very mild conditions and even at that, there are long waiting times. There is an 18-month wait for primary care psychology in Galway. This is not a service. We cannot tell somebody in acute distress that he or she must wait 18 months. It is not realistic.

With regard to on-site session counselling sessions in general practice, the improving access to psychology therapy in the UK has demonstrated that if the service is on-site in a general practice setting, with the therapist coming to GP surgeries, it improves relations. There can be informal chats and relationships develop between therapists and the GPs. There is less stigma associated with the service, it is more accessible for patients and there is a smaller "did not attend" rate compared with a service that is off-site. It is a win-win and I am really in favour of such a service. Both opening statements highlight this.

There was also a question about patients with severe and enduring mental illness and why they are dying more prematurely due to physical health conditions. There is not just one reason for this. The evidence points to increased risk factors for chronic disease. For example, approximately 60% of patients with schizophrenia may smoke, meaning a person with schizophrenia has five times the chance of being a smoker than a person in the general population. There is also the role of physical activity, diet and exercise, as these have an impact. GPs are well placed to advise and provide interventions on such matters with patients.

There is also the role of side-effects of medications, which can cause weight gain and possibly increased cholesterol. They can predispose patients to diabetes. These matters should be dealt with and monitored and, again, GPs are best-placed to deal with them. There is also the question of healthcare utilisation in these patients. For example, it is known that patients with schizophrenia present later for appendicitis and will have a worse outcome. Patients with schizophrenia may have similar morbidity with cancer but they have worse mortality. There is an inequity of service provision as well.

The final evidence-based piece is that the integration between primary and secondary care is very poor, and this will not really improve without upscaling of digital technologies, particularly in secondary care. GPs numbering in the high 90s in percentage terms have electronic communication funded by general practice rather than by the HSE. The lack of such technology, or the standard where it is provided, in the mental health services is appalling.

Dr. Sumi Dunne

I thank the committee for inviting us here today. I am a GP in Portarlington, County Laois. I echo and agree with everything my colleagues have said. In general practice we are seeing the very rate-limiting aspects in trying to get patients through services to access timely care. That is in keeping with everything Dr. Osborne and Dr. McCauley have said.

For example, if we opt somebody into counselling in primary care, we must write a letter and give the patient a number that he or she can call. It is an opt-in service and the patient must call in order to say the service is being accepted. There is a waiting list before patients get an appointment and then they must travel repeatedly in order to access the service, which is also capped after ten visits. Coming back to Dr. Osborne's comments, having access to the service within the general practice building would be much more cohesive.

Looking at funding models of chronic disease management, it has already been demonstrated that this is working extremely well within the general practice setting and there is no reason we cannot consider mental health in the same category in order to adequately resource and support general practice to provide this service. It is not acceptable that we must repeatedly send our patients away after a short consultation for them to return again and again just to tell them they are still on a waiting list. These are the palpable issues we are facing as general practitioners on a daily basis.

Dr. Diarmuid Quinlan

I will focus on some of the examples we have given, particularly the woman with postnatal depression and suicidal ideation. We can all visualise such young women or mothers and the pressures they are under in our community. There is a lack of access to high-quality psychological supports and secondary care.

As for the issue Dr. Dunne has just raised of travelling to and from secondary care services, I ask members to put themselves in the shoes of the young mother with a new baby. She has to travel repeatedly potentially long distances by bus with her new baby to access psychological support. That helps show why these services need to be provided in the community, close to the patient for him or her to engage with them.

The other case, as the committee will be aware, is that of a 38-year-old man brought to an ambulance after a serious overdose and the failure of engagement of the psychiatric services with that man on the grounds that the case involved drug misuse. That is not an uncommon factor we find, and that is just one example. There are multiple barriers to patients engaging with psychological and psychiatric services in my area of Cork. Deputy Colm Burke would be familiar with this. To access psychological support, my patients must first be seen by the psychiatrist. The waiting list for psychiatry services is quite long, so they have that barrier and, as Dr. Dunne said, it is a physical barrier and a transport barrier in addition to the waiting. Once they pass that barrier, then there is a waiting list for the psychological support. We need these psychological talking therapies, as Dr. McCauley said, readily available in the communities, ideally in the GP practice. My vision is that every town would have such services readily available to our vulnerable patients.

The second issue Dr. Osborne raised concerned the physical health and well-being of these patients. Regrettably, the life expectancy of these people is reduced by ten to 20 years. Suicide plays a substantial role in that, but so does the physical well-being of these people, with smoking, drug and alcohol misuse, metabolic diseases such as diabetes and chronic obstructive pulmonary disease, COPD, all taking a very real toll. General practice is particularly well placed to manage the physical well-being of these patients with severe mental illness. I see this as involving the physical well-being of people, integrated care, chronic disease management and the availability of psychological supports where and when they are needed for these very vulnerable patients.

Chairman

Deputy Ward asked about green prescriptions. Would any of the witnesses like to respond?

Dr. Denis McCauley

That initiative is more centralised now. It has developed further. I was involved in the Connecting for Life strategy for suicide prevention here in Donegal. It has developed further. The green prescription has expanded further such that there is a service provider who is like a director of all services that are available, including things such as walking groups and self-help groups. There is a whole range of self-help mental health services in our area, including in Finn Valley. People in the community work together. All those services are available. There is a central point of contact, a community director who will try to assess what is going on and direct people to the relevant self-help group. This would involve, as Deputy Ward said, the green prescription. A GP invites people to meet and walk together and that group of people starts that on a regular basis. This was started to combat isolation and to improve people's general physical health as well. That is developing.

Dr. Brian Osborne

I echo what Dr. McCauley has just said. The ICGP is involved in an initiative with Parkrun, which the committee might be aware of. It is not a race; it is a run or a walk that, pre Covid times, took place on Saturday mornings and that, it is hoped, will take place again. It is a community of runners. GPs are encouraged to inform patients about Parkrun. Again, it supports their physical health and their mental health. The Parkrun initiative has links to Sanctuary Runners, which involves asylum seekers and refugees living in the local community in an attempt to be inclusive. All these social initiatives are very good and are a positive.

Deputy Mark Ward

May I ask just one more question about that? The witnesses may correct me if I am wrong, but social prescribing and the green prescription seem to be more localised rather than nationalised. What would help to push them back out at a more national level? Dr. McCauley mentioned that up in Donegal there was a co-ordinator within the services who directed people into various services. That is a good idea, but what would help to push that kind of initiative onto a more national instead of a localised level? I am well aware of the park runs. I myself have walked many of them instead of running them.

Dr. Denis McCauley

As far as I am aware, the mobile director of services who is aware of all these things is HSE-based. That is expanding through all the community healthcare organisation, CHO, areas. I agree with Deputy Ward that it is an excellent idea. The examples given show how simple planning and directing people to a service can potentially change their lives. That is being formalised through all the CHO areas, mainly through Connecting for Life, the umbrella movement. This involved regional pilot sites but is now being extended nationally.

Chairman

We have representatives of the HSE coming before the committee next week so we will take that up with them.

Deputy John Lahart

I thank the witnesses. I hope they believe, as I do, that politics can make things happen. Their presence is very important and significant. Some of the recommendations in their documents ought to be considered for prioritisation on our behalf, although sometimes I am sceptical about throwing money at issues. That is obviously part of the solution, and I will come to that.

I was a practising psychotherapist. One of the things I had to do every so often to build a business was to reach out to GPs, and I was continually amazed by the number of them who did not know what a psychotherapist does. The witnesses need to look at that because it is important. Then there were excellent GPs who did know what a psychotherapist does. They were very intuitive with their patients and favoured a blend of options, not always medication-led but sometimes a mix of both. Medication clearly has a place, which is beyond what I am qualified to talk about, but some GPs require an information and educational element. That might surprise the witnesses but it was quite commonplace, in my experience.

I am very taken with how succinct the witnesses' documents are and the lack of verbiage in them. They are direct, and the conclusions, recommendations and concerns are very clear. The Ernst & Young report was produced for the Government in a pretty short space of time. It fed into some of the Government's recommendations on the latest Covid guidelines. Are the witnesses familiar with this, or were they surprised by some of its findings on the mental health impact of lockdowns and the pandemic in general? My question is directed at anyone who wishes to take it.

Dr. Denis McCauley

May I try to answer the first question about training and knowledge and so forth? I would be happy to answer the question about the Ernst & Young report, but Dr. Osborne would probably know much more about it than me. May I answer just the first question?

Chairman

Sure.

Dr. Denis McCauley

I agree with Deputy Lahart that some GPs do not have a great knowledge of the various therapies. I do not want to be like a ha'penny book but, unfortunately, this is because of the absence of a service. We are all taught how to treat a condition and, therefore, that is what is known as best practice, but then, when one is living in the real world and has access only to certain services, it becomes common practice. During our undergraduate career and even our postgraduate career we are taught how best to approach things, but then we must deal with the absence of a service from day to day.

If we had free access to psychotherapy, we would use that service. We could get positive feedback from it and it would reinforce the good learning. Unfortunately, its absence makes us develop bad learning, which is the non-talking therapies. The way to overcome that is to have a structured approach. We have a very good continuing medical education, CME, group in general practice. We need to take a chronic disease approach to this, similar to that contained in the GP agreement we negotiated last year through the Irish Medical Organisation whereby we look after chronic diseases in general practice. Part of that involves additional training to bring GPs up to speed and achieve best practice. Training that is followed by an ability to do things reinforces good learning. That is why we recommend that mental ill health be treated as a chronic disease and be part of a resourced chronic disease scheme in general practice. Part of that will involve further training, and if the services are available, they will be used. I agree that common practice is not always best practice but common practice evolves due to circumstances.

Deputy John Lahart

I think that is key. Instead of best practice, what often develops is common practice. That is a key piece for us to include in our deliberations. I came to psychotherapy late in life - it was not my first profession - but I learned from it that lack of expression leads to depression. That is a very useful phrase and there are different forms of expression. I am very taken with the reports on who has access to counselling and talk therapies in medical practice and primary care and who does not. I was not aware of that and it is important.

As Deputies, we are very much at the interface for lonely people. A decade ago it was difficult for people to say that they felt depressed or had suffered from depression at some stage in their lives, but now for people to articulate that they are lonely is the big thing. People find it a little easier to talk about their mental health, although we do have a long way to go. My public representative colleagues here will agree that loneliness is at epidemic proportions in Ireland. We would see that, no more than the witnesses would in their practices. There are repeat callers to our clinics and offices, very often daily, and in many cases that is their only form of communication. That loneliness piece is really significant. I have always believed in a voluntary corps which is mentioned in some recent documents by the Minister. There is a real outreach piece there and amazing work is done at community level by NGOs but we need an awful lot more resources in that area.

I acknowledge what the witnesses have said in terms of there being no funding available for mental healthcare in general practice. I also acknowledge the point made about the need for a contract covering the provision of mental healthcare service along similar lines to the existing HSE GP contract. That is something that this committee will take on board.

The witnesses specifically mentioned grief, anxiety and depression and I spoke in the Dáil a few months ago on this subject. The witnesses referred to loss when citing the UN report and what troubles me most is the fact that anger is the most underestimated response to loss. We are only beginning to enumerate the losses that we have experienced this year. It is not just the loss of loved ones but the loss of status, health, mental health, jobs, contacts, engagement and the loss of hugs. These are significant, particularly that loss of physical intimacy and engagement. As Dr. Tony Bates would say, the pandemic has diminished everybody to a greater or lesser degree and that gets manifested in different ways.

The Ernst & Young report flagged the fact that we are facing a very serious crisis in mental health and the witnesses have said the same. We all know of people with adult dependants or children with special needs who have not had one minute of respite since February. How should this be addressed? What are the resource issues and what have the witnesses experienced? Have they experienced any escalation?

Dr. Diarmuid Quinlan

I thank Deputy Lahart for that very insightful and personal view, based on his own experiences, and I agree with what he said. Before the pandemic, I had an older patient who used to come to my surgery well in advance of his appointment time. Initially when I would see him sitting there, I would call him out of order, ahead of his scheduled appointment time, but I very quickly realised that he lived alone in a rural part of Cork and that he was coming in for the social interaction, for the chance to meet other people in the waiting room. Loneliness, as the Deputy has said, is a real challenge. It was a challenge before the pandemic and the pandemic has made it much worse. Reports show that around 40% of people experience loneliness, which is a really crushing emotion for people.

In terms of what can be done, the availability of counselling in primary care, close to patients, would make a huge difference. I use what psychological therapies are available and encourage a lot of my patients, if they can afford it, to see psychologists privately. One of the challenges I face is that there is a wide range of psychological supports available in the private sector, many of which are short-term and the people providing them come and go. It is very hard, as a GP, to quality-assure these services and be satisfied that the counsellor to whom I am referring vulnerable patients is appropriately qualified. It is a real challenge to do that, which is a barrier. Deputy Lahart may have experienced that himself. I use the Psychological Society of Ireland as a validated resource because I am assured that if I refer patients to members of that society, they are appropriately qualified to care for them. Getting appropriately qualified counselling in primary care, close to the point of access and readily available for patients is something practical that we can do which would address the issue of GP engagement with psychotherapy support services.

Dr. Brian Osborne

I wish to respond on the mental health impact of the pandemic and loneliness. Social prescribing is a known factor that can help with loneliness. GPs refer lonely patients to local networks within their communities which can be very helpful. Also, with regard to the mental health impact of the pandemic, research from previous pandemics has shown that in the initial stages there is a pulling together of society and a sense that we are all in it together. However, as a pandemic evolves and as the social and economic impacts hit home, there can be a large increase in mental health distress. The other issue to remember is that while we are all affected by this, the impact is not equal. People in more socially deprived areas, those with low incomes and in insecure jobs, as well as those suffering from domestic violence, are being hit harder by the pandemic.

Deputy Gino Kenny

I thank everybody for their contributions to this fascinating and ongoing debate. The pandemic has affected everybody in this country.

Whether someone is young or old and regardless of their social class, Covid-19 has left its mark and will continue to do so. Dr. Osborne touched on the social solidarity that still exists around fighting Covid, medically and physically, which can often be done in the most rudimentary ways. It is that kind of coming together that has brought many through the grimness of Covid-19, simple things like street parties, coming together and talking to neighbours or sometimes strangers. That has helped with the social glue, but there is obviously a down side. There is a demand for services. When people go back to their homes things can manifest, and things such as loneliness, anxiety, and depression around Covid-19 can be amplified. I believe it was a recent UN report that noted the mental health issues of many people around Covid, but especially healthcare workers, the people who are really on the front line, such as nurses and doctors, have been really affected by what is going on in their workplaces and the horrors that come with that.

Will Dr. McCauley speak about the trends he has seen in recent months among people of all age groups presenting with anxiety, depression and the loneliness that comes with simple things, where, say, a man or woman living in the country cannot go out for a drink or two three or four nights a week? That is a big thing for somebody and that is all gone, and a void exists. There is a vacuum, which is often the darkness of Covid-19.

Dr. Denis McCauley

Rather than talk about the weather, we like to talk about Covid to our patients coming in. It is a good entry point to asking them how they are doing. I have noticed two things in particular. There is a general anxiety in people. Some are predisposed to an anxiety condition, and there is an ever-present anxiety and agitation in that group, young and old. That anxiety sits in a person's tummy and can come out as fear, and as physical symptoms such as chest pain. We see a lot of anxiety just because of the relative fear of infection. Much of what we do in medicine is to tell people what they do not have and reassure them but it is very difficult to reassure somebody when they know that each time they go outside the door there is something that could potentially cause significant illness to them, and that worries them. Social isolation is the other aspect. It is not only older people, but also younger people. There was a stigmatisation of younger people as spreaders of everything. They were the bad people, going out and mixing. Not going out has a psychological effect. Social media is a useful adjutant, it helps people, but nothing beats social contact. The fear of Covid and the absence of social contact has had significant psychological effects among the population of all ages. That then manifests in inappropriate behaviour, such as going out when they are just so tired of it. One has to understand that, although one can still ask for it not to happen. The background fear, all of the time, exacerbates conditions that are already there. We could go into specific examples but that is the general trend that I have seen on a day-to-day basis.

Dr. Sumi Dunne

I echo everything Dr. McCauley said. I work in Laois and our practice covers the rural hinterlands around the midlands to include Offaly and Kildare. There are issues around isolation and being on one's own, and having general practice as the first port of call has somewhat diminished because people are unable to come in due to travel barriers, fear and economic reasons. There are people who are counting pennies. For those in the rural hinterlands, coming into a general practice might involve taking a taxi. We do not have an infrastructure of community small buses to bring people in. Multifactoral aspects add into this and add to people's distress. As Deputy Gino Kenny said, we are not seeing this in one age group, but across cohorts: younger children, teenagers through to pregnant women, mothers with new babies, older teens, parents of older children and through to older people. The overwhelming predominant aspect is anxiety, anxiety with stress and with finance, with a very expensive period coming where people feel they have to provide the best Christmas they can. All this will feed in and leave a legacy that will last longer than we anticipate.

Deputy Gino Kenny

Dr. Osborne's opening statement was very good and interesting on CAMHS. Recruitment is an ongoing issue. It is shocking that the current capacity is at 57% of the recommended level. What professionals are needed for CAMHS? Health services across the world are looking for psychologists and so on. If CAMHS is only working at 57% capacity, the children who need the services cannot get them. How do we address that? Has Covid made it worse?

Dr. Brian Osborne

I do not know the ins and outs of the various staffing issues in CAMHS, whether psychologists, occupational therapists, social workers, psychiatrists, psychiatry registrars, however there are times when a GP might have concerns about a child or teenager and they need to see CAMHS. They may not need to see the psychiatrist but they many need to see the psychologist in CAMHS or they may not need to see the psychologist but they need to see the occupational therapist. We have an issue around the very restrictive referral criteria to CAMHS which makes it very difficult. I can give examples, as, I am sure, can the others. Attention deficit hyperactivity disorder, ADHD, is a not-uncommon diagnosis among children and teenagers, unfortunately. I might refer a teenager who I might think has ADHD, and nine times in ten, that child will be referred back to me and I am advised to refer to primary care psychology, which has an 18 month to two year wait, or for the parent to contact the school and go through the National Educational Psychology Service, NEPS. There is a waiting time for NEPS in schools because they might only have three or four slots per academic year for the children they have concerns about.

We refer, and the child is bounced back to us. It is very distressing for the child, very distressing for the family and very frustrating for us, as GPs trying to do our best. At times, people who may not have the resources are spending large amounts of money to get private psychology, to try to get an initial diagnosis from a psychologist in primary care privately, and then they go to see CAMHS.

While I cannot answer the question directly with regard to the ins and outs of the staffing requirements within CAMHS, what I can say is that they need to increase staff, change the referral criteria and make services more accessible and equitable for patients and their families.

Dr. Sumi Dunne

With regard to the specificities, what we do know is that there are currently 100 unfilled consultant posts that need to be filled, and there are 75 who are in a temporary locum consultant post. Again, this is not acceptable for our children.

I echo exactly what Dr. Osborne has said. Sitting in front of me, I have four letters that have come back to me from CAMHS within the last three to four months stating “do not meet criteria”. Again, children who may have behavioural issues, children who may have ADHD and children who are acutely distressed but not suicidal are being labelled as not meeting the criteria. This is increasingly common and very distressing for families, extended families and the children themselves. To continually have to go back to rewriting letters to see if one can engage with the services is not an inappropriate use of anybody's time.

If we then add in dual diagnosis or add in a child with a neuro disability who also needs a psychological assessment through CAMHS, this is an even more rate limiting service, with very poor access. I have children who are waiting for early interventional assessment for a putative diagnosis on the autistic spectrum, and they are yet to be seen. I would be very hesitant and very worried about this. It is something we need to address very quickly.

I want to clarify that the 100 unfilled posts are both in the adult and the children services but, obviously, this has an impact across the board for all.

Senator Annie Hoey

As I said last week, this is rapidly becoming my favourite committee and it is great to be able to come here and to listen to experts.

We talked about ADHD. With regard to adult ADHD, I seem to know umpteen adults who are struggling to get the support they need and, unfortunately, many of them attended GPs who simply did not engage with them or simply did not believe them. There are almost these underground Chinese whispers as to what doctors to go to and how to get the supports. As an adult who suspects they may have ADHD, or a family member of such an adult, obviously, they have gone through their whole life without a diagnosis. It seems to be really difficult for adults to access the supports around ADHD, although this issue came up in regard to children.

With regard to loneliness and isolation, I got a call last week from the daughter of a man in his 70s. She was at her wits' end at this point because he will not go to the GP. He has a variety of light medical issues - nothing to fall over about, just the standard ones that men in their 70s get - and she is worried that he is depressed. He says he will not go to the GP and that it is not right because there are too many other sick people, with Covid and so on. I do not know how to help her. I do not know what to say and I do not know whether to tell her to ask the GP to ring him. I am sure she is not the only person in the country right now who is deeply worried about an elderly person. It seems to be mostly men in this situation. She needs to know how to get the supports for her dad, and I am sure there are many others who are worried about parents or elderly relatives. They have seen what has happened to them over the past couple of months. They have perhaps fallen into loneliness and depression and they cannot figure out how to get these people the support they need. Perhaps the witnesses have a comment on that.

When I was in the Union of Students in Ireland, a student union official spent the night in accident and emergency with a student because they had got into such a state of distress and suicidality. The student union officer did it, and that was fine, but it is a worrying indictment of where we are at. Students are in a particular situation. They are away from their primary care and primary supports, and they are out of their community. It has always stuck with me that that student had to reach that level of despair and distress, and it was effectively a stranger they ended up having to bring with them to accident and emergency because they simply could not find or access the supports they needed.

That is possibly a little outside the realm of GP services but it has always stuck with me that students, who are a transient community, are perhaps away from their primary care setting and their families who are not able to keep an eye on them. That is not a lone story. I know of a number of stories of students in deep distress who are flailing and cannot get the supports they need, either because the student services are not there or because they do not know where to go and are isolated from their communities.

Last week, in the session with Mental Health Reform, I asked the speakers to outline the long-term, lifelong impacts on children and teenagers who cannot access these services. They talked about the lifelong mental health impacts, and we know early intervention is the best way to support someone. From a GP perspective, what would the witnesses see as the lifelong impacts for adults and young children who cannot access services? We have had some stark discussions today about long delays, the sending back of referrals and people bouncing all over the place. I sometimes think there is a perception that it just goes away. I sometimes think people say that these children will just fall into adulthood and somehow - ping - it is all gone and we do not have to worry about it anymore. I think we all know that is not true. From a GP perspective, will the witnesses outline what they see as the lifelong impacts when children and young adults cannot access the services they need?

To follow on from that, a speaker last week also referred to the fourth wave of Covid, which they thought would be the largest and longest wave. The speaker warned that we are not prepared. Can the witnesses offer any comment on how this potential knock-on wave will impact on GP services? We have heard many stories about under-resourcing and how we do not have mental health as a central point of care in GP services. I have spoken to many GPs who say they have a room, they have the space, if only they could have integrated care in the GP offices, with mental health supports as well. Perhaps the witnesses could offer a comment around this fourth wave, whether they see it coming and how, as GPs, they will be able to deal with that.

Dr. Diarmuid Quinlan

I thank Senator Hoey. Two of her questions repeat in a very interesting way. She spoke about the person with adult ADHD who had not been diagnosed. That goes back to the absence of diagnostic services within our psychological support services. It is an awful shame that somebody would reach that stage in life without a diagnosis, given the impact that has had upon them. It is a testament to the chronic underfunding of our psychological support services.

I absolutely feel for the elderly people who are at home and do not want to be a burden on their GP and do not want to access services which they feel other people may need more. As Dr. Osborne said in his opening statement, general practice has been open throughout the pandemic, seeing patients, although we have pivoted and we went from seeing people largely in person to doing a lot of virtual telephone and video consultations. I estimate that well in excess of 50% of my consultations and my appointments nowadays are face-to-face, particularly with older people, and we do all the social distancing and use PPE. I encourage everyone to appreciate that general practice is open and we are seeing people. We are particularly interested in sending that message to vulnerable groups, like older people, who, through their own compassion for others and in not wishing to overburden the service, may actually disadvantage their own well-being.

Two of my sons are in college at the moment. They are living at home and attending UCC, so their situation is very different. I have an insight because I worked in UCC student health for several years. Students, to my mind, are a very vulnerable group.

The Senator recounted the case of a young person ending up in casualty with a student union officer. That person is very vulnerable. Our student population is vulnerable, particularly those who are living away from home, as some of them still are despite the fact that college is largely virtual. There are many vulnerable groups in the pandemic but young people, and especially college students, are not spared in this.

Regarding the failure to access care and the lifelong impact of that, the Senator asked about personal perspectives. Many of my patients come to me in their middle years to talk about traumas that happened to them in their childhood, be it bullying, child sexual abuse or a range of traumas. They have suppressed these for many years partly because, although I would say largely because, the services are not available. In my experience it impacts them in particular when their children have reached the stage when this happened to them. If they were bullied, they can suppress it for many years but when their children reach that age, they must deal with it. It is similar with child sexual abuse. People often suppress it and they only reveal it decades after it happened, often when the abuser may have died. People still need to address these issues and the support services are very limited with long waiting lists. It comes back to the fact that there must be proper access to the talking therapies in a timely fashion for vulnerable patients.

I will let Dr. McCauley take over. I thank the committee for listening.

Dr. Denis McCauley

My self-esteem was enhanced when I was called a specialist, which is great. The ADHD aspect is quite common. When one gets to adulthood with ADHD that has not been diagnosed, it is probably because it is part of a dual diagnosis. I was treating a young lad quite recently and when we treated his depression and general anxiety disorder we then realised he had ADHD. One of the reasons is that it is very mild and the person can function. We all probably grew up with people with ADHD and they just adapted, but in many cases the very severe ADHD is because the person has a dual diagnosis. The service, unfortunately, is through the adult mental health service. I say "unfortunately" because there is no specific service for it, but it is a service and it is one I have used to good effect.

I agree with everybody on the isolation aspect. People would ring and say, "Doctor, I did not want to bother you", but one of the reasons is that they were afraid to come in. They did not want to leave their house because of Covid, and the last place they wanted to go to was the GP's surgery, which they recognised would be full of Covid. That has been changed with the development of the hub and the visual psychological effect whereby people recognise that those who have Covid-19 will not be seen in the GP's surgery but are seen in the Covid assessment hub. These are all visual psychological effects we have. From a very early stage we have tried to convey the message that general practice is open because there are many other sicknesses and if they are not seen they will get worse.

Regarding the older person, we can send the public health nurse or the community psychiatric nurse around, but generally we used to say to people to tell the person that he looks a bit pale and needs to go to the GP for a blood test. He is going in for a physical reason but, in fact, he is going in for a psychological assessment. That is generally the way we would do it.

On the long-term effects of a person's psychological illness, it very much depends, particularly for a child, on the person's development and the context in which he or she has that illness. If the psychological illness does not prevent the person from developing educationally and so forth, that is positive, but if it delays the person's development, whether it is psychological or educational development, it has a major effect. The context of the illness is that if the person is in a middle class family that has access to services privately, it does not have as much effect. If the person is from a lower socioeconomic group or, indeed, a group that is not functioning, whether it is middle class or a low socioeconomic group, the illness has a big effect, even if it is a milder illness compared to that of somebody with good family supports and money. The societal context in which the illness occurs has a massive effect. One can have somebody with severe illness and somebody with a minor illness, but the minor illness has a greater effect on the person's development in that person's context.

On the fourth wave, and hopefully we have not gone through the third wave yet, the best way to prevent the fourth wave is to vaccinate everybody and just get rid of Covid-19 so we can get on with our lives and allow the mental development to continue in the dysfunctional way it was previously. At least it would be better than what we are experiencing now.

Chairman

Dr. Osborne, do you wish to contribute?

Dr. Brian Osborne

I wish to address two points. With regard to ADHD, to the best of my knowledge there is no formal transition into adult mental health services for children and teenagers who have ADHD when they reach 18 years of age. There is no formal follow-up plan for them unless there is haphazard access to adult services in some parts of the country. Currently, however, there is no formal plan. I also mentioned in the opening statement that when one is 17 to 18 years of age one can fall between two stools if one has a mental health problem. If one is seventeen and a half, CAMHS might say the person can hang on for another few months when the person can go to adult services, and if one is referred to adult services, they tell the person to go to CAMHS. Being 17 to 18 years of age in this country and having a mental health problem is not a good place to be.

I wish to echo what Dr. McCauley said about the context with regard to the lifelong impact. Particularly crucial times are when teenagers are transitioning to college or to work. If they have a mental health issue that is not addressed, they can feel left behind. They see friends and family advancing and they feel stuck. That can stick with them for years and it can have a long impact on them. It is important to address these issues early. The earlier mental health issues are addressed, the better the outcome.

Dr. Sumi Dunne

I echo what Dr. McCauley and Dr. Osborne said. In our local area if one is aged 16 years and over, one will fall between two stools. In CAMHS, there is very difficult access, as I said already, and the adult services will not take the person. When one reaches 18 years one will not be accepted by both. For me when looking at real-time examples, 16 to 18 years of age is a time when people will fall between these stools. It is a particular gap for families as well, and they are struggling with this. Again, we can look at it from the other aspect of school and into college. If there are primary school supports, they tend to diminish as one goes through secondary school, and certainly these supports, if they have not been augmented and set in place, will not be there for college as one moves forward. It is pivotal and vital that we have access through general practice to good talk therapies at the earliest possible stage in a cohesive, distributive manner.

Deputy John Lahart

I am grateful for the opportunity to ask brief supplementary questions. Can the doctors point to what we are doing well and need to augment, whether it is with services or personnel? This is a difficult question, but what proportion of mental health presenting conditions may dissipate when the population is vaccinated and we become free of this pandemic, please God, and what conditions will endure? It is probably difficult to say but it could be based on their clinical experience in the last six or seven months. How are general practitioners and their staff doing? What difference has it made to the doctors and what type of reports are they getting from their colleagues? Finally, can the doctors quantify any increase in self-harm or suicide incidence from their experience in the last seven or eight months?

Chairman

Will those who are not speaking mute their microphones, if that is okay?

Dr. Denis McCauley

I thank the committee for the questions. Perhaps I will talk about what we are doing well and the last thing with regard to self-harm and suicide. I am a coroner for County Donegal so, unfortunately, in both my roles I encounter suicide and then self-harm in general practice. What are we doing well? I mentioned before that I believe the approach of the mental health services and the health services generally to Connecting for Life is an excellent example of what we are doing well from a mental health point of view. Every death from suicide is a disaster. It is important to put it into context that we are probably one of the lowest countries in Europe. I believe we are 11th lowest with regard to general suicide. We have a terrible problem with young people committing suicide, particularly young men. I do not know if it will follow through. This year, unfortunately, I have seen more female suicide in our area than I have seen for a while. Regarding what we do well, the Connecting for Life issue is a good template for an overall assessment and approach and for all the services coming together to try to find and prioritise a problem, implement a system and audit it.

With regard to self-harm, especially, as part of the Connecting for Life strategy in County Donegal, we have self-harm nurses who are attached to the accident and emergency department. When somebody presents with self-harm, he or she is brought into the system and approached, assessed and exposed to the dialectic behavioural therapy, which has been proven to be particularly good for people with self-harm and suicidal ideation. They have been a wonderful development and have received positive feedback and results.

We also have a service which has gone nationwide called the suicide crisis assessment nurse, SCAN. A doctor might encounter somebody in his or her practice who is not actively suicidal but would rather not be here. I believe that is a summary way of actually saying it. Such people are not planning to kill themselves, but if someone took them away today, they would not really care. It is that active evolution towards active suicidality. We have access to a service, which is generally within hours here, and within days a person will have an appointment in a surgery with a trained person to assess that and try to direct him or her away from that suicidal development. I can say categorically that those two developments, which came as a result of a well-planned system, have had positive effects. We hope that is what we have done well in the context of self-harm and suicide.

Dr. Diarmuid Quinlan

I thank Dr. McCauley for saying what we are doing well. I might address what we need. To my mind, we need more GPs and practice nurses. We have approximately 3,500 GPs and approximately 1,800 practice nurses. I would like to see an uplift in those numbers of GPs to approximately 5,000 and, similarly, practice nurses to approximately 5,000, which would put us on a par with the ratios for practices in the UK. This would mean we would have more time to spend with our patients. Most of our patients who come in and have multiple issues they want to discuss with their GP, perhaps two, three or four issues. More GPs and more practice nurses would make a big difference in our ability to support our patients during and beyond the pandemic. We know that more than 90% of all the care is delivered in the community so it is a relatively small ask.

What else do we need? As we have already alluded to in this meeting this morning, we need talk therapies and we need them readily accessible in all the towns across Ireland. To help support specifically what we are looking at this morning, we need a chronic disease management programme for people with mental illness. That will help resource and deliver care to this vulnerable group of patients.

Deputy Lahart asked how our staff are managing. The evidence is that healthcare professionals and healthcare workers, especially those on the front line, have all the pressures that the general population has in terms of the pandemic. In addition, however, they have concerns about their health, and older healthcare professionals who contract Covid-19 have a much greater risk of dying. That is a real worry for them. Other healthcare workers may have chronic diseases. Our staff have real concerns about picking up Covid-19 at work and going home and bringing it to their families despite the best and ever-evolving protection we provide them. It is a challenging time for everybody. It is a particularly challenging time for all healthcare staff.

Dr. Brian Osborne

I might be repeating some things but I have some other points as well. What are we doing well? To be honest, I know we have said some things here about child and adolescent mental health services, CAMHS. When children and teenagers are seen by CAHMS, and I can specifically speak about local colleagues in County Galway, they are treated well. CAMHS, however, needs extra resources as well as general practice needing extra resources.

We mentioned earlier about patients with schizophrenia. Dr. Karen O'Connor, who is the clinical lead for early intervention psychosis in the HSE, is developing excellent responsive programmes for early intervention for psychosis. There are two sites in County Cork and one in County Dublin. I believe there are plans to roll them out in counties Sligo and Meath. They need to be expanded. These are not pilot schemes. These are demonstration schemes that can be tweaked to an Irish model. Apart from those being expanded, however, we also need the physical healthcare of these patients. There needs to be a funded integrated programme between primary and secondary care with a GP-led care of the physical health of these patients.

With regard to self-harm, the HSE has a psychosocial response, which is very good. I work with Dr. Anne Jeffers, who is the clinical lead in the self-harm programme. It has been based in the emergency department but now we are working on expanding it out to primary care and having a single point of contact, be that a SCAN, which is a suicide crisis assessment nurse, or some other mental health professional, where GPs can make contact and refer patients in a timely fashion.

Under Connecting for Life, which is a very good strategy, the Irish College of General Practitioners also works with the National Office for Suicide Prevention. With Dr. Philip Dodd, who is the clinical adviser with the college, we have rolled out a programme of suicide prevention training for GPs. More than 600 GPs have been trained this year. In the past month, more than 100 extra have been trained online with another session coming up shortly. There is, therefore, a lot of activity going on in this area and many positives but there is definitely more to do.

Dr. Sumi Dunne

I thank the committee and Deputy Lahart again. If we look at how we can help moving forward, certainly addressing mental health as a chronic disease and looking at that integrated care approach, which can be manifested and structured from general practice giving yield to a follow-through pathway to robust psychological care, are very important. We need to look at mental health as a chronic disease.

To address this and get our pathways, we must look back to the consultant pay differentials to retain and recruit qualified specialists in the service. As Dr. Osborne has alluded, once the patients are within the service of CAMHS, it is an excellent service, but we cannot get our patients in at the moment. Together with this, we need then to come together to develop our community and specialist care teams in tandem. We cannot be seen to be doing one in isolation. We need to work together in developing these pathways moving forward to have distributed care for all our patients across the board.

Senator Aisling Dolan

I thank the speakers very much. I know they are representing many different groups such as the Irish Medical Organisation and the Irish College of General Practitioners.

I come from the west, which is covered by CHO 2, or Community Healthcare West, and the Saolta University Health Care Group. I am glad to note there is representation from the west among the witnesses. It is good to get a flavour from all around the country.

We are here to discuss access and continuity of care at community and voluntary levels. I mentioned earlier that today is International Day of People with Disabilities, the theme of which is that not all disabilities are visible. This is very much the case in the context of mental health, including for people who have suffered traumatic neurological or brain injuries. I was heartened to hear reference to the importance of sport to our mental health. There are many funding programmes in place. I am interested in hearing the witnesses' views on access to funding under Sport Ireland or Healthy Ireland within the HSE to support mental health within the community and at GP level? The sports capital programme was launched recently. The witnesses mentioned Parkrun. Are there other areas where funding to support mental health within the community can be accessed? A group in my local area in Ballinasloe, known as Walks and Trails, started up two years ago. Prior to lockdown, there were approximately 40 or 50 people benefiting from walking as part of that group. I agree with the witnesses on the importance of physical health when it comes to mental health.

In terms of Government investment, €1 billion has been allocated in respect of health, which is a €50 million increase, of which €38 million is for new measures. I know it is not directly within the witnesses' remit as GPs but one of them mentioned a 15% lack of recruitment in terms of CAMHS. I am curious to hear how we can improve retention and recruitment in this area. I know that retaining GPs in regional rural areas is also an issue. I am interested in hearing the witnesses' ideas on the challenges facing the HSE in terms of these posts.

I was shocked to hear of a life-expectancy reduction of 15 to 20 years among people with mental health disorders and the impact that this can have when dealing with suicide. The witnesses also spoke about related issues to do with diabetes, alcohol and drug abuse, etc. They may be aware of St. Brigid's Hospital, which is the former psychiatric hospital in Ballinasloe, that is no longer in use. We have moved from institutionalisation towards community living. I am concerned that there is a lack of access to acute services which previously provided rehabilitation, particularly addiction services. I would welcome the witnesses' comments on that.

On interventions, reference was made to the importance of early stage counselling, cognitive behavioural therapy and psychotherapy. I am impressed to hear that 50% of consultations include some degree of mental health input and that 15% to 20% of the workload relates directly to managing mental health. In the context of early intervention, the witnesses mentioned that publicly funded counselling and psychotherapy should be provided. As I understand it, currently, only people with medical cards can access those counselling services free of charge. I am interested to hear from the witnesses what publicly funded counselling and psychotherapy might look like? In terms of a clinical programme of care, what might that look like? Between primary and secondary care within the HSE, there are a lot of challenges in terms of lack of technology to even improve the connections between both. We need to see a lot more use of technology and eHealth. In terms of technology, how do the witnesses see it being used to support people with mental health issues? I am speaking in this regard about telemedicine and other routes of access in light of lengthy waiting lists. It was mentioned that there are 2,229 people on the CAMHS waiting list and that over one third of them have been waiting for longer than six months. That is my assessment of what was said. How can we use technologies to help reduce waiting lists and to improve access to interventions for people who need them as soon as possible?

Dr. Denis McCauley

On disabilities in the community, the Senator is correct that they are not always visible. There are two issues I want to talk about, namely, autism services and learning disability. On access to clinical psychology in general practice, we have not highlighted it. It is a bit like best practice and common practice. We do not refer to the psychological services here in the community because there are none. The waiting list is double that of the CAMHS services in that people are waiting up to two years. Dr. Osborne mentioned in his submission that when it comes to learning disability all we can do is encourage parents to engage with the school principal in regard to the provision of a psychological assessment. It is a peculiar situation in Ireland that a school principal has more chance than a GP of getting a psychological assessment for a child.

The Senator also raised the retention issue. I am older than the CAMHS. I was there when the service was commenced in Donegal. A Vision for Change recommended four consultants for my area but for a long time it had only one, Dr. McDwyer, who gave valiant service, and that later increased to two. In the past week, a third consultant was appointed. Since 2006, it has been working at 25% or 50% in terms of service. As mentioned by Dr. Dunne, as a result of this the criteria being applied for CAMHS is higher. CAMHS is supposed to deal with a particular group of illnesses but because the service is stressed the criteria for access is higher and it is only accepting people who are self-harming or suicidal, which means all the other morbidity is not being addressed in any sort of acute way. An adult or child who may have waited six to nine months to access CAMHS in Donegal, for whom cognitive behavioural therapy or counselling is recommended, will have to wait one another year to see the psychotherapist. The service has only 50% of the staff it needs. Consultants are working on reduced levels and the criteria for acceptance are becoming more severe. The environment they are working in is very difficult. I know from speaking to colleagues in secondary care that child psychiatry is a much sought after service. If they think that a service is under-funded and stressed they will not stay. As Dr. Dunne mentioned, if new staff are expected to work at a pay differential of 30% to their colleagues that is another disincentive.

On technology, it has been used in the Covid crisis because that was necessary. It has a place in mental health assessment but only laterally once the full treatment strategies have been implemented. A face-to-face consultation is infinitely better when it comes to assessing somebody. Technology is only of benefit when a doctor is reviewing or checking in on a patient. If there is any deterioration in a person's condition it never replaces a face-to-face consultation.

Dr. Diarmuid Quinlan

I thank Senator Dolan for posing quite a number of questions. I was very taken by her comment that not all disabilities are visible. While people with physical illness such as diabetes and heart issues can suffer silently for prolonged periods and nobody may be aware of their illness that is true equally, if not more so, for people with psychological disabilities. It is something we all need to keep in mind at all times.

The role of sport is extremely important. It is fantastic our voluntary supporting organisations are continuing as best they can to support our young sports people, in particular, to get out and train. There are many other sporting facilities. I cycled the Waterford greenway earlier in the summer. My parents go walking in a local public park on a weekly basis. There are many sporting facilities for people of all different ages. It is important we should try to open up access as best we can.

To touch on the issue of life expectancy, I share the Senator’s abhorrence that people with severe mental illness die ten to 20 years younger than they otherwise should. That is a major loss of social capital. We are losing our brothers, sisters, friends, neighbours and parents. General practice has an important role to play in supporting the physical health of these people. We already know about many of the issues. It is related to smoking, alcohol, diabetes, heart disease and high blood pressure, all of which are very much within our remit to treat. However, we are not resourced to manage the physical health of many of these patients. This committee could support a chronic disease management programme for people with severe and enduring mental illness and all mental illness.

Regarding the role of counselling, we should have counselling for everyone. I see no benefit in restricting it to those with medical cards and acknowledging it is important we have it for those people. Lack of access is a huge barrier for people who are just above the income thresholds and who have to face the choice of whether to buy food or go for counselling. We all know what the answer to that is.

The role of technology is important. We have massively adapted technologies across our country but, as Dr. McCauley said, in terms of building relationships with people, we as a group would much prefer to be meeting the members in Leinster House this morning. While there are some benefits to meeting remotely, in terms of building relationships, technology has a limited role. It is not a replacement for GPs, practice nurses or CAMHS staff. Those are my thoughts on the issues. I thank the members for listening.

Chairman

Does anybody else want to come in?

Dr. Brian Osborne

Could I come in briefly?

Chairman

Yes.

Dr. Brian Osborne

One of the questions related to encouraging doctors to practise in rural areas. In general practice the fewest number of doctors are to be found in rural areas. It is most difficult to recruit doctors in urban deprived areas and in rural areas. There is good evidence from rural areas of Australia and Scotland on what works to get people to work in these areas. Students can be targeted at medical school, even at that early stage. Training can be provided in these areas. The Irish College of General Practice has training schemes throughout the country in rural, urban and urban deprived areas. When people set down roots they are more likely to stay. They also need personal and peer support. If a person is the only doctor in an area and does not believe he or she has any support from other colleagues in our profession, he or she is less likely to stay. We need to incentivise people, including financially, to practise in these areas.

Chairman

Is the Senator happy with those responses?

Senator Aisling Dolan

Yes. I thank the witnesses for their time.

Chairman

I have a few questions. I want to get an understanding of the position. It sounds like GPs are really stretched and that they are firefighting, particularly at this time in the midst of a pandemic. I cannot imagine what it must be like to be working non-stop and having to face into issues concerning not only physical but mental health. We all know that poor mental health has an impact on physical health and other impacts. I am a therapist. Like Deputy Lahart , I set up an organisation called the RISE Foundation. It supports family members who have a loved one with an alcohol, a drug or a gambling problem. We do not deal with the person in addiction. We only work with the family members. We find that family members have huge stress, anxiety and sometimes it leads to physical illness. Stress can lead to breast cancer in women, anxiety and having migraine headaches all the time. Living in that feeling of distress and anxiety can bring family members into a very dark place.

I have a specific interest in this area but I also have a specific interest in dual diagnosis. In the witnesses' experience has the issue of dual diagnosis been regularly explored for patients who display substance misuse behaviours, whether it be alcohol or drugs? Three people in Ireland will die today from an alcohol related issue. It costs the Exchequer €1.3 billion a year. That is alcohol related issues alone and does not take account of drugs or gambling, which involve a high suicide rate. Do GPs need support to better recognise dual diagnosis? In the case of everybody who has a problem with alcohol or drugs, that problem stems from a trauma and in that way every such person would have a dual diagnosis, whether they drink or use drugs to numb out. Do GPs need support to better recognise dual diagnosis cases or family members who have high stress of anxiety around living with addiction?

Dr. Diarmuid Quinlan

I will reply to those questions. The answer to the Senator’s first question about the workload of GPs and the challenges facing general practice, it is borne by the entire team, including the front of desk administrative team, the practice nurse and the GPs. We have all our routine work, the everyday work in treating people with diabetes and heart disease. In addition, we have all the Covid related work. With 76,000 Covid referrals per week, that involves at least 76,000 consultations with general practice and probably as many more where people ring inquiring about it but do not meet the criteria. The workload is substantial. We will have the Covid vaccination campaign, which is welcome. Nationally, it has not been decided how it will be rolled out but there will still be a role for GPs in supporting patients and their colleagues in that vaccination campaign. The workload is substantial, particularly, as my colleague said, in rural areas. There is a real challenge in recruiting and retaining young GPs in rural Ireland. Many of our GPs practices are single-handed operations or have only two doctors. There is ample evidence to show that in practices where an older doctor retires, it is impossible to get a replacement GP to provide anywhere near the same level of service. Rural Ireland is facing a crisis in attracting and retaining GPs.

In terms of alcohol misuse, and with respect to alcohol, drugs and smoking, all those noxious lifestyle choices, GPs are well placed with respect to the identification and management of these. We know if GPs raise smoking cessation with people, it is one of the most effective ways of doing it and also signposting those people towards the HSE’s supports which are available.

Similarly, if GPs are supported, encouraged and resourced to identify alcohol misuse, it is something we can definitely do but all these things take time. When general practice is under considerable pressure with other issues, it is a matter of trying to prioritise for an individual patient at any one time. These issues are important and it comes back to the point that we need a chronic disease management programme for mental well-being among our patients which will clearly feed into the physical well-bring of those patients.

Chairman

I thank Dr. Quinlan for that. I have two other questions. Regarding referrals to local and voluntary services, how active are GPs in giving referrals to organisations such as BodyWhys and GROW? If people present to GPs, do they have a list of voluntary services such as Pieta House to which people can go? How does all that work?

Dr. Denis McCauley

I will answer that question.

On the social and prescribing aspect, most local areas have a directory of these services. In Donegal, for instance, before Covid-19 the GROW meetings took place in our surgery buildings. While we have become accustomed and confident with many voluntary services, clinical governance can also be a problem. About 90% of the time, we are completely comfortable with these services.

With regard to being a coroner, we had a great deal of interaction with Console initially, in regard to post-suicide bereavement for families. Unfortunately, as we know, that organisation had clinical governance issues and has been replaced by Pieta House. That is very active, although with Covid, there are fundraising issues. For the voluntary sector, particularly those organisations that are dependent on donations, it could be a somewhat lean period for the next four to five months. We applaud their help. We also have to be conscious of clinical governance. In the case of organisations that depend on donations, in the next five to six months some of these services may be restricted.

Dr. Sumi Dunne

I very much echo what Dr. McCauley said. What we know, what we are experiencing and what the committee has been hearing is that, to date, our global response as a State to mental health management is suboptimal, and we need to act on that. In regard to the voluntary sectors, we need to start considering embedding our mental healthcare within our existing services and having less dependence on these voluntary charities, which, as Dr. McCauley noted, face a lean period in these Covid-19 times. There is something we can do at a national level to address this, and we need the State to consider providing help for same.

Dr. Brian Osborne

I fully agree with Dr. Dunne. She made a really good point and I echo it. I might add that in Galway in recent years, there have been zero alcohol addiction services to which GPs can refer patients with alcohol problems. There is funding in the programme for Government, so that is awaited, but the lack of alcohol and benzodiazepine addiction services in the country is really dreadful. Opioid substitution services are very good, but for alcohol and benzodiazepines, they are pretty much non-existent.

Chairman

I totally agree. I thank all of our guests for attending and sharing their expertise and experience. There is no doubt that the role of the GP is vital in mental healthcare and is the first port of call for anybody struggling with mental health difficulties. We have heard during the meeting that the role is difficult. I cannot imagine how they are all coping, not least during this pandemic, and how their own mental health is surviving with everything that is going on. We greatly appreciate their attendance and the fact that they have been so generous with their time. I thank them for their fantastic presentations.

The joint sub-committee adjourned at 11.04 a.m. until 9 a.m. on Thursday, 10 December 2020.