Access to Primary Care through Community Mental Health Teams and Day Care Centres: Discussion

I welcome the witnesses, all of whom will present remotely to discuss access to primary care through community mental health teams and day care centres. I welcome from the Department of Health, Mr. Colm Desmond, assistant secretary, and Mr. David Maguire, principal officer; and from the HSE mental health unit, Mr. Jim Ryan, head of operations, Dr. Amir Niazi, national clinical adviser and group lead, and Mr. John Meehan, assistant national director of strategy and planning.

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

I call on Mr. Desmond to make his opening remarks.

Mr. Colm Desmond

I welcome the opportunity to update the sub-committee on the subject of access to continuity of mental healthcare at primary care level through the community mental health teams and day care centres. A Vision for Change, published in 2006, was recognised as a progressive strategy for mental health in Ireland. Many of its recommendations are still considered relevant to the ongoing development of mental health services.

The mental health landscape has changed considerably since then, however, with much wider societal awareness of the issue, increased demand for services, advances in technology and a greater emphasis on recovery, all requiring a refresh of the policy and recommendations tailored to meet present day challenges. The refreshed policy, Sharing the Vision, was approved by the Government and published in June 2020. It is a ten-year plan which seeks to place mental health policy as central to the broader development of Irish healthcare. It recommends a whole-of-government, population-based approach, involving interdisciplinary working to meet the needs of the individual at the appropriate level over the whole of his or her life cycle. In line with Sláintecare, the policy advocates improved linkages between the community, primary and secondary sectors and ease of movement between each, as required. It also supports the further development of non-inpatient services to ensure that minor issues may be addressed as quickly as possible and that they do not become larger problems.

Under the subject of community mental health teams and child and adolescent mental health services, CAMHS, A Vision for Change recommended the development of multidisciplinary community mental health teams to facilitate a move away from institutions and to provide treatment in a community setting. This policy was prescriptive in the membership and numbers of each team, recommending that there be one community mental health team CMHT for every 50,000 people. In recent years, the demand for mental health services has increased substantially. This is illustrated in CAMHS, where between 2012 and 2019 demand increased by 24% and referrals accepted by the HSE increased from 10,700 to 13,200. It should be noted that waiting lists for CAMHS over this period increased by only 4%. As of September 2020, CAMHS waiting lists nationally total 2,137. While this is down from the December 2019 figure of 2,327, and the HSE has initiatives in place to address the waiting lists, it is accepted that more needs to be done in this area. With this in mind, the 2021 national service plan will provide funding for the expansion of CAMHS hubs, which have been piloted in Galway since 2019. This will involve the recruitment of 29 whole-time equivalents, WTEs, specifically for CAMHS. The hubs will complement rather than substitute face-to-face care and will help address improved access and reduce waiting lists by establishing closer links with other parts of the health services. In addition, funding was provided in 2018 for the recruitment of 114 assistant psychologists and 20 psychologists in primary care. This initiative has helped to reduce demand on the specialist services by dealing with issues at a local level before specialist intervention is required.

Sharing the Vision continues this work, making a number of recommendations to enhance the performance of CMHTs. Access to such teams is usually through GP referral or follows from attendance at an emergency department. Sharing the Vision proposes a new referral option to out-of-hours crisis cafes. These will be appropriately staffed and will reduce demands on emergency departments, providing an environment more suited to the needs of those who present. I will offer another example. To facilitate greater flow between the different sectors, the introduction of a key worker from the community mental health team for each individual is also proposed. This worker would help to facilitate improved integration, for the individual's benefit, between the various service strands. In addition, the new policy recommends greater flexibility around the formation of the teams. It proposes additional workers, such as peer support workers and job coaches and, rather than specifying absolute numbers of specific professionals per team, will determine the needs of each team by assessing the needs and social circumstances of each sectoral population. Crisis resolution is a key component of the CMHTs. Sharing the Vision recognises its importance in that it offers out-of-hours psychiatric assistance for those presenting with a mental health issue. Finally, the provision of information is important. The new policy recommends that directories of information on supports available in the community and voluntary sectors should be made available to CMHTs to ensure they are in a position to advise service users of such supports.

Funding of mental health services has increased from €711 million in 2012 to €1.076 billion for 2021, an increase of €365 million, or 51%, over this period. This increase includes the allocation of €23 million to begin the implementation of Sharing the Vision in 2021. This will fund an additional 123 posts in mental health, as well as an additional 30.5 individual placement scheme, IPS, workers. This funding will also help to further develop CMHTs generally, crisis resolution teams and peer support as part of the first phase of implementation of the new policy.

Regarding implementation of the new policy, a national implementation monitoring committee, NIMC, has been established by the Minister of State, Deputy Butler, to drive the new policy over the next ten years. The NIMC structure will comprise a steering committee and a specialist subgroup panel, which will provide a wide base of expertise to advance specialist areas of action in Sharing the Vision. The steering committee includes experts from the fields of psychiatry, counselling, social work, youth mental health and occupational therapy. There will be strong service user representation in the NIMC structure to ensure that the service is developed around the needs of both service users and their families. Specialist groups will be established in areas such as Travellers' mental health, the transition from CAMHS to adult mental health services and acute mental health beds. Membership of these groups will be drawn from those on the specialist group panel. Panel members include representatives from Traveller and LGBTI+ organisations among others. On 4 November the Minister of State, Deputy Butler, announced the appointment of Mr. John Saunders as independent chair of the NIMC. The selection of the membership of the NIMC has been completed and the steering committee will have its first meeting on Friday, 11 December.

Regarding Covid-19 and mental health, in March 2020, the Department of Health introduced emergency legislation for holding mental health tribunals that review involuntary detentions. The legislation permits one-person tribunals to be held. This allows for continuation of tribunals where there is pressure on clinical staff availability due to Covid-19 and to prevent the spread of infection. To date, no one-person tribunal has been held. The legislation has now been extended by resolution of both Houses of the Oireachtas until June 2021. At the Department's request, and in response to Covid-19, the Mental Health Commission developed a monitoring and reporting framework for residential mental health facilities. Under this framework, Covid data are collected and reports provided on issues arising regarding suitability of premises, preparedness, training and equipment levels. The commission reports weekly to the Department and the HSE, which greatly assists the overall sectoral outbreak response. The Department, along with the HSE and the commission, has also established an oversight group to monitor any developments in this area and to ensure a quick response is available in respect of any issues arising.

I thank the committee. My colleague, Mr. Maguire, and I look forward to answering any questions Members may have.

Mr. Jim Ryan

I thank the Chairman and Members for the invitation to meet with the subcommittee to provide an update on access to, and continuity of, mental healthcare at primary care level through CMHTs and day care centres. I am joined by my colleagues, Mr. John Meehan, assistant national director of mental health strategy and planning at the National Office for Suicide Prevention; and Dr. Amir Niazi, consultant psychiatrist and national clinical advisor group lead for mental health. I am very pleased to attend the committee to speak to members about HSE mental health services. As they will be aware, Covid-19 has brought new challenges to all of society, including the mental health services. The October 2020 World Health Organization, WHO, report on the impact of Covid on the delivery of mental health services highlighted that the pandemic had either "disrupted or halted ... mental health services in 93% of countries". Staff in our mental health services continue to work hard to meet these challenges and to provide effective person-centred mental health interventions within the restrictions imposed by the pandemic. I will begin by giving an overview of these services.

Building on existing services, in budget 2021, mental health services were allocated an additional €35 million with a further once-off Covid investment of €15 million. Since 2012, a total of €278 million in additional funding has been provided under programme for Government to HSE mental health services. Over these years all funding allocated to mental health by the Government has been spent on providing mental health services. Members will be aware of a number of national policies and strategies that inform the direction of mental health services. Sharing the Vision was launched in 2020 and is our national mental health policy, building on A Vision for Change from 2006. I look forward to the implementation of this action-oriented, outcome-focused policy, which places the individual at the centre of service delivery. Connecting for Life, Ireland's national strategy to reduce suicide, was recently extended to 2024. This is a very welcome development, and our National Office for Suicide Prevention will soon publish a new and detailed implementation plan to support this extension. Existing structures which have worked well to date, including the national cross-sectoral steering group and 17 local Connecting for Life action plans nationwide, will continue to drive implementation from here on. Sláintecare is a ten-year health reform programme, which focuses on providing integrated care with a focus on community-based services. We have also been informed by the 2018 report of the Joint Committee on Future of Mental Health Care. Mental health services in Ireland are integrated with primary care, acute hospitals, services for people with disabilities and a wide range of community partners.

Services are provided in a number of different settings, including health centres, day hospitals, inpatient units and sometimes in the service user’s own home.

Over 90% of mental health needs can be successfully treated within a primary care setting, with less than 10% being referred to specialist community-based mental health teams. Of this number, approximately 1% are offered inpatient care with nine out of ten of these admissions being voluntary. Regionally, the nine community healthcare organisations, CHOs, have responsibility for the delivery of community healthcare services within their respective geographical areas. While the chief officer of the CHO has overall responsibility, the head of service for mental health in each CHO area, in conjunction with the executive clinical director, is responsible for the delivery of mental health services across the CHO area.

In terms of universal services, the HSE reaches the whole population in a number of ways, including our Little Things campaign and more recently our digital mental health service improvements. Interventions at primary care level are important to support people when they initially start to struggle with mental health issues. Primary care services include GP services, primary care psychology services and counselling in primary care, CIPC, in addition to funded services provided through our NGO partners, for example, Jigsaw.

HSE specialist mental health services are provided to respond to the varied and complex clinical needs of those individuals with greater need. These specialist mental health services are divided into child and adolescent mental health services, CAMHS, general adult and psychiatry of later life teams. Services are provided by multidisciplinary community mental health teams, day hospitals, acute inpatient units, continuing care settings and community residential services.

Additionally, further specialised services are available in the form of specialist rehabilitation units, SRUs, and the National Forensic Mental Health Service. In addition, specialist HSE mental health clinical programs provide support and expertise to ensure the standardisation of quality evidence-based practice across mental health services in complex areas of service delivery.

Mental health services have progressed over recent years from provision that was based around large hospitals to care in the community and new models of care supported by the clinical evidence base. We also now work extensively with service users to ensure service user engagement is central to our service developments.

I thank everyone for their opening statements. This is a very trying time for everyone when it comes to access to healthcare and mental healthcare under the spectre of Covid. It has taken its toll, no matter who, and has disrupted our lives incalculably.

Mr. Desmond spoke about the CAMHS hubs. He said the first pilot project was in Galway. Will he expand on the concept of what they will look like when they are rolled out?

Have the 114 assistant psychologists been recruited? If so, how many have been retained in the primary care sector? What is the position with the 20 psychologists? How many have been recruited, retained and how many have been funded to date?

The Mental Health Service Commission has stated that resourcing of the community mental health service for older people is seriously underfunded. These services are vastly understaffed in all the CHOs. We can all agree that if there was ever a time when such services were needed for older people because of Covid-19, and the isolation and lack of interaction during the pandemic, it is now. All these fault lines have been exposed by underfunding, understaffing and under-resourcing of resources that are critical for all age groups but particularly for older people. Will the officials expand on this?

Mr. Colm Desmond

There may be some operational details that the HSE can complete for me. I will ask my colleagues in the HSE to speak on the detail of the CAMHS hub pilot and development of the concept.

The posts in psychology and assistant psychology were secured and funded fully about three to four years ago and that service was put in place. It was as a result of a determined effort by the mental health services and the Department supporting the HSE to build up the response for psychology at what might be called the primary care level. The HSE mental health specialist budget funded that and I understand the service is running and operating fully since then. I would ask my HSE colleagues to give details on retention. Retention of people - psychologists and assistant psychologists - in that service has not been raised with us as a significant issue.

Mental health services for older people - psychology of later life, as we call it - is relatively new, I will admit, as a specialist area in the mental health services. That is not as a concept, as it was recommended in A Vision for Change, but it is around five years ago that serious efforts began to be made actually to fund that service within the overall mental health services. It is a function of the changing demographic of society that there will be greater focus on the psychology of later life. It is a commitment for continued funding within the new policy into the future.

I do not know if Mr. Ryan has any details to add from the operational perspective.

Mr. Jim Ryan

Deputy Kenny asked about CAMHS hubs. The first was initiated earlier this year from last year. It is trying to provide an out-of-hours, seven day a week service for young people. We have discovered that, especially in rural Ireland, it is quite difficult for people to attend a service, particularly at weekends if some distances are involved. The idea of the CAMHS hub is that there is a service available online. The feedback so far has been very positive.

We have 120 assistant psychologists employed in recent years. As of July, there were 95 in post. There is a normal turnover of assistant psychologists because many go on to obtain doctorates and become clinical psychologists, which is very good in that we are growing the number of psychologists that we require.

We recognise the need to invest further in services for older people. In 2013, we had 224 whole-time equivalents and we now have 318, with 22 teams in 2013 up to 32 teams now. That is approximately 60% of the figure in A Vision for Change. We would like to have up to 48 teams. It shows progress but there is further to go.

On the mental health services for older people, what would the normal composition of healthcare professionals be in that kind of model? From the CHO figures, some of the numbers are extremely low compared with the recommended levels of staffing. The lowest is in CHO 4. I am not sure what part of the country that is but it is at less than one third. The highest are in CHO 1 and CHO 2 which are in a percentage in the mid-70s. The average in resourcing, at 54%, is just over half. Why is that the case?

Mr. Jim Ryan

I ask my colleague, Dr. Niazi, to outline the make-up of a psychiatry of later life team.

Dr. Amir Niazi

The Deputy is right. Psychiatry for later life is still somewhere in the region of 60% of staffing, which is low in comparison with what was envisaged in A Vision for Change and with other areas. The team is composed of a consultant psychiatrist, junior doctors, a psychologist, social workers, occupational therapists, nurses trained in the area and administrative support. It is a multidisciplinary team working with over-65s. We have built a good deal in the past eight years, starting from a low base. As Mr. Desmond said, it was a new development which we did not have for a long time. We are catching up.

As to why it is still 60%, there are multiple factors. Even when money was allocated for recruitment, we did not have the trained staff available to take up those posts. We are working with the training bodies to make sure we have trained staff to take up those posts and with the nursing discipline to get appropriately trained nursing staff who can do memory clinics, assessments in respect of dementia and so on. These are skills that are required. We are catching up and we will continue to do so in the coming years.

A new development is that, along with colleagues in geriatric service in acute hospitals, we are trying to work on a model of care involving a service-improvement project whereby geriatric service and mental health will work hand in hand. We are already discussing that. Covid has delayed it but the model of care of that was presented in February. There was a bit of delay due to Covid but work has started on implementing that model.

I thank the witnesses for their presentation. I have a couple of questions so I will go back and forth. I am interested in the topic, which Deputy Kenny mentioned, of the psychology of later life and older people care. I asked about it last week at a meeting of this committee. Someone contacted me who is worried about their father, who is in his 70s, and is trying to get him to access care. Do the witnesses have thoughts on that?

There seems to be a service available for older people but the difficulty is in the attempts, usually by family members, to get that person to avail of those services. Maybe there is stigma for members of the older population or they do not recognise that they need to access that care. Do the witnesses have any thoughts as to how one gets the person to that care? It is not like a teenager or child who can be shuffled in or a younger person, where somebody might notice and be able to talk them through it. It is an age group to whom it is quite difficult to talk to mental health. How do we bridge the gap and get the person to that care? Is there outreach or are there strategies the witnesses think are important or that they are doing?

Mr. Jim Ryan

Will Dr. Niazi take that?

Dr. Amir Niazi

The Senator is right that there is probably still a stigma. This model of care involves not only mental health, but also primary care and acute hospital care. Bringing those together will make it easier to get to those people who are reluctant or who have not accessed mental health services.

The Senator can be confident that her area has probably the best resources available in the country. The colleagues working in the area are providing services in their own acute units. They have a separate old-age or psychiatry-for-later-life unit in Drogheda. They are providing services in nursing homes, doing domiciliary visits, having liaison meetings with GPs and with the services in Our Lady of Lourdes Hospital, Drogheda. Efforts are being made. We are taking a step further. The recent model of care which my colleagues have worked on in recent years will be another step in the right direction.

Referring to another committee, we talked a lot about the general population being able to access care. Last week, we heard from some GPs about how hard they find it to get patients into care. Either they do not have a medical card, they have to pay for themselves privately, there is back and forth and long waiting lists or they have to travel. We talked about the benefits of GP surgeries having more centralised care where they could avail of counselling services there as opposed to having to go elsewhere. That is two questions as one. The first concerns who can access these services. I hear from people saying they cannot get the services they need because they do not have the money and they do not qualify. There is also the idea that one cannot avail of all services in a GP surgery. Often, they have room but there is not funding to put a counsellor there.

There is a physical issue of having to move from location to location. Obviously, we cannot have everything in one place but 90% of care relating to mental health can be done at primary level. Do the witnesses have any comments on the fragmentation where many GPs feel they have the physical space to provide a counsellor or counselling service in their surgeries but there is no support or funding available?

Mr. Jim Ryan

I can answer some of those questions and bring in one of my colleagues if that is okay.

I thank Mr. Ryan.

Mr. Jim Ryan

The Senator mentioned accessing care. I read last week's transcript in relation to the GPs. As they outlined, we have a system called CIPC. It is accessible for people who have medical cards. That is a development we have had for the last seven or eight years, which has been quite successful. We recognise there are parts of the country with waiting lists. We have allocated additional funding both in 2020 and 2021 to reduce those waiting lists.

On the case the GPs made about those who do not have medical cards and who found it difficult to access counselling, one thing we have done as part of the digital intervention from the beginning of the pandemic was to provide counselling and support through a variety of external NGOs, including SilverCloud, MyMind, Turn To Me and Jigsaw, which is for younger people. They all now have a more significant online presence. We believe this is a helpful way to provide care.

On people finding it difficult to travel to get access to counselling, this type of intervention and support is within the person's home and at a time that suits him or her. We think this has significant benefits. There are challenges and limitations to the people who want to access that type of care but for those for whom it works, it is a useful option. It is quicker than a service that requires a building and there are many benefits. Those are my two responses. I am not sure if Mr. Meehan or Dr. Niazi want to add to them.

Dr. Amir Niazi

Regarding access to the service, we usually advise that a patient or family should contact a GP, which is the starting point for any patient to access our service. Most of our patients who are aged over 75 years have, alongside their mental health issues, physical health issues. The GP is usually the person who is aware of all of the comorbid information and complexities that relate to a mental health referral. We have never seen a problem with GPs contacting us. There might be a waiting list, but if there is an urgent case, the patient will be advised to present to one of our acute units, which are open 24-7 and where a doctor can assess him or her. If someone's condition can wait for some time, he or she is given an outpatient appointment in his or her outpatient sector headquarters and will be seen there.

Since Covid, many of our assessments are done using telemedicine or digital platforms. As such, assessments are happening in people's homes. We are providing a service to those people through that medium. From our perspective, we are offering services with all of these features, but we always ask patients whether they can contact their GPs first. The GPs then liaise with us. As my colleague, Mr. Ryan, stated, more services could be provided at GP hubs, but once a GP contacts mental health services, we have different ways of helping people, and that is what we do.

It was mentioned that NGOs were helpful. I know some of the work that they do. When Jigsaw appeared before the committee, it spoke about having long waiting lists. Would it be more prudent of the Government to provide funding for services as opposed to relying on NGOs and the like to provide these services to the HSE? While that is the situation we are in and I am presupposing the answer to the question, surely it would be more efficient to provide funding directly to services as opposed to requiring our mental health services to rely on NGOs. The committee has discussed the significant number of voluntary groups and the fundraising that is done for mental health services, but it would make sense to resource the sector directly and properly.

Mr. Jim Ryan

We take the Senator's point. What we try to provide in mental health services and through the HSE is mainly a secondary care system alongside our primary care colleagues. In some respects, the benefit of the NGO sector is that NGOs tend to be responsive and flexible in a way that, at times, the statutory system is not. They can also focus on particular thematic issues, which the committee will have heard from Jigsaw it can now do. Jigsaw has increased its level of online support and counselling. There are a number of benefits to this approach, for example, in the subgroups of the mental health field. If a body has a national reach, it is much better and more effective to have groups that deal with a particular issue within, for example, youth mental health. If that was being done by area, there might only be one or two bodies. Nationally, however, there is a significant number. That has been some of the feedback we have received. The other benefit is that there are various age cohorts that find dealing with health issues easier than others. We find that working with our NGO sector means that we can be more flexible and responsive. NGOs also have good and strong connections within our communities. Ultimately, that is where we want to try to provide as much of our care as possible.

Mr. Colm Desmond

For the Department, I support what the HSE just said. The new policy places much greater emphasis on stepped care and care at the point at which it is needed in the first instance. We need to develop this front line, if I can call it that, from a primary care perspective. I have demonstrated that through the psychology development, the CIPC service and the continual funding for a range of NGOs such as those that Mr. Ryan outlined from the HSE's perspective. This year, we have provided significant funding because of the obvious need of a wider societal demand. While there are challenges in ensuring that when someone approaches a GP, he or she can be referred to a service, the availability of flexible, on-the-ground organisations is of significant assistance to the HSE once they fit within an overall funding and resource structure, which we need to do.

The Senator asked why we did not just fund services. As the new policy underlines, we want to fund the right types of service. The amount of funding for mental health and new development in other areas had been consistent for six or seven years, albeit after catching up from a base that had become low by 2011 and 2012. It is not just about the development of CAMHS, adult teams and specialist teams like psychology of later life, but about developing and cascading back down to the front line. We welcome the work of the NGOs. Importantly, they are thematic in their approach and people identify with them for particular needs.

Since that is a perspective from which I would not have considered the matter, the witnesses' replies were helpful.

According to new statistics from the Central Statistics Office, CSO, 19% of those aged 18 to 34 years reported feeling downhearted or depressed most or all of the time in November, an increase from 11% in April and from 2% in 2018. The statistics show a stark gender divide emerging. Women are now twice as likely as men to report feeling downhearted and-or depressed all or most of the time at approximately 16% versus approximately 7%. These are startling figures.

There is a Covid global mental health crisis. I am interested in seeing how we can reach out to people and get them into services and how the services are set up to deal with this potential influx of people. Someone who appeared before the committee spoke about the fourth wave of Covid. We have not had the third wave yet, so we might not make it to the fourth, but the idea is that the fourth wave would be the consequential mental health wave. Obviously, the Joint Sub-Committee on Mental Health discusses the impact that Covid will have on people's mental health a great deal and it has been briefly mentioned today how services are being prepared for it, but will the witnesses comment on the stark increase in the 18 to 34 age group and the figure relating to women and how these people will be reached so that they know services are available? There is a concern that people feel that they cannot express their mental health struggles during this difficult time because we are all going through Covid and everyone talks about us all being in this together. I have spoken to people who believe that they have no right to feel this way. They tell me that they are going for walks, listening to podcasts, working from home, using separate spaces and so on, but they are struggling much more than I am or someone else is. They feel that they do not have a right to express their mental health needs.

There are three parts to my question on Covid. Will the witnesses comment on the increases in the figures relating to the young age group and women? How we will reach them and let them know that they have a right to express their mental health difficulties during this time or post Covid? How the services will deal with this potentially large increase in mental health needs in the community?

Mr. Colm Desmond

We are acutely aware of the stress across society from all of the issues emerging at this time. Regarding the CSO's findings in respect of the 18 to 34 age group and women expressing significant issues of concern, we are aware of those statistics and they are of significant interest to us. From the beginning of the pandemic, through the NPHET process, Amárach Research and other work, we have been keeping a close eye on not just the public health measures and the different components of the response to the pandemic, but also on gauging the impacts on society.

We have recognised from the beginning that there was a need to respond to the impacts. There have been a number of steps over the past six to nine months, which leads into preparing for what may be termed another wave. It remains to be seen exactly what those impacts will be.

Two initiatives were announced over the summer period. The first was a health and well-being initiative, and the second followed quickly, with more specialist mental health supports through the sort of specific counselling organisations to which my colleague, Mr. Ryan, referred. We provided €2.2 million in addition to what was already being provided for wider supports for counselling to be available across communities and society in general. We still have additional capacity under some of those headings. It was a response to the evident challenges to society from the significant stress of different stages of regulation and restrictions which were necessary in the public health context. We have demonstrated that we have been able to bring forward those supports where they were needed.

The overall approach of the Government and the Minister and the Ministers of State at the Department of Health this year has been one of openness with regard to health and well-being, resilience and the specialist response. The work done for the general public health response has included widespread publicity about people taking care of themselves, holding firm and so on. What the Senator and I are interested in is the next level down, where people show issues and what is bubbling underneath. The CSO statistics may indicate that. They show a shift in recent times. We are interested in the 18 to 34 age group, because we have focused a lot on the elderly and those who are at greater risk, but we are aware and it is useful to have those CSO statistics because they confirm that we need to be vigilant at all times in the context of wider age groups and women also.

We have also recently announced a new resilience campaign to follow the In This Together campaign. The resilience campaign has a Keep Well programme, promoting health and well-being and positive mental health. Some €7 million was invested in this campaign, in a range of initiatives, including keeping contact and community calls, isolation assistance and befriending services. HSE colleagues may wish to speak about more detail but I do not think there is an issue about the right to speak out. My sense, from the Department and HSE perspective, is that there is significant encouragement for people to express a wish to keep contact with people and be there to support each other. A range of Departments, including the Department of Rural and Community Development, have put in significant work, particularly for vulnerable groups at the community level.

The more specialist services are the subject of the Senator's question. We have responded with counselling supports and we continue to remain vigilant for what may emerge. The Senator is correct that we need to remain vigilant going into the new year and as we move towards 12 months of the pandemic. Hopefully, things will begin to improve but we cannot avoid having to deal with the potential delayed impacts across society. I do not know if that helps. Colleagues in the HSE may wish to add to that.

Mr. Jim Ryan

We have seen significant additional traffic through yourmentalhealth.ie in recent months. As Deputies and Senators may be aware, we would previously have tried to co-ordinate and amalgamate all of the mental health supports through yourmentalhealth.ie to try to ensure that there was more streamlined access. That provides signposting of services and gives us an opportunity to measure the level of demand. We have seen a significant increase of that over the last months which shows the point that the Senator is making and that we are in a position to be able to signpost the services that we have available.

Mr. John Meehan

As the Department has stated, the HSE has taken a psychosocial response involving a layered care framework. The international evidence shows that the majority of the population will require early intervention. We look at level 1 as well-being and resilience in society. We then provide self-help online through yourmentalhealth.ie. We look at the people who require support. It is important that it is not only individuals who work within the system and the general public, but also for staff and service users, which is a priority. The 18- to 34-year-old cohort was mentioned, which has been recognised. We then move into primary care and voluntary services. We have a hybrid approach with voluntary services. It then moves to specialist mental health services for those with severe and enduring mental health problems. The challenge is to provide intervention at each of those levels. The research shows that be providing the level 1, which is resilience in society, and level 2, which is self-help, that will help people to maintain their mental health and prevent them from graduating into secondary mental health services. The focus during Covid has been to identify those level 1 and 2 cases, and at the same time to ensure that supports at primary care and secondary, specialist mental health services are maintained.

Moving away from Covid, the matter of adult ADHD diagnosis seems to keep coming up in my own life. People have been talking to me about this matter. It may not fall within the witnesses' remit but I wonder if they could offer any commentary on it. There is no dedicated adult ADHD service or support. I hear of many adults who have come to a point in their life where they realise that they may have ADHD. A person goes to his or her GP and is informed he or she does not believe in it or else the individual involved is shuffled around. There is nowhere to go. A person may have come through his or her whole life without this diagnosis and it is difficult to realise this when a person reaches to adulthood. There is a barrier for these people in terms of getting the support and care they need. There are underground whispers about who to go to. These are sent via WhatsApp and text messages, with someone knowing the right person to go to in order to access the required support. It is an arduous, difficult journey. It may be outside the witnesses' remit but I wonder if anyone has commentary on that. It seems to keep cropping up in my own life and it is difficult when there does not seem to be that standard of care for adults who may have a diagnosis later in life.

Dr. Amir Niazi

The Senator is right. Until recently, ADHD was considered to be a diagnosis for children. In the past few years, however, we have seen that many of those patients who move into adulthood may not have the same level of hyperactivity, but there are other symptoms which warrant an assessment and, if required, treatment. We are almost at the verge of finalising the model of care for adult ADHD as a service improvement. There are three pilot sites throughout the country and we are trying to see if we can train people to start a pilot programme. If successful, we will roll the model of care out to another three sites. The Senator will understand the challenge.

Getting people who are trained in this area is not going to be easy but we are working hard to see how we can train people. We are working with the training bodies in the College of Psychiatrists of Ireland on ways to get trained staff. Certainly that is an area on which we have worked as a model of care and service improvement project and there will be an improvement in the coming years in this area.

It is great to hear that there is a pilot scheme and more. Anyone I know who is listening today will take great comfort from that news and be relieved that this is moving in the right direction because, as Dr. Niazi knows, it has been quite difficult for those adults over the past few years. I look forward to seeing how the initiatives are rolled out.

I have a lot of questions. There is no doubt that mental health policy has remained aspirational. From 2016 we had a good policy in A Vision for Change. What barriers have prevented the full implementation of A Vision for Change? Do the witnesses think that mental health remains in the Cinderella place?

Mr. Colm Desmond

From the Department's perspective, there was a prior policy but A Vision for Change was the first attempt to put a major structure on health in terms of adult, child, specialist and forensic services. It was visionary in that sense. In the early years it suffered from the funding base not increasing significantly enough but that began to be remedied from 2012. There have been a range of achievements, under A Vision for Change, that very often may not get the credit they deserve, including increasing the number of child and adolescent mental health services, CAMHS, acute inpatient beds from 16 to 74 from 2008 to 2018. They are specialist and expensive beds whose number will increase further with the new Central Mental Hospital. The CAMHS teams increased, clinical whole-time equivalents increased significantly and services increased in that area. Likewise, in the adult services.

Without a doubt we had recruitment challenges in the period from 2012 to 2016 and onwards. The situation has somewhat improved. It is a specialist area where the individuals who work in specialist services are trained to a high level in this country and they are in demand internationally. When we began to increase new development funding for A Vision for Change, from about 2012 onwards, we ran into the challenge of retention and recruitment. It was a confluence of circumstances that made the implementation of the policy more challenging. The policy was also a programmatic structure around the areas and headings that I have mentioned.

Our new policy takes a different approach and builds on the valuable aspects put in place by A Vision for Change such as psychology of later life and other areas that need further development, which my HSE colleagues have spoken about in detail. The new policy recognises that the individual has experiences in mental health over the whole lifecycle that are not to be bounded or defined within one type of condition. Most important, it recognises the need to develop services at the lowest level of complexity and the point of contact where the individual might benefit at an early stage from promotion, prevention and early intervention and then, where necessary, as Mr. Meehan has explained, where one needs to go to the next level if that is absolutely necessary.

About three years ago we commissioned a refresh of A Vision for Change. Significant research was done under the aegis of an oversight group that informed the development of a new policy and it was launched in June or July of this year. The policy is now really firmed up as there is a new monitoring committee in place and there is a specialist committee of groups representing all of the disciplines with an interest. That committee will meet for the first time tomorrow, Friday. The Minister of State at the Department of Health, Deputy Butler, has done that, as promised, within the period that she set for herself when she came into Government.

The policy is evolving and I am not sure one can apply the general and generic word "Cinderella". We have always acknowledged the challenges. In the early stages of A Vision for Change the previous Governments did come up with the funding but we had retention and recruitment challenges. What we now have is a rights-based approach to mental health that recognises the whole of the lifecycle. That is a challenge for the mental health services but one that the Department and the HSE is up for in terms of developing a flexible model that makes the very best use of the funding we have at an appropriate level of complexity. I have given a general answer. The Chairman may have specific questions, and maybe my colleagues in the HSE might want to expand as well if she has further questions.

Expenditure on mental health has fallen to 5% of the health budget while it is 12% in Scotland. Can we address the mental health requirements in this State if the percentage is only 5%?

Mr. Colm Desmond

My colleagues in the HSE may wish to speak about the percentage of the overall health budget. It is difficult to make international comparisons because it depends on the structure of the delivery of services within other jurisdictions.

We started from a low base. We have responded now, in the service plan for 2021, to the wider societal needs in the area of acute services, for example, in primary care with very significant increases. It is a statistical fact that it does then demonstrate a percentage decrease compared with what it might have been in terms of the overall percentage of the health budget. The Chairman has made a fair point about the percentage. At the same time, it really is about what one does with the funding provided. We had challenges with the new development funding in recent years, which have been resolved in the past two or three years with improvements in recruitment and retention. Successive Ministers of State have made the point that it really is what one does with the funding that is made available and what the Government demonstrates by providing that additional funding. For instance, in 2021 we have provided a total of €23 million in new funding to start off the new policy and another €15 million for once-off funding of similar bed capacity and other responses at primary level, plus additional funding for existing services. A total of €50 million has been put up again, which is as equal an increase as mental health has got in recent years. In fact, the amount may be slightly higher than other years but I am open to correction. It really is about what one does with the funding and how flexibly one can develop services. In other jurisdictions, such as Scotland, they may have slightly different delivery structures that may encompass primary care and other funding elements within their percentage but I am open to correction. It is difficult to make comparisons. My colleague, Mr. Ryan, may like to say something.

Mr. Jim Ryan

To reiterate a couple of points, A Vision for Change was launched in 2006 and, as I am sure we all remember, the country went into a recession for a number of years. Essentially, the programme for Government funding commenced in 2012-2013 and revenue increased, as members will have seen from the figures mentioned earlier. There has also been quite significant investment in all capital infrastructure around acute inpatient units as well as community services through primary care centres.

Over the past number of years we have found a limiting issue to be our access to or the availability of trained professional staff, particularly on the nurses and consultants. I have read the transcript of the debate at which the GPs spoke last week and that point was made. We are trying to do a couple of things. We are working with the College of Psychiatrists of Ireland to increase the number of basic and higher specialist training to create additional capacity within our consultant body over the number of years. We do so because where there are niche areas, whether it is mental health, intellectual disability liaison or psychiatry for later life, we need to increase the number of consultants coming through to take up these posts. As Mr. Desmond has said, these people are in high demand worldwide. I will outline an unusual and unique thing that we have done for psychiatry nursing.

We have invested mental health funding in our third level colleges to increase the number of psychiatric nursing places that are available each year. We have done that for the past four years and 2020 is the first year in which an additional 60 psychiatry nurses will graduate, on top of the usual 260. We would expect that over the coming years, that figure will increase to well over 100 additional places. We recognise that to deliver services, we must have sufficient numbers of professionally qualified staff. This was one of the issues that limited our ability to develop additional services. Funding is not always the issue.

I am involved with the International Initiative for Mental Health Leadership, IIMHL. In trying to make comparisons across the world in terms of the percentage of budgets spent on mental health, it can be quite difficult to interrogate the figures because some countries add in what they spend on social inclusion, for example, in the context of addiction, some include primary care while others include capital spending. As Mr. Desmond says, the real issue is what we are doing with the money we have rather than the actual percentage.

Mr. Ryan referenced problems with recruitment. Are we offering permanent posts? Is there an issue with the adequacy of pay?

Mr. Jim Ryan

We are offering permanent posts. It is useful to note that while people are employed through agencies or as locums, we would much prefer to have people employed permanently with us because it gives us continuity of care. That said, there are individuals for whom the agency-type arrangement works, especially those who want to do particular hours. It is a dynamic workplace.

On the issue of pay, as was mentioned in a previous meeting, consultants entering service now are paid at a different level to their in situ colleagues. That matter is outside the control of the mental health services but it does have an impact.

We had GP representatives here last week who spoke about primary care counselling services. One of the issues that arose was inappropriate referrals. We heard from GPs who shared experiences of having referred a patient displaying mental illness to CAMHS only to have the same patient referred back. This is not uncommon, apparently. Often CAMHS will say that the patient does not meet the criteria for treatment when the GP believes that he or she does. Why is this happening?

Mr. Jim Ryan

I will ask Dr. Niazi to comment on that in the first instance.

Dr. Amir Niazi

We have heard about the issue of inappropriate referrals in terms of primary care and CAMHS. When we are also supporting primary care psychology and those referrals, it becomes easier for us to address some of these problems. When our trained colleagues raise this issue, we try to support them. We try to address these issues but there are very few examples of it. I sit with my colleagues in primary care and I hear about examples of this but they are few in number. We keep supporting and working with them.

Mr. Jim Ryan

This issue comes up quite regularly and a number of years ago we came up with what we call the CAMHS cog, which is an operating guideline. That document identifies specifically what CAMHS does. CAMHS is essentially for the 2% of the child population who requires specialist care. It is not for those who should and could be treated in a primary care setting. One of the challenge for GPs is that if the local primary care psychology service is poor or unavailable, they have little option but to refer patients to CAMHS. However, CAMHS will revert to them and say that the patient does not meet the criteria, which is not to say that the young person does not need treatment. CAMHS has limited numbers. We have only 74 teams throughout the country and we must make sure that those teams are available for the young people who absolutely need them. It is a very small number of young people who actually need such specialist services.

We are trying to ensure that we provide the right service for the right people at the right time. As Dr. Niazi said, an important part of that is the communication between GPs and CAMHS. Certainly, as part of the CAMHS operating guidelines, we try to work as closely as possible with our GP colleagues in the community so that they understand what it is that CAMHS does and their referrals are not deemed inappropriate. I can understand that, from a parent's point of view, patients are being referred from one body to another and are not being treated. That is not the intention. We are trying to ensure patients are treated at the correct level. As Mr. Meehan outlined earlier, a psychosocial response may be more appropriate where young people are concerned. They may not need to be going to a CAMHS team and could be treated more appropriately at a lower level of care.

One of the other areas touched on last week was prescription medicine. GPs mentioned that the lack of primary care counselling services resulted in a tendency to prescribe medication but medication should not be the first resort when it comes to mental health care. Why are primary care mental health services not better resourced to ensure prevention and early intervention? This ties into issues around CAMHS. If patients do fit the criteria for CAMHS, where do they go? In the service with which I work, we have prevented people from going down the prescription road. Prescription medicine can be extremely addictive. Sleeping tablets and such like can be very difficult to come off. What is the view of the witnesses on that? What can we do to ensure prevention and early intervention, particularly when patients present to their GP?

Mr. Jim Ryan

I will ask Dr. Niazi to comment first.

Dr. Amir Niazi

There are huge gaps at primary care level in terms of the availability of counsellors and psychologists, and recruitment is a particular issue in that regard. If something that could be resolved by primary care psychology is not resolved, parents looking for an answer will ask for medication on prescription. That is where it starts. CAMHS works on the basis that many issues can be resolved with counselling or talk therapies and should not reach the stage where medication is prescribed. However, the challenge is to get enough trained staff recruited to primary care psychology. Efforts are being made to address the gaps but it is difficult in the absence of sufficient staff. There are areas where the waiting lists are two to three years long. Referrals are made to CAMHS but many are not appropriate. CAMHS is a secondary care service and many of the referred patients should be dealt with at primary care level. All of the problems with regard to overprescribing and inappropriate referrals start from the lack of resources at primary care level.

My next set of questions are around Covid-19. Has the demand for mental health services increased since the start of the pandemic? More importantly, what additional care capacity has been provided? This is an issue that we will have to consider carefully in the time ahead because the realities for people who are struggling at this time have not hit home yet. Everywhere I look I see people struggling with their mental health, including front-line staff, musicians who have lost their jobs and so on. What additional capacity for care can we provide?

Mr. Jim Ryan

We have looked at the statistics on referrals accepted by our community mental health teams.

Up to October 2020, when compared with 2019, we have had approximately a 13% reduction in the number of referrals that have been accepted for general adult, a 10% reduction for psychiatry of later life and a 13% reduction for child and adolescent mental health services. What that is telling us is that when the pandemic hit last March, people were reluctant to come forward because of concern about contracting the virus, so there was a delay in people coming forward. The challenge that has created for us is that we know the demand and the need is still there. We have tried to work with people who have understandable fears about coming forward to some of our centres because of the contrasting need for their mental health care and their need for a feeling of safety in regard to the virus.

What we have seen is that the number coming forward has gone down, although that has changed since September and October, when some of the restrictions were lifted. We do not have up-to-date figures for the last couple of weeks to see what impact level 5 has had, but our view, anecdotally at least, is that the level of acuity of people coming forward is more significant. People are delaying coming forward, which means their level of acuity is greater and the pressure on our acute inpatient capacity is very significant, particularly in some of our niche services, like forensic services. What we see is delayed demand and then a surge from the point of view of acuity.

As to what we have done, our acute services maintained their presence during the pandemic and we had 90% capacity across our acute inpatient services. The services in our day programmes and community mental health teams were impacted. That was because of trying to manage the dual responsibility of providing care in a safe fashion but also trying to do it using, for example, Attend Anywhere, Zoom or other platforms in order to make sure we kept in contact with people.

We recognise there is an increase in the level of demand. What we are also trying to do is to ensure that for all cohorts, as Mr. Meehan mentioned earlier in regard to our psychosocial response, our community responses can be done by either NGOs or through online supports. We have to make sure our secondary care services for people with severe and enduring mental illness can also continue because they are a group that, at times, perhaps do not have the voice that others have. Those are some of the initiatives we tried and some of the statistics we have seen in recent months. Perhaps other colleagues would like to add to that.

Mr. John Meehan

I note the Chairman mentioned the music industry. Within all our strategies, both our mental health strategies and our suicide prevention strategy, we have identified priority groups and we have front-loaded services, particularly during Covid, to address that. I bring to the attention of the committee Minding Creative Minds, which was introduced during Covid and which is an organisation that offers free 24-7 well-being support for the Irish music sector. In other examples, we linked in our policy, looking at our priority groups and at groups that are vulnerable. There is also online counselling, which is free counselling provided by MyMind for individuals. Anybody within our population can access that if they require counselling as a result of any issues that have come up during Covid.

Again, that brings us back to the layers and the intervention within the different layers, and we are trying to get into that space of ensuring that each of those layers has an intervention that is appropriate at the right time in the right place for individuals. As Senator Hoey mentioned, it is important we link with the NGO sector to provide that, particularly to our priority groups.

Dr. Amir Niazi

My colleagues have reflected some of this and I want to separate some of the issues. I will give a few examples. International practice says that one in five people will be affected by Covid-19 and they will have mental health issues, in that they will feel anxious, low and upset. However, when we do our comparison, our admission numbers have not rocketed, and even the GMS prescription of antidepressant medication has seen a slight decrease in comparison with last year. On the other side, if we look at websites like yourmentalhealth.ie, there has been an almost 500% increase in activity on those sites, with many people feeling down.

What I am trying to say is that if we separate people who are very unwell mentally and need admission, medication or care at the secondary or tertiary care level, that figure has not gone up. However, it is different in regard to the care which is required at the psychosocial level. In mental health, we treat people using a biopsychosocial model and, biologically, for people who reach a stage where they need medication or admission, we see that this figure has not gone up significantly. In comparison, with regard to the psychosocial, where people need help through counselling, talking therapy and so on, and also support from the family and socially, we have seen a significant increase.

That is where my colleagues are saying that we are putting in place work with the voluntary sector and with organisations. This afternoon, in the HSE press conference, a lot more information will be given about the psychosocial response that we are implementing in the community for all of these people who are worried and anxious, and who need support and need to talk. I am just trying to explain the distinction between people's needs and how we are trying to address that.

Mr. Colm Desmond

From the Department's perspective, I reaffirm the point I made earlier that what the HSE colleagues have outlined confirms our view on the need for vigilance. The Department supports fully, first, the need for continued psychosocial responses, and I gave some examples of the funding that has been put in place. More importantly, not just in the Department of Health but centrally across government, there is a significant vigilance around what we will call vulnerable and high-risk groups, and persons with mental health or potential emerging mental health or psychosocial issues are high up on that scale, among other vulnerable groups. We keep a fairly vigilant eye on that.

It is a challenging area, as the experts in the HSE and others have outlined, to actually see the evidence. What has been explained by Dr. Niazi and Mr. Ryan corroborates that we are not seeing the specialist demand but it is something we need to keep a very close eye on. However, on the broader societal pressures, the Government is certainly vigilant in regard to the response on that and I outlined some of those points earlier.

I thank the team for their public service through what I suspect has been the most challenging time they have experienced as healthcare administrators and professionals. We owe them a great debt of thanks for trying to keep front-line services going. I am sure they have had sleepless nights in regard to the inability, because of the pandemic, to provide what might have been considered basic services from time to time, and I thank them for the efforts they have made to bring them back up to capacity.

I want to ask some general questions. First, what have we learned about the nursing home setting in regard to older people's mental health care as a result of the pandemic?

Mr. Jim Ryan

As the Deputy knows, we provide a broad range of services within the mental health services. We have our community services, day programmes, acute inpatient units, longer-term care units and high support processes. When the pandemic hit, obviously, one of the issues we had was around longer-term care, which is similar in some respects to nursing homes. On a community level, that support is provided to nursing homes as part of our community provision of community mental health services.

It is reasonable to say that we have learned from the pandemic that those relationships should be stronger because the issues that this has created for those who were directly involved and affected are very significant. That is one of the lessons we learned over the last six months.

Dr. Niazi might have something else to add from his recent clinical practice.

Dr. Amir Niazi

Deputy Lahart referred to learning. We were providing a domiciliary service to nursing homes, but when the pandemic hit we worked very closely with the acute sector with regard to testing, PPE and all the issues that were relevant to see what type of guidelines and policies needed to be followed when we were providing services in nursing homes. Some 80% to 90% of residents in our long-term care hostels are in the age group similar to that in the nursing homes. We were very keen to work closely with it and learn from it how we could use those policies, guidelines or protocols and implement them in our residential care facilities or our hostels. We worked very closely, even up until last week, to see every change that is recommended at the HSE for nursing homes. We try to learn from it and see how that corresponds in our residential care facilities and our hostels. We are probably a great deal more aware now of nursing home policies than we were before the pandemic.

I am not trying to catch any of the witnesses out. It is a question arising from the latest level 3 recommendations and guidelines which allow one visit per week from a family member. That must be quite traumatic. What has been learned about the nursing home setting during a pandemic from the point of view of the mental health of those in the care of the professionals? I am not trying to catch the witnesses out with errors that were made or the like. When we emerge from this and if another pandemic were to occur, what has been learned if the witnesses had all the resources at their disposal? First, can they quantify the impact of the lack of visits and the anxiety about one's mortality, which is heightened as one gets older? It is the general impact on the patient. A patient-centred response is what I am looking for in terms of the lessons.

Mr. John Meehan

The Deputy is 100% correct. As part the process with the HSE, we looked at the general public and the responses that were required for the general public. We also looked at responses to staff and healthcare staff, not only in the statutory facilities but also in the non-statutory facilities, which would include nursing homes. The Deputy is asking about what has been learned. I will refer to residents. Residents in nursing homes become a family to the residents, staff and carers. What we have learned in international practice from the evidence that is emerging is that residents in isolation, particularly in long-stay facilities, feel very anxious and experience low mood. They are also dealing with the loss of fellow residents in the family within the nursing home. Staff also may be required to isolate and many residents who are receiving care may be redeployed from other areas within it, so that was a challenge. Then there are patients who are seriously ill and dying, and the experience of separation from their loved ones and families. International experience also highlighted the devastating impact this has on patients and their families. It caused additional distress for families and friends, particularly for grieving families, during the Covid pandemic.

The HSE provided a guidance document We did that at double quick time during the Covid pandemic. As Dr. Niazi explained, later today there will be an overview of the HSE psycho-social responses, but during the intervening time when we were developing the responses, we had to quickly provide a guidance document that would help our residential facilities, which also included the nursing homes, on how to access care and provide counselling not only to staff but also to clients, and using digital supports through that. One of the positive outcomes of Covid has been the better use and the fast-tracking of how we use our digital services. Heretofore, it may have taken a great deal of time. On 3 December, when the committee spoke to general practitioners, I note they said there is nothing like face-to-face contact, but in the HSE we have had to utilise and reconfigure to provide alternatives to face-to-face contacts, which the evidence is showing is having the same outcomes as face-to-face contacts. We will always need both face-to-face contacts and development of our digital responses. That is the response the HSE gave to that in the interim.

We wish to acknowledge all residential care and nursing home colleagues, both statutory and non-statutory, for the work they have done. Hopefully, the guidance we provided to them has benefited them.

Mr. Meehan answered a question I was going to ask about the digital care. I am interested in the digital space. I do not wish to take up the time now, but perhaps he could furnish the committee with examples of digital interventions, where they are appropriate, what works, what might be coming down the tracks and what is working in the international setting. If he could do a short paper on that for us, it would be much appreciated.

I am getting closer to what I am seeking. I am probably looking for some case studies. One of the papers that was supplied to us today was a review of A Vision for Change and the mental health services. It struck me, and this is not a judgment of anybody, that elder mental healthcare is something of a poor relation of mental healthcare. I believe the pandemic will have given nursing homes a bad name and will make people fearful of the setting, not because of the level of care but because of the restrictions, rules and Government and NPHET guidance relating to visitation, isolation and so forth. As a setting it is not something any of us would wish for ourselves. I doubt that anybody, either among the witnesses or on the committee, has not had a relative or received some close examples of elderly loved ones who have been caught in that situation and find themselves incredibly isolated. Could the witnesses give a richer example of some of the narratives that have been experienced in nursing homes from a mental healthcare perspective, if that is possible?

Mr. Colm Desmond

I will set the broad scene and colleagues in the HSE might wish to give more specific examples relating to the restrictions. Obviously, the public health criterion was first and foremost setting the level of access or, unfortunately, restricted access for the safety of residents due to the international experience, which sadly was also experienced here at the early stage of the pandemic, regarding very vulnerable groups. The long-term residential care setting proved to have that level of vulnerability, as it did in other countries. In the first instance, the public health safety piece has always driven the restrictions. Over a period, various initiatives that the Department put in place quickly and urgently - this is outside my area of competence - have seen an improvement in the visitation. On the mental health piece, perhaps colleagues in the HSE have spoken about the responses that were put in place in that regard. Is that what the Deputy is seeking?

What I am looking for is some narrative or case study examples from a patient-centred perspective rather than from the HSE's perspective. What has life been like for people in nursing home settings?

How has it changed? How has that manifested itself? What have the witnesses heard that has informed the type of interventions they think need to be made? In other words, what has changed in the nursing home setting for the patient in the past nine months?

Mr. Colm Desmond

It would probably be best to give the Deputy an example by way of written response because the nursing home piece is slightly wider than the remit of my policy area, which is specifically mental health. I would welcome the opportunity to provide the Deputy with more detail on the matter following the meeting unless colleagues in the HSE would like to add further to the points I made earlier.

Mr. Jim Ryan

I think Mr. Desmond's suggestion is the most sensible and appropriate for Deputy Lahart. We have experience in our long-term care facilities which is similar to that in nursing homes, but I think it would be better if we took the Deputy's question offline and came back to him with a written response.

Okay. The Mental Health Commission review, entitled Mental Health Services for Older People, was published earlier this month. It makes for very harrowing reading. I am a fan of Dr. Rónán Collins, as I am sure are the witnesses. He is a great advocate for older people. He did his best to diminish the impact of fear and anxiety around the pandemic for older people. I recall Dr. Collins having said that 80% of those over 85 who would get the virus would survive. People found that very reassuring. The review states, "Despite the increasing elderly population, we are currently not providing a nationwide comprehensive mental health service for older people." I was struck by that. It seems to be the poor relation. How can this committee help the witnesses to improve that situation? What areas need to be improved and where are the resources needed? How did we, as a society, come to this? I do not want to create tabloid headlines. Rather, I want to highlight that the elder piece, given it is an increasing piece, is being excluded or has been ignored.

The report goes on to say:

We have highly trained and committed specialist clinicians yet we have only 66% of the recommended number of specialist teams, which themselves are only staffed at on overall level of 54%. There are only 0.26 day hospital places per 10,000 population over 65.

That is really frightening. Again, this is not a criticism of the witnesses; it is my observation. What level of resources are required? When the pandemic passes, when, I hope, we can see it in the rear-view mirror, one of the narratives will be how stigmatised older people felt. I suggest younger people felt stigmatised in their own way, but we are focusing on mental healthcare for older people. The elderly were angered at not being allowed to leave their homes even to go for a walk. Those restrictions were inhumane to some degree. They were also very paternalistic and did not pay any attention or heed to the ability of older people to exercise personal responsibility and care for themselves. They were highly impactful.

Rather than offer me HSE-speak - I mean that respectfully - I ask the witnesses to give us a broad brush of how things have changed in terms of the mental healthcare challenges facing older people since the arrival of the pandemic. What have they noticed has changed? What are the new challenges and what challenges are likely to remain post pandemic not from a service point of view but a person-centred pointed of view? What new challenges face the witnesses and how can this committee assist them in informing Government and policymakers generally of what they need to do?

Mr. Jim Ryan

In the first instance, I ask Dr. Niazi to report his experience from a clinical point of view.

Dr. Amir Niazi

I understand the Deputy's focus is patient centred. All of the services that we provide are also patient centred, but I would like to bring in a slightly different direction.

Currently, we have 32 psychiatry for later life teams in the country, which means there are 32 consultants who are leading those teams. Under A Vision for Change, each consultant looks after a catchment area population of approximately 100,000. This means for every 100,000 people there is one consultant. We need to ensure we do not lose that one consultant who is looking after people in acute psychiatric units, nursing homes and communities as well as looking after and supporting his or her team. Losing that person would have a significant impact on that 100,000 population. It is about balance. We have continued to provide the service in the past nine months, ensuring that people are protected and teams are available to provide the services. We know from the agencies and so on that it has been very difficult to recruit consultants in these times.

The Deputy needs to understand the difficulties that we face in making sure that the teams are on the ground providing services. We found the best way of doing this was to use the digital platform. Rather that one consultant in a catchment area visiting two nursing homes and then providing services, bearing in mind the travel time involved, consultants were able to provide more services from their offices virtually than they could have done in face-to-face or domiciliary visits.

If the mental health component from the pandemic is removed, internationally, what we heard whenever a pandemic broke out in a nursing home was that so many people were infected and the mortality rate was significantly higher. That cause fear, anxiety and depression. The Mental Health Commission undertook a review of the work done by the HSE over recent years to come up with a model of care, which was published in February this year. It recommends that, acute psychiatric services aside, we should have a service that provides consultant-led support to nursing homes and consultant-led support in acute hospitals. We will be working with our colleagues in the Department of Health in that regard.

Workforce planning was a huge challenge in terms of recruiting and training staff for placements. Even if we had money today, I do not think we would be able to recruit staff for all of those posts. We need to strike a balance. We need money but at the same time we need a plan for the next five or ten years on how we build out capacity to recruit consultants and the necessary teams. There needs to be a significant focus on this issue. Mental health has drawn significant focus during the pandemic. The support we have seen from Government and across the board from Members and colleagues in the Department of Health in terms of support for mental health reflects that. That is the best I can say.

I will rephrase the question. If I am a resident in a nursing home, what has changed for me daily since February?

Mr. Jim Ryan

A few things have changed. For example, the type of supports that would have been in place around people going into nursing homes to do residents' hair or nails or to entertain them have been ceased. Understandably, this will have an impact on residents' feelings about their wellness. As mentioned by Mr. Desmond, this is slightly outside of our area. It is more an issue on the nursing home side. However, we want to ensure we provide a mental health service to those who need it and mental health and well-being for those need it. We have to try to separate them out. We are aware of the type of issues that will affect people's mood and well-being.

This tells us that the communications, connections and collaborations we have with our colleagues in the nursing home sector must be strengthened. We must also recognise that communities, which have done so much with the residences, provide a vital element of support which no statutory service is fully able to deliver.

Mr. John Meehan

Deputy Lahart is trying to get to the learning from the real issues that have been developing. I was involved in the psychosocial response to the pandemic. I can only provide the Deputy with anecdotal evidence that has come from the HSE up. There is obviously evidence and ongoing research with regard to the effects, such as loneliness and separation, particularly in nursing homes with a family-type atmosphere where there may be a fear of dying because other residents have passed away due to Covid. There is also a fear of the unknown. A social worker who was part of the psychosocial group and linked directly with residential care including nursing homes highlighted the importance of communication. As Mr. Ryan stated, residents' communication with their family and loved ones was very important because nursing homes became bubbles as a result of the NPHET guidance to go into lockdown for fear of the spread of coronavirus. The subsequent psychological first aid intervention online and in person as restrictions lessened was very helpful. At the beginning, t was necessary for those with elderly relatives or friends to apply from afar the common touch in terms of communicating with them, reassuring them and listening to any challenges. As restrictions decreased, that could be done on a one-to-one basis. I have been visiting two 80-year-olds who are in nursing homes and their use of technology to communicate with their loved ones on the other side of the Atlantic has been very positive. There are those who say that older people will not get into the new digital era. If we support them and if nursing homes, both statutory and voluntary, support them, we can bridge that divide in an appropriate fashion. We like to think that the support we provide to nursing homes is equivalent to the support we would expect a member of our family to be afforded if they were in a nursing home. Research is ongoing in order that lessons can be learned and responses made in the future. Those are anecdotal observations. I hope I have in some way provided the answers the Deputy is looking for. I think he is seeking answers regarding the emotional impact and what is happening on the ground in real time.

The committee will take everything into consideration, but one thing that strikes me is that the witnesses separated the nursing homes piece from the HSE piece in terms of elder care. That surprises me. In terms of responsibility, I would have thought elder care was elder care and that the nursing home setting would be a big focus for the HSE. I did not intend to focus exclusively on the nursing home piece because there were other questions I wished to ask. It am surprised that the witnesses stated that this issue is more a nursing home piece than a HSE piece.

Mr. Colm Desmond

It is not so much that it is a nursing home piece rather than a HSE piece, it is about recognising the variety of nursing homes settings, which span public and private provision. It is wider than the mental health subject matter but the HSE and the Department were very much to the fore in stepping forward in terms of putting in place appropriate responses for the nursing home sector in the early stage of the pandemic when the international trend sadly began to be manifested here. The Department worked very closely with the sector, the various experts and the HSE in the field to do that. That has been the subject of more detailed presentations to the Oireachtas. For the facts relating to that response, I would refer the committee to those presentations because they illustrate the broader nursing home long-term elderly care perspective better than our particular subject focus, namely, the mental health piece, which is, admittedly, very important.

The Deputy referred to potential stigmatisation and anger in the context of the experience of older persons. The approach was always guided by recommendations for individual safety in the first instance. I do think the health service, including the Department and the HSE, owes a significant debt of gratitude to the daily contacts of older people, with the obvious such contacts being general practitioners, community nurses and so on, as well as family members. Of course, not every older person necessarily has that sort of family support, depending on their circumstances. It has been very much a cross-sectoral response to assist elderly in the community but it has been guided by the public health safety aspects in the first instance. As the Deputy alluded to, we have learned, over the very short period that seemed like a very long period for everybody because of what has happened, how to manage and assist the elderly population more widely to keep their contact up in society by setting aside guidance for particular times in which they can and should go to public spaces for exercise and general movement. I wish to make that general respect and support point which is challenging for everybody but which is to the forefront of the minds of those who deal with the elderly, both in the community in general and also within specific settings where they have particular needs.

One of the aspects that struck me in the review of A Vision for Change with regard to the mental health of older people was the statement that a range of programmes in other countries that target particular at-risk groups, including older people, had been identified. Can the witnesses provide examples of international best practice which we are not following now because we do not have the necessary resources but from which we could learn? What can the committee do in that regard? I am seeking examples of international best practice for at-risk groups, specifically older people.

Mr. Colm Desmond

A significant amount of research has been carried out on that area. We will provide more detail by way of a written explanation of the research that was done. The research was published as part of the overall launch of the new policy. Unless my colleagues wish to contribute on this issue, I would prefer to provide the Deputy with a more detailed explanation of the international research and the lessons it pointed to for us.

When Mr. John Saunders comes before the committee, we can look at that issue from our side. We will hold a session on that issue.

I ask the Chairman to recap the papers the witnesses have promised to send to the committee.

The first issue relates to IT and digital. The other relates to the real life experience. I ask the witnesses to provide the committee with further information relating to digital information and the models that exist in that regard, as well as the experience of patients, particularly older persons.

We want to work with the witnesses, so they should let us know what they need from us to support them in their work and we will do our best. I thank them for giving of their time today and for their helpful contributions.

We will adjourn until 9 a.m. on Thursday, 17 December when the committee will meet representatives of the College of Psychiatrists of Ireland, the Irish Medical Organisation and the Psychiatric Nurses Association to discuss access and continuity of care at acute and specialist levels.

The joint sub-committee adjourned at 11 a.m. until 9 a.m. on Thursday, 17 December 2020.