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

I welcome the witnesses and thank them for joining us. I have taken the Chair in the unavoidable absence of Senator Black. The format of the meeting is that each witness will have a few minutes to make a presentation, followed by questions and answers. Normally, the time limits would be very strict, but given that this is a sub-committee, we can be a bit more flexible.

I welcome Dr. William Flannery, Ms Jeanine Webster, Mr. Peter Hughes, Ms Aisling Culhane and Dr. Matthew Sadlier. I invite Dr. Flannery to make his opening statement.

Dr. William Flannery

I am delighted to have been granted the additional time because I ran a little over the limit earlier when I was preparing for my presentation. I thank the members of the sub-committee for their interest in mental health and mental illness, as has been deduced.

I am the president of the College of Psychiatrists of Ireland. I am a doctor and specialist in psychiatry and am employed by the HSE as a consultant psychiatrist treating those who are marginalised with an addiction in inner city Dublin, where I work in the same services as Dr. Sadlier. Also speaking for the college is Ms Jeanine Webster, who is a member of the college's REFOCUS committee. REFOCUS stands for "recovery experience forum of carers and users of services". It is our patient, service user and family member committee, which also includes psychiatrists.

The college was formed in 2009 and is the only professional body for psychiatrists in the country. Our mission, of which I am very proud, is to promote excellence in the practice of psychiatry, at the heart of which is training and recruitment and retention. A trainee in psychiatry holds two contracts, namely, a contract with his or her employer, the HSE, and a learning agreement with us, the college. I will focus on training, whereas the numbers that need to be trained, or recruited, and their experience of employment, or retention, are matters for the HSE. To support the work of the HSE, the college strongly advocates for the appointment of a chief psychiatrist in the Department of Health and a national director for mental health, both of which are in the programme for Government.

The first step to becoming a psychiatrist is to go to medical school and then to complete an intern year. After that, one can start training to become a specialist in psychiatry, which takes at least seven years. While working as a doctor, the training over those years comprises workplace-based assessments with a consulting trainer, placements in various settings, professional examinations and an annual review of progress. Besides consultant trainers, training is delivered through the college by a dean of education, chief examiner, vice deans and mentors.

Besides consultant trainers, training is delivered through the college by a dean of education, a chief examiner, vice deans and mentors. The college is accredited for training by the Medical Council and in turn the college accredits centres for training. Upon successful completion of this, the doctor is entitled to be registered with the Medical Council as a specialist in the practice of psychiatry.

I am very proud of our training and the standards we set. We usually top the annual Medical Council survey of trainee experience entitled Your Training Counts, and entry to training is competitive meaning more doctors apply to train with us than we have training spaces. The cost to the college for training is €1.9 million a year but we receive €1.2 million a year from the HSE to cover that cost. The balance comes from membership subscriptions. The college gets the least amount of funding for training when compared to other medical bodies. This is not sustainable, particularly if we want to recruit more trainees into psychiatry.

As to current numbers, the college is allowed to recruit about 60 new trainees a year and there are about 350 trainees currently. There are just under 600 consultant psychiatric posts, but just under 100 of those are either vacant or filled by a non-specialist. As to future numbers, the number of trainees is determined by planning for consultant numbers into the future. Much work has been done on this by the national doctors training and planning, NDTP, unit of the HSE, HSE mental health division, the mental health unit of the Department of Health, and of course ourselves. There is a draft document outlining the psychiatric medical workforce needed for the next ten years. I am told this has been signed off by the NDTP and now rests with the chief clinical officer. We have an estimated number of just over 800 consultant posts needed for 2030.

The next step is to estimate the number of trainees that need to be recruited. Training is about treating and working with patients, their families and carers. It is a collaborative experience. REFOCUS, which is part of the structure of our college and central to many aspects of training, plays a key role in giving the lived experience to our trainees and also in continuing professional development for specialist members. With that, I am delighted to hand over to Ms Jeannine Webster who will speak to the committee.

Ms Jeannine Webster

I thank members for giving me the opportunity to outline my family’s experience of mental health problems. I am a mother of three, a midwife to many and a carer to an exceptional young man, my son James. I have been a member of the College of Psychiatrists REFOCUS committee for ten years.

James has had a diagnosis of schizoaffective disorder since the age of 15. James first became unwell in 2006 when he began to hear voices. He was referred to CAMHS. This was, overall, a positive experience although it involved two admissions to an adult mental health unit. A multidisciplinary approach was adopted in his care which involved not only his psychiatrist, psychologist, psychiatric nurse, medical social worker and occupational therapist, OT, but also, importantly, his family.

At the age of 18, James’s care was transferred to the public adult mental health services. At the time, the adult services were a stark contrast to CAMHS for us. His care was disjointed and lacked continuity of any sort, and the multidisciplinary team, MDT, approach diminished to just input from his doctors and psychiatric nurses. Many of the gains James had made through the adolescent services disappeared.

After two years and a deterioration in his mental health, James, who was five years into his diagnosis, was transferred to private healthcare. Although continuity returned, he entered a revolving door of admission and discharge, because outpatient community support to maintain his progress was not available. The responsibility of being psychiatrist, psychologist, nurse, social worker and OT, fell to me, as his mother, and to his family. Family dynamics changed and relationships became stressful and fraught with tension and sometimes despair.

In 2018 James returned to public adult mental health services, the same practice he entered at the age of 18, however, it was now a very different service. James attempted to take his own life not long after his transfer. Our experience of his care since has been transformative. Like the MDT approach, which framed his adolescent experience, James's care included not only medical input from psychiatrists, psychologists and psychiatric nurses, but also as he needed it, peer support and an individual placement and support, IPS, worker. This transformative and supportive approach meant that last February James undertook his first job. This is something we never envisaged two years ago. Importantly, I have been able to revert to my role as his mother.

How can our family experience inform the future development of psychiatric services? Access to the right person, the right care, at the right time is key and continuity of care and carer is essential. A multidisciplinary approach enhances psychiatric care, and supports the patient and the consultant's team. As a cautionary note, during the Covid pandemic this continuity diminished greatly, and it is obvious that services are under increased pressure. It is important that those with severe and enduring mental illness, like James, are not forgotten and continue to have the input and support required to maintain them at a level of wellness which is needed to lead a fulfilling life. James has not seen a mental health professional in person in ten months.

I thank Ms Webster for sharing her very personal story with us. Her testimony is extremely powerful. We thank her and really appreciate it. I call on Mr. Hughes to share his experience with us.

Mr. Peter Hughes

I am general secretary of the Psychiatric Nurses Association, PNA, and I am joined by my colleague Ms Aisling Culhane, who is the research and development officer with the association. We represent the vast majority of psychiatric nurses in the country. I thank members for the invitation to address the committee this morning.

I want to raise our concern about the mental health budget. Despite all the concerns expressed regarding the impact of Covid-19 on the mental health of the community, no extra funding was allocated for mental health in the HSE’s winter plan. Several weeks later an extra €4 billion in spending was allocated to the health budget for 2021, with just €50 million allocated to mental health. Of this €50 million it emerged that €12 million was to support existing levels of services. This equates to mental health receiving less than 1% of the overall €4 billion budget increase.

The health budget is now €20 billion, including the additional €4 billion, and of this, mental health has a budget allocation of €1 billion. This means the mental health budget has been reduced from just over 6% to 5% of the overall health budget. Reducing the budget by 1% is incomprehensible and a retrograde step, especially when it comes just four months after the launch of the latest ten year Government strategy entitled Sharing the Vision. The PNA has always been a strong advocate for the implementation of Government policy on mental health, and has endorsed and supported the move from residential services to comprehensive patient centred community based services.

It is important to address the matter of policy from a sequential perspective, noting that Sharing the Vision builds on its predecessor, A Vision for Change. In this regard the committee may note that the recommendations of A Vision for Change have never been achieved in relation to the development of services. The definitive PNA and RCSI 2016 review of A Vision for Change concluded that only 30% of the promised community developments were delivered, yet 76% of the beds were removed from the services. We continue to have the third lowest number of psychiatric beds per 100,000 population in the EU, with only Cyprus and Italy having fewer. Some of the knock-on effects of this include: 120% bed capacity in some acute admission units; 12.3% of acute beds being occupied by patients who are resident for six months or longer; and a high proportion of people with mental illness in prison, of which the recent report by the European Committee for the Prevention of Torture was highly critical.

It is evident that the necessary agreed closure of inpatient beds has not coincided with a well-developed and resourced comprehensive community-based alternative in line with national policy. Indeed, in its February report, Access to Acute Mental Health Beds in Ireland, the Mental Health Commission cites "an almost total absence of crisis houses, intensive care high support hostels, rehabilitation high support hostels and specialist rehabilitation units in each mental health area". At our conference last month Mr. John Farrelly, CEO of the Mental Health Commission, noted that "creating a proper evidence based integrated community health care system must be the primary goal of our generation".

We also have a responsibility for future generations, which leads me to highlight the deficits and under-investment in the child and adolescent mental health services, CAMHS. These inadequacies have severe consequences for service users, families and staff throughout the country. Once again, A Vision for Change recommended one day hospital per 300,000 population, which currently leaves a shortfall of 12 day hospitals nationally. It also recommended 100 beds nationally, of which only 74 are operational. The multidisciplinary teams remain inadequately resourced and the present waiting list for CAMHS is 2,200. To address the inadequacies regarding the delivery of CAMHS, the following are required: full provision of CAMHS day hospitals; full provision of the 100 recommended beds; and the provision of small regional, units. Fully resourced multidisciplinary teams and pathways of support need to be examined, such as 24-7 crisis support and the provision of a network mental health nurse at primary care level. We also endorse the proposal of the Youth Mental Health Task Force report cited in Sharing the Vision, which recommends the age range for eligibility for CAMHS be increased to 25 years of age in order to improve continuity of care and ease the transition.

Having regard to specialist training, some members may be aware that the 1998 Commission on Nursing expressed the view that we should have a distinct pre-registration education programme for psychiatric nursing. Today, psychiatric nursing in Ireland is an internationally regarded module-based degree programme. Psychiatric nursing is continuously adapting to policy and service user needs, which are underpinned in mental health legislation. This programme provides an excellent foundation for the complexities in the nursing role.

In the present climate, fresh ideas are emerging that provide a vocabulary for the need to recognise the community dimension to mental health, and the mental health dimension to public health. Nurses encounter persons with mental health problems and mental illnesses in all areas of healthcare, such as people with depression after surgery, drug induced psychosis, or a person suffering from a crisis with post-traumatic stress symptoms. Covid-19 presents additional challenges, including fear of the virus itself, collective grief, prolonged physical distancing and associated isolation, which compound the impact on our psyches. A critical part of the psychiatric or mental health nurse’s role is helping people recognise mental disorders, seeking assistance with the same urgency as any other health condition and making recovery the expectation. While there will always be a requirement to provide acute inpatient facilities, the future of psychiatric or mental health nursing has to concern itself with leading the development and integration of mental health in primary care.

The primary focus for mental health, both within Sláintecare and Sharing the Vision, is the need to integrate services in a dynamic and robust fashion. This integration is at present missing between mental health services and primary care. To bridge the gaps between these services we assert the need for a mental health care network nurse, which would facilitate the integration of care in the community while working within the primary care team. This will allow for a more seamless delivery of designated care across each multidisciplinary team and contribute to the facilitation of a lifespan or chronological approach across all locations of care.

In the context of reframing mental health with the associated priorities of our national health policies, A Vision for Change 2006, Sharing the Vision 2020 and Sláintecare, we need to emphasise the care gap for people affected by mental disorders, the quality gap, which is the quality of care received by people with mental disorders, and the prevention gap, that is, the coverage of interventions that target the risk factors for mental disorders. Having regard to the that, I will leave the committee with these key messages. Current research suggests that by the age of 13, one in three young children in Ireland is likely to have experienced some type of mental disorder. By the age of 24 that rate will have increased to over one in two. Clearly, time is not on our side to address this crisis. The mental health share of the budget has to be at a minimum the percentage recommended in Sláintecare, which is 10%. Notwithstanding that, all evidence shows that mental health must have parity of esteem with physical healthcare. Psychiatric or mental health nursing is intrinsic to an enhanced, comprehensive and community-based mental health service. Collaboration, human interaction and the working alliance between nurse and service user are integral to a service that offers respect, compassion, equity and hope.

I thank Mr. Hughes. I call Dr. Sadlier.

Dr. Matthew Sadlier

I am representing the Irish Medical Organisation. We welcome the opportunity to discuss issues around acute mental health services. Today I will focus on the following three areas: deficits in manpower and bed capacity; issues resulting from the governance model in certain areas of the mental health services; and the need to better integrate mental health services into the wider healthcare service.

On medical manpower and bed capacity deficits, the consultant and multidisciplinary team staffing deficits across our community and hospital-based mental health teams have been highlighted to this committee on a number of occasions, as well as by my colleagues who presented before me. In 2018, the report of the Public Sector Pay Commission recognised the need to address the two-tier consultant pay issue that has directly contributed to the current consultant crisis, which is particularly visible within psychiatry where a third of consultant posts are either vacant or filled on a temporary basis. This is the highest for any specialty within medicine. In addition to medical staffing shortages, there is also a shortage of inpatient psychiatric beds. Currently there are just over 1,000 acute adult beds which operate at almost 90% capacity. That is well above safe occupancy levels, which are estimated to be around 80%.

While A Vision for Change has seen an overall shift in the delivery of care to a community outpatient-based model there is still and, critically, always will be a need for acute inpatient beds within the mental health service. Patients will continue to present in crisis and will need admission. Despite this, psychiatric inpatient beds were excluded from the health service capacity review in 2018. Covid-19 has had a dramatic impact on the availability of psychiatric inpatient beds. In recent months we have had a number of acute units closed for admission for a period in order to manage outbreaks, as well as a reduction in beds to facilitate infection control guidance. Despite this, there was very little attempt by the Government or the HSE to increase the provision of acute psychiatric beds or to provide any emergency alternatives. While additional resources were provided across the hospital, primary care and long-term care services to support the continuity of healthcare provision during Covid-19 in the HSE winter plan, in psychiatry the services have been expected to carry on as usual with the limited resources already in place. If similar closures and bed reductions had happened in the acute medical sector the response from the Government and the HSE would have been of a very different nature.

The governance model for mental health services has created a number of difficulties within the service that those working on the front line experience on a daily basis. Over the past 15 years, since publication of A Vision for Change, we have seen significant changes in mental health service provision, with the creation of a mental health division and the governance of mental health services moved under the remit of the community health organisations, CHOs. At the same time, however, there has been a national policy to move acute inpatient psychiatric units to the campus of general hospitals. This co-location was advised in order that patients requiring care would have access to the diagnostic and therapeutic services of the general hospital. However, what has happened in practice in many areas is that due to the split governance model whereby the psychiatric unit is under the control of the CHO, but in a unit that is under the control of a hospital, we have created a "hospital within a hospital". The general hospitals did not receive a significant boost to their budget to accommodate the additional patients because of the psychiatric unit being on site and they are not able to provide the services that it was envisaged that the unit would receive. The situation has been more acutely highlighted during the Covid-19 pandemic. I refer to difficulties with separate infection control policies, different occupational health services and testing protocols and a lack of communication between the two units on the same campus. That has potentially placed patients at risk, especially during this very difficult time.

My final point relates to the integration of mental healthcare with the wider healthcare system. As the IMO represents doctors from all specialties, this is an issue that has been highlighted at our committee meetings over a period. Overall, there is a greater need to improve the integration of mental healthcare into the wider healthcare system. Patients with chronic and enduring mental illness have a much greater mortality than the rest of society. This is largely due to co-morbidities and access to healthcare rather than due to the direct effects of their mental illness or disorder. Problems such as cardiovascular disease, diabetes and hormonal difficulties are more prevalent in this population than in the general population.

Mental illness is also a physical illness, which is something that has often been overlooked in national policy and reports. Patients who attend mental health services require access to ongoing diagnostic and other medical facilities such as scanning and blood tests. As psychiatric care improves, this puts a further demand on services such as access to diagnostics. Many medications and treatments that are prescribed to patients require long-term medical monitoring and blood tests being carried out at regular intervals, yet access to diagnostics and medical care is largely absent from both A Vision for Change and Sharing the Vision and have never been a priority despite this being one of the reasons for greater mortality in this patient group. The need for mental health services to access diagnostics and medical care is most needed for my specialty, the psychiatry of old age. This was highlighted in the recent report from the Mental Health Commission on mental health services for older people and has recognised the need to better integrate the psychiatry of old age with the integrated care programme for older people and the national clinical programme for older people.

Finally, the issue that is often raised at our committee relates to urgent psychiatric care in emergency departments. There are more than 12,000 presentations to emergency departments every year for self-harm alone, which is only a fraction of the presentations that arrive at emergency departments. Despite many policy attempts to divert these assessments away from emergency departments, this has not been successful and, in fairness, it is unlikely it ever will be. People attend emergency departments when they are in crisis and often they do not realise they are in crisis until they are in a crisis. As such, the emergency departments should be able to cope with this patient group and their assessment. This would include having adequate buildings and staffing to provide timely assessment and care for psychiatric assessment. It would also mean having an integrated patient record system that would allow for sharing of information from the community mental health team to the emergency department and vice versa. It is very important to have bespoke key performance indicators, KPIs, for patients that attend emergency departments with mental health issues. I fully understand the need for emergency departments to have KPIs on a four-hour turnaround for patients to be seen. That is probably adequate for someone who has attended with a broken leg, but a psychiatric assessment takes longer and it puts a lot of pressure on the services to discharge people from the emergency department and it can often create a pressure that leads to inappropriate admissions.

To summarise, what we are looking for is the urgent implementation of measures to address the recruitment and retention of consultants across the health system. This includes specifically addressing the two-tier consultant pay issue. We must fully resource community and hospital-based mental healthcare teams in line with the recommendations of A Vision for Change. We must urgently assess the number of acute inpatient psychiatric beds required to ensure timely admission of patients presenting with acute psychiatric illness. We must also address the governance model to ensure inpatient psychiatric units have access to the necessary services in their co-located general hospital. We seek to better integrate the mental healthcare services into the physical healthcare services. We call for the roll-out of the national patient identifier and the electronic shared care record, as per the 2019 GP agreement. I thank committee members for their time. I look forward to answering any questions.

I thank Dr. Sadlier. The structure of the question and answer session is that each member has ten minutes in which to put the questions and to get the answers.

I thank the witnesses for their comprehensive statements. Each of them could have had a stand-alone committee given the merits of the issues they raised. In my limited time I will pose three questions and then make a statement and rather than go back and forth, the witnesses can respond at the end.

My first question is for Dr. Sadlier. He referred to the 12,000 people every year who present to emergency departments following self-harm. I have anecdotal evidence from people in my area of Dublin Mid-West who turn up at accident and emergency departments at night. They feel they do not get the care they need. They are often either turned away or they are seen and discharged very quickly without any follow-up care. There seems to be a big gap in the services. I have a couple of questions in that regard. It is not appropriate to have 12,000 people presenting in accident and emergency departments. Is this the main access route to acute mental health services? Are there health systems we can examine that do this better? I am very interested in hearing a response to the question. What is the ideal pathway out of acute inpatient care? Do we have the community resources to support people when they are released? What do we need to do in that regard? We have moved away from acute beds and we were meant to get comprehensive community care to go with that, but it has not happened. All the evidence points to that being the case. I am interested to get a response to that question.

The second question is for Mr. Hughes and relates to the budget he spoke about. He outlined that Sláintecare calls for a minimum of 10% of the health budget to be provided for mental health. We are in the middle of a pandemic and at the special meetings on Covid and mental health we have heard about a tsunami of people presenting with mental health issues.

Many of our services are at full capacity. It is really worrying that the overall health budget has been reduced from 6%, which is inadequate, to 5%.

The delegates mentioned that all the evidence indicates there should be parity of esteem between mental and physical health services. Does Dr. Sadlier believe this will happen if the budget is not appropriate? As Dr. Sadlier is aware, Sinn Féin has a Bill on Committee Stage calling for parity of esteem between the services. I will probably be touching base with the delegates before Committee Stage. I might be looking for witnesses to talk about it.

There was no reference to mental health in the winter plan. We are slap bang in the middle of a pandemic in which people are crying out for help, but mental health services are at full capacity. My point, therefore, is on the budget and parity of esteem. Do the witnesses believe we will ever have parity of esteem between mental and physical health services if the budget is not increased to provide the required services?

I am asking my next question as a layperson. Mr. Hughes mentioned that there are a number of consultant psychiatrist posts filled by non-specialists. In layman's terms, what does this mean? Why is it the case? What is the impact on the service? Mr. Hughes gave a figure of 100. He also said approximately 800 posts will need to be filled by 2030. How confident is he that this will happen in the current system? What changes can be made now that will allow it to happen?

I thank Ms Webster for her very honest testimony. I always love to hear about people's lived experience in their testimonies. She seems to have been a multidisciplinary team on her own in respect of many of the services that James was not getting at the right time. As she said, the right person at the right time is key. She also said that while one can have all the statistics and evidence, she and her family were subject to a ripple effect. It was important to hear that because it sometimes gets lost in statements and statistics.

Ms Webster pointed out what was really missing in the care James was getting, that is, continuity of care between youth and adult mental health services. There does not seem to be any joined-up thinking between the adolescent and adult mental health services. Could the witnesses put anything in place in this regard? What do they recommend? How would it work and what could we put in place that would ensure continuity of care so people like James would get the healthcare they need when they need it?

I thank Deputy Ward for his questions. Dr. Sadlier can kick off, followed by Mr. Hughes. If any of the other witnesses wish to contribute, they should feel free to do so.

Dr. Matthew Sadlier

I thank the Deputy for those questions. Regarding the emergency department presentations, the difficulty is that if there are 12,000 cases in which people have unfortunately self-harmed, almost all will require some degree of physical healthcare as well as mental healthcare. This is the case if they have taken an overdose or unfortunately inflicted a wound on themselves. Therefore, the concept of completely moving mental healthcare off the site of a general hospital is not necessarily to the benefit of the patient because, quite often, many need two types of care at the same time. My opinion and that of my organisation is that the best way to solve this is to have a specific area within every emergency department that has adequate provisions to allow for a proper assessment. It is a question of changing the key performance indicators according to which the emergency department is run, which are such that patients have to be in and out within a certain time. I believe it is four hours. That timeframe is completely inappropriate for a psychiatric assessment, as we know. A psychiatric assessment takes longer than the assessment of a broken leg or finger, for example. The patients often require the suturing of a wound or treatment for an overdose and then they require a mental health assessment, which means their time in the emergency department is longer. Emergency staff come under pressure because they will get some sort of punishment from management if they do not move the patient on within the very restricted timeline. This means there is pressure to discharge the patient or admit him or her to a ward. If the staff had a bespoke set of key performance indicators for the patient group, it would be much more beneficial.

The other point concerns how one improves continuity of care between the emergency department and the community mental health service. This relates to one of the issues concerning the transition from adolescent mental health services to adult mental health services, which is that we need an electronic patient record across all healthcare services. I do not know how many of these committees I have to attend to say this. Reform keeps coming in other areas while this is the one simple thing that we could do to improve the care of every patient in this country. If in the Mater I see a patient who has been in St. Vincent's Hospital in Fairview, which is literally two miles away, I have no ability to gain access to his or her records at 2 o'clock in the morning. We have no ability to access any of the patient's history. One has to start from scratch every single time one sees a patient. In this era of information technology, in which I can log on to my bank account and find bank statements dating back years, how can we not organise this? Having the records available would make the transition between all the different parts of the service so much easier. We would be able to access the information. If a patient came to see me at 2 o'clock in the morning, I would be able to access his or her records and know his or her problem, previous medication, what has been tried and what has not worked, etc. At the moment, patients are constantly being assessed as if it were the first time they ever met a health professional despite the fact they may have been availing of the service for many years. I will pass over to my colleague.

Mr. Peter Hughes

I concur with Dr. Sadlier on the necessity of an electronic patient record for the transition of care and continuity of care. No matter where a patient arrives from, the record should be easily accessible.

I will refer to the question on the budget. In the 1970s, 30% of the health budget was for the mental health services but in 1984 we saw, in the Government policy Planning for the Future, the deinstitutionalisation of the mental health services to a more community-based service. At that time, many beds were closed. Once again, the promised community developments did not materialise. Over time, the budget for mental health services has reduced. Regarding A Vision for Change in 2006, our own research indicated a reduction in beds, with only 30% of the community services put in place. One could conclude, therefore, that mental health budgeting has been used as a cost-saving mechanism in Government policies over the years because the funding has reduced in line with the bed reduction. We are not advocating an increase in beds; we are mainly advocating a comprehensive 24-7 crisis-intervention service and the honouring of all the promises that were in A Vision for Change but not delivered on, including promises related to rehabilitation, assertive outreach teams and intensive-care rehabilitation units. The policy needs to be delivered on from now on. It will obviously require an increase in the budget. The ultimate goal is parity of esteem between mental and physical health services. As outlined, one in four people will develop a mental health disorder.

One in four people should equate to 25% of budget, but we are down to 5%. It is incredible that the percentage for the mental health budget has been reduced during a pandemic. We did not get included in the winter plan. As mentioned earlier, some of our beds needed to be restricted because of the structure and social distancing. However, no emergency beds were made available in the mental health services.

We always look for parity of esteem, but it will need a significant increase in budget. Mental health needs to be taken seriously. We need to invest. We need to get the services that have been promised in policy after policy. Mental health does not stop at 5 p.m. It needs 24-7 crisis intervention which has been common practice in the UK, Canada and Australia for the past 30 years. It is incredible that we do not have one 24-hour crisis intervention service in this country. My colleague, Aisling Culhane, may wish to add to that.

Ms Aisling Culhane

I endorse what previous speakers, including Mr. Hughes, said. The issue of transitioning of care is incredible. My background is in child and adolescent mental health even though I work now with the Psychiatric Nurses Association. The transitioning piece has been an issue for some time. As human beings we are complex individuals and need a multiplicity of care. With the stepped approach an individual comes to a health service, physical or mental, at a certain level. Irrespective of whether it is a mental health issue, diabetes or chronic airways issues, if we ignore treatment at that point, we increase the complexity of the issue which, as some of our colleagues have mentioned here, causes crises further down the road.

This is obvious stuff for how we step our health services. We need a stepped approach involving the least level of complexity and integrated patient records irrespective of whether it is a child, adult or older person. That is the common thread from all colleagues who have spoken this morning. I have listened to discussion about pandemics and vaccinations and what kind of IT system is required. As Dr. Sadlier said, some people need to move from south Offaly to Tipperary, to an acute system in Kilkenny and maybe over to Clare in a crisis at 2 a.m. without a health record. We need to get real in some of this stuff.

We come from various professions, but there is a commonality in our approach.

Ms Jeannine Webster

When giving testimony like this, it is hard to get across some of the issues. One of them is the transition from CAMHS to the adult mental health services. In my statement I think I said that James was 18 when he first experienced mental health problems. He was, of course, 15 years of age, which meant he was part of the CAMHS for up to three years. That transition was very rough. The people on the CAMHS side were all ready to transfer and had everything done, but the adult service was very overstretched at the time and that is where it probably did not go so well. It was not a very well supported service. As a family we were left floundering and on the outside. In his adolescent care, he was part of this team and when he went into an adult service it was the opposite, which brings its own frustrations. We need to make that transition smoother.

We had the experience of attendance at the emergency room, ER, when he attempted to take his own life. He was left in an emergency room until he slept off what he had taken with no input. That went on for hours. I had to take him home and then engage with the psychiatric services the following morning once I felt we were safe.

Regarding electronic records, when James transferred from service to service or in his accident and emergency department admission, it was inadequate to have one piece of paper describing an individual's care for five years. Even when he went from the private service back into the public service, he just had a two-page letter. That really needs to be addressed.

Dr. William Flannery

I wish to speak about three items: the definition of specialist consultant; the number of consultants at the moment; and the future. The definitions are hard to follow in a way. To be a practising doctor it is necessary to be on the medical register, which has four divisions based on level of competency and whether a doctor is training or non-training. One of those divisions is the specialist register and there is a list of specialties, including four for psychiatry. I call myself a specialist in adult psychiatry because I am licensed to practice and am registered with the Medical Council under that category. I am also employed as a consultant. A consultant is what is defined on one's contract. In other words, one holds the position of consultant following competitive interview. Therefore, it depends on the employer; in my case the HSE employs me. It is not required to employ a specialist and sometimes it does not do so for a variety of reasons.

I hope that explains some of the definitions. They are hard to follow. If members have any further questions, they should feel free to come to me. For a patient, particularly one who is unwell, it can be confusing as to whether it is a specialist, a consultant or a trainee.

Just under 600 people have a licence to practise as a specialist in psychiatry. I believe approximately 450 are employed by the HSE. Of the just under 100 places I mentioned, those are within the HSE. The other numbers are in the private sector, the voluntary sector and other areas. We have all mentioned IT and transparency. It is a very hard and complex process to get the numbers. In fairness to those in the HSE mental health services, they have spent months if not longer to allow me to say with some level of confidence what those numbers are. The systems behind this are not up to the speed that they should be. That is one of the reasons we support the programme for Government call for a national director within mental health. I feel that is tied into all this.

As to the future, the document exists, and it would be nice to see it fully launched. It is going through the HSE processes and I would be grateful if the committee would support and advocate for that. At least we will then have a number and we can work backwards from that from a training point of view. If someone is working in an area where there is no bed and is turning people away from an emergency department, ED, it is not nice for the patient or for us. That is the bigger piece. We are in an international market. We recruit about the same number as we would internationally. If we want more, it will be difficult and that comes down to the quality of the training and work experience.

Regarding delivery of service, some of the speakers have mentioned the high rates of mental illness in the prison system. Those people with mental illness in that system are treated by forensic psychiatrists. It is good to note that hopefully the National Forensic Mental Health Service Hospital will move and there will be increased capacity. We have a training path specifically for forensic psychiatrists who want to work in that area. They are recognised as a specialty in their own right elsewhere but not in this jurisdiction. We are working with the Medical Council to get that over the line for two reasons. The main one is to get the right care at the right time, so that the people who are trained in this area can treat the people with mental illness in that area. There appear to be struggles in the Medical Council's process to get this over the line and I would welcome further discussion and support for this.

I thank the witnesses for their contributions. We live in surreal times with regard to the pandemic and when people need each other probably more than ever for social interaction, with social isolation and what Covid-19 has done to society, mental health services and our public health system are needed more than ever. The services have stepped up to the plate, to the front line of Covid and the grimness that comes with it. People who are watching this testimony are appreciative of what is happening in our health service when people need it the most.

On retention and recruitment, I know Mr. Peter Hughes from the Psychiatric Nurses Association spoke to the Committee on Future of Mental Health Care last year. I was struck by what he said about retention and recruitment of psychiatric nurses. There seems to be a crisis with regard to retaining and recruiting them. How are we at present with regard to recruiting and retaining nurses in the psychiatric services?

Mr. Peter Hughes

Recruitment and retention remain a problem with psychiatric nurses. There is still substantial reliance on overtime and agency staff, and on retired staff coming back to work part-time in the services. As things stand, if A Vision for Change was to be implemented, we reckon it would require a further 1,200 nurses. Regarding what Dr. Flannery said about forensic services moving from Dundrum to the new state-of-the-art service in Portrane, there is a shortfall of 200 nurses to open that. There is a 170 bed campus but it is envisaged that 120 beds will open initially. It remains an issue. There is still significant reliance on agency staff and overtime. One part of it is that forensic services will not fully open. We would like a timeframe for when that will happen. We need to look at training more psychiatric nurses and at social science graduates converting to being psychiatric nurses, and the sponsorship scheme that was there a number of years ago for healthcare assistants becoming psychiatric nurses. They could help to address it. Elements need to be put in place to maintain staff and retain them in the services. The development of a community service might be of assistance.

Ms Aisling Culhane

The Deputy will recall that when we came before the committee last year to speak about recruitment and retention, we illustrated a 25-step approach about how to recruit a nurse. Unfortunately, this organisation was involved in a dispute in 2016. The assurance given at that time was a seamless approach to recruiting nurses and, in that space, to recruit psychiatric mental helath nurses. I am sorry to report that the 25-step approach to recruiting a nurse still exists in this jurisdiction. It is incredibly cumbersome. My colleagues who spoke here today speak of a similar approach to recruiting consultants. It is a joke. While one will see advertisements on the HSE's website for psychiatric mental health nurses, that advertisement remains up all the time. One does not see what has to be done to try to recruit that nurse, including pay bill, vacancies, individuals who are retiring, matters off the books and on the books. I will not bore the committee with the details. The 25 steps are on the record and there still remains a recruitment process which is tardy and cumbersome, to say the least.

My question for Dr. Sadlier is about the two-tier pay system. I know the FEMPI cuts have dogged the IMO and consultants in the last ten years. They are having a detrimental effect on those who have trained in Ireland for seven years. When a high percentage of those doctors qualify, they leave Ireland. That is almost mirrored in the nursing profession. Where are those doctors going? How can we keep doctors in this country? Regarding FEMPI and the two-tier system that has been created, how, in Dr. Sadlier's opinion, has the Government addressed the issue, and aside from the obvious, what solution is needed to end the two-tier pay system for doctors?

Dr. Matthew Sadlier

The 30% pay cut for new entrant consultants was in addition to the FEMPI cuts and the other cuts for new entrants. It was a 40% cut because there was a 10% pay cut that all new entrants took in 2010, and an extra 30% in 2012. We compete with other English-speaking countries for medical staffing, so largely Canada, Australia, New Zealand, the United States and England. We recruit doctors from overseas, including from Africa and countries in the developing world. We know there are issues with the World Health Organization guidelines but we can talk about them another day. The problem is not so much the quantum of money but the fact that two people are doing the same job with the same responsibilities but they are paid different salaries. That is the issue that doctors find hard to cope with. It leads to issues with parity of esteem, not feeling valued and other such problems. We have noticed over the last eight years that it is not that doctors are training in Ireland, finishing it and becoming specialists, whether with Dr. Flannery in the College of Psychiatrists or in other specialties, but that doctors do not see a future in Ireland and they are not even working here as trainee doctors.

We are seeing that doctors do not see a future in Ireland. They are not even working here as trainee doctors but they are emigrating to these countries, specifically Australia, New Zealand and Canada, at a much earlier stage. Not only are the salary levels higher in some of these countries but it is also to do with how the medical services work there and that they have better services, a better overall quality of life and more family friendly policies. That is the difficulty.

We can solve that problem by equating the salary. I want to make this point strongly, as I have done before, that this was allegedly done because of the financial crisis but it was a cut on new entrants. That meant that the day this cut was applied, the Government did not save one cent. It took a number of years for any savings to be made. The amount of money that has been spent on agency staff to cover the gaps has probably been significantly more expensive than if the Government just offered the same contract to all consultants.

Dr. William Flannery

I was interested to hear the mention of social interaction. I am an addiction psychiatrist so I treat a lot of people who activate their reward systems using substances. Social interaction is another healthy way to activate our reward system. That is one of the challenges of this experience that we are all going through and will be a challenge into the future. In fairness to all of our colleagues, in general our mental health services were 90% up and running throughout Covid-19 but the difference was that a lot of it moved onto an IT platform, as Ms Webster said. The core of what we do means that one has to meet the person.

The numbers are interesting. As a percentage of the total number of doctors coming out of colleges, we recruit a similar percentage as are recruited internationally, so that is good. However, we are in a globalised international market and so roughly half of the trainees we have are non-Irish graduates, which means they are footloose. They are coming here to train, which is good, but they see the system and like all of us, they make up their own minds.

As an example, I will refer to the transitioning from child to adult care. We know they are good models and I heard a good presentation on the origin system in Australia. We know that three quarters of severe mental illness presents from the age of 15 to 25. From that presentation it seems like a fascinating place to work. One looks at the experience of that and then one looks at what our solution to transitioning is, namely Sharing the Vision, which is a fairly blunt instrument of just moving the age range up from 18 to 25 and already knowing that of all the areas in mental healthcare, this is the one that is struggling the most. There may be a reason behind that but from afar or for those looking to work here long-term in an innovative or interesting service, we all know the impression that this leaves.

Has Dr. Flannery noticed, particularly in the past nine months, new trends in people presenting themselves, such as people with substance abuse addictions and so forth? Has he noticed something different from what has been happening in the previous five years because of Covid-19?

Dr. William Flannery

It is a good question and there is emerging data on this. There have been good and bad trends. A lot of what was happening before has essentially been exacerbated. There is much use of substances, which have much more serious psychiatric or mental health consequences. These people then tend to present in crisis and need a mental health intervention. There is much more use of tablets, as we know, such as benzodiazepines and other related products. There are much more innovative substances, which have complex physical and psychiatric sequelae. These substances are challenging this integrated approach because patients are not presenting in the traditional way, which is with injection related harm but they are presenting with other physical or psychiatric illnesses. That was a pattern that was there before and that has been accelerated by the current experience.

In fairness to all of my patients, they really knuckled down and did their best with all of the recommendations. We radically adapted our services and we all worked well. That has been impressive to see. The good thing is that, as I said, they are a marginalised and complex group with a lot of physical health problems. Going into this period, I was terrified that there would be a huge change and I am delighted to say that so far that has not been the case. In fairness to the public services and the voluntary and community sector, we all got together and did the best for ourselves and for those we treat. So far, thankfully it is working. That has been an initiative on the ground that we all worked on together. It is interesting to see how that has been matched through the wider system.

It goes back to parity of esteem and the meaning of that is to have mental health right at the table with a national director and to have the voice of a psychiatrist in the Department of Health.

We all appreciate the great work and commitment of Dr. Flannery and his colleagues. I call Deputy Casey.

I thank the witnesses for their honesty. I listened to them and I thought that first of all I want to wish them a happy Christmas. Maybe we could come together and write our own little wish list for Santa for next year on mental health and see what we can get out of it.

I want to ask the witnesses how frustrated they are on a scale of 1 to 10 with the system, with 10 being extremely frustrated. I listened to the witnesses talking about the recruitment and retention issues and they are right. How can anybody go through a process of 22 to 25 stages? They will just walk away. I remember I tabled a parliamentary question a while back about a post that was being advertised for ten years and it still has not been filled. That is a big issue.

How do the witnesses feel the mental health services have fallen back, in terms of years, since Covid-19 came in? The witnesses mentioned the 24/7 services for which we have been fighting for ages. These are vital services that have to be community-led, as does joint interaction in e-health. I know from parliamentary questions that the HSE spent over €11 million in one year on taxis. These were not patient taxis but taxis bringing files from one hospital to another. That is a ridiculous waste of resources.

I do not know if the witnesses will be able to answer this question. The last Government made a commitment to hire 114 assistant psychiatrists. I would like to know where they are within the service because I am well aware that some have left. Their procedural work last year was basically to send out cancellation appointments.

I know I have asked a lot of questions but if the witnesses can help me with those queries I would be appreciative.

Mr. Peter Hughes

On the question of how far back services have gone since Covid-19 started, I would ask how far forward services have gone in the past 20 years? As I outlined before, the likes of Australia, Canada and the UK all have 24/7 crisis intervention services.

They have far more developed community services. Once again, we used the resources we had to make savings elsewhere, at the expense of mental health.

We are not moving forward at a particularly good pace. For example, since the start of the new forensic services in Portrane, we have constantly brought up at numerous engagements that the sale of the land in Dundrum needs to be ring-fenced for mental health. This is a lucrative piece of land and it would be a small start. The budget needs to be extensively increased to develop compounds of community services. We really have to catch up, as we are a long way behind. I worked in Australia a long time ago, and I do not want to say how long ago, on a 24/7 crisis team. I am absolutely astonished that we do not have one in this country. This is not the only thing we are missing. We are missing many of the community services that had been promised over the years.

We need recruitment retention in psychiatry, and this remains a huge issue. As Ms Culhane outlined, the recruitment process needs to be brought to local level. This thing of having to get documents signed at different desks is just incredible. There was a recruitment and retention campaign last year, which brought about the enhanced nurse contract. There are huge delays in our nurses getting paid that. This does not send a good message to any nurse who fulfils the criteria for that. The majority are still waiting to get paid and we are talking about a year plus since that was agreed.

Can I bring in Dr. Sadlier because I am conscious of time?

Mr. Peter Hughes

I have one last point as regards the pandemic. The borders have closed for the moment but once the borders to other countries open again, unfortunately, we are going to see many of our nurses going abroad again.

Dr. Matthew Sadlier

I thank Deputy Buckley for his question. To rate my frustration out of ten is a very difficult thing to do because I actually quite enjoy what I do. Although the teams we work in are not perfect, we have excellent colleagues in those teams, such as Dr. Flannery, who works in the office below me. We have excellent colleagues in nursing teams, occupational therapists, psychologists and social workers. I really hope I do not leave anybody out. It is a wonderful place to work, however, the sad thing is that it could be so much better. We could provide a better service to our patients with some tweaks to the service. There are some things that will require significant investment.

I agree 100% with Mr. Hughes on the issues about the 24 hour crisis teams and the provision of home care teams, trying to deal with more crises in the community and trying to deal with more crises that we can offset. I am rushing through my answers because the Deputy asked a number of questions.

The issue of Covid will be complex from a mental health perspective. As is seen in any big crisis, whether it be a disaster, a war or something like that, the mental health impact will actually be felt next year and the year after. As human beings, our nature in a crisis is to go into our shell or go into our bunker. We put up our resistance and we are able to cope with an acute crisis. The problem is picking up the pieces after the hurricane has come through the town. That is what we are going to see next year and the year after, with people who may have lost jobs, people who may have had relationship difficulties, people who have had long separations, people who were not able to attend their parents' funerals, etc. It will be in the years after this that we will see an increase in referrals. They are my quick answers.

I thank Dr. Sadlier. I am conscious there are three members who have not come in yet and we have to be out of here by 11 o’clock. I know Dr. Flannery wanted to make a point. Can he make it as brief as possible?

Dr. William Flannery

We should just follow the money. As was said, funding was 6% but is now down to 5%. I think that is a nice measure. Before Covid, there were psychiatric beds in the greater Dublin area, whereas now, on an average night, there are not. In saying that, from a training point of view, and from the experience of the college, we are all working very well together across the organisation with the Mental Health Commission, the NDTP, etc. We received a small bit of once-off money from a development fund. It is not all bad. Certainly, the way we all work with each other has improved.

I think the figure of 114 refers to psychologists. A psychologist does psychology for his or her primary degree and then does clinical psychology, whereas a psychiatrist is a doctor first, and then does psychiatry. We both use talking therapies, however, I am licensed to use medication. A psychiatrist tends to work with more severe mental illness, whereas a psychologist tends to work with moderate mental illness. I do not have an answer to that very good question. I think that is part of the issue, in that getting data like that out of the system is hard. That is all I have to say.

I thank Dr. Flannery. I call Deputy Buckley if he would like to sum up and make a quick comment.

I will be very brief. I thank the witnesses and look forward to working with them on this. We will see where we can go from here, so enjoy yourselves.

I thank all the witnesses for their presentations. It has been quite stark but I am sure they have done this before. I have seen some of the witnesses present about the very stark situation. I feel like we have been talking about the need for investment and have been going around in circles for years. It is really incredible that the percentage of funding has gone down and not up. That is just awful really.

Nearly every week, I ask the professionals to give an outline of the long-term impacts of young children and adults not being able to access the care they need. It was great to hear Ms Webster talking about real-life experiences and the opportunities that come when a person can actually access services. That really highlights the fact this requires advocacy and care from a family member or a carer, such as Ms Webster. It makes me think of all the young people in the care of those who cannot advocate, either due to their own health needs or simply not having the know-how. I do not think one’s mental health or access to care, particularly for young people, should be dependent on that. I do not know if Ms Webster would like to come in on this point, or if she has any experience of other people who are not able to do that.

It was helpful that Ms Webster outlined the opportunities that come with accessing care. I sometimes wish the money makers or the decision makers could hear about those opportunities. To me, outside of the lack of care and compassion, it seems like bad business not to provide this care to young people. It is a bad business model not to invest in mental health services. I do not know how much more starkly we can put this. Take the care, the compassion, the kindness and all the things we believe are basic needs for young people or anyone who needs to access mental health services, it is bad business not to invest in mental health. Maybe I am speaking out of turn but it seems to be bad business, if I were to break it down to something as basic as that.

As someone who has moved around the country and who has come through things, the point about health records has been deeply frustrating. I am sure everyone can agree with that. Do witnesses see a solution to this? Is there a willingness here because there seems to be constant mantra that we cannot have records here and we cannot centralised this? Do witnesses think there will ever be a move to deal with this? Does this need to be driven from a Government policy level or should it be driven from within the medical community, or is there a cross-over between both needed?

I was astonished to hear about the recruitment process for nurses. I have a particular grá for student nurses. It made me think of a survey we did when I was in the Union of Students in Ireland in which 93% of student nurses replied to say they were considering emigrating. When one puts that with the 25 step recruitment process, once again, this seems like bad business to me. It seems like an absolutely crazy way to do things. Do witnesses see any light at the end of the tunnel for that process to be made more streamlined or are we stuck in a Groundhog Day of not being able to get out of this bizarrely complex process?

Finally, it seems there are silos in mental healthcare. Do the witnesses think that is driven by the way the funding is decided at Government level? Do they think it is a strategic decision or is it simply the way it is? They all alluded to the fact it is not just mental healthcare as people need other physical care. However, it seems that people are driven into these silos and everyone is just sent zipping around the place. Is that a strategic thing, a Government thing or a historical thing? Where can we go from there?

The witnesses outlined that things could be better. Obviously, things have improved in mental health and we all talk about mental health a lot more, but I do not think the measure of anything should be that it could be worse and that it has been worse. That is a poor measure in 2020. I want to commend all the witnesses on the work they are doing in this area. It should not be like this and I am sure everyone says that, although these eternal platitudes do no good and what we need is action. However, our measure should not be that it could be worse and that we have come a long way. It needs to be better.

I am throwing thoughts and a few questions at the witnesses and I would be obliged if they could address them.

Ms Jeannine Webster

I am a healthcare professional, a midwife, so I understood a little bit of the system. As a parent trying to navigate my child through a service, knowing the rudiments of the system, such as what is a registrar or who my child was going to see, probably supported me to support him. Both of my parents were psychiatric nurses and I had worked within psychiatric services as care staff myself before I became a midwife, so I knew how to navigate the system. For a parent going into that system who does not know some of the subtle differences in regard to staff and so on, it is incredibly difficult.

I want to re-emphasise that being somebody's advocate within that service can be very difficult. An advocate is sometimes welcomed by people within the service but not at other times, or there are confidentiality issues. It is a process and it is a journey. To be valued within that service is very important. Again, that comes down to different issues, such as confidentiality. It is a very difficult system to navigate as a parent.

I want to go back to the Covid issue. As I said in my statement, James has not seen a healthcare professional in person in ten months. We need to be very cognisant that this needs to change. His greatest supporter at the moment is his individual placement and support, IPS, worker, who supported him getting into work. She is providing his sounding board at the moment.

Dr. Matthew Sadlier

I thank the Senator for the questions. In regard to the medical records system, two issues need to be addressed. One is the responsibility of the Legislature in regard to the laws on confidentiality and patient records and these issues which have always come up as one of the blocks to adopting an integrated patient care record across the whole of the health service. That requires legislation, which will require the Oireachtas, as the legislative assembly, to address it.

The other issue is investment and the rolling out of the service. There is a phrase that always comes to mind when we deal with medical records, which is that the perfect is often the enemy of the good. So often, we have this system blocked because there is an idea there is a better system or that, somehow, it will be done in another way. We just need to get down to dealing with this issue and to start developing the national patient record. It will not be perfect when it starts, it will have problems and it will have to evolve over a number of years. However, if we try to introduce it a perfect level, it will never happen. We just need to get down and do it.

The other questions are all valid. Some of the issues are solvable and some are not, and it is difficult. That is why I think something like the integrated care record is important. Many NGOs and charities operate in the mental health sphere. They all do very good work and are very good at supporting patients or providing care, but that obviously leads to a certain fracturing of the service because there are different agencies and different people. I do not know if anyone would like to remove them from the system as I think they do a good job. However, if we could have an overriding controlling of the records and the information, we would get better co-ordination between systems.

I will pass over to any colleagues who have other points to make.

Dr. William Flannery

That is the nub of it. The information on what we need to do is out there. All we have to do is look at the Mental Health Commission reports, for example, the most recent one on services for older people, which was the first time that services for those in later life were looked at. That is very damning but, nevertheless, it gives a path.

The issue of silos is interesting. I am delighted to share that, during the Covid experience, the silos between the different agencies were broken down out of necessity. From the patient point of view, that certainly has improved. From an official point of view, there are national clinical programmes, which are designed to look at those silos. There are paths for integrated care. The step that needs to happen, which really is over to the Oireachtas, is funding, but it is also where that funding goes, how it goes and, in particular, the systems to support transparent and open funding.

We all know that decisions have to be made about money. We all know from our own lives that we have to pick and choose. What I and the college advocate is that this is transparent and those choices are obvious to everybody through the processes the Oireachtas has in place. The Oireachtas makes those calls, so at least we all know what is happening. Somewhat like the position with the patients I treat, it is the uncertainty as to whether something will happen or not happen, or where something is going to go, that makes it very difficult. If my service is not going to get what I would like it to get, so be it, but it would be easier for me to accept that if it happens through a transparent and open process decided by central government.

Ms Aisling Culhane

I thank the Senator for raising the matter with regard to student nurses and the knowledge base with regard to the 96% leaving at that time. Mr. Hughes mentioned that borders will open and that we will get over all of this, but our students may travel. We are at an opportunity and a point in time right now in respect of the current cohort of student nurses. We have a situation where psychiatric and mental health student nurses are trying to travel across communities between their placements on €50 a week. It is unsustainable. We welcome the fact the Minister has offered a review in respect of that but if we do not address this matter and if we come to the end of this year without addressing the issue for student nurses, we will see our borders open and they will leave.

I am reminded of the fact that when they tried to introduce a stepped approach back in the Haddington Road days, and introduced what was considered a very poor transition programme for those students, they left in their droves. For those members listening to this meeting, I ask them to please support the issue with regard to this cohort of student nurses. While we have a opportunity, we face a danger that if we do not address this, they will leave.

I thank the witnesses. I am not the bean counter but the public is not aware of some of the costs associated with care in the community. I am aware of one house at a constituency level that is run by an NGO. It is a fantastic facility in a residential house located on a housing estate in Dublin for which I sought the costings a number of years ago. It cost €250,000 a year for three shifts of care workers to provide care to the three adults who resided in the home. When the rental cost of the property, the staffing and the ancillary services that were offered as part of the care provided to the three people is considered, one realises that the cost of care is colossal and wonders where the funding comes from. I do not want anybody to misinterpret me when I say that I was shocked by how much it costs to provide care in the community, particularly to adults. I do not want to deny anyone care but I do not know what the public will think when they see the ballooning costs of both the HSE and the healthcare system. When we think of hospitals we think of overruns and big projects. The public, therefore, needs to be aware that community care and care in the community is the right and good thing but it comes at a phenomenal cost. It is for people to call for add-on services but the reality is different when one analyses the costs line by line. My comments are open to misinterpretation so I wish to confirm that I favour care in the community. However, if I was an accountant in the HSE or in various different Departments who analyses the figures I would wonder whether we could balance the books, etc.

The witnesses have pointed out the problems. It is exasperating as a layperson, and as a politician, to hear yet more contributions from professionals who work in the field saying that we need to move towards a closer integration of mental healthcare into healthcare. One of the reservations that I had about the establishment of a sub-committee was a feeling of yet again we are separating mental health from the mainstream health stuff. I now understand the need for a sub-committee and ask that each of the five witnesses briefly tell us what we need to do because we will report on these matters.

I have re-read some of the reports and the policy documents entitled A Vision for Change and Sharing the Vision: A Mental Health Policy for Everyone. They all had noble aspirations but, again, it is very frustrating to read of the difficulties and shortcomings of emergency departments in dealing with the admission of people with acute psychiatric issues. If the witnesses could wave a magic wand, what model would they recommend we replace the existing model with so that if I presented myself at Tallaght University Hospital, for example, with a psychiatric issue that I am dealt with promptly by triage personnel and do not end up in the emergency department or the wrong unit? Of course there is a lot of confusion in medicine when people suffering a psychiatric issue present themselves at a hospital and medical staff wonder where to send them when they might need a multidisciplinary care. What do the witnesses recommend is done when people suffering a psychiatric event present themselves at emergency departments? What can we do because we, as a committee, will make recommendations?

Dr. William Flannery

I do not have a specific answer and I do not think there is one. The Deputy answered his own question when he said there must be transparency and funding. At least if there is a process in place we will know where the money goes, we will know what we get for it and we can make decisions on what we can pay for. All illness is dynamic so it is the right care at the right time. What we need is a dynamic system or what is usually termed an "integrated system" to manage this matter.

I believe one of the strengths of the College of Psychiatrists of Ireland is that we brought in the voice of those whom we treat and those who look after them - so the carers and families like that of Ms Webster. We brought them to training and brought them into our professional competence, which has been very valuable. The key is to listen to those who go through and use the system because they will say what is the right care at the right time. Having chief psychiatrists in the Department would help because one would have a voice that one could turn to and at least bounce these challenges off as well as bringing in that clinical experience.

Dr. Matthew Sadlier

The Deputy made so many points that it will be difficult for me to answer them in a minute but I will refer to one or two bits of my experience. Care in the community is a very good policy but if any policy is slavishly adhered to sometimes, it can cause problems. I work in Dublin though I will not say which hospital. We had a clinic based in the hospital outpatient department and a clinic in the primary care centre. The vast majority of our patients wanted to be seen in the hospital outpatient department and not in the primary care centre. The hospital is in an urban area and the bus routes served the hospital better than the primary care centre. Even though the centre is closer to people, with the way the bus routes work, it was easier for them to get to the hospital than elsewhere.

We need to have psychiatry as a presence in general hospitals. Patients with mental health disorders will turn up at general hospitals. In crisis, people often need medical care as well as psychiatric care. The plan to have crisis assessment units separate from general hospitals creates the other issue whereby patients will, unfortunately, if they self-harm, have to been seen in a general hospital to receive care and then be transferred to another unit. We need to integrate psychiatry services on the campuses of general hospital but to do that in an integrated way that involves management structures and, for integration, there needs to be clinics in the general hospital. I appreciate that if one lives outside of urban areas, primary care centres are more accessible. I know that in a lot of the urban areas, and I have also worked outside of Dublin, hospitals are the easiest places to get to because that is where buses and other public transport go, etc.

Finally, developing an appropriate electronic patient record would be a saving. There would be a certain infrastructure cost at the start but in the long term it would be a saving to the health service because it would be cheaper than the amount spent on record management at the moment. As Deputy Buckley pointed out earlier, €11 million was spent on taxis to ferry charts around the country. That sum would buy a hell of a lot of computers.

Mr. Peter Hughes

On the situation in emergency departments, I believe that a 24-7 mobile crisis intervention team would greatly improve the system and we need a timeframe, which is the normal protocol for a crisis team. I mean that a person would be assessed within one to two hours of presentation whether that is at an emergency department or anywhere else. Our goal should be that the majority of people with a psychiatric problem are treated at home, as best as possible, with the support of 24-7 community-based services.

In response to the point made that community care is more expensive I reiterate the point that when we had large institutions in this country, 30% of the budget was spent on mental health. It is no coincidence that the money was spent on maintaining institutions and that resources did not follow patients. If patients are treated in the community and the resources had been put in then, most likely, we would have a cheaper service but a far better quality one that is far better for both patients and families.

I thank Mr. Hughes. We have ten minutes left.

I thank the witnesses for their answers. Perhaps they could send us a little bit more detail in writing about how the mobile intervention team model they have spoken about would operate in practice. I knew I would be misinterpreted, so I would like to clarify my point and give another example. Orphan drugs are a very difficult issue for all politicians. We are sometimes faced with situations where an orphan drug for one patient could cost €250,000 per year. We have finite resources. We need to interrogate this system every so often. When one is asked subjectively, one of course says "Yes", as this is going to save someone's life. One might then see that it costs €250,000 to provide one patient with one year's supply of a medicine and consider what that sum could do for multiple patients. I am absolutely not advocating letting people die. However, the committee could drill down into the question of whether these finite resources are being spent in a worthwhile way. I am not advocating a return to institutional care in any shape or form. If one is the accountant examining where a budget is going, there is nothing wrong with asking questions about the cost.

I thank the Deputy for that clarification.

I thank the speakers from the Psychiatric Nurses Association and the Irish Medical Organisation. I very much appreciate the input of the College of Psychiatrists of Ireland, which is a newer organisation. I am very happy to see a new focus on the voices of the stakeholders and carers. I refer particularly to Ms Webster. I very much appreciate the witnesses' contributions.

I come from Ballinasloe, where St. Brigid's Hospital was located. It was the acute hospital for psychiatric care for the west and the midlands. Mention was made of 1,000 beds. How does the acute capacity of 1,000 beds break down across regional areas? I refer particularly to the Saolta University Health Care Group and community healthcare organisation, CHO, 2.

I refer also to the integration of services. I heard references to electronic patient records. I am very supportive of such a facility. I worked in Health Innovation Hub Ireland previously. I have a question around e-health. Could the witnesses state the top two reasons we do not have an electronic patient record? I know some of the reasons. What two things could we do to work with the HSE and with stakeholders more broadly to deliver that?

Mr. Peter Hughes

Investment in e-health is obviously required. We will probably have to come back to the Senator with the details on the beds and where they are located. I do not know if anyone here has the exact numbers. There are 50 beds in the unit in Galway. There is also a unit in Roscommon and a unit in Mayo. My colleague, Ms Aisling Culhane, may have more information.

We will allow Ms Culhane to comment but I think it is really more a question for the HSE.

Mr. Peter Hughes

Yes.

Ms Aisling Culhane

I cannot give information about those beds off the top of my head. I appreciate that the Senator is looking at the Saolta University Health Care Group and wants to understand the situation regarding acute beds. We would have to consult the HSE to get the full picture. As Dr. Sadlier said, the beds may be in existence. It is a 50-bed unit. The question is how many beds are open at present. I would like to add nuance to that question.

The committee secretariat will write to the HSE requesting a breakdown.

I understand. I would like to ask one final question of the representatives of the College of Psychiatrists of Ireland. I reviewed the information on retention and recruitment. Sharing the Vision calls for governance to be moved to CHOs. If I understand it correctly, psychiatrists are part of hospital care. They are outside of primary care. Is that correct, or are they based within the rubric of primary care and the CHOs?

Dr. William Flannery

From the HSE's point of view they are within the wider primary care area managed by the CHOs. That raises problems. Some services are very much in the community and some are based in the hospitals. Formal governance takes place through the overarching arm of primary care within the HSE. That governance approach is very typical of the HSE. I support a flexible approach, which meets patients where they are at the time, matched by overall governance that can vary from place to place. From a governance point of view, my work falls within the rubric of social inclusion. Most of my colleagues are within mental health services, which ultimately fall under the primary care structure of the HSE. That is also why we would advocate for a national director for mental health on the board of the HSE. This arrangement existed previously. From an aspirational point of view, there is parity of esteem, but from a practical point of view, it would be easier to push e-health through the health service while getting answers to these very reasonable questions.

The provision of a laptop or desktop computer for every trainee would be one very simple step. A lot of the necessary changes are at that level. They would not be that sophisticated.

I will call on Deputy Ward again, who I know has a supplementary question.

It is not a supplementary question. I thank the witnesses for their really comprehensive testimonies. They were absolutely brilliant. As a layperson listening to this, if I was asked to rate my frustration with mental health services from one to ten, it would be approaching ten. That is no reflection on the witnesses.

Key performance indicators, KPIs, do my head in. Instead of enhancing performance, they are seen as a stick with which to beat people. We need to move away from that approach. Universal access was discussed. I have worked in addiction services for years as an addiction support worker and behavioural therapist. The witnesses mentioned care plans not being followed. The same patient might go to both mental health services and addiction services, but never the twain shall meet. I am currently working on a Bill to implement a "no wrong door" policy. Getting that through the Oireachtas might help with that issue.

There are loads of issues, but the biggest seems to be the share of the health budget allocated to mental health. It has gone from 30% down to 5%. That really needs to be addressed. We cannot move patients from acute to community settings without bringing the budget with them, otherwise we are merely moving money away and making overall savings for the Government. I was not previously aware of the need for an electronic system for storing and sharing patient records. That could benefit the entire health system, not just mental health services. I would like to push that issue forward. I do not have questions if the witnesses do not have time, but I thank them for their testimonies. They were really enlightening. I stayed for the whole meeting because I was afraid I would miss something.

This has been a very productive two-hour engagement. On behalf of the committee I would like to thank the witnesses for their time. I know how busy they are. The run-up to Christmas is always a very busy period for everybody. Their engagement with us will absolutely influence and benefit the report we will present to the Government.

Before I conclude, I would like to wish the witnesses and the members a very happy Christmas. I would also like to thank the secretariat, including Mr. Ted McEnery, Ms Emma Greene, Mr. Denis McKenna and the rest of the team, for the work they have done during the year. This committee has been very busy since it was formed. I thank them for the work they do on our behalf and wish them a happy Christmas.

The sub-committee adjourned at 11 a.m. until 9 a.m. on Thursday, 21 January 2021.