Joint Sub-Committee on Mental Health debate -
Tuesday, 30 Nov 2021

General Scheme of the Mental Health (Amendment) Bill 2021: Discussion (Resumed)

Acting Chairman (Deputy Mark Ward)

Apologies have been received from the Cathaoirleach, Senator Black.

I welcome the witnesses. They will be presenting virtually to our meeting to discuss the mental health (amendment) Bill. I welcome from the HSE Mr. Michael Ryan, head of mental health engagement and recovery, national mental health; and from Mental Health Reform, Ms Fiona Coyle, CEO, and Ms Bernadette Grogan, policy and advocacy co-ordinator. You are all very welcome to this meeting.

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

Without further ado, I call Mr. Ryan from the HSE to make his opening remarks.

Mr. Michael Ryan

Good morning everybody. I am thankful for the opportunity to speak to the subcommittee on mental health. As outlined in the introduction, I am head of the office of mental health engagement and recovery in the HSE. I will give a brief outline of the work of mental health engagement and recovery because it will help inform the discussion on the Mental Health Act and why it needs to facilitate the recovery approach. The office of mental health engagement and recovery was established in 2018. It aligned the previous function of advancing recovery in Ireland and the office of the mental health engagement into one function. The role of engagement and recovery is to ensure that the experience of service users, family members, carers and their supporters inform the design, delivery and evaluation of our mental services through co-production processes and to ensure that the personal lived and recovery experience of service users, family members and carers is utilised as a service improvement and therapeutic resource within our services. The work of mental health engagement and recovery is central to achieving the person-centred and recovery-oriented service as set out national policy Sharing the Vision.

Currently, in engagement and recovery, we have area leads for engagement in all community healthcare organisation areas and these facilitate 35 local engagement forums of local service users, family members and carers. Additionally, we are continuing to develop a lived experience cohort to our workforce through the introduction of peer support working on to our multidisciplinary teams and through our recovery education and recovery college structures in partnership with our NGO colleagues, Mental Health Ireland. Through this we empower service users, family members, carers, staff and other stakeholders to an enhanced knowledge of recovery and their role in achieving recovery for themselves or facilitating others to do so. In 2022 we expect to increase our number of experts by experience working directly in the HSE to around 130. Engagement and recovery also oversees the individual placement and support, IPS, programme which supports people with long-term and enduring mental health challenges find meaningful work. As of March 2021, more than 100 people are registered the IPS programme, with 441 people having secured meaningful employment since the start of the programme.

In response to the Department of Health's request for submissions to the drafting of the new Mental Health Act, we partnered with our Mental Health Reform colleagues, and I am delighted they are with us today, to hold a consultation process with service users, family members and carers on their views on the draft heads of Bill for the new Mental Health Act. Some 135 people registered for our consultation process which took place over two days.

Mental health engagement and recovery recognises and very much welcomes that the current Mental Health Act draft heads of Bill is more person-centred, promotes autonomy and shared responsibility and has more recovery-focused language but we think there are still opportunities to strengthen this further. In this regard and based on our consultation feedback, we believe the Act should be underpinned by the core values and principles that reflect a recovery-oriented and person-centred service. These principles include recovery, autonomy, accessible language, partnership, co-production, empowerment, transparency, and quality and evidence-based and evidence-led interventions.

We received a substantial amount of feedback through that consultation process, which is available for review and which we will use to inform our planning and service improvement processes in the HSE. The overarching themes of the consultation feedback can be broken down into a number of areas, namely, the need for a human rights approach; the autonomy of people in relation to their own care, treatment and recovery; the importance of co-production and shared decision making; a range of service provision that meets the diverse needs, preferences and choices of people on their recovery journeys; the vital that role family members, carers and supporters can play in facilitating recovery; and an effective system on how to complain to an independent body for mental health.

We have fed back direct commentary to the Department on 12 heads of the Bill, which are listed in my presentation. As the members have a copy of it, I will not name them all individually. This feedback relates to suggested change of language, omission or addition of wording. We also make recommendations on additional themes we believe should be covered in the Act. They include the rights of families, carers, supporters or a nominated person and the recognition of that expertise in the care and recovery processes of individuals; an evaluation by a second consultant psychiatrist; and advanced healthcare directives and complaints procedures.

I acknowledge the contribution of the following in this consultation and feedback process: the national mental health engagement and recovery team, the area leads for mental health engagement, the local mental health engagement forums, and other individual service users, family members and supports. I also thank this subcommittee for the opportunity to present the perspective of service users, family members and carers today and while the subcommittee will engage with many stakeholders in informing the content of the Mental Health Act, the views of service users, family members and carers must be one most important areas for its consideration. I thank the members for their attention.

Acting Chairman (Deputy Mark Ward)

I call Ms Fiona Coyle from Mental Health Reform to make her opening remarks.

Ms Fiona Coyle

Glacaim buíochas leis an gCathaoirleach agus le baill an choiste as an gcuireadh teacht in bhur láthair inniu. I am the CEO of Mental Health Reform. Today I am joined by Ber Grogan, our policy and advocacy co-ordinator. Mental Health Reform is Ireland’s leading national coalition on mental health, with more than 75 member organisations working for progressive reform of mental health services and supports in Ireland. We welcome the opportunity to take part in this historic pre-legislative scrutiny of the mental health (amendment) Bill. This is a once-in-a-generation opportunity for positive change in our mental health legislation.

The work of this subcommittee will profoundly affect some of the most vulnerable people in our society, namely, those who find themselves in need of inpatient mental health treatment and care. The reform of the Mental Health Act 2001 is a key step in the transition towards person-centred, recovery-focused services, as set out in our national mental health policy, Sharing the Vision. We now have an opportunity to be world leaders in the delivery of mental health legislation that adequately protects human rights. The heads of Bill before the subcommittee are very welcome and propose to make fundamental reform in our mental health legislation. However, there are a number of proposed areas of improvement, three of which I would like to highlight today on behalf of our member organisations. These are part 8, admission of children to approved inpatient facilities; part 6, restrictive practices; and an additional part relating to provisions for an independent complaints mechanism.

Part 8 of the heads of Bill provides for all aspects of legislation relating to under 18s. While this is welcome and necessary, we have some concerns on the specifics. Head 128, section 108 on admission of a child to an adult approved inpatient facility, still provides for the admission of under 18s to adult facilities. The 2020 Mental Health Commission annual report showed that there were 27 child admissions to nine adult units during that year. The commission also reported that there was 0% compliance with its code of practice on the admission of children to approved centres as none of the services provided age-appropriate facilities and programmes of activities in adult units. It is very concerning that the legislation still allows such practices. As such, we request that an express provision should be contained in the amending legislation that no child or young person shall be admitted to an adult inpatient unit.

On issues relating to under 18s we wish to also highlight a lacuna between the heads of Bill and the Assisted Decision-Making (Capacity) Act 2015. Part 8 of the mental health (amendment) Bill is set to provide for 16- and 17-year-olds to give or withdraw consent to treatment in mental health services if they are deemed to have capacity. The heads of the Bill state that the Assisted Decision-Making (Capacity) Act 2015 would apply for the purposes of conducting the necessary capacity assessments. However, the Act does not provide for decision supports for under 18s. Mental Health Reform has written to all relevant Ministers highlighting this lacuna and we hope that a remedy will be found as a matter of urgency. We request that such a recommendation be included in the subcommittee report and that members engage with their counterparts on the Joint Committee on Children, Equality, Disability, Integration and Youth.

I would like now to draw the subcommittee's attention to part 6 in regard to restrictive practices. Mental Health Reform considers that as a first principle, force should not be viewed as a method for engaging service users in treatment. Force is not the way to support recovery. We advocate for a zero restraint, zero seclusion policy as set out in Sharing the Vision.

This year, Mental Health Reform commissioned an independent, human rights analysis of the heads of the Bill to reform the Mental Health Act 2001. This has been provided to the subcommittee. In this paper, there are a number of recommendations to transition to the abolition of coercive practices in mental health services. The recommendations are adapted from those developed by the Council of Europe Parliamentary Assembly and the work of the World Health Organization QualityRights initiative. The full list is in the accompanying paper but some of the recommendations include the following: additional funding should be provided for the development of pilot community-based responses such as peer-led crisis or respite services, and other initiatives identified as international best practice; and additional funding should also be dedicated to the development of prevention and early identification of mental health conditions and early, non-coercive intervention, especially for children and young persons. This should be included as a stand-alone section in part 7 of amending legislation. Persons with lived experience of involuntary detention should be involved in the development and delivery of this human rights training.

I want to now draw the subcommittee's attention to the omission of a provision for an independent complaints mechanism. Since 2014, Mental Health Reform has been highlighting the need for an independent complaints mechanism. People have been, and continue to be, deprived of their liberty through involuntary detention. This is contrary to Article 14 of the United Nations Convention on the Rights of Persons with Disabilities, UNCRPD. While Ireland, belatedly, ratified the UNCRPD in 2018, we did not ratify the optional protocol. People with psychosocial disabilities and experiencing mental health difficulties should have a safe and independent avenue for complaints. The need for such is continuously highlighted to us in consultations with people using services and their families, friends, carers and supporters. Therefore, we propose the following recommendations. First, the heads of the Bill should provide for an independent direct and specific complaints mechanism for mental health services. This needs to be separate from the existing HSE Your Service, Your Say complaints mechanism. Both adults and children should be entitled to avail of this complaints mechanism. Second, the Inspector of Mental Health Services should be conferred with a statutory obligation to receive, investigate, and determine individual complaints relating to mental health services.

It has been 20 years since our last major change in mental health legislation. A whole generation of people will be impacted by the long-awaited reform of this legislation. We must grasp this opportunity to make fundamental improvements to the delivery and support of mental health services in our country to ensure horrors of the past are not revisited. Time for reform is long overdue, but we have this historic opportunity now. Reform should be brought about with expediency and due process. This subcommittee has a vital role to play in ensuring that our updated mental health legislation puts people at the centre of the support and services they need; respects their human rights; and respects their will, preferences and experiences. This legislation must fundamentally be about people and we commend the subcommittee for its work and diligence in this important process. We look forward to the discussion today with members and thank them for their time.

Go raibh míle maith agat.

Acting Chairman (Deputy Mark Ward)

Go raibh míle maith agat Ms Coyle. I will now open up the meeting to questions and answers. The first speaker is Deputy Gino Kenny.

Deputy Gino Kenny

Deputy Hourigan should go first.

Deputy Neasa Hourigan

I thank the witnesses for their time. This is such an important subject. I think of these sessions as some of the most important work that I will do this year. As stated, this legislation has been a long time coming. Almost all of those who have appeared before the subcommittee over the past year have said that this legislation is so badly needed. I thank the witnesses for their time and their diligence around it.

I have a number of questions around issues raised in today's opening statements and I want to follow-up on some issues brought to our attention by the Mental Health Commission in previous sessions. I will start with the definition of "mental disorder" versus "mental illness". I am also a member of the Joint Committee on Disability Matters which is tasked with implementing the UNCRPD. I am concerned around the idea that "mental disorder" would include intellectual disability as a means for questioning somebody's capacity. I would like to unpack that a little with the witnesses. What are the dangers there?

I misunderstood this, but my understanding is that the reason we have held on to the term "mental disorder" is that it appears, or has previously appeared, in other legislation. Is it time to move on from that? Does it clash with the United Nations Convention on the Rights of Persons with Disabilities, UNCRPD? I suspect that it does. Is that something that the drafters of the Bill should consider further?

Acting Chairman (Deputy Mark Ward)

Would the witnesses like to speak on that? I call Ms Coyle.

Ms Fiona Coyle

I am happy to jump in first and then give Mr. Ryan an opportunity. I thank the Deputy for raising this very important matter around language. It is one of the other areas that we have been advocating for further reform in. While we support the replacement of the term "mental disorder", we do not believe the term "mental illness" should be used in its place. The reasoning behind this is that it is quite medicalised language and it does not adequately reflect the full diversity of mental health difficulties and their causes and the combination of origins and contributory factors. The impact of mental health difficulties for those who experience them are unique to each individual. For some, medical diagnosis and focus will be helpful and useful but this is not the case for everyone. The use of medicalised terminology can be quite exclusionary and such terminology can have an unintended effect of narrowing how mental health difficulties are understood and responded to and the Deputy raised some of those points. We recommend aligning this legislation with the policy sharing division, which uses the term "mental health difficulties" or, indeed, with the UNCRPD language, which refers to "psychosocial disabilities". "Psychosocial disabilities", as a term, is not widely used in Ireland, which is why we put both forward. We recognise that the language is something that the drafters should further focus attention on. Does Mr. Ryan have anything he would like to add?

Mr. Michael Ryan

I thank Deputy Hourigan for her question. Head 4 was one of the areas that came up in on our consultations as well. I note that in the earlier drafts the word "disorder" had been dropped but it now seems to have resurfaced. As Ms Coyle said, in understanding the context of this and the importance of language, in the last few years, thankfully, there has been a growing understanding of the spectrum of mental health from mental well-being to acute mental health challenges. We have to be careful that we do not lessen or reduce the significance of people who suffer from severe mental health challenges in our attempts to get people talking about mental health and so on. We have tried to make it as populous as possible. There remains a difference between somebody who has anxiety at the milder end of the scale and somebody who has severe and enduring mental health challenges. In our consultation, there was a lot of feedback on this and there certainly was not consensus. Many people believed the word "illness" captured the enduring and severe end of the spectrum well and people are familiar with the word "illness". I certainly would not be happy with the continuation of the word "disorder" but on balance, the word "illness" would be more acceptable. The Deputy raised a very important point about people with intellectual challenges and that needs to be decoupled. That is a different condition and it is not appropriate that it is classified there.

Deputy Neasa Hourigan

That is good to hear because, as Mr. Ryan can imagine, for somebody such as myself who is living in that kind of world and very involved in disability rights, that is a concern. One of the things we heard from the Mental Health Commission was around renewal orders and intermediate admission and the concern that, to some extent, these changes could set up a parallel track to the 2015 legislation whereby a person could be entered into the system without full oversight or full use of the legislation already in place as well as perhaps the capacity legislation and that in a way some of the suggestions around renewal orders and intermediate admission might bring a kind of an opacity or greyness into the route of entering services. Do any of our witnesses agree with the Mental Health Commission on that or is there more work to be done in that area?

Ms Fiona Coyle

My colleague, Ms Grogan, will come in on this.

Ms Ber Grogan

I thank the subcommittee. It is great to be here this morning. I watched the subcommittee's two sessions of pre-legislative scrutiny with the Department officials and with the Mental Health Commission. The subcommittee is doing brilliant work so far.

That was one area that I was linking back with. We commissioned the independent human rights analysis from Dr. Charles O'Mahony and Dr. Fiona Morrissey from National University of Ireland Galway, NUIG, and I checked back with the recommendations that they had made around the intermediate category and that whole area. It comes back to everything within the amending legislation and the general thrust of it, in that the intermediate category seems to have been introduced because of the grey area between voluntary and involuntary. For example, if someone were a voluntary person and there was perhaps seclusion, restraint or restrictive practices used against them, Mental Health Reform has previously said that that should be questioned whether that person is voluntary or involuntary. It is a very grey area across the board and that is why this intermediate category was introduced. From my understanding, the heads are trying to firm up what is voluntary and what is involuntary and the fact that there can be people in this in between piece.

Obviously, there are concerns that it would just widen the net of coercion. "Coercion" is a very strong word, but again, if someone does not want to be secluded or there is use of quiet time, it comes back to the main general thrust of the legislation of it being person-centred and that the person is involved in the decisions being made. If it is all done properly, we can see why the expert group recommended an intermediate category.

Similarly, in our human rights analysis and the recommendations we have, there are some recommendations around strengthening the legislation around it. There are some tweaks and things that could make it stronger, but, obviously, the Mental Health Commission members are experts in their own right as well, and that is the joy of all this pre-legislative scrutiny and hearing from as many voices as possible. If it is to give protection to people while their capacity is being questioned between voluntary and involuntary, if it is strong enough, it should work for people.

Deputy Neasa Hourigan

Does Mr. Ryan have any thoughts on that? I totally understand that this is an incredibly complex part of the legislation.

Mr. Michael Ryan

The question here is around supports for people who may be in our system and acutely unwell. First, to comment on the language around that. The Act refers to "intermediate persons", which is a rather unfortunate term. That is the first thing we could change. We could change it to "persons of intermediate status".

When a person is in a state of unwellness, it is hard for him or her to know what is going on. I welcome the additional supports this legislation is trying to put in place. We need to define more what we mean by what a person is entitled to if being considered for this intermediate status. This opens up to us the question of the person's natural supports, such as the role of the family and the role of advocacy, whether the person being provided with all of the services he or she needs and whether all of the these services are linked in order that we can know if the person is in a position to consent or not. It would be useful to have a definition of "consent" for this particular section, perhaps, under head 124, which deals with definitions.

We broadly welcome this because we see it as an additional support in a time of crisis, but there needs to be good boundaries around it. In terms of the second opinion, we need to know who gives that and the independence of that person or entity? Those are our thoughts on that.

Deputy Neasa Hourigan

Does Ms Grogan want to come in again?

Ms Ber Grogan

In his points about advocacy, Mr. Ryan reminded me of the importance of advanced healthcare directives as well, which I know come up throughout the legislation. Anybody going into an inpatient unit who is in need of care and support and has had his or her advanced healthcare directive prepared during a time when he or she was well and things were better in his or her life will have already discussed types of treatment, consent and so on. This ties in with the decisions for services and advocacy.

Deputy Neasa Hourigan

I want to stay in the realm of supported decision-making. I have a few questions with regard to individual care plans. I totally understand that there has to be a huge amount of discretion and that care plans should be tailored to the best medical advice of the team that is dealing with an individual. One of the recommendations of Mental Health Reform is that there should be a requirement in care plans to develop a decision-making strategy and that there would be certain constraints around care plans. I take that point around supported decision-making, but I want to widen it out. What should be the framework for care plans for the individual, but also for the care team such that they know what the constituent parts of it are? What would be the oversight of those care plans and how would they relate to the advanced healthcare directives, AHDs? I do not quite understand the relationship between the two. If somebody could explain it to me, I would be very grateful.

Ms Fiona Coyle

As Mr. Ryan does a lot of work in this area, he might like to go first.

Mr. Michael Ryan

This is one of the areas that came up in our consultation. I want first to note that earlier drafts of the heads of the Bill reference "care and recovery plans", but the reference now is to "care plan". That would be a concern. We have to think about what we are trying to achieve here, namely, better recovery outcomes for individuals using our services. That is about getting them back to a life of their own choosing.

I refer to my opening statement where I referenced the individual placement and support programme which gets people back to work. That is a very legitimate goal for every person. It is a recovery goal. It would be important that when we are talking about care and recovery planning we are very clear that this belongs to the service user or the patient. It is the person's plan. The role of the treating team is to facilitate the individual's personal recovery objectives, be that to get a job, to go back to college or to be able to walk to a bus stop. For me, the process is around care, treatment and the recovery interventions which lead to a state of well-being for people. We need to empower people to be able to fulfil their role in their own recovery journey. That means that they are an active partner and able to lead on decisions that have huge impacts on their own lives. We need to provide opportunities to empower them through recovery education, recovery colleges, peer support and advocacy so that the person is able to make the most informed choice about his or her life. We come from a culture where, unfortunately, there is an expectation that people cannot recover. Everybody has the potential to recover and to achieve personal goals no matter how lofty or how little they are. We need a recovery and care plan approach that supports that, but also supports teams to be able to work in that way and to understand their role.

Ms Fiona Coyle

Care plans already exist. This area is monitored by the Mental Health Commission. Recent reports have shown that compliance with individual care plans has been not very strong over recent years and has declined. This is one of the reasons Mental Health Reform has advocated for the right to a care and recovery plan to be put on a statutory footing. In terms of oversight, that is already contained in Mental Health Commission reports, but we would hope that with the strengthened statutory footing of such it would, perhaps, lead to increases in adherence. This cannot be a tick box exercise. There is further work needed on what a care and recovery plan looks like, which is individual to each person. Each person has his or her own recovery journey. That is a piece of work that we would recommend could be done over the coming years to support the centres in rolling this out and ensuring the service users have access to a really strong care and recovery plan process.

On how the plans relate to the assisted decision-making, I will ask Ms Grogan to respond.

Ms Ber Grogan

I have had a quick look at my notes on the Mental Health Commission and that issue. Articles 12 and 14 of the CRPD require that mental health laws are replaced by consensual practices and services based on a social and human rights model rather than a medical model. This comes back to the person-centred approach, working with the person on his or her care plan. A welcome addition to the heads of the Bill relating to mental health is the review board.

There will be a psychosocial assessment, because, again, it is about looking at the person as a whole, including their housing situation, their financial situation, their supports and at all of those kinds of aspects. The Assisted Decision-Making (Capacity) Act 2015 was passed in 2015 and there has been a huge amount of work done to get us to this point where it will hopefully all be amended and commenced by June 2022. The decision support service has been doing great work on having open consultations on its codes of practice and guidelines. There are, therefore, many opportunities for people with lived experience and family members, supporters and carers to feed in to the process. Members probably saw the "RTÉ Investigates" piece a couple of weeks ago on wardship and on how it will be replaced but it will take up to three years for people who are already in the wardship system to be processed and to be given new decision making supports, depending on the level of need for them.

One of the things around the capacity assessments and the Assisted Decision-Making (Capacity) Act 2015 is that the heads call for two professionals to undertake the capacity assessments, whereas in Mental Health Reform's submission we called for three professionals so that there is a broader view from mental health professionals and not necessarily from the same cohort. On that as well, our My Voice Matters research piece, which was done in 2019, is the largest piece of research of people who access mental health services, and there was another one done on the family supporters and carers. A huge number of people want to be more involved in the care plans and maybe there is an over-reliance on the medical model rather than treatment as a whole, which includes talk therapies and all of that kind of stuff. It is really about what is right for the person. As Ms Coyle said, it is not a tick box exercise; people are not going to fit neatly into standardised care plans, therefore we have to meet them where they are at.

Deputy Neasa Hourigan

I wish to come in for a second round. I realise I have taken up a huge amount of time, but I have more questions.

Chairman

I will bring Deputy Kenny in first. There will be plenty of time for Deputy Hourigan to come in again after Deputy Buckley.

Deputy Gino Kenny

I thank the witnesses for their statements today. Mental health care in Ireland is a very complex issue as it has been in the past and will be in the future. I have a number of questions. On mental health crises, the issue of children in adult units has been in the news in the past and probably will continue to be in the news. In the statement on mental health reform, it was said that 27 children have been admitted to nine adult units. What happens in these situations? Obviously, there is no suitable age-specific unit for that child, so where do they end up? How bad does it get for a child in a unit and in an environment that is not suitable for them? How bad does that kind of situation get as it evolves?

Ms Fiona Coyle

In terms of the number of children being referred to adult inpatient settings, this has decreased over the past number of years. However, from our position, any child being admitted into an adult unit is one child too many and we need to move towards that not happening. Our current legislation has been in place for two decades. When is the next time we will update this legislation? We would ask the Government and the Oireachtas to be ambitious in the goals that it sets and to ensure there is agreement that this should not be happening and, therefore, we should put it on a statutory footing.

The understanding from the service is that this is done as a last resort and these are not decisions that are taken lightly. Unfortunately, it speaks to the availability of services and Mental Health Reform would advocate that everybody, in particular, children and young people, gets the supports and services they need at the earliest possible time so that they may not need to be admitted in an emergency into an adult inpatient unit. While we need to ensure that this does not happen, we need to look at how we prevent that and go back to the root causes, which is investing in the services that are available to children and young people to ensure they are getting the supports and the services they need and that they are not spending up to a year on a waiting list and perhaps ending up in a situation where they need to be admitted. Does Mr. Ryan have anything he would like to add?

Mr. Michael Ryan

Just to reiterate what Ms Coyle said, we need to ensure our young people are treated in the most appropriate and best settings. Not to contradict it, but one interesting piece of feedback we received was that on some occasions young people might request that they are treated nearer to their homes and the only option might be an adult unit. We just have to try to bear that in mind as well. Is there a benefit in having the person close to their natural supports that might not be available if they were in a different part of the country? The question is about ensuring our young people get the appropriate supports and treatment in the appropriate environment.

Ms Ber Grogan

If I can just jump in quickly, the United Nations Convention on the Rights of the Child, UNCRC, Article 37(c) states that every child deprived of liberty shall be separated from adults unless it is considered in the child's best interest not to do so, and, obviously, the State is up for review under the UNCRC next year. That we need to stop this practice is something the UNCRC flagged in previous years. I completely understand the Department of Health officials, who were in for the first session, and the Mental Health Commission, which was in last week, saying that in emergency circumstances it might happen, and that they might be 17-year-olds and it might be for one night until they are transferred to an appropriate child and adolescent mental health services, CAMHS, unit. However, that is not the ambition we should be striving for; it should be that age appropriate facilities are available when needed.

Deputy Gino Kenny

Obviously, those are exceptional circumstances where children have to go into an adult unit. However, I presume we are talking about children who are in their teens, rather than children younger than 12 years of age. I am guessing that. Is that correct?

Ms Fiona Coyle

That would be my understanding. I do not have that information in hand, but certainly it is our understanding from what we have heard from the Mental Health Commission that they would be over 12 years of age and a number of them would be 16 or 17 years of age.

Deputy Gino Kenny

My final question is on restrictive practices and restraint. Obviously, this is also a very complex area and we are all advocating for, as Ms Coyle said in her statement, a zero restraint and zero seclusion policy. However, in certain circumstances, it may be appropriate - I emphasise "it may be" - not only for the health of the person but also the health of the staff and other patients. What kind of restraint is being used in mental healthcare in Ireland that would be concerning, particularly in respect of children?

Ms Fiona Coyle

In the heads of the Bill, there are a number of areas of what we would call "coercive practice", such as practices of seclusion, mechanical restraint, physical restraint and the newly introduced separate category of chemical restraint, which we welcome. Currently, the Mental Health Commission monitors the use of these restrictive practices. We have seen some interesting and quite worrying trends over recent years in terms of the increase in the number of practices, such as in 2020 the increase in seclusion. Our policy commitment is there in that we are trying to move towards zero seclusion and zero restraint by 2030. We are urging that this legislation would go much further and beyond 2030. We should show ambition and set out in this legislation that we are moving towards zero seclusion and zero restraint. It is widely acknowledged that for staff and service users the use of such practices can be quite traumatic. There is a great deal of evidence and many really interesting international practices, such as we provided in our expert analysis, which show that with investment and the right approach we can, as a country, move away from any type of seclusion and restraint.

Mr. Michael Ryan

I thank the Deputy for the question. We need to reduce the use of restraint as much as possible, but it happens on occasion. I have spoken to people who have used our services who were happy that on occasion restraint was used but, as I said, we need to be moving towards reducing its use. The HSE is working with approved centres on an initiative looking at methods of reducing restraint. This ties in with the question of care planning and the recovery approach. For example, are we communicating with our service users as much as possible? Are we de-escalating the situation and using advance directives and, if this has happened before in the debrief, has the person said what would have helped and what, if it happened again, he or she would like to be done? There is a commitment to reduce restraint. Nobody wants this to be happening, but on occasion it is necessary.

Deputy Gino Kenny

Ms Coyle mentioned chemical restraint which, I presume, is drug intervention. I am unsure what is meant by mechanical restraint. Perhaps, Ms Coyle would explain that. I am sure that currently, and in the past, the wrong terminology has been used. In terms of isolation, the person would, I presume, be isolated from staff and so forth.

Acting Chairman (Deputy Mark Ward)

I am not sure if the witnesses picked up on Deputy Kenny's final question.

Ms Fiona Coyle

I am sorry; I did not.

Deputy Gino Kenny

On chemical restraint, I ask Ms Coyle to clarify what that is.

Ms Fiona Coyle

Chemical restraint is a new category introduced in the heads of the Bill. There is a definition that I do not have to hand. I do not want to give the Deputy the wrong definition so we will follow up with him separately on what is contained in the Bill. Generally, it is the use of chemical interventions to restrain an individual outside of his or her normal therapeutic interventions. I can provide the Deputy with more information on that.

Deputy Gino Kenny

I thank Ms Coyle.

Ms Ber Grogan

For the Deputy's information, in December 2020 the Mental Health Commission published its annual report on restrictive practices, which provides a breakdown by percentage of the use of physical restraint and seclusion - male, female and so on - and the times of day where it was most used. That is available on the commission's website. There is a lot of information available on the Mental Health Commission's website.

On chemical restraint, as far as I can remember, in the heads of the Bill it was stated that it has not been used but, again, it is that case of making provisions for a just-in-case scenario.

Acting Chairman (Deputy Mark Ward)

I thank Deputy Gino Kenny. The next speaker is Deputy Buckley.

Deputy Pat Buckley

Good afternoon. Many of the areas have been already covered so I do not propose to rehash them. The Assisted Decision-Making (Capacity) Act 2015 was mentioned. We appear to be tripping over ourselves in terms of that legislation and this Bill. Head 7 of the Bill deals with the capacity issues in regard to people making decisions. Head 87 deals with the nursing home supports scheme. I have listened to what the witnesses had to say about how people are being treated in the system. We know that the system is poorly staffed and under-funded. Many of our nursing homes are pre-1970, pre-1960 or even pre-1950. Today, we are discussing how we can bring about change on paper. In my experience, over the years the system has not moved quickly or progressed in a positive manner.

The term "person-centred" was mentioned. In 2018, the Committee on the Future of Mental Health Care was told that the State was spending roughly €10 million on cognitive therapy and various other therapies, but it was spending more than €400 million on medicines. There is a massive gap when it comes to person-centred assistance. This legislation is welcome and we are going in the right direction. My biggest fear is that it will be 2023 before all of this is ironed out and the Bill is enacted, as it should be. There are a couple of sections in the Bill dealing with law and the inability to provide this care as provided for in the UNCRPD. I do not think there is one centre in the Thirty-two Counties that deals persons with a specific mental health issue and, say, autism. I do not like to use the word "disability". It labels people. For many years, people with a disability were labelled as people who were not sick but nevertheless they were tagged and this caused them to be excluded. We have not legislated on a rights basis for these people.

The following is an open question to anybody who might want to answer it. If this Bill, as currently drafted, were to be enacted in late 2022 or early 2023, what would be the biggest worry in terms of its enforcement? The Bill provides that a person with a disability needs a special, individual care plan.

Let us be honest. We know the system is not capable of providing that. In terms of the assisted-decision making capacity element, reference was made to coercion and I see there is a piece in the Bill that indicates you do not automatically become a guarantor for somebody because you are related to them. I welcome that, but it is about the ability to provide all these services. We know the system is creaking at the moment, yet I feel we are going backwards with mental health.

I will finish on this point. We are probably in the worst pandemic that we have ever seen in our lives. People are losing their jobs. You could write a book on marriages. We are not planning for what is going to happen next year in March, April or May. In terms of where we are, what would be the witnesses' biggest fear about the capacity to provide what is outlined in the Bill? Perhaps they could break it down into percentages. Implementation of the Bill in its entirety would be 100% but, for example, it might only be possible to implement 10% of it. Do the witnesses understand where I am coming from?

Ms Fiona Coyle

I thank Deputy Buckley for the question. I am happy to give the first answer. I acknowledge that the process of setting out the legislation does not directly speak to issues of resourcing and funding. While, on paper, this is a fundamental change to how services are going to be delivered and supported, we must also recognise and acknowledge that for this Bill to be implemented as it is envisaged it needs adequate resourcing and funding behind it. It is important that is acknowledged. We are concerned about language contained in the Bill such as "in so far as possible". Human rights should not be dependent on funding or on what is or is not easy to do and what might be more complex. We need funding and we need leadership to push it through. We must also be aware of the people who will come under the legislation. The focus must always be on the last source. We must ensure all appropriate alternatives to inpatient mental healthcare and treatment are adequately resourced and supported by the Government. That includes access to early intervention at the point of care. There will always be a need for acute care, but we can perhaps look at reducing it and ensuring individuals get the support when and where they need it in their own community. Resourcing and leadership are the two big levers that are needed to make this happen. Aside from resourcing, the Mental Health Forum has been calling for the reinstatement of the director of mental health post within the HSE. It would be very important to have a senior decision maker reporting directly to the CEO of the HSE to move forward these strategic pieces of legislation.

Deputy Pat Buckley

Does Mr. Ryan want to comment?

Mr. Michael Ryan

I thank Deputy Buckley for his question. The word "vision" is used in the mental health policy, Sharing the Vision. I would like to reflect on that a little. I came into this work about ten years ago and I bring my own lived mental health experience. That is why I am employed. The progress we have made in the past ten years is significant. The first point is to acknowledge the will and desire to try to create more recovery-orientated services. The 2006 policy, which has a butterfly logo - the name escapes me but someone might fill it in - as Ms Coyle said, was about trying to move care from the institutions into the community. That work is still going on. A lot has been achieved. Sharing the Vision needs to build on that in terms of more social and peer-led services that will allow people to partner more in their own recovery. The fear for me is that we do not miss the opportunity in the Bill to embed the structures that would allow that to happen. I refer to enshrining the co-production processes and the partnership processes that are needed for truly recovery-orientated services.

Deputy Pat Buckley

I will be brief. As Mr. Ryan said, most of us involved in this have had personal experience. It is closer to our hearts and we get more embedded in it as the debate goes on. As we speak today, some people are not being given chances within the mental health system for their own decision-making capacity. Family members, who have their best interests in mind, want to look after them. I know we should not rush things, but surely we should take a parallel approach in getting the Bill through. It is great to see so much collaboration between services. It is about time. In other committees I have asked why all those involved cannot get into one room and agree one plan rather than be divided and have five individual plans. It is a common-sense approach. I have gone off the point. We are pushing mental health forward. Do the witnesses think there should be something running parallel with the Bill to try to start putting things in place so that when the Bill eventually crosses the end line, we will have appropriate buildings, services, back-up services and integration with the community? I feel that we are moving away from community integration and back into centralisation in the cities because of a lack of resources. I will leave it at that because I know other members wish to contribute.

Acting Chairman (Deputy Mark Ward)

For Mr. Ryan's information, the document he referred to is A Vision for Change.

Deputy John Lahart

I will be very brief. I found the conversation and the reading material fascinating. I have what I hope will be considered a constructive observation to make on what Mr. Ryan said. His paper was so full of acronyms that I kept getting lost in it. We all do that when we are in the system. I got the thrust of what he was saying.

As someone who had a professional connection with mental health, when ordinary members of the public talk about updating the Mental Health Act, we must be aware that this is the very acute end of the mental health piece. What struck me was that it is no wonder people are reluctant to come forward for fear of stigmatisation given that mental health covers everything from the mild to the seriously acute. I listened to the previous discussions about restraint.

I am aware it is a comfortable place for legislators to comment on this and that there are extreme circumstances. It is like asking the Garda to be physically restrained with prisoners. Sometimes that is regrettably not possible. Our role as legislators is to ensure those occasions when it has to be used are appropriate, humane and person-centred, which is what I liked about the Bill. I ask Mr. Ryan not to take that to heart as it is not a criticism. It is just that as I read through it, I suspected that Mr. Ryan was under pressure to get this done and that he was used to dealing with a particular audience. I found it difficult to follow and I had to read it a few times, and I am reasonably bright. Other than that I have been fascinated by the inputs made.

I have never come across the phrase "experts by experience" before and I really liked it. That would represent such a shift. We traditionally had such experts by experience in the health system who had no qualifications and then we moved towards a qualifications-centred approach, which was appropriate as well. Can Mr. Ryan elaborate on that phrase? We are talking about people who do not necessarily have to have PhDs or master’s degrees but who have been immersed in this in a caring role or in an assisted role?

Mr. Michael Ryan

I apologise for the anachronisms. I thought I had minimised those but the Deputy is highlighting the need for all of us to be aware of language and how important it is that it is as accessible as possible. When the Bill is finalised it would be important that it is in language that is accessible to those it affects most.

The phrase the Deputy mentioned refers to people who have had their own lived mental health experiences and would now be in recovery. In our traditional model of healthcare we would go to the doctor and expect him or her to fix us if we had a broken toe. Our role is then to do whatever he or she says to do, be it to rest or whatever else. In a mental health setting the people who have to recover are experts in their own lives and they know what recovery means and what they want to achieve. These people will have lived with a mental health challenge 24-7, possibly for years, so they will understand it a lot better than anyone else. That also applies to their family members or supporters. They will be able to recognise what is going well for someone, what triggers them and what helped them. There is that expertise of living with a mental health challenge that only a person who is going through it has. We would call that person an expert by experience and we would say from an organisational point of view that this expertise of lived experience can be used in a service improvement function.

The Deputy just gave an example of language, accessibility, time of appointments and simple things like that which work for people. There is also a therapeutic value for the person and for others. That is why we have concepts like recovery education, which are led by people with lived experience to say that they had condition X, this is their understanding of it and this is what they did to help. Other people who are going through a similar experience find that beneficial. We have also moved to integrate that experience into the HSE more systematically by developing the role of peer support workers, who are people with their own lived experience who are now in recovery and are part of multidisciplinary teams. The Bill needs to ensure that it recognises the value of experts by experience and they must be incorporated into it.

Deputy John Lahart

I like that idea of incorporation and multidisciplinary teams. I do not want to place a burden on Mr. Ryan so rather than asking him to make further submissions, I will ask him the following question. The public would be interested in the process by which those people are selected. Is it based on the expertise of the medics involved - in other words, they work with a patient and they realise that he or she is an expert by experience who could fill the role? It is just that it is new, although it is fantastic that they are part of multidisciplinary teams and that there is recognition that there is no one better to speak on and assist in this than someone who has been in those shoes and walked the walk. I would like to hear more about the process of selection and how these people can become part of those teams without going into too much detail as I do not want to take up much time.

Mr. Michael Ryan

The HSE needs to be acknowledged for the work it has done in this area in terms of the office I head up, which involves the area leads for engagement, the recovery education and the peer support working. It has been recognised internationally that we are aspiring to be leaders in the field on this. We have to be careful that we are not creating arbitrary divides in people’s experiences and so on. Every person who has a mental health challenge is an expert in his or her experience. That is a valid experience which needs to be honoured and listened to. When introducing people to the multidisciplinary teams it is important to listen to their experiences because that is an important resource in how they will co-produce the intervention or treatment with the person. As that person moves into recovery, he or she overcomes the challenge and starts to get back to work or achieve life goals, and that is his or her recovery experience. On reflection he or she is able to objectively think about what happened, what the experience was like, how he or she recovered and what he or she has learned from it. When these people are able to reconcile their experiences, then they are in a position to share it with others in a more formal way. We would call these people experts by experience at that point. At all times we have to realise that we are asking people to share something personal and something that is at the core of them. It is important that-----

Deputy John Lahart

My question is on how they become part of the multidisciplinary teams.

Mr. Michael Ryan

The peer support workers we have are part of the multidisciplinary team. People express a desire that they want to use their lived experiences in the role of peer support work. What happens is that we developed a training programme where people with lived experience could train as peer support workers. That is a level 8 special purpose award.

They would gain training in how the HSE and teams work and how to use their lived experience and manage their own wellness and self-----

Deputy John Lahart

That is useful in that they do not just walk into it. There is an accredited process and avenue.

Mr. Michael Ryan

There absolutely is.

Deputy John Lahart

If I am right, the impetus is from the individual who expresses an interest. The HSE then responds to that. Probably not in all cases, but in some cases it may have an accredited course to bed in the structures and how that peer support role can be fulfilled to the best of the individual's ability.

Mr. Michael Ryan

We have been working on that model for three years. We have done an evaluation on it and it has been very successful. I can share that with the Deputy.

Deputy John Lahart

That is terrific.

Ms Ber Grogan

Deputy Lahart made some great points about how this legislation deals with the acute end of mental health difficulties. Over the past two years the Covid pandemic has resulted in considerable discussion on mental health, well-being and looking after our mental health. However, as the Deputy said, these are for people at the more acute end. In preparing for today, I looked at some of the HSE national clinical programmes, one of which is the early intervention in psychosis programme. One of our member organisations, Shine, has a particular interest in that programme.

During Covid, we had partnered with the HSE on a youth mental health Covid online webinar. There was the voice of a lived experience from someone who started to hear voices and such and did not feel he could talk to people about it, whereas other people were talking about going for a walk and getting out in the air. The clinical programme has 20 years of data, according to which an estimated 1,500 people could develop a psychosis disorder in their lifetime. There would be a delay of between 18 months and two years in looking for the support and treatment because people try to get through this themselves. They feel there is still a stigma and no conversations around this mental health difficulty.

On the economical side of it, it is said to be an invest-to-save programme. For each €1 invested in the early intervention in psychosis programme, €18 is then saved by reducing admissions, relapse and such. Some very good national clinical programmes are happening in some parts of the country. It would be a pity if it were to be a postcode lottery of where they can be accessed.

It also comes back to the community and voluntary sectors, which are doing great work in their communities and having the first point of contact before it gets to that point of needing acute care. If those facilities are locally accessible and affordable in our communities, it is hoped a greater cohort of those starting to go through psychosis, eating disorders or other mental health difficulties will be caught.

Acting Chairman (Deputy Mark Ward)

The need for an independent complaints commission has come up a couple of times, especially in mental health reform. We have spoken about it mostly in terms of involuntary access to services. However, could the witnesses outline to what it would relate? Would it encapsulate all services? Would it include care plans? Can the witnesses unpack whether we would have an inspector or commissioner and how that would work? Can they also point me in the direction of where it works well in another country? I can imagine where involuntary access is placed within services, direct access to that service would be complex. Do the witnesses know of a model at which I can look?

Ms Fiona Coyle

The idea of an independent complaints model came out quite strongly in the HSE consultations. The optional protocol, which we have not ratified, in the Convention on the Rights of Persons with Disabilities, UNCRPD, gives a way for individuals to make complaints and hold the state accountable. The fact that optional protocol has not been ratified leaves a gap in the avenues for people living with disabilities to raise a complaint.

We have to acknowledge there are mechanisms for individuals to raise complaints through services. However, we have heard through our consultations, and the HSE consultations have heard similarly, there is some fear among the service users or the family members that raising complaints may have consequences for the future use of the services. We have to acknowledge there is a mechanism. What we would be looking at would be an independent body, almost like a ombudsperson for mental health.

Deputy Lahart made an interesting point about the gardaí. There are similar deprivations of liberty in other parts of other legislation, but an independent complaints body or mechanisms are there to ensure that legislation which can only be used in specific circumstances can be independently reviewed.

With regard to this legislation and other rights under the UNCRPD, that model would first look at those rights and then perhaps be extended more broadly. We can come back to Deputy Hourigan with more information about some best practices and how that would look.

Ms Ber Grogan

As it is one of our main asks, I have been trying to do much more research on it. Mental Health Reform has been raising this since 2012. We did a paper on complaints mechanisms. In Wales, there are concerns teams to which people can complain. In New Zealand, there is an independent advocate called the health and disability commissioner who is the ombudsperson for mental health. In 2018, the World Health Organization's European region did a piece about the rights and standards of care for institutional care. Some 28 countries in that report have different independent complaints mechanisms. Even though the heads of the Bill state people should be informed of the facility's complaints mechanisms, that does not go far enough at all.

In the session with the Mental Health Commission, Deputy Ward asked about what recourse or routes there were for the people refused care. In its submission on the heads of the Bill, Mental Health Reform has also called for the capture of the data of people who cannot get community-level care to find out who is being missed. That may be separate from the independent complaints mechanism and complete wishful thinking that we would have these data on people who are not accessing community care. However, if people are turned away from emergency departments, EDs, or from one that does not have the national clinical programme, will those data be captured and where can those people go if they feel their rights are not being met?

Deputy Neasa Hourigan

Does Mr. Ryan want to make a comment on that?

Mr. Michael Ryan

I agree with what Ms Grogan and Ms Coyle have said. To add one additional point in terms of some of the feedback that has come back to us, one of the current problems is that there is no complaint system around what is considered a clinical decision. People cannot challenge those decisions and find that very frustrating. They may not agree with a particular diagnosis or with a particular course of treatment or whatever and there is no way of challenging that. We believe there needs to be some mechanism where those kinds of complaints can be dealt with independently.

Deputy Neasa Hourigan

I have one more question before I finish, but first I have a quick follow up question on that. In some of the submissions we received there have been very affecting descriptions of mental health incidents and how this legislation might interact with Garda powers. Do our witnesses envisage that there would need to be changes to practice or legislation around Garda powers or a review of those powers in light of this piece of work?

Ms Ber Grogan

I will jump in quickly. I am glad Deputy Hourigan brought that up. One of the things in the heads was around how the Mental Health Commission may make codes of practice for An Garda Síochána. Again, that was something the Deputy raised already in pre-legislative scrutiny, namely, that in the final draft of the Bill, the word "may" should be changed to "shall" so that the Mental Health Commission has an input into the codes of practice that are linking in with the gardaí. That is something we will be looking very closely at when the final draft is before us.

Deputy Lahart spoke about parallel processes and things such as that. There is a high-level task force being chaired by a former Minister of State, Kathleen Lynch, looking at justice, the Probation Service, the Prison Service and people experiencing mental health difficulties. It will be interesting to see what comes out of its work.

There is a pilot happening in Limerick at the moment around the crisis intervention team. Again, it would be interesting to get more information on that. In our expert analysis, we call for gardaí to have human rights training and training around the United Nations Convention on the Rights of Persons with Disabilities, UNCRPD, de-escalation techniques and all of those aspects. It is not happening in a silo with this great subcommittee. It has resulted in conversations across the board, particularly with justice.

Deputy Neasa Hourigan

Would anyone else like to come in on that?

Mr. Michael Ryan

The first thing I would like to do is to acknowledge the role of An Garda Síochána in its work in mental health in sometimes very difficult situations where someone needs to be taken into care. We received much positive feedback around how people experienced that process. Gardaí themselves would be the first to admit that they would need more upskilling and training to support them in that work, and in the kind of things Ms Grogan outlined.

One of the things that might be relevant to this discussion is around the role of authorised officers and the fact that in the Act, gardaí can no longer perform that duty. As it stands, the Act could, potentially, leave someone in Garda custody for 24 hours, because it allows up to 12 hours to get an authorised officer and another 12 hours to organise a transfer to an appropriate unit. It is a concern. These people are ill and are not law-breakers and should not be detained longer than necessary. At some stage, it might be useful to discuss authorised officers and who can perform that duty.

Deputy Neasa Hourigan

I will ask my final question. One of the things the Mental Health Commission raised with us was the need for perhaps parallel legislation around the regulation of all settings for services to include approved centres, community residences and any community services. Would our witnesses be in agreement on the need for that legislation?

Mr. Michael Ryan

Yes, absolutely. We need to ensure there is a standardised approach and there is equality of care across the spectrum, so we would welcome that.

Ms Fiona Coyle

Similarly, we believe that there needs to be high quality services and quality assurance frameworks put in place. We have called for that in the past.

Acting Chairman (Deputy Mark Ward)

I will give my tuppence worth now. I usually get in earlier than this. All the good questions have been asked at this stage but that is part of stepping in as Cathaoirleach today.

I will bring up something that has not been touched on yet. I agree with the statement that this is a once in a generation opportunity to positively change mental health legislation. It is probably the biggest piece of work this subcommittee will do in its lifetime. We also need to make sure we have the resources in place that will underpin, or will be the foundations of, this legislation.

Deputy Hourigan touched on the authorised officers. Last week, the Mental Health Commission said that they do much of the work. My concern is the HSE is not planning properly for this and that the law will be delayed as a result of these authorised officers not being in place. All the good work we are doing at this subcommittee and all the good work you are doing as stakeholders could be delayed because the authorised officers will not be in place.

For example, in the past couple of weeks I have been doing a little bit of digging and a bit of research on it and I tabled a couple of parliamentary questions. In 2019, there were 159 authorised officers in the State. Currently, in 2021, there are 126. The number is going down. Someone mentioned postcode politics. In my area of community health organisation, CHO, 7 it has dropped from 25 authorised officers down to 11, which seems to be the biggest decrease in any area.

We say language is important. The response I received from the HSE stated that there is a review going on and that based on this review there may be a need to recruit additional authorised officers. "May", again, is back in there. Does anyone have insights into this review? Is this Bill part of that review? What is the importance of having authorised officers in place as soon as possible? Those are my first questions for whoever wants to take them.

Mr. Michael Ryan

I can start and I thank the Deputy for his questions. It is my colleagues on the business side of operations who would deal with that sort of thing, so I cannot give specific details on the review. I can just talk about the feedback in terms of service user experience around authorised officers.

It is important to understand the role. It is the medical practitioner who will make the decision to admit somebody to a unit or not. The role of the authorised officer is to support of the person and the family and in regard to the accountability of that process. In practice, a family member or whoever will still have to make a phone call saying that a loved one is in distress and may need admission. That has not changed. We need to ensure they are supported in that process. Who can become an authorised officer should be part of the review. We mentioned peer support workers earlier and how they currently cannot perform that duty. Therefore, we should look at who else might be able to provide that service.

In terms of resourcing, last year there were something like 2,000 involuntary admissions and maybe there is a need to map where they happen and to see where the need is. I imagine that would be part of the review. The point I want to make is that we cannot lose sight of what the role is. It is a supportive role for individuals and families, and it is about how best we can do that.

Acting Chairman (Deputy Mark Ward)

I have a quick question which Mr. Ryan may not have the answer to. On the 2,000 involuntary admissions last year referred to, my understanding is that the vast majority of them were through An Garda Síochána and not authorised officers. This is why we need these authorising officers in place to underpin this legislation and to make sure we take the best human rights approach to this. Does Mr. Ryan or any of the other witnesses have any comment to make on that?

Mr. Michael Ryan

I do not have details of those figures but I am sure we can secure them for the subcommittee. It begs the question as to the role of An Garda Síochána and how the authorised officer and the admission processes can be best done in that context.

Acting Chairman (Deputy Mark Ward)

Do any witnesses from Mental Health Reform wish to comment on that?

Ms Fiona Coyle

This is one of the most significant changes that will impact the lives of the service users and the family carers and supporters. In that regard, Mental Health Reform has been broadly in agreement with what has been proposed but there is a need to take stock of how this will happen, what resources will be needed, how this will be rolled out and that all-important communication piece. Such a significant change could cause some fear in service users and we have been hearing about that already, such as how this will work and whether the situation will be worse than it is at present. There is a piece of work there for the Department, in partnership with the HSE, in scoping out how this can be run and to communicate it to those who are using the services.

Acting Chairman (Deputy Mark Ward)

My concern is that the current review of authorised officers will take in the current need for authorised officers. When this legislation comes into place, there will be additional needs and a greater need for authorised officers. It is incumbent on this review to take into consideration the Bill before us. That is my tuppence worth.

I have a couple of other questions. There was talk earlier about a direct connection between children admitted into adult mental health facilities. It was stated that 27 children were admitted into adult mental health facilities in 2020, which is very worrying, and that there was 0% compliance of codes of practices. There is a need for us, as a subcommittee, to make sure it is in the report. I would like witnesses' opinion on this in the context of the lack of early intervention for children. At present, 8,500 children are waiting for primary care psychology appointments, for example. Another 2,500 children are waiting for appointments with the child and adolescent mental health service, CAMHS. Some of these children are waiting up to two years for appointments. Do witnesses think that connection needs to be referred to in the report from this subcommittee? It probably will not be included in the heads of the Bill, but I would like to know their thoughts on that because early intervention is key.

Ms Fiona Coyle

Mental Health Reform welcomes any reference to ensuring the supports and services are available to both adults and children at the earliest possible intervention and that these services are available and resourced as required. That is a fundamental underpinning of us delivering high-quality mental health services.

Acting Chairman (Deputy Mark Ward)

I might have three more questions but I will ask two for now. There has been a lot of talk around the assisted decision-making (capacity) (amendment) Bill and the Bill before us. In June, I introduced a Bill providing for the capacity to consent for 16- and 17-year-olds because I could see the gap in legislation on that. The amendment Bill is set to provide 16- and 17-year-olds with the ability to give or withdraw their consent to their mental health treatment. As it stands, the Bill about which we are speaking does not provide decision supports for under-18-year-olds.

Engagement with counterparts on the Joint Committee on Children, Equality, Disability, Integration and Youth was referred to. I am probably the only member of this subcommittee who is on both committees. I have brought this to the attention of the secretariat and the Chair of the committee and it should be before the committee soon. I am not sure of the date. I take it that the witnesses will be feeding into that committee, with a bit of luck. If not, I will try to get them invited in. If this Bill is not amended, what impact will that have on the assisted decision-making (capacity) (amendment) Bill coming down the line?

Ms Fiona Coyle

Two very important Bills are undergoing pre-legislative scrutiny at present, namely, the mental health Bill, which we are discussing today, and the assisted decision-making (capacity) (amendment) Bill. It is a complex question because timing will primarily impact the answer and outcome. If the assisted decision-making (capacity) (amendment) Bill is passed prior to the updated mental health Bill, it will be based on the Mental Health Act 2001 and there would be a subsequent amendment needed to Part 8 of the Assisted Decision-Making (Capacity) Act, the part under the auspices of the Department of Health. It will require further amendments to ensure the mental health Act will be fully commenced and that the supports will be available for under-18s in the context of their health care because the Assisted Decision-Making (Capacity) Act goes beyond that to include financial remits and property rights, which is not the case and is very specific. There is a bit of choreography involved there but an amendment would be needed. More time and effort would be needed at a future stage.

Acting Chairman (Deputy Mark Ward)

Does anyone else want to come in on that?

Ms Ber Grogan

I really like Ms Coyle's use of the word "choreography" because I was thinking of a jigsaw of fitting all the pieces together and having joined-up thinking between the assisted decision-making (capacity) (amendment) Bill, which is now under the Minister of State, Deputy Anne Rabbitte, and has moved from the Department of Justice. The Assisted Decision-Making (Capacity) Act 2015 was originally under justice. Sometimes these can be reasons people outside the Oireachtas switch off from the pre-legislative process because it is very technical and all about the timing. It is great that the Acting Chairman is on both committees. It was also in our human rights analysis, our expert piece, from National University of Ireland, Galway. It flagged the lacuna, and we acknowledge that the Department officials who have worked on the reform of the mental health Act have tried to work around it and have said that the Mental Health Commission will come up with guidelines. However, as we all know, we need the protections on a statutory footing. There are some jigsaw pieces and nice choreography between the relevant Departments will be really important.

Acting Chairman (Deputy Mark Ward)

That gives us the benefit of the cross-departmental approach that we are looking to take in many areas of mental health. The issue of people in different Departments working in silos was referred to and the pilot crisis de-escalation team that is due to start in Limerick in the new year. It is really important the Department of Health is involved as well as the Department of Justice in that, and any other Department instead of just the Department of Justice working in a silo, which could happen.

The last question I have, which was mentioned already but I want to tease it out further, is on the admission of the provision of an independent complaints mechanism. Usually when witnesses come before this subcommittee, most go in the same direction and have the same opinion.

The Mental Health Commission appeared before us two weeks ago and spoke against the need for one. The witnesses before us today spoke about the need for an independent complaints mechanism. As a person with an element of distrust in some statutory bodies, I believe there is a need for an independent complaints mechanism to be involved in the process. What might the benefits of having an independent complaints mechanism in this legislation be? I am not asking witnesses to speak on behalf of the Mental Health Commission. Could they give an insight into the difference between both approaches?

Ms Fiona Coyle

I am happy to speak first. We need to acknowledge and recognise that complaints mechanisms are in place for service users to raise any complaints they may have. From our perspective and based on what we have been hearing from service users and given that within the area of mental health there are differences from other health areas such as deprivation of liberty or more openness to coercive practices, there is a need for that stand-alone independent complaints mechanism whereby people can raise their complaints and be independently supported. As I mentioned, we have not ratified the UNCRPD optional protocol, which is another mechanism for people to make those complaints. From our perspective and in regard to human rights and international best practice, we advocate for some kind of independent mechanism.

Mr. Michael Ryan

The feedback we get in engagement and recovery is that when people have a complaint, they do not feel there is a sufficient redress process or a proper forum to bring it to where it can be worked out. We hear on the ground about a need to provide that.

Ms Ber Grogan

To supplement that, it ties into the other supports available to assist people in making complaints or in accessing the complaints mechanisms. That is around the advocacy piece. Depending on the situation or what difficulty a person is going through at a particular moment, if there is no support network, a fully funded resourced independent advocacy service is needed. There is the Irish Advocacy Network which is a member of our group, and the Patient Advocacy Network and National Advocacy Service. It is about having somewhere that people can go. In the case of an involuntary detention or a crisis moment, a person may not be fully aware of the coercive practices or such things that occur, so having that support system outside is necessary. It is something that was interesting during Covid-19 especially. There was much talk about visiting hospitals or attending hospital appointments with people. What about people in the inpatient facilities at the moment? The youth advocacy programme conducts meetings online. There has also been that piece over the past two years where people in inpatient units have perhaps not had visitors, so how have they been able to access advocates or talk things through?

Acting Chairman (Deputy Mark Ward)

Do members have any supplementary questions before I return to the witnesses? I will ask the witnesses to make closing remarks.

Ms Fiona Coyle

I thank the Chair and wish Senator Black a speedy recovery. To reiterate this is probably one of the most important pieces of legislation that any committee will scrutinise over the lifetime of this Government. I thank the subcommittee for its work. A huge amount of work has been put in by Department of Health officials and by the Minister for Health, Deputy Stephen Donnelly, who managed to get it over the line after other Ministers failed to do so. We in Mental Health Reform are very much available to further support the subcommittee and provide any further information that is needed. I thank members for their time today. I look forward to engaging further.

Ms Ber Grogan

In preparing for today, I saw the OECD has released the Health at a Glance for 2021. It indicates that mental health and cancer are two areas where a delay in healthcare can have particularly adverse health effects. We also know that having a mental health difficulty increases the risk of dying by suicide. It is one of the things around the national clinical programme on self-harm and suicide related ideation. There is a programme there but for me one of the big things that jumped out was that there were more than 11,000 incidents of self-harm where the person ended up in an emergency department. It also estimated that in the community there were around 60,000 incidents of self-harm. It comes back to early intervention and prevention. We are starting to collect this data and to join the dots and talk to each other.

Sharing the Vision also has the cross-departmental aspect to it. It is about talking to each other and working together. It is an exciting time. The subcommittee doing this work is such a sea change and a cultural change. This is long-awaited, overdue legislation. I echo Ms Coyle's thanks. We have also had meetings with the Department officials, the Minister and the HSE. There is a great sense of wanting to get the best person-centred human rights combined legislation over the line. Best of luck to everyone with it.

Mr. Michael Ryan

I would like to raise one other point from our feedback that I feel is important. It relates to the role of families, supporters and carers. They are pivotal in a person's recovery. We talked earlier about experts by experience and they certainly are that. It is a well debated topic around confidentiality and the right of privacy of service users to their own information and I fully support that. The point that has been raised with us is where somebody who might have been involuntarily detained is being released back into a family home or to their primary carers. They are entitled to some information as to why the risk is considered to have reduced and what the warning signs must be. It is a complex issue to deal with but it is important it is on the table.

The other point that was raised with us on family involvement relates to head 9 and the criteria for a detention. At the moment the legislation refers to where there is a clear and imminent risk. However, family members and supporters would say to us that crises do not start at 3 a.m. and that there is a lead up to them and that there should be some provision where there is a clear escalating risk.

Acting Chairman (Deputy Mark Ward)

I thank the witnesses for their very helpful contributions. As usual, these meetings are a mine of information. I will read the transcript during the week to make sure I do not miss anything. I again thank the witnesses for their contributions. I thank members as well.

The joint subcommittee adjourned at 1.11 p.m. until 11 a.m. on Tuesday, 14 December 2021.