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Joint Sub-Committee on Mental Health debate -
Tuesday, 8 Feb 2022

General Scheme of the Mental Health (Amendment) Bill 2022: Discussion (Resumed)

I welcome representatives from the Irish Hospitals Consultants Association, IHCA, and the Irish Medical Organisation, IMO, to our meeting. They will brief the committee on the general scheme of the mental health (amendment) Bill. I welcome, from the IMO, Dr. Aideen Brides, IMO GP committee, Professor Matthew Sadlier, IMO consultant committee, Ms Susan Clyne, CEO, and Ms Vanessa Hetherington, assistant director, policy and international affairs. From the IHCA, I welcome Ms Alice McGarvey, assistant secretary, Dr. Anne Doherty, consultant liaison psychiatrist from the Mater Hospital, Dr. Brendan Doody, consultant child and adolescent psychiatrist, Linn Dara CAMHS, Dr. Donal O'Hanlon, consultant adult psychiatrist, Naas General Hospital and Kildare-west Wicklow mental health services, and Mr. Martin Varley, secretary general.

Before we hear opening statements, I need to point out to witnesses that there is uncertainty about whether parliamentary privilege will apply to evidence given from a location outside the parliamentary precincts of Leinster House. Therefore, if they are directed by me to cease giving evidence on a particular matter, they must respect that direction. All members and witnesses are again reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

I ask Ms Susan Clyne to make her opening remarks.

Ms Susan Clyne

I thank the committee for the invitation to attend. The provisions of the Bill will impact on the delivery of care for patients across both acute and community settings. That care is already compromised in a service that is inadequately staffed and has significant structural and system issues, some of which have been highlighted in recent weeks by the review of the Kerry child and adolescent mental health service, CAHMS. Those issues are the inevitable result of years of inattention and underfunding of critical health and mental health services across the State and the introduction of unsupported structures to deliver optimum care. In the context of the Bill and our views on the provisions of the Bill, it is also critical for this committee to understand that to enable any legislation and to provide safe care to patients, we must address the ongoing problems within the service itself. We have known for many years of the unmet needs of patients and we also know that this will continue to grow significantly as a direct result of the pandemic, yet we are still woefully unprepared.

Funding for mental health now stands at just 5.5% of healthcare funding compared with 10% in the UK and Canada, 13.5% in Norway and 15% in France. It is not that Ireland has less need than those countries. The mismatch between the allocation of funding and the needs of specific catchment areas combined with the sectoralised multi-disciplinary teams approach has created postcode lotteries and difficulties for patients in accessing essential services. We have a consultant recruitment and retention crisis. It is the worst in the State's history. The Kerry CAMHS review highlighted the key role of the consultant clinical lead in ensuring quality of care, providing clinical governance, leadership and expertise to the multi-disciplinary team. However, as a direct result of the 2012 pay cuts to consultants, 136 out of 485 consultant psychiatry posts are unfilled or are filled on a temporary locum basis. That is almost one third of posts in the whole country. It is impossible to expect that we will deliver a proper service with that level of vacancies. Additionally, the working environment for consultants and the lack of streamlined and workable structures between community and acute makes the role difficult and, in some cases, unmanageable.

Particular difficulties arise in our CAMHS, where more than 3,300 children are waiting for a consultant appointment. Some 6% of these have been waiting for more than a year while many others are not deemed ill enough to even qualify to go onto the waiting list. Even when they are referred, their referral is sent back, and there is nowhere else for them to go, because within general practice, there is not a service resourced for them. We have an over-reliance on non-training non-consultant hospital doctors to deliver services when services should be delivered by consultants and non-consultant hospital doctors in training with the support of the multi-disciplinary team. National Doctors Training and Planning estimates that 628 additional consultants are required over the next ten years to cope with additional demand and to replace those retiring or leaving the service.

There are also significant shortages of psychiatric nurses, counsellors, psychotherapists, occupational therapists, social workers, with staffing levels up to 40% below recommended levels. Sometimes we say that we have a team, but it is a notional team, because the full team is not there to deliver the service which the patient requires. Ireland has only 33.5 inpatient psychiatric beds per 100,000 population, which is less than half the EU average of 68 inpatient psychiatric beds. In addition, acute adult psychiatric units operate at almost 90% occupancy, well above the 85% safe occupancy levels. There is no dedicated resource within general practice to deal with mental health issues and in many cases the only option is to refer. This again brings back the issue of postcode lotteries or teams that are insufficiently staffed.

It is right that legislation should be subject to regular review, but we have to bear in mind that we have failed to adequately resource mental health care in Ireland. We must ensure that when amending our legislation, we are not further lowering the standard of care and services provided or creating additional barriers to access. Today, we would like to hone in on the areas that cause us the most concern in the Bill. The committee has received a copy of our detailed submission to the Department of Health’s review of the Act, which contains our full list of concerns.

Regarding the interdisciplinary approach to care and treatment, a multi-disciplinary team approach underpins the model of mental health services in Ireland as per A Vision For Change from 2006 and the new mental health strategy, Sharing the Vision, from 2020. Sections of the draft Bill seek to legislate for an interdisciplinary approach whereby the consultant must consult with at least one other mental health professional before certifying an admission order, renewal order or before recommending or administering treatment or medicine to a detained patient who lacks capacity. This provision does not have sufficient evidence to support its effectiveness and does not refer to existing clinical and legal governance, under which the consultant must operate.

The IMO recognises the value of multidisciplinary care. This is happening across all disciplines, including psychiatry, whereby teams of healthcare professionals, non-consultant hospital doctors, nurses, counsellors, therapists and social workers work together in a team under the clinical leadership of the consultant psychiatrist in the best interest of the patient. Each member of the team is trained in their own discipline, brings their own unique skills and strengths to the team and the care of patients with severe mental illness. However, to suggest that the roles and skills of each team member are interchangeable, or that teams are even homogenous, represents a significant misunderstanding of the different education, training and roles of each health care professional within a team. After receiving their medical degree, doctors must undergo between seven and ten years of specialist training in psychiatry, before they can enter the specialist register and qualify to apply for a consultant post. Consultants in psychiatry are uniquely qualified in the diagnosis and treatment of patients with psychiatric illness.

Under the current contract, a consultant is clinically independent and retains overall responsibility for the care of the patient. Whereas the consultant psychiatrist may, and in most cases does, confer with other members of the team with regard to aspects of patients' treatment, any legal requirement to do so poses a risk to the patient's safety, undermines the contractual responsibility of the consultant and blurs the line of accountability and clinical responsibility.

In respect of authorised officers, when a person is in crisis and requires admission for inpatient care, whether voluntary or involuntary, we must ensure the legislation supports their access and does not create further barriers to care. Authorised officers have a very useful and valuable role to play in making an application for involuntary detention where a patient has no family or where there is a dispute among the family members. However, we have concerns that the requirement that the authorised officer be the only person allowed to make an application to a medical practitioner for involuntary detention will bring an additional layer of bureaucracy and potentially lead to delays in treatment for patients.

In advance of any implementation of this measure, there would need to be a significant increase in the number of authorised officers in place across all healthcare settings in the State and to ensure 24-7 availability at a maximum of one hour's notice. We can talk to the committee later about some real and practical examples of how this affects both GPs and consultant psychiatrists.

The other area where we have significant concerns is around the definition of a child. We must address the loopholes in care for vulnerable teenagers. There are over 12,000 presentations to accident and emergency departments annually following an episode of self-harm, with the highest rates among young people aged between 15 and 24. However, discrepancies in the definition of a child have led to gaps in the service for some young people. Under the Mental Health Act 2001 and for the purposes of admission to CAMHS, a child is defined as a young person under the age of 18, unless married. On the other hand, paediatric emergency departments, including the new children's hospital, are only accessible to children under the age of 16. As a result, emergency presentations of young people between the ages of 16 and 17 years occurs at adult general hospitals, most, if not all, of which have no child psychiatry cover. Admission of this age category to adult psychiatric units remains a cause for concern and is a national scandal.

The IMO recommends that in order to have a Bill that safely and properly provides for patients and a service behind the Bill that enables the legislation to be enacted, serious action must be taken by the Government and the HSE to address the recruitment and retention crisis affecting consultants across our health services, including psychiatry, where, as I mentioned, a third of posts are vacant. The 30% pay cut imposed unilaterally on consultants in 2012 - in addition to the cuts generally applied during austerity to public servants - has had the inevitable devastating effect on recruitment, especially in psychiatry. The reversal of this cut has been promised by successive Ministers for Health, including the current Tánaiste, Deputy Varadkar, and his successors, Deputies Harris and Stephen Donnelly, yet to date there has been no attempt by the Government to resolve the matter. There has been plenty of acknowledgement that this has caused a crisis in manpower and consultants in psychiatry services.

The current consultant contract talks are delayed as we await the appointment of a new chairperson. These talks must recommence as a matter of urgency and address all the matters that currently make Ireland unattractive for consultants to practice in. We must expand the number of psychiatry training places across our health services. Half of our consultant psychiatrists are over the age of 50 and between 276 and 350 will retire from the service over the next ten years. Whereas ten years or a decade might seem like a long time, in the context of medical manpower and training planning, it is the blink of an eye.

An urgent review is required as to how care can be provided to patients in the community while ensuring the governance issues, clinical pathways and ongoing systems are supported within the acute sector and enhanced. There are issues and we would like to discuss with the committee questions relating to consultants in isolation in the community.

Dedicated support for mental health services must be directed towards general practice so they can work more effectively with local specialist services. GPs do not wish to burden the acute services with over-referral but they operate in an environment where they have no resourced time to see these patients. What these patients need most is time, and their issues are not solved with going in and out from a ten-minute consultation. We have been appealing to the HSE for some time now to look at where we treat chronic disease, such as diabetes, in a structured way and realise that we must treat mental health in a structured way and offer those presenting the time they need. It is not always about choosing the referral option because we can now see that referrals, particularly for young people, are coming back because the service is overly burdened and the children are not deemed ill enough.

On the proposed legislation, the IMO recommends the role of the consultant in providing clinical governance, leadership and expertise to the multidisciplinary team be valued and respected. This is of paramount importance if we are to provide safe, quality care and attract highly qualified psychiatrists to our mental health services. Unless we can guarantee that authorised officers will be available nationwide on a 24-7 basis, we should not introduce a requirement that they be the only category of persons allowed to make an application for an involuntary detention.

We need clear and unambiguous definition of what constitutes a child that is consistent across all healthcare services so that those aged 16 and 17 can receive care appropriate to their needs and they do not fall between two stools. The IMO welcomes amendments to the legislation to expand the role of the Mental Health Commission but believes that does not go far enough. In the first instance we call on the Mental Health Commission to engage an independent body to carry out an in-depth analysis of the role of community multidisciplinary teams and to assess whether the current model of community-based mental health teams is the best model for the provision of mental health services to patients.

When inspecting mental health services, the Mental Health Commission should assess the budget allocation received by that service to ensure it has the correct staffing levels and is capable of meeting the needs of patients within their catchment area, as well as identifying areas of national policy where the recommended services have not yet been delivered.

In light of the proliferation of private and voluntary organisations providing mental health services to the public, the IMO is of the view that all agencies providing mental health care in Ireland should be required to achieve accreditation to international standards. The IMO is calling for the remit of the Mental Health Commission to be expanded to allow for the inspection of all agencies, public, voluntary and private, which provide mental health care, including those providing psychotherapy and counselling services. Our belief is that patients need safe care everywhere. I thank the committee for its time and we look forward to answering any questions members have.

Dr. Anne Doherty

I thank the Chairman and her colleagues for the opportunity to join in the pre-legislative scrutiny of the mental health (amendment) Bill. The association represents around 95% of hospital consultants working in Ireland’s acute hospitals and mental health services, including psychiatrists.

The pandemic has exposed the cracks in the public hospital and mental health services. Our mental health services are at breaking point due to existing large capacity deficits, combined with significantly increased demand for treatment impacted by Covid-19. This has rightly brought a renewed focus on the urgent need to dedicate increased funding and resources for the provision of more timely, safe and quality mental health services. Consultant psychiatrists are committed to the provision of expert medical care to patients with moderate to severe mental illness. We appreciate the opportunity to discuss our views on some of the proposed changes in the Bill and wish to ensure that the proposed legislation will be in patients' best interest. We are concerned that some of the proposed changes, if included in the legislation, would give rise to unintended negative consequences for patients, their families and the overall provision of care.

The first concern relates to involuntary admissions. Involuntary detention in an approved centre is a very difficult experience and can be a distressing and vulnerable time for both patients and their loved ones. The Mental Health Act 2001 currently permits members of An Garda Síochána, a family member, an authorised officer or another person to arrange admission for people presenting with an apparent risk to self or others owing to a mental disorder or a perceived need for treatment. Head 9 proposes that family members will no longer be able to apply to have their loved one admitted to a psychiatric hospital when they believe that this is necessary for their care and treatment.

Waiting for an authorised officer to arrange an admission, as proposed, would present significant problems for the timely assessment and provision of care to patients. First, the general scheme provides that authorised officers should be available on a 24-7 basis, these positions are not widely filled within the health service and recruitment is a challenge. In the United Kingdom's National Health Service, NHS, approved mental health professionals, AMHP, the equivalent of authorised officers, undergo extensive training for the role.

The NHS is also experiencing challenges in recruiting and retaining AMHPs and there are reports of significant stress and burnout in this group.

Second, it is unclear from the Bill where clinical responsibility lies if an authorised officer decides not to complete an application, and if the patient comes to significant harm because of having been denied admission to hospital. Consultants have a continuing clinical and professional responsibility for the diagnosis, treatment and care of their patients and an ethical duty to protect vulnerable people who are at risk or who may suffer harm.

Third, removing the role from An Garda Síochána in such admissions, made in consultation with a Garda GP, may have the unintended consequence of leading to prolonged detention in Garda stations for those who are in need of timely specialist psychiatric care. Other patients who require admission may also have to wait for lengthy periods in emergency departments, EDs, for an authorised officer to attend. Emergency departments are often chaotic environments and are not an appropriate setting for treating patients with acute mental illnesses. This in turn may adversely affect ED services for other patients.

On admission orders and renewal orders, consultant psychiatrists are compelled to advocate on behalf of patients to ensure the provision of timely and appropriate care. We believe that the proposal to shorten the period of review for admission and renewal orders from 21 days to 14 days, as per section 18(3), while perhaps well intentioned, may in fact cause increased distress for patients and provide inadequate time to evaluate those patients who have complex presentations. In addition, the inevitable associated increase in costs has not been quantified.

Shortening the period would also result in a reduction in the time available to consultant psychiatrists for the direct provision of patient care, adding to the existing overstretched mental health service situation. Over the past decade, we have been trying to manage a growing and serious consultant recruitment and retention crisis. Of the 485 approved consultant psychiatrist posts, as of 1 February 2021, approximately one in four were vacant or were filled on a temporary or agency basis only. It is understood this figure has since increased to closer to one in three.

On restraint and seclusion, patients have a right to be safe when they are in hospital. Staff members, including doctors, nurses and other staff have the right to work in a safe place. While the vast majority of violence in society is unrelated to mental illness, we must acknowledge that aggression may indicate an unmet treatment need, for example, an untreated psychotic illness. The purpose of seclusion on psychiatric wards is to prevent serious violence to other patients and to staff members. Seclusion should only ever be used for the minimum time possible and to prevent serious violence. Section 69 states that the rules on seclusion and restrictive practice shall be made by the Mental Health Commission, without further input from the Oireachtas. This is a clear democratic deficit. The Bill also states that failure to comply with the rules or breaches of these rules are punishable with summary convictions and fines, meaning that consultant psychiatrists can receive criminal convictions for matters that may include errors on seclusion forms and paperwork. We do not think it is appropriate that criminal convictions apply to staff who are acting to prevent violence on wards. This will likely have a detrimental effect on recruitment into psychiatry, further exacerbating existing recruitment challenges.

Rapid titration of medication is referred to as “chemical restraint” in the Bill. This is not an appropriate term, and we consider it to be misleading, stigmatising and it could be frightening to patients and their families. Rapid titration of medication is often necessary when very unwell patients are admitted to hospital. It is a means of ensuring that they are stabilised as quickly as possible to minimise the need for seclusion and to reduce the length of stay in hospital. The prescription of all medication is already under the legal provisions of the Medical Practitioners Act and is subject to review, if needed, by the Medical Council of Ireland.

The IHCA respectfully asks this committee that the rules pertaining to seclusion, restraint and restrictive practice be set out clearly in the Bill, and that the power to change these rules rests with the Oireachtas alone. We ask that the term “chemical restraint” is changed to “rapid titration of medication”. We ask for removal of the clause permitting the criminalisation of doctors.

On the admission of children to approved inpatient facilities, the proposed timeline of 21 days to review the admission of a child aged 16 years or older as an intermediate person in section 87 is appropriate, given that court proceedings can be stressful and that overly frequent reviews, for example when treating a patient suffering from an eating disorder, could be unnecessary and counterproductive. It is not necessary for a child to be brought to an approved centre by gardaí without the necessary safeguards, as is proposed in section 90. Children presenting in crisis do not necessarily have a mental illness and they require appropriate assessment, including medical assessment, in an appropriate setting. The Bill is silent on section 25 applications made under the current Mental Health Act regarding children in care and subject to court orders. This is a critical protection that should not be removed, as the courts can ensure a child does not remain inappropriately in the approved centre.

In conclusion, our mental health services are facing huge challenges. The decisions taken by this committee and the Oireachtas on the proposed legislation may profoundly affect some of the most vulnerable members of our society. It is imperative that we address the concerns for patients, families and those who are responsible for their care. I thank the committee for its invitation to its discussions on these important matters. We are available to address its questions on these issues.

I thank the witnesses for the presentations. Our first speaker today is Deputy Mark Ward. If witnesses want to come in at any time, I ask that they put up their hand. If any attendees who are joining online want to come in at any time, I ask that they use the raise-hand function.

I thank the Chair and both groups for their comprehensive opening statements. One of the areas on which I would like to touch relates to, as the witnesses also mentioned, the chronically underfunded and understaffed mental health services. These are impacting the care the people receive. It was mentioned that Ireland's percentage of the budget is almost half of the international best practice. I have been trying to change the postcode lottery of treatment for a long time and I have highlighted this for a long time. Treatment should be based on need and not where someone lives.

I want to mention CAMHS in Kerry, because it was brought up. I travelled down to Tralee at the weekend, where I met parents and children who are directly impacted by the situation in CAMHS. It was heart-breaking. As a parent, I could see the devastation and the look in the parents’ eyes. They trusted medical professionals to give the best care possible to their children and they did not receive that. As the report said, children were misdiagnosed, they were over-medicated, and they were also offered little or no supplementary therapy. I heard directly from the children's mouths how their lives were affected and how they have lost so many opportunities because they were basically sedated.

I know that there were some objections in Professor Doherty's opening statement to the term "chemical restraints". However, in my opinion and from listening to these parents at the weekend speaking about CAMHS, this is exactly what happened to these children. One of the most common themes that came up was that children had been instantly medicated after their first consultation. They were not offered complementary treatments, such as psychology, occupational therapy or speech and language therapy. There are currently 71,000 children waiting for these life-changing therapies. Therefore, my first question to both groups, is that in their own professional opinions, do they believe that other therapies, such as talk therapies, are important? Do they feel that these can aid or replace the medical model?

Professor Matthew Sadlier

I thank the Deputy for those important points. Talk therapies are essential. However, the Deputy's last sentence is the one that I would rile up on. He said "replace the medical model". I think they work in conjunction with each other. Mental health services throughout this country and internationally have had an ongoing battle between two ideologies that are actually not in opposition with each other but are complementary. If one looks at all the evidence towards mental health, it is a combination of medicine and therapy that works best. Neither one should be alone. Too many different services either go down one road or the other, largely due to ideology, without accepting that there is a middle road. That would be like asking that if people broke their leg, should they go to a physiotherapist, or should they have their leg in a cast? The answer is that they have to have both. That is the way I always try to look at it. Yes, talk therapies are important.

We have in our submission, as the Deputy knows, asked about how community mental health services are structured. This is because, as they are currently done with strict sectorisations, postcode lotteries do arise. We can talk about that in more detail if the Deputy wishes. We have asked for an independent review of that. Ultimately, the services are under-resourced. This is core problem. However, we also know that they are poorly structured. We know that posts are vacant all over the country. There are posts that the HSE is very happy to fund. It is very happy to pay salaries for them. However, it cannot recruit people into those posts. Therefore, just throwing money at the problem to an extent is not helpful.

There is a deficit of funding so we need to increase the funding but we also need to look, in a structured way, at how we recruit and retain staff. The fact that we increase a budget in an area often does not result in any improved service because people cannot be got to work in those services. We need to look in-depth, with the various different professions, be it psychology, social work or medicine – and we represent doctors so that is our emphasis but I am sure the committee has met the other professional groups and I will not speak on their behalf – to see why certain posts are vacant. We must also look at why it is more difficult to recruit in certain areas of the country than others and at what can be done to recruit people in those areas.

Dr. Aideen Brides

I thank Deputy Ward; he has raised some very good points there. From a GP perspective, the only option we have is to give medication and we often know it is not the answer. As Professor Sadlier correctly mentioned, it is part of the answer and they work together. Where I am based in Monaghan, I have a 16 to 17-month wait to send a patient for primary care psychology. In Laois and Offaly, I think it is nine months. As the Deputy knows, if somebody has a problem that needs to be dealt with he or she is either cured or in hospital by that stage if he or she is going to access that service. Time and again we see patients who we know do not need to be seen by psychiatry but we have no other option. We send them for psychiatry because we are giving them medications that they do not necessarily need or that they might need in combination with psychology and other therapies but we just cannot access them. It is important that if we are going to look at mental health as a whole we start at primary care level and put in the other resources like the multidisciplinary team, MDT, psychology and other supports. This will filter onto secondary care and more time will be available for people who have specialist psychiatry illnesses to be seen. We can then deal with the issues that it is possible to deal with in primary care. It is a good point to make that it is not just one factor but is multifactorial.

I believe that both should be running in tandem with one another in complementary therapy. Dr. Brides mentioned that 8,500 children are waiting for primary care psychology and over 4,000 of them are waiting for over a year. That is the deficit in services we have. If these services were running properly and in parallel with one another, there might not be the need for children to be on medication for as long as they are. That is one of the issues I have heard from talking to parents of children in CAMHS.

Dr. Brendan Doody

To provide a specialist mental health service, a multidisciplinary team with a full range of skills is needed. Such a team is led by a consultant child and adolescent psychiatrist with the necessary skills and training. Children who present will require a proper and full assessment of their needs and then it is part of the care planning to identify how those needs are best met. That may require a number of inputs from different members of the team and a number of therapies. It is not only about having the resources but about having the skills available on teams. That is one point. Medication may be a part of that but it would never be the sole intervention.

The other point my colleagues have made is that it is important for specialist services that services for primary care at other levels are available too in order that children whose needs could be met in primary care are not being referred to specialist mental health services. The Deputy made the point that often, an earlier and more timely intervention can have the effect of the problem not developing such that children require later referral to a specialist mental health service. That holistic approach has to be taken, rather than just looking at the importance of resourcing and having those skills and specialist mental health teams. We must also ensure that resources are available at primary care level to allow timely support and access. A whole-of-system approach has to be taken.

I want to ask a supplementary question on that because it came up in respect of the 3,500 children who are on the CAMHS waiting list. In response to a parliamentary question, I was recently told that 4,900 children were refused a service by CAMHS because they were deemed inappropriate after being referred to it by a medical expert. I do not have an answer for this but what happens to these children? At one stage a medical expert deems that they need a service in CAMHS and then they are deemed inappropriate for it. Are they referred on somewhere else? Is there any reason they were deemed inappropriate? Parents have got in touch with me who have children who might have a dual diagnosis, who may be on the autism spectrum and who have mental health difficulties. They feel their children were turned away based on these issues. Could Dr. Doody comment on that?

Dr. Brendan Doody

If a child is referred then there is an identified need so it is not a case of saying the need does not exist. CAMHS has a specific remit for moderate to severe mental health disorders and these children are being redirected to other services. It will depend on how well resourced and how available other services are but it is deemed that these children do not meet the threshold for entry into a specialist mental health service. That does not mean that child and family do not have a need that must be addressed.

I know there is probably another long waiting list for that child to get a service. Are they referred back into services?

Dr. Brendan Doody

What should happen is that there would be a clear signposting as to what other services the child would be more appropriately directed to.

Dr. Aideen Brides

I will add to that. I entirely agree and often in primary care we send a referral to CAMHS when we know that is not the best place to send it to. However, due to a big fragmentation of services at primary care level, we often do not know where it is best to send them. Sometimes a child may have needs that would be best dealt with by Enable Ireland’s child development team but because there is such a fragmentation of services it is hard to know where it is best to refer them. They may be sent to CAMHS knowing there is no medical need and as was mentioned, CAMHS is a specialist service. If we are to look at reforming mental health services we have to start looking at all the services provided having a centrally referred process and from there it can be assessed which would be the most appropriate service. I imagine there are many children on that waiting list whose needs would be better met elsewhere.

I refer to the admission of children into adult psychiatric inpatient facilities and these cases are a regular occurrence. The proposed Bill uses the words: “in so far as practicable” and to me that just leaves a loophole open. We passed a motion last week calling for this loophole to be closed and to stop this practice. Why is this needed in the legislation? Can other safeguards be put in place if we legislate to stop this practice? The Ombudsman for Children was here in recent weeks and it was telling that he mentioned that:

We have become lazy about it and we have let the idea that we do not have the resources in place rule the fact that the best interest of the child is being overrun.

Those are the words that were used.

Professor Matthew Sadlier

The IMO has been banging the drum throughout the past ten years that we need a definition of what a child is. You can smoke at 16, you can drive at 17, you can get married at 16, the Mental Health Commission says you are a child at 18 and there are various different other examples we could list off. As people are trying to drop the voting age to 16 as well, where does childhood end? The Mental Health Commission and the mental health legislation have always had a strict rule for 18 years of age, despite the fact that the national children’s hospital and national paediatric services for medical illnesses define childhood as ending at 16-years of age. Are these numbers being picked out of biological physiology and psychology or are they being picked out of legal ideology? I do not know but we need to align these services. If a 17-year-old unfortunately harms him or herself or something like that, he or she is brought to an adult hospital, not a paediatric one and he or she is within an adult health service. It comes back to a point I am sure I will raise over and over. Mental and physical health are intermingled in a large number of cases. If somebody severely harms him or herself and might need plastic surgery, for example, that will be delivered in an adult hospital but his or her mental health services have to be delivered in a paediatric hospital. The adult services that are trying their best to treat this person in the adult hospital are being condemned all the while. There are areas where we need to align those numbers.

As for the loophole, I will give the Deputy an example although I will not mention names and I will obfuscate the details a little bit. I remember many years ago a patient was referred to us who was 17 years and 355 days old.

The patient had a first episode of schizophrenia and needed admission into our unit. Would it have been appropriate for us to transfer this person to a child inpatient unit for ten days, until the age of 18, to then come back to us to be treated? I think there needs to be a loophole with these age cut-offs. We had a motion at an annual general meeting years ago that sought to define the loophole. When people are close to their 18th birthday, with their first presentation, there has to be a loophole, otherwise one will be bouncing people.

Situations could arise, no matter what age is defined for what a child is, where there are loopholes.

Professor Matthew Sadlier

If the adult physical and mental health services were at least somewhat aligned, we would have more clarity and we would avoid this eventuality.

Dr. Brendan Doody

The vast majority of children, who are under 18, are admitted to child and adolescent mental health facilities. In certain situations, in the best interests of the child, it may be prudent and necessary for the child to be admitted to an adult unit. In the last two years, the numbers admitted accounted for less than 7% of all admissions. The vast majority were aged 17. Over half were transferred to a CAMHS unit within four days and the average length of stay in the adult facility was four days. We also have to bear in mind that the recommended provision of inpatient beds for child and adolescent services in A Vision for Change is 100 beds and 70 are currently in place. We have 70% of the recommended level. The population has significantly increased since 2006. As I said, if somebody is very close to his or her 17th birthday, it may be in his or her best interest to remain in the adult unit rather than having to travel a significant distance to the four regional child and adolescent mental health units. If admission occurs, a transfer should take place as quickly as possible. The number of bed days that under-18s spend in adult units is very small. One would want to minimise that number. It is set out in the legislation that we should strive towards that. There will be exceptional circumstances where it is in the best interests of the young person to be admitted to an adult facility in an emergency situation.

I might come back in at the end. I thank the witnesses.

I want to address the issue of seclusion. There is a recommendation that there be no reference to criminal prosecution of doctors. Will a witness unpack that for me and outline concerns about it? One matter raised in the opening statement is that people can be criminalised for simply filling out a form wrongly. Is that a serious concern? Will somebody outline that in more detail?

Dr. Anne Doherty

The problem with this part of the proposed Bill is that it is unclear what the rules will ultimately be. The rules can be made and changed at will by the Mental Health Commission. We have some concerns about rules that could potentially create a situation where a doctor might face criminal sanction being made anywhere except the Oireachtas. We feel that changing the rules about criminal criteria should remain with the Oireachtas. Seclusion is not used regularly. It is used only as a last resort if there is extreme violence and other patients need to be protected from somebody who is extremely unwell to allow that person that extra space to get better. In that situation, any decision is made in the context of protecting people. It is not about being restrictive or for any other reason than protecting patients and making sure that if somebody goes into an acute hospital, with severe self-harm or severe depression, for example, that person's recovery is not occluded by somebody else nearby potentially being very agitated, who might be better in a separate environment. We are concerned that the provisions of the legislation in this area are quite vague. Given that we have such difficulties at the moment with recruitment and retention of people to consultant and to training posts in Ireland, we are concerned that provisions like this could get in the way of us being able to adequately staff these services.

For clarity, the issue is not the criminal aspect itself, because doctors and medical professionals have liability if they are found to misuse the responsibility they have. The UN recognises seclusion as a possible form of torture if misused. Nobody is suggesting that is what is happening, but there is a criminal aspect to this. For clarity, Dr. Doherty's first point is that the decision-making process is not vested in the Oireachtas but somewhere else, and she is concerned about that, but not the criminal aspect itself.

Dr. Anne Doherty

We are all responsible for our decisions and for any treatment decisions that we make. We are all answerable to the Medical Council for the decisions we make, as are our nursing colleagues, who are potentially also open to this provision of the legislation. They are responsible to their governing body. There are already clear checks and balances. We are concerned about additional rules that are not reviewed by the Oireachtas and which could result in colleagues potentially facing criminal sanctions. I think that will be a real issue.

I am sorry to cut across Dr. Doherty. I am trying to get a correct sense of this. Obviously, the Medical Council is not a court. Where there has been a breach that has had a serious impact on somebody's human rights, physical well-being or mental well-being, that can become a criminal matter. I am not speaking specifically about this jurisdiction, but we have seen medical professionals prosecuted for various transgressions that meet a criminal bar. I am just trying to understand where the seclusion aspect meets that criminal bar. We are not suggesting that the decision-making there would be vested in the Medical Council. Dr. Doherty's point is more that any issues of legality or criminal matters should be overseen by the Oireachtas.

Dr. Anne Doherty

Absolutely. It is really about the fact that the rules are currently unclear and they could change. There could be a situation where people are being prosecuted for errors in paperwork and we do not want to see that happen.

Professor Matthew Sadlier

I want to back up what Dr. Doherty said. It is about the concept of malicious intent. One concern that everyone working in the mental health service has is that some of the processes around involuntary admissions and the inpatient unit have become too pedantic and technical. Patients' health, well-being, risk and safety are often secondary to pedantic things like filling out the wrong date on the form, such as writing 1 January 2021 on New Year's Day when it is actually 2022. The risk to the patients, their families and society is completely ignored in those processes. If there is going to be a criminal prosecution, there must be some concept of malicious intent by the doctor. The concern is about having some phraseology or words within the legislation to ensure that people will not be prosecuted in a criminal way for what is, as Dr. Doherty said, an administrative or technical failure. If people are to be criminally prosecuted, there should be a concept that they have done something intentionally to harm another person. "Malicious intent" is a phrase included in other legislation that maybe provides some comfort. Without that wording and with the Mental Health Commission devising rules and guidance that could potentially lead to a criminal prosecution, those rules and guidance would need democratic oversight by the Oireachtas rather than allowing an agency to define what is a crime or not.

I take that point, although considering how long we have been waiting for the report on the Tánaiste I am not sure I believe the Garda will be looking at dates on particular forms.

I wish to discuss the use of the phrase "chemical restraint". The phrase "chemical restraint" may suggest perhaps not malicious intent but that it is not about the best care of the patient but about the care of everybody else. Some of what we have discussed today relates to the safety of staff and other patients. I can understand the concern from medical professionals about the language here and language has a value. However, is it fair to say that chemical restraints could be a fair reflection of what is happening with patients who might be in particular difficult circumstances and in services that are not funded correctly and not do not have the resources to deal with them? Is it useful to completely eradicate that from the legislation?

Dr. Donal O'Hanlon

The term itself is misleading. We use medications to alleviate distress and treat illness. Most people who come into hospital are suffering from a very acute phase of illness. That is the criterion for admission. Even the use of the term "chemical restraint" is quite misleading. In any other branch of medicine, we would be using medication to relieve suffering, treat the illness and relieve distress.

There is a further problem with the section regarding physical restraint and chemical restraint as it is termed and the draft Bill. Some 80% of admissions to inpatient units are voluntary. We really encourage people to come in as voluntary patients. It is highly preferable. That has been very much the ethical position from psychiatrists and other multidisciplinary staff for years. We are very comfortable with that. However, they are coming in in a very acute phase of illness. Unfortunately, some of them exhibit behaviours that are difficult to control, for example, self-laceration on a ward or attempting to harm themselves by banging their head on the wall. These are very much a minority of those patients who come in as voluntary. However, they present a real challenge in how to keep them safe and how to keep their neighbour in the next bed safe.

I am not sure this is workable if there is an absolute ban on using such techniques in order to ensure safety and in order to relieve distress for 80% of the patients coming into adult-approved centres. In the centre I am most involved with, we have 29 beds and at night we have four nurses. I do not know how we are going to make that work. I think there will be many injuries for other patients and for staff. I ask the committee to take that into consideration.

Are there other jurisdictions where physical restraint has largely been phased out? Are there statistics reflecting the impact of that which we could look at? I get the impression that the medical community works on an international best-practice basis.

Dr. Donal O'Hanlon

I do not personally have that to hand. We could look for such statistics. Physical restraint in general is a very short-lived intervention. It takes just minutes to get a situation under control. It is not as if someone is being physically restrained for hours and hours. In my experience, that has been an extremely rare event.

I wish to discuss how consultants and doctors relate to the interdisciplinary teams. Some of the phrases used in the opening statements expressed concern over the blurring of the lines of accountability and the various roles. I am not a medical professional, but I was under the impression that multidisciplinary teams are being introduced across a number of European countries or have been in operation for quite a long time because it is a move towards a more rights-based model of care. It is an effective way of dealing with complex needs. I frequently hear of complex needs with mental health where, as a previous speaker said, people have both mental and physical requirements. Can one of the witnesses outline the concern over responsibility or the lines of power within interdisciplinary teams? Does this present a wider problem? The opening statements reflect very serious concern about interdisciplinary teams. I am also a member of the Joint Committee on Health and we frequently discuss the importance of those teams for Sláintecare in the future. Could somebody outline some of the concerns and how we move forward?

Ms Susan Clyne

We did not express any concern about multidisciplinary teams as a concept. All doctors, consultants, GPs and everyone else are now working in multidisciplinary teams and the IMO is very supportive of the concept of the multidisciplinary team. No concern was expressed in our opening statement on that. We expressed concern about the provision in the legislation that the consultant must consult with another member of the team for a variety of tasks. This is not in line with the consultant's overall clinical responsibility for the patient or their clinical independence as outlined by contract. We feel that the lines would be blurred there. I want to be very clear that the I am always very supportive of all our colleagues within the multidisciplinary teams each of whom has value and each of whom brings something to the care of the patient. I will ask Professor Sadlier to expand on that.

Professor Matthew Sadlier

Ultimately, responsibility needs to lie with individuals and named individuals need to have responsibility. Historically, the doctors and the consultant psychiatrists have been that person within the team. There must be a straight line on responsibility and clinical responsibility. One of our concerns is the blurring of that level of responsibility and whether other members of the team step up to take responsibility as well as decision making. Nobody is opposed to-----

I wish to clarify this because two things have been thrown out there. I would have assumed that consulting with another member of staff would provide some extra oversight which I cannot imagine is a bad thing. I can understand that a person is either responsible or not. Is this a contract issue because the previous speaker said it did not reflect what was in the consultant's contract, or does this relate to the actual operation of the multidisciplinary team on a day-to-day basis?

Professor Matthew Sadlier

Two issues are being conflated here. One is the requirement relating to an involuntary detention and the need to consult with another member of the multidisciplinary team which, in fairness, is a very small but very important part of every consultant psychiatrist's work. However, as previously said, only a very small fraction of the patients are admitted as involuntary patients. We would have serious concerns about having to consult with another member of the multidisciplinary team given that in the current structure only doctors are people who work on-call and who work on 24-7 basis. Obviously, nurses work in staffing the inpatient units on a 24-7 basis, but involuntary admissions occur at all times of the day and night. The other members of the multidisciplinary team invariably work a 39-hour week. There are variations and obviously I will let other specialties and professions speak for their own contractual entitlements. Historically and up to now they have not worked on a shift rota pattern; only doctors have done that. Will we be delaying involuntary admissions that occur at 4 o'clock in the morning waiting for somebody to be there?

To have that level of staffing, we would need to double, if not triple, the numbers of staff and I am not sure enough qualified people are available internationally to fill the number of posts this requirement could create. That relates specifically to the issue of approved centre admissions.

The other area relates to the general principle of multidisciplinary or interdisciplinary team working. The documents even show what the difficulties are, such as the confusion between multidisciplinary and interdisciplinary team working. Nobody is against the concept of multidisciplinary working with patients. As for how the health service structures that in a way that avoids issues such as postcode lotteries and allows complicated and specialist care to be given to complicated and specialist patients, which is a much longer discussion about how we structure mental health services, that is a different issue.

For clarity, there is no particular clash with contracts as they stand?

Ms Susan Clyne

There is a clash with contracts as they stand.

Will Ms Clyne outline that?

Ms Susan Clyne

Again, it relates to the language that has been proposed in the legislation. It is the use of the word "must". There will be circumstances where that is not possible. It depends on the various members of the team, their availability and their qualifications to do some of this work. Not all the team members will be qualified to do some of this work. Team members' skills are not interchangeable. Everyone on the team has a role to play. Not just in psychiatry but in all areas of medicine, consultants work well with their multidisciplinary teams. Everybody recognises the value of all the professions within the healthcare setting. There is no inference to be taken that, because we have an issue with the use of the word "must", those team members are not important.

I take that point but I am trying to get a clear sense of the issue to assist with this pre-legislative scrutiny. If there is a clash between language in the legislation and a contract that is widely used among consultants, we need to be aware of that. For the sake of clarity, our guests might indicate whether they believe that would be a clash.

Professor Matthew Sadlier

The Mental Health Commission’s report on multidisciplinary team working, published in 2006, highlighted significantly that it relates to the contracts of all the various staff. The report showed there are difficulties with multidisciplinary team working. which are not unsolvable but nobody has ever really examined trying to solve them in this country. They include deprofessionalisation and what happens if there is an attempt to work as an interdisciplinary team. People all have different skills and abilities, which is why it is an interdisciplinary team. If there is an attempt to get everyone to do the same tasks, does it lose people's individual skills and abilities? How do we maintain our individual professional competence while amalgamating the team? It is a complicated process.

Sometimes we conflate service delivery and legislation. The legislation contains the word "must" and we think that will create a conflict in respect of issues where the consultant psychiatrist heretofore has been the person who held clinical responsibility for the treatment of the patient. Our belief is that having one named person who holds clinical responsibility is of benefit to both the patient and the service. As members can appreciate, words such as "consult" are difficult to define in legislation. What does it mean to "consult"? What happens if there is a disagreement and how is it to be resolved? We do not find such ambiguity in legislation to be beneficial in the long run.

I wholeheartedly agree with the suggestion in the IMO's opening statement regarding increasing the remit of the Mental Health Commission, but I have a query about the suggestion that we should examine whether services have suitable funding. Is the suggestion that the commission would undertake not financial auditing but financial overviews of services? Some services receive funding from various streams. Could one of our guests unpack that a little and explain what it would look like?

Ms Susan Clyne

The issue is that, currently, there are postcode lotteries. The legislation must ensure a service will be provided equitably to all citizens regardless of what areas of the country they live in. It will be up to the Mental Health Commission to ensure two outcomes. The staffing levels must be appropriate and the funding allocated to that service must be sufficient to meet the requirements of that catchment area. In the recent agreement the IMO reached with the Department of Health, for example, there is specific funding for areas of deprivation. It is recognised, therefore, that within a catchment area, there are some areas where additional funding will be required to deal with them. The lines get very blurred in respect of funding. We talk about millions of euro being spent on health but, when we bring it down to individual catchment areas or to the fact that there are mental health teams throughout the HSE, they are not fully staffed teams. I keep on having to come back to this. In many cases, they are notional. They allow us to tick a box and say something has been done but they do not deliver an holistic, comprehensive service to the patient.

I thank our guests for assisting us in this profoundly important pre-legislative scrutiny. A review of mental healthcare in Ireland is very much warranted. My first question relates to what happened in south Kerry CAMHS. Like other statements, that of the IMO has shone a light on the inadequacies in respect of mental healthcare in Ireland, but it paints a picture that is not only very honest but also quite bleak in regard to the current state of our mental healthcare. In light of the consequences of inadequate staffing and so forth, is there a systemic failure in respect of CAMHS throughout the State? I fear that this overprescription of medicine for children is not an isolated scenario. If that is the case, there is a serious issue of trust in the context of CAMHS throughout the State. What happened is very serious and people want answers. It is in everyone's interest to find out what happened. Is it symptomatic of the wider service? The IMO's statement refers to the consequences of a lack of resources and to other structural issues that are ongoing. Is what happened in south Kerry one of those consequences?

Ms Susan Clyne

I might come in there and I am sure the representatives of the IHCA will also have plenty to say on this topic. I do not think anybody in the profession is surprised at what has happened in CAMHS, and nor should anybody in the HSE or the Department of Health have been surprised. It is absolutely a system failure, and the rush to conducting an audit to find somebody to blame or to hold someone accountable will not address that system failure.

There is no easy solution to this and it may well be replicated across not just mental health services, but other services as well.

There has been a decade of austerity in the health service. There has been much longer than a decade of inattention to mental health services. Therefore, mental health services got it on the double,

We are incapable, as a public health service, of attracting people to work in it. That is not just consultants. It is across the board and across all services. We ask people to come into working environments that are extraordinarily stressful. I do not think there is a professional body now that represents anybody in the health service that is not saying that all healthcare staff are suffering from stress and burnout. The answer will be to do a bit of baking or yoga at the weekend.

We are putting people under enormous pressure. We are not funding services appropriately. We are letting services be delivered when we know that they are inadequate and have a lack of supervision. There is an issue with the lack of a consultant being there in the delivery of health services and in psychiatry and CAMHS. Consultant colleagues form Wexford have spoken very eloquently about the difficulties of CAMHS services and the interaction and community within the acute services. I am very sorry to say that we are not shocked. It is 100% a systems failure.

I will ask what is probably a very obvious question.

Hang on please, Deputy. Some others wish to come in.

Dr. Brendan Doody

Let us be very clear. Child and adolescent mental health services are specialist services. Delivery of the service requires a full multidisciplinary team with the necessary skills mixed across a range of disciplines. A consultant child and adolescent psychiatrist will have done up to ten years of post-graduate training, including at least three to four years of higher specialist training. Clearly, if that consultant is not on the team, one cannot expect the service to be delivered to the standard as the public expects of a specialist mental health service.

Across the country, there are particular circumstances that we need to take into account, such as in Kerry. We need to look at the fact that although there has been investment in CAMHS over the years, we started from a very low base. In a sense, we had that coupled with a growing population and increasing rates of referral of young people to CAMHS. In addition, as we know, post-Covid there has been a significant increase in referrals to community services, inpatient services and a large increase in, for example, young people presenting with eating disorders.

On one hand, we should not be surprised that this is a phenomenon across the world. Across the world there has been a recognition of a need to expand services. The question is not just resourcing, but it is how we ensure that posts and the structures are there to make recruitment to these posts attractive. We are not competing only with Ireland, we are competing internationally. The standard of training in Ireland for child and adolescent psychiatrists is on par with the best anywhere in the world. Unfortunately, the world is currently experiencing a worldwide shortage of child and adolescent psychiatrists. Child and adolescent psychiatrists trained in Ireland will have no difficulty getting positions anywhere across the world. This is a reality.

If we are to deliver the services, we need to look at the recommendations in the report. It is about resourcing and also having the necessary structures in place to support teams so that we can deliver services across the country to the standards we want them to be delivered to. We need to be able to attract not only doctors, but also attract and retain other skilled disciplines within the service as well.

Dr. Anne Doherty

I wish to expand on that and make a slightly broader point. These difficulties have obviously beset a specific CAMHS in Kerry. However, we know that there are resource issues across the country and across pretty much every mental health service that exists.

In 2005, which is now 17 years ago, A Vision for Change was published. That set out the numbers of staff and multidisciplinary team members that were needed in every team, from CAMHS to adult psychiatry to all of the specialist areas. In many areas, some teams are running at 20% or 30% of the staffing. Even the more general community adult teams will often be without key multidisciplinary team members for prolonged periods of time. We have colleagues all the time talk about how they have no social worker for six months or the psychologist on their team has become unwell and they have not been replaced.

This problem does not only affect CAMHS. In some ways, until mental health services are properly resourced and the required team members are put in place, we will probably see further problems. It is inevitable that if services operate under such a strain, they will crack at some point. It is inevitable in many respects. Unfortunately, a service that is under such strain all of the time is not an attractive place for people to work. If people are getting job offers from New Zealand where there is a very nice quality of life and pleasant working conditions, it is very difficult to dissuade them from going there.

I will ask a very obvious question. How do we address very serious issues in the here and now? Obviously, there are huge problems, such as the retention and recruitment of staff. I understand that. That has been a legacy issue for more than a decade.

Under these circumstances, children who need intervention are being failed. That is the most serious of the consequences of this. How do we amend the structural issues, particularly around CAMHS, for the here and now? Obviously, the review will take place. As I said from the outset, I do not think this is an isolated situation. How do we address the immediate issue of trust in relation to children and adolescents who are seeking CAMHS?

Ms Susan Clyne

I wish there was a quick easy answer; however, unfortunately, there is not. The first thing is that we cannot just have an audit alone. We have to have a full review that looks at all of the issues and not only focuses on the action of a particular staff member who was left unsupported.

It really does come down to recruitment. If there are not the professionals on the ground to deliver the care, the care will not be delivered. You can have all the shiny buildings you like, or you can have terrible buildings, and there is a big mixture of both - not everyone is operating out of purpose-built centres - but we cannot solve the problem without recruitment policies in place.

I do no not accept that the recruitment policy is a legacy issue. The recruitment policy is a live issue and it has been a live issue since the day it was brought in by a former Minister for Health. It has had devastating effects. Until that is dealt with and we accept that we cannot run a service without the correct number of people delivering that care, it is the patients who will suffer. There is no quick fix that we can do today.

I would make the point that every single person working in that service goes in to do their best for the children who are accessing care in that service. Everybody is committed. However, there is not the level of shock within the service that there might be within other areas looking in on this, because they are working with this day to day.

No more than my colleagues at the IHCA, we are exhausted from talking about this for ten years and saying it must happen. This will keep happening if we keep taking the same attitude toward recruitment and our public services will continue to absolutely fail to be able to encourage doctors to stay in Ireland or come back to Ireland. Our trainees will not stay here. They see what it is like for their consultant colleagues.

They know they will come in on inequitable and unfair contracts. Abroad, they have systems that will support them in order that they can support and deliver best care to the patient. I am afraid there is no quick fix, but it is certainly not a legacy issue. It is very much a live issue, and the Government absolutely has it within its power to address it. It has committed to it. The last three Ministers for Health have committed to it and have failed to do it.

My final question relates to the last paragraph of the statement from the IMO and private and voluntary organisations that provide mental healthcare. There is a plethora of those organisations. The IMO says in the statement that there should be a requirement to achieve accreditation to international standards. Is there a situation at present where these voluntary bodies or private bodies do not achieve the proper accreditation in respect of standards of care? Are there instances of this happening in the State at present?

Professor Matthew Sadlier

I have a very simple answer. I am not sure, and the issue is that we are not sure. The fear is that the Mental Health Commission will become a body that only regulates the State services. We know that mental healthcare is provided by non-governmental organisations, some of which accept State funding and some that do not. It is provided by fully private, insurance-based hospitals and a variety of different services. What we are seeking there is to ensure that the Mental Health Commission, when it expands its remit from inpatient units to community services, does not just look at the State-provided community services and that it looks at the other sectors. It is up to the Mental Health Commission to determine how it does that, what standards it sets and how that is operated.

We know that the difficulty with talking-type therapies is the regulation of them. There is no central register of therapists. I have a qualification, but anybody can put a plaque on the wall in the morning and say he or she is a something-or-other therapist. There could be somebody with very little qualification who has been engaged in exploitation of clients of various different types who, unless the person is criminally prosecuted, can just walk down the road and put a plaque up on a different wall and set up again.

It is that security, so my answer is, "I do not know". The problem is that we do not know. The issue is that the Mental Health Commission not only gets involved in State services but that it also has some type of remit towards the non-State orientated talking therapies, the therapists and qualifications that are out there and that it sets standards of some description. That probably would require a session by itself, to be honest. However, it is that setting of standards.

It is probably quite concerning that there is no central register in respect of private and voluntary organisations. I am sure they can provide a very good service, but where there is no regulation then one has the opposite. That would be a concern. Professor Sadlier has answered the question but with the lack of monitoring of voluntary and private bodies, how concerned would he be, in his professional opinion, that there is a sense that there is no regulation or there is no sense of oversight with regard to those who are in an important and responsible position in the context of advice and intervention? There could be a situation where there is no oversight, and where there is no oversight that could lead to serious difficulties as in what happened in south Kerry.

Dr. Aideen Brides

This is a very real concern. As I mentioned earlier, in primary care we have essentially no access to talking therapies. Often when I have a patient in front of me who is in extremis I resort to Google just like anybody else. Unless I have had a personal recommendation or know from previous patients how somebody performs, I have nothing else to go by. People are paying money to these people, money they often do not have. However, as they are so desperate to access services, this is what they will do. Anecdotally, one often finds that people who may have accessed counselling services themselves previously then want to go on to counsel. All of us - doctors, social workers or occupational therapists - are part of a regulatory body and we have to meet certain standards. If people are having a very big impact on another person's life, and that is what happens in these talking therapy sessions, they have to conform to some type of regulatory body.

I thank the witnesses.

The next speaker is Deputy Buckley.

First, I thank the witnesses for attending. Second, I love their honesty. I can sense from some of them that they are angry and feel disappointed and let down. I understand that people who work within the services are fully committed. I suppose it is like trying to bake a cake in that if one does not have all the ingredients initially, one will not get the cake one wants.

I will refer to a few matters. The witnesses spoke about funding, the demographics, the postcode lottery for services and so forth. They also referred to the CAMHS teams. Is it an 11-a-side team or a 15-a-side team? We never get that because it is always work time equivalents. When they spoke about audits and the like, I suspect the issue that is arising out of a full audit of the 70-odd so-called CAMHS teams we have is how many of them can be put into the premier league to play against each other. I suspect there are perhaps three that are fully staffed. We are met with the Department saying that we have X amount of CAMHS teams but that it has an issue with staffing and so forth. It is total misinformation.

I have worked in committees previously. In the previous Dáil, I was lucky enough to be a member of the Joint Committee on Future of Mental Health Care and I was also privileged to work on the Sláintecare report. There is one bugbear I have, and this is a question for all the witnesses. If we are so under-resourced, I think it is an Irish thing where Paddy will not buy into it unless he sees it. If we want a new community centre, he wants to see what the building looks like first before he will support it. What I am trying to say, and I have appealed to two or three Ministers about this over the years, is that we should start rolling out pilot projects. We have access to a lot of data. We know where in mental health there could be a spike in suicides. It is very simple. In my town between 2000 and 2002 there were 59 suicides in one area. That should have put up a red flag straight away that we need to put resources into that area to nip it in the bud. Our guests spoke about primary care. I am a firm believer in it, but we have a situation where we are now at a crisis level and people who could have got early intervention have now escalated to what we will call the "". There is no going back, but they cannot move forward. We have a massive crisis there.

It goes back to funding. How many are in the teaching profession at present, how many psychologists or psychiatrists are being taught, is there a limit on numbers? Do we have to look at all of that? There are certainly incentives. I have seen this in England. Even for basic nursing, one particular city has on-site campus accommodation for the nurses so they can afford to work and live in the area. We cannot get a trainee to come to Dublin and expect him or her to pay extortionate rents while basically living on nothing and working in an over-stressed and over-stretched job when somebody can go to Australia or Dubai and have all the incentives, as well as the opportunity to progress. I will look at the brass tacks, because the witnesses have covered so much in this regard. Through parliamentary questions, I have seen evidence of posts being advertised for more than 13 years that will never be filled.

How is it they can fill agency posts but we cannot fill permanent posts? I would love an answer because that is a bugbear. What about the value of funding a fully staffed, fully resourced pilot project and show it to people, the Government - it does not matter what Government will be there - and the HSE how and where it works? Then we could start replicating it and use a common-sense approach. If you are in County Cork and County Donegal, it is probably cheaper than in Dublin city. You would have to find an equalisation or incentive from there.

The three main questions are around how we can get people to fill agency posts when they are needed. I do not want to bring it up now but I would like to revisit what Dr. Hanlon said during the first round of questions. I suspect there is some danger in the lack of support in the hospital and ward setting. I heard Dr. Brides speaking on the GP side of things. Either the GP or the Garda is the first port of call. I heard her say GPs do not have an option to send them anywhere because the service is not there. She is right. It has been happening for years and years. I am tired of hearing about retention and recruitment. The reason they cannot be recruited or retained is because they will not pay them. Second, who wants to work in a toxic system? Third, the only thing that you get is blame, and that is totally wrong. It is very frustrating. There are any number of parents who are roaring at us that they cannot get their children into X, Y or Z, and it is correct to say that in the private sector, if a parent has cash, it does not seem to be an issue. How do we find a balance?

What do the witnesses think of the pilot project? Could it work? Why are we getting agency staff but not permanent staff? Is a tsunami of mental health issues coming down the road not only for patients but also for staff in the system? It has been said we are talking about this for ten years. If we are not going to invest now, do we just close the book and let it crash or what do we do? There is a lot in that.

Dr. Aideen Brides

The Deputy asked about how we could actually do this and about pilots. I would suggest looking at something like the Australian model for funding mental health. First, it has about twice the budget dedicated to mental health than Ireland. Second, it has great resources and funding at primary care level. GPs are funded to spend 20 or 30 minutes with a patient and they know they can resource their practices with extra nursing etc. to take that time out with the patient. GPs can allocate up to ten sessions of psychotherapy, psychology or talking services per year for an individual patient. I spoke to a colleague this week who has worked as a GP in Australia. She said that she loved working as a GP from a mental health perspective when she was there. She prescribed medication in about 30% to 40% of patients because she knew she had other options to give them, whereas since returning to Ireland she said that she is prescribing in almost 100% of cases because she has no other option. The number of patients she is now referring to secondary care services has quadrupled because, again, there is no other option.

Taken as a whole, there are many pilot studies around the world. We do not need to reinvent the wheel here. That would feed into the secondary care services because it would take the pressure off the consultants. They would not have to look at endless waiting lists. They know that perhaps three quarters of that is not in their remit. It would allow us to keep secondary care for specialist psychiatry services that are badly needed.

Ms Susan Clyne

We did a survey last year specifically on staff burnout. Seven out of ten doctors across the board are at high risk of burnout or are suffering from it. They carry that with them into their daily lives. There are many reasons for that.

I can see where the Deputy is coming from on the pilot projects. We have a lot of evidence on what works. We have some concerns about the systems in place now. That is why our submission calls for a review to see if it is actually the best way to have consultants operating in isolation in some areas with insufficient teams in place. That is not to say that the patient would not continue to receive care in the community, but that does not mean the whole team needs to be based full time in the community. Consultants rely very much on talking to colleagues. Not all of discussion on patients and moving treatment on is formal. I would be against a pilot project because we already know what is needed.

No more than the IHCA, I am sure all the members are tired of organisations such as ourselves saying the funding is not there. I hear people say all the time that resourcing is not the issue, but resourcing is the issue if the resources you are applying are not sufficient to attract people in to work in the service.

I love the honesty.

Dr. Anne Doherty

I thank the Deputy for his very interesting perspective on all this. As some colleagues have already said, there is a lot of international evidence about what works. We could take some of that and apply it to the Irish context, perhaps as a pilot but also perhaps, if it works really well, we could just implement it. Even if we could just implement the requirements set out in A Vision for Change, which is now 16 or 17 years old, we would at least be moving in the right direction. However, as everyone keeps saying, we need to be seriously investing in mental health services at secondary and primary care level.

The Deputy asked about a tsunami of mental health problems. I work in an emergency department. Obviously, if people are coming in through an emergency department, they have reached a serious point of crisis. That is not how people should have to access mental healthcare. It should be possible to access secondary mental healthcare in a much more structured way. We are seeing an increase of about 150% or 160% of pre-Covid levels now. The numbers coming through are enormous. They are people who are very unwell who need very expert care. In some ways they are the tip of the iceberg because they are the people we are seeing in that setting. There certainly does appear to be an increase in people who need our services at the moment.

Professor Matthew Sadlier

The Deputy made some very valid points. On the matter of agency staff, it can be a question of different pay rates. I would love to be able not to say that. It is not necessarily true that we can always fill posts with agency staff either. They can often be short term or temporary. I know of a post in an area where there was something like 14 different consultants in a two-year period. The fact a post is listed as being covered by agency staff does not necessarily mean they are they same agency staff there last week or in two weeks' time.

My only gripes, as it were, are around two things. First is about when we get reports like A Vision for Change, Sharing the Vision, Sláintecare, but looking at those on mental health in particular. They need to be accompanied by an operational report. We get reports that are ideologically driven. They outline how a utopian mental health service would work. For instance, they might say we will have mental health team and a primary care centre all over the country without anybody having established whether people will work in a mental health centre or a primary care centre across the country. How much will this cost? Have we engaged on the operational side of how to deliver this? Sometimes we set out health policies with a utopian ideology of where we want to get to without necessarily understanding if that will happen in the real world. Consultant psychiatrists work as per the Sláintecare concept of a consultant. It is about 20 years since a consultant psychiatrist was appointed when he or she has had access to private practice. I am not sure of the date but every consultant in psychiatry since then, and it is well over 90-odd per cent, do not have access to private practice.

They work in a community base yet this is a speciality where, give or take, one third of posts are vacant. The process in psychiatry is supposed to be this ideological one that we are supposed to be getting to but it is the one where we have the biggest problem.

My final point is one I get tired of trying to bang home. I am not against the delivery of care in the community or against basing care in the community, but delivering and basing care in the community is more expensive and less inefficient and requires a redundancy. Where a mental health team is comprised of one consultant, one junior doctor, one psychologist, one social worker and one occupational therapist and it is based in a primary care centre in a rural area and the consultant wakes up some morning with a sore throat - in the current world environment we are told not to attend work if we have a sore throat - the outpatient clinic for that morning is cancelled. If one member of the team gets sick or has to take leave, that area does not get another staff member. We are dispersing our teams into small teams rather than having a more departmental or larger hub model of the type operated in Australia, where there are four or five consultants or a larger team assigned to one area, such that you have that redundancy. They are the questions that were not built into this. There is no mental health services report issued to set out how the structure would work. I have never seen in an appendix how we cover annual leave. Every staff member gets four, five or six weeks' annual leave, depending on their contract. How do we cover that? They are the type of operational issues that are not being considered.

Dr. Donal O'Hanlon

With pilot projects one has to start somewhere. If one adequately funds a pilot project and can show it can be done that would be great. What can happen is that over time the degree of commitment to funding the pilot programme can be eroded. For example, in multidisciplinary teams colleagues who are on leave are not replaced and immediately a whole arm of the team no longer functions properly.

Over the ten years this has gone on, it has been a progressive demoralisation of the whole service. I say that genuinely. It has been a repeated wearing down of staff morale. According to a recent survey, this year, 44% more trainees are applying to go to Australia than applied in 2018. Over the years, I have recruited many consultants who stayed for a year or two and then went to Canada, including one about two weeks ago. These are people we have trained here. They may have spent about ten years in our system but are originally from another country. They would have integrated well and provided really good service. The reason they are going is they cannot see any political will to change things and they believe they will be treated in a more inferior way than their longer established colleagues. I do not think we are addressing that. That has knock-on effects.

Many speakers here today have spoken about multidisciplinary team working. As mentioned by Professor Sadlier, we have been doing that since the community psychiatry initiative started in the late 1980s. We have always had a multidisciplinary team. We recognise the role of medication. We also recognise the need for talk therapies, social assistance and the human contact of a very skilled psychiatric nurse. That is the way we have worked for years but we have not had the teams to deliver that. It has been kept going on a shoestring. One cannot convince people in the system that things will start to change unless there is a real political will to do so. I hope that answers some of the questions.

Dr. Brendan Doody

I agree with what my colleagues have said. I have spoken to higher skilled trainees finishing their training about the posts they would be attracted to. It is not just about money. It is about the supports and the structures around them. They want to be in supportive structure. The report on CAMHS raises the question as to whether there is need for a complete separate support structure for child and adult mental health services. Where there is a child and adolescent psychiatrist reporting to another child and adolescent psychiatrist, they would find that more supportive. The risk is about professional isolation. It is not surprising that it is not just in mental health services that consultant posts which are seen as peripheral are the ones that are least attractive. People said there are posts around which there is no certainty about who will cover for them when they are not there. It is about that level of isolation and the need for that support, which sustains them for a career of 30 to 40 years. They are thinking about how they are going to sustain this not just now, this year and next year but for all of their careers. We need to look at the structures but it is not just about money; it is about the structures and how we support the services.

It is not possible to grow services overnight. That requires sustained investment over years. It is about identifying need across a range of disciplines and training people through college for them. That is going to take time. That is the need for that multiannual investment. As mentioned earlier, we have a vision. It is about how we operationalise that vision, how we make it happen and how we address the need for the huge amount of investment required for training. When we lose a consultant, we lose the huge investment made by the State in training that person. In a sense, it is about how we create the conditions to hold on to that investment when we know that they are skills that are highly mobile and highly valued. These are the real issues. It is about we operate, about structures and all of those things. Within the structures we need to look at how we develop and innovate. Building innovation on a shaky or not so good foundation is not sustainable. We sometimes have service innovations that prove not to be sustainable. We need a sound foundation to sustain and support innovation.

Professor Doherty mentioned the Australian model and the Beat the Blues programme. My wife does not like it when I say that prevention is better than cure but it is a fact. It is about the destigmatising of mental health issues. There are many areas where it is difficult to do that. For example, a member of the Defence Forces would not admit to suffering with mental health issues because it would mean he or she could would not be allowed to travel overseas or to use live rounds. That is a different issue.

As mentioned by Professor Doherty, this already works in one country. We should have the capability to look at how it works, how it is written in legislation and how contracts are addressed. As mentioned by other speakers, it is about the work plan. When a report is issued, it should be accompanied by an operational report on how X operates in X country with X population, which we should then try to mirror to our population. We need to identify the cost of X, Y and Z and then bring it to Government as the best way forward.

I did not choose this path but it is where I am today. I have always been very passionate about it, but it can be very disheartening to be here so many years on listening to the witnesses still saying that if we do not do X, Y and Z, which we have not been doing for the past ten years, we will be back here again in another ten years and things are probably going to be worse.

I thank the witnesses for their honesty. These things have be said.

Ms Susan Clyne

If I may, I would like to respond briefly to the Deputy's point. It is important to recognise that there is a difference between the specialist service and what could be provided in the community. The CAMHS issue is focused on the specialist service. We are trying to make the point that there is a lot of work that can be done in the community. There are many other pathways. There is a lot of work our GPs and their in-house teams or the services coming in can do them for them.

I think we have failed across the board.

Some of the stigma around mental health has been lifted, but there is no point encouraging people to talk about their mental health if there is no one to talk to.

Dr. Aideen Brides

The chronic disease programme that came into general practice over the past year to 18 months looks at diseases such as diabetes, hypertension, ischemic heart disease or stroke, and cerebrovascular accidents. It is a structured care programme that offers two visits a year to patients who have these illnesses. They come to the GP, have their bloods done and are seen by the GP after that. It has been resourced and is working unbelievably well. The hope is it will move many of those diseases out of crowded outpatient facilities into general practice.

If there were a similar system for mental health, it would work really well, but without funding it cannot happen. The Deputy mentioned figures. I did the maths last night, and Australia’s budget for mental health is exactly double that of Ireland. There are many solutions but funding is needed. As GPs, we say that if someone has a physical problem, he or she will take treatment, and the same should be true of mental health. The Government, however, pays much lip service to mental health provisions, but very little action is ever taken. If that is happening at Government level, we will find it very difficult to get patients to accept the same changes.

I welcome all the professors, doctors and psychiatric consultants, who have taken time out to present to us. I very much appreciate the time they are giving to the committee to discuss this really important legislation. As they said, it is for the most vulnerable people in our community and is about putting patient health first.

I come from Ballinasloe, which was once home to St. Brigid's psychiatric institution, a wonderful place that managed acute episodes of need. Some of our guests' submissions mentioned the lack of acute beds and I take that on board. This year, there has been an increase of more than €47 million for mental health, under the remit of the Minister of State with responsibility for mental health, Deputy Butler. I am curious whether the increase of 5% is to be taken against the increase that has been invested in the health service due to Covid-19. I do not know whether that is a percentage of what would normally be invested in the health service or whether it is because of what has been invested following the emergence of Covid-19.

Our guests made very relevant points about parts of the legislation. I do not know if it was the IMO or the IHCA that pointed out that it will remove the right of family members to apply to have a relative admitted. Our guests indicated there is a lack of authorised personnel to allow families to bring their loved ones forward when they are going through an acute episode. I understand very much the significant recruitment processes within the HSE. I worked previously in health innovation within National University of Ireland Galway, NUIG, but linked with University Hospital Galway, UHG. A considerable bone of contention related to recruitment. We had a part-time person working with us from the HSE and I got to know very well the term "backfill", which I had never heard previously. That was pre-Covid, so I can only imagine the challenges that exist now. When someone is moved internally from post to post without that position being filled or that person being allowed to come into role, it is a big issue. Are there ways we could examine the recruitment processes to speed up bringing people into role?

Professor Matthew Sadlier

I might come in on that and pass over to my GP colleague to give some examples from her practice. The issue whereby the authorised officer has to approve every involuntary detention is a false solution to the problem. The idea that it destigmatises the relationship between the family member and the person who is involuntarily detained is not necessarily true because, obviously, it will be the family member who will have called the authorised officer, who will have to sign the forms. I am not sure, therefore, that it will necessarily solve the animosity problem. It is a bit like saying that, if there were a car crash, the family could not call an ambulance but rather would have to call somebody else who would then arrive on the scene and determine whether an ambulance should be called. Most of these involuntary detentions, when a family signs for one, occur in a moment of crisis. They happen when there is not necessarily time for a calm period of reflection or to wait for somebody to arrive. I am sure Dr. Brides, as a general practitioner, will have much more experience of managing these cases in the community, so I will pass to her.

Dr. Aideen Brides

As the Senator and Professor Sadlier noted, this happens at a moment of crisis. It is an extremely fraught scenario when somebody requires an involuntary admission. It usually starts with a phone call from a family member. Thankfully, as a GP, we will often know the patient and the family and we might even know the scenario is coming. To think we would have to delay the process to allow another person to become involved is beyond comprehension.

I might give two examples. I have a patient, a lady in her 50s, who manages to hold down a job for two years at a time while attending psychiatry services. She might then stop attending and taking her medication, and it is often somebody she works with or a family member who will call us and say she is starting to slip. She will isolate herself in her house and become extremely paranoid. Thanks to the family member contacting us in a timely manner, we can get her to hospital for a period. She is usually in hospital for only a few days but it is enough to get her well. This involves a degree of communication and negotiation, as was mentioned. The encounter can sometimes be turned into an opportunity to encourage the patient to be admitted on a voluntary basis. If, however, we have to sit there in a stressful environment and wait for somebody else to arrive, that just will not happen.

In another case, I was working in psychiatry as a senior house officer as part of my GP training. There was a case where somebody in their early 20s was on the other side of a bedroom door, in possession of several knives. We did our best to encourage them and coax them out of the room, hoping they would not harm themselves, but we could not know what was going on behind the door. As soon as we got the chance to encourage the person to come out so we could get them to a place of safety, we took the opportunity. I have heard of GP colleagues travelling in cars to hospital with patients who need involuntary admission. I heard of one such example where the person travelled with a shotgun on their knees. We do what we need to in these circumstances to get the patient to a place where he or she will be safe. If it involves more legislation and designated officers who may not be available for 24 or 48 hours, that will not be in the patient's best interest.

Speed is required in such cases.

Dr. Aideen Brides

Yes, absolutely.

Dr. Donal O'Hanlon

The logistics of introducing an authorised officer as the only means of starting an involuntary application really have to be thought through on a service level. Staffing one of those positions 24-7 will probably take about five whole-time equivalents. Those five whole-time equivalents will come from the existing pool of mental health professionals, and we have real difficulty recruiting at the moment. Moreover, given the nature of the work, it will take two or three hours to conduct an assessment, so they may get through two or three assessments per shift, and then travel time must be included. In some urban areas, perhaps it is possible to get to a Garda station or a person's house within a half an hour, but that is not going to be true in Cork, Kerry or even Kildare, where I work, given it takes two hours to get from one end of the county to the other. My main fear relates not to the principle of authorised officers but to the practicality. I think it will suck all the trained staff out of the system, and they will be doing this rather than providing care, if they can be recruited.

What does Dr. O'Hanlon believe is the premise behind including this provision in the legislation?

Dr. Donal O'Hanlon

The role of authorised officers is valuable in some cases where a family member will feel intimidated or worry it would rupture his or her relationship with the loved one. I do not have a problem with the use of authorised officers, but making them the only route without resourcing the rest of the health service will be counterproductive.

Could there be a role for an authorised officer in, perhaps, an e-health or telehealth setting? Is there any way an assessment could be carried out virtually?

Dr. Donal O'Hanlon

I think there is in some cases but, having done a bit of telehealth, I know that emergency situations are the hardest telehealth consultations to do.

That is because it is not at an early stage.

Dr. Donal O'Hanlon

Yes. If I may make one other brief comment, the criteria for involuntary admission are also changing under this Bill. One of the criteria will now be "where such treatment is immediately necessary to protect the life of the person, or to protect the health of the person from the threat of serious harm, or for the protection of other persons". I can see the rationale for that but it means that many people who are severely ill and whose condition is deteriorating will not be covered by the Bill. We will have to wait until their position is dangerous. I am concerned about that because, with schizophrenia, the longer you go untreated, the more functional damage and disability you will have. That is a big choice for society.

Dr. O'Hanlon is talking about immediate access to care so again it comes back to speed, practicality and access.

Dr. Donal O'Hanlon

The wording of Bill precludes people whose condition is slowly deteriorating into a chronic psychotic state from being admitted. I do not believe families will want that and I am not sure the individuals concerned will want that, ten or 15 years later.

There were some other comments. I will come back to the issue of recruitment but my second point is on the legislation. I was listening to the meeting virtually as I was coming in and there was discussion on the age. I was very interested in that. I apologise because, although I was listening, I did not get to see who was making the comments. Someone spoke about how a child is defined as someone aged under 16 in paediatric hospitals but as someone aged under 18 in this type of legislation, child and adolescent mental health, CAMHS, units and other mental health facilities. What would be required to align those age profiles? What is the logic behind the age being 18 for CAMHS and, I am guessing, for legal services? I direct that question to Professor Doody. He may have commented on it previously.

Dr. Brendan Doody

In the 2001 Act, children are defined as those aged under 18. Looking at the legislation, this also pertains to inpatient units. The child unit is for those up to the age of 18 and children are defined as those aged under 18. That is not the practice in medical treatment, where it is now moving towards 16. At one stage, the cut-off age for paediatrics was 14. The Mental Treatment Act 1945, if we go back that far, set the age for adulthood at 16. Until the current Mental Health Act, you were an adult from the age of 16. That changed with the enactment of the 2001 Act, under which those aged under 18 were defined as children. The 2001 Act vested that those aged under 18 did not have capacity to consent whatsoever. That was not in line with provisions on consent for medical treatment and other forms of treatment covered under the Non-Fatal Offences Against the Person Act.

Practically, which is to say, from the point of view of the clinical director of an inpatient service, even though the Act states that you can be admitted on the consent of your parents, the views and assent of the young person will be involved. The same point comes up here again, which is that to rely solely on parental consent when admitting a young person is not appropriate. In such a scenario, admission may cause stress in the relationship between the young person and their parents. We have been using the best interests principle, that is to say, the decision is made and children are being admitted as involuntary patients, even where their parents consent to admission, because that is in their best interests. In effecting the admission of a young person who is unco-operative and who does not want to be admitted, any such assistance requires the making of a court order.

Bearing in mind that the Act, as it applies to children, involves a court process, the appointment of a guardian ad litem is very helpful. The guardian ad litem is an independent court officer. That can be very helpful because the young person then has someone who will engage with them and represent their views to the court while also forming an independent opinion or view, which they can then bring back to the court. In doing so, they will meet with the parents and the treating team and participate in planning meetings. They become very integral and are a very important part because we are trying to ensure that the young person receives treatment but not in a way that adversely impacts on relationships within the family.

In one respect, the new Bill brings us back to allowing 16-year-olds and 17-year-olds to consent. Consent is vested and, as a 16-year-old, you can give consent. The amendments to the Act will bring that age to 16. Legally, 16-year-olds and 17-year-olds are most definitely not adults. There was a High Court challenge in respect of section 25 of the Act a number of years ago and the judge talked about the continuing role of parents. In the Act, it seems that families and parents continue to be an important part. Even though there is talk of young people and their consent, parents remain a very important part. The High Court judge pointed to this fact, in a sense, in that particular case. Consent is a very complex area and, of course, the capacity to consent is not the same as the capacity not to consent. Those of us who are child and adolescent psychiatrists feel more comfortable with how this issue has been teased through in these latest amendments to the Act. However, the principles set out in the Act are very helpful.

It is also helpful that the part of the Act that addresses children is to be completely separate. The 2001 Act referred to large sections of the Child Care Act, which allowed us to, for example, undertake nasogastric feeding under restraint, where necessary, through an order under the Mental Health Act. That is a very important step. We can do that with the permission and oversight of the courts. We are very much mindful of ensuring the rights of the child are respected and advocating for those rights.

With regard to an omission in the proposed amendments, the 2001 Act specifically precluded social workers from giving consent for children in care to be admitted. The expert review group did not make any recommendation for that to be removed but it does not appear in the proposed amendments to the Act. It was very important and there was a reason for its inclusion in the 2001 Act, which was to ensure that an agent of the State would not provide consent for children to be placed in inpatient units while they are in the care of the State and that the courts would have oversight because it is important that young people not remain in an inpatient facility if they do not need to be there. In our experience over the years, that provision has been very important safeguard for children who are in the care of the State.

I thank Professor Doody. I know that it is crucial. I had not realised how complex the challenges were with regard to the ages between 16 and 18 and how acute general health episodes and mental health episodes are managed. That leads on to issues relating to admission to adult units. Professor Doody mentioned that the number of days children or young adults under the age of 18 have spent in adult units has reduced. That is important. We need much more access to beds.

The submissions were great and provided feedback on areas outside of the legislation as well. As I mentioned earlier, the area of recruitment is of interest to me. Salaries are one thing. A very good article in The Journal was forwarded to me by someone in healthcare. It was about the increase in the number of young doctors going to Australia.

Mention was made of the GP experience in Australia and the fact that there are so many things we would love to bring on board, but I know from GPs in my area — the Ballinasloe–east Galway area — and south Roscommon that they do not have access to Westdoc. They do not get access to night-time supports, from 12 midnight to 8 a.m. This is absolutely incredible. I very much recognise the lack of funding and investment in these areas. I would like to hear the views of Ms Clyne, Professor Doherty and a few others on this. My questions are informed by my understanding of the multitude of challenges that exist, the burnout and the incredible weight on people, particularly on women, including young women, but also on families and young dads. It is just so hard. What are the other quality-of-life measures to be considered that relate to the university training hospital, the likes of University Hospital Galway and work with research? While all of these are great draws, how do we retain the excellent graduates that come through our system?

Ms Susan Clyne

The article was by Dr. John Cannon, who is the chair of the non-consultant hospital doctor committee in the IMO.

Very good. I did not realise that.

Ms Susan Clyne

It was based on some of the research we had undertaken.

The problem with consultant recruitment starts with how we treat our trainees, how they work in and are treated by the system, what they see as expected of their senior colleagues and whether they wish to aspire towards working in the same system. There is a changing demographic involving women in medicine, yet the whole structure pertaining to how consultants are trained has not changed. There are no significant efforts towards family-friendly policies, work–life balance and flexible training. There is some commentary around this and we talk about it, but we do not address it. It is almost a shock to us when we hear that women will have babies and that their posts will have to be filled. We do not have a workforce plan anyway but we certainly have no workforce plan for the changing demographics in medicine.

We know our trainees can go to a better system. Let me refer to a very simple practice in Australia. If an individual and her or his partner apply for a post in Australia, the service there will do its best to ensure both work the same shift pattern and do not work hundreds of miles away from each other. These are the things an employer does. One of the things we have forgotten is that doctors in Ireland are highly trained and valued, and they are being headhunted daily.

Of course. I very much understand that is thanks to the fantastic colleges of medicine in our institutions across the country, but also the experience the trainees get in the hospitals themselves. The challenge we have is related to population. The population of Australia by comparison with the population of Ireland has to be taken into account.

Dr. Anne Doherty

All the aforementioned workforce pressures exist, but, on a more fundamental level, most people who go into medicine or any area of healthcare want to provide excellent care. It is most frustrating if the system does not allow them to do that, if they have no beds for patients they would like to admit to hospital and if there are no talking therapies for patients who need them. It is these sources of frustration that make it very difficult to have any sense that patients are getting good care and that one is managing to change anything by going to work in the morning. These factors are probably the most important. Senator Dolan mentioned access to additional research facilities etc. These are definitely draws and make areas more attractive, which is often why the cities and academic centres find it easier to recruit than more peripheral areas.

Journal publications go up.

Dr. Anne Doherty

Absolutely, so these elements are really key. However, if the structures and services were such that patients were getting good care, there would be a much more incentivised workforce.

I have a question for Professor Doherty. Some €1 million has just been announced by the Minister of State, Deputy Butler, for talking therapies. It will be accessible through MyMind, for example. How has Professor Doherty approached or found access to online support, particularly with the pandemic? How are consultants and general practitioners engaging with those online supports when it comes to early intervention for their patients?

Dr. Anne Doherty

It is funny because we have all changed how we work. In the setting I work in, online services are probably not as appropriate because we see people who are extremely unwell who really need face-to-face assessment. However, there is evidence that services such as talk therapy can be helpful online but a certain proportion of people will need face-to-face therapy. Once things open up and we are able to allow people to have more face-to-face therapies, they will opt for them a little more.

I thank the delegates so much for their time. I do not know whether anyone else wishes to comment. I do not wish to take up any more time.

Ms Vanessa Hetherington

I want to address the question on the financing of mental health services. Our health services did receive an increase in funding because of Covid but mental health services did not receive any increase directly related to Covid. Therefore, the proportion of funding has fallen substantially. We know the demand on our mental health services will increase because of Covid and that our population is expanding and ageing, so there are huge demands. Despite this, our pot for mental health services is very much shrinking.

What budget is the 5% a proportion of?

Ms Vanessa Hetherington

The 5.5% is a percentage of our total funding for health, which is about €1.4 billion. It is a very small percentage. A Vision for Change recommended 10%. As members will have seen, a much higher percentage of the funding goes towards mental health services in other countries.

From what I understand, I believe €47 million extra has been allocated this year, but I would love to know how it has been allocated.

Ms Vanessa Hetherington

Compared with the additional funding the rest of the health services received, it is a smaller proportion.

It is a smaller percentage.

Ms Susan Clyne

We accept that, after many years, funding is-----

It is much needed.

Ms Susan Clyne

It is much needed. As said, it has to be sustained. While there may be announcements of some millions of euro going here and €1 million going towards talk therapy, the funding has to be sustained. We must then address how much of it needs to be used to recruit people to deliver the care.

It is also a question of the requirement where there is a cultural change involving the use of e-health services, innovation and technology and of how our GPs engage with new technology.

Ms Susan Clyne

Everybody has changed the way in which they practise medicine but there is an element of patient choice and of what constitutes best clinical practice, as Dr. Doherty said. Not everyone will be dealt with appropriately through e-consultation, be it in mental health services or other kinds of services. If one needs to physically test people's blood pressure or hopes on a wing and a prayer that they are telling one the truth about their blood pressure based on some monitor they have-----

We are really looking forward to investment, innovation and research. It is great to see that people can monitor the likes of blood pressure remotely. The use of technology to support our health services is really where I would like to see funding coming in.

Ms Susan Clyne

That is important but we must determine what we can gain through innovation and e-technology. One of the biggest gains in e-technology during Covid was e-prescribing.

Ms Susan Clyne

That made a whole system for patients and professionals better. There are some very basic things we need in e-health. We need a national patient record.

Ms Susan Clyne

We need disease records. We are not way ahead of the e-health curve; there are some very basic things we need to do. We need a unique patient identifier.

On primary care and secondary care, I very much agree with Ms Clyne.

Ms Susan Clyne

In fairness to HSE IT, the COVAX system was set up, but a lot of detail had to be included. GPs had to identify whole ranges and cohorts of patients during vaccination because there were no disease records. Hospital colleagues had to do the same. Therefore, very basic e-health measures need to be put in place so we can build on the foundations, but ultimately it is a question of what is in the best interest of the patient, be it face-to-face consultation or online consultation.

Of course. I thank the delegates for their time.

This has been a really interesting session. I was listening in but had to leave briefly.

Dr. Brides talked about prescribing and mentioned a colleague who was prescribing to about 30% of patients in Australia and nearly 100% here. Does that mean we are overprescribing? My comments are not intended to take from and do not reflect on the quality of medication for mental health issues.

Does Dr. Brides think we are, therefore, over-prescribing or that GPs are forced into over-prescribing or becoming overly reliant on medication because they simply do not have access to talk therapies or the other supports we would ideally be offering patients?

Dr. Aideen Brides

I agree with the Senator. I have no evidence to support this but I know from being in practice that when people in distress come to me, and often they do need medication but also need talking therapy along with it, they come back to me a couple of weeks later because they have not had access to talking therapy and I have no other option but to increase their prescription. That will happen again a couple of weeks later. I might even find myself adding medications I know the patient does not really need but I do not have the allocated time to go through his or her problem. I do not have the qualification. I am not a psychologist and am not trained in therapies.

Once again, if we refer to the Australian model where there might be an in-house person trained in this discipline, if I was able to refer on this person on the first occasion either with or without medication, it would be much more advantageous to the patient. As Dr. Sadlier referred to earlier, there is a lot of evidence that certainly with moderate depression, it is not just medication or just talking therapies but a combination of both. We are not providing adequate services to our patients. We are simply ignoring half of their treatment because we do not have access to that level of care.

If we think back to something mentioned earlier, that is, the lack of regulation among the talking therapies, for want of a descriptive term, we can see that the people are out there or certainly there are vast numbers of them. I would imagine that a lot of them are of a certain standard so it is just about using them appropriately. It is about making them more accessible.

Yes, e-health is good and some patients can engage in online therapies but really therapies need to be accessible. It is a bit like general practice. We need it on the ground and to be accessible to patients and not something they must travel for. Our counselling and primary care service is based in Navan, which is about an hour and 15 minutes from Monaghan. That is just pointless because people need to be able to access it. Often these are patients with very limited means. We need as few barriers as possible to accessing these services. To answer the Senator's question, I do think there is far more prescribing in general practice than we would ideally like to see happening.

I do not know if this is the kind of thing where we would look to say, "Oh that could be a wake-up call to Government to invest in things". That is a really pertinent point to take away from this.

Professor Matthew Sadlier

I know the focus is often on the idea that there is a dichotomy between medications and talk therapies. The benefits of both at times are oversold a bit. One of the best projects I was ever involved with in my professional career was one we did with the FAI in west Dublin where a number of service users went on an eight-week training programme and got a Kick Start certificate. The way it changed their lives and activation was literally a miracle. As well as the non-provision of talking therapies, the non-provision of these group activities that can help mild to moderate depression and anxiety and would be more in the realm of occupational therapy than psychology is also a significant deficit. It is not that I am trying to downplay talk therapies. I just think that when we get into this discussion, this is an area that is often ignored. I know it is often called social prescribing. Certain mental health services throughout the world offer free gym membership, physical exercise, physical fitness or weight control programmes - various aspects that can be done that quite often are very cost-effective because they are done in a group manner and can be just as beneficial as the one-to-one counselling or the use of medications. We must keep an eye on those sorts of programmes as well and not lose them in the discussion.

Dr. Brides spoke about the regulation of certain talk therapies. The Irish Association for Counselling and Psychotherapy has been trying for years to get a regulatory underpinning of the work it is doing. I do not want to stray too far from the topic we are discussing but I know the association has been talking to other members of this committee about its frustration about being able to provide a service but not having a regulatory framework to do it. It seems to be taking forever. This may be a reflection of where we are in general with this sector.

The witnesses spoke about workforce planning or the lack of it, and the changing demographics of medicine. Many different groups would come before this committee representing the diversity of Ireland's population. The witnesses spoke about people entering training and rapidly backing out again, which is a problem. Is there any commentary the witnesses can offer about the diversity of those seeking training? Is there a realistic prospect in the future of seeing services in communities staffed by people who represent them? I will not go too far down into the diversity of the communities but it is important when we are talking about medicine and the diversity of people who are going and training in different sections. As the witnesses said, we do not even have workforce planning so perhaps this is a comment that is too far down the line.

Ms Susan Clyne

There is no workforce planning. Obviously, workforce planning would take all of these things into account. Anybody who wants to be a doctor has to start thinking about it at a very young age. He or she is asked to get a huge number of points in the leaving certificate and must then do the health professions admission test, HPAT, and go into the very long university and training period. We see more diversity in medicine. Obviously, we see more women in medicine. We see through the graduate entry medical programme that people with previous degrees as their primary degree are coming into medicine.

One of the issues we have is the number of training places. We have a reliance on international doctors who work mainly within our acute system and are not on training pathways and whose visa regulations and critical skills are not dealt with very quickly. While they can go on to apply for training pathways, if the training pathway number is not increased, all we are doing is having more people apply for a static number of posts. We talk about needing "X" number of GPs and consultants in the future and these retirements happening over five years or even ten years. We talked about this a decade ago. We have the problem now. What we are saying is that we really have to do something about it now. It takes a very long time to train a doctor so we need the training places to be increased. We need our international doctors to be valued, to be able to see a future within Ireland and to be respected and treated appropriately and equitably within the system.

There is probably more diversity in psychiatry than in many other areas of medicine. It is certainly a specialty that tends to have quite wide representation of the population. As Ms Clyne has just said, sometimes it can be very difficult for international doctors to access training programmes, which is a problem that needs to be addressed. Again, it is important that we represent the population we serve and that patients can feel comfortable talking to any mental health professional they see not just in psychiatry but across the other disciplines as well.

Dr. Brendan Doody

Again, we need to look at what other countries have done because it is important we learn. Other countries have experienced difficulties regarding service, service planning and development. In our workforce planning, we need to look at what the current workforce is because sometimes we might think we have created more posts but over the next five years, there may be an increased number of retirements given the age profile. It might be a case of "We have created all these additional posts so why hasn't that resulted in an increased number of consultants on the ground?"

If we do not invest sustainably, there will be periods when certain specialties suddenly expand and many consultants are recruited at the same time. That is fine until it comes to retirement when a large number of retirements happen together. A service must be grown and invested in sustainably. We cannot just put a lot of money into it and expect changes to happen overnight. Health services - not just mental health services - are delivered by people and technology. Investment in people is taking a long time. We want to invest, but we need to do that on a multi-annual basis.

We must then ensure that we attract graduates. This is about providing undergraduates with exposure to psychiatry. In our service, we are fortunate to have two psychiatry intern posts. Interestingly, they are very sought after. This is a question of how to provide early training opportunities. Psychiatry has often been at a disadvantage in this respect, with doctors making their career choices early. As such, it is important that they have an opportunity to be exposed to working in mental health services before they complete their training and their pre-registration year.

We have spoken about an operational plan. A workforce plan is required, by which I mean a plan that sets out what we want the service to look like. We must then determine how to put in place the structures to make that happen and train people. It is five-year, ten-year and 15-year planning as opposed to believing that we can invest a great deal of money in the short term and expect change. We are just chasing people, which has been an issue previously. An interesting point was made about increasing the number of posts. All that means is staff moving from one part of the country to another. Additional staff are not being recruited. Instead, vacancies are being created somewhere else. Staff drift from areas where there is a high cost base. Although there are advantages in some respects, there is a disadvantage to services being in cities where there are high accommodation costs.

Many elements feed into this situation. As a result, we need a co-ordinated operational plan and workforce plan if we want there to be change. It will not happen unless we address these aspects simultaneously.

I thank Dr. Doody. It is bonkers that we do not have a workforce plan. It is so obvious when listing issues like expanding bubbles of employment and retirement. It seems ineffective and inefficient that we are not getting to grips with a sustainable and steady workforce plan. I will not go into it too much, though.

Ms Clyne spoke about what was going to be my next question. At this and other committees, she has spoken about bringing in international doctors, the ethics of a brain drain out of countries, in particular developing ones, and our unacceptable treatment of them by not providing training pathways. I will not go into that matter again.

If the points that the witnesses have made are included in the final draft of this Bill, will we be on track to having gold standard, world standard or just good legislation that will protect, support and provide care and compassion for the people who will be affected by it? Are we going in the right direction in terms of how we need to treat our patients with mental health issues? I mean that in terms of this Bill specifically as opposed to the overall situation.

Dr. Anne Doherty

That is an interesting question. Overall, the heads of the Bill come to more than 300 pages. This is a large document. We have only raised a tiny number of problems with it at this meeting, but the majority of it is fine. There are many good elements in it. We have not emphasised them because one cannot emphasise all of the hundreds of good elements. The change in the management of anorexia is a positive. People detained under the Mental Health Act will now be able to get physical treatment if they need it. To date, we could not feed an adult patient with anorexia under the Mental Health Act. One would have to make him or her a ward of court by going to the High Court and through a convoluted process in which he or she would have to be declared to be of unsound mind and unable to manage his or her affairs. That is an archaic way of going about things. This part of the Bill will make a major difference to patients' lives, in that their physical healthcare and the elements of their mental healthcare that involve physical health treatments will now be given in the appropriate setting.

The main issues that we have raised are those that we believe might get in the way of people having access to healthcare and the right to prompt treatment with dignity and in the appropriate setting. If some of these changes can be included, we can develop a health service that allows people who need it to get treatment in the right place at the right time. We are speaking about people who are admitted under the Mental Health Act. We have probably spent most of this meeting talking about the thousands of people in mental health services more generally. A small proportion of those will be admitted to mental health units, and probably only 20% of those will be held under the Mental Health Act. We are speaking about a tiny proportion of a tiny proportion, but because they are so vulnerable, we need to ensure that their right to treatment and their access to treatment are promoted as much as possible.

To answer the Senator's question, the direction of travel is excellent overall, but we need to ensure that everyone can access treatment in a timely way.

Dr. Brendan Doody

Under the Act, we have been able to initiate and deliver nasogastric, NG, feeding for seriously unwell people with eating disorders in our inpatient services and where restraint has been necessary. We have a colleague working with us in the inpatient unit who has long experience of working in inpatient services in the UK. He is able to compare and contrast the Act's provisions that apply to under-18s. He says that the system here, which goes through the courts, is a far superior mechanism than what he experienced in the UK. The oversight by a court provides protection, in that we are going to court to vindicate and protect the rights of the young person. It provides oversight, even where parents are consenting. There is also the important guardian ad litem role. In a sense, the Act and the amendments to it as they pertain to children make it clear that it is a separate Act. Most of those provisions were in the Act initially but were just seen as references to sections of the Child Care Act.

The rules and regulations that come with the Mental Health Act and apply to children and adolescents need to be separate from those that apply to adults. The initiation and use of NG feeding and, if necessary, the use of restraint constitute a form of restrictive practice, but one that delivers a necessary and life-saving treatment. It is important to remember that, until three years ago, children who required such treatment were being sent abroad. That is no longer happening. We have the legal framework. The amendments to the Act clarify and build on the experience that we have gained in the use of the Act over the past number of years.

It also clarifies the anomaly in respect of 16- and 17-year-olds, even though in practice we would not have been admitting 16- and 17-year-olds or even younger, if they did not consent to admission, solely on consent of parents. In a sense, it is bringing the status of 16- and 17-year-olds in line with that for other treatments. It is important that 16- and 17-year-olds have that capacity to consent.

There are lots of positives with regard to the Act. I have been in court many times, explaining to the a judge that we are here, even though the parents are consenting - and this may be for a young person who is only 11 or 12 - because it is important that we vindicate and safeguard the rights of the child. It is important that they are properly safeguarded and vindicated and are appointed a guardian ad litem. There are many positive aspects to the legislation. The safeguards with regard to children who are subject to care orders have been omitted from the amendment in the Act but there is a very good reason they should be there. They have been omitted without a recommendation of the expert group for them to be so omitted.

Ms Susan Clyne

While there are lots of good provisions in the Act, it is good to see it being reviewed. Perhaps the Act should be reviewed more regularly, rather than waiting for long periods when things change so much in medicine, in the delivery of care and in people's rights. We chose to home in on a number of issues today that we think will inadvertently have negative consequences for immediate, crisis care to patients. We commend the legislators and look forward them seeking the necessary funding to have mental health services in place around the country.

Professor Matthew Sadlier

I agree. The 2001 Act, which updated the 1945 Act, created a stepped change in mental health care. We can date all the improvements in terms of rights to that Act, which introduced tribunals and rights of appeal for people involuntarily detained. We have questions, as pointed out earlier, with regard to issues that can slow up the delivery of care. There are also some areas of ambiguity in the Act and obviously ambiguity in a legal document might lead to difficulties in operation.

To echo Dr. Dooley's point, my specialty is psychiatry of later life where we deal with patients aged over 65. The vast majority of our work in psychiatry of later life deals with disorders related to dementia. In that context, the Assisted Decision Making (Capacity) Act will have a big impact. Similarly to Dr. Dooley's call for a separate set of rules and guidance for young people in mental health facilities, there is an urgent need for a separate set of rules and regulations for older people within mental health facilities. I can give the committee one or two examples of that. We had a patient come to our unit who was in a particular wheelchair that had a curvature of the back because of severe degeneration of the spine. The wheelchair was designed to match the curve of the spine but to benefit from that, the patient had to have a seat belt. That was not allowed to be used when the patient was admitted to the psychiatric facility because it was seen to be mechanical restraint, and it was not a restraint that was related to pain relief. There are issues around ligature points in older age care where patients might need oxygen or hoists to be lifted. Unfortunately, when people develop dementia, it is not just a brain disease but an all-over body disease and they have many other deficits. It is very difficult to say that our units are fit for purpose. We have to remove oxygen points because they are seen as potential ligature points, despite the fact that the vast majority of our patients are in a state of frailty where that is not really as much of a concern as it would be in younger patients. We would absolutely be asking that as part of this process there would be a separate set of guidance and rules for the provision of care to those with medical frailties within units.

As an aside not related to legislation, I would also be advocating that the provision of services specifically for psychiatry of old age are moved more into the older persons' programmes than programmes for mental health because we have more in common with our colleagues in medicine for the elderly. Often our units need significant hospital support, which they do not get, because there is a basis under which our services are constantly being moved to the community. A DaTscan is used to differentiate dementia diagnoses and in the UK, the highest orderer of DaTscans is the psychiatry service. In Ireland, we have no access to them whatsoever. The provision of physical health care to mental health services is difficult with this constant move to the community, which is totally suitable for many people with various diagnoses but within the psychiatry of later life we need a more centralised system because of the need for hospital care, access to scanning, blood testing and so on.

That was my last question and I thank the witnesses for talking a lot of sense. While I do not speak on behalf of everyone on the committee, I can say that we are extremely committed to making this legislation the best it can be. That is always our job as legislators, of course, but we are particularly focused on this Bill at the moment. Hopefully with everyone's suggestions, we can think of ways that this can be done. It is really useful to get a sense from experts as to whether we are going in the right direction and how we can ensure the legislation is the best it can be. Some of the additional suggestions are really important and I thank the witnesses for their contributions. I have no more questions and I thank the Chairman for facilitating me.

I thank the Senator and I thank the witnesses for their presentations, which were a real eye-opener. I am glad that the final question from the Senator allowed us to hear their thoughts on the legislation that is coming. Reference was made to the fact that three Ministers agreed that there was a shortage of resources for recruitment. What is the blockage there? Why did previous Ministers not act on what the witnesses spoke at length about today, in terms of issues with recruitment? What is the blockage?

Ms Susan Clyne

The blockage is the Government's attitude towards consultants and the Department of Public Expenditure and Reform allowing that to happen. Consultants had to go to the High Court to have their contract upheld following a decision by another former Minister for Health, Mary Harney. Ourselves and the IHCA ended up in the High Court. The current Tánaiste was Minister for Health at the time of the cuts. Everyone understood those cuts in the context of austerity but it was the targeting of this additional cut that was problematic. We believe it was a politically motivated cut. It had no basis in evidence and did not save the State a fortune by any means. In fact, it had the opposite effect in that it was devastating. When Deputy Harris was Minister for Health he attended the AGMs of the IMO and the IHCA and acknowledged and recognised that it was a mistake and said that it would be fixed but it was not. The current Minister has spoken at length on the record of the Dáil several times and at various meetings acknowledging that this is a problem. We are in contract talks at the moment that are stalled because there is no chairman.

We have to accept that people will vote with their feet. There has been a very big reliance on doctors doing the right thing for their patients, putting up with it and not taking any kind of industrial action - options that are open to many other workers in the public service. Consultants support a partnership approach. They want to see health reform. We have to get over that, accept that consultants want better services for their patients and want to advocate for their patients but also want to be treated fairly. It is the inherent unfairness that has had a toxic influence.

It is difficult for consultants to be working on a team where a consultant appointed two weeks before another consultant, and appointed before the deadline, earns 30% more than the other consultant, despite being as qualified and doing the same amount of work. It creates such a toxic feeling in the health service and it has driven morale down. Unfortunately, our trainees see it. They see how they are valued by the employer and by Government and they move along. I would like to hear from those three or four Ministers why they promised something they are now not delivering.

I thank the witnesses for coming in today and giving us very comprehensive opening statements. It was good to listen to them and to hear that they think the legislation is, overall, excellent. The aim of the committee is to see human rights compliant legislation introduced. We believe the Mental Health Act is outdated. We are very happy to be doing the pre-legislative scrutiny on this. Again, I thank everyone. Our meeting is now adjourned sine die.

The joint committee adjourned at 1.51 p.m. sine die.