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.