I am grateful for the invitation to discuss the general scheme of the mental health (amendment) Bill 2021. I am Dr. Lorcan Martin, vice president of the College of Psychiatrists of Ireland and a consultant specialist in general adult psychiatry. Accompanying me and representing the college today are Dr. Imelda Whyte, consultant specialist in child and adolescent psychiatry; Dr. Atiqa Rafiq, consultant specialist in later life psychiatry; and Dr. Norella Broderick, senior registrar in learning disability psychiatry.
The College of Psychiatrists of Ireland is the sole accredited training, education and professional body for psychiatry in Ireland, representing more than 1,000 psychiatrists, both specialists and trainees, across the country. The mission of the college is to promote excellence in the practice of psychiatry in all its components - training for doctors to become specialists in psychiatry, lifelong continuous professional education and advocacy for evidence-based standards of care in mental health services in order to achieve a fit-for-purpose contemporary service for Irish people.
While obviously there are other pieces of legislation governing the delivery of mental health services in Ireland, the primary legislation is the Mental Health Act 2001 which focuses primarily, though not exclusively, on the management of patients who are admitted for treatment involuntarily. As members are aware, one of the necessary reasons to review and revise this Act is to update the legislation to bring it in line with human rights, including the United Nations Convention on the Rights of Persons with Disabilities, and for it to be compatible with the, yet to be fully commenced, Assisted Decision Making (Capacity) Act and other Irish legislation. The college actively supports such a review.
While the rights to autonomy and dignity are fundamental, so too is the right to person-centred, evidence-based care, and to the timely access to such care. This includes support for mental health challenges and distress and for treatment of mental illness and disorders. Similarly, families and carers have the right to expect timely and appropriate treatment for their loved ones and those in their care.
We believe the heads of Bill, while going further to incorporate human rights principles into mental health legislation, have gone so far as to now potentially prevent seriously ill people from getting the treatment they urgently need.
We note agreement with many issues and concerns highlighted by our colleagues in the IMO and IHCA who presented to the committee on 8 February 2022.
I draw the committee's attention to a number of figures. In 2020, just over 15,000 people were admitted to psychiatric units or hospitals. Just under 2,500 of these were involuntary admissions, of which just under 950 were admitted for the first time. These people, by definition, represent the most seriously ill. By far the biggest number in this group had diagnoses of schizophrenia, schizo-affective and delusional disorders. Followed by this are other serious illnesses, namely mania and severe depression. All of these conditions, whether it is a first or recurrent episode, are best managed by early and comprehensive intervention and specialist treatment to maximise the potential for recovery, restore function and optimise quality of life. While specialist, community-based treatments are sufficient for most people attending mental health services, people with severe illness and more complex needs require a much greater level of support and care to manage life-changing mental illnesses. Unfortunately, this may include involuntary admission. Detailed reports with data are available. However, these figures represent real people, with real illnesses and real suffering. Consequently, it behoves us all to alleviate that suffering and treat illness in whatever way is necessary.
Such is the concern of the members of our organisation that the current draft Bill will deny patients and people treatment and care that the college held an EGM recently, which is unusual. We also surveyed our full membership and the results indicate the same concern. A summary of those results has been provided to the committee. A total of 80% of survey respondents believe that the proposed revisions would impact on their ability to treat patients effectively, while 70% believe that the proposed revisions will have negative implications for families because they will increase barriers to care for those who have concerns about mental illness in their relatives. More than 70% of respondents believe the proposed revisions will increase their workload, increase burnout, and impact further on the already major issue of staff recruitment and retention in psychiatry, while more than 60% of those surveyed believe that the revisions will increase risk to staff in inpatient units, which would be likely to impact staff recruitment and retention in this environment.
Committee members have our detailed submission, provided to the Department of Health, which outlines the specific parts of the draft heads of Bill we believe are not tenable or require further examination, explanation or reasoning. I will refer to some specific issues. The first concerns the increased risks for patients, families and society. The Mental Health Act allows detention on the ground of the presence of a mental disorder and either presence of risk or need for treatment. The proposed revised criteria state that admission must be “immediately necessary for the protection of the life of the person, for protection from [...] serious threat to the health of the person" and protection of others. We argue that this will increase the risk to patients and families, as the proposed amended Act cannot be used until there is a serious risk.
Families and health professionals who are familiar with the person can detect early signs of relapse, which is, unfortunately, sometimes accompanied by lack of insight in the patient. This allows for families and health professionals to begin to seek treatment for them before the inevitable progression of the illness. However, serious mental illness such as psychosis or bipolar disorder under the proposed revisions will need to be advanced to the point where there is a risk to life or health before treatment can commence. There is no other illness where doctors have to wait for a patient to deteriorate to a life-threatening state before treatment can be initiated. Furthermore, sometimes individuals can be severely mentally unwell with an inability to function. However, if they do not seek treatment, they will go untreated indefinitely, until they present a serious and immediate risk. The stipulation that someone with severe mental illness who lacks capacity cannot access treatment unless they pose a serious threat to themselves or others is also stigmatising for mentally ill patients.
A core feature of all illness is the impact it has on functioning, no more so than severe mental illness. It is recognised that untreated mental illness will cause the person to be increasingly less able to socially function, potentially leading to homelessness, substance misuse and imprisonment. This is one of the main drivers, if not the main one, behind mental health legislation: to ensure that those who are unable to function and have impaired capacity due to severe mental illness have a safety net. Those with severe mental illness also disproportionately account for those who are homeless or in prison. The removal of this safety net will increase this and further marginalise those with severe mental illness. This finding has been recognised since the 1930s and is referred to as Penrose's law where, as the number of psychiatric inpatients goes down, the number of prisoners goes up. A clear example is that, although there are many remarkable sights in San Francisco, sadly one of these is the number of psychiatrically unwell homeless patients, whose right to health and treatment is not being met.
Another concern is a delay in patients accessing treatment.
Currently, an application for detention in hospital under the Act can be initiated by a range of individuals, including family members, emergency department staff and members of An Garda Síochána. There also is provision for applications to be made by individuals designated as authorised officers, but this was only used in the minority of cases due to the difficulty in accessing such officers. The draft heads of Bill provide that only authorised officers can now initiate an application. We have a number of concerns about this. Some services do not have access to any authorised officers and, in the remainder of the country, there are insufficient numbers of officers to provide 24-7, 365-days-a-year cover. The cost implications of having sufficient authorised officers available are significant. Additionally, it is likely that there will be marked difficulties recruiting such individuals. Family members will no longer be in a position to make an application, even though they may be the ones who know the person best, are best placed to identify early warning signs of relapse in the quickest time and may wish to be involved as much as possible in the care of their loved one.
The revised proposals make considerable additional demands on consultant specialist time, which will have obvious knock-on effects on patient care. Based on the survey of our members, the impact on consultant time is estimated to be an additional six hours-plus per week, which will lead to cancellation of clinics and increases in waiting times. As members know, the services already are stretched and overburdened and we struggle to provide the support and care people deserve. Currently, there are approximately 485 approved specialist consultant posts but more than 100 of them are unfilled or do not have a specialist in post. We need more than 835 consultant specialist psychiatrists by 2028, based on current and projected demand. In the meantime, between 276 and 350 of those currently in post are expected to retire or leave the services over the next ten years. Half of our consultant psychiatrists are over the age of 50. The proposed new Act, in its current form, will be a significant disincentive to psychiatrists taking up posts in this jurisdiction. Quite simply, we are training doctors to leave.
I want to highlight the main aspects of the proposals that will impact on consultant time. The current Act specifies that mental health tribunals, which are to be renamed mental health review boards, must take place within 21 days of the commencement of a detention. However, under the proposed revisions, the review boards will take place within 14 days. This will inevitably lead to more consultant time being taken up with the administrative work associated with the frequent and more numerous sittings of boards. Time spent in review boards is time not spent in outpatient clinics, on ward rounds or supervising junior staff in training. Most important, it is unclear what benefit will be gained by the patient from this change. Review boards will take place at a time dictated by the Mental Health Commission to suit the panel, not, as in the present situation, where the time and day of the tribunal is agreed between the consultant and the commission. It will be extremely challenging to reschedule clinics if review boards are scheduled at the same time as outpatient clinics. This will further affect the ability to prioritise working with our patients, which is, after all, why we become doctors.
There also will be an impact on safety in inpatient units. College members have expressed concerns in this regard arising out of the significant restrictions, punishable by fines, convictions and a potential criminal record, on the management of agitated patients. No behavioural management of any type will be allowed on voluntary patients and, if it is necessary to detain such patients, no treatments are allowed in the period during which the application process is taking place, which could take 12 hours. Should a voluntary patient become agitated on an inpatient ward, which is a common occurrence, there will be very serious risks to other patients and staff, as the latter will no longer be able to provide treatments that previously were possible while the application process is taking place.
A further concern among members is the current proposed provision for the criminalising of breaches of the Mental Health Commission regulations relating to seclusion and restraint. First,the threshold for the use of seclusion or restraint should be clearly set out in the parent legislation. As it stands, under the draft heads, the commission seems to be given the power to make any changes it wishes to the use of seclusion and restraint. It is important to have this power clearly defined as a matter of policy in the legislation. The regulations, as developed by the commission, deal with matters such as record-keeping and documentation, frequency of clinical review, etc. These are not matters properly within the purview of the criminal law. A separate matter is the misuse of the power to initiate or continue seclusion or restraint. Any offence relating to the abuse of this power should be clearly set out in the primary legislation and should include a requirement to show malicious intent or intention to misuse seclusion or restraint.
Regarding admission of children to approved inpatient facilities, the current Act provides important protections for children in care and subject to court orders. The new draft Bill is silent in relation to these vulnerable children, leaving them without the protections currently afforded to them. The proposals allow for children to be brought directly to approved inpatient facilities by An Garda Síochána. This is not in a child's best interest. Just because a child is presenting in crisis does not mean he or she has a mental illness. Children require appropriate assessments, including medical, in an appropriate setting.
I thank members for their time and their consideration of our views of proposed legislation that is complex and also, we believe, seriously flawed. In its current iteration, it will make it harder for psychiatrists to do their jobs, exacerbate the current recruitment and retention crisis and, most important of all, make it more difficult for seriously ill patients to be treated and to return to their lives and their loved ones.
My colleagues and I represent some of the varied specialties in psychiatry and, between us, we treat people from early childhood through to late old age. We are all deeply passionate about providing the best possible outcomes for those in our care and it is for this reason that we have such concerns about the proposed amendments to the Mental Health Act. We will be happy to answer the committee's questions and to provide any further explanation it may require. I thank the committee again.