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Joint Sub-Committee on Mental Health debate -
Tuesday, 22 Mar 2022

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

I welcome the representatives from the Irish Association of Social Workers and the College of Psychiatrists of Ireland to our meeting this morning as part of the sub-committee pre-legislative scrutiny of the Mental Health (Amendment) Bill 2021. I welcome Mr. Vivian Geiran, chair, Irish Association of Social Workers and Mr. Eoin Barry, Irish Association of Social Workers member and chair of Social Workers in Child and Adolescent Mental Health Services, CAMHS, Special Interest Group. From the College of Psychiatrists of Ireland, I welcome Dr. Atiqa Rafiq, consultant specialist, later life psychiatry; Dr. Imelda Whyte, consultant specialist; child and adolescent psychiatry,; Dr. Lorcan Martin, vice president and consultant specialist, general adult psychiatry; and Dr. Norella Broderick, senior registrar, representing the college faculty of learning disability psychiatry.

Before we hear the opening statements, all members and witnesses are again reminded of the long-standing parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the 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 they comply with any such direction.

I call on Mr. Vivian Geiran to make his opening remarks.

Mr. Vivian Geiran

I thank the Chairman and the committee for the invitation to present to the committee this morning. I am chairperson of the Irish Association of Social Workers. My colleague, Mr. Eoin Barry, is chair of the IASW Child and Adolescent Mental Health Services, CAMHS, Special Interest Group and a systemic psychotherapist and social worker working in CAMHS.

By way of background, the Irish Association of Social Workers, IASW, was founded in 1971 and is the national representative professional body for social workers. The IASW currently has a membership of 1,600 social workers. We are an active member of the International Federation of Social Workers, which represents professional social work associations from more than 55 countries. The association is a registered company run by a voluntary board of directors, which is elected annually by the membership. The board is supported by the activities of council representing the principal areas of social work activity in Ireland, including children and families, mental health, probation, primary care, disability, medical social work and so on.

As the representative group for social workers, we welcome, in the main, the recommendations of the report of the expert review group and the overall changes proposed, including those previously suggested by the IASW and now incorporated in the draft heads of the Bill. We also broadly welcome the provisions of the Mental Health (Amendment) Bill, as outlined in the draft heads of the Bill currently under consideration. We believe these changes, in general, will improve mental health services, including giving an amplified voice to service users, both adults and children.

We would emphasise the following points. Under the definition of treatment, the proposed replacement of the word "medical" by the term "clinical" more accurately reflects the broad range of care provided as opposed to using a solely medical lens. We would emphasise that every involuntarily detained person should have a right to a psychosocial assessment conducted by a CORU registered mental health social worker. Regarding a psychosocial assessment completed by a mental healthcare professional member of the multidisciplinary team, we propose such assessments be completed by a CORU registered mental health social worker. Mental health social workers are best placed to complete such psychosocial assessments as they have an appreciation for complex systemic factors assessment, risk management and the various therapeutic approaches.

Regarding assess to forensic assessments, “In the instance that a person is detained to ensure safety of others, access to a forensic assessment needs to be made available", this is especially important in the context of families where there is risk of domestic violence, intimate partner homicide, parricide, filicide and intra and extra familial child homicide.

The new Act should be informed by the guiding principles of trauma-informed care relating to manual or other forms of seclusion and restraints.

We would be particularly concerned by reports that mechanical restraint has been used in some of the inpatient child and adolescent facilities. We would ask that this legislation explicitly prohibit the use of mechanical restraint on children.

We note the legislation mandates the Mental Health Commission to visit and inspect every community mental health service at least once every five years. We would ask that it is clarified that this encompasses community mental health services for all age groups. We would also ask that the Mental Health Commission’s remit is extended to regulate low-, medium- and high-support HSE hostels. We would ask that all inpatient facilities are mandated to have a space where families can meet in privacy.

We support the change of terms in the report, including the use of mental disorder in appropriate contexts and the renaming of mental health review tribunals to mental health review boards. This is an important change as people often felt they had done something wrong if they needed to attend a tribunal. Such changes in terminology are positive and welcomed.

We also welcome the changes related to provision for children. We would ask that there is further exploration and development of issues related to the transition of children to adult mental health services. This area can be inconsistent around the country, leading to serious issues in both child and adolescent mental health services and adult services.

We welcome the changes regarding consent for children. We seek appropriate clarity in the legislation of what would happen if a young person consents to treatment, but their guardian opposes it. We would also ask that the family or guardians of a young person are specifically included in the care of young people in inpatient facilities. This would ensure the best possible outcome when they return home.

We welcome the importance placed on advocacy and the role of the guardian ad litem.

We strongly suggest that the provision of services be recovery focused, human rights based as well as trauma informed and based on international best practice. They should also take full account of the psychosocial context and issues arising. In that context they should incorporate registered mental health and social work practitioner inputs. In the context of development and implementation of the legislation this will require increased resources in the area of mental health and social work services. I again thank the committee for the invitation. We are happy to answer any questions members may have.

Dr. Lorcan Martin

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.

I thank Dr. Martin. Our first member to put questions today is Senator Conway.

I thank our guests in the first instance for their time in being here this morning. These engagements are very important. Dr. Martin is clearly not at all happy with this legislation. Can he tell me if there is any element of the proposed Bill that he is satisfied with?

Dr. Lorcan Martin

We are obviously very happy that the Bill encompasses a greater awareness of human rights, which would be the most important thing. Otherwise there are a number of areas with which we would have serious concern in the implementation of the Bill. Fundamentally, the spirit of it is admirable and is a very good thing. However, it is the actual process and the implementation that is likely to cause significant difficulties for us. Obviously the knock-on effects there, most importantly, are the difficulties for the people we look after.

This is the issue. Dr. Martin says that the human rights element is admirable and I agree with him. How would he go about achieving what we want in respect of human rights and equipping the service user, or whatever one wants to call the person, to advocate for themselves? The objective of this legislation is to try to give people as much freedom as possible and as much scope as possible to decide on their own health treatment. The "as possible" element is very important. Given that Dr. Martin acknowledges that the human rights sentiment here is admirable, how would he then go about helping or advising us in order to enshrine people's human rights within legislation? Clearly, a significant number of people have appeared before this committee who would not agree with his analysis. I am interested to hear what measures Dr. Martin would propose. He went through the Bill forensically, identified the areas he was not happy about and gave a very strong and passionate critique of the Bill, but I am asking him now for actual solutions and proposals to counter the negatives that he has pointed out.

Dr. Lorcan Martin

Before I deal with the Senator's question, I should point out that in using the current mental health legislation, we attempt to use the least restrictive possible approach. Obviously people come in only when absolutely necessary and are made voluntary, or are discharged as soon as possible.

However, moving on to the Senator's question, it is very important for people who suffer from mental illness to be as involved as possible in their management. For the vast majority of people, they have a good awareness of their illness and are able to engage with the mental health services as fully capacitated individuals. The difficulty arises when people no longer have that level of capacity. We would obviously expect that this particular Bill, regardless of its format, would work in conjunction with the Assisted Decision-Making (Capacity) Act and that every possible support would be put in place for the individual to involve themselves in their own treatment and to have supports, advocates and any necessary aids they would require to advocate on their own behalf or to understand what is going on.

As I have said, the difficulty arises when people become so ill that they no longer have that level of capacity. I am speaking from personal experience because I had a family member who had a very serious mental illness. While he was never a threat to himself or anybody else, he would deteriorate to a point where he required hospitalisation involuntarily. What would happen, and again I do not want to make this too personal, is that he would stop taking his medication and every effort would be made to have him take it.

He would stop, deteriorate and eventually would require involuntary admission, when he no longer believed he was ill. The difficulty arises when people no longer believe they are ill and are at risk of social embarrassment and their lives coming apart in terms of their ability to function. I can give another example of a lady I care for who never becomes an immediate and serious risk of harm to herself but would socially embarrass herself in the community because she becomes unwell, stops taking her medication, gets into trouble with the law and so on. When she comes into hospital involuntarily and is treated, she recovers and then a package of care is put in place. It is important to put as many supports as possible in place for people to be involved in their care. We talk about patient-centred or patient-focused care. The patient must always remain at the centre of our practice, whether by a doctor, nurse or allied health professional. That is very important.

Supporting families and carers is very important also in terms of helping them to identify when people are becoming unwell and to engage with the person so that they may perhaps prevent the illness getting to the stage where somebody needs to come to hospital. Mental illness is incredibly complex unfortunately, as I am sure members are aware. So many different things are at play, whether it is the biology of the illness, social circumstances or adverse events. It is important for us to put everything in place that would enable the person to engage in their own treatment and make sure all the supports are available, but also then to have a safety net for when everything else fails. That is what we are talking about with involuntary admission. It is a last resort. It is the "when everything else has failed" approach. However, it has to be done with adequate safeguards and in a compassionate fashion in order that the individual continues to be involved in his or her care insofar as possible throughout that whole process.

We all acknowledge that the vast majority of practitioners go about their business in an honourable, ethical way but our responsibility as legislators is to ensure there are measures in place to protect people in the minority of cases where that does not happen. I am sure Dr. Martin will understand that. I thank him for sharing his personal experience with us because it certainly helps to inform us as to where his positioning comes from. Does he believe the current legislation is sufficient and provides enough safeguards? If not, what needs to change?

Dr. Lorcan Martin

Some of my colleagues may have some suggestions on this.

Dr. Norella Broderick

I was going to address the question on how we would best manage the issue of human rights. Senator Conway was hoping to hear specific examples. There are many provisions in the proposed legislation that we are happy with, as set out in the submission from the college. Specifically, to answer the Senator's question about human rights, we need to balance human rights. There is obviously the right to be involved in one's own healthcare and the right to liberty and so on that we are focused on. However, we also want to balance that against the right to treatment and to access treatment in a timely manner. We want to vindicate that right as well, and that is a big issue for us today. In terms of specific suggestions, we would not recommend changing the current standard for involuntary admission because the threshold has been raised and that is a concern for us in terms of people’s right to access healthcare. The second issue is who can initiate involuntary treatment. We think that restricting that to just authorised officers as Dr. Martin has set out would also restrict people’s access to timely mental health care when they are very unwell. I wanted to respond specifically to the question on human rights.

Dr. Atiqa Rafiq

I am an old age psychiatrist. I will briefly highlight how we work. We see many people with new onset mental illnesses who present for the first time after 65 years of age. We see many people who may have dementia of all degrees. We treat BPSD. We have an outreach model. We see patients where they live, in their homes, in nursing homes and day centres.

It is a small fraction of patients who require the protection of the Mental Health Act in order that they can access treatment when they need it.

As Dr. Broderick said, and as Dr. Martin indicated in the submission, the old age psychiatrists have a particular concern about the change of the threshold of admission and, as the Senator just mentioned, balancing it with human rights. It should not be the case that the focus becomes so severely in its entirety on patient will and preference that you lose sight of years upon years of learning and good clinical practice guidelines which advise that you start the treatment as and when it is clinically indicated and you aim for full restoration of occupational social functioning of the adult.

Section 8, which deals with who can be admitted under the proposed legislation, deviates so much from the good practice guidelines in many ways that the fraction of patients with most severe mental illness who require treatment under the Mental Health Act and who can access such treatment under the Act will no longer be able to access it. If they do, if they were admitted so late, which would not be clinically or ethically right, in waiting for the time when that criteria was satisfied, within the course of recovery, the capacity and the insight may not recover. Then we are into a different round about continuing the detention of these patients. You cannot do it; you have to discharge the patient based on the current proposed legislation, which means there will be serious deterioration of the patient-doctor relationship falling out from the care plan and poor outcomes all along for the elderly person and for the patients in general for whom we are advocating.

There has to be a balance struck. We believe the current Mental Health Act to some degree absolutely respects that balance. There have been issues, and it is admirable to see the thinking and the incorporation of the emphasis on the patient’s will and preference. However, you cannot ignore years and years of medical research, good clinical practice guidelines and the right of the patient to get the treatment when they need it. That balance has to be struck. Section 8 needs to be amended.

I have one final question. On the issue in regard to where a child wants help and a guardian does not and refuses to admit the child, will the witnesses elaborate a little more on that? That would be a very difficult situation. What is the view on that? What has their experience been when that happens?

Mr. Eoin Barry

One of the areas that CAMHS sees this arises is during the transition when young people are transitioning to adult mental health services. A concern that the vast majority of parents talk about is how involved will they be once they reach adult services. Often, that is a fear. However, the reality is that adult services involves and integrates families into the care of young adults. What we, as clinicians, are talking about is that this would be clarified in the eventual legislation. How would it operate? Really to emphasise the role of families so that working with families and young people to resolve it should really be a key part of this and would be best-evidence treatment. It will be a fear for parents and for young people. If somebody attending CAMHS is approaching their 16th birthday, there are issues involved. This is a scenario that is likely to arise.

We suggest that there is a role for a conversation between families and the young person, which happens anyway. To clarify, we emphasise the importance of families being the best advocates for young people in these situations.

In addition, as legislators, committee members have to consider the many young people who do not have family backgrounds and who are in care. There is also the issue of young people in direct provision centres etc. We emphasise the importance of advocacy services, especially for those young people who might not have advocates, to look for the service or to know what treatment young people are seeking. Those are the kinds of areas. There is the situation where a young person is in a family and is involving the family in that conversation, and the situation where young people, unfortunately, might not have the support of families and the need to make sure they have access to the correct advocacy service to address that.

I am conscious of my time. I beg the Chairperson's indulgence for one final question.

Dr. Whyte wants to respond to the Senator's last question.

Dr. Imelda Whyte

On that specific question, I am a consultant child and adolescent psychiatrist. The provisions proposed in the new Bill that relate specifically to the child component are robust. It is quite different from the adult part. As it stands, and it was part of our submission on behalf of the college, a guardian ad litem would be appointed to the young person. There is also provision for legal representation in that a solicitor would be appointed as well. In the actual day-to-day operation of the Act, the young person's voice is communicated to the judge through the guardian ad litem and parents are also offered legal representation in those situations.

A young person who is willing to be admitted to hospital but whose parents are not in agreement is something that happens regularly enough. I work in an inpatient unit and we are on the receiving end of these situations. As our colleague from the IASW suggests, the first option is to try to work with the family to see if we can support them in some way in their decision-making to ensure that their child receives the most appropriate care. Sometimes, when the family meets with the inpatient team, their concerns and fears might be reduced, they might feel that the care is appropriate and they will give it a trial for whatever period to see if it will help their young person.

It is also the case that we are ethically and professionally bound, if there is a young person who has a mental illness who is not going to recover or receive the treatment he or she requires in the community, and it is incumbent upon us, to use the Act in that regard. Sometimes, the use of the Act can take it away from the family. Instead of a young person, and we sometimes see an adult too, stating that a family put him or her in hospital and consented for him or her to come in, there is a judge, somebody who is quite separate in the District Court, who listens to all the evidence and then makes a decision. That can work quite well for families. There is a lot of strength in the Act but it is only used as a last resort when required.

I have no doubt that is what happens in the vast majority of cases. I have one final question. We are in a situation, as is the rest of Europe now, where Ukrainian refugees are coming to our country. We expect we will have anything up to 200,000 of them. Have the representatives looked at recognising the qualifications of citizens from Ukraine to practise in Ireland?

Dr. Lorcan Martin

I should point out that it is not the college that recognises qualifications. It is the Irish Medical Council, which is the regulator, and it will ultimately be up to it. Specialist qualification recognition comes to us and we are in a position to review any applications that come our way. On a complete aside, the college welcomes any Ukrainian psychiatrists who are appropriately qualified. We are very happy to work with them, but the first thing is they need to go through the Irish Medical Council because it is the initial regulator and the body with which they register.

That makes sense. The latter part of my question relating to that is if there are Ukrainian students currently studying abroad, will the college engage with them so they can continue their studies here?

Dr. Lorcan Martin

I am not quite sure I follow the question.

I met a young person who had completed five years studying medicine in Ukraine. This person had to flee and wants to continue their studies in Ireland. Similarly, in respect of Dr. Martin's profession, if an individual has done three or four years study in Ukraine, will the college recognise that and take that person in to complete his or her studies in the College of Psychiatrists of Ireland?

Dr. Lorcan Martin

The College of Psychiatrists of Ireland is responsible for postgraduate training, which concerns people who are already qualified as doctors and are now specialising in psychiatry. For somebody who is at university, matters would need to be arranged with the university faculties. We have no input into that.

If somebody has completed his or her primary degree and wishes to undertake a postgraduate course with the college, has it done any body to work to see how it can help? In other words, how can it help the people who may wish to continue their studies in the College of Psychiatrists of Ireland?

Dr. Lorcan Martin

We have not had anyone come to us yet but we are very happy to consider anybody who does. As the Deputy can imagine, postgraduate education is a very large department in the college. We would be very happy to receive any applications and we will attempt to review them.

I have questions for both sets of witnesses. I will split my time between them, if that is okay. I only read the College of Psychiatrists of Ireland survey this morning as soon as we got it. The questions seemed to be skewed in a certain way to get certain responses. The questions were littered with sentences that included terms such as negative implications, increased workloads, affected activities, ability to treat patients, the cancellation of clinics, the ability to supervise staff, ability to keep patients safe and risks to staff. I presume the representatives will see where I am coming from. Why were the questions included in the survey not framed in a way to evoke more of the benefits and positive changes outlined in the general scheme?

Dr. Lorcan Martin

That survey was based on feedback we got from our members based on the draft heads of Bill. These were the issues that arose repeatedly on foot of all the feedback that came in. Unfortunately, none of our members seemed to be in agreement that they were likely to be able to provide a better service to patients based on the proposed legislation.

Was the question of the benefits of the proposed Bill not considered at all? We talked about balance earlier. That question should have been asked for balance. Results may come back indicating that there are no benefits and psychiatrists do not see any, but the fact is these questions were not asked. For a layman like me who read that survey this morning, I was very disappointed to see that it seemed to be skewed in a certain way to elicit answers in a certain way. Dr. Martin stated what it was based on, but was any sort of consideration given to see whether there are any benefits to the changes outlined in the general scheme?

Dr. Lorcan Martin

Unfortunately, as I said, it was based on the feedback that came in. The Deputy is correct that the question could have been included and it was not. He is absolutely right, but all those questions came up from repeated feedback we got from members.

I read the article in The Irish Times at the weekend in which it was mentioned that the changes in the Bill could be catastrophic. I found that very disappointing. It seems to be case that minds were made up before the representatives even came to this meeting today. "Catastrophic" is a big word. That word was not used in respect of the CAMHS in Kerry, where it probably should have been. We saw it used in an article at the weekend where it seems that minds have been made up.

The changes proposed in the general scheme, as has been mentioned, are about patient-centred rights and not staffing issues. However, staffing issues are mentioned in it. One of the final things mentioned in the opening statement was that the changes could "exacerbate the current recruitment and retention crisis" we are going through. For example, if I could wave a magic wand and solve all the issues in recruitment and retention, and reduce the workload on psychiatrists, maybe through more funding and resources or whatever it might be, would Dr. Martin's opinion and view of this proposed legislation be different? If the proper resources were in place, what would those resources look like? Can the Government do more to support psychiatrists to support this proposed Bill?

Dr. Lorcan Martin

It would certainly deal with one of the issues, but there are a number of issues involved.

You can throw money at something and provide financial resources but if you want people to work in a job, it has to be attractive. That is one of the big problems. From speaking to junior colleagues in training and people who have just qualified to become consultants, I know they are finding the current situation quite difficult already. If something like this were to be added in, they will start thinking about the fact there are other places they can work. That is going to be a problem. We could suddenly wind up with a shortage, regardless of how many millions of euro are put into the system. We are aware that the mental health portion of the health budget is way lower in Ireland than in most other places and we would look for an increase in funding. However, it is not just about funding. It is about providing the wherewithal to make jobs attractive. It can be very difficult to fill posts. Many of our consultant posts are already vacant and if we are looking to double the number between now and 2028, difficulties are likely to arise.

I mentioned that the threshold for admission will be immediate and serious risk. The problem with somebody who becomes unwell and does not display an immediate and serious risk is that that person can easily become a very serious risk. I do not want to dwell on any individual instances but we all know of some very tragic cases over the last number of years where people might have had a sense that somebody was unwell but would not necessarily have been aware of the severity of that risk. That is where the difficulty arises. As Dr. Rafiq said, raising the threshold to that extent is going to cause big problems. I can almost guarantee that tragedies will happen because it is very easy to go from being unwell but not at risk to suddenly being at risk, or to go from being unwell and the risk not being identifiable to something tragic happening. That is one of the biggest concerns we have about that change in threshold. Not only will people who require treatment and have a right to it not get it, but also there is that added risk. Ironically, the risk threshold has been set as the key to admission but risk can change. That is important. Anyone who does risk assessments will be able to say what a risk is now but I could see somebody today and something awful could happen tomorrow because I do not know what will happen between today and tomorrow.

We can talk all we want about putting more resources in, such as more psychiatrists and so on, but fundamentally this comes back to seriously ill people. The Bill primarily revolves around people who are going to be involuntarily admitted. By definition, these people are very unwell. No psychiatrist, from a moral or ethical standpoint, will admit somebody involuntarily unless the person really needs it. That is partly for practical reasons because it involves more paperwork, but also we have a massive duty of care to our patients and the doctor-patient relationship is something fundamental that goes back millennia. First, do no harm. If we are going to bring somebody in and deprive them of their liberty, we want to be really certain there will be a significant benefit to that in getting that person back into their life, functioning, living with their loved ones and getting back to work or to college. That is the core of it. It is about providing the best possible service in the fastest possible way to the people who most need it.

Dr. Martin mentioned risks and change and I agree with him on that. However, there are other ways of looking at things as well. I am on the committee that is currently going through the Assisted Decision-Making (Capacity) Act 2015 and we are going through the draft report this week. If there was more emphasis on advanced healthcare directives, would that assist doctors in making decisions? For example, if somebody who had a psychosocial disability was able to make an advance healthcare directive, would that assist doctors going forward?

Dr. Lorcan Martin

It would be very useful. We welcome these types of directives and patients willing preference. The difficulty arises when somebody loses insight. That is the big problem, when they no longer have the ability to make a decision. Advance care directives can be extremely helpful in managing somebody when they are no longer able to make the decision in a capacitous way. The difficulty arises if somebody says, for example, that they do not want to be treated with antipsychotic medication, and they then become psychotic. We obviously cannot abide by the advance care directive at that point. If someone says they do not want to be treated with a certain medication because it gives them side-effects, that is a very reasonable thing to look at, but to say they do not want to be treated with medication when the only treatment that is likely to ameliorate their condition is medication is a different story.

Our primary aim is to alleviate suffering and treat illness. Advance care directives and those levels of patient involvement are important and helpful.

Mr. Barry spoke about needing to explore children's transition from CAMHS to adult mental health services. What would that transition look like? It is something that has been talked about for a while. What ages would be included in this transition? Does it need to be legislated for in this Bill? How does he see that working?

Mr. Eoin Barry

As CAMHS operates at present under an operating guideline nationwide, there is a policy in place for the transition on the CAMHS side, which is not necessarily replicated on the adult side. As far as I am aware, there is no equivalent on the adult side of things. There need to be policies that work between the two different services in order that they work together and there is agreement about where young people transition. There has been a lot of debate about 18 as the age of transition, particularly around the updated Sharing the Vision document. There is debate over whether we should have a young persons service, going from adolescence up to 25, or a child and adolescent service with an adult service to which people transition at 18. The problem is that while 18 is legally a very important age consent-wise, in the life of young people it is actually quite an arbitrary line. A young person could be in the middle of his or her leaving certificate year and could have been going to CAMHS for years and in some places he or she might go straight into adult services. That creates an issue. The other problem is when a young person presents in a mental crisis a month before his or her 18th birthday. Do such people go to CAMHS for a month and then transition to adult services, or does the adult service take them for that month?

This does not necessarily require legislation but it requires very clear protocols between the different services so that every young person, regardless of where he or she lives in the country, knows the way it should work. At the moment it is highly inconsistent and very much dependent on the consultants, which puts a lot of pressure on the consultants to negotiate in their own local areas. It is something that must be addressed in order that young adults know well in advance. They should not be worrying at 17 that they will not get the supports they need or will not be accepted into a service. It is more a matter of protocol and policy than addressing it in legislation but we feel it is very important to raise it as an issue when considering this Bill.

I agree with Mr. Barry. Anywhere there are gaps in services, vulnerable people tend to fall through those gaps and end up being harmed. Mr. Geiran mentioned banning the use of mechanical restraints on children. How often is this practice used? What are these mechanical restraints? Even reading those words, it sounds very draconian. How long are children being restrained for? What alternatives can be used instead?

Mr. Eoin Barry

I will take that question if that is okay. We are not going to comment on how often that is happening because we do not have that information. This would not be the appropriate forum for it. The least restrictive measure is generally what happens. We are trying to address a tiny minority. The vast majority of times, this measure would never be used. We are suggesting that other measures, which are the ones used in inpatient facilities, are used. It is more about removing it as an option. It is not necessarily that there should be some consequence for professionals who are acting in the best interests of patients. We are saying the legislation should basically prohibit its use among children. As I said, we would not comment on how much it is used but our understanding is that it is very rare anyway.

As Senator Conway said, even though something like this may only be used in very small instances and is not common, we have to make sure we are including everybody in this legislation. I thank the witnesses. I may come back in at the end.

Dr. Imelda Whyte

On that last question regarding the use of restraints, all types of restraint and seclusion are the last option and the last resort. The Mental Health Commission, which is the agency that monitors and licenses approved centres and inpatient units for both adults and children, has specific regulations and guidelines around the use of restraint, including mechanical restraint.

Restraint and seclusion are words that have a lot of highly negative connotations and they absolutely should only be used as a last resort but I would add a caveat. Imagine a situation where there is a young person - I am going to talk about a young person because I work with younger people - who is acutely psychotic, a danger to himself or herself and potentially a danger to the other people in the environment. We know the young person is psychotic and needs medication but will not take that medication willingly. In that situation, the option is to let a very difficult situation progress to a point where somebody gets hurt, possibly another young patient in the environment, someone who might only be 11 or 12, or to make a clinical judgment call that this is a psychotic presentation, that the young person can be treated with medication but is not currently able to co-operate to take it orally and requires an intramuscular injection. For that to happen safely, a restraint might be necessary. It is important not to make general statements that restraint is bad and seclusion is bad. They have their role and their place and there are specific guidelines and protocols in place by the regulating authority, which is the Mental Health Commission. It collects data on the use of restraint and it monitors its use closely. When the units are inspected, we have to explain its use to the commission.

Dr. Whyte would not be in agreement with those who are looking for the removal of mechanical restraints for children and would advocate their retention. Is that correct?

Dr. Imelda Whyte

What I would say is that these are extremely rare occurrences but there are occasions when things like restraint, although not necessarily mechanical restraint but any type of restraint that is physical, is necessary. It can be necessary for the person's safety and to enable him or her to be treated and to get better. I just wanted to put that out there.

The next speaker is Deputy Hourigan.

I want to touch on a number of areas but will start with a question that follows on from other sessions that we have had. It is not something that came up in the opening statements of either group today but I would like to get feedback from them on it. I will start with Mr. Barry and Mr. Geiran. The issue is multidisciplinary mental health teams, which we discussed with the Irish Medical Organisation, IMO, previously. Concerns have been raised that the shared governance model might result in a lack of clinical responsibility. I am particularly interested in this question from the perspective of social workers. Do the current structures work well now? Will they work well with Sláintecare? How could they be improved?

Mr. Vivian Geiran

My colleague will probably want to come in on this as well. As recent investigations in various areas have shown, the current models of governance and management do not always work. Sometimes they do not work for reasons other than the type of structure or model in place. Part of the issue is that the different professions, rightly in my opinion, need to have their own chains or lines of accountability but at the same time, within a multidisciplinary team there needs to be somebody who has clear responsibility in terms of leadership or governance in certain areas. My own professional background includes several decades in the criminal justice system and even there, where multidisciplinary teamwork approaches operate, it is essential that the different members of the team identify who is responsible for what area of work and that they are supported to do that. The overall point I am making is that within a team, there must be a clear co-ordinator, leader or manager and that the different disciplines within that team need their own respective lines of accountability and governance, which should add to the overall effective functioning of the team. Specifically, from the-----

Is that how it works now?

Mr. Vivian Geiran

I will ask Mr. Barry to respond to that specifically with regard to mental health services, which is one of the areas where issues have been identified.

Mr. Eoin Barry

While not commenting on specific cases, there are some parts of the country where there might not be appropriate discipline-specific line management structures in place. We would really strongly advocate that all of the professionals on a multidisciplinary team would have their own management structure within their discipline. We would also strongly advocate for high-quality supervision. One of the issues we have heard our colleagues from the College of Psychiatrists of Ireland talk about a lot is recruitment and retention. One of the best ways to keep staff once they start working is to support them. The best way to do that is through the provision of high-quality supervision. The same lesson was learned in Tusla where new staff got more supervision than other social workers. We would advocate for a similar approach, with increased supervision during the first year or so of practice-----

Sorry to interrupt. We are all trying to skirt around a particular instance. Having sat through some committee sessions relating to that matter, however, it seems that the professionals involved did have a line manager and also had somebody within the team who was meant to be at the top of the decision-making tree. What I am asking is what difference this proposed legislation would make. Would it improve the situation? The IMO seems to be pushing back a little against the idea of multidisciplinary teams. Does the IASW have a position on that or does it believe that the current structure, which seems to be what Mr. Barry is describing, is adequate?

Mr. Eoin Barry

What I am saying is that if the current structure was adequately resourced, with an emphasis on increased quality supervision, that would be a change. It would be a change if there was a very clear plan for new staff working in the area of mental health. That is the change I am talking about but it is not necessarily covered in the general scheme.

Thank you. I also want to put that question to the psychiatrists because I have been a little bit surprised by the conversation on this issue. Sharing the Vision states:

Clinical leadership,as described in AVFC 2006–16, was vested in the consultant psychiatrist role, in keeping with the requirements of legislation. Consideration should be given to amending legislation to facilitate the delivery of a shared governance model.

That seems to be what this Bill is moving towards and I would be interested in the view of the College of Psychiatrists of Ireland on that.

Dr. Imelda Whyte

We all work on multidisciplinary teams here and the four consultant psychiatrists here are the clinical leads for our teams. Part of our training is very much around leadership. We have a specific set of clinical skills and our various team members all have their own unique set of skills and unique backgrounds. It is when all that comes together that a multidisciplinary is working at its best and its richest because it has multiple perspectives on a particular situation and a particular patient with particular struggles. That is how we get the best result.

I think Deputy Hourigan is probably referencing the situation in south Kerry-----

I am trying not to because I think it is a bigger issue.

Dr. Imelda Whyte

Okay, sorry. What I would say in terms of accountability is that all of the different disciplines would generally report to their own line managers within their own discipline but the consultant is the clinical lead for the team. If there are clinical issues pertaining to particular patients, it is the consultant that is clinically responsible. If there is an issue or an adverse outcome, the consultant is responsible. There is a dual reporting relationship which absolutely has its issues but it is a long standing situation, I would say.

Just to be clear, the reason I am asking is that in previous sessions with other professional groups it has been raised as an area of concern that they would like amended in the Bill. The new definition of community mental health service teams is of concern to some groups and I was wondering if today's witnesses share those concerns. At the previous session, we talked about out-of-hours service provision, for example. Reference was made to admitting patients out of hours and having to have a second person considered in that decision-making process.

Do our guests share those concerns? If not, do they think the proposed Bill goes far enough in terms of that shared governance model?

Dr. Lorcan Martin

There are two issues to consider. The Deputy referred to matters such as out-of-hours services, admitting patients and so on. Consultant psychiatrists have a specific set of skills and very extensive training. They have a remit within their contracts as clinical team leaders. The difficulty will arise when another professional disagrees with the consultant psychiatrist about whether somebody needs to come in. How is that going to be resolved? If somebody needs to attend out of hours, we have an on-call system whereby we are available at any time to see somebody who is seriously ill. The same thing will have to be arranged from a logistical point of view.

More fundamentally and philosophically, we have a very specific set of skills and specific training. We are trained not only in mental health; we are also trained as doctors. Nobody presents purely with mental illness. They are going to present with other illnesses that may compound the mental illness. They are going to present on medications from their GPs that may interact with psychiatric medications or that may, in fact, be a part of the cause of the so-called mental illness presentation. That is why the consultant is uniquely placed to be clinical team leader.

I totally echo what our colleagues from the IASW are saying. It is entirely appropriate for individual professionals to have their own line manager and accountability. A well-functioning multidisciplinary team - and I feel blessed to work in one - is not simply a bunch of professionals working together. It is a bunch of professionals dovetailing together to provide the best possible outcome for a patient. There will be overlapping roles where people help each other out but also a clear delineation of individual roles and functions within that team. It also involves a common vision and moving forward to provide the best possible outcome for a patient. If governance is shared, that system begins to fracture. People need someone to whom they can turn for a focus. They need someone they know has the background and training for the overall maintenance of the welfare of the patient. That is where the consultant is uniquely placed.

No one is saying that other people should not have a voice; they absolutely should have. As Dr. Whyte said, everyone brings their own unique perspective and set of skills and that is what makes for a functional team. There are a number of issues around redefining the multidisciplinary team. Working as a multidisciplinary team as currently defined, if well resourced, well supported and working well, is a very good way of working. I have seen that to be the case. The whole issue of individual accountability within professions and supervision and training are important. I have, unfortunately, seen situations where people come in to jobs as, for example, managers of a particular allied health profession without a background in mental health. That causes real problems and it is very frustrating then for the people who work below such a manager because they turn to the manager for supervision and, in fact, the manager know nothing about it. It is not only important to have adequate supervision but adequate supervision by people who are in a position to supervise. I absolutely endorse what Mr. Barry and Mr. Geiran have said about having well-resourced teams with individual accountability for the professions and which pull together at a clinical level with a single vision under a clinical team leader, who I believe should be the consultant psychiatrist for the reasons I have outlined.

I am going to infer from what Dr. Martin has said that he broadly agrees with some of the concerns that were raised previously.

Dr. Lorcan Martin

Yes, I do.

I know a number of people have already touched on this area but I want to go back to the concerns that have been raised around the change in threshold when somebody is involuntarily detained. I am trying to understand the situation as a layperson. We are hearing from representatives of professional bodies who say one thing and community and representative groups who say the opposite. I am trying to read various pieces of research. I came across a paper from 2019 in Psychiatry Research, which I presume is an accepted and peer-reviewed journal, but it is hard to know when one is outside one's field.

The paper suggested that people receiving mental health inpatient treatment had either full capacity, which applied in 47.4% of cases, or partial capacity, which applied in 50.7% of cases. The paper was looking at the difference between clinical and legal definitions. In the current system, are most involuntarily detained persons deemed to lack capacity within the definitions we currently have? Are the majority of people who are involuntarily detained considered to lack capacity?

Dr. Lorcan Martin

Capacity is time specific. That is important. Depending on when that study was done, a person may have been involuntarily detained but thereafter developed capacity over a period of time. At the point of admission, the vast majority of people who are involuntarily detained lack capacity because they lack insight. The vast majority of patients who are admitted under the current legislation are not the ones who are at serious and immediate risk of harm to themselves or others. The bulk are those who require treatment under Part 3B of the current Act. Those people require treatment that is otherwise unavailable in the community and admitting them under the Act would benefit them to a material extent. The bulk of patients coming in would lack insight and capacity but would not necessarily be at immediate serious risk. As they are treated, their capacity improves. Best practice would be that when somebody reaches that threshold, the whole issue of whether they should be involuntarily detained anymore comes into play. That is why we have the option of regrading somebody from an involuntary patient to a voluntary patient. My understanding is that psychiatrists do that. I know psychiatrists who at the first available opportunity it is reasonable and safe to do so would convert someone from involuntary to voluntary. As patients get treatment, their capacity, hopefully, improves. That does not happen in every case but in the vast majority of cases, as people improve, their capacity returns.

In the vast majority of cases where people are involuntarily detained, they are reviewed in a timely manner and recategorised as voluntarily detained.

Dr. Lorcan Martin

Yes. Under the Act, people must be seen and examined by a consultant psychiatrist within 24 hours. Some people are sent in on involuntary forms and the consultant psychiatrist may decide they do not meet the criteria for admission. Such people are free to stay as a voluntary patient or can be discharged home. That is an important point. Not everyone who gets sent in through involuntary forms is detained. That is the first bit.

Assuming the admission order is completed, the person remains and the safeguards are put in place. That person would be reviewed frequently by a consultant psychiatrist.

What does "frequently" mean? I am a layperson. Does that mean every week?

Dr. Lorcan Martin

It would be more frequent than that. It would be a minimum of two to three times a week. By definition, these are a psychiatrist's most seriously ill patients and the ones who will be monitored most closely. A consultant psychiatrist would see those patients regularly and reassess their capacities, specifically their capacity to remain in hospital as a voluntary patient, because many people when treated will be able to make a decision. They may think they are not very well at the moment and should stay in hospital. In other cases, the consultant psychiatrist may decide, in consultation with a patient and his or her family, that while the patient is not well at the moment, he or she could be managed in the community with supports. There are other people who do not regain that level of capacity early in the process and may need to remain in involuntary detention for a longer period and go through a tribunal and so on.

Capacity is fluid, as is the decision to keep somebody in hospital as an involuntary patient. People sometimes have the notion that if a patient is signed in with an initial admission order for three weeks, that person will automatically be in hospital for three weeks. That is not the case. The bulk of patients I have received as involuntary patients go home before they ever reach a tribunal or they become voluntary patients and choose to stay. It is an important distinction. Not everyone who comes in on involuntary forms is kept. Not everyone who comes in on involuntary forms remains involuntarily for the duration of the admission order.

That is useful information. Dr. Martin helpfully outlined in his survey the number of posts we currently have, those that are vacant and the fact that we will probably need more than 800 posts by 2028. Half of those currently in posts are over the age of 50. I am interested in the survey in terms of the perception that this Bill might increase burnout. At that level of staffing, the issues of burnout and overwork are more complex than can be dealt with simply with a Bill or the definitions within a Bill.

It might be more relevant to the issue of understaffing. This law reform has long been needed. We are talking about more than a decade. Is it fair to say that creating law on the basis of current understaffing or the inability of a particular Government to fix levels of staffing is not a good principle for legislating?

Dr. Lorcan Martin

Absolutely. While it will have an impact on burnout, recruitment and retention, the primary concerns we have around the Bill relate to patients getting the treatment that they require. I know I am harping on it a little bit, but they have to be the focus of everything. As Deputy Hourigan rightly points out, burnout is an incredibly complex thing. I do not know anybody in the health service, who is doing their job properly, who does not experience some amount of burnout. It is to do with demand exceeding supply, under-resourcing and people not being available. When someone goes on maternity leave, they are not replaced. When someone retires, it takes three or four years before the post is permanently filled again. The list goes on as to why burnout might happen. However, the inability to treat one's patients is going to have a significant impact on people. If patients are not able to get the treatment they need it will cause problems in society at large and cause stress for families. That will result in more people sitting and waiting in emergency departments and more people homeless or in prisons. Then there is going to be the added level of frustration on the part of the doctors who want to treat these patients and find they are unable to do so. In terms of burnout, the proposed Bill is only one component, but it is a very important one. What I do not want is that people see our objections to the Bill as being about burnout, recruitment or retention. They are certainly issues, but the biggest focus in all of this has to be the patient.

I know I am really pushing my luck, Chair, but I have one super quick question for Mr. Barry and Mr. Geiran. One of the points raised in the opening statement was that the Mental Health Commission, MHC, would inspect every community mental health service at least once every five years. This has been raised at other sessions on pre-legislative scrutiny as well. It would be hard to argue with that. It was also stated that there should be clarity on mental health services for all age groups and that the remit of the MHC would be extended in a number of areas. The IASW is not the only group to have suggested that. It is very welcome, but what I notice is that none of the groups so far has come up with any constraints around how those inspections and reports can be used. For example, the witnesses rightly say that the facilities should have a space for families so that they can meet in privacy, which is a very good point. I would not argue with that for a second but if we put that requirement in an inspection and a facility does not have it, considering that we are all living in the real world and we have a dearth of health facilities of this nature, have the witnesses considered that the Mental Health Commission needs to put some constraints on how the reports can be used so that they do not lead to closures or the removal of beds based on inspections?

Mr. Eoin Barry

Specifically on a private space for families to meet in inpatient facilities, we would consider that as an important issue, partly because the Constitution expressly puts a lot of importance on families, but it is also the case that when families are in that kind of distress it is very important for them to have a private space to meet. We did not envisage that resulting in the need for a bed to be closed in a facility, for example. It would be more the case that at times a private space could be made available. Generally speaking, we would not think it is a significant demand that would result in units or anything else being closed, but to be fair, we had not considered the possibility of closures, as Deputy Hourigan correctly points out.

When facilities are inspected and a report is generated, sometimes the report can be used in unintended ways. I just put that out there for the witnesses to take on board.

Mr. Eoin Barry

We take the point.

Mr. Vivian Geiran

This is partly coming from my background in the criminal justice system, but it is critically important to set standards in the first place because if we do not set the standards we will never get to where we need to be. In the criminal justice system, as in health services, there are various systems of inspection.

Even within the prison context, the European Committee for the Prevention of Torture visits Ireland, as well as every other country, every so often and points out - as does the Inspector of Prisons here - faults and failings and so on.

Is that with a view to improving facilities?

Mr. Vivian Geiran

Yes, it is. If we do not have the standards to begin with, however, we will not go anywhere. Equally, having the standards is no use unless there is monitoring and inspection. I agree with the point about how the inspections and reports are used, but, ultimately, they are or should be about making improvements over time.

I thank Mr. Geiran.

I thank the witnesses for attending. It is always very interesting to hear what is said. The question I always ask going through pre-legislative scrutiny is about whether the witnesses think it the proposed legislation is good. We have got some kind of answer in that regard from the witnesses in that they have a lot of concerns about the general scheme. If they want to respond, they are more than welcome. They have raised some concerns and referred to what could be tweaked and improved. I feel a bit silly asking this, given what has been said, but do the witnesses feel we are heading in the right direction and that this proposed legislation underpins human rights that can help patients? Every week, we emphasise that this is for a very small number of people but that does not make it any less important. I would welcome the witnesses' thoughts in that regard.

Mr. Eoin Barry

As a professional group representing social workers, the area of human rights is very important to us. There is a campaign going on at the moment because CORU removed human rights from our regulations, which is a key part of our profession. Broadly speaking, we welcome most of the provisions in the general scheme from a human rights perspective. We would also agree with some of the points our colleagues have made, and we believe it needs adjustments, but broadly speaking we believe this improves human rights and it also improves advocacy and the voice of people that are attending services both inpatient and community facilities. Broadly speaking, we welcome the proposed Bill.

Mr. Vivian Geiran

I fully agree with what Mr. Barry has said, but I will just add to that. In particular, in the context of human rights, which both ourselves and our colleagues have been emphasising, I would refer to something Dr. Martin said earlier about services being a safety net for when everything else fails. That is a very important point for a number of reasons. In Ireland we traditionally had various bodies or services acting as a safety net. We had decades when we had far too many people in psychiatric hospitals and other institutions. When that pendulum swung, as Dr. Martin said, we ended up with the number of people in prison going up, because they ended up as the safety net for when other measures were failing. In this proposed legislation, we have a once-in-a-liftetime chance to make significant strides in the specific area of mental health services. It is not just about legislation.

Going back to Deputy Hourigan's question, the legislative change must be based on principles, values and ethics. They are very important, but even all of those good ingredients will not be enough, we also need to have implementation following on from the legislation. As has been said various times, we must also consider the issues that are being addressed by the legislation and otherwise in a systemic way because, as we have said repeatedly today, it is not just about adult services, child and adolescent services, medical practitioners or social work practitioners. It is not just about this piece of legislation. We need to take into account the UNCRPD and the assisted decision-making legislation. There are significant areas of overlap which make dealing with the issues we are talking about a lot more challenging and complex, but we have to take that on. This is a really positive move to develop the mental health services we have and to put in place modern, evidence-based, trauma-informed and human-rights-led legislation we can build on. As I said earlier and as our colleagues stated, with the best will in the world - and the best legislation - unless it is adequately resourced and structured, we will not derive the benefit.

Everybody in the room ultimately wants this legislation to benefit the people who use the service, their families and wider communities.

Dr. Norella Broderick

I would echo what everybody has said about the human rights focus in the legislation and I think everybody here is in favour of it and would want to protect human rights. What we are advocating for is how we find the optimum balance between various different and almost competing rights at times, for example, the right to liberty and the right to autonomy sometimes versus the right to access care when needed. One issue in the legislation that has been raised as an area of concern among learning disability psychiatrists concerns the provisions on research. For example, the proposed Bill prohibits research with respect to any patient who is unable to consent, which I can understand in terms of the desire to protect people from exploitation in research. However, if we consider, for example, a person with a severe learning disability, who will never realistically have the capacity to consent, there is no way for research of any sort to be gathered with respect to such persons' needs, what they need to access healthcare and to know what treatments they need. The way this has been approached in the UK is that where it is in the person's interest, there is provision for that person to be allowed to take part in research. With the new capacity Act coming in where capacity can be supported, that might be a more helpful way of approaching the research issue. That is just one example of where we do not feel the balance has been correctly struck by this proposed legislation and we would argue for some tweaking of it if that makes sense.

Dr. Atiqa Rafiq

I thank the members for their unloaded questions and apologise, on behalf of the college, for sounding like what might come across time and again as being negative or more critical of the legislation but we are advocating for our patients, especially the most seriously ill ones. From the point of the capacity in the capacity Bill, some of the concerns of psychiatrists dealing with later life psychiatry are that, in its current state, the proposed legislation is very deeply contingent upon a fully functional capacity Bill, implemented with all of its supports in place, and it is not trying to achieve something in its own right, parallel to that Bill. If the proposed legislation were implemented as such, if there was a patient with severe dementia, who was admitted at a time when that person needed psychiatric nursing, a safer, calmer environment, for a short time where that intensive treatment and care is needed, after that it can potentially turn into a safeguarding concern because following a few weeks, the patient may no longer require that level of care and treatment but the patient still lacks capacity. Section 14(a) of the proposed legislation basically suggests that if two consultant psychiatrists agree a patient lacks capacity, the patient can walk out and one just lets the patient go. We have determined the patient needs treatment and care, that is the prerequisite of that section at this point in time, and the patient lacks capacity. It is important to remember how essential it is for this law to address those gaps and meet in a space where those protections are in place for the patients for whom we are caring.

To return to the threshold for admission, one of the concerns we, as psychiatrists dealing with later life psychiatry, have is that the proposed legislation does not speak for or provide for many patients who require treatment under the Mental Health Act. For example, it is the nature sometimes of severe mental illness that it does not involve harm to someone else or to the person and it does not involve a serious harm to health that is being proposed in section 8 in the proposed legislation, but there are all kinds of serious harm, as Dr. Martin, alluded in his opening statement.

For example, a patient with mania, who has been under our care, was ready to buy a piece of land, having already lost a considerable amount of money due to a severe lack of insight because of the nature of that illness, which is an episode of an illness. He had left the house a few times, had driven unsafely and demanded he would only return home if so many thousands of euro were handed over to him to make certain purchases. There are all kinds of harms one must consider. Under the proposed legislation, that patient who was admitted and treated and who is now functioning extremely well would not have been able to do so. The law must have the needs of the patient at its heart and soul. I agree with Deputy Hourigan that it should not be driven by resourcing but should be driven by a much better balance between the will and preference of the patient and what it is the patient's best interest up to the level of good common sense, protecting and safeguarding the rights of the patient based on evidence and good clinical practice. The law needs to speak for the patient first and foremost. Those are the two main concerns.

As has been said time and again and we cannot say it often enough, we need to address the exclusion of families and carers. Psychiatrists dealing with later life psychiatry work very closely with family members in many cases and the majority of patients would not have it any other way. They would want their families involved. The families have been excluded to a point where there is no provision in the proposed legislation that they can even request an authorised officer assessment or initiate some kind of mechanism where such an assessment can take place. The legislation needs to provide for that.

Dr. Imelda Whyte

Regarding the increased threshold in the proposed legislation, I work in CAMHS and I am mindful of young people with eating disorders. Within my service we have experienced a 300% increase in the presentation of young people with eating disorders during the past year. That is undoubtedly linked to the pandemic. Those young people are the cohort; people with a chronic illness. They may not be at imminent risk but they are at risk of suffering chronic malnutrition and without intervention and treatment in an inpatient facility, their prognosis would be significantly worse. With the higher threshold, those types of cases will potentially miss out on getting the care and treatment they need.

Is it in order if I come in?

Does Dr. Whyte believe with what is being proposed, there is a potential that will happen?

Dr. Imelda Whyte

With the threshold being high, absolutely. That is our concern. As the proposed Bill will no longer pertain to people who need that treatment and who would otherwise not get it, therefore, they will not get that treatment.

Staying on this topic, Mental Health Reform and a couple of organisations very much advocate for that culture shift away from the concept of best interest to guiding principles. We would have heard a good deal about that in previous sessions. It was interesting to hear the language used, the view of the sector and the area in which Dr. Whyte works and it is useful for us to hear the other side on that. It is not that I am struggling with this but I am interested in how and where we can find that balance. I very much a human rights-focused person. I was interested when Dr. Whyte said there can be patients where she knows down the line that this could happen.

If they still have capacity to consent how is that line figured out? They still have a legal capacity to consent even though we know the road they are going down. I am trying to get it clear in my mind how we find that line. Dr. Martin knows it because of his expertise and training. He has seen it and he knows what will happen but how do we do that from a human rights perspective? Dr. Martin is saying he would not wait for any other patient to get to such an ill stage. In many other areas there are things doctors know will happen but until a patient consents to it, you cannot step in, outside of mental health situations. I was struck when Dr. Martin said that. How do we find that line? Where is the human rights line? It would be ideal if Dr. Martin could give a quick PhD on that.

Dr. Lorcan Martin

We are in favour of patient autonomy and of patients taking an active role in the management of their mental illnesses. That is the most important thing. Often you will see someone becoming unwell and they will still have capacity. They will have the capacity to say they do not want a particular treatment or to go to hospital and if they have capacity, you have to respect that. The difficulty we have with the legislation in its current format is that there is a subgroup that no longer has capacity but that is also not a risk to themselves or somebody else. They no longer have the level of insight required to realise how ill they are and it is that group which we are particularly concerned about. The immediate and serious risk of harm to self and somebody else is easy to identify. It is generally telegraphed, verbalised or seen and observed by family, carers or whoever. There will be examples of people who are becoming increasingly more depressed or who perhaps are displaying the warning signs of a relapse and schizophrenia. If those people have capacity, you have to go along with them. You can advise, support and psycho-educate them but if they still have capacity, they have autonomy.

There is a subgroup in between that no longer has that level of capacity but that does not represent a serious risk of harm to self or others. They are the ones who do not get the treatment to which they are entitled but to which they do not have the capacity to refuse. They would tend to make up the bulk of our involuntary missions and they are an at-risk group because, as I said earlier, when you do a risk assessment, it is a risk assessment for now. We do not know what will happen tonight or tomorrow so we cannot sit tight and watch somebody progress because by the time they lose capacity or insight, they are already seriously ill. You are waiting for someone to get more seriously ill in that scenario. You might not be around to deal with it when that immediate and serious risk kicks in. Families and carers may be so used to the individual's behaviours or idiosyncrasies that they do not notice the subtle changes that indicate a serious risk, and that is where the tragedy happens. The other issue is that even if a risk never occurs, there is this patient going around who is seriously ill and who might be spending recklessly, as Dr. Rafiq mentioned. They might also involve themselves in reckless sexual behaviour, which puts them at all sorts of risk. I have seen patients standing naked in the street or in the local shopping centre when they have become unwell and the Senator can imagine the sheer level of social embarrassment for that person when he or she becomes well again. There have been situations where people have behaved like that and then attempted suicide afterwards when they realised what they did.

There is a significant cohort, however small, of people who require that level of intervention, namely, involuntary admission, who do not represent the traditional, immediate and serious risk of harm to self or others. The Senator is right that when someone has capacity, they must be negotiated with. You advise and educate them, you give them your opinion and you involve advocates, carers or whoever else they trust, and you encourage them to make the best possible decision. You cannot make sure they make the best possible decision because even if people make unwise decisions, if they have capacity it is their decision.

I am trying to conceptualise examples. Dr. Martin mentioned scenarios like being naked on the street. Without breaking anyone's confidentiality, what kind of actions would not fall under a serious risk to someone or others but that Dr. Martin believe would be reasonable enough to involuntarily detain someone?

Dr. Lorcan Martin

That lady I spoke of is a real case. There was another lady under my care who was always very particular about her appearance and social standing but when she became unwell she would become unkempt and would wander around looking like a homeless person. She would go into shops and steal, which would be completely antithetical for her, and she would get herself in terrible trouble locally. There is a level of social embarrassment and difficulty in that. Then there are also people who do not develop the more dramatic presentations but who maybe just do not look after themselves, sit at home, do not eat properly, do not exercise, become socially withdrawn, do not go out, do not take care of their personal hygiene and develop ulcers and do not get seen to. These are all real cases; I have not manufactured them for an example. This is the sort of stuff you are looking at. For example, recently I saw someone who did not come to the attention of the services, unfortunately. When we saw her she was not an immediate and serious risk of harm to herself but she had dreadful leg ulcers and was ferociously malnourished because she had not been minding herself and that was secondary to her depression. You can have these situations where people wind up suffering and in trouble because of mental illness, even though you cannot identify an immediate and serious risk of harm to self or somebody else. These are the sort of examples I would be thinking of.

Dr. Atiqa Rafiq

We are talking about what serious harm is the proposed threshold for same in the legislation. It is not always harmful. Much of the time it is what we would call mood-congruent delusions. This is when somebody becomes extremely depressed and psychosis comes when the sense of reality is changed. A patient we treated last year went to the accident and emergency department first and his firm belief was that any moment now he would be kidnapped, tortured and killed. These things are more common than we think. He would sit at a place and not move from there. He was of the belief that imminent harm was going to come to himself. More and more people who he previously trusted were getting embroiled into the delusional belief so he had been eating and then he stopped eating from the hands of certain people. He deteriorated and this is an example of depression in older adults. The Senator might have heard of the The Irish Longitudinal Study on Ageing, TILDA, and depression is a common condition. What is specific about older adults, which Dr. Martin touched on, although I do not know about the age of this particular patient who he treated, is that cognitive deficits, memory problems, application of attention over time and self-care decline pretty quickly, even before people meet the threshold for the Mental Health Act 2001. I would argue that even now these patients will sometimes lack insight and capacity but will come to the services rather late. Due to the nature of their illness, delusional beliefs, psychosis, symptoms and the severity of lack of insight, these people will not meet the threshold for the proposed section 8.

That is interesting because I am sure there are people watching and listening who would probably baulk at conceptualising social embarrassment as being a reason to involuntarily detain someone. That is something we will have to think about because I even have people messaging me about it. That must be a difficult concept to understand for people outside the social work sector.

That is a very difficult concept to understand, and then to understand how we as legislators would approach it. I believe the people are certainly struggling with that, especially around involuntary retention.

Mr. Vivian Geiran

I just want to make a couple of points. In what I am going to say, I do not want to minimise the suffering of people, as has been described, or the acute situations that they end up in or can end up in, nor do I want to negate or deny the need for biomedical or pharmacological treatment in certain cases. I am, however, reminded of the phrase that "hard cases make bad laws". I would be wary of the potential for going down a route where we would open a doorway into a certain type of treatment on the basis that certain bad acute things can happen in certain situations.

As I said earlier, in the legislation and the principles involved we should be looking for the most inclusive and the least restrictive types of treatment. This does not mean that people do not need medication at particular times, but we are tending to focus to some extent on the extreme scenarios that might, arguably, include involuntary admission or whatever. If that is the focus for the legislation and what we are about, I do not believe the legislation should be about just ensuring access to a kind of inner circle - and I do not want to sound disparaging - of extreme treatment on the basis of certain extreme types of situations that might arise.

Going back to my first point, I do not want to negate the suffering or the tragic situations that people can end up in at certain points, but I do not believe that is where we should be starting from with regard to the legislation.

Dr. Imelda Whyte

The Senator talked about reasons and who would lose out in this increased threshold. I work with young people and people who are reaching the age of majority. When we consider the prognostic implications for the young person, there is a whole lot of evidence to support that the duration of untreated illness in presentations such as psychosis has very direct implications on how one manages the prognosis and recovery. The greater the duration of untreated illness, the greater the risks. From what I see day to day, this is a cohort who would be at risk of not being included in the context of requiring treatment. I know there is talk of them maybe taking their medication at home, but for the small group of people we are talking about who have these difficulties this is not an option because they are too unwell and they do not have insight. The Mental Health Act is very important for this small group. Mr. Geiran has said that hard cases make poor law, but we do have a responsibility for the most vulnerable and the most severely unwell. In this instance we are not talking about the vast majority of people who attend community services or even those who attend inpatient services. We are talking about a very small number of people who require this and for whom, without that care and treatment, would not get it.

Especially as it pertains to children, the way that it is done is a court process and a legal process. It is not about a tribunal. One applies to a judge in a District Court. It is a very comprehensive way of dealing with it. At times, if one is going into court it might be for a young person with an eating disorder and we might be going back very regularly because the young person with the eating disorder might be in hospital for a period of nine months. It is extremely important because it is due process and everybody's views get heard. We are ensuring that somebody independent is weighing up the evidence around what the person needs, what the person wants, what their parents want, and what the guardian ad litem is recommending.

I repeat the concern around the threshold, that there would be people who do not get the care and treatment they need.

Dr. Lorcan Martin

We need to remember that the vast majority of people who attend mental health services attend as outpatients. We could have hundreds of outpatients and there may be four, five or six inpatients at a given time, and maybe even fewer. Many of the patients will not be on medication. We need to get away from the notion that the doctor is all about prescribing. Management of mental health in the modern context is a biopsychosocial model. It is delivered by a trained multidisciplinary team and, as we discussed earlier, with everybody bringing their own particular skill set and training. However, to come back to the point about hard cases making bad law and using extreme examples, these are the examples we work with. These are the people who are going to be affected by this legislation. The 400 people that I have in my outpatients will, by and large, not be affected by an amended Mental Health Act other than maintaining standards of mental health facilities. They will never need to be involuntarily admitted, and most of them will never even need to be admitted, full stop. This legislation pertains to the illest of our patient load and, of the people who attend us, to the ones most in need of care.

The other point is that people will, hopefully, get better. If they come in as an involuntary patient, we treat their illness, provide them with the requisite medication and all the other appropriate multidisciplinary supports. The care plan continues into the community and, all going well, they will return to live a life that is functional and meaningful, and is back with their families, loved ones or carers. The idea of somebody going into hospital for months on end is really not something that generally happens. On a very rare occasion, one will find somebody with such an intractable illness that they will require long-term hospitalisation. That is absolutely the exception. It is important to remember that this legislation relates to the illest and the most vulnerable of individuals. It should confer upon them every necessary protection but also every necessary right to have that illness treated, treated properly by trained professionals, and in a multidisciplinary fashion that will enable them to live the best possible life they can. What we want for our patients is that through the ministrations of our treatment - in the broader context, not just doctors - and they would then go on and have an optimal quality of life. The legislation is pertaining to those very vulnerable patients and this is something we cannot lose sight of.

Dr. Norella Broderick

I will come back briefly on some of the examples that my colleagues had brought up and which the committee were concerned about. In admitting people who are very unwell who are presenting, for example, with extreme social embarrassment, or the person who is sitting at home very depressed and developing an ulcer, they are not being admitted for the ulcer or for the social embarrassment, it is that those are signs of the level of illness they have reached. They are that unwell. Those are the kinds of signs we are using to judge the level of their illness. This is why we give those examples. It explains how we can see they have become so unwell. I hope this helps and makes sense.

On the initial question, if I am not mistaken I believe that the Senator is looking for the correct level at which to pitch the admission standard. We are advocating that the current threshold for admission be retained. As Dr. Martin said earlier, the vast majority of patients who are admitted under the threshold outlined in the current Act, will lack capacity. At the same time, it still allows for admission for such cases as we have discussed, for those who do not reach the new threshold of immediate harm but who may be at extreme risk of deteriorating, without that harm part.

Mr. Eoin Barry

This legislation is very much focused on the smallest cohorts, which are in the most at-risk group. One of the ways for legislators to look at this when they are considering this legislation in the broader reform of mental health services, is not just as the house being on fire and how does one respond in an emergency. We must also look at how to prevent it happening in the first place. This means ensuring that the correct supports and the best interventions happen earlier in the process, ensuring the person is attending the services, and making sure that they are into the services as quickly as possible.

For example, if there is an emerging disorder, there should not be artificial barriers put in place, like the person having to reach a certain weight threshold. By the time the person reaches that threshold, he or she has restricted his or her diet and done a whole load of things to make himself or herself reduce the weight down to the thresholds. We would say it is about the earlier the intervention happens, so I am concerned this legislation is also considering the preventive piece and dealing with the systemic issues that cause the mental health disorder in the first place. That is a point I wanted to make.

Would it be alright if I asked two more questions?

I want to circle back around. We talked briefly about 18 years and this kind of arbitrary age. We are obviously bound by certain laws and requirements but which sort of system would our guests advocate for? Would it be a mid-range one, if you will, with people aged from 16 to 25 years, that is, young adults or is there an international standard of what is the best approach? In politics for example, a person is considered sprightly and young up to the age of 40 years and one can get funding to do all sorts of things - so I have loads of time left. Is there an international example of what the best framing is? As was said, someone doing his or her leaving certificate is suddenly told: "Now you are an adult; go forth", and goes into a completely different system. It is not serving anyone. We have heard many people say if someone presents aged 16 years he or she is not going to get seen before he or she is aged 18 and therefore it is just a waste of everyone's time. I do not know that the age framing is working. Maybe that is because of our lack of resourcing. Would our guests be able to tease that out a bit for us?

Mr. Eoin Barry

I have a couple of points to make on that. One is that the age changed recently enough, in the greater scheme of things, for CAMHS particularly, from 16 years of age to 18 years. It was raised. I do not want to speak for Dr. Whyte but I think most people working in the area would say the resources probably did not reflect the change in work, because as young people get older the complexity of their problems increases. The most complex cases CAMHS deals with would in the main be the patients aged between 16 and 18 years. Not always, but the majority would be.

Internationally there are a few different models. In Australia there is the young persons mental health service which covers early adolescence up to those in their early twenties. That is probably the best model but it is really the CPI that should answer this question because of the different specialty registry. There is a specialty for children and adolescents and one for adults. That is the difference. As social workers, we work generically so the age does not make as much of a difference but for young people attending services the difference has a very real impact for where they are attending. As I said, the age of 18 years legally has major change. The age of 16 years has a change but it is where they attend services. That arbitrary line, depending on how strictly it is enforced, and it is enforced in different places in different ways, can have a big impact on them. It is an area we need to address. I defer to my colleagues regarding how the specialties impact on it as well.

Dr. Imelda Whyte

It is not a straightforward answer. Transitions are always difficult. They are difficult, to various degrees, for everybody. As my colleague has indicated, Iocally I know from my own experience some services will say a patient is going to be doing his or her leaving certificate in June so we are going to keep her or her on and then once he or she transitions, so there is flexibility. I suppose it is our own responsibility to engage with the adult services and CAMHS and figure out what is in the best interest, believe it or not, of the patient, what will work for him or her and what will make it easier.

Introducing another mid-way service for those aged between 16 and 25 years has merit but also brings its own issues. Are you going to have two lots of transitions, that is, are you going to transition aged 18 years and then again aged 25 years? It will depend on your presentation and the cohort. There are implications for how health services are set up at the moment and how that gets broken down. What impact does that have on CAMHS? What age does it start at? What age does it end at, and all of that. Again, as somebody has already referenced, CAMHS previously worked up to 16 years and in more recent years has been extended up to 18 years. From an inpatient unit perspective that works quite well. CAMHS inpatient units have people aged up to 18 years. One cannot have an adult in a child unit. Are inpatient services going to reflect that new proposed form? As I said, there is no simple answer to it.

As part of the Sharing the Vision working group there are many different people looking at that and many different views but whatever will be patient-centred is what you would hope would come out. There is the training aspect. Are the people who work in those services going to be trained in child and in adult services? Where do those jobs exist? What do they look like? I am raising more issues than I am giving answers but what I am saying is-----

I am asking the questions here.

Dr. Imelda Whyte

What I am trying to say is it is complex.

Dr. Imelda Whyte

It is not straightforward. We have looked to international practice and what has and has not worked. Again in Australia that was a particular area and we are a small country and it is something you would hope we would be able to apply nationally. There is much thinking to be done on it.

Dr. Lorcan Martin

Following on from what Dr. Whyte said, one of the concerns I have is if something is not working you try something new and sometimes they say: "If it ain't broken don't fix it". However, sometimes it is worth fixing. Many of the systems and services we have in place at the moment, if they are done properly, actually work really well. The current model of community mental health teams works really well if adequately resourced with the right people. One of the big difficulties with the transition from CAMHS to adult is very often it is quite abrupt. As the Senator mentioned it is an unusual time and could be around the leaving certificate. However, many CAMHS would be flexible enough, as Dr. Whyte said, to get over that hump but you can ease that transition and we have done it ourselves. Maybe six months beforehand, let the person know that at age 18 years he or she is going to be moving on to the adult services. For six months beforehand there is a joint working between the two teams so the person gets to know the personnel on the new team, the new systems, that the clinic might be in a different building and how to make the appointment - all that stuff that comes as a complete culture shock when you go from being completely minded as a child to suddenly being on your own feet as an adult.

Also, things change because when you are a child, as it stands, the parents have a huge say. When you become an adult suddenly aged 18 years, the parents can be excluded if the person has the capacity to exclude them. Therefore, there are many changes in how services are delivered but if you overlap them properly there is no reason that should not work, and I have seen it work but it takes a will to make it work. As I said, to change something simply because it is not working without looking at why it is not working can be a mistake. Much of what we have in theory is very useful and very helpful. It is a question of getting it adequately resourced and then getting the will to make it work with the people who are involved.

That is an interesting point. We hear all the time that it is a mess, a disaster and we must rebuild the whole thing from the ground up. It is interesting to hear Dr. Martin say there are good systems in place that, if they were resourced properly, can and should be able to work. Certainly from some of the outside stuff, we would swear there was no hope for some mental health services. There are very impassioned speakers on this area.

Dr. Lorcan Martin

For the person trying to use the service, if a service is not working well it can seem impenetrable.

Dr. Lorcan Martin

That is probably where those impassioned pleas are coming from. They see services not working and they are getting nowhere. You can totally understand the frustration. Coming at it from the other side we can say that if we had x, y and z in place we could actually deliver a, b and c. It is really important that it is about properly resourcing services but also ensuring posts are filled by adequately-trained personnel. Dropping somebody in from an agency does not work. Putting somebody in charge of a system who has no background in the area does not work, so you need to ensure people are adequately trained for the jobs they are doing. When it comes to doctors, it is really important they are either on the specialist register or ideally somebody who is currently in training. Many posts are filled either by non-consultant doctors not in training or people taking consultant posts who are not on the specialist register. It is important to delineate the difference between a specialist and a consultant because one is a medical qualification and the other is a contractual situation.

That is why it is important for safety and governance to have adequately trained people in the posts.

Mr. Eoin Barry

I agree. In certain areas, there is a model that works well with transitions. There is a meeting between CAMHS and the adult team. Young people attend the meeting. The clinician they have worked with all along meets the person they will go to next. That works well, without having a radical change to the other type of service, which also has merit. In the short term, it is more achievable and would bring consistency to the transition, which would be a significant change. The postcode lottery has a major impact. The individuals involved take on a lot. To improve it, there should be a protocol and approach, with this approach being the best. Regardless of where people live in the country, when they reach a certain age, they should receive services that they need. The vast majority of people do not transition to adult services at the age of 18, but this is how it will work for those who do. When the model works, it works well.

That question was a little outside the witnesses' remit. My last question is about restraints and seclusion, which has been mentioned. A number of mental health organisations advocate for a zero-restraint, zero-seclusion action plan. A report entitled, The Use of Restrictive Practices in Approved Centres, showed that restrictive practices were used in 73% of inpatient mental health services in 2020, including seclusion, mechanical restraint or physical restraint. Maybe the witnesses will contest that figure. The number, 73%, seems high. Will the witnesses offer any comment on that? Do they agree with the idea of progressing to a zero-restraint, zero-seclusion plan? We spoke about youth services, but I am interested in the witnesses' thoughts on that more broadly.

Dr. Lorcan Martin

Some 73% of centres may have used it, but using restrictive practices on one person, once, puts a centre on that list. There are thousands of admissions every year and restrictive practices are not used that frequently. As my colleagues pointed out earlier, it is an absolute last resort. It is strictly controlled by the codes of practice from the Mental Health Commission, to which we all adhere. We would be found non-compliant if there was as much as one date out of place on the seclusion register. The standards of governance have improved substantially over the last years. There are now specific seclusion-related care plans, so it is not simply a question of it being written in a chart or register book.

Using seclusion as an example, patients would be in seclusion for the shortest period possible. They get regular reviews. If they go in for an hour, a nurse will watch them full-time for an hour and for 15 minutes thereafter. They have regular medical reviews to make sure that their dignity is maintained in accordance with the codes of practice. It is often a more humane way of dealing with people who are incredibly distressed and agitated and are putting themselves at risk. Having a quiet time-out area can be extremely useful. Seclusion may be more appropriate than restraint for some people. One example is people who may have been sexually abused, for whom the notion of physical restraint or being held down could be extremely triggering or traumatic. Using a time-out area, which is locked for their own safety and the safety of others, may be the way to go.

The notion of zero restraint and zero seclusion is unrealistic when managing seriously ill patients. We should aim for the absolute minimum use of seclusion and restraint and every other avenue should be tried before it is used. All the care plans that we use talk about de-escalation techniques, use of oral medication and so on before one gets to the last resort. Zero restraint and zero seclusion is not practical or clinically humane. However, we should aim for minimal use of them and preferably try everything else.

Mr. Eoin Barry

The point we made in our opening statement was about a particular type of restraint and considering the impact of the trauma of certain restraints on children. When dealing with behavioural difficulties, there is a toolkit of different techniques and ways to address the challenging behaviour. We would like to see the balance tip towards de-escalation, which already exists, with the least intervention possible being the best approach. That often depends on the atmosphere in a unit at the time. The total elimination of seclusion and restraint is a bit beyond what we suggested in our statement. We are saying that certain tools are available and we would like to see one removed when dealing with children.

Dr. Norella Broderick

The current standards require that seclusion or restraint only be initiated when there is an immediate risk of serious harm to the patient or to someone else on the ward. The people who are admitted under the Act or who are in secure units and might potentially be restrained are the most unwell people. One thing that comes to mind when talking about this is improving the use of de-escalation and ward atmospheres. That is important for us to consider, as is having adequate facilities and nursing staff on the wards to make sure patients can be managed as effectively as possible with de-escalation to reduce the need for restraint or seclusion. We need to consider whether we have adequate nursing staff. Maybe the nursing unions will be able to speak more about that. We do not know of any country in the world which has successfully eliminated seclusion and restraint. There are always extreme situations where somebody is very disturbed, as has been described. For their own safety and that of others, some kind of intervention will be required.

Dr. Imelda Whyte

The risk is that approved units for our most severely unwell will be unable to safely manage that very small number of acutely, seriously unwell people. This goes back to Dr. Martin's opening statement about Penrose's law. If approved centres are unable to safely manage these people, where do they go for care? The reality is that when a certain small number of people are unwell, they are a risk to themselves, to others and to other patients in their environment. That has to be kept in mind. It is incumbent on all units to reduce all restrictive practices. When we talk about restrictive practices, we often think about seclusion and restraint. Admission is a restriction. A patient with an eating disorder who is on a meal plan is under a restriction. There are levels of restrictions. We are talking about the serious ones, which are restraint and seclusion. To echo my colleagues, the expectation that serious restrictions would be reduced to zero is probably unrealistic. If that provision was no longer there, one would wonder what would happen to that small number of patients.

Dr. Lorcan Martin

I would like to make two points regarding seclusion and restraint. The rules and codes of practice specify that it must never be used for operational reasons. In other words, a ward being short-staffed is never a reason to use seclusion or restraint to manage patients who may have challenging behaviour. Following an episode of seclusion or restraint, there is an obligation to conduct a multidisciplinary team review with the patient to talk through the experience.

It can be a very upsetting experience, particularly in the case of seclusion. Of course, good practice dictates we should talk to the patient about it in any event, but it is mandatory under the codes of practice and rules from the Mental Health Commission that it be done.

We are talking about legislation that sits between a recruitment issue, a systemic issue and all sorts of other issues, so I appreciate all our guests having indulged me circling around a number of the topics. I thank the Chairman for allowing me to take so much time.

I have a couple of questions before we conclude. To return to something Mr. Barry said about CORU, did he refer to human rights practices being removed? I may have heard him wrong.

Mr. Eoin Barry

I may not have got the quotation exactly correct. In fact, Mr. Geiran might be better able to answer this.

Mr. Vivian Geiran

Human rights were included in the code of ethics and practice for social workers under the CORU framework. As I understand it, however, it seems CORU, in taking in the responsibility for the registration of an increasing array of professionals, has genericised the code of practice and ethics, part of which has involved the removal of the human rights aspect of the code of practice and ethics, which is core to social work but not to other registered professionals. It is my perception that in trying to make a code of practice and ethics that will cover all the registered professionals, that has been the upshot, which is regrettable. The IASW is opposed to that and is seeking to have it reversed.

It is very regrettable. To return to our guests from the College of Psychiatrists of Ireland, is there are any training for psychiatrists in human rights with regard to the UN Convention on the Rights of Persons with Disabilities, UNCRPD, in the college? Is any work done on that?

Dr. Lorcan Martin

Yes, absolutely. Dr. Broderick might speak more to that because she is nearing the end of her training. A specific human rights and ethics committee within the college reviews new legislation and areas relating to human rights and ethics in general. Not only are there modules for those in training but there are also continuing professional development events that deal with issues relating to ethics, law and so on. It is a case of lifelong learning that starts in the period of training and works through to the continuing professional development period.

Dr. Norella Broderick

The college is currently revising all the teaching it gives to trainees and it will probably include human rights training as part of that. There is certainly a great deal of interest among trainees in human rights. For example, I am pursuing a master's degree in disability law, which will cover the UNCRPD, and several other trainees are pursuing research in trying to reduce restrictive practices and so on. There is certainly an interest and self-pursuit of training in that area, and the college is continuing to develop its teaching in all areas, including this one.

To return to the IASW, is there any consultation process between the HSE and social workers on the upcoming changes to this mental health legislation? Has there been any interaction?

Mr. Eoin Barry

I am not aware of any at this stage, although that does not mean it does not happen in certain areas or that it is not planned to happen.

Mr. Vivian Geiran

In certain aspects, that does arise. In the IASW's current continuing professional development programme, for example, there have been a series of training events in respect of the assisted decision-making capacity legislation. However, I am not aware of anything that has happened, or is thus far planned, in regard to this area of legislation.

Mr. Eoin Barry

We were involved in the working group on A Shared Vision, so we have been involved in earlier items of legislation.

What additional resources will social workers need to provide the necessary support in the community in general?

Mr. Eoin Barry

My understanding is that the original A Vision for Change, which refers to a percentage of staff per size of population, is still in force, although there are different interpretations of that provision. We maintain that staffing levels up to the level provided for in A Vision for Change would be a good starting point, and while we all might have wish lists, it would be an adequate start. My understanding is that the staffing levels announced in respect of social workers is quite a bit lower than that figure. Social workers do much of the preventative work, particularly in the case of adults and many of the issues that have been discussed during this meeting, relating to self-care or people not looking after themselves. Social workers have a very valuable role to play on multidisciplinary teams. Overall, we suggest that the model in A Vision for Change, and the percentage of funding it recommends go towards mental health, is probably the best basis for recruitment.

Mr. Vivian Geiran

I might add to a point that was raised by Dr. Martin in response to a question relating to the issue of multidisciplinary teams, which is a very important part of both the current and the envisaged system. As he pointed out - this follows on from Mr. Barry's point a moment ago - a multidisciplinary team is not just a collection of people from different professions working in the same building. It is much more than that.

Dr. Martin stated that in his view and that of others, the consultant psychiatrist on such a team would be the clinical leader, and I do not have a huge issue with that. The point I want to make about disciplinary teams is that we tend to be waffly and fudgy about them, and to some extent, we feel that if there is a collection of professionals and a medic among them has been identified as the leader, we will all be grand. We need to be clear about what the individual roles are, including the role of the clinical lead on the team. Moreover, the clinical governance of the team is not just about the clinical side of it. I mentioned the need for appropriate supervision and line management of the various professionals. Any registered discipline can lead a team, in certain respects such as operationally or in co-ordinating the work, and there have been examples in some areas or fields of practice where that has been the case. I would argue that can sometimes free up the person who has been otherwise identified as the clinical lead to focus more on his or her specialism. There is probably a need to explore that issue of the multidisciplinary team or to deal with it to some extent in the legislation. It is probably an Irish trait to some extent, whereby we feel we are all in the one boat, we are all buddies and so on, but there is a need for clarity.

Whether it is the co-ordinator, the operational lead or whoever - along with, clearly, the clinical lead - they need, in all scenarios, to be registered professionals. As Dr. Martin said, they should be not just a registered professional but someone who has been registered, and has experience, in the appropriate area. There is a possibility to tease that out further to ensure the multidisciplinary teams we end up with will work at the best capacity and utilise the various skills of the different members and the professions they come from.

I thank Mr. Geiran. For the benefit of anybody watching this debate, supports are available for anybody who is struggling with mental health issues or who has in any way been triggered by this session. They can visit to the HSE's mental health services directory.

I thank all our guests for their very informative contributions. We have certainly learned a great deal.

The joint sub-committee adjourned at 1.30 p.m. sine die.