I move:
That Seanad Éireann calls on the Minister for Health and Children to take immediate action to tackle the lack of acute psychiatric beds and other problems in the psychiatric services.
I welcome the Minister to the House and am aware of his interest in this area. However, I was disappointed that an amendment was tabled to the motion, as there is no service so good that it cannot be improved and that would not benefit from being improved speedily rather than slowly. I brought this motion before the House because I attended an interesting conference last week which was attended by some of the Minister's officials.
About 30 years ago there was an international consensus among those treating patients with psychiatric disease and among communities in which such patients lived that it would be better if people with psychiatric disease were treated in the community where that was possible rather than in large mental institutions as was the international practice. Society in general agreed and in many countries, including Ireland, the large psychiatric institutions were closed. However, there are some psychiatric patients who require in-patient treatment, and with the decrease in the number of beds available a situation has arisen where patients with an acute exacerbation of their illness cannot be admitted. Regrettably, this can happen even when patients may be a risk to themselves or to other people. In addition, patients with long standing illness who may need in-patient treatment cannot be re-admitted. This is very important from the point of view of the patient's family, who may have been extremely supportive of the patient. Families feel neglected when they cannot get respite in the event of an acute exacerbation of a person's illness.
When we talk about waiting lists we are inclined to talk about hospital waiting lists for physical problems. However, it must be made known that there are also waiting lists for psychiatric beds.
The report commissioned by the Department of Health and Children and carried out by the Health Research Bureau is excellent. It was carried out by Fiona Keogh, Ann Roche and Dermot Walsh and is entitled "We have no beds: an inquiry into the availability and use of acute psychiatric beds in the Eastern Health Board region". The Health Research Bureau held an excellent meeting to discuss it last week.
The situation with regard to beds is interesting as it appears we have an adequate number of acute psychiatric beds when compared to international norms. The study focused on the use of acute beds and whether they were being used properly. The study was carried out in the Eastern Health Board area, but an examination of the last report of the Inspector of Mental Hospitals suggests that the experience in the Eastern Health Board area, where the worst delays occur, does not differ greatly from other regions in many respects.
I am disappointed that we still have not discussed the 1997 report of the Inspector of Mental Hospitals, although it was published much earlier than usual as the Minister promised. The report is interesting as there has been a dramatic improvement in the situation in psychiatric hospitals. Last year the House discussed the report of the Inspector of Mental Hospitals for the first time in the history of the Oireachtas. When such reports are made public there is a greater impetus for action on a local level.
Mental illness is higher in areas of highest deprivation. The report says that urban areas can be associated with a high rate of social and economic problems which have been shown to be related to increased psychiatric admission rates. It also says there is a tendency for people with psychiatric disorders to be concentrated in inner cities. This is an international and not just an Irish problem. If one visits London, one sees the same situation as exists in Dublin. The same can be seen in Rome, except that it is much worse there because their shortage of beds is even more acute. The motion I tabled is not an attack on the Minister, his Department or the Government but to try to get some sense of urgency about what needs to be done because we have a serious problem. Furthermore, when we talk of waiting lists, we are usually referring to general hospitals waiting lists.
The study surveyed district electoral divisions to see which had the greatest deprivation. It found the areas with the greatest number of deprived district electoral divisions also had the least in the way of services. This is the same in all cases; those who are best able to organise themselves are the most likely to receive the best services in their areas. This is not surprising but it shone out in the report. The greatest proportion of deprived areas are in the catchment areas in the west of the city and in the north inner city. These were also the areas with the fewest services. Eight of the ten most deprived areas in the country were in these two locations.
Another important factor in psychiatric services is the age of the population. The population of Ireland is aging and people in older age groups are more likely to develop dementias which can be an important cause of acute admissions. At the same time, an increasing number of people are going from adolescence to adulthood. This is a time when major psychiatric illnesses, such as schizophrenia, often become florid. Most catchment areas were seriously short of old age and adolescent psychiatric facilities and there was none in some areas.
Another problem which was relevant to the survey was the influence of homelessness on the number of acute beds in the psychiatric services. This is an increasing problem in Dublin. We know there is an association with psychiatric illness but the number of beds for homeless people in hospitals, be they psychiatrically ill or otherwise, is deplorably low in the city. I have heard people say no one need be homeless in the city. I do not believe that. Some people are difficult to house because they prefer a life on the streets. I walk down Baggot Street every night and, between the back of Leinster House and Waterloo Road, I can meet ten people half of whom suffer from psychiatric illnesses.
Why are we so short of beds? The investigation felt that about 80 to 85 per cent of cases in the cohort studied had been justified in their admission to hospital. However, it pointed out that 40 per cent of those admissions took place between 6 p.m. and midnight, a time when only junior hospital doctors were in charge. The Minister suggested to the manpower forum the other day that it should address the hours worked by consultants. This could be important in the psychiatric service regarding the admission of patients to hospital. Many patients who want to be admitted are drug addicts or alcoholics who are sometimes apparently escorted there by members of Alcoholics Anonymous. In many cases they seek a night's lodgings. However, it is difficult for a junior doctor to refuse admission, especially if a threat of suicide enters the equation. It would be better if the Minister's suggestion that the hours worked by consultants were examined and if there were a higher proportion of consultants working at times of high admission because they are in a better position to refuse admission than people with less experience. There is also the constant threat of litigation.
It is extremely hard on compliant patients to have drug and alcohol addicts who use the hospital as lodgings admitted late at night, and it is undesirable. They can be moved from bed to bed, from ward to ward and even from hospital to hospital. I am a conservative person and expect to wake up in the morning in the bed in which I went to sleep the night before. One can imagine what this moving must do to a person with a psychiatric illness. One can also imagine the outcry there would be in the newspapers if people went to bed in Beaumont Hospital and woke up in the Mater Hospital. It is unfair that psychiatric patients should be treated in a manner in which neither physically ill patients nor members of the population would be treated.
About 50 per cent of patients are discharged after a short stay in hospital, but there are some groups it can be difficult to discharge. Women, married men and those who were employed can be discharged back into the care of their families or friends much earlier than young, homeless, unmarried and unemployed men. There is nowhere to send the latter. Communities welcome the increased use of small hostels, sheltered accommodation and day hospitals for psychiatric patients as long as they are not in their locality. Even if funding is provided for them, there may be trouble establishing community psychiatric services.
Along with this is the serious situation regarding prisoners. The report by the Director of Prison Medical Services said some gloomy things about patients with psychiatric illness. There is a waiting list for admission to the Central Mental Hospital, Dundrum, and it is freely admitted that the treatment of prisoners with psychiatric illness is unsatisfactory. Apparently about one-third of prisoners have a psychiatric illness. While at present these patients are under the remit of the Department of Justice, Equality and Law Reform rather than the Department of Health and Children, many people, including the Director of Prison Medical Services, think it should not be so and that they should be under the care of the latter Department. There is nothing for these patients on their release.
In the recent case of Fr. Fortune, a judge tried to admit him to the Central Mental Hospital, Dundrum, but could not because of a dispute. The priest was sent to Mountjoy Prison, was discharged on bail and committed suicide. No matter how vile his alleged deeds, this was unacceptable and it begs the question, to how many others did this happen. We know of the rising suicide rate and the fact that many victims suffered from psychiatric illness. Would any of them have been greatly assisted if there had been an acute bed available?
Families who are normally supportive become frustrated if they cannot get a service for their ill family member when they need it. It is especially ridiculous that alcoholics can easily gain admission to these units. Doctors are in a vulnerable position if they refuse to admit them. Dr. Moosajee Bhamjee went before the Medical Council last year because he refused the admission of two alcoholic patients at night. The wives of these men reported him to the Medical Council. While he was exonerated, he wrote movingly of the great distress he suffered while being investigated.
Hospitals need to have a policy when a patient is admitted of putting in train a process of management towards their discharge. The severity of the illness should be assessed rapidly, as it usually is, but frequently little thought is given to the onward progress of the patient until it is time to discharge them. This is a multi-faceted problem and multi-faceted solutions are required promptly. The report reckoned that 91,000 bed spaces were wasted. At £100 a night, that is £9.1 million. The Minister could do a great deal with that money, so there is a need to rapidly tackle the abuse of acute beds in the psychiatric service.
