Seanad Éireann debate -
Tuesday, 6 Mar 2001

Vol. 165 No. 11

Inspector of Mental Hospitals Report, 1999: Statements.

Minister for Health and Children (Mr. Martin)

I welcome the opportunity to make a statement to the Seanad on the Inspector of Mental Hospitals Report, 1999.

Under the provisions of sections 247 and 248 of the Mental Treatment Act, 1945, the inspector issues an annual report on psychiatric hospitals and services and the care of patients therein. The report serves to highlight areas within the service which require particular and sometimes urgent attention from service providers.

In the first chapter of the 1999 report, the inspector details some general matters affecting the psychiatric services at the time of inspection and highlights the main developments envisaged in the psychiatric services in each health board. The report then proceeds to deal with each individual service. Each health board is allocated a separate chapter, with a chapter also being devoted to registered psychiatric hospitals. Finally, there is a presentation of the latest statistical information on the psychiatric services.

I am pleased to inform the House that substantial progress has been made in addressing the matters raised by the inspector in the 1999 report. One of the recurring themes in the annual reports of the inspector has been the standard of accommodation provided for users in the old style mental hospitals. The Psychiatric Services – Planning for the Future, published in 1984, recognised that old institutional hospitals are unsuitable for the delivery of a modern mental health service and developed the concept of a comprehensive psychiatric service located in the community close to where people live and work. This policy is still valid today.

The shift to a community oriented mental health service as an alternative to institutional care for persons with mental illness is progressing significantly. New mental health centres, day hospitals and other facilities have been set up and, at the same time, additional community-based residential accommodation has been made available. The number of community residences established in 1984 stood at 121, providing 900 places, increasing to 392 in 1999, providing 2,875 places. In the same period the number of day hospitals and day centres increased from 32 to 270. However, it is recognised that further improvements in providing alternative facilities are needed and, while there continues to be a steady decline in the number of patients in psychiatric hospitals, the rate of progress in developing alternatives to this institutional service needs to be accelerated.

In response to the inspector's concern at the delays in this area, substantial capital funding under the national development plan has been allocated to the development of mental health facilities. Almost £150 million capital will be provided for mental health services over the lifetime of the national development plan. A significant part of this funding will go towards the development of acute psychiatric units linked to general hospitals as a replacement of services previously provided in psychiatric hospitals. In addition to the 18 acute units already in place, a number of units are currently at various stages of development, including Beaumont Hospital, Dublin, St. Vincent's Hospital, Elm Park, James Connolly Memorial Hospital, Ennis General Hospital, St. Luke's Hospital, Kilkenny, Portiuncula Hospital, Ballinasloe, and Nenagh, Portlaoise, Castlebar and Sligo general hospitals. A further four acute psychiatric units are planned, as part of the national development plan, in Dundalk, Wexford, Mallow and Mullingar. The aim of this programme is to provide people with accessible treatment facilities which are of a high standard and to phase out admissions to the older larger-scale psychiatric hospitals.

A sum of £18.64 million has been made available to the mental health services for 2001 to address specific areas, including those highlighted by the Inspector of Mental Hospitals as requiring special attention. These include the development of community mental health services; the expansion of child and adolescent services; the provision of liaison psychiatry services in general hospitals; and, most importantly, the development of old age psychiatry. This funding, which represents a major increase on the funding made available in previous years, will be used as follows: £8.2 million is being allocated in 2001 directly towards the further development of community-based mental health services, including the improvement of psychology and social work services. The lack of multidisciplinary teams in many areas of the mental health services has been highlighted by the Inspector of Mental Hospitals in his report. This funding will provide for the establishment of additional multidisciplinary teams and the recruitment of additional staff to strengthen existing services.

Priority is being given to the development of mental health services for both older people and child and adolescent psychiatric services. Additional resources are being made available by the Department to enable improvements to be carried out in these services. An additional £3.2 million was allocated to further developments in child and adolescent psychiatry services in 2001. This will provide for the appointment of additional consultants in child and adolescent psychiatry and for the development of multidisciplinary teams to focus on specific areas, such as attention deficit-hyperactivity disorder – ADHD. A working group has been established by my Department to review child and adolescent psychiatry and to finalise a plan for the further development of this service. The group has been meeting since June last year and presented its first report last week.

The report emphasises that the treatment of ADHD-HKD is an integral component of the provision of a comprehensive child and adolescent psychiatric service. It recommends the enhancement and expansion of the overall child and adolescent psychiatric service throughout the country as the most effective means of providing the required services for this group. It also recommends that priority should be given, in the first instance, to the recruitment of the required expertise for the completion of existing consultant-led multidisciplinary teams. The report also calls for closer liaison and interaction with the education system and other areas of the community health services.

The report recommends that a total of seven child and adolescent in-patient psychiatric units for children ranging from six to 16 years should be developed throughout the country. It is envisaged that the focus of the centres will be the assessment and treatment of psychiatric, emotional or family disorders, including major adjustment disorders, anxiety disorders, mood disorders, eating disorders and schizophrenia, using a combination of family systemic, individual psycho-dynamic and medical model perspectives. Five in-patient units for children and adolescents are to be developed and funded under the National Development Plan, 2000-2006. At present, three of the units are at the planning stage and project teams have been appointed to oversee their implementation. These are the units to be based at Bessborough House, Cork, for the Southern Health Board region, Limerick Regional Hospital complex, Limerick, for the Mid-Western Health Board region and Merlin Park Hospital complex, Galway, for the Western Health Board region. It is proposed to develop two child and adolescent in-patient units for the ERHA and the location of these units will be decided by the authority.

The increase in the number of people living to advanced old age requires the development of specialist mental health services to meet their specific needs. Old age psychiatry services have been expanded in recent years and £1.87 million is being provided in 2001 towards the provision of additional consultants in old age psychiatry. The Inspector of Mental Hospitals recommends this development in his 1999 report.

There is a small number of individuals who for shorter or longer periods require special facilities because of the extent of their disturbed behaviour consequent on severe illness. The appropriate interventions and skills required for these patients are not ordinarily available in acute units. My Department is committed to providing dedicated facilities for disturbed mentally ill patients. These facilities will cater for approximately ten to 15 patients and will be staffed by specially skilled professionals in each health board. Discussions with health boards on this matter are ongoing and capital funding has been provided under the national development plan.

Concern was expressed in the report at difficulties in recruiting qualified psychiatric nursing personnel, which were particularly acute in the eastern region. However, over £1 million has been provided for local and national marketing campaigns undertaken by the Nursing Careers Centre and the schools of nursing around the country. The success of these campaigns is evident from the fact that the schools of nursing have since succeeded in filling a record 254 training places in psychiatric nursing in 1999. This was exceeded last year, rising to 300. Increasing the annual intake of student psychiatric nurses is a key element in the Government's strategy for addressing the current shortage of nurses.

The provision of psychiatric services to those in the criminal justice system is essential and the inspector has rightly expressed concern regarding the current forensic psychiatry services. Resources were provided last year to enable the establishment of four additional consultant forensic psychiatrists and associated support staff. There has been a delay in progressing these posts due to inexperience on the part of the health boards and their staff in the area of forensic psychiatry. However, discussions are now under way with both the Mid-Western Health Board and the Southern Health Board regarding the structure of the consultant posts and the service implications of establishing this service.

At national level priority is being given to education awareness and promoting a better understanding among the public towards mental health, thereby facilitating a greater and more positive acceptance of the transfer of mental health services from institutional to community-based settings. I am sure the House shares our concern about recent developments where communities have opposed the location of such needed facilities in community settings. It is important to develop far more positive approaches by community groups. Links with the voluntary sector continue to be strengthened, both at national and local level, and an additional £730,000 has been made available in 2001 to strengthen these links and services. There is ongoing co-operation between the boards and several voluntary organisations such as AWARE, GROW, Schizophrenia Ireland, the Samaritans and local branches of the Mental Health Association of Ireland.

In response to some of the ongoing concerns expressed by the inspector over many years, legislative change is now under way. The Mental Health Bill, 1999, published in December 1999, is expected to be enacted later this year. The purpose of the Bill is twofold. First, it will provide a modern framework within which people who are mentally disordered and who need treatment or protection, either in their own interest or in the interest of others, can be cared for and treated. In this regard, the Bill will bring legislation on the detention of mentally disordered patients into conformity with the European Convention on the Protection of Human Rights and Fundamental Freedoms.

The second purpose of the Bill is to put in place mechanisms by which the standards of care and treatment in our mental health services can be monitored, inspected and regulated. The vehicle for achieving this will be the mental health commission, to be established under the legislation. The commission will have responsibility for promoting and fostering high standards and good practices in the delivery of mental health services; improving and modernising the criteria and mechanisms for the involuntary detention of persons for psychiatric care and treatment; estab lishing a system of automatic and independent review of all detentions, including the provision of legal aid to all those who are detained; the establishment and administration of a legal aid scheme for detained persons; the maintenance of a register of approved centres, in which hospitals or residential facilities providing psychiatric care and treatment must be registered; and the appointment of the Inspector of Mental Health Services. This important Bill is on Report Stage in the Dáil at present and I hope to bring it to this House before the summer recess.

In response to the specific proposals and recommendations set out in the 1999 inspector's reports for individual health boards, plans for implementing those changes have been prepared by each board. Progress is steady and health boards keep my Department informed of developments. I am satisfied that the inspector's concerns and recommendations are being addressed both at national and local level. I understand my officials have made available additional information regarding details on implementation to Members of the House. If not, we will make available a summary of each health board's response to the issues raised in the report. I have a copy before me which might be of use to Members in terms of their health board areas.

The 1999 report was published earlier than in previous years and I am informed by the Inspector of Mental Hospitals that the inspection of facilities for 2000 have been completed and the process of preparing the 2000 report for publication is well under way. As an independent office holder, the inspector plays a crucial role in providing an accurate and detailed account of services in the mental health sector throughout the country. It is generally accepted that his reports have acted as a catalyst for improving the services and highlighting the inefficiencies in them. I thank him and his office for their constructive input into the development of services for the mentally ill. It is my intention to facilitate the health boards in as far as possible to bring about the improvements and developments identified by the inspector. We look forward to an ongoing and constructive relationship with him.

Mrs. Jackman

I welcome the Minister and wish we were—

Mr. Martin

The documentation was sent to the office. I will arrange for copies to be brought to the House.

An Leas-Chathoirleach

Copies were given out.

Mr. Martin

Were they?

Mrs. Jackman

Relating to the health boards.

An Leas-Chathaoirleach

No.

Mr. Martin

As additional information.

An Leas-Chathaoirleach

Yes. If the Seanad staff receive copies, it will be circulated.

Mrs. Jackman

I would prefer if we were discussing the inspector's report for 2000 rather than 1999. Since the formation of the current Dáil and Seanad, Senator Henry and I have been pushing to have the inspector's reports discussed. We could not understand how they were left lying on the shelf given the tremendous efforts made by the inspector to produce such detailed documents. It was extraordinary that they were left there during the years without any effort being made to give them a hearing. Have Members of the Dáil discussed this report and, if not, do they intend to do so? While it was the subject of debate on the Adjournment, the reply to which I read, I do not believe it was discussed in the Dáil.

Vincent Browne devoted a tremendous amount of time on his 10 p.m. radio programme to the findings of the 1998 report. I have listened to tapes of the responses, which I have kept, over and over again. The coverage stimulated much public debate. If we seek to disseminate the information needed on psychiatric services, it would be no harm if the findings of the report were compared to those of previous reports and relatives and friends of those who suffer from psychiatric illnesses as well as the sufferers themselves had an input to the debate. It is important that there is a media response to the findings of the report.

In many instances psychiatric services do not receive the airing they deserve. I refer in particular to a seminar held in Limerick last night, a local community's reaction to the incidence of suicide, four having been committed within a short time. It had to respond as it did not receive help or support from anybody. An awareness group was started. The seminar was packed with young people and parents who responded to the excellent presentations made.

The inspector must be complimented on producing such a thorough report which I have read three or four times. On each reading I noticed a different aspect. The detail in the introduction on the numbers in public and private psychiatric hospitals is revealing. Private hospitals account for 16% of all admissions while the number of involuntary admissions rests at approximately 2,400 or a constant 10%. Given the time spent debating the Mental Health Bill, I would have thought that increased awareness of this issue among the public would lead to a reduction in the number of involuntary admissions.

In the context of the Mental Health Bill, it is interesting that we have received a submission today from the National Disability Authority. It is important to indicate what it wants to have included in the Bill. As the Minister said, it is difficult to separate the Bill from the report. The authority seeks our support in having the Bill amended to include a commitment to review the legislation within five years of its enactment. It also indicates that the Bill, as drafted, will not effectively safeguard the rights of those admitted voluntarily or involuntarily to psychiatric facilities, to which the inspector refers.

In the context of an overview, the words "rehabilitation" and "additional occupational activity" are mentioned following questioning of those within institutions. Meeting those requirements should not involve much funding. These are practical ways of ensuring patients detained in institutions are kept occupied. Patients state that find the days very long. The necessary measures must be implemented to brighten their lives.

There is reference in the overview to substandard accommodation due to a reluctance to improve accommodation because of a move to new premises. An effort should be made to improve it. It would be money well spent. Even within the Limerick area, progress in that direction has not been made as quickly as I would have expected following publication of the 1998 report. The quality of patients' environment must be taken into account. They should not have to wait until they are told they will be moving to new premises. Substandard accommodation cannot be excused. I am only quoting what the inspector has to say in the overview.

There is no excuse either for poor standards in newer residential accommodation and I ask the Minister to investigate the matter. Why should there be poor standards in newer residential accommodation? It does not make sense.

There is a reference in the overview to the prescribing of medication, the polypharmacy and the need for frequent review. Senator Henry will devote time to this issue which falls within her area of expertise.

Regarding the clinical review of long stay patients, the inspector put tremendous effort into examining the position of older patients with a physical disability and an age related disability as opposed to mental disabilities. It would be shocking if a distinction was not made between catering for physical needs and physical and mental disability.

The most important element of the report is dedesignation from psychiatric services to the establishment of high quality services for older people to cater for their physical ailments in respect of which the inspector states no progress has been made. I am amazed as we addressed the issue on the last occasion we discussed the report.

It is shocking that there is a poor level of communication with relatives on documentary matters on patient care issues. There should be proper communication with relatives of those suffering from mental illness.

The report states that patients' rights are not on public display. I would have thought that it would be a simple matter to ensure their rights are displayed. Is it the case that patients are not treated democratically? The report refers to a code of practice. It appears the introduction of specific codes of practice in this area is dependent on the implementation of new mental health legislation.

The report also deals with psychiatric units in general hospitals. It states that the commitment to transfer patients admitted to acute units in psychiatric hospitals to units in general hospitals continues. I am glad that there is movement in that area. There is negative coverage of other areas, accommodation in particular, in the report.

The inspector perceived that in the future in-patient care, to which the Minister referred, would consist of general hospital units for acute cases and a wide range of community-based residential centres with a strong rehabilitation ethos. This word rehabilitation is repeated constantly in the report. The inspector stated that for continued care, there should be intimate semi-domestic units not catering for more than 20 patients.

The last time we debated this report, I referred to the units in Lisnagry, which are to cater for 36 patients. Like the Mid-Western Health Board officials and the patients concerned, I had hoped that all 36 patients would have been transferred by now. The six accommodation units are in place and six people will be transferred there between now and 19 March. I would hope that the transfer of the remaining patients would be concluded expeditiously because the units are in place and it would obviously free up capacity at St. Joseph's Hospital, where those patients are currently accommodated. That transfer should have happened a long time ago. I do not know what causes such delays. Perhaps it has to do with the building. When I asked last year I was told it was due to lack of funding, and this year I am sure the reason would be the same.

Mr. Martin

It was not due to lack of funding.

Mrs. Jackman

I hope not. The Minister might be able to tell me the reason. I am always told it is due to lack of funding. Maybe it was due to building problems.

Mr. Martin

It is on the way now.

Mrs. Jackman

Six will have moved there by 19 March but that is only six of 36.

Mr. Martin

The whole lot is being done.

Mrs. Jackman

They have not moved in yet. I want to see the 36 transferred. It is not that I am a doubting Thomas, but up to yesterday they had not moved.

Mr. Martin

I would say that I will not be able to provide it by tomorrow.

Mrs. Jackman

I do not expect them to be there by the end of the debate but it is a question of the Minister giving the necessary push. I am only going on what I have been told by health board officials. As I live next door to Lisnagry, I am aware that there is nobody accommodated there at present but that they will move there eventu ally. I want all 36, and not just the six, to be transferred there over the next fortnight.

While speaking about the Mid-Western Health Board, I am glad that certain units of the Perry Square Mid-Western Health Board headquarters have already been installed in St. Joseph's Hospital. Some progress seems to have been made in that area but I would hope that there would be a little more. There may be some trade union problems regarding certain aspects.

I am glad the Minister referred to attention deficit-hyperactivity disorder. I had hoped for more progress in that area. The other day I asked the Minister about the project which was given to the Mid-Western Health Board. I would have preferred it to have been left to the psychiatrist, Mr. Michael Fitzgerald, and Dr. Deirdre Killilea because they did a tremendous amount of work in a multidisciplinary project regarding the lack of services. They are the experts. I had hoped the prevalence study would have been left in those safe hands which had submitted such an excellent report to the Oireachtas Committee on Health and Children. I am disappointed that it went to a health board, not because of any problems with health boards but because I am a strong believer in continuity. They produced a successful report and it seems logical to give the project to those anxious to continue the work done in that report, on which £30,000 of the Department's money was spent.

I am disappointed that people are still coming to me about ADHD. Some have had to go to the High Court to fight for the appropriate educational entitlements of their child and some are still pursuing High Court proceedings. At last night's seminar, a person told me that her child, who she believes suffers from ADHD, has suicidal tendencies. The woman, who is herself involved in the medical field, asked me where she should go to have the child assessed. Perhaps because she is not Irish, she was unaware that there was a mid-west support group. The links between ADHD and autism can lead, according to reports I have read, to attempted suicide or even suicide in later life. As the Minister will be aware, those are the main areas in which I take a particular interest from a teaching perspective.

The multidisciplinary teams, to which the Minister refers, do not relate only to the health services. They also involve the Minister for Education and Science because the Minister, Deputy Martin, put a great deal of effort into that when he was in that Department. This also involves the Department of Justice, Equality and Law Reform because these people are at risk in later life, and even in their teenage years. Therefore, an integrated approach by personnel from the Departments of Education and Science, Health and Children and Justice, Equality and Law Reform would speed up the process. Dr. Walsh referred to multidisciplinary teams moving away from the traditional doctor and nurse model. The word multidisciplinary crops up throughout his report.

At last night's seminar I found that in one particular area of the Mid-Western Health Board there is still a shortage of psychiatrists and psychotherapists. I ask the Minister to push to provide the expertise where there are such shortages. There is a shortage of psycologists, social workers and occupational therapists. This may mean that the Minister must advertise abroad or conduct a publicity and awareness campaign about the fact that there are jobs in the area which people would find fulfilling. There are people who would work in those areas. Indeed, my daughter wanted to be a social worker. Although she took up psychology and is now living in America, she would have to study social work independently of psychology. When I think of where she is and what she would be doing if she were in Ireland, I recognise that there are young people of her age who want to work in very difficult occupations. It is not easy being a social worker in America but that is what she wants to be. She drifted into psychology because she did not know what she wanted to do. As a second level teacher, I believe that that whole area is not given enough emphasis within career guidance. People fall into it later, having done nursing, medicine or psychology. It is good that they come to it when they are older, but it is important that these professions should be highlighted.

According to what I hear in the health services and also from what the inspector states in the report, there are a shortage of such professionals. In the report the inspector asks for an awareness campaign of career opportunities in those areas. Are there promotional prospects? The inspector refers to this in his report and he obviously feels these people may not be as well paid as they should be. Those jobs are extraordinarily difficult and they take a tremendous toll on people, but there are still people who would like to work in those areas.

The report makes reference to specialisation and rehabilitation. The inspector states in the report that the number of disturbed mentally ill patients in the units should not exceed 120. He states that he would expect funding to be provided under the national development plan.

The Minister referred to forensic psychiatry. Last night's seminar was addressed by a member of the Garda and the debate centred on whether some members of the Garda should get particular training when they must deal with the issue of suicide. There was a difference of opinion. The general public felt that specific gardaí should be trained, whereas the Garda representative stated that if there were specific people trained in the area, they might not always be available. That is something which the Department of Justice, Equality and Law Reform should look at. Last night the biggest criticism from the community, which set up its own support group, was that there was nobody to deal with a parent brought to the hospital to be told that his or her son or daughter was lying on a slab with a identity tag. This I was told last night by people who recently were in such a situation where there was no service provided to them. They received no counselling because people were not trained in how to deal with this most upsetting of family traumas. That is something we should look at also.

I will deal with the child and adolescent services of the Mid-Western Health Board because it is the one I know most about. The report states that there should be provision of in-patient care for children so that they do not have to come to unit 5b. I thought following the 1998 report that the unit would have been up and running, but unfortunately it is not. It is shocking that teenagers are in units with elderly patients and never the twain shall meet. Each group causes trouble for the other. The elderly group is demented with the noise from the youngsters and youngsters cannot live happily with elderly people suffering from psychiatric illnesses.

I cannot understand why moneys are not put into that area immediately. Both groups need the best care that we can give. I wonder how young people will deal with this in later life. It is bad enough having their own traumas without having to witness the traumas of elderly patients. The elderly are deeply affected by the young people and wonder if they will suffer for the rest of their lives. It is something that must be addressed and it has to be a priority in relation to moneys within the national development plan. I am disappointed the unit is established in Limerick Regional Hospital where there is designated space for it.

In relation to the reference to the Garda and mental hospitals, the inspector states that he is unable to resolve that. It is obviously something for the Department of Justice, Equality and Law Reform and the Department of Health and Children.

I will finish on the saddest note, the issue of suicide. We have to be proactive about this matter. There has been a slight decrease this year in the incidence of suicide, but people are not aware that it is the leading cause of death among young people. That must be stated over and over again. It exceeds death from cancer and fatalities from road traffic accidents. That is a shocking indictment of all of us. More has to be done in this regard. The most tragic element of the inspector's report is that there is no support for those bereaved by suicide except that from their communities. They must get whatever financial support is needed to ensure they cope with this most devastating event in their lives, something they will never get over, although they may come to terms with it. It is interesting that they are rising above their trauma and asking how they can help others, either by prevention or support.

That is the most important aspect to be dealt with, together with attention deficit hyperactivity disorder, for which there is no multidisciplinary team, and young people suffering from autism, many of whom commit suicide in adulthood. I have read that in Dóchas reports and I have to believe it. Those are children at risk and their educational needs are not being met. They have to fight. I have attended many public meetings in the past few months and there is always a lobby of carers, friends of the mentally handicapped and ADHD and autism groups. The four groups come together because they are marginalised. They are crying out for help, and that should be the priority from now on. It is definitely hinted at by the inspector who has done a magnificent job in compiling the report, which should be compulsory reading for every GP, teacher, and social worker. It should be made available throughout the country. It should be on the syllabus for transition year students and for political education up to junior certificate because there are more and more young people at risk. It should be widely distributed and I applaud the inspector for such a detailed report. It is a sad report but it shows some ways in which we can positively address the issue of mental health.

Mr. Glynn

I welcome the Minister to the House and appreciate this opportunity to commend him on the report of the Inspector of Mental Hospitals. It is an ideal opportunity for Members of both Houses to review the comments made by Doctor Walsh in the 1999 report and to take account of what has been done in the interim.

The Inspector of Mental Hospitals has a statutory obligation to inspect all psychiatric hospitals and units at least once each year. The report of 1999 summarises his findings following his inspections for that year. He gives his overall views on the services in the first section and follows with a detailed report on each service. The inspector's comments on the service in the area I know most about, the Midland Health Board area, covering counties Laois, Offaly, Longford and Westmeath, are set out on pages 73 to 81.

The inspector comments on all aspects of the services, including the standard of accommodation in acute units, long stay units and community facilities, the level of services provided and the quality of these services. He also comments on the quality of clinical and administrative practice and progress made in developing services and facilities to meet the needs of those with mental illness. These annual reports have an important input into the preparation of annual service plans and support for capital investment plans. The following are the main points referred to in the inspector's overview of psychiatric services in 1999. The number of patients in psychiatric hospitals and acute psychiatric units fell from 5,101 at the end of 1998 to 4,768 at the end of December 1999. I am quite sure that the 2000 report, when it is published, will show a further decrease, and that has to be welcomed.

I will have something to say later in my contribution about the patients who are no longer in what we call the old psychiatric institution. In 1999 there were 8,668 additions to acute psychi atric units and 15,398 admissions to public and private psychiatric hospitals.

A mental health Bill was published in December 1999 which seeks to further refine the legislative provisions and standards of care for detained patients. The inspector carried out a survey of each inspection to ascertain patients' views on service provision. It is very important to take into account the recipients of services provided by the Department of Health and Children. The commitment to transfer all existing acute units from psychiatric hospitals to units in general hospitals increases. The growth of non-residential, community-based services for persons with mental illness was uneven in 1999. I am concerned about difficulties regarding the recruitment of various members of staff to multidisciplinary teams.

The inspector also commented on the importance of delivery of psychiatric services to those citizens coming within the sphere of the criminal justice system and the considerable deficits in current forensic services. Reference was made to the funding of the mental health services and, in particular, to national development plan funding on which I will comment later.

The inspector referred to the absence of any statutory requirement for continued professional training and education of consultant staff and stated that schemes of continued professional development are essential and should be put in place. That is a common sense statement by the inspector. All grades of people working in the service, both professional and non-professional, should have in-service training. That is important if we are to ensure the delivery of a top class service.

The difficulties in recruiting nursing staff is acknowledged and the inspector is happy to report that all psychiatric student nursing places were filled in 1999 and that this should help to alleviate the current shortages. The inspector expressed concern about patients in the Central Mental Hospital not being willingly accepted back into local services. Consideration is being given to the advisability of setting up an obligatory register of drug trials involving psychiatric patients.

Reference was also made to the fact that at national level there are still approximately 300 intellectual disability patients inappropriately placed in psychiatric hospitals. I strongly support that comment. As a member of the nursing staff at St. Loman's Hospital, I, with a colleague, compiled a list of patients who were inappropriately placed pertinent to the diagnosis contained in their case notes. Pat Lynch, the director of nursing at Lough Sheever's centre, which is a "de-designated" part, if one wants to use that term, of St. Loman's psychiatric hospital, and a number of his colleagues set up an excellent service, which is top class and is expanding. All concerned deserve the highest commendations of this House for that great work.

The Minister referred to the number of community residences. It is important that this House notes the progress, or lack of it, that has been made over the years since the whole concept of community services became a buzz term. I do not think it is a buzz term, it is a very important one because it is an extremely important service. The Minister highlighted the number of community residences available in 1984. Some 121 community residences were available, providing 900 places. The number of residences has increased from 121 in 1984 to 392 in 1999, providing 2,875 places. In the same period, the number of day hospitals and day centres increased from 32 to 270. All fair-minded people would say that we cannot sit back on our oars and say we are great and that there is much more to be done. Let us continue to do what we can to improve on that.

The Minister went on to refer to the steady decline in the number of patients in psychiatric hospitals and stated that the rate of progress in developing alternatives to this institutional service needs to be accelerated. While the Department of Health and Children, under the guidance of the Minister and his predecessors, and those working in the service have done a great job in devolving the service from the hospital to the community, the existing psychiatric hospitals – I have said this before and I say it again if only to underline it – were not built to provide an acute psychiatric service, but as asylums. While many may have noteworthy architectural features, that is where it begins and ends –"ends" being the operative word. They should end as facilities providing acute psychiatric treatment because they are not, and never were, suitable for that purpose.

I was delighted the Minister said that £150 million in capital is being provided for mental services over the lifetime of the national development plan. In tandem with earlier remarks I made about devolving the service from the hospital to the community, it is important that this happens. A number of acute units have been located at various general hospitals throughout the country, namely, Beaumont Hospital, Dublin, St. Vincent's Hospital, Elm Park, James Connolly Memorial Hospital, Ennis General Hospital, St. Luke's Hospital, Kilkenny, Portiuncula, Ballinasloe, and Nenagh, Portlaoise, Castlebar and Sligo hospitals, and a further four units are proposed for Dundalk, Wexford, Mallow and Mullingar in my area, which is part of the amended brief for phase 2B, of which the Minister is very much aware and on which he will be keeping an eye.

I refer to the expansion of the child and adolescents service. That is and has been a major deficit in the psychiatric service. It is something with which I have been involved during my professional career in the psychiatric service. There was an appalling lack of facilities for this service. I am pleased – I suppose this is drawing water to my own well in Mullingar – that under the review brief, there are proposals pertaining to child and adolescents services. Another aspect of the psychiatric service which leaves a lot to be desired is the psychiatry of old age. I am pleased that when the new unit is up and running in my health board area, a consultant skilled in the psychiatry of old age will be recruited.

Multidisciplinary teams, which are very important, have been mentioned. In an evolving discipline such as psychiatric medicine, it is essential that the multidisciplinary team is brought into being as soon as possible. I acknowledge, as the inspector has done, that there is a difficulty in recruitment.

I agree with what was said by the Minister and Senator Jackman in regard to children with attention deficit-hyperactivity disorder. I, with the Senator, was responsible for arranging to have a number of those groups heard by the Joint Committee on Education and Science and the Joint Committee on Health and Children. We have to progress the need areas outlined by those people in whatever way we can.

Apart from the acute units in the psychiatric hospitals and community residences, there is another very important area which the Minister mentioned. A small number of psychiatric patients are not, or will not be, suitable for location in community residences. A number of small units need to be established in each health board area and we are helped by the fact that the health boards are regional boards. This is something that has to be done as soon as possible. I remember a horrendous occasion when I was sent by a consultant to a house in the Meath area. Time does not permit me to relay to Members what I encountered on that occasion, but it was outrageous. The boy concerned had the entire school, including the teachers, totally intimidated. This young man should have had the benefit of what could be called a secure unit or a special needs unit. I think everybody knows what I am talking about.

When we spoke in this House on nurse shortages, we applauded ourselves that we had made certain progress in recruiting nurses in all disciplines. One of those disciplines lagging behind was psychiatry. I am pleased that all the psychiatric nursing places were filled in the last year. That is tremendously important. It is to the credit of my colleague, the Minister for Foreign Affairs, Deputy Brian Cowen, the former Minister for Health and Children, that he established a college of nursing in Tullamore. These psychiatric nurses are both male and female. I know I should not say that anymore, because nurses are not supposed to be specified by gender under the Employment Equality Act, but for those of us who remain in the real world I think it is incumbent on me to say it.

I give praise to the Mental Health Association, Grow, the Samaritans and Schizophrenia Ireland. They have played a marvellous, complementary and supportive role to the psychiatric services and long may they continue to do so.

When the Minister is drawing up the Bill, it should be made mandatory that relatives, especially of long stay patients, visit their relatives in psychiatric hospitals. It is appalling that some people who have been in psychiatric hospitals for a number of years never see a member of their family. I believe the support role provided by relatives and loved ones is key to rehabilitation in the psychiatric services. The lack of such support is one of the contributing factors to institutionalisation. I have been as guilty as anybody else of not showing up on special occasions in those people's lives like wedding anniversaries and birthdays. It is left to the nurses on the ward to fill in, along with the other residents and staff. It should be mandatory on people to visit their relatives a statutory number of times each year. There may be exceptions where people have no relatives or the remaining relatives are incapacitated and unable to do so. I know the community psychiatric nurses who are carrying out domiciliary visits are playing a major role in supporting those people, some of whom have never been under the psychiatric services and others who are out on trial leave or have been discharged.

Senator Jackman said that rehabilitation does not take much in the way of resources. The point is that it does. It takes a lot in the context of human resources. From my experience, rehabilitation, especially for psychiatric patients, is very time consuming. The one thing that costs money is the time of the personnel involved.

Much more could and should be done in the non-pay area of rehabilitation, especially in the community residences. I hate to use the term sheltered workshop, but I know there are a number of them and they provide a great outlet for patients, especially day patients who are brought there by transport provided by the health boards or the relatives. This is a great service in the context of rehabilitation.

One of the very vexed questions is that of inappropriate bed occupancy and this has been the bane of my life. It often happens that in the early hours of the morning, someone will show up in a state of inebriation and wake the whole place up. There is no choice but to take them in and lodge them for the night. They have been brought there by the Garda. The hospital is being used as a hostel. Under the terms of the new Mental Health Bill, I think I am correct in saying it will be illegal to have such people accepted as patients. They may have other needs and may be homeless but it is not the business of the psychiatric services to provide bed and breakfast accommodation. Doctors' time is being wasted. That is very wrong and should not happen. It is an outrageous abuse of the psychiatric services.

Another very vexed question is that of escorts for psychiatric patients, a matter I will take up when the Mental Health Bill comes into this House.

The Garda should be trained to deal with suicide. All sections of the community should have some knowledge of suicide, given the incidence especially among young males. It is incumbent on all of us to prevent the spread of this terrible malaise.

Dr. Walsh does a very difficult job. Sometimes I agree with him, sometimes I do not but mostly I do. The location of acute psychiatric units at general hospitals is the best way forward in removing the stigma of mental illness, because it places psychiatry in a multidisciplinary campus setting. It is a marvellous concept.

The Inspectorate of Mental Hospitals should be devolved into an Inspectorate of Hospitals, naturally incorporating the psychiatric discipline. Psychiatry is a discipline even if some people do not appreciate it. I ask the Minister seriously to consider this because if that were to happen it would be another step forward in removing the stigma of mental illness.

Dr. Henry

I welcome the Minister into the House. I am delighted this debate is eventually taking place. The Inspector of Mental Hospitals has been presenting reports to both Houses for decades, but the first time one was debated was when I had the 1996 report debated in Private Members' time. The following year I had to use the only Private Members' time I had available for the 1997 debate. Fine Gael generously gave me one of its slots for the 1998 debate. I was very disappointed in having to wait from July last until March of this year for this debate to come before the House. I know there has been a ten minute Adjournment debate in the Dáil on the report but, considering that the psychiatric services are so important to patients, relatives and staff, the Government should ensure there is a slot to debate this report before it becomes a historic document.

When I read through the report I wonder whether the unit at Beaumont is up and running and whether improvements have been made in Mullingar. It is difficult to debate reports which become historic documents. These cost money and effort. Will the Minister give the Department his view on the importance of the debate and will he suggest to the Department that it be debated within a month of its publication? It need not even take Dáil time but could be debated in the Seanad as there are plenty of us here to express views on it.

As well as my concern about the delay in debating this report, I am also concerned with the slow progress of the Mental Health Bill in the Dáil. When Deputy Cowen was Minister for Health and Children he introduced this Bill in December 1999. It is now March 2001 and we still have not reached Report Stage in the Dáil. I have been following the debate carefully and I can see there are difficulties with various aspects of it. Deputy McManus said it could be described as the involuntary detention mental health Bill as that is the main aspect being addressed because of criticisms we have had from various European committees which have inspected our facilities and our legislation. We are repeatedly criticised in the courts for the delay in updating our legislation. We are still working under the 1945 legislation.

A colleague who returned from England to practise as a psychiatrist here could not believe the differences when he compared the English 1984 mental health bill with our 1945 Act. The delay is extraordinary. Supreme Court Judge Catherine McGuinness, a former Senator, was the last judge, as far as I am aware, to criticise the tardiness of the Legislature in bringing forward this legislation. I urge the Minister to get Report Stage in motion. We are in breach of numerous human rights conventions and must make progress.

Senator Glynn was right to point out that psychiatry is now a multidisciplinary team effort. I congratulate all those working in this field. They are often short-staffed with poor working conditions and there is not much public enthusiasm behind them. When the psychiatric services plan for the future document was published in 1984 it was grossly underestimated how much it would cost and how much work would be needed to implement it. It is much easier and cheaper to treat patients in the old psychiatric hospitals where you just lock them up and leave them. However, we have put our minds to producing a community service. It is what people expect and is the right thing to do.

This report, while improved, is in some ways astonishingly like the first report. There is still an emphasis on the fact that there is substandard long-term accommodation. One part of the inspector's report says that furnishing and decor in premises in which patients spend their lives is unsatisfactory and that there seems to be an understandable reluctance to spend money on the expensive maintenance of old buildings whose life is limited when there are many newer projects in the mental health field competing for limited resources. The Minister in his speech implied that resources are unlimited. Why then does the inspector think there is competition for limited funding? I do not understand that. We are constantly told that cash is unlimited, yet it is not available apparently to upgrade the decor within the mental health services.

We also have a situation where long stay patients have very little to do. There is little occupational therapy or entertainment for patients and the major complaint of these patients would be that life is boring. I commend the committee in St. Ita's which set up a staff-patient artwork co-operative. When I was on the Eastern Health Board there was tremendous artwork in St. Patrick's hospital. This was initiated by Dr. John Cooney and supported by others. It was a splendid idea and I suggested to the Eastern Health Board that we should try it in some of its psychiatric hospitals, but I got nowhere. One day I visited St. Ita's and there, high up on the wall, were three prints. I was told that that was the art. Someone in St. Ita's, however, must have taken notice of the suggestion because they brought forward the idea that the staff and the patients should start their own programme, and they are to be commended for it. Dr. Abdul Bulbulia has been important in promoting paintings in hospitals and he has pointed out that art is more important for patients and workers in psychiatric hospitals than anywhere else. These types of improvements should be put forward in an imaginative way.

Earlier this year Dr. Fenton Howell suggested that it was unwise to give little gifts or tokens of approval in the form of cigarettes to psychiatric patients. He was abused for this and told he was trying to make their lives more miserable than ever. I do not think that is what he meant. The Minister has started promoting a tobacco policy. Why should psychiatric patients be outside this? Do we not want to ensure their good health as much as anyone else's? It is important to look at the whole lifestyle of psychiatric patients. We should not just look at long stay patients as people who can be put to one side and forgotten.

Another point raised by the inspector was poly-pharmacy. Patients are frequently on large amounts of drugs of different types and there does not seem to be much assessment as to their value. He also mentioned medical and nursing notes. I thought that with litigation fears we would have a better situation regarding careful medical nursing notes. In one case only six medical notes were taken over a period of two years. That is not satisfactory. I suggest that individual hospitals, doctors and nurses examine this matter carefully.

I was sorry the inspector had to mention that medical and nursing staff do not always wear name badges. It can be confusing for people when they do not know who said what to them. Under the patients' charter, it is obligatory for staff to be identifiable. The inspector pointed out something very important. Many of the long-stay patients in psychiatric units are now quite elderly and their psychiatric illness is perhaps of very little import any longer. He wondered why facilities could not be developed for these elderly people rather than have them stay in the psychiatric units. This would also help to free up beds and it would be a better way of dealing with their physical disabilities.

We need high quality resources for these people and I am not at all sure that this is the case in some of these institutions. We are still talking about patients not having their own clothes. Senator Jackman is correct when she says that these reports should be more widely disseminated, because psychiatric illness is very common. There are 25,000 admissions every year and about 10% are involuntary admissions.

Senator Camillus Glynn is right when he complains about people being admitted to psychiatric hospitals because of drunkenness. They cannot be admitted involuntarily. Fortunately, if they turn up voluntarily and are intoxicated, they can be admitted. Perhaps we could make an amendment in this regard when the Bill comes to this House.

There are still complaints of poor communication with relatives. There is also an absence of public display of patients' rights, as set out in the Mental Treatment Act of 1945. This was the case six years ago and it is extraordinary that there are still no public notices about patients' rights.

I am worried about one aspect of the report. The inspector does not have access to nursing homes where elderly patients may have developed psychiatric illness but where the homes are not specifically for psychiatric patients. Has this been considered in the new Mental Health Bill? The Bill will change the inspector's role the inspector of mental services, so perhaps this will be covered.

I have spoken in the past on the importance of psychiatric illness in the development of homelessness and sleeping rough. There are varying figures on the incidence of psychiatric illness among those who are homeless and sleeping rough – some official reports say 35% and the Simon Community says up to 60%. It is a very important aspect of the life of people who are not in fixed accommodation often because of life crises, sometimes to do with their psychiatric illness, loss of employment, marriage breakdown or family disruption. These people have then become homeless. Trying to deal with their psychiatric illness is very difficult. Even to ensure that patients within the community are taking their medication can be a problem. It is much harder to follow up homeless patients.

I am pleased that the Eastern Regional Health Authority is in the process of appointing a psychiatrist on the north side of the city to deal with those patients. I hope the same will happen in other areas.

I commend those members of Dublin Corporation who have become involved in the Bus for the Homeless project. This was started before Christmas and a group of volunteers, employees of Dublin Corporation, travel around the city at night collecting people who wish to go into overnight accommodation. This has been a great success and is being continued. This is an initiative from private individuals and I praise them publicly.

There has been very slow progress in the opening of acute units in general hospitals. The progress in Beaumont Hospital has been so slow, about 12 years, that Professor Dinan resigned and went to Cork. A great deal of the dispute about opening acute units seems to be a turf war between professionals. I ask those working in the psychiatric services to put their professional considerations to the fore and consider how serious it can be for patients when units are delayed. There was considerable delay in opening the unit in Tallaght because of the dispute with St. Loman's. The inspector urgently requests the opening of a unit in Mullingar and Cavan because of deficiencies in the general acute admissions procedures. I suggest to staff within the psychiatric services to resolve their problems speedily because patients are affected. The integration of the psychiatric services into the general hospitals, as Senator Glynn said, would be the best way of removing the stigma from psychiatric disease.

I am very concerned about the situation regarding children and adolescents. I do not see how the sections of the Bill dealing with children and adolescents can be enforced if it becomes law. The new Bill will raise the age of childhood to 18 years, as recommended by the United Nations universal declaration of the rights of the child. The services deal with children up to the age of 16 and there are virtually no in-patient child psychiatric services. I have been contacted by people who were in adult wards as children and they have asked me to ensure that the new Bill will prevent the admission of children to adult psychiatric units. The most disturbing information of all was the admission by some of these people that they had been sexually abused by other patients when they were child patients in adult psychiatric wards. When one thinks of the paucity of staff in some wards, one can see how this could happen. It is very serious to have children in the same units as adult patients, especially adult patients who may be disturbed or have some mental illness which may have involved sexual abuse before admittance. These units must be up and running as soon as possible.

Some places are praised for better progress than others. I see that Laois-Offaly, Sligo-Leitrim and south-west Dublin were considered to be making progress in the provision of acute units.

In the current institutions, half the psychiatric beds are not used for psychiatric purposes. There is a shortage of acute beds, particularly in the Eastern Regional Health Authority region. There has been a rapid growth in population and this has exacerbated the situation. Despite the increase in community accommodation there is still a serious deficit in non-residential services in day hospitals and community mental health centres. Multidisciplinary teams are very short-staffed at times. It is unacceptable that there is such difficulty in getting planning permission for units in the community. As Senator Glynn graphically pointed out, some of these patients have already been abandoned by their families, so much so that the staff in the psychiatric hospitals are now their nearest and dearest. That they find themselves rejected by the outside community when they are well enough to leave hospital is appalling. Those who have family members with psychiatric illness would feel terrible if they were constantly rejected by the community outside hospital.

Rehabilitation is possible. I am delighted that Senator Fitzpatrick will be able to tell the House that the modern treatment of psychiatric illness could be administered in primary care by the general practitioner. If more was given by GPs we might not have such a problem with hospital waiting lists for psychiatric patients. Because of the shortage of beds, psychiatric patients may often not be treated as rapidly as desirable and early admission is important in resolving this illness. I suggest that those objecting to patients being brought back into the community by rehabilitation in residential units are doing a serious wrong. There have been remarkable successes by voluntary groups which are to be praised for their co-operation with the Department, as the Department and health boards are to be praised for co-operating with the groups. Many of these voluntary organisations contain members or those with relatives who suffer psychiatric illness and they have good insight into the condition. As Members know, insight is very important in treating psychiatric illness.

The multidisciplinary team has a difficulty getting staff but if we can show the social rewards that psychiatric staff are bringing to patients we might get somewhere. Psychotherapists, psychologists, social workers and occupational therapists who work with doctors and psychiatric nurses are doing a splendid job and more public praise for them would be useful. There are tremendous local initiatives and we need to give more praise in this area also, something we constantly shy away from.

The Minister mentioned the issue of residential units for the disturbed mentally ill. This is in the national plan but I would bet that progress is poor as Ministers for Health have been trying to implement initiatives such as this for decades. If there is difficulty getting those recovered from illness into local units, we will have just as much if not more trouble trying to settle those who are disturbed and mentally ill.

Forensic psychiatry is often criticised in Ireland and the inspectorate of the committee for the prevention of torture, and inhuman and degrading treatment or punishment has been very critical of facilities here. We have very little psychiatric, psychological or psychiatric nursing input into the courts or the prison services.

I am glad to see that there have been improvements in the Central Mental Hospital. There are now psychiatric nurses as well as care attendants on all rosters, but it took a long time to get this vital reform in place despite its being known for decades that psychiatric nurses were necessary. It is interesting that four forensic psychiatry jobs advertised have not been filled and perhaps this is because the work is in very poor conditions.

We must upgrade the commissions and the staff who give support in prisons because a huge number of prisoners suffer psychiatric illness. In a survey by Dr. Paul O'Mahony, 40% of prisoners in Mountjoy prison needed psychiatric help. This is a serious situation as there are no facilities to transfer prisoners, particularly from Mountjoy, to the Central Mental Hospital due to shortage of beds there. This shortage occurs Central Mental Hospital patients cannot be transferred to other mental hospitals because these hospitals will not set up units to take patients, even if no longer dangerous. There has been a serious knock-on effect from this over many years and I do not envy the Minister dealing with the problem.

It is important to remember that intellectually impaired people are at risk of mental illness and we also need to ensure that psychiatrists have continued training and education. Almost 100% of non-consultant hospital doctors in psychiatric hospitals are non-EU doctors. This is despite the culture of doctor and patient being so important in psychiatric treatment and there is a problem with the lack of Irish culture in psychiatric training and practice which should be rectified.

There were 14 suicides in psychiatric hospitals in 1999 and this is a serious problem as this incidence is far higher than in the general population. Dr. Dermot Ward has done a considerable amount of work on the subject and published his findings in 1999. He said that social factors which contribute to the suicide rate in the general population are relevant to the increase in hospital in-patient suicides. While suicide has increased outside hospitals – and we do not know how important psychiatric illness is in that increase – it has also increased inside. Interestingly, while males are eight times more likely than females to commit suicide outside psychiatric hospitals, the ratio inside is 2:1.

More comprehensive services to meet the needs of those with severe mental illness, particularly young adults, are essential. The results emphasise the importance of managing in-patients in a safe, secure environment. The person/year method is appropriate for monitoring changes in suicide rates. Although the suicide victim is dead, the event has a terrible effect on patients, relatives and on staff at hospitals. Suicides frequently take place when staffing levels are not at 100%, and sometimes when the victim has absconded from the unit. There are often not enough staff present to ensure that high-risk patients are carefully watched. Further study on the incidence of suicide by psychiatric patients in hospitals is very important, as it is for those outside.

The situation is not all bleak, but patients should expect a better reception from the community when they are discharged. There is a view that when patients are in hospital the problem has gone away and this is wrong. It was mentioned in the report that we should have legislation covering drug trials as it is difficult to ensure that there is informed consent from those with psychiatric problems.

The greatest care should be taken to ensure that psychiatric research is looked at carefully by committees, but that research should not stop as it is of great importance for patients.

Dr. Fitzpatrick

I ask to share my time with Senator Norris.

An Cathaoirleach

Is that agreed? Agreed.

Dr. Fitzpatrick

I welcome the Minister of State, Deputy Moffatt. We have laboured long and hard as GPs and he will be familiar with the statistic that 90% of those who attend GPs do not proceed to secondary or tertiary care, a testament to GPs' efforts.

I welcome the inspector's report which could be discussed in more detail by the Joint Committee on Health and Children than by the Dáil or Seanad. The report raises legal and ethical medical issues in addition to cultural issues. Psychiatric patients are treated within a cultural context. Treatment which may be appropriate to someone from an urban environment may not be appropriate for someone from a rural environment, although I concede that the boundaries between rural and urban are becoming increasingly blurred.

I do not intend to go over the ground covered in great detail by previous speakers. We must disabuse ourselves of the notion of cheap health treatment, prevalent in the 1960s. That day is long gone. There was a view that by removing patients from hospitals and placing them in the community they could be better treated at less expense. Ongoing medical treatment requires highly skilled, highly motivated, well trained personnel. Such treatment is labour intensive, whether provided in hospitals or the community.

As a member of a health authority and health board, I am often struck by the difficulties associated with a bureaucratic system. The bureaucracy is not vindictive, obdurate or obscurantist, but it takes a long time to get things done. It takes at least 12 months to have a ward painted from the time of the initial concept to putting paint on the wall. The day the position of hospital matron was abolished in favour of a director of nursing heralded the start of a slippery slope. In my experience matrons ran their hospitals well and efficiently and made decisions quickly. The world has moved on and become more complex. We have lost the ability to do simple things well.

I would like to see greater co-operation between the Garda and the psychiatric profession on the issue of escorts to hospitals. It is extraordinarily difficult to have a patient escorted to a psychiatric hospital. This was not the case 30 years ago when the system was not abused.

I take issue with Senator Glynn's comments on inappropriate hospital admissions. Such admissions are a fact of life, irrespective of the hospital involved. Those who are a danger to themselves, as a result of drink or drugs, must be admitted to hospital for observation, although they can sign themselves out the following day. That will not change.

The practice of psychiatric hospitals of not admitting those with alcohol problems for detoxification when they have consumed alcohol must be examined. An examination of this issue should not be driven by the reluctance of consultants or other members of the psychiatric profession to become involved in what they perceive as social problems. Alcoholism may be a social problem, but it is also a medical one and all health professionals must play a role in addressing it. We will never cure all the world's ills, but we must play our part.

I concur with Senator Glynn that the inspectorate should be broadened to encompass all hospitals. I may be contradicting my earlier comments about bureaucracy in calling for this expanded remit, but Senator Glynn made the valid point that a stigma may attach to the inspector and that this would diminish if the role was expanded. The inspector of mental hospitals serves as an ombudsman for patients in psychiatric hospitals, but does not have any remit in regard to those in community care.

Our psychiatric services are good. I pay tribute to all health professionals in this area, consultants, nurses etc., who are sometimes obstructed by the services in delivering the care they want to deliver. Psychiatric services are improving all the time; I have witnessed enormous improvements during the course of my years in practice.

On the north side of the city, we have a psychiatry of old age service second to none. Any service which can provide appointments in less than a fortnight, not alone see a patient but to visit him or her is praiseworthy. It is no accident that good and efficient services are staffed by full-time, adequately resourced and well supported consultants. When the Minister examines choke points in health services, he should take this on board.

Mr. Norris

I thank Senator Fitzpatrick for sharing his time with me. I wish to comment on a number of issues before coming to my principal point. I listened with interest to Senator Fitzpatrick's contribution and was heartened to hear of the rapid referral to psychiatric services for the aged in his area.

The Senator also spoke about involuntary admissions. The Irish Times often carries reports on landmark court cases towards the back of the newspaper. A recent judgment created a precedent in this area. It concerned a male in Waterford with a serious psychiatric disturbance, probably schizophrenia, who acted in a wild and disordered manner. He realised his condition and signed himself in voluntarily to a hospital. The following day he refused to take the medication prescribed for him and demanded to be released. When he was not allowed, he hired a solicitor and managed to have the case heard in court. The judgment held that, although he had signed himself in voluntarily in circumstances where he could have been a danger to the community or himself, he had no corresponding right to sign himself out voluntarily. This is an area on which civil rights groups have a certain amount to say, but the judgment appears reasonable. If a person signs himself or herself in voluntarily and is assessed by two doctors as being likely to be of danger to himself or herself or others, it is appropriate that professional personnel are able to insist that he or she stay to receive appropriate treatment.

The issue of suicide was raised. Surveys conducted within the gay community indicate a spectacularly high rate of suicide among young gay men or young men with a sexual identification problem. The Department of Health and Children should recognise this. A number of Departments must examine the special problems of those in this and related positions. An example which does not come within the report, but with which I have dealt is where young men who are HIV positive or have full blown AIDS find it impossible to obtain adequate or proper housing. With the co-operation of sections of Dublin Corporation, I have managed to resolve one case, but it is an area in which we need to be caring and compassionate.

I am glad the issue of St. Ita's was raised. I remember raising it many times and there were a number of interesting and provocative radio programmes on the subject. It was ventilated in the House on a number of occasions in different ways. Senator Henry quoted from a report which suggested that it would be a waste of resources to decorate some units because they would not be in use for long. I also received a briefing suggesting that the intellectual attainment of many inmates was such that they probably would not be aware of or appreciate the decoration. We cannot assume that this is so and that patients will not respond to an improvement in the aesthetics of their surroundings. This operates in such a subliminal way through colour and texture that we may not be intellectually fully conscious of the effects, but they do affect the human psyche. Apart from this, is there not an argument for the mental health of staff? It would be extraordinarily depressing for staff, who are remarkable people, to have to work in these areas. There is a strong argument, especially when we have adequate resources, for this, even in circumstances where at first it may not appear to be the most practical of measures.

The Minister referred to a report dealing with attention deficit hyperactivity disorder. He said the report recommends the enhancement and expansion of the overall child and adolescent psychiatric service throughout the country as the most effective means of providing the required services for this group.

It should be provided for other groups also. I make a special and specific plea to the Minister of State to determine if anything can be done about the provision of speech therapists. It is at a critical level. I raised the matter a year ago at the behest of the parents of a severely autistic child who had benefited greatly from speech therapy available through Stewart's Hospital in west County Dublin. As that service has been terminated, they have been left with no speech therapy service. They have had to go through the agonising process of watching their child, who had made steady improvement, go all the way back to his original condition. They are also aware of the heartbreaking fact that he will be worse off when they begin again, if ever. Although I raised the matter on the Adjournment, I could not receive a satisfactory undertaking from the then Minister that anything would be done. One can imagine the position of parents in this position. Although the people concerned have subsequently relocated in pursuit of a speech therapy service, I am not sure that they have found a satisfactory one yet.

I accept that this is a long-term issue. I spoke to Sister de Montfort, head of the very good speech therapy school in Trinity College, who told me that there is a problem with recruitment. Remuneration is significantly lower in Ireland than in other countries, such as the United Kingdom, with the result that 25 out of every 30 who undertake the course in Trinity will not seek employment in Ireland. We must examine not just the deficit in the delivery of care to those who need it, but also the surrounding circumstances in terms of the courses on offer in universities, how people train and prepare and why so few end up in the system. If it means bringing their remuneration into line with that in the United Kingdom at least, that must be done, especially when the Exchequer is buoyant. I appeal to the Minister of State to examine that matter. I realise that something cannot be done overnight, but the delivery of speech therapy services to the mentally disabled, especially children, must be examined.

Mr. O'Dowd

I wish to respond to what Senator Norris said about the speech therapy issue. I understand 60 go through the system in Trinity College. The training of new speech therapists requires existing professionals to take them into their practice. The difficulty lies in finding placements for them. It is one of the major blockages. More students could be taken in, but placements would not be found for them. I agree with Senator Norris's remarks about pay.

The inspector's report is an excellent one. I congratulate Senator Henry on the excellent work she has done in this area during the years. It is important that we debate the issue.

On the spend per health board, I have an analysis prepared by the North Eastern Health Board based on the 1998 report. The analysis for 1999 has not yet been completed. The figures vary considerably between health board regions. The per capita spend on mental health services in my region, the North Eastern Health Board, as itemised in the inspector of mental hospital's report, is £52 per head of population compared with a figure of £107 in the Western Health Board region, a significant difference. The national average is approximately £67 per head. There are significant differences in the spending on mental health services by health boards. I do not know the reasons for this on which the professionals will, probably, have different views. There is an obvious imbalance. We would like each health board to spend at least £107 per head on these services rather than the paltry £52 per head spent in the North Eastern Health Board area. There is a need for equity in spending and for a better planned programme in mental hospitals and other areas.

The best statement in the Inspector of Mental Hospitals report is that the numbers in psychiatric hospitals dropped by 90% in the previous year. We all want to get people out of mental hospitals and the number leaving such hospitals has increased significantly in recent years. The days when hundreds of people were in large psychiatric hospitals in the north-east are long gone. However, unfortunately, many elderly people remain in mental hospitals. Many of them should be in the community but they have become institutionalised over the years and, sadly, there is nowhere for them to go. Many of them would have been discharged if ideas in this area had been sufficiently progressive in the past.

I note the Minister's reference to primary school children with attention deficit disorder. However, I received a letter from a primary school principal recently which stated that on 5 October 1999 the school rang the Department of Education and Science seeking a psychological assessment of a child. However, the awful news the school received was that, as matters stand, the child will not receive a psychological assessment until 2004. The child will be in fifth class by then. Some primary schools can have assessments carried out while others cannot. There appears to be a bias against smaller primary schools. If one is from a larger urban area, one is more likely to get an assessment than a person in a smaller primary school.

I am aware of the significant increase in the number of psychologists employed by the Department of Education and Science to deal with psychological assessments in primary schools. However, the service is still not good or fast enough. I do not understand why some students can be assessed while others in the same county cannot. The need is the same and this area needs to be addressed. If the view of a school principal is that a pupil needs a psychological assessment, the child must receive it regardless of his or her school. As the Minister said, we must have a culture of care, understanding and help for children in the early stages of their lives. The child to whom I referred will be in fifth class before an assessment can be carried out. Given the Celtic tiger economy, it is disgraceful and unacceptable that the child must wait five years for an assessment.

I do not suggest some children will require psychiatric services in the long term, but they need psychological assessment and help now and they are not receiving it. When they progress to second level, the problem is exacerbated and their difficulties are much more serious. These begin to impact not only on the school, but also on society. In my town of Drogheda, there is need for special units for children whose behaviour in schools is unacceptable. Their significant behavioural problems, which are not related to educational understanding, mean they are outside school most of the time. It may not be within the Department of Education and Science's rules, but such pupils are continually on suspension because the schools cannot look after them due to a lack of services. Special education units, staffed by teachers and involving the input of psychiatric and other services, are required for such children. These children, although technically on suspension, leave school early. They start drinking, get into trouble with the law and eventually end up in prison.

The inspector stated that the psychiatric services in prison are very poor. On Wednesday, 20 December 2000 the High Court judge, Mr. Justice Dermot Kinlen, called for radical alternatives to the current system for dealing with convicted criminals and said that a large number of offenders should be taken out of prisons. Mr. Justice Kinlen also said it was regrettable that the Central Mental Hospital and the prison services were under the control of different Departments and he called for more psychiatrists to be appointed to deal with prisoners' mental problems. He added that the whole area of medical intervention in prison needs to be considered. The significant problem in this area is not being dealt with adequately. I know people who have been in prison, but they would not have been there if they had received the treatment and help they needed at a much earlier stage. Ireland would be a much happier country if people with serious emotional and other problems received treatment as early as possible.

The Minister referred to psychiatric services for the elderly in the community. I welcome the trend towards attaching psychiatric services to general acute hospitals. In the past, such services were located in mental homes. I am concerned about the number of senior citizens in private nursing homes who suffer from Alzheimer's and other psychiatric problems. I understand that the staffing levels and the care that can be provided in such homes is limited. The Minister can correct me if I am wrong, but I understand that the law requires the attendance of one registered nurse each day. Private nursing homes are getting bigger, but the staffing levels are not increasing. I am concerned about the attention and care senior citizens who require high dependency care are receiving in private nursing homes.

The inspector or health board staff should put such institutions under much greater scrutiny. This should also apply in terms of the services provided by hospitals, private nursing homes and health boards. The significant problem in this area needs to be addressed and this is why I called for a review of the Nursing Homes Act, 1990, with a view to establishing a proper inspectorate. The role of the mental health services should also be included in that review. Elderly people go into private nursing homes, but the State checks up on them only twice a year through a visit from the inspectorate. This is not good enough and it should be changed radically. There should be more scrutiny by the State of the care of the elderly, particularly in terms of mental health services.

The state of New Jersey has an ombudsman for older citizens. Ireland needs a system of official care in the context of care by the State. Many people with mental health problems in long-term institutions, many of whom are elderly, have lost contact with their families. I do not have statistics but I suggest that people receiving long-term care in mental institutions receive few visits. There is a need for greater interaction with such people in terms of occupational therapy and physiotherapy programmes etc. In America, the ombudsman interacts with patients. Representatives talk to patients about issues that affect them and their feelings about them. They act almost like a family for them. We need to do more in this area because such people are forgotten. They are not receiving the care and attention they deserve. The people who would do such work must be well paid. One of the problems in our psychiatric services is that, while the people working in them are committed, they are underpaid.

The inspector does an excellent job and I welcome the debate. Senator Fitzpatrick made the most important point that the Oireachtas Joint Committee on Health and Children should discuss the report and invite the inspector and the health boards to appear before it. We are not proactive enough in these issues. As a member of a health board for many years, I am of the view that we are moving away from the concept of visiting committees which previously visited institutions at least once a year. This practice is coming to an end. In dealing with other important policy matters we are losing touch with the institutions. As part of their brief from the Department of Health and Children, health boards should be instructed to visit mental health institutions and long-term care facilities.

Mr. Glennon

I welcome the Minister and Minister of State. It is appropriate that congratulations are offered to all concerned on the tremendous progress made in this area of the health services, particularly in recent years.

I listened with interest to the Minister who outlined the progress made. He stated that the 1984 report, The Psychiatric Services – Planning for the Future, was the first to recognise that the old institutional hospitals were unsuitable for the delivery of a modern mental health service. It marked the beginning of the development of the concept of a comprehensive psychiatric service located in the community, close to where people live and work. In the 17 years since the publication of the report significant advances have been made, particularly in recent years with the allocation of appropriate resources to provide the service to which we all aspire for the clients of the health service.

The Minister referred to the fact that while the shift to community-based services is progressing significantly, the rate of progress in developing alternatives to an institutional service needs to be accelerated. That is at the core of the current difficulties in the health service. In the Minister's words, priority is being given to raising awareness and promoting a better understanding of mental health among the public, thereby facilitating a greater and more positive acceptance of the transfer of mental health services from institutional to community-based settings. This is a topic on which I wish to comment as it has recently been the source of controversy in my area.

I have lived all my life within ten miles of St. Ita's Hospital, Portrane which, although one of the great institutions of the State, has been the source of controversy, particularly in recent years. This controversy has been fully justified in terms of the lack of resources for the ongoing care provided by the staff of the hospital. There has been controversy concerning a step-down facility in the area. The Minister's words in relation to priority being given to raising awareness and promoting a better understanding are appropriate. I question, however, the amount of money being made available for this priority. The Minister mentioned a figure of £730,000. Given the circumstances this could be adjusted significantly upwards with great benefits to the service, community and patients.

The word "republican" has, unfortunately been hijacked in the past 30 years or so. We should be conscious of its full meaning, however, and the aspiration in the declaration of independence to cherish all the children of the nation equally. This implies that greater attention should be paid to the weaker sections of the community and it behoves us to ensure, particularly at a time of relative wealth in the economy, the rush for material wealth for the stronger sections of the community is not facilitated at the expense of its weaker sections, particularly the patients referred to in the report. We, as legislators, must ensure they are not ignored.

We must strike a balance between the needs of patients and those of the multidisciplinary teams caring for them. The report refers to the move away from the dominant doctor-nurse model to the area of multidisciplinary teams such as psychologists, social workers and occupational therapists. In referring to the move from the doctor-nurse model to multidisciplinary teams and institutional-based care to community-based care there is no reference to the role of the community in dealing with the step-down and other facilities in the community.

Unfortunately, our recent experience has not been good. This could have been avoided if the information and education campaign referred to by the Minister had been taken on board at an earlier stage. A huge degree of misunderstanding tends to arise, with unfortunate consequences. It is time to take on board the role of the community and its place on the team caring for patients. Respect and dignity are at the core of any health service. I suggest that in this aspect of the health service respect and dignity for all concerned are absolutely crucial elements, not just in fulfilling our duty to patients but in ensuring maximum comfort and recovery, where possible. Dignity and respect are required in relation to the conditions in which patients are treated and live. Dignity and respect are required for the caring team looking after patients. I speak not just in terms of pay and conditions but in terms of an appropriate working environment. For far too long, the vocation of those in the health service has been exploited to a significant degree. If we are to maintain the goodwill of those working in the health service, we must be careful not to continue this exploitation of the vocational nature of their devotion to the service and patients. We have been very lucky in the past in this regard and we should be extremely careful that the goodwill that exists is maintained and preserved for the benefit of future generations.

Dignity and respect are also required in relation to the community in which the step-down facilities are being located. If we do not have respect for the community, it is difficult to encourage respect for the institution being located in their midst. A negative community reaction can have a very negative effect on the purpose of the institution, which is the treatment and recovery of patients. The sum of £730,000 would not buy a lot these days in terms of an information and education campaign. A significantly greater sum of money could be made available with considerable benefit, not just from an economic point of view but in terms of the feel good factor within the community.

There is a responsibility on us all not simply to throw money at a problem in the expectation that those who are paid will deal with it. This applies not only to the health service but across the public service. All in the community have a material role to play in addition to paying our taxes.

We must to some extent help to facilitate the treatment and recovery of patients. Where that involves apparent or real sacrifices on the part of some sections of the community, so be it. We are looking after our own people and modern standards require a realistic input on the part of the community. By this I do not mean the appointment of token representatives on consultative committees or boards of management, as was the vogue in various institutions around the country, but an active role for members of the community. If necessary, appropriate training should be provided to ensure a sense of ownership and belonging and a real relationship between the institution and the community. This reciprocal arrangement would significantly benefit the quality of life of all parties. I urge the Minister to give serious consideration to the development and maximisation of the education and information campaign which is a part of this aspect of the health service.

I note from the statistics that in 1999, 2,400 of a total of 24,500 committals to institutions, or 10%, were involuntary. In another role I am aware of the justifiable serious concern in general practice about the role of the general practitioner in the processing of involuntary committals and the relationship of the general practitioner, not only with the hospital but with the gardaí with regard to the effective processing of involuntary committals. A greater degree of co-ordination of the roles of general practitioners, health boards, hospitals and the Garda Síochána must be achieved if the unfortunate people who are the subject of the process are to be afforded the dignity and respect I referred to.

I welcome the Minister and the Minister of State to the House and I congratulate them on the progress they have achieved. I look forward to accelerated progress to the benefit of patients, carers and the community. It is the aspiration of us all that this unfortunate area of Irish life be looked after to the fullest extent possible. At a time of relative plenty it is incumbent on us to ensure that the appropriate resources, both financial and human, are devoted to that goal.

An Leas-Chathaoirleach

When is it proposed to sit again?

Mr. Glennon

At 10.30 tomorrow morning.