Seanad Éireann debate -
Thursday, 31 May 2001

Vol. 166 No. 20

Mental Health Bill, 1999: Second Stage.

Question proposed: "That the Bill be now read a Second Time."

Minister of State at the Department of Health and Children (Ms Hanafin)

The introduction of new mental health legislation is an important milestone in the development of our thinking in relation to mental illness in modern Ireland. Since the mid-1980s we have seen the development of an integrated and community based approach to the care of the mentally ill. This process has been based on the fundamental objectives of policy on the care of the mentally ill which have been adapted by successive Governments since the publication of Planning for the Future in 1984. Advances in the management and treatment of mental illness allow many sufferers to live within their own communities, carry on with their lives and continue to contribute to society in a positive and fruitful way.

Alongside the development of a community based service there is a need for reform of the statutory safeguards for those with mental disorders who are considered to be in need of hospital care. Since the 19th century powers have existed in law to protect those with mental disorders from the consequences of their behaviour and, more particularly, from abuse and exploitation in society. The current criteria under which mentally disordered persons may be detained involuntarily are set out in the Mental Treatment Act, 1945, which was last amended in 1961. The Act was innovative in the 1940s and its principles have been described as enlightened for its time. However, successive Governments have acknowledged that this legislation is in need of substantial reform to bring it into line with current thinking and international norms on the detention and treatment of people with mental disorder.

Last year there were just over 24,000 admissions to psychiatric hospitals and units. Some 10% of these admissions, approximately 2,400, were involuntary. Ireland has a significantly higher rate of involuntary admission than other European countries. Commenting on figures for 1999, the Health Research Board stated that non-voluntary admissions in Ireland represented 75.3 per 100,000 of the total population compared to 40 per 100,000 of the total population in England and Wales, and 26 per 100,000 total population in Italy. It is hoped that the introduction of this new mental health legislation, with its more stringent procedures for involuntary detention, will cause the number of involuntary admissions to decline, bringing practice in this country more into line with the rest of Europe.

At the core of this Bill, therefore, is the need to address the civil and human rights of persons receiving care and treatment in our psychiatric services. 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 our legislation on the detention of mentally disordered patients into conformity with the European Convention on the Protection of Human Rights and Fundamental Freedoms.

Another 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 primary vehicle for achieving this will be the new mental health commission, to be established under this Bill. The commission's primary function will be to promote and foster high standards and good practice in the delivery of mental health services. The existing Office of the Inspector of Mental Hospitals will be replaced with the Office of the Inspector of Mental Health Services, who will be employed by the commission. Both the commission and the inspector will operate independently of the Minister for Health and Children and the Department. This independent status will be crucial in driving the agenda for change and modernisation in the mental health services in the coming years.

Specifically, this Bill focuses on improving and modernising the criteria and mechanisms for the involuntary detention of persons for psychiatric care and treatment, establishing a system of automatic and independent review of all detentions, including the provision of legal aid to all those who are detained, and putting in place a framework by which the standards of care and treatment provided in our in-patient mental health facilities can be supervised and regulated.

Central to meeting these objectives will be the establishment of the new mental health commission. The commission's main functions will include promoting and encouraging the maintenance of high standards and good practice in the delivery of mental health services; arranging for an independent review by a mental health tribunal of all decisions to detain a patient on an involuntary basis, and each decision to extend the duration of such detentions; 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.

Among the many improvements made to the Bill in its passage through the Dáil was an expansion in the membership of the commission. Its membership of 13 now includes a practising barrister or solicitor, three registered medical practitioners, of which two will be consultant psychiatrists, two representatives of the nursing profession, a social worker, a psychologist, a representative of the public, three representatives of voluntary bodies promoting the interest of people suffering from mental illness, of which two will be people who have themselves suffered mental illness, and a representative of the health boards.

A key provision of the Bill is that each decision by a consultant psychiatrist to detain a person involuntarily for psychiatric care and treatment will be reviewed. Another significant improvement, agreed by the Dáil on Report Stage was a reduction in the length of the period for the review of a person's detention from 28 days to 21 days. The review provided for under this Bill will be independent and automatic. The process will be put in train immediately on a person's admission. All patients will have a right to review, even if they are discharged before the 21 day period has elapsed. Section 27 of the Bill provides that they and their legal representative must be informed of that right when they are being discharged.

Each review will be carried out by a mental health tribunal, operating under the aegis of the new mental health commission. As a result of amendments made in the Dáil mental health tribunals will include a lay person among their members, in addition to a consultant psychiatrist and a lawyer. The mental health commission will also arrange, on behalf of the detained person, for an independent assessment by a consultant psychiatrist, whose report will be sent to the tribunal for consideration.

The review that is proposed in this Bill will be substantive and is fully in keeping with our obligations under international law. It will focus on whether the person concerned is mentally disordered and whether the correct procedures were carried out in detaining him or her. A tribunal will be empowered to order the release of a patient if it considers that he or she does not require to be detained involuntarily.

I take this opportunity to clarify a number of points in relation to this review. Some commentators have referred to the fact that the White Paper proposed a review of detention after seven days and have suggested that what is contained in the Bill offers less protection to involuntary patients than was promised in the White Paper. This is incorrect.

The White Paper proposed that a procedural review of the legality of a person's detention would take place within seven days of involuntary detention. The type of review envisaged then would have been a paper exercise, simply checking that all the correct procedures had been carried out. It would not have touched on the crucial question which must arise in all cases of involun tary detention, that is whether the person is mentally disordered to the extent that it warrants a restriction on his or her liberty. The White Paper did not consider that the type of fundamental, clinical review which is proposed in this Bill was necessary until a person had been detained continuously for over a year.

I believe that the proposal in the White Paper did not go far enough to ensure the rights and interests of the detained person are protected. The proposal in this Bill for a substantive review within 21 days represents a major advance on that put forward in the 1995 White Paper. The Bill which is before the House today is a culmination of a long and detailed process of consultation and careful consideration, which began with the publication of a Government Green Paper in 1992. That was followed by the White Paper of 1995 and the publication of this Bill in December 1999.

Since the publication of this Bill, the Minister has received many submissions from interested groups and individuals expressing their views and concerns about aspects of the Bill's provisions. The variety of groups which have been involved illustrates the importance and the complexity of this legislation. They include the following groups: the Irish Hospital Consultants Association, the Irish Council for Civil Liberties, the Psychiatric Nurses Association, the Law Society of Ireland, the National Disability Authority, Schizophrenia Ireland, SIPTU, Social Workers in Psychiatry, the Royal College of Psychiatrists – Irish division, and the Mental Health Association.

All submissions received were carefully considered, meetings were held with some of the groups and a great many of the amendments which were put forward, both on Committee and Report Stages in the Dáil were in response to the concerns expressed by the various interests. The Bill before the House today, therefore, has been significantly improved and enhanced as a result of amendments made to it during the course of its passage through the Dáil. In addition to those I have mentioned, the most significant amendments which have been made to the Bill are as follows.

A new section, section 4, has been inserted into the Bill, which provides that the best interests of the person concerned should be the principal consideration in making decisions under the Bill, with due regard given to the interests of others, such as family or friends, who may be affected. The definition of mental illness in section 3 has been strengthened, drawing on the model of mental health legislation in New South Wales, Australia. Provision has been made for ministerial regulations to define the qualifications of an authorised officer of a health board, who has a function in relation to applications under section 9.

Section 25 regarding the involuntary detention of children has been substantially revised in order that the involuntary admission of children for psychiatric treatment can take place with the minimum number of examinations and court appearances possible consistent with safeguarding their rights. Safeguards have been inserted in section 28 in order that patients are not prematurely discharged or discharged into homelessness and also to enshrine in the Bill the principle that patients should not be held involuntarily for any longer than is absolutely necessary.

A provision has been inserted in section 42 to require the mental health commission to report to the Minister within 18 months on the operation of the process of involuntary admission and review. Section 57 which relates to the consent of an involuntary patient to treatment has been amended to provide that the consent of a patient must be obtained whenever possible. Treatment should not be administered without consent except where it is necessary to safeguard the life or well-being of the patient and where he or she in incapable of giving consent.

A new provision has been added to section 64 to allow the mental health commission to attach conditions to the registration of psychiatric units and hospitals. This will give the commission powers to ensure standards are improved and maintained. A new section, section 75, has been inserted which provides for a review by the Minister of the whole Bill within five years of the establishment of the new mental health commission. The Minister will report the findings of the review to each House of the Oireachtas.

The provisions of the Bill lay the foundations for achieving a sustained improvement in the quality of care provided in our mental health services. Both the new mental health commission and the inspector of mental health services will play a pivotal role in this regard. The current inspector of mental hospitals has already begun this process. A document entitled, Guidelines on Good Clinical Practice and Quality Assurance in Mental Health Services, was prepared by the current inspector and published by the Department of Health and Children in 1998. The guidelines are an educational endeavour to increase awareness of the main quality issues in service delivery and their monitoring, refinement and improvement. They have been circulated to mental health professionals and service providers around the country. I anticipate that similar guidelines and other measures will be developed by the new commission to assist service providers in their pursuit of excellence in care delivery.

The present inspector of mental hospitals plays a crucial role in providing independent and detailed analysis of our mental health services. The inspectorate has provided both expertise and assistance in identifying problems and outlining the need for improvements. Under the provisions of the Bill the existing office of the inspector of mental hospitals will be replaced with the office of the inspector of mental health services, thus giving the new inspector a much broader remit than that of the current one. The new inspector will be employed by the mental health commission and have complete independence from the Minister and his or her Department. This represents a major improvement on the proposal in the White Paper that the office of the inspector be associated with the Department of Health and Children.

In addition to the annual inspections of in-patient facilities which are carried out at present the new Bill will require the inspector to carry out an annual review of all mental health services. This includes community residences and day centres as well as acute in-patient facilities. The inspector's review of the services, including reports on inspections carried out, will be published with the mental health commission's annual report and laid before the Oireachtas.

Another important responsibility of the inspector will be the regulation of standards in the mental health services. A register of approved centres, in which each hospital or in-patient facility providing psychiatric care and treatment must be registered, will be maintained by the new mental health commission. Regulations will be made specifying the standards to be maintained in all approved centres. It will include requirements on food and accommodation, care and welfare of patients, suitability of staff and the keeping of records. The execution and enforcement of these regulations will be the responsibility of the mental health commission through the work of the inspector of mental health services.

The Bill also addresses the need to provide safeguards for patients in relation to consent to treatment. The Mental Health Act, 1945, and subsequent amending legislation, does not cover the issue of informed consent to treatment given by a detained patient. However it had been widely assumed that if a person was involuntarily detained in a psychiatric hospital his or her consent to treatment was not required. Concern about the rights of mentally disordered patients has led to a questioning of this assumption. In response to this concern, Part 4 of the Bill clarifies for the first time the obligations of the mental health professionals regarding consent and brings our legislation in this area into conformity with the requirements of the European Convention on Human Rights. This Part of the Bill has been significantly strengthened and improved during its passage through the Dáil.

One of the major challenges facing the mental health services is to provide all in-patients with a good quality alternative to care in large psychiatric institutions. The overall number of in-patients in psychiatric hospitals and acute psychiatric units continues to decline and stood at 4,559 at the end of 2000. Unfortunately the rate of progress in closing down the old hospitals and building up the community service has not been as fast as had been hoped when Planning for the Future was adopted as Government policy in 1984. It has to be acknowledged that during the years the mental health services have frequently lost out to other services which have been given priority in the allocation of development funding. If we are to sustain and develop the concept of a compre hensive psychiatric service located in the community, adequate funding and support must be provided. I fully recognise that much needs to be done in this regard and it is intended to facilitate health boards as far as possible in bringing about the necessary improvements and developments.

It is time to make a concerted effort to tackle in a determined and comprehensive manner the problems in our mental health services. To this end, an additional £18.6 million has been allocated to the mental health services this year. This represents an increase of 50% on the additional funding provided last year, which represented a 100% increase on funding provided in 1999.

Priority is being given to child and adolescent psychiatric services, to which an additional £3.225 million has been allocated this year. Steady progress has been made in recent years in developing a specialised service for this particular client group. Each health board now has a minimum of two consultant-led child and adolescent multi-disciplinary teams. This year's funding will expand the existing child and adolescent psychiatric services by supporting the recruitment of additional consultants and the further development of multi-disciplinary teams.

A working group was established in June last year to examine current needs in the area of child and adolescent psychiatry and make recommendations on its future development. The working group presented its first report to me in March 2001. It recommended the enhancement and expansion of the overall child and adolescent psychiatric service as the most effective means of addressing current needs. The report also recommended that a total of seven psychiatric in-patient units for children aged six to 16 years should be developed throughout the country. Project teams have been established in respect of proposed units in Cork, Limerick and Galway and capital funding will be provided for these units and a further two units in the Eastern Regional Health Board area under the National Development Plan, 2000-06. The estimated cost of the working group's recommendations is £90 million and the required funding will be discussed in next year's health Estimates.

Other priorities in the development of mental health services include the continuing development and expansion of community based services, the development of old age psychiatry and the expansion of suicide prevention programmes now in place in all health boards. The provision of capital funding is also essential if the mental health services are to be transformed in the way that we would all wish to see. Substantial capital funding under the national development plan will go towards the development of mental health facilities. Approximately £150 million capital funding is being provided over the lifetime of the plan for this purpose, of which a significant part will go towards the development of acute psychiatric units linked to general hospitals which will replace services previously provided in psychiatric hospitals.

The Bill improves on the proposals put forward in the 1995 White Paper in a number of significant respects. I acknowledge however that a number of other issues raised by the White Paper are absent from the Bill. I am aware that this has caused some disappointment among those with an interest in the mental health services and would like to assure the House that these issues have not been overlooked or forgotten. The issues discussed in the White Paper which have not been included in the Bill – most notably, the proposals in relation to mentally disordered people before the courts and in custody – require further detailed consideration by the Department of Health and Children. Discussions on them must also take place with other Government Departments and agencies. It is the Minister's intention, when this Bill has been enacted, to ensure that these outstanding issues are addressed by the Department as soon as possible.

The Bill deals with the important issue of the civil and human rights of those who are involuntarily detained for psychiatric care and treatment. As a group, these people are among the most vulnerable in our society. They are often unable to speak for themselves. It is incumbent on us as a society to recognise our obligations in relation to these people. I am pleased to be able to bring before the House a Bill which will ensure that Ireland will now adhere to the requirements of the European Convention on Human Rights in this regard.

I would take issue with those who assert that this Bill does no more than the minimum required to bring us into line with the European Convention. In many respects, it goes further than what was proposed in the White Paper. Crucially, it provides for the establishment of the new mental health commission which will have the capacity, as an independent body, to drive the agenda in relation to modernising our mental health services. I am confident that the commission as proposed in this Bill, in conjunction with the enhanced inspectorate, will enable us to develop in the years ahead a mental health service which is in keeping with the needs and requirements of a modern society.

I commend the Bill to the House.

Mrs. Jackman

This Bill was first published in 1999 and a week has not gone by since then when Senator Henry and I have not asked for it to be introduced as a matter of the utmost priority. It is sad that, two years later, the Seanad is only now debating the Bill. We had hoped that it could have been introduced in the Seanad and that Members would, therefore, have had adequate time to debate its provisions. However, I hope sufficient time will be allocated on Committee and Report Stages to allow us to discuss the many amendments we intend to table.

I have received a huge number of representations and submissions from different organisations, the law reform committee of the Law Society, ordinary individuals, health boards, psy chiatrists and youth groups about this Bill, in respect of which there is intense interest. It is a pity it deals with only one aspect of mental health matters, namely, involuntary detention. I accept that this is an important issue but having had such a long period to consider matters, the Minister could have gone further and addressed other issues.

The Department of Health and Children's policy document, Shaping a Healthier Future, states that those in greatest need should be helped first, that we must include, with the utmost priority, those suffering from mental illness, in particular those suffering from severe mental illness, those who spend so much time in psychiatric care and that what we are really looking for is equity and also quality of service and accountability. The Bill only addresses the equity, quality of care and accountability in a narrow sense, namely, in respect of involuntary detentions.

Had it not been for the concerted efforts of Senator Henry, myself and others to have them debated, the reports of the Inspector of Mental Hospitals would have sat on a shelf gathering dust. Those reports make harrowing reading and show that there is little difference between health boards in terms of the type of service on offer. I compliment the Inspector of Mental Hospitals on the tremendous work he has done. I am sure he was very frustrated over the years and must have believed that the matters on which he reported were not being debated. I accept that efforts were made to improve the system when those reports appeared. If his reports had not emerged, we would not have had the opportunity to understand the conditions experienced by and the trauma undergone by people's loved ones who have been obliged to spend long periods in psychiatric institutions.

Improvements have come about as a result of the need to bring our legislation on the detention of mentally disordered patients into conformity with the European Convention of Human Rights and Fundamental Freedoms. That is one of the many reasons I am glad Ireland is so committed to the European Union. Would these issues ever be addressed if that was not the case? I may appear sad and cynical today, but as a nation we should be doing far more to address the needs of the mentally ill, who are the most vulnerable and weak in our society. This matter affects all families.

I am glad that standards of care and treatment will be monitored, inspected and regulated. The legislation provides for the compulsory detention of mentally incapacitated persons, in certain circumstances, under the parens patriae power vested in the State. It is important to stress that any restriction on the liberty of such people and any interference with their rights must be kept to a minimum and that their dignity and self-respect should be fostered. In addition, there should be ongoing updates and reforms to reflect what should be a mature society's understanding of mental illness and of the needs and the rights of the mentally ill. Society is changing and the proportion of elderly people within it will continue to increase. From reading about this issue, I am aware that our legislation and mental health regime are out of step with those in Northern Ireland, England and Wales. There is no doubt that we are far behind our near neighbours.

When we debated the reports of the Inspector of Mental Hospitals, we should have addressed many of the crucial issues which arise in respect of this matter. The last Act dealing with this area came into force in 1945. Some 55 years later the Green Paper and the White Paper – many of the recommendations it contained are not dealt with in the Bill – appeared. My party welcomes certain aspects of the Bill before us, particularly the procedures relating to involuntary detention. However, we intend to introduce amendments which will hopefully improve the Bill as passed by the Dáil.

I welcome the establishment of the new mental health commission which will have responsibility for promoting and fostering high standards and good practice in mental health services. In my opinion, the funding outlined by the Minister of State will fall short of what is needed to bring our psychiatric services and institutions up to a decent level and ensure that people receive adequate care.

I am glad the Office of the Inspector of Mental Health Service, which will replace the existing Office of the Inspector of Mental Hospitals, will be an independent entity. I stress again my thanks and those of the general public to the Inspector of Mental Hospitals for highlighting so many of the problems that exist in our mental hospitals. I welcome the fact that the new office will be independent of the Minister and the Department.

I welcome the establishment of a register of approved centres. When one considers the statistics to which the Minister of State referred it is incredible that 2,400 of the 24,000 admissions to mental hospitals last year were involuntary. Why is the rate of involuntary admissions in Ireland significantly higher than that which obtains in other European countries? As the Minister of State indicated, the Health Research Board estimates that the figure for Ireland represents 75.3 per 100,000 of the total population. That is high compared with 40 per 100,000 in England and Wales, our nearest neighbour and with which it is right to make comparisons, and 26 per 100,000 in Italy.

We hope it will not be just an aspiration to do something to reduce the numbers of involuntary admissions to bring our practice into line with other countries in Europe. I do not see any reference in the Bill to voluntarily admitted patients consenting to the treatment they are about to undertake. This has been the subject of research.

Prisons are an area that could have been addressed in the Bill and the subject has been highlighted repeatedly. It has received significant coverage on radio programmes, especially in the form of many excellent contributions from Dr. Smith, director of the Central Mental Hospital, who has stated starkly that at least 100 prisoners in Mountjoy Prison should be in a psychiatric institution and not in prison. He has repeatedly referred to the fact that incarceration in padded cells for up to ten days is the only option available for the treatment of these prisoners. The visiting committee asked why people with obvious psychiatric problems are committed to prison. That question has not been addressed and has been omitted because of the demarcation between the Departments of Health and Children and Justice, Equality and Law Reform, but that should not be a reason people in prison with psychiatric problems are not dealt with properly.

Suicide is an issue which has been debated repeatedly because of the initiative shown by Deputy Neville who, as a Senator in this House, pushed hard for the decriminalisation of suicide. This is something which could have and should have been dealt with in the Bill. There is a need for multidisciplinary teams which are accessible to all health boards. Services are fragmented and diffuse and there is a difference in the service available in the various health boards.

Another issue whose omission from the Bill upsets me enormously is illustrated by the fact that tremendous upset is caused to adult and teenage psychiatric patients in Limerick Regional Hospital because they do not have separate and designated units. This means the two different age groups are lumped together. This is extremely stressful for the elderly who are subjected to the energy of young people suffering from psychiatric illness. It is extraordinary that something has not been done about this. It is distressing for both groups and also for their relatives when they come to visit because they feel helpless and believe there is nothing they can do to deal with the matter. This area has not been dealt with, even though it is a simple matter of resources.

I have had contact with parents of children who suffer from attention deficit hyperactivity disorder who tell me that, because no designated service or integrated approach is shown to them by the Departments of Health and Children and Education and Science – with the result that, in many cases, the Department of Justice, Equality and Law Reform must be brought in – those children do not receive the assistance they need. I was shocked when examining this issue to find that six of the eight health boards do not have facilities to deal with children suffering from psychiatric illness. Where is the equity in that? The issue is not addressed in the Bill.

I know the confines of the legislation are narrow, but the Minister missed out on an opportunity to deal once and for all with the many problems associated with psychiatric illness, not just in the elderly and adult population but also in young people, among whom there has been an increase in the incidence of suicide, and in children who suffer from disorders such as attention deficit hyperactivity disorder. While there may not be an increase in that last group, parents now highlight the issue because they no longer accept that their children should be left without appropriate treatment. Dublin is the only area where girls who suffer from anorexia receive adequate and suitable treatment. The more opportunity we have had to examine the issue of the treatment of mental illness, the more I have become frustrated with the fact that the Bill does not go far enough to improve the lives of many young people with psychiatric problems.

The adult care order was debated intensively in the other House but is not addressed in the Bill. Why is this so, especially given the recommendations in the White Paper? Why bother even having a White Paper if its recommendations are not addressed? This is the fragmented approach to which I referred. Having had the opportunity of bringing forth recommendations from the Green Paper to the White Paper, we find they have not been addressed in the Bill nor have we been given a sufficient reason for that.

This debate is frustrating because I do not have time on Second Stage to deal with all the issues, such as the fact that, despite the psychiatric view that people with personality disorders are not amenable to treatment, form the greatest numbers who clog up general practitioners' surgeries and social workers' time and cause a crisis in the community because of their destructive and difficult behaviour, the Bill excludes them from any form of management. It is important to convene a high level task force on that matter. Another issue is the need for further training of social workers, prison service psychiatrists and especially gardaí, who are involved in detention and who have requested support and opportunities for training in the mental health area. There is much more to be said on the area of mental health and I will say it on Committee and Report Stages.

Dr. Fitzpatrick

I welcome the Minister of State to the House and I welcome this long-awaited and much needed Bill. It does not go far enough but that is a matter for another day. I pay tribute to those who work in the psychiatric services. They bring a great deal of concern, humanity and human warmth to what is often a difficult job with probably no result at the end in many cases.

The two central issues in the Bill are the proposed mental health commission and the mental health inspectorate. Senator Jackman said in the House the other night that we need a health inspectorate and health commission to oversee all medical facilities and to act as ombudsman or buffer between the health care system and the patients who are its customers.

Another point that should not be forgotten is that all the improvements made to the system have been made against a background of public indifference, if not outright hostility. Recently in the Northern Area Health Board area there was orchestrated opposition to patients being moved into a residential area. This was outrageous and scandalous but those responsible for it got away with it for months before the issue was resolved.

It would not be any harm to praise the Inspector of Mental Hospitals who, through his annual reports, has prodded the body politic, if not the public conscience, to improve the mental health and psychiatric systems. Apart from new forms of medication the first major development was the introduction of the movement of patients from the big old psychiatric hospitals into the community. In the early days this was not done with the required sensitivity or medical and financial support and there were one or two nasty upsets. The system has now settled down more satisfactorily. In my own area the health board moved patients into the general area around the hospital and no attempt was made to move patients into stable and established communities. That may change in time.

Part 2 of the Bill deals with involuntary admissions of persons to approved centres. Section 8(2) states, "Nothing in subsection (1) shall be construed as authorising the involuntary admission of a person to an approved centre by reason only of the fact that the person (a) is suffering from a personality disorder, (b) is socially deviant, or (c) is addicted to drugs or intoxicants.” I have enough experience as a general practitioner to know that one would have to be a genius to make such a clear distinction. I look forward to hearing the Minister explaining this section when it is discussed on Committee Stage. Several Members have worked in the medical or psychiatric services and we would all like an explanation as to how this section will be applied with due regard to the safety of the patient and the public and the general concerns of the patient's family.

Dr. Henry

I welcome the Minister of State and the Bill. It is always useful to hear Senator Fitzpatrick speak before me. He speaks such good sense that I can refer to much of what he says.

As I have the dubious distinction of being the first Member of the Oireachtas to have the report of the Inspector of Mental Hospitals discussed in either House, I am relieved to see that the Bill has reached the House today. There has been a great improvement in the Bill since it was introduced to the House in December 1999. I congratulate the departmental officials and all who have been involved on Committee and Report Stages in the Dáil on the amount of work done on the Bill.

Having expressed my congratulations I will not annoy the Minister of State by describing the Bill as the involuntary admissions and commissions Bill. There are however large areas in the White Paper published in 1995 which are not included in the Bill. The most important of these is chapter 7 which dealt with the diversion of those with mental disorders who came before the courts to mental health courts. The exclusion of this recom mendation from the Bill is a disappointment to many of us. One feels that the Bill has been driven forward by the fact that the European Union convention on human rights and treatment has placed pressure on the Government to regulate involuntary admission in this country. This lack of regulation has been a great problem for those working in the mental health service, whom Dr. Fitzpatrick so rightly praised, and for general practitioners, community psychiatric workers and others, as well as for patients and their families. A problem also arose because there was no method for those who had been involuntarily admitted to hospital to be discharged.

The Bill as passed by the Dáil is an improvement on the Bill as initiated but it is a pity it is not set out in a more logical way. It should deal with matters in sequence, beginning with the assessment of the patient. Senator Fitzpatrick has pointed out the difficulty presented in section 8(2). I am delighted I am not one of the geniuses who must decide whether a person is suffering from a personality disorder, is a social deviant or addicted to drugs or intoxicants. Many are precipitated into psychiatric situations by their addiction to drugs or intoxicants. I do not know how this provision will be dealt with. If we are to have these exclusions from involuntary admissions, why are conduct disorders in children not included. I will certainly propose an amendment to that effect in order that the question will at least be debated on Committee Stage when the House will have much work to do.

The Bill should then proceed from assessment to admission. I have concerns regarding the provision which allows the admission of a patient into a psychiatric hospital by a consultant psychiatrist, registered medical practitioner or registered nurse. I would like a medical practitioner or a registered nurse to have a certain number of years training before making such an admission. Our psychiatric service has a huge dependence on non-EU doctors. They occupy almost the entire number of medical posts at non-consultant level. I would not like to see someone who had arrived the previous night from Pakistan deciding whether a patient should be admitted to a psychiatric unit. I would not like to see a recently qualified registered psychiatric nurse doing so either. This provision must be re-examined.

I would like to have seen more in the Bill regarding a programme of treatment for patients. It does not appear to contain a provision giving a statutory right to a programme of treatment. A period of 21 days is a long time before a person comes before the mental health tribunal. If we are to have tribunals for adults, why will we not have them for children? I would like to have seen a statutory requirement for a pre-discharge programme for patients and planning for patients after their discharge.

The Bill contains no community element, the lack of which is one of the most serious deficiencies in the psychiatric service. Planning for the Future was a splendid document. A considerable number have been discharged from psychiatric institutions but unfortunately money has not been provided for community services. People are trying to provide community services for psychiatrically disturbed patients with inadequate facilities and money. The Bill is concerned with civil liberties. People have a right to their liberty but they also have a right to proper treatment. Despite the improvements the Mental Health Commission will make I would like to see a statutory right to proper treatment. No one wants people to spend an hour longer in hospital than is necessary but there should be a treatment plan for them and a logical follow-up in the community.

Chapter 7 of the White Paper made very useful recommendations. The same recommendations were made by the Henchy committee in 1978. The Council of Europe also made a recommendation that we should have mental health courts. There is no discussion as to what is to happen to the people who are referred to in section 8(2) as those who are suffering from personality disorders, are socially deviant or addicted to drugs or intoxicants. People like these would have been dealt with by mental health courts.

We are constantly trying to establish reciprocity and bring our legislation into line with legislation in Northern Ireland. The Mental Health (Northern Ireland) Order, 1986, is totally concerned with patients in criminal procedures or under sentence. It is really excellent and I hope to introduce a considerable number of its provisions on Committee Stage in the hope that some amendments might be accepted in order to deal with these people.

I thought the Bill would include an updated definition of criminal insanity but it does not. At present, if a person is found to be insane, as defined under Irish law, the person will be sent to the Central Mental Hospital but it is extraordinary that there is a waiting list for admission to that hospital. It is serious that people with severe mental disorders will not receive hospital treatment but will be sent to prison instead.

On numerous occasions I have received support from many Senators for my view that prison is not a suitable place in which to treat people with mental illness. In a recent Adjournment debate I described the treatment of those brought before the courts for minor offences who can end up in padded cells in Mountjoy and other prisons for days or even weeks in some cases. I am quite sure the Minister does not want such people to be there but neither do the people who are trying to run the prisons.

Miss Quill

Yes.

Dr. Henry

It is an entirely unsuitable place in which to hold mentally ill people. There is a psychiatric service in the prisons but the Minister for Justice, Equality and Law Reform himself admitted in a debate in this House that the service is totally inadequate. I do not think anyone would deny that. I am delighted that Senator Lydon is here because he will be able to state how totally inadequate the psychological services are.

A huge amount of work remains to be done in this regard but it is not covered by the Bill and this is a great disappointment. The Minister said that all this will come about after this Bill has been enacted but it should be recalled that 20 years ago the Mental Health Bill was never enacted. I am not saying that the same thing will happen to this Bill but I am very much against the "live horse and you'll get grass" attitude. It has not worked out in the past.

People who are mentally ill and commit offences, no matter how minor, frequently turn up in our prisons because judges have nowhere else to send them. The Judiciary has repeatedly deplored this situation. The state of the Central Mental Hospital is something else. Units to which acutely ill people are admitted have not changed since Queen Victoria was a girl. The hospital was built in 1850, yet it is almost exactly the same now when Queen Victoria's great, great, grandchild is on the throne of England and in her 70s. There is no in-cell sanitation for these acutely ill people, apart from a plastic bucket. This is absolutely unbelievable and there are tiers of wards like this.

Admittedly, a new unit was opened some years ago where those who are not so ill have been put. However, a great number of these patients could be transferred down the country to allow more room to transfer people from prison to the Central Mental Hospital where they would receive the best form of medical treatment available. It is a pity the Bill does not address the transfer of patients from the Central Mental Hospital to other psychiatric units, although some staff may have become deskilled from treating acutely ill people. We are supposed to be trying to get these people better. Many of them have improved considerably and there should be a system whereby we can transfer them from of the Central Mental Hospital to other units.

The legislative provisions for the treatment of children have been much improved, although I wish they could also be dealt with by way of tribunals. Perhaps we can deal with that matter on Committee Stage. There is a big problem concerning violent adolescents who are mentally ill. The facilities to deal with such children are totally inadequate because there are no secure units to which they can be sent. A £90 million building programme has been announced but when will it happen? I am aware of the difficulties there have been in trying to get even four-bed secure units within our acute general hospitals. There seems to be a blockage everywhere when it comes to obtaining treatment.

It is not just a problem for the Department which has to fight its corner on this awful problem. Recently, a general practitioner told me there is a terrible problem in finding sanctuaries for fathers who have been beaten up by their violent adolescent sons. He said that places can be found for mothers in this situation but it is extremely difficult to find anywhere for fathers.

It is a good job that the "person of unsound mind" forms are going because general practitioners have had terrible problems with them. Could we not do more about the admission of patients, be they adults or children? The applicant is nearly always a relation of the patient but the definition of an authorised person within the health board is not very carefully specified either. Could we not expand the definition to include social workers and psychiatric community care nurses? Patients who are admitted involuntarily later return to the person who admitted them, who may be their spouse, father or mother. The social tensions that can arise in such cases are undesirable and, therefore, we should put more thought and time into this matter.

Admission orders have been much improved but some work remains to be done on them. More needs to be done also in order to build up community psychiatric teams but there is not enough about community care in the Bill. The role of such community work needs to be stressed. In addition, the legislation contains no provision for hostels which are the equivalent of long-stay wards. There is a dreadful problem in getting people accepted from psychiatric institutions back into houses within the community. There has been disgraceful behaviour in Swords concerning people who are being kept in institutions when they could quite easily be living in the community. This area must be tackled more forcefully.

I am concerned about the Bill's provisions for clinical trials. I know this section has been inserted in the legislation to protect involuntary patients from being involved in what one could describe as major clinical trials by pharmaceutical companies. We must remember, however, that if it were not for clinical trials, psychiatrically ill patients would not have benefited from the improvements that have emerged from drug treatments over the past 30 years. Inserting this total ban on clinical trials will prevent us from even having trials on, for example, the value of psychotherapy.

My secretary, Ms Enda Dowling, who was undertaking some research on my behalf, drew my attention to a recent newspaper article in which someone who is a great enthusiast for fish oils described a trial involving such oils at the University of Sheffield. That trial showed a 25% improvement in the symptoms of patients suffering from schizophrenia. I realise that one cannot just give people things and say, "I think they got better". We all live in the age of evidence-based medicine nowadays. Yet if we were to have a total ban on clinical trials we would not even be in a position to give seriously ill people fish oils to see if they made any improvement.

We may have to arrive at a situation where someone could give consent to such trials if they were felt to be of therapeutic benefit to the pati ent. After all, the thrust of our deliberations should be to obtain better treatment for patients. There is a principle of reciprocity involved; the State has a duty to provide facilities for the treatment of those whom it deprives of their liberty. It must be ensured that facilities and treatment are available.

I am concerned about the tribunals. Has anyone informed the Minister for Finance about them? The cost will be astronomical. Significant legal aid will have to be paid to a large number of lawyers. Patients will have legal representation but will consultant psychiatrists be represented? That is not clear in the legislation. The tribunals are important but they will only see the patient at a moment in time. What happens if the tribunal decides to discharge a patient following which he or she leaves the premises and commits suicide or a violent crime? Judges and lawyers will be exempt from audit in these scenarios. Must the consultant who is not favour of the discharge of the patient take responsibility for what happens when the patient leaves a psychiatric unit?

An enormous increase in the number of psychiatrists will be required because some will be needed to sit on the tribunals. The experience in Great Britain when tribunals were introduced was that approximately 60% of patients sought to appear before them. It is good that psychiatrists who have retired within the previous seven years can sit on the tribunals. That at least will mean practising psychiatrists will only have to appear before them. What is the position regarding psychiatrists' clinics when they appear before the tribunals? Surely all their appointments will not be cancelled. A large number of extra staff will be employed as a result.

What will happen to the clinics of general practitioners who might have to chase around after a patient who does not want to be involuntarily admitted? The last person I knew who had to involuntarily admit a patient had to pursue him along a railway line in Inchicore for a considerable length of time. When the patient eventually agreed to go to hospital he got in the doctor's car but then ran off when they stopped at traffic lights. When he was later captured and it was thought he would go to hospital peacefully a large kitchen knife fell from his sleeve as he was being put into an ambulance. Will doctors be insured by the State while out of their clinics chasing patients? GPs are being asked to take on a great deal of responsibility in this area.

I am glad the position of the Garda has been regularised but psychiatric community nurses should become more involved. I do not like the notion of sending staff from the approved centre to bring in a patient because it smacks too much of the men in white coats coming to get somebody. There is no mention of the involvement of the ambulance service which could be considered as a possibility.

Committee Stage will be interesting because the Department has provided a list of all those who have contacted it. However patients, former patients, their relatives, numerous GPs and psychiatrists and various organisations have been in touch with me. Promises were made in the Programme for Prosperity and Fairness regarding the psychiatric services on which I am quite sure the Department of Health and Children would not like to default.

Miss Quill

I will be brief because we will have an opportunity to visit the detail of the Bill on Committee Stage which I hope will be taken before the end of the session. The legislation has been a long time in gestation. It is almost a decade since the White Paper on Mental Health was published and it is not before time that the legislation has come before us. There has not been much merit in the delay but at least an opportunity was provided for widespread consultation.

The Bill is narrow in focus but is good, promising legislation in terms of what it sets out to do. I welcome the framework proposed, particularly the establishment of the mental health commission and the appointment of an inspector of mental services. These two vital provisions will enable us to work much more systematically towards the betterment of services in the years ahead.

We must hang our heads in shame in regard to the provision for mentally ill citizens in many cases to date. Earlier I read the report of the Simon Community which was published yesterday. It points out that a minimum of 25% of homeless people on the streets of our cities are mentally ill. That tells its own story. When it was rightly decided to close grim, grey institutions such as Our Lady's Hospital, Cork, no proper provision was made for an alternative system. A promise was made to put a community care package in place to provide a more humane and respectful alternative to the grim, grey institutions but it never materialised. Minuscule provision was made as a result of which people were driven out of institutions which provided a certain security onto the streets.

The statistics relating to mentally ill people who are homeless on our streets make grim reading. In addition we are regularly reminded by people such as Dr. Smith about the large number of mentally ill people who are incarcerated. This highlights the dearth of provision in terms of proper care for the mentally ill. We must catch up in terms of providing alternative institutions and community care. I hope the legislation and the money that has been promised will at least start a new drive to make up for the lack of provision through the years to look after the mentally ill. To do any less would be a shame and an indictment of all of us.

I welcome a number of provisions in the legislation. The appointment of a commission and an inspector is a significant step in the right direction. Senator Henry will not have to argue like a fish woman in future to have the report of the inspector of mental hospitals debated in the House. She had to do so in the past because it was not considered a priority. I hope such a debate will become a priority of both Houses in future in order that we will have up-to-date information on the level of provision. Without such information we will not be in a position to make adjustments, vote more money or sanction the recruitment of more staff and therefore make proper provision for the mentally ill.

I welcome the provisions for young people who have psychiatric problems. When I was chairperson of an all-party committee juvenile justice was debated and we received reports from a number of sources about young people with psychiatric problems but there was no centre where they could be properly cared for. They were lumped in with other young people in institutions such as Oberstown House where a proper assessment of their needs was not conducted and the care and treatment they needed was not available. Ailments which could have been addressed were left unattended.

Under this Bill better provision will be made for young people, which is important. It was accepted as part of our culture that once a person was committed, he or she stayed there for the rest of his or her life. There was a tolerance of or a containment approach to mental hospitals in the old days. I hope the new psychological and psychiatric insight we now have means we will adopt a different approach and that we will seek in so far as possible to treat people with a view to putting them back into the community as ordinary citizens like the rest of us. Good things are also happening in this area. Voluntary groups, for example, provide art and crafts in psychiatric hospitals which help to motivate people. They seek to exploit the intellectual gifts of a number of people who are mentally ill and to help them to live a better and more rounded life. I compliment those who do such work.

We have a narrow focus in this area. However, I take heart from the proposals in this Bill. We must make proper provision in certain areas without delay. We must revisit the area of court judgments, particularly the judgment of guilty but insane because it is unsatisfactory as it currently stands. There are also areas where medical and psychiatric opinion must be examined before sentences are handed down. There is a number of cases, which I will specify on Committee Stage, where proper and adequate psychiatric, psychological or medical opinion should be engaged before a sentence is finalised.

I welcome the Bill, which is a major step in the right direction. A number of other related steps must be taken quickly if we want to have modern and satisfactory services for our mentally ill people. The key to the success of this Bill is the provision of adequate staffing at every level to ensure that this Bill is enacted.

Mr. O'Dowd

This is important and useful legislation. Things have changed dramatically and radically since the mid-19th century when many psychiatric hospitals were built. While the dark and dismal buildings with the high walls still exist, they are occupied by groups other than those suffering from mental health disabilities. The policy of the State and of successive Governments has been to deal with mental health issues, where possible, in the community, not in institutions. That is a positive, constructive and worthwhile approach.

Other speakers mentioned homelessness and that a number of people with mental health problems are beyond the help and care of the institutions, health boards or community welfare officers. It is a shame that there are many homeless people in the country. I understand that a disproportionate number of homeless people in London are Irish and that a significant number of them have mental health problems. That is an issue which must be addressed not just in this country but in cities, such as London. I am not aware of the proposals the Department of Health and Children has to deal with that. Perhaps now is the time to move these issues up the Department's agenda.

I was a teacher for a number of years and I saw young people of 14 or 15 years of age whose behavioural pattern caused them to be expelled from school and to end up in the courts or on junior liaison officer schemes and eventually in prison. A number of them have disturbed patterns of behaviour. I am talking about people who do not respond to the normal positive pressure from parents and schools. More needs to be done by the Department of Education and Science, rather than the Department of Health and Children, to keep people in society and to stop them from becoming ill. We need constructive and positive intervention at an earlier stage. These young people are readily identified by the schools. There must be liaison between health boards and schools to determine what can be done to help such students.

One student's parents referred their son to me recently. He had been expelled from his second level school because of his behaviour. He was extremely disturbed. The best the Department of Education and Science could offer was one to one teaching for eight hours a week. However, there were other issues, including mental health issues, which needed to be considered. This problem can be tackled by more and better liaison between the various groups.

Our mental hospitals or long-term care institutions are extremely well invigilated, according to the report of the Inspector of Mental Hospitals. I acknowledge the many improvements in the system and the professionalism of all the people concerned. Nevertheless, when one visits these hospitals one sees the patients looking into blank space. Many of them have been there all their lives or for a significant portion of them. There is no interaction in many cases between the excellent medical care and the occupational therapy they receive.

I received a report recently from the North Eastern Health Board about occupational therapy services in Meath and Louth. There is one vacant occupational therapy post in the mental health services in County Louth while there are two such posts in County Meath. However, both posts in County Meath have been vacant since they were approved four years ago. There are no occupational therapy services for mental health patients in Counties Louth or Meath. That is disgraceful. I am not blaming the health boards which advertised the posts. Are people not getting enough pay or are the work conditions unsatisfactory? What is special about the mental health services that we cannot get occupational therapists to work in them? I ask the Minister of State to carry out and publish a survey on the occupational therapy services in the mental health area in all our health board regions. This area needs special care and attention. Perhaps we need to pay people significantly more to work in the mental health areas. I would be happy to do that to get it right. The current situation is unacceptable.

I welcome the importance the Department and the Minister are attaching to the mental health services. I hope my contribution will ensure there is an immediate and serious examination of this issue and a recommendation and result as quickly as possible to ensure those in institutions covered by the mental health services get the attention and care to which they are entitled and deserve.

According to figures the spend per head in the mental hospitals in each of the health board regions is disproportionate. While I accept that some regions contain more hospitals, the spend per county indicates that the spend in County Louth is much less than in others. There is a need to look at spending on the mental hospital services on a per capita basis to see the reason there is such a disparity at regional and county level.

In the North Eastern Health Board the trend in recent years has been not to visit the hospitals. Hospital committee meetings and community care committee meetings are held but visits to hospitals have been stopped. I am unhappy with this. The Minister should ascertain if this applies throughout the country or only to the North Eastern Health Board area. Visiting committees should continue to visit, meet and speak to patients in the hospitals. It would at least improve our knowledge of what is happening. I acknowledge the dedication and professionalism of all the caring staff in the hospitals to which there is a need to add.

Dr. M. Hayes

It is a pleasure and a difficulty to follow Senator Fitzpatrick and Senator Henry on matters like this because they bring so much direct knowledge to the House. Senator Henry cheered me by referring to the Northern Ireland 1986 Mental Health Order because I recall giving instructions to the draftsmen for that legislation. I am glad the Senator thinks it has stood the test of time.

These are very difficult balances to hold. Previously people were incarcerated far too easily in the old mental hospitals. This was followed by a trend where it became virtually impossible, even in the most difficult situations, to secure an involuntary admission. The 1986 order was intended to deal with this in a way that at the same time asserted and protected the human rights of the patient.

The Bill is primarily concerned with protecting and asserting the rights of the patient which I favour. Like other speakers I regard it as nothing more than a building block towards a more fully developed legislative approach to mental health and mental health services. We would have expected a response to other parts of the White Paper but while it would not be helpful to recast the Bill so as to make it encyclopaedic, I hope the Minister does not regard it as the last word on the issue.

I am less worried than Senator Fitzpatrick or Senator Henry about section 8. It is a question of definitions and exclusions to be read in the context of section 3. However, while I welcome the Mental Health Commission as a wonderful development – I hope it is given full support, resources and powers – I am concerned that the commission and the tribunal will be established virtually side by side. That may cause difficulty in European legislation. European courts increasingly insist that those who make quasi-judicial findings should be separate from those who make executive decisions. It may be possible to proceed by ensuring there are different personnel in each of the two structures.

The commission should be viewed as an important instrument for driving up standards, ensuring registration and that patients and staff are properly looked after and trained and that modern standards of care and treatment apply. The tribunal is somewhat different. It protects the human rights of the patient. It is more judicial in scope and I am less worried than Senator Henry about it becoming some kind of monster staffed by predatory barristers and others. That has not been the experience in Northern Ireland.

More attention should be given to adolescent psychiatry. When children are being seen it should be specified that those who express views on them should be qualified in adolescent psychiatry. In this regard I reiterate the importance other Senators have attached to the community psychiatric nurse as a resource.

It might be worthwhile to sometimes think in terms of the potential for cross-Border co-operation. It may be that in aspects such as the provision of secure accommodation, especially provision for adolescents who need psychiatric care, there should be at least one place on the island. Services are deficient, both North and South, and there is much to be said for aligning the legislation to ensure patients can be admitted to the most convenient facility or location to them.

It is a pity that there has not been greater provision for the question of diversion, the treatment of people from prisons and keeping those out of prisons who should not be there. Perhaps it is an issue for the Department of Justice, Equality and Law Reform. I am sure the Minister and other Senators have received, as I have, representations from the Irish Prison Reform Group which I commend. Prison is not the place for many of those who are there.

The Minister of State spoke about the higher levels of involuntary admission in Ireland than elsewhere. This is largely true. However I advise against regarding Italy as a desirable place to emulate because it is still suffering from the disastrous results of a radical programme, Psychiatrica Domestica, introduced some years ago.

It is ultimately a question of resources. It is hugely important that we do not finish up with nothing other than what may be described as a nice Act. If these provisions are to be carried out, they will require considerable resources. I hope they will be available. However I commend the Minister and his Department on introducing the Bill. It is a very good model in terms of what it sets out to do. It may be improved on Committee Stage but we would all like to think it is not the Minster's last word on the matter.

Mr. Norris

I welcome the Bill, but the congratulations are a little over-emphasised because it is minimalist and also a reaction to two significant factors. The first factor was the decision in the Croke case in the European Court of Human Rights recently where the Government conceded that existing mental health legislation did not provide an independent formal review of involuntary detentions, contrary to the European Convention on Human Rights. It also had to pay a substantial sum of cash to Mr. Croke in the case.

The second factor is the criticism of the Government by the United Nations Commission on Human Rights in Geneva for providing for involuntary detention for up to 28 days before the review became necessary. The Attorney General, Mr. McDowell, said another look would be taken at that provision.

The Bill proposes tribunals that will consist of a psychiatrist who will sit with a legal assessor, but there is no provision for a lay person, a move that was sought. One must wonder from where the members of the tribunal will come and how they will be financed. The solicitor who took the case to Europe is on record as saying that they will need to recruit and train solicitors, paid for by the public purse, as each patient will be entitled to be represented by a solicitor. The real question is not when the legislation will be passed – that will be soon – but when it will be brought into full operation and properly financed.

The Minister of State referred to the many submissions made. The Irish Council for Civil Liberties made a pointed submission in which it stated that the Bill deals solely with involuntary admissions which can, because of the circumstances in hospitals, occasionally become a blurred matter. The provision for a review of detention within 28 days is meaningless and falls significantly short of the seven day period recommended in the White Paper on Mental Health. If one looks at the figures for 1997, they indicate that 71% of voluntary patients were released within a month. A 28 day review period means nothing. The Bill is not as comprehensive as one might have assumed.

It is interesting that Members on the Government side of the House, particularly Senator Fitzpatrick, who has a clear professional acquaintance with this area, and Senator Quill welcomed the Bill but said it did not go far enough. I also want information on why such a high proportion of admissions in Ireland are of an involuntary nature, which is uncharacteristic of the rest of the European Union. This aspect concerns many of us. However, I welcome the establishment of the commission and the review.

One point may be considered minor, but it should be considered, particularly in the light of recent court cases. The Government has rejected amendments that would lead to the possibility of treatment for patients in the Gaeltacht in the Irish language. Is the Government serious about this matter because somebody who is unwell needs to be able to deal with medical practitioners in the language with which he or she is most familiar, particularly if it involves a mental illness which may include communication difficulties?

Another problem relates to the definition of a child. We are told that a child is anybody under the age of 18 years unless he or she is married. Apparently, the act of marriage immediately transforms one into an adult. This is a slightly bizarre proposition, particularly from my point of view, and it is a pity.

A further issue relates to children refusing to give consent and what can be done in such a dangerous situation. Section 25 radically changes the application procedure that was proposed in the White Paper. There is no reference to the need for a medical psychiatric assessment prior to the health board applying to the court for an order to detain a child in an approved centre. It states that if it appears to a health board that a child has a mental disorder and one or both parents fail to consent to making an application under section 8 in respect of the child, the board can go ahead. On the recommendation of the consultant psychiatrist, the child can be detained in an approved centre for 28 days with extensions by three, six and 12 months. However, there is also provision for an ex parte application to be made where the court could direct the admission on an interim basis of a child without any prior medical or psychiatric opinion.

There are specific concerns with regard to people under 18 years of age. They could find themselves detained in a psychiatric unit, in either an adult or an age appropriate facility, without a prior medical or psychiatric assessment. They are denied an automatic right to have a voice in the process of their admission and detention. They are also denied access to a tribunal, a member of which will be a consultant psychiatrist who provides an independent psychiatric opinion. There is no automatic provision for them to have legal representation and they are denied the opportunity afforded to adult patients under section 59 to participate in decisions about their treatment beyond the initial three months detention.

I referred to the issue of consent during the debate on another Bill yesterday. This legislation indicates that my concern was correct. There should be an examination of the principle of consent rather than the arbitrary age related provision. There has been a major debate in Britain about this issue as a result of a series of cases in the courts. They have been in favour of supporting parental authority to override the child's refusal of consent for essential treatment. At least there has been a debate in England; there has not been such a debate in Ireland.

Mental health legislation should be used irrespective of age. Conduct disorders should be included in section 7(2) to ensure that children and adolescents who are out of control are not inappropriately detained in psychiatric facilities. It should not be an absolute requirement that both parents should give consent. The exclusion of young people from the safeguards which are central to the proposed legislation must be in conflict with the United Nations principles for the protection of persons with mental illness and the improvement of mental health care and the United Nations Convention on the Rights of the Child.

There are many problems with the legislation in terms of aspects that are not covered, for example, diversionary schemes. It was stated in the White Paper that there would be diversionary schemes for mentally ill people who, by virtue of their illness, would otherwise be put in prison for relatively minor public order offences. If this had been included, it would have brought Irish legislation into conformity with the European convention for the protection of human rights and fundamental freedoms. The Minister, Deputy Cowen, recognised this problem in a reply to an Adjournment debate. He accepted there were indications that an increasing number of vulnerable and mentally disordered people were being committed to prison. He continued that, in this regard, there is a risk that prison may be used as a refuge of last resort by the courts for some mentally disordered people who may be charged with public order offences that are by-products of their illness.

The Minister said it would be beneficial if such minor offenders could be given medical treatment either on an out patient basis in the community or, in extremis, in a hospital until their condition stabilised. However, there is no provision for this in the Bill. Such a provision was contained in chapter 7 of the White Paper. The paper suggested that judges should accept medical opinion from the health board before sentencing and, where possible, divert to the community services. In the Bill, the screening process by the Judiciary no longer exists. Furthermore, section 12 appears to place undue reliance on the decisions of the Garda in this area.

I wish to put on record a statement from a distinguished child psychiatrist who contacted me. On the issue of prisons as an answer to the problem she stated:

Mentally dysfunctional people who end up in prison tend to act even more dysfunctionally in prison. Prison life perpetuates a cycle of trouble-making from which a mentally ill prisoner cannot escape because there is not the appropriate medical treatment. There is now evidence that instead of proper treatment in prison, a prisoner is likely to be put in solitary confinement. The recent Penal Reform Trust report, Out of Mind, Out of Sight, revealed that the medical services are so inadequate that prison staff have no option but to put sick prisoners in solitary confinement for an inordinate length of time – one prisoner for as long as 20 days out of 33.

It is bizarre that society would respond to somebody who is mentally unwell by jamming him or her into prison but, because of a lack of facilities, not provide any treatment. This aspect needs to be addressed in the Bill.

There are also problems with the definitions, for example, the definitions of parents and spouse. It includes cohabitees of longer than three years duration, but it excludes cohabitees of the same sex. This is probably contrary to Articles 8 and 14 of the European Convention on Human Rights which will soon be incorporated into Irish law. There are a number of difficulties in that regard.

The Schizophrenia Society of Ireland briefed many Members and indicated that there are difficulties with the 28 day review proposal. It has particular concerns about prisoners with mental health problems who are not covered properly by the legislation.

I received a communication from a qualified social worker who pointed out that in Northern Ireland, England, Wales and Scotland, professional social workers are employed as authorised officers. Intensive training is given before these workers are legally empowered to make arrangements for involuntary admission. In the Bill, community welfare officers are being allowed to make these applications. Social workers should be properly trained and appointed in this respect.

I echo the concerns about the involvement of the Garda Síochána. I have the height of regard for the Garda Síochána, but they are simply not trained in this regard. If they are to be involved, the State has an obligation to provide them with training that would make them capable of making such decisions.

Mr. Dardis

We had ordered an interruption of business at 1 p.m. Will the House conclude Second Stage of the Mental Health Bill by 1.30 p.m.?

Acting Chairman (Dr. Henry)

Is the amendment to the Order of Business agreed? Agreed.

Mr. Lydon

I welcome the Bill. It has taken a long time but is worthwhile. There are a number of aspects to it that must be improved, even after its passage through the Dáil. In section 8, those suffering from personality disorders, the socially deviant, and those addicted to drugs or intoxicants are referred to. The term "personality disorder" needs to be defined if it is to be used. Depending on which psychiatric textbook one reads, the number of personality disorders varies. Are borderline personality disorders included? This must be clarified.

The reason that personality disorders are included at all is that it is so difficult to treat them. I think psychiatrists have shoved the problem aside. I have seen cases over 30 years in which psychopaths have been cured, not merely helped. Some may have argued that this was not possible.

There is a very successful programme running at the moment in Cluain Mhuire Family Centre, run by psychologist Liz Lawlor, who is helping people with personality disorders. There are also a few more psychiatrists in Dublin who treat such disorders successfully. The problem is that the work is so intensive and unrewarding. This refers to cases of admission to hospital. I can think of one case pertaining to a woman who suffered from a paranoid personality – she did not have paranoid psychosis but suffered from morbid jealousy. Her health deteriorated, as did that of her family, to the extent that she had to be hospitalised. She might have had to be hospitalised for depression or anxiety, but she was hospitalised because of a personality disorder. That must be made clear.

There are many issues in the Bill that will have to be discussed further on Committee Stage. Let us look at section 48, which deals with tribunals. There is nothing wrong as such, but one must know if the decision of a tribunal has to be unanimous. How are differences of opinion resolved? Does one member have a deciding vote? If a barrister or solicitor has the deciding vote, the psychiatrist becomes an adviser to a tribunal, one whose opinion may or may not be considered. The psychiatrist's opinion could coincide with that of a treating psychiatrist, but both could be over-ruled by a barrister or solicitor. Tribunals in other jurisdictions allow for more than two members, in which case a majority opinion can obtain. We must examine this more closely.

Let us consider section 49(20). Many patients are detained under the Mental Health Act solely for the purpose of crisis intervention. The certificate is often lifted after a few days when the patient agrees to stay in hospital as a voluntary patient. Other patients may be discharged before a tribunal can review their retention. In such cases, the treating psychiatrist has no authority to compel the patient's attendance. I may be wrong.

Section 59 alludes to a second consultant not being allowed to review the choice of medication. Suppose a second consultant cannot review the choice of medication and that the first one is a world authority. Certain legal and ethical problems arise. If a colleague were to refuse to authorise a particular medication, should the first consultant continue to treat the patient?

The guidelines of the Medical Council are very pertinent in this regard. What happens if the second opinion is contrary to the first and the patient proceeds to commit suicide or homicide? Is the second opinion open to a suit of negligence? Would any self-respecting consultant undertake this role? The medical legal position on a consultant refusing to carry out treatment is that it is an unprofessional act. Will the ultimate outcome be the suffering of the patients involved? The section does not answer these questions adequately.

Much of what I have to say has been said by the Minister of State. The rest will have to be considered on Committee Stage. It is a very important Bill and I would hate to see it being passed without due consideration because it has so many implications for treating psychiatrists and other health professionals, as well as for patients.

The term "personality disorder" is too broad and requires definition. Remember that it is only a few years since homosexuals were regarded as psychiatrically ill. Fortunately, we have abandoned this perspective. There are other provisions in the Bill that are delicate, to say the least. We are not dealing with clear-cut matters in some areas, but the definitions need to be clear because the mental health and well-being of people is at stake. The Bill represents a step forward, but many questions still have to be answered.

Mr. Quinn

I welcome the Bill's late arrival to the House. Despite its narrow scope and many shortcomings, I hope it will be speedily passed and, more importantly, that the various sections will be brought into effect by the Minister without undue delay. Legislation on this subject seems to proceed at a snail's pace and some may think my wish unrealistic.

I am not an expert on mental health, unlike some Members. I was delighted to hear Senator Maurice Hayes relating his experiences in the North of Ireland. I freely admit that most of what I know about the subject I have learned from debates in this House and from the annual reports of the Inspector of Mental Hospitals. Senator Henry has requested on many occasions that the latter be debated more thoroughly.

The inspector's reports have made me increasingly uneasy, not only because of the truly dreadful conditions and the inadequate level of care in the mental health system. Terrifying as those matters are, they are merely symptomatic of a wider problem. Put crudely, the problem is that there are no votes to be gained from addressing the issue of mental health. I listened to Senator Henry today, who gave the impression that only European demands and the demands of the European Commissioner are pushing forward our legislation. This is why mental health is the Cinderella of our health system, as someone said recently.

Over the past few weeks, we have been given a glimpse behind the scenes. I find very credible the judgments of the top civil servants in the Department of Health and Children, which claim the service is chronically under-funded and has been in the past. In such a context, what gets done is what people scream loudest about. Very few scream about mental health, with some exceptions in this House, despite the work of some lobby groups and a few dedicated legislators. Their voices are simply drowned out in the general clamour from the public about the widespread inadequacies in the health service. That makes me very uneasy.

The test of a democracy, especially a republic where the people are sovereign, should not be about who can shout loudest but about looking after as best it can the needs of all its people. A democracy should give special priority to those who, through no fault of their own, are not properly able to look after themselves and their own needs or to care for themselves. If we were being truly democratic and republican, we would put the needs of mental health patients first, instead of letting them trail in last, as we have done for many years. Our national priorities on mental health are upside down.

There is one reason I deplore the narrow scope of the Bill which is framed and focused almost entirely on the issue of involuntary admissions to psychiatric hospitals. Given that the main existing legislation affecting this area is, I was amazed to see, 56 years on the Statute Book and given that the White Paper on mental health was published as far back as 1995 the Bill is hardly an adequate response to a very real and pressing need.

There is a need to tackle the issue from two angles. We need to clean up our act and review the whole issue of mental health, to start from scratch as it were, in creating a healthcare system for this area. The need for such a root and branch look at the way in which we deal with mental health is borne out by two recent statements, both of which require our special attention.

The first was by the Governor of Mountjoy Prison, Mr. John Lonergan, who said that in his estimation up to half of the inmates of Mountjoy Prison should not be there at all but were in need of psychiatric care. A total of 5%, 10% or 15% would have been serious but he said 50%. To say that half of all Mountjoy inmates are basically in the wrong place is a shocking indictment of how we approach the question of mental health.

The second statement was made in recent days by Mr. Greg Maxwell of the Simon Community. He had another startling figure to offer. He estimated that fully a quarter of homeless people using the Simon hostels were suffering from serious psychiatric problems, serious enough to warrant their receiving continuous care in a psychiatric hospital but that is not all, he also said that when all the cases of mental problems among the homeless were taken into account the proportion of those affected would probably rise to about one half. It seems that this shows the downside to the popular phrase, "care in the community". If "care in the community" literally means throwing people out on the streets, perhaps the time has come for us to rethink our approach. If "care in the community" is simply a cloak for the State washing its hands of those who need its services most of all, that time has certainly come.

I was impressed by what I received – I am sure a number of others also received it – from the Schizophrenia Ireland group. It used a term which rang a bell in my mind with regard to the environment. We use the term "the polluter should pay", it uses the term "the detainer should prove that there is a need to detain somebody who is involuntarily locked up". From that point of view it seems that there is a very strong case to be made to do so at the earliest possible date. I welcome as it does the fact that the Minister in the other House reduced the length of time where a review has to take place from 28 days to 21. Will the Minister consider reviewing his thoughts on the matter at this stage and reduce it to seven days for somebody involuntarily held? In other words, the detainer should have to prove that a person has to be detained and they should do so in seven days rather than 21.

I welcome the Bill on the understanding that it represents a small step forward but our focus now needs to turn to the rest of the journey. We have a long way to go.

Minister of State at the Department of Health and Children (Dr. Moffatt)

I thank all the Senators who contributed to the debate. It is fair to say that there is broad agreement that the Bill marks an improvement on what is already there. There are lacunae and much more to be done. The Minister said in the Dáil that he will be coming back to this issue again and that there will be a review within five years of the whole Bill.

There are recurring issues that came up with most speakers, of which child and adolescent psychiatry is one of the major ones. This is an area that needs more attention. A lot of money is being put into the sector but it will take some time to deliver a good system. Each of the health boards received money recently to improve this area.

I am glad to see that psychiatry of old age was also mentioned. It is a very important area, one in which I have an interest. We are appointing more psychiatrists of old age throughout the country, at least one in every health board. We will have more than this as time passes.

Suicide prevention was mentioned by Senator Jackman. Since the publication of the report of the national task force on suicide in 1998 there has been a positive and committed response in the statutory and voluntary sectors on ways of tackling the problem which is multi-focal and one that we need to address. I am sure it has been dealt with previously in the House on numerous occasions. It is one to which more attention is being devoted and on which I hope there will be progress.

Attention deficit disorder was also alluded to. The first report of the working group on child and adolescent psychiatry was published in March 2001. It contains proposals for the development of services for the management and treatment of attention deficit hyperactivity disorder and hyperactivity kinetic disorders. It is therefore another area that is receiving attention.

Everybody brought up the issue of services for prisoners. I agree that the most appropriate place in which to treat prisoners with psychiatric problems is in the setting of the prison. Many speakers said many people in prison should not be there in the first place because it is mainly psychiatric problems that they have and that we should be treating their psychiatric problems, not just dumping them in prison. I am sure the matter will come up again on Committee Stage when there will be a major discussion on it.

Homelessness was another issue raised. A large number of people who are homeless have psychiatric disorders. We must remember with regard to the changeover in our psychiatric services and the improvement in community services that those who did go out into the community did not give rise to the same problems as in the United Kingdom with regard to homelessness among those who had been discharged from psychiatric hospitals. The problem here is primarily one of people who are homeless having psychiatric problems. They have not been in psychiatric institutions and discharged later into the community.

Many other issues were raised, especially by Senator Maurice Hayes who brought up the interesting point of further co-operation, North and South, with which I agree. I agree with the Senator when he says that we do not have to be unduly worried about the tribunals, as Senator Henry appeared to be. Adolescent psychiatry services need much improvement. Senator Norris brought up some points about the Irish language which he said should be brought up again on Committee Stages regarding the terms in regard to consent. The Senator highlighted some interesting points in regard to children and consent.

Most speakers were happy enough that for the first time something was being done in regard to mental health to which Senator Quinn alluded to as the Cinderella of the healthcare system as it has been for years. More attention has been paid to mental illness in recent years. I thank Dr. Walsh who has done tremendous work for the psychiatric services during the years in highlighting deficiencies in the system.

For the first time we are taking the issue of mental illness very seriously. As the Senator said, it should be at the top instead of the bottom of the list. It has also been pointed out that it is not sensible to discuss mental health services if we do not allocate the resources to them. I am pleased that an enormous amount of additional resources have been put in over the past three years in comparison with previous years.

Services in the community are constantly improving. The way forward in the long term is to improve psychiatric health services in the community and the basic structure of our psychiatric hospitals. I note that most counties will have psychiatric services associated with their county hospitals. That is another step forward.

I thank the Senators who contributed to this debate. We will clearly have a very lively Committee Stage when we get around to it.

Question put and agreed to.

Committee Stage ordered for Tuesday, 12 June 2001.

Sitting suspended at 1.25 p.m. and resumed at 2 p.m.