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.