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Seanad Éireann debate -
Wednesday, 29 Apr 2015

Vol. 239 No. 11

Mental Health Services: Statements

I welcome the opportunity to discuss mental health policies and services for children and adolescents. The promotion of positive mental health and well-being in general is important to us all. For many reasons and in many respects, mental health is a complex and emotive issue. It is encouraging that in my time as Minister of State, I have generally found that Members of Houses have taken a non-partisan approach to improving the area of mental health and implementing A Vision for Change, which is a widely supported policy. While I remain as open as ever to constructive criticism or realistic suggestions, I ask for objectivity and, above all, the best interests of service users to remain paramount today.

I welcome the increased focus on mental health in recent years. The service was, with some justification, tagged with Cinderella connotations, primarily due to historic neglect and under-investment. In particular, the question of developing mental health services for young people, coupled with a real appreciation of changes required to meet evolving need, was only highlighted by an ever-widening gap against non-delivery of both agreed policy and best international provision. This Government has, therefore, prioritised investment in mental health, including community and mental health services, CAMHS, and the HSE has been steadily implementing change on the ground. Given our starting point, and the many variables that influence real change, I have always said that this can only be achieved on an incremental basis and that there is no magic wand solution to developing the modern service we all desire.

Reforming mental health has led to much needed additional investment, but it also requires new approaches to enable the capacity of our system, in terms of new delivery models, to realise a common vision. This ranges from overcoming staff recruitment and retention issues to rebalancing services at local level between acute and community-based care in order to achieve the objectives of A Vision for Change. Until relatively recently, mental health was an issue hidden away, reinforced by high walls of stone and the higher walls of stigma and attitude. Fortunately, our culture is changing to one of greater sympathy, understanding and tolerance. Most importantly, better treatment options for the individual now exist to the point that recovery is much more achievable, including for the most severe cases requiring inpatient care. It is in this context that the HSE mental health services nationally has set about tackling the challenges of re-orientating from a hospital and bed-based focus to developing structures and processes required for enhanced community provision in line with A Vision for Change. Notwithstanding the difficult financial position we faced, the Government nonetheless prioritised the development of our mental health services. The genuine implementation difficulties we face on the ground in some areas, and which I have often acknowledged, do not primarily relate to a lack of money. It is, as I have indicated equally often, more a question of change catching up with the funding provided. Overarching factors coming into play on CAMHS range from securing the type of specialists we need in the right place to increasing demands on our CAMHS system in recent years.

The Government has provided €125 million ring-fenced funding for new service initiatives. Many of the initiatives undertaken to date, or planned, have a clear dimension to improve community and mental health services on the ground. This involves new posts and a more integrated client-centred service. Overall, we have provided funding this year of some €790 million to the HSE for mental health, including the €35 million I secured in the last budget. Every region has benefited from additional consultant psychiatrists, social workers, occupational therapists, nurses or allied professional staff. We have approved more than 1,150 new posts since 2012. Around 260 of these were specifically designated for CAMHS of which the majority are now in place or well advanced through recruitment.

At the end of 2014, despite staff turnover and recruitment difficulties, there were some 520 staff in HSE community and mental health services. Actual clinical staffing of CAMHS teams increased by 47, or around 10%, from September 2013 to December 2014. This is in a context of wider staffing difficulties elsewhere in our health system. A further 100 new posts in 2014-15 will improve CAMHS resources by around 20%. I acknowledge that issues such as recruitment, retention or staff mobility between regions present particular difficulties. It should be remembered also that the child and adolescent service is without doubt one of the most challenging work environments across our entire health and social care system. I will be the first to admit that the pace of acquiring additional staff to strengthen community teams has been slower than desired, but steady progress is being made.

The HSE mental health division, MHD, is committed to ensuring that all aspects of CAMHS are delivered in a more consistent and timely fashion across all regions, including the key issues of assessment and access. Therefore, a child and adolescent mental health services improvement steering group was established last year, together with a dedicated project group to improve key performance indicators for CAMHS nationally. One of the primary objectives is to develop a standard operating procedure for both inpatient and community and mental health services. The purpose of better standardisation is to ensure that delivery of services is carried out in a more consistent and transparent manner across the State; the care and treatment offered reflects the identified clinical needs of the child; and those who access treatment programmes for similar clinical presentations will receive a level of clinical care consistent across all child and adolescent services. There is clearer direction and information for CAMHS teams, and other partner services, about service provision.

These objectives are being underpinned by various new initiatives which the HSE hopes to advance this year to promote robust preventative and quality mental health services for all children and adolescents. Examples include a CAMHS community forensic team to work at national level with at risk children accessing mental health services and known to Tusla and the juvenile justice system. This team will be a precursor to the new ten bed CAMHS forensic inpatient facility being developed as part of the new forensic hospital in Portrane, due for completion in 2018. A clinical care eating disorder programme will design pathways of intervention for both children and adults with moderate and severe eating disorders. A new eight bed inpatient unit will also be developed in collaboration with the national children's hospital. There are proposals to expand the day hospital model for adolescents in need of intensive mental health service supports in the geographic areas of the north west and south east as well as other provincial sites. Funding will be provided for Headstrong to provide Jigsaw programmes in ten sites to support young people's mental health, and further access to psychological therapies, both psychology and counselling, in primary care for young people who would otherwise be referred to the more specialist CAMHS care.

In addition to these planned initiatives, the National Office for Suicide Prevention currently funds approximately 40 agencies to provide health promotion programmes and support to children, adolescents and adults. There is continued investment in health education campaigns such as Let Someone Know and Your Mental Health that promote positive mental health, and stress the importance of talking and listening.

The provision of inpatient beds and community mental health services are integral components of a range of services required to appropriately meet the needs of young people with mental health issues. Interventions are provided, in the first instance, through community mental health teams and, if required, access to relevant inpatient services is also available. Nationally, inpatient bed capacity has increased from 12 beds in 2007 to 58 at present - 26 in Dublin, 12 in Cork and 20 in Galway. This represents an increase of almost 400% in the number of beds over eight years. A new purpose built 22 bed child and adolescent inpatient unit located on the grounds of Cherry Orchard Hospital is due to be completed shortly and to become operational towards the end of the year. The existing 14 beds in the current temporary facility will transfer across, thereby giving a net increase of eight beds in the facility. The HSE intends also to open an additional eight beds, currently closed, in the Eist Linn Unit in Cork when current staffing recruitment issues are resolved. Overall, the Health Service Executive is targeting a total operational capacity of 74 beds nationally in 2015 which, if achieved, would be a significant increase in capacity.

It is a priority for me to address the issue of children and adolescents having, at times, to be admitted to adult acute units. While these inappropriate admissions have decreased continually in recent years, there is room for improvement. Figures for 2014 indicate that there were 89 admissions of children to adult psychiatric units, with the majority being, voluntary and involving parental consent. Approximately 85% of these admissions were 16 to 17 year olds, with a third of these discharged within two days of admission, and two thirds within a week.

Some of these admissions relate to a crisis situation where no adolescent bed is immediately available. Some may only last for a few hours - to help cope with a short mental health episode and where the practical solution is to temporarily place the child in an adult unit. Distance to the nearest CAMHS inpatient unit can also be a factor when immediate clinical assessment and treatment may be an inevitable requirement. In some cases, the presenting clinical needs of the young person, who may be nearly 18 years of age, may also have to be taken into account. The HSE has recently refocused various operational initiatives to achieve improvements in this area in 2015. This includes priority actions to enhance performance and national oversight to reduce admissions of children and adolescents to adult units to only 5% in 2015. This is an ambitious and challenging target, notwithstanding the increased funding available for child and adolescent mental health services. I firmly believe, based on my direct experience of visiting centres, that there is still scope to ensure better use of existing CAMHS beds in some local units and I am strongly pushing this with the HSE.

Central to an improved CAMHS service is the need to address waiting lists. I would like to take this opportunity to correct statements made during the course of a Topical Issue debate on mental health in the Dáil on 22 April last. In the first instance, Deputy Boyd Barrett alluded to the Minister, Deputy Varadkar, that I may have misled the House recently by indicating that staffing levels in child mental health services were filled up to 80%. It may be a question of misinterpretation by the Deputy but in a written reply to a parliamentary question to him on 16 April 2015, I stated that since 2012, around 260 new posts have been allocated specifically to CAMHS and approximately 80% of CAMHS posts were in place at the end of March 2015. I was, therefore, referring clearly to 80% of the 260 new posts approved to date by this Government, and not to all CAMHS posts in the HSE. Second, Deputy Keaveney stated in the course of the same debate on 22 April that 3,000 children this year will wait 12 months for a CAMHS appointment. However, in a reply on 20 April last from the HSE to the Deputy, it was stated quite clearly that at the end of January 2015, the total number of children on the CAMHS waiting list was just under 3,000. Furthermore, of these,1,200 were seen within the first three months. Some 470 children were waiting 12 months or longer and not the 3,000 as indicated by the Deputy. I have always shared the common view that it is highly unacceptable for a child to wait longer than 12 months to be seen by any of the 62 CAMHS teams. I have also said that misinformation does no one any favours, particularly parents worried about their child's mental health. The reality is that a number of factors influence the complexity and provision of individual CAMHS cases. These include at local level the number of emergency cases presenting, CAMHS capacity and administrative supports or links with related services such as Tusla or the National Educational Psychological Service, NEPS. These in turn can impact on discharge rates, increased numbers on waiting lists or longer waiting lists for routine assessments. In respect of CAMHS waiting times, I wish to highlight that all cases are triaged and urgent cases are seen as a priority. Many of these urgent cases are seen within days. In 2014, 55% of children who were seen were seen in under four weeks. This is against the backdrop of an increasing number of referrals to the service, including 16 year olds and 17 year olds.

The CAMHS waiting list nationally currently stands at around 3,000, representing a 10% increase in demand over the corresponding period last year. At my request, the HSE recently commenced a specific and urgent validation exercise on the list to clarify if all children are being referred to the appropriate specialist psychiatric service. It should be remembered that mental health problems are not the sole remit of CAMHS. The new level of validation now being undertaken will help to determine if all children are being referred to the appropriate specialist psychiatric service or if they actually need other services. There is some evidence that children are being referred to CAMHS due to difficulties in accessing less specialised services. In this context, the HSE is examining proposals to enhance related service provision jointly with primary care. This may involve a new early intervention initiative to allow some children and adolescents to be seen by a more appropriate service. Those assessed as needing CAMHS treatment could then be expedited.

A number of issues are of relevance in the context of the ongoing validation exercise. Despite the increased rate of referrals, the CAMHS teams nationally are achieving the targets set out in the HSE service plan. However, these targets are set against the backdrop of teams which need improvement, as I indicated earlier. The first phase of the validation is concentrating on those waiting for more than 12 months and will then move to those in the three month to 12 month waiting list category. The greatest possible focus is being placed on CAMHS referral sources such as general practitioners, child health services, NEPS and primary care services to help inform what operational improvements can be adopted in the future for the most appropriate referrals. While those with a co-morbid presentation, such as ASD with mental health issues would require a CAMHS service, others with general emotional difficulties may not require specialist CAMHS intervention and might, for example, be covered more appropriately by disability or primary care services. There are many examples of good work being carried out by CAMHS teams across the country and it is obviously necessary to extent this to all areas.

I would be the first to accept that while some progress has been made, we have some way to go to achieve the type of CAMHS we need. We owe it to our most vulnerable citizens - young, middle-aged and elderly - with mental health issues to keep working in partnership as politicians and administrators to change our laws and services for the better to meet their needs. However, it must be acknowledged that we are righting a wrong in this country that put mental health at the back of the queue for funding and reform until very recently.

The Minister of State talks about progress. Both she and the Government are always willing to blow their own trumpet. We saw this in the Dáil Chamber all week. I do not know if we are going to discuss the spring statement here but the Minister of State's speech is in stark contrast to the self-glorification in the Dáil during the spring statement about how great things are. What the Minister of State describes as progress is a 10% increase in the waiting list every year, or certainly for this year. The figures I have correspond with what the Minister of State is announcing in respect of waiting lists with 3,000 children and teenagers waiting to access mental health services. The Minister of State thinks this is an achievement and that the Opposition is giving the wrong figures but these are the real figures. The real figures are absolutely terrible. They are the figures over which I am standing and with which the Minister of State seems to agree. The number of people waiting for over a year is far in excess of 400 and there is a fairly wishy-washy commitment to deal with those in terms of priority.

My party and I are very committed to the issue of mental health. In fairness, the entire country is wising up to mental health. It is time it is taken very seriously at the highest levels of Government. If we are looking for a decent society and country, we would put things like this and try to deal with young people's mental health problems first before we start talking about spending again, having an election and bribing the electorate. The public will not wear it because in all parts of this country, there is a lack of decency. Deputy Kathleen Lynch is there as Minister of State and is certainly doing her bit but this Government does not seem to be committed to this issue. People in this area, in many other parts of the health service and throughout wider society are falling through the cracks.

Approximately 3,000 children and teenagers are waiting to access mental health services in the community and the number waiting for more than a year is substantially in excess of 400. The waiting lists are going up. The Minister of State said that much progress has been made but the waiting list seems to increase by 10% every year at a time when we realise that there is a national crisis in this area.

It is a crisis that can be dealt with if we make sufficient resources available and, perhaps, change the approach. The demand for services is increasing and the Minister of State gave some unverified information that this may be because people are trying to get on other waiting lists, but she did not give any evidence of that. That is just an excuse.

We do not seem to be serious about this at all, or about the fact that many young people get admitted to adult wards. Those of us who have visited adult psychiatric wards, including Senator Gilroy, who worked in this field, will realise they really are not very nice places. One would question whether one would bring one's own children in to see a patient one had to visit. Saying this is not discriminatory or insulting to anybody; it is a fact that the facilities are not nice places. They are not a suitable environment in which to treat children.

Approximately one third of all child and teenager admissions are to adult wards. This is completely and utterly inappropriate. That we are allowing this betrays an incredible lack of decency in society. This has been highlighted by the Mental Health Commission, which has said it is not acceptable. Nobody believes it is acceptable in any way, yet it still continues to happen. The chairman of the commission stated:

We’re talking about teenagers who may find themselves in wards with much older people in environments that can feel threatening and fearful. They lack the kind of therapeutic input that is the norm in a children’s setting.

That stands to reason and is common sense, and nobody would need to be a professor of psychiatry or expert on children to realise it.

It looks like the increase is continuing and that there will be year-on-year increases in the number of children and teenagers admitted to adult units. Therefore, there are many problems. For the Minister of State to come in here and criticise the Opposition and claim there has been much progress is not appropriate. We have developed our own strategy on youth mental health and also proposed the establishment of a mental health authority. Having a national agency focusing on one particular issue could result in some good work. The Road Safety Authority comes to mind. Such an agency seems to have an effect if given the necessary budget and resources and the power to be independent of the Government. Such agencies seem to make an impact. The one I propose could play a useful role in tying together the work of all the great voluntary organisations around the country that are working very hard. In some cases, they may do a better job if they are co-ordinated better or given more resources to do the job they want to do.

The reality is that mental health issues now comprise a considerable problem given the suicide epidemic. One in four students is said to experience psychological problems at any given time. Our policy will greatly enhance the role schools and colleges play in promoting positive mental health and equipping young people with coping skills. Many schools do operate effective strategies but there needs to be much more co-ordination in this regard because some schools do not have such strategies. That is simply a fact. Some have very good anti-bullying policies, for example, while others simply do not. There needs to be a focus on positive mental health promotion at all levels of the education system. Some 20 years ago, there was a considerable discussion on sexual and reproductive education and protection for children and vulnerable people as they grow older in school. There was a big controversy at the same time. This is now covered and the strategy applies at all levels of the education system. Perhaps a structure similar to that of the relationships and sexuality education framework could be introduced in respect of mental health. Such a strategy does not appear to exist, nor does there appear to be a will to produce it.

With regard to bullying and cyberbullying, there is considerable emphasis on peer support. It is a question of informing people what social media are appropriate and how to operate social media. Some people may be ignorant in this regard. All schools and colleges should have their own mental health promotion plans, with students, staff and parents involved in their development and implementation.

There is an implicit criticism by the Minister that nothing was happening in regard to mental health until very recently. At the same time, she wants to implement A Vision for Change, which was the policy of the last Government. We support it and want to see it implemented fully. It is the policy for future services in the area of mental health. We are glad the Government states it is committed to it. It obviously needs to be reviewed. We believe it should be reviewed and the work should start on that process. Clearly, there is more to be done.

I would like to see this issue treated with much more seriousness. It is totally and utterly wrong that a child or teenager should be put through the trauma of going into an adult psychiatric ward. In many cases, the wards are absolutely horrible places, including for the adults who have to attend. Adults have said that. We have visited the places and noted they are absolutely awful. My saying this does not disrespect the staff because they would agree that, in many cases, the facilities are in old buildings of the old style that we should be moving away from. There is some work going on.

I would like the Minister to answer my question on Navan. There has been much confusion there about the move to Drogheda and about what is staying in Navan and what is going to Drogheda. Perhaps the Minister could clarify that in terms of the general service.

I welcome the Minister of State, Deputy Kathleen Lynch, to the House and thank her for the work she has done in her Department on giving priority to increasing resources for child and adolescent mental health services and the establishment of community-based multidisciplinary child and adolescent mental health teams, as set out in A Vision for Change. The community mental health teams are the first line of specialist mental health services for children and young people who are directly referred from a number of sources, mainly by general practitioners and the National Educational Psychological Service.

There have been many negative comments on the number of children on waiting lists. As the Minister of State said, all cases are triaged and urgent cases are seen as a priority. Some 55% of children seen in 2014 were seen in under four weeks. I remind Senator Byrne that we have come a long way from the times of Fianna Fáil in government when waiting periods of four years for an initial assessment of children presenting with symptoms were the norm. At that time, budgets set aside for mental health services came back unused.

I can rely only on what people tell me from their first-hand experience of dealing with the services. I know levels of service and waiting lists vary in different parts of the country. I have several friends with children attending mental health services and know we have travelled a long road and made great progress since the days of waiting periods of three and four years. Urgent cases are often seen within days. One friend, whose 11 year old child was having difficulty with learning in school and life, and who had worrying symptoms, had that child seen by the mental health services within three days of referral. This child was subsequently diagnosed with anxiety disorder, neurological development disorder and borderline intellectual disability. Thanks to early intervention and diagnosis, he is still attending mainstream school and his mother cannot speak highly enough of the team that has helped her and her child at every hurdle. She tells me that if there is an urgent problem, the child will be seen within hours.

The Minister of State, Deputy Kathleen Lynch, and her Department have made great strides in improving services and continue to work to improve services in areas where they do not meet the standards the Department would like. Great headway has been made in difficult financial circumstances over recent years.

I wish to mention the restoration to the cuts made to the respite care grant, although I realise it is not within the direct remit of the Minister of State. The cuts have adversely affected parents of children with mental health issues in addition to children with physical disabilities whose grant was subsequently cut. The Minister of State will use her influence to ensure the grant is fully restored.

When children are having difficulties that cannot be addressed by outpatient services, the next level of service is inpatient services. A Vision for Change recommends the provision of 80 child and adolescent psychiatric inpatient beds. There are currently 58 beds nationally, with plans to raise the number of operational beds to 74 by the end of this year. The planned national paediatric hospital will include a 20-bed inpatient CAMHS unit, including a specialist eating disorders service for children and adolescents.

I know that 58 out of a perceived need of 80 beds is progress and 74 beds operational by the end of this year would be more progress. It is extremely important, particularly with regard to children with eating disorders and children who are in danger of self-harm, that they have access to inpatient services without delay.

This brings me to the issue of the admission of children to adult psychiatric units. When there are no inpatient beds in adolescent units, then the adult services are the next port of call. The fact that so many are admitted to adult psychiatric units means there is an urgent need to increase the number of inpatient beds for children. The figures for admission of children to adult units have from a peak in 2008 of 247 admissions been reduced to 89 admissions in 2014. While this is progress, it is still hugely worrying that so many vulnerable children will find themselves admitted to adult psychiatric units. Children who are vulnerable should not be exposed to adult psychiatric units under any circumstances. I know the Minister of State will do her utmost to reduce this figure.

I also mention the need for interdepartmental co-operation with regard to children and young people and other policy documents relevant to this debate. I refer to Better Outcomes Brighter Futures, the national policy framework for children and young people issued by the Department of Children and Youth Affairs. The policy identifies five national outcomes for children and commits the Government to a range of actions on mental health, including ensuring equity of access to mental health services for all children and young people and the promotion and improvement of early intervention approaches for combatting mental ill health. The need for interdepartmental co-operation also extends to the Department of Social Protection. A great many children with mental health issues, autistic spectrum disorders, intellectual and learning disabilities are refused the domiciliary care allowance in the first instance and subsequently awarded the allowance on appeal. Many are turned down on medical grounds. I dealt with a case last week of a 16 year old, diagnosed with autism by a leading consultant child psychiatrist, who was turned down for a disability allowance on medical grounds, despite the fact that he had been in receipt of the domiciliary care allowance since his diagnosis. Either the Department believes the consultant or it does not. The parents were asked to submit additional medical evidence and they are at a loss to understand what further medical evidence they should submit.

This discussion is about children's mental health services and while we talk about multi-disciplinary community-based teams, it is imperative to have multi-disciplinary departmental teams and greater co-operation between Departments for better outcomes for children. Parents have to do battle with three Departments, the Department of Health, the Department of Social Protection and the Department of Education and Skills, to ensure that children with any disability get their entitlements.

We need better outcomes for parents also. Life is difficult enough for any parent dealing with the pressures of modern life but parents of children with mental health issues have added worries, concerns and difficulties. We must do our best to ease the burden on them. Parents should not have to fight for their children to get their entitlements. We are here as legislators and that is our job. We should do it better and make it easier.

The inability to recruit and retain appropriate levels of staff has a significant impact on the quality of services provided and access to these services. The Minister of State recently announced that 63 CAMHS are operational and that since 2012 this Government has provided an additional €125 million for mental health services from which 260 dedicated CAMHS posts were funded and that 80% of all CAMHS posts were in place by the end of March this year.

The Minister of State has completed a significant body of work and I am confident that she will continue until 100% of the posts are in place. I have no doubt that she has the will and the ability and that she will do her utmost to ensure this outcome.

I welcome the Minister of State. The Royal College of Surgeons in Ireland produced a report on the mental health of young people in Ireland. It found that by the age of 13 years, one in three young people in Ireland is likely to have experienced some type of mental disorder; by the age of 24 years, that rate will have increased to one in two. Significant numbers of young people are deliberately harming themselves and by the age of 24 years, up to one in five young people will have experienced suicidal ideation. The experience of mental ill health during adolescence is a risk factor for future mental ill health and substance misuse in young adulthood.

This gives an idea of the scope of the issue we are discussing today which is children's mental health and the need for the services to be developed. As the evidence clearly shows, and I can speak from my experience in this area, when there is a deterioration in mental health in those adolescent years, how that is dealt with frames the person's health for life. For me it is even more urgent that we ensure that we have appropriate and timely mental health services for our children and our young people.

I called for this debate on several occasions and the latest occasion was following the results of the national review panel report chaired by Dr. Helen Buckley. Those findings were produced on 26 March 2015. They reviewed the cases of 26 vulnerable children or young people either living with families known to the child protection services, in the State care system or in aftercare. Of those 26 vulnerable children, eight young people died by suicide, compared to four such deaths in 2013. Shockingly, when I read the report, three out of the four teenage girls who died by suicide were known to child protection services and for lengthy periods before their deaths were on waiting lists to be seen by psychological services. According to the individual reports pertaining to the circumstances surrounding 12 of the deaths, one of the young girls - Jennifer - at one point before taking her life, had been on a waiting list for psychological services for two years. Her mother had tried to access mental health services the week before she died. This happened last year.

I refer to another case of a teenage girl named Zoe who had been in and out of State care in childhood. Her case with the social work department had been closed months before she died by suicide. Dr. Helen Buckley, who is the chair of the national review panel, said that mental health difficulty is very prevalent among young people and among their parents. She referred to the long waiting lists for psychological services - the report cited up to two years - and the treatment time is often limited. A person may have access to a service but there is very little scope for ensuring he or she has recovered. Dr. Buckley also called for more integrated mental health services. She said that a strong theme was the difficulty in accessing appropriate psychological and mental health services for suicidal young people. Indeed, this is replicated by the child care law reporting project which is being led by Dr. Carol Coulter and her team and which gives us an insight into child care proceedings in the courts. When I read the reports from the child care law reporting project the characteristics and the demographics and all those interplaying factors identified by Dr. Buckley are strikingly similar to those identified by Dr. Coulter. This is the most recent research but it seems to me to be a groundhog day. I could have been making the same speech four years ago and that is my frustration. In my opinion, which I think is shared by others, there is a systemic and endemic problem within our child and adolescent mental health services.

The Minister of State has identified that it is not an issue of funding. There have been delays in staff recruitment under three successive budgets. The money is ring-fenced but we cannot get the people and yet, children like Jennifer and Zoe are in need. Many child and adolescent services are under-resourced. The waiting list has increased by 8%. More people are seeking help. Community teams are struggling to cope with the increased demands on services. There are too many agencies involved in children's mental health care and inadequate inter-agency communications and collaboration between the services. I have raised this matter with the Minister of State. I strongly believe the child and adolescent mental health services should have been part of the Child and Family Agency and this should be rectified. I do not understand what part of child and adolescent mental health services does not fit into the Child and Family Agency because when I talk to parents or study the reports, the pathway to CAMHS is not there. It should be available through the Child and Family Agency. Families are finding it difficult to access CAMHS due to lack of information, restrictive referral criteria and pathways, lengthy waiting periods and the lack of out-of-hours crisis services. Our mental health does not switch on at 9 a.m. and switch off at 5 p.m. and that one can choose to access services between these times. Many mental health services in Ireland offer support to young people with moderate and severe mental health problems and they rely on formal diagnosis. However, I have been informed many times that there is a lack of services for those experiencing mild and emerging mental health problems. We need to wait until it comes to a crisis point and that is not good enough.

We know we have to be dealing with it earlier.

I also have a concern that the doors of some CAMHS are only open to those under 16 years of age whereas others are available to those up to 18 years of age which means there are fewer clear pathways for those between the ages of 16 and 18, depending on where one lives. As a result, these young people do not always receive the developmentally appropriate care in a timely manner.

It is shocking that one third of all children concerned, that is, 89 of them last year, were admitted to adult wards. We have all agreed it is wrong and should not happen, and yet one third of the children went into an adult ward.

I will try to be more constructive about what we can do. We need to increase information. In fairness, the National Office for Suicide Prevention is doing excellent work at empowering and encouraging NGOs and civil society organisations to promote positive mental health. The key on which we need to focus is the delivery of and access to services and that is the role of the CAMHS and the HSE. We need to resource mental health services, particularly in primary care. There needs to be a clear framework for co-operation, which needs to be published and which everyone needs to know in order that we can hold people to account.

We also need to get better data. It is an issue I have raised previously with the Minister of State, Deputy Kathleen Lynch. I want to be able to applaud her but if we are not collecting the data, I cannot know whether services are improving or deteriorating. My problem is the reports tell me it is getting worse.

We need to develop local alternatives to inpatient services such as an assertive outreach early intervention in psychosis and other community-based intensive supports. This is a recommendation from the Children's Mental Health Coalition. We need the HSE to develop community-based alternatives to those inpatient services. We need to ensure there is accessibility to developmentally appropriate and evidence-informed specialist inpatient services for children with complex or acute mental health difficulties, including children or adolescents with a dual diagnosis of mental health and substance misuse, which diagnosis arises increasingly in my experience.

As we are discussing the issue of CAMHS, I applaud in particular the work of Headstrong and the Jigsaw initiative. This innovative initiative for those between the ages of 12 and 25 is in ten communities in Ireland, and I hope it will expand. The preliminary evaluation findings of Jigsaw are what we all want to aim for. One young person stated: "When I came here to Jigsaw first, I was always crying. Now I walk out smiling." That is what we want to achieve. We want to intervene early with young people and equip them for life, but also ensure the services are in place when they need them. We should not wait for it to be a crisis but, equally, the services must be in place when there are crises.

I welcome the Minister of State to the Chamber. I am glad to see her here again. No one in this Chamber or outside would ever doubt her commitment to reform of the mental health services.

I will take a look at the historical or legacy obstacles that face us to put in context some of the challenges with which we are faced in the mental health services, both child and adolescent services and adult services. More than 30 years ago, as a young student nurse I walked into a mental hospital in Cork where 1,000 patients were living in Dickensian conditions. They were segregated, between male and female, and never the twain would meet. Male nurses looked after male patients and female nurses looked after female patients, and the level of abnormality was only compounded in that situation. Over the years, the system has gradually and achingly changed.

Before 1984, in Cork, in the same hospital I was working in, there was a child and adolescent unit on the campus of St. Stephen's Hospital which had a complement of 20 inpatient beds. We closed that unit in St. Stephen's Hospital in Cork and we did not replace it with any beds until five or six years ago when we opened eight temporary beds, also on the campus of St. Stephen's. We closed those because they were temporary and we built a special unit for the purpose on the grounds of Bessborough. Now we have eight beds there. I am not even sure how that is working.

There are 12 at present.

There are 12 at present but my information is that not all these are functional.

In 1984, there was another momentous development. In 1984, the report, Planning for the Future, was published. Planning for the Future proposed a pathway through which we would close the large institutions and move psychiatry and mental health into the community. That was followed by a series of seven-year plans, which worked and built upon the policy framework set out in Planning for the Future. Then, in 2006, we published A Vision for Change.

A Vision for Change is a visionary document. It really is the way forward. It is, on paper, the single best document that I can find in the English-speaking world where mental health services are provided. I am disappointed by the piecemeal roll-out of A Vision for Change, and I am not the only one because many, including the Mental Health Commission, have commented upon it. It seems to me, as someone who has worked in the services for more than 30 years, who was involved in the trade union movement and staff representative organisations and who remains linked in to this day to all the hospitals throughout the country, that despite the existence of A Vision for Change, there is a lack of strategic planning in the delivery of mental health services.

We are in a period of transition which is exciting for the staff working in the services. We are moving from the paternalistic sort of delivery system we have currently. Even though we closed most of the institutions from 1984, we did not really open our hearts to the new way of delivering the services. While we moved people from the institutions into the community, the walls that were around the institutions, while not physical anymore, were just as real as if they were. New therapies are evolving and older, more established therapies are expanding, and yet the mindset in the mental health services is not accommodating these new changes.

There are many matters I want to talk about in this regard and I hope I will be able to keep my talk coherent. Before Christmas I visited a major general hospital, not in Cork but in this city, where we discussed the admission of children to adult services, which is utterly unacceptable. Some 84, one in three, of all children who were admitted in that year were admitted to adult units. Those figures are not truly reflective of how bad the situation is because the staff in the hospital told me that in the previous week, 13 children suffering with mental health issues were admitted to the hospital, which is a general hospital, because there was nowhere else for them to go. If we were to say it is bad having them admitted to adult wards of psychiatric hospitals, which it undoubtedly is, those figures are not the true figures of the poor situation existing among the child and adolescent units.

Senator van Turnhout correctly mentioned the difficulty in recruiting staff. All the information coming to me from the coalface indicates that there is a problem with staff in the hospitals. There are not enough staff within the mental health services at every level. It is quite simple. Senator van Turnhout highlighted this, but why must we ask this question at all? What is so unattractive about the mental health service that it cannot keep its own staff? There are several causes. A systemic problem within the services that we have not dealt with is the cause of the lack of staffing and, indeed, of all our problems in the mental health services. I refer to leadership at local level. Leadership at local and regional level is not what we would desire it to be and leadership at national level, not at political level but at operational level, is appalling. We do not have a director of mental health services at present, rather we have someone acting in that capacity. The Minister of State spent a long time trying to find someone to fill the role of director of mental health services and as soon as the post was filled, the person was seconded out of it to a financial role somewhere. At present, we are looking. Why have we not got someone in this role?

Perhaps even more important than someone in the role is, as I have suggested for a long time, the need for us to appoint someone senior, a competent, capable and credible person, with responsibility for the roll-out of A Vision for Change. That visionary document is being criticised left, right and centre. Unfortunately, it is like Planning for the Future in 1984 which, unbelievably, is still not implemented.

There are still 400 people living within the walls of large institutions as we speak, which is a fundamental breach of anybody's human rights. It was recommended 31 years ago that should not happen. I am afraid A Vision for Change is going down the same road.

I wish to speak about the €125 million extra investment. What is the number of net jobs created as a result of this investment? Concerns have been brought to my attention in several places in regard to some of these jobs. Some of these jobs are new jobs but not new posts within the service as people within the service are being promoted to different jobs within it and that is being counted as a new job, although the salary for the old job has been reabsorbed by the HSE back into general funding. How many child and adolescent mental health teams are in the country and how many have been fully populated with competent and appropriately qualified people?

As the Reach Out national suicide prevention policy expired last November, we expected the Minister of State to have a framework for suicide prevention published last November. I am disappointed it is six months late. There are many areas in mental health services that are not receiving the service provision they require. Does the Minister of State intend to provide more resources for a very intractable and serious problem affecting young people, that is, specialised care for people suffering from anorexia nervosa? There are many other questions I would like to ask but I will leave it at that.

Three Members are offering. I must call the Minister of State to reply at 5.20 p.m., so perhaps they might take account of that.

I welcome the Minister of State. As Senator John Gilroy said, we have absolutely no doubt about her genuine commitment to her portfolio. However, the Minister for Health, Deputy Leo Varadkar, and the Minister of State have a major job to do to live up to the 1916 Proclamation. I have said on numerous occasions that I do not regard Ireland as a true republic. In particular, in the area of children's mental health, it is more like a Third World country. I draw attention to the line in the Proclamation that we cherish all the children of the nation equally. The Minister of State knows as well as I do that if one has money and one's child has a mental health problem one can get fast access to services. I am surprised at times we do not have a revolution given the various inequalities in the country.

Children who do not have access to private medical care face unacceptably long waiting lists for mental health services, patchy service provision across the country and a lack of focus on early intervention that could prevent future problems. In a shocking violation of their human rights, children continue to be treated in adult inpatient mental health units. We have been talking about this issue since I became a Member in 2002. It is deplorable that children with psychiatric issues continue to be accommodated in adult units. I am deeply concerned at the continued delays in children accessing the mental health services they need. Our services are completely understaffed and overstretched. HSE figures show that at the end of last year there were more than 3,000 children and teenagers waiting to access mental health services in the community and more than 400 of these were waiting for more than a year. If this was highlighted on television about an African country we would not be surprised but in what we call a developed country, it is pathetic.

A new study by the Children's Mental Health Coalition shows that while demand for services is increasing, the number of staff in the area is falling. The report states that at the end of last year, community and mental health teams for children and teenagers have just 42% of the staff recommended in the much-lauded Government's mental health strategy, A Vision for Change. A Vision for Change is purely vision, nothing else. Children have a right to enjoy the highest possible standard of mental health but this right is not fully respected in this so-called Republic of Ireland. The shameful practice of admitting children to adult mental health units is also continuing.

Last year the Mental Health Commission reported that significant numbers of children with mental health problems continue to be admitted to adult psychiatric units despite repeated warnings that the practice should be a measure of last resort. Figures show that in the first half of 2014, 53 young people were admitted to inappropriate adult mental health units, representing one third of all acute admissions involving children or adolescents. This is totally unacceptable.

It must be remembered that a child's needs are very different from those of an adult. Mr. John Saunders, chairman of the Mental Health Commission, said we are talking about teenagers who find themselves in wards with much older people in environments that can feel threatening and fearful. They lack the kind of therapeutic input that is the norm in a child's setting. Alarmingly, if the numbers continue to rise at their current rate there will be a year on year increase over the 91 children admitted to adult units last year. The ongoing policy of admitting children to adult wards constitutes a human rights violation of the children involved. Up to one in four students at any given time experience psychological problems.

Fianna Fáil strategy includes proposals to improve supports in schools and colleges and reduce the alarmingly high rate of suicide among our young people.

The Senators has 30 seconds remaining. I am sticking strictly to the time.

Our policy would greatly enhance the role that our schools and colleges play in the area of mental health.

I am a bit cynical about the Minister for Health, Deputy Leo Varadkar. I know he is a media person and is glamorous but he is very much a PR man. On 17 October last year, he launched the roll-out of the free breast care screening. I was shocked when I realised it would not begin until the end of 2015. Why is he launching a screening programme a year in advance if it will not commence until the end of the following year? Let us see him deliver something other than fancy pictures in the newspapers and smart talk. Obviously, he is intelligent but let him sort out the impracticalities and inefficiencies in his Department.

I thank Senator Colm Burke for allowing me to contribute. I know we are pressed for time, having started 20 minutes late. Much of what I wanted to discuss has been raised by my colleagues, so I will not deal with that. I will concentrate yet again on an area in which the Minister of State knows I have a major interest, namely, the mental health of children with a disability. I have requested debates on that topic on several occasions since becoming a Member of the House and I do not believe there has been a debate on mental health in which I have not raised it.

In March 2014, I raised an issue that had reached a crisis point where a family was refused help by CAMHS and the paediatric services. When they visited their general practitioner, the only option given was sedation. There was no child psychiatrist for the Louth-Meath area. As of today, we still do not have a child psychiatrist in that area. The recruitment process is ongoing.

This is an issue I have raised with the Minister of State and members of staff but it is still an issue. I went to see the director of mental health services and was again told it is a case of recruitment, which other people raised earlier, but where should children between the ages of 16 and 18 go when there is no local child psychiatrist? They do not fall under the CAMHS remit or the paediatric services. Where should they go? It is now over a year later and I am still asking the same questions.

I have been told that funding for the child psychiatrist is available. As the child psychiatrist is not in place, can that funding be allocated to parents who have paid more than €700 in many cases for private assessments? Would it be possible to provide for that? I welcome members of ServiceSource who are in the Visitors Gallery. It provides an excellent alternative in terms of recruitment facilities and it reports, as do Bluebird Care and other agencies, that it has the staff.

Can we access that a bit better or can we engage more with them and listen to their models, so that we can improve the situation? Others have raised the issue of children in adult units. Again, 89 were admitted last year. In my maiden speech in the Seanad four years ago, it was something I was very vocal about and about which I felt very strongly. Four years on, I appreciate the work the Minister of State is doing, but it is another area we need to look at. Some 400 people are on a waiting list for mental health services. That is 400 too many. We are looking at people who are extremely vulnerable and, as a result, families that are extremely vulnerable. People are on waiting lists for more than a year. It is not acceptable. I spoke with someone yesterday who was on a waiting list for a year and a half and the only options they were given were sedation or to wait and see. That family has lived in trepidation, waiting for an appointment, which, they are told, will be 18 months down the line. It affects the whole family.

Could the Senator finish up?

I will. I would like us to talk about adult mental health when we talk about children's mental health.

It is about local services. I do not apologise for making it local, but in my area, Drumcar respite facility for children and adults with an intellectual disability closed its doors last week to facilitate training for the next six weeks. I believe there is a HIQA inspection going on. It is unacceptable that a facility that is providing the only respite for families can decide it is closing for six weeks to facilitate this and give parents and family members a couple of days' notice that it is closing for up to six weeks. Will the Minister of State look into this as a matter of priority with St. John of God's and the HSE and see whether an alternative is being provided? It is not acceptable in this day and age that we can deny the most vulnerable people and their families respite care.

May I move that we extend the sitting by ten minutes? This debate started 20 minutes late and it is not unreasonable to ask, but I am in the Acting Chairman's hands.

We started late.

I have received instructions from the Leader's office, through the Seanad Office, that it will not accept an extension of the time, so I have a dilemma. I do not wish in any way to prevent that, but it seems that is the advice to the Seanad Office from the Leader's office. One of the Senator's colleagues already sought an extension of time and it was declined by the Leader's office.

It is an important issue and the debate was delayed by ten minutes.

The Senator is the Acting Leader.

It is only taking ten minutes off the two hours of the other debate.

I know that, but I also have a difficulty in that I already advised Senator Cullinane, who was sitting throughout the debate, that he would not be able to speak, and now Senator Craughwell, who came in after Senator Cullinane had left the House, is also seeking to speak. It is a difficult issue, but Senator Burke is the Acting Leader and is entitled to move as he has said, and if the House agrees-----

I only require 30 seconds.

It is not about that. It is about the fact that Senator Cullinane was waiting here for over an hour.

I move that we continue the debate for an extra ten minutes.

No. Ten minutes might be sufficient for one speaker from the Government, but two Opposition speakers are waiting to speak. Senator Cullinane is probably in his office watching this. If we give the chance to one, we must give it to the other.

In fairness to Senator Byrne, I only intend to speak for two to three minutes, so I do not think-----

For three speakers, we would be looking at an 18 minute extension.

I have asked it and it is not agreed.

It is not agreed in that it is not enough. It is not fair to people who have been sitting here all day that the Government can come in and decide to give its speakers extra time.

The Minister of State has also indicated that she cannot stay beyond 5.30 p.m., so-----

I assure the Minister of State that I will not take longer than 30 seconds.

If Opposition Members thought this issue was so important, they would not now be opposing a ten-minute extension.

We do. We are looking for a sufficient extension. We are not objecting to an extension.

Give us another 15 minutes. It is a very serious issue for our culture.

I propose an amendment that we conclude at 5.35 p.m. to allow the Minister of State to respond.

The Leader wants the Minister of State to respond at 5.35 p.m.

The Leader wants the Minister of State to be called now. Is that agreed?

It is not agreed.

We have other Ministers to come in as well.

We cannot agree to those terms, from the Government that just closed down debate. It is not agreed. We cannot accept orders like that from across the Chamber.

I am putting the question that the debate conclude at 5.35 p.m. Is that agreed? Agreed.

I want to make clear that I am not closing down this debate, just in case there is any misunderstanding.

I will start by responding to Senator Byrne's remarks. It was never my intention to blame the Opposition. I was simply setting the record straight. I do not have the information on Navan, but if there is any information to be got, I promise that-----

I just want to know what services will be where.

If there is information on that, I will ensure that the Senator receives it.

Senator Henry spoke about the respite grant. Thankfully, that is one of the areas for which I do not have responsibility, but I understand the Senator's position.

Senator Henry also spoke about people under 18 in adult wards. That came through in the contributions of most Senators. It is an issue we must be very conscious of, but, as I outlined in my speech, the majority of people who were inappropriately placed - I fully accept that they were inappropriately placed - were there for very short periods of time. Parents contact me from time to time at a local level and I go and see for myself the circumstances experienced by people who should be in an adolescent unit but who are in an adult unit. In my experience, and I have checked this out on several occasions, they are always cared for by a psychiatric nurse on a one-to-one basis and they always have an individual room, so there is no way that they would be sharing facilities or that there would be any great threat to the individual. I have seen that personally and have confirmed it by checking it out. That must be some kind of consolation to the parents of these children, because it must be distressing enough to have a child with mental health difficulties without adding to that distress by saying they are in some sort of danger. They are not. They are inappropriately placed, and that is completely accepted. I set the target of 5% in the service plan. The HSE wanted it to be higher and I refused and said that is what we will aim for and we will insist on it. I also asked the Mental Health Commission to ensure that if 87 children are inappropriately placed, we are also looking at how many appropriate beds are vacant in CAMHS units.

From time to time beds which could be accessed are not being accessed. I have asked for that but it will take a while to come through the system. It is a relevant piece of information that we should be looking for.

Senator Gilroy talked about appointing a particular person. We cannot do that any more as the legislation provides that it must come through the Public Appointments Service. That is just as well because if we did not do that, no matter how well qualified a person might be in terms of mental health expertise, we would leave ourselves open to the accusation of jobs for the boys or the girls.

There are 80 people on the panel with the HSE at the moment. Why have they not been appointed?

It is not done that way any more. I am talking about a head of mental health services, not lower grades. I know what the Senator's concerns are and I hope to address them in my summing up.

I agree with Senator van Turnhout. In the past number of weeks, I have looked for verification of the waiting list and I know that sometimes strikes terror among people on the list, as if we are asking if they really needed to be on it. I am accepting fully that the 3,000 children on the list need to be on it but I wonder what they need and if they should be waiting for the intensive CAMHS assessment. There is a different service, as Senator Moran has said, that can provide what those people need at a much earlier stage and that intervention needs to take place. My argument to the unit is that if someone is 12 months on that waiting list, he or she cannot be acutely unwell because if someone is acutely unwell, he or she should not be 12 months on the waiting list. It is about applying logic to all of that. Maybe the service for which those children are waiting 12 months could be delivered in a different way by a different organisation.

I fully accept what Senator van Turnhout says about Jigsaw and that is why we are increasing its provision. We are constantly looking at that list. There will always be the 5% which needs the kind of intensive care that only CAMHS, as a specialist service, can give. Surely, we should be able to treat children at an earlier stage and more appropriately. I still do not understand why we are referring children to CAMHS to see whether they need a classroom assistant. I am in talks with the Department of Education and Skills about all of that.

I still have not received clarification on the issue of why we cannot employ counselling psychologists, which was Senator Coghlan's issue. That is another part of the verification and I must ask why we are not doing that. There are people on that list who could very well be treated by counselling psychologists. We have the money - we have not returned any of the money in respect of recruitment - but we have huge difficulties recruiting clinical psychologists and psychiatrists for children. Senator Gilroy has asked what is so unattractive about the area and I do not know. Maybe it is the whole corporate thing in that we have damaged the health delivery system so much that people do not want to work for us. I am not certain.

Of course, it is. It has never been easy in psychiatry and the psychological services in this country. None the less I do not know why it is so difficult now when we are putting more resources in. We are now on our second recruitment campaign in a year and are still not getting enough people. If service delivery, as it is currently structured, is not working, we will have to look at a different way and that is exactly what I am doing. I do not believe in asking the same question and getting the same answer all the time.

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