Seanad Éireann debate -
Wednesday, 22 Jun 2016

Vol. 246 No. 5

Mental Health: Statements

Minister of State at the Department of Health (Deputy Helen McEntee)

I am pleased to have been appointed to this position. Mental health and, more importantly, promoting positive mental health are close to my heart, as they are to the hearts of many in this House. It is also an area in which there is so much more we could do to help each other, work with each other and try to remove the stigma that is still attached to mental health issues. I refer not just to politicians but also to society as a whole. While we have made great progress during the past decade, we still have a long way to go to remove the stigma attached to mental health issues.

There has been much discussion recently about the funding of mental health services, some of which has been constructive but some of which has not. I will outline a number of facts. The national service plan mental health budget for 2016 is €826 million. Since 2012 the budget has been increased by €115 million. This year there will be an increase of €41 million, or 5.2%, on the outturn for last year. The numbers of child and adolescent community mental health teams and acute inpatient beds have increased substantially, while waiting lists for child and adolescent mental health services, CAMHS, have decreased and initiatives are under way to reduce them further. We have to understand there is also a great deal of work to be done in these areas.

In broad terms, we have facilitated the move away from institutional to community care, providing service users with more accessible treatment in better environments. We have closed many of the older psychiatric hospital inpatient units, providing new, improved facilities such as The Phoenix Care Centre, the new acute unit in Cork University Hospital and those due to open shortly in Galway and Drogheda. Preliminary site work has also commenced on the new state-of-the-art national forensic hospital to replace the Central Mental Hospital in Dundrum. We have helped to foster a greater awareness of mental health promotion in society through campaigns such as Little Things, while the suicide prevention strategy, Connecting For Life, has helped to increase awareness of suicide in society. While much good work has taken place in recent years, I am under no illusion that more work and further effort are required. For example, we need to continue the development of counselling services across primary and secondary care services. We need more community mental health teams, together with improved 24/7 response and liaison services. Most important, we need to ensure no group, regardless of age, ethnicity, sexuality or circumstances, is left behind or overlooked. Changes initiated as a result of new funding allocated by the previous Government have paved the way for real and lasting change for service users. We need to build on that change.

The national mental health strategy, A Vision for Change, is ten years old this year. Within the next 100 days I will initiate an evidence-based expert review of progress in the implementation of this policy and the improvement of mental health services. The review will take account of international best practice in mental health services and inform how we will develop policy.

Perhaps the main challenge to the mental health service is presented by the recruitment and retention of staff. Many well trained, highly motivated individuals are taking up employment outside the public service, either in the private sector or abroad. I touched on this issue yesterday with a number of Senators. I am conscious of the difficulty in recruiting and retaining nurses in the mental health service. For that reason, I am happy to inform Senators that the HSE is reintroducing a one-year post-registration programme in psychiatric nursing for nurses who are registered in either the general, intellectual disability or children's divisions of the register maintained by the Nursing and Midwifery Board of Ireland. A total of 30 places have been made available on the programme which is due to commence in the autumn in association with UCD. While this is a positive move, there is a great deal of work to be done in the further recruitment of staff within the HSE, for which I intend to push.

We live in an evolving world. While we can communicate with people more quickly, in many ways, perhaps, we are becoming more isolated owing to the pace of our daily lives and the pressures we are under. Our pace of life is getting faster. This puts people under pressure and they are in need of assistance. The need to reform and update mental health policy and services is clear. We need to plan for this, but we also need to address changes which are happening now. Education is key and most important at an early stage. Mental health issues often manifest at a much younger age than we like to think or even discuss, but that is the reality today. The pressures young people face today compared to when any of us was in school are completely different. Every second of a young person’s life is online and while it is visible for everybody to see, it is also visible for everybody to criticise - what they look like, how they dress, who their friends are, who they hang out with, where they go to school and how they do in examinations. There is a different dimension to young people’s lives that was not there a few years ago and we need to start dealing with it.

In the next 100 days I will establish a youth mental health task force, on which I am actively working. It will consider how best to assist young people in developing resilience and coping skills to support their emotional well-being at an early stage and to build awareness of how to access high-quality effective services when they need them. It will include a number of non-political, non-governmental members with significant expertise in youth mental health services and be supported by a significant cross-departmental effort to establish a new, co-ordinated way of working across government to promote youth mental health and well-being. This will be a critical aspect of our work. The mental well-being of young people is not simply a health issue and should not relate specifically to the Department of Health. It is not simply an education issue either. It is an economic, social and community issue that requires the public, private and voluntary sectors and all of us to co-ordinate and pull together in order that our combined efforts will achieve more than the sum of their parts and that every young person will have the full support of the community in which he or she lives to reach his or her full potential.

I again refer to the marriage equality referendum last year. It was not mental health legislation, but it had a massively positive impact on the mental health of many people. We need to identify the everyday issues that affect young people’s well-being and, as a community and society, equip them with the tools they need to deal with them effectively.

I thank the House for giving me the opportunity to contribute. I am here to listen to what Members have to say. I will take on board what they say and work them with them into the future.

Senator Gerry Horkan

I congratulate the Minister of State on her appointment and wish her the best in her important role.

On behalf of the Fianna Fáil Party, I would like to outline our message on mental health. Mental health issues continue to silently inflict immense damage on our society. The undercurrent of depression, anxiety and addiction is a profoundly ingrained problem for society and no family is untouched by mental health issues. Beyond the striking statistics for suicide rates, the affliction of depression exacts a heavy toll on the day-to-day lives of many people. We have successfully confronted dangerous challenges such as this. The spike in the number of road fatalities that endangered a generation of motorists was tackled head on with the establishment of the Road Safety Authority, RSA, through increased investment, the penalty points system and so on and significant numbers of lives have been saved annually. We need a similar concerted national approach to tackle the devastating impact of mental health issues. In an Ard-Fheis speech a number of years ago Deputy Micheál Martin referred to the setting up of a mental health authority. If the Government were to set up such an authority with the same funding and emphasis as, for example, the RSA, it could prove similarly effective.

As a republican party, Fianna Fáil believes mental health policy is, ultimately, a question of citizenship. We believe people with mental health problems must be brought in from the periphery to the centre and encouraged and enabled to give full expression to their citizenship through employment, social engagement and the opportunity to contribute to their communities. As citizens, people with such problems have the right to equality of access and the full range of modern, cost-effective and therapeutically impactful treatments and not to be bound to the classic services of the past. Access to services must not be dependent on where people live or their earnings. The citizenship approach dovetails well with the recovery model of mental health care, whereby recovery is built on a partnership approach between the person and his or her mental health care team. The recovery model moves away from the paternalistic psychiatrist model of the past towards a more multidisciplinary co-operative approach. It recognises that treatment is not merely about the alleviation of symptoms but also about working with the person to ensure he or she can live a productive and meaningful life, despite the vulnerabilities that may continue. He or she should be equipped with the skills, self-understanding and resources he or she needs to help to prevent a relapse.

Flowing from this is the vision that mental health promotion is a whole of society concern, given the prevalence of mental health problems and their impact on individuals, their families, communities and employment. Mental health policy should be aimed primarily at preventive measures, early action when problems begin to surface and early intervention with children and their families.

This approach must extend beyond the health system and be integrated with all aspects of life, including education, planning, employment and communities. The ultimate aim is to create a mentally healthy society.

Fianna Fáil's vision for mental health and well being is built on five key principles. First, public policy ought to ensure people with mental health problems are included in society and enabled and assisted in playing their part therein. Second, the recovery model of mental health care is the most appropriate in terms of individuals' well being and enhancing and defending citizenship. Third, mental health should be taken as seriously as physical health in the deployment of resources, health and safety measures and public planning. Fourth, the emphasis should be on early intervention and early action, as the Minister of State mentioned. Fifth, mental health policy must be mainstreamed across society in order to promote mental well-being and reduce the risk of mental ill health.

We need to enhance the National Office for Suicide Prevention, NOSP, increase the number of suicide prevention resource officers, expand their role and link them directly with the NOSP. We must ensure all general practitioners, GPs, are adequately resourced to provide comprehensive help for individuals at risk of dying by suicide. A system of GP practice must be put in place whereby the prescribing of anti-depressant medication must be reviewed on a monthly basis until the GP is satisfied that the taking of medication is the best course of action. We must establish out-of-hours emergency social worker teams across the State.

Regarding Child and Adolescent Mental Health Services, CAMHS, the principle of early intervention is critical, as properly addressing mental health problems in early childhood and the adolescent years leads to better educational outcomes, avoids severe mental health issues later, improves quality of life and is more cost effective than later treatment. We need to end the practice of placing children in adult inpatient units and should focus on holistic and accessible services that minimise the use of inpatient beds. The provision of counselling and a seamless integration with schools and education policy must also be central to plans. Within schools, all teachers should receive mental health training so as to equip them to identify, support and refer children with mental health problems. We must restore guidance counsellors to secondary schools; every school should have a named CAMHS worker and all children should have access to counselling services through their schools. We would anticipate a universal health check being carried out when children receive their booster vaccinations in sixth class or first year in secondary school. This check would include a mental health assessment to identify developing or existing mental health problems, thus allowing for early and efficient treatment.

We all know that this is a major issue. It affects every family in the country, every neighbourhood, every community and every workplace. We must ensure we will do everything possible to improve the service provided. I wish the Minister of State well in her role.

Senator Kieran O'Donnell

I welcome the Minister of State, Deputy Helen McEntee, and wish her well in her brief.

I wish to speak about the issue of suicide, particularly in the context of the position in my constituency of Limerick City. Studies have shown that, between 2011 and 2013, it had the highest suicide rate in Ireland. At more than 21 deaths per 100,000 of population, the rate was almost twice the national average. The most recent statistics from the Central Statistics Office show that there has been a decrease to 16 deaths per 100,000 of population, but the rate is not decreasing among men. In 2015, 2014 and 2010 the figure in Limerick was nearly 29 men per 100,000 of population. In 2015 the figure for females was 3.5, although in 2014 it was very high, at 17.3. It was nil in 2010.

I want these issues to be addressed. We are attending too many funerals of people who die by suicide. It is a national emergency. More people die by suicide than in car accidents, yet there is considerable reporting, justifiably so, of deaths on the roads. Deaths by suicide must receive the same level of concentration.

Studies have shown that 70% of young males know of someone who died by suicide. For 17% of them, it was a close friend. We must address this issue. A further feature of the statistics is that 60% of people who die by suicide are 44 years or younger. They are a young cohort. This issue should be addressed in a practical way.

The Minister of State is carrying out a welcome review of A Vision for Change which is now ten years old. In the context of the position in Limerick, the fact that the rates have been consistently high needs to be addressed. A Vision for Change committed to the opening of 20 inpatient child and adolescent mental health beds in University Hospital Limerick, but that has not happened. It must happen. As part of the Minister of State's review, this should be a priority. If a child or an adolescent has mental health issues, he or she will end up in an adult ward, which in the modern age is unacceptable. Given that the levels of suicide have been consistently high in Limerick City, will the HSE or the Department carry out a specific study of the reasons for this? There is a myriad of factors, for example, alcohol and drugs.

In 2014 St. Patrick's Hospital's mental health services presented the stark result of a survey. Some 65% of Irish people believed being treated for mental health problems was a sign of failure. We must get rid of this taboo. Among young males, there appears to be a fear of admitting to any mental health problem because it is seen as a sign of failure.

Will the Minister of State discuss a suggestion with her counterpart, the Minister for Education and Skills? As part of the curricula at primary and secondary levels and as Senator Gerry Horkan referenced, CSPE subjects should include modules on physical and mental health and well-being which must be on a par. This would have a major benefit, as people would feel it was not taboo and that, if they had mental health problems, they could treat them just as they could a broken leg. We cannot afford to have 451 people dying by suicide, as we did last year. That is the reported figure, but many suicides go unreported.

As promised in A Vision for Change in 2006, 20 inpatient child and adolescent beds should be provided in University Hospital Limerick. A study should be undertaken by the Department of Health and the HSE to discover why the suicide level in Limerick City is so high. Mental health and well-being should be included in the curricula at primary and secondary levels.

Senator Gerard P. Craughwell

The Minister of State is welcome. This is my first time to address her in the Chamber. As I told her privately yesterday, she has taken on a tough portfolio and I wish her the best with it.

Research produced by the ESRI last year indicated that workers exposed to bullying and harassment showed high levels of mental distress, anxiety and ill health.

There is ample anecdotal evidence that at least one in ten workers experiences bullying, leading to episodes of low self-esteem, anxiety and even suicide.

While a lot of work has been done by organisations in drawing up and implementing dignity at work policies, there is an epidemic of bullying in the workplace the likes of which has never been seen previously. Last year I hosted a series of meetings with individual workers who related to me horror stories of bullying incidents and the impact on their mental health. Paragraph 5 of the Industrial Relations Act 1990 (Code of Practice Detailing Procedures for Addressing Bullying in the Workplace) (Declaration) Order 2002 describes bullying. There is a huge difference between robust management and bullying in the workplace. During my time as president of the Teachers Union of Ireland a colleague contacted me to tell me that they were suffering horrendous bullying because of their timekeeping. When I asked what the problem was, they said, "I am usually in by 9.05 a.m.", to which I replied that that was not bullying but a management issue. That is what it was all about.

I have looked into the eyes of cowardly bullies. I have seen the way they work first hand. They destroy the individual psychologically. They break him or her down little by little until he or she becomes a shadow of his or her former self. It is in the loneliness of that existence that I raise this issue in a debate on mental health. It is when one is in one's sitting room, bedroom or dining room at 3 a.m. or 4 a.m. looking into the darkness and wondering why one has found oneself in this position. Usually, those who suffer from what I call character and personality assassination are the strongest, best workers one will find. They are the most innovative and friendly of the staff. They are the ones who are held in the highest esteem by colleagues, yet they are the ones who are broken down.

Only last week a person came to see me. It had taken him two years to realise what was happening to him. It involved sly remarks such as, "We have heard enough from you, John; we do not need to hear any more," or "John, do not attend the next meeting; we do not need you," or "John, would you stop trying to make out that that job you are doing for us is the greatest thing that ever happened?" That is what brings a person slowlyu down. Sadly, I have experienced two examples of this in my lifetime. I am convinced to this day that the people concerned took their own lives for one reason only - they had been broken by the managers with whom they had worked and I mean they had been destroyed by them.

Currently, there is only a civil redress option for those affected by workplace bullying, but within the criminal justice system there is legislation entitled the Non-Fatal Offences Against the Person Act 1997. We are crossing two Departments and probably three and four - perhaps we should look across all Departments - but when we talk about bullying and the Non-Fatal Offences Against the Person Act 1997, the Minister of State might work with her colleague, the Minister for Justice and Law Reform. We all talk about managing the problem of bullying among children in schools. Yesterday we heard statements following the murder of Jo Cox, MP. Politicians in this and the other House, from all parties and none, related stories of the horrendous treatment they were receiving online, including in telephone calls or when people came into their offices and pounded the table, which in itself is a form of bullying. It is time we took the bully out of the equation and became a bully-free society that will not tolerate that type of attack on an individual. Every person has a right to his or her dignity. Every person has a right to do what it is he or she believes is his or her best at work, in his or her contribution to society or whatever else, yet we have those who seek to destroy. I am not talking about physical destruction but the mental destruction that takes place. While the issue crosses a number of Departments, the Minister of State can take the lead and offer those who are suffering this horrendous treatment a lifeline by saying she will take an interest in the problem of bullying in the workplace and its effect on the mental health of those affected. If she does this, she will do the greatest service ever for those suffering this horrendous problem. I thank her for her time.

Senator Ray Butler

I welcome the Minister of State to the Upper House and congratulate her on her appointment as the new Minister of State with responsibility for mental health services and older people. I believe she will take the necessary measures to address the ever-growing number of pressing issues surrounding mental health.

I am also encouraged by the fact that the Cabinet approved the restoration of funding for mental health services in 2016. Commitment was clearly shown by the previous Government which is continued by the Government in the programme for Government. A Vision for Change provided for the ring-fencing of an allocation of €35 million within the overall health budget to develop community mental health services and ensure early access to more appropriate services for both adults and children.

A key focus has been the provision of additional posts to strengthen community mental health teams for both adults and children. They have been used to enhance specialist community mental health and forensic services and increase access to counselling and psychotherapy services by way of suicide prevention initiatives. Appropriately, 1,550 new posts have been approved since 2012, up to the end of 2016, of which 1,153 had been filled or were part the recruitment process by the end of last year. The posts facilitate the policy of moving away from the traditional institutional based care to a patient-centred, flexible and community based mental health service in which hospital admissions will be greatly reduced, while providing inpatient care, when appropriate. While all of these steps are towards a common goal in looking after the needs of those suffering from mental health difficulties, there is a very long way to go. I will outline some key areas which need urgent scrutiny, together with a change in legislation, to help those most vulnerable in our society.

Ireland has the fourth highest rate of youth suicide in Europe. Suicide is everybody's problem. One in four of us will at some stage throughout our lives suffer from mental health issues, regardless of age. Those at local general practitioner level and staff working in emergency departments are not sufficiently trained to recognise or deal with patients who present with a mental health issue. What training is provided in this area? Is it updated and, if so, how often? Emergency departments are not equipped to deal with a person in crisis. Access trained crisis support 24 hours a day, seven days a week, is essential. Let me give another example. A young man with mental health issues had been in a Dublin hospital for a medical procedure but was discharged at lunchtime the same day. That evening he was seen by his general practitioner for a check-up and despite the fact that he was attending Pieta House, the medical professionals did not deem him to be suicidal. He took his own life before the day was out.

A major factor that works against those suffering from mental health issues is patient confidentiality for anyone over the age of 18 years. Those who have a member of their family suffering from a mental health condition understand how frustrating it is to have their hands tied and unable to intervene to help their loved ones owing to this confidentiality provision. In reality, we have a system under which the family or a loved one of someone suffering from a mental health illness is not permitted to access the most basic information to support him or her. That does not make sense at any level. Families must be involved in the care of someone suffering from a mental health illness. I ask the Minister of State to make this a priority and bring forward legislation to ensure the best possible care for all.

In the case to which I referred the mother involved said, "As a mom looking after our son, I should have access to as much information as possible in order to keep him safe." In my constituency I dealt with a person with mental health issues and her neighbours and I watched her die. Her house was filthy and there were maggots all over her body. The HSE told us it could not do anything. She had to sign herself in. We had to look at this, knowing what was going on behind closed doors.

Access to counselling needs to be a priority. Private services are not affordable for the majority. There are those who desperately need this assistance and shorter waiting times. Someone in crisis may not always have time on his or her side. People have been referred by the public sector to a private service as the public sector does not have specialists available. The cost is €140 per session and it is not suitable for everybody. Sometimes there is no alternative except to endure endless waiting lists and hope and pray loved ones will be able to hold on.

I know that the Minister of State's portfolio is close to her heart and it has touched all of ours also. I am excited to know which changes she will bring about. I wish her every success in her new ministerial role.

I will finish with a sobering thought written by Shane Gillen:

I am a 28 year old male in Ireland. Some day I will die, and the chances of me dying by suicide are higher than the chances of me dying of liver disease, leukaemia, stomach, pancreas, oesophagus, liver or colon cancer, kidney disease, lymphomas or from a serious injury or car crash. Today's Ireland sees suicide ranked among the top ten killers in the land.

Senator Máire Devine

I thank the Minister of State and all Senators for their passionate speeches and statements on mental health. According to the World Health Organization, mental health is the most important public health issue. Even every poor society must afford to invest to promote and protect it. Mental illness is the world's most neglected disease and the leading cause of disability worldwide. As previous speakers said, anyone can experience it. Depression and anxiety are very common conditions and affect almost 500,000 people in this country. One in four of us will be affected by depression at some point in our lives and, tragically, each year several hundred people take their own lives, with grief and shockwaves rippling through family, friends and communities forever. We are a society in distress and have a moral responsibility to demand resources to guarantee the provision of a modern mental health system to meet today's needs. Public demand has never been so high. Since the establishment of the State, all Governments have failed miserably in this regard. They have had no comprehension of mental distress and appeared not to possess compassion, a word we need to use repeatedly. Yesterday we lauded A Vision for Change, which takes us from the antiquated Victorian era. Instead, Governments have used it as a fiscal scalp to cut services without any community replacement.

Many reports by the Mental Health Commission and Mental Health Reform rage against the failure of mental health services. Yesterday saw the launch in Buswells Hotel of a wonderful document by the Psychiatric Nurses Association, PNA, and the Royal College of Surgeons in Ireland, RCSI. I hope the Minister of State has a copy and will go through it. It details the failure of A Vision for Change and the stark fact that the budget was drastically reduced from 14% to a measly 6%. This is unpardonable and inexcusable. Of the recommendations made in A Vision for Change, 75% have not been implemented. Regarding inpatient bed status, A Vision for Change was to seek community replacement of inpatient facilities. Figures taken from the report show that in 1984 there were 12,500 inpatient beds, whereas in 2004 the figure had gone down to 4,000 and in 2015, to 1,600. The percentage drop between 2004 and 2015 was 60%. The budget was drastically reduced at the same time. The document speaks about broken promises and the heartbreak felt throughout the country. The mental health service has always been the Cinderella of the health service, but it needs to be at the top of the agenda in every Government's decision and policy-making. It needs to be a central focus of health policy.

I applaud and congratulate community groups and families who are standing up and innovators in the vanguard in leading the fightback to inform communities and demand the provision of appropriate care and understanding for those who are in distress. They are the mental health advocates and warriors who are challenging attitudes and changing lives. We do not need further reviews. What we need is implementation. We have reviews coming out our ears, so to speak. We all know what needs to be implemented. The will is needed to do so. I hope the Minister of State will work with us all in this regard.

On the issue of stigma, to which the Minister of State alluded, it was hopeful to witness the See Change Green Ribbon campaign which was fantastic and really well done. It started a conversation. If people wear the green ribbon, they are open; they want to talk about mental health and disperse the stigma attached to it. The research See Change has carried out in recent years has shown that people are much more comfortable in discussing mental health issues; we just need to keep it going. In addition, last week in the Mansion House there was a fantastic community-initiated report on suicide and its effects on communities and families in the Dublin 8 area. I would like to see the Minister of State invite the South West Inner City Network to present the report and to be part of the youth group she wants to put together. It speaks from the heart and is a community initiative. Those involved are not professionals but concerned about the matter on the ground. Dublin 8 has had its fair share of pain and grief. The report speaks mostly about the love they have for those whom they have lost.

I welcome the Minister of State's report and the postgraduate course to try to convert some nurses into specialist psychiatric nurses. We need to tackle the concerns of student nurses. The intake is 300-odd a year, with drop-outs, yet there are 1,000 vacant posts this year and we will spend 15 years trying to catch up to provide nurses to care for families in distress.

Senator Maura Hopkins

I welcome the Minister of State, Deputy Helen McEntee, and wish her every success in her new role.

Minding our mental health is a constant requirement every day of our lives. How we feel filters into everything we do and experience, from being involved in our community to having a job, meeting friends, financial stress, online criticism, feelings of inadequacy, bullying and feelings of depression. We must ensure at all times that all people know how valued they are. We must ensure in times of difficulty that we have someone to whom we can turn, someone who will listen, that we are equipped with the coping mechanisms to deal with life's challenges and, above all, that we have a mental health service which supports us when we need it.

The annual report of the Mental Health Commission for 2015 published a number of days ago clearly emphasises that a lot of work needs to continue in developing a properly resourced community-based mental health service with a focus on prevention and recovery. It is of major concern that just under half the HSE's community mental health services provide support seven days a week. It is unacceptable that in 2016 substantial areas of the country are still without full weekend support services for people with a mental health difficulty. I very much welcome the contribution of the Minister of State that we need more community mental health teams, together with improved 24/7 response and liaison services.

The intensive home treatment team established approximately a year ago in Roscommon works on a seven days a week basis to treat more people at home. It also allows for greater family involvement. It has a consultant psychiatrist, an occupational therapist, a psychologist, a nurse and a social worker. The feedback I have received from a number of service users is positive, but teams such as these need to be further developed and properly resourced in order that an holistic service is provided, the service user is very much at the centre of his or her own care plan and appropriate supports are provided, where necessary.

The restoration of the allocation of €35 million for mental health services was absolutely necessary in the light of the challenges we faced in delivering a proper service. I thank the Minister of State, with the Minister for Health, Deputy Simon Harris, for ensuring its restoration. Following publication of the report recently, the chairperson of the Mental Health Commission stated there was still a significant absence of psychology, social work, occupational therapy and other multidisciplinary team members. There are distinct difficulties in recruiting specific professional staff, despite funding being made available in 2015 for an additional 700 staff. I welcome the focus of the Minister of State on the challenges we face in recruitment. The HSE's reintroduction of a one year post-registration programme in psychiatric nursing is most welcome. What changes will the HSE and the Department of Health recommend as needing to be made to recruit increased staff to fill all multidisciplinary team positions?

I very much welcome the establishment of the youth mental health task force, to which the Minister of State referred. It is absolutely critical that, from an early age, young people have the coping skills they need to deal with life's challenges in order that we deal with prevention rather than cure. As the Minister of State is well aware, a lot of urgent work needs to be done in child and adolescent mental health services which are not properly resourced. Children and adolescents are being assessed and treated in inappropriate facilities.

Voluntary organisations provide vital services, particularly in the context of education on mental health well-being and counselling services. However, they need to be provided with proper funding support from the HSE.

I am enthusiastic about the need for a review of A Vision for Change which the Minister of State mentioned. It is absolutely critical that we respond to the changing demands of our society and I hope a review would allow us to plan mental health services to respond to these needs. I very much look forward to working with the Minister of State and thank her for giving me the opportunity to contribute to this debate.

Senator Frances Black

I will share time with Senator Collette Kelleher. It is lovely to see the Minister of State here and I congratulate her on her new role, in which I wish her well.

As many Senators are aware, ensuring we address mental health needs throughout the country is an issue that is dear to my heart. On a daily basis I hear from families and family members who are finding it difficult to access mental health services. Despite some excellent services and dedicated staff, the supports available are sporadic, at times unco-ordinated and not always fit for purpose. There is a prevalence of mental health difficulties in Ireland and we need to stop writing reports, policies and strategies and start acting to implement international best practice.

One in seven adults in Ireland will have experienced a mental health difficulty in the past year, while 9% of the population aged 15 years or over have a mental health problem, according to the Healthy Ireland survey. The survey also shows that mental health difficulties are an issue of inequality. Mental health problems are considerably more prevalent among people living in deprived areas, at a level of 13%, than among the overall population, the figure for which stands at 5%. The Minister of State can see from these facts that writing reports and not implementing them fully is costing Ireland dearly, in that we are not looking after the welfare of the people. Many good people work hard in delivering mental health services throughout the country, but problems in the mental health system felt are far and wide. Mental health service staffing is still 25% lower than that recommended in the mental health policy A Vision for Change. Specialist 24/7 mental health crisis services are not evenly available throughout the country. As a result, people may be obliged to wait for hours in emergency departments. In 2015 approximately one third of child and adolescent admissions to hospital were to adult units. There is no national advocacy service dedicated to families of people with mental health difficulties or to those with such difficulties who live in the community.

We must not ignore the contributing factor that alcohol is and how it exacerbates pre-existing mental health difficulties. It affects our ability to cope with everyday life and can have significant consequences when we face traumatic life events. It has a key impact on the number of suicides, being a contributory factor in more than 50% of cases. A total of 11,000 cases involving self-harm present to emergency departments each year, one third of which involve alcohol. The World Health Organization has estimated that the risk of suicide where a person is abusing alcohol is eight times greater than if he or she were not doing so. Suicide is the leading cause of death among young Irishmen aged between 15 and 24 years.

In tackling mental health issues it is imperative that we look at matters in an holistic way. In particular, we should look at a gender analysis. The HSE and the National Women's Council, with others, have been successful in securing the visit to Ireland in 2017 of the World Congress on Women's Mental Health. The HSE has had a successful project in policy-proofing gender analysis and we should work hard to ensure it is implemented in all mental health services.

We must not forget about the families impacted on by addiction. This issue is extremely close to my heart. We need to ensure the appropriate support services are available to the families concerned, that their risk of mental health issues is reduced by early intervention and that funding is found for the organisations supporting them. On a daily basis I deal with family members who are absolutely heartbroken because somebody they love has an alcohol, drug or gambling problem.

The task before us is huge. It is difficult but certainly one from which we should not shy away. We need direct action. We need to hold Ministers, officials and service providers to account and ensure we achieve the highest quality of services for the thousands of people throughout the country who are affected by mental health issues. Mental Health Reform has been campaigning for the implementation of the recommendations made. I support it in calling on the Government and the Minister of State to implement them and have the nation's mental health as a top priority. In acting now we will save further heartache, anguish and distress for our fellow citizens. A country is judged by how it treats its vulnerable. As I want us to be judged well, please let us start acting.

Senator Colette Kelleher

I congratulate the Minister of State, Deputy Helen McEntee, and look forward to working with her to improve the lives of those with mental health issues and older people.

I draw attention to a particular group in our society. The rate of suicide among Travellers is six times higher than among the general population. What immediate supports are in place to address this crisis, tragedy and source of heartbreak for Travellers? Will the Minister of State provide an assurance to the effect that the independent Traveller counselling service established on a pilot basis in 2008 is now on a firm and regular footing in the context of the provision of funding?

Senator Maria Byrne

I welcome the Minister of State. I support what my colleague, Senator Kieran O'Donnell, stated about the extra beds that were to be provided at University Hospital Limerick. I am dealing with three families who have members with various mental health issues. I am very concerned about one particular family.

An older mother who lives with a son and a daughter suffers from a mental illness, but she is very much in denial and it is hard to convince the family members to say there is an issue, even though the neighbours are involved and very concerned about what is going on. We must explore ways to encourage people, especially family members, to say there are issues within a household and provide the family with support. Some support services have been provided in this case, but the matter needs to be explored.

The shortage of beds in University Hospital Limerick has been mentioned, but I wish to commend the service provided by the hospital. I have had dealings with one family who have had two members in and out of a unit in the hospital. I can confirm that the services and treatment they have received are second to none. It is important to compliment the staff involved on providing such care. I urge the Minister of State to ensure extra resources and support will be provided.

Senator Gerald Nash

I welcome the Minister of State at the Department of Health, Deputy Helen McEntee, and congratulate her on her appointment. She is passionate about her work in this area and her passion and commitment will make a big difference in the Department. Everyone in the House admired the work done by her predecessor, former Deputy Kathleen Lynch. Even though the Minister of State has big shoes to fill, she will make her own mark in the Department. She will work very hard to deliver better services and change in the essential mental health service.

There is unanimity in the House on what needs to be done to promote positive mental health and the services we need. Just like the debate yesterday on health services, there will be no shortage of ideas on the services that need to be resourced and towards which resources should be directed. We need to be very clear on the need to stop the almost routine threat of pilfering the budget for mental health service in the context of the overall and politically sensitive general health budget. It is not an overstatement to say that, traditionally, the mental health service has been the Cinderella when it comes to the overall funding envelope for the health service. My colleague, former Deputy Kathleen Lynch, fought a Trojan battle to try ensure resources would be ring-fenced for mental health services during what were very difficult times for the State in the past few years. If we are serious about funding mental health services, we need to adequately and properly fund positive promotional campaigns. We must also fund good services that are proved to work and responsive to people's needs.

Yesterday I met part of the leadership team at the Union of Students in Ireland, Mr. Kevin Donoghue and Ms Aoife Ní Shúilleabháin, to discuss the organisation's mental health priorities. It is an organisation that works on the front-line with young people in vulnerable circumstances. I pay tribute to it for its "I Am A Reason" campaign which promotes positive mental health and identifies the need for improved services across the country. Like others, the campaign directs much of its attention towards the absence of 24/7 crisis intervention services across the country. As we all know, personal crises do not occur on a nine-to-five basis, Monday to Friday. The official policy suggests a network of 16 crisis houses be provided around the country. They would deal with and provide accommodation and support for people in crisis on a temporary basis until such time as connections could be made with community and mental health teams to develop proper care programmes to deal with some of the issues experienced by them. They would also address the underlying problems that precipitated the crisis in the first place. I have no doubt that the Minister of State supports this objective and I look forward to hearing her views on how the policy objective can be achieved.

I shall conclude by responding to comments made by Senator Gerard P. Craughwell on bullying in the workplace. It is an insidious phenomenon. Many mental health crises can be put down to experiences in the workplace that may have been inadequately dealt with. The Senator is right when he says there is only the option of civil redress available, but it is a costly and slow process. Bullying in the workplace is a scourge. One of the reasons is no clear procedures have been set down. In 2006 the report of the task force on bullying commented on the lack of clear and formal procedures needed to deal with bullying complaints. It also mentioned the need to outline a formal route for an adjudication on such complaints because all too often they were not addressed quickly and efficiently and thus ended up in the courts, which is damaging both for the employee who may be the victim and the employer who may, in many circumstances, be doing his or her utmost to address what is an insidious problem. I wish to correct Senator Gerard P. Craughwell by stating this is not a matter for the Minister of State or any colleague in the Department of Health to address, even though I am sure the Minister of State has a view on it. It is a matter for the Minister for Jobs, Enterprise and Innovation whom I ask to accept the will of the Dáil as expressed in the support shown for the Labour Party's motion tabled three weeks ago which included a provision to counteract such bullying by providing for statutory redress, thus providing a formal route to ensure the scourge of bullying in the workplace that can lead to enormous mental distress could be addressed efficiently and effectively. That is not the case at present.

Senator Jennifer Murnane O'Connor

May I share two minutes of my time with my colleague, Senator Aidan Davitt?

An Leas-Chathaoirleach

Yes.

Senator Jennifer Murnane O'Connor

I congratulate the Minister of State on her appointment. I know that she will do well in her new position. It is great to see the appointment of a woman.

No family is immune from mental health issues in some form. Beyond the striking statistics for suicide levels and the affliction of depression which is extracting a hefty toll in the day-to-day lives of countless people, the recovery model recognises that treatment is not merely about the listing of symptoms but also ensuring the person affected can live a productive and meaningful life, despite his or her continuing vulnerabilities.

I want to ask the Minister of State about funding. As she knows, her Department receives an annual allocation of €35 million for mental health services. I ask her to increase it to €37.5 million because the Department has stated it needs this amount to provide all of the services which are necessary. The provision of increased funding is critically important as I firmly believe the provision of funding holds the key to everything. We need to ensure we provide a proper service for people in need, particularly those who need mental health services.

I ask the Minister of State to establish a national mental health authority. Such an authority would show a sense of urgency in tackling mental health issues and reducing the levels of self-harm and suicide. In this regard, we must ring-fence the funding provided for mental health services. Far too often, as the Minister of State is aware, funding is pulled from the mental health budget and allocated to other services. I ask the Minister to ensure none of the mental health budget will be touched, rather that it will be increased. Early intervention is critical. Addressing mental health problems in early childhood and the adolescent years leads to better educational outcomes and the prevention of further mental health issues and can lead to a better quality of life. That is why it is important that extra funding be allocated.

The provision of counselling is essential. Teachers should receive mental health training to equip them to identify whether children need support. In particular, where they believe a child has mental health issues, they should be able to mention their concern to someone. We must restore the post of guidance counsellor in schools.

In the past such a service was in place, but it has been removed. I ask the Minister of State to reinstate it in every school as it is crucial.

A study of children's mental health in 2015 identified that while demand for the service was increasing, the number of staff was falling. A report has found that mental health services for children and teenagers are understaffed and overstretched, while access to support is confusing. Given the confusion, I ask the Minister of State to look at the issue. Some 61 approved centres were inspected in 2015, of which only six were rated as compliant. The remainder were non-compliant to varying degrees. It is critical that the Minister of State establish the youth mental health task force within 100 days. I make this request as a person who lives in Carlow and who has been a councillor for 19 years, during which time I have witnessed many changes. There have been several suicides of young people in Carlow recently. Like many other counties, it wants to be represented on the task force being established to examine the issue of youth mental health. The Minister of State has mentioned that within the next 100 days she will initiate an evidence-based expert review of progress in the implementation of policy and the improvement of mental health services. It is crucial that counties such as Carlow and neighbouring counties play a role in the task force. Every local authority and every part of the mental health service can play a role and have its say as it is crucial that we all know what is happening. The provision of information will be crucial. I, therefore, ask the Minister of State to set up a national mental health authority which is key the to getting everything on track. I would appreciate it if she came back to me with some answers.

Senator Aidan Davitt

Comhghairdeas leis an Aire Stáit. I have two queries, both of which relate to St. Loman's Hospital, Mullingar. Does the Minister of State have plans for the main building which is about 95% unoccupied? It is a landmark structure as one approaches the town of Mullingar. Funding has been put into some of the new infrastructure.

An issue was brought to my attention by HSE staff concerning the level of care provided in the community. The policy has been to return people to the community. Some staff members have expressed their concern that there are people being cared for in the community whom they consider should not be cared for in it. There have been a few incidents and I am sure Mullingar is not the only town in which this has happened. Has any assessment being made of how some clients are being cared for in the community? Perhaps some mistakes have been made and, if so, the people concerned should be assessed differently.

Senator Lynn Ruane

I wish to speak about dual diagnosis, an issue which is not raised too often in debate. Working in the homeless sector I have become increasingly worried, especially in the past decade, that having made the transition from institutional and asylum centre-type treatment, a large proportion of people end up on the streets owing to the fact that there is a big gap in service provision. They are not treated in the community and begin to be treated within a hostel setting by project workers who are not mental health professionals. To provide a little background information, on any given occasion 12 or more people would have to be subject to hourly checks because of their mental health. As one opens the door one does not know what one will find. I have had to cut people down from nooses. At one stage I had to use my stockings to stem the flow of blood from a man who had slit his throat. These are people who definitely should not be cared for within a hostel setting that does not have adequate services available to treat them. Ambulance personnel arrive, but the resident may refuse to go with them. A project worker can invest hours in trying to convince a person who is suicidal to go to the emergency department where two things can happen. Because of the dual diagnosis, the addiction takes over and the person goes into a state of withdrawal and leaves without receiving adequate treatment or he or she is seen and told the wounds will be looked at but not be treated. Given that dual diagnosis is normal, care plans should be in place to deal with a person's mental health and addiction rather than sending him or her from one door to another. On many occasions people have left the emergency department. Last year a man walked out straight under a car after he could not handle waiting in the emergency department owing to suicide ideation.

The report, Homelessness: An Unhealthy State, by Dr. Fiona O'Reilly and Dr. Austin O'Carroll, in the compilation of which I was involved and which looks at the issues of health status, risk behaviours and service utilisation by homeless persons in Dublin and Limerick, points out that almost half of the sample, 47%, experienced mental health issues and addiction problems. This has been termed dual diagnosis. People with both substance misuse and mental health problems have particular difficulties in exiting homelessness in taking care of their physical and mental health. The research shows that more than half the sample had previously experienced suicidal thoughts, while more than one third had attempted suicide. One in three homeless persons had been so desperate that they had attempted to commit suicide. Shockingly, the statistic gets even worse for those with mental health problems, with half of those with a diagnosis reporting that they had attempted to commit suicide in the past. The depressing statistics which reflect my experiences show mental ill health as being the norm among the homeless population, with 58% having had at least one mental health issue diagnosis. Some 13% had been diagnosed with schizophrenia or psychosis compared to a figure of 1% among the general population.

The inverse care law states those most in need of care are least likely to receive it. That a cohort of the population exists on the margins of society where mental health problems are the norm demonstrates the existence of this inequitable inverse care law. Will the Minister of State commit to turning it on its head and bringing equality and fairness to light by ensuring those most in need of mental health care will receive it? Will she commit to the following as a matter of urgency? A coherent and specific step approach to presentations by homeless persons in crisis in line with national suicide prevention guidelines should be established within the homeless sector. A crisis house for homeless persons, as recommended in A Vision for Change, also needs to be provided. This could take effect immediately by ring fencing 24/7 the allocation of a number of existing beds within the homeless sector, with nursing staff linked with inpatient psychiatric care provision for homeless persons at risk who are not best served within an emergency department. Professional care services need to be equipped with specific skill sets to meet clients' needs, that is, mental health social workers are needed on site in homeless accommodation, given the very high level of mental health service need evidenced in the study. These professionals can identify need among homeless individuals and navigate the many excellent mainstream services available, remove barriers for homeless personsand allow them access to appropriate care services. Mental health training and guidance for workers in the homeless sector and the provision of appropriate supports for clients are needed. There is also a clear need for recognition of dual diagnosis in a reconfiguration of services which should be treated as the norm rather than the exception. Addiction and mental health services have evolved separately and without reorientation towards the service user. As a consequence, the homeless person continues to be shifted back and forth between the two services.

Minister of State at the Department of Health (Deputy Helen McEntee)

I thank Senators for their contributions. This debate has been useful, like the continuing debate in the main Chamber. I assure Members that I will take on board absolutely everything that has been said. I may not be able to come back with a response on all of the specific issues raised, but I will certainly do my best to do so during the course of the next couple of weeks.

Across the political divide there is consensus that we need to improve services. We are all on the same page in that regard. It is important that we work together, listen to each other and work with the services to improve what is already in place. It is reasonable to say, however, that there have been real and significant developments in the service which were initiated by the previous Government. I acknowledge the work taken on by my predecessor, former Deputy Kathleen Lynch, and all those involved in the Department.

Additional funding of up to €115 million has been allocated to mental health services under the HSE’s national service plan. The funding will be used to enhance all aspects of the service. New investment and new personnel have been directed towards developing specialised services which, until now, did not receive the attention they deserved and needed. I will stand over the commitment to increase mental health funding every year. Obviously, the restoration of the €35 million development fund was important to me and I am glad that it has been restored. While I am Minister of State, I would like to be able to say it will never happen again.

I acknowledge the work carried out by the HSE and the voluntary and statutory organisations because they are working with those who are often at the lowest point in their lives. It is a difficult environment and, with increased demands and resource limitations, we need to ensure they will get all the credit they deserve.

There is a real and genuine will across all political parties to modernise services and bring us into line with best practice. Fundamental to this is our attitude to mental health. While we have come a long way in a short time, there is still a long way to go. To reduce the stigma and associated isolation, we need to start thinking of it in the same way as physical illness. If a person breaks a bone or cuts himself or herself, he or she will go to an emergency department or his or her doctor. If people feel under pressure or do not feel they are supported, we need to get to the point where they will believe it is okay for them to seek help and the stigma will thereby be reduced. In that regard, we need to make a concerted effort with men in their 40s in the same way we targeted women through BreastCheck to deal with a specific problem and stop it at an early stage. We need such a programme to target men who are at risk, particularly those in the workplace. I hope to progress this in line with our Connecting for Life strategy and by placing greater emphasis on health and wellness, early intervention and prevention. Education is key in this regard. My colleague, the Minister for Education and Skills, Deputy Richard Bruton, is rolling out the wellness programme through his Department. Through the task force I am establishing, I would like to see it being brought back to an even earlier stage.

The review of A Vision for Change is necessary, but I agree that progress cannot be halted at the same time. The vision will not change, even with a review. The review needs to operate in tandem with continued investment and implementation. If changes are to be recommended at the end of the review, they should be incorporated into policy.

As I have said previously, it is not just the Department of Health which needs to deal with this issue. It also touches on homelessness, the Traveller community, work environments and the judicial system, meaning that I will need a lot of support from my ministerial colleagues. I intend to ask them to identify key areas in which they need support from me.

I will come back to Senators on the matter of St. Loman's Hospital and other specific issues. If there are other specific questions on which I have not touched, they can contact me about them.

Sitting suspended at 2.05 p.m. and resumed at 2.30 p.m.