Mental Health Services: Motion

I move:

That Seanad Éireann recognising the shortfalls in 24 hour access to mental health services, resolves to ensure that resources in the mental health budget are allocated to ensure that there is comprehensive 24 hour access to mental health services, including weekend and out-of-hours services across Ireland.

I wish to extend my sincere thanks to the Minister of State at the Department of Health for personally attending the House to discuss this important motion. Once again, I really appreciate his support in all we are trying to do for mental health in this country.

When we talk about the provision of 24-7 crisis intervention, we need to consider the following question. Who are the people we are trying to serve? By considering this question and what is presently in practice, we will give this House a clear indication of how appalling mental health services are in this country. In some cases, the services are so appalling that they take one's breath away. There are some good news stories scattered around this nation but the overall picture is bleak.

Let us start with what adults need. There are men and women who need crisis intervention due to several factors. I am referring to people who have threatened or attempted suicide and those who have engaged in self-harm. In general, around 11,000 people present themselves to hospitals across the country each year. There is a known fact that approximately six times that number, or almost 70,000 people, attempt suicide every year in this country but those who are outside of the hospital catchment usually try to get better by themselves.

The people who need crisis intervention also include those in a psychotic state and people who are going through a dangerous breakdown where they and their families are in danger of their out-of-control state. These are the people that we need to serve. These traumatic incidents do not usually take place during working hours. Indeed, research shows that most presentations to hospitals take place at night and at weekends. In fact, Sunday night is the peak time for people who are in crisis.

The adults and their families who experience this terrible trauma soon realise that because of the absence of community-based supports, their only port of call is the emergency room in their local hospital. This busy, noisy and often chaotic environment that was created for physical health emergencies is now the only place a person in crisis can go. It is a place where these men, women and their families often encounter indifference, impatience and stigma from overworked staff. The unkind environment and uncompassionate approach is also coupled with the fact that the professionals who work in the emergency department have not undergone specialised training that would allow them to appropriately respond to someone in emotional distress.

The anxiety and deep distress experienced by our most vulnerable people is re-enforced by the lengthy waiting times that can last up to 12 hours. It is because of this that many people will not and cannot wait as the lack of care only adds to their crisis. Even if people are eventually seen, the lack of follow-on care when they leave can sometimes develop into a tragic death.

Eleven years after the publication of the policy document called A Vision for Change, mental health services for adults still do not provide the very basic model of care that includes 24-7 crisis intervention. Truly, and without being simplistic, there is a very simple, effective and economical solution to this problem, namely, extend the hours of the existing general adult mental health services and completely remove the service from the emergency department.

I shall now give an example of a communication that I received today from Wexford General Hospital. The hospital has 210 beds but it does not have a psychiatric unit or ward and yet, in the first eight months of this year, 606 emergency presentations involving a mental health issue were seen in Wexford General Hospital. Due to the fact that the hospital has no facilities, the adults are held pending a transfer to the acute unit at University Hospital Waterford. Let us consider that situation for a moment. A person is in a chronic state yet he or she must wait until he or she is ferried to another hospital that is located an hour and a half away. That is just one example of what one hospital is experiencing.

I would like to talk about the second group of people who need crisis intervention, namely, vulnerable children, the most vulnerable of whom have mental health issues. The boys and girls of Ireland are treated as second class citizens and the Government needs to see this. The reason they are treated as second class citizens is because of the Government's relentless avoidance of improving children’s mental health services and ignoring the fact that these services are dying on their feet. If services are not improved in Wexford, the CAMHS in the area will probably close down completely within the next 12 to 18 months because of the lack of consultant child psychiatrists.

The only way I can ask the Minister and the Senators in the House to experience this, and to realise what it is like out there, is to paint a picture of what our children and their parents have to go through. I shall tell the House about a few lived experiences. Take the case of Sam - this is not his real name - who is 14 years old. Sam attempted suicide. He was brought by gardaí to the local hospital but because there was no child and adolescent service available for him he was taken to another hospital one and a half hours away. The nearest child and adolescent unit was two and a half hours away so he had to be brought to this general hospital. Sam was placed in the adult psychiatric unit in the part of the general hospital locally known as the dungeon. Sam was left in this unit for 41 days. He thought he was being punished for attempting suicide.

Consider the case of a young 17 year old who, in a suicidal state, spent the whole night in an emergency room until the following morning at 8 a.m. when he was admitted into the adult psychiatric unit. He was told that he could not leave the room as he would be in danger from other patients there. Imagine that a child who was in very acute distress was told, "You cannot leave this room because you will be in danger." His parent was told to leave so that the staff could calm him down, and when the father returned an hour later he found the child all alone. The laces from his shoes had been removed and his belt had been removed but he was left in an acutely distressed state all on his own. There was no available staff so the hospital eventually had to take on an agency nurse to look after him 24-7.

Finally, take the case of the 16 year old girl who had taken an overdose and was admitted to a chair in the Kilkenny adult mental health unit. After she received carbon, a substance given to those who have taken an overdose of paracetamol, she was given a bucket to vomit into while her mother stood helplessly next to her in a very busy corridor.

I could tell horror story after horror story and none of what I tell will remotely describe the traumatic lifelong effects that these experiences will have on our children. The ISPCC has been calling for comprehensive 24-hour supports for more than a decade. The ISPCC child line receives more than 1,000 calls from children needing help every single day. Some 70% of these calls are out-of-hours. The UN committee on the rights of the child has also called on the Government to put in place a 24-hour service. UNICEF Ireland’s latest report card on child well-being shows that Ireland has the fourth highest teen suicide rate in the EU. While suicide in Ireland has decreased, thanks be to God, it has increased among children in the 15 to 19 age group. These are the children who have nowhere to go.

Finally, in February of this year, the Minister of State's predecessor, Deputy Helen McEntee, declared that work was under way on a roadmap for developing out-of-hours access to mental health services. The HSE mental health division has not even completed a costing model for a 24-7 mental health service. We do not need a roadmap, we need action. We do not need another task force and we certainly do not need another report or a review of a report. We need a practical and easily implemented plan that can be rolled out over the coming months.

Senator Victor Boyhan is down to second this motion. In his absence I call on Senators Ó Céidigh or Lawless. I have Senator Boyhan listed as part of the group.

Senator Kelleher has advised the group that she will second the motion.

Okay. I can allow that.

I am delighted to second Senator Joan Freeman's motion on 24-hour access to mental health services. I support this motion and I am very much informed and driven by my eight years of experience working for the Cork Simon community. Access to 24-hour mental health services was a major pressure point for those who were looking for support and also for the staff who were trying to handle and cope with people who were in very distressed situations and seeking support outside 9 a.m. to 5 p.m. hours. Homelessness is a factual situation but it is also a label that covers a multitude. Many of the people who sought support from Cork Simon community were certainly roofless and often penniless and friendless. Addiction and mental ill-health loomed large in people’s lives. Considering the life histories of people, one would not be surprised of that. Only last night I listened to a young woman, Caroline, tell her story as part of a Cork Simon action research project. One can listen to her story, as told directly by Caroline herself, and it is available on Twitter. It is well worth listening to. I shall speak some of her words for the House:

I never really had a childhood. My mother and father were both heroin addicts. There was an awful lot of fighting and violence as well in the house. A lot of death threats, hanging ropes left outside the door. There were plenty of times when food wasn’t even in the house. My Dad was always in and out. Mam was also locked up. They were on and off, on and off. My Mam would throw us all - me and my brothers and my sister - into the car up to her cousin's house, but they’d be all smoking heroin. My Dad would be on to her "The kids need to be at home, going to school, bring them back down." And we’d go back down and they’d get back together again. I would have been verbally abused by my father for it, for sticking up for her. If there was a fight kicking off I’d have to go with her, with my Mam, because I’d get the backlash from my Dad if I wasn’t gone. Before we went to care I was saying it to my Mam. Like she was going out at 9 o'clock at night and she wasn’t coming in till the next morning. And I was there on my own with a new-born baby, a two year old and my sister who was eight. I used to be saying to her "we are going to be taken". The hardest part of it was when we were taken. The four of us were put into an emergency foster home together, and then after the weekend was up, the social worker came and took the two boys. That was the hardest.

We can only imagine the stress and strains of Caroline’s young life and what would have brought her, in the end, to Cork Simon. People do not neatly turn up Monday to Friday between 9 a.m. and 5 p.m. Caroline and others like her could turn up at any time during the day or night. I remember clearly one Christmas Eve when a woman in her nightie, in a state of complete distress, turned up to the emergency shelter where they did the best they could. It is, however, not the place for somebody with mental health issues. It is a roof but not the place. It is not just that they are homeless; they are often in a state of mental distress. Workers would do their best to keep the person safe until Monday or until the Christmas holidays had finished, when the official mental health services resumed.

During the recent Seanad public consultations on child mental health, very ably chaired by Senator Freeman, the Oireachtas Library and Research Service summary paper shows the record number of submissions received. I believe it was the highest number ever received to any public consultation.

This reflects public concern about the issue. Among the submissions, the most commonly mentioned gap in services was the lack of emergency services available to children in crisis. People like Louise Walsh gave powerful testimony at the hearing when she described her "brainy boy", a 17 year old whose mental health broke down after the sudden death of his father. In Louise's words, her son could not cope with life or school and was suffering with severe depression brought on by grief after losing his dad. She stated:

I took some time off and brought him to the doctor. The doctor rang the nurses on the 24-hour helpline but he was too young to be helped... He was put on anti-psychotic drugs, not suitable for under 18s.

These drugs can trigger suicide. Louise's son had several more emergency episodes. Without access to a 24-hour mental health service, his episodes involved gardaí in squad cars, ambulances, flashing lights and accident and emergency departments, a scenario that was also described by Senator Freeman. Louise said her fit and healthy son was supposed to line out and play a hurling match the following day but instead was brought in on a stretcher and wheeled, in a catatonic state, from the ambulance into the emergency department.

Caroline, Louise's son, the people whose cases Senator Freeman described and other vulnerable persons with difficult lives not of their making need organisations such as Cork Simon community. They also need access to mental health support on a 24-hour basis. The Simon Community, Women's Aid, Barnardos and the Irish Society for the Prevention of Cruelty to Children are putting their fingers in the dam because this service is not available. For all of the people in need, I fully and wholeheartedly support Senator Freeman’s motion that Seanad Éireann, recognising the shortfalls in 24-hour access to mental health services, resolves to ensure that resources in the health budget are allocated to ensure comprehensive 24-hour access to mental health services, including weekend and out-of-hours services. I hope the Minister will respond positively to the motion and that we can look forward to a good day for people in need of 24-hour mental health services when the budget is announced next week.

This is my third time speaking in the Chamber since yesterday and I believe the Minister of State has also been in the Ceramics Room three times. I am sure he is becoming used to the surroundings in the Seanad's new home.

I acknowledge the issues raised by Senator Freeman and sincerely thank her and Pieta House for the work they do. A new Pieta House centre will be launched in Athlone soon and I wish everyone involved in the project the very best.

Senators Kelleher and Freeman recounted some harrowing stories. Senator Kelleher referred to people who are living difficult lives that are not of their making. Sometimes we do not realise that people are dealing with mental health difficulties that are not of their making. It is our job to try to provide resources to deal with these problems. I am not qualified in the area of mental health, which is a difficult issue to address. I thank all those who work in the mental health services.

There is a concern in County Roscommon and many other areas about how existing resources are used or, more to the point, not used. As Senators are probably aware, a recent report on the mental health service in County Roscommon showed that the HSE in the region prioritised cutting costs over meeting the needs of vulnerable service users. This is an unacceptable finding and it is shocking to note that in an aggressive bid to cut costs, almost €18 million in funding was returned by the Galway-Roscommon HSE area between 2012 and 2014. While there are obviously reasons for this, we cannot condone the decision not to use this funding as it would have gone a long way to addressing resource issues in County Longford. The failure to spend it clearly had a serious impact on service users. The report produced 27 recommendations. While it shines a light on the sorry saga, the mental health service in my region and every other region face many challenges. We must get this issue right.

On the broader issue of the prevalence of mental health problems, I can say with a fair degree of certainty that every family in the country has been directly affected by mental health issues, whether depression, anxiety or alcohol and drug abuse. From my small number of interactions with service users over the past 15 years, I have seen the difference access to the service makes. It is nice to see people who are suicidal or depressed accessing services but more services are needed.

I am staggered each time I am reminded that many more people die by suicide every year than die in road traffic accidents. We have gone a long way in addressing suicide but we must go much further. Youth suicide rates in Ireland are the fifth highest in the European Union. However, older people, especially men, may be vulnerable as suicide affects significant numbers of people of all ages. I thank again Pieta House, the Lions Clubs and many other agencies for their work in this area.

According to the HSE, more than 11,000 cases of deliberate self-harm are seen in hospitals annually, while many more cases do not come to the attention of the health service. It is clear, therefore, that mental health should be a priority issue when it comes to resources. Historically, as all Senators are aware, the sector has been underfunded. In 2002, Senators discussed the need to ring-fence funding for mental health services. We are moving towards that position but we have been behind the curve in prioritising and resourcing mental health services.

While many challenges remain, the overall gross non-capital mental health budget increased from €711 million in 2012 to €850 million in 2017. This significant increase, despite wider Exchequer funding pressures, reflects the priority given by the Government to mental health. I hope the Government will prioritise the sector even further in the forthcoming budget.

A Programme for Partnership Government contains a clear commitment to increasing the mental health budget annually, as resources allow, to develop services. Progress, while slower than originally anticipated, primarily due to the recent recession, also continues to be made in implementing the recommendations of A Vision for Change, the ten-year policy framework for mental health services published in 2006. The strategy recommended that interventions should be aimed at maximising recovery from mental illness and building on service user and social network resources to achieve meaningful integration and participation in community life.

Preparations for a review and update of A Vision for Change policy have been under way since early last year. In September 2016, an external evidence and expert review was commissioned as the first step in determining the parameters of a revision of A Vision for Change. The review, which was completed in February 2017, provides evidence to determine the policy direction for a revision of A Vision for Change, both in terms of international best practice and the experience of implementing the framework.

I am pleased to note that a new oversight group will progress the development of a new policy for mental health based on the outcome of the expert review. The group will meet for the first time in the coming weeks and the policy review process will also involve consultation with key stakeholders. I hope the issue of a comprehensive need for 24-hour access to mental health services will be considered in this context.

It goes without saying that mental health must continue to be at the very top of the Government's agenda simply because it affects so many people, young and old. I thank again Senator Freeman for raising these important issues which require careful consideration.

I welcome the Minister of State, Deputy Jim Daly, to the House. I congratulate Senator Freeman on her election as Chair of the Joint Committee on the Future of Mental Health Care and I commend her on bringing this motion before the House. It is unfortunate that she has had to introduce a motion asking the Government to spend money that has been allocated for vital and often lifesaving services. It is not unreasonable to ask for resources in the mental health budget to be allocated to ensure there is comprehensive 24-hour access to services at weekends and out of hours. Like all other health emergencies, mental health crises are not confined to the hours between 9 a.m. and 5 p.m. from Monday to Friday. The requirement for crisis services can be demonstrated in the prevalence of individuals presenting to emergency departments with mental health difficulties. While there is a lack of data in Ireland, a UK study has found that a significant 5% of all accident and emergency presentations are related to mental health issues.

A Vision for Change recommended that arrangements should be evolved and agreed within each community mental health team, CMHT, for the provision of 24-7 multidisciplinary crisis intervention; and that each catchment area should have the facility of a crisis house to offer temporary low support accommodation if appropriate. More recently, the suicide prevention framework, Connecting for Life, included a commitment to "provide a co-ordinated, uniform and quality assured 24/7 service" for individuals in need of mental health care. Over ten years on from A Vision for Change, mental health services are not uniformly providing a basic model of care that includes 24-7 crisis intervention and home-based and assertive outreach treatment with crisis houses as the norm in all areas. In the absence of community-based supports, the accident and emergency department is often the only option for an individual in crisis. As a doctor who spent time working in the accident and emergency unit in Connolly Hospital in Blanchardstown, I can tell the House truthfully that an accident and emergency department is not the place for a person who is suffering a mental health crisis. I also had the pleasure of working as a psychiatric registrar in St. Ita's Hospital in Portrane. I see many patients with mental health difficulties on a day-to-day basis in my surgery. Thankfully, most cases can be handled in the community setting. We are talking today about crisis cases, however.

During the Seanad Public Consultation Committee's consultation on mental health, which took place before the summer recess, we listened to parents who told horror stories of having to bring their children to accident and emergency departments. One mother told the committee:

On another night my son attempted to seriously self-harm and we took him to the emergency department because it was out of hours. Rhys and I were put into a small waiting room and we had to wait for over two hours for the on-call psychiatrist. Rhys escaped from that room that night and ran through an emergency department full of adults screaming, "Please let me die". He was trying to escape from the hospital and get outside. He said that he wanted to run under a car and die. I took flight after him. Security and a nurse did likewise. We caught him and had to bring him back. It was so distressing. We were in this room and all these people were looking at us. It was awful. An emergency department is not the answer. It is not able to deal with this situation. The environment is wrong. It is not very safe. I was in that room with him and he was still able to get out of that room. It is not a suitable situation for a child. When we saw the on-call psychiatrist that night, he was put on medication to calm him and help him sleep, but he was sent home that night. He slept in between us. He did not really sleep but spent the night hitting his head in an attempt to get the voices out.

We need to approach this situation in a pragmatic manner that is driven by solutions. What is wrong with my suggestion of a 24-hour GP phone line that would ensure there is rapid access to child and adolescent mental health services in emergency situations? It would cost practically nothing to provide such a service to vulnerable young adolescents who are suicidal. I do not think it would be abused. I would say my own busy practice would probably use it twice a year. The 24-hour emergency helpline I am proposing would be specifically for GPs who need to contact child and adolescent mental health services so that their patients can access such services rapidly. It would prevent unnecessary referrals to accident and emergency departments. The remarks made at the Seanad Public Consultation Committee that I have quoted have stayed with me not only because I am a father of two small children and cannot imagine ever being in that situation, but also because I have worked in accident and emergency departments that are frightening for a grown man, let alone a child in distress.

A Vision for Change committed €35.4 million over five years for the development of mental health services. However, €20 million of that fund went unspent in 2017. There are extensive waiting lists in mental health services. I refer not only to child and adolescent mental health services, but also to psychology appointments in primary care. Some 520 approved positions that were allocated in 2015 and 2016 remain unfilled while these waiting lists continue to grow. A further 390 posts were to be provided for by the end of 2015, but by July 2017 just 150 of them had been filled. Similarly, 360 positions were allocated as part of 2016 funding, but by the middle of this year a mere 80 of them were in place. As there are severe staff shortages, these crucial positions urgently need to be filled. Realistically, almost 2,000 new staff need to be recruited in mental health services if the Government is to provide the level of care envisaged in A Vision for Change. Fianna Fáil is seriously concerned with the slow pace at which the HSE is recruiting. At this rate of increase, it will take another 11 years for A Vision for Change to be implemented in full. The Government and the HSE need to up their game in this regard. It is not acceptable to take 22 years to fulfil a ten-year plan.

I thank Senator Freeman for bringing this vital issue to the attention of the House. Along with my Sinn Féin colleagues, I was delighted to add my name to the list of those supporting this motion. I am aware that during the last term, Senator Freeman worked extensively with my colleague, Senator Devine, on the Seanad Public Consultation Committee, particularly on the issue of children's mental health. Mental health has been referenced extensively in the Oireachtas and in the public domain in recent times. Now it is time for us as legislators to work out the details of how we can revolutionise mental health care in this country. Senator Freeman spoke poignantly about who we are trying to serve. I worked in community development for many years. I tried to draw up a community response to mental health as a way of addressing this key issue. I can honestly say the system has got worse and worse. The services and supports that are given to people right across the life cycle have deteriorated year on year. I accept that there are areas of good practice. Some models of good practice are never brought into the mainstream.

I would like to speak about waiting lists. I can only speak about my experience in my local area. People who want counselling have to wait for up to 12 weeks. If people who are feeling down come to me to say they need to see a counsellor because they need some help, I think it is great that they are taking a positive step. However, when I make a phone call to try to get an appointment for such a person, I am told it will be months before he or she is seen. What happens to that person, wherever he or she is on the life cycle, during the intervening months? It is absolutely atrocious. If such a person opts for hospitalisation and presents at an accident and emergency department, the facilities are absolutely unsuitable. Services like addiction services that were previously provided at hospitals so people could avail of them have been taken away over the years.

When people go to accident and emergency units, they often have to wait for many hours and sometimes leave without getting any treatment. In other cases, they get minor treatment before being discharged into the hands of the community mental health services, which have impossible case loads, the next day. This goes on and on when people could be treated. People deserve to be treated so that they can have a proper quality of life. Many of the things they present with are temporary. When they present with things that are more permanent, they can get suitable treatment that will not impede their quality of life. Young people present with self-harm all the time. Part of the problem is that proper statistics are not captured. The statistics that are available show that many young people have died and are no longer with us because action has not been taken on the issues mentioned by Senator Freeman.

However, if one were to look back on their records, one would see many of them presented multiple times at their local accident and emergency department and went into the revolving door system that they would not leave until they went to their graves. That is the situation people are facing. Twiddling around will not work. The system needs to be revolutionised. It is as if everybody within the system has authority but nobody has responsibility. There is almost a relief that some areas of the mental health services are so complex because a person can say it is not part of his or her role to deal with a particular situation and leave it to somebody else to take responsibility. That has to stop. As Senator Freeman said, the current system is designed to support the system and not to support access or those it is there to serve.

Affordability is another issue. There are people making fortunes in this country from the poor mental health of those who, because they cannot access a public health system with proper mental health services, must do so privately. They are making absolute fortunes from it. The system is designed to facilitate the privatisation of mental health services and that must stop.

If a person from my home area of Erris wants to access a CAMHS service he or she will have to make a round trip of up to 100 miles to do so. If a 16-year-old child wants to access that service, he or she will have to get out of school, get transport to where he or she needs to go and then try to afford the cost of it all. It is absolutely brutal and has to stop. Services such as CAMHS should be available at primary care level near to where such young people live. I beg the Minister of State to take that on board because this issue affects human beings, not numbers, and for many young people a minor intervention for a short period of time could change the whole course of their lives and the lives of those they meet.

The system is not fit for purpose and has to be changed. That is why Sinn Féin's alternative budget launched earlier this week outlined how we would gradually switch the current Monday to Friday daytime hours to a model that is flexible to the needs of those who depend on it. That would require services to move to a seven-day-week roster. The weekend service is very important but the services needed are not currently available even during the five days they are meant to be, in particular in rural areas.

Sinn Féin is happy to support the motion and I hope it receives cross-party support. I want to be positive and optimistic about that but cannot be because my party has tried to walk this road before. The seriousness with which it takes this issue was illustrated by the appointment of its deputy party leader, Deputy MacDonald, to this portfolio. In September 2016 a Sinn Féin Private Members' motion in the Dáil demanded that the Government put a timeline on the delivery of 24-7 crisis intervention services and that is on public record. The motion proposed that there first be a published plan for implementation of seven day a week, in-community services and then required the Government to invest in services to move towards a 24-7 model. The motion was very moderate in its demands and the timeline it put on Government, giving it a year to implement the initial changes. The Government neutered the motion with an amendment removing any commitment to 24-7 services or a timeline for delivery. Fianna Fáil, as silent partner of the Government, sat on its hands and abstained on the motion as it was gutted by Fine Gael.

I could go on but I will finish. The figures speak for themselves. Since 2012 there has been a drop of 13.4% in the number of psychologists employed in the CHO2 mental health division, which is my own area in the west of Ireland. It is hard to believe that the number of psychologists in primary care in CHO2 remains the same as it was in 2012. The figures speak for themselves. CAMHS staffing levels in Mayo, Roscommon and Galway were only at 57% of those recommended in A Vision for Change. I plead with the Minister of State that it is never too late to do the right thing and support this motion. Those services are desperately needed in Mayo, the west of Ireland and throughout the country and our children deserve it. We will get back our investment in mental health financially and socially many times over.

I commend Senator Freeman for her work to date in trying to remove the stigma from mental health and in advocating strongly, as do all Members, for improved mental health services.

Last Monday the Minister of State, Deputy Daly, went to Galway to meet Tony Canavan, the chief officer of community health care organisation 2, with regard to mental health services in Roscommon, following an external report commissioned to consider the quality, safety and governance structures of those services. It is a very damning report and we must learn from its recommendations that services should be delivered to a very high standard. That is not what happened in previous years in our mental health services. We very much need to learn from the mistakes of the past. We need to look at where they were made and we need to look for improvements.

I want there to be better accountability. There is much discussion of budgets but we need to ensure that every euro given to a particular service is used in an appropriate manner and to achieve maximum impact for service users and their families. We need to ensure that proper clinical supervision is in place to support staff. In order for mental health teams to work well, there needs to be excellent communication, good teamwork, a good knowledge of clients and the service needs to be adequately resourced to deliver that. That is not what has happened in Roscommon mental health services to date. The recommendations clearly set out the need for proper accountability, better mentoring and for management to properly engage with staff so that they all feel the need to achieve goals to ensure the aims of A Vision for Change are delivered. There have been some improvements, in particular with regard to home-based care, and we need to move towards that service of helping people in their own communities at very difficult times for them. As a public representative based in Roscommon, I want to see improvements in mental health services in the area and that is why the Minister of State went to Galway on Monday.

An implementation team has been set up and is meeting on a fortnightly basis. I have been assured that the Minister of State will receive monthly reports on the progress of the group. We need to see actions arising from it, in particular with regard to management properly engaging with staff. We must ensure that our mental health service is modernised in order that clients of every age can access it during times that are very difficult for them. We also need to help families support clients with mental health difficulties.

That is my key message. We need proper accountability regarding budgets. We have particular difficulties also with staff recruitment. While some improvements have been made, we need to make greater strides to attract staff to work within our mental health services. The teams need proper human resources to function as they should.

This motion deals with crisis intervention, but we also need to look at mental health services across Departments as well as from an enabling and well-being point of view. The preventive aspect is also extremely important. I acknowledge, however, that today we are dealing with the 24-7 crisis intervention service. A service must be available to people and their families when they need it most. We all know of very difficult and sad cases of individuals who felt they did not have the assistance they needed. We must do more. Specifically, I refer to Roscommon mental health services on which I want to see action. I want to see improvements in the quality of the service that is delivered. Management has signed up to the 27 clear recommendations in the report and now we need to see action. We need modern mental health services that reach out to people when they most need it.

I welcome the Minister of State, Deputy Jim Daly, to the House. I am very happy to speak in favour of the motion and I commend my colleague, Senator Joan Freeman, for bringing it forward. I join colleagues in stressing that 24-7 access to mental health services is essential. The funding must be made available to address this need.

Currently, thousands of children are struggling to cope with mental health problems due to the failure to properly resource emergency and acute services. Since 2014, demand for mental health services has gone up almost 30%. As of July 2017, however, almost 2,500 children and young people are still on waiting lists and unable to get the help they need. Many have been waiting for over a year. This is just one example of the urgent need to invest in better public services. It must be a priority for the Government.

From my experience of working in the field of addiction, I know that problems do not arise solely during working hours. The need for 24-7 access to mental health services is essential as it is often out-of-hours or weekends when people need urgent help. People will talk about the cost, but the cost of providing 24-7 access to proper mental health services can be met by the savings on future treatment. The World Health Organization suggests that, in the field of mental health, early intervention is fundamental in preventing progress towards a full-blown disease, in controlling symptoms and improving outcomes. We need to focus on prevention, not cure, and early intervention through proper services is the key to this.

We have made big strides in our ability to speak openly about mental health, but we need the investment in services to match it. Particularly with young people, investing in mental health at early ages represents the most cost-effective action to prevent the continuous increase of mental health problems in all age groups. Our understanding of effective treatment needs to move beyond the concept of recovery as the getting rid of a disorder to the idea of instilling positive values and behaviours which enable young people to flourish, contribute to society and be happy and healthy.

People's younger years are often the peak period of incidence for mental health problems, yet this is where supports and services are most lacking. A major Irish study found that at least one in four Irish teenagers had experienced serious personal, emotional, behavioural or mental health problems, while almost one in ten had self-harmed. Ireland has the fifth highest rate of youth suicide between the ages of 14 and 24 in the EU, with 90% of suicides linked to mental health difficulties. Proper services are key to bringing these figures down. The figures are really shocking and show that we are in a real crisis around mental health.

Dr. Shari McDaid, director of Mental Health Reform, has called on the Government to allocate additional funding to meet the core funding gap in the HSE's mental health budget. It is estimated that €65 million is needed just to meet the current level of demand for care. This is not extra money; it is core funding to ensure that there are adequate beds for people with highly complex and severe mental health difficulties who need long-term residential care. It is the funding to provide residential services for people with eating disorders and it is the funding for services which have a shortage of inpatient beds for people in acute mental distress. It is the resource needed to respond to the 26% increase in referrals to child and adolescent mental health services between 2012 and 2016.

A key area I want to stress, particularly from my own work in this area, is that of dual diagnosis. This is where a person suffers from both a substance abuse problem and another mental health issue such as depression or an anxiety disorder. If we do not treat both together, we cannot beat either. I have worked as a therapist in the Rutland Centre with those who have been in addiction and I have not met anyone who did not also have an issue around anxiety, depression, stress or some form of trauma in their life. As such, these things really go hand in hand.

It is the same with mental health services. People who present with mental health issues will turn to alcohol or drugs to numb out. These issues are very closely linked and we must look at them together in the context of dual diagnosis. Most mental health services and addiction treatment centres in Ireland are currently not organised to treat people holistically. For example, if one has difficulties abstaining from alcohol due to anxiety, one cannot enter rehabilitation services as most residential drug services insist one be "dry" before entry. This is where it gets confusing because one cannot get one's anxiety problem treated until one's addiction to alcohol has been addressed. That is where people are falling through the gaps. As such, we need a joined-up approach and a real system for dual diagnosis.

If we integrated addiction and mental health services, it would help to reduce the suffering of people and their families and the resultant savings could help fund the badly needed 24-7 service which has been spoken about so passionately today. Father Peter Mc Verry, who has been providing accommodation to homeless people in Dublin since 1979, is clear on this. He says:

The holistic needs of the individual are not being addressed. There are too many borders between homelessness, drugs, mental health; you need to be in one category or the other to be dealt with, when you are in multiple categories the system breaks down. And it’s when you are in ‘multiple categories’ that you are most in need of assistance. I don’t see any joined up thinking, or at least the practical delivery of services in a joined up manner. We need to develop multi-disciplinary teams that are capable of dealing effectively with the totality of the problems that people have.

I set up an organisation, the Rise Foundation, which deals with family members who have a loved one with an alcohol, drug or gambling problem. The foundation is in fact a mental health service because it deals with family members who are under huge stress and who are very anxious. In particular where they are the adult children of alcoholics or drug addicts, a lot of them end up with severe depression, suicidal tendencies and sometimes even physical ailments. Unfortunately, this service gets no Government support notwithstanding the fact that approximately 3,000 people have come through our doors. It is very worrying. If even that does not get support, things are not looking good.

I strongly commend Senator Freeman on her fantastic work. She has done unbelievable things. Pieta House is, as we all know, beyond anything else. I know many people, including family members, who have attended Pieta House when they were in crisis. The staff there have been brilliant and I pay huge tribute to the Senator for that.

I commend the motion again and offer my full support for it. My key message today is that we must do better on dual diagnosis and look at the issue around family members who have been reared in homes where there has been alcohol or drug misuse. People are slipping through the cracks and it is not acceptable. If we show leadership on this issue, the savings we make in properly addressing mental health and substance misuse problems will more than compensate for the additional funding needed for these services. I hope the Minister of State can hear what we are saying today. I know he is a good man, that his heart is in the right place and that he is passionate about this issue. I hope that is reflected in next week's budget.

The Senator who moved the motion will close the debate.

That is fine. I had anticipated that I would have two opportunities to speak and that I would be making an opening statement and a closing statement, but I believe I will make one contribution so I will do my best to be as efficient as I can and to combine my statements. I wish to respond to as many of the individual issues as I can.

I thank Senator Freeman, who moved this motion. I acknowledge the sentiment that has been widely expressed throughout the House in acknowledging her contribution to the area of mental health. Senator Freeman is held in high regard across the board from every side of the House. Everybody recognises the benefit of the real and practical experience that she brings to this debate. With that in mind, I welcome this Private Members' motion. It provides an opportunity to discuss an issue that is so real and relevant that there is no family in the country that is not affected by this issue. I am delighted to have an opportunity to discuss it, to listen and most importantly of all to learn from people such as Senators Freeman, Black, Kelleher, Hopkins and many others, including Senator Swanick who has left the Chamber who all have real life practical experience of dealing with it upfront. I have learned and what I can do with that learning remains to be seen. That is a work in progress for all of us.

The Government will not be opposing this motion, as it is aligned with our direction and focus on this issue. We continue to be committed to the ongoing development and improvement of our mental health services. This can be seen in the undertaking outlined in A Programme for a Partnership Government to increase the mental heath budget annually to build capacity in existing services, along with developing new services. I know that figures which are trotted out ad nauseam can become boring, but it is worth reminding ourselves of the investment since 2012, which were not very sunny years economically, of €140 million which has been added to the mental health budget in the past five years. Of course, the money is never enough, but to be fair, the commitment to the service in times of scarce resources, particularly in the earlier part of that five year period, must be acknowledged. There were no additional resources. The overall budget allocated to mental health services has increased by more than 20% in that period. I do not know of a budget for any other service that has increased by that much in that period. In itself that signals a commitment on the part of the Government to the issue of mental health. I welcome the Ceann Comhairle's initiative at the opening of this session, where he had a symposium on mental health. It is the second time such an initiative was rolled out. Last year it was Brexit, which is an all encompassing noble topic. This year with Brexit out of the way in terms of dealing with it, the Ceann Comhairle very rightly identified mental health as a top priority for the Oireachtas to debate. I welcome the new political focus that has come on mental health and the ensuing additional budgets that have become part of that.

Staffing, of course, has an impact on the overall delivery of the mental health services, including the movement towards increased seven day cover and ultimately a full 24-7 service, and as such it is important that there is an understanding of the current landscape.

In line with the recommendation in A Vision for Change, our national mental health policy, the Government has prioritised the development and expansion of community-based mental health services.

As of June 2017, the mental health division has 9,738 mental health whole-time equivalent staff. Since 2012, despite recruitment challenges, roughly 1,500 new posts have been approved, of which 1,200 have been filled. We are all aware of the continuing challenges but in the interest of balance and fairness it is important to acknowledge the work that is being done in the HSE. The HSE has developed a broad range of initiatives, including the conversion of agency employed staff into HSE direct employees, national recruitment campaigns and offering all graduating nurses full-time contracts.

The Department, the HSE and the psychiatric nursing unions reached an agreement in August 2016 that included a number of measures to address the position. In particular it was agreed the number of undergraduate student places would increase by 130 to increase the supply of graduating nurses. It was agreed to put 60 additional places in autumn 2016 and a further 70 in autumn 2017.

There are other positive developments to note in this area also, such as the recent commencement of the recruitment of 114 assistant psychologist posts in primary care. Many Members spoke about the need to have lower level intervention and to have better access within primary care. The assistant psychologists will be key to reducing waiting lists for child and adolescent mental health services. Introducing mental health expertise in primary care has the potential to provide quicker access to mental health supports for families and children where difficulties have arisen.

By taking an overview of the problem and the contributing factors we can progress innovative solutions such as these alongside further recruitment and retention efforts. It is just such a measured and concentrated approach that is necessary in progressing what we want to do today, that is about bringing about a seven day 24-7 service in mental health.

When it was launched in 2006, A Vision for Change was universally welcomed as a progressive, evidence-based and realistic document which proposed a new model of service delivery which would be patient-centred, flexible and community based. The Government accepted A Vision for Change as the basis for the development of our mental health services and significant successes can be noted in how the supports and services in place serving mental health have changed in the intervening years. I think everybody acknowledges that progress has not been fast enough but as a society we have moved far away from the deplorable actions of consigning mental health to institutions where people were locked up. Moving away from that has been a gradual and steady shift, but one that has been very welcome.

One important point noted in the document is that "mental health services must be accessible to all who require them; this means not just geographically accessible but provided at a time and in a manner that means individuals can readily access the service they require". This relates directly to the motion that Senator Freeman has brought before us, which has been seconded by Senator Kelleher.

The Government recognises that mental health crises do not operate on a nine to five schedule. We know that for those who are in need of our mental health services, timely and considered supports are crucial to successful care outcomes. For those in need of urgent care, this is currently provided through a number of interlinked components across the service. This includes community mental health teams, which are available to respond to crises during normal working hours. These teams have an established pathway of contact for existing patients, and other individuals can be referred through their GP. All of these mental health teams keep slots for urgent referrals when a person is acutely suicidal or severely depressed. I think everybody in the House acknowledges that there is a service available from 9 a.m. to 5 p.m. Outside of normal working hours, an individual in crisis may present to the emergency department. The HSE's mental health division has now ensured that all level four hospitals have a liaison psychiatry service available on the site of the acute hospital, with this service providing prompt assessments in the emergency departments. Additionally, most level three hospitals now have either a service in place or one planned. This is one of the ways we are striving to provide those among us who may be experiencing distress with efficient, quality mental health care.

Another initiative which began in 2014 was the National Clinical Programme, NCP, for the assessment and management of self-harm in emergency departments. It has trained and deployed 25 senior mental health nurses at clinical nurse specialist level to emergency departments around the country. This facilitates an on-site, rapid response to those who have self-harmed and-or are suicidal. It supplements and works with the liaison psychiatry service to provide a bespoke response to those who are suicidal or have self-harmed.

There are other services available such as consultant psychiatrists on-call outside normal working hours who together with a psychiatric registrar or senior house officer on duty in acute hospitals, provide the urgent crisis response to people presenting to emergency departments.

A review of weekend access by the mental health division of my Department earlier this year shows that weekend mental health services are provided in nine of the 17 mental health areas. A further seven areas have partial cover.

We know that more than 90% of mental health needs can be successfully treated in a primary care setting, with less than 10% being referred to specialist community-based mental health services and of this number, a further 10% being offered inpatient care. However, this does not mean that we can ignore the very real needs of those who need access to seven day services and 24-7 services and whose mental health can be drastically impacted without such access - a point that all the speakers stressed today. With this in mind, while the HSE currently provides a range of services on a 24-hour basis through the interlinked components just outlined, work is ongoing to expand upon the services available in the community to ensure a comprehensive seven day cover. The recognition of timely connection is seen in the inclusion of the development of a model for the provision of enhanced seven day services within the HSE mental health division 2017 operational plan.

Specific steps have been taken to further that aim since early this year. These include: the establishment of a steering group with agreed terms of reference; the completion of a scoping exercise; and the identification of pilot sites, with subsequent consultation with the relevant management teams to discuss the requirements of a seven-day service.

There is a specific focus on ensuring that the design and delivery of such a service will be informed by international best-practice models so that a consistent model of care can be adopted. This service must be integrated and evidence-based to ensure the provision of high-quality services to service users, which must at all times remain at the centre of our efforts. The current situation is that, following the collection of extensive data and information nationally, the HSE has now identified the areas that require additional resources to achieve seven-day cover. I am happy to say that engagement with local management teams has commenced, with the aim of achieving implementation of seven-day cover by the end of this year.

Alongside this, the HSE mental health division is establishing an evidence-informed model, including detailed clinical, governance, training and performance measurement structures, for the operation of a full 24-7 service. A working group is capturing views from across the service pertaining to what form these extended services should take. Building on the development of seven-day services, these views will be presented to management for consideration and implementation. Funding has been secured for the move towards a full seven-day service, with €1 million agreed for 2017 increasing to €4.5 million in 2018. This measured and deliberate approach - the scoping of services and the identification of what needs to be implemented with considerations first for a seven-day service and then a 24-7 service - is the best we can take. It will ensure that the service we ultimately provide will be evidence-based and high-quality and, most importantly, effective in meeting the needs of service users. It shows that the Government recognises that we cannot afford to be complacent about mental health.

If time permits, I will refer to some of the issues that were raised. Many similar points were made in the context of all of them. I do not wish to speak on the individual cases that were mentioned, each of which is heartbreaking. The individuals are real people and their cases are a great way to illustrate the human effect when a system fails or lets us down. I welcome listening to that but I do not wish to comment on the cases when I am not familiar with them. One point is worth making. I am not attempting to be defensive in what we are discussing here because I appreciate that we are all working collectively. However, the report I launched last week for the National Office for Suicide Prevention, NOSP, shows that the number of people dying by suicide in this country is stabilising. That is not a great jump-up-and-down story but it is a significant step in the right direction. It is an important message. At the launch in question, I spoke to a gentleman who is the CEO of a prominent charity in this area. He told me the organisation was holding a dinner the following week and the report would be helpful news as the number of people who give their time and volunteer to fundraise, help and support need to hear good news and that their efforts count for something. It is important that we recognise the positives as well as the negatives to give due deference to all of those who are contributing such vast amounts of their time, energy and effort into achieving a more successful and sustainable life for all.

Senator Kelleher mentioned the Cork issue and CUH. That has improved dramatically. She is probably aware of the consultant, Professor Eugene Cassidy, who provides an excellent service for adults in CUH. I acknowledge that homelessness and associated issues are a huge challenge in light of the number of people who are homeless and presenting with additional challenges.

The Roscommon report was mentioned by Senators Feighan and Hopkins. While the report is very local in its substance, it is national in what we can learn from it in terms of the lessons in it and the implementation of the recommendations. The reason I am taking a particular interest in it is that there are lessons to be learned and replicated across the country.

Senator Swanick asked about the slow pace of HSE recruitment. It is one of the questions I asked in my Department soon after my appointment. The HSE does all its recruitment nationally and Tusla recruits regionally and locally. I asked the Secretary General to talk to the HSE about the possibility of it conducting some more localised and regional recruitment. I believe that would be more efficient. The Senator also suggested avoiding the accident and emergency department by providing a GP telephone line to the child and adolescent mental health services for out-of-hours service. That is an idea I have not heard previously and I will take it on board.

I am conscious of time so I will try to be brief.

The Minister of State is over the time limit but I will allow him to finish.

In response to Senator Hopkins, I have addressed the lessons to be learned and the regular oversight of implementation.

Senator Black spoke about the additional funding. It is accepted that funding is necessary. We can focus our debate on the funding and on pumping millions more into mental health services, but I have far more concerns about what we are doing with the money we have. We are spending €850 million on the delivery of mental health services and there should be better management and focus and more appropriate referrals. For example, when a young person presents to their GP, accompanied by his or her parent, and says he or she is experiencing anxiety and is nervous about something, he or she is referred straight to CAMHS. That is not an appropriate referral. CAMHS is headed by a consultant psychiatrist and there is no need for somebody with a low level of anxiety to be on a CAMHS waiting list. That leads to a self-perpetuating vicious cycle. CAMHS will prioritise who must be seen and that young man or girl will be left on the list in perpetuity. The same people could also be on a National Educational Psychological Service, NEPS, list. In a number of respects what we do and how we do it are as important as additional funding. My job would be very easy if I could tick the box by securing an extra €20 million for mental health. I could head off into the sunset with my work done. It is more important that I take on board some of the ideas the Senators mentioned.

I wish to make a final point, and I thank the Acting Chairman for his indulgence. I appreciate it. I am fascinated by what Senator Black said about the dual diagnosis, the challenge that presents and the vicious cycle for those people whereby they cannot be taken in to have their alcoholism dealt with until the anxiety is dealt with or vice versa. In other words, one must get on top of one before dealing with the other. It also applies to homelessness. Canada has a system whereby the first thing that is done is that the person is given a house. Then the person is in a far better position to deal with his or her issues. In Ireland and in many other western countries, we tend to take the position that the person must deal with his or her alcoholism or one of the other issues before we can house the person or take him or her in. We are the reverse in that regard. It is an interesting issue that is worthy of further debate.

I wish to make a brief comment and I thank the Acting Chairman for allowing me the time to do so. I thank Senator Freeman for championing this important issue for young people. Sinn Féin is proud to support the motion.

We all know that mental health has never been adequately resourced and that services for young people are particularly absent. Mental health can no longer be left as an add-on at the end of the health budget. Sinn Féin's pre-budget submission and alternative budget allocated a €20 million fund in 2018 to speed up the roll-out of 24-7 crisis intervention services. I commend the Oireachtas on the parliamentary forum on mental health. I made the comment at the parliamentary forum that Dr. Tony Bates from Jigsaw speaks about the pillars of good mental health as having agency and control. Another contributor remarked on addressing injustices in society. I do not believe we can talk about building an inclusive society without acknowledging the urgent need to enable citizens to live at peace with their lives. Bulking up and expanding our mental health services must be done in parallel with addressing injustice and enabling people to live at peace with their lives, realising a person's right to a home, to marry the person they love, to live free from direct provision, to access gender recognition, to modern universal health care for women and to decency and democracy at work.

These are all affected by political choices and many of our citizens are continually dissatisfied with their existence. They do not feel they are listened to by the Government and very often that dissatisfaction leads to a search for the other and to scapegoating and marginalisation, as we see throughout a fractured Europe and across the world.

Ireland's response to that must be to have a rights-based society where we build on the core human decency that is so common among our people. The expansion of our mental health service must be done in parallel with addressing justice and enabling people to live in peace. Many Members believe in social justice and many believe in proper mental health services. Can we own and run with those beliefs?

It was lovely to hear the speech of the Minister of State. There was great sincerity there, but what he said also sounded nearly believable. It is very typical of his Department to roll out figures, but we are still waiting for action. He has to defend his Department and that is his job, but there is also the practical element of being truthful about the very serious shortfalls. He mentioned the National Office for Suicide Prevention. I was involved in this issue when the first national strategy for suicide prevention, Reach Out, was created and implemented. Ten years later, nothing had been done. In its wisdom, the Department decided to create another document, Connect for Life, which the Minister of State recently launched. This is an example of something the Government is very good at and that happens all the time, which is its really good way of kicking the can down the road by creating and reviewing reports. The Minister of State spoke of a charity that sees the report as good news it can tell its donors about how suicide rates are decreasing. A critical point he missed is that there are approximately 500 charities in Ireland that deal with suicide and it is thanks to those charities that suicide rates have gone down, not thanks to the Government nor the NOSP, which really is just monitoring everything.

The Minister of State said he was not defensive but it is fine to be defensive. He mentioned that €140 million has been added to the mental health budget in the past five years. He said it is the only service that has had a 20% increase in its budget. The section of that budget allocated to children's mental health services was 13% in 1984. In 2004, it dropped to 7.6% and last year it was 6.1% so there has been no increase but, rather, a chronic decrease in that allocation. This debate was about the budget for mental health services. Even if the overall budget is not to increase by €1 million, I ask the Minister of State to seriously consider increasing the portion allocated to children's mental health from that miserable 6% to 12%. That must be fundamental. Our services will never get better if they are not brought back up to the proper standard. Children make up 23% of those accessing mental health services in Ireland but we are giving them 6% of our mental health budget.

I again thank the Minister of State for coming to the House on this issue. He could have sent somebody in his place but had the courage to listen to me giving out and I appreciate that. I also thank the Senators who gave their very important input into this important topic. I thank everybody else for the continuing lovely comments they have made. I appreciate it and it makes me want to work even harder.

Question put and agreed to.

When is it proposed to sit again?

Next Tuesday at 3.30 p.m.

The Seanad adjourned at 5.55 p.m. until 3.30 p.m. on Tuesday, 10 October 2017.