Mental Health (Amendment) Bill 2017: Second Stage

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

It is my pleasure to speak on the Mental Health (Amendment) Bill 2017, brought forward by Fianna Fáil before Seanad Éireann. A significant contribution to the formulation of the Bill came from Mental Health Reform, representatives of which are in the Gallery today. I thank them for the support they have given to Fianna Fáil and particularly Deputy James Browne in spearheading the Bill and bringing it to this Stage.

In agreeing to facilitate a minority Government, Fianna Fáil inserted in the confidence and supply agreement a condition that A Vision for Change would be fully implemented within the lifetime of the Government. A Vision for Change was developed under the then Fianna Fáil Government as a strategy document that sets out the direction for mental health services in Ireland. Since 2001, our understanding of mental illness and the rights of people suffering mental illness have advanced. In particular, we have had the UN Convention on the Rights of Persons with Disabilities, to which Ireland is a signatory. We need to change how we look at Acts of the Oireachtas that affect peoples' rights. They should be viewed as living Acts that can be readily amended and updated to reflect how we live our lives physically and emotionally. I echo my disappointment about yesterday's budget and measures targeted to mental health funding. I am disappointed the full amount of €35 million was not secured and funding was hidden in other measures. I understand the total comes to less than €15 million.

This Bill seeks to implement some of the recommendations contained in the report of the expert group on the review of the Mental Health Act 2001. The Bill was passed by the Dáil in July this year and it would deliver immediate improvements and legislative protection for adults and children accessing acute mental health services. It would also contribute in some part to the Government's fulfilment of international human rights law, including the European Convention on Human Rights and the Convention on the Rights of Persons with Disabilities. The Mental Health (Amendment) Bill contains certain significant changes that strengthen the rights of people in hospital for mental health care. The Bill also supports the rights of inpatients to make decisions about their own treatment by linking the 2001 Act with recent law that affirms that everybody should be presumed to have capacity to make decisions. This includes providing people with the supports they need to make these decisions.

In total, the expert group made 165 recommendations relating to the updating of the Mental Health Act. This Bill does not address all 165 recommendations but it goes some way to addressing some of them. It is a first stepping stone to ensuring those with mental health difficulties have more autonomy to make decisions on their care when they are getting treatment. To date, only one of the 165 recommendations has been implemented by the Government and the pace of reforming our mental health legislation and services is far too slow. The Bill we have put forth seeks to address some of these issues.

The Bill will deliver immediate improvements in legislative protection for adults and children accessing acute mental health services. It will also contribute in some part to the Government's fulfilment of international human rights law, including the European Convention on Human Rights and the Convention on the Rights of Persons with Disabilities. One of the key changes put forward in the Bill is to introduce a definition of "voluntary patient", including only individuals with decision making capacity and who have consented to admission. The Bill also seeks to ensure that people are given the right to the highest attainable standard of mental health and the right to receive the least restrictive care possible. It seeks to enhance awareness of the special needs of children when interacting with the mental health services, proposing that each child has the right to be heard in decisions made regarding their care in the mental health service.

It also affirms that involuntary patients could not be given treatment without their consent, except in certain circumstances. The detailed proposals we have made would help in the process of reforming mental health legislation and, in effect, mental health services. It is important that we move quickly to implement the recommendations made by the expert group. I will not go through all of the recommendations made. I will focus on some of them and my colleague, Senator Paul Daly, might reflect on others when he is seconding the proposal.

Section 2(1) of the Bill introduces a definition of "voluntary patient" to include only those who have the capacity to make their own decisions, with support if required, and who give their consent to be admitted to hospital. People who do not have the capacity to consent to admission and who do not object to it are considered to be voluntary patients under the law, even though they are not able to consent to admission. This means that they do not have an external review of their status or receive the oversight protection provided for involuntary patients. Under the Mental Health Act 2001, a person is considered to be a voluntary patient only if he or she is not the subject of an admission or renewal order that would make him or her an involuntary patient. In other words, a person is a voluntary patient only by virtue of the fact that he or she is not an involuntary patient. The 2001 Act does not refer to capacity or consent on the admission of an individual as a voluntary patient. Critically, it does not distinguish between individuals who have the capacity to consent to their admission and those who do not.

The Bill also addresses the question of putting the person first. Section 3(2) would eliminate the principle of "best interests" for adults. It would keep the principle of "best interests" for children under the 2001 Act. The Bill would replace the "best interests" principle with the guidance principles under the Assisted Decision-Making (Capacity) Act 2015 which relate, for example, to respecting the will and preferences of a person. The Bill also introduces other human rights principles such as the right to the highest attainable standard of mental health and the right to the least restrictive care. The Government has already signed up to these human rights standards. The Bill would confer a right to "the highest attainable standard of mental health consistent with least restrictive care". The expert group has identified that this should be in the context of giving due respect to "the person's own understanding of his or her mental health". The existing principle of "best interests" under the 2001 Act has been interpreted very paternalistically in the courts and sustained a culture where, at all times, the views of doctors have been given priority over those of patients who are the service users.

This section of the Bill also retains some of the principles already set out in the 2001 Act, including the right of a person to autonomy, privacy and bodily integrity. The shift from the term "best interests" would empower people to be decision-makers over their own mental health, which is the core value of the Bill. Its ultimate aim is to give people more autonomy when they receive treatment for their mental health issues. This change in perspective values the expertise and knowledge of the individuals in understanding their own mental health difficulties and recognising what is best for them in their own care and recovery.

I would like to address other aspects of the Bill such as the provisions relating to children and young people under the age of 18 years. While the Bill would eliminate the "best interests" principle for adults, as I have explained, it would retain it for children and young people under the age of 18 years. Section 4 is in line with the expert group's recommendation which recognises that where there is an intervention on behalf of a child, his or her best interests must be the primary consideration. It is imperative that the term "best interests" be defined in a way that is informed by the views of the child, bearing in mind that these views should be given weight in accordance with his or her age, evolving capacity and maturity, with due regard to his or her will and preferences. This is important because it is still appropriate for decisions on the mental health care of children and adolescents to be made with their best interests in mind. In keeping with international human rights law, the "best interests" principle should take account of the views of the child or adolescent, as well as his or her will and preferences. The "best interests" principle is in keeping with international human rights standards. The UN Convention on the Rights of the Child provides that "in all actions concerning children, whether undertaken by public or private social welfare institutions, courts of law, administrative authorities or legislative bodies, the best interests of the child shall be a primary consideration".

One of the biggest issues covered in the Bill is consent to treatment. Section 5(1) would amend the 2001 Act to include both voluntary and involuntary patients in the existing provisions relating to the definition of "consent to treatment". The consent to treatment provisions set out in the 2001 Act do not specify that they apply equally to voluntary and involuntary patients. This section of the Bill would expand the definition of "consent to treatment" and explicitly provide that all voluntary and involuntary patients would have to consent to treatment delivered in acute mental health services. Section 5(1)(a) would amend the 2001 Act to include the definition of "decision-making capacity" set out in the Assisted Decision-Making (Capacity) Act 2015, thereby bringing the 2001 Act into line with the 2015 Act in this respect. Section 5(1)(b) would amend the 2001 Act to ensure both voluntary and involuntary patients would be given adequate information in a form of language that he or she could understand on the nature, purpose and likely effect of the proposed treatment. This provision currently applies to involuntary patients only.

This section of the Bill also affirms that voluntary patients could not ultimately be given treatment without their consent. It also affirms that involuntary patients could not be given treatment without their consent in certain circumstances. More specifically, it would amend the 2001 Act by narrowing the circumstances in which treatment could be administered without the consent of the involuntary patient. It provides that treatment could only be given without consent as a very last resort. in keeping with international human rights law. At a minimum, human rights norms require that the law must specify that compulsory treatment can only be administered as a very last resort and, ultimately, where necessary.

As I said, the Bill does not address all of the recommendations made in the expert group's report. There are certain limitations on the Bill which addresses some of the issues only. As I said, it would be a stepping stone and I hope the Government side of the House will support it. I look forward to hearing what other Members have to add to the debate.

It is a great pleasure for me to second motion on Second Stage of the Mental Health (Amendment) Bill 2017. I join Senator Catherine Ardagh in complimenting Deputy James Browne on the Trojan work he has done to date to get the Bill to this point. While it gives me great pleasure to support the proposal, it aggrieves me that many of the contents of the Bill are only being introduced in 2017. One would have thought that these basic human rights would already be in situ in our society and that legislation of this nature would not be need to be introduced in 2017. The Bill would make certain significant changes to strengthen the rights of people when in hospital to receive mental health care. It would support the right of inpatients to make decisions on their treatment by linking the Mental Health Act 2001 with recent law which affirms that everyone should be presumed to have the capacity to make decisions and should be given the support they need to make such decisions.

In addition to making some valuable improvements, the Bill is important because it highlights the need to amend the Mental Health Act 2011 in full and the seriousness of the continued violations of the human rights of people who are being treated in hospital for mental health difficulties. To date, just one of the 165 recommendations made in the report of the expert group that reviewed the 2001 Act has been implemented. The Government has failed repeatedly to meet its own timetable for updating the Act in question. The enactment of this legislation would be a positive step towards achieving the full amendment of the 2001 Act in line with the recommendations made by the expert group on mental health reform. It could contribute in some part to the Government's fulfilment of international human rights law, including the European Convention on Human Rights and the UN Convention on the Rights of Persons with Disabilities. It is clear that the 2001 Act is not compliant with either convention.

I would have liked to have seen much greater emphasis on mental health services in the Budget Statement yesterday. The enactment of many of the items included in this legislation would not be severe from a monetary point of view. It would have been nice if a greater contribution to the mental health service had been made. We all know of horrific stories within our own families or circles of friends. If we do not know those affected personally, we read and hear about cases that depict how people suffering from mental health problems are treated in the health service.

I know of cases where people who suffer from mental health issues have been in the care of the health service, not for the treatment of their specific diagnosis but for other health issues, and the treatment they received has often been impaired due to the fact that they suffer from a mental health disorder.

It gives me great pleasure to second the Bill but it is unfortunate in this era that we are only reaching the stage of its introduction in 2017. It should have happened a long time ago.

I am delighted to speak on this important matter. I welcome the Minister of State to the Seanad again. He has been in this Chamber five or six times in the past two weeks. It is always nice to see him coming in here.

I take this opportunity to thank all the stakeholders, including Deputy James Browne, on his work in progressing mental health reform. Progress, while slower than originally anticipated, primarily due to the recent recession, continues to be made in implementing the recommendations in A Vision for Change. I was in this House in 2006 when A Vision for Change was published. It set out a ten-year policy framework for Ireland’s mental health services. We had a long, frank and detailed debate on it and there were many calls for ring-fencing funding for it. It recommended that interventions should be aimed at maximising recovery from mental illness, building on service user and social network resources to achieve meaningful integration and participation in community life.

Preparations for a review and updating of A Vision for Change policy have been under way since early last year. This review was completed in February 2017, and 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 A Vision for Change.

Turning to this Bill before us, I understand Deputy Browne is seeking a number of key changes to the Mental Health Act 2001, which will give more to patients in their treatment. One of the changes concerns a proposal to amend the definition of a voluntary patient to explicitly include the need to consent to such admission. That is very welcome. It is essential that we do all we can to protect vulnerable people, including those who need psychiatric inpatient care. Currently, the definition of voluntary patient in the Mental Health Act 2001 states that a voluntary patient is not subject to an admission order - in other words, a person is a voluntary patient if he or she is not an involuntary patient subject to detention. This definition makes no reference to consent.

In order to be compliant with the UN Convention on the Rights of Persons with Disabilities and in line with the provisions of the Assisted Decision-Making (Capacity) Act 2015, it is necessary to include a specific reference to the need for a person to consent to admission. However, I understand that this change cannot proceed on its own without any associated changes being introduced. The suggested definition of voluntary patient would immediately result in some people being denied inpatient treatment. Such persons would be those who lack capacity and, therefore, cannot provide consent. While they would need inpatient treatment, they would not be sufficiently mentally ill as to warrant admission as an involuntary patient. As they lack capacity and cannot consent to treatment, they could not be voluntary patients but, equally, as they do not suffer from a mental disorder within the meaning of section 3 of the 2001 Act, they also could not be detained. Before we have any new definition of voluntary patient which explicitly refers to capacity, I agree with the Minister of State that we also need to include lawful measures which ensure that at no stage would the compliant incapacitated be denied treatment.

As the Minister of State has said previously, it is essential that the change to the definition of voluntary patient occurs simultaneously with the commencement of provisions relating to deprivation of liberty. He also proposes to prioritise a change regarding the definition of voluntary patient, including the associated deprivation of liberty changes, to continue work on the general scheme of a Bill to amend the 2001 Act, the text which, it appears, will be progressed by the end of 2017, and to look at Deputy Browne’s other changes in light of progress on the general scheme of a Bill.

I am encouraged by all this good work in the area of mental health reform. The Joint Committee on the Future of Mental Health Care, which has been established, has met on two or three occasions. We have set out a programme of work. We have been asked to propose child and adolescent mental health services in our areas that we would like to visit. That is very important. As politicians, we come in here and talk about issues, but it is important to get access to these facilities and services and see them first hand. It helps us to understand the complexities, issues and challenges we face. I look forward to visiting such facilities, along with my colleagues on the joint committee. I also look forward to working with my colleagues in that group. We have been tasked with the responsibility for progressing the development of a new policy for mental health. The policy review process will involve consultation with the key stakeholders, which is very important.

We can come in here and debate Bills and sometimes they are drafted by people who have accessed a service, but politicians should be seen to identify the problems and come up with solutions to them. There has been much talk of this minority Government but it has been quite successful. Many Bills are coming to this House. When I was a Member of this House from 2002 to 2007, Fianna Fáil, which was then in government, would bring in a Bill and that would be it. In 2011 when my party was in government with the Labour Party we would bring in a Bill and that would be it. There was limited debate and the Government used its majority to push Bills through. Most of the time the measure was probably right but sometimes we did not tease out the recommendations or the amendments. This new way of Government, for which the people voted, is quite interesting and successful. This is the way to do business.

I look forward to listening to the views of all my colleagues on this very important Bill. I thank Deputy Browne for his work in progressing this mental health reform.

I would like to speak briefly in support of Deputy Browne's Mental Health (Amendment) Bill 2017. It is a very worthwhile item of legislative change and I fully support that it seeks to address shortcomings.

The legislation proposes five key amendments to the Mental Health Act 2001, which serve to strengthen and protect the rights of people embarking on mental health care. I would like to speak briefly on each amendment. First, the legislation proposes to amend section 2 of the 2001 Act and will provide a definition of voluntary patient as a person who has a capacity to be admitted. The existing structure is where people with no capacity and who do not object to being admitted are considered to consent to admission. The existing framework whereby a person who has no capacity is nonetheless deemed to consent to treatment is quite wrong, both in law but also logically wrong. This is an important amendment that respects the capacity of persons to have a proper say in their own treatment. I note that mental health reform representatives are in the Gallery today. They also, as a group, recommended this amendment in the past and are fully supportive of this change.

The second amendment is to section 4 of 2001 Act where Deputy Browne proposes to insert four guiding best interest principles in regard to the treatment administered to people treated under the Act. I would like to speak about each amendment in turn. The second paragraph in section 4 proposes that the existing standards of autonomy, privacy and bodily integrity in treatment should be beyond dispute.

The second best interest principle is that capacity is presumed until proven otherwise, in accordance with the provisions of the Act.

The third amendment provides that a person shall not be considered to be unable to make a decision until all practical steps have been taken to help him or her to do so. Section 4 (5) requires that unwise decisions should not be evidence of the absence of capacity. Let us just think about that. Many of us make unwise decisions but we are not deemed to have the absence of capacity. Overall, the inclusion of these principles represents a movement away from the outdated and somewhat paternalistic approach to treatment in the 2001 Act. Section 25 of the principal Act, which relates to the involuntary admission of children by the District Court, is also amended and supplemented to contain stand-alone best interest provisions in respect of children who are subject to these kinds of unique orders. I fully support this section, in particular as it serves to put into primary legislation best interest principles on assessments, admissions and care of children where these orders are often made. These orders are often made in particularly stressful and tense situations where very basic considerations such as bodily integrity and autonomy can get lost.

It is important that section 25 spells out the rights of the child that need to be considered by the courts when this kind of order is made. I also note that the retention of the best interest provisions proposed here by Deputy Browne would reflect and protect international human rights law and the necessity for children to have a say in their own treatment. The next amendment proposed by Deputy Browne is to section 56 of the Act. I will give the Deputy a heads-up here regarding where the proposed legislation states he is substituting the following for subsection (1). Section 56 appears to be made up of two subsections. This is a small technicality and not significant but I thought it worth mentioning. The overall intention of section 56 is to update the meaning of consent by reference to the Assisted Decision-Making (Capacity) Act 2015 and specifically to section 3 of that Act. This is an excellent amendment in that it proposes to update the interpretation of a patient's consent in the 2001 Act in line with the 2015 Act. This is far more descriptive and widens the understanding of consent by highlighting a holistic approach to capacity, including a person's ability to understand. Section 57 also affirms that involuntary patients cannot be given treatment without their consent except in certain circumstances. It is not currently clear under the Act that consent to treatment is required from both voluntary and involuntary patients.

I again congratulate Deputy Browne on this excellent legislation. I despair, however, as to how these modern treatment principles can be appropriately implemented in an inadequately staffed health service. We also have to swallow the fact made public today that only €15 million of funding has been applied to the mental health budget for 2018. I will not allow this depressing thought to take away from the excellent and comprehensive legislation that Deputy Browne has put before the House.

I support the Bill. Medical staff, in my experience, know that a hazy area exists and I hope that this Bill will clear that haze. There are many good points in the Bill. I will not go into the amendments in detail but I welcome a Bill that will replace the existing principle of best interest under the Mental Health Act 2001 with the guiding principles of the Assisted Decision-Making (Capacity) Act 2015, which respects the will and preferences of the individual. I am also happy to see the retention of the principle of best interest in decisions made under the Act about the admission and treatment of children and young people under the age of 18. This principle should take account of the views of the child or adolescent as well as their will and preference. I welcome too the fact that the Bill will introduce the other human rights principles of the right to the highest attainable standard of mental health and the right to the least restrictive care. The Irish Government has already signed up to these human rights standards. I wish the Bill a speedy passage through these Houses.

I do, however, have a sharp word of warning. In light of the budget announced yesterday, propped up and supported by Fianna Fáil, none of this will happen. There is a severe lack of vision, courage and political will in Government - and I include Fianna Fáil in that term - for the much-needed revolutionising of mental health. A Fianna Fáil representative on RTÉ yesterday asked us to look at the confidence and supply agreement so as to see if it had delivered on this budget. This agreement states that the Vision for Change strategy must be fully implemented. Sadly, the term "aversion to change" would be more apt.

This Bill is above politics.

This legislation, though good, is minuscule when compared with what is needed to change mental health on this island. We need to enact the A Vision for Change strategy, as 73% of the recommendations made in that document remain unenacted. We cannot allow it to languish and gather dust for another decade. As others have mentioned, it has been clarified that the supposed €35 million increase in the mental health budget actually includes €20 million carried forward from last year. This means a measly €15 million of new moneys, amounting to a percentage of 1.7%. The HSE service level report estimated that an increase of €65 million is needed just to accommodate demographic shifts and pay deals. There is a huge risk that this new money, tiny as it is, will be swallowed up just to keep existing services on life support.

We know what the Government did last year and yet instead of asking questions, like we did yesterday, we are now plámásing around and letting spin go unchecked. I welcome the warriors in the Gallery from Mental Health Reform and I commend them on their Trojan work for mental health in this country. Mental Health Reform has stated that it is deeply concerned that essential services may not be in place to help distressed people when they need them. We call on the Government to fulfil the commitment in the confidence and supply agreement that A Vision for Change be implemented. The Psychiatric Nurses Association of Ireland, PNA, has also expressed disappointment. We all know of the deficits in the services, which include closed beds, long waiting lists, zero 24-7 crisis intervention, zero out-of-hours services and leaving nothing but hours of waiting at the very inappropriate location of the accident and emergency departments. Many in severe distress eventually just leave these departments, often with tragic results.

The litany of problems goes on. The Government and Fianna Fáil chose in this budget not to act in the health area but instead chose to offer tax cuts which will provide, at best, a cup of tea and a few biscuits. They will not provide hospital beds or community mental health services. We could wait and see what the communications unit, also known as the Government spin machine, will conjure up here. Its annual funding of €5 million amounts to a third of the €15 million mental health budget. Public opinion, sentiment and rage will see through this manipulative deception. I commend the Bill but the most important matter for us to discuss here is the paltry €15 million given to our mental health services when our people are calling out for 24-7 services and for meaningful engagement in their own mental well-being.

I will endeavour to speak to the Bill rather than score political points. It is a basic human desire to have one's voice heard. Whatever the context, each of us likes to know that our opinions will be listened to and, more importantly, taken seriously. This is particularly true when it comes to decisions made on our health and on treatments for ill health, and this should be as true of mental ill health as of any other illness. The fact that someone's capacity may be impaired by mental health difficulties does not and should not mean that they are not entitled to have their views heard and their values respected.

That is why I am supporting the passage of the Bill today.

Many people, in their more nostalgic moments, yearn for a time when people had more respect for doctors, teachers, the clergy and other authority figures, but that time was also characterised by a society with very unequal power relations, where the ordinary folk were spoken down to by authority figures. The experts told us what to do and we did not question it. They did the talking and we did the listening. The attitude that the doctor or the teacher knows best and the unquestioning acceptance of anything said by the clergy are now, thankfully, gone. Nowadays most doctors, teachers and others who interact with the public have a more enlightened approach and have come to understand that allowing people's voices to be heard and treating them with dignity is important as it demonstrates that the service user is valued. In the field of health care, patient-centred communication and shared decision making are even more important. People may feel vulnerable when they experience ill health of some sort and treating them respectfully is a matter of common courtesy. More important, scientific evidence demonstrates that a patient-centred care model contributes to improved outcomes for patients, better use of resources, decreased costs and increased satisfaction with care.

This Bill supports the right of inpatients to make decisions about their own treatment and starts from the basis that people should be presumed to have capacity to make decisions about their own welfare rather than the clinician deciding what is in the best interests of the client. The Bill focuses on the will, preferences, beliefs and values of a person. I am not for one moment suggesting that all doctors involved in the provision of mental health services are currently approaching their patients in a paternalistic manner. I am saying, however, that by putting this legislation in place we are making an important statement about those who suffer from mental ill health. As a society we are saying that their voice matters and will be listened to. This is important because such an approach fulfils the basic human desire to be heard, which I would characterise as a human right. We need to move towards a more human rights-based mental health system.

The Bill is only one step in reforming our mental health system but an important one. By passing it and working towards implementation of some of the other recommendations to come from the expert group on mental health reform, we will begin to move towards the fulfilment of international human rights law, including our obligations under the European Convention on Human Rights and the UN Convention on the Rights of Persons with Disabilities.

I support the Bill because the approach outlined in it promotes positive interaction with the patient. It promotes better treatment and better outcomes. Most important, it promotes well-being because it clearly states that the person's voice matters.

That the Minister of State has been here so often shows the depth of our interest and concern in matters that fall within his portfolio. This issue - mental health - is close to our hearts and comes up time and again. The Bill is a key example of the concrete action we can take to address this pressing issue. It is important that we hold onto that because there really is hope. We can do well by people who have mental ill health. There is hope, and it is important that we communicate that message. I congratulate, in particular, Deputy James Browne and the other members of Fianna Fáil for bringing the Bill forward.

The Bill updates the Mental Health Act 2001 in key ways. The Bill contains significant changes to the 2001 Act that strengthen the rights of people when in hospital for mental health care. We would hope that this is the minority of people and that those with mental health issues would not need to get as far as the hospital, that is, that we could act, intervene and support them at an earlier stage. When we met in the summer, the Minister of State told us of a psychiatrist in Cork who is working hard to ensure that children never darken the doors of a hospital. We hope that we can support people at home. There are clear, progressive, people-focused and patient-focused changes contained in the Bill. It is a clear step in the right direction.

The Bill supports the right of an inpatient to make decisions about his or her own treatment by linking the Mental Health Act 2001 with recent laws which affirm that everyone should be presumed to have capacity to make decisions. If it was a physical issue, we would not think twice about asking the person if he or she wanted particular treatment. Those with mental health issues are, in fact, their own experts. They know better than anyone what is going on in their head and the supports that they need. It is, therefore, great to see this affirmed in law.

The Bill introduces a definition of a voluntary patient, which has been ambiguous. The definition will include only those who have capacity to make their own decisions, with support if they require it, and to give consent to admission to hospital. As the House will be aware, at the moment those who do not have the capacity to consent to admission but do not object are considered by default to be voluntary patients. This is even though they were not able to actually consent to the admission. They do not receive external review of their detention, which can go on for a long time, nor the oversight protections provided to involuntary patients. We need this additional clarity on who is a voluntary patient and who is not.

The Bill replaces the existing best interests principle for adults and inserts the guiding principle of will and preference. Again, the most important thing is to be cognisant of the person, to spend time with him or her and to find out what is going on and what might help. There was an interesting presentation on adult safeguarding yesterday. It was about hoarding and what it might mean to a person. Often hoarding can go right back to a person's childhood. Understanding that rather than incarcerating or drugging a person can be the key to unlocking that person's recovery.

On NGOs working in the area, Dr. Shari McDaid and her team from Mental Health Reform noted that what we had was a very paternalistic approach that sustained a culture where at times the views of the doctor, as Senator McFadden said, were more important than those of the person. The Bill would also introduce other human rights principles to the highest attainable standards of mental health as well as the right to the least restrictive care. This is a welcome shift from a time when the best we could offer those with mental ill health was to lock them up in places like Our Lady's Hospital, shock them or medicate them with what is known as "liquid cosh". I shed no tears when I saw vandals setting fire to some of the buildings on Lee Road. These are places of sorrow and tears that contain the spirits of people who were deprived of their liberty, segregated, silenced, sequestered and forgotten about. We can do better and this Bill is part of that.

The Bill also rightly affirms that voluntary patients cannot be given treatment without their consent. It affirms that involuntary patients cannot be given treatment except in clear and transparent circumstances. When it has to happen, as it unfortunately sometimes does, we are clear about the circumstances that must exist. Currently it is not clear under the Act that consent to treatment is required from both voluntary and involuntary patients. Obtaining consent is key. In addition to making these valuable improvements, the Bill is also important because it provides us with the opportunity to highlight the need to amend the Mental Health Act 2001 in full and the seriousness of continued human rights violations of people who are being treated in hospital for a mental health difficulty. People of my age will remember the film "One Flew Over the Cuckoo's Nest", with the unforgettable Nurse Ratched who had so much power over those in her care. We need to continue to shift the power back to the people themselves and to support and understand them rather than control them. This Bill is an important part of that shift.

Mental Health Reform highlights that to date only one of the 165 recommendations of the expert group on the review of the Mental Health Act 2001 has been implemented. The timetable for updating the Act has not been met time and time again. What is going on with our inability to face up to mental health issues? There is a long story there in terms of our history. We fail to act so often.

We adopt fantastic policies and carry out fantastic reviews but fail to translate them into action. Passing the Bill will also contribute in some part to the Government's fulfilment of international human rights law, including the UN Convention on the Rights of Persons with Disabilities which is being championed by my colleague, Senator John Dolan. As constituted, the Mental Health Act is not compliant with either convention. Beyond the changes to legislation, we must also increase the resources available. Again, I note with disappointment the failure to provide adequately for mental health services. It is disappointing that we are underspending in this important area. That is part of the lack of imagination shown in providing for mental health service interventions. I am sure the Minister will say doctors and nurses could not be recruited. These are very important professions, but the mental health service goes way beyond this to what happens in the community. It is extraordinary that the first port of call for a child with a diagnosis of mental ill health is not the family therapy service. Very often the child who is ill is a conductor for what is going wrong in the family, yet he or she is often neglected and does not gain access to the intervention needed. We should be willing to look anew at the issue and I hope with the new committee we will look at how we can spend the moneys allocated and move beyond the nurse and doctor model. These are important professionals, but they are not the be-all and end-all. When I was involved with Cork Simon, one of the measures we introduced was a walk-in counselling service for people with addictions because they were not getting support they needed as they were mentally ill. They were not being treated for their illness because they had addictions. People were disclosing the most shocking histories and there was no place for them to go. We provided the service which we also funded. With imagination, there is no reason we cannot do better.

I am delighted to support the Bill. I commend the Fianna Fail group, Deputy James Browne and the Minister, and I look forward to more work being done in progressing mental health service reforms in Ireland.

As Senator Colette Kelleher said, I am in this Chamber very often dealing with this issue. I find it engaging, always learn something new and leave more informed than when I entered. It is a pleasure to be back again.

I again thank Deputy James Browne for introducing the Mental Health (Amendment) Bill 2017 which has progressed through all Stages in the Dail. I recognise the importance that he and others in both Houses attach to the need to introduce these changes to mental health legislation. It is timely that we have the opportunity during World Mental Health Week to continue our national conversation about mental health, with a particular focus on this occasion on improving the standards set out in legislation.

From a personal point of view and the point of view of the Government, I again stress the significance we place on providing and improving services for all those in society who suffer from a mental illness. Thankfully, the majority of people who live with a mental illness will never come within the provisions of mental health legislation, with such individuals recovering on their own terms with the support of family, friends, the community and mental health services, where required. That is the point Senator Colette Kelleher was making. For those who require involuntary inpatient care and treatment, there is an onus on the Government, the Oireachtas and society to put in place appropriate legislation which will provide the safeguards necessary to ensure involuntary admission and treatment will take place in a structured manner with the individual's needs at their core.

In speaking about the Mental Health (Amendment) Bill 2017 I should also say legislative change is only one part of the important reform process that is ongoing in the mental health sector. Regarding the national policy A Vision for Change - Ireland's Health Service Senators will be aware that a newly established oversight group is in place to oversee the next stages of the review of this seminal document. It will also be something at which the newly established Joint Committee on the Future of Mental Health Care will be looking in the near future.

Senators will be aware of the announcement made yesterday in the Budget Statement that an additional €35 million in development funding for mental health services is to be provided in 2018. Let me clarify and make it absolutely clear to everybody that my door is open to any Senator who wishes to have the conversation with me. An additional €35 million in new development funding is being given to me as Minister of State with responsibility for mental health services to initiate new developments in the sector. It is not funding to maintain existing services or to be used towards pay costs. I look forward to debating in this House how the money will be spent. I will take personal responsibility to ensure every cent of the allocation will be spent on mental health services and not returned to the Department of Health or rolled over to any other health sector. If Senators can assist me or offer any guidance in that direction, I would welcome it. Also announced in the budget was an additional allocation of €40 million to be spent next year. I can clarify 100%, despite some of the commentary, that I have been given responsibility to oversee the spending of the additional €35 million in new development funding for the mental health sector. I look forward to doing so. As I said, my door is open to any Member who has concerns or doubts the veracity of what I am saying. It will help us to build on the work commenced in 2017, particularly in the enhancement of community teams for children and adults, as well as later life and mental health intellectual disability services. It will also help us to continue to move towards a fully 24-7 service. It is planned to further improve services for those with eating disorders and a dual diagnosis. I have asked the HSE to use the extra funding to ensure that not only are services of a high quality but also that we are providing as seamless a service as possible for every service user. We now have an opportunity to address our common desire to ensure mental health legislation is as fit for purpose as it can be and meets the highest international standards.

The Bill we are discussing reflects one of the clear priorities of the Government, but it is also a strong reminder that stakeholders in the mental health sector want to see progress in updating mental health legislation. I join other Senators who have acknowledged the presence of representatives of Mental Health Reform in the Visitors Gallery and thank them for their contribution for many years in improving services. That is what we are all focused on. We can split hairs on differences, but essentially we are here to improve services for the service user. I acknowledge the debt of gratitude the State owes to Mental Health Reform and the work Members have continued to do in the mental health sector. We can all agree that mental health legislation needs to be changed. However, we also need to ensure that when the changes are made, they will be made in the right manner and have the intended effect.

It is important to recall that in 2015 the review of an expect group of the Mental Health Act 2001 was published. This first significant review was informed by A Vision for Change and the UN Convention on the Rights of People with Disabilities, both of which had been published since the 2001 Act was passed. The review provides a clear and complete roadmap for how we should amend mental health legislation for the better. The review, which contains 165 recommendations, is progressive in nature. First and foremost, it set out to promote and protect the rights of persons with a severe mental illness. This is in addition to promoting access to the most appropriate and highest achievable standard of care and support. One of the key recommendations which I welcome and which is referenced in Deputy Jame Browne's Bill is that we move from paternalism and best interest to providing a service that is guided by autonomy, self-determination and respect for a person's dignity, with a presumption that he or she is best placed to determine what promotes or constitutes his or her own dignity.

The previous Government agreed with the broad thrust of the recommendations made in the expert group's review and approved the preparation of the general scheme of a Bill to reflect the changes in revised legislation. That work is under way at official level and expected to be progressed by the end of 2017. This Private Members' Bill, the Mental Health (Amendment) Bill 2017, which is sponsored by Deputy James Browne and which was published on 23 February 2017, has three main goals, the first of which is to seek to amend the existing definition of "voluntary patient" in the Mental Health Act 2001 to include the need for the patient to consent to admission. It also seeks to replace the existing consideration of best interest with a number of principles, including, inter alia, the highest attainable standard in mental health, autonomy, dignity and due respect for the person's own understanding of his or her mental health.

Finally, the Bill seeks to link the issue of consent more closely with the provisions under section 3 of the Assisted Decision-Making (Capacity) Act 2015, which deal with a person's capacity to be construed functionally.

The last two changes, relating to best interests and consent, closely mirror recommendations of the expert group review of the 2001 Act. They represent a move away from the often paternalistic interpretation of the existing legislation, best identified by the inclusion of the principal consideration of best interests, which is both necessary and welcome. We all want a situation where, in so far as is possible, individuals have the final say in what is in their best interests and where they receive the best possible quality of service to help them to reach the highest standard of mental health. These changes will effectively move away from paternalism and place greater autonomy in the hands of the individual.

On the issue of consent, while the Assisted Decision-Making (Capacity) Act 2015 was not in place when the expert group reported, what Deputy Browne is proposing is broadly in line with what the group proposed in regard to consent and capacity. The first change, relating to the need specifically to include consent in the definition of "voluntary patient", was fully accepted by the expert group and is my top priority change at this time. Moreover, it is required in order to comply with the UN Convention on the Rights of Persons with Disabilities. While what is proposed is absolutely necessary, there is one significant issue which I bring to the attention of Senators. If we change the definition of "voluntary patient" as proposed, then persons without capacity who need inpatient mental health treatment but who do not have a mental disorder will not be able gain admission to a psychiatric hospital because they cannot personally consent.

A new definition of "voluntary patient" which includes the need for consent must commence only when other changes are introduced to allow patients without capacity to access treatment. In this regard, my Department is in discussions with the Department of Justice and Equality on introducing new legislative provisions relating to deprivation of liberty. This is a complex piece of new legislation which will cover anyone who lacks capacity and requires admission to a nursing home or facility for persons with disabilities or mental illness. Subject to the agreement of the Department of Justice and Equality, the draft provisions form part of the Assisted Decision-Making (Capacity) Act 2015 and the changes, when agreed, will be introduced on Committee Stage of the Disability (Miscellaneous Provisions) Bill 2016, which has already completed Second Stage in the Dáil.

The expert group initially recommended that persons who lack the capacity to consent to voluntary admission, often described as "compliant incapacitated", should be placed in a new patient category under the 2001 Act to be known as "intermediate". The idea was that such patients would also have available to them all the safeguards currently available to involuntary patients under the Act. Since then, however, it has become clear that all persons going into residential care who cannot, due to lack of capacity, consent to such admission must have safeguards in place. This is to ensure their rights are protected and their will and preferences, to the greatest degree possible, are respected as set out under the Assisted Decision-Making (Capacity) Act 2015. With the new deprivation of liberty safeguards now being framed, there is the opportunity to devise a better and more consistent route to deal with "compliant incapacitated" patients seeking treatment in a psychiatric hospital or unit.

While the proposed changes, particularly the priority amendment relating to changing the definition of "voluntary patient", can be amended by the Oireachtas in the short term, any such change cannot be commenced until the decision support service, DSS, to be established under the Assisted Decision-Making (Capacity) Act 2015 is operational. This is because the draft safeguards currently being worked on at official level use the framework set out in the Assisted Decision-Making (Capacity) Act 2015 and envisage a role for the decision support service. Therefore, before such provisions can be operationalised, the Act must be commenced and the DSS must be in place. A steering group of officials from the Department of Health, the Department of Justice and Equality, the Mental Health Commission and the Office of the General Solicitor for Minors and Wards of Court, which is chaired by the Department of Justice and Equality, is working on the establishment of the decision support service. The first director of the service took up her post on 2 October. There is no doubt, however, that the establishment and operation of this service will be a complex undertaking requiring significant preparation.

I once again thank Deputy Browne for introducing his Bill in the Dáil. We are in agreement that the changes he is proposing need to be made. As I stated during the passage of the Bill through the Lower House, my officials will need time to revisit some of the text to ensure it is fit for purpose and does not have any inaccuracies. My officials plan to discuss the wording of the Bill with the Office of the Parliamentary Counsel and get a legal sign-off before introducing necessary changes on Committee Stage. I ask that my Department be afforded the time to get this right before the Bill is returned to the floor of the House. Members can be assured that my officials and I will review all the comments made here today and will bear them in mind as work progresses on the wording of the Bill. The Government does not intend to oppose the legislation.

I thank the Minister of State for his comprehensive reply. The issue of consent is a complex one and it is important we get it right. There has been a great deal of reform in the mental health services in the past 20 years and it is important that those reforms continue. On the broader issue of the health services in general, I am concerned that there is a view being given out, including in this debate, that the 100,000 staff in the public health sector are sitting around and doing nothing all day. There were 3.2 million outpatient attendances in hospitals last year and 1.2 million patients attended accident and emergency departments. On a weekly basis, that works out at 63,000 people attending outpatient departments, 23,000 presenting at emergency departments and another 16,000 undergoing day care procedures. It is wrong that an impression should be given that the health service is doing nothing for anyone. In fact, people in this country are living longer than ever before and a comprehensive service is being provided in a range of areas. There are difficulties in certain areas that must be dealt with, including in emergency departments and mental health services, but improvements continue to be made. The false impression must not be allowed to go out that dedicated and committed staff are sitting around and doing nothing.

I travelled recently to the United Kingdom as part of a delegation to look at how health services are being delivered there. At the location we visited, the staff were very pleased that the average waiting time for securing a GP appointment had been reduced from 15 days to eight. We have not reached that situation in this country and I hope we never will. In all areas of our health service, staff work to provide care to patients in the quickest possible time. Many improvements have been made in mental health services, for example, as I have seen in my home city. Staff there are working in teams and seeking to reduce the level of hospital admissions by engaging with the community. That system is working well in the southern region and it is important that further progress is made in other areas. We must recognise the work that is being done. Mental health is a complex area, presenting difficulties both for staff and for the families who are trying to support a loved one facing issues. It is important that we continue to provide the back-up support to those families and to acknowledge the professionals who are providing that support.

I appreciate the detailed response the Minister of State has provided today. The report of the expert group contained some 165 recommendations and it is essential that we proceed to implement them in a timely manner. The report must not be put on a shelf for further consideration in five or ten years. We must set a clear agenda and clear targets and we must move ahead with meeting them. We should not focus only on the here and now when it comes to health services but also plan for the long term. That is especially the case in regard to mental health services.

The one area on which we need to focus in terms of nurses and medical staff is how we retain in the service the people we train in this country so that they can continue to work here. We should also try to bring back those who have gone away. We are making progress on this area and it is important that it would continue and that the implementation of the recommendations that were published in 2015 is not delayed any further. The Department and the various interest groups are working on drafting further legislation and it is important as well that that is brought forward at an early date. I thank the Minister of State for dealing with this matter in a comprehensive way.

I welcome the Minister of State, Deputy Jim Daly, back to the Chamber. I am very happy to speak in favour of this Bill. I commend Deputy James Browne for his work on it. It is great that the Bill has progressed through the Oireachtas very quickly, which goes to show the strong cross-party support for it. That is fantastic.

I also congratulate Mental Health Reform whose representatives are present today. In particular I pay tribute to Dr. Shari McDaid and Kate Mitchell for the extensive input they made to the Bill, and their wider advocacy. We have definitely made big strides in Ireland on how we think about mental health, how prominent the issue is and how comfortable we are talking about it. It is brilliant that in the past five to ten years there has been a definite change. Although we still have some way to go it is good to see progress on this issue, and this Bill is another example of that.

The core aim of this legislation is about respecting people and their right to make their own decisions about their care and the services they access. One does not need to look far for stories about how people have been mistreated in mental health services in this country or about the coercion or domineering attitudes they have had to face, so this shift is much needed.

There is a changed understanding here in what we consider the best interests of a person seeking mental health care. We are moving away from a situation where the views of a doctor are given too much primacy over the views of the person who needs support. It empowers people to be more active decision-makers in the care they receive, and that approach is more consistent with human dignity and respect.

It may seem technical, but the new definition of a "voluntary patient" is an important change that will provide better protection for people accessing mental health services. It better caters for people who have the capacity to make their own decisions and give consent on admission to a facility. Importantly, it also ensures that people without the capacity to consent are not considered voluntary patients by default, as has happened in the past. That will give such patients greater access to external review and oversight protection.

I am also pleased to see that consent is central to the Bill. It ensures that voluntary patients cannot be given treatment without their consent, and that involuntary patients must similarly give consent except in some circumstances. Again, that brings in a much stronger role for the individual, and a much greater respect for his or her own capacity, desires, dignity and rights. It is a change in our attitude towards people seeking mental health support.

Overall, while I am happy to support the Bill progressing to the next Stage, I think we can also be honest and say that it is quite a modest Bill. The Mental Health Act 2001, which it reforms, is still out of date in many ways. I accept the Minister of State has addressed the issue. I would like to show support for Mental Health Reform's call for progress on the recommendations of the expert group report on the review of the Act. The Minister of State referred to the 165 recommendations made but, according to Mental Health Reform, only one has been implemented to date. Again, that shows there is so much more to do before we have adequate mental health services in Ireland. That is especially important as, in line with improved attitudes toward mental health care, demand for services is rising. As my colleague mentioned earlier, that is particularly true for children, many of whom still cannot access the support they need. Since 2014, demand for mental health services has gone up almost 30%. However, as of July 2017, almost 2,500 children and young people are still on waiting lists, and many have been waiting for over a year. While we need gradual improvements in care, as outlined in the Bill, we also need significant resource investment in proper public services. That must be a priority.

Last week I was happy to speak in support of Senator Joan Freeman's motion on 24-hour mental health services and I reiterate that now. I beg the Minister of State's forgiveness for repeating myself but I know from my experience working in the field of addiction that problems do not arise solely in working hours. We would not accept accident and emergency departments that did not offer 24-hour access, and we should take a similar approach to mental health support. It is often out-of-hours or on weekends when people really need urgent help.

I again stress the major importance of dual diagnosis, which is when a person suffers from both a substance misuse problem and a mental health issue such as depression or an anxiety disorder. The reality is that if we do not treat both conditions together, we cannot overcome either one.

Senator Colm Burke talked about families. I again highlight the impact on family members who are living with someone who has either a mental health issue or an addiction. It can really impact them in the long term. Therefore, while I welcome the Bill and I am happy to see progress being made, I think we should also see it as an opportunity to refocus, push on and demand further improvements.

It is great to see that the Minister of State is so passionate about this issue and that he is taking such an interest in it. I really get that energy from him. I am pleased he is offering us an open door. I will certainly take the opportunity to call on him.

I thank the Minister of State for coming to the House to address this issue. As my colleague, Senator Black, said, his commitment and dedication to this issue is evident and that is most welcome.

I reaffirm my gratitude and thanks to Deputy James Browne for putting a lot of work into this Bill and bringing it to this Stage. He has done that with the help of Mental Health Reform, especially Kate Mitchell and Dr. Shari McDaid. I thank all of the people involved in that regard. I also thank Members of the House for their contributions today. I am pleased that we are all ad idem and that the Bill has received cross-party support from the House. I thank all concerned for that.

Question put and agreed to.

When is it proposed to take Committee Stage?

Committee Stage ordered for Tuesday, 17 October 2017.

When is it proposed to sit again?

At 10.30 a.m. tomorrow.

The Seanad adjourned at 5.20 p.m. until 10.30 a.m. on Thursday, 12 October 2017.