Seanad Éireann debate -
Wednesday, 30 May 2018

Vol. 258 No. 7

Report on Children's Mental Health Services: Statements (Resumed)

Minister of State at the Department of Health (Deputy Jim Daly)

Gabhaim buíochas as ucht an deis labhairt ar an ábhar tábhachtach seo. Is pribhléid dom é a bheith ar ais arís sa Teach seo ag plé an report seo.

I am here with my officials, Mr. Jim Ryan from the HSE and Mr. Greg Canning, principal officer at the Department of Health, who have been monitoring the development of this report. I thank them for their interest and work to date on that.

I welcome the opportunity to speak on the report produced by the Seanad committee. This report is an important contribution to advancing the debate around how mental services for children and adolescents might be framed and delivered over future years. Members of the committee will be aware that I addressed the committee last July, as its work was beginning. Since then the work of the committee has been complemented by other initiatives such as the symposium on mental health organised by the Ceann Comhairle in Dublin Castle last September. We also had the report on positive mental health in schools by the Joint Committee on Education and Skills and the work of the Joint Committee on the Future of Mental Health Care. All these initiatives are to be welcomed and have formed an important part of the parliamentary duties and work in the year since I took office as Minister of State.

I have noted in particular the context, themes and recommendations of this report. We all share a common desire to have the best possible mental health policies and services for children and adolescents. This must take account of the practicalities involved in order to achieve real and sustainable change. Nobody seriously concerned with having the best possible services for some of the most vulnerable children in our society could disagree with the principles and overall themes reflected in this report. My Department, the HSE and all providers of mental health services to young people have long advocated for the three high-level themes - access, recruitment and service outcomes - highlighted in the report. There is broad consensus too regarding the 12 recommendations and other concepts highlighted such as better prevention and early intervention, listening to and learning from service users, acknowledging service improvements while tackling service gaps and addressing staff shortages. I also agree with the need for better transition arrangements for those leaving CAMHS and the need to promote more seamless care for those aged 18 to 25 into adult services. All of these strategic aims have been embedded in HSE service plans for mental health in recent years.

In conjunction with my officials and the HSE, I have given full consideration to all aspects of this report. That includes the submissions made and quoted in the document and the personal stories highlighted of experiences of child mental health services. All the recommendations have been reviewed to see how improvements might be incorporated into better policy and practice. Some of these, such as triage and improving links between child mental health and other services, are long standing practice in the HSE. The report and various legislative proposals suggested by Senator Freeman, among others, raises the practice of placing those under 18 in adult psychiatric facilities. Good progress has been made by the HSE on this compared with ten years ago. The position has been reversed since then, with approximately 75% of young people now placed in age-appropriate facilities. This is minimised in practice to the greatest extent possible by the HSE with built-in safeguards for the young person. Relevant factors here include, for example, individual assessments, duration of stay, distance to CAMHS units and the wishes of the young person and families.

Similarly, the views on other matters raised in the report, such as the organisation or expansion of CAMHS, have been noted, along with the need for improved mental health intellectual disability care. Members will appreciate, on the other hand, that proposals regarding remuneration for nurses or other health care staff can only be addressed in the wider context of pay discussions. We look forward, therefore, to the forthcoming publication of the Public Service Pay Commission's report.

I strongly reiterate this afternoon that mental health remains a key priority for the Government. The HSE mental health care programme has to be prioritised and delivered in the context of the annual budgetary process and in line with its annual service plan. My commitment and that of the Government is reflected by the allocation of an additional €35 million for mental health services in 2018. That is for new developments in addition to the increases that have come about in the previous five years. This brings the total amount available to approximately €910 million for the year. This amount is significant by any standard but I will continue to press for further resources annually in line with programme for Government commitments. However, it is important to note that funding availability in itself is not the only issue right now for mental health. Staffing recruitment and retention are currently proving difficult and the lack of availability of specialist grades in the area of mental health is a global issue that requires new and innovative approaches to recruitment and retention to be identified and implemented. The emphasis must be on putting in place the correct skills mix to ensure that we modernise services in line with A Vision for Change. This may have taken longer than we had hoped but progress must be made in recruiting and training appropriately skilled personnel rather than staffing for outdated systems.

The HSE service plan for 2018 commits to further development of CAMHS and wider services and supports for young people to meet evolving demands. This is against a background where the population of children is increasing and where the demand for CAMHS has increased by 26% between 2012 and 2017. Approximately 18,800 referrals are expected for HSE CAMHS this year, with approximately 14,300 being seen by this specialist service. CAMHS has been prioritised in new funding provided by the Government over recent years. Additional resources and facilities means there are now 69 CAMHS teams and three paediatric liaison teams supported by approximately 75 CAMHS beds nationally. Further beds are planned to come on stream as quickly as possible.

The staffing difficulties I mentioned are also an issue for CAMHS teams, particularly with consultant psychiatrist posts. Recruitment efforts are ongoing, notwithstanding a serious shortage of suitably qualified CAMHS consultants, at both a national and European level. The HSE is working to provide the best possible service within available staffing resources. A key focus is on managing clinical risks and prioritising referrals accordingly.

Mental health services, including CAMHS, will continue to deliver service improvements aimed at increasing productivity and efficiencies. Other CAMHS-specific measures in the HSE service plan include an initiative to increase the number of CAMHS referrals to be seen this year by 27% compared with 2017. It is an ambitious target but I am very confident we can achieve it. There will also be provision for a seven day per week service for CAMHS to ensure supports for young people in line with the recommendations in Connecting for Life, as well as improvement of day hospital services within CAMHS and development of eating disorder specialist community teams for young people. The HSE is also focusing on enhanced access by older adolescents to specialist mental health services in parallel with continued appropriate placement and care in CAMHS-specific settings. Detailed data in respect of waiting times for CAMHS is published by the HSE in its regular performance reports.

A key approach to developing early intervention services for young people at primary care level was the decision by the Government to increase access to counselling services in primary care with the recent appointment by the HSE of approximately 114 assistant psychologists and 20 psychologists. It is anticipated these posts will deal with the less complex child and adolescent cases, thereby reducing the burden on CAMHS.

Since becoming a Minister of State, one of my priorities has been to look beyond existing funding and structures to see what practical new measures can be applied to better plan and deliver services.

This new approach sits in the context of wider initiatives such as the review of the Mental Health Act and the refresh of our current mental health policy A Vision for Change.

I share the objective reflected in the report to explore the potential to make progress where possible, without awaiting completion of these inherently longer and more complex processes. A key focus for me is continued investment in innovative, digital technologies which are well placed to support access to appropriate services particularly to prevention and early intervention services. The HSE has established a working group to progress a national telephone-text helpline and digital information supports for those requiring access to services. It is my intention that the roll-out of the new telephone helpline will commence before the end of this year. I have also requested the HSE to pilot a project providing remote access to counselling services in the primary care setting. This approach will help underpin improved implementation of Connecting for Life and the report of the task force on youth mental health.

The national youth mental health task force report contained 22 recommendations that will be implemented over a period of three years. Many of the recommendations are already being delivered, such as the development of an interdepartmental youth mental health team known as the pathfinder project, the establishment of additional training supports, online and in schools, and the creation of a pilot tele-psych unit. The introduction of mandatory mental health training for teachers and medical staff, along with additional training for parents in both the NGO sector and online is also being progressed. It is hoped that this additional focus on prevention will reduce the numbers being referred to specialist care and thereby improve wait times for those accessing child and adolescent mental health services, CAMHS.

The expert group review of the Mental Health Act 2001 made a number of recommendations regarding the provisions of that Act which relate to children. In particular, the group recommended that legislative provisions relating to children be included in a standalone section of any future mental health legislation rather than being spread though the Act as is currently the case. Work is under way on this comprehensive review, with text of the heads of a revised mental health bill to be advanced by the end of the year.

Senators will be aware that two Private Members' Bills related to mental health have been discussed in this House recently. Both Bills include revised provisions relating to children. Deputy James Browne’s Bill seeks to introduce a set of guiding principles for children while Senator Freeman’s Bill seeks to ensure that orders to detain children are necessary, in line with protocols and to age-appropriate facilities.

There is a broad range of initiatives under way or planned across mental health, including child mental health. Some of these are CAMHS-specific, while others are interrelated by legislation, policy and service links across care programmes or with other Departments. The core objectives of this report are reflected and being progressed, to varying degrees, in annual HSE service plans. These cover, for example: promoting mental health on many fronts; having more integrated, evidence-based and recovery care; delivering timely, effective and standardised services; listening to the voices of service users and advocates; and having highly trained and engaged staff.

I thank the Members of this House for inviting me here today. I look forward to a constructive and collaborative discussion.

Senator Diarmuid Wilson

I welcome the Minister of State at the Department of Health, Deputy Daly, back to the House. He is a frequent visitor to this House. I am speaking on this matter on behalf of my colleague, Senator Keith Swanick.

Fianna Fáil welcomes the report on children's mental health services which was published last year following public consultation here in the Seanad. The report highlights the deficiencies in mental health services for children, and it is critical they are addressed. We have been aware of the deficiencies highlighted in the report for some time. Just over a week ago, my party colleague, Deputy James Browne, obtained information to the effect that there has been a 10% surge in the number of children and young people waiting longer than 12 months for an appointment with CAMHS. Twelve days is an excruciatingly long period for any parent to wait for their child to get an appointment with CAMHS, let alone 12 months.

It is perfectly clear for all to see that the CAMHS service is simply not able to meet current demands. There will be well over 3,000 children stuck on waiting lists before the end of this year if the current trend continues. This is quite frankly unacceptable. I regret to say that it shows that the Government's mental health strategy is floundering.

The submissions received by the committee reinforced previous findings that there was a chronic failure by the HSE to recruit psychiatric nurses and consultant child psychiatrists to operate the existing bed complement in Ireland, matched with a failure to alter pay agreement structures and working conditions to attract employment. I regret to say that it appears that there is no will on the part of the HSE to deal with this urgent crisis.

The committee made a number of key recommendations, which have been alluded to, which should be given appropriate consideration in the review of A Vision for Change. They include: a recommendation that waiting lists should be triaged in accordance with urgency and need; CAMHS must be extended nationwide to children up to the age of 18; admissions to adult psychiatric units should be prohibited; 180 child and adolescent psychiatrists should be in their posts by 2020; primary care should be urgently staffed with the level of psychologists recommended in A Vision for Change; and the two-tier remuneration system for nurses and consultants qualified since 2012 should be scrapped. The preceding are only a few of the recommendations in the report.

I commend our colleague, Senator Joan Freeman, who is working towards these recommendations and has already brought a Bill before this House to stop the admission of children to adult units. I also want to pay tribute to the Chairman of the Seanad Public Consultation Committee, Senator Paul Coghlan, and the rapporteur, Senator Freeman, and the other members of the committee who engaged in this process, along with all of those who gave evidence which helped in the compilation of this report, especially the parents who have been referred to by Senator Freeman.

I congratulate Senator Freeman on her very forthright contribution here this afternoon. She posed some very important questions to the Minister of State, and I have no doubt about his genuine desire to ensure the provision of these services. I ask him to reflect on some of the questions posed to him by Senator Freeman this afternoon. I commend this report to the House.

Senator Pádraig Mac Lochlainn

The Seanad Public Consultation Committee report on children’s mental health, similar to the Citizens’ Assembly work that led to the recent referendum on the eighth amendment, is a body of work led by the citizens of Ireland who have lived experience of the issue. We see how well politics works when citizens are authentically engaged, heard and listened to. This must be the case for this report too.

The integrity and power with which the service user witnesses spoke is an inspiration to legislators and policy makers trying to improve mental health services. Parents, who had to fight so that their children could gain access to mental health treatment, continued the fight on behalf of other children and families by coming into the Seanad and sharing their stories with raw sincerity. We are indebted to each of them.

We also owe gratitude to the stakeholders who provided invaluable insights, knowledge and data for use in the report. It is powerful to take the stories of the service users and then apply them to the knowledge and insight from the NGOs who live this issue day in, day out. The committee itself deserves commendation for collating and analysing all of the submissions and making solid, tangible recommendations within this report. It is an excellent piece of cross-party work, and can serve as a roadmap to improving children’s mental health services.

We cannot take our eye off the ball, and while this report is solid and worthy of existence, we are only beginning the work that is clearly so necessary. Since this report was published in October, how many of the recommendations have been looked at by the Government?

How many have been implemented? Has an implementation plan been formulated? The findings of the report are deeply disturbing. To quote the main finding of the report: "...there is a chronic lack of standardised services and a lack of clarity surrounding the operation of CAMHS in Ireland". This is not a finding that children's mental health services need improvement. This is a finding that children's mental health services are in complete disarray and are continuously failing our children.

We need to drill down into the detail of this issue now, and with urgency. Take, for example, community healthcare organisation, CHO, area 1, which covers counties Donegal, Sligo, Leitrim, Cavan and Monaghan. A parliamentary question tabled by my colleague, Deputy Louise O'Reilly, last June found that staffing levels in CHO 1, which is my area, were at 53% of the recommended levels in A Vision for Change. A reply that I received only yesterday stated that by December, that percentage had dropped to 48.7%. How can we possibly believe that the Minister will take this report seriously when, in parallel to the report being drafted, the situation is getting worse in some areas, including mine?

The success of this report will hinge on accountability. Unfortunately, there is no reason to believe that this will be an easy task when it comes to the HSE. Extensive work has been done by the Oireachtas Joint Committee on the Future of Mental Healthcare to draw out figures and data on mental health spending, but to be honest it is harder than drawing blood from a stone.

My party asked for a simple breakdown of CAMHS spending in a parliamentary question two weeks ago. The reply today stated: "The existing national financial systems do not currently provide for reporting at specialty sub specialty level." Was this information not provided to the committee when it was deliberating on CAMHS? I accept that the HSE is changing the way it records its finances, but it is absolutely imperative that Members of the Oireachtas get the most up-to-date and accurate information available when requested through parliamentary questions and other mechanisms. If we do not, how are we to monitor and progress the recommendations of this report?

Will the Minister of State go back to the parliamentary question unit of the mental health division of the HSE and re-examine the information, or lack thereof, that is being provided to Members of these Houses? If the staff who provide this information need support and resources to improve the information they are providing, I urge the Minister of State to support them without delay For us to allow this report to remain a fleeting dream would be an absolute disservice to those who gave testimonies during its development. We are seeing now that storytelling is making real change in Irish society, and in the world of mental health this is a real opportunity for us to hear the stories and allow them to make the impact that they deserve. Those keepers of the harrowing stories within this report have already done their jobs. It is now up to us, and to the Minister of State, to take the gift they gave us, treat it with the respect it deserves, and take strategic action to commit to and plan to achieve the recommendations of the committee.

Senator Colette Kelleher

This is an opportunity not only to consider the report of the Seanad Public Consultation Committee on children's mental health services but also to consider more generally what is happening to our children's mental health. I spoke on this issue over three months ago, often citing the report we are discussing. It is disappointing that we have made so little progress, and it is devastating for the children and young people affected and their families that we are falling so short. The suffering and distress is overwhelming. We do not seem to get to the nub of the issue. We talk about the HSE and the opacity of budgets as well as recruitment difficulties, all of which are current issues. The Minister of State gave a good overview of the range of issues but there are children and young people in distress today and they are not getting anything like the kind of helping hand they deserve. We know there are approximately 115,000 people younger than 18 years who have mental ill health and that 23,000 of those have very serious and disabling mental ill health. The State continues to fail to provide the range of supports that our children so desperately need. While it is not true to say that nothing is being done, nothing like enough is being done to support them.

Over the past decade there has been a gross inadequacy and even decline in budgetary resources across the mental health service. We could spend time proving that it has gone up or down and we can change our accounting methods but the resources have not kept pace with the need. Successive Governments have continued to fly in the face of the recommendations in the HSE's 2006 report, A Vision for Change, for example, the recommendation to provide 100 inpatient beds for a child population that was 21% smaller than it is now. There are currently 47 beds which is fewer than half that number. We are ignoring people's plight. As Senator Mac Lochlainn said, we seem to require people's stories before making any change in this country. People have to bare their souls, pain, lives and miseries before we wake up and listen. We have all the reports and statistics but until we reach in to people's hearts and souls we are not motivated to change.

Mental ill health affects people individually but it also affects people from specific backgrounds disproportionately and while it is critical to take individual cases seriously, we must also note how specific groups are affected. A study in June 2017 entitled Homelessness and Mental Health found that those suffering from housing related burdens are far more susceptible to mental ill health. One does not need to be a psychiatrist to figure out that a child living in a hub or hostel, or not knowing where he or she will be next month or next year, will not have the same sense of well-being and security in his or her life as a child for whom that is not a reality. We know that the child who may feel different from his or her peers and has come to an awareness that he or she is lesbian or gay may also feel under greater pressure. It is no wonder Traveller children commit suicide at a rate that is completely disproportionate compared with the rest of the population. One does not need a degree in psychology, sociology or social work to figure that one out. As well as looking at individual cases we need to look at the circumstances of particular groups and ensure our response addresses those most in need of assistance.

Nowhere in the country is there a fully functioning, fully staffed and resourced CAMHS. It does not exist. There is no model of good practice that we can point to. Parents had to come in and tell their stories over and over again. We should not have to do that to people to get the change we need.

When I worked in the Cope Foundation it was not possible for children with mental health difficulties to be looked after by CAMHS. We had a letter from a parent saying that his daughter, who was in a most appalling state, had to be taken through an Aldi car park to get into CAMHS privately only to find there was no one there to meet and greet them. We also need to think about the fact that we have a culture of over-medication and about the dominance of psychiatry in the treatment of children's mental ill health. The dominant narrative today is that distressed or troubled children need to be fixed, without considering the societal system they have come from. This belief is deeply damaging, particularly for children and young people. I cannot stress enough the benefits of family therapy. Where is it? Such a service should be as common as dentistry for people.

It speaks to the early intervention we talk about. A child does not come into the world mentally unwell, feeling anxious and worried; everything around them causes the child to end up in that situation. In our reform of mental health systems, we must also look at that. Dr. Elizabeth Gregory has written a great article on why we need to talk about children's mental health and the elephants in the room. I ask the Minister of State to accept that there is a serious problem.

Last year, I asked the Minister of State rather glibly what marks out of ten he would give the child mental health system. I would ask him that again and if he is willing to make radical and bold moves about making things such as family therapy a normal part of our response to children and young people and their families in distress.

Senator Victor Boyhan

I will not use all my time as I am conscious that others have things to say. I thank the committee and particularly my colleagues, Senators Freeman and Coghlan, for their work. Apart from the report itself, I found two things most important. I attended on the day of the committee's public hearings and heard the service users and those who wanted to use the service and their families. It was harrowing and the best work ever done in the Oireachtas, as far as I was concerned, because we got to meet them and we heard their personal experiences. One after the other spoke of needing and wanting to access services.

Then on the other side, we heard from the service providers, the people on the ground who also shared a frustration. When it came to the policy makers, the HSE and people within the Department we saw the worst performance. It seemed to me that there was a big issue there, and I found it hard to believe that the gap was so wide.

Each day in this Seanad, I say that this Government, however long it lasts, will be judged on its performance on health, in its broadest sense, and housing and homelessness. Those are the two things that resonate with people across the country. We are here to speak on health and mental health as part of the bigger health agenda.

I refer to the Minister of State's speech to the Seanad this afternoon when he spoke of prevention and early intervention. He will recall that on a previous occasion here, I told him how we need to provide early intervention. I was encouraged by what he said then. I know the issues, including financial issues, that the Minister of State faces but this is not about him or me, but people who need services. It is a question of whether the Government is up to it and prepared to fund and resource the appropriate measures needed, particularly regarding CAMHS.

I would like the Minister of State to respond to the points I will make here, if not today then he can circulate a response to Members, this week if possible. Earlier, the Minister said the following:

A key approach to developing early intervention services for young people at primary care level was the decision by Government to increase access to counselling services in primary care with the recent appointment by the HSE of around 114 assistant psychologists and 20 psychologists. It is anticipated these posts will deal with the less complex child and adolescent cases thereby reducing the burden on CAMHS.

Will the Minister of State enlighten Members about these appointments and whether they have all been filled? That is important. People are waiting for CAMHS services. How will the Minister of State reduce this vast list of people who need support?

Senator Frank Feighan

I will share some of my time with Senator Devine.

I am delighted to be here to put this issue centre stage once more. I thank Senator Freeman and all the Members of the Oireachtas and the stakeholders who had an input into this very valuable report, particularly the service users and their families. As the report notes, mental illness should be treated no differently from physical illness. We all know someone in our family or community who is affected by mental health issues. The effects this has on their families and friends cannot be overstated. As a politician, I had never known the services that were available until I had to use them with friends and family. I was very happy that they were there but they can always be improved. However, I was shocked, although not surprised, to learn that mental health problems start when we are young and that by 13 years of age, one in three people is likely to have experienced some type of mental illness. It is obvious and sensible that early intervention is crucial.

The committee Chairman noted in the foreword to the report that if we invest in early intervention, we will make savings into the future as the number of cases which present will fall. That is what Senator Boyhan just said.

Unfortunately, this report comes against the backdrop where the quality of some child and adolescent mental health services fall short of the targets recommended in A Vision for Change. This is exacerbated by the rise in mental problems in the child population. The key recommendations are that primary care should be urgently staffed at the level of psychologists recommended in A Vision for Change and updated in accordance with the child population data 2017. The CAMHS referral criteria should be expanded to include children with intellectual disabilities.

I have a lot more to say but I want to let in Senator Devine. Unfortunately, many areas have suffered from underfunding over many decades. With each set of new recommendations it is evident that there is a case to be made for additional funding in order to close the gaps in services that currently exist.

Senator Máire Devine

I thank Senator Feighan, he is very kind and generous. I welcome the Minister of State.

Picking Senator Coghlan as Chair of the hearings into child mental health services was a no-brainer. I thank Senator Joan Freeman and everyone on that committee. It was both harrowing and enjoyable. I also thank the parents and the young adults who allowed us into their lives, and their trauma, in public in the Seanad. Senator Freeman and I also met a number of people privately, who had been unable or unwilling to go into the public eye which can be horrific, especially when sharing stories of access, or lack thereof, to our child and adolescent mental health services.

Equality of access emerged as a major point, as well as waiting lists and continuity of care. People who were lucky enough to get to speak to a professional kept having to tell their story to a different person time and again. That goes against the formation of any therapeutic relationship. It is not a broken leg, but a broken heart, mind, soul or spirit of children and adults in mental distress. Medication policy was another major factor.

Senator Boyhan referred to time. People are losing their time of childhood. Most of us here were lucky enough to have stability in our lives and were allowed to be children, to grow, mature, make mistakes, whether emotional or intellectually, and grow up. That makes us the adults we are. Our children in mental distress do not have that. They are frozen in time because by the time they reach adulthood, if things are not addressed early, we will have condemned them for life. I do not say that lightly but we need that early intervention, the immediate, rapid response to allow our children to experience childhood. That is what is not happening.

The recommendations are there for all to see. One recommendation is to allow experienced nurses to do clinical assessments.

Another is that for those with intellectual disabilities, the referral criteria for child and adolescent mental health services, CAMHS, should be expanded. We could talk about recruitment but it comes down to a chaotic working environment. Many staff have left and new people are not being attracted into the service. The report on public service pay will be published at the end of June but this is a priority and it needs to happen now.

As for Senator Freeman's Mental Health (Amendment) Bill, will the Minister of State speed up the passage of that Bill? Can he find time soon to allow Report and Final Stages be taken? It would be one measure to prevent children in adult psychiatric hospitals suffering trauma. They are not being allowed to heal from the trauma they witness in psychiatric hospitals. Will he provide time for the taking of Report and Final Stages to allow us do something about that prior to summer?

Acting Chairman (Senator Diarmuid Wilson)

Senator Mullen and Senator Black are offering. There is exactly nine and a half minutes remaining so they will have less than five minutes each. The debate is being adjourned at 4 p.m. so whoever is in possession at that time will be in possession when the debate resumes on the next day.

Senator Rónán Mullen

I join other colleagues in congratulating Senators Freeman and Coghlan and all those involved in the creation and bringing about of this thorough and thought provoking report on child and adolescent mental health services. It has been said many times in this House, and is restated in Senator Coghlan's introduction to the report, that mental illness should be treated no differently from physical illness. I wholeheartedly agree.

Mental health and mental illness can take a terrible toll on individuals, families and communities. It takes many forms. I think of my own father's condition, Alzheimer's disease, which is formally recognised as a mental illness. That has brought me closer to this issue from one particular perspective.

Public discussion around mental health has come on significantly in the past decade. I can still remember a time when to discuss depression was considered a personal failing and some kind of secret shame to be concealed. Thankfully, we are moving away from such times. To paraphrase the report, we all know somebody in our family or community who is affected by mental health issues and the effects of that on family and friends can never be overstated.

The focus of our public discussion is often on adult mental health services in the context of the A Vision For Change report launched in 2006. That report was a comprehensive blueprint of how we, as a country, were to recognise and properly fund our mental health services but, sadly, significant gaps remain. Today's report shines a welcome and much needed light on the neglected area of children's mental health services.

In that context, it is sad to be reminded that according to the United Nations children's emergency fund report, Building the Future, published in the weeks before the committee sat, Ireland has the fourth highest teenage suicide rate among 37 nations of the developed world. That report further highlighted that Irish children aged between 11 and 15 are presenting with emotional issues on a weekly basis at the second highest rate in Europe. That shows graphically that our young people and children are vulnerable to mental health issues. Even more shocking is the fact that the report shows that the increases in mental health problems in the child population in Ireland are not matched by an increase in services.

Senator Freeman and her team have catalogued the fact that there has been a reverse trend in overall budget funding for services. The percentage of the total health budget for mental health has decreased from 13% in 1984 to 7.3% in 2004 to the current 6.1%. At a level of percentage, that declining allocation of funding is in stark contrast to many other western European health systems such as those in France, Germany and the United Kingdom, where spending on mental health services comes in at approximately 10% to 12% of the overall health budget. This chronic underfunding shows a repeated failure by State agencies and reflects that failure to build the necessary capacity to provide adequate mental health services to children and adolescents.

In the weeks prior to the committee's oral hearings, which took place on 29 June and 6 July of last year, one of four child inpatient units in Ireland for acute mental health problems closed 11 beds, lowering the national bed complement in Ireland, with a population of 1.25 million children, to 48 beds. The reasons for the closure cited by the Government were nurse shortages.

Before I speak about staffing problems, I want to return to an area colleagues will have heard me highlight in the past, that is, the provision of community based mental health services. If we look at Galway, my own county, we will see in microcosm the dysfunction in Health Service Executive, HSE, community mental health services. The HSE in Galway has decided to centralise all mental health treatment into an overcrowded mental health unit in the university hospital. That is partly the result of the fact that in 2015, the HSE closed a state-of-the art mental health facility at St. Brigid's Hospital, Ballinasloe, which cost over €3 million to renovate. At the core of the vaunted A Vision for Change plan for mental health services was the recommendation that care be given close to the communities where the patient lives. In Galway, the opposite is now happening. All mental health care is being centralised in the city hospital.

In addition to poor use of physical resources, there is the ongoing chronic failure to recruit and retain staff. I am glad the report has highlighted that issue as a major problem.

The Government recently committed to invest tens of millions of euro in child and adolescent mental health services over the next five years. Those commitments also include the creation of a 29-bed inpatient unit at the new children's hospital that is due to open by 2021. This service will increase the bed complement in Ireland but ignores the HSE's chronic inability to recruit the nurses and child psychiatrists who will be needed to put these beds into commission. Crucially, there is no point in opening beds without a nurse or a doctor to operate them. That is the lesson the renovated and subsequently closed unit in Ballinasloe teaches us.

This report reinforces what many of us have been saying for years about mental health services in this country. We cannot provide a service where there is a chronic failure by the HSE to recruit psychiatric nurses and consultant child psychiatrists to operate the existing bed complement in Ireland.

We need a plan by the Minister of State to show how he will target pay and working conditions to attract specialists in this area. Unless we can find and keep the staff, there is little point in unveiling expensive new units with empty beds. The last I heard they were storing records in the expensively refurbished St. Brigid's unit in Ballinasloe.

I welcome this report. I agree with the conclusions regarding recruitment of staff and I look forward to hearing innovative proposals from the Minister of State.

Senator Frances Black

I welcome the Minister of State. This is a vital issue and none of us can be happy to be standing here again debating it. The point has been made endlessly in these Houses, and this report is further evidence, that our child and adolescent mental health services are falling well short of what is expected. We are not delivering anywhere near the standard expected by Irish people, and we are not delivering the targets recommended in A Vision for Change, which for so long has been the blueprint for mental health services in Ireland.

I do not say this to score points or point the finger. We are all committed to fixing this problem, and I know the Minister of State is passionate about it, but it is important to be honest. I want to commend the members of the Seanad Public Consultation Committee, the Chair, Senator Freeman and all parties involved, and none, who put so much work into making sure this report painted a clear picture of mental health service provision in Ireland, even if it is shocking and worrying. The honest, heartbreaking testimonies from parents stand out in particular. These are the real-life stories that illustrate starkly the human cost of our failure and they are as good a measure as any of how well our system is working.

A few minutes ago, just before I walked into the Chamber and while writing this speech, I received a phone call from a woman who was in awful distress. She had been going through the private system for treatment but when her money ran out she had to go into the public system. What she experienced was traumatic. When she came out from seeing somebody she felt suicidal. Her mother and sister were with her and they had to prevent her jumping into the local river. It was a horrendous experience. Whoever she saw that day is probably suffering from burnout. That person told her to go to her local doctor and get prescription tablets. That was all she was told to do. That is not on.

My worry is that all this work and progress will be fatally undermined if increased awareness and demand are not met with similar investment in services. We cannot in good conscience urge young people to speak up and seek help and then fail to ensure that someone is there to listen. The waiting times quoted in the document clearly illustrate the issue.

It has been said that since 2014, the demand for mental health services has gone up by over 30%.

Thousands of children and young people are still waiting on treatment and many have been there for well over a year.

On the other side of the issue, I talk to people working in these services and it is also devastating for them. I know because I work in therapy. This sector is understaffed. Burnout is huge in this area. Service providers are simply not able to meet the demand. It is unfair on those seeking treatment and on those working in the front-line services. Again, I do not want to sound too critical, but we are in a crisis. I know the Minister wants to fix this, but the stories in this report and the many reports that have gone before it should shock and shame us. It is like homelessness in that we hear what is happening every day but I do not see the urgency that is required to deal with the issue. There has recently been talk of investment in a rainy day fund, the need for which I can fully appreciate. However, if a suicidal young person has to wait 18 months for help, surely it is already raining pretty heavily.

As I have limited time, I will not pore over the specific changes recommended, other than to thank Senator Coghlan, Senator Freeman and the other members of the committee for their work. They have outlined a long list of changes, some requiring increased financial investment and many focused on common-sense reform to our structures and procedures. I urge the Government to listen to them.

I will touch briefly on the link between alcohol harm and mental health. We have to talk about that at some point, particularly as it relates to young people and intergenerational trauma, which causes young people to suffer from mental health issues. They do not feel worthy. This is an important issue. Alcohol is a depressant, with more than 50% of suicides alcohol-related. I wanted to highlight that issue before I concluded.

Minister of State at the Department of Health (Deputy Jim Daly)

I will be as brief as I can and try to answer as many queries as possible. To give a holistic overview, Senator Freeman asked a specific question about her Bill going through the Houses and Senator Devine asked the same question. It is not within my gift to decide when Bills come before the House. I do not order the business of the House. In the Dáil that is the function of the Business Committee, and I suspect the position is similar in respect of the Seanad. The Senators should raise the matter with the relevant authorities in the Houses. As Minister of State, I am happy to come before the House when requested. It is not within my gift to decide when the House progresses legislation.

I will first address the issue of child and adolescent mental health services, CAMHS. I thank the Chairman of the committee, Senator Paul Coghlan, and the rapporteur, Senator Joan Freeman. I became Minister of State in June of last year, almost 12 months ago. Within that time, children's mental health services has been a salient issue. I very much welcome the focus and energy this House has brought to that particular area and to ensuring that we can home in on it. I accept the point made by Members that we cannot continue to repeat the same narrative that services cannot be delivered because there are recruitment challenges in the mental health area. I have accepted that from day one, including when I spoke here last July, and I accept it again today.

What have I done since? I have tried to build a lower level of intervention. Addressing waiting lists deals with the symptoms. I could introduce a waiting list initiative to get rid of the waiting lists, but they will build again and they will still be there in three years' time. I will not be dishonest or try to fool anybody by doing that. It is better to fix the system, not the symptoms that display the faults in the system, by addressing the faults. We have tried to build in a lower level of intervention in order that we can catch these issues at a lower level before they escalate to requiring specialist services. How do we do that? We have put in place a lower level of teams, consisting of 114 assistant psychologists and 20 psychologists, to deal with teenagers and young people. This approach captures the issues much earlier, before they escalate to a specialist service.

There is also an issue with referral. Most teenagers who have a mental health issue are referred automatically to CAMHS. This is inappropriate. They are left on a waiting list for a long time. Not everybody needs to see a consultant psychiatrist or requires medication or the assistance of a CAMHS team. However, all of those who are referred need help. They have anxieties and similar issues they want to deal with. For this reason, I have appointed 114 assistant psychologists and 20 psychologists to build a lower level infrastructure to prevent issues escalating to CAMHS. That is how I am treating the waiting list in CAMHS.

I have also spoken about the telephone line. That is a referral issue. People are not being appropriately referred. There are some wonderful services available, such as Pieta House, Alone, Aware, Jigsaw and many others. However, knowing where to go is very confusing for people. General practitioners do not know where to send people so they send most teenagers automatically to CAMHS, which is not always necessary. The phone line is intended to be a referral pathway. Any teenager with any form of mental health issue can dial in and be told the most appropriate service. If Jim Daly of Clonakilty is experiencing serious anxiety ahead of his exams and cannot get rid of it, he will be directed to Jigsaw in Bandon, the nearest town. We are progressing this referral pathway at a fast rate. I intend to have substantially developed this concept before the end of the year. It will have a significant knock-on effect on waiting lists by assisting people who are currently being inappropriately referred, do not know where to go and are lost in the system. We will also have a listening pathway as part of that.

I always make the point that addressing this issue is not only about providing more money. We are spending an additional sum of more than €60 million this year, with €35 million specifically for new initiatives. We could throw another €200 million at the issue. It is important to look at what we do and how we do it, with a view to doing it differently. What I have done for the past 12 months is challenge the system. I appreciate the challenges Senators addressed to me. They can rest assured that all those in the Department and Health Service Executive who have dealt with me in the past year will say that questioning is one of my hallmarks because I question everybody, as Senator Devine knows. I do not take anything for granted or as a given. I question and challenge at all times and it has been my honour and privilege to do so, as Minister of State with responsibility for mental health for the past 12 months.

Senator Máire Devine

On a point of order, if the Mental Health (Amendment) Bill 2017 is passed by the Seanad, will the Government prioritise it in the Dáil?

Acting Chairman (Senator Diarmuid Wilson)

The debate has concluded. I thank Senator Devine, the Minister of State and all Senators who contributed.