Mental Health Services: Motion

I welcome the Minister of State, Deputy Jim Daly, to the House. I understand the motion will be seconded by Senator Freeman.

I move:

That Seanad Éireann:

notes that:

- adequate mental health services are vital to secure the dignity and wellbeing of all those within the State, including asylum seekers within the direct provision system;

- Ireland's spend on mental health services is now just 6.6% of the total health budget, compared to 13% in the 1980s;

- there are now 472 consultant psychiatrists in Ireland, approximately 240 less than are recommended by the Hanley Report to provide safe and effective psychiatric services, and that 20% of consultant posts are currently vacant;

- Ireland has the fourth-lowest number of in-patient psychiatric beds in the European Union, at 2.3 beds per 1,000 population;

- almost 2,700 children and adolescents are awaiting appointments with psychiatrists, with almost 400 waiting over 1 year; and

- there continues to be major shortfalls in 24-hour access to mental health services, including weekend and out-of-hours services;

recognises in particular that:

- persons seeking asylum in the State who are within the direct provision regime have particular mental health needs which are not being addressed;

- the Royal College of Surgeons has found that depression and mental health problems are five times higher among asylum seekers in direct provision than in Irish society generally;

- the mental health and psychological development of young people is particularly affected by long stays in the direct provision system; and

- many of those who have undergone trauma prior to or in the process of seeking asylum, and particularly those who have fled war and/or persecution, may have complex mental health needs which require intervention;

and calls on the Government to:

- ensure that staff shortages in this sector are resourced as a priority in order to meet current requirements;

- work with the College of Psychiatrists of Ireland to maximise the number of specialist training posts for psychiatrists, to alleviate the shortage of suitable candidates for vacant positions;

- ensure that a designated consultant psychiatrist is identified in each area in which a direct provision reception centre is located;

- establish multidisciplinary teams led by consultants on a regional basis, to support all mental health services that provide treatment to asylum seekers;

- introduce early and adequate assessment of asylum seekers for mental health issues and referral to specialised services as required;

- ensure that specialised services, such as psychotherapy for survivors of torture and other violence, can be accessed by those who need them; and

- ensure that interpreters are available to assist professionals to deliver services, and that existing core staff receive additional linguistic training where possible.

Cuirim fáilte roimh an Aire Stáit, an Teachta Jim Daly. Creidim gur ócáid thábhachtach í seo. Tá ábhar an-tábhachtach á phlé againn inniu. It is fair to say that Ireland's attitudes to mental health have transformed for the better over the past five decades. The most recent staging post in the development of our services was the Government strategy, A Vision for Change, which was launched in 2006. Thirteen years on, its implementation has been uneven at best. There has been partial delivery across all its core elements, but a substantial amount remains to be done. Progress on the strategy was hindered by severe staff shortages and funding cuts during the recession. I will give two examples. Despite the recommendations of the strategy and the code of practice issued by the Mental Health Commission, children continue to be admitted into adult mental health inpatient services. There were 84 such admissions in 2018. The strategy puts a focus on the need to provide mental health treatment in primary and community care settings and to avoid premature recourse to specialists. The failure to make such provision is forcing people onto psychiatrists' waiting lists. Almost 2,700 children and adolescents are awaiting appointments with psychiatrists at present, approximately 400 of whom have been waiting for more than a year. I understand that some 6,000 people are waiting for appointments with psychologists, approximately 1,600 of whom have been waiting for over a year. These figures are stark.

There are continuing shortfalls in 24-7 access to mental health services. All these problems are persisting despite record funding of our health service. The State is spending more than €20 billion on health this year. According to an OECD study last year, we spend €4,706 per capita on health each year, which is approximately 30% more than the average across the OECD. Are the mental health services available to our young people 30% better? I am afraid not. Have they improved in line with the increase in the health budget? Absolutely not. If anything, our mental health services are treading water, at best. Far from being among the best internationally, we are very much towards the bottom of the table. We have the fourth lowest number of inpatient psychiatric beds in the EU, where community care is desired. We have approximately 2.3 psychiatric beds per 1,000 people. As I said last week, our spend on mental health services as a proportion of the overall health spend is just half of what it was in the 1980s, which was a time of crippling unemployment and economic stagnation. We spend 6.6% of the overall health budget on mental health services, compared to 13% in the 1980s. I admit that the total amount was lower back then. As this House will recall, the Government has twice - in 2012 and in 2016 - raided the budget for mental health to plug holes elsewhere in the health service. This will not have helped the yawning gap in the number of psychiatrists in Ireland. According to the Hanly report, an additional 240 consultants are needed to provide a safe service. Some 20% of posts are currently vacant and approximately one third of the posts that are filled are filled by locums, which is not satisfactory.

One of the greatest tragedies of modem Ireland is the prevalence of the mental health problems faced by young people. I am honoured to have Senator Freeman, who needs no lessons on the importance of this topic, here to second this motion. W.B. Yeats wrote that this "is no country for old men", but is it a country for young people, given that so many of them are forced to struggle - often alone - with problems which make them question the value of their own lives? There is an average of just over one suicide per day in Ireland. While men account for 80% of suicides, a recent study showed that the rate of suicide among young and adolescent girls in Ireland is the highest in the EU. Some 9,103 people presented to hospital due to self-harm in 2017, which represented an increase of 21% on the 2007 figure. Remarkably, or perhaps unremarkably, self-harm is 30 times higher among homeless people. This reality is all the more startling when we consider that more than 10,000 people are homeless in Ireland at present. Factors such as alcohol and drug abuse, decreased involvement in social and sporting activities, a decrease in religious belief, spiritual life and religious observance and pressure to perform well academically are recognised as being linked to the problem we are discussing. Bullying on social media is a factor we must consider. As a society, we need to get grips with the ugliness that has entered much of our discourse in politics and across all levels of society. I am mindful that Senator Freeman has sponsored the Children’s Digital Protection Bill 2018. I hope her Bill will give the Seanad a good opportunity to develop our discussion of this dimension of these issues.

The issue of direct provision has also been discussed in the Seanad on many occasions. Sadly, the plight of people in direct provision has not improved much since I introduced a Private Members' motion on the subject in September 2014. At that time, more than 4,000 asylum seekers were in direct provision centres. This number has increased to 6,100. As we know, many of the 40 centres are above their capacity. While waiting times have reduced somewhat, applicants still have to wait between 18 and 20 months for initial hearings. For children in the system, a significant portion of their young lives are lost in the limbo of direct provision. As many Senators have said on many occasions, the direct provision system is an affront to the dignity of human beings. The working group on the protection process and direct provision, chaired by Mr. Justice Bryan McMahon, recommended that people in direct provision should be given the right to work. This right is key to human dignity and is a positive for a person's mental health and well-being, just as the absence of that right is a negative. Under a new Government regulation, 1,743 people have been granted access to the labour market. Nasc has criticised the slow implementation of many of Mr. Justice McMahon's other recommendations. The mental health needs of asylum seekers, or of ethnic minorities more generally, was not considered in A Vision for Change. In recent years, research into their mental health needs has demonstrated the impact on them of long stays in the system. According to a paper published in 2016 by the faculty of public health medicine of the Royal College of Physicians of Ireland, "refugees and asylum seekers often have unique and complex physical and mental health needs that require specific and comprehensive healthcare attention". The paper in question, which was entitled "The Health of Asylum Seekers, Refugees and Relocated Individuals", also found that "people fleeing war and persecution in traumatic circumstances may have complex mental health needs requiring intervention".

According to a paper that was published by the College of Psychiatrists in Ireland in 2017, children "are the frequently forgotten element of the migrant crisis" and "failure to deal with their needs can result in the storing up of social difficulties and mental pain that could have serious problems for the individual as well as society in the future". The paper in question cited a range of studies from Sweden, Denmark and other countries in support of its findings. Other research has drawn a clear link between the length of the asylum application process and adverse effects on mental health. Doras Luimní has found that "residents frequently speak about how the uncertainty of their future, the overcrowded living conditions, and the prolonged periods of inactivity impact upon their well-being and mental health". This conclusion has been supported by other research for the Royal College of Surgeons in Ireland.

A range of measures can be taken to assist and improve the well-being of those in direct provision, and there is broad agreement on what can be done. We need to do all we can to ensure that staff shortages in this sector are minimised. The College of Psychiatrists of Ireland has suggested that more could be done to bring suitable candidates for consultant psychiatrist posts through the system, and the Government should work to maximise the numbers. It needs to be ensured that a consultant psychiatrist can be identified in each area where there is a direct provision reception centre, which would allow for the provision of early and adequate assessment of asylum seekers for mental health issues and referral to specialised services as required. Such specialised services, including psychotherapy for survivors of torture and other violence, should be accessible immediately for those who need them. It also needs to be ensured that interpreters are available to assist medical professionals, and to avoid remarkable and unacceptable situations where children have to act as interpreters for their parents, as often happens. These are just some measures which, with increased investment, could lead to a clear and genuine improvement in the well-being of those in the direct provision system.

I turn to what can be done to help young people within the school system. Dr. Eve Griffin of National Self-Harm Registry Ireland has said that there is "an unmet need in terms of mental health services for children and adolescents ... School-based programmes to promote positive mental health should also be a priority.". I strongly agree with this, and based on my own interactions with teachers and parents, a number of measures could be taken, which could have a significant impact on problems faced by children and adolescents at an early stage. The State should make psychotherapists available to schools, perhaps on a shared basis between a number of schools within a district. I know of one school in Leinster which engages a psychotherapist for one day per week who sees 15 of their 700 students each week, and this is funded from the school’s own resources. Clearly, the vast majority of schools cannot afford to do this on their own, unsupported by the State. Professional development for teachers in mental health is needed since they face these issues in classrooms. This kind of training should be as routine as first aid training, and it should apply to people in management in all workplaces, not just schools. Pieta House runs an excellent six-week resilience programme for 14 year olds entering their second year of secondary school. Perhaps this should be rolled out throughout the second-level sector. One important point is that there needs to be strict regulation of qualifications and standards for all psychotherapists and cognitive behavioural therapists. There are some concerns about the quality of some of the services on offer, and the cost of these services needs to be more affordable for families. The HSE runs a programme which allows schools to become health promoting schools, which schools with a focus on mental health can avail of. That is very much to be commended. More needs to be done to advertise and promote this scheme to schools. These are just a brief selection of measures which could be addressed by the Government. I do not believe that it need involve significant additional expenditure within the health or education systems, particularly given our economic circumstances at this point. However, investment would result in tangible improvements in outcomes for the mental health and well-being of our young people and those in direct provision in particular, on whom I seek to place particular focus today. I look forward to seeing what colleagues have to say.

I second the motion of my colleague Senator Mullen.

I feel apologetic every time I see the Minister of State, because I know I am going to attack him. I am sorry, but he is the face of his Department so I know he will not personalise it. What does it take for the Government to listen to the people of Ireland when it comes to the mental health services? If we look back over the past 18 months to two years, we have done some positive things. I am not talking about the Department of Health; I am talking about outsiders, including Senators and Deputies who have singly done things to try to improve the mental health services. I know the Minister of State is trying very hard too.

Let us recap what has been achieved. We had our first public consultation days on mental health, which were the first in the history of the State. It was a wonderful opportunity to bring people who use the service, people who provide the service, and policymakers together to let the people of Ireland know what is happening. We then formed the Oireachtas Joint Committee on the Future of Mental Health, which again was incredible as it was the first in the history of the State. It allowed us to hold the HSE accountable. That, more than anything, was the most perfect part of that committee.

The other positive development is that legislation was passed by the House, which tries to end the placing of children in adult psychiatric units. It has not gone through the Dáil but it has at least gone through the Seanad. There have been marches outside Leinster House, in Wexford, and all around the place, which shows that people are not satisfied with what is going on in our country. Organisations such as the Mental Health Commission have suddenly had a change of attitude insofar as they are saying it is not acceptable any more. They published reports stating that there were problems with mental health services but they did not do anything else other than mouth it; now they are complaining vocally and bringing it to the attention of the media. Mental Health Reform has written report after report about the gaps, the needs, and the limitations of our services, and yesterday, we had the announcement of the My Voice Matters report in the AV room, which is a good report, again listening to the voice of the people of Ireland.

The final positive development is that I had a formal meeting with the Taoiseach about a year ago that lasted an hour. I could not believe it. I brought two issues to his attention. One was to make the Oireachtas Joint Committee on the Future of Mental Health a permanent committee and he agreed to that. Second and I hope no one finds this an underhanded, I asked him if the Child and Adolescent Mental Health Services, CAMHS, could be removed from the HSE and put under the remit and care of the Department of Children and Youth Affairs. I do not get why children are lumped in with adults, especially when it comes to mental health. They need their own care, and they need to be minded because they are desperately neglected.

How has the Government responded? It formed a committee to review the A Vision for Change report which was published 13 years ago. It then formed another committee to review the review of A Vision for Change. Is this the third review? It is a lovely example of kicking the can down the road.

One of the things the Minister of State has been doing, which I can see the advantage of, is updating Oireachtas Members. He has had two information days in the AV room and while they were good, interesting, and very professional, he did not tell us anything new. He is forgetting the basic things that need to be done. He should forget the new stuff, including the digital stuff. Let us examine the basic stuff, such as waiting lists, children being turned away because they are in the wrong queue, and other children being placed in adult psychiatric units.

I hope the Minister of State will be reply on another issue. A few weeks ago, a Fianna Fáil Member announced in the House that there will be a permanent committee on mental health. That was followed by the Minister of State's statement in the newspapers that there would be a permanent committee on mental health. I then formally asked him via email whether there was going to be one, because I was the chairman of that committee after all, and I think the chairman should know and be able to pass it on to the committee's members. I was told that he does not know, and that he is still investigating it. That upsets me deeply because that says that there is no need for a mental health committee because we are highlighting and putting a spotlight on too many problems.

I am asking him, in his role as a Minister of State with responsibility for mental health, to make sure that a permanent committee is put in place. I do not care who is the Chairman, by the way. I have nothing to lose because the chances are that I am never going to be called back to Seanad Éireann. I am talking here on behalf of the people of Ireland.

Finally, the Government is not in good health at the moment.

That is not true.

It is in lots of trouble and there has been lots of bad publicity. There is one thing that could turn things around, which is the Government looking after the mental health of our country. This Government must stop losing the appetite for mental health and must put it first on the agenda.

I welcome the Minister of State to the House. This morning, the Oireachtas heath committee met representatives of the Mental Health Commission and of a group campaigning for mental health reform. Presentations were made to the committee and many interesting issues arose at that meeting. I raised a number of issues myself about which I am concerned but it is important to recognise the progress that has been made. The budget for mental health has increased from €711 million to €987 million over the past four to five years, which is a substantial increase. The number of CAMHS units has increased from 49 to 70 and the number of new posts created is over 1,700. Progress is being made in relation to mental health. A new national forensic mental health hospital is being built. It will have 130 adult beds, as well as a ten-bed unit for children and a 30-bed intensive care rehabilitation unit, giving a total of 170 beds. That project is progressing, is being built and will be delivered.

The Mental Health Commission provided figures at the meeting this morning relating to regulatory compliance, which is improving. Regulatory compliance went up from 74% in 2016 to 76% in 2017 and it reached 79% in 2018. One of the examples given to us related to the department of psychiatry in Roscommon hospital, which was only 52% compliant over 12 months ago but at the last inspection was found to be 83% compliant. Similarly, St. Brigid's Hospital in Ardee was way down the list but has now reached 93% compliance. Progress is being made in relation to mental health, albeit not enough and not fast enough. That said, it is important to note that it is not static and that the necessary changes are being made.

Senator Mullen referred to the number of beds in the system but we have now changed the whole focus of mental health services. The focus is on community and working in community teams. This is not just about in-care beds but also about working within the community; it is about working not only with the patients but also with their families, which is extremely important. Families are so important in terms of providing support and we must make sure that they are involved in the care of their loved ones who have difficulties in their lives. People need care and must have someone available to them when they have a down-time and need support.

I raised a number of issues at the health committee meeting this morning about which I have concerns. One is the issue of adolescent mental health, with which I have been dealing over the past 12 months. It is an enormous challenge at the moment, particularly with regard to geographical boundaries. In the Glanmire area of Cork city, for example, no adolescent mental health consultant was available. As a result, parents with whom I was dealing could not get access to consultant assessments for their children because they were living in a particular catchment area. It is unfair that people living on one side of a boundary cannot get access to a service while those who are fortunate enough to live on the other side of the boundary can access such services. That issue must be addressed. I have never heard previously of boundaries being created in respect of healthcare but that appears to be what has happened in the psychiatric services. This is something that needs to be examined further because there is a reluctance to roll over access to services for those who need immediate care.

Another issue is the fact that there is no intermediate support for people if they have not been assessed by a psychiatrist. They cannot get access to a CAMHS team because of the way the system is currently structured. That needs to be examined again in the context of making sure people can get access to services. The other issue that must be dealt with is one that requires forward planning. We have a large number of people living in this country now who were not born here. I dealt with a very difficult case recently where a GP told a landlord whose tenant had serious mental health problems to contact me and that I would sort it out for him. Eventually, after four weeks of back and forth, we got the GP to call to the person, who was then admitted to the psychiatric unit in Cork University Hospital. The sad part of this is that the person involved does not have family support. We are going to have a problem in the future with people who have come into this country but who do not have the support of immediate family or relatives and we need to start planning for that. The person to whom I referred has now been discharged from the psychiatric services but is facing issues with regard to accessing accommodation and the necessary supports. We must look at these two areas.

Finally, I wish to refer to the connection between drug abuse and the development of mental health problems. We are not doing enough to educate people that the use of illegal drugs can lead to mental health problems. We need to do a lot more to educate people in that regard, just as we did with tobacco and how smoking affects health. The use of illegal drugs causes mental health problems in the long term and we need to get that message out.

I thank the Minister of State for the work he is doing and commend his Department and the HSE on the work they are doing in this area. However, there are issues for which we must start planning now.

I welcome the Minister of State to the Chamber. I thank Senators Mullen, Freeman and all those who put their name to this motion for tabling it. I was glad to co-sponsor it. We all know that mental health is a hugely important issue. It is important to me as a legislator and through my work with the RISE Foundation. I have been working with the RISE Foundation for many years, as I have said previously in this Chamber. We work with families who are struggling with mental health issues. In reality, if somebody one loves, whether it be an adult child, partner, brother, sister or a parent, has an alcohol, drug or gambling problem, then one will really struggle with anxiety. One wakes up in the morning thinking about that person and one goes to bed at night thinking about them. One cannot eat or sleep. One must watch the person going down a route of self-destruction, slowly killing him or herself. Senators have spoken about families and the impact this has on the mental health of families is serious. It is absolutely soul-destroying. I am working in the area, at the coalface but there is absolutely no support for the work of the RISE Foundation.

Senator Mullen referred to the figures, which speak for themselves.

Some 2,700 children and adolescents are waiting on appointments, 400 of whom have been waiting for more than one year. These figures are not acceptable. They are also dangerous. If a young person is feeling depressed or suicidal, he or she cannot be asked to wait a year to be seen. It is not feasible. There is only a small window in which to deal with that person. I received a phone call from a woman whose daughter was in Galway. Only 14 years of age, she had attempted suicide numerous times. She is attending CAMHS and has been in hospital before. She needs to return to hospital, but there are no spaces available.

We have made major progress in our attitudes towards mental health. Thankfully, the stigma is slowly being peeled back and people are being encouraged to speak out and seek help if they are struggling, but we cannot ask them to seek help without ensuring that someone will be there to listen when they make contact, be it their doctors, Pieta House or anyone else. This is a resourcing and staffing issue. My latest figures show that, since 2014, demand for mental health services has increased by approximately 30%, yet the resources are not being allocated to meet it. People are being let down. The Minister of State is aware of all of this, though, and I do not want to repeat myself.

I wish to touch on another issue. I am a member of the Joint Committee on Justice and Equality. I would love the Minister of State to read the presentations that I listened to this morning. The committee is reviewing the direct provision system. We were joined this morning by a group of incredibly brave asylum seekers. I was very emotional listening to their stories. They explained to us what it was like to live in the system, and they spoke about the dehumanisation, indignity and damage being done to residents' mental health. They spoke about people coming from countries where they had been tortured and sexually violated, only then to come to direct provision centres where they face disrespect and a lack dignity. We would not treat our animals that way. There is barely any support for such people.

At a previous meeting, I heard of a heavily pregnant woman who needed to walk miles just to make a hospital appointment. When she eventually had her child, she had to walk miles back to the direct provision centre carrying her newborn baby in her arms. There was someone at the centre who gave her a hand every so often and drove her back and forth, but such an experience has an impact. We heard from women about having children while in direct provision and how their children had become institutionalised. One woman spoke this morning about how her nine year old child was suicidal. The meeting was upsetting. Last week, the Immigrant Council of Ireland told the committee about the number of women arriving in the system who had been trafficked and sexually abused. They have been through unspeakable trauma, yet they are being placed in a system where they cannot access mental health services. These people are being retraumatised in the centres. I would love it if the Minister of State read this morning's presentations. They were very upsetting.

We are a humane country. We have great humanity, but I sometimes wonder whether we are losing it. If Ireland is to have a humane and sensible asylum system, it must be based on reality. We must accept the fact that people who have fled war and persecution and who have sought asylum have been through traumatic experiences and have specific and complex needs. We cannot compound that trauma by placing them in a dehumanising system that lacks proper supports. We must acknowledge the increased mental health needs of highly vulnerable people and ensure that centres are equipped to deal with them. I urge every Member present to listen to the residents when they say that hotel managers and security are not suitable for or trained to help people who have been tortured and sexually abused. They need proper, specialised attention. Without it, the system will not be fit for purpose. There are many larger issues with the system, but they are all linked, and we will not be able to address the mental health issues properly without addressing their causes, for example, a meaningful right to work, the ability to cook their own food and the chance to make small, dignified choices about their daily lives. One woman talked about looking for toilet paper and being refused. She had to talk to her children about the reason.

All of this has an impact on the mental health of residents in direct provision centres. We must highlight it. It is up to us to refuse to let it go away. At a minimum, we should support the call in this motion and ensure that reception centres are equipped to deal with the vulnerable people whom they are supposed to be helping. Proper mental health services are a crucial part of that. I have spoken a great deal about direct provision, although I could have discussed mental health in Ireland. I would love it if the Minister of State considered this issue. This morning's meeting was upsetting. Everyone in my office was crying while listening to the stories. It was difficult for me not to cry. The residents are people like the Minister of State and me. They have children and are going through horrific experiences and indignity. Last week, a man was asked about his current legal status. He said that he had a wife and three children and that he did not care about or want to discuss his legal status. All he wanted to do was work. He just wanted to be allowed to get up in the morning, go to work and return in the evening and tell his three children that he had done a day's work. He said that he did not even want payment, that he would have done it for free. He just wanted to be given back his dignity so that he could show his children that he was a proud man and that he was going to work. This is the system's impact on people. We must consider this matter. Apart from that, there are issues of mental health, sex trafficking, what women must go through, and children being leered at in corridors.

I have said it all already. Please, will the Minister of State examine this vital matter?

I commend my colleagues, Senators Mullen and Freeman, on placing this most important matter before Seanad Éireann. It is a very significant issue that we in this country must face. When I ran for the Presidency in 2011, I isolated three main planks, the first of which was mental health. I visited Pieta House and various other institutions and was impressed by the work being done.

No one could object to the first phrase in the motion. I am glad to understand that the Government will not oppose the motion. That is a positive sign. No one could disagree with the statement that "adequate mental health services are vital to secure the dignity and wellbeing of all those within the State, including asylum seekers within the direct provision system". I am glad that Senator Mullen has isolated for particular attention people who are in the direct provision system. I introduced a Bill a couple of years ago that would have addressed most of the problems that were faced by asylum seekers. I believed it would get through, but at the last minute Sinn Féin Members changed their vote and voted against it. I think that was because they had an interest in the issue and wanted to keep it for themselves. I notice that no one from Sinn Féin is present now. They said that I had not addressed working or the introduction of cooking facilities. I told them to look at pages 6, 7 and 8, where all of those issues were specifically mentioned. They did not have a leg to stand on.

It is shocking that, since the 1980s, the amount of money spent on these services has dropped by half. Presumably, that is as a result of the financial emergency, but we are assured by the Government that the emergency is over, everything is back on track and we have full employment. There certainly should be an increase in this area.

It is not acceptable that young people should be kept waiting before they get access to psychiatric services. I will quote the motion: "almost 2,700 children and adolescents are awaiting appointments with psychiatrists, with almost 400 waiting over 1 year".

How, in God's name, is it conscionable that someone with severe mental issues and issues of distress or someone who is possibly suicidal can be told to come back in a year's time? It is madness. That is madness. That is mental illness in my opinion.

I am a bit of a grammarian and I want to point to one grammatical flaw. The motion states "there continues to be major shortfalls" rather than "there continue to be major shortfalls".

The next section of the motion deals with asylum seekers. It is perfectly appropriate to say they have particular problems with mental stress; of course they do. They have been wrenched out of their family circumstances and wrenched away from the country and culture in which they were brought up into an alien culture in very difficult circumstances. They are given an absolute pittance - pocket money. Most children in this country get more pocket money than we give to asylum seekers. The Royal College of Surgeons in Ireland has found that depression and mental health problems are five times higher among asylum seekers and I am not at all surprised. Many of these people are suffering from post-traumatic stress. I have dealt with people from Iraq who have been tortured. It takes a lot of recovering from a situation in which one human being has decided as an instrument of policy to inflict severe pain on another.

I am particularly pleased to note that Senator Mullen has included the phrase at the end stating "specialised services, such as psychotherapy for survivors of torture and other violence, can be accessed by those who need them".

I will end on that note. I commend my colleagues on putting this matter before the House. I acknowledge that the Government will not be opposing this motion. That is a very good day.

I welcome the Minister of State to the House and thank him for coming. I know he has special responsibility for this. I wish to thank in particular my colleagues, Senators Mullen and Freeman, for drafting and working on this comprehensive motion. It is worthy of support and I was delighted to co-sign it.

Three words that jumped off the page when I read the motion were: dignity, respect and well-being of the person. We can never deny dignity, respect or well-being of anyone. That flows and ebbs through every word of the motion and it is important to acknowledge.

I wish to acknowledge the great work of the former judge, Mr. Justice Bryan McMahon. Senators may have heard him recently on RTÉ in an interview. He is a wonderful man and advocate for reform especially for people who are seeking asylum and for the issues around how their welfare or lack of welfare is being cared for and the attention being given to them. We are lucky to have this brave and courageous man and advocate.

The motion refers to the 2,700 children and adolescents who are waiting for appointments. That is a shocking indictment on the Government and the issue needs to be addressed, as does the issue that so many people are waiting for over a year.

I wish to focus on the issues of asylum seekers and direct provision because I believe these particular aspects do not get the same attention. Many of these people are not involved in the political process. Many have not embedded themselves in the community and do not have advocates. We hear horrendous stories of abuse of these people, whether mental, physical or emotional. They are particularly vulnerable when they are isolated and that is a terrible story in itself. I spoke to one woman - I will not mention the centre where she stayed. She described to me how, at night time when she got back into her room with her husband, they pulled up the mattress to the door to keep her children in so that they would be safe. For a mother to have to pull up the mattress from the floor and prop it up against the door and lie down and sleep there to keep her children safe is startling. She spoke about her deep concerns for the safety of her children and their welfare. No family should be put through that.

I am reminded of a good speech by the Taoiseach in Sligo recently in the context of the Famine. He talked about our people as a migrant people and our experiences of going from or fleeing these shores and our homeland. He spoke of how many of our ancestors sought refuge, support and shelter whether in the USA or wherever and how many people there were badly treated. They were our people. Many people had good experiences too. One would imagine we would be more sympathetic to people in asylum or waiting for asylum in these centres, as well as those in direct provision. That is really important.

I am not going to rehash all the things people have said because they have made excellent contributions. What is this motion attempting to do? The motion is asking the Minister of State to commit to seven simple principles. These are set out in the motion. The motion calls on the Government to ensure staff shortages in the sector are resourced as a priority to meet the current requirements. It refers to working with the College of Psychiatrists of Ireland to maximise the number of specialist training posts for psychiatrists to alleviate the shortage of suitable candidates for vacant positions. It calls for a designated consultant psychiatrist to be identified in each area where a direct provision reception centre is located.

I want to focus on the next two priorities set out in the motion. They call for the introduction of early and adequate assessment for asylum seekers for mental health issues, as well as referrals to specialist services as required. The motion also calls for specialist services, such as psychological services for survivors of torture and other violence, to be available for access by those who need them.

I am keen for the Minister of State to spend the next portion of his time in the House today addressing these seven key points. They are simple. I am pleased that, as Senator Norris has said, the Government is accepting the motion. I would be appalled if the Government did not accept it. I really want the Minister of State to use his time constructively today. He should deal specifically with these seven key points and where he sees difficulties. I see no difficulties but if the Minister of State has difficulties, we want to hear them. It is grand for all of us to come to the House and talk about the issues we all know about, but I would like to leave the Chamber today knowing that the Minister of State is absolutely committed to the delivery of the seven key points that the motion attempts to secure. I want to hear the Minister of State address these seven issues one by one. If we can go away with some assurance then at least that is a start. It is then up to us to keep engaging with the Minister of State and the people in authority to ensure the calls are realised.

Let us be clear about something: people are entitled to their dignity, respect and well-being. We should do nothing less than support these reasonable objects. We live in a republic. We guarantee principles of security and respect for the citizens of our Republic. The Constitution sets out and covers many aspects of the entitlements and rights of people. I am keen to hear what the Minister of State has to say on the matters we have raised.

I thank Senators and welcome the motion as the promotion of positive mental health is a common objective within the Oireachtas and throughout Irish society.

The issues raised by the Senator provide the opportunity for us to consider the various and ongoing initiatives aimed at enhancing our mental health legislation, policy and services. These issues are being addressed in the context of progressing the commitments and priorities for mental health under A Programme for a Partnership Government. We are, for example, modernising the Mental Health Act 2001, refreshing A Vision for Change and we have been improving the existing capacity of our mental health service while introducing new initiatives.

My core objective, as Minister of State, is to improve how we plan services with an emphasis on delivering assessed and appropriate services to all of our population, especially those most needing care. We face increasing demands, evolving needs and heightened expectations. We also face limits in staffing resources. To meet these challenges, we need to look at new approaches and imaginative solutions.

I appreciate that the Senator has raised comparison of mental health funding as a proportion of overall health expenditure with 1980s figures. This, I suggest, should be considered in the context of changes to the health system as a whole. This includes, for example, various new service elements introduced across our health system in such areas as disability or services for older people. Such services simply did not exist in the past. In addition, the mental health system has totally transformed from primarily institutional-based care to largely community care, allied of course to modern inpatient care units that emphasise short-stay and recovery.

Significant mental health promotion and expenditure is undertaken in other areas for both children and adults, such as in HSE primary care or across other sectors such as education, Tusla or the judicial systems.

Expenditure comparisons with other countries should also allow for the fact that they can have significantly different healthcare, social care or funding systems. Notwithstanding this, I reiterate that developing mental health services remains a priority for me as Minister of State and for the Government. This is being realised in practical terms by the additional €55 million to progress new developments this year, which brings overall mental health funding to nearly €1 billion. The HSE mental health budget has increased by more than €275 million since 2012, a significant investment by any measure or viewpoint.

In recent years, our services have broadened. They now range from mental health promotion and early intervention through to specialist acute forensic care. They extend also, for both adults and children, beyond the traditional HSE mental health programme to other areas or sectors. This involves, for example, better links to primary care, disability services and health and well-being. Increasingly, an improved response is also occurring across other sectors spanning education, childcare or the justice systems.

In recent years, the mental health system has received, rightly, considerable scrutiny from politicians, the media, advocate organisations, service users and many others. I welcome this scrutiny because it helps us to identify any areas in which performance can be improved. In this regard, I acknowledge the contribution of the Oireachtas. While mental health is a complex area relevant to us all, often involving profound issues and implications, steady and real progress has been made collectively over recent years. From my extensive interaction with many Members on many fronts, I am confident that this positive direction will continue, as it must do if we are to realise the further improvements we all wish to see. On this note, I held a presentation late last year in Leinster House to inform Members of the Oireachtas about our mental health service overall, and I arranged another one about a month ago specifically on child and adolescent mental health services, CAMHS. Many of the issues being aired today were covered in detail on these unique opportunities by officials of both the Department of Health and the HSE.

I will now update Members on some of the strategic developments on mental health and then address the more specific issues raised. The Department of Health is drafting a general scheme of a Bill to amend mental health legislation to reflect the recommendations of the expert group review of the Mental Health Act 2001. It is anticipated that draft heads of a Bill will be completed by the end of June next. The draft legislation at that stage will then be referred to the Mental Health Commission for its consideration. Mental health legislation must always seek to strike a fine balance between the rights of the person and the requirement to protect others. The comprehensive updating of the Mental Health Act 2001, along with the recently enacted Mental Health (Amendment) Act 2018, will ensure that in future a greater emphasis will be placed on the autonomy of the individual rather than relying on the principle of "best interests", as set out in the 2001 Act. It is accepted that people should have the right to make their own choices and that, where necessary, supports should be available to ensure a person's "will and preferences" are fully respected. The updated Act will put the focus firmly on protecting and promoting the human rights of those with mental health difficulties, thus ensuring their voice will be more clearly heard.

When launched in 2006, A Vision for Change was universally welcomed as a progressive, evidence-based and realistic document that proposed a new model of service delivery that would be patient-centred, flexible and community-based. The Government accepted A Vision for Change as the basis for developing our mental health services, and significant success can be noted in how the delivery of mental health services has changed in the intervening years. One important principle within this document reads: "Mental health services must be accessible to all who require them; this means not just geographically accessible but ... provided at a time and in a manner that means individuals can readily access the service they require." This relates more than ever before to the issues at hand today. It is generally accepted that A Vision for Change has been highly regarded, both nationally and internationally, for its underlying principles and objectives. The refresh of this policy, which will conclude shortly, will reinforce and improve these fundamentals while taking account of emerging needs and changing best practice for future years. We should recall where we have come from in that bed numbers have been reduced and old institutions closed. The new focus on mental health and deinstitutionalisation, which will be further supplemented and informed by updating A Vision for Change, looks beyond traditional psychiatric provision to include a more holistic approach and an agenda for social inclusion.

Of relevance also today is our suicide policy in that the Connecting for Life cross-sectoral steering group has an agreed national implementation plan. This was published in January 2018. In addition, all 17 local Connecting for Life plans have been launched and are being progressed satisfactorily throughout the country.

Improving access to the range of HSE specialist mental health services, whether they relate to CAMHS, general adult services or those for psychiatry of later life, is a priority under the recently agreed HSE service plan 2019. The plan highlights delivering timely, clinically effective and standardised mental health services in adherence with statutory requirements. It is important to note that mental health services are available to the entire population. Specialist consultant-led mental health teams are configured for this purpose and every person is eligible to avail of services. This includes asylum seekers and those in direct provision. These services are accessed mainly through primary care referrals, although referrals to community mental health teams can be made by any doctor who considers a psychiatric review necessary. This again is usually through primary care but these can sometimes come through emergency departments or other sources. The location of direct provision centres does not specifically feature in HSE resource allocation models or the available resources in specific catchment areas. However, each HSE community healthcare organisation allocates resources to provide the best possible level of service based on the needs of all the population served, including asylum seekers and those in direct provision.

Mental health services are mainly provided by community mental health teams. A HSE review of out-of-hours services in 2017 revealed that 60% of these teams were already providing seven-day-a-week services. Additional funding provided by Government in 2017 was allocated to increase this coverage to 100%. HSE mental health services are in the final stages of completion of this project, which will allow for the provision of 7-day-a-week services nationally.

As reflected in its service plan, the HSE is developing its prevention and early intervention services at primary care level. This includes a 24-7 mental health contact line, a crisis text line and a range of online e-mental health digital responses. The first of the electronic GP referrals to mental health services went live very recently. I will look at the potential of such initiatives in the context of the specific issues under discussion here today.

CAMHS is understandably an issue that is of interest to us all. It is designed for children and adolescents presenting with moderate to severe mental health disorders, as opposed to other HSE supports at different levels of care provision. The number of referrals accepted to CAMHS has increased by 24% between 2012 and 2018. Despite this increase, the CAMHS waiting list has increased by only 4%, or just over 100 cases, since 2012. The HSE service plan 2019 commits to developing all aspects of CAMHS services. This includes developing a seven day a week service to ensure improved supports for vulnerable young people as well as related initiatives around enhanced early intervention and day hospital care. When a referral is accepted, CAMHS teams are expected to offer an appointment and see an individual within 12 weeks. All community teams screen referrals received and those deemed urgent are seen as a priority. This can sometimes impact on seeing other cases within three months depending on local resources and circumstances. There has been an overall 8.2% increase in the number of referrals accepted between April 2018 and April 2019. In that time, the CAMHS waiting list decreased by 3.9%. At the end of April 2019, there were 2,606 cases waiting to be seen. This is an increase of 105 cases on the same period in 2018. The number of cases waiting more than 12 months decreased by 36, or 10%, to 316 in April 2019 compared with the same period last year. The HSE has established a CAMHS waiting list initiative to reduce waiting lists with a focus on those waiting more than 12 months. The community healthcare organisations with individuals waiting more than 12 months are taking dedicated actions to ensure no child is waiting beyond this period. However, this can be influenced by various factors such as an increase in population, increase in referrals, staffing retention issues and challenges in recruiting. CAMHS inpatient units operate a 24-7 tertiary model of care to young people with severe or complex mental health issues. There are 74 CAMHS inpatient beds in four units in Dublin, Cork and Galway. This number will increase to 104 with the opening of the new forensic complex in Portrane next year and the new children's hospital in the longer term.

Medical workforce planning within the HSE is the responsibility of the national doctors training and planning group, which considers the needs of service delivery across the healthcare system. It aims to bring the number of doctors in postgraduate medical training programmes in line with future demand for specialists in the health service and to help inform the consultant appointments process. The HSE maintains a doctors integrated management system that collates the registration, training and employment details of all consultant posts and whole-time equivalents on a single national system. The recording of all consultant posts allows for greater reporting at local and national levels and otherwise informs workforce planning decisions. A total of 452 consultant psychiatrist posts are documented on this system, with 418 consultant psychiatrists in post. The national task force on medical staffing was a Government policy document in 2003 that recommended that a ratio of 15 consultants per 100,000 of the population be achieved by 2013. This was followed by A Vision for Change, which recommended a target of 9.4 consultants per 100,000 of the population. In England, the current ratio of consultants to the population is similar to Ireland at 9.8. Workforce planning is under consideration in the refresh of A Vision for Change. I understand that around 12% of all consultant psychiatrist posts are either vacant or unmatched. Therefore, around 88% of all consultant psychiatrist posts are currently filled.

Regarding the question of bed ratios, I again stress that international comparisons often fail to take account of variations within countries in terms of mental health policy. Our health policies, Sláintecare and A Vision for Change, emphasise the importance of modern, high-quality care in the community with, of course, equivalent provision in hospital settings as appropriate. In Ireland, there are 1,035 acute beds for a population of 4.761 million. This means we have 65 acute adult beds per 300,000, or 21.6 per 100,000. This is in a context where A Vision for Change recommends a total of 16.6 beds per 100,000 population. Therefore, we have more than the recommended number of beds.

I acknowledge, however, that continued investment in community services will be necessary to deliver fully on national policies.

Through its mental health engagement and recovery team, the HSE now has local fora for service users and their family members across the country. The HSE is ensuring that the views of service users, their family members and carers are central to the design and delivery of services. This is evidenced by service user participation on the HSE's management team. Improvements relating to embedding a recovery culture within teams and services are being supported through the implementation of the national framework for recovery in mental health. The talk therapy national service improvement project will further improve mental health services.

There is a whole-of-Government approach to direct provision in Ireland. The Reception and Integration Agency, RIA, provides material reception conditions - accommodation and related services - in line with the European Communities (Reception Conditions) Regulations 2018 to those in the international protection process. Other sectors are responsible for providing services directly through a mainstreamed approach. The Department of Education and Skills provides education services; the Department of Employment Affairs and Social Protection provides daily expense allowances and other exceptional needs payments. Some Departments and agencies have seconded staff to the RIA, and this system works extremely well in the provision of effective and efficient services to recipients. Mainstream health services, including mental health services for those in the international protection process, are provided directly through the HSE and the Department of Health. The HSE and other health providers arrange for translation services as required. The RIA works collectively with all agencies and Departments to co-ordinate the provision of services. There is ongoing liaison between the HSE and the RIA to best meet the health and related needs of protection applicants. There is a specific health screening team funded and managed by the HSE and located on the site of the Balseskin reception facility to assess recipients who have just arrived in the State. The team comprises GPs; a medical officer; a clinical nurse specialist and two nurses; a primary care social worker; two primary care psychologists; and clerical and administration support. The team offers a range of individual services and screening for medical and psychosocial needs, with onward referral as necessary. The individual professionals communicate with the RIA - within the bounds of patient confidentiality - if a need is identified that will affect the applicant's accommodation requirements.

The HSE social inclusion unit has commissioned research to explore the concept of vulnerability, good practice in assessment, timing of same and implications for effectively improving on the processes already in place. It is important to emphasise that all agencies involved in the delivery of direct provision services play a part in identifying and supporting applicants who present as vulnerable. This is particularly the case where vulnerabilities may become evident at different times in the protection process. Applicants can also obtain a General Medical Services, GMS, card on receiving a temporary resident card or a PPS number and can therefore visit a local GP or primary care service as required.

The next few years will see considerable change in the mental health landscape, with new legislation, improved infrastructure and refreshed policies in place. I assure the House of my personal commitment to a high-quality, person-centred mental health service, including for asylum seekers. Mental health problems, of whatever nature, do not differentiate. Everyone deserves the best possible response our care system can give. In this context I will give full and proper consideration to all contributions made today. I thank my officials, Mr. Gerry Steadman and Mr. Michael Murchan, who are here with me for their work on this issue and their presence today.

I thank the Minister of State for what was a pretty detailed response. I compliment him on concluding five seconds ahead of time. I now call Senator Rónán Mullen, who has five minutes to wrap up.

I thank the Minister of State for his response. I thank Senator Freeman for seconding the motion and Senators Colm Burke, Black, Norris and Boyhan for their contributions. I thank especially Mental Health Reform and all those who are active in agitating and lobbying for a better quality of mental health services in this country. I do not wish to single out Mental Health Reform as our leading national coalition of organisations campaigning to transform mental health and well-being supports. I wish to note some of the excellent contributions and I acknowledge what Senator Colm Burke had to say. He always has the unenviable task of defending Government policy, which he does very faithfully, but it would be unfair to him to leave it at that because he did point out some of the challenges that are definitely there. He mentioned that there is no immediate support for people who have not been assessed by a psychiatrist. You could sing that. It was also very important he mentioned people with mental health problems who are non-nationals and have no family support. Senator Black referred to her work with the RISE Foundation, and I am very grateful she mentioned her experience of asylum seekers and people in direct provision coming before the justice committee. Senator Norris always finds a way to say something very memorable. He pointed out that most children get more pocket money than we give to asylum seekers. Senator Boyhan properly paid tribute to Mr. Justice Bryan McMahon and others.

I know the Minister of State will not take this comment personally but I recall, I think it was in the 1980s, Ronald Regan sitting down with Mikhail Gorbachev and starting off his commentary in the presence of the media by saying, "Let me tell you why we do not trust you." It is not the Minister of State personally I am talking about here, but let me tell him why we do not trust Government responses such as the one he has given. It is long on history, analysis and purported explanation, but when I see a ministerial speech that talks up and finds the positive spin on statistics but which is not at the same time honest about what are manifest shortcomings in the system, I really worry because I get the impression - it is hard not to - that we are being spun a line. I ask the Minister of State to accept that he has not directly expressed support for the seven deliverables mentioned in the motion that Senator Boyhan rightly went through. I ask the Minister of State to take the opportunity, before we break up today, to do so.

I will give an example of what I am talking about in terms of the statistical analysis in which the Minister of State engages. He talks about the number of consultants, for example. It is beyond dispute that Ireland has half the number of consultants per 100,000 population of the EU average. We rank below countries such as Romania, Slovakia and Greece in this regard. We have less than a quarter of the number of consultants Finland employs. The Minister of State cannot explain this away simply by reference to the fact that there are different systems in different countries because it is psychiatrists themselves who are pointing out the starkness of this problem. It was Professor Patricia Casey who said such an argument was preposterous and inconceivable - those are the terms she used - in pointing to the grave shortage and deficit in posts being filled, not just psychiatric consultancy posts, but also psychologists, social workers and occupational therapists. It is right to point out that we have moved to a community-based system but it is wrong not to acknowledge that there are severe shortages. There is no sense of urgency, worry or acknowledgement in the speech of the problems that are there. What I am getting is a massaging of statistics in order to put the best possible léamh ar an scéal, but that is not good enough given the real human suffering. Only recently I was listening to a GP in Cork talk about persons attempting suicide, going into accident and emergency departments, being sent home with an appointment with a psychiatrist some weeks hence and then further attempting self-harm, forcing the family to go private in order to get the urgent care required. That is the system as it is now affecting real people, and the problem this presents to us as a society needs to come across much more in ministerial speeches.

I thank my colleagues for what they have said. I would greatly appreciate it if there were a much clearer and franker acceptance that there are real problems and that they cannot just be wished away by taking the most optimistic view of comparative statistics. We are not where we should be, and mental health services in particular are the poor relation because twice the budget has been raided. The money that was to accrue from the sale of psychiatric institutions was supposed to benefit mental health services. As far as I know, this did not happen. The €12 million that Deputy Varadkar when Minister for Health said he was taking from the budget in 2016 was supposed to improve 24-7 mental health services.

Time and again it seems to me that mental health services have been treated as the poor relation in order to fill gaps. We must shudder at the consequences of the overspend on the children's hospital for mental health services as well as other important areas that need public funding. I am sorry to say I am not satisfied with the Minister of State's response although I appreciate the difficult position he is in personally.

Question put and agreed to.