Mental Health Bill, 1999: Committee Stage.

This meeting has been convened for the purpose of considering the Mental Health Bill, 1999. I welcome the Minister for Health and Children, Deputy Martin, and his officials to the meeting. I suggest that we should consider the Bill today until 6 p.m. If we have not concluded by then we will resume again at 10 a.m. tomorrow morning. Is that agreed? Agreed.

SECTION 1.

I move amendment No. 1:

In page 7, subsection (1), line 20, after"Mental Health" to insert "(Involuntary Admission)".

The amendment aims to clarify the Title to the Bill by inserting the words "(Involuntary Admission)" after the words "Mental Health". I propose this because it is a more precise description of the Bill which is primarily about involuntary admission. When we are dealing with legislation it is important to be precise, absolutely clear and unambiguous, and we should follow such discipline even in the Title. The Bill arises from the White Paper which dealt with many issues that are not dealt with in the Bill. We all recognise the need for legislation to be updated. It is out of sync and inappropriate to depend on legislation produced in the 1940s. At the same time, it is wrong for anybody to presume that the Bill will do things that it can not. The impression one would get from the Title is that this legislation flows from the White Paper and deals with areas that, in fact, it does not deal with.

We must remember that there are approximately 25,000 admissions to psychiatric units every year, but only 10% of those are involuntary. So, it is largely focused on a very small minority of the total population of psychiatric admissions. In itself, that requires that the Bill should be more clearly defined. The White Paper suggested many reforms that simply do not appear in this Bill. The White Paper argued clearly for a full and fundamental reform of mental health legislation but no explanation is being given as to why this reform does not appear in the legislation. This is almost fraudulent in the sense that what we are presented with is a Bill that appears to flow from the White Paper and deal with the issues raised in the White Paper, yet it does not and the Title itself does not declare the difference. The issue of the adult care order is not included.

A review of the interaction of mentally disordered persons and the legal system notes in paragraph 7.3 that unless insanity or unfitness to plead arise the courts have no formal mechanism to seek a report or arrange a treatment. One of the points which has particular importance now because of the historical context in which we find ourselves with the new dispensation is highlighted in the White Paper which states in paragraph 11.19:

In view of the many similarities between the care of the mentally disordered in Northern Ireland and in the Republic, new legislation will provide for the closest possible co-ordination of the two systems of law for the detention and protection of those with a mental disorder in need of treatment.

Clearly the Bill does not deal with this aspect, goal or target set out in the White Paper. Voluntary patients are not given rights or protections. Issues exist relating to treatment and its effective monitoring and the provision of aftercare.

We will doubtless complain that amendments have been excluded by the Chairman because they impose a charge on the State. However, if we are to have a Bill which truly reflects the proposals in the White Paper, there would be a charge and such a charge would be an aspect of any new legislation. That will have to be faced up to especially given that much criticism of psychiatric units related to facilities and poor standards. This is still a matter of concern if anyone reads the reports of the Inspector of Mental Hospitals, although clearly there have been improvements which we all recognise and welcome. Staffing is a recent issue and, as reported as recently as in today's papers, units are being closed, beds are being lost and treatment is being denied to people because of staffing problems. These issues are part and parcel of our debate, yet they are not to be because they are excluded because of cost implications. I strongly recommend that the Bill be described for what it is rather than for anything else and that we accept this amendment. I hope the Minister will accept it.

I support this amendment. If the Bill were to deal with real and extensive mental health issues it would deal more carefully with the need to protect the interests of the elderly, for example, but it would also deal with psychiatric services in prisons, something with which it does not deal. Many people incarcerated in places of penal servitude need proper comprehensive psychiatric and other mental services and they do not receive them comprehensively in that setting. If the Bill set out to deal with such issues I could accept it as a comprehensive Bill dealing extensively with mental health issues but it does not. It deals literally and almost exclusively with involuntary admissions. For that reason the amendment is worthy of support. I have other concerns about sections of the Bill which I will address as we go along. This amendment defines the content of the Bill more crisply and clearly.

I support Deputy McManus's amendment. We need to call a spade a spade. This is concerned with involuntary admission. At a press conference yesterday, Schizophrenia Ireland, the Irish Council for Civil Liberties and service users asked for this amendment to be pressed. I am happy to do so and I hope the Minister will take on board the views of the Opposition in this case.

I also support the amendment. There is a glaring need for a comprehensive mental health Bill because of the neglect of successive Ministers. The Minister has not been in office that long and I am not personalising it. There has been neglect of the mental health service since the foundation of the State. It has been ignored for many reasons, most of them sociological rather than anything else and related to the way society viewed and, in some ways, still views psychiatric illness. That needs to be comprehensively changed.

One way of doing it is for the State to recognise that mental health should at least be on a par and be funded as if it were on a par with the general health services, even though we would have problems with the level of quality of those. Not until the funding and facilities are on a par with the general health services can we say that a comprehensive mental health Bill has been introduced. There would be uproar if patients in general hospitals were treated in the conditions in which some psychiatric or mentally ill patients are treated.

Even a modern facility in Limerick built some 20 years after being bought by the regional hospital is now locked. One must ring a bell to be admitted and one must be let out of it. I understood that such places were opened for easy access and to be similar to a general hospital. On one occasion I came to the door and rang twice and was not admitted.

Please confine your remarks to the amendment under discussion.

I am giving an example. Not until a Bill is introduced to bring the services to the level of the general medical health services can we say we have a mental health Bill.

I do not want to engage in another Second Stage debate but I made it clear on Second Stage that I acknowledged that this legislation did not deal comprehensively with all the issues encapsulated by the White Paper published in 1995. I made it clear in my speech that there was a necessity to provide urgently for a reform of the legislation, especially regarding voluntary detention, to bring Ireland into line with the European Convention on Human Rights. I made that clear. At no stage in this process have I said that the Bill deals comprehensively with every issue raised in the White Paper.

It would be equally wrong to suggest that the Bill is just about involuntary detention. The Mental Health Commission, which will be established as a result of the Bill, is about much more than involuntary detention and will have a very strong role in setting, promoting and fostering better standards within mental health centres and institutions and in terms of mental health generally. The Bill also deals with other issues regarding treatment, etc. Whereas people may say the Bill is not as comprehensive as the White Paper envisaged, on the other hand, it would be equallyinaccurate to narrowly confine the Title of the Bill, with which this amendment deals, to just involuntary detention.

We will deal with other issues in the White Paper. I said on Second Stage that we will deal with other issues. There will a requirement for additional substantive legislation to deal with all the outstanding issues which are not dealt with in the Bill but which will have to be dealt with in subsequent legislation. I point out to Members that the history of mental health legislation in this House has not been great and there have been many false starts going back to 1981 when legislation was passed which did not quite see the light of day subsequently. Progress has been at a snail's pace over the past 20 years and Deputy Neville has made that point.

To a certain extent it is important that we pass this legislation and proceed to deal with other issues. In the case of prisoners, the prison service and health services within prisons generally, for example, we are engaged in a substantive review with the Department of Justice, Equality and Law Reform which will involve the psychiatric services within prisons. Clear recommendations will emerge from that review which we will have to see through. We are increasing resources in terms of forensic psychiatric teams in all the health board areas and additional resources were made available in 1999 and again this year.

Notwithstanding that, complex issues exist in terms of the interface between the prison service, the psychiatric service, the professionals and health boards which will need detailed treatment. We do not forget or overlook that issue. I do not propose to accept the amendment on the grounds that the Title would not be accurate in terms of what is contained in the Bill.

The Minister has made a very good case for not calling it the Mental Health Bill.

That was the idea of the legislation.

The Minister is saying it is not a comprehensive Bill, which is the impression one gets from the way it is described. I do not see how a comprehensive Bill could be described as other than a Mental Health Bill.

We all have generic titles for legislation. The same could be said in respect of a Social Welfare Bill.

We must, as far as possible, define what we are dealing with. The Minister would have to accept that there is a lot of disappointment at the restrictive nature of this Bill. Even yesterday the organisations representing the psychiatrically ill strongly criticised this aspect. It is important to acknowledge that and for the Minister to acknowledge that the Title is an inappropriate description of a Bill that is restrictive and limited in its capacity and that may be a forerunner - I hope it is - of more comprehensive legislation. I accept the Minister's good faith on that point. It is irrelevant if the Minister will be in office to introduce such legislation, but it is important that a commitment is made that will be honoured. If anything, that is a stronger argument for describing this as something other than a Mental Health Bill. It does not present the comprehensive reforms that we agree are required.

My proposal is nearer to the mark because it primarily deals with the fact that involuntary patients will get certain protections. At present we are in contravention of international law. We must pursue this legislation and we generally support its limited objective, but it is disingenuous for the Minister to retain the Title of the Bill because it pretends that the Bill is something it is not. It would be better to err on the side of caution and describe the Bill as per my amendment. It is not unusual to include the prime objective of a Bill in the Title. This would be better to the promotion of an erroneous Title.

People believe that insufficient attention has been paid to their concerns. Much disappointment has been expressed and there is a view, justified or not, that there will be no further significant legislation. The Bill is a reaction to international obligations.

If there was a radical party it might resolve the issue.

The Minister should look at this question again. While my amendment may not be correct and I am willing to allow his experts produce a better Title, a further definition is required in it.

The argument is over stated. This is a Mental Health Bill. I acknowledge there is much more to do in the area of mental health legislation.

Amendment put and declared lost.
Section 1 agreed to.
SECTION 2.

I move amendment No. 2:

In page 7, subsection (1), between lines 7 and 8, to insert the following definition:

"the 'establishment day' means the day appointed by the Minister undersection 30.”.

The purpose of this technical amendment is to define the "establishment day" as the day on which the Mental Health Commission will be established.

Amendment agreed to.

I move amendment No. 3:

In page 9, subsection (1), before line 1, to insert the following definition:

" 'registered proprietor' has the meaning assigned to it bysection 61;”.

This is a technical amendment.

Amendment agreed to.

Amendments Nos. 5 and 26 are related to amendment No. 4 and amendments Nos. 4, 5 and 26 will be taken together by agreement.

I move amendment No. 4:

In page 9, subsection (1), line 2, after "person" to insert "or the spouse of the person".

The amendments in my name propose to extend the definitions of "spouse" and "relative" to reflect the social reality of Irish society today. The definition of "spouse" is being extended to cover co-habitees as well as married couples. The amendment to the definition of "relative" will ensure that relatives of a co-habiting partner are included.

The effect of these amendments will be that co-habiting partners will be able to make an application for involuntary detention in the same manner as a marital partner. They will also be subject to the same exclusions, such as in cases where a couple has separated or where proceedings are under way under the Domestic Violence Act. For technical reasons the exclusion of these cases has been moved to section 8 and are the subject of a separate amendment. The effect of the amendments in my name will also mean that doctors will be prohibited from participating in decisions regarding the detention of their own co-habiting partners or their partners' relatives.

The amendment in the name of Deputy Gay Mitchell appears to deal with the issues I have addressed, namely, the inclusion of co-habitees in the definitions referred to and the exclusion of spouses and partners who are in dispute or part separated. However, I do not favour the method proposed in his amendment as it is preferable that on an issue of such importance the legislation be specific in intent rather than leaving it to subsequent ministerial regulation.

I am anxious that this section be tightened up, which is the purpose of my amendment. When I was a young boy a person in my neighbourhood who should have been in care arranged for his wife to be admitted to care despite the fact that there was nothing wrong with her. Those days have gone.

However, where there is a dispute of any kind I am anxious to ensure that no person acting out of malice could arrange for or influence the involuntary admission of a spouse. Given that the definition of "spouse" is very narrow, it is important to ensure that one spouse should not be able to apply for the involuntary admission of another where, for example, judicial separation or divorce proceedings are ongoing or where proceedings have been issued over the custody of children pursuant to the Guardianship of Infants Act, 1964.

My amendment proposes that the commission shall be empowered to make recommendations to the Minister to extend or limit the circumstances in which a person is allowed make an application for the involuntary admission of his or her spouse. The second part of the amendment proposes that the Minister would be enabled, by statutory instrument, to make provisions for such recommendations and that these would have the force of law unless either House of the Oireachtas passed a resolution within 30 sitting days rescinding the instrument.

If the Minister assures me that amendments Nos. 4 and 5 in his name deal comprehensively with this I will not press my amendment, but I wish to return to the issue on Report Stage when I will have had an opportunity to further consider it. Given that marital separation is now sadly a reality, I would be concerned about any provision that would allow a spouse to in any way influence the involuntary admission of another spouse. The provisions here must be watertight and I seek the Minister's assurance that his amendments fully meet my concerns. If they do not, perhaps we could return to this on Report Stage.

I would take the Deputy up on that offer. A spouse at present can apply to have a person involuntarily admitted. Obviously there are a number of steps to be taken subsequently. Between now and Report Stage I would be willing to discuss tightening the provision. I do not think there is disagreement about the principles involved. If the provision needs to be strengthened, I can discuss it with the Deputy. I am happy that we have tightened down the provision but if that is not the case, we can return on Report Stage with a tighter wording.

Society is changing and there is a need to respond to what is happening in society, not only in this area but in other areas. It is important that we recognise that and the amendment facilitates that for the future.

I welcome the fact that this covers a situation of a man or woman who is co-habiting with a person of the opposite sex, but it does not state how long they must be co-habiting. Is it where they have been co-habiting for a week or a month? Is there a timeframe envisaged?

That is a fair point. I must consider that. The Deputy has disturbed another hornet's nest.

The courts will define it if we do not; it is our job to define it.

I thank the Deputy for raising that issue.

I share the views of my colleagues, perhaps because I have come across a few cases where a person was involuntarily admitted by a spouse for the worst reasons. I see, from the way the Minister answered my colleague, that he genuinely wants to overcome this difficulty. I am sure this happened in urban areas also, but over the years it certainly happened in rural areas. I will not outline the reasons behind it, but generally it was done to get a spouse out of the way. I welcome the Minister's flexibility on this matter. I recognise that he, like Deputy Mitchell, is trying to solve it.

There is one other point I did not make earlier and I wish to make it in a sentence or two. The Bill should cover a situation where spouses are involved in nullity proceedings, obviously where there is a contention involved. That is a matter which needs to be looked at carefully.

On the use of the phrase "co-habiting with a person of the opposite sex", although I appreciate that there are difficulties with this, as Deputy Neville pointed out life in Ireland has changed radically in recent years and there are obviously couples of the same sex who have been co-habiting for a long time. I know of one cases, in particular, for example, of two women who were co-habiting for a long time and when one of them was admitted to a psychiatric unit, it was extremely distressing for her partner because of the lack of recognition of her special status in the woman's life. I wonder if it is possible in some way to address this. Perhaps Deputy Mitchell has outlined a possible way of reconsidering this particular section. Is the Minister saying, as Deputy Neville stated, that if a couple is co-habiting for a month, they have a status? However, they may be of the same sex and co-habiting for 20 years and not have a status. I realise that this is complicated and I am not making it easy for the Minister, but it is a reality.

I recognise that. Apparently legislation on social welfare and other matters does not include a definition for the timeframe to which the Deputies refer.

What is the timeframe?

There is none. Across the board there does not appear to be a timeframe. Deputy McManus raises an interesting point. Section 8(1) states that, subject to the provisions of subsection (2), an application may be made by any other person. Section 8(1) states that an application may be made by:

(a) the spouse or a relative of the person,

(b) an authorised officer, or

(c) subject to the provisions of subsection (2), any other person.

Therefore there is also provision for a person who is co-habiting with a person of the same sex to make an application.

Subject to what I stated regarding Report Stage earlier, I will not press amendment No. 26.

Amendment agreed to.

I move amendment No. 5:

In page 9, subsection (1), to delete lines 5 to 8 and substitute the following:

" 'spouse' means a husband or wife or a man or a woman who is cohabiting with a person of the opposite sex but is not married to that person;".

Amendment agreed to.

I move amendment No. 6:

In page 9, between lines 28 and 29, to insert the following subsection:

"(3) This Act shall, in so far as it is practicable, apply to persons detained in prison at the discretion of the Commission and the Inspector of mental health services.".

What I am trying to get at here is that there are many people detained in prison who should not be in prison and who should have access to the Inspector of Mental Health Services. I cannot quantify this but I suspect there are quite a number of people involved. These people are in prison for many reasons, some of which are historic. They may have had a disorder at a young age at school and it was never picked up, and they now find themselves, perhaps through habit, in the criminal fraternity.

The psychiatric services available in prison are not sufficient to meet the needs of those in prison. It would seem to me that it would be beneficial if, at the discretion of the commission and the Inspector of Mental Health Services, many sections of the Bill were applied to persons who have been imprisoned and who have a form of mental disorder. Accordingly I would like to see the Inspector of Mental Health Services and the commission given a role in quantifying the extent of mental disorder among the prison population and in making recommendations on how to meet the needs of those persons. I can see how an amendment of this kind to a Bill about involuntary admission might jar with the Minister, but these people have been admitted involuntarily in that they have been admitted by direction of the court. In many cases they need to be assessed properly and dealt with in a different environment and I want to use this opportunity to raise that question.

The reality is that about 75% of prisoners in Mountjoy Prison come from five identifiable areas of Dublin and one would get no great credit for guessing the areas involved. They are all disadvantaged areas. Whereas, for example, in normal communities eight out of ten sit the leaving certificate, one out of ten who abuse heroin sit it, according to research conducted by a group called Area Response Crumlin in my constituency. Similarly one will find that in those areas perhaps less than 5% of the population has participated in third level education. Often there is a reason for that dating back to other childhood disorders which were not recognised and dealt with.

I would like to see some role for the Inspector of Mental Health Services in trying to ensure that the best interests of prisoners who have a mental disorder are dealt with in order that they are given the maximum opportunities. Most of them did not get these opportunities before they became part of the prison population. Otherwise they will just become recidivists, offending again and again, because we simply do not invest necessary resources in them. Clearly some of them should not be in prison. I am trying to introduce to the Bill some way of extending the services available to prisoners, particularly those with some form of mental disorder or impairment.

I support this important amendment. Talking about the neglect of the psychiatric services generally, there have been practically no psychiatric services in the prisons. There are two psychiatrists for the 2,600 prisoners in this country. People in authority in our prisons, including a head chaplain, have commented about the level of psychiatric services on offer.

At present, a prisoner who becomes suicidal is placed in a cell with a mattress and no blanket and he or she is expected to eat his or her meals off the floor. While they are feeling suicidal, prisoners are confined to these cells and totally deprived of any stimuli. Such people should be placed in a psychiatric hospital. If a prisoner breaks his or her leg, he or she will be taken to a general hospital. If a prisoner has a serious psychiatric condition and may be in danger of becoming suicidal, they should not be kept in prison but should - like prisoners who develop cancer, have heart attacks, etc. - be admitted to hospital. We are discriminating against a group of vulnerable people who are in prison for many reasons.

At a conference in Cork a number of months ago, John Lonergan the Governor of Mountjoy stated that up to 60% of those incarcerated in the prison suffered from attention deficit disorder as children. If a prisoner meets a psychiatrist, the meeting usually lasts five minutes and tablets are prescribed. There is no serious treatment of these people in psychiatric hospitals. The State is being criminal in depriving people who are extremely ill of sensory stimuli.

I support the amendment. It is important that people suffering from psychiatric illness who are incarcerated in prison should be included under the provisions of the Bill. I support Deputy Neville's stance on this issue because it appears that many people in prison suffer from psychiatric illnesses of one form or other. In addition, it is disturbing that there is such a high level of suicide in prison.

It is no longer acceptable for the health service in our prisons to be operated by the Department of Justice, Equality and Law Reform. This service does not function well. We do not need a service in prisons that operates as well as the service outside; we need a better one. That applies particularly to the service on offer to those who suffer from psychiatric illness. I urge the Minister to transfer responsibility for the prison health service from the Department of Justice, Equality and Law Reform, which, I understand, does not even have a dedicated budget for that service, to the Department of Health and Children.

The amendment is not expansive but it recognises that those in prison who suffer from psychiatric illness are part of the community of people who with illnesses of this type. The individuals to whom I refer are not receiving sufficient attention.

Whatever about the mental health of individuals before they enter prison, when they are in prison there is sometimes a marked decline. We all consider ourselves to be of good mental health but prison is a harsh regime and, as John Lonergan has stated, it has a detrimental effect on individuals. We must be mindful of that fact. When contemplating this amendment, that fact must be considered.

The author Mannix Flynn appeared on "The Late Late Show" a few years ago and he compared prison life with life in a mental institution. On one occasion he made the famous comment to a psychiatrist "I am fine now but if you leave me in here for much longer I cannot vouch for my sanity after a certain period of time."

This is a difficult area because how does one distinguish whether a person is mad or bad? One need only consider the case of John Gallagher in that regard. Where does one draw the line between criminality and insanity?

I recently visited Mountjoy where I met Governor Lonergan with whom I had a good discussion. I visited the women's prison there and met some women with whom my wife had dealt in her job as a social worker. I know for a fact that these women had psychiatric problems and yet they were in prison. The women's prison is a model in terms of the way prisoners are treated. Governor Lonergan is excellent in the way he considers these issues. However, as legislators, we must look at this matter because the situation is not being dealt with properly at present. I hope the Minister will take on board the amendment but I accept his statement that he intends to introduce further legislation in this area. We must consider this problem in detail.

I accept the bona fides of the Deputies who tabled the amendment and of those who spoke about it in terms of their being anxious that prisoners with psychiatric difficulties would be treated in hospitals. However, there are a number of key issues to be considered.

The vast majority of people in the country with mental problems are not immediately institutionalised. In fact, the thrust of mental health policy from the mid-1980s has, to a large extent, seen a dramatic shift towards removing people from institutions and returning them to the community. Much more needs to be done in that regard and we must follow through on our policy by creating further community based services, day centres, etc.

While I accept that statistically, perhaps, the same analogy does between the general population and the prison population, we must nonetheless be careful that we do not state that anyone with a mental health problem in prison should automatically be referred to a mental hospital or institution. The key part of any treatment is the primary treatment of any patient who presents with difficulties. The Minister for Justice, Equality and Law Reform and his Department established towards the end of 1999 a review group on the structure and organisation of prison health care services. The Department of Health and Children is represented on that group by one of its officials. Part of the remit of that group will be the reorganisation of psychiatric services for prisoners through the provision of a properly structured forensic psychiatric service.

Until the recent past, very little was provided in the way of services for those with psychiatric problems and the services on offer now are not what they should be. However, decisions must be made on a number of fundamental issues by the health boards, consultant psychiatrists, the prison health service and the Department of Justice, Equality and Law Reform. These issues include the areas in respect of which different agencies will have responsibility, the location from which the new service will be offered and the way in which we should continue to provide care.

In the interim we have increased resources for the first time in many years in terms of trying to put in place additional forensic psychiatric teams in Cork, Limerick and the ERHA area. Two additional consultant posts for the ERHA area have been advertised. With regard to Limerick and Cork, discussions with the Mid-Western Health Board and the Southern Health Board in respect of the structure of the posts are required. The fact that resources have at last been made available for those additional psychiatric posts illustrates the fact that until quite recently a significant deficit existed in terms of the kind of professional services available.

The amendment is not really practical in terms of its application to the Prison Service. It also could pre-empt what may emerge from the review we are currently undertaking with the Minister for Justice, Equality and Law Reform. Key issues will have to be resolved in the context of that review.

Let us consider attention deficit disorder. I am not an expert but it is emerging, not only in Ireland but also in other jurisdictions, that the number of people in the prison population with attention deficit disorder is probably higher than in the general population. Attention deficit disorder is not in itself a condition that would lead to detention in the psychiatric services. Other avenues exist through which one endeavours to deal with and treat that condition. It is only recently that we have opened up to the debate on attention deficit disorder. I have provided resources to finance a national study on the prevalence of the condition within Ireland to try to obtain a proper database to ensure a different approach is taken in schools and other places than was taken previously.

I want to extend the role of the commission and the Inspector of Mental Health Services for the following reason. Section 50, which deals with the functions of the inspector, states that the principal function shall be:

. . . to visit and inspect every approved centre at least once in each year after the year in which the commencement of this section falls, and . . . in each year, after the year in which the commencement of this section falls, to carry out a review of mental health services in the State and to furnish a report in writing to the Commission . . .

Section 32, which deals with the role of the commission, states:

The principal functions of the Commission shall be to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centres under this Act.

This is why I want the Bill to be extended to include prisoners. Section 7(2) states:

. . . the involuntary admission of a person to an approved centre by reason only of the fact that the person-

(a) is suffering from a personality disorder,

(b) is socially deviant . . .

Is a person in prison not socially deviant? The reason a person is in prison is that he or she is socially deviant.

On Second Stage, the Minister said:

The Mental Health Bill, 1999, is significant legislation. Its purpose is twofold. First, it will provide a modern framework within which people who are mentally disordered and who need treatment or protection, either in their own interest or in the interest of others, can be cared for and treated.

He went on to say:

The second purpose of the Bill is to put in place mechanisms by which the standards of care and treatment in our mental health services can be monitored, inspected and regulated.

I am sure the Minister will accept that a substantial number of people within the Prison Service suffer from some form of mental disorder. The Bill should apply to them in so far as it is practicable. There may be things the commission and the Inspector of Mental Health Services cannot do because a person is in prison for a specific reason which means they cannot be released safely to receive treatment when others can be. In so far as it is practicable, the objectives the Minister has set out to achieve in the treatment of people with mental disorders or difficulties should also be applied to the prison population. The fact that they are already detained involuntarily for other reasons is neither here nor there. They are detained and do not have the facility to visit a psychiatrist or specialist for treatment. They depend on a very limited service within the Prison Service. It would reach the objectives set out in the Minister's Second Stage speech and those set out for the commission and Inspector of Mental Health Services and it would certainly meet the reference in section 7 to socially deviant were we to extend the positive provisions for the powers of the commission and the Inspector of Mental Health Services to cover prisoners. I would like that to be considered more fully.

Regarding the treatment of mentally ill prisoners, I was referring to the transfer to hospital of people who are suicidal and who are confined to cells. If people are so ill that they have no clothing and there is nothing in the cell but a mattress so that there is nothing in the cell with which they could endanger themselves, such as hanging themselves, they should be confined until transferred to a mental institution. Prisoners should receive the same treatment and have the same facilities available to them as people in the community. If that means visiting an outpatient department for mental treatment and returning the same day or if it means a proper psychiatric service being provided in prisons, so be it. The range of services available to the general public, limited as I believe and the Minister accepts they are, should be available to prisoners.

One of the key items in questioning the level of services is the report of the Inspector of Mental Hospitals. We commend him at every opportunity on the excellence of his report. The 1999 report is also an excellent report and we discussed it in the Dáil. The involvement of the Inspector of Mental Hospitals in the examination of the provision of psychiatric services to prisoners would be so revealing it would shock everyone, even those who have little interest in the area.

It is an important point that the Minister said that those with a psychiatric illness in prison are not necessarily those who would be detained if they were not in prison. The fact is that they are detained and it is important that someone assesses the conditions in which they live, especially when their illnesses becomes acute or they become suicidal. The Minister did not clarify the policy of the Department of Health and Children regarding those people in prison who require health care, physical or psychiatric. Does he not think it would be a good idea for his Department to have charge of providing that health care rather than the Department ofJustice, Equality and Law Reform?

We are discussing that in the context of the review with the Department of Justice, Equality and Law Reform.

I know the Minister is discussing it but he is not telling me.

I will not take any unilateral leaps in committee. I must work collectively. There are a number of issues but that is where it is at. The key issue is that I do not want to take a unilateral decision to move away from the process in which I and my Department are involved with the Department of Justice, Equality and Law Reform. We have a new prison service board and things are moving on the prisons front at long last. Other things may emerge from that review. If we pass the amendment it could——

Will the Minister consider examining this issue between now and Report Stage? The Inspector of Mental Hospitals will become the Inspector of Mental Health Services. Certain people are confined against their will for good reasons through due process, but that does not mean that the best mental services should not be available to them. I would like the Inspector of Mental Health Services to be able to report independently on the conditions therein. If the Minister undertook to consider the matter between now and Report Stage and discuss it with his colleague, the Minister for Justice, Equality and Law Reform, I would be happy not to press the amendment at this stage.

I will do that. The other key issue emerging from the debate is that of services within prisons. If a person is seriously ill, he or she can be removed to the Central Mental Hospital.

It is full.

What is clearly emerging in the debate is the need to improve services. We are providing resources but, along with that, there is administration and organisation and bringing everyone on board, because not everyone has been on board until now. I am not talking about the Oireachtas.

We are told the Central Mental Hospital is full. Beds are obviously available.

Is Deputy Mitchell withdrawing the amendment?

I will not press it to a vote.

I will come back to the Deputy before Report Stage.

If Deputy Neville agrees, we might table it for Report Stage.

Amendment, by leave, withdrawn.
Section 2, as amended, agreed to.
NEW SECTION.

I move amendment No. 7:

In page 9, before section 3, to insert the following new section:

"3.-(1) In every decision, whether under this Act or otherwise, concerning a person to whom this Act applies or may be applied as a patient, the best interests of that person shall be the first and paramount consideration.

(2) A person who has been or is liable to be affected by a decision under this Act shall have the right, so far as is reasonably practicable, to prior and informed consultation and to have his or her views given due regard.

(3) Subject to the extent-

(a) necessary for the provision of care and treatment, and

(b) authorised by this Act,

a patient who has been involuntarily admitted and detained, or to whom treatment not requiring consent has been administered, retains his or her right to dignity, bodily integrity, privacy and autonomy; and every decision concerning the provision of such care and treatment shall have regard to the need to respect those rights.".

This amendment sets out overarching principles to cover the legislation and to act as reference points. It is important to see the patient's best interests as the core of the legislation. That must be central and the amendment spells out that point. The person must, as far as is possible, be consulted about decisions made for or about him or her. There is also the principle of protecting a person's dignity and integrity. In a way it is an indication of imperfections in providing services over the years that one must include this in a Bill, but we must recognise that over the years persons who were incarcerated or in psychiatric institutions often were not treated with dignity and were not respected in the way they should have been. Indeed at times people in institutions were abused and exploited appallingly - there are also other categories, such as children - and it is important when we define legislation that we set out the principles that put people at the centre of the legislation and which ensure that his or her best interests are always served.

The Law Society law reform committee which looked at formal mental health referred to the issue of best interests and it is a matter of some precedent in Britain. The idea that best interests have to be defined in some way or included to ensure that legislation is based on an understanding of what principles have to be applied when dealing with people who are vulnerable, as those with psychiatric illness often are. If we do not include these principles there is always the danger that because of that vulnerability people may find their rights are undermined or abused. I ask the Minister to accept this amendment. There is no cost to the State but there is an onus put on everyone applying the legislation and working within its framework to adopt an attitude and approach which is respectful of the patient. That can only be to the good.

I support Deputy McManus's amendment. It seems to me that the best interests of the person should always be the first and paramount consideration. Perhaps the best way to ensure this is to enshrine it in the legislation. Deputy McManus went on to suggest that every decision concerning the provision of such care and treatment should have regard to the need to respect those rights she mentions. That seems reasonably straightforward and we should be able to assume that that is the case, but it may not be possible in every case to have prior consultation. The amendment suggests "as is reasonably practicable" and that may not be possible in every case; it does not tie anyone's hands or suggest consulting someone who is clearly not in a position to be consulted. We must be careful in passing legislation such as this that we do not leave a vacuum which others fill. If we include reasonable care in the legislation then reasonable care will have to be taken and can also be vindicated. I support the thrust of Deputy McManus's amendment.

I too support Deputy McManus. The rights of patients have not always been addressed in mental institutions. There are questions about the proper dispensing of drugs and the Inspector of Mental Hospitals has questioned the procedure in this regard in our hospitals for many years. There is a lack of review of the administration of drugs and it is the right of a patient in a mental institution to have proper dispensation of drugs. There are also questions about the recording of medical histories in some of our institutions and the inspector has called attention to this also. Surely a patient has the right to have his or her case history written up for their records at the time a psychiatrist or doctor makes a deposition, as happens in general hospitals. That is not happening in some cases and these rights must be backed up. Deputy McManus's amendment will help to do so.

I support the amendment. Deputy McManus is setting out important principles here and if we look at our recent history, there has been appalling treatment of patients. It was very much a case of out of sight, out of mind and once patients were in institutions they were treated as lesser human beings. They lost their dignity and rights. This amendment is a safeguard and sets out safeguards for patients. I hope the Minister accepts it.

I accept the general spirit of the amendment and would be prepared to accept it in principle if the Deputy agrees to our looking at the wording for Report Stage. I have no disagreement with general principles being included at the beginning of a Bill. There are some areas we may have to look at, such as the "paramount consideration" in subsection (1). There may be people other than the patients in certain circumstances, such as a family, and we will have to work on this as it could be in the interests of others if someone was threatening a family, for example. However, that is an issue of phrase-ology. Some of the issues in subsection (2) are covered in an amendment I have tabled to section 56 regarding consent to treatment, but it is no harm to have a statement of first principles covering it. Subsection (3) applies to what are constitutional rights, but I have no problem with them being affirmed in the Act. I support the broad thrust of having a general statement of the best interests of the patient at the beginning of the Act.

I welcome that and thank the Minister.

Amendment, by leave, withdrawn.
SECTION 3.

Amendments Nos. 8, 9, 11 and 13 are cognate and amendment No. 14 is an alternative to amendment to 13. Amendment No. 15 is related. Amendments Nos. 8, 9, 10, 11, 13, 14 and 15 are to be taken together by agreement.

I move amendment No. 8:

In page 9, subsection (1), line 30, to delete "mental handicap" and substitute "intellectual disability".

I propose a number of amendments to this section to change the term "mental handicap" to "intellectual disability". During the debate on the Health (Eastern Regional Health Authority) Bill, 1999, an amendment was agreed which changed all references to mental handicap in that Bill to intellectual disability. Since that Bill's enactment the term has become more widely used among service providers and users and these amendments will bring the Bill into line with existing legislation and current usage. The other amendments are on the same issue.

Amendment agreed to.

I move amendment No. 9:

In page 9, subsection (1)(a), line 31, to delete “handicap” and substitute “disability”.

I did not refer to section 3, page 10. Will we come to that? Just in terms of discussion, we are deleting the term "significant". The remaining amendment relates to the deletion of the term "significant" in section 3(2) from the phrase which includes "significant impairment of intelligence". As drafted, this phrase refers to the level of intellectual debility which may exist.

I am confused. Is the Minister saying that amendment No. 15 is being taken with amendment No. 8?

Yes. They are all grouped together. Given that the intention is to enable persons without a mild, moderate or severe intellectual disability to be covered by this section, it is preferable not to use the term "significant" in this context. It is technical.

The Minister is deleting the term "significant". The definition is "significant mental handicap" which means a "state of arrested or incomplete development of mind of a person which includes significant impairment of intelligence". Should it not be the other way around? "Impairment of intelligence" can mean anything. Half of us have impaired intelligence from time to time.

Three-quarters of the Deputies have impaired intelligence.

I presumed the Minister was deleting the term "significant" from line 6 which would make more sense. However, he is deleting the term "significant" from line 7. How can he say it is "significant mental health"? Surely he is not saying that "significant mental handicap" means a "state of arrested or incomplete development of mind of a person which includes impairment of intelligence and social functioning?" That is broad. "Significant impairment" means one thing.

The intention is to facilitate access to the services from a wider continuum.

It must be accurate.

If we do not make this amendment, we could restrict the services to people along the continuum of intellectual disability. In other words, those with a mild form of intellectual disability, as we describe it in current usage, and who present with difficulties could be denied access to services. It must be read in conjunction with the rest of the section. I can look at it again on Report Stage and try to tighten it up.

I am concerned about it.

There is a genuine motivation behind it. We want to ensure that people who require access to services can gain access to them.

No one would argue with that.

The Deputy is worried about the language.

I am worried about doing it this way. Perhaps the Minister should reconsider it.

I will hold it until Report Stage.

Amendment No. 14 seeks to delete the word "handicap" and substitute "impairment". However, I am prepared to accept what the Minister said. I have an older sister who is what I have always called mentally handicapped. I find it difficult to be told by someone that I should not call it that anymore. I have been happy to call it that since I could speak. I am a little concerned that we will become too politically correct. I understand that internationally some people might take offence at the term, therefore, we must try to be inclusive. While I am at ease with the term "mental handicap", I do not like being told by someone what I can or cannot say. The changes the Minister proposes to make, such as using the terms "intellectual disability" and "disability", deal with the matter. However, we must not become too politically correct about these issues. I do not want to exclude people.

Deputy Shatter came up with this in the Health (Eastern Regional Health Authority) Act, 1999.

That is not helpful. I read that on Second Stage.

It is now in wide usage.

I accept that.

It is in the report of the Inspector of Mental Hospitals.

Amendment agreed to.

I move amendment No. 10:

In page 9, subsection (1), lines 35 to 41, to delete paragraph (b) and substitute the following:

"(b) (i) because of the severity of the illness, disability or dementia, the judgment of the person concerned is so impaired that failure to admit the person to an approved centre would be likely to lead to a serious deterioration in his or her condition or would prevent the administration of appropriate treatment that could be given only by such admission, and

(ii) the reception, detention and treatment of the person concerned in an approved centre would be likely to benefit or alleviate the situation of that person to a material extent.".

If this amendment is not accepted, we could interpret the section as meaning that these approved centres are either places of security to stop people being a danger to themselves or to others or places where deterioration would be arrested rather than places where treatment might make people better. It is important to find a role for and to express confidence in these approved centres so they benefit people by helping to alleviate their situation. This amendment seeks to include that aspect of the work of these approved centres. Without it, it is a bleak scenario in terms of the type of care these people receive.

I am prepared to accept the amendment, subject to one correction which I hope we can agree orally so we do not have to go back to it on Report Stage. I would like to substitute the word "condition" for the word "situation". The word "situation" could refer to social situation.

That is a better word.

Amendment to amendment agreed to.
Amendment No. 10, as amended, agreed to.

I move amendment No. 11:

In page 9, subsection (1)(b), line 35, to delete “handicap” and substitute “disability”.

Amendment agreed to.

I move amendment No. 12:

In page 9, subsection (2), to delete lines 43 to 46 and substitute the following:

" 'mental illness' means a condition which seriously impairs (temporarily or per-manently) the mental function of a person which is characterised by the presence of one or more of the following:

(a) delusion,

(b) hallucination,

(c) serious disorder of thought,

(d) severe disturbance of mood,

(e) sustained or repeated irrational behaviour indicating the presence of anyone or more of the above symptoms;”.

Like other members, I have received representations from ICCL, Schizophrenia Ireland and other interests. They often quote legislation from New South Wales. The Mental Health Act, 1990, gives a more specific definition of mental illness. Section 9 of that Act states that a person is a mentally ill person if they suffer from a mental illness and, owing to that illness, there are reasonable grounds for believing that care, treatment or control of them is necessary for the person's own protection from serious harm or for the protection of others from serious harm. Given that the service users have asked for this definition, I hope the Minister accepts my amendment.

The definition in the Bill emanated from the deliberations prior to the White Paper which involved consultations with almost everyone, including service users and experts, in 1995. It is five years since the White Paper was drafted. We have asked our people who have access to expert advice and who are experts themselves to look at this. I am prepared to examine this, perhaps in terms of incorporating it with our definition, and to return to it on Report Stage. We want to be careful that we are not unduly restrictive in terms of definition. People admitted involuntarily might have a form or mental illness which would not be comprehended by the proposed definition in the amendment. I think this is the definition in the South Wales mental health legislation.

That is correct.

I am prepared to again examine the definition.

So that we define it in terms of symptoms, diagnosis and in a more comprehensive way.

At this stage all I am saying is that I am prepared to look at it.

Amendment, by leave, withdrawn.

Amendment No. 13 has already been discussed with amendment No. 8.

I move amendment No. 13:

In page 10, subsection (2), line 6, to delete "mental handicap" and substitute "intellectual disability".

Amendment agreed to.

Because amendment No. 13 has been agreed, amendment No. 14 cannot be moved.

Amendments Nos. 14 and 15 not moved.
Section 3, as amended, agreed to.
SECTION 4.

Amendment No. 16 is ruled out of order.

I understand we may discuss the content of the amendment.

The text of the amendment is as follows:

In page 10, between lines 10 and 11, to insert the following subsections:

"(1) The Commission appointed under this Act shall, within 12 months of its appointment, publish a comprehensive plan to address the totality of psychiatric service needs, together with a time plan for such needs to be met. Such plan shall be laid before both Houses of the Oireachtas.

(2) The Commission shall, within six months of appointment oversee the creation of an extensive network of community based psychiatric services with specialist and multi-disciplinary teams accessible to all who need such services, and especially those in danger of suicide."

Deputy McManus moved an amendment to change the name of the Bill from the Mental Health Bill, 1999, to the Mental Health (Involuntary Admissions) Bill, 1999, but the Minister declined to accept the amendment. Therefore, the Minister claims this is a mental health Bill. However, there is a real need to bring mental health services into the 21st century and to provide a much more comprehensive treatment of the needs of people with mental health problems. The amendment which has been ruled out of order proposed to bring about that the commission, which it is proposed to appoint under the Bill, would "within 12 months of its appointment, publish a comprehensive plan to address the totality of psychiatric service needs, together with a time plan for such needs to be met" and that the plan be laid before both Houses of the Oireachtas The amendment also states that "The commission shall, within six months of appointment oversee the creation of an extensive network of community based psychiatric services with specialist and multi-disciplinary teams accessible to all who need such services, and especially those in danger of suicide".

Unless we get to the stage where we have comprehensive and multi-disciplinary, community based services we will pack our prisons and mental institutions and hospitals with people who could otherwise be dealt with in the community. Deputy Neville, who has co-sponsored the amendment, has been a leader in this area. For many years we have swept the incidence ofsuicide, particularly among young males, under the carpet. The incidence of suicide among young males is increasing as we become more prosperous. They seem to have lost their role in society and no longer know what is expected of them, which is contributing to mental disorder and suicide. For good or ill there was a time when the male was the provider and he knew his place in society.

If we could return to the stage where we could deliver on a community basis preventive psychiatric services in a comprehensive way I do not think that many of those in prison would be there. Equally, many of those in mental institutions would not be there. We are losing a golden opportunity to empower the commission to address the totality of needs of the psychiatric service, as is proposed in the amendment. If this really was a Bill concerned with mental health we would be dealing with this. We have unprecedented resources to deal with these issues.

I am very disappointed that my amendment has been ruled out of order on the basis that it would impose a charge on the Exchequer. However, that does not mean the Minister cannot introduce such an amendment, as he can introduce proposals which would result in a charge on the Exchequer, and I ask him to consider doing so on Report Stage. We should have a comprehensive approach in terms of the Bill.

One fundamental issue underpins the amendment which may not have been the intention of the Deputy. We established regional health authorities as the service providers of all health services in 1970-71. That issue is again centre stage in the amendment, even if that is not the intention. We will have a national agency to set standards, which is what the commission will do in terms of psychiatric services, foster best practice and be in a position to put it up to the service providers to deliver according to those standards. However, if it becomes a service provider then there will immediately be a conflict of roles. The health boards are the providers of our health services, including psychiatric services, and will continue to have that role.

Suicide is a key issue. We are all concerned about it and I accept what Deputy Mitchell said regarding the work Deputy Neville has pioneered in this regard. As a parliamentarian he has been very strong on this issue, maintaining a very high profile for it. He has given much time and attention to groups concerned with suicide. We have already established the national Suicide Research Foundation, set up by the executives of the health boards to develop proper research in relation to suicide. We have funded, again through the health boards, the National Suicide Foundation, which is based in Cork and which was established by the late Dr. Michael Kelleher who did much pioneering work in the area of mental health, particularly suicide. We have also established a national para-suicide register which we are funding through the health board structures.

In 1999, for the first time, the suicide figures decreased by about 65 in comparison to the 1998 figure. However, the figure is still too high. As in many other countries the critical and most worrying issue is the significant rise in the male suicide rate. Of the deaths in 1999, 79% can be accounted for by male suicides, which includes young males as well as those aged over 65 years, which seem to be the two at risk age categories. Clearly, research is central to a proper understanding of the issue and in terms of informing us on how to move forward in dealing with suicide, the implementation of measures aimed at risk groups and devising a proper strategy.

The report of the task force on suicide was published in 1998 and signalled the development of a national suicide strategy. We have moved on that front within the context and structures of the existing service provider. If the mental health commission was given the role of service provider, that role would be taken from the health boards and I do not necessarily agree with that at this point. It is an issue to which people may wish to return to at a later stage.

I welcome the fact that the amendment was tabled and I regret that it has not been allowed to be moved as it is very important and central to the debate on mental health. The Minister is probably overstating it by interpreting the amendment as saying the commission will become a service provider. As I read it, it will have the role of planning and overseeing the creation of extended services which is slightly different from taking over the role of the health boards. Nobody is taking the role from health boards, but we are all very much aware that there are grave disparities in service provision between different health boards, that there are many county boundaries which make no sense and that patients are losing out.

There are all sorts of county boundaries which make no sense. Patients are losing out in terms of quality care because they live on one side of the street rather than on the other. These deficiencies are well known to the Department and to public representatives. We must do what we can to try to improve matters but there is not a national context within which to do so. A group of health board chief executive officers now advise the Minister. When this structure was established by way of legislation I argued it was inappropriate given that a group with tremendous powers and resources did not have public accountability. At the time the Minister's predecessor tried to rubbish my argument but we are now seeing the outcome of that decision. Reference has been made to this in relation to a particular aspect of psychiatric illness - suicide. It is clear there is a national dimension to the provision.

By way of clarification, is the Deputy referring to the executive board of the health service?

No, I am saying that under the legislation the chief executive officers have already met.

The executive has not beenestablished in the sense that an executive has not been appointed. That element of the Eastern Regional Health Authority Act has not been implemented.

That is correct, but the chief executive officers meet.

Yes, they meet.

Is the Minister saying that the statutory provisions have not been complied with?

I am saying we have not implemented the legislation.

That is very interesting. The commission has accountability and the potential to provide a national perspective whereby the health boards have a statutory responsibility with which it will not interfere. However, it must ensure there is equality of provision. The Minister has made great play of the inequality of health care provision in the general health service. We are now talking about a particular form of health care relating to the psychiatrically ill. It seems to me that no other body can take on the role of overseeing, planning and policy development to ensure that whether a psychiatrically ill patient lives in Dingle or Dublin that patient will receive the same quality of care and have the same access to that care. I thought this would be the commission's natural role, not one of setting up centres.

I do not think we are dealing comprehensively with this issue. If community based multi-disciplinary teams are to be accessible, the health boards must be involved. Who else would provide multi-disciplinary teams and who else is community based? My amendment proposes the appointment of community based psychiatric services with specialist and multi-disciplinary teams accessible to all who need such services. I am suggesting the commission prepare the plan, not carry out the work.

What does "oversee the creation of" mean?

It means the commission should put a plan together in consultation with those who are capable of contributing to that plan. This is not being done at present. If one lives on the boundary of two health boards, the rules that apply in one area may not apply in the other. Surely the objective should be to have a national body which would set out a comprehensive plan, in consultation with the providers, which would be community based and multi-disciplinary.

This goes back to the core issue to which I alluded in the beginning. Under the Health Act, health boards have the planning function.

They do not plan for each other, therefore, there are irregularities and disparities.

There are disparities in a range of areas, not just mental health. This is the case in relation to nursing home subventions. There is a whole range of disparities between the regions because different regions approach matters differently or put greater emphasis on one section of the health service. If one goes regional, one does so at the potential expense of uniformity because regional autonomy is then devolved to a regional board. This gives the board autonomy within its region to deliver services and plan strategically for these services. All helpers are now obliged to produce strategic plans for the elderly, mental health and so on. This decision was made 30 years ago but, given all the parliamentary questions tabled to me, we never accepted it. I am answering parliamentary questions which should be answered by the chief executive officers of democratically elected health boards. There is a double think in terms of how we have bought into regionalisation. We do not want to accept this aspect because, in the end, the buck stops with the Minister of the day.

There is a need for national standards to which every health board should adhere. There should be a yardstick against which the performance of the service providers could be measured. In terms of the standard of care, there is a question of uniformity from the patient's perspective. I take the point that patients do not care whether they live in the Western Health Board or Southern Health Board area unless they find a different level of care in these areas. I am prepared to accept Deputy McManus's amendment No. 105 which seeks to provide that the inspector would monitor the degree and extent of compliance by approved centres with any code of practice prepared by the Commission under section 32(3)(3).

Section 31(1) seeks to establish a mental health commission. Section 32 reads:

(1) The principal functions of the Commission shall be to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centres under this Act.

(2) The Commission shall undertake or arrange to have undertaken such activities as it deems appropriate to foster and promote the standards and practices referred to insubsection (1).

This does not refer specifically to persons in approved centres. Section 31(1) says "and to take all reasonable steps" in addition to its other responsibilities. If the Minister is seriously setting up a mental health commission and if he is saying it will have this responsibility as its principal function, which is welcome, why not extend it to the areas I have suggested? It should not be confined to people who are involuntarily detained.

We are already creating an extensive network of community based psychiatric services. Resources are being provided to the service providers for this reason. However, it is important that there is a national entity - the commission in this instance - which will ensure proper protocols and standards are followed.

I suggest the commission should have an overseeing role. The commission should oversee the creation of an extensive network. In other words, there should be some consistency between one area and another and the commission should be responsible for ensuring this is the case. The commission is given this function in section 32(1).

So why are we putting it in again if the Deputy thinks it is there already?

No, the Minister gives them the function but then he does not allow them to carry it through. I am suggesting that the Bill provide for them to make a comprehensive plan to address the totality of psychiatric needs. Section 32(1) says:

The principal function shall be to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services and to take all reasonable steps to protect the interests of persons detained in approved centres under this Act.

I propose that we complement this section by requiring that they prepare a plan and present it.

We have already passed legislation providing for service providers to do all of this. It has not happened in the past to the degree we would have wished. This may be due to a lack of resources. I do not blame health boards or anyone else because adequate resources were not provided in the past, for a variety of reasons.

We are missing a golden opportunity.

We are not really.

The Bill creates a mental health commission but restricts what it can do.

I move amendment No. 17:

In page 10, subsection (1), lines 19 to 27, to delete paragraph(c).

It is unacceptable thatcarte blanche be given to the Minister. Paragraph (c) states that the Minister may:

if any difficulty arises during the period of 12 months from the commencement of this Act in bringing this Act into operation, by regulation do anything which appears to be necessary or expedient for bringing this Act into operation and regulations under this paragraph may, in so far only as may appear necessary for carrying the regulations into effect, modify a provision of this Act if the modification is in conformity with the purposes, principles and spirit of this Act.

It appears that having gone through the tortuous democratic process of enacting legislation, the Minister can play around with it, not if it is necessary but merely if it appears to be so. Can the Minister tell me I am wrong? I believe the Bill would be improved by removing that paragraph.

Previous mental health Bills did not see the light of day because of possible logistical difficulties. The last Mental Health Act was passed in 1945. There is some concern within the Department that logistical difficulties might arise in the first 12 months of the implementation of this legislation. I will return to this amendment on Report Stage.

An identical provision was included in the Freedom of Information Act to ensure the smooth implementation of the Act in its first 12 months. It does not give the Ministercarteblanche to change the Act.

We all know how regulations can have a major impact on the implementation of an Act. It is always a matter of concern that regulations seem to have a major impact on changes proposed in an Act.

This legislation can not be compared with the Freedom of Information Act. We are all agreed that this is a modest Act. It does not meet the comprehensive reform requirements of mental health. The Freedom of Information Act was a complete new departure which altered a mindset.

This Bill might do so too.

There is no comparison between legislation to end government by secrecy, which was the essential nature of Irish government - I do not criticise a particular Government; that was simply the nature of the beast - for hundreds of years and this Bill. The Freedom of Information Act was a new departure. Here we are talking about complying with a modest requirement placed on us by international law. I do not believe this is necessary.

If the Department is not confident that it has got the legislation right, it should have another look at it now.

That is not the issue and Deputy McManus's comment is unfair. I am prepared to withdraw the paragraph if people interpret it as an endeavour to wriggle out of the Bill subsequently. That is not the intention.

Legislators on all sides of the House underestimate the detailed implementation of Bills when they have been passed and the impact that has on the Departments involved and the service providers. Parliamentarians - and I include myself in this - sometimes take alaissez faire approach and think we can pass what we like. We do not always keep an eye on subsequent implementation and when things do not happen as quickly as we think they should we attack a wide range of people, invariably the five or six civil servants who are dealing with the issue.

Major logistical issues will arise out of the Bill, not least the establishment of mental health tribunals. If one considers the number of involuntary detentions at the moment one sees the significant logistical operation which will have to take place once the Act is passed. We will discuss this matter when we deal with the sections on involuntary detention.

I have no personal desire to include a measure in the Bill which would allow me to wriggle out of implementing its provisions.

Is the Minister accepting the amendment?

I accept the principle of the amendment.

That is fair enough. I assure the Minister that if things go wrong, we will not be blaming five civil servants. We will be blaming him.

Of course. Or someone else.

At the end of a 12 month period does paragraph (c) become redundant and the full impact of the rest of the Bill apply?

Amendment No. 16 not moved.
Section 4 agreed to.
Sections 5 and 6 agreed to.
SECTION 7.

I move amendment No. 18:

In page 11, between lines 13 and 14, to insert the following subsection:

"(3) The Commission shall, within 6 months of its appointment, publish comprehensive guidelines and definitions on what constitutes 'personality disorder' or 'social deviance' as described in this Act.".

Section 7(2) states:

Nothing insubsection (1) shall be construed as authorising the involuntary admission of a person to an approved centre by reason only of the fact that the person

(a) is suffering from a personality disorder,

(b) is socially deviant, or

(c) is addicted to drugs or intoxicants.

My later amendment to section 8 proposes that involuntary admission may be permitted for a person who is incapable of caring for himself as a consequence of the consumption of alcohol or other drugs.

What qualifies as social deviance and how is personality disorder defined? The purpose of this amendment is to tease out the meanings of these terms. It proposes that the commission publish comprehensive guidelines setting out what constitutes personality disorder or social deviance. However, I accept this may not be the way to proceed. Some might think an Attorney General who was anxious to change the nature of a political party, or even an Opposition spokesman who persists in pressing the issue, to be socially deviant. In times gone by homosexuals, even consenting adults, might have been considered socially deviant. What do the terms "social deviance" and "personality disorder" mean? They are not defined in the Bill and I would like to know the meaning of these terms.

What was socially deviant in my father's time would not be considered so now. In the Middle Ages one would be burned at the stake if one were a homosexual. Social deviancy can differ within groups, for example, there is a debate about the Romany gypsies and their customs. They do not consider themselves to be social deviants. I know that is an extreme case but people from different backgrounds may perceive others to be socially deviant when they are not. Their behaviour might be acceptable and normal within their class. As we become a multi-racial society, who will decide what is socially deviant among the diverse groups who will come to this country and contribute to life here? It is important, as Deputy Mitchell said, to define social deviancy.

We were talking earlier about protecting those who may be described as socially deviant from involuntary admission and so on. Deputy Mitchell asked for a definition of social deviancy or personality disorder. The reality is both are contentious in terms of their definition, even among clinicians and those we would consider to have a particular expertise in the area. There is extensive literature on the issue. What is at issue is the question of clinical definition and clinicians differ on whether an individual suffers from a personality disorder or is socially deviant. I have no difficulty with the principle of the amendment. It would be helpful if the mental health commission were to give guidance on these matters. I would like to work with the Deputy on the wording of this for Report Stage.

These concepts can change over time. There is a group of people who, 100 years ago, would have been classified as criminals. We now regard that with horror. The Attorney General can state his views. In another country he could be classed as a socially deviant person for daring to question the orthodoxy of the State or political parties. In some countries people are locked up for questioning the political order.

I accept the points made but the Council of Europe has recommended this type of approach in such legislation in order to protect people. I can quote chapter and verse for the committee but I accept the principle behind the amendment and will work on the wording for Report Stage.

I am happy with that. It states that it shall not be "by reason only of the fact". It is one of the facts, in other words, being socially deviant and something else. We are putting this into the legislation and I would like to see guidelines on it.

They have to have a mental disorder.

Yes, but you could say that about someone who does something you do not like, such as parading outside the Dáil, and that they are socially deviant. It is too loose and I would like it to be defined.

In 1967 a person was arrested and charged in the courts with attempted suicide.

That is only 33 years ago.

Amendment, by leave, withdrawn.
Section 7 agreed to.
SECTION 8

Amendments Nos. 19 and 21 are related and may be taken together by agreement.

I move amendment No. 19:

In page 11, subsection (1), lines 20 and 21, to delete paragraphs (b) and (c) and substitute the following:

"(b) an authorised officer,

(c) a member of the Garda Síochána, or

(d) subject to the provisions of subsection (2), any other person.”.

These amendments add a member of the Garda Síochána to the list of persons who may make an application for a person's involuntary admission. The text as it stands does not exclude a member of the Garda Síochána from making an application as they are covered by reference in paragraph (c) to any other person but, for reasons of clarity and given the important role the Garda Síochána can often play in such cases, I have decided a specific reference would be more appropriate.

I do not have a difficulty with the amendment but it is important to mention one or two points on the role of the gardaí. It is interesting that it is a point referred to at length in the 1999 report from the Inspector of Mental Hospitals where he speaks of the concern expressed at the lack of involvement by the gardaí in community mental health, particularly in the Dublin area. There is a requirement on the Minister to look at the training of gardaí in relation to dealing with people with psychiatric illness and their role in community mental health. I know of one instance where there is an ongoing problem in a community in Dublin where a psychiatrically ill person is constantly harassing people living in the area though not in a dangerous way. The gardaí do not seem to have a role to play in that. Because it is an area where, in the past, there were many attacks on people there is much unease.

The gardaí are key players in cases of involuntary detention and we understand that but there are concerns about their lack of training, experience and engagement in this area in terms of accompanying people who are ill and have to be brought to institutions. Will the Minister look at the role the gardaí play and ensure there is good quality training for those dealing with a complex area that requires great judgment to get it right?

I accept that. We are working with the Garda at present and have met them with a view to devising a national programme of training.

Amendment agreed to.

I move amendment No. 20:

In page 11, between lines 21 and 22, to insert the following subsection:

"(2) Where a person is incapable of caring for himself or herself as a consequence of the consumption of alcohol or other drugs, involuntary admission to approved centres may be permitted.".

I indicated earlier that I noted in section 7(2) that involuntary admission of a person to an approved centre only by reason of the fact that he or she is addicted to drugs or intoxicants would not be considered under subsection (1). I am anxious to ensure the legislation permits that in the case of a person who is incapable of caring for himself or herself as a consequence of the consumption of alcohol or other drugs involuntarily admission to approved centres may be permitted. I do not know if that is covered elsewhere. I know of people whose lives could have been saved had they been involuntarily admitted and treated. Representing the constituency that I do, and particularly in some inner city flat complexes, I know many people who have simply drifted into alcohol or drug abuse and are literally living in stairwells. If they could be saved from themselves they might well benefit from involuntary admission. We must be careful that there are adequate checks and balances in place. I am not saying "shall" but "may" and I hope the amendment is reasonable in that regard.

I have sympathy with Deputy Mitchell although I am not sure I agree with this amendment. The intention behind the Bill is to try to ensure that psychiatric approved centres are for psychiatric patients and no one would argue with that, but what happens to someone with a chronic addiction problem who is incapable of caring for himself or herself? Who is providing care for them? The health board is supposed to look after these people but we all know they can end up in a psychiatric hospital or institution, if they are willing to take them in, where, strictly speaking, they do not belong but where else can they go? This does not happen just in cities; if anything it is more problematic in rural areas. Some of them end up in prison.

It is not a mental health issue but one that has more to do with people who suffer such grave addiction that it is, in a sense, life threatening. The psychiatric services have been looking after these people to a great extent even though they may not be equipped to do so. It is a question of making sure there is an even distribution across the country because it is an area where geographic unevenness is particularly acute. If the health boards are providing for these people, who is responsible for making them do so and ensuring they provide adequate and suitable care?

With increasing alcohol abuse and drug addiction, and particularly as young people's lives can be destroyed, irrespective of whether this is the correct amendment, the issue should be discussed.

This is an important area. Homeless people who abuse alcohol and have a mental breakdown have no place to go when they are discharged from a mental hospital and they go back on the streets again. This issue should be discussed. There should be hostels available where such people could remain until such time as they can be reintegrated into society. There should be out-patient and out-reach psychiatric services.

I know the Deputy tabled the amendment for good reasons but it goes against the grain in terms of how we treat drug and alcohol addiction. The central tenet of our national alcohol policy, going back to 1996 when the national alcohol strategy was launched, has been to treat alcoholics in community based settings with access to community based groups that deal with addiction generally and alcohol addiction in particular and also through local facilities. The same applies to drug addiction. It is not correct to deal with these two issues in the context of a mental health Bill or involuntary admission.

At the end of the day, involuntary admission is not dealing with the core issue in terms of addiction. We have made significant progress in terms of creating community based facilities for heroin addicts in the Dublin region in particular. There are still waiting lists but the improvements over the past four or five years, even by European standards, have been dramatic in terms of the places that have been created and so on. The only obstacle to the creation of community based services for drug addicts is the unwillingness of certain communities to accept drug treatment centres in their communities. In certain parts of Dublin health boards have had difficulty in establishing centres for drug addicts who may wish to avail of the methadone programme. Drug addiction must be dealt with in that context, in other words, giving health boards the resources to provide community based services for drug addicts in their catchment area.

The same applies in terms of alcoholism. More damage could be done to an alcoholic through involuntary admission to a psychiatric hospital. There are no easy answers to alcohol addiction. The person must acknowledge there is a problem in the first instance and then deal with it.

Section 7(2)(c) states that a person may not be detained only because he or she is addicted to drugs or intoxicants. There is a clear implication that addiction to drugs and other intoxicants together with something else would “qualify” someone for involuntary admission. Yet that is not spelled out in the Bill. In the amendment I suggest “may” not “shall”. I strongly support the community based treatment of people with alcohol and drug problems. I do not suggest that they should be involuntarily admitted but, in extreme cases, it would be good if they were capable of being admitted where they have become socially deviant, which we do not define, or have some clear psychiatric condition where they are harming themselves.

I will not press the amendment as I accept the general thrust of what the Minister said. I do not want to put people who should not be admitted in the way of qualifying for involuntary admission but the point I make is worth considering.

It is a mental disorder which is the defining factor in terms of involuntary admission. It is a very serious step and the Bill has been criticised in terms of certain aspects of the involuntary admission procedure we are putting in place. It would be correctly perceived as placing a signficant limitation on a person's human rights if they were to be involuntarily admitted on grounds of addiction to alcohol or drugs alone.

For the record, that is not what the amendment sets out to do. Section 7(2)(c) strongly implies that addiction to drugs or intoxicants may be taken into account.

Section 7(1) governs subsection (2). It states:

A person may be involuntarily admitted to an approved centre pursuant to an application undersection 8 or 11 and detained there on the grounds that he or she is suffering from amental disorder.

Subsection (2) states:

Nothing insubsection (1) shall be construed as authorising the involuntary admission of a person to an approved centre by reason only of the fact. . .

Yes, "only".

Obviously we do not want people admitted to institutions on the grounds that they are alcoholics or drug addicts.

No, that would not happen. Under subsection (1) we have agreed that he or she is suffering from a mental disorder.

No. Section 7(1) states the reason a person may be involuntarily admitted. Subsection (2) states these may not be construed as reasons.

It does not state that. It is "only".

Yes, if a person has a mental disorder. That is the primary issue.

If you say it cannot "only" be considered, the implication is it can be considered with something else.

No. To protect people and prevent them from being abused, one has to provide for exclusions. To get rid of problems, there may have been a tendency to place people in a psychiatric institution because there was nowhere else to put them.

Absolutely, but there is another way of looking at the matter. The other side is that in certain circumstances the only safe place where the people concerned can be placed is a psychiatric institution. We have to ensure provision is made for them. That is my concern.

Surely not involuntary admission.

Somebody who is not psychiatrically disturbed could go mad with drink that be a danger to themselves and their family. I am aware that it should not be done in a mental health Bill——

No, it should not.

I have no problem with the principle of excluding them in terms of the Bill, but I am concerned that in excluding them we are cutting across current practice. It is my experience that people are either voluntarily or involuntarily admitted to psychiatric institutions because there is nowhere else for them to go. Given their circumstances, it may not be a great place to be, but it is better than having no place to go. That is my concern about the people concerned.

I take the Deputy's point, but if we are to be consistent with the policies we have developed on alcohol and drug addiction, there is an obligation on service providers to ensure there are facilities available for such people outside the mental health arena.

The amendment reads, "Where a person is incapable of caring for himself or herself as a consequence of the consumption of alcohol or other drugs, involuntary admission to approved centres may be permitted". The word "shall" is not used. The amendment has to be read in conjunction with section 7(1) which states that a person may only be detained on the basis "that he or she is suffering from a mental disorder". There are, therefore, checks and balances. I will not press the amendment, but I ask the Minister to think about it between now and Report Stage. When somebody gets to the stage where they are incapable of caring for themselves, they are at death's door, because they are not functioning mentally.

Amendment, by leave, withdrawn.

I move amendment No. 21:

In page 11, subsection (2)(b), line 25, after “authorised officer” to insert “or a member of the Garda Síochána”.

Amendment agreed to.

We now proceed to amendment No. 22. Amendments Nos. 23 to 25, inclusive, are alternatives. Is it agreed that amendments Nos. 22 to 25, inclusive, be discussed together? Agreed.

I move amendment No. 22:

In page 12, lines 12 to 17, to delete subsection (8) and substitute the following:

"(8) In this section-

'authorised officer' means an officer of a health board who is of a prescribed rank or grade and who is authorised by the chief executive officer to exercise the powers conferred on authorised officers by this section;

'spouse', in relation to a person, does not include a spouse of a person who is living serparately and apart from the person or in respect of whom an application or order has been made under the Domestic Violence Act, 1996.".

Concerns have been expressed by several interest groups that authorised officers should be suitably qualified. The amendment will allow the Minister to specify in regulations the grades of health board staff who can become authorised officers for the purposes of the section. These grades will include paramedical staff such as social workers, therapists, psychologists and district nurses, but exclude clerical or administrative staff employed by the health board. It is my intention to make these regulations as soon as possible after enactment and before the commencement date for this part of the Bill.

Amendment No. 23, in the name of Deputy Mitchell, which would require all authorised officers to be trained in the mental health area, is more restrictive than what I have proposed and would give rise to practical difficulties if, in an emergency, none of the health professionals available, for example, a general practitioner or district nurse, fell into that category. Amendment No. 25, also in the name of Deputy Mitchell, would have the same effect as my amendment. I suggest, therefore, that it be withdrawn.

The reference in my amendment to "spouse" excludes a spouse who is separated or against whom proceedings are under way under the Domestic Violence Act from making an application for the involuntary detention of their partner. This is being moved for technical reasons from section 2.

The Minister said that he will make regulations to ensure, for example, a higher executive officer or executive officer with no qualifications——

We are excluding——

That is what I am saying.

I am sorry, I thought you were going to say that we were making it possible for them.

It would help if the Minister listened to what I have to say. He is giving an undertaking that he will make regulations to exclude untrained staff such as higher executive and executive officers and to ensure authorised officers have received relevant training. That is what I have set out to achieve in amendment No. 23 which seeks to include the words, "who is professionally trained in the mental health area", but the Minister does not want to apply this in every case on the grounds that in an emergency, for example, a psychologist or other trained person may not be available. How will this matter be dealt with in the regulations? How will the Minister ensure, if he makes an exception in the regulations that he will promulgate, that a higher executive or executive officer who is straight out of school and has received no training will not be given authority by the chief executive officer of the health board?

On amendment No. 25, is the Minister happy, using the formula proposed by him, that he will have the power that I propose to give him? The amendment seeks to include the words, "The qualifications of authorised officers shall be specified by regulations issued by the Minister" but with the rider "following recommendations by the Commission". I am anxious to ensure the Minister will have this power and that regulations will be made following recommendations by a body such as the commission which would look at the matter independently and recommend what needs to be done.

On amendment No. 23, on a bank holiday weekend, for example, there may not be a psychologist or other specialist available. In such a circumstance I would not want the chief executive officer to delegate this function to a person straight out of school and with no qualifications. I wish to ensure the proper powers have been provided to deal with the matter with the proper checks and balances.

While I am happy enoughwith the amendment, I have a query. It is not stated in the amendment that the rank orgrade will be prescribed by way of regulation. If this will be done by way of regulation, I would be happier if the normal conditions applied whereby they would be placed before the Houses of the Oireachtas, but this is not written into the Bill. It is always a difficulty I have——

Where? What am I missing?

Section 4(3) reads: "Every regulation under this Act shall be laid before each House of the Oireachtas as soon as may be after it is made. . . ".

On the question of following recommendations by the commission, there is the technical point that regulations may have to be in place prior to its establishment. We are anxious to move once the Bill is enacted.

Will there be checks and balances to ensure in an emergency, for example, the prescribed ranks and grades will not extend to somebody who does not possess the necessary professional competence?

It is being made clear that we will not be providing for a role for civil servants. This will be made clear in the regulations.

Will the Minister repeat what he said about what will be in the regulations?

I do not have the regulations with me.

The Minister mentioned what will be in them.

The amendment I have tabled will allow the Minister to specify in regulations the grades of health board staff who can become authorised officers for the purposes of the section. These grades will include paramedical staff such as social workers, therapists, psychologists and district nurses, but exclude clerical or administrative staff employed by the health board.

Amendment agreed to.
Amendments Nos. 23 to 26, inclusive, not moved.
Section 8, as amended, agreed to.
SECTION 9.

I move amendment No. 27:

In page 12, subsection (3)(c), line 39, after “person” to insert “or”.

This is a technical amendment.

Amendment agreed to.

Amendment No. 28 is in the name of the Minister. Amendment No. 35 is related so we will take Nos. 28 and 35 together, by agreement.

I move amendment No. 28:

In page 12, between lines 40 and 41, to insert the following subsection:

"(4) A recommendation undersubsection (1) shall be sent by the registered medical practitioner concerned to the clinical director of the approved centre concerned and a copy of the recommendation shall be given to the applicant concerned.”.

The purpose of sections 9 and 13 as they currently stand is based on the existing model of mental health care where people in crisis are usually admitted to hospital on the recommendation of a general practitioner and subsequently examined and assessed by a consultant psychiatrist. That model is changing, however, and in some parts of the country innovative schemes are being piloted whereby following a referral from a general practitioner, patients are visited and assessed in their own homes by mental health teams. I see this as the way forward for the future of the mental health services and the Bill should provide for the development of such a community based service.

The amendment to section 9 requires the general practitioner to send a recommendation to the clinical director of the hospital. The amendment to section 13 removes the requirement for the consultant psychiatrist to examine the patient in the hospital after his or her arrival, thus allowing for the person to be assessed by the consultant psychiatrist in their own home, if possible.

Amendment agreed to.
Section 9, as amended, agreed to.
Section 10 agreed to.
SECTION 11.

I move amendment No. 29:

In page 13, subsection (1), line 5, to delete "may" and substitute "shall".

Section 11(1) states that the member of the Garda Síochána may, either alone or with any other members of the Garda Síochána, take the person into custody and enter if need be any dwelling or other premises or any place in which he or she has a reasonable grounds for believing that the person is to be found there. The word "may" is appropriate in relation to subsection (1)(b) but in relation to subsection (1)(a), which states that if a member of the Garda Síochána has reasonable grounds for believing that a person is suffering from a mental disorder and that because of the mental disorder, there is a serious likelihood of the person causing immediate and serious harm, the word “may” is not strong enough. Should the garda not be required, in circumstances where there is a serious likelihood of the person causing immediate and serious harm to himself or herself, to take that person into custody? The words used in the section are “serious likelihood of the person causing immediate and serious harm”. Is the Minister satisfied that the word “may” is sufficiently strong?

I am, and again one is anxious to achieve balance in terms of the Bill. If we change the word from "may" to "shall" we would be imposing an obligation on members of the Garda Síochána to immediately take a person into custody if they felt that they were suffering from a mental disorder and that there was a likelihood of them causing serious harm to themselves or to other people. That is a serious issue and it is serious for any member of the Garda Síochána to take into custody a person who has not committed a crime. The proper course of action for the gardaí in these cases is to contact the health services in the first instance and ask them to come to the person's assistance. It is only when there is no other avenue open to them that the Garda Síochána should take a person into custody and forcefully remove them to a psychiatric hospital. There are many concerns about the Bill as it stands in terms of the rights of patients and people out in the community. It is safer to leave this aspect to the discretion of the Garda and hence leave the word "may" instead of "shall".

Amendment, by leave, withdrawn.
Section 11 agreed to.
SECTION 12.

Amendment No. 30 is in the name of the Minister. Amendment No. 73 is related so we will take Nos. 30 and 73 together, by agreement.

I move amendment No. 30:

In page 13, lines 38 to 44, to delete subsection (3) and substitute the following:

"(3) Where the clinical director of the approved centre and the registered medical practitioner who made the recommendation are of opinion that there is a serious likelihood of the person concerned causing immediate and serious harm to himself or herself or to other persons, the clinical director or a consultant psychiatrist acting on his or her behalf may, if necessary, request the Garda Síochána to assist the members of the staff of the approved centre in the removal by the staff of the person to that centre and the Garda Síochána shall comply with any such request.".

Amendments Nos. 30 and 73 deal with the difficult and sensitive issue of escorts for patients who need to be admitted urgently to a psychiatric hospital, and in particular they deal with the role the Garda Síochána should play in the provision of such escorts. The amendment to section 12 provides for the escort of a patient who requires to be admitted to hospital and the amendment to section 26 covers the retrieval and return to hospital of its patient who has absconded. Both amendments provide clarity as to the precise circumstances in which the Garda Síochána may be called to assist in the provision of an escort. The amended text, which has been agreed by my Department with the Department of Justice, Equality and Law Reform and indeed with the Garda authorities, specifies that only in circumstances where the person concerned constitutes an immediate and serious risk to themselves or to others may they call for the assistance of the Garda Síochána.

It is vital that everyone involved recognises and accepts that the primary responsibility in relation to the provision of escorts rests with the mental health services. This amendment is in keeping with that principle. It is acknowledged that the gardaí have a role to play in the provision of escorts where a patient is potentially a danger to himself or herself or to others. The role of the gardaí, however, must always be a supporting role, ideally in the context of a multi-disciplinary team of trained personnel, including psychiatric nurses. I recognise and accept that the obligations which this particular section will impose on the mental health services will require additional resources. Additional staff will be needed and specialised training is likely to be required also. It will be worth the investment, however, and most people would agree that the current situation with regard to the provision of escorts is clearly unsatisfactory.

As I understand it, the clinical director and the registered medical practitioner would have to agree before they can request and expect the gardaí to accompany the person. What concerns me is the old phrase "doctors differ and patients die". What happens if one of them is convinced that that is the case and the other is not? It is possible that the clinical director of an approved centre may, for whatever reason, decide it is not the case but the GP is at the coal face struggling with a patient who is clearly a danger. What happens if one of them is absolutely convinced and is seeking help from the gardaí but the gardaí will not help because the clinical director has to be convinced first? Is that a possibility?

It probably is a possibility but they must agree.

I know but a clinical director may have——

Deputy McManus is talking about when they do not agree. That can happen even in relation to the treatment of the patient or the admission of the patient to the hospital.

Yes, or the clinical director may say that he or she will not take in the person immediately but in two or three days' time. The general practitioner is the one who is closest to the problem and he or she may be absolutely convinced that this matter has to be dealt with immediately.

Perhaps there is a waiting list.

They do not go on a waiting list but the experience is different. The clinical director's perspective may be different to that of the general practitioner who is in the person's living room trying to stop him or her killing the children. That is the reality——

On the ground, yes.

——and a clinical director may want to reflect on the decision but meanwhile the GP has the person on the ground and needs the gardaí to help him or her, but the gardaí say that under the Bill they cannot move. Is that not a possibility?

It is a possibility but the clinical director has to send out his or her own staff to verify that. People could differ but how do we legislate for that? I will have a look at it on Report Stage in terms of calling in the gardaí.

That raises a civil rights issue in that a GP could be quick off the mark to commit people and we must have protection against that.

We have put in a lot of checks and balances in the Bill which dramatically improve the situation from that which currently exists.

I am just responding to what Deputy McManus said.

That is the other side of the coin.

I accept there is a difficulty.

I will leave the amendment stand, but I may table a subsequent amendment on Report Stage, if we can come up with an appropriate way to deal with this.

Can one amend an amendment?

One can if one indicates that at this Stage. We have reached clarification with the various authorities and we need to include that in the Bill.

Amendment agreed to.

Amendments Nos. 31 to 34, inclusive, are related and may be taken together by agreement.

I move amendment No. 31:

In page 13, subsection (4)(a), line 49, to delete “patient” and substitute “person concerned”.

These are technical amendments.

Amendment agreed to.

I move amendment No. 32:

In page 14, subsection (4)(b), line 1, to delete “return” and substitute “removal”.

Amendment agreed to.

I move amendment No. 33:

In page 14, subsection (4)(b), line 2, to delete “patient” and substitute “person concerned”.

Amendment agreed to.

I move amendment No. 34:

In page 14, subsection (4)(b), line 3, to delete “patient” and substitute “person concerned”.

Amendment agreed to.
Section 12, as amended, agreed to.
SECTION 13.

I move amendment No. 35:

In page 14, subsection (1), lines 4 and 5, to delete "Where a person is received at an approved centre pursuant to a recommendation undersection 9” and substitute “Where a recommendation in relation to a person the subject of an application is received by the clinical director of an approved centre”.

Amendment agreed to.

Amendments Nos. 36, 51 and 90 are related and may be taken together by agreement.

I move amendment No. 36:

In page 14, subsection (1), line 7, after"person" to insert "in the language of communication of that person".

The subject of this amendment needs to be addressed. People who are native Irish speakers expect to be dealt with in their first rather than their second language and that should be accommodated. It may not always be practicable to do that. I accept the words "where practicable" should be included in the amendment. We are living in a multicultural society. Many people whose first language is not English are now living here. People may find themselves in a situation where they do not understand what is happening because the language in which they are being dealt with is inappropriate. I am not suggesting all service providers will have to speak every modern language, but we must recognise that language is important and that some people's first language is Irish not English, and that should be recognised in the legislation.

I accept the subject of the Deputy's amendment is valid. How can a consultant examine a person if he or she cannot communicate with that person? We must, however, be careful of providing for something in the Bill that we will not be able to deliver. I would like to consider this matter for Report Stage to see if we can come up with something appropriate. There should be a model of providing interpretative facilities. While we will not be able to produce consultant psychiatrists who are multilingual, there must be ways and means of ensuring a high level of communication in such circumstances, which are realistic possibilities.

That is an important point. There is also the issue of foreign doctors. The Medical Council had to introduce an examination in recent years, as many doctors did not speak English. I know of one psychiatrist who had very poor English. It is hard to imagine how he could do his job properly with such a language barrier. There are various aspects to this issue.

He might have been a goodpsychiatrist.

He must have done a lot of listening.

Amendment, by leave, withdrawn.

I move amendment No. 37:

In page 14, subsection (2), line 19, after "24 hours" to insert "(or such shorter period as may be prescribed after consultation with the Commission)".

Since publication of the Bill, concern has been expressed by some interested parties that this period of 24 hours during which a person may be held for the purposes of carrying out an examination is too long. It is an upper limit and the majority of patients will be assessed within a few hours of the recommendation being made by their GP. Given the current strains on staff numbers in the health services and in order to provide hospital staff with some flexibility, I would be reluctant to reduce the 24 hours maximum limit at this stage. However, I am prepared to provide for its reduction, by way of this amendment, at a later stage under ministerial order. I expect the mental health commission to keep the position under review and to advise the Minister when such a change becomes appropriate.

Amendment agreed to.

I move amendment No. 38:

In page 14, between lines 22 and 23, to insert the following subsection:

"(3) A consultant psychiatrist shall, for the purposes of this section, be disqualified for making an admission order in relation to a person the subject of an application-

(a) if he or she is a spouse or a relative of the person, or

(b) if he or she is the applicant.”.

The amendments prohibit a consultant psychiatrist from making an order for the involuntary detention of a person if he or she is married to or living with that person, a relative, or the one who made the original application for detention in respect of that person. A similar provision is in place in section 9 in respect of general practitioners. The intention of these provisions is to protect the interests of the patient and to avoid any possible conflict of interest on the part of doctors concerned.

What is the Minister's definition of a relative of the person concerned?

That is covered in the Bill.

That is in order once that is clarified.

Amendment agreed to.
Section 13, as amended, agreed to.
SECTION 14.

Amendments Nos. 39, 40, 41, 43, 44, 45, 55, and 56 are related and may be taken together by agreement.

I move amendment No. 39:

In page 14, subsection (1), line 25, to delete "28 days" and substitute "14 days".

I will address amendments Nos. 39, 43 and 45 in my name and Deputy Neville's name. I have grave concerns about this section. I hope it does not prove necessary to divide the committee on this matter, but it is an issue we need to address and to ensure sufficient checks and balances are in place regarding the length of period of detention. The section deals with the duration and renewal of admission orders. Amendment No. 39 seeks to amend subsection (1) to ensure that an admission order shall authorise the reception, detention and treatment of the patient concerned and shall remain in force for a period of 14 days - as opposed to the 28 days currently provided for in the Bill - from the date of the making of the order and, subject to subsection (2), shall then expire.

Subsection (2) provides for a renewal order to be made by the consultant psychiatrist responsible for the care and treatment of the patient concerned for a further period of three months. That is excessive. The purpose of my amendment No. 43 is to ensure that the consultant psychiatrist should be empowered to extend the detention for periods of 14 days up to a maximum of three months. In other words, the consultant psychiatrist would have to ensure that he or she does not renew a patient's detention for three months and on the sixth or seventh week decide to review that person's progress. The consultant psychiatrist would be required to do that every 14 days.

Subsection 3 suggests that further extensions may be made by the consultant psychiatrist concerned for a period of six months beginning on the expiration of the period of three months referred to in subsection (2). I propose that subsection should be amended in line with the amendment I propose to subsection (2). I notice my amendment does not go far enough. A consultant psychiatrist should not have the power to extend an order for a period of six months. That is excessive. We need to build in regular checks and reviews. It could be for a period of up to three months but the reviews would have to take place every 14 days or something of that nature.

The provision as drafted gives too much power; it is virtually executive, judicial and legislative all at once. It gives the doctor the power to assess, decide and detain for excessive periods. I will insist that some checks and balances are included, particularly in relation to staggering the periods. In other words, a consultant psychiatrist must at least see the person every couple of weeks to determine whether the person has reached the stage where he or she can be discharged or needs further treatment. Just to detain somebody for three months and to have the power to extend the detention for another six months is wholly unacceptable. It is too raw to be passed intolaw. I hope the Minister will accept the amendments.

I agree with Deputy Mitchell that this is a crucial part of the Bill. It goes to the heart of the traditional psychiatric approach of detaining people for most of their lives. We are all aware of people who have been detained for up to 40 years in psychiatric institutions. It was a different culture and time but we still see people being detained in these institutions.

We must break the mould and introduce a different ethos and way of looking at how we treat psychiatric patients. The detention option was the key option through the decades and it decided people's lives. I do not believe anybody, except in extreme circumstances, should decide the detention of an extremely ill or moderately ill person. We now know that most psychiatric conditions are treatable and curable. In that context, the more often a psychiatric consultant is presented with a decision to continue detaining a person, the better. Her or she should not be givencarte blanche and be allowed to come back in three months to see how the patient is.

My amendment, No. 55, seeks to substitute ten days for 28 days as the maximum number of days for review to be carried out. This is the most important section of the Bill. The provision is a welcome change because until now there was no proper review procedure. This has been criticised many times and again recently at the UN because of our failure to address it. The UN was also critical of this provision in the Bill due to the length of time it proposes.

The Irish Council for Civil Liberties and Schizophrenia Ireland have pointed out that the tribunal is welcome but the proposed manner of its operation is seriously flawed. The ICCL continues: "It is well established that 70% of involuntary patients are, at present, released within one month. This renders the review after 28 days practically useless." It points out that the White Paper recommended seven day periods for review. I suggested ten days as a more than reasonable timeframe.

Given all the effort that went into this provision and the efforts of the Department to set up a framework for a decent review procedure, its impact is reduced by the long timeframe. It will only have a minimal impact on patients who are involuntarily put into care. I hope the Minister will take on board the concerns expressed by organisations that are providing for these people and enabling some form of advocacy, something which is extremely underdeveloped in this country, for the psychiatrically ill. I hope he will deal with these concerns in an proactive way and accept that the 28 day timeframe for review is not hitting the mark in terms of providing the review framework that is necesssary.

It was the subject of criticism at the UN committee. We must look again at this proposal and accept there is a serious issue there which needs to be addressed.

It is a serious issue. This is a substantive part of the Bill. It should be reiterated that there was nothing in place until the introduction of this Bill in terms of a review period. Irrespective of one's problems with the legislation before us, it should be acknowledged that it is a dramatic improvement on what we had before with regard to involuntary detention of people in mental health institutions.

Many people have commented that the 28 day period during which a person can be detained is too long before due process takes place. I will deal first with the key point about the White Paper. The White Paper provided for a procedural review within seven days, not a substantive clinical review. The Bill goes further than the White Paper in terms of protection of the patient in that it provides for a substantive review, which involves a clinical review, within 28 days. The White Paper referred to the legal niceties and procedures being completed within seven days but it envisaged up to a year thereafter before a substantive clinical review was held. The impression appears to have been given that the White Paper had a more liberal approach or a better regime in terms of protecting the patient. I argue that the Bill is an improvement on it because it provides for a fundamental clinical review within 28 days.

I accept the period of 28 days is still an issue. I have put forward two amendments. We would like to see the 28 days reduced and in the amendments we want to work towards a situation where they can be reduced. We propose that the 28 day period be retained in the Bill for the present but that it may be shortened at a later stage by ministerial order on the advice of the mental health commission. I will speak later about what I intend to do about this but it should be remembered that logistics are important. There are about 2,400 involuntary admissions per annum. Approximately 55% of them are discharged within four weeks. About 45% are renewals after 28 days, 17% after three months, 5% after one year and approximately 2% after more than a year. That involves approximately 1,656 renewals per annum which means that over 1,600 tribunals will have to be established in a given year. Given half a day for each tribunal, there are over 800 man days involved in the administration of this.

Is the Minister leaving out all the people who will leave before the 28 day period?

As matters stand, yes.

Even allowing for those who are only there for a short stay?

You are taking them out of the figures?

The idea is to have the 28 day period beyond which there would be a review. If one takes that alone into account, one is talking about almost 40 weeks of sheer work for the mental health tribunals that will be established by the commission to review each case. There are huge logistical issues in getting the people and there are other issues we will have to look at again. At present, we propose that a consultant psychiatrist would be on the tribunal and that the patient would have a legal representative.

Am I missing something here? We are talking about admission orders and renewal of admission orders. We are talking about this being the responsibility of a consultant psychiatrist, and giving that consultant psychiatrist the power, once the first three month period has passed, to extend that for a period of six months, beginning from the expiration of the three months.

They will all be reviewed. The mental health commission will——

My point is that in the initial——

We will not sort this out in one exchange. I am just saying, by way of information to the committee, that whatever we do there are logistical issues, in terms of subsequent administration of what we ultimately decide upon. Another issue which will arise, in terms of the progress of this Bill, is whether we are happy with the composition of the tribunal as it currently stands. Some people have argued there should be some lay involvement in it. However, we must be satisfied we can actually do that, in terms of the logistics.

Are there enough people in Cork to fill these tribunals?

That is a very low comment.

Could we pitch for Donegal at this stage?

The provisions in the Bill, as it is currently constituted, are not in contravention of our country's obligations and international law, as has been asserted.

They were the subject of——

The argument was made recently that we were contravening both the convention on human rights and the international covenant on civil and political rights. Our advice from the Attorney General is that we are not in any way contravening either.

Does the Minister mean in this legislation?

Yes. The Attorney General also sought the advice of a senior counsel, who is an expert in the field of international law, on the related question of whether the Bill is in contravention of article 9 of the international covenant on civil and political rights. The legal advice was that article 9, in its express terms, says nothing about either the period for which a person can be lawfully detained or the necessity to review the initial detention order within any specified period of time. Our legal advice sees no basis for interpreting article 9.1 of the covenant as imposing a necessity to either have a shorter period of detention or to review sooner than 28 days. The Attorney General has made it clear to us that we are not in breach of the European Convention on Human Rights.

Having said that, I am prepared to look at this again for Report Stage to see if we can reach some degree of consensus on this. However, it may not be possible to move on the 28 days issue or the review issue.

My point is that we will deal with the tribunals when we get to them. I am concerned that we are empowering a consultant psychiatrist to extend an order for a further period of three months, and then later, when that expires, for a period of six months, beginning on the expiration of the three month period. We are not saying "up to" or "by 14 day periods", we are saying they can have this power. That implies a consultant can detain someone for three months, then detain them for a further six months and never see them again during that six month period.

There is a mistake in my amendment No. 45 - I should be seeking to delete the "period of six months" and substituting it with "periods of 14 days up to a maximum of six months in total", rather than three months in both cases. We should make some provision, before we get anywhere near a tribunal, for the consultant psychiatrist to carry out regular reviews. That is what I am concerned about.

Am I missing a point there or am I wrong in that? It seems as clear to me as night follows day. Is it possible for a consultant psychiatrist to detain somebody for three months, see them after three months, detain them for a further six months and not see them again for six months? Should we not require somebody who is given the power to assess, legislate and detain for that period to go through some due process, and perhaps to review it at 14 day intervals? That is the objective of the amendment. This is a very strong power. I know there is nothing in place at present. However, we have to be very careful how we fill that vacuum. What we enshrine in law will be there for a very long time.

If a consultant psychiatrist makes a renewal order, the correctness of that decision is subject to further review. The mental health tribunal can look at the fact that a renewed order took place.

Who requests that?

It automatically has to happen.

It does not even say "up to six months". It says "for a period of six months". It is mandatory.

It is subject to review by an independent consultant psychiatrist on the mental health tribunal.

What if the first psychiatrist said the person did not need to be detained for six months, that four months or one month would be enough?

These are clinical decisions and I do not think they are made that way.

Why are we saying——

In between all this——

We are making six months mandatory.

No, we are not.

With the 28 days, for example,we are saying that a consultant psychiatristmay discharge a patient at any stage before 28 days are up. Some 45% of discharges are before 28 days.

Section 27 deals with the whole issue of discharge of patients. It states: "Where the consultant psychiatrist responsible for the care and treatment of a patient becomes of opinion that the patient is no longer suffering from a mental disorder, he or she shall by order in a form specified by the Commission revoke the relevant admission order or renewal order, as the case may be, and discharge the patient." In other words, some-one will not be kept there for a mandatory six months.

My difficulty is that as the Bill is currently worded - leaving aside any second opinion or appeal - it mentions specifically the "treatment of the patient concerned for a further period of 3 months". It then goes on to say in subsection (3) it "may be further extended by order made by the consultant psychiatrist concerned for a period of 6 months". It does not say "up to six months" but specifies six months.

Every order is reviewed within 28 days, be it a commencement or renewal.

Why are we requiring the first consultant psychiatrist to fix the period at six months? He or she may determine in the beginning, before it ever goes to the review, to look at the case in two months' time. In my view, even that is too long.

They will be doing that anyway. The desire in any situation like this is to have people discharged as quickly as possible, subject to the person being in a position to be discharged. I gave the figures. Some 45% of discharges are made before 28 days. There were 408 renewals, or 17%, of over three months.

Why are we not saying "up to six months", for example?

It is a maximum. In reality, it is up to six months.

That is not how it is worded.

It actually is, because the person can be discharged any time up to six months. We are saying it must be reviewed within six months if the patient is still there. However, the patient can be discharged before that if he or she is ready. It is a protection, in one sense, because up to now people could be there forever without anybody going near them. We are now saying there are limits of three, six and 12 months, at which there must be further checks and substantive clinical reviews.

Yes, but we are not saying that. We are saying——

No, we are not. I am sorry but I do not agree with that. We are saying in section 14(3): "The period referred to in subsection (1) may be further extended by order made by the consultant psychiatrist concerned for a period of 6 months". We are specifying six months.

The Deputy must read it in conjunction with the other parts of the Bill which qualify that. He cannot read it in isolation.

I have read the other parts of the Bill. We want to amend this section so it is up to six months and then we can continue to read it in conjunction with the other sections. I have a serious problem with this.

I want to resolve this issue. I will examine the Deputy's point again to satisfy myself. I intend to come back on Report Stage to the core issue of 28 days and whether we can shorten that, but not to the point the Deputy is making.

I suggest it should be shortened to 14 days but Deputy McManus thinks that is too long.

I am not happy with subsections (2) and (3). If subsection (3) stated "a period up to six months", I do not understand how it could not be read in conjunction with the other sections of the Bill. The Minister may need to satisfy himself, but I am a legislator and I want to satisfy myself.

So am I.

That is what we are here for. I am not satisfied with the explanations I have received.

We will look at the argument the Deputy has made to see if it has validity, although we do not think it has.

Perhaps the Minister could send me a detailed note on this section setting out the reason he believes it is necessary. I will resubmit my amendment on Report Stage.

The Deputy's main point is that we are not putting a mandatory sentence on people.

I do not know why this subsection could not state "for a period up to" instead of "for a period of".

We can do that.

I do not know why 28 days in subsection (1) cannot be 14 days.

We will look at it.

I welcome the Minister's undertaking to review the period of 28 days. If I withdraw amendment No. 55, I would like the option to resubmit it on Report Stage. The Minister has taken legal advice and he is happy this complies with international law. I do not argue with that if that is the advice he is getting. I do not have the text in front of me but I recall that when the Attorney General addressed the UN committee and made the point about the provisions in this legislation, the timeframe issue was raised as a matter of concern.

That is true.

I presume it is not a matter of someone deciding they do not like the timeframe. I presume when the UN committee expresses a view it is based on a legislative framework. We cannot disregard it; we must take it seriously. The issue was about a shorter timeframe than 36 hours. It referred to European practice where the timeframe is shorter.

It is like the divorce legislation where people were afraid the system would crack, although it did not. I understand the logistical argument about dealing with the backlog. I thought the way to approach this would be to set the correct timeframe and then allow time to deal with the provisions. That is a better and more coherent way to get the timeframe correct for the future. I hope this legislation will not be amended once it is passed. It would be better to set the correct timeframe and 28 days is not correct. We should set the right timeframe in law and, if necessary, we can include a provision to deal with the interregnum.

It is another way of dealing with the amendment we have tabled.

That is a different arrangement because it will be driven by resources or lack thereof in the future.

That is not what I was going to say.

I know it is not what the Minister was going to say but that is the effect of his amendment. It does not deal with the interregnum. It is stating that if we do not want to provide the resources, the commission has 28 days and that will become the norm.

The commission will be independent and it will tell us what we should be doing. The inspector of mental health services will be independent of the Department. That is stronger than what it is now. I do not disagree with the Deputy's point which is helpful and constructive. We want to do it the other way around in that the mental health commission would come back to the Minister and say it is now ready after a year to do it for 14 days. The Deputy is saying we could reduce the period, set the correct timeframe and then have a window period for implementation. Is that what the Deputy is suggesting?

Yes. I would not take the example of the inspector. The inspector has been making recommendations for years which were not heeded.

I know that. They were not heeded by successive Administrations.

On a technicality, amendment No. 45 should be amended so that "3" is changed to "6". I may resubmit amendment No. 45 on Report Stage.

Amendment, by leave, withdrawn.
Amendment No. 40 not moved.

Is the Minister moving amendment No. 41 or will he leave it for Report Stage?

I will leave it for Report Stage.

Amendment No. 41 not moved.

I may have a difficulty being here tomorrow at 4 p.m. because I have been asked by the Government to meet the Minister from Uganda.

We hope to finish by 1 p.m. if at all possible.

We can order the business in the morning at 10 a.m. Will that suit the Minister?

I hope we will finish early.

I wanted to alert members to the possibility that I may not be here. I was going to ask one of the Ministers of State to come in but the committee might not like that.

I have a problem because the All-Party Committee on the Constitution is meeting at 1 p.m.

We will try to finish at 1 p.m.

That would be great.

As it is now 6 p.m., we will conclude the business for today. I thank the Minister for attending.

Are we withdrawing all the amendments?

We have dealt with the amendments up to and including amendment No. 41. We will start with amendment No. 42 at 10 a.m. tomorrow.

The Minister said he would send us a note and that we could deal with the issue on Report Stage.

I will table an amendment arising out of discussions here and submissions made by interested parties. The Deputy made a suggestion about three and six months. He is concerned about the terminology.

I am also concerned about the issue of 28 days.

It will be on the issue of 28 days.

Will we deal with amendments to section 14 tomorrow?

We will commence with amendment No. 42 to section 14. We cannot withdraw amendments until we deal with them. I thank the Minister and his officials for attending here today and the Deputies for the constructive way in which they approached their work.

The Select Committee adjourned at 6 p.m. until 10 a.m. on Wednesday, 25 October 2000.