Non-Covid Healthcare Disruption: Mental Health Services

I welcome our witnesses from Jigsaw and Mental Health Ireland, who are in committee room 1. I advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

From Jigsaw, the National Centre for Youth Mental Health, I welcome Dr. Joseph Duffy, CEO, Mr. Paul Longmore, acting clinical director, and Ms Royanne McGregor, youth advisory panel. From Mental Health Ireland, I welcome Mr. Martin Rogan, CEO. From Mental Health Reform, I welcome Ms Kate Mitchell, senior policy and research officer. I will not be calling on the witnesses to make opening statements as they have been circulated in advance. I will give the floor to Deputy Ward from Sinn Féin, who is taking ten minutes.

I thank the Chairman and the witnesses. It is my first chance to address the committee. I have been going through some of the reports that were circulated. The World Health Organization has warned that the Covid-19 pandemic risks sparking a global mental health crisis. It was very telling this morning to see the Mental Health Reform survey on the impact of Covid-19, which was published this morning and in which all 75 Mental Health Reform member organisations were invited to take part. Some 74% of Mental Health Reform members agreed that the Government has not done enough to address the mental health impact of the Covid-19 pandemic; 92% agreed that the mental health services required additional resources to deal with the mental health impact of the Covid-19 pandemic; 48% reported that the Covid-19 pandemic has had a negative impact on their organisation in the month prior to completing the survey; and 55% had to cancel fundraising events or delivery of services while another 10% are expected to do so in the near future. Some 76% had to withdraw services they normally provide due to the Covid-19 pandemic. It goes to show the strain that seems to be coming down the line for mental health services and mental health provision over the next while. How do Mental Health Ireland's members see themselves addressing these issues? What additional resources and supports are needed, financially and organisationally? That is taking into consideration that the World Health Organization recommends that 12% of the health budget should be allocated to mental health. Currently, Ireland stands at 7%.

Ms Kate Mitchell

I thank the Deputy for his comments. The survey we published today really does show the increase in prevalence of mental health difficulties, but also the increase in demand on mental health services and supports. While the sector has been incredibly responsive and has adapted very quickly to the increased demand and need in terms of mental health, it does not negate the fact that there are challenges for these services. As the Deputy rightly mentioned, many of our member organisations have stated that the Covid-19 pandemic has had a negative impact on their organisation.

Some 75% reported that they had to withdraw services they would normally provide, while 35% reported that there has been a negative impact on fundraising and earned income in the past month. More than 50% reported increasing demand on their services and more than 80% identified that they expect increased demand in the future. It is imperative that the community and voluntary sector, in addition to public mental health services, receive additional support and resources. The survey indicates that 50% of the members who responded had not received assurances from the relevant Departments and agencies that their funding under existing funding agreements and periods was guaranteed. That is a very practical measure that could be taken in the first instance. We are coming up to budget 2021 and it is imperative that there is a clear commitment to adequate resourcing for mental health services in the public and community and voluntary sectors.

Ireland's new mental health policy was published on 17 June. It places an increased focus on a continuum of mental health services and supports, from early intervention and mental health promotion right through to specialist and acute services. It identifies the need for enhanced community and primary care supports. Through that policy we need to see adequate funding of and investment in services. The new policy should be fully costed this year and there should be a commitment to funding for the years to come.

All politics is local and this is, to some extent, a local issue for me. I represent the Dublin Mid-West constituency and grew up in north Clondalkin. As the representatives of Jigsaw know, that is where the service was first located. It was borne out of a need for intervention after a spate of youth suicides in my area. Many of those children were the sons or daughters of friends and neighbours of mine. Jigsaw decided to restructure, move out of the area and go from providing a five-day comprehensive service within our community to a proposed one or two-day satellite service. I was part of a very strong campaign to retain the service in north Clondalkin. The campaign is a testament to the work of Jigsaw in north Clondalkin. The community rallied around to keep the service there because of the vital work it was doing in our area. With the onset of Covid, many residents and others in the greater Clondalkin area are a little in the dark regarding the current status of the service that is available. What will the new service look like? When will it be operational? Where it will be located?

Dr. Joseph Duffy

I thank the Deputy for his question and for his support of Jigsaw over a considerable period, particularly in Clondalkin and its surrounding areas. As he will know and other Deputies will probably be aware, there has been a significant surge in demand and need for support across all of the Jigsaw services. We suspended face-to-face services on 12 March but, from today, we will be able to again roll out those services. It is particularly important to state that, given the significant increase in demand - there has been a 200% increase in those seeking support through our e-mental health platforms - we have worked very hard in recent months to provide phone, video and online support.

In regard to support offered in Dublin south-west in particular, we are providing support in Tallaght which will cover all of the south-west Dublin area. We had planned to open outreach support in the Clondalkin area in April but, as a result of Covid-19, we obviously had to suspend that face-to-face support. Our plan is to roll it out and continue to do so. From next week, we will be able to provide face-to-face support in the Dublin south-west area. We are currently able to provide phone, video and online support and have been able to do so since March.

One of the problems with the service being moved from Dublin mid-west to Dublin south-west is the lack of public transport and infrastructure.

There are many areas that would not have a direct bus route up to Tallaght in the Clondalkin and Lucan area, which makes matters quite difficult. It is also quite difficult for young people who are suffering from mental health trauma, or whatever they are experiencing at the time, to get on a bus or some other form of public transport and make their way somewhere when they may have something that is really local to them. When consideration is being given to the location of the satellite service, could this to be taken on board? This would be really appreciated by the people in Clondalkin because they would have easier access to the service there than to that in Tallaght. In a further question on the face-to-face operation that is due to start on 20 July, how does Jigsaw see this happening and will it have an impact on waiting lists and waiting times?

Dr. Joseph Duffy

We are following all of the HSE and Government guidelines as to providing face-to-face supports, adhering to social distancing and so on. We have conducted an audit of our 12 centres across the country and are providing the appropriate supports within them. We have been offering young people phone and video support and will continue to offer that combined level of support. Some people need direct, face-to-face support and they need to be able to come into the centre and have it as a safe space. We will be prioritising those young people. We hope that some young people will be able to have their initial assessments within the centres and can then continue the support either through the video service or by phone. We are hoping to be able to provide a wider breadth of entry points into the service by using various different technologies, as I have outlined. We will have to wait to see if there is an increase in referrals, particularly in the context of young people looking for face-to-face support. We will be encouraging them to avail of a number of different options.

I was really enthused by my interaction with young people in the Clondalkin area regarding mental health. There was a stigma about talking about how one felt when I was growing up around the area, especially among young men. One would be worried about what other people thought. I commend Jigsaw because one of the impacts it has had in north Clondalkin is that it allowed young people to have a place where they could talk about how they were feeling. Not only could they speak in a safe place with Jigsaw, they were also bringing knowledge of this back out into the community and having that peer support and help for each other. I thank Jigsaw and the witnesses for coming here today. Gabhaim buíochas leo.

I thank Deputy Ward and call Deputy Caroll MacNeill.

I thank Jigsaw for all the work it has done in recent months. On different service delivery types, options and pathways for young people coming in, does Dr. Duffy believe that the online options are working better for people than the face-to-face service or is the interaction different? What is his experience of the nature of this enforced change? Can Dr. Duffy speak about this in a qualitative way?

Dr. Joseph Duffy

For some young people, it is an adjustment, particularly if they were attending the service before and had relationships with particular clinicians. For some other young people, the idea of getting support online is a very good introduction because they can do that anonymously and build up their confidence in terms of connecting with it. We are seeing a 50-50 split between phone and video. There are certainly young some young people who need the one-to-one support because, based on family circumstances or the physical space at home, they may not have a safe space in which to make a call.

On that particular issue, being locked up at home for some people in very trying situations has been extremely difficult. The problem in this regard has been exacerbated in certain circumstances. Are our guests concerned about an increase in the number of referrals relating to abuse or to domestic issues that are having an impact on the children who are presenting? Have our guests seen something of this nature or not?

Dr. Joseph Duffy

I will pass that question to the acting clinical director who can discuss some of the data.

Mr. Paul Longmore

We are always cognisant of child protection issues and the need to refer those on to the proper statutory bodies for attention in circumstances where they come to our attention as a mental health service.

It has been interesting to hear from young people about the experience of lockdown in that, for some young people, their family situation has proven very supportive. We have seen the importance of a supportive adult in the life of a young person and some young people have been, shall we say, pleasantly surprised by how their family have come together to support them at a difficult time, when they are missing out on some of the normal structures, such as school, friends and sporting activities.

There are certain families who are experiencing extreme distress and stress at this time and, sometimes, that is manifesting in more conflict in relationships at home. Certainly, as Dr. Duffy was explaining, having different entry points to the mental health system, and having low threshold entry points where people can engage anonymously, provides an opportunity for some young people to flag if they are experiencing abuse at home and to receive the appropriate support or be signposted and directed to the appropriate support.

It is very interesting what Mr. Longmore says about the surprise of some children at finding a level of support they had not expected or anticipated. Is that what he is saying? It has been a very different picture for different children, has it not?

Mr. Paul Longmore

Absolutely. One of the messages we always talk about in Jigsaw is the importance of trusted adults in the life of young people. We see that communities and families can play a very important role in supporting young people's mental health. Maybe some adolescents might have been a bit sceptical about that but when they were trapped at home with their parents, they actually found that families bonded and came together, and that shared time together proved to be a supportive thing rather than a difficulty. There has been a range of experiences, without a doubt, and it is very hard to say there was only one experience for young people during the Covid restrictions.

I am very glad to have had this chance to talk with Mr. Longmore about that because my own sense is that this has been very mixed. Of course, when a young person has a relationship with a clinician, to move that online is very difficult. On the other hand, we have all of these different entry points that we are all experiencing in different ways, which can provide greater access, and we have had this different, disrupted experience of having more time with family, more time at home and a slower pace, all of which have different impacts on general well-being and mental health. It is interesting.

While I have enormous time and respect for Mr. Longmore's sector, other sectors are experiencing similar disruptions in the delivery of their services. For example, I was talking to Multiple Sclerosis Ireland about the difficulty in providing physio and other support. It is happening in every sector but it is interesting to hear about the complexity of the different experiences. As I am out of time, I thank the witnesses.

The World Health Organization recommends that 12% of total health spend should be allocated to mental health care and, in Ireland, it was said that the figure is less than 7%. How do we compare to other countries in Europe with that spend?

Older people who have been cocooning, many on their own, have experienced increased isolation and increased pressure, and some may have early-stage dementia. There is a lot of concern that while older people have historically been very independent and very settled in their communities, they are particularly isolated. How can we improve our services for older people, particularly mental health services?

Mr. Martin Rogan

I thank the Deputy for the question. It is a very important piece. We have received some very good advice from the WHO in recent weeks in regard to the management of Covid but it also gives advice on the level of resources we should invest in our mental health services. Its minimal recommendation is 12% of the entire health allocation. In Ireland, in the past we spent up to 23% of health spending on mental health and when I began my career in the mid-1980s, it was at 12%. We have drifted downwards and, unfortunately, we do not compare well with our European colleagues and we do not even compare well with ourselves in that regard.

To provide a mental health service in the best of times with 7% of health spending is difficult, and this clearly is not the best of times as there is an additional demand coming. We hear some unhelpful language about a tsunami of need coming.

That will present itself in a variety of ways in that people have been dislocated and unsettled by the experience. The lives of everyone, including individuals who have not been ill with Covid, who have not had an ill family member or who have not experienced a bereavement, have been changed. It would be very unusual and, in fact, quite unhealthy if this did not provoke some degree of anxiety and upset, or anger in some instances. It has been discovered that many families have bonded more when cocooned together in close proximity but some have found that very difficult. Covid has had an amplifying effect, therefore.

Some of conversations with international colleagues have been fascinating. Some of our US colleagues have teams who specialise in dealing with major adverse events, such as weather events or terrorist events. They have described not only the important need for additional investment but also the question of how it should be used. They have said that in the two years after Hurricane Katrina, for example, additional expenditure on just three conditions - anxiety, depression and post-traumatic stress - was $13 billion. That was the same as the amount needed to fix the levees that had flooded during the event.

It is important to remember that we need a series of tiered responses. Most communities will rally together and respond well. We have seen a huge upswing in volunteering and neighbourliness, and we have also seen a huge community bond. Many have never experienced it except in the past couple of months. That has been a real positive for us. We have demonstrated what we can achieve when Irish people pull together, with good leadership, support and information. People have used a range of techniques, particularly technology, to reach out.

Deputy O'Dowd mentioned older persons. Sometimes they are referred to as people who need care but our older persons are elders and they are very wise individuals. They have considerable life experience and want to contribute it. While they were cocooned away, we were at a loss for that expertise and wisdom, in addition to their gravity of experience, which is really useful at a time of crisis and difficulty.

We know loneliness is very impactful on a person's physical and mental health. It is said that loneliness is the equivalent of smoking 19 or 20 cigarettes per day. If one does not have a connection or a relationship, it is very difficult to mobilise, motivate oneself, self-regulate and share one's concerns. This is why we have been able to use various services through our volunteers and mental health associations right across the country. We have provided over 30 Zoom licences, for example, just to reach out so older people do not feel so isolated and can make an active contribution. That is what they wish to do.

Mental health services have adapted and they have demonstrated extraordinary innovation in recent months. Practices and behaviours that were considered science fiction four months ago are now routine. That has been remarkable. We must regain those learnings and advantages but we also need to make sure the capacity of the service is replaced.

I have a small point. I agree with everything Mr. Rogan is saying but I believe there is a cohort - I honestly cannot measure it - of older people living alone who have not been coming out at all. We need to reach out to them. They are afraid for their health and do not have family supports. They are becoming increasingly isolated and there is an increasing number of issues in this regard. I welcomed everything Mr. Rogan said. Perhaps other speakers may take up these points with him.

Do the witnesses have proposals on what we should be doing? Could they prioritise where we need to spend more money urgently and immediately? I am aware the list could be endless. Could the witnesses prioritise the key needs so we can present them in a report, if necessary?

Good morning to the witnesses. I thank them for their attendance today. We have all received calls from people in distress and in need of mental health services. I note that approximately 90% of the mental health services are provided through GP care or primary care teams. The remainder are provided by the community mental health teams. What has been the volume of the increase since the outbreak of Covid-19 in Ireland, in particular since mid-March?

Mr. Martin Rogan

We have seen that the profile of need has changed owing to an increase in urgency. Voluntary agencies such as mine and other organisations running helplines and support lines have seen an increase in the intensity and duration of calls.

People are often very distressed and people sometimes find it difficult to step over that threshold to seek help. This is something they might not have done before and they have often been relieved and surprised to realise the level of support that is there. Agencies would always say that no problem is too small. If it is a problem for someone and it is impacting on his or her quality of life, relationships, ability to go forward or view of the future, he or she should definitely reach out for help. Most people gain these supports in the context of their families, communities and social relationships but as the Deputy mentioned, about 90% of all mental health issues present to primary care in the first instance and that is about 30% of all GP activity. That was abated somewhat with telephone visits, etc., during the early stages of the lockdown and that was a real challenge for people in terms of gaining access and beginning such a conversation.

Huge progress has been made in the area of mental health in recent years. Recovery is a real prospect and it is important that people step forward and avail of the services and do not shy away or stay back for fear of Covid-19 as we have seen in other parts of the health system. The pathways have been cleared and are easily navigated but there are some additional delays because of the requirement for personal protective equipment, PPE, which poses a particular issue in the mental health context. Engaging with a person who is in distress or experiencing a vulnerable time while wearing a mask is a real limitation. We have been interacting with some of our international colleagues and some world designers to explore ways to get past that and to have PPE that is appropriate to mental health.

There has definitely been a different nature of mental healthcare need. Many of these needs can be resolved through local community engagement with volunteers, NGOs and different organisations that are happy and pleased to help and that sometimes use mental health technologies. Mental health services are available 24/7 for young people and older people and for the general adult population. That is the important message we want to send out today.

I refer to the previous question on the WHO recommendation that 12% of health service budgets be spent on mental health services and in Ireland we spend in and around 7% as I heard said. Does Mr. Rogan have a percentage breakdown of the age and gender of those he has seen in the past 12 months or so or has there been an increase in any particular cohort seeking mental health services? Mr. Rogan mentioned young people, for example. One of the common issues we all come across is the dual diagnosis case of those who may have a drug addiction as well as mental health issues. What is the panel's overall view on how we go forward in treating that? Is the lack of funding going into mental health services a barrier to that?

Mr. Martin Rogan

One of the things we have seen in recent weeks is that sometimes when people have mental health issues they do their utmost to pretend they are fine and they minimise and carry on with things. When family members came together, they suddenly discovered that their partner, son or daughter was masking a significant mental health need, be that anxiety, depression, an eating disorder, drug or alcohol use or gambling. These difficulties have then come forward quite pointedly and urgently. In the last week, the HSE has published its 2019 service update on all population areas and the different age ranges. We can expect to see a slow burn effect as a result of Covid-19. People cope in the immediacy of the here and now and having come through that, sometimes when people look back they feel the dislocating effect and the fact that certain routines and supports protected their health, such as outdoor exercise, connection with friends and a range of activities. When these supports are withdrawn, it is only over a period of time that the real effect of this becomes more apparent. We can expect to see this emerging more over the course of this year.

Ms Kate Mitchell

I will come in on that briefly. On the Deputy's first comment, most of the data we have on the demand on services is in the community and voluntary sector and we have seen that from numerous groups such as my colleagues in Jigsaw. SpunOut.ie, the youth online information service, has seen an increase of 44%. MyMind, which provides online and face-to-face mental health services, has seen a tenfold increase. We are seeing particular challenges in accessing services for particular groups of individuals, such as people who are experiencing eating disorders, for example.

We need to ensure that those services are adequately resourced and that people have easy access to services.

The Deputy commented that primary care should be meeting 90% of the need. That is accurate but there are issues about lack of capacity, and primary care services need to be appropriately resourced. We can see that in the long waiting lists for primary care psychology, for example, where more than 8,000 people are waiting for a first appointment. Approximately one third of those have been waiting for more than a year to be seen for the first time. While services are already under strain and we are seeing increased demand, the Government needs to match that with appropriate resourcing.

In terms of particular groups of individuals, the UN and the WHO have identified particular groups of individuals that may be at risk, including young people, those experiencing domestic violence, and front-line healthcare workers so our services need to be prepared to meet that need. One of the ways we can do that is to immediately establish the implementation group that should be set up to ensure implementation of the new mental health policy, Sharing the Vision: A Mental Health Policy for Everyone, to ensure that the particular needs of these groups of individuals are adequately met.

Mr. Paul Longmore

If I may answer the Deputy's question also, in terms of Jigsaw specifically, while we saw a brief initial dip in the level of referrals around the end of March, since April the level of referral has been rising steadily and is now at the same level it would have been last year. It remains to be seen if it continues to increase. Of note is that there is an increased level of referral among young adults. We are a little unusual in Jigsaw in that we work with 12 to 25 year olds so we are seeing an increase in the level of referral from young people around the ages of 18 to 20. That could be because many of those young people may have been affected by the loss of jobs as they would often be working in sectors that have been particularly affected such as the hospitality industry, retail, etc.

One fact that we know about demand is that even pre-Covid-19 the demand for mental health services for young people far exceeded the capacity within the system. We can only anticipate that that will be exacerbated post Covid-19 but in some ways we already know that we do not have enough capacity within the system. That is something we knew in January, February and early March of this year and it remains to be seen to what extent those difficulties and that lack of capacity is exacerbated by Covid-19.

I thank everybody for those responses. We spoke about primary healthcare services. I would say they are patchy, to say the least, in certain parts of the country. My fear is for those who live in areas where they cannot avail of services and also in terms of the strain on GPs across the country. That could create barriers, unfortunately, for those who are trying to access services. That is an important element in terms of either funding to assist with that or for the review of services. I thank Ms Mitchell for her comments on Sharing the Vision: A Mental Health Policy for Everyone. There is certainly a need to see the implementation of that as soon as possible.

I thank all the witnesses for attending. I would like to explore online mental health services - the phone line and the Internet aspects. We have spoken about some of the benefits of that, and there are many benefits to it, but I am concerned about part of it in respect of people who do not have Internet access or phones, which I know was an issue with, say, young people in care or young people who had recently left care who would not have computers or phones to allow them engage in these projects. The witnesses might talk about some of the pitfalls of working in that kind of remote setting. We have spoken about some of the cohorts who did better but I refer to cohorts who engaged on a less frequent basis who found it difficult or cohorts who could not engage at all. They are the demographics or cohorts the witnesses would normally engage with but who disappeared during this time of Covid-19.

One of the witnesses spoke about communicating with older people via Zoom. My parents took to it, but other people's parents hated Zoom and would not engage with it. It is not necessarily a service for everyone. Can the witnesses talk about the pitfalls and the demographics or cohorts who could not engage with that service?

Mr. Martin Rogan

In recent months, we have seen the rapid adoption of a range of technologies. As the Deputy says, we have all become very conversant with Zoom, FaceTime, Skype, Microsoft Teams, etc. These have been very useful tools. The technology can do certain things that human services cannot easily do with regard to availability, making geography irrelevant, providing a low threshold of access, proactively providing information that people can tailor and dynamic signposting. In our organisation we have hosted conferences for families. We have provided training for older people's services and a range of partners across the community and voluntary sector. The technology can do many things but we must be mindful of its limitations. Some of those are to do with the individual, who may not be comfortable with these technologies or may not have access to them. There can be a digital divide. To ensure the reach of our organisation's messaging we found ourselves buying space in provincial newspapers in areas where we knew broadband coverage was not sufficient for people to access our website. There is a range of new materials on the website. In the next ten days, we will be hosting an international conference which was originally due to be in Kilkenny. Colleagues from all over Europe, perhaps 500 or more, will be tuning in. The technology confers certain benefits but there are very real limitations.

As has been said, individuals are sometimes cautious of mental health services or reluctant to avail of them. Sometimes family members are very concerned and ask how they can make sure that their son, daughter or family member is seen. That simply cannot happen when a person is in great distress, is actively unwell or declines service. In some cases, we simply cannot reach out.

Good quality mental healthcare is about creating a therapeutic alliance between a skilled professional and the person availing of the service. We are providing more and more peer-led services through co-production. Almost half of the staff of our organisation is composed of people who have recovered from significant mental health needs and are now providing educational programmes and a range of different activities through a network of recovery colleges. There is very little that can substitute for that human contact and presence. We also know that people sometimes find it more comfortable to avail of services on their own terms and in their own time. Quite deep psychotherapeutic assistance can be offered online. However, this presupposes that the person has a private space at home, has access to technology and will not be interrupted. Moreover, if a person becomes unsafe or unwell, the technology does not allow us to reach out, hold that situation and keep it safe.

We also recognise the benefits of technology with regard to inpatient admissions for young people in child and adolescent mental health services, CAMHS, units. Many of these patients have not seen their parents since March. That is a precautionary measure which has kept them safe, but it is a huge sacrifice to ask of young people. Skype and FaceTime have been a bridge, but it is not quite the same as being in the same room as one's child when he or she is going through a period of distress.

There are very real limitations. We are learning more and more about this technology and some of the clever things it can do. We need to know when we can apply that tool most effectively and when it becomes a barrier to the formation of the therapeutic relationship which is key to quality mental healthcare.

Mr. Paul Longmore

I thank the Deputy for the question. I echo much of what Mr. Rogan said. One of the key lessons for us in Jigsaw and part of what we have been told by young people during the Covid-19 restrictions is that there is no one-size-fits-all solution. There is no single way of providing a mental health service which works for everybody or meets everybody's needs. We have worked hard to provide a suite of offerings to provide access to as many young people as possible. These include working via telephone, video call and live webchat, asynchronous communication via email and the reintroduction of our face-to-face services. The most effective approach is to tailor our clinical therapeutic offering to the unique circumstances and preferences of the young person and his or her family. That is what is most likely to have good outcomes.

We are trying to have a suite of services that offers choice to young people, that is flexible and adaptable and which can therefore reach as many young people as possible. The young people who avail of our services are more likely to receive a service which is suitable and effective for them and which provides them with a good outcome. There can sometimes be a temptation to think that there is a holy grail, that there is one way, and maybe that is online. We have found that online does not suit everybody in the same way that face to face does not suit everybody. Having a suite of offerings is the best way to offer a quality mental health service to as many young people as possible.

I thank the witnesses for their presentations and for answering the questions so far. Mr. Rogan mentioned that in July, Mental Health Ireland allocated €90,000 to local mental health associations to replace lost funding. I imagine that is not a euro-for-euro reimbursement. Approximately how much money has been lost due to the inability to fundraise for Mental Health Ireland's associations in recent months?

Mr. Martin Rogan

Mental health associations are volunteer driven and raise funds in their local communities. They spend those funds within their communities promoting positive mental health and supporting people with significant health needs. Right across our network people have discovered they have had to cancel different events, sometimes very low-key events. It is really important because communities really want to support the activities of local mental health volunteers. People have been very generous, particularly online, and Mental Health Ireland is very careful to ensure our own fundraising does not impinge on our local volunteer network. We opened up an application scheme and invited groups to come forward. Some found they were doing fine and could manage. We also had a second round of funding. In July we have allocated more than €90,000 in a series of grants to ensure that services can continue and improve in their adherence to social distancing. I was on a Zoom call yesterday evening with some colleagues working in the Rathmines area. A simple device such as adding an awning creates additional outdoor space which means that people who could become very isolated, perhaps living in bedsits etc. in inner city Dublin and in the Rathmines area, can still avail of the service, albeit in a measured and socially distanced way.

Mental Health Ireland's strategy is called empowerment from ideas to action. We are asking how we can give pragmatic expression to public policy and ensure that people do not in any way feel isolated or left behind. We have had to reach out to try to bridge that gap to some extent. It is something we have not done before, but because of the generosity of people donating online, we have been in a position to do that on this occasion.

It is really difficult to quantify the degree of loss on that. Each association has submitted its accounts and I can return to the Deputy with that detail.

Mr. Rogan mentioned that many new referrals to his services from younger people aged between 18 and 20 would be due to lost jobs in the retail and hospitality sector, which is very understandable. Perhaps Mr. Rogan will not be able to answer this. What level of new referrals are for people suffering from anxiety over how the State is responding to the pandemic? I refer to people who have issues with physical social distancing, people wearing masks, hand hygiene etc. Are we seeing a big spike in referrals for people who are directly anxious about these issues that are to the fore in this pandemic?

Mr. Martin Rogan

Across our entire population, people are at different levels in terms of their understanding, their comfort with risk and the adaptations they have had to make. We recognise that some people who use mental health services have sometimes found it difficult to adhere to the social distancing limits. That has been a challenge and quite a concern for family members who have made contact with us. Going into lockdown was probably a bit easier. It was a simple message to stay at home. Now it is a graded message and people have to adapt to that and take back more personal responsibility. Sometimes we are inclined to surrender decision-making by saying: "An expert told me to do the following and that is what I will do." We are now at a point where we are depending much more on the individual along with their family contacts and their local communities, including the business community, to take responsible steps to stay safe and not to allow the virus to return.

Wearing masks can be uncomfortable for some people and can induce a degree of discomfort or anxiety.

What has been really important has been the sense of sonder. Sonder is where we appreciate that other people have complex lives and, in a mental health context, that this is not a solo pursuit, that it is a collective, pooled exercise and that when we care for each other, which we signal by wearing a mask in a public space or on public transport, it is a courtesy to others and it is reflected back. That bond has been really powerful and has been quite protective and supportive of people's mental health over these past weeks. We need to retain that as we go into the next stages. There are many supports for people who are concerned about anxiety and lots of good information on websites, which can provide practical solutions on how to overcome any sense of fear that people have. Paul also has some references on this.

Mr. Paul Longmore

With the young people we meet in Jigsaw, we continue to see anxiety and low mood as very prominent reasons for referral. Many young people are experiencing a significant amount of disruption to their routines and to their relationships. Their expectations of what their lives would have been like this year are very different, whether in the context of school, college or sitting the leaving certificate. That sense of uncertainty and disruption to routine is difficult. There is also the concern regarding family members who might be ill or elderly. All of these things contribute to a sense of anxiety. The restrictions relating to Covid-19, while necessary and required, impact on people's mental health and may make it harder for some to use the day-to-day mechanisms that they would use to manage and support their own mental health. If these mechanisms are disrupted, it can make it difficult to be resilient in the face of the challenges we are all facing at this time.

I welcome both groups and thank them for their presentations. Given that Covid-19 has such a major impact on young people right across the board and from a very young age, it strikes me that one has to ask who is actually providing supports for children under 12 years of age. It is probably an issue to raise later with the HSE, and I will pursue that.

There is no doubt that the crisis has a huge impact on those young people in their teens and early 20s. The crisis has given rise to all kinds of questions about their future, restrictions with regard to meeting their friends have been imposed and they are subject to the same uncertainty and fear that we are all experiencing. In view of the fact that before the advent of Covid-19 there were long waiting lists for all mental health services for young people, one must wonder how we will cope as we come out of this pandemic. Has consideration been given to providing schools and college programmes as a way of reaching a wider cohort of young people?

Dr. Joseph Duffy

Jigsaw has been doing significant work in supporting schools, particularly post-primary schools. This work is done under the auspices of One Good School, which looks to support the whole school as an entity in itself. We provide training for young people around peer education and support for classes, and we also provide training for teachers and parents. What we have noticed in the three months of the Covid period is that 7,500 of the online e-learning courses we offer were downloaded. Almost 5,000 of those courses have been completed by teachers. This shows a significant need to get the support for teachers and schools in supporting young people.

As we move back to school in September, we are looking at the transition back into the school setting, managing anxiety, reconnecting with the classroom, minding one's mental health and self-care for teachers. Jigsaw, operating very closely with the HSE, is very conscious of working on the broad psychosocial model. This takes the view that mental health supports are not just provided on an individual basis, they are also provided on a community and societal basis. The supports we can provide to schools will be very important as we continue to see the impact on young people.

We know that some young people will be anxious coming back to school, some will be delighted for the experience of something new, and many will be in the middle. They will be concerned about their exams and what it means for their projected future. The important thing is normalising that experience and providing as much support as possible. A lot of positive work has been done linking National Educational Psychological Service, NEPS, the Department of Education and Skills, and the health and well-being section of the HSE, which have worked together on this. Obviously, a huge amount more is to be done. The new Sharing the Vision policy and the new well-being guidelines from the Department of Education and Skills will help.

Is the intention to deliver a school-based programme? Has work been done on that?

Dr. Joseph Duffy

Yes. That is work we are already carrying out.

A programme will be provided.

Dr. Joseph Duffy

Yes.

A programme will be provided in all schools.

Dr. Joseph Duffy

No, it will not be provided-----

How has funding been impacted?

Dr. Joseph Duffy

We have very good and steady funding from the HSE for the service delivery element. Our fundraising has decreased by about 40%. It has been significant in community fundraising.

How much does that amount to?

Dr. Joseph Duffy

It amounts to about €700,000.

Okay. My next question is for Mr. Rogan. What has he come across in terms of substance misuse arising from mental health issues associated with Covid, particularly relating to prescription drugs, alcohol and other drugs?

Mr. Martin Rogan

This is a really important point. An earlier question referred to dual diagnosis. Often when people are in difficulty and they do not recognise a range of different supports that are helpful and constructive in their lives, people are inclined to resort to old familiars. Especially in the Irish context, alcohol is a huge issue. We have seen Central Statistics Office, CSO, data on this. Even though pubs were closed, consumption of alcohol in the home, often at dangerous levels, has been a feature. It is something we need to be very mindful of. We are also seeing people moving towards prescription drugs. We spoke earlier about the importance of primary care, but it is important it has a whole range of tools and not just a prescription pad. We know, for example, that 10% of the Irish population are on antidepressants.

Has that increased? I am asking what is being found in the context of Covid apart from the general problems we have. Have the problems been exacerbated?

Mr. Martin Rogan

I think they have been exacerbated. It is having an amplifying effect so that people are inclined to use and overuse their traditional coping mechanism. Every one of us has experience of this over recent months, of being overwhelmed and having to take time or space out to try to reset our normal levels of equilibrium. Unfortunately, many people are inclined to use prescription drugs, street drugs or alcohol to excess to achieve that. We do not yet have a full measure on that but the CSO data on alcohol, which is probably best tracked, and some of the recent drug seizures, something the Garda has been very successful in, suggest an escalating demand on that too.

Ms Kate Mitchell

While we have some very valuable data and research, it is limited in what we know about the current impact of Covid-19 on mental health. Some research has been carried out by Maynooth University and Trinity College Dublin in collaboration with universities in the UK, and Mental Health Reform has carried out consultations with its member organisations. However, what is essential is a firm and solid commitment from the Government to measure and monitor the impact of Covid-19 on mental health across the population and particular groups of individuals, whether that is people from ethnic minority groups, people experiencing dual diagnosis, or members of the homeless community. That is essential if we are really to understand the impact and plan accordingly.

I thank the groups for their submissions. They were very insightful on what has happened during the past four months in the public health emergency. There is a juxtaposition between the amazing outpouring of solidarity and support, with people coming together across society, which might not normally happen, and self-isolation and the isolation of the public health emergency.

It has taken a significant toll on many people and is almost unquantifiable in terms of its extent. The unintended consequences that will arise as a result will probably be with us for a long time.

The fault lines in the public services that have not met the needs or demands of the populace through the past 12 months have become clear in the past four months. There has been much reference to pent-up economic demand, but there will be significant pent-up demand for mental health services. Can that demand be met through the resources currently available to mental health services?

The submission of the Mental Health Commission states that 114 staffed community residences are unregulated. Why are they unregulated? Alarm bells ring when one sees the word "unregulated". Who is regulating those services? Such regulation is of particular importance currently, in what is, for most people, an extremely challenging time.

My first and substantial question was whether mental health services can meet the demand that will inevitably arise as a result of the current public health emergency.

Dr. Joseph Duffy

On the Deputy's question regarding whether demand can be met, it will be a struggle to meet it. It was a struggle before Covid and it will continue to be a struggle now. Reference has been made to the importance of further investment in mental health in the context of the overall health budget. That would be very welcome. It is very important that we look at the mental health budget in the context of a system of care, taking account of the areas of prevention and early intervention, on which Jigsaw is focused, as well as longer-term and tertiary care. It is about having appropriate targets and supports at each of the levels.

Ireland has embraced the idea of prevention and early intervention in the context of Covid-19 and people understand those concepts very well. It is important to promote the concept of early intervention in the area of mental health. My colleagues present mentioned the importance of identifying and understanding the mental health problems that will arise due to Covid as well as getting the important supports for those in place as soon as possible. The level of investment needs to be considered not just in the context of traditional mental health services and the CAMHS and adult mental health service teams, but looking at wider supports and the broader psychosocial model of mental health.

Mr. Martin Rogan

It is particularly important that we recognise that mental health services are a component of services provided to meet the needs of the entire population and that the profile of needs can vary. For example, CAMHS is designed to cater for 2% of the population who have an extreme level of need. The question is what comes before that. There is an increasing movement in the mental health space towards promoting positive mental health. A public health model is beginning to emerge in which consideration is given to urban planning and how and where people live their lives. Many lessons have been learned from the pandemic. We have seen an extraordinary community bond and solidarity. It has also shone a spotlight on the need to address certain dependencies with regard to terms and conditions of employment, particularly in the context of precarious work. We are at a reset moment. Before we repack the boot of the car, we must be sure that we are packing things that we really want in our communities. These are significant decisions that we have an opportunity to reflect on and revisit.

On how we invest in our mental health service, it is very important when it comes to, for example, promoting positive mental health that we do this in an evidence-based way. We have worked with Professor Margaret Barry of NUI Galway who is a world expert in this area and developed a new level 9 programme that will produce 25 graduates this year. Taking an evidence-based approach means that we are much better informed regarding what works, what is effective and what is acceptable to communities. It allows us to create strategies and life approaches that people can use to protect their mental health, that of their family members and that of those in their community.

The Deputy also mentioned unregulated residential settings. This is not quite something of a legacy from our past but one must remember that in 1950 Ireland held the world record for psychiatric hospitalisation. Almost 1% of the Irish population lived in what were then large mental hospitals. As people moved back to their communities, and were received well back there, often with the support of volunteers and staff members, large numbers of community houses were established. These were often quite congregated settings which were sometimes not ideally or purpose-built. Often convents, old nursing homes, or small hotels were taken on for this function. We can still see the last embers of that. Unfortunately, as we saw in the tragedy in the Maryborough Centre in Portlaoise where eight people who lived there passed away as a result of Covid-19, this has had a hugely traumatic effect on their families and for the staff members who have made valiant efforts to protect that group. The physical infrastructure did not lend itself to that. It is very difficult for a person to live a dignified independent life where they do not have their own accommodation or space and where they are sometimes even sharing bedrooms with an unrelated adult. We can do better in 2020. We have made big progress but we need to finish that task to ensure that everybody has good quality accommodation, can live in their own space and make their own decisions. That whole message around recovery and stepping back into a full life within the community is absolutely critical to what we do across the mental health sector.

I thank Mr. Rogan and Deputy Kenny. I call Deputy Michael Collins now to speak.

I thank the Chair and our guests for attending today.

It is estimated that mental health problems cost the Irish economy more than €8.2 billion a year. During the past four months face-to-face counselling has ceased for the thousands of adults and children who are supported by the mental health services in Ireland. Experts are warning that our social healthcare should be prepared for a tsunami of need which will emerge in the aftermath of this crisis. Along with the many thousands of people who are currently attending mental health services, we are being told that there is a new at-risk group emerging from this unprecedented crisis. These include children, young people, adults and old people whose lives have been disrupted by economic and social upheaval. The distress suffered by this group may already be evident while others will suffer from delayed trauma. Given that mental health services are already stretched to the limit and that extensive waiting lists exist due to a shortage of qualified clinicians, what do our witnesses know of any plans that are in place, if any, to deal with this emerging crisis in mental health services?

Mr. Martin Rogan

That point is very well made and it is very important where we put this resource. We need to frontload it and to be very careful because for the whole population we have had this extraordinarily unique experience. It has been a time of uncertainty and is a space that we have never been in before. We have all also been learning our way across this path. We need to frontload this to keep people well and in community, in their routines and in employment. We know that unemployment is perhaps one of the most dangerous occupations to have. In Ireland we have seen this in very recent memory, where Irish people remember the very corrosive effects that unemployment and recession have had and the losses and tragedy associated with that. We know what not to do.

A whole series of measures are very important across quality of life, people’s health and that people have access to services that are informal and easily accessible, be that in the community and voluntary sector, in primary care, or indeed in mental health services. These need to be properly resourced and to be in a position to respond to people in a very constructive and creative way with a series of choices that are comfortable to the individual. With Sharing the Vision: A Mental Health Policy for Everyone, we have a very strong outline on how we can do this. It is about outcomes and what our objectives are. As a community, what is it that we wish to see so that everybody can live a full life and people can come in from the margins? We have seen people who have rejoined our country in recent years and who have come back from overseas. We have migrants joining us, we have had members of the Travelling community and we have had people living in precarious situations in homelessness. We can revisit these things because we know that these are damaging not just to our physical health but also to our mental health.

It is unedifying for all of us if any of our fellow citizens live like this. This is like what the Americans used to say, which is that nobody should be left behind. We need to have systems in place in our educational establishments and in our workplaces that are conducive and supportive to people’s mental health, in recognising that people have sometimes been traumatised by this experience, and have been seriously unsettled. The uncertainty has had a corrosive effect.

We need to be patient, a little kind, and mindful of people’s experiences. Family members have often struggled over the last number of months trying to do their day job by Zoom together with homeschooling children at the same time. This has been extraordinarily stressful and there is a recognition of that.

Employers have been very good at stepping forward and most have been responsible in that space, although not all unfortunately. We need to be alert to that piece as well. Across all of our community, we need to mobilise and be extra alert. We have all been through a tough time and we need support, affirmation and acknowledgement from our colleagues around us and our neighbours, which has been a really powerful learning in all of this. We could almost consider Covid as something of a dress rehearsal when it comes to addressing some of the huge issues facing our society in terms of the economy, unemployment and climate change. We have demonstrated what we can do when we pull together and if we can mobilise that attitude again in the coming months, we could be unstoppable.

Have inspections of mental health facilities continued during Covid-19?

Mr. Martin Rogan

I understand the Mental Health Commission is coming in later in the day and it is probably better positioned to respond to the question.

Does Mr. Rogan have an idea how many cases of Covid-19 were detected in mental health facilities?

Mr. Martin Rogan

Again, the HSE is coming in later today and it will have that data up to speed.

During the lockdown period, many parents of adults and young children who suffer from mental health issues found it incredibly difficult to manage their special needs children around the clock with no break or respite. Now that restrictions have been lifted to a large degree, when will respite resume for these vulnerable people?

Mr. Martin Rogan

Again, perhaps the HSE is in a better position to respond to that. Certainly, many families get support from a variety of different providers, including the HSE and providers in the disability NGO sector. Many of these services have had to be wound back and hours reduced. Even an element like transport to the services has to be adapted in the context of social distancing and the provision of PPE, so there will be an additional cost to how the services are provided. There will also be time streaming to provide services to people who cannot observe or may not fully understand the limitations, and who find it very difficult in terms of sensory stimuli and so on to engage with a person wearing a mask or other forms of PPE. There is still a lot more learning in this and it is at the early stages of reopening on a highly prioritised basis, as I understand it. However, it is not a field I am actively working in.

Mr. Paul Longmore

I want to go back to the Deputy’s first question in regard to resources. To make a further point, there seems to be general acknowledgement of the need for further resourcing of mental health services but we also need to get best value from the resources already in place. We spoke earlier about having multiple tiers of support and service available at a universal level and at a population health level, as well as in primary care and specialist services. I also believe that what we need is better integration across those different levels of service provision and better integration between the community and voluntary sector and statutory services. In some communities and localities this worked extremely well but it could be more consistent. The better the integration between services, the more likely it is that a person who presents to any point of the service system will be facilitated to get to the service they need in a timely fashion. That is another important matter for us to bear in mind when we think about resourcing in that we need to get the best use of existing resources in addition to the need for further resources.

With regard to care of the elderly facilities, the HIQA standards recommend that 80% of bedrooms should be single occupancy. Do the same standards apply to mental health facilities across the country?

Ms Kate Mitchell

One of the key issues is that mental health community residences are not currently regulated, and Mr. Rogan explained the historical context to that. The reason that practice continues is that there is a flaw in current mental health legislation that allows the non-regulation of those residences. Mental Health Reform has been campaigning for years for the urgent reform of Ireland's mental health legislation to ensure it is updated in full so that, if and when people go into hospital for mental health care and treatment, their rights are adequately protected. However, reform of that legislation will also address that existing flaw and extend the powers of the Mental Health Commission so it can regulate those community residences across the country.

As my colleague mentioned, there are concerns about the practices in some of those residences that make their regulation even more imperative. These practices have been well reported by the commission.

The next speaker is from Sinn Féin.

I have a number of questions for Mr. Rogan. The Mental Health Commission can obviously speak for itself but Mental Health Reform and Mental Health Ireland have a role to play in advocating for improved mental health services. Did Mr. Rogan read the commission's latest report, published on 2 July?

Mr. Martin Rogan

Yes.

There was a press release on the report that stated too many residents are still being treated like second-class citizens. Does Mr. Rogan agree this is how some residents in acute settings are treated?

Mr. Martin Rogan

Unfortunately, some of the historic dimensions are still being acted out in real time. There is a real challenge for services to come forward into a more modern format. It is wholly inappropriate. The housing needs of people who can live in the community are predominantly the responsibility of the local authorities, and their health needs are the responsibility of the HSE. It has not always transpired that way. Often the health service has continued to provide both a home and care. Sometimes the people affected have been a hidden people, and sometimes their voice has not been heard. Our organisation works with people with lived experience, some of whom live in residential settings, to make sure their needs are fully articulated according to their preferred choices. It is important that we do not speak on behalf of them. In fact, all our work is done in co-production, which means programmes, projects and policies proceed only when people use services and when family members are actively consulted. That is where we take our-----

I thank Mr. Rogan. He said in his submission to the committee, which we took as read, that we need to ensure easy access to mental health services and supports across the continuum of care, including primary, community, acute and specialist services, as well as supporting individuals with existing mental health difficulties. Obviously, I would want to see that and we support that, but we have to base that on what the Mental Health Commission itself said in its report and on its experience of some of the acute settings. The CEO of the organisation said the fundamental human rights of residents are being overlooked and that many mental health residents are still being admitted to outdated and unclean premises. That is not a very good start if we are seeking to make sure there is a continuum of care across all the settings, including acute settings.

Mr. Martin Rogan

I completely concur. The quality of care for people at all stages in the mental health services, be it in acute, community-based or residential services, has to be of the highest standard. A Vision for Change set out a programme whereby older mental health facilities would be sold and the proceeds reinvested. That was 2006. It involved almost €1 billion in new investment, but unfortunately the recession that followed did not make that possible. Many new resources were put into acute inpatient residential settings. Regarding inpatient settings for children, for example, the number of beds was quadrupled. The residential programs for people who often spent many years in institutional settings and who were taking the step forward into the community, however-----

If we are not getting the basics right, there is something fundamentally wrong. If the premises are not suitable, there is something fundamentally wrong. The Mental Health Commission refers to no meaningful care plan for some patients in 31 centres throughout the State. One would imagine that one of the very first things put in place would be a care plan for the individual. If that is absent, we are not even getting the basics right. Is that a fair statement?

Mr. Martin Rogan

Absolutely. There is little point in being admitted to hospital unless it is a purposeful event. It is a question of what the admission is about, what the care plan is, what the person's contribution is and what the staff contribution is. This is a statutory requirement. Therefore, all service users in acute settings must have a care plan. The people in the community need to have a purposeful pathway as to how they are going to regain their independence and recover and be authors of their own care plan in collaboration with healthcare staff. Where that is not happening, there is a serious failing on the part of the services.

May I give an example of a unit in my constituency, the mental health unit in University Hospital Waterford?

There were a number of reports into that unit. One of them found it was not clean and there were overflowing bins and stains in some toilets. Patients reported sleeping on the floor in the unit. According to the Mental Health Commission, this year's report "once again demonstrates that the needs and wants of mental health service users are not being prioritised". I wish the position was better but when the commission is reporting that patients are being treated like second-class citizens, their human rights are being violated, there is no individual plan for many of the patients in centres and that in some centres patients with psychiatric needs and acute mental health difficulties are sleeping on the floor, that does not paint a rosy picture of mental health services. Is that not the case?

Mr. Martin Rogan

As the Deputy said, these issues are found on inspection so they are taken as read. These are facilities that are open to the public to see. We are not talking about second-class citizens. We are talking about Irish citizens who have needs and vulnerabilities and often have issues with their sense of personal dignity. For them to go into a setting that is not clean or adequately maintained is simply not good enough. The Mental Health Commission not only inspects but also licenses approved centres and it has a responsibility to make sure these standards are adhered to and held to the highest level. With regard to the unit in Waterford, every unit has a licence for a number of beds and it cannot go beyond that number. It is then a question of mobilising additional resources, either in the private sector or in surrounding services, when there are additional pressures. These are fundamental issues and it is extraordinarily difficult to promote a person's dignity and independence in a setting that is not up to standard.

I wish Mr. Rogan well in his ongoing work in advocating for mental health patients and good mental health.

I thank the witnesses for appearing to give us their views and advice on the challenging times we have experienced in the past three or four months. One of the problems I am coming across is that of young people aged over 18 who have challenges, either depression or mental health problems, and are distancing themselves from their parents. The parents, who want to give support, find it frustrating that they are being excluded. Is there a need to provide support for parents in such circumstances? I have encountered a large number of such cases in recent months. It is challenging for parents to try to deal with this issue.

Mr. Paul Longmore

Parents are the people who are most concerned about their children and the young people in their lives and that does not cease when their children turn 18. It can be particularly difficult for parents when their young adult children are experiencing difficulties and they are seeking to support them. We have to provide support to those parents and one of the measures Jigsaw took during the Covid-19 restrictions was to introduce a freephone service. Young people contacted us in other ways but it was interesting that the freephone service was primarily used by parents who were seeking advice, guidance and information about their children who they were concerned about. In some cases, these were adult children.

A balance needs to be struck between respecting the autonomy and independence of young people who are over 18 and providing them with avenues to access supports that are suitable for them. To that end, Jigsaw has tried to introduce low threshold entry points into service support, such as live webtext and email contact, which might make it easier for those over 18 who are not necessarily being facilitated by a parent to come to a service. They can take that initial step themselves. They do not need to have a referral from another professional. They can choose to access a service and explore it to see if it might meet their needs. We must be cognisant that the needs of a young person aged between 18 and 25 might be slightly different from those of the general adult population.

Is that an area on which we should do more work? In the case I found, the parents found themselves locked out. They could not get any information. They wanted to give supports but found they were hitting a blank wall in that regard. Should we have a more constructive mechanism in place to assist in that situation?

Mr. Paul Longmore

Good mental health services always try to engage with the system around a person and do not seek to individualise the difficulties or the support. Any service working with young people will try to engage with parents, friends and the support system around the young person. If a young person is over 18 and they decide that they do not want that, that is a difficult situation.

I want to move on to the Mental Health Reform report. Paragraph 2.5 states that many of the participants in a survey advised that they were no longer accessing treatment and were less likely to seek help from a GP, community mental health service, charity or voluntary organisation. In that survey, were people asked the reasons they would no longer engage with any of the services?

Ms Kate Mitchell

I thank the Deputy for that question. Unfortunately, it did not go into detail as to the reasons they would not engage, but what is important is that that finding indicates pent-up demand for mental health services in Ireland. He will see from that report that the findings in terms of percentages are quite high in that approximately 40% indicated that they would need fewer community health services, even if needed, and approximately 70%, which is a huge percentage, indicated that they would not use emergency departments for a mental health need. That indicates the pent-up demand for mental health services and demonstrates the need for our services to be ready for a surge or increased demand across the continuum. When we talk about mental health services and supports, we are not just talking about acute or specialist services. We are talking about a continuum of supports for mental health promotion right through to the professional element.

Ms Mitchell talks about the increased demand. How will she deliver on that demand if people who had already engaged with the service no longer want to engage with the same services they did previously? How does she now deal with that issue?

Ms Kate Mitchell

We need to learn from lessons learned during the Covid-19 crisis in terms of how to engage with people during this time, how to ensure that they are adequately protected during this crisis and that they do not have fears, if they engage with a service, that they will contract Covid-19, that adequate protections are in place, including personal protective equipment, PPE, that a blended approach is taken, and that there is a scaling up of different options of supports, including mental health infrastructure, so that people can access supports from their own homes. They are all the lessons we need to draw on from this time if and when we experience a second wave.

I go back to the issues regarding GPs. We said earlier that approximately 90% of support is provided by GPs. Is there not a pressure point with GPs in that one aspect of dealing with mental health is giving time to the individual but one of the problems we have is that GPs are under great pressure because of the volume of work they are doing? What additional supports do the witnesses believe we should be providing now to GPs to ensure they can come on board and give that time to the person who requires it?

Ms Kate Mitchell

I can start with that. The Deputy makes a very important point. As we know, primary care can meet a substantial demand of mental health need but it has to be adequately resourced. The first point to make is that GPs are one professional but there is an entire cohort of primary care professionals that can be used and adequately resourced to ensure they can provide mental health supports.

Earlier in the discussion I mentioned the fact that primary care psychology is usually under-resourced and there are significant waiting lists. Ensuring that there are a range of talking therapies for both children and adults at primary care level is one very practical way of enhancing capacity at the primary care level. Other primary care professionals, such as occupational therapists and social workers, can provide support.

Does Ms Mitchell feel there is a sufficiently joined-up approach to this? A GP running his or her practice knows that there are supports, but they are difficult to follow through on from his or her point of view. Should there be more co-ordination between GPs and the backup support services?

Mr. Martin Rogan

It is of critical importance to understand the role of primary care. As the Deputy has pointed out very well, a GP's practice can be a very busy place at the best of times, even without Covid-19. It has been suggested that a GP visit can take seven minutes. That is composed of two minutes of meeting, greeting and seating, two minutes of formal diagnosis, two minutes of prescribing treatment and a minute in which to ask the patient to move forward. That time constraint should be reduced somewhat with the implementation of Sláintecare and better access to primary care.

GPs have been very creative and responsive. Their viewpoint is really important because they do not just see patients at one moment in time. A GP sees a patient in the context of his or her family and knows the individual over a period of time. He or she can recognise if things are different. On average, about three GP visits by either an individual or a family member can elapse before the difficult topic is raised and a patient expresses concern about his or her mood, anxiety, drinking patterns etc. Mental Health Ireland works with the Irish College of General Practitioners, and Professor Tom O'Dowd to understand the tools and skills of GPs. They play a really important role in early recognition and sometimes in watchful waiting. They have an array of options. As Ms Mitchell has mentioned, this includes access to psychology, the counselling in primary care service and other initiatives. They are not limited to their prescription pads.

People are sometimes reluctant to avail of mental health services. That can arise from historical stigma or a sense of hopelessness. Sometimes it comes from a fear of losing control or a sense that the service will somehow take over a patient's life. We need a much better understanding of this. People are increasingly availing of peer-led services such as recovery colleges, where people can equip themselves with new understandings of mental health and manage their own care in a much more effective way. People who have used the service often bring a unique insight that we as professionals do not have through our training. They also carry a great sense of hope. While acknowledging that things are difficult and a patient's story will not necessarily be the same as their own, they can point to things that were helpful and unhelpful in their own lives. Those are really powerful messages for a person who is feeling deflated, frightened about the future, alienated or disconnected. This is about having an array of options that are acceptable to the patient.

When we are supporting a person with his or her mental health or promoting positive mental health, we approach things on three levels. We aim to strengthen the individual, strengthen the community and reduce barriers. Covid-19 has become an additional barrier that we must find creative ways to address. We have seen some really strong examples of that in recent months. Services that routinely go the extra mile have now gone the extra kilometre. That does not just apply to front-line services. Support teams and managers working the system have had to move heaven and earth to ensure that people can access quality services in a timely way. Waiting lists are not really helpful when a person is in acute distress or considering self-harm. That situation must be addressed immediately. GPs are at the front line of that in many instances.

There will probably be some time at the end if Deputy Burke wishes to speak again.

Based on what everyone has said, it is fair to say that we are starting in the wrong place where mental health services and funding are concerned. Many people have stated that mental health comprises 7% of health spending, which falls short of the 12% minimum called for by the WHO. I would like to commend the witnesses for their work, advocacy and service provision. Web-based services are limited by geography, Internet access and privacy, so face-to-face care is often necessary. We all fear that people suffering from adverse childhood experiences and older people who find themselves in bad situations will have had much worse experiences when cut off from school, work or other means of escape.

In the long term they will require more services.

My first question is on dual diagnosis, addictions particularly drugs and alcohol and the crossover with mental health. Very often these people fall between services. That happens at the best of times and it is obviously possibly worse at the moment. They become a disaster for themselves, their family and the State services, particularly the Garda. What are Mr. Rogan's views on the protocols, resources and possibly legislation required to ensure that the no-wrong-door approach to access to services is put into operation?

Mr. Martin Rogan

Sometimes the apparent artificial separation between mental health and addiction services does not serve the individual well. We need to build services that are person centric without structural factors in terms of who is funding this programme. It is about how we respond to the person in the complexity of their lives at that moment. People often resort to alcohol, and prescribed and street drugs to respond to the great stress they are feeling, sometimes, as the Deputy mentioned, related to adverse childhood events, ACEs, as they are known. There is the whole trauma-informed piece. They can descend into a period of chaos for themselves and their family members who are reaching out and trying to support them and at the same time limit the damage.

The no-wrong-door approach is particularly important. People should be received at point of presentation and the engagement should continue on - what our American colleagues refer to as a warm handover - meaning that they do not leave the service until they have been successfully integrated into one that is more appropriate to their needs. There are degrees of shared care. It seems bizarre to say to a young person with psychosis, "If you just stop smoking the weed and then come back to us, we'll talk about schizophrenia and how we are going to treat that." That is not a realistic model and it is not one that we are seeing.

There are also opportunities. For example, in the prison population where people with addiction issues are well over-represented, it presents an opportunity - a period of stillness of calmness - to address a range of both mental health and addiction issues. All prisoners are assessed on arrival and about 7% are found to have a psychosis, which is about twice the international norm. About 80% of these people who had availed of mental health services in the community sometimes had fallen out of the service, declined service or lost the service. We need to understand these pathways and design services built around the individual as they are rather than as we would wish them to be.

There has been quite a complex history with alcohol. I am reluctant to criticise policy. Even in the previous policy, A Vision for Change, the word "alcohol" appeared about three times. It looks more like a mental health policy for Saudi Arabia rather than one for Ireland. We need to be much more honest, own these situations and respond accordingly. GPs are often left asking where the treatment portal is for a person who is now ready to revisit their alcohol use. Does that happen in an acute hospital or a specialist detox programme? At one point in the past, half of psychiatric admissions related to alcohol. That is no longer the case since the late 1980s. The question is: who has stepped into that void? It is not always obvious who best does that.

There should be straight protocols to ensure this happens.

Another group that falls between stools are people who are often told they have a behaviour rather than a mental illness. These people can display behaviours dangerous to themselves and others. Sometimes only the gardaí can take action when a crime occurs. It is a waste of services and puts people in real harm. What needs to be done? What can be done?

Mr. Paul Longmore

Some of the issues the Deputy mentioned, speak to the situations in which some people find themselves whereby the nature of their difficulties seems to exclude them from all services for some particular reason. Referrals end up going between services without any clear line of responsibility and any clear service offering support to that person.

I spoke earlier about service integration, which is often key in these situations. Mental health services and services generally are often presented with unique and complex situations which require some making sense of and understanding. If services can do this in a collaborative way and come together to discuss these things, they can decide which service or combination of services is the best fit for the difficulties that individual is experiencing.

Greater levels of communication and collaborative decision-making ensure that nobody is left without a service or to be bounced, in the context of referrals, as some people experience. As Martin Rogan stated earlier, it also allows for shared care where different services come together to offer a suite of supports that might meet different needs in a person's life or within a family.

There have been various concentrations of Covid-19 in the population, one of which was in direct provision and another occurred in meat plants, where there is a very high proportion of non-Irish workers, including third-country nationals who are not from the EU. Where and how can persons in direct provision or migrant workers who are undocumented seek mental health support in Ireland?

Mr. Martin Rogan

The model of mental health care in Ireland operates on a catchment area or sectoral basis. A person should first present to his or her GP who will then guide the person towards services. Mental Health Ireland has worked with migrant communities in a variety of settings. Sometimes people come in difficult circumstances and with a traumatic history, such as that relating to conflict situations, abuse or human trafficking. These are very difficult circumstances. Where a person lives largely determines which mental health service will engage with him or her and how it progresses. This has its limitations, especially for people with unstable addresses or for those who are homeless. They can find themselves shuttling from place to place. This comes back to the earlier reference on points of presentation where the service needs to embrace the individual, stabilise his or her situation and then see where are the four pathways for the person to move forward.

The outbreaks that were seen in meat plants are sometimes about close proximity working. It is also about people living in very limited and poor housing conditions, feeling unsupported, and sometimes there are language issues where the person does not fully know what services are available. These are elemental questions about equity, respecting people's work and minimum wages, and they simply must be addressed. If we know that the living wage is €2 north of the minimum wage it means that this staff member is contributing €2 to the employer and to the State for his or her labour. This does not respond to human dignity and it does not promote positive mental health. We need to revisit these issues, which are difficult topics for all of us. When we go to the supermarket we want cheap cuts of meat. The question is: "Who is contributing to the cost of that?" We need to be honest and respectful to take a human rights approach and a human dignity approach by asking if the person is being fully respected and fully rewarded for the work and skills at all stages of a product lifecycle. We have certainly learned a lot on that in the last months.

There is an opportunity for us, as an island, to pull together and work alongside each other to properly respect people who come to our country and make a huge contribution to our economy. This would promote mental health. If these people run into difficulties, local GP services may have a mental health model incorporated, and the local mental health services will engage with the person also. There can be linguistic and cultural issues. The HSE has invested in providing interpretation services and so on. It is, however, not ideal for a person to avail of a mental health service through a different language, which can be a challenge.

There has been a high proportion of cases among healthcare workers. There were some startling revelations at this committee that were subsequently disputed. The unions that primarily represent healthcare workers will come back before the committee. I note from a World Health Organization report that 47% of healthcare workers in Canada reported a need for psychological support, in the People's Republic of China 50% of healthcare workers reported high rates of depression, 45% reported anxiety and 34% reported insomnia. Have the witnesses seen a prevalence of healthcare workers seeking mental health supports recently?

Mr. Martin Rogan

There has been collaboration with some international colleagues, including Dr. Joshua Morganstein and Dr. Brian Flynn in the United States of America who are experts in this field.

They described how, when there is a huge event that is traumatic, such as a terrorist event, school shooting or major weather event, it is timebound. They know that it is really difficult, time becomes elastic in the middle, but in three or four days the dust, sometimes literally, will have settled and people can get back to their lives again. It can be really difficult during that three or four day period but people know it has a terminus - it comes to an end. One of the challenges with Covid is that we do not know if we are midway through it or only, say, 10% of the way into it. We do not know where we are on the Covid time bar and that makes it particularly difficult. Healthcare staff have the added concern that they are working very intimately with people, using PPE and all the protocols and professional skill sets but they always have a concern that they will bring the virus home to their family and undermine their household health and that of vulnerable people they support. The HSE has introduced models whereby staff can stay in hotels and so on to avoid doing this.

Another phenomenon to which we need to be alert, which was also described on the recent tele-call with international colleagues, is one known as moral injury. This is when a person in a leadership role takes a decision based on the information he or she has at that moment, and that is absolutely correct based on that, but new information comes into the frame days later and the matter takes on a different complexion. For people who others look to for expertise, wisdom and experience in a given area, that can have a corrosive effect on their ability to lead and make decisions in the future. We need to be very mindful of that. People have been exposed to difficult and graphic circumstances and fast-moving and overwhelming situations. Working in closed spaces with PPE is very difficult over long shifts. The provision of employee assistance programmes-----

The specific question was whether a specific increase in healthcare workers seeking mental health supports had been observed and, if so, whether Mr. Rogan can quantify that as a percentage. I appreciate that I am trying to reduce the question to sums.

Mr. Martin Rogan

As Ms Mitchell noted, it is still too early to have that data. Monitoring and understanding this is an extremely important task for us so that we can learn from it.

I will bring Jigsaw in on this issue and on collaboration with associations such as the FAI, GAA and IRFU.

Dr. Joseph Duffy

From our perspective and a community perspective, it is very important to see the young person at the centre of the community. The supports young people have been getting from sports and community organisations are about trying to nurture and support that. During Covid, we have continued to look to support those online as much as possible and we have had some opportunities to do that. As restrictions continue to be relaxed, it is important that those organisations are coming on board and continue to support young people to interact more with the community. We have understood the importance of those organisations but also the contribution young people are making in leading and supporting them.

Do Mr. Rogan and Dr. Duffy have concerns about prescription policies and the reliance on pharma to treat mental health or the prevalence of that approach as a treatment policy?

Mr. Martin Rogan

In primary care, it is important that the GP has a range of strategies to offer the individual. Pharma has an important role to play in some instances, specifically where there is a proper diagnosis, the person is very comfortable and other programmes are also offered, for example, psychotherapeutic approaches or even social prescribing, green prescribing and exercise programmes. These programmes are very important. It is also important we work with the individual not only solo but in the context of his or her family or chosen supports, such as friends and family. Ireland has a particularly high use of pharmaceuticals in mental health. Sometimes this is in the absence of other options. Availing of the wrong tool because it is the most available or useful one at one's disposal does not make it the correct one. Mental Health Ireland does not have a viewpoint on particular types of medication. We do not prescribe certain treatments or anything like that. That is a matter for the service user and his or her prescriber. However, it is really important that there is a range of options and not just a prescription pad used in isolation.

My last question relates to whether the witnesses are concerned that the way Covid is being reported on in the media is somehow contributing to mental health difficulties and the need for supports. There have been more than 1,700 deaths from Covid-19. Eight of those who have died were under the age of 65 and did not have an underlying condition. Of course, each of the 1,700 deaths is a tragedy. That said, it is possible that we have lost a sense of perspective, given that there have been three times as many deaths from cancer in the same period. Typically, there are 3,100 diagnoses of breast cancer in any given year, 2,680 diagnoses of bowel cancer, 1,161 diagnoses of gynaecological cancer and 3,300 diagnoses of prostate cancer. The screening programmes for those conditions are currently in abeyance. Some reporting in the media gives the impression that the only thing of which one might die is Covid-19. Some sectors are just short of calling for lynchings at airports of people who come to Ireland. Do we need more perspective? Is a lack of perspective contributing to distress and mental health problems?

Mr. Martin Rogan

In recent months we have seen that some people have been glued to their television sets and consuming a large amount of media content, sometimes from responsible sources and other times from less responsible sources, particularly in the context of social media. In general, the Irish media have been very responsible and an important tool in communicating updates to ensure we are all in sync and in step with the various phases of reopening, as well in terms of supporting individuals. They have been quite sensitive in the context of human dynamics with regard to family and other interactions. We need to be mindful that some people may spend their whole day on social media or a screen of some description, which can give a very distorted world view.

As the Chairman noted, other medical conditions continue to occur in the background. As Covid is new and contagious, it is an immediate concern and risk. People are mindful that they do not wish to be a vector or agent that will compromise a family member or loved one. In general, media reporting on the issue has been responsible. There has been active denial in certain other countries and that, unfortunately, has been reflected in the R number and the number of cases. In general, the media in Ireland have been responsible and tried to give a balanced viewpoint. As the Chairman noted, there are many other conditions, including mental health issues, that can be life-limiting and seriously impact on the quality and duration of people's lives. It is important that Covid-19 is seen in context. It has had a profound shifting effect on all our routines and usual practices, and that is something on which the media have a responsibility to report. They must do so in a respectful and responsible way.

Ms Royanne McGregor

From the perspective of a young person, much of the media reportage on Covid has been through traditional platforms such as newspapers, RTÉ and radio or television news programmes. That is not where young people are at. They are more active on social media and on their phones. We recently held a discussion in collaboration with young people and run by Jigsaw and the HSE. Many of the young people involved stated that information on Covid was not accessible to them. They were of the opinion that information was not being provided in understandable language or on a platform that they can access. That may be a source of much anxiety. Young people may not have certainty with regard to guidelines being up to date with the stages and phases. They are seeking more accessible, youth-focused and youth-targeted resources and information such that they can be informed. Many young people in care or with disabilities, for example, do not have an adult or other person whom they can ask these questions. They are responsible for understanding the message but it is difficult for them to do so if it is not focused on them or meeting them where they are at.

If it is through the newspapers or on the news that is not where young people are. If we focus on that and on delivering the information to young people in a way that is accessible to them, that will definitely help anxiety and help them manage and keep up to date and plan, which will help to reduce the distress of the experience.

I thank Miss McGregor. I call on Deputy Caroll MacNeill to speak now. As we did not start until nearly five past nine I will then bring in Deputy Colm Burke.

I thank Miss McGregor who made a very interesting point. We believe that there is a great amount of material going out on social media but it may not be delivered in a way that is reaching people where they are at. Perhaps it is not the right tone, message or connection that is made. It is very important to get that feedback.

In returning to an earlier point we have discussed with the Department of Education and Skills, the parents counciI and the unions the issue of going back to school in September. No matter what one’s stage is, there is an uncertainty there for young people, as much for the period spent out of school as for lingering anxiety about Covid-19 or the risk of transmission, etc. What interaction has there been with the Department of Education and Skills or others about the provision to meet the psycho-social needs of children going back to school, anticipating increased anxiety, regressed behaviour, or any other symptoms? What has been the engagement for the provision of support for teachers who are often trying to meet the psychosocial needs in the classroom setting? I asked about the colleges of education providing, for example, web seminars, play therapy and additional types of therapy to help support teachers to support children as they come back. Is there additional psycho-educational information for parents to enable them to support their children through any disrupted period as they go back to school?

Dr. Joseph Duffy

One of the things that we have noticed, which I commented on earlier, was that we have had a significant increase in teachers accessing e-learning courses in Jigsaw, looking at mental health literacy and promoting mental health in school, but particularly around self care for teachers. We have noticed that has continued across the summer. We are working with schools but we are particularly working with the Educational Support Centres in Ireland, ESCI, and developing webinars for teachers to support them in the transition to the return to school and supporting pupils in the school. It is also about creating an environment where we have a conversation about returning to school, where it is not just about focusing on exams but also about focusing on the young people and their experience from early March, before St Patrick’s Day, not having that support from their peers or teachers. It is about looking at that as a transition rather than thinking about how we get right back into the curriculum. One of the things we will have consultation about with teachers and with schools at the moment is the timing of supports and how we manage that.

Social distancing is a big issue. We are looking now to see how much support we can continue to put online for teachers. That is something that has really been picked up. Again, as has been echoed this morning, it is about the collaboration and the networks, particularly between ESCI, the Department, the National Educational Psychological Service, NEPS, and others. A great amount of work is happening there which need to be more co-ordinated to ensure that schools do not feel overwhelmed. It is also important that they know where the right and valuable support is.

I thank Dr. Duffy. He is correct in that there is much good work going on in different places. We asked the Minister for Children and Youth Affairs for a stand-alone, cross-Government paper on the priorities for children as we reopen society because there is much work going on but it has to be integrated.

Can Dr. Duffy provide me with an update on the recommencement of assessments for children under the Disability Act? Does he know what the status of that work is at this point?

Dr. Joseph Duffy

I am sorry but I do not have that information myself.

That question may be for the next session. Does anybody else from the Mental Health Reform group know?

Ms Royanne McGregor

I do not have that information but we certainly can try to get it for the Deputy.

That is okay. I will be able to pick it up at the next session. I thank the witnesses.

There is an issue as to the use of social media and young people. Is there a planned programme to do something on this issue and if there is, are all of the players involved in this, from young people, to the health service and all of the voluntary agencies involved, through a co-ordinated plan? It is very important to get that message out to young people and to address the urgent need to have a planned programme to deal with that.

Dr. Joseph Duffy

As far as I know, there is not a very clear, structured, national, planned approach but there is good co-operation, particularly within the youth sector and the youth element of the mental health sector. We have a lot to learn from listening to young people themselves. What my colleague-----

Is now the time to look at this and see how we can improve matters? A great deal of good work is being done, much of it by people on a voluntary basis, as well as by having very good professionals involved. Do we need to be far more progressive and consider what is being done in other jurisdictions? Now is the time to do that, rather than looking back at the matter in six or 12 months' time.

Dr. Joseph Duffy

Absolutely. It is one of the real lessons in the context of learning from this. In terms of our own experience in Jigsaw, we have really been influenced by young people in terms of how much they have embraced and used technology such as TikTok and Instagram and we have used it to provide good, adequate and supportive messages for young people. It is an important and valuable time and not a time to be wasted.

How did Jigsaw decide where its centres are located? Obviously, it is in the bigger cities but, outside of those, how did centres come to be located in certain areas?

Dr. Joseph Duffy

Historically, it occurred in different ways. In the very beginning, approximately 14 years ago, it was through consultations with local communities, particularly where there was a high degree of mental health concerns, particularly in respect of suicide, and that was when we were funded from a more philanthropic base. We have worked closely with the Department of Health and, in particular, the HSE in recent years in looking at the spread of services throughout the country and at where we would best be able to use the resources.

The difficulty is that we know there is a need for support in many different places. What we are now looking at is how we can expand and develop existing Jigsaw services. For example, the service in Offaly has expanded into Laois and we are looking to see if we can develop further services. What we are looking at right now, especially as a result of Covid, is the idea that national coverage would mean both online and offline support. What we have moved into is providing phone support and online support, which can provide a greater level of support for more people. The issue overall is how we get a balance between face-to-face and online support, and it is really about looking at resources.

One of the bigger issues is that we do not have three or five years of planned funding and we are always looking at it on a year-to-year basis. If we had that plan of structured funding, we would be able to work with communities and really support them to see where Jigsaw fits within a system of care. At times in the past, people have wanted us to develop a Jigsaw service and we have been very careful and clear that we are providing a service on the prevention and early intervention side. The reality is there needs to be a lot of other supports in communities for all of us to work successfully together.

I thank all of the witnesses who attended this morning. We will suspend until 11.30 a.m., when we will meet representatives from the Mental Health Commission and the HSE.

Sitting suspended at 11.05 a.m. and resumed at 11.30 a.m.