Non-Covid Healthcare Disruption: Mental Health Services (Resumed)

I welcome our witnesses from the Mental Health Commission and the HSE, who are in committee room 1. I advise them 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.

I ask Mr. John Farrelly to introduce the delegation from the Mental Health Commission and make a short contribution outlining the key points of his submission to the committee. The submission has been circulated and will be published on the committee's website today.

Mr. John Farrelly

Dia dhaoibh go léir. I welcome the opportunity to appear before the committee with my colleagues Dr. Susan Finnerty, Inspector of Mental Health Services, and Ms Rosemary Smyth, director of standards and quality assurance.

The Mental Health Commission is the regulator for mental health services in Ireland. It is an independent statutory body. Its mandate is to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services. Under the 2001 Act, the statutory scope of mental health regulation for us is limited to inpatient services. Therefore, we have quite a limited scope in terms of the full mental health service. We perform a critical function in vindicating the rights of people who are put into mental health units against their will or in an involuntary way.

Over the course of the period of Covid-19, we monitored 181 residential mental health services, comprising 67 regulated inpatient centres and the rest were community hostels. The written submission of the Mental Health Commission sets out the number of concerns identified as part of our role in monitoring the progression and impact of Covid-19. We found that staff on the ground, people in the unit, the clinical staff and the management pulled together well. We could not say it was a success because people died but I have to say that the mental health services and the professionalism of staff protected many people. I want to emphasise that.

We found that the national governance was one to three weeks behind the services themselves. That is fair enough in that the services knew what was happening in the here and now. We found issues with facilities with shared accommodation and a limited ability to isolate and there was a lack of public health guidance, specifically for mental health settings. We found delays and inconsistencies in testing in the early phase of lockdown. We have to be frank that people were caught on the hop. From what we could see, resources were taken out of mental healthcare provision and diverted into other parts of the system, based on the thinking at that time. There were also delays and inconsistencies in testing, as well as inconsistency in the continuity of services. Community-based services were also suspended. Those were the key issues for us.

To come back to the main point, we have been giving evidence to two Ministers for Health, the HSE and basically anyone who would listen about our mental health services for the past ten to 15 years. It is clearly documented and transparent and it is in the public domain. Covid-19 has shown us that we need to address this issue, we need to put money into infrastructure to make sure buildings are fit for purpose for people, we need to put money into making sure our services are well staffed and we need to set about building a proper community mental health service in Ireland.

I ask Mr. Ryan to introduce his delegation from the HSE and to make a short comment outlining the key points of the HSE's submission, which has been circulated. I ask him to be relatively brief, if possible, to allow as much time as possible for questions and answers.

Mr. Jim Ryan

With me are Dr. Brendan Doody, clinical director, Linn Dara child and adolescent mental health service and Dr. Amir Niazi, national clinical advisor group lead. We appreciate the opportunity to come before the committee this morning.

The committee will have received our statement. Our role is to provide services across the Twenty-six Counties, including community, day, acute and long-term care. Covid-19 has had a significant impact on all of our services, as it has had on all health services. We have learned that we have a resilient and committed staff and we have adapted well, given the circumstances. The lessons we have learned have been taken on board and we see the challenges the Mental Health Commission and the regulator have outlined to us, which we would share. It is something we need to plan for in the future.

I remind members that they are speaking for either five or ten minutes. The first speaker is Deputy Carroll MacNeill from Fine Gael.

I thank the witnesses for their attendance today. I have a couple of questions. My understanding is that the National Forensic Mental Health Service had no patient positive case of Covid-19. Is that correct?

Mr. Jim Ryan

That is correct.

What lessons can we learn from that? Why did that happen? What steps were taken at the different stages to ensure that was so? That is a congregated and closed setting, as are other settings we have looked at so what was different about the National Forensic Mental Health Service?

Mr. Jim Ryan

At the early stages, a clear plan was put in place at the front gate to ensure that anybody coming in had a temperature check, our public health guidelines were followed rigorously and we ensured that where there were positive cases among staff, they were split into different cohorts in an effective manner.

We also managed to set up what we would call an infirmary within the hospital whereby if we had a positive case, we had a plan in place to deal with that. We probably learned from what was going on in the rest of the country but there was clarity from the word go about what we needed to do in terms of people coming in. Having to restrict visits was very difficult for patients and for everybody concerned but it was right thing to do and we had to do it. We also looked at the way we managed our staff and ensured that we looked at managing contractors, etc., who were coming in. We learned from all of those aspects. It was similar to what was happening in many of our other centres across the country. There were times when I will not say that we were lucky but when we worked hard to be lucky.

I congratulate to Mr. Ryan and also, crucially, the staff in the Central Mental Hospital in Dundrum in that regard. I ask about the timing of the move to Portrane, which is a much more suitable, dedicated facility for mental health detention.

Mr. Jim Ryan

As the Deputy is probably aware, we moved nine patients from Dundrum to Portrane in order to set up additional capacity within the forensic service as part of our response to Covid-19. In terms of the plan, we are awaiting the hand-over from the builder. Our understanding is that will be towards the end of September. There will then be a period of commissioning and training, which is built into the transition process. We would hope that we are on track for the end of the year.

I thank Mr. Ryan. Could I ask the witnesses from the commission, in terms of mental health services and training, how they will deal with the training records of the therapeutic management of violence, for example, where it is difficult because of distancing? I do not believe that is happening nationally. They might make an observation in respect of this matter. Is there any possibility of making allowances for people, when their records are reviewed, in the context of their, for example, being unable to complete their training where that was the case?

Mr. John Farrelly

I will make a quick point and I will then ask Ms Rosemary Smyth to speak. Violence, restraining people or secluding people is not therapeutic in any way, irrespective of what people call it. It is not good for people.

Excuse me. I meant the therapeutic management of violence. If I have misspoken, I apologise.

Mr. John Farrelly

I am sorry.

Ms Rosemary Smyth

Yes. We have taken into consideration the training records of any training that relies on point-to-point contact between individuals. That would include CPR, manual handling, and prevention and management of aggression and violence. In our inspection plan for going back out to do inspections, which we did this week, we have built in an allowance for that and how we intend to address it. I will ask Dr. Finnerty to address that.

Dr. Susan Finnerty

We have recommenced inspections today. We will be looking very carefully at services where training is difficult for them to do in light of Covid-19. We have found over the years that it is extremely difficult for the services to release staff to do training, even in terms of mandatory training. Matters have improved over the years but we are still not at 100% and, obviously, this year we will certainly not be at 100%. We will take into account, as Ms Smyth said, the fact that people cannot do face-to-face contact and do training in a group setting.

On that and in the context of the additional time pressure on people working in the services, how will Covid-19 impact a patient detained under the Mental Health Act in terms of not just their detention but also the review of their detention?

Mr. John Farrelly

People are entitled to tribunals under the Act, and we are quite rigorous around that. A couple of thousand tribunals happen each year. We continued with those tribunals. It was the previous Government that changed the Mental Health Act to enable us to have the tribunals in order to vindicate people's rights. We are worried about one issue. It is about ensuring that people do not take that for granted and that they know their rights.

There is now a bigger onus on the clinical teams to make sure that people who are detained know their rights. We must not forget about people's human rights while keeping them safe. That seems to be going relatively well. This is scrutinised quite rigorously by an independent group composed of a barrister, a consultant psychiatrist and a layperson whom we recruit independently.

I would like to ask about family visits for patients. They have obviously been difficult. What impact has Covid-19 had on visits, and what is the thinking on allowing them to recommence? I would like to address this question to both the Mental Health Commission and the HSE.

Dr. Susan Finnerty

The impact of Covid-19 on service users has been very difficult. Social distancing, staff wearing masks or being unable to come into approved centres and the suspension of visits have made for a really isolating experience for some people within the mental health services. As the restrictions are lifted, people will be able to meet and communicate with their relatives and families, but it has had an impact. The same is true for all the measures and restrictions that have been put in place because of Covid-19.

Mr. Jim Ryan

As Dr. Finnerty said, it has obviously had an impact on our service users. We have tried to use technology to assist with this. Some of our organisations, such as the Irish Advocacy Network, have placed iPads in the approved centres to enable contact with patients. That has worked very well and we think it has a lot of potential. Parental visits are a key element of the therapeutic programme in child and adolescent units. We have looked at using our own transportation. Parents can come in by car. We have looked at a wide variety of ways to ensure a connection between the service user and his or her family, notwithstanding the need to ensure that public health guidelines are followed at all times.

Could I ask for a bit more detail? I am concerned about children detained under the mental health system. Is Mr. Ryan saying that service providers drove children to meet their parents in a different setting? Could he explain exactly what was done?

Mr. Jim Ryan

I might ask Dr. Doody, who has first-hand knowledge as clinical director of the Linn Dara inpatient unit, to comment.

Dr. Brendan Doody

Ongoing contact with parents is hugely important to any young person who is admitted into an approved centre. As soon as there were restrictions with regard to visiting we were very keen to put in place a mechanism by which young people could keep in regular contact with their parents using technology such as Skype. Clearly that does not replace actual physical visits. At the same time we had to be mindful of the restrictions the units needed to impose to limit the spread of Covid-19 and other public health considerations. In recent weeks the inpatient units have been able to reintroduce visits by family members and parents on a limited basis. That has been rolled out in child and adolescent mental health services, CAMHS, inpatient units throughout the country.

Was contact maintained solely by technology in the interim?

Dr. Brendan Doody

We used technology in the early phases. In recent weeks visiting has recommenced on a limited basis.

To contextualise that for the committee, what is the typical period for which a child would be in detention in that way?

Dr. Brendan Doody

The average length of stay in inpatient CAMHS units is about 40 days. That will vary. For some young people it is shorter and for others, depending on the reason for their admission, it can be much longer. In the Linn Dara inpatient unit we have now moved to facilitating visits twice weekly. Again, that takes restrictions to minimise the risk of Covid-19 into account.

As we open up visiting, it is also important to manage the risk of introducing Covid into the inpatient setting. It is a balance between managing that risk and at the same time facilitating very important contact young people have with their family.

I thank the witnesses. I want to focus on the access to mental health services. As we know, even long before the Covid pandemic, it was problematic to access those services, particularly after hours. How are child and adolescent mental health services expected to resume? What challenges will Covid present in delivering those services? Can we expect to see further waiting times or a reduction in service delivery?

Mr. John Farrelly

I will ask the inspector to respond to that, but I just want to emphasise this point. This week the HSE published a report that shows significant issues with waiting. Our mental health system is not fit for purpose and is out of date. We need to invest in it and we need to invest in the community. A child who gets into a unit is very lucky. In the services we regulate, the children's services and the private services tend to be of a relatively good calibre. Until we invest properly in our community services and stop making excuses that we have some sort of a service, what we need for our children will not improve to the degree it should be in this day and age.

Dr. Susan Finnerty

Specifically during the Covid-19 crisis, access to some services has been limited, especially the therapeutic services and programmes offered by occupational therapists, psychologists and social workers because they have not been able to get into work. As Mr. Ryan has alluded to, there has been some move to use videoconferencing techniques to enable people to have therapy sessions, but there would be no group work or skills-based programmes in the hospital or approved centre.

Access to community services would also be quite limited at times for the same reasons - that people are unable to attend their occupational therapist, social worker, psychologist or other therapist because of the Covid pandemic. Access to non-medical, non-psychiatric treatment has been limited and very inconsistent, with widespread variation throughout the country as to where services are able or unable to provide therapeutic programmes.

Mr. Jim Ryan

I might ask Dr. Doody to answer the CAMHS-specific questions. The secondary care mental health service is being provided through our community mental health teams, our day programmes, our acute inpatient units, our long-stay units and our community residences. They have been affected in a variety of ways. For example, at the moment we are operating at approximately 91% of our pre-Covid capacity on our acute units. We are most challenged in our day programmes and therapeutic programmes, which require much more significant face-to-face contact between patients and clinicians. From that perspective we need to look at creative ways in which we manage that. One of the platforms we use for engagement between clinicians and patients, Attend Anywhere, has proven very helpful and useful.

I ask Dr. Doody to outline the point of view from CAMHS.

Dr. Brendan Doody

The demand for inpatient services has not diminished appreciably during the period of the Covid pandemic. Notwithstanding, obviously, the implications of Covid on service delivery, the inpatient services are running at about 85% of the number of admissions this time last year.

It is important to remember that the total number of admissions to the HSE-funded units last year increased 50% on the previous year. The increased capacity has meant a greater number of admissions. It has also allowed services to respond more quickly to admissions of children when inpatient treatment is required and has resulted in a reduction in children being admitted to adult facilities.

In the inpatient setting, while there are obviously restrictions around service delivery, all the young people have access to full multidisciplinary inputs. In community services, there has been a shift away from face-to-face consultation to greater use of technology such as telephone calls, Skype calls and similar technologies offering a video link. This has proved very effective and useful in some instances. It does not, however, totally supplant face-to-face interactions. At this point, services are looking at how to increase capacity to deliver more services in a face-to-face context, taking into account considerations around Covid-19. This involves looking at facilities and conducting risk assessments to ensure there is a process in place. There was a fall-off in demand for community services and the number of referrals received. However, services are expecting the numbers to increase significantly when young people start to return to school in the autumn. We usually find that referrals to mental health services reduce during school holidays. This is not a school holiday as we have experienced and known school holidays until now. Young people remain under a significant degree of stress and one would expect there to be a pent-up demand for services. It is important, therefore, that services plan for the expected increase in referrals after the summer.

Can Dr. Doody express in percentage terms the current level of service compared with pre-Covid service levels? Have service levels in the community setting returned to 80% or 90% of their previous levels?

Dr. Brendan Doody

The figures for the community setting up to May show a 29.8% decrease in referrals received and a 21% decrease in the numbers of new cases seen. Effectively, the numbers of referrals are dropping but cases with more severe or acute need are still being referred. Although the number of referrals dropped, referrals continued and young people continued to be seen, even during the early phase of Covid-19. However, it was young people with a more severe presentation who were being referred and seen.

Dr. Doody alluded to the pent-up need, especially as we head in to the new school term. Will he outline how the HSE will respond to that need at a community level? In my experience, many people who have not experienced mental health issues in the past have been profoundly impacted by the lockdown period and changes in society. Has any work been done in planning for that expected need?

Dr. Brendan Doody

Planning for mental health is everybody's responsibility. I speak from the perspective of the specialist mental health services. Work needs to be done in education for parents and teachers to inform them so they are more aware of the mental health issues young people will experience because of what we have gone through.

For specialist mental health services, it is about how we ramp up capacity to see the increased numbers of young people who will be referred. That means looking within buildings and facilities, how we will ramp up capacity, particularly with face-to-face consultations, and how to do that taking into account public health considerations and restrictions because of Covid. Then there is examining programmes and how we might facilitate the use of technology. There has been quite a leap forward in the usefulness and use of technology. In future, we will see a balance between face to face and online and the use of technology to support young people who are referred to specialist mental health services.

I welcome the witnesses to the committee. I thank Mr. John Farrelly from the Mental Health Commission for his very candid and upfront appraisal of what is going on in mental health service by saying that it is not fit for purpose and is out of date. I agree 100%. We can have no half measures with mental health provision, especially as the Covid pandemic has only increased pressures on already under-resourced mental health services which were already there. Does the HSE agree with Mr. Farrelly's appraisal?

Mr. Jim Ryan

We fully respect the view of the independent regulator. Our role is to ensure that the resources and services which we provide are appropriate to the needs of the population that we serve. Looking at recent years, our budget has increased and there has been an increase in service. This year we will open a new unit in Sligo. We have refurbished units in Limerick and Tralee, and there are new units in Cork and Drogheda. The national forensic service will be completed by the end of the year. There has been quite significant investment in the infrastructure. That most certainly is not to say that there is not a need for more. I fully agree that there is always a need for more resources in mental health, but working within the resources that we have and trying to make the maximum use of them, as well as of the staff we have, who are highly trained and committed, as we saw in recent months. Our role is to make the very best use of the resources that we have in the circumstances in which we find ourselves. We look forward to Sharing the Vision, the new national policy, which builds on the very successful A Vision for Change from 2006, to drive that investment into the future.

One of the biggest things which arises in my experience in the provision of mental health services is getting staff and retaining those already there. Are those problems ongoing or has Mr. Ryan seen light at the end of that tunnel?

Mr. Jim Ryan

It is an ongoing challenge. Part of the reason is that our staff are very highly trained and marketable across the world. We have seen that over recent years. In psychiatric nursing, we have increased the number of places in our third level colleges in the past four years. This year we will see the first group of additional nurses coming out in September, although they are already on units because of Covid. Next year, there will be a further tranche of additional nurses on top of those who would be traditionally trained through third level institutions. From the HSE's perspective, we invested in that because we saw the need and logic for those nurses. Similarly, with consultants, we have increased the number of basic specialist training, BST, and higher specialist training, HST, places in 2020 so that we might have a better pipeline of staff coming through in the next few years. Staffing by allied health professionals, AHPs, can be a challenge in some areas, particularly around psychology. This is something we are working on continuously. To answer the Deputy's question directly, it is an ongoing issue but one on which we are committed because we want to try to ensure that we have the proper staff in place for our service users.

There has been an upsurge in people drinking at home during Covid-19 and in numbers presenting for treatment for drug and alcohol issues. My question relates to dual diagnosis.

I did not see any mention of it in the report published today. I have worked in several addiction centres across Dublin in a professional capacity. All present know that drink and drugs give people the ability to self-medicate and calm the anxiety in their world for a certain amount of time, until it stops working. It becomes a learned response. Will new or additional addiction and mental health services be provided in order that they can work together instead of working apart? That is one of the biggest challenges. If the mental health service solely focuses on mental health issues and addiction services solely focus on addiction, people will fall through the cracks of those services. Will an approach be taken whereby the services will be more aligned and more resources will be allocated, especially to community addiction services?

Mr. Jim Ryan

I will ask Dr. Niazi to respond on that issue. I worked as a drug task force co-ordinator in the early 2000s and I understand entirely the point being made by the Deputy, particularly with regard to alcohol and substance misuse and their impact on mental health. I fully understand his perspective.

Dr. Amir Niazi

The Deputy is absolutely right. The way we are currently delivering services is such mental health services look after patients whose primary diagnosis is of mental health difficulties, even if the patient attends in respect of addiction issues. If the patient's primary issue is addiction, he or she is looked after by the addiction services and we provide support. The Deputy is correct that the services are not working together. We are currently looking at a clinical programme or service improvement whereby the two services can work together. I have started working on it and hope that a programme will be announced very soon. It is in the programme for Government and is clearly mentioned in the Sláintecare programme. The integration of services is one of the key elements on which we are trying to work.

Mr. Ryan referred to being involved in a drugs task force in the 2000s. I was a board member of the board of a local drugs task force at that time. The budgets of such task forces have probably not increased since 2000. That is one of the problems they are facing. A drugs task force may wish to provide, for example, some sort of mental health service or dual diagnosis service, but if that is not specified in its service level agreement with the HSE, it is restricted from implementing its wishes They are trying to fight with one hand tied behind their back. As a result of budget constraints, when something new comes in, something else must go out.

A report from the child care law reporting project, which mainly relates to children being taken into care, came to my attention yesterday. It involved a heartbreaking case of a girl who was admitted to a psychiatric unit as a result of a serious eating disorder. Due to Covid-19 restrictions, her parents were not permitted to have face-to-face contact with her during her stay in the inpatient unit. Access was only possible using Skype. In court, her father agreed that his daughter was getting the right care in the right place and needed to be there, but he also emphasised how stressful the lack of face-to-face contact was in the context of the family relationship and for him as a father supporting his daughter during her stay. What protocols are being put in place to allow the resumption of face-to-face contact in order that families in such situations can at least see each other during these very difficult and challenging times?

Dr. Brendan Doody

In the initial phases, in step with Covid recommendations, visiting was suspended and contact was permitted only through Skype, as the Deputy stated. The inpatient or CAMHS units have all reinstituted visiting. Obviously, visiting is permitted mindful of Covid and necessary precautions being in place. It takes place twice per week and is being reviewed on an ongoing basis. As soon as we could reinstate visiting by parents, that was done.

In the report issued today, many patients and advocacy groups contend that mental health services need to be expanded and that the new Government mental health strategy, Sharing the Vision - a Revised Mental Health Policy for Everyone, should be adequately resourced and implemented.

We spoke earlier about the minimum recommendation by the WHO for 12% of the overall health budget, whereas the figure in Ireland currently stands at 7%. Would that increase from 7% to 12% adequately resource mental health services across the State or would more be needed?

Mr. Jim Ryan

Clearly, as head of operations, I would always welcome additional resources being made available to mental health services, and over recent years we have seen significant additional resources, although more are required. One of the things we want to look at is our tiered level of care, and some of the contributions earlier from Jigsaw, Mental Health Ireland and Mental Health Reform spoke to that. We have a very strong relationship with our NGO partners, and part of that is about ensuring that where the HSE can fund external organisations to deliver, particularly on primary care and universal supports and in particular where young people are concerned but also for the entire population, in a way that is much more flexible, we have been trying to do that to try to reduce potential waiting times. We are also seeking to use technology. We now have service agreements with a number of organisations to deliver services on our behalf. Covid has made that even more urgent than it was previously, although it has also made it more possible.

We would welcome additional funding. If the Deputy looks back at A Vision for Change, although it was not possible during the recession, since 2012, significant additional resources have been made available. We would hope that in the implementation of Sharing the Vision: A Mental Health Policy for Everyone, which is really the key element, additional resources would be made available.

I want to pick up on some of the points made by Deputy Ward, in particular the excellent point about the failure of mental health services to meet the challenge of dual diagnosis, which is very significant. Dr. Niazi said that if there is a primary diagnosis of mental health, the psychiatric services would deal with it, and if there is a primary diagnosis of addiction, the addiction services would deal with it. My personal experience of working with and supporting people trying to access these services is that both services claim the primary issue is for the other service, which is what leads to people falling between the cracks and points to the problem of these services not working together. It fundamentally illustrates Mr. Farrelly’s point that the mental health services are not fit for purpose. I thank Deputy Ward for raising this very important issue.

I would like to pick up on Dr. Finnerty's point around the inconsistency throughout the country in community services. Will she talk more about that, especially focusing on areas that have done it well? What can we learn from them? What can other services that have not done it well learn from the services that have done it well? What has contributed to the success of those services amidst the inconsistency?

Dr. Susan Finnerty

Regional variation is a feature of the Irish mental health services. There is no uniform staffing and no uniform provision of service throughout the country. Covid has probably highlighted this in some sense in that, given the provision of therapeutic services by a small number of allied health professionals, when they were unable to deal with people during the Covid crisis, this set it up in sharp relief that there are not enough services or enough resources in community services.

The difficulty is that if there are not enough resources in the community services, then people will naturally gravitate towards the admission units, which leads to a difficulty on discharge because there is very little follow-up. Therefore, the problem of lack of access to community services is not just part of Covid, but Covid has made it worse.

Some areas are particularly poorly staffed with allied health professionals and consultant psychiatrists. This can be for a number of reasons, including difficulties with the retention and recruitment of staff and with staff not working wanting to work in isolated areas. It is multifactorial. Where there has been a history or tradition of intensive provision of service, the funding will stay. It is more difficult for areas where there has not been a very high level of provision of inpatient services. I refer to when the old asylums were open. It is difficult for the affected areas to get the funding to match that of other areas. There is a wide variation in funding and staffing resources across the country.

I thank Dr. Finnerty for that answer.

Mr. Farrelly mentioned how the mental health tribunals were able to continue. Were there any challenges? Was there a sufficient number of tribunal members to be able to deliver? Were there any legislative challenges, including in terms of meeting remotely? Is there anything we should be considering in case we face delivery challenges in the future? Are there positive lessons that have been learned or mistakes whose recurrence we need to prevent?

Mr. John Farrelly

It has been a very positive experience because we are clear that people should not be deprived of their liberty unless they absolutely have to be and that their rights should be vindicated. Working with the Department and tribunal staff, our staff, led by my head of legal affairs, did good work.

On the lessons learned, the biggest worry concerned people going into centres. Many of our panel members tend to be older and there were worries about them going in because they might have secondary conditions. It actually worked very well. We have to analyse it even more. The little worry we have concerns making sure patients' rights are absolutely vindicated in terms of a solicitor representing them. Maybe we need to consider this. We are learning all the time but in this instance the HSE performed well in this area.

I welcome all the witnesses. I want to start off by asking some questions about children who have been very severely affected by the restrictions arising from Covid. I refer to the fear, being closed in, the loss of contact with friends, and the loss of involvement in school activities, in particular. These have had a pretty severe impact on children in the early stages of development. We heard earlier about the services Jigsaw is providing for young people at second level. What services are in place or what specific programmes are proposed for primary school children? We know significant issues will arise. Presumably, given the long waiting lists for all children's mental health services, it would make sense to deliver school-based programmes and public health messages. What is proposed for that age cohort?

We are all very familiar with the terribly inadequate services for preschool children with potential mental health difficulties. An example comprises the early intervention teams. We probably have all heard from constituents whose children were on waiting lists for so long that they reached the age of five before the HSE could provide a service to them. They might have been waiting for services for three or four years and aged out. Specifically, what do the witnesses intend to do to address the issues affecting that cohort and primary school children?

Dr. Brendan Doody

I can address the issue of the specialist mental health services. Although there are children waiting for appointments, there can be some regional variation to this issue and it is important to remember that more than 80% of children referred to specialist CAMHS services were offered an appointment within 12 weeks.

What period is Dr. Doody talking about?

Dr. Brendan Doody

Community child and adolescent mental health services.

Yes but what period is Dr. Doody talking about? Was this prior to the period of Covid-19?

Dr. Brendan Doody

These are up-to-date figures.

In the context of the significant impact of Covid-19 on that age group, specifically what is the HSE proposing to do to address those needs?

Dr. Brendan Doody

During the acute phase of Covid-19, there was a decrease in referrals to specialist mental health services and community specialist mental health services. There was less of a drop in demand for inpatient services.

With all due respect, I am not asking Dr. Doody about that and many people did not want to access services because of the dangers involved. Given that we know there are significant needs in that age group, what services, if any, is the HSE proposing to provide to respond to that need?

Dr. Brendan Doody

I can only speak for the specialist mental health services. The restrictions on the delivery of services were mentioned earlier. It is important we examine how we can maximise the availability of community services to respond to this demand. Just because the referrals have not been made to date, that does not mean that the demand-----

I appreciate that. Is the HSE proposing to provide any new services to deal with mental health issues in the primary school and preschool age cohorts?

Mr. Jim Ryan

To answer the Deputy's question directly, we are not proposing any such new services. It must be remembered that we are a secondary care mental health service so we work with our primary care and health and well-being colleagues, as well as maintaining contact with the school system. This is something we will need to take on board but our focus is on stepping back up both our primary and secondary care services for the overall younger age group. However, I take on board the point the Deputy has made.

It is disappointing the HSE has not arranged any additional services. Before Covid-19, the HSE's services were not coping and there is a clear need for additional services arising from Covid-19. It is disappointing that we are at a point where we hope children will be back at school in September but no work has been done on developing new school-based services to meet that need. I respectfully suggest the HSE needs to get on with that job.

I also want to add to the points that have been made on dual diagnosis. It never made any sense to separate addiction and mental health problems. That is a structural issue for the HSE, which should be resolved. Given the level of mental healthcare need emerging as a result of Covid-19 and what we know about the additional substance abuse and misuse with alcohol, prescription drugs and illicit drugs, surely now more than ever there is a strong case for combining those two services and for stopping the practice of making that false distinction?

Mr. Jim Ryan

I want to briefly respond to what the Deputy mentioned earlier. We work with the Department of Education and Skills, which is the most important thing we can do to protect children's mental health, because it has to be done in an appropriate manner and the schools are a key element of that. Dr. Niazi has responded to the Deputy's point on dual diagnosis earlier but we take on board the fact that there is a need to do more.

Are we going to see those two services being combined and will the HSE stop making that artificial distinction between mental health issues and addiction?

Dr. Amir Niazi

We are looking at that. I have already spoken to the leads in addiction and mental healthcare services. Much work was done beforehand but I need to bring it together and implement it. I can reassure the Deputy that we will be working on that.

When can we expect those services to be combined and delivered as a single service?

Dr. Amir Niazi

I am hopeful we will be able to submit the document from the process we are working on soon. It is also outlined in the programme for Government that we will be working on it.

I have two specific questions. The first relates to the submission by the Mental Health Commission. Section 2 refers to mental health services and regulation. Could a spokesperson for the commission define what is meant by the term "unregulated" here? The submission states a further 10% of mental health services are delivered within specialist mental health services, including a 24-hour nursing staff community residency, which are unregulated. Will the witnesses define the term "unregulated"?

Mr. John Farrelly

Under the Mental Health Act, we register, monitor and can take action on approved centres. They are the inpatient centres that are registered, and we have powers around that. Regarding all other mental health services, the inspector has the power to visit but we do not have powers to make them how they should be. For example, some of the hostels or community houses that people are in are not fit for purpose. That came across in the Covid-19 pandemic. For example, someone could be sharing a room with three other people he or she does not know. They would not be family members. No one else in society, apart perhaps from members of very big families, does that. There is that element.

The other aspect is the primary care services. If an individual or his or her child is unwell, he or she visits the GP or accident and emergency department. The idea is that people can go to secondary services before going to the final 1% of services. The idea, as Mr. Ryan said, is tiered services and that people are seen as early as possible in their communities. For example, if we take Clondalkin, people in that area will not go to Tallaght Hospital. The services are in Rowlagh, Neilstown or Palmerstown and people's needs are met in those services or in their home. We do not regulate any of that. In a way, this is unfair on the acute units because the very strong light we have shining on them means there is great transparency and all the issues are visible. That is caused by not having any scrutiny of the services in the community, which are not regulated.

Why are they not regulated? Who runs those services?

Mr. John Farrelly

Hopefully, the Mental Health Act will be changed to allow us to move out a bit more. I am very interested in vulnerable people. I do not mean to be paternalistic but I mean the people who become unwell, may not have supports in society and fall through the cracks. As far as I am concerned as a public servant, my job is to make sure that those people are protected. They number in the thousands, approximately 1% of the total. The reason the services are not regulated is that Government policy is that they are not regulated.

My final question is for the HSE. I spoke in the previous session about the highs and lows of the public health emergency. The highs were the coming together of people and the solidarity and support they showed one another. One cannot buy the bonding that took place over the past four months. However, there were also huge lows for the many people who had to self-isolate and were unable to be part of that gathering. We are social animals and the loss of contact is incalculable. What has been the lasting effect of the past four months on the national psyche but also on individuals in the population in terms of depression, anxiety and so forth?

Mr. Jim Ryan

Part of the challenge is that we are not sure. We have seen research on what happened in previous traumatic situations. Covid-19, considering that it will be with us for a considerable period of time, poses a greater challenge. I am a member of the International Initiative for Mental Health Leadership, IIMHL. Our international colleagues have done a good deal of work on the medium-term effects. The concern, as the Deputy said, is that initially there is a buzz about people coming together and then there is a flatter period. One of the things we need to ensure is that from the point of view of primary care and universal support - I spoke earlier about our tiered level supports - we do not say that everybody who is feeling down has a mental illness.

That is not the case. We need to preserve our secondary and tertiary care services for those who need them most.

From the point of view of primary care, we have attempted to use technology to deliver additional counselling services and sessions online. This has been done through platforms like SilverCloud Health, MyMind, spunout.ie, turn2me.ie and any number of other organisations that we have funded. This is about giving people the tools to deal with an issue which we hope will be finite but which we now recognise will be with us for a while. We want to ensure two things, namely, we want to provide upfront services while making sure that the services required for those with a longer-term mental illness are not adversely affected.

I thank the witnesses. The former CEO of Mental Health Reform, Dr. Shari McDaid, has advised successive Ministers of State with responsibility for mental health, senior civil servants and senior HSE executives on solutions to improve the mental health service. She has recommended the organisation of a cross-governmental cross-society task force to develop the country's mental health recovery plan, with a commitment that the plan would be published within six months. The groundwork for such a plan has been laid in the review of the national mental health policy, A Vision for Change. The review of the latter was completed at the end of 2019 and the refreshed version is awaiting publication. It should be published immediately in order to provide the framework for planning the services that will prevent people from developing severe mental health difficulties and help them to recover their mental health and well-being after the pandemic. Dr. McDaid is asking the Government to commit to increasing protected funding to implement the mental health recovery plan. Before the pandemic occurred, she also recommended rapidly scaling up and implementing the use of digital technology in mental healthcare at primary and secondary levels. The HSE had been working on piloting online mental health services for several years. A major effort must now be made to scale up these initiatives in order to increase the reach and capacity of services so that anyone who needs an intervention by a mental health professional can get it quickly.

Dr. McDaid states that we must embed trauma-informed approaches across public services. She notes that common sense tells us that many people of all ages, from young children to those in their later years, will have experienced personal trauma during the pandemic. In a sense, we all have. For those children whose families have struggled to cope with the isolation and who face sudden economic hardship, the threat of losing their homes, domestic abuse, bereavement or separation from a loved one who is dying, the personal trauma must be quite profound. Every teacher, school staff member, garda, health professional, social welfare officer, housing officer and provider of social care needs to know how to respond appropriately to their service users so as not to retraumatise them.

What plans are in place for the implementation of Dr. McDaid's recommendations in order to streamline the mental health service for the new challenges it faces?

Mr. Jim Ryan

If I understand the Deputy correctly, he is speaking about the refreshed version of A Vision For Change, which is entitled Sharing the Vision: A Mental Health Policy for Everyone.

Mr. Jim Ryan

As the Deputy is aware, that was launched by the previous Minister for Health, Deputy Harris, several weeks ago. It is Government policy. I understand that it is mentioned in the programme for Government. As a provider, the HSE will work very closely with the Department and Health, from which the policy document originates, in order for it to be implemented. Similar to A Vision for Change, which was launched in 2006, it is a ten-year document. The next stage will be an implementation plan. Dr. McDaid was involved in the writing of the refresh document.

The HSE welcomes the policy document. A Vision for Change provided a very helpful roadmap for the development of services. It also enabled us to secure additional funding. We expect that an implementation plan will soon be put in place with the support of the Government and the Department of Health. We hope to be involved in that.

I thank Mr. Ryan. Have site visits and inspections continued during the Covid-19 pandemic?

Dr. Susan Finnerty

I will answer that. The inspections before the Covid pandemic ended around the beginning of March. On advice we were not able to continue our inspections during that time. We have consulted Dr. Kevin Kelleher in public health who now deems it fine for us to start inspections again and inspections started last week.

How many cases of Covid-19 were detected in mental health facilities?

Ms Rosemary Smyth

I will answer that question. To follow up from the Deputy's previous question, we monitored all the mental health services by phone throughout the period that we were not allowed into the service. We had in excess of 2,500 calls during that period. We were in contact with services weekly if not more often. We have developed very good relationships with services on that basis.

We monitored all the services for suspected and confirmed cases. I am pleased to note that this week was the first week in which we have no cases to report within mental health services. Overall, 28 services had positive cases, 19 in inpatient approved centres and eight in community residences. A total of 47 services had positive results for staff members, 32 in inpatient services and 15 in community residences. This is what the services have advised us, and we are validating those data with services to ensure their accuracy. That is the status of the numbers as of this week.

I thank the people who are here this morning for their work. It has been a very challenging time for everyone in the healthcare sector, and for those in the mental health care sector it is even more challenging. I thank them and all the staff working in mental health services for their contributions in dealing with this very difficult situation over the past four months.

How many beds are available in the mental health care sector at the moment? What percentage of those are in single occupancy rooms? What is the plan for moving away from having six or eight patients in a room?

Mr. Jim Ryan

We have approved centre beds, long-term beds, and high, medium and low-support hospital beds. I do not have the figures for single occupancy. We have approximately 1,030 public approved centre beds. It is more than 2,000 when high-support and continuing care beds are taken into account. That is not mentioning medium and low-support beds. I do not have the detail for single occupancy. The majority of our new units, particularly on the approved centre sites, are single or double occupancy rooms. We have tried to eliminate multi-occupancy. Our latest unit in Lakeview, which is going to design stage, will be single occupancy.

Did the occurrence of Covid tend to be in multi-occupancy rooms as opposed to in single occupancy rooms?

Mr. Jim Ryan

It might be useful for Ms Smyth to respond.

Ms Rosemary Smyth

From our monitoring of sites we have a fairly good oversight of it.

Initially, when we started our risk assessment only 25% of services could provide single room accommodation. In fairness, the HSE moved rapidly on this and within a very short period the majority of services were able to provide single room accommodation.

On the current status, with the exception of three, all inpatient approved centres have the ability to isolate up to two people. Due to reconfiguration only one service is not able to do that. Every approved centre out there at the moment has that capacity to isolate.

Would Ms Smyth agree that up to two people is not adequate in any one of these facilities?

Ms Rosemary Smyth

Yes. That was my next point. Many of the facilities are dormitory style with four, five and six-bed rooms. These were reconfigured, in a lot of situations, to accommodate social distancing. This, however, has an impact on other types of facilities such as therapeutic services because these areas were used to cohort patients.

Has a target been set for goals to be achieved in this area? Is there a timeframe within which we will try to have the single occupancy issue dealt with?

Ms Rosemary Smyth

This is one of the Mental Health Commission's concerns. It has worked very well with regard to disease management, but for disease progression it needs to be addressed. Perhaps the HSE would also like to respond on this.

Mr. Jim Ryan

The HSE has a multiannual investment programme for mental health services. Covid-19 has highlighted the need to further expedite that. Our multi-occupancy rooms are our greatest concern with regard to the spread of the disease. As we speak, we are advancing this.

My next question is about the facilities for staff. I have received a number of calls where staff expressed concern that no appropriate changing facilities were available for them when they came to work and when they were leaving work. These complaints applied exclusively to mental health facilities.

Mr. Jim Ryan

Without the details I might not be able to answer that directly.

Perhaps Mr. Ryan will come back to me in writing on that-----

Mr. Jim Ryan

Absolutely.

-----to confirm there are appropriate changing facilities for staff for arriving at work and when leaving work, the same as those available in general hospitals. From the calls I have received on this matter, I understand that no facilities are available in some mental health units for staff changing.

Mr. Jim Ryan

I will do that.

Could I get in writing a confirmation that each unit now has appropriate changing facilities, be it showers or other facilities, available for staff, who are coming on duty and who are leaving duty?

Mr. Jim Ryan

I will respond to the Deputy in writing.

Will the witnesses clarify the number of patients in mental health settings who contracted Covid-19? What kind of number are we talking about for those who were directly affected or who contracted Covid-19, and do we have numbers for staff also?

Ms Rosemary Smyth

Those are figures I gave earlier. The numbers were quite low within mental health services, which is good. I reiterate that 28 service users and 47 staff members contracted Covid-19.

Is that for the entire country?

Ms Rosemary Smyth

Yes. This includes independent public services and private services.

What is the number of bereavements?

Ms Rosemary Smyth

We had 17 bereavements.

Is that the total number who were in mental health facilities across the country?

Ms Rosemary Smyth

Yes. That incudes acute inpatient units and community residential units.

I want to go back to a question from my first round of questions to Dr. Doody, which has also been touched on by other Deputies.

Other Deputies have raised the inevitable impact on mental health perhaps by people who have not previously accessed mental health services. There is also the matter of altering treatment plans for those already engaged with the service being altered. I return to the point made by Mr. Farrelly at the beginning, which I agree with as do many other Deputies, that our current community mental health services are not fit for purpose. We have spoken about returning to some level of service that resembles normality even though, for example, there will not be any new primary school service. Has the HSE examined the expected increase in demand for acute mental health services? An answer has not been fleshed out here. Inevitably, there will be a further reduction in service for those in real need.

Dr. Brendan Doody

It is not feasible for services to deliver the type of service that was delivered pre-Covid. Services must look at how they will deliver the maximum amount of service to the maximum number of young people who require the service at specialist mental health service level. The majority of children and adolescents accessing specialist mental health services access community mental health services. Numbers of referrals annually to community services are approximately 12,000. The first challenge is how we maintain that level of activity being mindful of the restrictions about being able to deliver the service with regard to public health considerations and the need to minimise the risk of the spread of Covid. We must look at a new service which is both delivering a service face-to-face but also remote access using technologies, and a more blended approach. At the same time, we must also scale up services in anticipation of an increased demand. We know, as Mr. Ryan said earlier, from international research and current surveys of young people with mental health difficulties that the Covid pandemic has had a negative impact on their mental health and that we need to be mindful of that. As we live in a time of increased uncertainty, we would expect increased levels of anxiety disorders and other mental health disorders. We need to look across the spectrum, from how people are supported in their mental health across services from community to primary care to specialist mental health services.

When Dr. Doody says "scale up" is he saying the committee should be confident that is being done and will be done?

Dr. Brendan Doody

I can speak for our service that what we are doing is examining, with regard to restrictions, face-to-face contact and the restrictions that services will have to work under for the foreseeable future, and how we maximise the access of young people and families to services.

Dual diagnosis was raised earlier. My question is for Dr. Niazi. I appreciate his assurance that he will bring forward reports. The programme for Government does talk about the protocols and the legislation. I had the great pleasure of attending the launch of the Finglas Addiction Support Team report on dual diagnosis which was researched with Dublin City University. No doubt Dr. Niazi is familiar with the report. It is a very thorough body of research. It made four key recommendations including changes to the Mental Health Act, that no door is not an option, the idea of a clinical programme around dual diagnosis and changes in training and education for those engaged in both parts so that they are seen as two sides of the one coin. There might be an opportunity to discuss this with Dr. Niazi in further detail when the joint committees are established.

Does Dr. Niazi wish to come in on that matter or does he wish, as the Deputy suggested, to discuss it before the Joint Committee on Health, at which point it will be possible to go into further detail?

Dr. Amir Niazi

As already stated, we have started working on the issue. I will be in a better position once I have done the homework and rolled out the programme. I have started meeting key stakeholders to discuss the matter. The work had started even before this meeting.

I thank Dr. Niazi. I will forward to him a copy of the report, which, I am sure, will be useful in his work.

I welcome the witnesses. My first question is for Mr. Farrelly. I commend him and the commission on their work. I read the 2018 and 2019 reports in advance of the meeting. They make for very sober reading. Mr. Farrelly stated in a press release that accompanied the publication of the report on 2 July that too many residents in acute psychiatric settings or acute services in mental health settings are still being treated like second-class citizens.

Mr. John Farrelly

That is correct.

He also stated that the fundamental human rights of patients were being overlooked.

Mr. John Farrelly

That is true.

Mr. Farrelly further stated that many mental health residents are still being admitted to outdated and unclean premises. He went on to state that the commission has consistently and repeatedly underlined the failings in our mental health system, but that these shortcomings are yet to be acted upon. Is that correct?

Mr. John Farrelly

That is true.

Is it the responsibility of Mr. Ryan to ensure that those shortcomings are acted upon?

Mr. Jim Ryan

My responsibility, as head of operations, is to work with my nine chief officer colleagues and heads of service throughout the country on the implementation of our mental health services. I absolutely appreciate the role of the regulator. As stated earlier, I have to work with the funding resources and staffing we have in order to make the best use of those resources and-----

I asked whether it was Mr. Ryan's role. I will get to what he does in a few minutes. It is fairly obvious what he does. I asked whether he has a role in ensuring that any shortcomings pointed out by the independent regulator are addressed. Is he the operational officer within the HSE who deals with acute psychiatric settings?

Mr. Jim Ryan

I am the assistant national director for mental services, so, yes, that-----

The answer is "Yes".

Mr. Jim Ryan

That is correct, with-----

Okay. The report goes on to cite critical risks in several areas, including premises, therapeutic programmes, services and staffing, as well as a lack of individual plans for patients in these settings. I wish to talk Mr. Ryan through some of the figures in the report because they are quite stark. The figures are broken down for each hospital and acute centre. The centres are licensed and have conditions attaching to them, as Mr. Ryan is aware. I refer to the psychiatric unit in Waterford. Its compliance rate was 77% in 2017, 73% in 2018 and 67% in 2019. That is going in the wrong direction. The same is true in several other areas. I will move to the compliance figures broken down by area. The compliance figure for premises was 31% and that for individual care plans was 52%. It was 57% in 2018. Compliance with rules on electroconvulsive therapy was 45%, down from 58%. The level of compliance with rules on seclusion was 21%, down from 33%. Compliance with regard to the admission of children was 7%, down from 11%.

How can Mr. Ryan, as one of the people with responsibility for this area, stand over situations in which the independent regulator is stating that residents are being treated as second-class citizens, that their fundamental human rights are being breached and that many of the residents are being treated in places where there are compliance issues in the context of cleanliness, a lack of individual care plans and other difficulties? How can he, as a person who is responsible for making sure that those actions are delivered, stand over the report to which I refer and the figures it contains?

I know that the Deputy will be a member of the new health committee and that the hope is to get it set up as soon as possible.

While I completely agree with him on this point, we are dealing specifically with Covid and the response to it. We may be moving away from that slightly.

Many other speakers have strayed into this area. This is one of the few opportunities, if not the first opportunity, we have had in the Oireachtas to put questions to both the Mental Health Commission and the person responsible for the commission's findings in this very important report.

I accept that.

Incidentally, the report states that Covid exacerbated the position and it took account of this. I ask Mr. Ryan to address the questions I asked.

Mr. Jim Ryan

As the Deputy will have seen from the report of the regulator, the HSE has until 24 July to provide a response to that report. We are working on that response, as we speak, and our report will go into all the areas the Deputy has raised and about which we have been aware. That is the best way I can answer the question in the short time available as the Deputy raised many issues. I assure him that I will provide that documentation. It will go to the commission in the first instance, as a response from the HSE.

I have read all of these reports going back a number of years, all of which point out the same shortcomings, problems and failures. Mr. Ryan will be aware that in my constituency a number of reports were published specifically about the department of psychiatry in University Hospital Waterford. The position does not seem to be improving. I have given an example where the figures are going in the wrong direction. The reports point out that there are staffing problems. The report on Waterford unit found that the unit was not clean, bins were overflowing in some toilets, there were cigarette butts and stains in toilets and patients were on floors. This does not paint a very good picture of some of these centres and how patients are being treated.

To come back to the fundamental point, notwithstanding whether we have Covid-19, if the regulator says that some people patients are being treated as second-class citizens, it is a damning statement to make. I am sure it was not made lightly.

Mr. Ryan indicated he would provide a written report. If there is anything else the Deputy would like to ask Mr Ryan, I ask him to do so.

Returning to the regulator, I raise the example of the unit in University Hospital Waterford because I know something about it as it is in my constituency. Mr. Farrelly points out in his report that overall compliance is going in the wrong direction, as the breakdown of the figures shows. Why were conditions attached to the unit in Waterford removed given that overall compliance was going in the wrong direction?

Mr. John Farrelly

The conditions, in the first instance, are supposed to be specific to solve a particular risk. Waterford is a very good example of how things can go wrong in a system. If one tracks back over 20 years, with the closures of the different hospitals and the lack of community services, what one gets is people going into this place which is overcrowded and operating above capacity. The clinicians are afraid that if the person is outside, he or she will come to harm. There is a systemic issue, as well as a governance issue in the HSE, which we are raising with the HSE. There is a board in the HSE and mental health needs to be brought up the agenda. The old Government policy was that there was a national director for mental health. That person was taken out contrary to Government policy. Improving governance in community services is definitely an issue. We have done a large amount of work with community healthcare organisation area 5 in the past six or seven months. The decision for us was that this was really not good and something needs to stop. At the same time, we do not want to leave the families and residents in the lurch.

I have one final question for Mr. Farrelly. If things are improving in Waterford, that is fine but the Mental Health Commission's report shows that compliance overall is going in the opposite direction. Page 24 of the report refers to the enforcement model. The commission has the option to remove a unit or service from its register. Has it ever done that?

Mr. John Farrelly

No.

Why not? Is the reason that the situation has not been bad enough for that to happen?

Mr. John Farrelly

On balance, it is a big decision to make and one has to consider who would suffer as a result.

The one we were really going after this year has actually been replaced. it was in Sligo, where it was just not physically acceptable anymore. I do not think it would be in anyone's interest to close the unit in Waterford. However, I definitely think it is improving.

One of the models we use is transparency. People get forgotten about. The idea of transparency and having people like committee members being able to read the report wakes people up to the reality of how we are treating people. To me, that is the best weapon.

I was not advocating that we close any unit. I am just asking the question. It is one of the powers the Mental Health Commission has. If things got so bad in some of them that it warranted closure, I am wondering why those powers were not used.

The main point I am making is that if Waterford is an example, it is not a great example because the services have not improved to my satisfaction. I would imagine that what Mr. Farrelly is saying is that it is a carrot-and-stick approach to some degree, and that he wants the HSE to solve the problems that he addresses. My point is that in regard to premises, staffing and cleanliness, time and again we are seeing problems and lack of individual care plans, and these are not being addressed. That is a fundamental problem for me, given the vulnerable people we are dealing with.

Mr. John Farrelly

I agree. It is a fundamental problem for me in terms of the response we get back. However, it is about the governance, the board, the CEOs, the people who sit at the executive committee and the politicians. We have to own this. With regard to the 50% figure for the care plans, I trained in England 30 years ago and that was just a given, whereas in Ireland, we nearly have to force people to do things. We are not going to get people to come into our service if people cannot even do a basic care plan properly. That is what it is all about - basic human rights and working with the person.

I agree with the Deputy. I can assure him that we in the commission have a new strategy which started last year. Our tolerance levels are now gone, and the Deputy will have seen our first prosecution in Kilkenny.

I would add that it is not just Waterford but also Wexford and all of that area, including Kilkenny, where a lot of work is needed, particularly in regard to community services, if we are not going to have the right number of acute beds.

We will move back to the issue of Covid response. I call Deputy O’Dowd.

I want to follow on from some of the questions. I welcome the witnesses and welcome the improvements in the Crosslanes facility in Drogheda. There are still issues about people who may be in drug treatment but who cannot get care because of the drug they are dependent on, although that is a separate issue. As I understand the OECD statistics, one in five of our citizens has mental health issues and we have the lowest bed capacity in Europe, with 34 beds per 100,000 compared with a European average of 69. That adds to the point made by Deputy Cullinane. If a person has severe mental health problems, they will live on average 20 years less than their peers of the same age, so it is a huge issue. Mr. Farrelly is right to be concerned, as we all are. We support what he is saying. The system is not fit for purpose and Covid is allowing us to contribute to the debate on this. I agree that we should put it top of our priority list. As politicians from the Government and Opposition sides, and I am a Government supporter, we need to get this right.

There is a very significant readmission rate and something like 64% of patients who have been in care or treatment go back in. Do we need to have different responses in terms of appropriate recovery and step-down facilities? Will the witnesses comment on whether we have inadequate or any step-down facilities for people who have been in treatment, who should go back to the community but who need a period of care outside the acute setting?

Mr. Jim Ryan

I will ask Dr. Niazi to comment shortly. As a precursor, as the Deputy is aware, the refresh of A Vision for Change, Sharing the Vision: A Mental Health Policy for Everyone, envisages a review of acute bed capacity in the country. That is welcome and timely, and the HSE will absolutely be involved in that. I hope it will address over time the issues raised by Deputy Cullinane.

There were 20,000 people in psychiatric hospitals in 1960 and now there are approximately 1,039 beds. Therefore, we have moved much of our care to the community but we must be cognisant that the pendulum may swing too far at times.

The service has half the bed capacity of the average European state. That is obviously for us to address. What about my question on step-down facilities?

Dr. Amir Niazi

Certainly, we will welcome a review of bed capacity. A review of acute services has already started. I believe there is a meeting today in this regard.

We have an opportunity now. We have Sharing of Vision and the programme for Government so we can plan for step-down services for the next ten years and see how it should be done. I welcome Mr. Farrelly's recommendation on taking a unified approach to deal with all this.

In previous years, even when the Government allocated funding for mental health services, there were times when we were unable to use them. Much of our funding is for manpower. Even if services had funding, they might not have been usable because consultants or nursing staff were not available. As Mr. Ryan says, there should now be a unified approach. We are working with the HSE's national doctors training and planning division and the training college to determine how many consultants we need to train for the next ten years? Similarly, our nursing colleges are considering what numbers will be required over the next ten years, how many beds we will need, how many units that are single occupancy units that-----

I do not have an issue with what Dr. Niazi is saying, and I support it, but I asked a different question.

Dr. Amir Niazi

I am coming to the Deputy's question. We had the acute units and we had the day centres. We are now trying to open up day hospitals to achieve a stepping down from acute admission facilities. We want most of our day centres to be community resource facilities whereas the day hospitals will have a very targeted approach to admissions. Instead of having patients proceed straight to admission with nothing in the middle, we are trying to introduce the day hospital model as a multidisciplinary model to address the gap. That is the answer. We are trying to move to day centres to step down from acute admissions.

There is a need for residential step-down facilities, which would be far less expensive than full acute care. I can talk to the witnesses about that later.

There are over 30,000 people in nursing homes and an average of 70% of these have dementia. Given the significant relationship between dementia and psychiatric co-morbidity - if that is the right phrase to use - and considering that thousands of people living in nursing homes have lost contact with their relatives and communities in a significant way, what interaction do the psychiatric services have with nursing homes generally as a result of Covid? Is there any formal relationship? How do the services react? What proposals do the witnesses have in this respect?

Dr. Amir Niazi

Under the Covid restrictions, our services were not stopped. All our acute units continued to function. All the psychiatry for later life teams continued to function. They had a different way of providing services. We made the best use of technology. Whether it was by telephone, BlueEye or Attend Anywhere, or even Zoom, we tried to maintain contact. Face-to-face contact was limited because of the public health guidance. I have never heard of any services being withdrawn although the way services were provided to nursing homes changed. That is the best evidence I can give.

Regarding our model of care, there is a discussion taking place on allocating resources for those in nursing homes and for liaison services in acute hospitals. More than 70% of beds in acute hospitals are filled with patients over 65 years of age.

That is an area which is highlighted in the model of care in our psychiatry of later life service, and again we are looking at how we can improve that in our ten-year programme.

I appreciate that answer and I respect what Dr. Niazi has said to me, but the question is what formal relationships the HSE has had since Covid-19 with nursing homes generally, if any. Is there any network in place?

Mr. Jim Ryan

I am not aware of any formal network. We operate through our psychiatry of later life and our old age psychiatry services. If an individual has to be seen by an old age psychiatrist, then he or she is referred in the normal process to our psychiatry of later life teams.

I am making a different point. If 70% of these 30,000 residents have some psychiatric problems or issues, what should the HSE be doing or can the HSE come back to us with a model or proposal for this? I appreciate there is not much time for an answer but do the witnesses see that as an issue that urgently needs to be addressed?

Dr. Amir Niazi

I will go back to the faculty of psychiatry of later life and clarify that and I can write to the Deputy with a response.

I welcome the witnesses and thank them for their presentations today. It was interesting and I thank them for providing the report in advance.

I represent Dún Laoghaire in the Dáil and one of the big issues I have had over the years has been the staffing resource for community healthcare organisation, CHO, area 6. It has been difficult to retain and recruit staff in various departments, but I want to look specifically at CAMHS and how the children and adolescent sector is resourced. Will the HSE comment on the overall recruitment process? I do not want to be too parochial but will the HSE comment on how the level of staffing for mental health services has been filled so far?

Mr. Jim Ryan

As the Deputy will be aware, the service that is being provided in the Dún Laoghaire area is run through the Lucena clinic in St. John of God Hospital. Different parts of the country will have different recruitment challenges, and the south Dublin area has previously been challenging for us from the perspective of recruiting, particularly for allied health professionals, AHPs. That can be down to many issues such as economic issues etc. Looking at our A Vision for Change numbers, throughout the country we are at about 65% of what was set out in 2006 and we have more than 70 teams in place. The recruitment challenges have been most strenuous in specialist areas and CAMHS is one of those. Dr. Doody might comment more specifically on that because he is involved in running a unit on a day-to-day basis.

Dr. Brendan Doody

There are particular challenges in south Dublin in recruiting and retaining staff, and those may be issues that are not necessarily linked with the services themselves but more with people's personal circumstances. That is one issue, but overall one has to be mindful that services need to be grown in a sustainable way or else skilled people will just move from one service to another. It is important that services are only grown at a sustainable level. There needs to be a proper plan for growing services in a way that AHPs in particular and other specialists who are required to staff multidisciplinary specialist teams are trained. The issue of physical infrastructure also has to be looked at. There is quite a significant timeline with regard to bringing inpatient services on stream from design to building and roll-out.

The Deputy must remember that with child and adolescent mental health services, the A Vision for Change document in 2006 made a significant change in that it recommended that the age range for such services be extended to 18. We were looking at services which up to then had been resourced for those under the age of 16. Effectively, a significant additional investment needed to be made. Over the past number of years there has been a significant increase in the number of teams and of staff on those teams. Some of that growth has been limited by the availability of skilled professionals but one needs to be mindful that there has been significant population growth also. Even though it may appear that there is investment and that new teams have been developed, one also needs to take into account that there has been significant population growth over that period of approximately-----

I am conscious of the time but I thank Dr. Doody for that response. I appeal to the director and to the staff from the HSE in particular to keep that focus on south Dublin. I have been aware of the challenges for many years but I ask them to redouble the efforts to retain and recruit staff for the CHO and the wider field.

In the earlier session, I raised the issue of dual diagnosis. A problem that arises time and again is in terms of people who have an addiction but who also have mental health issues. Could the witnesses comment on that? Primary healthcare services are patchy, to say the least, across the country. Some areas have a functioning primary healthcare service and a centre but others do not, and that presents challenges.

Finally, to the witnesses from the Mental Health Commission, it is stated on page 17 of the report we received in advance of this meeting that the commission was reporting on a weekly basis to the Department of Health. If a second wave of Covid-19 were to hit or just in general the coming weeks or months, is that likely to continue?

The witnesses might briefly answer the final question because it is Covid-related and perhaps provide a reply in writing to Deputy Devlin in respect of the other questions.

Mr. John Farrelly

On the final question, we have been closely monitoring that. In fact, we have a particular risk framework that we use to ascertain if a centre could react, even if it had bad premises. Ms Smyth has the exact details on what we are requiring.

Ms Rosemary Smyth

To clarify, is the question that we will continue to report to the Department of Health?

On a weekly basis, yes.

Ms Rosemary Smyth

We are still continuing to report the numbers on a weekly basis. Each week, we submit a summary report and the metrics to the Department and the HSE. We will continue to do that for as long as it takes.

A reply in writing might be provided on the other questions.

I thank our witnesses for attending and for the information they have provided. My first question is to Mr. Ryan and it relates to a matter raised earlier by another member on the low level of Covid-19 in the forensic services. Am I correct in stating that the forensic services are in one building or are there additional services throughout the country?

Mr. Jim Ryan

The Central Mental Hospital is the one building in Dundrum, as the Deputy is aware. We also have Usher's Island in the city centre and our prison in-reach staff go into the main prisons across the country. As a forensic service, we are national but the Central Mental Hospital is within one facility in Dundrum. As the Deputy is aware, we also opened a nine-bed unit as a response to Covid-19 in the new facility but we have since moved patients on from that.

When Mr. Ryan refers to the forensic mental health services, it sounds as if there are multiple locations but that is clearly not the case. On what date were visits to the Central Mental Hospital restricted ? I imagine Usher's Island would have been closed in the early stages and then the visitor restrictions relating to the Central Mental Hospital would have kicked in. What date was that?

Mr. Jim Ryan

I cannot remember the exact date. It would have been in line with whatever were the recommendations of the public health authorities at the time.

It was done exactly in line with the NPHET recommendations. The HSE did not close it ahead of that time.

Mr. Jim Ryan

I do not think we did.

Can I ask Mr. Ryan to check that so he is certain?

Mr. Jim Ryan

I will.

That is not my understanding. It would be very helpful if he could correspond with me on that.

Mr. Jim Ryan

I will.

I am sure Mr. Ryan, like me and the other witnesses here, is more than familiar with the Central Mental Hospital. It has a massive high wall around it and double gates at the front. It is very hard for anyone or anything to get into or out of it. It is set up similarly to a prison. I would not want the impression to be given that this is an open facility when clearly it is not.

I wish to discuss the restarting of care. I apologise if I have missed this because I have been dipping in and out of the committee. Is there a plan for catching up on services that have been missed or providing for people who might require more intensive engagement or therapy? We have spoken at length about the impact this pandemic will have on the mental health of the population. That will be even more acute among those who were already users of mental health services.

Mr. Jim Ryan

I might answer generally and allow Dr. Niazi to follow up. As the committee will be aware, the HSE produced a document on business continuity. The care groups have all looked at their own services to determine what they need to bring services back on stream. That plan is almost complete. We are trying to determine what we can do safely and whether we can use some of the technology we have learned about in recent months. We must also take the potential impact of a second wave of Covid-19 into account.

Dr. Amir Niazi

Regarding the recommencement of services, as I said earlier, our acute units continue to function 24-7. Our 24-hour residences are open, with limitations placed on visits. The services which were impacted were day centres, day hospitals, group therapies and group activities. They are gradually starting again, with social distancing and following all the guidelines from the Health Protection Surveillance Centre, HPSC.

Covid-19 has impacted the mental health of the public, not just mental health service users, and the public requires the help of mental health services. The HSE has worked very hard to address the psychosocial and mental health needs of the public. We are targeting carers, families and staff members who were impacted by Covid-19. A comprehensive national plan is being rolled out to serve the public, staff and carers.

We are recommencing secondary mental health services slowly and gradually, in keeping with the guidelines from the Institute of Public Health and the HPSC. Our success in controlling the virus will guide us in how we restart.

As such, there is no specific catch-up initiative. There were serious recruitment and retention issues before the pandemic. They were partly caused by recruitment embargoes imposed by the previous three Governments, even though their members give out about them now. With regard to the need to catch up on services, which the witnesses have not addressed, and the restart of services which were already understaffed, has the HSE identified the need for a specific recruitment campaign? Does the HSE have a target for the number of staff members that will be necessary in each grade, group and category, and has this target been published?

Mr. Jim Ryan

That target has been published. As part of our business continuity plan, we are determining what we need to bring services back in a safe way. That will depend on whether the service in question constitutes inpatient services, day programmes or community care. That number will be determined by our business continuity plan, which is being worked on at present.

Mr. Ryan referred to the use of technology. I have my own opinions about telemedicine, particularly in the area of mental health. I have made those views known and I am sure Mr. Ryan is well aware of them. I would like to draw his attention to some information provided by Samaritans Ireland. That organisation has described an increase in the number of emails it has received because service users find it difficult to talk on the phone in private during the lockdown.

This is not an ideal scenario. However, the measure was a stopgap. I would hate to think that a stopgap that was not ideal would somehow replace face-to-face services. It was part of a presentation and the slide indicates that phone calls appear to centre on a need for human contact. Replacing face-to-face services, even in a socially distanced way, with telemedicine will never be right. I do not believe that has any place. Based on when those services were replaced with a telemedicine service, calls to the Samaritans appear to centre on the need for human contact. How many of the services will be replaced with a telemedicine service? Does Dr. Niazi believe that would be an adequate replacement for face-to-face services.

Dr. Amir Niazi

The Deputy is absolutely right. When we are sitting with a patient face-to-face, it is not only the words that the patient says; we look at many other things. We look at the body language, their hygiene and other dimensions of our assessment. There are patients who even are paranoid who are not well when they on the other end of the phone because they have their own anxiety about the technology. It was used during the pandemic. We are not saying that we are replacing it. Even during that phase of the pandemic, when the use of technology was happening, a doctor, who was concerned about somebody's mental health or felt that the information required from those assessments was not gathered appropriately, asked the patient to present to one of the acute units where separate areas were developed, keeping social distancing and other guidelines in place.

Now that the pandemic is settling a little, those face-to-face assessments have started to increase. Patient need dictates how much of that can be done by technology. If a patient is not sleeping and asks for a sleeping tablet, we can address that issue. However, if we feel a patient's assessment requires face-to-face detailed assessment, he or she is invited to attend one of our units. We are looking at the layout of all our outpatient areas and our sector headquarters and what needs to be done to make them safe. I totally accept that we are not replacing technology, but that is another tool in our arsenal and it is available if we need to use it.

Someone working in the HSE mental health services in the mid-west has suggested to me that there is no consistent or coherent plan on when or how to return to face-to-face meetings. I ask one of the HSE representatives to comment on that.

Mr. Jim Ryan

At all times, we are attempting to stay within the public health guidelines, which as the Chairman is aware, can change. As part of the return-to-business protocol that has been published, that needs to be worked out on an individual area basis. While we can have principles, guidelines and protocols, we need be able to implement them. Each of the areas are looking at their own premises and services to establish how they can meet the twin approach of return to some degree of normality-----

Is it correct to say that there is no consistent plan in place yet and that it is still being worked on?

Mr. Jim Ryan

The guidelines that have been issued need to be implemented locally.

Therefore, they have not been implemented locally yet.

Mr. Jim Ryan

I think we are in the process of doing that.

With regard to more remote care, it has been suggested that, rather than smartphones, the staff have Nokia 3210s. These are the type of phones that people were seen using in the programme "Love/Hate", but for very different reasons. It has also been suggested that staff have no handsets and that, several months into the coronavirus restrictions, approval is still awaited in the context of videoconferencing facilities. I ask Mr. Ryan to comment on that.

Mr. Jim Ryan

As Deputies will appreciate, once Covid-19 hit we had to look at all ways of trying to ensure a continuation of provision of services. From an ICT perspective this posed significant challenges. There have been significant developments over recent months, probably greater than we would ever have deemed feasible. The issue was raised about voices, which has certainly been a difficulty over the most recent period. We hope that it will no longer be a difficulty because our investment in those devices will help meet the demand.

Deputy O'Reilly referred to face-to-face communication. We are trying to have a blended approach so those who need face-to-face support can have that access and we can try to ensure we maintain a level of service where we use technology to the best advantage. As the Deputy has outlined, that coverage throughout the country can sometimes be patchy. We are working on this daily.

A United Nations report on Covid-19 and mental health states "Reports from Chile, Italy, Spain, the Philippines, the United Arab Emirates, the United Kingdom and the United States of America document how dedicated teams provide mental health support for health-care workers." Were there any such dedicated teams in the HSE or anywhere across mental health services providing mental health supports to front-line healthcare workers in Ireland?

Mr. Jim Ryan

Ireland has done that through our psychosocial response. As Dr. Niazi said earlier, the HSE has specifically arranged for counselling services through SilverCloud Health. I understand that counselling sessions have been taken up by some 3,000 HSE staff. We have used technology in this way to our benefit. This is the main way we would address it.

Dr. Amir Niazi

Yes. That is the main way at the moment.

Would the witnesses agree that the impact of Covid-19 and the necessary restrictions had a negative impact on mental health?

Mr. Jim Ryan

They have had a negative impact across a whole range of health services, notwithstanding in mental health-----

I am sorry. I do not refer to a negative impact on mental health services but a negative impact on the mental health of the population.

Mr. Jim Ryan

Yes.

Given that, does Mr. Ryan feel it is surprising or alarming there were no mental health representatives or psychiatry representatives on the National Public Health Emergency Team, NPHET, when all of these decisions were being made?

Mr. Jim Ryan

I do not think that is-----

If Mr. Ryan does not wish to comment on that, maybe a representative from the Mental Health Commission will comment, and if they do not, then that is fine.

Mr. John Farrelly

I believe that Dr. Siobhán Ní Bhriain, who was previously the clinical lead in the HSE, was on NPHET.

I understand it was not as a representative of mental health or psychiatry but rather in her new role. Is that correct?

Mr. John Farrelly

I do not know. We inputted into the structure with regard to the vulnerable person. There was a fair bit of feeding in from professionals who understand mental health. Now the context is about getting ready again when we know we have a service, which I really want to reiterate. I would not want that to get lost. I appreciate that the mental health of the nation and individuals is important, but within this there are highly vulnerable people with mental illness who really need to get the services. For me, these are the people on whom I want the HSE to concentrate in building the service for people with mental illness.

Okay. Mr. Farrelly has been very clear with that message and I thank him very much. I also thank the other representatives from the Mental Health Commission, Ms Rosemary Smyth and Dr. Susan Finnerty. I thank Mr. Jim Ryan, Dr. Brendan Doody and Dr. Amir Niazi from the HSE.

I will suspend the committee until later this afternoon, when it will meet in private session.

The committee adjourned at 1.35 p.m. until 9.30 a.m. on Friday, 17 July 2020.