Committee on the Future of Healthcare díospóireacht -
Wednesday, 9 Nov 2016

Integration of Health and Social Care: St. Patrick's Mental Health Services

Chairman

I remind those present to ensure their mobile phones are switched off or in aeroplane mode so that they do not interfere with the sound system. I welcome our visitors, the members of the committee and those who are watching the committee's proceedings online.

During this morning's session, we will examine how we can move towards an integrated model of health and social care. We have decided to focus in this discussion on two important pillars of community and social care: mental health services and social supports for older people. To reflect on these themes, we are having two sessions this morning with stakeholders who made submissions to the committee. Representatives of St. Patrick's mental health services are present to discuss mental health and community services. We will meet representatives of Mental Health Reform, the Forum on Long-Term Care for Older People and Family Carers Ireland at approximately 11 a.m.

I welcome Mr. Paul Gilligan, who is the chief executive officer of St. Patrick's mental health services, SPMHS. He is accompanied by Professor Jim Lucey, who is the medical director of SPMHS, and Mr. Tom Maher, who is the director of services of SPMHS. This long-standing and well-respected institution has over 700 staff members, who deliver 12% of the country's total inpatient mental health care at two inpatient campuses: St. Patrick's University Hospital in Dublin 8 and St. Edmundsbury Hospital in Lucan. It offers a range of services for adults with mood disorders, psychosis, addictions, anxiety disorders and eating disorders. Adolescent mental health services are catered for at the Willow Grove facility on the grounds of St. Patrick's University Hospital. A wellness and recovery centre offers day service programmes and community clinics in Dublin, Cork and Galway. There are also some other national services.

I want to go through the formalities in respect of privilege. I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given. They are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any persons or entity by name or in such a way as to make him, her or it identifiable. I remind members of the long-standing ruling of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

I invite Mr. Gilligan to make the opening presentation. He is very welcome.

Mr. Paul Gilligan

St. Patrick's mental health services is Ireland's largest independent not-for-profit mental health service provider. It is committed to providing the highest quality of mental health care, promoting mental health and advocating for the rights of people experiencing mental health difficulties. In 2015, the service had over 3,000 inpatient admissions, over 14,300 day-care attendances and over 14,600 visits to its Dean clinics. The organisation runs an extensive advocacy programme, the highlights of which are the Walk in My Shoes and Mind Your Selfie campaigns. It also runs a comprehensive service user involvement and training and research programme. We welcome the opportunity to make a submission to the development of the new health strategy. We would like to thank the Oireachtas committee for the opportunity to make this presentation. We are eager to work in partnership with the Government and all key stakeholders to form and deliver on a new mental health care strategy. The prevalence of mental health problems in Ireland is well documented, with one in seven adults experiencing a mental health difficulty in the past year. Recent studies suggest that young people in Ireland may have a higher rate of mental health problems than similarly aged young people in other countries.

St. Patrick's mental health services believes Ireland should be committed to the establishment of a world-class mental health service. Such a service should be built on human rights principles, with a core emphasis on service user participation. In our view, the right to be given the opportunity to live a mentally healthy life should be enshrined in legislation. Everyone should have access to basic mental health care services as a right. The exact services to which people should be entitled to access should be set out in law so that it is clear to service providers and service users that legal obligations exist, and that a right of remedy exists where these obligations are not met. It is essential for any new mental health care strategy to be grounded in a recovery model in which service user empowerment and choice is paramount. These principles pertain particularly to young people, whose existing constitutional rights to appropriate mental health care need to be recognised and realised. The funding model for any new strategy needs to be grounded in principles of value, which we define as outcomes per euro spent. No strategy will be successful unless the existing stigma surrounding mental health within Irish society is acknowledged and tackled. This cannot be achieved unless all stakeholders work together.

Mr. Tom Maher

The budget for mental health care in Ireland as a percentage of overall health spend reduced from 13% in the mid-1980s to 6.2% in 2015. The comparable budget for mental health care as a percentage of overall health spend is 12% in Britain and Canada and 11% in New Zealand. St. Patrick's mental health services recommends the implementation of the recommendation in A Vision for Change that the mental health budget should represent at least 8.24% of the overall health budget. The future health strategy must be informed by and include all stakeholders and must be conducted in a way that ensures buy-in from service users and their families. It is essential that we find a way to actively include families in the care system while protecting the rights of service users. We note that the UN Committee on the Rights of the Child, in its concluding observations at the start of 2016, urged consideration of the establishment of a national specialist independent advocacy service for children under the age of 18 who are in receipt of and engaging with mental health services in Ireland. We are recommending the establishment of such a service.

There is no definitive model of an integrated health care system that ensures patients have access to high-quality and efficient care. However, enough research is available to indicate that a number of principles are associated with the successful integration of such services.

These include issues such as maintenance of a patient focus when integrating services, providing standardised care delivery through inter-professional teams, the implementation of performance management systems across all employees, the availability of information systems that fully support the integration of services, strong organisational culture and leadership, strong clinical and corporate governance structures and sound financial management. St. Patrick's suggests that any proposals to integrate primary, secondary, tertiary and community health care services be informed by these key principles.

St. Patrick's has worked with health insurers to develop a funding model for all ambulant care in ambulatory care settings. This model should be considered and included in any new strategy. The independent sector has an essential role to play in the delivery of a world-class health service and it is therefore vital that any strategy includes involvement of this sector.

Professor Jim Lucey

At St. Patrick's, we believe it is essential that we make the best services available to all those who need them, in particular to those people who are more disadvantaged in our society. Service development must be aware of the social determinants of ill-health; these are the real determinants. Groups of society on the margin who are homeless or disabled need more access to health services, not less.

There is a need for greater support for family members, in particular for family members caring for persons with mental health difficulties or disability.

Future developments in health care need to be evidence-based and new technologies introduced that are efficient and cost-effective and appropriate to an Irish context. This development will need the establishment of a continuing commitment to research into health care service implementation. We should begin this research by looking at the services required to address the mental health needs of our increasingly aging population.

We must identify the challenges present in recruiting and retaining staff to health services, and in particular to mental health services, and take steps to address the shortfalls that exist. To do that we should start by consulting with health care staff on the proposed changes we need to make and ensure they are sufficiently supported to allow them carry out their new and challenging roles.

Mr. Paul Gilligan

St. Patrick's mental health services are committed to working with Government and all other stakeholders to build a world-class mental health service where all people are given the opportunity to live mentally healthy lives and where the rights of people to access recovery-based mental health care is enshrined in legislation.

Chairman

I thank all three witnesses for that presentation. I will open up the debate to members, who I will take in groups of three. The witnesses might bank the questions before responding.

Deputy Mick Barry

I thank the three speakers for their interesting contributions today but also in terms of the overall work of the committee. I have three questions. First, I would like to focus on a sentence in Mr. Gilligan's statement in which he states, "The exact services to which people should be entitled to access should be set out in law so that it is clear to both service providers and service users that legal obligations exist". That is an interesting and important statement. It seems to me that it is not possible to do that unless services are free at the point of use. Otherwise, people will have an entitlement but they will not have the wherewithal in their pocket to follow through on the entitlement. I do not see how that can be done without having a health service that is free at the point of use. I would like the witnesses to comment on that. It seems to me that such an approach is very much in sync with the idea of a national health service-type model for a health service. I ask the witnesses to comment on that. If we had such a system, the witnesses might comment on how they would see St. Patrick's mental health services fitting in or its relationship as part of that.

Second, Mr. Maher made interesting points about overall health spend. It is ironic that at a time when consciousness in society about the importance of good mental health and mental health services is probably at a higher level than ever before, although there is still a long way to go, the percentage of health spend is at an all-time low or close to it. To be blunt, the expectations of ordinary people are in conflict with what the political establishment has put in place, but we know that. What I would like to learn from the witnesses is the position on the ground on a day-to-day basis. What does that mean in terms of the type of services they would like to provide, and that should be provided, and the type of services that exist for people with mental health challenges? What kind of problems is that low spend causing?

The last question is on the relationship of pharmaceutical companies with the health services in general on which the witnesses might comment. For example, The Sunday Business Post recently reported that the College of Psychiatrists of Ireland has banned donations from pharmaceutical companies because of evidence that it influences prescribing. This position was also endorsed by Dr. John Hillery, who is governor of St. Patrick's. My question is whether it has been adopted by St. Patrick's and by all medical staff who work in the hospital.

Deputy Josepha Madigan

I thank the witnesses for coming in to speak to the committee. We appreciate it. I have had many clients going through St. Patrick Hospital and I know the work it does. I spoke on the issue of mental health in the Dáil. It is an issue I feel very strongly about. I did not see the word "addiction" in the submission. How many people in St. Patrick's Hospital have addiction problems? In my humble layperson's view I believe there is a close link between mental health and addictions, whether it is alcohol or drugs but particularly alcohol, and particularly for young people. It also is becoming more prevalent in the middle-aged and aging population. What programmes does St. Patrick's Hospital have for people with addictions, and what else would the witnesses like to see provided to help those families?

Deputy Pat Buckley

I thank the witnesses for their presentation. The previous speaker touched on the issue of addiction or the dual diagnosis, as we call it, which appears to be a major problem in this country. Having met many people in recent weeks and months I am aware that accessing help within the system seems to be a stumbling block for many people. Could the witnesses point us in the right direction in that regard? Is that about leadership and responsibility on the part of the individuals who have been elected by the people to take on that responsibility or do we need to set out rules on it?

The witnesses mentioned staffing, which is a major issue that arises in almost every meeting of this committee. Would the witnesses consider a new wages package for staff? Do we have to start paying big bucks to get the required number of nurses for the health services?

The witnesses stated that the budget for mental health services is extremely low. We are well aware of that. Would they recommend a doubling of the mental health budget for the specific services? Mr. Maher stated that the budget for mental health care was 6.2%. Should that figure be 12% or 13%? It is not rocket science. We have to spend the money on the services to get what we want out of them.

Mention was made of A Vision for Change. This is a broad question. If any section of A Vision for Change was implemented, do the witnesses believe it would still work?

My strong view is that it will but I wanted the opinion of the experts.

Chairman

I thank the Deputy. Members asked a wide range of questions. Will the witnesses respond to them please?

Mr. Paul Gilligan

There is the issue of the legal requirement. A rights-based model of mental health care would have four key components, namely, availability, accessibility, acceptability and quality. The issue of payment is very much a decision that would need to be made by the Government around what services it believes should be available free to any individual at any given time. We should remember that there is no such thing as a free service. In the view of St. Patrick's mental health services, people pay for their health care through their taxes. The question is what services should be made available to people as a result of them paying those taxes.

The issue of a national service is very important. St. Patrick's mental health services believes that all the key players need to form partnerships and there must be a partnership approach. For too long we have debated the role of the private, voluntary, independent and statutory sectors. Any future health strategy must include a role for all those people. That, combined with a rights-based approach, will effectively help us shape the financial model that will fund such an approach. There are inconsistencies in the system now. Where mental health care is concerned, it is difficult to argue against people being entitled to basic, high-quality care because it has such an impact on all the rest of their lives, not just their physical well-being but that of their families, as well as employment and schooling. It would be hard for any strategy to not consider making an extensive, high-quality mental health care service available to people. The State should effectively be paying for that, regardless of how it is structured.

Mr. Maher will speak about spending and Professor Lucey will comment on the pharmaceutical aspect. I will pick up on A Vision for Change. We believe the strategy is good and robust, although there are some shortfalls. When the strategy was put together, perhaps the role of the independent sector was not envisaged. Any development of that strategy should include an active role for the voluntary and independent sectors. The key principles of A Vision for Change are nonetheless robust. There are some difficulties around the interpretation of A Vision for Change and at times it is interpreted as amounting to the closing of all inpatient care and the opening of community services. A Vision for Change discusses a comprehensive care model that involves all those key components. If we delivered A Vision for Change, there is no doubt we would have the highest quality mental health service. I will come back to staffing and salaries.

Mr. Tom Maher

With regard to a national or single service, the National Health Service, NHS, in the UK is an interesting example. It is a single service but many of the authorities within the NHS are becoming commissioning agents for services. Those services are accessed through any number of different providers. In terms of the mental and physical health infrastructure that exists at present, there is enough there to provide for that single health service. It is more about how those providers are used, as opposed to subdividing the health infrastructure into state, independent, voluntary and private. The NHS model of commissioning would work well.

Members asked about the implications of a relatively low health spend with regard to the overall health spend. There are three impacts in this regard. The first has been mentioned briefly already. Staffing levels are a difficulty in the context of providing a high-quality service. I refer specifically to recruiting and retaining high-quality staff. The other major impact on a low spend or relatively low spend is access. People do not have access and with mental health care, there are sociological barriers to accessing mental health care in the first place arising from stigma. This arises where people simply will not access services because of the stigma associated with mental illnesses. Where services are not available it is an additional barrier. If people do not access services, particularly with mental health, over a long period - the research we have done suggests some people wait up to ten years to access quality care - it will only disimprove a person's mental health. That will then lead to a longer recovery time. Lack of investment will reduce the quality of services generally.

Professor Jim Lucey

To respond to Deputy Barry, I will pick out the issue of the relationship with pharmaceuticals before taking on the questions from Deputies Madigan and Buckley on alcohol. The pharmaceuticals issue is something on which we welcome discussion. We also support entirely the position outlined by Dr. John Hillery and the College of Psychiatrists of Ireland. The committee may be interested to know that we introduced this policy more than ten years ago and we were the first in the nation to introduce a comprehensive policy with regard to the pharma industry that sets out very clearly the limits that need to be placed between prescribers and the industry. We did so in a policy we published and that was commended by the then inspector of mental hospitals from the Mental Health Commission, Dr. Pat Devitt. In his report in 2010, he indicated this should be the industry standard for health services as a whole and recommended that it should be adopted. We can give the committee that information.

The facts are that all human beings are influenced by a variety of inputs, including the market. We need to ensure that the highest possible standards determine how physicians and clinicians prescribe and determine care for patients. This is really the unifying theme of our presentation. It is about human beings and a holistic service that is centred around the patient, person, service user and citizen. That is where the issue about addiction comes in as we have a national problem with addiction. We cannot deny that we are in many ways dominated and distracted by it all the time. Our service, historically, has been associated with a commitment to those with addictions. Many believe our service is primarily associated with that but of course addiction is not our only mental health agenda. We are leaders in the delivery of addiction services, with the understanding that addiction is part of a mental health problem. Most often a dual diagnosis, as has been described, is a better term. It is a part of a journey for many people. Very few people take their lives in this country without having alcohol involved with that process, which is so tragic. From the beginning to the end, recovery that denies the place of substance use is probably mistaking and misunderstanding the needs of people.

We have introduced dual diagnosis services and approximately 12% of inpatient services relates directly to alcohol and dual diagnosis. We have a consciousness of this right across the services. As the Chairman stated, we have over 700 staff but we have hundreds of highly qualified therapists and trained staff who are aware of the duality. We have a coherent delivery. We also recognise that the delivery of mental health services must be a population health system, community-based in the sense that it returns people to the community and to where they live, work and love. We were the first centre in Europe to introduce Alcoholics Anonymous in the 1950s and we have just celebrated the 70th anniversary of its arrival.

We have a long-standing commitment to supporting people struggling with addiction where it matters and where they are in the community. We are about delivering those services and returning people there. I hope our contribution can help the committee's vision, which should be about returning people to wellness where they are and providing them with excellent services. The question of cost is really important, and as Mr Gilligan has stated, cost can never be taken out of the issue. There are also questions about standards, commitment and vision, which need to be addressed as well. We believe in the provision of excellent services to people in the community.

Mr. Paul Gilligan

I will pick up on some of the specific questions. At least 8%, if not 9%, of the health budget should be spent on mental health. That is what is recommended in A Vision for Change. It is possible that more is needed but we are miles away from that now at approximately 6%.

In terms of staffing, salaries is one issue. There is also a belief in what people are doing. Having a commitment to an overall strategic vision for an organisation and support are also key because working in the health sector is extremely stressful. If one feels one does not have the supports and that one is not working in a worthwhile organisation then one will leave, which is one of the reasons we lose people. Our competition is Australia, New Zealand and the NHS. We have got to address the issue of losing staff as a priority.

Mr. Tom Maher

Deputy Buckley asked how can we enhance services for people with a dual diagnosis. As Professor Lucey has said, it is important not to separate the mental health service from the addictions and dual diagnosis service. Addiction issues and problems are mental health problems and, therefore, should be under the remit of mental health service and not disaggregated or separated from the mental health services. That specific point is quite important.

Deputy Pat Buckley

I thank Mr. Maher for his answer. The following simplistic scenario seems to have been prevalent with people with whom I have dealt directly over the years on this issue. An individual presents himself or herself at the accident and emergency department in a highly intoxicated state and threatens to take his or her life. The health care staff cannot touch the person because he or she is drunk and so the person is advised to go home. Can a system be put in place in the health service where a person is accountable and takes responsibility in cases where a person presents himself or herself at an accident and emergency department or wherever? We need a person to take responsibility for the person presenting and to address the system on both sides. First, the addiction in the form of either drugs or drink must be addressed. Second, when the person is back on a level playing field an effort should be made to discover the underlying mental health issue.

Professor Jim Lucey

The answer includes a number of complex things. The Deputy is right that one cannot put up barriers to care for people who need that care. The way to tackle the issue is to make a commitment to holistic care and seeing these problems as integral to each other at a human level. The policy document entitled A Vision for Change radically separates addiction services in a way that we had fundamental difficulties with at the time. Our service has not made that separation in the same way. We see the duality and holistic nature as being primary.

One can deliver accountability and being responsible by agreeing to integrate addiction and mental health in a much more meaningful way. One must start by agreeing that and we would argue that in the Irish context it makes no sense to separate these issues.

Deputy Pat Buckley

I thank Professor Lucey.

Chairman

The main problem arises from the fact that addiction and mental health services are in different directorates in the HSE.

Professor Jim Lucey

That is correct.

Chairman

The directorates are separated structurally by the HSE.

Deputy Pat Buckley

I thank the Chairman.

Chairman

Yes.

Deputy Josepha Madigan

Can I comment?

Chairman

Does the Deputy wish to comment on the same issue?

Deputy Josepha Madigan

Yes. I may not have been clear when I asked my question. What percentage of patients and day patients who avail of services at St. Patrick's Mental Health Services have addictions? I understand that the delegation may not know the exact figure. Did Professor Lucey say 12%?

Professor Jim Lucey

Yes.

Mr. Paul Gilligan

Between 10% and 15% of the people we work with on an inpatient level would be people who-----

Deputy Josepha Madigan

Do the rest of the patients have other types of mental illness?

Mr. Paul Gilligan

Their diagnosis would be different. The point has been well made that one often gets addictions as part of other difficulties. In terms of diagnosis, it is between 10% and 15%.

Deputy Josepha Madigan

The percentage is low enough and I expected it to be higher.

Mr. Paul Gilligan

A number of specific services deal with alcohol and drug addiction only. We deal with a whole range.

Professor Jim Lucey

We provide a whole range of communal services. There is a distinction between alcohol abuse that would probably be prevalent in about one quarter of Irish homes. Alcohol abuse is a factor right across a whole range of mental health difficulties and that would be larger than 15%.

Deputy Josepha Madigan

Yes. What about alcohol dependency?

Professor Jim Lucey

Alcohol dependency would be a narrower number.

Deputy Josepha Madigan

I thank the witnesses.

Mr. Tom Maher

Deputy Buckley expressed a concern for individuals who present at an accident and emergency departments. In any process-driven industry, and mental health care is one of those industries, the key to continual quality improvement is standardisation. We believe it is strategically imperative to develop standards for situations when persons present themselves at an accident and emergency department. There should be a clear clinical pathway with an infrastructural basis available that does not involve saying to a person: "Go home until you're sober." If we standardise the approaches to care, which is what the strategy should consider doing, it will lead to improved access to care and people getting the care that they need much quicker. The notion of standardisation and developing care pathways for a variety of different presentations should be key in a mental health strategy.

Deputy James Browne

Why did the percentages spent on mental health decrease so much relatively? Was money directed elsewhere when the Victorian institutions were shut down? Did expenditure not keep pace with the population? I know why funding decreased but I want to know what happened operationally. Where did the percentage of moneys go?

I would like to hear the views of the delegation on cross referral, especially by allied health professionals. Nurses today hold honours degrees and very often they have masters and PhDs. Public health nurses work out in the community and can spot something in a person they see regularly. At the moment all referrals must be made by GPs. I would like to hear the views of the delegation on allied health professionals referring a person for help and support.

I wish to ask about the witnesses' experience. By the time people with mental health issues present at emergency departments, they often have physical problems, for example, they may have attempted to take their own lives. The physical issues need to be treated as much as the mental health ones. These people are often known to the system, but the system is shut down except between 9 a.m. and 5 p.m., Monday to Friday. Should 24-7 services be prioritised in emergency departments or in the community systems of which these people avail? Is there a moment before they get to that stage at which they might access supports but those supports are not there? This is a question on priorities, although we would ideally want both.

Deputy Louise O’Reilly

I thank the witnesses for their presentations. My first question relates to staff. Having represented staff at St. Patrick's for many years, I am familiar with its set-up, but will the witnesses tell us about the skill mix? This committee is debating a ten-year vision. What is the extent to which the skill mix is utilised? I understand that it is utilised at St. Patrick's. Is there potential to broaden that utilisation within the current staff cohort?

I would be interested to hear more of the witnesses' views on staff recruitment and retention already, not just of nurses, but of all staff. My understanding is that we are short staffed. One reason that was cited – it is not a reason that I accept – for some of the mental health budget not being spent in previous years was that there was a difficulty in recruiting staff. Do the witnesses believe that this committee has a role in providing that vision? If this is the reason for losing staff, would a detailed vision for the health service help the staff retention issues?

My last question relates to the commissioning.

I think it was Mr. Maher who said that it might be good for the committee to explore the way commissioning is handled by the NHS. I would be interested in hearing the views of witnesses on how to commission services. We all know how to commission a bed, which is relatively simple.

We know the silo nature of access to services, where addiction services are kept separate from mental health services. People with multi-morbidity need to access a range of services. In a model in which we focus on commissioning beds or commissioning services, will the witnesses give us some insight on how we can commission the type of services that will make a real and meaningful difference for people in a mental health setting?

My understanding is that St. Patrick's mental health services is a not-for-profit group. It is not a private hospital in the strictest sense of the word. When we discuss private and voluntary health services, I would see St. Patrick's as being more in the voluntary sector than in the private sector. When we talk about a role for the independent sector, I am not endorsing the for-profit companies in any way. I think that should be made clear.

Chairman

What is the arrangement for inpatient and community services in St. Patrick's in terms of access for public patients? Stigma and the obstacles it causes for people accessing care have been mentioned. How are we doing in regard to stigma and are we making significant progress in breaking down the stigma of mental health issues?

From my experience in the constituency, alcohol is the number one substance of abuse and benzodiazepines are number two right across the spectrum. What is the experience in that regard? What treatment options are available to people?

Mr. Paul Gilligan

The structure and nature of St. Patrick's mental health services is quite tricky. We are eager to ensure people do not have any misunderstanding about the nature of our organisation. We are a not-for-profit organisation, so there are no shareholders and nobody is taking money out of the organisation. In that sense, one could describe us as a voluntary institution per se. There is a group of organisations that provide health care where money is paid to investors. All of the money we generate is reinvested into the organisation and those who serve on the board do so voluntarily. To describe St. Patrick's mental health services as voluntary raises difficulties because 90% of the people who use our services have health insurance. That is something we have tried to address in the past ten years. We want our services to be available to everybody. It is quite simply that if the HSE does service level agreements with us, we are then in a position to provide care to people through the HSE system. Without that we cannot provide care. We have a small philanthropic fund whereby we try to ensure people who could not otherwise access help can access it.

In the past eight years, we have developed our community clinics, our Dean clinics, and as part of our philanthropic purpose we have introduced the concept of free assessment. The difficulty is that it needs to be linked to a care pathway and it can be perceived as cynical. We have done it as a genuine gesture. This initiative has been protected by our board in order that people can get a free assessment in our dean clinics, but we need to generate a care pathway from that because otherwise we are providing something that is irrelevant. This is something we grapple with all the time. We want our services to be available to more people and we want to provide our services to everybody.

In response to some of the other questions that have been raised, the key issue is staffing. We strongly believe that salary is an issue. There is a problem with the salary levels in the health services. Nobody can dispute that. At our salary levels, we have to try to compete with the jobs on offer in Australia, the UK and so on. Job satisfaction and support are equally important. We find ourselves going into a downward spiral. When there the required number of staff is not on a particular team, the staff on the team lose heart as they feel they are carrying responsibility at weekends and on evenings when there is no backup. That causes burnout. It is not just about salaries.

There are also difficulties around the number of staff available. We are not training sufficient numbers. As part of the cutback measures, we reduced the number of training places and this is having a significant impact on professionals such as nurses and doctors. In St. Patrick's mental health services, our approach is to have a multidisciplinary team service. One of our core aims is to meet the Mental Health Commission's regulations and standards and we therefore employ multidisciplinary teams. The team comprises consultant psychiatrists, psychologists, social workers, occupational therapists, dietitians in some cases, depending on the service we are talking about, and numerous different types of counsellors, addiction counsellors and cognitive behavioural therapists. We pride ourselves on ensuring we take a multidisciplinary team approach because that is best practice.

Mr. Tom Maher

Deputy Browne asked a specific question on the expanding role of other disciplines. We absolutely agree that is necessary. We would have trained nurses to become clinical nurse specialists and advanced practitioners. The same applies to occupational therapists, social workers, clinical psychologists, speech and language therapists and dietitians. We have the full range in St. Patrick's. We use them to the best of their ability. We have approximately 350 clinical staff, of whom 30 to 35 are doctors. There is multidisciplinarity across the entire service. As we train people to higher levels, we use their skills in tasks such as referring between teams and doing specialist assessments. We see the value of enhancing people's roles and not relying on a GP, a consultant psychiatrist or a nurse. We use the broad spectrum of disciplines. We have to. The Mental Health Commission specifies exactly what should comprise a multidisciplinary team. It includes as a core team a consultant psychiatrist, nurse, psychologist, occupational therapist and social worker. However, we would include on enhanced teams cognitive behavioural psychotherapists, psychodynamic psychotherapists, family therapists, speech and language therapists and dietitians because we realise that mental health is a continuum into physical health.

In response to the question on how we look after somebody's physical health, we have established in St. Patrick's in our approved centre, which is the name given to our inpatient services, a primary care service, in other words a GP service for our inpatients in order that they get adequate physical health care at a sufficiently high quality rather than having to transfer people out to other services in accident and emergency departments. We take advantage of other disciplines and we realise their importance.

Professor Jim Lucey

I would like to add to Mr. Maher's response to Deputy Browne's question about physical ill health. The figures are striking in the mental health agenda for the nation. People with enduring mental health disorders have a life expectancy that is significantly shorter than their neighbours by more than a decade, and perhaps two decades in terms of some of the enduring mental health difficulties. This is a significant shock. What people may not realise is that the deficit in life expectancy arises from physical ill health. It is remarkable that the theme throughout all of what we said today is about removing barriers. One of the barriers that has existed for centuries is the barrier between mind and body. The Deputy asked how should we look at things. We need to look at our services in order that we cease to divide mind and body in this way in our structure. We could do that. In many ways presentation at an emergency department is probably an end event.

It is obviously an emergency but it is not where we want to be in terms of prevention, health of population and well-being. We need to address these at an earlier stage. However, we need to do it with a mindset that already integrates mental health with physical health and does so where it really matters. In the case of 70% of adults with mental health difficulties the issues emerge before the age of 25 years. One of the key things the committee needs to be aware of is the need to get in early and young and to target the part of the population where it matters, in other words, young people. Physical and mental health problems co-exist but overwhelmingly it is mental health problems that matter until the age of 50 years. That is the truth in terms of actual outcomes.

The barrier idea unifies the three areas I wish to comment on in response to the questions from Deputy O'Reilly and the Chairman. It is important for the committee to examine ways of reducing the barriers between allied professionals, the independent sector and the public sector. It is important to place the burden at standard levels. The idea is to set standards. We should relish the opportunity to meet the standards set by the Mental Health Commission. It corresponds to standard setting as set by the body politic of the State, and everyone must rise to it. This is how we unify the service. Such a change would mean the committee could do exactly what it has sought to do, that is to say, to ensure no barriers between the professionals.

Reference was made to general practice. Less than a quarter of general practitioners have postgraduate medical health training of any description. This is extraordinarily important. This is a seriously burdened group and yet they do not have the skill set. When it comes to training and education, the body of staff who work in mental health are not motivated primarily by a desire to get higher earnings - I am saying this carefully. They need decent, sustainable and respectable returns, of course. However, they are motivated by many other things that can be captured by a culture and a commitment to their development throughout their careers. They also have to overcome the tremendous challenge of burnout. Education is a factor. This is one of the reasons for the deep commitment in St Patrick's Hospital to education. One of the problems with other providers of mental health is that they do not provide training in the way we do. We have an extraordinary dedication with a dependent department in terms of research and training. This fosters the development of staff in all our disciplines, including psychologists, social workers, occupational health staff and mental health and psychiatry staff. We will end up eating our seed corn unless we train and deliver the people who can flourish and deliver the integrated services of the future. That is what people need. There is not necessarily one particular barrier to take down. We need to take down all the barriers by recognising that allied staff, so-called professionals, patients and their issues can no longer be divided by the various sectional groups.

Deputy Louise O'Reilly

When I referred to the issue of skill mix, I was specifically referring to the introduction of the health care assistant grade and the way in which that grade can be integrated. We are looking at the issue of skill mix and the way in which we can best utilise the skills that exist. Professor Lucey has referred to training and its importance. This is relevant specifically in respect of the introduction of health care assistants and the way this grade can integrate in the mental health sector. I realise those responsible have moved faster in terms of the acute hospital setting and the introduction health care assistants. Will Professor Lucey comment on the nature of this grade in the mental health setting?

Chairman

I will let Deputy Madigan in with a supplementary question.

Deputy Josepha Madigan

I was struck by what Professor Lucey said earlier almost as a by-the-way comment. He probably has all manner of statistics in his head. He said there is someone in a quarter of all households in Ireland who suffers from alcohol abuse.

Professor Jim Lucey

That figure comes from the ESRI.

Deputy Josepha Madigan

That is alarming statistic. I am always in favour of prevention rather than cure. There is a wealth of experience among the three members of the deputation in dealing with thousands of people coming through the doors of St. Patrick's Hospital annually over many years. What are we doing wrong? I will re-phrase the question in less general terms. What can we do that has not been done already and that we could be doing?

Society has a great deal to answer for in terms of addiction and mental health, bearing in mind what Professor Lucey said earlier about those under the age of 25 years. Many of these issues stem from home, families and parents. What can we do that we are not doing? I am keen to know. We want to see fewer people going through the doors of St. Patrick's Hospital in future.

Chairman

We have legislation coming before us shortly that is relevant. One thing we could do is support it.

Deputy Josepha Madigan

I know about that, but other than that.

Chairman

I could not resist that point.

Mr. Paul Gilligan

First and foremost, I will comment on the point on health care assistants. It is important for us that our multidisciplinary teams are considered to include everyone who works in our organisation, including household staff, porters and catering staff. All play a key part in creating a recovery ethos. The health care assistant development has been important for us. We envisage that in future this will be even more important.

Naturally, there are delicacies around introducing a new role. It has been particularly successful for us and we see it having a strong future. The way to develop it appropriately will stem from discussions with the other professions to enable us to maintain the multidisciplinary team approach.

Earlier, a question was asked about funding models. We are strongly of the view that a bundled care model is the only way forward. The difficulty is that the separation of services is reflected often in the separation of the types of experience to which a person is subject. Parts of a person's care transfers from one person to another. It would take years to resolve this unless we follow the money. When a bundled care approach is introduced, the system is informed that for a given amount of money a given patient needs to be treated from illness to recovery. The way the components of care are provided is down to the service provider.

This model is the only way that we will be able to develop an integrated service model and to ensure real outcomes for people. At the moment, the itemised service delivery is not working. It creates real difficulties.

The issue of stigma is important. We have taken two steps forward and one step back. There is far more awareness around mental health at the moment in Ireland. Certainly, there is more acceptance but there are deeply ingrained beliefs and misunderstandings around mental health that will take a long time to resolve. It all comes back to the issue of education. Indeed, education and prevention are key in the area of alcohol usage and mental health. Most young people begin using alcohol because of social pressure, anxiety or depression. That is the reality. We need to educate and help our young people to understand the dangers. Moreover, we need to educate them around their emotional awareness and how they learn to understand their emotions and deal with them. Such an approach would have an impact on their alcohol and drug usage.

Professor Jim Lucey

The Chairman asked a question about benzodiazepines. This is relevant to us. We have introduced a major initiative around benzodiazepine reduction. We have published it and it is available on our website. It has been striking how successful the initiative has been. Since benzodiazepines are prescribed, we need to address the standards around prescribing practice and manage them. When an organisation does that, it can bring about dramatic reductions in the volume of benzodiazepines dispensed. We have evidence to show that this works. This is something to which we are deeply committed.

This also speaks to the question of what we can do about addiction. As a society, we need to make choices and set goals for ourselves which we can then standardise with regard to services. If we, as a society, decide to make alcohol cheaper and more readily available or ubiquitous, then we will get the consumption of cheap alcohol everywhere. However, we can make a decision to make the choice in a balanced way in a free society and still protect those who are made vulnerable by having ubiquitous access to this substance. We must support the legislation to realise that aim. I take the Chairman's point. We very much support the legislation to which she referred. Indeed, we are keen to enhance it as a statement of where we should be going in terms of the health of the population. We are mental health specialists and advocates. We are interested in the health of the population. There is no health without mental health.

Mr. Tom Maher

A statement was made to the effect that we know how to commission a bed. It would be inadvisable to go down the route of simply concentrating on beds, especially where mental health is concerned. It is a simple and easy approach to take. We have moved the clinical model within mental health care in the past 20 years from what was a bed-based or inpatient approach across to what we have now, whereby most of the services we provide are either in day services or in the community.

The committee's role in developing a strategy over the next ten years should include a way in which we can develop a funding model, particularly for mental health care, but I imagine it applies across the entire spectrum of health, whereby we fund care and treatment rather than the commissioning of beds. As I said, the latter is a very simple trap into which to fall because of the very simple per diem rate. We have worked with the insurers to try to get to a stage at which we have a proper funding model that matches the clinical model, that is, care across the entire continuum from one's home to the most acute inpatient facility. The continuum would range across the entire facility and the entire spectrum. This is difficult but it can be done.

Deputy Louise O'Reilly

Could St. Patrick's share that information with us?

Mr. Tom Maher

Yes.

Deputy Louise O'Reilly

That funding model is incredibly difficult to achieve. That is the point I was making: it is easy to commission a bed because of the per diem rate that applies but commissioning the services and the way in which that is done is where the real challenge lies. If St. Patrick's has that information, we would be grateful to receive it.

Mr. Tom Maher

If the services could be commissioned, it would be a huge step forward in the improvement of mental health services.

Chairman

Regarding patients or potential patients, how do people access care in the community from St. Patrick's? I have one additional question which concerns service level agreements. Mr. Gilligan said that attempts had been made to negotiate such agreements with the HSE. What is the stumbling block in that regard? Is St. Patrick's making any progress?

Mr. Paul Gilligan

The referral pathway is from general practitioner to our Dean clinics. Our Dean clinics are our first port of call. Since we established them, approximately 50% or 60% of the people who come to us have come through the clinics directly. Accessibility in the first instance is, therefore, through Dean clinics. They offer free assessment so they is pretty much available to anybody. However, there is no point in our seeing people at Dean clinics for free assessment if there is no identifiable care pathway for them. That is where service level agreements become an issue. We have had some very successful service level agreements whereby we have done work for the HSE. We have helped clear child and adolescent waiting lists in some areas but, as an overall philosophy or strategy, the service level agreement is difficult to negotiate. Quite rightly, the HSE wants to build its own services, but that is the core reason we are here today: partnership and all of us playing a role is the way forward. The HSE on its own cannot build a world-class mental health service; neither can any of the independent providers. Therefore, we all need to work together to break that barrier. There is a need to try to get all of us around the table talking about how we would best do that.

Chairman

I thank all the witnesses for appearing before the committee, giving of their time, delivering their excellent presentation and responding to our questions.