Private Members' Business. - Mental Treatment (Amendment) Bill, 1992: Second Stage (Resumed). – Dáil Éireann (26th Dáil) – Wednesday, 6 May 1992

Private Members' Business. - Mental Treatment (Amendment) Bill, 1992: Second Stage (Resumed).

Question again proposed: "That the Bill be now read a Second Time".

An Leas-Cheann Comhairle

Deputy Callely was in possession and he has 28 minutes remaining.

Mr. Callely

Thank you. I wish to share my time with Deputy Lenihan.

Mr. Callely

Last night I commended Deputy Fennell for her efforts on behalf of mentally ill patients. I agree wholeheartedly that new legislation is required.

In his response to Deputy Fennell's Bill, the Minister for Health, Deputy O'Connell, indicated his intention to introduce appropriate legislation. He said that he would be putting forward ideas for discussion on these and many other areas in a Green Paper. He outlined various intentions in the Green Paper and stated:

What I have outlined demonstrates my intention and that of the Government to undertake the most comprehensive review of psychiatric services and we wish to ensure that all interested parties and individuals are given the fullest opportunity to contribute to this review.

Miss Fennell

It should not be linked to civil rights and rights to services.

Minister for Health (Dr. O'Connell)

I have a Green Paper almost ready.

An Leas-Cheann Comhairle

Could we hear Deputy Callely without interruption, please?

Mr. Callely

I am happy to be interrupted if it will clarify a point for Deputy Fennell. The Minister went on to state that he and the Government are determined on this issue. He said that he knew the task would not be easy and that many conflicting views as to the correct approach would have to be teased out to the greatest possible extent. He said that the bottom line was that if we would succeed in doing this we would, at the end of the day, have a more effective, caring and acceptable mental health service which would be of benefit not only to patients, who are our primary concern, but also to all those who work in providing the service and to society as a whole. That would be everyone's intention, including Deputy Fennell's. The Minister is giving a firm commitment to introduce the necessary legislation and to involve all interested parties.

Let me briefly revert back to 1981. In 1981 legislation was rushed through the House and the experience now is that it cannot be properly implemented. If we are to introduce new mental health legislation we should ensure that it is as comprehensive and as wide-ranging as possible and conforms with our obligations under the European Convention on Human Rights and the United Nations principle on the care of mentally ill patients.

Deputy Fennell's Bill has certain merits but focuses too much on the wrong issues. There is an implication that most mentally ill patients are wrongfully deprived of their liberty and badly treated by the psychiatric services. I cannot agree with this. First, 90 per cent of all psychiatric patients are admitted to the service on a voluntary basis and 10 per cent involuntarily. In every case there are good clinical reasons for admission and professional supporting evidence for such admissions.

There have been great changes in our psychiatric services. Those working in this very difficult and sensitive area are extremely committed individuals and I would like to take this opportunity to congratulate all those involved in the delivery of the psychiatric services. As chairman of the Eastern Health Board I have had the opportunity to meet those people and to visit many of the premises where services are provided. It is no exaggeration to say that many changes have taken place in this area particularly since the adoption of the document Planning for the Future.

Previously services for people with a mental illness were provided in large institutions and not only the patients but the buildings were ostracised by the community proper. There have been many radical changes since then. Services are now orientated towards community care catchment areas and sector headquarters, providing a network of newly defined services. Years ago these asylums catered for large numbers of people from all walks of life. Some were inappropriately placed in such asylums. Some were placed there by relatives who were happy to leave them in these asylums. The records show that some lived in asylums for anything up to 60 years with few if any visits from family or friends. I am glad to say that that does not happen today. Today there is a huge network of services to accommodate the now defined illnesses with a specialised approach and counselling services which encompass long stay care, crisis intervention, day places in hospitals, training workshops, day centres, hospital accommodation and community residences providing varying degrees of support and proper integration of patients into the community.

Formerly, patients were referred to as inmates. That this is no longer the case shows the change in attitude to people with mental illness by those who are providing the service. Walls have come down and doors have been opened. There is no doubt that there have been changes. Side by side with that is the question of monitoring and evaluating and a stage has been reached where we must assess the situation.

I was pleased to note that the Minister in his speech when referring to the document Planning for the Future said that eight years after the publication of the document it was necessary to take stock of the situation, to evaluate what has been achieved and to consider how we will move forward. He also referred to the Green Paper he intends to introduce. During the past eight years we have seen great changes, development and progress in relation to the provision of services and, as the Minister indicated, it is about time to take stock. I do not wish to pre-empt what might emerge from revision or taking stock but we will never revert to the old days of asylums or institutionalised settings. We will see a further development of a comprehensive, more integrated and community oriented caring service for those suffering from mental illness.

The Bill really addresses only two issues, medical certification for temporary reception orders and the establishment of mental health review bodies. Any new legislation must go a great deal further. I already covered the changing trends in psychiatric services, particularly since the introduction of Planning for the Future, and we must now introduce the necessary legislation which will cover the providers of services and the patients as well as many other proposed developments and the changing trends in the psychiatric services. Unfortunately, for that reason, like the Minister and Government speakers so far, I cannot support the Bill. I welcome it in so far as it gives people an opportunity to bring to the fore matters of concern in relation to mental health and the service at present being provided. It is an opportunity to review and assess the situation.

I welcome the Minister's commitment to introduce a Green Paper on this and — which is very important — to involve all the people working in the service on a day to day basis. We will have to continue to closely monitor the area of mental health because I have received complaints which greatly concerned me. A constituent of mine received inappropriate and an unacceptable level of care by a private concern offering psychiatric treatment in the city of Dublin. I will focus on this point very briefly. A young gentleman went to his GP who decided he needed long stay care in a psychiatric hospital. He was admitted to a private psychiatric hospital; after five days the administrator in the hospital — not one of the medical team — was informed that the individual's VHI would not cover his stay there. When he was admitted he was told that his stay would be in the region of 21 days and that during that period he would receive therapy to address his illness. However, after the fifth day, when the administrator was aware that VHI would not cover his stay in the private hospital his bags were packed, his bed was changed and he was advised to leave the hospital. This individual could have had suicidal tendencies and we should ensure that no private hospital can treat a patient, particularly in the area of psychiatric and mental illness, in this manner. I brought this matter to the attention of the Minister's predecessor and authorities in various capacities but little or nothing has been done to date. I ask the Minister to bear this problem in mind when he introduces his Green Paper because a huge number of people use private hospitals and there is a problem in relation to VHI which must be addressed.

I welcome the change which Planning for the Future has brought about, particularly in relation to the whole area of stigma which used to be attached to mental illness. That is changing and is being assisted by the manner in which Planning for the Future services are being provided. We should continue to go down that road.

Mr. Lenihan

The Bill is welcome in so far as it creates an awareness of the need for legislation in regard to mental health. It attempts to focus on the rights of persons involuntarily admitted and detained in psychiatric hospitals. Highlighting issues of this kind in relation to mental health is always welcome. The Bill contains provisions which will be included in the Minister's proposed legislation in regard to mental health. In so far as it generates a mood of urgency which is not required in the case of the Minister — the debate is welcome and I am sure he will deal in his reply with the introduction of a Green Paper, a White Paper and legislation of a more comprehensive kind which will cover a broad range of issues not included in Deputy Fennell's Bill.

There was a reference in the debate to the extent to which our existing legal procedures conform with this country's obligation under the European Convention on Human Rights and Fundamental Freedoms and the United Nations Covenant in the same area. It was suggested by Members of the Opposition that the Mental Treatment Act, 1945, did not conform to the European Convention or the UN Covenant. I repudiate that; in relation to the European Convention, case laws developed and as a result of those laws which were before the European Court through the seventies and eighties, new judgements have elucidated the obligation to provide a review of every order detaining a patient in a psychiatric hospital, to provide an automatic review of people who are detained on a long term basis in psychiatric hospitals, to inform detained persons of their rights and to provide legal representation for detained patients. All these matters must be dealt with in a Green Paper and subsequent legislation and the volume of case law makes it important for the Minister to do this.

I am glad the Minister highlighted the importance of introducing a patients' charter for those cared for in our psychiatric hospitals. The central position of a patient in all aspects of the organisation and delivery of health care is required. I understand that the patients' charter is at an advanced stage of preparation and is designed to ensure that all hospital patients are treated with the respect they deserve. That is a very important development which the Minister has seized on as being essential.

The standard of nursing care is high and the introduction of the patient's charter will ensure equally high standards in dealing with patients in a professional and courteous manner, respecting their privacy.

The charter will be based upon the following principles: the right of access to services in accordance with need; the right to considerate and respectful care; the right to privacy; the right to information; the right to confidentially of all medical records; the right to refuse to participate in research projects; the right to respect for religious and philosophical beliefs; and the right to make a complaint. That is all very important. We have already moved in the direction of reform. The report Planning for the Future, published in 1984, was the first real acknowledgement of the need for reform. The Minister's Green and White Papers and legislation will put the coping stone on the reforms envisaged in that report. The thrust of the recommendations of the report was clear. It recommended a service which was comprehensive, community oriented, sector based and integrated with other health services. The core recommendation related to sectorisation — the provision of a comprehensive psychiatric service for a population of known size resident within a clearly defined district. There would be a multi-disciplinary team of health professionals comprising nurses, psychologists and social workers. Planning for the Future outlined in detail the goals to be achieved to improve our psychiatric service.

We need a statutory framework to effect these changes. The fundamental shift in the delivery of our psychiatric services from institutions to community oriented services must be underpinned by appropriate legislation to facilitate full implementation of the recommendations. We are agreed on all sides that the 1945 Act does not provide a satisfactory legal basis to promote and put in place suitable facilities designed to provide modern methods of care for the mentally ill. Fresh legislation to take account of this caring philosophy will encourage a change in attitudes among those members of the public who may find if difficult to understand why people whose condition once made it necessary for them to be shut away are now considered fit to be in society. An extreme view might be held by a few that there are enough problems in the streets without adding to them. Some families with mentally ill members may fear that the decrease in the number of mental hospitals could mean the transfer back to them of the full burden of care and support without the clear and full endorsement by Government of alternative and improved care facilities for the mentally ill through the enactment of legislation to reflect the current direction in the delivery of psychiatric services.

I would suggest that the dominant thrust of the Bill before us is to safeguard the rights of detained persons in our psychiatric hospitals. This issue undoubtedly needs to be addressed and deserves to figure prominently in the new mental treatment legislation to be introduced by the Minister. Notwithstanding the importance of this matter, new legislation will also need to embrace the full range of issues reflecting the recent transformation in the delivery of our psychiatric services.

The House is aware that the Minister for Health approved on 15 April 1992 the Government's decision to publish a Green Paper on the development of services for the mentally ill and new mental treatment legislation. The clear purpose of new legislation is to provide a framework for the development of the psychiatric services and to meet our commitments under international law in respect of patients detained in our psychiatric hospitals. Publication of the Green Paper will allow all interested parties to engage in full and open discussion on options put forward to adequately protect the rights of detained persons and measures designed to develop the psychiatric services.

The Government are determined to avoid a repetition of the failed attempt to bring into operation new mental treatment legislation which occurred following the enactment of the Health (Mental Services) Act, 1981. They are also conscious of the need to achieve broad consensus on safeguarding the rights of detained patients and future development of the psychiatric services. In relation to the former, it is important to ensure that proposed legislation will fully comply with this country's obligations under the European Convention for Protection of Human Rights and Fundamental Freedoms and the International Covenant on Civil and Political Rights under the auspices of the United Nations. While the provisions of the proposed Mental Treatment (Amendment) Bill, 1992, mark an improvement in the rights of detained patients, they would not in fact completely satisfy this country's international obligations under international law. It is clear therefore that the approach agreed by Government to introduce new mental health legislation offers the most practical and open method to ensure our psychiatric services are developed to meet the needs of the mentally ill into the next century.

While Deputy Fennell's Bill is excellent in so far as it goes, and the Deputy is to be commended on the work put into it, it can be subsumed in the comprehensive legislation envisaged by the Minister after full public debate following the production of the Green and White Papers. The Minister has already given sufficient evidence of an urgent approach to medical and health problems to warrant the support of this House in his endeavours to introduce this comprehensive legislation which will embrace and subsume the points embodied in Deputy Fennell's Bill.

Mr. Howlin

I wish to share my time with Deputy Richard Bruton.

Acting Chairman (Mr. M. Barrett)

Is that satisfactory? Agreed.

Mr. Howlin

I will confine my remarks to 15 minutes so that Deputy Bruton can have an equal share of the time.

I congratulate Deputy Fennell on focusing the attention of the House on an issue of very real importance. I know the amount of work she put into this legislation. She and the Fine Gael Party are to be highly commended.

This Bill has shone a light into a dark area. The notion that we could possibly be incarcerated against our will in a mental institution and deemed by society not to be in control of our faculties probably constitutes our worst secret nightmare. Unfortunately, that nightmare is a reality for some individuals. Our history in relation to mental hospitals is not a glorious one. We have often used these very large Victorian buildings dotted around the landscape as convenient places to put away people who cause social embarrassment. For much of the early part of this century and into modern times people such as unmarried mothers or prostitutes were deemed not to be in control of their mental faculties, such was the social nature of their great sin, and they were put away from society, often for years on end, expected to live out their lives in isolation and deemed not to be full citizens. For many years these mental institutions were a convenient refuge for those individuals in our society whom we did not want to recognise. Our history in relation to those people, who in many instances had literally nowhere to go, is not a glorious one.

We have made some progress since that time. Those dark days have been left behind but we have a long way to go still in providing a legislative framework within which to operate in particular our mental institutions. It is interesting to note that one can find in the Oireachtas Library annual reports on, for example, the prison system or places of detention. Also available are the current reports on the Probation and Welfare Service and the Garda Síochána Complaints Board. One simply has to ask for them. Ireland has a reasonable record of openness with regard to those whose rights have been taken away because of their criminal activity but we have a much less acceptable record when it comes to openness and concern for those whose liberty has been taken away for health reasons or for alleged health reasons.

The Mental Treatment Act, 1945, created the post of Inspector of Mental Hospitals. The inspector's powers under that Act are wide ranging and include the visiting of all mental institutions and the examination of patients. Under the legislation the inspector may inquire into the propriety of receptions and discharges relating to mental hospitals and can inquire into any form of restraint, coercion or treatment. He may inspect any part of an institution. Section 238 of the Act states:

Where the Inspector of Mental Hospitals visits any mental institution, he shall give special attention to the state of mind of any patient detained therein the propriety of whose detention he doubts or has been requested by the patient himself or any other person to examine, and if he becomes of the opinion that the propriety of the detention requires further consideration, he shall indicate such opinion in any register of patients kept in the institution.

That power is further developed in section 239, which states that when the inspector forms the opinion that the propriety of such detention requires further consideration he shall report that matter to the Minister. The power applies to both private and public institutions. Section 247 of the Act requires the inspector each year to furnish a report to the Minister on the administration of the law relating to mental institutions and the care, welfare and treatment of persons of unsound mind. Under section 247 (2) it is provided that every such report be laid before each House of the Oireachtas and a copy be sent to the President of the High Court.

In theory, we should have a clear understanding and overview of what is happening in mental hospitals because even the inadequate 1945 Act provides that that information be available to the Minister and those in authority. What is the present position?

I understand that the most recent published report of the inspector covered the years 1977 to 1979. I know that the former Minister for Health Deputy O'Rourke, promised in January of this year that the reports of the Inspector of Mental Hospitals for the years 1988 and 1989 would be amalgamated and presented to the Houses of the Oireachtas in the near future. In January 1992 the reports for 1988 and 1989 were still being prepared. Minister O'Rourke also stated in January that the inspector was preparing the 1990 report on his inspections, which she hoped would also be laid before the Houses of the Oireachtas in the near future. That is a completely inadequate and unacceptable position. It is an indicator of the regard we have and the importance we place on the proper monitoring of our mental institutions that reports of the Inspector of Mental Hospitals are not compiled and published within a reasonable period of time. That is in stark contrast to monitoring of people committed to our prisons for criminal offences, who seem to get a better deal, which is most inappropriate.

There is undoubtedly considerable disquiet here about a number of cases that have recently come to light. Those cases of suffering and hardship require immediate attention; they require action by the Oireachtas. I listened with alarm as Government speakers indicated their support for the theory, thrust and intent of the Bill but they were unwilling to support it because it was not comprehensive. That is a very poor and unacceptable response.

Mrs. Fennell

It is crazy.

Mr. Howlin

Our greatest responsibility is to the most vulnerable in our society. A hallmark of recent cases has been the domination of women, in particular by their husbands. In a society that is gradually moving towards equality — or so we thought — from the evidence presented, there seems to be a greater reliance placed on the word of a man over that of a woman. That is horrendous when what is at stake is the basic rights of liberty.

The notion that this Bill should not be supported because it is not comprehensive defies logic and reason. If the Minister accepts the thrust of the Bill, he should vote for it and allow his colleagues, who, I think, are minded to vote for it, to do the same. The Bill might not be comprehensive, and nobody suggests it is, but it addressed an issue of great concern to the people of this country and it could well dovetail into the more comprehensive legislation the Minister intends to bring before the House in the near future.

I am not suggesting — and I do not consider that anybody who supports the Bill does — that a huge number of people are incarcerated against their will who are of sound of mind, as if a squad was out on the streets to take people into mental institutions. That is not so. It is not correct that a significant number of people are detained in mental institutions against their will. The reality is that if a single such case exists it is of such horror that it has to be addressed. If under our procedures that can happen — as evidenced by the cases that come to light in recent months — those procedures must be changed. They should be changed immediately, and the way to do so is to accept this very welcome Bill, which is very good in so far as it goes. The issue is of such fundamental importance that the scale of the problem does not matter — one case of incarceration on an involuntary basis of somebody who should not be in a mental institution is one case too many and the procedures that allow that to happen must be changed.

The Minister promised — a promise he reiterated last week — he would publish a Green Paper on the whole issue. That was very welcome, but there has also been a promise from the Government benches of a Green Paper——

Dr. O'Connell

Not from me; there has not.

Mr. Howlin

We shall test the Minister. The proof of the pudding is in the eating. There was a promise of a Green Paper on education. That was promised by three Ministers but we have yet to see it, although the most recent development was a leaking of its text. I will give the Minister the benefit of the doubt — I believe him to be a man of his word — but he must act quickly on this issue. I hope my trust will be well founded.

In the report Planning for the Future there is focus on community based psychiatric care. In this regard I wish to issue a warning. A similar policy decision was made in the United Kingdom in recent years when it was decided that large institutionalised care was not the right decision to follow and that community care should be evolved on a small, localised basis. Most progressive people say that that is the right prescription for a caring society. But what happened in Britain? The large institutions were closed down and patients were virtually turfed out on to the streets. Many of those patients ended up in bed and breakfast accommodation and roaming the street during the day. That is an appalling situation. It was an appalling situation because the institutions were closed down and corresponding resources were not placed in the community to deal with the issue. We must get the right sequence of events. The community provision must be put in place before we start closing institutions. I trust that the Minister will accept that and that we will not repeat the dreadful experiences in the UK in this matter.

This Bill addresses one clear problem in the procedures that govern admission and monitoring of patients to mental institutions here. It does not purport to be a comprehensive solution to all the problems of the psychiatric services or the medical institutions. It purports to address one real problem that nobody in this House suggests does not exist. I appeal to the Minister to accept it as a welcome interim measure. The Minister should not vote it down because he thinks he can do better in a holistic way. The Minister should accept the good measures in it now. For that reason my colleagues and I will support the Bill. I hope that when the time comes the Minister will be gracious enough also to accept it as a worthwhile, positive and welcome step in the right direction.

Mr. R. Bruton

I thank Deputy Howlin for sharing his time with me. I am glad that Deputy Fennell brought this Bill to the House. It was the former Deputy Noel Browne who said many years ago that there are no votes in mental illness. All around us we can see the evidence of the truth of this in our psychiatric services. The 1945 Act which governs mental treatment is totally defective and it does not provide properly for patients' rights. It actively creates a stigma surrounding psychiatric care which is most unhelpful if we want to see a modern service develop to intervene in a timely way in crises.

Cuts in this area have been more severe then in any other area of the health services. Since this Government took office there has been a staggering 22 per cent cut in real terms in resources for the psychiatric services. This is more than three times the cut in any other area of the health services. Conditions in many of our psychiatric institutions bear testimony to this. Some wards have been widely described as warehouses rather than places where people can get dignified care. It is very disappointing that the Minister will not accept that this Bill is a badly needed step in the direction of reforming the 1945 Act. The Minister should accept this rather than wait for a series of Green Papers followed by consultation and then the publication of the Bill followed by a lengthy debate here.

Minister for Health (Dr. O'Connell)

A Green Paper is a consultation.

Mr. R. Bruton

Presumably there will be a lengthy consultation on this issue. The Minister has accepted the need to recognise this sort of provision. The simple way to show that acceptance is to accept this legislation.

Dr. O'Connell

That is the mistake that was made in 1981. We do not want to repeat it.

Acting Chairman (Mr. M. Barrett)

I must call for order and allow Deputy Bruton to continue.

Mr. R. Bruton

The Minister must be aware that the Department of Health, if they have been doing anything since 1981, should have been consulting on the way to tackle this and they should be well prepared to deal with this point in our mental health legislation. The Minister should not say that we need more consultation on something with which he agrees in principle, with which the officials agree and with which the House agrees.

The 1945 Act is far too narrow. It deals with institutionalisation but not with the much wider issue of care and treatment. Institutionalisation is only a tiny part of psychiatric care nowadays and most people can be treated successfully as out-patients. Sadly, this 1945 Act creates the impression that psychiatric care is about putting people away. It gives the perception that if people go for psychiatric help they will lose control over the sort of treatment they get. The ECT was always the great scare. It creates the perception that people might be committed even though they may have voluntarily presented themselves. I know of many cases in which patients who did not wish to comply with the prescribed treatment were subsequently committed.

The procedures here are highly unsatisfactory. There is concern about the fact that there may be only one doctor but a much deeper concern is that very often not enough thought is put into the acceptance of a patient. There is not a rigid procedure whereby the certifying doctor should set out his reasons for taking the view that a person is dangerous to himself or to the community and whereby that information would be made available to the patient so that he could challenge it. There should be an obligation on the psychiatric consultants in the hospital to have fully examined the patient within 24 hours and within another stated period there should be an obligation on the head of the unit to have made a similar examination.

These procedures are badly needed. A judge cannot deprive a person of his freedom without giving him a right to a defence or an appeal and without the right to know why he is being imprisoned, but in the 1945 Act we are denying people these rights. This Act perpetuates the terrible bad image of seeking psychiatric help. There has been an alarming growth in suicides among the 20 to 30 age group and it is worrying that it has been suggested at international level that many of them should have received psychiatric treatment. They are plainly not presenting themselves and part of the reason for that is the extremely bad image of our psychiatric services. It is time we eliminated fear of the psychiatric services. This Bill is a very important first step in that direction.

Like Deputy Howlin, I am concerned by the reports of conditions in our psychiatric hospitals. There is acute overcrowding in admission units. I have heard descriptions of patients coming into wards catering for perhaps up to 40 people. These are people in acute crisis. To throw people like that into an overcrowded ward is not putting them into a setting in which they can receive proper care. We need to give priority to the admission units so that people in crisis, needing psychiatric services for the first time, will have their cases dealt with in reasonable privacy and with access to the sort of therapy they should be getting. That is not what is happening at the moment. It is not right that people should be crowded into wards, perhaps meeting patients who are old timers and getting terrible disturbing acounts of what they will face. That sort of situation is very damaging to the service and it must be addressed.

While I commend this Minister for his decision to publish for the first time in 13 years the report of the Inspector of Mental Hospitals, he must recognise the enormity of the scandal that these reports have not been published to date and that as I understand it, they have effectively been suppressed within his Department.

Dr. O'Connell

I understand they were not published because of the 1981 Act, which did not require that to be done.

Mr. Howlin

That did not become law. We were still operating under the 1945 Act.

Mr. R. Bruton

If the Minister did not bring in orders to implement the new set of regulations to provide protection for and assurance to the public about conditions, then he had a moral obligation to continue to operate what was there before. The Minister will correct me if I am wrong, but as I understand it the only channel through which a patient who felt aggrieved about his conditions could make a complaint was to this Inspector of Mental Hospitals; that was the main channel for a person to have his or her view heard. The Department were actively suppressing that channel getting the light of day, not letting people hear investigations of complaints being lodged.

Dr. O'Connell

The report has gone to the printers and it will be out in two to three weeks.

Mr. R. Bruton

I accept that, but the Minister must be aware that he is responsible — he represents the Government — and must give us a reasonable explanation why this was allowed happen. He must also give us an assurance that we will not be furnished with a report that may be, say, three years out of date when it comes from the printers, a report that might tell us about the conditions in, say, 1989, when what we are all concerned about are the conditions obtaining in 1992. The Minister has an obligation to carry out investigations whenever there is prima facie evidence that conditions are not what we would like them to be.

Dr. O'Connell

I have already started that. Within two weeks of coming into office I ordered its publication and I have already visited the mental hospitals.

Acting Chairman

Perhaps Deputy Bruton would address the Chair. I would ask other Members to refrain from interrupting

Mr. R. Bruton

I am addressing the Chair constantly, but the Minister is offering to intervene.

I think his Department sabotaged what was an important channel of complaint. While the Minister has put that to rights, we want up to date information. We want information to hand on what are the conditions prevailing at present in the black spots. We do not want a report three years out of date, when the Minister would be in a position to stand up and say "Ah well, of course, that unit is now closed". That would be no good to us. We want to know where are the present black spots and what is being done about them.

As I said earlier, all of us in this House are alarmed at the growing rate of suicides in this country. We are committed under the WHO "Health For All Targets" to reduce our suicide rates by 25 per cent in the period 1985 to the year 2000, whereas in contast we have had a 150 per cent increase in suicides in the past decade. It is not good enough for Ministers to wring their hands and contend that that is just the nature of the world in which we live today. If we are serious about tackling this problem we must go out into the community and provide the type of support services necessary for people at risk. That means educating the community to recognise warning signals and, even more important, giving family doctors the back-up they need to identify and successfully manage patients who may be at risk within the community.

As I understand it, at present many general practitioners find it extremely difficult to gain access to the advice of psychiatric services. That should be rectified; psychiatric advice should be readily available to general practitioners so that they can manage their patients in the community, where they should be managed. Let us face up to it, most psychiatric illness has to do with social, economic and family conditions in which people find themselves, such as bad housing, unemployment, family difficulties. Those problems must be revolved within the community in which they live. Psychiatric illness is more acutely linked to socio-economic deprivation than any other illness. The ratio of admissions is five or six times to one across the social classes. The ratio for widows is much higher than in the case of people with support in their home.

All of this is evidence that very often psychiatric care has to do with managing crises in their homes. We must revert to circumstances in which the front line, the general practitioners, and most importantly, the community psychiatric nurses are there to provide that service. I am very worried about rumours and reports I hear that there is a progressive dismantling of the community psychiatric nursing service — the nurse who would be dedicated exclusively to providing that support service in the community. I have heard that their position has been downgraded, that more and more ordinary hospital nurses undertake this task on a temporary basis rather than having community psychiatric nurses dedicated on a long term basis to providing this service. That is crucial, because very many of the high risk patients are those who just after discharge from hospital need access to that vital support.

The Minister must also tackle the scandal of suicides in our prisons. As I understand it, there is a waiting list for access to the Central Mental Hospital. The result of that is there are known high risk suicidal cases in cells in our prisons who cannot hope to receive the care and supervision they need. This issue must be tackled as a priority. The Prison Officers Association rightly raised this matter last week. There are facilities lying idle that could be brought into use. The Minister has an obligation to deal with this problem.

I have strayed somewhat from the Bill, because it is seldom we are afforded an opportunity to talk about psychiatric services. I would like to warmly endorse the case Deputy Fennell put forward so well last week. It is vital that we give people access to proper information about the reasons they were committed. It is vital that we give them access to a proper system of review of cases when they feel they have been wrongly committed. It is important that people who are admitted voluntarily should not in some way slip into compulsory committal without having the option of demanding a review and their entitlements and to have their views about care taken into account. Consent is an absolute pillar of medical treatment; the patient's consent must be there. That must be enshrined as a basic principle in our Mental Treatment Acts.

I warmly support Deputy Fennell on her introduction of this Bill. I would ask the Minister to have a change of heart. I realise, as does Deputy Fennell, that this is not the answer to reform of the Mental Treatment Act. But it is the answer to a particular problem which would give people greater confidence in what is happening in our psychiatric institutions. That much would be under the Minister's belt within weeks, would be a nick in the post and worthwhile. We would all welcome his further proposals.

Dr. O'Connell

There are too many flaws in the Bill.

Mr. R. Bruton

There is Committee Stage to amend any flaws if the Minister wants.

Dr. McDaid

I should like to share my time with Deputy Davern, if that is agreeable to the House.

Acting Chairman

Is that agreed? Agreed.

Dr. McDaid

Since its establishment some 25 years ago the Mental Health Association of Ireland have played a major role in educating public opinion about mental illness, especially in latter years creating a more informed, tolerant general public attitude towards psychiatric illness. The success of caring for people with psychiatric illnesses in our community is to a large degree dependent on an informed public awareness of the overall position so that their deep rooted fears and misunderstandings can be allayed. For that reason the Mental Health Association of Ireland, all of us in the medical profession and the many people who deal with the psychiatrically ill are indebted to Deputy Fennell for having introduced this Bill at this time enabling us to deal with what might be described, and was by the Minister, as the most outdated legislation on our Statute Book at present.

In recent days I listened to some of the most horrendous stories; thankfully, they appeared to be few. Indeed I am grateful at not having come across any in my area. Nonetheless, as other Members have said, it is regrettable that any should exist. Every effort must be undertaken to close the loopholes in the 1945 Act.

Great progress has been made in this field through the development of new drugs and a growing awareness of the issue among members of the community. A better community care system has been responsible for the gradual shift from a custodial regime of care to a more positive rehabilitation regime. Many patients have been placed in community care which, as we all know, is in line with the recommendations made by the review body in their document entitled Planning for the Future. We have implemented this recommendation to the best of our ability over the past number of years. The review body also recommend that large institutionalised hospitals should be dismantled. Despite what the Deputies opposite have said, we are continuing to act on that recommendation. The need for community care was advocated throughout the eighties. When Deputy O'Hanlon was Minister for Health he recommended the placing of more and more people in the community and tried to get the necessary resources to ensure that they would be looked after properly.

While I applaud Deputy Fennell on her Bill, I have to be critical of Deputy Bruton and my professional colleague, Deputy Lee, who criticised the Minister for the remarks he made. The Minister is a very honest man who is trying his utmost to improve conditions in this area. He was appalled at some of the statements made in the 1989 inspector's report on mental hospitals. He said that some of the conditions in hospitals were disquieting and that this was probably due to a lack of resources. These were all very honest statements, particularly the latter one.

Like most members of the Opposition, Deputy Lee suggested that the more money put into this area the better the conditions would be. Unfortunately, the solution is not as simple as that. Ireland is a small and relatively poor country and the provision of extra resources is always a problem for us. It is cynical in the extreme for Opposition Deputies to demand large amounts of money for just about everything. All parties have been guilty of this attitude in the past. While I am sure we would find enough things on which to spend an extra £100 million it would not gurantee that all our problems would be solved. I hope the Government and the Minister will establish the priorities in the health area and do their best to ensure that they get value for money. After all, the Constitution charges us with responsibility for looking after all the children of the nation equally.

I think there is a consensus that this area of medicine has been somewhat neglected. However, we need to ensure that we get value for money. I believe the Minister has a great feeling for this area of medicine. If there is to be discrimination in favour of any area of medicine, I ask the Minister to look favourably at this one. As Deputy O'Donoghue said last night, extra funding will be needed if the recommendations contained in the report Planning for the Future are to be properly implemented. I am sure the Minister is interested in ensuring that this is done. The Minister is a man of integrity and high standards, and I am sure he will see to it that as many of those recommendations as possible are implemented and that value for money is obtained.

This is an issue which needed to be discussed and I compliment Deputy Fennell on her initiative in bringing this Bill forward. Even though Deputy Howlin will probably criticise me for not voting in favour of it tonight, I have to say I read Deputy Fennell's Bill, and also the 1981 Bill. The Deputy has been accused at times of delving into the 1981 Bill but that is not the way it appears to me. While I would not go so far as to say they are flawed, I do not think either Bill could be implemented. In view of its importance, we needed to have a proper discussion on this area of medicine. Deputy Fennell can take credit for affording us that opportunity. I am not making excuses for not voting in favour of the Bill: I have problems with certain sections of it and I believe this issue deserves a much wider discussion.

Deputy Fennell has proposed the setting up of a review body or tribunal for assessing people who are already in psychiatric institutions. I have difficulty in understanding how such a tribunal or review body would work in a health board area. She referred to the members of the review body. I have difficulty in accepting her proposals in this regard as I believe a review body should include a psychiatrist, a lawyer, a lay person and various other people. However, I believe there would be tussles between the psychiatrist and the hospital who have kept the patient in for so long and the review body — they would pull one another apart; there would be a clash of interests. I presume the tribunal or review body would meet as often as required. They would have to gather all the facts, examine the history of the case and visit general practitioners. In some cases patients might have to wait for one or two months before the tribunal issued their report. I believe the members of my profession are capable of dealing with patients who are already in hospital, even though some of them may have been institutionalised unfairly or against their will. While I appreciate the Deputy's proposal in this area I do not think it could be implemented.

Deputy Fennell said she wanted to ensure that there would be more rigorous certification. I would agree with that proposal. However, it is debatable whether this could be achieved if there are only two doctors involved. While it could be achieved in large urban areas it could give rise to difficulties in rural areas. Some patients who come into the psychiatric hospital in my area have not seen their own doctor.

Reference has been made to the large number of involuntary admissions. It is true to say that there are more involuntary admissions in Ireland than in most other countries. We have been blaming husbands, wives and other relatives for this. However, I have to say that doctors are not blameless in this regard. Doctors may be responsibile for a large percentage of involuntary admissions because for a long time they have not even been implementing the provisions of the flawed 1945 Act.

To go back to the last point I made, who should be certified? In my opinion a person should be certified only where there is clear evidence of a psychotic condition such as schizophrenia, manic depression, severe paranoia and so on. In England, alcohol and drug abuse are major problems in terms of psychiatric illness. People with an alcohol or drug problem should not be certified except in severe cases of psychotic addiction to drugs and, perhaps, in cases of the DTs and alcoholism. I have seen young wives who have been battered by their husbands and then use the psychiatric hospital as a refuge. The Garda will not charge these people because they have a psychiatric background.

There is much in this Bill that could be discussed and there are many areas in which we are all at fault. I compliment the Deputy for bringing forward this very vital legislation, but I would perfer to wait for the Green Paper. Unfortunately, therefore, I will be voting against the Bill tonight. I will share the remainder of my time with Deputy Davern.

An Leas-Cheann Comhairle

Deputy Davern must conclude not later than 8.15 p.m.

Mr. Davern

The Chair is extremely generous.

An Leas-Cheann Comhairle

The Chair knows that the Deputy has the capacity to make his comments in that time.

Mr. Davern

This matter deserves a much wider debate than is allowed for at present. Since I came into this House in 1969 there has been a total change in attitude to psychiatric illness. While that change has been slow it has been tremendous over the last couple of years. If we are going to adopt legislation in this area we need a much wider debate than that allowed for in this Bill. I would say to members of the Opposition that there is a slight element of hypocrisy in their thinking. During the time of the Fine Gael-Labour Coalition Government, from 1983 to 1987, the mental health reports were never published. Deputy Fennell was Minister during that period.

Mr. Fennell

I was not in the Department of Health.

Mr. Davern

You were Minister of State and you were part of this——

An Leas-Cheann Comhairle

Deputy Davern, I can appreciate your attack——

Mr. Davern

You are taking up my time.

An Leas-Cheann Comhairle

The Deputy should address the Chair rather than Deputy Fennell.

Mr. Davern

I was making the accusation more against the Chair than against Deputy Fennell. There is a deeply held view in Ireland on mental health and in view of the changes that have taken place in the last number of years a review is necessary. This matter must be considered in a broad way rather than on specific issues. I would impress upon the Minister the need to consider section 21 of the Mental Health Act whereby a psychiatric nurse, on the basis of a complaint by a patient, may be suspended without pay. In my brief period as Minister, I removed the suggestion without pay element from the Vocational Education Act, 1944. In this case the measure should also be removed. The fact that a person is suspended without pay automatically means they are assumed to be guilty.

The life of one man in my town has been destroyed by an accusation made against him, which everybody believed. The man who made the accusation was mentally ill and withdrew the allegation afterwards, but that was no good to the person involved. Everybody believed the allegations against him because the authority suspended him without pay for three months ending an inquiry. This is an area that needs to be addressed immediately so that confidence can be restored to psychiatric nurses who have done tremendous work over the years. These people are susceptible to allegations, and too many false allegations have been made against them.

Deputy Bruton mentioned the rejection of suicides. For too many years in this country we did not recognise suicide for various reasons, religious, insurance and so on. Suddenly the suicide figure seems to be very high. I am extremely alarmed at the number of suicides among young people. We cannot legislate for a reduction in the number of suicides but we can consider the problems involved and the causes, many of which are totally unexplainable, of this horrendous act, carried out in some case by people who are reasonably happy.

This is not a Bill that should be dealt with in two or three nights. It is as important as the Companies Act which took several years to be put through the House. The attitude to mental health has changed tremendously in the last 20 years, with people now being allowed to go for walks outside the hospitals and in some cases they are allowed home. The legislation in this area dates back years and if we are to legislate for the year 2000 we should discuss the matter fully in a calm way with no time pressure.

Mrs. Fennell

I rise to respond to this debate with a heavy heart. First, I thank all the speakers who contributed over the two weeks. It was quite an extraordinary, interesting, stimulating and, for me, very informative debate. A record number of Deputies contributed to the debate — I counted 16 excluding the Minister and the Minister of State, Deputy Flood. They were Deputies Browne, Ferris, Moynihan, Barnes, Fitzpatrick, Roche, O'Hanlon, Lee, O'Donoghue, McCartan, Callely, Lenihan, Howlin, McDaid, Davern and my colleague, Deputy Richard Bruton. I thank these people sincerely for their keenness to contribute to the debate and the role they played in widening the content of the Bill.

I would like to thank the other people who helped in the presentation of this Bill. A number of lawyers who were interested in this legislation helped me enormously over the months. I thank the FLAC Trinity students who have a great interest in and commitment to research in this area. I thank the members of WIP, the newly formed organisation for Wrongly Institutionalised People, who take a constructive and reasonable approach to seeking legislative change. I would like to thank Irish Women's Aid and the Council for the Status of Women who have come out publicly in support of this Bill; the Irish Council for Civil Liberties and the Women's Political Association. I also thank the drafting section in the House who were of enormous help to me.

It was interesting to listen to the contributions and the kind comments and to the congratulations extended to me for bringing forward the Bill. It showed an understanding and an appreciation for the work involved in producing a Private Member's Bill with only the resources of one's Dáil office. Many speakers said they appreciated the opportunity to discuss mental health issues. Tonight again we heard that a long time has passed since this matter was properly debated. I agree that this was a good feature of Private Member's time, but I did not set out merely to provide a vehicle for a debate on mental health. I set out seriously to produce a Bill that would be accepted and enacted into law. My aim was to fill the legislative vacuum in the mental health area. I know this Bill is not perfect and that it is flawed but there will be flaws when somebody puts together a Bill without the resources and back-up of the Department. The Bill is not cast in tablets of marble and I accept that it needs amending. I do not have any great maternal feeling about this Bill and I would have liked it to be amended but I know that is not possible. There my goodwill ends.

The Government's and the Minister for Health's approach to this legislation is not only regrettable, it is downright sick. It would be hard to find a subject on which there has been such political neglect over the years while at the same time such a cause of public concern and desire for legislative action.

What we are seeing tonight in the rejection of the Bill by Government is once more pointing up the irrelevancy of this Chamber to people's lives. How can the action of Government Deputies who are going to walk through the "no" lobby tonight not contribute to an even greater public cynicism of their work as politicians? It is particularly sad in view of the excellent and reflective speeches made by Government Deputies, who showed a high degree of understanding on the matter, who expressed great concern and the desire to see changes made. I accept their sincerity and I thank them, but concern and compassion are poor currency in a fight to establish civil rights and basic freedom, which is what this Bill is all about.

What is happening here tonight emphatically makes a nonsense of the proposals for Dáil reform we heard about last weekend. We are seeing a Minister failing to act like a Minister, failing to take the initiative and the power that is at his disposal, in order to change draconian measures in our mental health system and refusing to bring in an appeal or a review system, the urgency of which is well documented.

I, like many others, very positively welcomed the appointment of Dr. John O'Connell as Minister for Health and in approaching this legislation I had every reason to believe that this commitment to the subject would leave him no option but to break the stranglehold of the traditional departmental response to Private Members' Bills and lead him to accept this Bill and amend it in whatever way necessary in special committee.

My expectations I have to say were well founded given the views expressed by Dr. John O'Connell during a similar debate in this House in November, 1980, when discussing the Second Stage of the Health (Mental Services) Bill, 1980. I now quote from column 712 of the Official Report of 19 November 1980:

We have had a very bad attitude towards mental illness through the years. Patients' rights have been flouted. Patients have been committed to hospital by people, under the direction of doctors, and they have never got out again. People have ended their days in such hospitals simply because the person who originally signed them in was not available and but for that fact they would have been discharged.

The Minister for Health, Dr. John O'Connell, then an Opposition Deputy, said as reported at column 714 of the Official Report of the same date:

All this Bill will do is give certain rights to the mentally ill. Despite what has been said I do not think the provisions requiring two doctors to certify a patient for admission will cause much inconvenience. Already this is a requirement for private patients and all we are doing is extending it to public patients. This will give more rights to patients. The number of patients admitted by one doctor only is an indictment not only of the State but the medical profession. The attendance of two doctors is a vital safeguard which must not be allowed to be sidetracked.

The provision of a review body is another safeguard for mental patients.

...The existence of such a body will ensure that people will not be detained for life in mental hospitals, and the composition of the review body would therefore be considered with great care.

These are commendable views which I know were very sincerely meant in 1980. The question I am concerned about is, has the powerful mantle of Minister now knocked that sincerity and commitment into the margins in the interest of departmental expediency? If the detention provisions of the 1945 Act were wrong in 1980, which they were, and the Minister and Minister of State and every other speaker in this debate agree that they are wrong now and that there is an urgent need for an appeal system and for a review body, why are they voting the measures down tonight? The case should be resolved now, not next year or the year after or when there has been a Green Paper or a White Paper.

I accept that there is a broader debate about services and conditions for people in mental hospitals, but I do not accept that these should be linked to the issues of civil liberty, which are so much in question. Services and conditions in mental hospitals require funding — planned budgeting, it is cruel to marry them to rights as the Minister is doing.

Contrary to what the Minister and Minister of State have said regarding the limited nature of this Bill, I suggest that because of its limited nature and its deliberate focus on the detention provision, it must be easier to accept than broad based legislation which might deal with the wider issues in the mental health area.

I was impressed with the number of sound proposals and the amount of clear thinking that has come through in this debate. In my opinion if these were channelled into an all-party select committee, and working on the consensus that already exists, a composite Bill would be forthcoming in a very short space of time.

I deeply regret that there has been no meeting of minds on this issue tonight. The contribution of the Minister of State, Deputy Flood, requires a special response. Because there is a degree of uncertainty about the intention of section 3, I will repeat what it aims to achieve. In the opinion of most people there should not be any difference between the approach to public patients or private patients in the medical certification. I am aware that the third stage of the reception includes the signature of the medical officer of the psychiatric hospital, it is at the second stage, I believe, two medical practitioners should sign in all cases. This concurs with the views expressed by Dr. O'Connell in 1980 and brings us to a further point in the Minister of State's speech. On the question of who makes the decision in other countries to detain a person the Minister made the following interesting points:

The decision to detain a person in a psychiatric hospital (in European countries) is either a function for the courts or each medical decision is subject to review by an independent administrative body. The European Convention obliges that where a court is not involved in the decision to detain, that there should be a review of each order by a Judicial or Review Body.

This is precisely what is needed and what we should have here. It makes the Government's rejection of this Bill quite untenable. There is further food for thought in the Minister of State's speech when he talks about the composition of the review procedure. These proposals could be discussed and if we can come up with more ideal procedures, they could be inserted on Committee Stage. Similarly, the Minister's view on the thinking behind the arguments in providing information for detained persons is well worth considering and shows a degree of research and examination.

The most revealing aspects of the speech concern the civil proceedings in which we discover that section 259 of the Mental Treatment Act, 1945, which puts a time limit of six months on proceedings, was repealed by the Public Authorities (Judicial Proceedings) Act, 1954. This was news to me and I know it will be news to a number of doctors, lawyers and legal researchers interested in this area.

The Minister of State is more ambivalent on section 260 of the 1945 Act. This worries me. It requires that a person who has been detained seek the permission of the High Court before taking proceedings. The High Court must be satisfied that the person against whom the proceedings are taken acted in bad faith or without reasonable care. This is a much more difficult test than applies to any other proceedings for medical negligence. The intention is very clearly stated in the speech too — this provision was there to protect staff involved in the care of psychiatric patients from civil suits in the courts which might arise from the mental instability of the patient. This section, in effect, has given total immunity to all involved over the years and removes the important safeguard of an individual's right to have access to the courts in the event of wrongful detention. In the event that the Minister is not aware of the facts, let me assure him that there are cases of wrongful detention in the legal pipeline and one case is imminent.

I am aware that in proceedings under the 1945 Act some judges have been concerned about the weakness of our current laws, although they are bound by them. I suggest this is another area in which it will be perceived that as legislators we are reneging on our obligations and leaving it to the law courts to dictate how and where legislative change is necessary. If and when the honourable judges hearing future cases under the 1945 Act decide to point the finger at politicians over this disgracefully neglected area, I hope they will realise that the Government parties alone are solely responsible in this case. After tonight's vote let us hear no more about open government because it can only be seen as a rhetorical figment in the Taoiseach's imagination.

I genuinely approached this debate in an effort to get all-party support. I am very happy and grateful that I got all-party support on this side of the House. I did not want it in any triumphalist way but because I recognise the grim situation of the people who need the measures I am proposing. I know them personally as I have dealt with them this year, last year and a number of years ago. I am particularly surprised at both the lack of contribution to this debate and the lack of response to my letter seeking support from the Progressive Democrats. I and many others can only presume that they are unconcerned and not interested in the rights of people wrongly committed to mental hospitals. How can the Progressive Democrat Deputies, so expressly concerned and so vocal on other liberal issues, walk through the "no" lobby on this issue? Their hearts obviously do not bleed for the constituency who look to this Bill for recourse to justice and I say: "shame on them".

By his decision tonight the Minister for Health will fundamentally undermine public confidence in his ability to take decisive action — to break with tradition and do the right thing. Nothing he will do, I would suggest to him, equates with producing substantial legislation — not opening or closing conferences, meeting delegations, producing Green Papers, setting up committees or, indeed, distributing toothbrushes, as one of his predecessors did.

The Minister for Health, Deputy O'Connell, will be judged by the number and substance of the Bills he produces. Tonight he will have pushed one very important Bill into oblivion and will have compounded the image in this country of mental illness as related to men in white coats, forced medication, no accountability, no access to legal action and a suspension of human rights for those unfortunate enough to become victims of the 1945 Act.

It is the function and obligation of legislators to provide clear legal guidelines to those working in the psychiatric services and firm safeguards to users of the service against malpractice.

This debate is ending on the same barren note on which it began: we have an outdated, 50-year-old Act; we have no immediate possibility of amending that Act; we have no appeal procedure for those wrongfully committed; we have great difficulty in obtaining information for those people; we have no official reports — required by law — on conditions in mental hospitals. In short our mental health as a health service is on hold. No one, it seems, is in charge. Should someone turn out the light?