Mental Health Bill, 1999: Report Stage.

I move amendment No. 1:

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

It is important that we should clarify both what this Bill is about and what its limits are. There is great concern about the issue of mental health and a great need for legislative reform. On Committee Stage, the Minister acknowledged that the Bill was only one of a number that are required to reform mental health legislation. We should have clarity when it comes to defining any legislation that goes through this House. The White Paper dealt with many issues concerning the reform of legislation in this area but some of them are absent from the Bill. This Bill deals largely with those who are admitted involuntarily to institutions and with ensuring that they have certain rights and protection. It would be appropriate for the Government to deal with these issues in new legislation, rather than trying to put a spin on it as the Government is adept at doing. When one sees the title, Mental Health Bill, one would automatically presume this is major legislation dealing with the mental health area. However, many of the outstanding issues are not dealt with in the legislation, although we welcome the Bill and support it. It is perfectly normal practice to specify in the title of any Bill, what areas are being dealt with predominantly. I would ask the Minister to accept this amendment.

I support the amendment in the name of Deputy McManus. Throughout the debate on Second Stage it was emphasised that this was a very limited Bill dealing with a small, though important, aspect of the whole area of mental health. A comprehensive mental health bill is required to bring mental health services not out of the 20th century and even out of the 19th century. Many practices in the mental health area come from a time, in the 1940s and early 1950s, when mental hospitals were known as lunatic asylums. In an historical context that is not so long ago. Many of the country's mental hospitals were constructed in the mid-1800s and some had been adapted from old workhouses. They still have that sort of atmosphere inside. I am familiar with St. Joseph's Hospital in Limerick and one certainly goes back in time when one enters such a hospital, despite the best efforts of the staff and departmental officials.

Over the decades sufficient finances have not been put into such institutions. Similarly, legislation has not been updated and new facilities have not been made available. It is recognised internationally that the best approach to mental health is a community one. The first line of a patient's treatment, no matter how serious their mental illness, should be community-based, multi-disciplinary teams who can deal with those who are mentally ill. Only in a minority of cases should people be institutionalised. We still have a situation where people who are not mentally ill are in mental institutions. I refer in particular to the intellectually disabled who are not mentally ill and are not suffering from any illness but who have a condition from birth. These people do not need mental health treatment; they need assistance to cope with the circumstances arising from their mental disability. A psychiatric hospital is not the place for such people, yet up to 300 of them are still in such institutions.

We need a comprehensive Bill to deal with those and many other areas of mental health. As Deputy McManus has said, in all the contacts we have had with the Department, the Bill is described as if it is comprehensive and all-inclusive but it only deals with a very small, though important, aspect of the reform needed. We should call the Bill exactly what it is – a very limited Bill dealing with involuntary admission. As such, the Title should reflect that. Deputy McManus is right.

I cannot accept the amendment because this major Bill deals with much more than the process of involuntary admission. Half the Bill is concerned with providing for the establishment of the mental health commission and the new office of inspector of mental health services. Part 5 deals with provisions regarding the registration of approved centres in which both involuntary and voluntary patients will reside, and for a system of regulation and inspection whereby standards will be maintained in those centres.

The functions of the mental health commission, as described in the Bill, will extend far beyond the involuntary admission process. The commission will be concerned with the interests of all patients, both voluntary and involuntary, and with ensuring that the highest standards are adhered to in the provision of mental health services. Accordingly, it would be doing the Bill a grave disservice to rename it the Mental Health (Involuntary Admission) Bill.

Deputies have said, quite rightly, that on Second and Committee Stages the Minister referred to other issues. He said those issues have not been forgotten about or overlooked. They are being addressed and will be addressed further in other legislation following the enactment of this Bill. This is equally true in the provisions that are being made for mental health services this year, including not only this legislation but – following up on Deputy Neville's points – the allocation of £8.25 million for community-based services for the establishment of multi-disciplinary teams and the recruitment of additional staff to strengthen existing services. Some £1.75 million is being made available to enhance the level of psychiatric services available in hospitals. I have a personal interest in the area of child and adolescent psychiatry and I know Deputy Neville has an interest in the suicide prevention programme. Much investment is going into those areas.

The national development plan provides funding for community facilities, including mental health centres, day hospitals and community residences to accelerate the phasing out of the old institutions to which Deputies referred. I hope Deputies will accept that this legislation is just one element of ongoing reform of the entire mental health services. To accept the amendment, however, would give far too narrow a title to a Bill which is much more broad reaching in these respects.

I regret that the Minister is not choosing to define the Bill more clearly because she has referred to many other areas which are not addressed in the Bill, as well as the areas that are. I am rather concerned at her sanguine approach to child psychiatric services, since she has raised the issue. There are serious concerns among professionals in this field about the failure to deliver good quality care evenly across communities in which there are children who are in desperate need of psychiatric or psychological services. Proposals have been forwarded and work has been done in providing the Government with information but the response is not always adequate.

I caution the Minister of State regarding complacency about what is happening in child psychiatry and the significant lacuna that exists within that service at a time that psychiatric needs among children and young people are increasing rather than reducing because of changes in society.

I regret the Minister of State has not seen fit to clarify the Title. I agree psychiatric and psychological services for children and young people are extremely limited. Up to recent decades it was not recognised as an issue but now we realise it is a major problem. The level of coun selling and advice available to young people in crisis is non-existent. Teachers experience great difficulties in schools regarding how to deal with pupils in crisis. There are sophisticated systems in other countries but the service is non-existent in Ireland.

Psychiatric services have improved but I refer to one instance. A special ward was introduced in Limerick Regional Hospital for psychiatric patients, ward 5B. The intention was that it would be an open ward and the doors would not be locked as was the case in the old institutions such as St. Joseph's Hospital. However, every time I visit the ward the door is locked. One must ring a bell before being allowed in, sometimes through a side door. The reason for establishing the ward was to get us away from the lock up scenario where patients felt they were confined, but that still continues in this relatively new facility which has been in place for more than 20 years.

I am in no way complacent about the services needed in the area of child and adolescent psychiatry. We recognise there is such a need and I recently accepted the first report of the working group on child and adolescent psychiatry, referred to by Deputy McManus, which identifies what is needed throughout the State. Under the development plan five units are proposed, of which three are already in the planning stages, and funding has been put in place. There is a huge need and progress needs to be made. Investment must also be made, but these units are one of the other elements of this issue which is being dealt with separate from the legislation. I reiterate the legislation addresses much more than involuntary admission, which is why I am unable to accept the amendment.

Amendment put and declared lost.

I move amendment No. 2:

In page 8, line 8, to delete "the" where it firstly occurs.

This is a technical amendment to delete the word "the".

Amendment agreed to.

I move amendment No. 3:

In page 9, line 10, after "opposite sex" to insert "for a continuous period of not less than 3 years".

The amendment relates to the definition of "spouse" and the need for certain safeguards to ensure the power of a spouse to apply for involuntary admission in respect of his or her partner would not be abused. It results from concerns raised by Deputies Gay Mitchell and Neville on Committee Stage. Deputy Neville raised the issue of how long a couple had to be cohabiting before a person could be defined as a "spouse". This amendment defines that time as "a continuous period of not less than 3 years". I am happy to clarify the issue and I thank Deputies Mitchell and Neville for raising it.

I thank the Minister of State for responding to our concerns on Committee Stage. The amendment will improve the legislation.

I welcome the partial response of the Minister of State in providing a definition of the length of time required to recognise cohabitation. It is difficult to define as I suspect many marriages do not last three years nowadays. However, I raised a separate issue about which I am concerned partially because I am aware of one case which I raised on Committee Stage but which has not been addressed. A cohabiting couple who are of the same sex and who may have had a long-standing relationship, which is perfectly legal, are not recognised in the legislation.

There has been enormous media coverage of issues relating to high profile people who are separated and cohabiting with a new partner. There has been a national discussion about these issues and how they can be addressed. The discussion began because of the official event that took place to honour Cardinal Connell but other issues were raised regarding us coming to terms in a civilised way with the many different types of relationship which must be recognised.

The Bill in part recognises that cohabiting couples are a reality of modern Irish life, but cohabiting couples of the same sex are also part of that and they have not been recognised. I am aware, for example, of such a couple. One partner was involuntarily committed and the other had absolutely no rights. She had cared for this person, understood this person best and had been a loyal and dedicated partner in a close and intimate way for many years, yet when this couple faced a crisis she had absolutely no say, involvement or established right to be consulted or have any part to play in this distressing experience.

This issue must be addressed. Either we say cohabiting couples do not exist or we recognise them. The recent media debate demonstrates that the public recognises the difficulties involved. My party leader, Deputy Quinn, made the point that at some stage in the future we may well have a gay or lesbian Taoiseach. It is not beyond the bounds of possibility. Will we ensure there is protocol and procedures to allow for that eventuality? Can it be dealt with in a way that is accommodating and inclusive?

I raised the issue on Committee Stage and it does not require a specific example. What is required is recognition that there are circumstances where couples live together who are of the same sex. It is estimated that one in 20 men is a homosexual but I do not know whether that is true. It is a feature of Irish life, which is similar to other countries, but it is not recognised in the Bill. We are saying we will recognise couples who have co-habited for more than three years. They can obviously be married, which is well and good, but if someone is in this other kind of relationship, which may be a loving and long-standing one, we are saying we will not include them in the frame.

I would like the Minister of State to outline the Government view on this issue? She has had time to reflect on it and the civil servants have had a chance to look at it but it is very specific in the Bill that it is a person only of the opposite sex, and yet these relationships exist and are being sustained. Any form of discrimination is now considered to be unacceptable. Is this a form of discrimination? Does it discriminate? We have an Equal Status Act which requires people who traditionally were happy to discriminate for all sorts of reasons to change their practices, even though they may believe they are justified in trying to protect their interests by not doing so. They are required by law to do so but there is no requirement now for anybody within the mental health services to acknowledge a relationship of this type, certainly not in the way it is specified in the Bill.

Deputy McManus will accept that while recognising the changing face of Irish society, perhaps the debate on the Mental Health Bill is not the place to start defining different groups and relationships. What is important to recognise is that even though the spouse is one of the specific people mentioned in section 8(1), it is with regard to making an application for involuntary admission. There is also a subsection (d) which says “any other person”, so perhaps those people can be included under that heading and not excluded from the Bill.

On the question of whether there is discrimination, under the Bill same sex couples are not treated any less favourably than heterosexual couples so there is no discrimination one against the other. The only distinction that is made is for the spouse but this is not the place to start defining issues like that, save to say that anybody who is covered by section 8 can make the application.

I have to come back to the Minister on this because the Bill is where this issue has been raised. It has not been raised by the Opposition. There is a definition in the Bill of a spouse, which means a husband or wife, the traditional, unambiguous definition of a spouse. It is the Minister who has defined and extended that definition. It did not come from this side of the House. It has gone beyond marriage into the area of cohabitation. It is a practical recognition that couples do not all take the form of the married couple and that there are other family formations now and close partnerships and relationships. That argument is over. We have moved beyond that so the discussion now is about the way we define cohabitation so that it accurately reflects what is happening in our society. To simply bunch these people in under the heading "any other person" is discriminating against them in that if they are of the opposite sex, they have the status of spouse but if they are of the same sex they are simply "any other person". That is what happened in an individual case where somebody was treated as "any other person".

If I had a clear answer to this problem I would have put down an amendment but I raise it because it is a real issue affecting a certain number of people in our community. We are providing legislation for all our citizens and all our citizens are required to comply with it. The Minister of State glibly said we should not discuss this matter under a mental health Bill. If that is the case, it should not be in the Mental Health Bill because once the definition of a spouse is in the Bill, it is appropriate for us to discuss the different kind of relationships that exist. If we do not do that, we are simply being selective and discriminatory.

There is no recognition currently in law of same sex unions and for that reason it is not appropriate for us to try to define it under this legislation when perhaps it is more appropriate to family law legislation.

Amendment agreed to.

I move amendment No. 4:

In page 9, between lines 31 and 32, to insert the following:

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

I am pleased we are having a discussion on the mental health of prisoners with a Minister of State from the Department of Health and Children rather than someone from the Department of Justice, Equality and Law Reform, as is usually the case when we discuss the health of prisoners. It is a criminal justice issue in this House rather than a health issue so I am pleased that we will get a response from the Department of Health and Children on the health of prisoners.

There are many people detained in prison who should not be in prison. They should have access to mental health services. It is difficult to quantify but John Lonergan, the Governor of Mountjoy, has stated that up to 50% of prisoners in his care should be under the mental health services. These people are in prison for many reasons. They may have had a disorder at a young age, they may have had difficulties at school or they may have difficulties like attention deficit disorder and have now found themselves in prison because of habitual criminal acts resulting from a mental difficulty. John Lonergan said that up to 40% of prisoners in Mountjoy suffered as children and continue to suffer attention deficit disorder and they should have been treated at that time but the condition was not recognised then. It is only in the past five years that there has been any recognition of the presence of attention deficit disorder. Attention deficit hyperactivity disorder is now recognised as a condition but many psy chiatrists still deny its existence and refuse to treat it. It is recognised that many people with attention deficit disorder end up in prison because of their dysfunction.

The psychiatric services available in prisons is not sufficient to meet the needs of prisoners. It would be beneficial, at the discretion of the commission and the inspector of mental health services, if sections of the Bill applied to persons who have been in prisons and who have a form of mental disorder or a psychiatric condition. Accordingly, I would like to see the inspector of mental health services and the commission given a role in quantifying the extent of mental difficulties among the prison population and in making recommendations on how to meet the needs of people in prison who have a mental illness.

I would like to see some role for the inspector of mental services in trying to ensure that the best interests of prisoners who suffer from a mental disorder or breakdown or who are suicidal are treated so that they are given the maximum opportunity to recover. Most of these people did not get any opportunity before they became part of the prison population. If they had, they would not have become recidivists who repeatedly re-offend. We did not invest resources in people like that who had difficulties at a young age and who are now recidivists. Some of them are institutionalised. If somebody commits a crime to return to prison, because that is the only place to which they can turn, that person is suffering from a condition that should be treated rather than punished.

The level of suicide among prisoners is higher than ever. Prisoners suffer from overcrowding, drug abuse and psychiatric problems, for which they receive little or no treatment. They are in a threatening system as prisons are difficult places in which to survive if one has a disorder or if one is depressed.

Dr. Enda Dooley, director of prison medical services, said the problem faced by people trying to improve conditions is that the general public does not want to know and, therefore, there is no pressure on politicians to deal with the severe health difficulties in prisons. We are all human and we respond to public needs. That is part of democracy. However, there are occasions on which we must decide that, even though the public is not interested, it is a human right that prisoners receive the same level of physical and mental treatment as the general public. We are denying prisoners that human right.

The only occasion on which there is an interest in prison suicide is when one occurs. An 18 year old sent to prison for the first time could have a history of violence or drug abuse and can feel frightened. He or she may receive a sentence of six or 12 months and be placed with a hardened drug user or a violent prisoner. Instead of perhaps completing the leaving certificate and entering third level that young person is put in prison with hardened drug abusers who will exercise mental control over him or her.

That young person may suffer from a disorder such as attention deficit disorder, yet he or she is placed in an environment in which his or her senses are deprived, despite the fact that someone with ADD requires constant stimulus. What hope is there of reforming such a person so that he or she can live a full and productive life on leaving prison?

Ireland has the second lowest crime rate yet the highest rate of prison suicide. Dr. Dooley pointed out that there are the equivalent of two full-time psychiatrists in the prison service for more than 2,600 prisoners. A report published by the European CPT commission recommended that in-patient psychiatric services for prisoners be reorganised as a matter of urgency.

The Minister for Justice, Equality and Law Reform, Deputy O'Donoghue, stated towards the end of last year that improvements would take place in prison psychiatric services. However, we have heard no more about this. My information is that there are still only two full-time psychiatrists. I would welcome an update from the Minister on any improvements which have taken place since he announced that he would do something about this issue.

Fr. Fergal McDonagh, head of the prison chaplaincy service, stated that a prisoner might be lucky to see a psychiatrist for five minutes at the most. Unfortunately the psychiatric system's main function is to dispense prescribed medication, such as sleeping tablets and anti-depressants. Counselling is non-existent in the prison service.

Earlier this year Fr. McDonagh also stated regarding suicide in prison, that if a person says he or she is depressed or suicidal, the response within the prison system is that he or she is stripped to his or her underwear, is taken to a room six feet by five feet which is padded, or sometimes unpadded. The room will have a plastic mattress on the floor and a blanket designed so it cannot be torn and used as a ligature. The person is left in the room and has to eat meals off the floor. Some people might only spend one day in the room, yet some have spent weeks in such sensory deprivation. Fr. McDonagh pointed out that this would not happen in a psychiatric hospital.

Surely the mental health services should supervise this treatment. The inspector should be able to express a view on this situation. A person who is suicidal or deeply depressed should not be prison. If a prisoner breaks a leg, he or she is immediately taken to a general hospital under guard. Such people receive treatment and the service ensures that they recover fully. However, if a person has a mental breakdown and is suicidal, he or she is put into a padded cell. Surely a person who is deeply depressed is as ill as someone who has broken a leg.

There is no impediment to admitting a prisoner to a psychiatric facility. However, such prisoners are not admitted to hospital, unlike prisoners in need of surgical or medical care. The prison system has not insisted that prisoners can only go to one secure hospital, namely, the Central Mental Hospital, Dundrum. Most prisoners do not present a security risk to the public and have no intention of escaping. There is no reason they cannot be admitted to the local psychiatric facility or hospital. Many prisoners will be well-known to such services. Many prisoners who are very depressed do not threaten anyone as they are inward-looking, silent, meek and ill. However, we do not admit such people to psychiatric hospitals, even though they do not present any threat.

Health authorities are reluctant to take responsibility for mental health care in prisons. This amendment moves in the direction of identifying and recognising the mental health aspect of many prisoners. Only 1.5% of the prison budget is spent on health care – the lowest percentage in Europe. At the same time, the Government spends almost £900 per week to keep a prisoner in custody. The Irish Penal Reform Trust argues that some of this money should be re-routed into alternative custody methods, such as restorative justice programmes. Dr. Charles Smith, medical director of the Central Mental Hospital, has stated that there is no chance of rehabilitating or treating a person in prison, as there is too much negativity in such institutions.

This amendment seeks to ensure that the health services recognise that there is a health issue in prisons, and that they should have some input and report to the Department of Health and Children, not the Department of Justice, Equality and Law Reform. The latter Department has responsibility for keeping people in custody and ensuring that those who commit crimes pay their dues to society. That is not at issue. People must pay their dues to society, but there is a problem regarding people who are seriously ill, who are not being treated but are, and have been, ignored for generations.

We could significantly reduce the prison population by identifying early mental disorders and difficulties, such as attention deficit disorder. Families which are not dysfunctional have children who suffer from ADD. These families experience difficulties with these children in childhood and youth, and these children are now in prison. I am aware of one case in which a person suffering from ADD was being treated in prison with ritalin. Two elderly psychiatrists examined this prisoner and decided to take him off this drug as it is addictive. While on ritalin the young man was talking about leaving prison and sitting his leaving certificate examination. However, the next time his father visited him after he was taken off ritalin his condition had deteriorated. This is what is happening in the prison service. We must recognise this fact and this amendment would enable us to do so.

I support this reasonable, worthwhile amendment which would not create practi cal difficulties. I would be concerned that the main block to dealing with the whole issue of health care in prisons is a turf war between two Departments. I hope that is not the case. However, there tends to be great difficulties in transferring responsibilities between Departments, perhaps because one Department might feel it is losing face. However, in this instance it makes no sense that the health service for prisoners is run by the Department of Justice, Equality and Law Reform when the Department of Health and Children is responsible for the health of the people. Either prisoners are part of our population or they are not. Everybody recognises that they are and, as such, their health needs should be no different from the health needs of others and should be dealt with by the appropriate Department. That would be logical and would be helpful in progressing the health care of prisoners, both physical and psychiatric.

The history of such care has been appalling. Best medical practice demands that people living in institutions should have a higher level of health care than those outside. I am not simply referring to prisons but to other institutions where there is a continual problem, particularly in physical terms, of infections and other conditions being easily transferred among people. Other factors also impact on health status. In Britain, the medical view is that people living in institutions should be able to enjoy a better standard of health care than those outside. However, that is not being put forward in this amendment. The amendment proposes that people in prison who have psychiatric disorders should not be dealt with any worse than people outside. The standards should be equivalent and there should be the same protections. Unfortunately, the Minister's response to this proposal by Deputy Neville on Committee Stage was not positive. Disappointingly, he said it was being put back to the review that was established by the Department of Justice, Equality and Law Reform and on which the Department of Health and Children was represented. Even in that case it was not seen as a shared responsibility, let alone that it should become the responsibility of the Department of Health and Children.

Most prisoners are young, male and poor. Many prisoners, certainly a higher proportion than in the general population, suffer from psychiatric illness to some degree. The suicide level is alarmingly high, particularly given that it is not a huge prison population in terms of the ratio of prisoners to prison warders. We have a high number of prison guards. However, we have too many people in prison compared to other countries in the context of possible alternative penalties and forms of punishment. The concept of having other forms of punishment is becoming more popular but it is a slow process. In the meantime, there are many young people incarcerated in prison who are definitely and clearly at risk.

Anybody who visits Mountjoy Prison does not leave there feeling anything but great shame at the fact that we tolerate such treatment of prisoners and, to an extent, the people employed to care for them. The amendment seeks to include these people, in so far as it is practicable, within the oversight role of the commission and the inspectorate. Recently, the general population heard a debate on "Morning Ireland" about the forms of confinement that are still used in our prisons, following publication of the report by the prison reform group. Many people were probably astonished when the methods of confinement were described. People are not particularly interested in what happens to prisoners until it is brought home to them that there is such an archaic approach to dealing with people who are often extremely distressed, ill and in need of the benefits of advances in medical care which the rest of the population has but which they are clearly unable to access.

There is a benefit to society if we can deal with these issues. It would at least ensure the level of crime would be stabilised and possibly reduced because we would see both the crime and the person who commits the crime in a holistic way and in a way in which we can understand and differentiate between the different purposes, motives and outcomes of individual prisoners. The Minister referred to a review on Committee Stage. Will the Minister tell us about the review and the outcome in terms of the changes that can be expected? Why should such a review block this amendment? I read the Minister's statement again to see why there should be a conflict but I still cannot see it.

These are psychiatrically ill people who are part of the prison population. Studies show that there is a higher incidence of psychiatric illness among prisoners than in the general community. There is no argument about that. Why can that cohort of psychiatrically ill people not simply be included in the work of the commission so there is rationality and so they can enjoy certain safeguards? They are still human beings, regardless of whether they are incarcerated, and when they have a psychiatric illness they are sick people who could benefit enormously from the medical and therapeutic improvements that are occurring. People who suffer from schizophrenia, for example, have benefited enormously from the advances resulting from innovation and technological advances. It is important that we reach out to psychiatrically ill people, regardless of where they are, if we are serious about reforming mental health legislation.

While I do not accept the amendment, I agree with many of the views expressed with regard to the need for substantial improvement in the psychiatric services currently provided for the prison population. I support the principle that the health services in prisons should at least be on a par with those available to the rest of the community. I assure the Deputies that the Department of Health and Children is actively taking steps in this regard.

The Department is represented on the review group on the structure and organisation of prison health care services. The review will cover all aspects of health care, not just psychiatric services. The group was set up in November 1999 by the Minister for Justice, Equality and Law Reform to examine a number of issues, including the report of the Irish Penal Reform Trust on the treatment of prisoners with mental illness, the use of padded cells and so forth. It is also examining the need for a reorganisation of psychiatric services for prisoners and the provision of a properly structured forensic psychiatric service. The Royal College of Psychiatrists is also represented on the group.

This group is addressing many of the issues which have been raised today. It has visited every Irish prison and prisons outside the jurisdiction to consider best practice in the organisation of prison health care. The report is nearing completion. I hope that, perhaps taking the model of the drug treatment service, the work can be done through a partnership between the statutory and voluntary agencies, the Department of Health and Children and the Department of Justice, Equality and Law Reform.

Deputy Neville spoke about the need to quantify the extent of mental disorder among the prison population. The problem in verifying the real needs in this area stems, to a large extent, from a lack of consultant forensic psychiatrist input into the prisons. One of the objectives of the Department of Health and Children has been to address that. The Deputy asked what progress had been made. Since 1999, funding for five additional consultant forensic psychiatric teams has been provided. One of these has been appointed to the Central Mental Hospital and is now working in Mountjoy and Cloverhill Prisons. Two further posts in the Eastern Regional Health Authority area have been advertised to be filled this year. The remainder of one each in Limerick and Cork will be progressed later this year. In addition, the Department has been involved in discussions with the Prison Service and the Midland Health Board on the development of health services for the new midlands prison. It is hoped that the services developed there will serve as a model of best practice for other prisons in the State.

The concept of partnership and the admission of prisoners to local psychiatric hospitals are also being addressed. Discussions to this end have commenced in the midlands between the prisons and the health board. While I recognise that much remains to be done, we have made a start in this area with a view to addressing the problems of prison health care. I assure Deputies that the Departments of Health and Children and Justice, Equality and Law Reform are working closely on this issue to see what progress can be made. Action will be taken as soon as the review group issues its report.

The real reason this amendment is not being accepted is that the role of the Inspector of Mental Health Services is not appropriate to an inspection of prison facilities. The Minister for Justice, Equality and Law Reform is preparing proposals to establish an inspector of prisons in the context of a prisons Bill. The measures being taken to improve prison psychiatric services will go some way towards addressing the current problems and I hope Deputies will accept that this amendment would not enhance that work in any way.

I am deeply disappointed that the Minister does not believe the Department of Health and Children should have a direct role in the provision of psychiatric services to prisoners. She stated that such services would more properly be the responsibility of the Department of Justice, Equality and Law Reform under an inspector of prisons and that acceptance of this amendment would cut across that Department's proposal to establish the post of an inspector of prisons. This is the very issue we wish to address. Health issues in prisons should be the responsibility of the Department of Health and Children, not the Department of Justice, Equality and Law Reform. That is the core of this amendment. An inspector of prisons would have a broad remit ranging from the type of food available to the provision of educational services etc. We want to hone in on mental health issues.

The Governor of Mountjoy Prison, Mr. John Lonergan, who has been repeatedly praised for his humane attitude to prisoners, has stated that up to 40% of prisoners suffer from attention deficit disorder or attention deficit hyperactivity disorder. The implication is that if these disorders had been treated in time, these people would not be in prison. Prison is a depressing place; prisoners suffer from endogenous and exogenous depression and they require treatment for these conditions in the same way as they would require treatment for a broken leg. I am disappointed the Minister has not grasped this opportunity for the Department of Health and Children to become involved in this area.

The Minister's reply highlighted the real problem; while the Department of Health and Children is participating in the review, it does not have any decision making powers. The review process may result in the production of a magnificent report which will merely gather dust on a shelf. No dedicated health care budget was provided in the Estimates for the Department of Justice, Equality and Law Reform which does not, under normal circumstances, deal with health care issues. An inspector of prisons might not have any knowledge of psychiatric illness and although he or she might do a good inspection job, it is unlikely he or she would have the expertise to assess prisoners' health needs.

The Inspector of Mental Hospitals has trudged along for years in an effort to upgrade and improve services and has acquitted himself very well in terms of highlighting the needs of psychiatric patients. The inspector has knowledge in this area and has had the daily experience of dealing with a poor quality service for very vulnerable people. At this stage, he could look back and say that some improvements have been made.

Although I recognise the difficulties involved in appointing consultants within a reasonable time frame, the fact that only one of five consultant psychiatrists has been appointed at this stage is not very hopeful. If the Minister is sympathetic to these problems – and I do not have any reason to doubt her – she must recognise the logic of our proposal. Let us include prisoners in the provision of psychiatric services and ensure that safeguards and protections are provided for them in this Bill. Otherwise, the legislation will be flawed and the population it is intended to support and protect will not include prisoners. That would be most regressive.

The implication of the Deputies' comments is that health services are not being provided in prisons. Psychiatric services are provided by the ERHA in the Dublin prisons via psychiatrists from the Central Mental Hospital. It is unfortunate that in spite of funding having been made available, only one consultancy team has been appointed to date. Hopefully, the remaining four will be in place by the end of the year. The practicalities of service provision are being catered for at present. In spite of the fact that responsibility for prisons rests with the Department of Justice, Equality and Law Reform, services are being provided on a partnership basis.

Prison psychiatric services are totally inadequate; in some cases they are almost non-existent. The Minister implied that the psychiatric services provided at present are almost adequate. Let me again quote from comments made by Fr. Fergal McDonagh, head of prison chaplaincy services, during a "Prime Time" programme in January of this year. In regard to prisoners with psychiatric conditions he stated:

A prisoner is lucky to see a psychiatrist. A prisoner would be very lucky to see a psychiatrist for five minutes and that would be stretching it. Unfortunately, the psychiatric system we have is essentially one whose main function is to dispense or prescribe medication, sleeping tablets and anti-depressants. Counselling is non-existent in the prison system.

The Minister made a big play about the review group on health care. We debated the number of review groups yesterday with her senior Minister. My amendment proposes that the commission and mental health services inspector should be involved in inspecting prison psychiatric services. Their report would be of enormous benefit to the review group the Minister mentioned. If the amendment was accepted and the inspector of mental hospitals could visit prisons and the commission could examine psychiatric services in prisons solely from a mental health perspective, their views and reports would be of enormous assistance to the review group set up in November 1999. This opportunity should be used to ensure the views of the commission that will be established and the inspector of mental hospitals are available.

There was a discussion yesterday involving Deputy Gay Mitchell about the number of review groups in the Department of Health and Children. Such groups are cited by officials in the Department and the Minister for Health and Children, Deputy Martin, at every opportunity. It is the first time I have heard the Minister of State, Deputy Hanafin, refer to a review group, but the answer of the Minister, Deputy Martin, to every question is that a review group or committee is examining the matter. The Minister of State used the ploy that a review group is dealing with this issue, but that is not good enough.

Surely the Minister of State cannot accept a situation where the health boards supervise a psychiatric service that puts a suicidal person, whom the prison authorities consider might die by suicide, into a cell measuring four feet by five feet and strips him or her down to his or her underclothes. The person is placed on a plastic mattress and he or she must eat off the floor. Such people experience total sensory deprivation for long periods. I cannot accept that this service, which is supervised by the health boards, is adequate. It deprives people of their human dignity and rights. The amendment would enable a person in authority, who has experience and psychiatric training, to point out what is wrong and the changes that are needed. The Prisons Service favours such a development. Prison governors or those who work in prisons are not happy taking an ill person, who is in danger of dying by suicide, and placing him or her in a padded cell where he or she is stripped to his or her underclothes and given a plastic mattress. The person must eat off the floor because nothing that could pose a danger to him or her can be put into the cell. These people should be treated in hospital.

The amendment would begin a process where such procedures are questioned by those who know what they are talking about. My belief is that the Minister of State finds it difficult not to accept the amendment. Given her experience and humanity, she must have some sympathy for and understanding of our effort to ensure an input from the psychiatric services, the commission and the proposed development of the system involving the inspector of mental hospitals. They should have an input to cases involving people who are in deep crises and deeply depressed. Such people may be suffering from schizophrenia or other mental disorders. They may be incarcerated in prisons and in need of psychiatric help. However, as we were informed, they can only get a tablet that will put them to sleep or see a psychiatrist for five minutes at most. This is no way to treat people who are seriously ill.

The governor of the Central Mental Hospital expressed his concerns about the fact that if somebody is in need of treatment and hospitalisation but there is no bed for him or her in Dundrum, he or she remains in prison. The facilities in the Central Mental Hospital in Dundrum are limited in terms of dealing with people in prison who are mentally ill. If a prison doctor refers a person to the hospital but no beds are available, he or she remains in prison and is treated there.

If the commission has the authority to consider the treatment of people in prison with mental health conditions, surely the Minister of State would be happy if the inspector of mental hospitals could visit the prisons and examined the treatment provided there. Surely she would be happy that such reports would prod, coax and induce the Minister for Justice, Equality and Law Reform to accept the dire nature of the situation rather than set up a broad based inspectorate that will examine prison food, the rehabilitation and education of prisoners, prison clothing, prison exercise arrangements and even television hours and the psychiatric services. There should be a dedicated approach because of the unique relationship between psychiatric disorders, including personality disorders and mental illnesses, and those who commit crime and are imprisoned, particularly recidivists.

A person who continually returns to prison because he or she is institutionalised needs special attention. There is obviously a problem in that regard because who would want to spend his or her life in prison? However, some people are comfortable with spending their lives in prison and they need help, not incarceration. We fully accept the right of society to ensure that those who commit crimes pay their dues and that society is protected from crime by measures that include a level of incarceration. We have always supported that position and encouraged its extension. However, the other side of the coin is the direct relationship between psychiatric illness and the prison population which is not being addressed. It has never been dealt with and the amendment provides an opportunity for the psychiatric services to have a key influence in this area. I urge the Minister of State to change her mind.

I did not suggest that the services are adequate. However, where they exist, they are provided by the health service and not by the Department of Justice, Equality and Law Reform. My opening remarks were that substantial improvement is needed.

Amendment put.

Bell, Michael.Belton, Louis J.Boylan, Andrew.Bradford, Paul.Broughan, Thomas P.Browne, John (Carlow-Kilkenny).Bruton, John.Bruton, Richard.Burke, Liam.Carey, Donal.Clune, Deirdre.Connaughton, Paul.Cosgrave, Michael.Coveney, Simon.Crawford, Seymour.Creed, Michael.Currie, Austin.D'Arcy, Michael.Deasy, Austin.Deenihan, Jimmy.Dukes, Alan.Durkan, Bernard.Enright, Thomas.Finucane, Michael.Fitzgerald, Frances.Flanagan, Charles.Gilmore, Éamon.Gormley, John.Hayes, Brian.Higgins, Jim.Higgins, Joe.

Higgins, Michael.Hogan, Philip.Howlin, Brendan.Kenny, Enda.McCormack, Pádraic.McDowell, Derek.McGahon, Brendan.McManus, Liz.Mitchell, Gay.Mitchell, Jim.Mitchell, Olivia.Naughten, Denis.Neville, Dan.Noonan, Michael.O'Keeffe, Jim.O'Shea, Brian.O'Sullivan, Jan.Owen, Nora.Perry, John.Quinn, Ruairí.Rabbitte, Pat.Reynolds, Gerard.Ring, Michael.Ryan, Seán.Sheehan, Patrick.Shortall, Róisín.Spring, Dick.Stagg, Emmet.Upton, Mary.Wall, Jack.


Ahern, Bertie.Ahern, Dermot.Ahern, Michael.Ahern, Noel.Andrews, David.Ardagh, Seán.Blaney, Harry.Brady, Johnny.Brady, Martin.Brennan, Matt.Brennan, Séamus.Briscoe, Ben.Browne, John (Wexford).Callely, Ivor.Carey, Pat.Collins, Michael.Cooper-Flynn, Beverley.Cullen, Martin.Dennehy, John.Doherty, Seán.Ellis, John.Fahey, Frank.Fleming, Seán.Flood, Chris.Foley, Denis.Gildea, Thomas.Hanafin, Mary.Harney, Mary.Haughey, Seán.Healy-Rae, Jackie.Keaveney, Cecilia.Kelleher, Billy.Kenneally, Brendan.Killeen, Tony.Kirk, Séamus.

Kitt, Michael P.Kitt, Tom.Lawlor, Liam.Lenihan, Brian.Lenihan, Conor.McCreevy, Charlie.McDaid, James.McGennis, Marian.McGuinness, John J.Moffatt, Thomas.Molloy, Robert.Moloney, John.Moynihan, Donal.Moynihan, Michael.Ó Cuív, Éamon.O'Dea, Willie.O'Donnell, Liz.O'Donoghue, John.O'Flynn, Noel.O'Hanlon, Rory.O'Keeffe, Batt.O'Keeffe, Ned.O'Kennedy, Michael.O'Malley, Desmond.O'Rourke, Mary.Power, Seán.Ryan, Eoin.Smith, Brendan.Smith, Michael.Treacy, Noel.Wade, Eddie.Wallace, Dan.Wallace, Mary.Woods, Michael.Wright, G. V.

Tellers: Tá, Deputies Bradford and Stagg; Níl, Deputies S. Brennan and Power.
Amendment declared lost.

Amendments Nos. 5 and 7 are related and may be discussed together.

I move amendment No. 5:

In page 9, between lines 31 and 32, to insert the following:

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

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

(3) Subject to the extent–

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

(b) authorised by this Act,

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

I welcome amendment No. 7 in the name of the Minister, which essentially deals with this issue by the inclusion of the phrase, "with due regard being given to the interests of other persons who may be at risk." That is a reasonable addition to what is a setting out of fundamental principles to be adhered to within the legislation. It was important that I tabled the amendment and the Minister, in a very welcome move, took on the need to provide this set of principles to protect the individual. The idea of what is in the best interests of the individual is now being enshrined in the Bill, which will be welcomed by many in the community. They have been concerned about the area of mental health, looked at our history of treatment and failure to treat those suffering from psychiatric illness in a way that is dignified and respectful of their needs. There has been much abuse of vulnerable persons in institutions, be they the psychiatrically ill, children or women with crisis pregnancies.

It is important the way the legislation is framed recognises the individual's right to integrity, dignity, privacy and autonomy. These are the features of the amendment being brought forward by the Minister. They are fundamental and important principles which make this better legislation.

I welcome the amendment and the acceptance by the Minister of the proposal from Deputy McManus. The amendment is very important in that the history of treatment in the mental services has been one where the patient has almost been depersonalised. They were seen not to have a point of view and to be incapable of having one. They did not have the right to privacy, dignity, personal autonomy or question their treatment. We have seen, and unfortunately to an extent still see, people who have been in mental institutions for ten, 20, 30, 40 and even 50 years, who in today's more enlightened climate would never have seen the inside of those institutions. Many of their problems were social rather than ones of mental health and though what has passed has passed, we must ensure a total change from that approach. We must ensure we change the approach where the person who is mentally ill becomes the third party to any decisions taken about his or her treatment and confinement and his or her personal views are totally ignored.

I have received statements from people who have been involved in mental institutions over the years. I would like to know how clinical trials were conducted prior to the involvement of the board which granted permission to do so. When I say that people have mentioned the clinical trials which took place in some mental institutions in the 1930s, 1940s, 1950s, 1960s and perhaps in the 1970s where the person's dignity, bodily integrity, privacy and autonomy may have been ignored, I am asked to give examples. However, I do not have examples. People have asked me to examine that situation. I will return to this point on another amendment. I welcome the fact that this will give to people who suffer from a psychiatric illness the same status and dignity that is given to those who suffer from a physical illness. There is a charter of patients' rights for those who attend general hospitals. There should also be a charter of rights for people confined to a mental institution.

The interests of the person shall be the principal consideration. I have met people who were extremely concerned about a member of their family who was suicidal but who was discharged from a mental institution. They were extremely distressed because they were afraid the person would commit suicide. In one case a father and daughter came to me about their son and brother who was discharged from a mental institution but who was still suicidal. I spoke to the hospital authorities. However, six months later I met someone who told me he had been found hanged that morning. I am extremely concerned about discharging people who are suicidal. The best interests of a person who is suicidal in a mental institution or who is receiving mental treatment will only be served if we ensure their survival. We should have proper systems in place and we should not adopt the attitude that nothing more can be done for them even if they are suicidal. That attitude prevails, although I am not saying every psychiatrist is of that view.

There are too many cases of people whose families are concerned about suicide ideation and who end up committing suicide. A family's concerns are often ignored because a psychiatrist will say his or her relationship is with the patient and no one else should express a view. He or she will not discuss the patient's condition. If a person suffers from a serious mental illness and his or her family is concerned about suicide ideation and the psychiatrist decides to remain silent because of the patient doctor relationship, those concerns should be taken into account. One case is too many. The risk of suicide is 400 times greater for someone in the first four weeks after being discharged from a psychiatric institution.

It is a good idea to have a general statement of principles at the beginning of the Bill. This issue was raised by Deputy McManus on Committee Stage and there is already a precedent for it in the Child Care Act. These principles are important. The Minister's amendment differs in some detail from the amendment tabled by Deputy McManus but the general principles are the same. One important change is that while the text acknowledges that the best interests of the person should be the principal consideration when taking decisions about involuntary detention, it also stresses the need to be careful that the interests of other persons, such as family, friends or staff who may be at risk of serious harm, are taken into account. The wording of subsection (2) has also been changed but the principles of the prior consent of the patient and his or her views being given due regard are still intact. I thank Deputy McManus for raising this concept on Committee Stage and for acknowledging that the Minister's amendment follows the spirit of her amendment. Perhaps she will withdraw her amendment.

I am more than happy to withdraw my amendment in favour of the Minister's amendment.

Amendment, by leave, withdrawn.

I move amendment No. 6:

In page 10, line 3, after "judgment" to insert "and which seriously impairs the mental function of the person".

I understand the Minister gave an undertaking on Committee Stage to re-examine the definition of mental illness in section 3. A form of words taken from the New South Wales Act, 1990, had been proposed. However, on closer examination and following detailed consultations with medical experts, it was found that the New South Wales definition was over-prescriptive and could broaden the grounds on which a person could be involuntarily detained. The amendment now proposed by the Minister incorporates into the existing definition a key phrase from the New South Wales Act. In the revised version, the person's mental function must be seriously impaired to the extent that he or she requires treatment. Taken together with the definition of mental disorder in subsection (1) of this section, this amendment will ensure that a stringent test of mental incapacity will apply for those who are being involuntarily detained.

Perhaps the Minister of State could clarify that. The Bill states: "a state of mind of a person which affects ... to the extent that he or she requires care or medical treatment". The amendment states: "which seriously impairs the mental function of the person". That is different from what the Minister of State referred to, which is already in the Bill.

The words will be added after the word "judgment" in page 10. Section 3(2) will then state that ""mental illness" means a state of mind of a person which affects the person's thinking, perceiving, emotion or judgment and which seriously impairs the mental function of the person to the extent that he or she . . .". It strengthens the section.

I was afraid if it was left standing, some of us might be included. Our judgment is not always perfect.

Amendment agreed to.

I move amendment No. 7:

In page 10, between lines 15 and 16, to insert the following:

"4.–(1) In making a decision under this Act concerning the care or treatment of a person (including a decision to make an admission order in relation to a person), the best interests of the person shall be the principal consideration with due regard being given to the interests of the other persons who may be at risk of serious harm if the decision is not made.

(2) Where it is proposed to make a recommendation or an admission order in respect of a person, or to administer treatment to a person under this Act, the person shall, so far as is reasonably practicable, be notified of the proposal and be entitled to make representations in relation to it and before deciding the matter due consideration shall be given to any representations duly made under this subsection.

(3) In making a decision under this Act concerning the care or treatment of a person (including a decision to make an admission order in relation to a person) due regard shall be given to the need to respect the right of the person to dignity, bodily integrity, privacy and autonomy.

Amendment agreed to.

I move amendment No. 8:

In page 11, between lines 16 and 17, to insert the following:

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

Subsection (7)(ii) states that nothing in subsection (1) shall be construed as authorising the involuntary admission of a person to an approved centre by reason of the fact that the person is suffering from a personality disorder, is socially deviant or is acting through drugs or intoxication. The Bill does not interpret these terms. What qualifies as social deviance? How is personality disorder identified? The amendment proposes that the commission publish comprehensive guidelines setting out what constitutes personality disorder or social deviance.

The term "social deviant" has changed over the years. Many seen as deviants at different times in our history would not now be seen as deviants. Consenting homosexuals have been seen as deviants but we have advanced from times such as those. The terms are not defined. In the Middle Ages people were burned at the stake for homosexuality.

Social deviancy can differ between groups. For example, there is currently a debate in Ireland about Romany gypsies and their customs. Ireland is moving towards a multi-racial society. Other groups are entering the country with their own customs and norms which may to another group be seen as deviant. There are justifiable concerns about the Romany population in Ireland but that group does not consider itself to be socially deviant. Those from different social backgrounds may perceive others to be socially deviant when they are not. Particular behaviour may be acceptable and the norm within their class.

As we move to a multi-racial society, who is to decide what is socially deviant? Diverse groups will contribute to life in Ireland and it is important that we have a clearly defined interpretation in this section of the Bill. Social deviancy and personality disorder are contentious in their definition even among experts in the area. There is still a debate about attention deficit disorder. It is a recognised medical condition, but there are still psychiatrists who say it does not exist. Some claim that bad parenting causes the difficulties. Parents suffered extreme difficulty and guilt because they believed they were doing something wrong with a difficult child, even though they had no difficulties with their other children. These concepts change over time, thankfully. The previous Minister has accepted that condition exists.

We need a clear definition of what "personality disorder" and "social deviance" mean. A close examination should be made and the Bill should cater for this.

It is an important issue raised by Deputy Neville in this amendment. The terms "personality disorder" and "social deviance" are used in the Bill on the grounds that nothing shall be construed as authorising the involuntary admission of a person to an approved centre by reason only of the fact that the person is suffering from a personality disorder or is socially deviant. That is an argument for not committing a person but it is not clear what ground the terms cover. It will be difficult in a legal context to argue about these terms when they are not defined in the Bill. It is a genuine difficulty.

I appreciate that the definition of social deviance changes. That should not prevent us from defining what we mean at this time. If a change is needed in the future, that can be dealt with at an appropriate time. As a student in the 1960s, a young man was incarcerated in a mental hospital because he was Maoist. He was considered to hold views that indicated mental illness. One does not have to agree with Maoism, but it is now considered to be a political belief one could hold without ending up in a mental hospital.

That example is an indication that such things can happen, and can be the subject of court action. It is important that the words and terms of a Bill are explained and defined so that all agree what they mean. Lawyers make a great deal of money and people's rights can be infringed if there is fuzziness. Deputy Neville's proposal is a practical one asking the commission to come back with a full report, having reflected on and come to a consensus on these terms. It is a difficult job but somebody needs to do it. It seems a good avenue to ensure that this issue is dealt with in a way that people can buy into.

I foresee problems ahead if the issue is not dealt with. The Bill will be challenged as it is unclear what is meant. One can argue that people are socially deviant from time to time and are otherwise normal. However, one can also argue that social deviance is an expression of serious and dangerous psychiatric illness. It is important to clarify this and I ask the Minister to accept this amendment.

I understand that on Committee Stage the Minister indicated that he had sympathy with this proposal and that the commission will issue guidelines in relation to this matter. However, having consulted the legal experts I am advised that the amendment is outside the functions of the Mental Health Commission. A determination of whether someone suffers from a mental disorder, personality disorder or social deviance is a matter of clinical judgment best left to the medical experts handling individual decisions.

The Bill says that persons cannot be subject to involuntary admission by reason only of the fact that they are socially deviant etc.. Every consultant's decision made at the time a person is admitted involuntarily will be subject to a review by a tribunal, which is a further safeguard. It is not possible, as the Deputies indicated, to put in place a clear and concise definition of these terms. It is better that the consultant makes the decision and that the decision be subject to a review. We believe it is not within the scope of the commission to do this because its job is to promote, foster and encourage good practice in the provision of mental health services. The commission also has a particular function in relation to the protection of the interests of those who are involuntarily detained. For that reason, I am not in a position to accept the amendment.

Debate adjourned.
Sitting suspended at 1.30 p.m. and resumed at 2.30 p.m.