I move:
That Dáil Éireann:
– noting the recent critical reports on the treatment of people with mental illness by Amnesty International, the Irish Psychiatric Association and the Inspector of Mental Hospitals;
– concerned that Irish mental health policy and service provision remain out of step with international best practice and that the institutionalisation of the mental health services in Ireland has failed to live up to World Health Organisation standards;
– believing that the high admission and re-admission rates to psychiatric hospitals are due in large measure to the lack of community based facilities;
– concerned at the lack of dedicated psychiatric facilities for adolescents, the lengthy waiting lists for treatment and the lack of consistency in the provision of mental health services throughout the country; and
– deploring the fact that people with intellectual disability continue to be inappropriately accommodated in psychiatric facilities in violation of human rights law; condemns the Government for its neglect of the mental health sector and failure to vindicate the human rights of people with mental illness and for the reduction in the percentage of the health budget spent on mental health and calls on the Government to immediately bring forward a comprehensive package of measures, including appropriate finances, to provide:
– a comprehensive, needs-based, service-user-led review of the mental health care services, promptly and fully implemented, ensuring that they meet international human rights standards and best practice in line with the World Health Organisation 2001 annual report, with an emphasis on community-based care;
– regular quality research in all areas of mental health care needs and service provision, an essential prerequisite for the development of a quality service;
– full financial provision for all areas of mental health care;
– all necessary resources and assistance for the Mental Health Commission in its securing adequate care and conditions for people with mental illness;
– effective action on all relevant recommendations made in the reports of international treaty-based committees, annual reports of the Inspector of Mental Hospitals, and Government reviews and reports;
– a comprehensive system of personal advocacy and an effective complaints procedure to ensure that people with mental illness are assisted in exercising the full range of their rights;
– specialised mental health care for all who need it, including children, the homeless, prisoners, people with other forms of disability, Travellers, asylum seekers and refugees, and other minority or vulnerable groups;
– a public education and awareness campaign to counter the stigma of mental illness, emphasising the rights of people with mental illness; and
– rights-based disability and mental health legislation to give full effect to its international human rights obligations, with due regard to its obligation to enable persons with disabilities to exercise their rights on an equal basis with other citizens.
I welcome the opportunity to introduce this motion and welcome the Minister of State and fellow Limerick representative, Deputy O'Malley, who has responsibility for mental health services. Mental health is one of the most neglected areas of the health services. The Minister for Health and Children has chosen to ignore the great stress, pain and suffering caused by the scandalous lack of resources to deliver a semblance of a mental health service.
Society will be judged on how it protects and deals with its weakest members. Surely among the weakest are those with a psychiatric illness. The State practically ignores them and the mental health services are neglected. I will develop this argument in the course of my speech. I ask the Minister of State to deal with the issues rather than, as his civil servants often suggest, give us a history lesson.
John Saunders, director of Schizophrenia Ireland, has stated:
Mental health care services are in crisis, characterised by decreasing funding, inequitable distribution of resources, antiquated and poorly maintained facilities and poor community support services. This has lead to a situation of low staff morale, insufficient treatment and care programmes and higher involuntary admission rates to hospital.
The internationally respected psychiatrist Professor Anthony Clare stated:
The mentally ill are now the most systematically stigmatised group in our society. They . . . are the lepers of today.
We call on the Dáil to support our motion condemning the Government's neglect of the mental health sector and its failure to vindicate the human rights of people with mental illness. I sincerely welcome the Amnesty International report Mental Health – the Neglected Quarter, which has strongly voiced its concern at the inattention paid by the Government to a series of national and international reports critical of its failure to fully respect the human rights of people with mental illness.
Irish mental health care policy and service provision does not comply with the best practice. This report is one of the most comprehensive investigations and examinations of the mental health services and is a bible for anybody interested in this area. I again congratulate Amnesty International for putting in the time and resources to produce such an excellent report and for making 2003 its year for campaigning for those with a mental illness.
Amnesty International is clear where the responsibility lies. It states that "ultimate responsibility for compliance with international law lies with the Government, not with the individual Government Departments, health boards, Civil Servants or service providers". The House must recognise that the systematic discrimination against people with mental illness is an abuse of their human rights. The United Nations principles for the protection of persons with mental illness and for the improvement of mental health care, known as the M1 principles, were adopted in 1991. These apply to all persons with a mental illness, whether or not in in-patient psychiatric care. They state that all persons with a mental illness, or who are being treated as such persons, shall be treated with humanity and respect for the inherent dignity of the human person and shall have the right to exercise all civil, political, economic, social and cultural rights as recognised by the universal declaration of human rights.
It also provides that all persons have the right to the best available mental care. The Government is failing to provide this. In fact, Amnesty International has identified seven international treaties of which the Government is in breach. It is a disgrace that the human rights of those with mental illness are not being protected as a result of neglect over decades of the need to invest in facilities for those who have mental illness. The Government has failed to introduce a rights based disability Bill, which is the key to ensuring that the rights to which I have referred are implemented by law.
Prior to the last election an unacceptable Bill was introduced which was not rights based. We were informed in the Dáil that a short period of consultation would take place and an amended Bill would be introduced. One year later, on 13 May, the Taoiseach stated in the Dáil, in response to my question, that "It is the view of those who are authorities on this issue that the Education for Persons with Disabilities Bill should be brought forward and passed first". This was repeated today to Deputies Rabbitte and Kenny. This is an affront to our intelligence and is a recipe for burying the Bill indefinitely.
It is fairly well known that the Minister for Justice, Equality and Law Reform, Deputy McDowell, is not in favour of rights based legislation. Such legislation would force the Government to face up to its responsibilities to the 1,711 individuals living at home with intellectual disabilities who require full time residential service, 861 who require a day service and 1,014 who require a respite service and are being denied. The Government should come clean with these people and their carers and tell them the truth.
In general, our treatment of people with disabilities is often at variance with international standards. The UN Committee on Economic, Social and Cultural Rights, in its 2002 concluding observations on Ireland, noted "the persistence of discrimination against persons with physical and mental disabilities, especially in the fields of employment, social security benefits, education and health" and expressed concern that "the principals of non-discrimination and equal access to health facilities and services was not embodied in the recently published national health strategy".
It is a scandal that there are still more that 400 people with intellectual disability living in totally unsuitable conditions in long stay psychiatric hospitals. The inspector for mental hospitals has, over the years, pointed out the inappropriateness of this both for those suffering from an intellectual disability and those suffering from a psychiatric disorder.
We welcome the fact that the number of people in psychiatric hospitals at any one time has plum meted over the decades. In 1958 there were 21,075 in-patients in public psychiatric hospitals compared to about 4,500 at present. This has been largely due to a change in the approach to psychiatric institutions. In previous decades these were often used to overcome social difficulties and some people were in psychiatric institutions who nowadays would have no necessity to be long stay patients.
There was a certain view that once people had a psychiatric illness they were placed in a psychiatric institution and allowed to live out their days in the institution. Medical advances in the psychiatric area, society's greater understanding of the opportunity to treat those suffering from a mental illness and the policies of subsequent Governments to reduce these numbers have brought about the present situation. The reduction in in-patient psychiatric beds was largely due to the death of long stay patients and, to a lesser extent, to the community resettlement of long stay patients.
In the 1980s, the de-institutionalisation occurred with a move from placing people in large psychiatric hospitals to more a community based model of service provision. However, this process has met with some difficulties, with sufficient resources not being made available by the Government to ease the transition to community care. In 2001 the Health Research Board noted that "the number of admissions to psychiatric hospitals and units has changed little over the last 20 years. In all there were 24,282 admissions in the year 2000 and 70% of these were re-admissions. This exemplifies both the enduring or re-occurant nature of much major mental illness and the need for a greater expansion of community based alternatives to long stay hospital care".
In 2001, the World Health Organisation stated that the institutionalisation process had three essential components in preventing inappropriate mental hospital admissions, namely, the provision of community facilities, the discharge to the community of long-term institutional patients who have received adequate preparation and the establishment and maintenance of community support systems for non-institutionalised patients. Institutionalisation in Ireland has failed to live up to this standard. Ireland has excessively high admission rates to psychiatric hospitals, both voluntary and involuntary, due in large part to the lack of community-based alternatives. There is a shortage of acute beds for those in need of emergency admission due to inappropriate non-acute admissions of those who do not require emergency in-patient care because of the lack of appropriate alternative services.
The 1984 strategy, Planning for the Future, lists seven components of community care which are broadly similar to the WHO specifications. These include prevention and early identification, assessment and diagnostic treatment centres, in-patient care, day care, out-patient care, community-based residence and rehabilitation and training. The Minister must accept it is a disgrace that, almost 20 years after the publication of the strategy, none of these have been adequately provided. I call on him to immediately commence a comprehensive review of the mental health care services to ensure they meet the international human rights standards and those of best professional practice.
Fine Gael's programme, Health of the Nation, states that there is overwhelming evidence that psychiatric services concentrating on rapid response community settings are superior to more conventional services. It is Fine Gael policy to introduce a community-based early intervention service to provide a rapid response for patients with mental illness. This service will see patients in their houses, and other appropriated settings, including general practices, the community base, day centres, or, relatively rarely, hospitals. This will be styled on the hospice home service. The team will be multi-disciplinary including senior psychiatrists, psychiatric nurses, social workers, psychologists, and occupational therapists. The overall philosophy is to try to treat all mental disorders outside hospital in the first instance, with particular emphasis on joint working with other agencies.
While many people with mental illness will be best served by community-based care, for others admission to acute in-patient care is necessary and is the best available mental health care required by international law. In Ireland there is a shortage of psychiatric beds for acute admissions with the result that many are left waiting for the care they need or people in hospital are inappropriately moved. Mr. John Dolan of the Disability Federation of Ireland has stated:
People with mental illness continue to live in acute beds in mental hospitals for no reasons other than the lack of suitable accommodation for them in the community. People are remaining in long stay institutional care for far longer than they require. We continued to abandon people with mental illness in unsuitable and inappropriate institutions.
The 2001 report of the Inspector of Mental Hospitals, published in 2002, highlights that, in particular, older people, people with alcohol problems and homelessness are remaining in institutional care for longer than they require. The report states:
Currently close to 46% of persons in psychiatric units in hospitals are over 65 and in some instances, particularly among the long stay patients, this figure exceeds 50%. Many, but not all, of these older persons now show little sign of behavioural disturbance related to psychiatric disorder and, among the more elderly of them, in particular, their needs and disabilities relate to their age rather than to any psychiatric disorder. Their continued residence in long stay psychiatric facilities is neither appropriate nor best suited to their needs.
The report details a catalogue of substandard hospitals and units, overcrowding and poor living conditions and a failure to comply with the United Nations principles which provide for the right to privacy in patient care. The majority of patients interviewed by the inspector complained of a lack of privacy.
The report highlights a number of concerns. The physical health examination of in-patients, as documented in in-patients records, was often infrequent, desultory and superficial in nature. Given that psychiatric patients are known to enjoy poorer health and have higher mortality than the general population, it is particularly important that this be addressed, especially for long-stay patients in psychiatric hospital or community residence. The occurrence of sudden deaths in psychiatric in-patients due to asphyxia from the inhalation of food or other material, mainly in older patients, reveals a need to train staff in appropriate procedures in cases of foreign body airway obstruction and to provide the care necessary in feeding many older, feeble patients with poor swallowing capacity. Suicides among psychiatric patients at local level are not the subject of any formal audit, and there is a need for local services carefully to audit cases of suicide so that lessons may be learned to make risk assessment and management more potent and effective in the future.
I call on the Minister to immediately address these matters of concern to the inspector. Many of the long-stay institutions were constructed in the middle 1800s and many are totally inappropriate for modern day hospital standards and would be considered a national scandal if general hospital patients were being treated in such conditions. These substandard conditions are both an affront to the dignity of the patients and the working conditions of the staff. They are symbolic of a different era.
All psychiatric institutions in a poor state of repair should be closed down where practicable or refurbished where not. These should be replaced by modern purpose-built hostels for long-stay patients. Acute psychiatric units should be provided in general hospitals for patients in need of acute, short-stay treatment, or similar. Modern special secure facilities should be provided for the relatively small number of long-term, severely-disturbed patients. These changes should include the segregation of younger patients, functional psychotic patients and patients with intellectual disability so they do not share the same ward.
As many as 18% of the child population under the age of 16 will experience significant mental health problems at some period of their development, yet services in Ireland for them are very few. They are difficult to access and there are long waiting lists. The Royal College of Psychiatrists has noted that the lack of dedicated adolescent services reduces the child service ability to treat younger children so that waiting lists for child psychiatry services are lengthened further by the need to respond urgently to adolescents.
Many of the child psychiatric teams currently in place throughout the country do not have the full complement of team members. Psychiatric disorders increase in incidence and prevalence during adolescent years. The incidence and prevalence of deliberate self-harm and attempted suicide also increase with increasing age through the adolescent phase. Epidemiology studies show that psychological disturbance of varying intensity exists in up to 20% of adolescents, yet it is a disgrace that there is a lack of dedicated adolescent psychiatric services. Most areas are seriously short of adolescent psychiatric facilities and in some there are none at all. It is also a disgrace, as I said earlier, that children with mental health needs are placed in psychiatric hospitals. The Government must immediately recognise the difficulties experienced and redirect the lives of children with, or at risk of, mental illness with a comprehensive provision of dedicated mental care services, particularly given the relationship between mental illness and other life difficulties such as homelessness and poverty.
Information on the prevalence of mental illness, and the mental health care needs of Ireland's homeless, and research into appropriate effective responses is very limited. Policy makers and advocacy bodies must consequently operate on estimates and various sources put the proportion of Ireland's homeless suffering from a mental illness at between 30% and 50%. The Government has provided very few specialised mental health teams and outreach services dedicated to this population. Given that the community care services for the homeless are so deficient, with a particular shortage of community-based residential care accommodation, high numbers of people with mental health problems are becoming homeless.
In the European context Ireland is exceptional in the underdeveloped nature of its service to mentally ill people who are homeless. In particular, supported housing is a neglected and under-provided area in Ireland. Additional difficulties exist for homeless people in accessing medical care due to the sectorisation of psychiatric services into catchment areas, introduced on foot of the 1984 Government strategy Planning for the Future which is inappropriate to the needs of the homeless. Strictly speaking, homeless people in need of mental health care should return to their previous place of residence effectively leaving many of them without a service. It is obvious that a system, which operates on the basis of place of residence excludes the homeless. The Government must immediately and adequately address the high level of mental illness in Ireland's homeless population.
Many homeless people remain in hospital over long periods of time. The inspector of mental hospitals in his recent report stated "time and again the inspectorate has been struck by the number of current psychiatric in-patients who are homeless and are accommodated in acute or long stay hospital wards despite being suitable for community residential placement". In its report Health Plan for the Nation, Fine Gael states:
The practice of discharging those treated for mental health who are homeless back on the streets will be addressed. Each health authority will provide specialised hostel accommodation for three months for homeless patients discharged from mental institutions.
The abysmal failure to build adequate and appropriate community psychiatric and psychological services for the mentally ill and unwell people in prison has resulted in mental illness becoming criminalised. People who urgently need medical attention go unnoticed in society and are left unattended for years. Many become homeless. Some die by suicide. Others end up in prison. The Irish Penal Reform Trust estimates that almost 40% of the prison population may be suffering from some level of psychiatric or psychological illness or disturbance. The prison environment is detrimental to their mental health. To say there is inadequate psychiatric and psychological treatment in prisons is the understatement of the year.
The mental health service in our prisons can best be summed up by the use of the strip or padded cell. These cells are small, empty, furnished only with a thin mattress on the ground and a blanket. The prisoner is often left naked and at most with an underpants or night dress. The windows are sealed, thus the cells are inevitably stuffy. If there is a slopping out bucket, it is very smelly. Some prisoners are locked up for 24 hours. These are usually people who are suicidal. Prison records show that 78% of those detained in padded cells are detained for mental health reasons while just 13% are so detained for punishment. Dr. Valerie Bresnihan of the Irish Penal Reform Trust has stated that "to use these cells as a substitute for appropriate medical services is scandalous. Most of all it is an absolute denial of human rights". Dr. Smith of the Central Mental Hospital has stated that the gross overuse of the padded cell for psychiatric disability "is a grotesque way of storing a human being". If I had the time I could give the Minister of State numerous examples of people with mental difficulties who are in padded cells for up to 18 days. In one case the person was in a padded cell for 25 days out of 30 in solitary confinement when international research shows that after three days there is a psychological difficulty with confinement.
The results of a survey of psychiatric services in Ireland, conducted by the Psychiatric Association which was published in March of this year, indicated that psychiatric resources are already overstretched and, rather than being concentrated in areas of greatest need, have paradoxically been developed in areas of greatest affluence. The absence of an up to date national mental health strategy for developing the service is one of the main causes of current inequities in resource distribution. The Psychiatric Association states that the lack of a national strategy has also led to a situation where there is a very limited availability of specialist services. There is an urgent need for forward planning of mental health services in Ireland to avoid ad hoc and inequitable distribution of resources.
Rather than resources concentrating in areas of most need, this survey found that the reverse is true. The number of beds per head of population is widely accepted as a reliable index of medical resources. This survey found that resources were concentrated in the most privileged rather than the most deprived areas. This inequity was most marked in Dublin but was true for the country generally. The survey also found that the number of consultants relative to population levels was significantly reduced in areas with the highest levels of social deprivation, more significantly, the number of temporary, relative to permanent, consultant appointments was greater in deprived areas. Basic specialist services were generally not available outside Dublin and availability within Dublin is based on geographical proximity to special services. There is no neuropsychiatry service available to Irish patients with psychiatric disorders with the result that individuals with brain injury, brain disease or those with a psychiatric disorder as a result of a neurological disease do not receive specialist treatment.
Public services for those suffering from eating disorders are largely restricted to those in the east coast area health board in Dublin. Fine Gael's Health Plan for the Nation states that the need of this group must be recognised. It is Fine Gael policy to train people in the management of eating disorders in each health authority area. A dedicated service should be set up through out-patient and, where necessary, in-patient care.
In the first half of the 1960s, an average of 64 people died by suicide per annum. In the past five years an average of 456 died. In 2002, 451 people took their own lives and about 10,000 attempted suicide. The true figure is higher. If a jumbo jet crashed in Ireland and all the passengers died, the tragic loss would be greeted with horror. An immediate, extensive, and probably expensive, investigation into the circumstances of the accident would be held. The response of the Government to this serious public health issue is to cut the 2003 budget for suicide prevention and research by 40% to €655,000. A total of 379 people were killed on the road last year. Coroners have found that some of these were suicides. This was 72 less than the suicide rate. Yet the contribution to promoting road safety, which is under-funded, is €22 million, 33 times that spent on suicide prevention.
Dr. Connolly, secretary of the Irish Association of Suicidology has stated that "up to 90% of those who take their own life suffer from a psychiatric illness. The introduction of a community-based mental health service will have a considerable effect in reducing levels of suicide and attempted suicide." Finally, as my time is running out, mental health and mental illness are key questions deriving from the value structure of a rapidly expanding modern society like ours. Mental illness is not understood by many, and when a family is touched by one of these illnesses the reaction is often one of stigma, shock and incomprehension. This adds to the suffering both of the victim and the victim's family. Negative attitudes to mental illness need to be addressed. The low level of awareness in the general public of all areas of the service limits the assessing of those in need of the service. The Government should introduce a public awareness campaign through the media on all aspects of mental illness and positive mental health issues.
I wish to draw the Minister of State's attention to the fact that there is no dedicated service for those with personality disorders or with anti-social disorders. It is not appropriate that they are referred to psychiatrists, as they are not mentally ill. Each health authority area should provide a dedicated facility for in-patient and out-patient care staffed with expertise in cognitive psychology and forensic psychiatry-psychology. I commend the motion to the House.
I wish to share my remaining time with Deputies Crawford and Ring.