Dáil Éireann díospóireacht -
Tuesday, 1 Jul 2014

Vol. 846 No. 1

Mental Health Services: Motion [Private Members]

Deputy Caoimhghín Ó Caoláin

I move:

"That Dáil Éireann: notes that:

— mental health is an issue of vital concern to the nation in general and should be of special concern to policy-makers and legislators in particular;

— mental health services must be designed and delivered to aid the recovery of the individual;

— a person-centred approach is vital to the achievement of the best results; and

— the 2013 Annual Report of the Mental Health Commission, published on 25th June, 2014, has highlighted many of the key issues and requirements for action by Government; affirms:

— its continuing commitment to the implementation in full of A Vision for Change;

— its commendation of the work of the Mental Health Commission;

— its support for the work of the National Office for Suicide Prevention;

— its appreciation of those non-Governmental organisations, national, regional and local who actively promote positive mental health and seek to reduce the incidence of suicide and self-harm;

— its commitment to eliminate the stigma in relation to mental illness; and

— that the mental health of each citizen and of the nation as a whole is a positive resource that contributes to our general social, cultural and economic well-being; and calls on the Government to:

— ensure a consistent high standard of care and support for all requiring access to mental health services;

— provide for independent monitoring of the roll-out and progress towards full implementation of A Vision for Change;

— commit to an annual allocation of €35 million for the development of community mental health teams and to make good any shortfall in any given year in the subsequent year's allocation;

— properly resource mental health services across the board, including the provision of appropriate and adequate staffing and with a key focus always on recovery;

— promote awareness of the unacceptability of certain practices and continue to discourage their use e.g. the application of electroconvulsive therapy on detained persons against their will;

— end the practice of admitting children to adult psychiatric units;

— progress relevant legislative undertakings including completing the ongoing review of the Mental Health Act 2001 and to bring the Assisted Decision-Making (Capacity) Bill 2013 through Committee and remaining stages;

— require the Health Research Board to again carry out a national survey of psychological well-being and distress, last carried out in 2005-2006, and to continue to conduct such a survey at regular two or three yearly intervals;

— ensure a cross-Departmental response to the risk of suicide and self-harm, including from the Departments of Health, Education and Skills, Children and Youth Affairs and Environment, Community and Local Government;

— provide the necessary resources to establish and sustain a 24/7 crisis support service for people experiencing severe mental or emotional distress, to operate in conjunction with the local Community Mental Health Teams;

— arrange for greater co-ordination of all existing suicide prevention initiatives across all sectors and groups working in the area;

— ensure the prioritisation of address of the mental health needs of marginalised communities;

— guarantee that the new National Strategic Framework for Suicide Prevention will place mental health awareness among children and young people at the top of its programme; and

— provide an appropriate accessible alternative to general Accident and Emergency department presentation to victims of self-harm."

Molaim an rún ar son Theachtaí Dála Shinn Féin, rún tábhachtach atá dírithe ar shláinte intinne agus tá sé mar aidhm aige an Rialtas, an tOireachtas agus an pobal i gcoitinne a spreagadh chun go mbeidh sláinte intinne mar fhíor-thosaíocht againn.

We in Sinn Féin have chosen to return to the theme of mental health and suicide prevention for our final Private Members' time debate in advance of the Dáil summer recess. We think it is vital to focus again on these fundamental aspects of public health in Ireland. These issues are of vital concern to the nation in general and should be of special concern to us as policy-makers and legislators.

The motion is timely in that it comes immediately in the wake of the latest annual report of the Mental Health Commission. Some of the findings of the report are alarming. The report of the Mental Health Commission shows that only 44% of psychiatric hospitals and mental health facilities are compliant with staffing level regulations. The report also makes clear that since 2007, staffing in mental health services has been reduced by the implementation of recruitment embargoes and employment moratoriums.

The authors of the report pull no punches when they state that such policies are endangering the delivery of confident and responsive community-based services as envisaged in A Vision for Change, the Government's mental health strategy. It is also of huge concern that the commission reports that children are still being admitted to adult units. There were 91 such admissions in 2013, which represented 22.3% of all child admissions that year. These are some of the highlights of the report to which I will return in a moment.

In most cases motions such as this, tabled in Opposition Private Members' time, come in the form of indictments of Government failures, and in most, cases, deservedly so. There is more than ample material to take such an approach. However, in this case we have taken a different approach, recognising where progress has been made and encouraging, prompting and pushing for improvement and progress at all times. This is the outlook of the Oireachtas all-party mental health group and one we are continuing in this debate.

It was all the more disappointing therefore to find this afternoon that the Government had decided to table an amendment to this motion. It is my earnest wish that we not only continue but that we build on the spirit of interparty co-operation and working together on these issues, and I will therefore proceed with the all-party approach that I have intended from the outset. I appeal to all Deputies to support our motion as tabled. I also appeal to the Minister of State, Deputy White, on behalf of his colleague, the Minister of State with responsibility for mental health, Deputy Kathleen Lynch, to whom I send good wishes this evening as she is hospitalised and will not be able to participate or attend over these days. We will identify both the positives and the negatives, and endeavour to be constructive.

Fundamental change in the care of mental illness has been undertaken. Guided by A Vision for Change, it is a very significant, but, regrettably to date, a long-term project. It requires maximum support to ensure that it proceeds apace and that it is not allowed to stall as has happened too often in recent years. That is very much the purpose of this motion and this debate. It is to give a further push to a stalled process and to refocus on the needs and rights of those who use our mental health services.

The Mental Health Commission report acknowledges that there have been "significant improvements in many areas of patient care" since the passage of the Mental Health Act 2001 and the subsequent establishment of the commission. It is positive that, as the commission states, there is considerable commitment to the policy of A Vision for Change. However, the reality is also that the policy is being implemented unevenly and inconsistently across the country, and the commission identifies the requirement for innovative actions to be supported and reinforced by strong corporate governance at national level. This requirement hopefully will be fully addressed following the welcome appointment in 2013 of the director of mental health services and the creation of the national mental health service management team.

As our motion states there needs to be independent monitoring of the roll-out and progress towards full implementation of A Vision for Change. Regarding the focus on recovery there are two sides to the coin. The commission finds that the concept of recovery, where services are designed to assist in a person's recovery rather than to manage his or her illness, is now well understood. It welcomes the continuing development of the systematic initiative "Advancing Recovery in Ireland" by the HSE.

It is also the case, however, that implementation is uneven. The report points to "a serious deficiency in the development and provision of recovery-oriented mental health services". It identifies the absence of psychology, social work, occupational and other multidisciplinary team members. It calls for a change in attitudes and behaviours and for training in recovery competencies.

As our motion states, mental health services must be designed and delivered to aid the recovery of the individual and a person-centred approach is vital to the achievement of the best results. It is people who deliver mental health services. Visions, plans, systems are nothing without dedicated trained personnel to implement them. Adequate staffing is the biggest deficit in our mental health services.

To recognise the positives first, it is positive that 652 staff have been appointed in community mental health teams in the past two years. As the NGO, Mental Health Reform, states, this has the potential to transform the type of mental health care people receive to a more holistic approach, since the new appointments are resulting in more input from a range of disciplines including psychology, social work and occupational therapy. However, as the Mental Health Commission reports, the input of the latter professionals is still too limited. The commission's findings on staff levels and the adverse effects of the recruitment embargo is the most worrying aspect of its report. I have already noted its finding that only 44% of psychiatric hospitals and mental health facilities are compliant with staffing level regulations. It goes further and states:

Since 2007, staffing in mental health services has been reduced by the implementation of recruitment embargoes and employment moratoriums... The medium and long term effect of such policies is to endanger the delivery of confident and responsive community-based services as envisaged in A Vision for Change.

At the end of December 2013 the overall staffing level for community mental health teams was still about 25% less than recommended in A Vision for Change.

Unquestionably, this points to the need for continued and enhanced investment. I cannot emphasise enough the importance of that part of the motion which addresses staffing. Sinn Féin calls on the Government to commit to an annual allocation of €35 million for the development of community mental health teams, to make good in the subsequent year’s allocation any shortfall in any given year and to resource mental health services properly across the board, including the provision of appropriate and adequate staffing and with a key focus always on recovery. This is the outcome all Members seek and they must have a shared determination in this Oireachtas to achieve it.

I will now address some other key elements of the motion. The Government must promote awareness of the unacceptability of certain practices and must continue to discourage their use. The prime example is the application of electroconvulsive therapy, ECT, on detained persons against their will. The Mental Health Commission report expresses continuing concern at this practice. In 2011, a code of practice under the Mental Health Act 2001 came into effect and stated “no child under 18 years is to be admitted to an adult unit in an approved centre from 1st December 2011”. Although this was only to be breached in exceptional circumstances, in 2013 there were 91 such admissions. While this was a decrease on 2012, it is still not acceptable and the practice needs to end. Relevant legislative undertakings should be progressed, including completing the ongoing review of the Mental Health Act 2001 and to bring the Assisted Decision-Making (Capacity) Bill 2013 through Committee and Remaining Stages. The last survey of psychological well-being and distress was carried out in 2005 and 2006 and Sinn Féin believes it is time for the Health Research Board to carry out another such survey and to proceed to do the same at regular two or three yearly intervals.

All Members are conscious of the continuing toll of suicide and self-harm, especially but by no means exclusively among young people. The work of the National Office for Suicide Prevention is to be highly commended. Members need to ensure a cross-departmental response to the risk of suicide and self-harm, including from the Departments of Health, Education and Skills, Children and Youth Affairs and the Environment, Community and Local Government. It is crucial that a 24-7 crisis support service for people experiencing severe mental or emotional distress is put in place and is properly resourced and sustained. It frankly is an insult to expect that such emergency support can be provided on an office hours or even part-time basis.

The following quotes from public meetings organised by Mental Health Reform speak for themselves. They are the views and the expressed opinion of service users in this respect. The first is, "We need a system to bypass A&E ... Admissions in A&E are not working - it comes up time and time again - waiting around". Another user stated "Last time I was in A&E I was there for hours and started getting paranoid that people were talking about me". A third stated:

They need to change the environment [of accident and emergency] to make it more friendly for people in distress. All it does is compound their difficulties.

The final quote is, "When you are sick with a mental health difficulty, you can’t wait until 8 or 9 in the morning for a doctor to show up or for a certain place to open". An alternative to general accident and emergency presentation for those who self-harm and a 24-7 crisis support service in conjunction with local community mental health teams are what is required, in line with A Vision for Change. There also must be greater co-ordination of all existing suicide prevention initiatives across all sectors and groups working in the area.

Marginalised communities often have more acute and more particular mental health needs. Indeed, the treatment of some sectors of society by this State is undoubtedly damaging the mental health of many individuals. I need only cite the disgraceful conditions - the Minister of State has heard this issue referred to in this Chamber many times - in which people are detained in so-called direct provision centres. This, I believe, is creating a legacy of mental and physical illness, especially for the children held in these centres, in some instances for many years. The Government must guarantee that the new national strategic framework for suicide prevention will place mental health awareness among children and young people at the top of its programme.

I pay tribute to the work of Mental Health Reform, which has been of invaluable support to the Oireachtas cross-party mental health group. I thank in particular Dr. Shari McDaid and Ms Lara Kelly. I also acknowledge the work of Amnesty International, which previously provided secretarial support to the cross-party group. I also pay tribute to my colleague Members of the aforementioned all-party group. Each party participates in common pursuit of good outcomes and improved services right across this area. Sinn Féin's motion also commends the work of the Mental Health Commission, the National Office for Suicide Prevention and those non-governmental organisations, national, regional and local, that actively promote positive mental health and seek to reduce the incidence of suicide and self-harm. The funding supports of those organisations need to be restored at the very least. The reduction in core funding year on year since 2009 has placed serious pressure on their work, while demand on their services certainly is increasing. At this point, I will take the opportunity to acknowledge the presence in the Gallery of a small number of people from those organisations. I believe Members will be joined by an even larger body in the course of the debate tomorrow evening.

Much has been done in recent years to educate our society about mental health. Tribute should be paid above all to those who have experienced mental illness and who have used that experience to help right the wrongs in a society which for decades stigmatised, criminalised and institutionalised those with mental illness. Hopefully, those attitudes and practices have receded into the past. However, much more remains to be done. We must see the mental health of each citizen and of the nation as a whole as a positive resource that contributes to our general social, cultural and economic well-being.

I will conclude by quoting from the World Health Organization, which in 2007 stated:

Mental health is an indivisible part of public health and significantly affects countries and their human, social and economic capital. Mental health is not merely the absence of mental disorders or symptoms but also a resource supporting overall well-being and productivity. Positive mental health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and can contribute to his or her community.

In my last few words, I wish to express my hope that in the course of the Minister of State's contribution this evening, he will signal that Members will conclude this debate tomorrow night with one voice, una voce, on this most important issue and that Members can collectively and unanimously endorse the motion as tabled.

Acting Chairman (Deputy Marcella Corcoran Kennedy)

I understand the Deputy is sharing time with some of his colleagues. Is that agreed? Agreed.

Deputy Pádraig Mac Lochlainn

I commend this motion as for too many years, the whole area of mental health has been the Cinderella of the health service. Over the years while growing up and in common with many people, when visiting different towns I wondered what was this big house or what was the history of that big building. One often was told that it was the psychiatric hospital, which was where people were put out of the way. We lost our humanity somewhere along the way. In ancient civilisations such as, for example, in Roman times, if one visited a friend who was suffering from mental health issues, they had a phrase that the person was in Saturn. It was understood that such people were taking time out. They might be going for a walk or writing poetry. They were taking time out. Their family and friends supported them and they would be back again when they were ready. This was fully understood and the same applied in our ancient Celtic civilisation. Throughout all of history and in all the various civilisations, records exist of support being available when mental health issues arose.

In the industrial era people became units of profits and labour and we lost our humanity. If people did not show up for work, they were not paid and could not pay their bills. They were expected to toughen up and get on with it. We are supposed to have come a long way, learned lessons and adopted a community-centred approach. This motion is important because the supports required at community level - the key personnel who must be appointed to perform vital functions - are not in place.

Like my colleague, Deputy Ó Caoláin, I commend the individuals, community groups and non-governmental organisations in civic society that have filled the gap. They have, for example, developed strategies on suicide prevention, introduced supports and provided the infrastructure the Government and its predecessors have failed to establish. We have heard much rhetoric and many commitments and promises have been made, but none has been delivered. It was remarkable that, until recently, there were delays in filling almost every key post dealing with mental health supports in County Donegal. Not all of these delays can be blamed on the moratorium on public sector recruitment. Those providing front-line psychiatric services are extremely critical of the delivery of services, especially the slow pace involved.

A national campaign is required on suicide awareness, similar to the successful campaigns on road safety. We need to see people telling their stories. In addition, supports must be provided on the ground.

Every Member of the Oireachtas will have known someone who has taken his or her life. In some cases, they will have been people we loved and we did not see the signs. As with deaths from road traffic collisions, not every case of suicide can be prevented, regardless of what one does. Nevertheless, the number of deaths by suicide could be significantly reduced if supports were provided in communities. We must meet people halfway. I refer to the fantastic individuals across the State who spend an unbelievable amount of time working on this issue. They will deliver volunteer hours if they are provided with the supports they need. Every Deputy could tell stories about dynamic projects in their constituencies. In County Donegal, for example, we have youth mental health projects that have been developed and are led by young people.

The motion before us is a call to action that is necessary because we have had too many unfulfilled promises. We hope the Government can deliver resources in communities to show that Ireland has genuinely moved forward from the dark days of the big house on the hill where we locked away those we were ashamed of and failed to show decency or compassion. If we are to demonstrate that we have learned from the past and moved on, we must invest resources to match the fine words and plans that have been laid out.

Deputy Michael Colreavy

I am disappointed that the Government proposes to introduce an amendment to the motion. The vision and steps set out in the text we have introduced should have enjoyed the support of every Deputy in the House.

In 2011, RTE performed a valuable public service when it broadcast a two-part documentary, "Behind the Walls", which investigated the history of Ireland's psychiatric services. Made by the eminent investigative journalist, the late Mary Raftery, the programme examined how people who suffered from mental health problems have been treated by the State. It made for grim viewing as it showed a culture of institutionalisation. The patients who came under the care of the State suffered greatly. They were branded as lunatics and locked away. At one stage, Ireland had the highest number of people locked up in mental institutions per head of population of any country. As legislators, it is our duty to ensure the mental health of citizens is given the consideration it deserves. We owe this debt to today's citizens and those whom the State let down since its formation.

It is essential that our mental health facilities are adequately staffed to sufficient levels. A report published last week by the Mental Health Commission shows that only 44% of psychiatric hospitals and mental health facilities are compliant with staffing level regulations. Staffing levels for community health teams are 25% below those recommended in A Vision for Change. If one does not adequately staff services, patients suffer the consequences, as does the State. We need more than reports; we need political commitment, proper funding and action.

Suicide is an issue that must be tackled in a careful, considered manner. Sligo-Leitrim, the area I have the privilege to represent, has all too often witnessed the awful, hopeless legacy left in the wake of suicide, especially of young people. The issue must be addressed by means of a national, cross-departmental, co-ordinated approach. A key priority for suicide prevention is the development of an adequate 24-hour crisis support service for people experiencing severe mental or emotional distress.

I am delighted that 24-hour, community-based mental health services are being developed in north County Leitrim. While magnificent progress is being made in the area, I will monitor developments to ensure the necessary and desirable mental health service developments are not allowed to wither and die owing to a lack of adequate resources.

Crisis housing with adequate support services must be made available to those suffering a mental health crisis because hospitalisation and community-based services sometimes need to be complemented by housing for people with particular problems. Existing suicide prevention initiatives must be co-ordinated in order that members of the public know where to turn for advice.

Suicide services must be able to provide for minority groups such as black and minority ethnic communities, the Traveller community and homeless people. These communities often contain vulnerable people and are at greater risk of suicide and self-harm. Young people and children must be catered for also. We are often accused of not listening to the voices of the young and this is an area in which we must not fail them.

Community voluntary organisations in mental health services make an invaluable contribution to suicide prevention and support. The potential of these organisations is not being fully realised because statutory bodies will instinctively ring-fence whatever diminishing resources are available for statutory services. I have in mind the example of the Bill W Club in Sligo which provided 24-hour care for 365 days of the year for vulnerable people with various mental health issues and addictions. The club recently lost its modest Health Service Executive grant of approximately €55,000 on the somewhat spurious ground that its policies and procedures were not up to scratch. Instead of supporting these untrained, volunteer workers, the HSE withdrew the small grant available to their organisation. To whom will the vulnerable people who were helped so much by the Bill W Club now turn at midnight on a lonely bank holiday?

Deputy Jonathan O'Brien

I commend Deputy Ó Caoláin on tabling the motion. I hope that over the course of tonight and tomorrow night, we will reach cross-party consensus on prioritising the area of mental health and suicide prevention.

For many years, there was great stigma attached to mental health and while the position has improved in recent years, the stigma is only beginning to lift. This development can be attributed to the work being done on the ground by individuals, organisations, volunteers and, to give credit where it is due, policy decisions made by the Government.

Some of the initiatives, in terms of the Sea Change initiative, the healthy living campaign and the Green Ribbon campaign, all have certainly been positive contributing factors to lifting the stigma of mental health.

I have met individuals, in my constituency office and in passing at sports clubs and at social events, who are now more openly talking about their own battle with mental health and that is a positive development. The more people who talk about their experiences, particularly those who have come through very difficult times, such as in battling with depression, the better because depression is a huge issue in our communities.

When people talk about mental health and suicide, it is only fair to say that not everybody who has suicidal thoughts suffers with his or her mental health. There are various risk factors for those who contemplate suicide and that is why the part of the motion calling for a cross-departmental approach to tackling mental health is critical. We must tackle unemployment, social disadvantage and educational disadvantage because these all are risk factors for those who contemplate suicide.

We also must look at the associated protective factors, in terms of putting in place the resources, whether through funding, counselling or access 24 hours a day seven days a week to individuals who can help those who are in desperate need of help. These are the protective factors which need the funding and the resources because we must give people the tools to be able to cope with their individual issues. No doubt in times of economic downturn the number of those who are in desperation and who suffer from depression goes on the rise and unless we put in place those types of resources, we are doing them a disservice.

The other area I will touch on briefly is what Deputy Ó Caoláin calls for in his motion in terms of measuring the mental well-being of a nation, and it should be on a par with the physical well-being. No doubt if one is in a good mental and physical state, one is actively contributing to society and more open to getting out there and helping others. I know many who have suffered with their mental health who are now actively helping and encouraging those who are in dire need of help, either due to depression or suffering from a mental health disorder. They are actively encouraging those individuals to seek help. They are pointing them in the right direction.

I compliment the number of community and voluntary groups which are doing outstanding work. In many cases, some would argue there are services which duplicate in some areas and one of the tasks which face us is ensuring that all of those groups providing help and resources are targeting the correct areas and are getting the needed supports, whether from Government, from local government or from us in terms of legislation.

Deputy Peadar Tóibín

Maintaining and creating good mental health is one of the biggest challenges facing individuals, communities and Government in the State. Often, it feels as though the level of suicide, self-directed injury and depression are at epidemic levels and we as Deputies are powerless in the face of it.

Some 330,000 persons in the South of Ireland suffer from depression. There is not a home in this country untouched by depression at some level, whether through family and friends, and it leads to 10,000 hospitalisations in the State. Some 10% of adolescents experience some level of depression.

According to the Mental Health Commission, since 2007 staffing in mental health services has been reduced by the implementation of recruitment embargoes and employment moratoriums. The medium and long-term effect of such policies is to endanger the delivery of confident and responsive community-based services as envisaged in A Vision for Change.

On a number of occasions, I have stood in this Chamber and discussed the emerging two-tier society in which we live. We live in a fractured Ireland. Our country is split in many ways: politically, North-South; economically, east-west; and, increasingly, in the uneven rural-ruban distribution of key health services, including mental health. In Roscommon and Galway, an expert panel found that services were being run to outdated 30-year-old guidelines. It concluded that services in the west were still operating to 1884 guidelines.

A damning report out recently in Meath stated that services for young people in the county receive 90% less funding than the national average. According to voluntary organisations that work in the county, Meath children and their parents wait longer for services than their counterparts in other counties and in some cases, have no access to services at all. The report, Working For Children, commissioned by the Meath Children's Services Committee, found that the national average funding for child services was €22.31 per child, but in Meath the corresponding figure was €2.89 per child or just under 13% of the national average.

Recently, nine doctors wrote to the Minister of State with responsibility for mental health to express their serious concerns about local services in light of nine fatalities in the Carlow-Kilkenny and south Tipperary area. There are also significant problems in the State with the treatment of certain demographic cohorts. The level of Irish youth suicide is the fourth highest is the European Union and large numbers of children are continually being placed in adult psychiatric units, with children as young as ten being placed in wards with adults aged 30 and upwards because of the lack of out-of-hours emergency services.

This week, approximately ten persons will commit suicide. Eight of these will be men. Male suicides are much more prolific in rural areas, with those working in the area of construction making up 41% of male suicides and those working in agricultural services accounting for 13%. This level of outcome skewed on a gender basis is outrageous and needs to be tackled.

There is a broad range of complex contributing factors that may increase a person's risk of developing mental health problems. Many of these are not in the ability of any government to resolve. However, the Government, with good policy decisions and funds, can ameliorate indirectly other areas of risk, such as exposure to toxins, drugs or alcohol during pregnancy, financial problems, cultural issues, use of illegal drugs and neglect of children. Directly, the Government can make a radical difference through the proper funding and staffing of diagnosis and treatment services.

There are few good news items in this, but statistics tell us that of those with mental health issues who find treatment and diagnosis, 80% will benefit from this treatment. There is a significant lack of after-care facilities in many of the areas worst hit despite the importance of after-care services in dealing with this issue as those who have tried to commit suicide often attempt to do so again. It is only such after-care services that can help with that.

I appeal to the Government to support the motion and do all within its power to resolve this issue.

Deputy Gerry Adams

Last week, I raised the revelations on RTE that senior doctors cited nine suicides in mental health service users in the Carlow-Kilkenny and south Tipperary area between August 2011 and January 2013. This tragic development has highlighted the problem with the mental health services. I also raised the lack of out-of-hours services which contributed to 90 admissions of children to adult inpatient units last year.

The CEO of the Children's Rights Alliance says that this issue is a clear breach of children's rights. It must be tackled as a matter of extreme urgency.

The report of the Inspectorate of Mental Health Services has stated that hundreds of psychiatric patients who moved out of mental hospitals in recent decades are living in unsuitable conditions with limited access to health or care professionals. Since 2007, staffing in mental health services has been reduced by the implementation of recruitment embargoes and employment moratoriums. These policies are endangering the delivery of efficient community-based services as envisaged in A Vision for Change, the Government's mental health strategy.

Given the various issues that have arisen in recent weeks, it is clear that there is a crisis in mental health provision. I see that myself in my constituency clinics in Louth and I am sure that every Member of the Oireachtas has had the same experience.

I commend Teachta Ó Caoláin for bringing forward this motion, which seeks to refocus the Oireachtas, public opinion and the Department of Health on mental health and suicide prevention. It stresses the need to implement A Vision for Change by ensuring sufficient resources and a firm political commitment across all parties and by the Government.

We need to be able to measure in a regular and planned way the mental well-being of our society. A key priority for suicide prevention must be the development of adequate 24/7 crisis support services for people experiencing severe mental or emotional distress. That is not currently the case.

An Teachta Ellis has raised the issue of vulnerable young people presenting with serious mental health issues, but who are being turned away from hospitals due to a lack of beds and staff to provide care across the capital. Lives are being put at risk because there are not enough beds and not enough nurses and doctors in place to care for these citizens. They are citizens who, due to their mental health problems, are a danger to themselves and to others, yet they are being turned away. Doctors and nurses are working hard to care for these clients but cannot deal with the volume of people who need their care.

The Government's framework for suicide prevention should prioritise young people, given the clear evidence that early intervention is cost effective. We need to target marginalised groups such as minority ethnic communities, including Travellers among whom the incidence of suicide is much higher, and the homeless. This is not rocket science. It is quite obvious that people who are in difficulties in their lives or who are subject to disadvantage or discrimination will or possibly can experience mental health problems.

These difficulties affect thousands of people across the State. I meet more and more people who have difficulties that require attention. A mentally healthy citizen is a positive resource. We are a small island community and suicide does not recognise the Border, so there needs to be a joined up all-Ireland approach to the hugely important issue of mental health. The good mental health of one person contributes to and supports the overall well-being of society.

I do not see the sense of the Government's amendment. We are not in disagreement here and we support A Vision for Change. I would like to think, as Teachta Tóibín said earlier, that the Government will support the Sinn Féin motion. Having done that, we will then need action and implementation. I commend the motion to all Deputies.

An Leas-Cheann Comhairle

I call the Minister for Health to move amendment No. 1.

Minister for Health (Deputy James Reilly)

No, I will not be moving any amendment. Earlier today, I discussed this motion with Deputy Ó Caoláin and the Government has agreed to accept it. It is very closely aligned with our own policy and we see no reason to divide the House.

Deputy Caoimhghín Ó Caoláin

I thank the Minister and welcome that decision.

Deputy James Reilly

I thank the Deputy for raising this matter on Private Members' business. It is an issue of serious concern to all of us.

I wish to share time with Deputy Anthony Lawlor and Deputy Mary Mitchell O'Connor.

An Leas-Cheann Comhairle

Is that agreed? Agreed.

Deputy James Reilly

I am pleased to have an opportunity to debate in the House the important issues of mental health policy and services. Mental health and well-being, just as with physical health, are relevant to each and every person in our society. Members will be well acquainted with the complex and sensitive issues that arise where this subject is under discussion.

There has been, and remains, strong cross-party support for A Vision for Change, which was published in 2006. The motion reflects that. This Government has brought a strong and determined focus to the reform and development of our mental health services and we are committed to sustaining this into the future. I would like in particular to acknowledge the determination and commitment which my colleague, the Minister of State, Deputy Kathleen Lynch, has brought to her role as Minister with responsibility in this area since 2011. I want to assure Deputies that she would have been here for this debate had it been physically possible for her. However, she is indisposed following a procedure in hospital.

There is much in the Private Members' motion before the House which is closely aligned with the direction of travel as regards the delivery and reform of our mental health services. I will outline for the House what the current key objectives are and why a sustained commitment will be required for a number of years yet.

In 2006, A Vision for Change was widely welcomed as a progressive, evidence-based and realistic policy document that proposed a new model of service delivery which would be patient-centred, flexible and community-led. Much progress has been made in closing many of the old psychiatric hospitals and providing modern acute inpatient as well as community-based facilities and services.

We have therefore been moving away from the old institutional system of mental health service delivery towards comprehensive care in a variety of settings, including the home, community and in hospital. This common objective requires a change in attitudes generally towards mental health, especially in eliminating the unwarranted stigma that has caused so much pain in the past, as well as prioritising limited resources.

Although implementation of A Vision for Change has been affected by a number of factors, including the changed economic context, constraints in public spending and the moratorium on recruitment, the Government remains firmly committed to reform of our mental health services. This is in line with our clear programme for Government commitment to implement this widely agreed policy, reducing the stigma of mental illness, ensuring early and appropriate intervention and improving access to modern mental health services in the community.

It is in all our interests that we address this issue. Nobody in this House knows just how strong their mental health is until it is tested to breaking point and then it is too late.

A great deal of progress has been made with the accelerated closure of old psychiatric hospitals and the development of bespoke new facilities to support the community-based, recovery-focussed model of care recommended in A Vision for Change. A total of 19 old psychiatric hospitals across the four HSE regions have either closed completely or have closed to new admissions. Closure plans are in place for the remaining old hospitals. However, no closure will take place until the clinical needs of the remaining patients have been addressed in more appropriate community-based settings, in a planned way, and in consultation with them and their families.

Progress also includes the development of child and adolescent or CAMHS services, shorter episodes of inpatient care, the adoption of a recovery approach in delivering services, and the involvement of service users in all aspects of mental health policy, planning and delivery.

Similar to its reports in previous years, the Report of the Inspector of Mental Health Services for 2013 provides a balanced and valuable insight of what has been achieved in mental health and what improvements remain to be effected. None of us would argue with the purpose and objective of these reports, which reflect a realistic picture overall on an annual basis and highlight in an objective way where further work is needed.

While acknowledging that the pace of change towards a modern, patient-centred and recovery-orientated mental health service is slower than desirable, the inspector's 2013 report also highlighted continued progress towards ending the use of outdated and unsuitable buildings for inpatient services and the continued development of CAMHS care.

Last year, following the enactment of the HSE (Governance) Act 2013, I appointed a new directorate to replace the previous HSE board structure. In conjunction with this, the HSE organised the major elements of the services into divisions, each under a national director.

Each national director has responsibility for a defined budget, staffing and other resources and for delivering on specific service targets as specified in the national service plan. The establishment under these arrangements of the HSE mental health services division led by the national director for mental health delivers on a key recommendation of A Vision for Change. This new division carries operational and financial authority, coupled with clearer accountability, for all mental services. We will no longer see money that is put aside for one area being transferred into another area. The budgets will stay within the directorates. The new structure within the HSE has already made a real difference to improving the pace of and clarifying future pathways for developing mental health services.

The HSE national service plan for 2014 commits to a number of key deliverables, including progressing key multi-annual priorities from previous years, implementing access protocols for 16 and 17 year olds to CAMHS and reconfiguring general adult community mental health teams to serve populations of 50,000 each, as recommended in A Vision for Change. As part of the service plan, the HSE has committed to developing an implementation plan for the last three years of A Vision for Change, along with a standard model of care. The national service plan is supported by a detailed HSE mental health division operational plan which sets out how mental health services across all HSE areas will he delivered, following consultation with clinical and administrative staff in each area.

The mental health service is a secondary care service provided in the community and particular emphasis has been placed on the concept of recovery. Access to specialist mental health services is by referral from a GP or primary care practitioner, following assessment of each person's needs. The motion proposes that victims of self-harm should be enabled to present to an appropriate accessible alternative service rather than a standard emergency department. My advice is that such arrangements would not always be clinically appropriate. I note that the Deputy opposite understands this. If by "appropriate" we mean there is no physical or medical risk, we are on the same page. There are specific areas where one would be concerned as a clinician that the diagnosis is not clear on whether the patient has a psychiatric condition or, perhaps, a constitutional condition brought about by a metabolic disorder or, in the case of self-harm, a deep laceration involving tendon and arterial damage that requires extensive resuturing or self-administration of poison requiring stomach wash-out and monitoring, or even renal dialysis. I understand the thrust of the proposal is that, where appropriate, the referral should be to an acute psychiatric centre. Many GPs are skilled in this area and they know their patients. If such a GP is happy that a patient should be referred to an acute psychiatric unit, the patient should not have to endure an emergency department. Sometimes, however, the GP will want the patient to be seen in the emergency department for the reasons I have outlined.

Those with mental illness should have access to the same range of services as the wider community. We must also avoid any stigmatising of individuals who self-harm. Persons who self-harm must therefore first be assessed from a medical perspective to establish whether they have underlying medical conditions which must be taken into account prior to any mental health assessment. The community mental health team is the first line of acute secondary mental health care provision and its presence allows individuals to be supported in their recovery in their own communities. The teams are the primary mechanism for the delivery of community-based mental health care across the full range of mental health services, from child and adolescent, through general adult to psychiatry of old age. These teams provide a range of interventions in a variety of locations, including the service user's home.

The Government has demonstrated its commitment to mental health from the outset. The programme for Government makes a number of commitments on mental health, including ring-fencing annual funding from within the health budget to develop community mental health teams and services. We are also committed to ensuring patients can access mental health services such as psychologists and counsellors in the primary care setting. Early, appropriate and effective intervention is our key message. Since 2011 the Government has delivered on its commitment in these extremely challenging times, where the options for additional expenditure are generally very constrained. A sum of €35 million was made available in 2012, with an equivalent additional amount again in 2013 for new service initiatives. This was augmented by a further €20 million in 2014. This means that, despite serious resource pressures overall, development funding of €90 million has been made available to enhance mental health and suicide prevention. It is the Government's intention that funding for mental health services will continue to be maximised in future years, taking account of evolving resource and health service priorities overall. This will also cover the important area of delivering new infrastructural facilities for the national forensic mental health service. In the context of destigmatising mental health issues, all new primary care centres will be associated with mental health facilities in order that people using these facilities can go in the same door as everyone else.

Our priority capital project in mental health services is replacing the Central Mental Hospital in Dundrum with an appropriate modern facility allied to corresponding development of regional intensive care rehabilitation units. The first phase of the project involves provision of a new 120-bed adult forensic hospital at St. Ita's in Portrane, together with a ten-bed forensic child and adolescent unit and a ten-bed forensic mental health intellectual disability unit on the same site. The project is provided in the agreed HSE capital programme and is proceeding though detailed design and planning stages.

Community mental health teams need to have expertise from all the core disciplines of psychiatry, psychology, social workers, occupational and other therapists, as well as mental health nursing. This must be primarily a people-based multidisciplinary provision. To achieve this end, 1,100 new posts have been funded since 2012, primarily to strengthen community mental health teams for both adults and children and to enhance specialist community services for older people with a mental illness, those with an intellectual disability and mental illness and forensic mental health services in line with A Vision for Change. Some 740 of the 1,100 posts have been filled to date. The recruitment process for the development posts approved in 2012 and 2013 is continuing. Of the 414 posts allocated in 2012, the recruitment process was complete for 395 posts, or 94%, as of the end of May 2014. Of the 477 posts allocated in 2013, the recruitment process was complete for 326 posts or 62%, as at the end of May, with the remaining posts at various stages of the HSE recruitment or approvals process. There are a number of posts for which there are difficulties in identifying suitable candidates due to factors including availability of qualified candidates and geographic location. This is not unique to the mental health services. Options to enable more local recruitment are also being considered where this will assist in filling specific posts. I have received assurances from the HSE that the recruitment process for all new posts is being given priority. A further 250 to 280 development posts have been earmarked for this year. This will add capacity among the required range of health care professionals to deliver the community-based care which is at the heart of A Vision for Change.

Acute inpatient admissions for children and adolescents are prescribed in A Vision for Change as relating to age-appropriate acute inpatient units, which are approved centres registered with the Mental Health Commission. The provision of inpatient beds is integral to the range of services required to meet the needs of young people appropriately. Interventions are provided through community mental health teams in the first instance and, if required, access to relevant inpatient services is provided. The need for inpatient treatment has decreased greatly for both adults and children with modern techniques of counselling and medication. Nationally, bed capacity for children and adolescents has increased from 12 beds in 2007 to 56 at present. In 2008, only 25% of admissions of children to HSE acute inpatient units were considered age appropriate. By 2013 this figure had increased to almost 80% of admissions. While this is still not acceptable or in line with Mental Health Commission regulations which require that all children under 18 should be admitted to age-appropriate acute inpatient facilities except in exceptional circumstances, clearly significant progress is being made on this issue.

The ring-fenced funding allocations provided by the Government since 2012 have allowed for 230 appointments in the area of mental health services for children. Approximately 80% of these are in place, with the remainder being recruited. This is proof of our commitment to improve these vital services. The admission of children and adolescents to age-appropriate CAMHS inpatient facilities reflects best practice and supports better outcomes for the individuals concerned. This is a key priority for the HSE in its service plan for 2014. We have developed a specific quality key performance indicator to ensure the focus remains on meeting that objective.

After A Vision for Change was launched, an independent monitoring group was appointed to oversee implementation of the policy.

This group reached the end of its term in 2012 and A Vision for Change contained a commitment that it would be reviewed after seven years. The current priority, however, is to review the Mental Health Act 2001, after which consideration will be given to reviewing A Vision for Change and determining appropriate monitoring arrangements for any updated or successor policy. In the mean time, the HSE continues to implement the strategy and reports on a monthly basis in line with the performance reporting arrangements in place for the national service plan.

ReachOut, the national strategy for action on suicide prevention for 2005 to 2014, will come to the end of its ten-year term this year. Consequently, at the request of the Minister of State, Deputy Kathleen Lynch, earlier this year my Department and the HSE began work on a new strategic framework for suicide prevention for the period 2015-2018, building on the comprehensive work delivered under the current ReachOut strategy. The aim of the new framework will be to support population health approaches and interventions that will assist in reducing the loss of life through suicide while aiming for improved co-ordination and integration of services and responses in this area. The objective is to have the framework completed by the end of 2014. The work in hand includes consideration of a wide range of national and international evidence and existing good practice, addressing areas such as research, policy, practice improvement, engagement and communications and media. The process also incorporates a review of the implementation of ReachOut, a public consultation process and a review of the evidence base for suicide prevention initiatives. The strategy will be focused on a whole-of-Government approach.

General practitioner and primary care teams are often the first point of contact for a distressed person seeking assistance. The suicide crisis assessment nurse, SCAN, model, which allows for crisis interventions at primary care, is being rolled out this year, with eight new services to commence shortly. This service provides active liaison between primary care and mental health services. Built on a clear evidence base, the SCAN model brings confidence to health practitioners in choosing a care and support pathway for an individual. The locations for this initial phase are north and south Dublin, Waterford, Cork city, Galway, Sligo, Donegal and Laois and Offaly, in addition to an existing service in Wexford.

I acknowledge there is more to be done in developing a focused recovery and person-centred orientation for some patients. The problems and suffering associated with severe mental health problems are complex but there is a growing recognition that with a recovery approach, it is possible to live well despite any limitations caused by disability or illness. Deputies will be aware that on the legislative front this Government has made significant progress with the publication of the Assisted Decision-Making (Capacity) Bill 2013 and the establishment of an expert group to review the Mental Health Act 2001 which is expected to complete its final report in the autumn.

There is much more in the document before me, which was clearly designed to be read in a much longer slot. With regard to electro-convulsive therapy, ECT, we must always remember this treatment has a role which must be protected, and clinicians must be allowed to make a determination when somebody is not compos mentis. If somebody is psychotic, he or she is not in a position to make a value judgment, although the family may have a view, which should always be taken into consideration.

Prevention is better than cure and the launch last week of Healthy Ireland is as much focused on mental health as it is on physical health and well-being. It is important to state clearly that well-being reflects the concept of positive mental health, in which a person can realise his or her own abilities, cope with the normal stresses of life, work productively and fruitfully and be able to make a contribution to his or her community. Healthy Ireland highlights the need to combine our existing mental health promotion programmes with interventions that address broader determinants and social problems as part of a multiagency approach, particularly in areas with high levels of socio-economic deprivation and where fragmentation occurs.

We recognise the need to prioritise the mental health needs of vulnerable groups. As politicians, we hear tragic stories all too often which are directly associated with the economic crash in recent years, and as people have noted, nobody in this House is unaffected by this, with friends and family having suffered. The economic problems have put tremendous pressure on people. I know HSE mental health staff are keenly aware of the need to ensure that where treatment and care is required in these circumstances, it is provided as quickly as possible and in the least restrictive manner possible, consistent with the wishes of the individual. The expansion of our community mental health teams is an important step forward in this regard.

I saw Deputy Adams at the gay pride parade, which I attended last Sunday, and in the course of the events I came across some other information relating to mental health. It indicated that attempted suicide is seven times more common in teenagers who are gay or lesbian. Groups such as this must be supported, with strategies put in place to help them deal with these issues.

I thank the Opposition for raising this very important issue. I accept there is still work to be done but I assure the House of the Government's continuing commitment to implementing A Vision for Change and reforming our mental health services to ensure people can access modern patient-centred and recovery-oriented care.

Deputy Anthony Lawlor

I am grateful to the Opposition for bringing forward tonight's motion, and it is almost an annual debate. It does no harm for us as politicians to highlight the mental health problems that people have, and it is an individual issue for people. Each one of us has at some stage had mental health problems, whether we were aware of it or not. I welcome the opportunity to speak in this debate and I have contributed to similar debates each year. My first Dáil speech was on the topic of suicide, so I am grateful for the opportunity to speak to the issue again.

A Vision for Change was published in 2006 so we should see how we have progressed since. There have been six reports on the strategy, with the first highlighting that nothing had been done since the publication of the strategy. The Government decided to ring-fence €35 million per annum but that was not spent in the first couple of years, although in the past couple of years we have made much more of a commitment, which I welcome. I understand an increased number of staff are on board and it is important that such staff are available.

We should also consider how to change the system. There was an institution-type system in place for hundreds of years but we are moving to a community-based system. That will not happen overnight, no matter how strong the will of the Government or the people. It is difficult to change from being completely institutional to having more of a community base. There is a need for institutional care as well. I was involved in a case where I came across a young man who jumped from a bridge. He got out of an institution and tried to take his own life that day. Two of us were there and we tried to hold him so as to prevent him from going back into the water after we pulled him out. Institutional care rather than community was required in that case. We must be mindful that we cannot put all our eggs into one basket on the community side, as we also need the institutional side.

I will discuss two other issues in my limited time where I have seen major improvements. The first relates to awareness, and it is great to have the debate tonight because it increases the awareness of both mental health and suicide, which are individual issues. I took part in a safeTALK in the Oireachtas and I organised one in my community. I know if I did it again now, I would get a much better response because at the time I tried to organise it through GAA, soccer and rugby clubs. There was very little positive response at the time, and I got a negative response from one club secretary who told me the club did not have that "issue". That indicates how ignorant society can be.

Awareness also comes from other organisations, and I can highlight Pieta House in this regard. The first year I was elected I went on the walk it organises and I decided to bring the idea back to Naas. There were 800 people at the first walk and this year we had almost 5,000 people attending. That is itself a message and creates awareness of the issue of suicide.

Once people are talking about it there is a chance to prevent someone taking his or her own life.

"It's OK not to feel OK" is a good buzz phrase from the sporting community. A friend telephoned me six weeks ago about a friend of hers who was suicidal. She was worried that if she brought him to the hospital he might be let go. The hospital, however, had a psychiatric unit attached to it, which was able to respond quickly. The fear was that the person would leave without having been examined or treated and something might have happened later. My friend told me that six years ago her brother had been in a similar state, had not been cared for or examined and a year later took his own life. We have made some positive changes. We are moving on this issue and that takes time but we have a long way to go. It is not possible to change an institutional system to a community-based one overnight. We have to give ourselves time and have a path. I am delighted that within the HSE there is a pathway for what we are trying to do. We need to keep going on the right road.

Deputy Mary Mitchell O'Connor

Last March the Oireachtas Joint Committee on Health and Children heard several compelling presentations about suicide in Ireland from Pieta House, the National Office for Suicide Prevention and the National Suicide Prevention Foundation, to name a few. Three key messages which emerged were the need for greater awareness raising, communication and co-ordination among different organisations, and eliminating the stigma of mental illness. By this time next week, ten more people will have died by suicide, eight of whom will be men. Studies have shown that the uptake of mental health services is significantly higher among women than men. This uptake results in early intervention, assessment and in many cases saving of lives. If we want to reduce male suicide, which is what we should be concentrating on, we must further promote the "Mind Our Men" message and make everyone aware of the signs of distress and potential suicide. Awareness raising and education are keys to this.

I recently submitted a parliamentary question on the number and type of suicide programmes and organisations available in Ireland. I was informed that the National Office for Suicide Prevention has developed a range of initiatives to support people who are suicidal. At the committee hearings we were informed that there was anything between 350 and 500 initiatives. Does the Minister know exactly how many support groups and initiatives there are? Where are they and who runs them? Are their personnel trained in counselling, bereavement counselling, etc.? Where and how should one of my constituents in Dún Laoghaire, who is in a difficult state of mental health, reach out to one of these organisations? Which one is best? Which one should that person not contact?

Joan Freeman from Pieta House advised the committee, "[A]ll the agencies dealing with suicide, whether it be prevention, intervention or postvention, are all scrambling for the one pot. There is no cohesion whatsoever and one agency battles against the other". This is not good enough and cannot continue. This lack of cohesion is severely damaging. I urge these different initiatives to co-operate more and be made more widely known and available. I believe that work has been started by the National Office for Suicide Prevention to establish an inventory of all organisations working in this area. I hope this will result in a more comprehensive approach and more cohesion between services. There is still a stigma associated with suicide and mental illness, particularly for men in terms of opening up about their emotional literacy and welfare. We really do have another journey to make in this regard.

We must also not forget about the families bereaved by suicide. Stigma campaigns need to be balanced with campaigns that show the impact of suicide on communities and individuals. Finally, the growing problem of cyberbullying and its impact on mental health, particularly among young people cannot be underestimated. We are only too familiar with a number of tragic suicides of young children and teenagers who, it appeared, were being severely bullied and targeted online. I will chair a National Cyberbullying Conference in September in Dublin Castle. We plan to address the matters of education, awareness raising, the role of parents and educators in an effort to really tackle this problem. Some of the major social media providers will be there and questions need to be answered.

I thank the Minister for his time and look forward to updating him on the outcome of this conference and to his continued commitment to implementing A Vision for Change.

Deputy Colm Keaveney

Fianna Fáil remains deeply committed to the full implementation of A Vision for Change. It is the policy for the future of mental health services. I am, however, very concerned that progress on implementing A Vision for Change has been slowing down just when we most need a functioning mental health service. I deplore the fact that the programme for Government commitment of an annual ring-fenced €35 million fund for community health services was broken in budget 2014 when the funding was reduced to €20 million. Media reports the weekend after that budget indicated that just before the press conference to announce details of the health budget, the Minister of State at the Department of Health, with responsibility for mental health, Deputy Kathleen Lynch, complained bitterly and colourfully about being kept in the dark about the budget. The Minister said this funding will be restored in 2015. Can he confirm today that €50 million in funding will be provided in budget 2015 and ring-fenced?

This cut, and the deliberate policy of delaying hiring of critically important community health staff until close to the end of the calendar year has damaged the health of those who need us most. The recent annual report from the Mental Health Commission warns that the progress made over recent years in improving mental health services in Ireland is in danger of coming to a standstill. In the opinion of the chairman of the commission, Mr. John Saunders, "While some service providers are making progress toward providing a truly modern mental health care service there are many others that are struggling. There are many contributing factors including resource constraints". There is also an unwillingness on behalf of the Department to provide support. For instance, while more than 90% of approved centres comply fully in areas such as insurance, certificate of registration, hazard analysis and critical control point, HACCP, and health and safety requirements, only 60% are compliant with regulations relating to care plans and other staffing matters.

Mr. Saunders added, "There is potential to make more progress but the resource constraints and in some cases reluctance to change are making progress more difficult". This is critically important. A Vision for Change is being implemented unevenly and inconsistently across the country and there is a requirement on the Minister and the Department to be more innovative in their actions to support this, reinforced by strong corporate governance in the roll-out of a such an important national plan.

The emphasis on resource constraints is noteworthy, given that the Government cut its commitment by €15 million in last year's budget. The Mental Health Commission also expressed concern regarding a number of specific areas of service provision which impinge on human rights. In principle, for example, it is accepted that each user of mental health services is entitled to have an individualised care plan, designed to assist his or her recovery.

The commission estimates that just 60% of approved centres implement appropriate individualised care plans. The extent of the continued usage of seclusion and physical restraint is unacceptable. It is worth noting that of the nine conditions attached to each of the approved centres in 2013, four relate to non-compliance with care planning, two relate to the use of seclusion and restraint, one relates to transfer, one relates to staffing levels and one relates to unsuitable sleeping accommodation.

The presence of children in adult units remains a scandal. The Mental Health Commission report states that "in relation to younger service users, there is still a most unsatisfactory situation whereby children are being admitted to adult units". There were 91 children admitted to adult wards in the single calendar year of 2013. A themed report from the child and adolescent mental health services on the issue of the admission of children to adult units in 2013 was also published last week. The report highlights that A Vision for Change recommended that mental health inpatient services for children up to the age of 18 should be provided by dedicated adolescent mental health units. Despite this, some 91 admissions of children to adult units took place in 2013, with 60% of these children remaining in adult units for periods in excess of three days and 21% of them remaining there for more than ten days. When all notifications to the Mental Health Commission of child admissions to adult units were examined, it was found that in 64% of cases, such admissions were made on the basis that no child and adolescent mental health service beds were available on the date of the child's admission. However, an analysis of vacancies within child and adolescent mental health service units showed that there were significant vacancies in the various unit locations and administrative supports. It seems that on some occasions, children were admitted to adult units simply because there was no infrastructure for child and adolescent mental health services in the community.

Criticisms of the Minister and HSE management have been made by front-line staff and patient representatives in Roscommon, Galway, north Dublin and, most recently, Carlow, Kilkenny and south Tipperary. According to a HSE report released last weekend, mental health services in Roscommon and Galway are being run in accordance with an outdated model that is 30 years old. I want the Minister to be aware that when he makes a parallel with the Cavan model, he should look at the number of admissions relative to both of those administrative areas. An expert panel appointed by the HSE concluded that services in the west will operate under the new national planning guidelines for the future, with the out-of-date plan from 1984, which was agreed by front-line staff at the time, being shelved. The expert report into mental health services in the west describes an "astonishingly large" number of hostels, day centres, sheltered workshops and other supportive community structures. The experts suggest that such services have become the focus of all treatment. They are criticised as inflexible and expensive compared to using teams to treat people at home, as recommended by experts and dictated in A Vision for Change.

There is a huge willingness among the staff to whom I have spoken to address these problems and to move to the new model provided for in A Vision for Change. Their fear is that the community resources they currently have will simply not be transferred in conjunction with the move from the traditional system to the A Vision for Change system. The local experience of what has occurred since the closure of the state-of-the-art €3.2 million ligature-free unit at St. Brigid's Hospital in Ballinasloe has confirmed the worst of their fears. The unit in question was never opened. The promised community services in some parts of Galway and Roscommon have proven to be largely fictitious. Vulnerable people have been left to depend on a hopelessly inadequate, dilapidated and substandard psychiatric unit that is attached to the end of an acute unit. The people in question, who need help and support, have to admit themselves through an accident and emergency unit, which is a significant no-no. They have to go through an acute service to be triaged to a psychiatric unit at the other end of the campus.

We learned in June that a group of consultant psychiatrists in Carlow-Kilkenny have withdrawn their confidence in the clinical management of the mental health service there because they believe it is unsafe. Nine doctors wrote to the Minister of State with responsibility for mental health to express "serious concerns" about local services in light of nine fatalities that had tragically taken place in the local community. In a letter they sent to the Minister of State, Deputy Kathleen Lynch, last month, the doctors repeatedly questioned the safety of the governance of the service and said they felt "devalued" and "ignored" in their attempts to raise concerns about the HSE. As in Galway and Roscommon, the medical professionals who dared to speak out in Carlow-Kilkenny found themselves isolated, dismissed, ignored and ultimately ostracised. Those who criticise the Minister are regularly accused of acting in bad faith and wanting to go back to the institutional care model. They are subjected to intimidation by their managers. Their arguments are ultimately dismissed by the Minister.

I have experience of engaging with medical professionals who are deeply committed to securing the best outcomes for patients who are worried about the state of these services and the lack of resources. The Mental Health Commission has highlighted the need for ongoing independent monitoring of the A Vision for Change implementation body. The commission has said that since the dissolution of the second independent monitoring group in June 2012, there has been no independent monitoring of the implementation of any policy provided for within A Vision for Change. I have already called on the Minister to confirm that the €15 million that is to be provided in budget 2015 will be ring-fenced. I am also calling on him to re-establish the independent group that monitors the implementation of A Vision for Change.

Deputy John McGuinness

The consultants and front-line workers referred to by Deputy Keaveney wrote a letter and visited a number of public representatives in Kilkenny to outline quietly their exact fears regarding the delivery of proper health services in counties Carlow, Kilkenny and Tipperary, but they were not listened to. Their expressions of concern came as no shock to those of us who have been campaigning for service improvements at the department of psychiatry in Kilkenny for many years. People like Anne Ryan, who was a front-line campaigner in Kilkenny city, highlighted many issues relating to the health services. The campaign was based on specific information that was provided by such people, for example with regard to patients of the department of psychiatry who died by suicide or caused harm to others after being discharged, but nothing was done about it. I remind the Minister that the consultants and the front-line psychiatric service providers in Kilkenny were not the only people who raised this issue. Over a number of years, public representatives had raised it at the meetings of Members of the Oireachtas and HSE officials that take place in line with legislation. All of the issues that were raised were denied or ignored to the extent that the unchecked system simply got worse.

I believe in supporting the people in the community who require services. It is quite clear that there is no support for the families or the individuals in Kilkenny. There is no belief in those who say there is something wrong with the system. A Minister of State at the Department of Health said that the clinical director in Kilkenny has retired and has gone. We have been told locally that he is on leave. The HSE has said that somebody else has taken over the position. The fact of the matter is that the service is dysfunctional. The Minister needs to intervene in that service by asking for a clear explanation of what has happened. He should ask for a meeting with the consultants who wrote the letter and the staff who are delivering the services. If he talks to some of the families of the patients concerned, they will tell him that they see different people every time they have an appointment. No one seems to hold his or her position in Kilkenny. Everyone is being moved around. Patients and their families have no confidence in the service.

In spite of the concern expressed publicly by me and others at meetings with the Health Service Executive and through local media, nothing has happened. To this day, there is nothing only doubt and confusion. I ask Members to imagine if they were patients of that service and were seeing it crumbling in front of them, with no hope that it could deliver what is required to put them right. Nobody could have confidence in such a service. I am asking the Minister to intervene with management to request a report into what happened and an indication of what immediate solution it can offer beyond the appointment of a new clinical director.

The Minister referred to the concept of a "healthy Ireland". Is he aware of the case of a young Irish man who had an accident while on holiday in France which rendered him immobile? This man is anxious to be flown home with a nurse to his family and to be taken into care. The HSE, however, has told him that he is better off staying where he is and has instructed the French authorities accordingly. There is no evidence there of a healthy Ireland and it is not the type of response one would have expected from the HSE. I will give the Minister the details of the case and ask that he ensures something is done to address this man's plight.

Deputy Thomas Pringle

I welcome the opportunity to contribute to this debate and the Minister's decision to accept the motion before the House without moving the Government amendment. Indeed, there is nothing in the proposal that threatens Government policy. Mental health services have long been the poor relation in our health system and have suffered more from under-investment than any other service. The annual report of the Mental Health Commission for 2014 highlights the greatest problem facing the service when it points out that of the 63 premises it inspected, only 44% had adequate staffing levels and only 30% of the premises themselves were adequate. Across the community mental health services, the situation in regard to staffing is just as serious. The continued operation of the public service recruitment embargo is putting vulnerable people's lives at risk. It is beyond time it was lifted to ensure citizens can access the services they need.

When we consider the levels of suicide and self-harm in our society, it is clear what needs to be done. We must appoint the staff needed to provide the services. The motion before us this evening calls for adequate out-of-hours emergency services, but that cannot be achieved without putting in place adequate staffing levels. There are more than 30,000 hospital admissions each year due to self-harming. Providing staff in the community to support people at risk of self-harming will ease the burden on acute hospitals. It will, moreover, save money which can, in turn, be diverted into community services. I take this opportunity to pay tribute to the people behind SpunOut.ie and Jigsaw for their work to improve young people's mental health. When we consider that we have the fourth worst mental health record for young people in Europe, it shows the importance and value of the work they do.

I also commend the child and adolescent mental health services, CAMHS, community teams on the work they do in assisting young people in need of help. They are inundated with calls for help, however, and must be provided with the resources necessary to meet all the demands on their time and assistance. In the HSE west area, there is one inpatient CAMHS unit at Merlin Park University Hospital in Galway, with two teams operating out of it. One of the psychologists assigned to the unit has been on sick leave since last September, with no cover provided during that period. One has to wonder about the Government's commitment to providing child and adolescent mental health treatment when this situation is allowed to continue. It is a situation that highlights how lack of staffing is impacting on treatment for our young people. If we want to see A Vision for Change implemented, we must provide the necessary investment.

Deputy Maureen O'Sullivan

I take this opportunity to acknowledge what has been achieved in recent years and the good systems that are in place. Examples of such systems include the west Cork mental health service, which operates a 24-hour listening service, and the Celbridge community mental health team, which has a seven days per week service, with service users also having a telephone number to contact the acute unit if they need it. That type of service, encompassing a home care service, a key worker system and 24-hour telephone access, is vital and should be available in all communities. It can give people with mental health issues a sense of security that there is somebody at the end of the telephone line who will listen to them and help them. It is a factor which can reduce hospital admissions. I also acknowledge those people with mental health issues who have had the courage to speak out publicly. That has done a great deal to reduce the stigma around mental health problems.

There is a correlation between austerity and its associated cutbacks and mental health issues. Indeed, in times of austerity we see increasing demands on mental health services. In 2013, for instance, there was a huge increase in people presenting with mental health issues. A study conducted in one of the communities I represent showed that for one in every three people who presented with a medical problem to the local doctor, there was also a mental health aspect. Any further cuts in the funding of services will lead to an increased incidence of mental health issues and more demands on those services. In the long run, that will prove even more costly.

There are very significant gaps in services for those with a dual diagnosis, that is, persons in addiction who also present with a mental health issue. In many cases, in fact, such persons are also homeless. We need an inter-agency approach to the provision of supports for individuals in those circumstances. As it stands, people have to present to a different agency for each problem, namely, homelessness, addiction and mental health issues. I am a member of the board of a counselling centre in the north inner city which is very active on suicide prevention and working with those who have been bereaved by suicide. The centre regularly rolls out the applied suicide intervention skills training, ASIST, safeTALK training and mindfulness training. It is one of the few centres that will counsel people who are active in their addiction and it is taking referrals from leading agencies. However, none of this is reflected in the funding it receives. I hope that the review of the ReachOut initiative might lead to an improvement in this regard.

I understand the Minister of State, Deputy Kathleen Lynch, is in favour of introducing a requirement for informed consent from patients before electroconvulsive therapy is administered, an issue which is being examined by the expert group. I hope that provision will be brought forward. I take on board what the Minister, Deputy Reilly, said about people who cannot make an informed choice, but there is a need for families to be fully informed of what is happening.

We must work to ensure there is a linkage between physical and mental well-being. Ceapaim go bhfuil sé dearfach go bhfuil an díospóireacht seo againn anocht agus amárach. Ba mhaith liom aitheantas a thabhairt don Teachta Ó Caoláin.

Deputy James Reilly

With the Leas-Cheann Comhairle's permission, I wish to correct the record of the Dáil. Such is the commitment of the Minister of State, Deputy Kathleen Lynch, to this issue that even though she is in her sick bed, she is following this debate carefully via webcam. She has informed me by text that she never said that the gentleman in Carlow-Kilkenny had retired or resigned but that he was on sick leave.

Debate adjourned.