Dáil Éireann díospóireacht -
Wednesday, 22 Jun 2016

Vol. 914 No. 2

Leaders' Questions

Deputy Micheál Martin

Budget 2012 introduced perhaps the single most damaging cut to education, that is, the removal of ex quota guidance counselling provision in second level schools. The Institute of Guidance Counsellors conducted an audit since then and it states that the current practice is "a portrait of inequality". One member of the institute described a wave of self-harm among teenagers that would alarm any parent. Teachers who are expected to teach as well as be guidance counsellors described it as a "bottomless pit" and "fire fighting", saying "you can just do what you can". That is the story in second level schools throughout Ireland since this cut was introduced. I spoke to Senator Joan Freeman, founder of Pieta House, last week and she also told me about the extremely damaging impact of the cut in terms of the mental well-being of young students in second level schools who, until then, had access to guidance counsellors. This week, I met members of Comhairle na nÓg in Cork, the Cork City Comhairle or youth council. They conducted a survey on the absence of career guidance for them and their peers in second level schools. Again, there were very damaging conclusions regarding the absence of career guidance for them.

There has been a 51% reduction in one-to-one counselling supports in secondary schools. The Economic and Social Research Institute, ESRI, carried out a major study on this in the context of a report on the value of guidance counselling. It stated clearly that it has had a devastating impact on working class students in working class schools and that it has embedded disadvantage across our education system. That is the reason I was anxious, in the confidence and supply arrangement with the Government, to ensure that the reintroduction and restoration of ex quota career guidance would be part of that agreement and would be delivered by the Government. I realise there is resistance to this among, perhaps, officials within the Department or other people.

The suggestion that general improvements to the staffing schedule will somehow improve guidance counselling is not a runner, because we need the ex quota provision restored. Does the Tánaiste accept that the need to restore ex quota provision for second level schools is a very real issue for young people and teachers? Is the Government committed to bringing back ex quota guidance counselling to our schools?

The Tánaiste

The programme for a partnership Government strongly reasserts the central role of education. Indeed, the very first line is, "Education is the key to giving every child an equal opportunity in life." There are plans to commit a huge amount of extra investment in our education system at every level. I recognise what Deputy Micheál Martin says about the importance of guidance counselling. We had to take extremely difficult decisions because of the cycle of boom and bust our country was in. There is a commitment in the programme for a partnership Government to reduce primary school class sizes, reintroduce guidance counselling to secondary schools and increase financial supports for postgraduate students with a particular focus on those from low-income households. As the Deputy said, this was part of the discussions in respect of forming the programme for a partnership Government. There is a very clear commitment to reintroduce guidance counselling. Based on my own experience, I believe it is extremely important in terms of identifying issues in schools, dealing with mental health issues and working in a preventative way with children who need particular advice and support. That will be discussed during the Estimates and there will clearly be consultation in the appropriate committee about how this reintroduction will be carried out in the coming year.

Deputy Micheál Martin

I welcome the Tánaiste's response and her personal observations about the value of guidance counselling, particularly in terms of mental health. The real value of a career guidance counsellor is that young people with issues in their family environment or personal issues can go to a counsellor and have a one-to-one session without any stigmatisation around the issue of mental health. They can get counselling in a very good environment - again, with the proviso that there must be fully qualified and dedicated guidance counselling provision.

The reason I put the question is that some of the replies have been somewhat ambiguous. A spokesperson for the Department of Education and Skills said that the aim would be to provide a whole-school approach to guidance counselling, including group work, class-based activities and other activities that focus on providing the best possible outcomes for students rather than exclusively using one type of activity. In later replies to parliamentary questions, there was talk about discretion being left to the schools and principals. This is not good enough and is not acceptable. I put it to the Tánaiste that what is needed is dedicated ex quota provision of career guidance counsellors outside the normal staffing schedule in second level schools. That is the key point.

The Tánaiste

Obviously, the former Minister for Education and Skills, Deputy Jan O'Sullivan, made some provision for a 50% restoration of the cut that had been made in this area, which schools will have from 1 September.

Deputy Micheál Martin

It is not dedicated.

The Tánaiste

There is provision there for schools to examine how they want to approach this.

Deputy Micheál Martin

That is not good enough.

The Tánaiste

In respect of the Deputy's point about dedicated provision, clearly that will form part of the Estimates discussion. The Minister will examine the precise costings relating to that. There is a commitment in the programme for a partnership Government to reintroduce guidance counselling in secondary schools, but the Minister will discuss that with all members of the education committee and it will be discussed in the context of the budget.

Deputy Gerry Adams

There is not a single family across this island that has not been affected by the challenge of mental health issues. It is now accepted that one in seven adults will experience mental health challenges in any given year and that the real figures for suicide across the island of Ireland are as high as 1,000 people annually.

I want to ask the Tánaiste about the Mental Health Commission's annual report which was published on Monday. The State's mental health policy, A Vision for Change, has been in place since 2006 and the Mental Health Commission has undertaken a strategic review as part of developing a new strategic plan for 2016-2018. The commission's report illustrates how much remains to be done. This includes a need for independent monitoring of the A Vision for Change policy. Given that the policy is ten years old and allowing for increases in population and other demographic changes, I imagine the Tánaiste agrees that this is very urgently needed.

There are also significant issues around funding or the lack of funding. The current level of funding for mental health is still less than the 8.24% target based on the 2005 figures envisaged in A Vision for Change. The staffing levels are about 75% of the A Vision for Change recommended number. According to the Mental Health Commission's report, there is a serious deficiency in the development and provision of recovery oriented mental health services. This concept, which is about aiding a person's recovery rather than managing the illness, is crucial. The report states that the reason for this is the combined effect of poor manpower planning, lack of change in professional training schemes, cuts in public expenditure, delays in recruitment and a shortage of appropriately trained staff.

I do not have the time to go through all of the report's details but I would like to raise some very specific issues. One issue is 24-hour staffed community residences. The commission remains concerned that some of these are too large, have poor physical infrastructure, are institutional in nature and lack individual care plans. It goes on to say, which is very alarming, that there is a fundamental issue of identifying precisely the number of residences and people living in them. In other words, we do not know. This is an alarming revelation. The commission also expresses concern about the admission of children to adult services. In 2015, some 95 children were admitted to adult units. I am sure the Tánaiste will agree that this is totally unacceptable.

The Government has yet to introduce draft legislation to bring about the changes envisaged in the review of the Mental Health Act 2001 which was published in December 2014. My question is straightforward. Does the Tánaiste accept that the Government has to act on the findings of this report?

The Tánaiste

I accept that the whole area of mental health needs ongoing investment which we need to prioritise. I hope the health committee will prioritise a discussion of the full implementation of A Vision for Change, which also needs a review. The report that Deputy Adams referenced, the Mental Health Commission annual report of 2015, reflects the very widely accepted need to develop further a complete community-based mental health service with a prevention and recovery focus. I am sure there is no one in this House who does not agree with what the Deputy says about the need for priority focus and ongoing improvement and investment in the whole mental health area. Thankfully, we have seen changes and we have seen the move from residential to community care but unfortunately the economic situation impacted on the development and implementation of A Vision for Change. What we have to do now, given that we have the resources available, is make sure we accelerate funding in this area. That is what the Government has done. We are committed to providing additional resources in this area. If one looks at the recent Government decision to allocate an extra €500 million to the health area, that involved an increase in mental health funding from €785 million in 2015 to a projected budget of €826 million in 2016, which represents an increase of €41 million or 5.2%. That funding is very important.

The recruitment of front-line staff has been difficult but needs to continue and vacancies are being advertised as I speak. Hopefully that will begin to build up the complement of posts that are necessary. Up to 1,150 posts have been filled up to the end of 2015, with 270 posts approved for the child and adolescent services, which also need development and staff.

A number of priority development areas have already been identified that will be ongoing this year. They include the improved counselling services and the provision of three new Jigsaw centres, which are extremely important to young people in local communities. I am sure Deputy Adams will agree that the provision of those extra centres will be important, particularly for the more vulnerable children in areas across the country.

Deputy Adams made a point about children who were admitted to adult psychiatric units. Indeed, it is shameful that we continue to have such a situation, even though it has significantly changed, from more than 200 children being admitted to adult inpatient psychiatric units down to 95 last year. Every one of those is one too many and we must accelerate our efforts. There is increased funding and it will begin to deal with the issues I have identified in a more comprehensive way. The Minister of State, Deputy McEntee, is determined to have a strong priority focus on the mental health issues that Deputy Adams has identified and that we all know need continuing attention.

Deputy Gerry Adams

I, and other Teachtaí, have been raising these issues regularly and I do not minimise the challenges involved. I wish the Minister of State, Deputy McEntee, well. Sinn Féin will co-operate with her in dealing with this crucially important issue. In fact, the leasuachtarán of Sinn Féin, an Teachta Mary Lou McDonald, has national responsibility for our mental health and suicide prevention portfolio. I believe firmly that an all-party and all-island approach is required and there should be full co-operation with our colleagues in the North. I have long argued for an all-island suicide prevention strategy and for a campaign similar to that undertaken by the Road Safety Authority. Although the Taoiseach has made positive responses to this over the years, this has yet to be put in place. I commend that approach to the Tánaiste and to the Minister of State.

I welcome the Tánaiste's assertion that mental health services need investment and I look to her to deliver on that. However, I do not accept that the recession played a part in underinvestment. It was Government decisions which led to under investment. In fact, an unfortunate insight into the Government's attitude was the fact that funding which was ring-fenced for mental health was used for other purposes.

An Ceann Comhairle

I thank Deputy Adams.

Deputy Gerry Adams

That has been restored but this does not imbue confidence.

Another damning finding of the Mental Health Commission is that 10% of facilities inspected by it in 2015 were not compliant.

An Ceann Comhairle

All right. I thank Deputy Adams.

Deputy Gerry Adams

I am asking the question, le do thoil.

An Ceann Comhairle

Tá an t-am istigh.

Deputy Gerry Adams

When will the Government publish an implementation plan for the outstanding elements of A Vision for Change and when will we have an opportunity to discuss this here?

The Tánaiste

Regarding the compliance issue, six approved mental health centres achieved full compliance with all the regulatory requirements in 2015. While what Deputy Adams says is true that other centres were non-compliant to varying degrees, I am advised that, given the nature of the requirements where centres were non-compliant, the potential for full compliance is strong. Certainly, the Minister of State, Deputy McEntee, has urged the maximum effort on the part of all of those non-compliant centres to meet the requirements. It is important that we have such inspection and that there is a continuous monitoring of the implementation of the inspectorate regime.

Regarding Deputy Adams's point about North-South co-operation, when I was the Minister for Children and Youth Affairs, I was involved in North-South meetings and the topic of mental health was discussed and various North-South initiatives were considered. I agree with Deputy Adams that collaboration and best practice models need to be exchanged, North-South. I believe that has happened. Perhaps it could happen more but that certainly was on the agenda at some of the meetings I attended.

An Ceann Comhairle

Deputy Catherine Connolly is representing Independents 4 Change.

Deputy Catherine Connolly

Following up on the same topic, the ten-year strategy published in 2006 set out a comprehensive model of mental health. It gave a framework for building and fostering mental health across the entire community and providing accessible community-based specialist service for those with mental illness. In other words, it told the Government back in 2006 what to do, more importantly, how to do it and, even more importantly, in the knowledge that any government might not do it, made a strong recommendation that a monitoring body be set up. That monitoring body was set up. It was set up for two three-year periods, between 2006 and 2009 and between 2009 and 2012.

Significantly, it was disbanded for some reason, so we have no independent monitoring group, as per A Vision for Change. When it sat, the monitoring group and the Mental Health Commission repeatedly pointed out that the implementation of A Vision for Change has been slow and inconsistent. This week, the Mental Health Commission again confirms that A Vision for Change is extremely important and puts the patient at the core in terms of recovery. However, it points out that much needs to be done. Additionally, it points out a serious number of failures and issues to be rectified, with the first being the setting up of an independent monitoring commission. That has not been done and I would like the Tánaiste's answer on that. The second issue is an immediate review. Since coming to the Dáil I have heard statement after statement being made with goodwill. There is no answer from the Government as to when the review will be set up, who sits on the panel and when there will be a review report.

Some of the specific issues highlighted by the Mental Health Commission have already been mentioned. Although I am paraphrasing the Tánaiste, it is not appropriate for her to say they are not that bad. There are serious problems, notwithstanding the good work of the staff. Of the 61 inspections, only six facilities were fully compliant and only one of those was run by the Health Service Executive. Well done to that centre in Ballinasloe in east Galway. There were 95 children admitted to the wrong facility. In 1997, the European Commission of Human Rights indicated that we were failing to comply with our obligations by not providing appropriate facilities. We are doing the same thing 19 years later. Spending on mental health was as high as 14% of the budget in the 1990s, when we had very little money, but it is now down to 6%. A Vision for Change specifically asked for a figure of at least 8.2%.

With regard to improvements in the economy, it costs more not to deal with mental health. On page 176 of A Vision for Change from 2006, it is stated that the cost of a failure to deal with mental health issues is €11 billion. I believe that figure is wrong, but it is in the document. Will the Tánaiste answer those two specific questions?

The Tánaiste

I spoke about the importance of compliance and I certainly accept what the Deputy says about it. I did not mean to suggest in any way that the issues of the other centres which have not met full compliance were in any way insignificant. The point I made is that the potential for full compliance is certainly there. That is what the Minister of State will be pursuing with respect to the points made in that report. I have no doubt she will be addressing the range of recommendations in the report, including the question of monitoring. I do not have a specific date but I have no doubt it will be an important part of her consideration with regard to the implementation of the recommendations.

A full policy review in the area has been announced by the Minister of State, which is important. Everybody accepts there have been major changes in how we deal with mental health in this country. I am thankful that the stigma that was there has certainly changed, and I notice this very much among young people. We know issues remain and we need a more concerted effort across all society to ensure people get the kind of help they need with mental health difficulties at an early stage. The help, in the first instance, should be in the community, with inpatient facilities as needed.

There is a full chapter in the programme for Government on mental health and commitments on a variety of issues that have come to people's attention in recent years, including access to a GP and other mental health services in primary care, which is extremely important. A Vision for Change was accepted very much as a roadmap to improved mental health services. We now have the funding, which had, unfortunately, decreased at a time when there was little choice in the matter because of the cycle of boom and bust economy. I am thankful we are now in a position to reinvest in the area, and the Government has demonstrated its commitment to investment in the health services with the announcement of €500 million in extra funding just two weeks ago.

A proportion of that is for mental health services. There is also a commitment in the programme for Government to review this annually and to have increased investment in mental health services. The issues Deputy Connolly has raised will get the attention they deserve and I have no doubt that the Minister of State, Deputy McEntee, will be making a statement on the report.

Deputy Catherine Connolly

I thank the Minister for her reply but I do not think her reassurances are good enough at this stage. She has an obligation, as does the Government, to reinstate the implementation body. It was part of A Vision for Change, so she is not complying with her duty of care under that strategy. She has failed to tell me why it was disbanded and why it has not been reintroduced.

In respect of the review, this has been mentioned continually and yet no date has been given. I specifically asked what date the review started, when it will be finished and who sits on the review panel. A Vision for Change was a ten-year strategy, which finished last January. We are now in June and we still have no mention of the review and no date for it. The blueprint was written back in 2006. It had a chapter on suicide. In 2006, the incidence of suicide was at crisis levels. We do not need statements on how it should be done; it is all there. We need confirmation on how that report is going to be updated, reviewed and implemented. It will save the economy money, so saying the Government does not have money or did not have money is not an explanation. It is actually costing the economy more to do nothing.

The Tánaiste

I have made very clear in my reply to the Deputy that this is a priority issue for Government. I recognise her passion for this issue and it is shared by all of us. It is a priority issue, we are investing in this area and I will ask the Minister of State to communicate with the Deputy directly in respect of the specific points she raised about the timeframe for the review and why the original monitoring committee did not continue. It may have been time-limited. I do not have that information right now but I will ask the Minister of State to liaise directly with the Deputy in respect of the questions she raised.

Deputy Michael Healy-Rae

I want to raise the very important issue of medical cards. I have permission from an applicant to mention this case. I have written to the medical card processing unit on 11 occasions between 14 March and 10 June, contacted them by telephone on more than 15 occasions and asked two parliamentary questions of the Minister for Health with regard to the individual. The man developed encephalomyelitis, which is a general term for inflammation of the brain and spinal cord, in 2012. Since then, he has been left with a great number of neurological defects, which are proving impossible to manage. During this time, he has seen 22 consultants and attends the Santry Sports Clinic in Dublin weekly for treatment as this is the only place in the country that he can be treated. He needs regular botox injections to control the spasms and four times the normal amount of Lyrica to control the pain. As late as Wednesday, 15 June, he received 31 injections in his head. Another example of his condition is that if he was to run after his child in an emergency situation his rib cage would automatically go into spasm to protect his lungs and actually squeeze his lungs, restricting his breathing. He applied for a medical card on 19 January 2016 and was refused a card on 22 February 2016. His application was appealed and refused again on 5 May 2016. His case was then again reviewed by a senior medical officer and the decision was upheld on 8 June 2016.

This is one example of the many cases I have dealt with - I am only one politician in this House and we should think also of all the county councillors dealing with the issue of medical cards - where more than adequate medical information has been provided to entitle people to a medical card and time and again they are being refused. How could any right-thinking person have refused this individual his medical card?

With regard to the current waiting time for cataract operations, I must first compliment the staff in our hospitals providing this service as they are only operating within the resources that are available to them as the demand for the service is very high at the moment. However, I know of people in my constituency who have gone blind while waiting for cataract operations and this continues to happen.

I have been informed by the Minister for Health, Deputy Simon Harris, that as of 24 May 2016 in the south and south west hospital groups there are 461 people on the waiting list to be seen. The previous Minister for Health, Deputy Leo Varadkar, determined that the maximum waiting time should be 15 months but this is not happening as people have had to be taken off the list and are going blind because it has taken so long for their operations to be performed.

The Tánaiste

The details of the case described by the Deputy are very distressing. Greater discretion is being exercised by the HSE and the number of discretionary medical cards in circulation has increased from approximately 52,000 in the middle of 2014 to over 106,000 at the end of May 2016. The programme for Government commits to maintaining that humane approach to discretionary medical cards. The Deputy has provided many details today; perhaps he could forward precise details on the case in question to the Minister for Health. The medical card assessment team is now liaising much more closely with local health officers to ensure that any significant extra information is taken into account. However, the legislation is clear that qualification for a medical card is means tested and some people are not eligible because their income is too high. We want a humane approach and to take into account all the facts relating to medical situations, such as undue hardship that may be caused by the decision not to give someone a medical card. The case referred to by the Deputy has been refused on appeal but, given the details he has outlined, I suggest he forward them to the Minister for Health.

There is now increased funding to the health services for cataract operations and there is a commitment in the programme to the National Treatment Purchase Fund, which can address cases where urgent operations are needed. The Minister for Health can engage directly with the Deputy regarding cataract operations.

Deputy Michael Healy-Rae

I appreciate the Tánaiste's response but the case I gave her today is just an example. Every politician in this House knows of cancer patients and I recently had a child with a prosthesis who was refused a medical card. These decisions are being taken by deciding officers and, while I am not a medical person, I have enough cop on to know that a discretionary medical card is meant for a person in this man's situation, for others like him and for people with cancer. They might not always want a card but at a time when they are ill and their illness is causing them financial hardship, they should be entitled to a card. That is why we call them "discretionary" medical cards. I am simply asking for more discretion to be given. It is completely beyond me how any medical officer can stand over some of the decisions taken in this regard. It is outrageous to allow people to go blind for the sake of €2,700, the cost of a cataract operation. I personally know of people who have gone blind. I can give their names, addresses and PPS numbers and it is outrageous that this should happen in a civilised and modern society.

The Tánaiste

The Government's intention is to provide the best possible health service. There have been very significant increases for the health services over the years and €500 million was given to the health services just two weeks ago so that we can deal with the situations outlined by the Deputy and prevent the consequences to which he referred. A good health service works at a preventative level to ensure these situations do not arise.

The individual who assesses an application has to consider whether undue hardship exists in determining an entitlement to social and medical cards. Discretion is allowed and we want discretion to be used in appropriate cases. The Minister for Health will want to hear about it if there are ongoing issues regarding the appropriate use of discretion and I am sure he will address it.