Dáil Éireann díospóireacht -
Tuesday, 31 Jan 2023

Vol. 1032 No. 4

Child and Adolescent Mental Health Services: Motion [Private Members]

Deputy Mark Ward

I move:

That Dáil Éireann:

acknowledges:

— the commitment, dedication and hard work of staff within the Child and Adolescent Mental Health Services (CAMHS), children's health services and organisations that prioritise the mental health of young people;

— the work of the Mental Health Commission in reviewing CAMHS cases, and in publishing the interim report;

notes that:

— the Minister for Health, Stephen Donnelly TD, and Minister of State at the Department of Health, Mary Butler TD, have allowed the waiting list for CAMHS to increase by 86 per cent since the formation of the Government in June 2020, with the number of children waiting longer than a year for a CAMHS appointment increasing by 168 per cent;

— there has been a significant reduction of inpatient capacity for CAMHS, resulting in more than 700 young people presenting to emergency departments in 2022;

— the Report on the Look-back Review into Child and Adolescent Mental Health Services County MHS Area A (Maskey Report), identified 240 children in South Kerry CAMHS who were put at risk, and of those 46 who were put at significant risk in the handling of their care;

— arising from the Maskey Report, a national audit of CAMHS was launched by both the Health Service Executive (HSE) and the Mental Health Commission;

— concerns were escalated to the HSE by the Mental Health Commission before the report was completed; and

— many children and young people with open cases have been lost to follow-up, with 140 "lost" cases in one team;

further notes that:

— recruitment and retention issues are affecting all aspects of the HSE workforce, including those working in mental health; and

— ineffective recruitment panel systems contribute to this staffing crisis; and

calls on the Government to:

— urgently set out a timeframe for how they intend to review all open cases across all CAMHS teams as recommended by the Mental Health Commission, with a particular focus on children and young people who have been lost to follow-up;

— implement immediate regulation of CAMHS under the Mental Health Act 2001, as a priority;

— support the Mental Health Commission in completing its review into CAMHS;

— reinstate a national Clinical Director for mental health to ensure accountability within mental health services;

— improve integration between primary care, disability services and CAMHS;

— set out a clear multiannual funding plan with which to give CAMHS autonomy in delivering quality care, and in the medium-term to extend the current CAMHS to include 18-25 year olds, to ensure that there is no "cliff edge" and no "lost" service users, and to link this new service in with adult mental health services for a smooth transition between both services;

— develop national standards for monitoring of antipsychotic medication;

— urgently implement a CAMHS waiting list reduction and management plan;

— commit necessary funding to prioritise the rapid modernisation of healthcare information systems, including individual health identifiers, an integrated waiting list management system, and a centralised referral system;

— develop a joined-up, proactive, and comprehensive health and social care workforce strategy, to increase education places and training opportunities between the Department of Health and the Department of Further and Higher Education, Research, Innovation and Science, the HSE, Regional Health Areas/Hospital Groups, and higher education institutions; and

— legislate to prevent young people from being admitted into adult psychiatric wards.

The Government has not tabled an amendment to our motion and, therefore, I presume it will not oppose the motion. This is a tactic I will address further in my closing remarks. Sinn Féin is more interested in providing solutions than playing politics, such as the solutions to the woeful neglect by successive governments in the failure of children's and young persons' mental health services. Young people's parents who are desperately trying to get the proper mental healthcare for their children will be watching. There are a couple of parents I know in the Public Gallery to listen to us today.

I echo the Mental Health Commission report, which states that in some instances children and young people get excellent care from dedicated staff while under the care of the child and adolescent mental health services, CAMHS.

While this is true in some cases, it is the complete opposite for many families.

Sinn Féin's motion will ensure that mental health services for children and young people are properly resourced and fully staffed and provide support when and where they are needed. The scandals in CAMHS were laid bare once more last week. The Government needs to act urgently to ensure we have services that are fit for purpose for our children and young people. Current services are not. There are serious concerns and risks for patients accessing CAMHS. This is a second report concerning children being placed at risk while under the care of CAMHS.

Where the Government has failed, Sinn Féin want to offer solutions. Early intervention is key. All children and young people deserve the opportunity to reach their full potential. Children and young people must have access to mental health services when and where they need them. Eligibility for services should be extended to 25 years of age to prevent children falling off a cliff edge at the age of 18. This was outlined in Sharing the Vision. The majority of acute long-term mental difficulties develop between the ages of 16 and 25, and our mental health services must reflect this. We are calling for multi-annual funding for CAMHS so it can operate and forward-plan to be able to properly staff teams. We are calling for an integrated IT system to improve quality of care. It is 2023 and it is shocking to the extreme that we do not have an integrated IT system for children and young people's mental health.

There is a fundamental need for greater accountability and oversight across the health service. We are calling for the reinstatement of the national director of mental health services in the HSE who would report directly to the CEO of the HSE and the Minister of the day. There has been no national director of mental health services since 2016, despite the current programme for Government containing a commitment to reinstate the position. The Minister has called for this but the HSE seems to be blocking this appointment. There seems to be a big disconnect between the Minister and the HSE. Who is in charge?

The Government must prioritise the recruitment of a youth mental health assistant director in the HSE, as promised in budget 2023. This post is essential to ensure leadership in the improvement of mental health services for children and young people, but recruitment has yet to begin. Again, there is no urgency.

Sinn Féin wants to empower CAMHS to be able to respond to issues raised in the Mental Health Commission's interim report. I thank Dr. Susan Finnerty and the commission for publishing this report early. The report did not come as a shock to any family with experience of accessing CAMHS. They know too well that the Government has been failing young people as waiting lists have dramatically increased under its watch.

We must introduce national standards for monitoring anti-psychotic medication. We must develop a joined-up and comprehensive health and social care workforce strategy to increase educational places and training opportunities between the Departments of Health and Further and Higher Education, Research, Innovation and Science. We must increase undergraduate and postgraduate courses and training places for mental health professionals. Minimum staffing levels for CAMHS must be published so at least we have something to aim for.

Our mental health services are in crisis and we can do so much better. We owe it to our children and young people. Our young people deserve hope, solutions and mental health services that are fit for purpose. There is nothing worse than denying a child or young person every opportunity to reach his or her full potential.

Deputy Pa Daly

I welcome Valerie O’Sullivan, who has travelled from Tralee to be here. She can only be described as someone who has survived her treatment in CAMHS. Some other children in County Kerry and their parents, with whom I have spoken, must have laughed when they heard rhetoric about cherishing all children of the nation equally after, for example, scrambling around looking for a bed for their daughter with a life-threatening eating disorder. We see the physical and mental damage caused by overprescribing and over-medicating. Regarding children given anti-psychotic medication for relatively minor mental health difficulties, one child said it felt like she was in a cartoon with hallucinations and going around like a zombie when she only needed help for a sleep disorder. We see the loss of potential and the loss of family cohesion.

Since the Government came into power, waiting lists for CAMHS have increased by 86%. The number of children waiting longer than a year has increased by 168%. Coming up on the train this morning, I heard about the State strategy for defending nursing home charge claims. Last Monday week, as the news broke about the Mental Health Commission, the HSE gatekeepers, who are never slow to miss an opportunity, saw a good day to announce that it was going to carry out a full look-back review into the north Kerry cases. When looking into what was in the statement, the HSE said it was going to carry it out but that it would take what it described as a little time to put the clinical team in place. It should be remembered that this is from an organisation that said last October it would produce the north Kerry review in two weeks. The HSE said it would also need an independent expert to chair the review. We still do not have this expert. When I repeated a call for the review to stretch back over 15 years, the HSE said its priority was to review the young people currently under the care of the north Kerry CAMHS team, which is what the Mental Health Commission had already got earlier on that day, so a bit of a three-card trick was announced on that day.

I am calling for the HSE to review all the open cases, as is recommended by the Mental Health Commission; immediately regulate CAMHS under the Mental Health Act; reinstate a national clinical director to ensure accountability; most importantly, develop the national standards for monitoring anti-psychotic medication; and give us a timeframe for the review of all north Kerry cases going back over 15 years, particularly where Risperidone was prescribed. The children and people of north Kerry deserve no less than that.

Deputy Kathleen Funchion

I thank Deputy Ward for bringing forward this motion and all his work and advocacy on mental health. The motion clearly calls for straightforward reform in order that resourcing is matched with staffing and services are available when and where they are needed. That is one of the key issues because my experience with CAMHS is that people have difficulty accessing the service. First, the referral can be quite daunting. They are also fobbed off in many cases.

In community healthcare organisation, CHO, 5, which is the catchment area of my constituency, 314 children have been waiting more than 12 months for an appointment. These are 314 extremely vulnerable children. A recent case of mine involved a child who was suicidal, presented to their GP when they had been on the list for CAMHS for two years at that point and was told there was a drop-in psychology clinic, which was completely inappropriate. This child really needed the intervention of CAMHS. They were undergoing some level of counselling but we all know there is a difference between counselling and therapy and the very specialised intervention some children need with CAMHS. This child had to present to the emergency room in the end to get that appointment. As a public representative making representations, it was only when the appointment was given through the emergency department that the service came back to us to say there was an appointment, which I found quite cynical.

Time and again I say in this Chamber that we are letting our children down. In a meeting today of the Oireachtas Joint Committee on Children, Equality, Disability, Integration and Youth, we listened to parents trying to fight for the most basic services for their children with disabilities and here we are talking about children with mental health difficulties being failed. I urge all Deputies not just to support the motion; I call on the Government to ensure it is acted upon, we get the staff in place and the process is made much easier and more straightforward for parents.

Deputy Martin Kenny

I commend Deputy Ward on the motion. What we are dealing with this evening is years of underinvestment. This is the reality. We can see it across the entire State. CHO 1 in my area has not yet received a look back into all these issues but I am quite confident that it will be the same as everywhere else because the experience of young people and their families has been the same. They have been let down, there are long waiting lists and those who are in the service find it to be ad hoc. They meet a clinical psychologist, that person is gone, a new person comes in and they must start from the beginning again. This chopping and changing is the routine they have had to deal with and it has not led to good outcomes. In fact, it has led to very poor and sometimes tragic outcomes for many families. A couple of months ago, I was contacted by a father who told me that his daughter had been brought to CAMHS, diagnosed and put on medication.

He looked for an appointment for her to go back for a review of the medication which she was supposed to get after three months. She could not get an appointment. The only answer she could get from CAMHS was to go to her general practitioner, GP. She went to the GP, who said the medication would be continued but only for three more months because they were not qualified to do this. CAMHS did not have the resources to bring the child back to review her medication. That is a problem across the entire country. It is why we have many young people who have been on anti-psychotic drugs for years and have damaged their health, sometimes irreversibly. The State has to own up to having a problem with this service. The problem is that it has been under-resourced.

This is not just a matter of not having resources or not being able to find the particular qualified people to do the job. The problem is much bigger than that. It has not been recognised as something that is urgent and crucial. We all know the adage, a stitch in time saves nine, about early intervention and so on, yet in these cases, children and their families were left in distress for years before they were dealt with. The outcome of that has been continuous poor health outcomes, not just for the young person who has been visiting CAMHS, but for their families, siblings and others around them. It is an absolute mess. We need to get a grip on this. We need to implement what is in this motion and give urgent attention to this issue. It is no good talking about it any more. We need action.

Deputy Denise Mitchell

The latest Mental Health Commission report into CAMHS must be a wake-up call to the Minister for Health and the Government. The issue of access to mental health services for young people is not a new one. It is time for the Government to get its finger out and look at proper solutions to fix this instead of us constantly fumbling around in the dark. The aim of this motion is to provide some solutions for the future of mental health services and to present Sinn Féin's plan for a better future for service users. The Minister and the Government should come into this debate with a listening ear. My colleagues, Deputies Mark Ward and David Cullinane, are taking the opportunity to bring forward suggestions to the Government to help fix the issues in the service.

We all agree that all young people in this State deserve a chance to reach their full potential and be the best they can be. They need services that are fully resourced and staffed and available when and where they need them, even in areas like education. The removal of a national director for mental health by the Minister, Deputy Simon Harris, in 2016 was a poor decision. It must be reversed immediately. We all need to look at the oversight and regulation of CAMHS. We need to develop a framework around medication, particularly for long-term use, and develop standards of practice that must be adhered to and monitored.

There needs to be more in the way of joined-up thinking when it comes to staffing and resourcing of these services because they are dealing with vulnerable young people daily. It is not acceptable that young people are expected to put up with this service which is not fit for purpose.

Minister of State at the Department of Health (Deputy Anne Rabbitte)

I start by welcoming Valerie and the visitors to the Gallery for this evening's debate.

I thank Deputies for the opportunity to discuss the very important topic of CAMHS and the recent Mental Health Commission's interim report on the service. All of us on the Government side have listened closely to the views and contributions expressed and will continue to listen, including to the views of the non-governmental organisations in the Gallery. The motion is not being opposed as the Government recognises the challenges that CAMHS currently face and the value of the findings highlighted by the Mental Health Commission's interim report on CAMHS. The findings of the interim report highlight important areas where services can be improved and act as a point from which proactive activity can benefit CAMHS throughout the system.

This Government remains fully committed to the delivery of a high-quality, safe and compassionate mental health service for all, reflected through delivering our programme for Government commitments on mental health. I therefore welcome the opportunity to highlight the services and supports that are available for young people and their families experiencing mental health difficulties. It is important to me, my colleagues, the Minister of State, Deputy Butler, the Minister, Deputy Donnelly, and the Government as a whole that young people are aware of the services that are available to them, as well as the work that is ongoing to improve CAMHS.

The Mental Health Commission's interim report is one of a number of ongoing reports and audits into CAMHS. Between them, the reports and audits arising from the Maskey report, as well as the final report from the commission, will serve to provide important information on how mental health services in this country can be improved. They will also provide an opportunity to highlight good practice throughout the system and provide the occasion to share best practice. Nonetheless, as the Minister and the Minister of State, Deputy Butler, clearly indicated last Thursday evening, the findings in this interim report identify several issues which are simply not acceptable to anyone, including those providing CAMHS. Importantly, the Minister and Minister of State supported the commission in carrying out its annual thematic report into CAMHS. As they indicated in the Dáil statements last Thursday, the Government has accepted in full the recommendations of the commission's interim report. We await the final report on all nine CHOs and welcome the role the commission plays in ensuring high standards of service provision in our mental health services.

All areas of concern identified by the commission in carrying out its interim report were escalated immediately to the HSE for immediate action and resolution, including the review of open patient cases which the HSE is undertaking. This will initially consist of a review of all open cases where the patients have been prescribed medication by their CAMHS consultant or doctor and have not been seen in the last six months by their CAMHS team. In addition, the Department of Health will work with the HSE to immediately develop a model of care for prescribing practices in CAMHS. This review of open cases will provide assurances that these children and young people are receiving appropriate care, reflective of their current and future needs. The review will include a focus on physical health monitoring of those who are on medication.

On the interim report's recommendation for the regulation of CAMHS, it should be recognised that the need to regulate CAMHS was previously identified by the Department of Health and it is built into the provisions of the upcoming revised mental health Bill. It will empathise with young people and their families who may be worried about them receiving the care they deserve. Much good work is being done by our CAMHS health professionals across the country and, as is raised in the motion, it is appropriate to recognise their strong commitment to vulnerable young people and their families. While we recognise the challenges and concerns regarding service provision in this area, it is important to note that the majority of young people who experience mental health difficulties have access to a variety of services and supports. Of those who seek care from CAMHS teams, the vast majority also experience a positive outcome from CAMHS relating to care and recovery.

CAMHS teams receive and triage nearly 21,000 referrals annually and deliver 225,000 appointments for children and young people requiring assessment and intervention each year. Between 2020 and 2021, child and adolescent mental health services experienced a 33% increase in demand, while concurrently increasing their activity levels, seeing 21% more cases during the same period. There are currently 80 consultant psychiatrists in post working across the 73 teams. The HSE is continually working to ensure that all funded positions are filled and that staff are available to provide this important service. The HSE has a specific focus on supporting the recruitment and retention of staff, with a focus on optimising team capacity.

To this end, a new recruitment operating model is being implemented under the direction of the national director of human resources in the HSE.

On Thursday night, Deputies referred to staffing levels against recommendations in A Vision for Change. A Vision for Change was published in 2006. Sharing the Vision sought to build on this experience and set out a more flexible approach to team development and staffing. This approach was taken to ensure that local CAMHS teams could be developed and staffed to best meet local circumstances and local service pressures. As not every CAMHS team is identical, resources are put in place to make each team appropriate for its setting and to best meet patients' needs. I reiterate that a new post of youth mental health lead at assistant national director level in the HSE and a new post of national clinical lead for child and youth mental health have been announced, with recruitment under way this week.

We had a very intense and passionate debate in the Chamber last Thursday night, with what were overall positive contributions from all sides of the House. I remind everyone of the apt and welcome comments of the Ceann Comhairle during that debate which reflected a key point the Minister of State, Deputy Butler, has always made in her role as Minister of State with responsibility for mental health and older people, namely, that while any deficiencies in CAMHS need to be acknowledged, and addressed insofar as possible, we must always be conscious of the sensitivities and needs of those using the service. While the Government and we, as Ministers, accept constructive criticism, at the same time we must all offer reassurance to the public and instil confidence in the strong and important health services that operate here every day. A balanced and evidence-based approach is always the best way we can collectively analyse concerns and find the solutions we all seek.

At this point, it is important to correct the record. In CHO 5, the total number of persons waiting is 314, while the number who have been waiting longer than 52 weeks is 14. It is not the case that 314 people have been waiting for more than 52 weeks, as was stated earlier.

Real change in mental health has been under way in recent years and will continue through implementation of the current widely agreed policy, Sharing the Vision. There is a record €1.2 billion allocation in 2023. This means the Government has provided a significant increase in investment of some €220 million since June 2020. Importantly, dedicated funding for CAMHS is administered as part of the overall HSE mental health allocation each year. In addition, funding has been provided for two new CAMHS telehubs and a dedicated €6 million to expand the capacity of community mental health teams nationally, with a particular emphasis on CAMHS. The motion does not appropriately reflect the significant investment in our mental health services that I have outlined.

I highlight the emphasis the Government has placed on improving accessibility to mental health services for young people. Continued investment in community services continues to be prioritised. Over €80 million in funding was provided to community-based organisations in 2022. These organisations also provide important early intervention services. These services are a strong staple of mental health services for young people and provide an essential point of access to supports for those in distress or experiencing mental health difficulties. This €80 million in funding is provided to a wide array of service providers, often funded through the HSE. However, for those who do not need access to the specialist supports and services that CAMHS provides, it is acknowledged that children and their families can experience varying waiting times. Some 93% of urgent referrals to CAMHS are responded to within three days. Steps are also being taken to actively reduce waiting times. The Minister of State, Deputy Butler, will speak later.

Deputy Donnchadh Ó Laoghaire

The situation in Cork and Kerry is as bad and perhaps worse than in most places. There are 857 children waiting, the largest number in any CHO. Some 296 children have been waiting longer than a year. In recent days, we heard worrying news from SIPTU about serious staffing issues at the Aislinn inpatient unit at Bessborough, where only 58% of nursing posts are filled. This has a knock-on effect on the staff who are trying to plug the gaps and the pressure that puts on them. In such circumstances, it is hard to blame some of the staff for wondering about their future. These staffing levels have an impact on the services that are delivered. As I said, the waiting lists are enormous.

I always make the point in these debates that these numbers are far from abstract. Children coming forward are under severe pressure and their families may be at breaking point. To get into CAMHS, a child's circumstances must be serious. The review should not look only at open cases because there are children who were inappropriately refused access to CAMHS and others who were inappropriately discharged. I am not making that point to apportion blame - when there are huge pressures on the system cases must be triaged and decisions made - but there are children with serious mental health problems who are being refused access because of the numbers involved. I have heard an instance of the family of a child who was self-harming being told that their child was inadequately suicidal to be admitted to CAMHS. That case involved a child who was in an absolute crisis. Any review must take into account not only the children who were on the books with CAMHS but also those who did not get into the services because of the pressure on the system and those who were discharged even though their condition was far from resolved.

Much of this comes back to staffing, as identified in the motion. The challenge is serious and we must do an awful lot better because our children and many others across the State are under unbelievable pressure. They find this very frustrating and their families are heartbroken trying to access services in which there are delays.

Deputy Mairéad Farrell

When our young people and children ask for help we should be able to give them the support they need. We are very lucky to live in a society that has become far more open about mental health and mental health struggles. It is good to see that a generation of young people are growing up who are willing to speak out and say when they need support. It is devastating, therefore, to see so many children failed by the very body that is meant to help them. Different issues with CAMHS have been laid bare again in recent weeks. We need to see urgent action to ensure that children and adolescents get immediate care when they need it.

CHO 2 covers some of the west, including Galway. It is deeply disturbing that last November there were 247 children on waiting lists in CHO 2, with 40 of them waiting over 39 weeks, including eight who had been waiting over a year. In 2023, we are all well aware that early intervention is crucial. It is heartbreaking to see children and their parents left waiting, not knowing where they are supposed to turn. It is part of a larger issue with mental health supports in Galway. Jigsaw services in the county have a waiting time of 17 weeks, the third longest waiting time in the State. It is deeply concerning that the position is so bad in CAMHS and Jigsaw.

It is important that we make clear to families and children that they should turn to these supports in their times of need but we also need to ensure we are dealing with the issues. Tuigeann muintir na Gaillimhe cé chomh deacair is atá sé an chabhair a dteastaíonn ónár bpáistí agus ónár daoine óga a fháil ó CAMHS. Tá sé feicthe agam go bhfuil 247 páiste ar liostaí feithimh, le 40 acu ann níos faide ná 39 seachtain, agus ochtar acu ann níos mó ná bliain. Nuair atá a fhios againn cé chomh tábhachtach is atá idirghabháil luath, tá sé dochreidte go bhfuil sé seo ag tarlú agus is rud maith é go bhfuil daoine óga sásta labhairt faoi na deacrachtaí meabhairshláinte atá acu. Áfach, caithimid a chinntiú go bhfuil na seirbhísí ann dóibh, na seirbhísí Jigsaw agus CAMHS san áireamh, agus caithimid a chinntiú go bhfuil siad in ann an chabhair a dteastaíonn uathu a fháil.

Deputy Johnny Mythen

The mental health services are in a state of flux. The full report on CAMHS published last week laid bare the facts about threadbare services, bad governance and neglect. Many factors came to the fore, including the deterioration of services, the appalling, long waiting lists and the failure to look after our young people who are in danger and need on-the-spot protection, intervention and care.

We all have personal stories to tell, like the mother who came to me about her teenage daughter. She was self-harming and had suicidal ideation. This happened on a Friday night. She was offered a mattress on the floor. In another situation, there was a young girl who had attempted suicide on three occasions in one week and was basically told there was nowhere for her to go and no placement for her, even though the team on the night concluded that she needed to be admitted and medicated. To reach out and ask for help in moments of turmoil is a measure of desperation but also bravery. It is the Government's responsibility to ensure that the full suite of supports is available, with a timely, appropriate diagnosis given. This is not happening. Our young people are not receiving the duty of care they need and deserve. Recent figures show there are more than 100 people on the waiting list for CAMHS services in County Wexford. The average wait time is almost a year, with some waiting longer. That is 100 families in trouble. Imagine the turmoil, upset and suffering being caused to those people and their families.

This disintegration of services is happening for several reasons. First and foremost, it is because of funding. There must be a multi-annual plan to enable CAMHS autonomy in delivering quality care at source. We also need to address training issues and increase the number of graduate places for our next generation of mental health workers. Finally, we need to reinstate a national clinical director for mental health to ensure accountability within mental health services. Why was this position removed in 2016? I am sure every Deputy has stories to tell from their own constituencies about mental health services. We are appealing to the Government first to recognise the seriousness in the deterioration of CAMHS, which is happening right now, and the continuing consequential harm of the existing system, which is not fit for purpose, as stated in the CAMHS report, and is causing young people and their families to lose hope. We hope all Deputies will restore that hope and support this motion.

Deputy Dessie Ellis

My constituency of Dublin North-West is unfortunately an area with a very high suicide rate. According to statistics provided to the Joint Committee on Children and Youth Affairs in 2019, one third of young people were struggling with mental health issues. This is a very high figure, particularly as the services are severely underfunded. In the last few years, not much has improved. In fact, the provision of mental health services has gotten much worse. The pandemic has taken a toll on the mental health of young people. Its impact on young people is yet to be fully understood but it is clear that there has been a significant rise in both anxiety and depression among young people, triggered by the unprecedented stresses caused by social isolation during the pandemic. Recent studies have shown that a significant number of young people are deliberately harming themselves and that many young people are experiencing suicidal ideation. Expert evidence shows that the onset of mental disorders peaks during the adolescent and early adult years and this is one of the leading causes of disability among many young people. This is why early intervention is so important.

The recent damning report on CAMHS shows that this Government failed significant numbers of children at a time when help was most crucial. If provided with properly funded services, those children could go on to live productive and fulfilling lives, up to and into adulthood. The consequences of the failure to provide care to more than 100 children and the failure to follow up on care for another 140 do not bear thinking about. These failures have the real possibility of destroying lives and creating obstacles to the future potential of these children, as well as negatively impacting on their employment prospects. These vulnerable children have become even more vulnerable because of these failures. It is not an exaggeration to suggest that many of these failed children could be condemned to a lifetime of reliance on mental health services. This is shocking and distressing for both the children and their families. If young people access mental health supports early, they are less likely to continue to experience mental health issues into adulthood. These children represent a generation of adolescents and young people who are in urgent need of mental health treatment and who are being failed by this Government. Dual diagnosis is another area that requires special treatment and applies to young adults. Sinn Féin has put forward solutions that will ensure mental health services are properly funded and staffed and a national clinical director for mental health is reinstated.

Deputy Sean Sherlock

I welcome the motion and support it. I welcome the Minister of State's response because there is a tacit acknowledgement of the challenge that faces all of us in respect of the provision of services through CAMHS. I think everybody accepts the report of the Mental Health Commission and the recommendations therein. I am particularly taken by the part of the Minister of State's speech where she refers to CAMHS teams. She said:

CAMHS teams receive and triage nearly 21,000 referrals annually and deliver 225,000 appointments for children and young people requiring assessment and intervention each year. Between 2020 and 2021, CAMH services have experienced a 33% increase in demand, while concurrently increasing their activity levels, seeing 21% more cases during the same period.

They are extraordinary figures when you think about it. They present a picture of the enormity of the challenge that faces all of us in respect of ensuring that, where somebody needs access to a service in an acute setting or on an acute basis, they have that pathway within that 24-to-48-hour period. When there is a threat to life, there are so many pathways to save a life in conventional medicine. If there is a road traffic accident, the ambulance is called, you go to the nearest trauma centre and the resources are there to save life and limb straight away. When it comes to mental health, it is just not there. It is not guaranteed to the same extent.

I have sympathy for the position in which the Ministers of State find themselves. If I were Sinn Féin I would not be making promises or guaranteeing being able to fix this because it will be a long, slow road. However, the Mental Health Commission's report is very clear in respect of the regulation of CAMHS. This has always been a key point for us. There is an inconsistency in the service depending on where people live in the country. I live in CHO 4. The figures for CHO 4, which is the Cork and Kerry region, are frightening. I raised this in a parliamentary question to the Minister for Health and got my reply on 25 January. I asked for the number of persons waiting to be seen by child and adolescent mental health services by CHO and LHO and the length of time they were waiting. There are 857 people waiting in total in the Cork and Kerry region. That is too many people. There are 296 waiting over a year in the Cork and Kerry region. This is from 25 January so that is the most up-to-date figure there is.

Deputy Anne Rabbitte

Yes.

Deputy Sean Sherlock

There is a glaring inconsistency between what is happening in the Cork and Kerry region and the Galway region, if I am being a bit cheeky about it, or the Waterford region. The figures are incomparable.

Deputy Anne Rabbitte

You are right.

Deputy Sean Sherlock

In CHO 1, the Donegal region, there are 603 people waiting longer than 12 months whereas in CHO 2, the Galway region or the west of Ireland, there are 24. To go back to my earlier point, if someone presents to a hospital with an acute medical condition, they will get their surgery or intervention, they will get the medicine they need and they will get it pretty much straight away once they are inside the door of the hospital, primary care setting or secondary care setting. When it comes to mental health services for children and adolescents, that same level of urgency does not exist. The point made by the Mental Health Commission on the regulation of CAMHS is important because we need that consistency of approach. The Minister of State is saying that the revised mental health Bill should make provision for that. I am not sure where that Bill is or when it is supposed to come before us - I ask the Minister of State to respond to that question - but that provision needs to be nailed down. It is not fair that the people in Cork and Kerry have to wait so much longer than people in another part of the country. We should not have that inconsistency. The service should not discriminate against people based on their geography. We all face scenarios as public representatives, Deputies and Senators, daily where families approach us.

We pick up the phone to the chief officer of the CHO or whoever it might be. These are all inherently good people who want to help us. In some cases, it has taken my intervention with somebody of standing within the HSE on behalf of a family to get access to a service. Family members tell me about a young man or woman who has suicidal ideation and after my intervention, an appointment is made and the young person in question is back in the system. If the system were working correctly, it would not take an intervention by a Deputy, Senator or councillor for someone to get access to a service.

Deputy Anne Rabbitte

I agree entirely.

Deputy Sean Sherlock

That is wrong. There are many people out there - and I do not mean this in a patronising way - who may not have the capacity to advocate or the wherewithal to phone their local public representatives. They should not have to do that to get access to a service.

This is such a sensitive issue that one does not wish to be political or partisan about it but we are not seeing an improvement in the waiting lists, year on year. What the report of the Mental Health Commission showed us was illustrative, but it probably just crystallised our experiences, as public representatives, of mental health services. It did not tell us anything we did not already know. Many of us have been experiencing the CAMHS phenomenon for many years. I was provided with figures for waiting lists on 16 September 2022. The information was separated into people who had been waiting for an appointment for less than 12 weeks, between 12 and 26 weeks, between 26 and 39 weeks, between 39 and 52 weeks and more than 52 weeks. The total was 4,127. The figure as of 25 January was 4,293. The numbers on waiting lists are increasing. I take the point the Minister of State made that there has been a massive increase in the demand for services and that the number of appointments stands at approximately 250,000. However, we are not keeping ahead of the game and ensuring that people can get through the front door, in the first instance. It has been all of our experiences that once people get in through the front door, services start to wrap around them.

Why in the name of goodness have we spent €15 million on recruitment agencies? That money has been spent by the HSE on recruitment agencies to recruit for posts that are vacant. The Ministers of State should intervene. Taxpayers are not getting a return on their investment via the HSE. We are spending €15 million on recruitment agencies to recruit for the HSE to fill the posts that need to be filled in the areas we are talking about. That needs to be looked at. We must ask where is the value for money and the return on that investment for the taxpayer. Why are these posts not being filled?

We stand in this Chamber, week in and week out, and talk about the recruitment crisis. Is there a way to level the playing field between CHOs? Where there is some capacity in one CHO, can it be transferred to another CHO where there is an acute level of need? That could be done as we compare and contrast services. We have all now moved online. God forbid, but if I were looking for an intervention tomorrow and the service I required was in Sligo, I could have an online intervention. The tools of the trade are there to make that happen. In the interim, I am asking that we make services available to people. Even if they are made available as online resources or tools to begin with, it would be a start to ensure we level the playing field for the people I represent in the Cork-Kerry region, which has already been the subject of much controversy. We do not want any more.

Deputy Róisín Shortall

I welcome this motion. It is important that we talk about this issue until it is resolved. We seem to have been talking about shortcomings in mental health services for time immemorial and yet it seems nothing is being done to bring them up to the standard that is expected for a modern and wealthy society. Many of the problems impacting our mental health services, especially CAMHS, are microcosms of the difficulties within the health service. Those problems include the available capacity, the recruitment of staff and workforce planning. E-health is central and we know in the context of reports of poor record-keeping how important it is. There are also problems in respect of the structure and how we organise our health service. The HSE is structured in such a way as to avoid accountability in different areas. The local manager does not have to account for how he or she provided services or failed to provide them, or explain why money was not spent properly. There needs to be that level of accountability at local level, rather than having the chief executive apologise. That often happens. The chief executive comes on the airwaves to apologise for some serious failure and promises a report that we may or may not ever see. That lack of accountability has been descriptive of the situation in CAMHS.

The other issue relating to the structure of the health service was referred to by Deputy Sherlock. We have a postcode lottery. Whether a child can get access to services within a reasonable period is hit and miss. Children are in many cases left waiting indefinitely. That is why we need a new structure in the HSE where resources are provided on the basis of the needs of the local population. The plan is there and it needs to be implemented urgently.

Mental health services are victims of the bigger problems and issues impacting our health services and how we deliver them. It is worth reminding ourselves of the kinds of appalling figures and data we get from CAMHS. We have seen a couple of reports in the past year or so. As of 30 November, some 4,000 children were on a waiting list for CAMHS. Almost 1,000 of those, which is 25%, had been waiting for more than nine months and almost 600 had been waiting for more than a year. We all know from experience, or can imagine, that when a child has a serious mental health difficulty, the case is urgent and the child must be seen within a reasonable period. There are 1,000 children waiting for more than nine months for an appointment. That is an eternity in a child's life. Almost a year of childhood is lost waiting for an appointment. What happens in the meantime? What happens to the child and his or her distraught family? Families get distraught in those circumstances. What happens the child's education? What happens the child's social connections and networks? All of that is put at risk because of these long waiting lists.

We also know, shockingly, that almost half of last year's allocated health budget was not spent. Of the €24 million allocated in 2022, €11.5 million was not spent. It is unforgivable that at a time of crisis waiting lists, half the money available was not spent. That should pose a major challenge for the Government. It should address this issue.

Why has the money not been spent? Is it because we have awful recruitment procedures within the HR section of the HSE? Regardless of whether a post is in south Kerry or north-west Donegal, and irrespective of how much priority attaches to the post in the view of local management, approval for the post must be obtained from Dublin and somebody in Dublin decides whether funding will be approved. Then there is the long rigmarole of the recruitment process, with the likelihood that no people are available to fill the post. That raises all kinds of issues about the lack of responsibility by the Government, the HSE and the Department of Health in having proper workforce planning. Increasingly, we are seeing additional money being provided which cannot be spent because we do not have the intake and the graduation from colleges, and we do not have the healthcare placements.

We also know that the interim report of the Mental Health Commission found "serious concerns and consequent risks" for some patients in four out of the five CHOs on which it reported. That is a damning figure. There is no reason to think that the remaining four CHOs that have not been reported on are any different.

One of the worst aspects of the recent report of the Mental Health Commission was the question of lost case files. The interim report highlighted open cases that were lost in the system. When children's cases are lost in the system, children are lost to follow-up care. Children can wait nine months, 12 months or more to get into a service. They get some level of care and treatment and are then lost to the service. This includes children on medication, some of whom reached their 18th birthday with no discharge or transition plan. In one team, some 140 open cases had been lost to follow-up care. Another team did not follow up with children on continuing medication for up to two years. There is negligence involved in that.

In regard to the digital infrastructure to which I have referred already, we know that the e-health strategy is eight years old. There is virtually no record-keeping in many aspects of our health service. How can a service be supervised and managed if there is no proper data collection system? We cannot monitor and keep track of what is actually happening in the services. How long are people waiting? How many people are waiting? How many staff do we have? How many vacancies are there? What length of time do children stay in the services? These are key things. I often say that what matters gets measured. If we are not measuring activity within the health service, clearly it does not matter. We have a huge problem with the lack of data collection and analysis. Services cannot be run in such circumstances.

The interim report found that five CHOs use paper-based files in this day and age. The report states that patient files were frequently disordered with little logic to the filing, and clinical notes were frequently illegible and at times were incomplete. The report concludes that without a digital patient-management system, it is difficult to see how improvements in the quality of CAMHS can occur. The business case for the Department of Public Expenditure and Reform must be a priority in this regard. Key to restructuring how we provide health services is ensuring accountability. All of this money goes in but when there is a failure in the service, who is held accountable? Nobody. We get an apology – yet another apology – and a promise of a report, and nobody is held accountable. As long as a situation prevails where there are no consequences for failures in delivering services or spending budgets, there is going to be a dysfunctional system.

It is similar in regard to allocating resources. Resources are allocated on a historic basis or on the basis of what constituency happens to have a Minister. That has to end. As part of the regional health authority structure that was recommended by Sláintecare but seems to be taking forever, not only would there be integrated care and accountability of staff but there would also be objective resource allocation. That is critical. The budget that is allocated has to reflect the level of need in the area and not just be an ad hoc matter. So many of these problems relate to how we organise our health service, the lack of investment and the lack of priority being given to some of those big projects. The Minister and the entire Government need to get behind making our health service fit for purpose and fit for the modern day.

Deputy Gino Kenny

We spoke about this issue on Thursday when there was an in-depth debate about the present situation in CAMHS. I said on Thursday and I will say again that the lack of clinical oversight was the main critique of the interim report by the Mental Health Commission. Without oversight, there will be serious issues in regard to everything relating to a service such as CAMHS. I acknowledge the work that the staff in CAMHS do. They do a very good job. It is a vital service for young people in distress. Recovery is possible once they get the proper intervention. Children and young people can recover from trauma and lead fulfilling lives. That is what we all want. The lack of clinical oversight is an indictment on the CHOs that run CAMHS. Alarm bells ring for anybody with an element of knowledge about this. When children are on anti-psychotic medication for years without oversight, there is something very wrong. The lack of clinical oversight leads to problems with retention and burnout of staff. They are only human beings. It also leads to underfunding.

A good example of a service that should operate on full capacity is Linn Dara in Ballyfermot. Linn Dara is an amazing facility. It is a primary care inpatient centre for young people. However, every couple of years it has to close for a few months due to a lack of staff. That is a huge problem. It should not be closing under any circumstances. It has to close because it is extremely difficult to keep staff at the moment in our health service, particularly in CAMHS. How can we fix this? This is the most important thing. People are looking for solutions and do not want this to happen again. I hope the report, which will be finalised by the end of the year, will lay out why this happened and how it will not happen again.

The report is so serious that it warrants an independent inquiry into how this was allowed to happen and the implications for children. Children may be looking in on this debate with their parents who will ask serious questions of services that they thought could be trusted to look after children in their time of need but they were not looked after to the best standards. Once that happens there is a breakdown of trust. There are serious consequences in regard to children’s mental health, families and so forth. I do not know the Minister of State’s stance on this but I believe the seriousness of the interim report means that an independent inquiry should be put together on its findings now or in the future when the report is finalised.

An Cathaoirleach Gníomhach (Deputy Alan Dillon)

We move to the Regional Group. Deputies Peter Fitzpatrick and Verona Murphy are sharing time.

Deputy Peter Fitzpatrick

Last week, I spoke with a father pleading for sufficient care for his daughter's mental health. Thankfully, we got a bed for his daughter with the help of the Minister of State, Deputy Butler, and her team. However, this is just one of hundreds of children's stories and it highlights the lack of services available for child mental health services in my constituency of Louth and east Meath.

A lack of emergency CAMHS out-of-hours services is resulting in 16-year-old children presenting in accident and emergency. If they are lucky enough to speak with a CAMHS psychologist, they are commonly recommended for residential care. However, residential care is not available on an emergency basis and children have to wait until a bed becomes available. They are being passed from pillar to post. On top of this, when a child attends accident and emergency, if they are under 16, they are referred directly to CAMHS, but if they are 16, they are considered an adult and are admitted to an adult ward. The main issue here is that despite being eligible for an adult ward, they are not eligible to access the psychological doctor in Our Lady of Lourdes Hospital as that is for adults only.

This is highly contradictory yet is likely to be related to the skills gap and staffing issues I have raised in the House previously. There is a staffing shortage both in terms of consultants and in all of the therapies that are an essential part of the services. Skills gaps in teams and among the clinicians in posts that have not been prioritised have led to the CHOs having a lack of control as to the services they can provide. It seems that it has become very specialised. I often think that when services are in crisis, they get into the habit of turning cases away if they do not fit into a narrow definition of the conditions to which they are going to respond. In fact, having suicidal ideation will not guarantee access to CAMHS and, in some cases, having a disability will mean a child is likely to be diverted elsewhere.

The CHO 8 area, which includes Louth and Meath, has the second longest waiting list for these services in the country. There are 617 young people waiting for urgent attention from CAMHS and, worryingly, 245 of those have been waiting more than six months, with over 70 waiting over a year for care. I have constantly raised the issues of CAMHS waiting lists and lack of services on the floor of this House in relation to County Louth and east Meath. I have questioned why the HSE has not been able to fill an intellectual disability consultant post in the child and adolescent mental health services in Louth and Meath and asked when one would be appointed. I raised this issue because I am aware of at least 15 families who have adolescent children with autism or moderate learning disabilities who urgently require a review. In addition to psychiatrists not being available, CAMHS will not see teenagers who have a dual diagnosis, and these adolescent children cannot be seen by the mental health team until they are 18 years old. Where are they to go to be seen?

Young people's mental health issues are escalating and becoming much more acute because they are not able to access preventative early intervention. Every child who uses mental health services has the right to appropriate care and support. Due to unacceptable waiting lists and a substandard level of care, many children are being denied this right. Most parents I speak to are just trying to focus on getting help for their son or daughter and they do not have the energy afterwards to advocate. This is why, on the back of the publication of the interim report by the Mental Health Commission into CAMHS, I and my colleagues in the Regional Group called on the Minister for Health to outline the immediate steps being taken to protect children and to ensure proper access to the child and adolescent mental health services.

I acknowledge that the new clinical leadership, especially the appointment of an assistant national director, will ensure governance, consistency and integration across mental health services. However, we need consultants and all of the therapies that are an essential part of mental health services. We need to ensure that hiring is done quickly. We need to ensure that psychiatrists are trained to work with children and trained in risk management, clinical governance and paper-based record-keeping as these are major faults highlighted at present. We have the highest rate of youth suicide in Europe. We cannot afford to wait on more reports to act; the HSE and the Government must act now.

Deputy Verona Murphy

I thank Sinn Féin for bringing forward this motion to allow us another opportunity to place the spotlight on the systemic failures within CAMHS. I want to refer first to something noted in the motion in regard to 140 “lost” cases in just one team, which no doubt, across all teams, adds up to hundreds of “lost” cases nationwide. If I were a patient or a parent or guardian of a patient whose case was lost somewhere among the dense overgrowth of the HSE bureaucracy, I would want answers and accountability. Has the Minister identified how these cases were lost or are the failures in the system still present which would allow the continued losing of cases? Has the Minister identified what individuals were responsible for these errors? Have policies and procedures been put in place to ensure that such errors do not reoccur? Has anyone been disciplined or held accountable for these mistakes? I hope that, in response to the motion, the Ministers of State might provide some answers to those questions but since they relate to responsibility and accountability, I am fearful that they will just become rhetorical questions that will go unanswered.

One year ago, I had the opportunity to speak on a Sinn Féin motion related to the child and adolescent mental health services. On that occasion, I highlighted that I believed there was a general apathy or lacklustre attitude towards the solving of these problems. To be fair, it is mainly the continuous representation from the floor that the Government took action and ordered the review. To highlight the lack of staffing, I compared it to the Luas, Dublin Bus or Irish Rail, which would be in chaos every morning if they did not have enough drivers. A schoolroom would struggle to function if it did not have enough teachers and our ambulance service would fail if it did not have enough crew members. Yet, when we do not have the right staffing levels in CAMHS, it does not hit the headlines like it would for these services.

In 2020, the Government supported the motion from the Regional Group to protect mental health services but, unfortunately, little has been done in the interim to address the issues highlighted with CAMHS. The HSE mismanagement of CAMHS is leaving vulnerable children at heightened risk of mental health difficulties. The current system is not fit for purpose. Children and their families are being tossed aside and, inevitably, some of these families will end up presenting their children to emergency departments somewhere, following an attempt to take their own lives. This is a very difficult thing to say but it is the reality of what happens when the proper services are absent. Some of the stories I have heard about our services amount, in my mind, to neglect, and that must be rectified.

One thing that does worry me about this motion is the call to legislate to prevent children from being placed in adult wards. Unfortunately, with the current state of affairs, where there are no paediatric ward places available, the only option is to put a child into an adult ward. The reality has to be recognised that, regardless of how less than optimal it might be, at least care of some description, even if it is in a less-than-ideal setting, is surely more useful than no care at all. I have great sympathy for those who have to make these decisions in our hospitals daily and I would not like to see their job hamstrung by legislation which might prevent some sort of care being administered. While I agree with the principle outlined in the motion, it would come down in such a case to scrutiny of the detail of how that would operate in reality, or what exceptions would be made in exceptional circumstances.

The motion also calls on the Government to develop a joined-up, proactive and comprehensive health and social care workforce strategy to increase education places and training opportunities between the Department of Health and the Department of Further and Higher Education, Research, Innovation and Science, the HSE regional health areas, hospital groups and the higher education institutions. This is crucial. We can only continue to expand mental health services successfully if we have the proper qualified personnel to fill the roles. This starts with a long-term strategy to have sufficient places on college courses and opportunities for people to upskill in these areas. Almost every CAMHS-related issue comes back in some shape or form to staffing. Staff turnover and the inability to get staff in the first place are preventing services from operating as they should. I have highlighted that problem many times. In County Wexford we are trying to source a paediatric dietician and child psychologists. We are always just one resignation away from having to go months, if not years, without the filling of vital posts.

Yesterday, I provided the details of an eight-year-old boy whose guardians have been told that he does not meet the criteria despite being referred by his family doctor three times to CAMHS. I appreciate the Department is looking into this but the family needs a timely answer and also an answer as to who made this decision without even seeing this young man. It would mean he is on no waiting list when he clearly needs immediate attention. I am mindful of the issue that arose in the media at the weekend. I caution both Ministers of State to be mindful that not meeting the criteria does not in the future get declared as a strategy to keep numbers off waiting lists.

I regard that as an intent to cause harm, and very serious indeed. It is disturbing that 15 children with eating disorders in Wexford are currently without a dietician. These are children. The two Ministers of State, Deputies Rabbitte and Butler, and I are parents. When we hear figures, they are figures, but these are children. They could be the children of the Ministers of State or my children, but they are all meaningful individuals who need care and attention. I put my faith in both of the Ministers of State.

Deputy Carol Nolan

I welcome the opportunity to speak on this important issue. The report by the Mental Health Commission should be the line in the sand that we need in improving acute psychological and psychiatric services. Unfortunately, there is nothing in our history in terms of the response of the State to reports of this kind that gives me or others any hope in this regard. We need only to look at the "Grace" case in that regard, and in particular what happens to whistleblowers within State-run organisations who attempt to highlight systematic failures. My fear is that once the review of all CHOs is complete we will be back here again in a short time to discuss yet another scandal of this kind and magnitude. The report notes unacceptable variations in the care being delivered. Some services offer treatment for eating disorders with family-based therapy, dietetics and cognitive behavioural therapy, with ready access to inpatient beds if required, while other teams cannot offer such a service due to the lack of resources.

The report also notes that there is not only variation in the delivery of care across the country but also considerable variation in care within a CHO. It is difficult, as the report observes, to see this as anything except a postcode lottery for children and their families in the treatment they receive. The postcode lottery is something of which we in rural Ireland are only too well aware. Within my constituency, HSE services that deliver high levels of complex care to children and young adults with a mental and physical disability in counties Laois and Offaly are experiencing a significant staffing crisis. I have raised that in the House previously. There are also delays in the primary care centre in Birr. All of that has a knock-on effect on children. I hope there will be progress with the primary care centre very soon.

Deputy Richard O'Donoghue

The initial report on CAMHS in the mid-west looks damning, with an emphasis on the 140 children that were lost in the system. However, on further investigation, it seems that CAMHS brought this to the attention of the Mental Health Commission. A senior clinician had left the service, leaving a caseload behind him. One person leaving could result in 140 vulnerable children being left behind. That was brought to the attention of the commission in advance of the investigation. I have questions in that regard. Why did this not emerge before the investigation? It was notified, yet 140 vulnerable children were left behind as a result of one person leaving the system.

I have a few helpful solutions to make CAMHS into a robust, positive service for mental health in all areas. I referred to 140 vulnerable children being affected by one person leaving. CAMHS is specialised at working with children, yet qualified people who are professional in the field must also be overseen to reach the necessary standard.

Resourcing is a major issue, and the problem can be fixed by additional resources. First, we must make it viable for people to go into these positions and help other children. Investment in IT and in other ways is the way forward to helping CAMHS.

Deputy Danny Healy-Rae

I thank Sinn Féin for tabling the motion because it is pertinent to what has happened in south Kerry and now in north Kerry as well. Many young children have been damaged by the lack of proper care from CAMHS. The HSE blamed a junior doctor in south Kerry, but what is the cause of the problem in north Kerry? It seems that there is a problem all over the country. It is very clear that when these boys and girls needed attention and help, it was not there for them. I do not think it is there at present either.

I am very disappointed about that because families were and are upset that their children will never be the same again. Antipsychotic drugs were pumped into them regardless of the problem they manifested, and no time was given to them. What happened was criminal. If it was any other place, I am sure the Garda would be called in to investigate what was going on. The HSE is not at the races when it comes to dealing with young children. Why is it the case that the most of those who are waiting for attention are in Kerry and Cork and not in Dublin or elsewhere?

Deputy Michael Healy-Rae

I thank Sinn Féin very much for bringing this very important motion before the House. In recent years I have been working closely with the parents of the children who, by the HSE's own admission, were significantly harmed. It was an extremely damning report. We had interim reports recently and we are now starting to examine the service in north Kerry, following on from the results of the investigation and its outcome in south Kerry.

This is a worrying time. I acknowledge the good work that was done by sound people, such as Michael Fitzgerald in Kerry. It would be wrong not to compliment people in the HSE who have been diligent about their work, faced with an enormous challenge that was none of their doing, but they were left trying to fix the situation and to put it right.

Sinn Féin will agree that those whom we must think about most of all in this debate are the children affected by the service they received from CAMHS in Kerry, and their parents and extended families. They are the ones whom we must worry about in the future, no one else.

Deputy Michael Collins

The lack of mental health services in Ireland is having a significant impact on people with mental health problems. Many people must wait months or even years to access services, which can be detrimental to their mental health and well-being.

Due to a shortage of mental health professionals, many children are not able to access the care they need when they need it or are able to access only limited care. The lack of mental health services can contribute to the stigmatisation of mental illness, as people may feel ashamed or embarrassed about their condition if they cannot access the help they need.

In the short time available, in addition to the problem with access for children to mental health services, I also wish to raise with the Minister of State, Deputy Butler, the situation with the mental health unit in Bantry General Hospital. I asked her to intervene in this issue. The HSE told me it would appeal the successful intervention, but it appears that will not happen now and that we are going to lose beds. It is an astonishing situation that the Deputy and Senator in west Cork seem to believe that it is a good deal. It is not a good deal; it is a shocking deal for the people of west Cork. We cannot afford to lose one bed, never mind the three beds in the unit that have been mentioned. I again urge the Minister of State to do what I have previously asked her.

Deputy Mary Butler

It is only until the end of March.

Deputy Michael Collins

We are going to lose the beds permanently. The decision has been made and it was not appealed. There has been a continuous lack of investment in the mental health unit in Bantry hospital by government after government. We are going to lose three beds permanently now because the appeal is not going to go ahead.

Deputy Mary Butler

It will not be permanent.

Deputy Michael Collins

The Minister of State should make an announcement or put it in writing that there will be no loss of beds in Bantry General Hospital mental health unit. If she does, she will be a hero.

Deputy Mary Butler

I was here last week for a Topical Issue debate and the Deputy did not turn up.

Deputy Michael Collins

The Minister of State will be the first person I will praise in west Cork if that is the case, but that is the announcement that the HSE made. I was told the HSE would appeal it, but the decision was not appealed when it went to court and now we are left in a situation where there will be a reduction in beds.

Deputy Mattie McGrath

I too welcome the people in the Gallery, family members and others, who are in this cruel system. I thank Sinn Féin for tabling this motion. It is so savage. My late brother was a paediatrician of some renown. I want also to mention tonight Professor Michael O'Keeffe, who succumbed to illness and was laid to rest at the weekend and who did so much for patients.

There are many good people in the HSE, including doctors, professors, ordinary staff nurses and so on, who do tremendous work. However, there is an issue with a management that is chaotic, callous, cold and sickening, to be honest. The fact is that children, our future generations, could be left to languish. I have had families and parents in my office who have to fight - I thank those parents who are so brave - scramble, beg, scrape, and try to work and hold their marriage, family and other siblings together. Can the Ministers of State not see the blockages that are there, cut out the deadwood and allow the good people, such as psychiatrists and others, who want to treat these children do so? They should get rid of the management structures and deadwood that are costing a fortune. Reports are gathering dust, as I am sure this one will. It is sad. It saddens me and those people I mentioned. Both my late brother and Professor O'Keeffe brought patients away from the HSE, voluntarily on their own time, and treated them free of charge. They had a basic interest, as do many others, but there is too much deadwood and layers of management that have cannibalised the HSE and the Department of Health, as the Ministers of State should know.

Deputy Joan Collins

Like everyone who read the report on CAMHS last week, I was shocked by the lack of care and badly needed reform provided by the Government for some of the most vulnerable children in this country. In common with everybody I have spoken to regarding this area, I am deeply worried about the Government's plans to address the crisis. These do not reflect the urgency of the situation and do not go nearly far enough to addressing the issue adequately.

Mental health is a real issue in Ireland. We need to put real resources in place to address it. We need a national director of mental health, who needs to report directly to the CEO of the HSE. There needs to be real accountability and oversight in the system. Brilliant work is being done in CAMHS and across our mental health services but staff are overworked and under-resourced. A national director is needed to implement that brilliant work across the service, develop a strategy that can be applied across that service, and be held directly responsible when things go wrong. The position of a youth mental health assistant director needs to be recruited for immediately. The money for it is there in the 2023 budget. The Government has committed to it and in the face of the CAMHS report there is no denying the urgency of this role. The situation cannot go on and we need the people in place to react to it straightaway.

The mental health (amendment) Bill needs to be prioritised by the Government. We need an immediate legislative response to this that is focused on filling the gaps in our current system and ensuring a human rights-based approach for anyone using our mental health services. The current legislation is out of line with international human rights standards.

The response needs to be more ambitious than the Government's plans. We need a commitment to have no more children or adolescents in adult psychiatric beds. We need an expansion of the CAMHS system to those aged 25 and older to reflect that most people experience the onset of mental health issues before that age and to stop the cliff edge of services ending for young people at the age of 16. A more holistic approach to care based on strategy and implementation of a real multidisciplinary approach is also needed, as is the expansion of services to provide for the missing middle, who are not accepted by CAMHS but are too high-risk for other services.

I support this motion tabled by Sinn Féin. There is a deep need across mental health services, especially in respect of children and adolescents. The reform needs to be broader and more ambitious than the Government's current approach and the services need proper investment, planning and oversight.

Deputy Catherine Connolly

I thank Sinn Féin and Deputy Ward in particular for tabling the motion. The motion is practical and includes two of the recommendations in Dr. Susan Finnerty's report. It calls for the Government to accept there has to be a clinical review, and that there will be a timeline for it and when it will be completed. The second recommendation is equally important: the immediate regulation of CAMHS under the Mental Health Act. Dr. Finnerty's report has pointed out that the Mental Health Commission has "no legal power to enforce any action". The commission continues to monitor the actions taken on foot of these escalations, which I will come back to, but it has no legal power to enforce any action. That is a damning indictment.

We are here again, just over a year since Dr. Maskey's report in January 2022, which followed on from the actions of a brave whistleblower. I hope the Ministers of State can correct me, but my understanding is that this doctor, Dr. Sharma, who was courageous, has been treated badly. He was sidelined and obliged to leave the country. I ask the Ministers of State to correct me if I am wrong. Is he working in Ireland? If they tell me quietly, I do not mind. My understanding is that this man has suffered as a result of his courage. If that is what has happened, it is an indictment of our system. If the Ministers of State tell me I am wrong about that, I will be the first to acknowledge it.

As I said, this interim report come after the Maskey review of south Kerry CAMHS in January 2022. I should declare a particular interest. In a different life, I worked as a clinical psychologist in a community care setting for many years on three-monthly contracts. When I got a permanent, pensionable job I refused to take it because it was advertised as a community care psychologist, which was brilliant. This was in the bad 1980s but the system sought to put us back under what was called at the time child guidance, which was a retrograde step that became this entity that has proven so unsuited to the job. Children with mental health issues of a nature that determines they must go to a facility like this should not be the norm. All our effort should go into prevention and education support, which was the model in the bad 1980s, when people could walk into the health centre in Ballinasloe and theoretically get a service. We have gone backwards.

Not alone have we gone backwards, we have endangered our children. This is according to Dr. Susan Finnerty, who felt obliged to produce an interim report, although she has not completed her review of all nine CHO areas. Her concern was such that she decided to issue an interim report "because of the serious concerns and consequent risks for some patients [she is talking about children] that we have found across ... 4 out of 5 [areas]". These concerns include the risks to safety and well-being of children receiving - or not receiving - mental health services, or receiving services they should not be receiving, such as medication that is unmonitored, the management of that risk and the lack of clinical governance. Dr. Finnerty goes on to outline all of that. She states that so far, in this review, the Mental Health Commission has "made five escalations of risk to the HSE", and further up to the Department, as regards risk.

Quite startlingly, Dr. Finnerty states: "There were no risks pertaining to CAMHS documented within the HSE Corporate Risk Register and therefore no documented actions..." This might be seen to be in bad taste but three monkeys come to mind, where we see, hear or speak no evil. There is no risk so we will not have any action on it - that is clearly set out in the report. The symbolism of the three monkeys was not used by Dr. Finnerty, in fairness to her. The report goes on to state:

In some areas reviewed, risk management was poor, with lack of communication and lack of actions to mitigate ... a haphazard documenting of risks and minimalist generalised actions ... on the CHO ... register [and] All teams were significantly below the ... staffing levels.

She pays tribute to the good work of staff on the ground but also highlights the serious problems, including large variation in services, families who are frustrated and upset, the inappropriate use of emergency departments in local hospitals, the failure to facilitate the free movement between primary care, which is non-existent, and these specialised services.

On medication, the report states, "There was evidence that some teams were not monitoring antipsychotic medication". There were no national standards but patients were not even being monitored in respect of international standards. There was no follow-up with appropriate blood tests and physical monitoring, which is essential. Children were lost to follow-up, which has been mentioned by many Deputies. The report states: "Of serious concern was that in some CAMHS teams children and young people with open cases, have been lost to follow-up." There were 140 lost cases in one team, and a limited desktop review was carried out to identify these children and so on. Audits of clinical practice were rarely carried out. Four of the five CHO areas that were visited used paper trails and no electronic recording. According to the report, we appear to have breached, which is a very moderate comment, the rights of children as set out under the UN Convention on the Rights of the Child, which the State signed and ratified in 1992.

The report continues:

In the CHOs that we have reviewed to date [and that is only five out of nine], it appears that this right may have been breached for many children ... [I do not think there is any "may".] The long waiting lists, the lack of capacity to provide ... therapeutic interventions, the "lost" cases ... all point to a breach of Article 24.

Even the team on the ground that wanted to escalate risks said it was pointless because when it did so they went into a black hole and nothing happened.

There is absolutely no ring-fencing of funds for CAMHS.

Then we have a special position: the child rapporteur. It has been vacant since last July, I think. There was good news today; the Minister announced that there is a new rapporteur. Can the Ministers of State tell me why there has been no rapporteur since last July? The previous rapporteur, Professor O'Mahony, presented his annual report to the Government, pointed out that the delay in publishing these reports, after the Government gets them from him and generally, is totally unacceptable and pointed out the difficulties in attracting somebody to that post. Why was the Government not proactive? Maybe the Ministers of State can answer. I do not know.

I am not here to give out; I am here to express my outrage and upset, having read this report, that this could be happening now, on our watch, and at the failure to monitor medication. The question has to be asked: what was the role of GPs in this? Was the medication just renewed by them? The Ministers of State might elaborate on that. Each person has a responsibility, as does each Deputy, to do his or her best. Where was that with the GPs or whoever renewed the medication?

Minister of State at the Department of Health (Deputy Mary Butler)

I reiterate what my colleague, the Minister of State, Deputy Rabbitte, said in her opening remarks and thank all Deputies for the constructive and positive contributions to this important motion on the issue of CAMHS. I thank Deputy Ward for tabling the motion. Many of the same speakers were present last Thursday evening for three hours. We are here again today for two hours. I will be in the Seanad tomorrow. I welcome any opportunity we can get to shine a spotlight on mental health. We might be on opposite sides of the House, but I acknowledge Deputy Ward's advocacy for mental health every week. It is important that in one of the main slots of the day we are here talking about mental health. We can never talk enough about it. I also acknowledge Valerie O'Sullivan in the Gallery and the other people who have sat through this debate from start to finish. As my colleague stated earlier, the Government and I are not opposing the motion. We welcome the opportunity to discuss the important topic of CAMHS, and I assure all Deputies that our children's physical and mental well-being is a priority consideration for the Government at all times. That has been reflected in the policies introduced to safeguard their well-being as well as the targeted initiatives outlined earlier by the Minister of State, Deputy Rabbitte.

There were questions about the mental health Bill, that is, the restructuring of the 2001 Act. That is queued for priority drafting at the moment and I will introduce it as soon as it is ready. There are approximately 140 heads in the Bill and it is complicated but it is scheduled for this session.

I wish to touch on what Deputy O'Donoghue said. He highlighted the issue of the 140 cases that were lost to follow-up in CHO 3, which encompasses the mid-west. He mentioned that there was a consultant no longer working there, with 140 files piled up. At that stage there were 3.5 consultant psychiatrists; there are now seven. Those files have now been dealt with. It just shows how easily there can be a pileup when there is not an adequate number of staff.

A couple of Members mentioned funding. We are reviewing the €11 million figure. It is likely associated with delayed recruitment to posts. Last year in the budget I allocated funding for another three eating disorder teams, more ADHD teams and a team for mental health with intellectual disabilities. It takes 12 to 18 months to recruit a full multidisciplinary team, but I reassure anyone listening that all the money for the mental health budget stays within mental health services and is not handed back or anything like that. My Department still has that money and it will be spent wisely.

As I have indicated on many occasions since becoming Minister of State, protecting the mental health of all our population, including young people, has never been more critical. The Mental Health Commission's interim report shows that despite the progress of recent years, our services can fall short. We were here 12 months ago debating the Maskey report. As a result of that report, I engaged with the commission. I knew that the commission was doing a thematic report on CAMHS and I asked it to expand it and to look much deeper. I also funded it to bring in consultant psychiatrists from Scotland and the North in order that Dr. Finnerty would have the support and the resources she needed to do it. We have five CHOs done - CHOs 3, 4, 5, 6 and 7 - with four to come. We will be back here in a few months debating this, but it is important that I have these two reports coming. I have the independent reviews coming from the HSE as well, and I will have the Mental Health Commission's full report, but the two of them are working in parallel. We will have data we never had previously. There was no point in my shying away from the Maskey report. I had to try to build confidence in all the CAMHS teams. I had to give parents and children confidence. The only way I could do so was to initiate a review and an audit. That is why we are here now, 12 months later, debating this. I welcome the report and welcome equally the focus on service delivery and patient safety. I noted last Thursday that I await both the commission's final reports.

The need to act decisively and to do what is necessary to protect children using our mental health services is of paramount importance. We are immediately developing a model of care for prescribing practices in CAMHS. In the coming days I will organise a series of round tables with relevant stakeholders, including the College of Psychiatrists of Ireland. The HSE has confirmed to the Department of Health that the issues raised in the Mental Health Commission's report are being proactively acted on at national level so as to mitigate risk throughout the system as a whole and beyond the CHOs reviewed to date.

As part of the opening statement this evening, the Minister of State, Deputy Rabbitte, highlighted a significant investment that has taken place in community organisations across the country. I thank all those organisations and their staff for the incredibly important work they do every day. As has been noted, only 2% of children will need the support of CAMHS specialist services, with the majority of mental health supports for children and young people being met within the community. The €80 million provided by the Government to community organisations in 2022 highlighted that a variety of pathways are available to access mental health supports. For example, Jigsaw was allocated approximately €12 million in 2022 to provide essential supports for children. Jigsaw provided more than 2,600 appointments last year and 85 mental health workshops. Along with the significant funding to that service in the past year, €1 million was provided to MyMind to continue to deliver free-of-charge counselling sessions to clients in more than 15 different languages. A further €1 million was provided through Mental Health Ireland for community and voluntary agencies promoting mental health and well-being. Telehealth services such as the seven-day crisis text line, 50808, also promote access to services, as do approximately 1,000 HSE-supported mental health services available through yourmentalhealth.ie, including further details regarding the services we fund: Belong To, Bodywhys, SpunOut, MyMind and many other State support services for young people.

We also know that technology often plays an important role in the lives of young people. The Department of Health and the HSE are determined to fully utilise opportunities offered by telehealth technologies to mitigate recruitment challenges and modernise delivery of mental healthcare. Telemedicine is a recognised part of healthcare in many parts of the world and has a history going back more than 20 years. Clinical staff are present in the room with the young person during the consultation, and initial service user feedback has been positive. In respect of telemedicine, the first consultation with the child or young person is always in person. It is something we have had to use especially in Kerry, where we have been challenged in filling the recruitment areas.

There are 500 more people working in mental health since this Government came into office, of whom 85 are working in CAMHS, but we have a lot more to do. I stress that any young person or his or her family who have concerns about their mental health or well-being should seek help without delay. Help is there, recovery is possible, and our wide range of care services provide real help that makes a tangible difference to many young people day in and day out. HSE Live is available to support any children or families with concerns arising from the interim report. Its freefone number, 1800 700 700, is open Monday to Friday from 8 a.m. to 8 p.m. and on Saturdays and Sundays from 9 a.m. to 5 p.m.

I take this opportunity to acknowledge the immense commitment and contribution our specialist CAMHS teams makes to so many young people every year. We can look back at the last few years and ask ourselves how we are faced with these challenges. We have seen an unprecedented 33% more referrals to CAMHS in 2020 and 2021. We also saw an unprecedented 225,000 appointments offered to young people last year. We have seen the CAMHS teams expand their remit to include another 21% of referrals with the same number of staff, so they have been working very hard.

I have visited quite a few CAMHS teams over the past 12 months, in Kerry, Waterford, Dundalk, Galway, Roscommon and quite a few more areas, and I notice that all the CAMHS teams vary. I was struck by the young people I met when I went along to CAMHS teams, especially on the day I was in Dundalk. I usually go quietly into these places because they are mental health settings. I go in on my own and I speak to the staff and I speak to the young people if they are available. I was struck by one young girl there who was exiting CAMHS after four years. She told me she had 96 appointments over the four years and she had been seen every fortnight for four years. One of the things I am particularly worried about, and I said this last Thursday as it is something I am looking into, is the rate of acceptances of referrals across the country. It is as low as 38% in some areas and as high as 81% in others. I am not a clinical person and I am told some children meet the criteria and others do not but there is a huge difference in acceptance rates and that is something I want to explore.

I thank everyone for their comments; everyone had something positive to offer and we all deal with this every day in our constituency offices. As I said, I will not be opposing this motion.

Deputy Matt Carthy

I commend Deputy Ward on bringing this important issue to the floor of the Dáil for a Private Members' debate. I thank the Ministers of State, Deputies Rabbitte and Butler, for being here. I do not say the following to many Ministers or Ministers of State but I accept the sincerity of both when it comes to this issue and their bona fides that they want to address many of the issues and challenges that have been raised here tonight. However, that does not mean they can extradite themselves from the failings that have been exposed in recent weeks, some of which came as no surprise to many families the length and breadth of the country.

The Mental Health Commission was able to establish that there was a category of children who were lost from the service, children who were registered with CAMHS and who did not receive the necessary follow-up. I reiterate the call of the Minister of State to tell people, including parents, children and teenagers who need support, to seek it. My experience from listening to people who have accessed it is that when the CAMHS system works, it works exceptionally well. It saves lives, both in terms of physical lives and in giving new leases of life to those who benefit from the service. However, the counter is also true. When it does not work and it fails children, it has negative life-changing consequences for the rest of their lives.

When we hear that the number of children waiting for an appointment in CAMHS has increased by 86% since this Government took office, with nearly 4,000 waiting for their first appointment, that is deeply concerning. When we hear that 741 people had to present themselves in an emergency room last year, that is a fundamental problem. I welcome that the Government is not opposing the motion tonight. Deputy Ward has set out in the motion the solutions and steps that need to be taken to resolve the issue, to ensure that everybody who experiences the CAMHS system has a positive experience and that their lives are changed for the better. My call on the Ministers of State and the Government is not just not to oppose the motion but to actively support it and, more important, to implement the measures within it.

Deputy Pearse Doherty

Every child deserves an opportunity to reach their full potential. The State ratified the UN Convention on the Rights of the Child in 1992, and a child's right to the highest attainable standard of health, including mental health, is indivisible from other rights of the child. The Ombudsman for Children made that clear in 2018 in his report. He said that in the case of children and young people experiencing mental health difficulties, fulfilling this right means providing them with the mental health services they need, when they need them and where they need them. On that measurement or slat tomhais we are failing our children.

When we discuss this we need to put ourselves in the shoes of that young child, boy or girl who is sitting at home and for whatever reason feels there is nothing to live for any more or whose anxiety paralyses them to the point that they cannot even step outside their front door. We could also put ourselves in the shoes of a family that has seen their young child blossom into a young teenager and that is struggling because they cannot support or help them and do not know how to help. We should imagine the torture of all of that but one of the other tortures is the fact that they know there is help but they cannot access it because CAMHS is not available to them. That is the reality for far too many children. Parents are sitting at home knowing their children potentially have suicidal tendencies but they are on waiting lists for months to see the specialist who may be able to work with that child and help them with their illness.

In Donegal, for example, we have 300 people on waiting lists and 100 of them have been waiting for over six months. Our waiting lists have gone up by 86% since this Government has come into place. We can have all the nice words and all the rest, and nobody in this Chamber does not want to protect those children I am talking about, but we have to recognise that the Government is failing spectacularly. One child being failed is one too many and the fact that we have lost children, as detailed in this report, is devastating, but so many individuals are lost because they are not able to get the services that can help them at the time they need them.

This needs to be fixed urgently. I commend Deputy Ward on the motion he has brought and the solutions he has advocated for. I would strongly urge the Government to take those on board. It is failing on this because the indicators are all going in the wrong direction. This is not about politics; it is about children who need help and that help is there. These teams need to be resourced, empowered and extended to 25-year-olds and I mention the issues Deputy Ward and our colleagues have raised in the past.

Deputy Mark Ward

I also want to acknowledge the Ministers of State, Deputies Rabbitte and Butler, for their time tonight and last week on this serious issue of CAMHS. I will not question their bona fides or interest in mental health but interest is not enough; we need action. I am tired and frustrated and I have listened to all the contributions and there seems to be a lack of action. My frustration is nothing compared with the frustration the people in the Gallery feel when they are trying to get the care their children and families need. I mention the many people at home who are listening and the number of people who have contacted me in recent months.

The Government has a tactic of not opposing motions but there is a difference between not opposing motions and supporting them. It is a political game and if the Government does not oppose the motion then it does not have to vote against it when it comes down to it. I want to see the solutions I spoke about in the first part of the debate put into place. By not opposing this motion the Government is admitting that it has failed. It has failed the 4,000 children who are waiting on CAMHS lists for initial assessments. When this Government came into office there were only 2,000 children on CAMHS waiting lists; that is an 86% increase. The Government has failed the 13,000 children who are waiting for primary care psychology appointments. When this Government came into office that figure was 7,700; that is a 71% increase under this Government’s watch and that is not acceptable.

The Government has failed with the 14% increase in young people who are accessing Pieta House for counselling. I met Pieta House representatives during the week who told me that children as young as five are accessing Pieta's suicide and self-harm services. The Government has failed the children who are reliant on a postcode lottery for treatment. For example, there is a four-week waiting list for an appointment for a child or young person if they live in Wicklow but if you are a child or young person living in Cork, you could be waiting up to 30 weeks for that appointment, which is just not good enough. It was mentioned already that 741 children are admitted to hospital for mental health difficulties after presenting to accident and emergency departments. The report outlines this and I think there is a failure on the part of GPs because they feel they have no choice but to refer children into accident and emergency departments to get a psychiatric evaluation. They do so because they know the waiting lists in CAMHS and other services are not being dealt with.

There are also children who are waiting to be admitted into specialist inpatient care. There are fewer CAMHS beds available now than when this Government came into office. Only 51 of the 72 available beds for CAMHS are currently occupied. There are a further 16 beds - I hoped the Minister of State, Deputy Butler, would mention it in her closing remarks - in danger of closing in Cork at present, according to a statement during the week from the Psychiatric Nurses Association.

This issue regarding admitting children into psychiatric wards was raised at the UN Convention on the Rights of the Child in Geneva during the week and the Government responded to that committee stating that Ireland may never reach a point of no child being admitted to adult units, which shows a significant lack of ambition in this regard. We need to adhere to international human rights standards.

There were 32 admissions of children to adult units in 2021, up from 27 in 2020. Those 32 children spent 217 days in total in adult psychiatric facilities. This is Draconian and it is a violation of human rights.

By not opposing this motion, the Government is agreeing to the Sinn Féin call to legislate for this issue. I know the systems are not in place now. I live in the real world, but we have to be ambitious. We have to put services in place. We have to say that putting children into adult psychiatric facilities, whether they are 16 or 17, or younger than that, is not good enough and we must put measures in place to stop that. If that requires legislation, that is what we are calling for.

I mentioned statistics. I mentioned solutions at the start of this. Behind every one of those statistics is a child with hopes, dreams and ambitions, a child with a family who are lost with what is going on for them in trying to get the right care for their child at the right time and the right place. It is a ripple effect. As was said already, there is no greater crime than denying a child the chance to reach his or her full potential.

The Minister of State, Deputy Butler, did not oppose this motion. I have never pleaded with anybody in the Dáil previously but I am pleading that the Minister of State put the solutions that Sinn Féin brought forward into place.

Question put and agreed to.