Dáil Éireann díospóireacht -
Thursday, 16 Feb 2023

Vol. 1033 No. 5

Health (Amendment) (Dual Diagnosis: No Wrong Door) Bill 2021: Second Stage [Private Members]

Deputy Mark Ward

I move: "That the Bill be now read a Second Time."

I am sharing time with my co-sponsor, Deputy Gould.

The Health (Amendment) (Dual Diagnosis: No Wrong Door) Bill 2021 is important legislation that aims to plug the gaps between mental health and addiction services. This was one of the first pieces of legislation I submitted after I was elected. The reason was that, having worked in front-line addiction services, I have seen at first hand how vulnerable people can fall through the gaps between addiction and mental health services.

For the purpose of this Bill, dual diagnosis refers to the diagnosis of people who present for treatment with both substance misuse and mental health conditions. People who have a dual diagnosis often fall between the gaps. Addiction and mental health often go hand in hand. Addiction may lead to the onset of a mental health issue or a mental health issue can lead people to use substances as a coping mechanism. Due to the inadequacies in the State's mental health systems and addiction services, people can turn to drink and drugs to give calm to an anxious inner world. They basically self-medicate and this is where problems can occur. The mental health problems remain but are added to by an addiction.

This Bill will mean that no matter what door a person knocks on for help, whether for addiction or for mental health problems, they will be treated with dignity. One simple way to begin this process is to resource addiction and mental health services to produce a joint care plan. A joint care plan between addiction and mental health services needs to be developed to ensure people get the care they need when and where they need it. There can be no wrong door when it comes to dual diagnosis.

Having worked in front-line services, I know that compassion, empathy and understanding are at the core of many of our addiction services, but unfortunately they are not resourced or supported to deal with dual diagnosis. People do their absolute best when someone arrives at the door but they do not have the necessary resources to treat that person. Due to the way the HSE works, if an organisation is not given funding to deal with dual diagnosis and it does something outside its funding, it can be penalised.

This legislation will progress the provision of dual diagnosis services, which would have a knock-on effect for individualised case management plans. We must recognise that addiction is not a stand-alone issue. Wraparound supports and services are the only way to help people properly succeed in their recovery. In Sinn Féin's alternative budget, provision was made for funding for a mental health nurse to work in each of the 24 local drug and alcohol task forces. This is just one solution to strengthen teams and to ensure addiction services have the appropriate experience to treat people with a dual diagnosis. Keltoi, a trauma-informed State-run residential facility which treats addiction and mental health co-morbidities, was temporarily closed in March 2020 during the Covid-19 pandemic, but it is still not open three years later. This must be a priority. I will touch on that again in my closing statement. A number of stakeholders have contacted me recently who are desperate to get a proper dual diagnosis service in place.

Last year I was at the launch of a report by Mental Health Reform called Dual Recovery which is "A qualitative exploration of the views of stakeholders working in mental health, substance use and homelessness in Ireland on the barriers to recovery for individuals with a Dual Diagnosis". One of the findings was that mental health teams need to be trained in addiction and addiction teams need to be trained in mental health. That is the core of this issue. There must be understanding. Staff do not have to know how to fix it, but they must know where to get help. It basically involves simple signposting arrangements. The report also recommends staff have an understanding of how a dual diagnosis affects people and what they do. I fully support the recommendations published by the Mental Health Reform report, including the urgent implementation of a fit-for-purpose model of care; the development of an awareness-raising campaign on dual diagnosis and dual recovery; the provision of ring-fenced funding to support dual diagnosis treatment in existing services; and improving access to housing and social inclusion.

The recent announcement about the citizens' assembly on drug use is welcome. This is a conversation that needs to happen. We must ensure people who have a dual diagnosis are central to this conversation and that their voices are heard. We must ensure they do not fall through any more cracks. I am aware the Minister of State has tabled an amendment to the motion for a Second Stage reading proposing that it will be read a second time 12 months from now. While I would much prefer it would be dealt with now rather than kicking it down the road, I will accept the amendment. It makes sense with respect to the upcoming programme of work including the citizens' assembly on drug use, the mental health bill that is being drafted - I am on the committee that will deal with that - and the amendments to the Health Act 2004 which are currently being progressed. I will accept the Minister of State's amendment in good faith and I will work with her, as I have said from the first day I took this role, to ensure dual diagnosis is at the heart of this year's programme of work. In an ideal world, if the Minister of State's Department does the work, there will be no need to read this Bill this time next year. If the model of care, which I will touch on in my closing statement, the citizens' assembly, the mental health Bill and the Health Act are all inclusive of dual diagnosis, there will be no need to read this Bill a second time next year, but I will hold the Minister of State to account on that.

Deputy Thomas Gould

I will begin by thanking my colleague, Deputy Ward, for the hard work he has done on this legislation. I am familiar with the work he has done. Without him and other groups who work on the ground, we would not be here today discussing this Bill. Mental Health Reform has been especially supportive but conversations with groups such as CityWide, Soilse and others have helped us to get here today. The knowledge and experience they have shared with me and Deputy Ward has been invaluable and I take this opportunity to thank them for meeting us, sharing their experience and helping us to build a Sinn Féin policy that reflects what is actually happening and what people are facing on the ground.

Dual diagnosis, when a person presents with both a mental health illness and active addiction, is a complex area, but it is an area on which we must move forward. A study by Mental Health Reform found that individuals with a dual diagnosis face significant barriers to accessing appropriate care. Those barriers include poor collaboration between services, a lack of training for health and social care professionals, and limited access to planned and continued care. Participants also highlighted a number of social barriers, including homelessness, housing insecurity, social exclusion and stigma.

The Bill is entitled the Health (Amendment) (Dual Diagnosis: No Wrong Door) Bill. It is vital that we emphasise the importance of there being no wrong door. At present many doors are closed to those presenting. They are often forced to wait until they are in crisis, at which point they present to already overburdened and understaffed emergency services that are not equipped to help them.

The closure of the Keltoi rehabilitation unit was a huge blow to those helping people in addiction and working with those with mental health issues. The one facility we had that was properly equipped and trained to intervene in the most serious dual diagnosis cases was closed by the Government in March 2020, almost three years ago. It remains closed. This was a facility with evidence-based trauma-focused health interventions that offered wraparound care and treatment to those who desperately needed it. An independent review of Keltoi found that despite dealing with the most complex of cases the facility had a 10% higher success rate one year after treatment than many others. The Bill would not reopen Keltoi but it would force the HSE to lay out plans to provide services such as those of Keltoi throughout the State. It would be a step towards addressing the postcode lottery of dual diagnosis services that exists.

Dual diagnosis can come in many forms. People can have severe mental health issues and minor addiction issues or vice versa. Addiction can be used as a means to cope with mental health issues or mental health issues can develop from addiction. We welcome that a clinical lead has been appointed for dual diagnosis. We believe the Bill will give that person and the HSE a stronger statutory footing for the development of services. The Bill speaks to a commitment given by the Government and would aid it in progressing the commitment. We are not interested in political point scoring. We are interested in giving people the dignity and respect they deserve. We want to make sure that services are not forced to turn people away. When people need help, whether for mental health issues or for addiction issues, they need support.

We welcome the announcement this week of a citizens' assembly on drugs to begin work in April. We will engage with it and we hope it will be as positive as the other citizens' assemblies have been. In saying this, I note the Government intends to delay the Bill for 12 months. People need services to be provided. They cannot be waiting for a long time. Deputy Ward has said he will work with the Minister of State and we will work together to be constructive and positive. I hope I am not being cynical and I agree with Deputy Ward's hope that in 12 months' time we will not need to repeat Second Stage because the Government will have moved forward. We will work with the Government, the Ministers of State, Deputies Butler and Naughton, and the Department to try to achieve this. I hope we can do so but only time will tell.

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

I move amendment No. 1:

To delete all words after “That” and substitute the following:

Dáil Éireann:

— recognises that the Citizens’ Assembly on Drug Use will consider the legislative, policy and operational changes the State could make to significantly reduce the harmful impacts of illicit drugs on individuals, families, communities, and wider society;

— recognises the Mental Health Bill being drafted for introduction to the Oireachtas this year, which will allow further debate on this Bill to take place in the context of new, more progressive mental health legislation;

— recognises that amendments to the Health Act 2004 currently being progressed need further discussion, as the Bill as written will have impacts on the operation of other provisions in the Health Act 2004; and

— resolves that the Health (Amendment) (Dual Diagnosis: No Wrong Door) Bill 2021 be deemed to be read a second time this day twelve months.

I begin by thanking Deputies Ward and Gould for initiating the Bill on Second Stage and for providing an opportunity to discuss the very important topic of dual diagnosis for people with a mental health difficulty. I am delighted to be joined by the Minister of State, Deputy Naughton, who has responsibility for the national drugs strategy.

The Health (Amendment) (Dual Diagnosis: No Wrong Door) Bill seeks to amend the Health Act 2004 by inserting a definition of dual diagnosis in the interpretation section of that Act and by amending the general obligation on the HSE in section 31(3) to prepare a service plan outlining the type and volume of health and personal social services to be provided, including a specific requirement to include dual diagnosis in the HSE national service plan.

The Private Members' Bill is not being opposed as the Government recognises the challenges that those with a dual diagnosis face in accessing services appropriate to their needs. However, I and my colleague are seeking approval for a 12-month timed amendment to the Bill. This is for a number of reasons, which I will discuss and to which reference has been made.

Deputies may be aware that the Government this week agreed to establish a citizens' assembly on drug use. I know this has been welcomed throughout the Oireachtas. The citizens' assembly will be asked to consider the legislative, policy and operational changes the State should make to reduce significantly the harmful impacts of illicit drugs on individuals, families, communities and wider society. It would be prudent to allow the citizens' assembly to carry out its important work before the Second Reading of this Bill. This citizens' assembly will be an invaluable opportunity to discuss drug use in Ireland in an holistic manner and letting it take place prior to the Second Reading will provide for a more informed, comprehensive debate on the issue.

The Department of Health is progressing a mental health Bill to overhaul significantly our existing mental health legislation. A timed amendment of one year will allow the mental health Bill to be drafted and introduced to the Oireachtas and allow further debate on this Bill to take place in the context of new, more progressive mental health legislation. As I said to Deputy Ward earlier, the Bill has received priority drafting. There are three drafters working on it in the Office of the Attorney General and officials in the Department are doing phenomenal work. It is a massive piece of work. It is one of the biggest Bills I have ever seen. It is very important that we would be able to enact it and I thank Deputies Ward and Gould for their co-operation.

The Private Member's Bill as written would have impacts on the operation of other provisions in the Health Act 2004. As I have said, departmental officials are preparing a Bill to amend the 2004 Act. The purpose of this Bill will be to make amendments to the Health Act 2004 to include provisions primarily related to HSE service planning and financial management. It will formalise certain developments, requirements and timelines for specific documents, such as the replacement of the national service plan with a performance delivery plan. The Bill will also contain provisions relating to the transfer of functions with regard to disabilities and other miscellaneous items. A timed amendment of one year will allow discussions on this Private Members' Bill to take place in the knowledge of what the planned amendments to the 2004 Act will be.

Dual diagnosis is the term used when two medical conditions are present at the same time. Within mental health, dual diagnosis might mean a person experiencing a mental health difficulty and an addiction or a disability such as autism. Given the definition of "dual diagnosis" provided for in this Bill, I will limit my intervention to dual diagnosis of mental health and addiction difficulties.

The Government acknowledges that access to mental health services for those with a dual diagnosis has been an issue and can cause great distress for some. This has been recognised and the Government is actively seeking to improve our dual diagnosis services at policy and implementation levels. The Government is committed to improving all aspects of our mental health service, including dual diagnosis, in line with Sharing the Vision, which is the first national mental health policy to acknowledge dual diagnosis, and in line with Connecting for Life, our national strategy to reduce suicide.

Budget 2022 saw an unprecedented level of funding, totalling €1.149 billion, allocated to the overall mental health budget. This continued with a record €1.2 billion allocated to mental health services in budget 2023. This will allow us to progress a variety of mental health initiatives aimed at supporting people in crisis and to continue to improve mental health services to the benefit of all, including those with a dual diagnosis. New development funding in 2022 was also provided to allow further implementation of Sharing the Vision. Investment in 2022 of €750,000, with a full year cost of €1 million, was provided to enable the continued expansion of the specialist teams under the dual diagnosis clinical programme.

The HSE is a key stakeholder in the implementation of the recommendations of Sharing the Vision and sits on the national implementation monitoring committee for the implementation of the 100 policy recommendations. The work of the national implementation monitoring committee continues to progress following its establishment late last year. It is tasked with driving and overseeing implementation of the policy's recommendations, including those relating to dual diagnosis. Good progress is being made on the detailed implementation plan.

Sharing the Vision recognises that people with a dual diagnosis should have access to appropriate mental health services and supports by addressing existing service gaps and developing stepped and integrated models of care. Recommendation 57 states that a tiered model of integrated service provision for individuals with a dual diagnosis should be developed to ensure that pathways to care are clear. The HSE dual diagnosis improvement programme also emphasises the need for integrated services across primary care and specialist mental health services. Dual diagnosis is a particularly important area, as we know that service users living with both substance misuse and mental health difficulties are often among the most vulnerable in society.

The needs of people presenting with substance misuse and mental health difficulties are complex and may be coupled with other issues, such as poor physical health or homelessness. The HSE has recognised the need to improve services for people with comorbid difficulties and that an integrated approach between mental health and addiction services is necessary. The HSE clinical programme for dual diagnosis was developed to respond to this need.

The aim of this important programme is to develop a standardised evidence-based approach to the identification, assessment and treatment of comorbid mental health difficulties and substance misuse. This includes the following: increasing awareness of the frequent co-existence of mental health difficulties and substance misuse; ensuring there is a clear clinical pathway for management of people with such a dual diagnosis, including when they present to emergency departments; ensuring a standardised service is provided throughout the country; and ensuring adolescents are also included within the scope of this clinical programme. Work has already taken place to progress this aim, including the appointment of a national clinical lead and a programme manager and the establishment of a national steering group.

A key and integral part of the dual diagnosis programme is the development of a model of care. The HSE model of care for dual diagnosis for adults and adolescents of ten to 17 years of age has been drafted. The draft is currently with the College of Psychiatrists of Ireland for approval and the college is actively considering the model this month. I hope to see the model approved by the college later this month and its publication by the HSE shortly thereafter.

The overarching aim of the model of care will be to ensure a clear clinical pathway for all adolescents and adults suspected of having a dual diagnosis, as well as access to a timely mental health service nationally. The model of care has been developed in collaboration with recovery agencies and advocacy groups that represent the experiences of service users. It is vital that the voice and lived experience of people needing services is at the centre of developments. The model of care will be delivered on a community healthcare organisation, CHO, basis and provided in an integrated manner across the primary care division and the mental health service, in collaboration with the acute hospital groups.

One of the key components of the model of care is the establishment of specialist teams to support individuals with a dual diagnosis. The model of care recommends 12 adult specialist dual diagnosis teams nationally and four adolescent hub teams, each with 13 whole-time equivalents, including clinical and administrative staff members.

CHO 3, which covers Limerick, Clare and north Tipperary, was identified as the first adult dual diagnosis site, with many of the team members already recruited. CHO 4, which covers the areas of Kerry, north Cork, north Lee, south Lee and west Cork, has been identified as the second adult dual diagnosis site and the recruitment process has commenced there too, with the consultant post currently being advertised. CHO 9, which covers the areas of Dublin north, Dublin north-central and Dublin north-west, has been identified as the first adolescent dual diagnosis site, with posts being advertised shortly for this team.

Discussions are also under way to establish the HSE national dual diagnosis rehabilitation centre, as recommended in the model of care. A two-tier training programme also recommended as part of the model of care is currently being examined by the HSE, with a view to identifying gaps in existing training and plans to ensure that training is available to meet needs in the initial sites as roll-out begins.

Additional adolescent and adult teams for 2023 and 2024 will roll out according to the resources available for the dual diagnosis programme in the HSE's national service plan and the Government will continue to fund these posts within the annual Estimates process. It takes between 12 and 18 months to put a full multidisciplinary team in place and it is very important that the annual funding continues. Work also continues between the HSE national clinical programme for dual diagnosis and community partners to ensure local responses to dual diagnosis will complement the roll-out of the model of care.

Work on the use of digital interventions to support individuals with a dual diagnosis is being progressed collaboratively in the HSE between the national clinical programme for dual diagnosis and community alcohol, social inclusion, digital and mental health digital divisions. In addition, the HSE and Mental Health Ireland have developed a resource for people affected by dual diagnosis, at drugs.ie. The website provides advice for people to look after their mental health during crisis, including how to access mental health and addiction services.

Government policies including Sharing the Vision and Reducing Harm, Supporting Recovery set out clear commitments to improving services for people with a dual diagnosis. The cross-government high-level justice task force to consider the mental health and addiction challenges of those who come into contact with the criminal justice sector examined dual diagnosis among individuals who come into contact with the system. The task force was established in 2021 to meet the Government's commitment to ensure the critical mental health needs of people in prison are met, addiction treatments are provided and appropriate primary care supports are available on release. Overall, the task force put forward 61 recommendations which emphasise the shared responsibility of a number of Departments and Government agencies to deliver on meeting the needs of those with mental health and addiction challenges in contact with the criminal justice system. It is recognised internationally that vulnerable people with mental health and addiction challenges are over-represented in our criminal justice systems. We have a responsibility to ensure that as many as possible within this population are diverted away from the criminal justice system and provided with the appropriate health and social care supports.

We all know there is no quick-fix solution to the challenges highlighted by the task force. No one service can address the change needed on its own. The task force's final report, published last September, provides a clear path forward on how we can achieve this and work together to improve supports in the key area of forensic mental health care involving all relevant front-line agencies. The task force's recommendations relating to the health sector will be progressed in line with Sláintecare, Sharing the Vision and other relevant health policies, including the prioritisation of dual diagnosis services for vulnerable people with mental health and addiction challenges, and they will help to reduce the root causes of offending behaviours.

I thank Deputy Ward for accepting the amendment. Any time I speak here about mental health, I welcome the opportunity to speak about Government's commitment to improving these services. I look forward to discussing the Bill in 12 months' time, although maybe we will not have to, at which time I hope the citizens' assembly will have taken place and our dual diagnosis services will be further developed.

An Cathaoirleach Gníomhach (Deputy Marian Harkin)

From Sinn Féin, I call Deputy Ó Murchú, who is sharing time with Deputies Martin Browne, Patricia Ryan and Pat Buckley.

Deputy Ruairí Ó Murchú

I thank Deputies Ward and Gould. It is decent legislation and is absolutely necessary. We can even hear that from what the Minister of State has said. We all accept that dual diagnosis is a particular issue. It is almost the crossover between two huge issues that we are all dealing with. As politicians, we become well aware of some of these cases and, unfortunately, some of the cases we end up dealing with are particularly difficult.

We need to create a scenario where there is no wrong door. What is being proposed in this legislation, and what the Minister of State is accepting, is to lay out a legislative framework and a pathway to get to a better place as regards there being no wrong door for dual diagnosis, call it what you will. It is about ensuring we get to this point. We are talking about front-line services and ensuring those who work in addiction services and mental health services are properly trained in regard to dual diagnosis.

We know the issue is far wider than that and that this is necessary legislation. Hopefully, it is legislation that will not be needed in a year’s time and that what the Minister of State is promising will be seen to be delivered for those people out there. Beyond that, we will have to deal with the particular issue of hospitals and ensuring that an accident and emergency unit is not the wrong door. That is all well and good, and we can set the correct legal framework and put the correct legislation in place, but if we do not resource and train those people with the necessary skill sets and put them in position, we will still be dealing with the issue that we are dealing with today.

The matter was very well put by all the previous speakers. It is almost a chicken and egg issue in regard to dual diagnosis. I remember that Derek Pepper of Shine spoke at an event lately to remember Harry Taaffe, who we lost. It was a Dundalk FC event and Harry had done a huge amount of work for them over many years.

We recall with sadness the loss of Harry. I remember something Derek had spoken about previously, which was the fact that we all have within us, within the brain, a hand grenade. I think that was the term he used. He said anything can be the trigger that releases this in relation to mental health issues. We all know the issues there are with drug addiction, drug abuse and the issues there have always been with alcohol abuse and alcohol addiction, especially in this country. These can obviously be the means by which this grenade is released. Then it is a case, first of all, that the person is not going to get better unless there is a medical plan and gets the treatment needed. Unfortunately, this can for many of them be a recurring problem over many years, so it does not help when we have services that are not trained, not resourced sufficiently and basically turn people away.

We have all dealt with families and individuals that have been going through absolute psychosis. We all know gardaí deal with this on a day-to-day basis. We all know that at times people are brought up to the accident and emergency department in Drogheda and sometimes, depending on whether a doctor does or does not sign a form, they may be brought to Crosslanes, which is the department of psychiatry in the town. Then we deal with the dual diagnosis question. There are really no winners with that and we have a huge amount of people with a considerable amount of issues that are never actually dealt with. We can individualise these issues and deal with addiction and mental health services.

If we look at this from a hospital and HSE point of view, we know all the positions that are not filled and the positions that should be there. Whether we are talking about nurses, doctors, occupational therapists or psychologists, we all know the workforce planning and everything that needs to be done. I would hate to be the person dealing with addiction services at this point in time. We are all aware of people who have worked in the field of addiction services and the incredible pressure they have come under. At times people have been broken just by the amount of issues they are dealing with. The particular issue that arises when this grenade is released can mean somebody has no right door to go to at that point in time. We obviously need to ensure the front-line services are dealt with and that they are sufficiently resourced. We need to ensure we have all those positions and all the skill sets required from the point of view of delivering.

Beyond that, we must look at how we deal with the issue of hospitals, accident and emergency departments and emergency services. We will have multiple conversations here, probably until the end of time, about multidisciplinary strategies. The other thing we all love talking about is a whole-of-government approach. However, when we are dealing with these issues we need to ensure we have multidisciplinary teams. We need to ensure we can bring to bear what is necessary. The other thing is, as I said, when one is dealing with emergency services the main difficulty is at times we do not have the early interventions that are the easier ones. We have dealt with the issue of people with eating disorders. The Ministers of State know we do not have the positions for dieticians and other services required to allow us to possibly intervene at an earlier stage and deal with those issues. We need to get all our ducks in a line.

This legislation and the trajectory the Minister of State, Deputy Butler, is talking about are positives but we must ensure we can deliver on them. We need to do a wider piece of work. The Minister of State was talking about evidence-based approaches. If we look at CSO figures for my part of the world it can be seen we are utterly underrepresented when it comes to mental health teams and all the services that are required. We also know we have had fill-in services, whether in addiction or mental health. There are people there out of need and necessity whose families suffered from these particular positions. I am talking about the Family Addiction Support Network and Turas in Dundalk and the RedDoor in Drogheda. That is just dealing with the issues around addiction, family supports and all the rest of it. I think we are all very glad the citizens' assembly has been set for April. We must ensure we engage all the stakeholders along with the citizens and that we see best practice, whether domestically or internationally. It needs to happen because we all know the particular issues our communities are dealing with, from addiction to drug debt intimidation, and the sheer pressure individuals are put under.

The last point I will put to the Ministers of State is a specific constituency issue concerning Our Lady of Lourdes Hospital in Drogheda. It has a mental health liaison team that is in operation during office hours but we do not have a service beyond that. I think there have been discussions on it. It is a major failing because as we all know, when we are dealing with issues of psychosis and other such issues, and when gardaí and everyone else are dealing with them it is generally in the evening and night-time hours. That is something that has to be addressed. There are probably sufficient resources to put that in place at this point in time and we just need an agreement. That obviously involves all the players, including the department of psychiatry, the Royal College of Surgeons in Ireland Hospital Group and Our Lady of Lourdes Hospital.

Deputy Martin Browne

I commend Deputies Ward and Gould for this Bill. It provides for something that has been missing for far too long. We need only ask the voluntary organisations that try to fill the gaps left by the State. They will describe the level of demand they have for the services they provide in the area of combined addiction and mental health and how the State does not provide for it adequately. In my time in this House we have spoken about dual diagnosis on a number of occasions. We have outlined shortcomings in service provision on the State's part. I have outlined to the House how the former voluntary organisation Carmha Ireland in Nenagh was concerned about its future because it was prepared to go the extra mile while the State dithered and clinical lead positions remained vacant and action stalled.

As the Minister of State knows only too well, the nature of mental health issues and drug addiction is complex. However, there is no-one for whom it is more complex than the person dealing with these issues and those trying to get help for him or her. As in other areas of the health services, including mental health, dietary and so on, people can get moved from pillar to post because their needs do not fall into step with whatever services are available. This causes people who find themselves in these kinds of situations to fall through the cracks and go without the treatment they so badly need. Mental Health Reform, in its research on barriers to dual recovery for individuals with a dual diagnosis, spoke of the lack of interagency collaboration when it comes to helping people with dual diagnosis. Deputies Ward and Gould are seeking to address this through the no wrong door Bill. We need to see a joint care plan between the addiction and mental health services developed so no matter what door people knock on for help with addiction and mental health problems they will be treated appropriately and with dignity.

Like my colleagues, I understand the Government is accepting the contents of the Bill as is and I acknowledge and welcome that. However, I ask that the Government does not play politics with it by accepting it and then kicking it down the road. As was said earlier, we welcome the citizens' assembly and look forward to its recommendations and to working with it and the Ministers of State to implement its findings. Will they assure us they will not put this Bill on the long finger and will enact it for the benefit of the many people out there who need it and what it provides for?

Deputy Patricia Ryan

I thank my colleagues, na Teachtaí Ward and Gould, for bringing this Bill to the House. For far too long individuals with a dual diagnosis, which means having both a mental health and a substance abuse issue, have been left without adequate support and care. The current system often means individuals are passed forward and back between different services. This leads to confusion and a lack of continuity of care. The proposed legislation aims to address this by ensuring those with a dual diagnosis have access to streamlined and integrated services. The no wrong door approach of this Bill means persons seeking help for a mental health or substance abuse issue will be directed towards the appropriate service, regardless of where they first seek help. The approach removes any unnecessary delays in assisting the necessary services to ensure the best possible outcome for those in need.

The Bill also seeks to increase the number of mental health and addiction specialists to ensure individuals with a dual diagnosis receive the best possible care. By expanding the range of services available and providing greater access to professionals with expertise in this area, the Bill aims to help individuals with a dual diagnosis to manage their conditions and live their lives to their full potential.

The Bill also highlights the need for greater collaboration between mental health and addiction services. By bringing these services together and working in partnership, we can create a more comprehensive system that meets the needs of those with a dual diagnosis. This is a very positive step forward in mental health and addiction care in Ireland. It will undoubtedly have a significant impact on the lives of those with a dual diagnosis, providing them with greater access to the services they need to manage their conditions effectively.  For too long, mental health has been the poor relation of the health services. Sadly, delays in diagnosis and treatment cost lives. These are not only statistics. They are our parents, siblings, children, spouses and friends. Services must improve and implementing this Bill is a good step along the road.  I am also aware that Deputy Ward will accept the amendment. I would like to think as well that we will move forward more quickly than the 12 months, if possible.  

Deputy Pat Buckley

I acknowledge the work Deputies Ward and Gould have put into this. I also acknowledge that the two Ministers of State are here and that there is a joined-up consensus. The Minister State, Deputy Butler, would have been aware, as well as the former Minister of State, former Deputy Jim Daly, and the Minister, Deputy McEntee, that sometimes there is no colour, class, creed, religion nor politics when it comes to mental health. Sometimes we argue here and we agree to disagree at times. As legislators, though, whether we are in government or not, it is about doing the right thing. Specifically with mental health, this is an extremely tough subject but it goes across every sector of society. It does not matter what means someone might have in their back pocket, what kind of a house they might have or whatever.

I welcome what was mentioned in the opening statement from the Minister of State. We are on about dual diagnosis and it is not just about addiction and mental health. The Minister of State mentioned autism and disabilities and other things, because these have been things that have been neglected as well. I take on board the fact that she also mentioned the high-level task force within the justice system. I also acknowledge where her statement referred to it being recognised internationally that vulnerable people with mental health and addiction challenges are over-represented in our criminal justice system. This is a massive amount of work. In fairness, to Deputies Ward and Gould, as well as the Minister of State, we have a consensus to say that we need more time, nobody disagrees with what we are all trying to do and let us try to work together. I refer to the Mental Health Act 2001 and probably the Assisted Decision-Making (Capacity) (Amendment) Act 2022, because that legislation comes into this, and there will also be justice, children and disability aspects. On top of this, we also need the resources and the plans to be in place.

The very fact that we are still talking about this is a huge plus. We are not arguing about this anymore but talking about it. We are working together with the Government, which is a big plus. I also acknowledge that the plans have been put in place for these pilot projects. It is acknowledged that it is needed. I remember being here around 2017, when I think former Deputy Jim Daly was the Minister of State, and how difficult it was for parents with children with dual diagnoses. I will never forget a case where the mother sat up in the Public Gallery and asked me to tell her son's story. It concerned addiction, not alcohol or drugs but cigarettes. The poor young fellow went into an accident and emergency department. It is not his first time there. He was lucky to be kept in but he wanted a cigarette. He kept being refused but eventually he got out and he never returned, but he never returned home either unfortunately. There must also be a common-sense approach to this issue. I recognise the amount of work that has been put into this Bill by all Departments, committees, individuals and groups. I refer to NGOs as well.

As I said, sometimes we come in here and we criticise constantly for probably not doing the right things, but this is an opinion as well. I can stand here tonight, however, and say we are all in this together. We all know of, and we have all been touched in some way by, this issue, probably some of us personally. We are all touched one way or another, in our families, by being directly involved or having been impacted by it. The one thing I always feel about this topic, and I have always been very passionate about it, is that if we can do one thing right and that if in ten years' time, if God spares us, we meet each other walking down the street, hopefully, we will be able to say to each other that we are glad we stuck together and worked together on this and that we have a system now that works. When I say a system that works, we must be empathetic with the people who are struggling and with those working on the front line. There must be a massive, joined-up approach that really must be resourced and supported.

Speaking on my behalf, and accepting what Deputy Ward said, this is all in good faith. We need trust and good faith to have a good working relationship. I just hope that in 12 months' time that we may not be back here discussing this Bill but that we might instead be discussing the overall Bill and saying that we have put in place X, Y and Z, we have moved forward and we have certain plans in place. We may need to work together again at that point and hopefully that can be achieved.

As I said, we are all in here as legislators and we need to try to do the right thing. I have been in and out of here for seven years. If we do not give this generation the support they need, then we will not have them in the near future. The way things are going with the world economy means these people need help.

The most important thing about the citizens' assembly on drug use is that we must start to take the criminal aspect out of helping these people who are using alcohol or drugs as their self-medication because they are in a bad place. The justice system has a massive part to play in this context as well. I commend the two Ministers of State who have the responsibility for their respective portfolios being here and taking this issue seriously. I again thank Deputies Ward and Gould and all the speakers. I also thank the Acting Chair for her patience. Hopefully, it will be onwards and upwards with this issue and we can do the right things.

Minister of State at the Department of Health (Deputy Hildegarde Naughton)

I too thank Deputies Ward and Gould for the opportunity to discuss the important topic of dual diagnosis. I highlight the progress made in relation to dual diagnosis under the national drugs strategy, which comes under my remit as the Minister of State with responsibility for public health, well-being and the national drugs strategy. The national drugs strategy, Reducing Harm, Supporting Recovery, represents a whole-of-government response to the problem of drug and alcohol use in Ireland. As Minister of State with responsibility for the national drugs strategy, I assure Deputies that the Government is committed to its full implementation. Giving people a say in their own treatment and supporting them to play a role in their own recovery as part of a health-led, person-centred approach is at the heart of the strategy. Improving outcomes for people with co-occurring mental illness and substance misuse problems is a key strategic action under the national drugs strategy.

In this context, I welcome the work under way in the HSE on dual diagnosis. It is important that people with a dual diagnosis receive an assessment, onward referral and timely access to appropriate treatment. People presenting with both addiction and mental health problems are often among the most vulnerable in our society. We must ensure that the treatment given to these individuals is based on a strong evidence base and drawn from best practice. I am aware the recent Health Research Board evidence review on dual diagnosis treatment services demonstrates that there is good evidence that greater integration of mental health and addiction services leads to improved treatment outcomes among this group, and this is very welcome.

Enhancing access to and delivery of drug and alcohol services in the community was identified as one of the six strategic priorities in the mid-term review of the national drugs strategy, which was completed in 2022. I understand that the strategic implementation group as well, which includes representation from drug and alcohol task forces, the HSE, Tusla and the community and voluntary sector has identified dual diagnosis as a priority area of focus for enhancing services in community settings. I look forward to seeing this new initiative implemented and to hearing about the progress that will be made. I am confident that this initiative will help in improving people's lives and help them on the road to recovery.

As mentioned earlier by the Minister of State, Deputy Butler, this week the Government agreed to establish a citizens' assembly on drug use. This assembly will look at all aspects of drug use in Ireland today, including what changes might be made at a policy, legislative and operational level to reduce the harmful effects of illicit drug use. The work of the assembly will be very important to ongoing discussions on dual diagnosis, including the Bill before us. Allowing the work of the assembly to take place will better inform the debate on this Bill in 12 months' time.

As we all know, mental illness and addiction frequently occur together but have traditionally been treated separately, often in isolation. I echo the comments of my colleague Deputy Butler about the progress of the HSE's clinical programme for dual diagnosis and welcome the implementation of the HSE's model of care following approval from the College of Psychiatrists. I welcome the progress with the selection of the dual diagnosis sites across the country and the commencement of recruitment of posts for these sites, beginning with CHOs 3, 4 and 9, as mentioned by Deputy Butler. I look forward to the further roll-out of the model of care across the remaining CHOs. As the Minister of State, Deputy Butler, stated, further resourcing will be needed to continue the roll-out of the teams and the model of care and we will continue to seek any additional funding required in future Estimates processes.

I confirm that we as a Government are not opposed to the Bill before us. However, the timed amendment will afford the Department of Health the space to progress the matter in collaboration with Deputies to ensure the challenges faced by those with a dual diagnosis in accessing services appropriate to their needs can be met and tackled. I thank everyone for the valuable contributions they have made this evening. I thank Deputies Ward and Gould for raising the matter and I look forward to further progress being made on it in due course.

Deputy Mark Ward

I thank my colleagues for supporting me and for all their contributions. They are vital. I welcome the Minister of State, Deputy Naughton. This is my first engagement with her as the Minister of State with responsibility for drugs. I wish her the very best in her new role because it is an important one. It is something we need to do better on as a society. I also thank the Minister of State, Deputy Butler, for being here. In fairness to her, through all my time here - three years at this stage - she has never ducked a debate. This is probably one of the more collegial debates we have had so far because a lot of this is being done in good faith. We are willing to work with the Government in constructive Opposition, as I said from the start.

I got a response to a parliamentary question this week about the model of care the Minister of State mentioned. According to the response I got off the HSE, the draft model of care for dual diagnosis was approved by the HSE's chief clinical officer on 7 April 2022 and was sent to the College of Psychiatrists on 13 April 2022 for approval by the clinical advisory group. It goes on to say that the HSE is waiting for a response from the College of Psychiatrists. The College of Psychiatrists, according to the response I got, has had this report for the last ten months and has not responded. There does not seem to be urgency about this. Can the Minister of State make it a priority that the College of Psychiatrists responds and make sure there are no more delays?

Deputy Mary Butler

We will have it in the next two weeks. We checked that today.

Deputy Mark Ward

Okay. The response I got this week said it had not responded yet and it is ten months down the line.

Deputy Mary Butler

I am sorry for interrupting.

Deputy Mark Ward

It is fine, work away. If it is good news the Minister of State can interrupt me. I have no problem with that.

According to the response from the HSE, CHO 3, which includes Limerick, Clare and north Tipperary, has been identified as the first adult diagnosis team and many of the team members have already been recruited. That is welcome. However, the response also stated that CHO 3 had recently identified possible issues with the building site and that the HSE was advised in December 2022 that a building inspection by an engineer is planned to take place, possibly in January 2023. I am not sure whether an inspection has taken place yet. We are now in February. It just seems to be another hold-up. I ask the Minister of State to find out what is happening with that.

CHO 4, which includes the Cork and Kerry teams, has been identified as the second adult dual diagnosis team site. The HSE said that as there were no applicants for the consultant post, external agencies, through the Public Appointments Service, have been involved in trying to recruit a consultant from other countries. Has any progress been made in filling this post yet? What concerns me is that the letter says the remaining posts in CHO 4 will only be advertised once the consultant has been identified. Why is this? Why can we not start building whatever multidisciplinary team is needed while there is a vacuum with the consultant psychiatrist? There seems to be an issue with recruiting consultant psychiatrists in the Kerry region in general at the moment with the Maskey report and CAMHS and everything else that is going on. While we are still looking, and I have no doubt that the HSE is actively looking for a consultant psychiatrist for this post, why can we not start recruiting the multidisciplinary team? That would make a lot of sense. The response also says that accommodation for this team has been identified and that it is co-located with the community alcohol programme and the HSE addiction services, which will enable better cross-divisional working. This is welcome but we need urgency around staffing this facility.

CHO 9 has been identified as the first adolescent dual diagnosis hub team site. It is welcome that adolescents are being looked at as well. A team will be advertised shortly in partnership with HSE social inclusion. This is positive but it is also not. I mentioned the Keltoi centre already. The HSE says that following discussions with CHO 9, it has been agreed in principle for the Keltoi centre in St. Mary's Hospital in the Phoenix Park to be used as the HSE's national dual diagnosis rehabilitation centre. Deputy Naughton's predecessor in this role, Deputy Feighan, was sick to the back teeth of me bringing up the Keltoi centre with him every chance I got. I welcome that there seems to be progress on this. The site was closed temporarily three years ago as part of Covid measures and then it stayed closed due to the emergency with international protection applicants and Ukrainian refugees. I welcome that it looks like the facility is reopening. This would make a real difference for those with a dual diagnosis who detox from whatever substance they had been addicted to. It is a vital facility for rehabilitation.

The reason I talk about it so often is that it is a facility I know very well from my previous role. I know it has saved lives. Previously, if someone was going into say Cuan Dara in Cherry Orchard for a detox and coming off whatever street drugs they were on or coming off methadone, there was no door-to-door service from Cuan Dara to the Keltoi centre. What used to happen was they would do their detox and then they might wait four, five or six weeks to go into the Keltoi centre. In that gap after they left, some people would have a relapse and go back to drugs. They would start using drugs at the same level they were using before they detoxed and they would overdose and sometimes die. I know a lot of people who would have passed away like that. There was a campaign on the ground by me and other front-line addiction workers at the time to close that gap and provide a door-to-door service. That way, people would finish their detox and could go straight into the Keltoi centre for rehabilitation. It was vital. Since that centre closed, that piece is not there anymore and it is a missing piece of the jigsaw. I urge the Minister of State to do everything she can to make sure that promise is kept and that facility is reopened.

In some CHO areas, we have the staff but we do not have the buildings and in others we have the buildings but not the staff. Let us put our heads together and see if we can get this working. We have a chance here to get this right. I will leave it at that. I am positive today. I had a good week this week. As I said to the Minister of State earlier, I had a good engagement with the HSE on CAMHS and I genuinely believe things will start moving in a positive direction. Hopefully with the programme of work around dual diagnosis that is coming in the next year, we can see progress on this as well. I thank everybody who took part in the debate and I thank all the staff for staying back for the late shift. I will shut up now so we can all go home.

Amendment agreed to.

Motion, as amended, agreed to.

An Cathaoirleach Gníomhach (Deputy Marian Harkin)

The Bill will be read a Second Time on this day 12 months.

Cuireadh an Dáil ar athló ar 7.19 p.m. go dtí 2 p.m., Dé Máirt, an 21 Feabhra 2023.

The Dáil adjourned at 7.19 p.m. until 2 p.m. on Tuesday, 21 February 2023.